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Despite a large effort in EEG signal processing, classification algorithms, deep-learning approach, predicting the sensitivity to general anesthesia (GA) remains a daunting hurdle. We compare here the ability of the Bispectral Index™ (BIS™), developed more that twenty years ago to monitor the depth of anesthesia, with the real-time checkpoint-decomposition algorithm (CDA) to evaluate the patient sensitivity from the early induction phase of GA. Using EEG recorded in children anesthetised with propofol, we computed three parameters extracted from the BIS: 1-the minimum value (nadir) of the BIS, 2-the time to reach the minimum and 3-the duration spent below 40 during the first 10 minutes. Using a logistic regression procedure, we report that these parameters provide a poor prediction of sensitivity compared to the CDA, that combined the first occurrence time of iso-electric EEG traces, fraction of suppressions of theα-band and its first occurrence time. Finally, we correlate the BIS values with the maximum power frequency of theα−band, the proportion ofα−suppressions (αS) and iso-electric suppressions (IES) as well as theαandδpower ratios. To conclude, the checkpoint-decomposition algorithm complements the EEG indices such as the BIS to anticipate the sensitivity to GA.

La crise sanitaire de la Covid-19 du printemps 2020 a peu touché les enfants avec peu d’hospitalisations dans les hôpitaux pédiatriques. Le défi a été d’apporter une aide aux hôpitaux adultes avec un personnel principalement formé à la pédiatrie tout en maintenant la permanence des soins urgents pour les enfants atteints ou non de la Covid-19. À l’hôpital universitaire Armand-Trousseau, nous avons créé des unités dédiées pour les enfants atteints de la Covid-19, identifié les spécificités des enfants atteints de la Covid-19 et notamment les formes de Kawasaki like ou PIMS (paediatric multisystem inflammatory syndrome), créé une unité de réanimation adulte au pic de l’épidémie pour augmenter les capacités en lits de réanimation dans notre région, mutualisé notre centre de dépistage pour le personnel d’hôpitaux adultes. Enfin, nous avons envoyé plus de 140 personnels médicaux et paramédicaux dans les hôpitaux adultes de notre groupe hospitalier. Cette aide a pu être organisée grâce aux liens étroits établis par des cellules de crises communes avec les hôpitaux adultes de notre groupe hospitalier. Nous rapportons ainsi un retour d’expérience d’un hôpital pédiatrique au cours de la crise de la Covid-19 en Île-de-France.

Resume Les auteurs exposent les recommandations de la Societe francaise d’oto-rhino-laryngologie et de chirurgie de la face et du cou (SFORL) concernant le traitement de la douleur apres amygdalectomie de l’enfant et de l’adulte. Un groupe de travail multidisciplinaire a ete charge d’effectuer une revue de la litterature scientifique. A partir de ces textes et de l’experience de chacun, des recommandations ont ete redigees. Elles ont ensuite ete relues par un groupe de lecture independant du groupe de travail. Une reunion de synthese a permis d’aboutir a la version finale de la recommandation. Les recommandations proposees ont ete classees en grade A, B, C ou accord professionnel selon un niveau de preuve scientifique decroissant. A domicile, en association avec le paracetamol : il est recommande de privilegier les anti-inflammatoires non steroidiens (AINS) en cas de risque respiratoire accru, notamment en cas de syndrome d’apnees obstructives du sommeil severe ; en cas de risque hemorragique accru (troubles de l’hemostase, difficultes chirurgicales…), il est recommande de privilegier le tramadol. Il est recommande l’evaluation des deux autres schemas therapeutiques (AINS modifies et corticoides) qui n’ont pas fait l’objet d’etudes specifiques. Le traitement de la douleur de l’enfant apres amygdalectomie repose sur un compromis benefice-risque individualise.

Objectives The present clinical practice guidelines cover the entire field of management of post-tonsillectomy pain. Given the French and European regulatory restrictions on the use of codeine, an update appears necessary to clarify the management of post-tonsillectomy pain in adults. Method A work group approached the issue of pain management, following the chronological pathway from initial consultation to postoperative period. As exhaustive a study of the literature as possible assessed the pain impact of the various surgical techniques and the efficacy of the various analgesia schedules. Results Guidelines on the management of post-tonsillectomy pain in adults were drawn up and graded, based on the levels of evidence of selected articles and on work group consensus. The guidelines stress the importance of patient information and seek to harmonize practice, reduce the risk of postoperative complications and above all improve control of post-tonsillectomy pain in adults.

Resume Objectifs Cette recommandation de pratique clinique porte sur l’ensemble de la prise en charge de la douleur apres amygdalectomie. Dans le contexte particulier de la restriction par l’ANSM et l’EMA de l’utilisation de la codeine, il nous a semble necessaire d’effectuer une mise au point afin de clarifier la prise en charge de la douleur post-amygdalectomie chez l’adulte. Methode Le groupe de travail a pris le parti d’aborder cette problematique de la prise en charge de la douleur en suivant l’ordre chronologique du parcours du patient, de la consultation initiale a la periode postoperatoire. Une etude la plus exhaustive possible de la litterature a permis au groupe de travail d’evaluer l’incidence sur la douleur des differentes techniques chirurgicales et l’efficacite des procedes analgesiques. Resultats A partir du niveau de preuve des articles selectionnes et de facon collegiale au sein du groupe de travail, des recommandations ont ete proposees et gradees concernant la prise en charge des patients adultes apres amygdalectomie. Ces recommandations insistent sur l’information du patient et ont pour objectifs d’harmoniser les pratiques, de reduire les risques de complications postoperatoires et surtout d’ameliorer le controle de la douleur post-amygdalectomie chez l’adulte.

International audience; An experiment was conducted to evaluate the ability of two spectroscopy methods to distinguish between pasture and preserved-forage cheeses. The reflectance spectra of 308 fresh and freeze-dried samples of cow's milk cheeses were recorded at wavelengths in the range of the visible, using a portable MINOLTA CM-2002 spectrophotometer. The reflectance spectra of the same samples were also measured in near infrared range using a non-portable laboratory monochromator NIRSystem 6500. The proportion of cheeses correctly classified by NIRS and visible spectra was respectively 0.96 and 0.91 for pasture samples, and 0.96 and 0.79 for preserved-forage samples. No significant differences were found when fresh and freeze-dried cheeses were compared. We conclude that NIRS is able to classify cheese samples from different regimes (here, pasture vs. preserved-forage). (c) 2013 Elsevier Ltd. All rights reserved.

Introduction L’obesite est un probleme epidemiologique majeur de nos societes actuelles. La Sleeve gastrectomie est une des techniques chirurgicales restrictives de l’obesite morbide, avec un risque de fistule de 2,4 % dans la litterature. Aucun parametre clinique ou biologique ne permet a l’heure actuelle de predire la survenue d’une fistule. La procalcitonine est un marqueur preditif de la survenue d’infection post operatoire.

Acute burn is a more or less profound destruction of the skin envelope. The depth of the injury determines the severity of functional and aesthetic sequelae. Local care prevents the infection, factor of deepening of the burn. Currently the dressing used in most Burns centers is a bandage covering a bacterial product applied to the burn. The advantage of this dressing is to prevent the occurrence of local infection. In contrast, open-air method of treatment is based on the notions that the wound is infected. His purpose is to reduce the effects of infection by creating an unfavourable environment to the growth and multiplication of bacteria. The principle of this method is the formation over the burned area of an eschar. The eschar acts as a natural dressing to protect the injured area against infection. The residual skin islets are preserved. The surgical cleavage of the eschar is easy; the deep surface of the crust defines the surgical plan. Deep tangential excisions are not necessary. The implementation of this technique is easy and it is particularly well suited to pediatrics. Treatment is not painful and the child's activities are not hampered by bandages. Respect of the children's quality of life and medical-economic efficiency of this method give it a prominent place in the treatment of burns in children.

Gestational diabetes insipidus is an uncommon clinical disease whose prevalence is approximately two to three pregnancies per 100,000. It may be isolated or associated with preeclampsia. We report a case of gestational diabetes insipidus in a twin pregnancy, originally isolated during two months, and secondarily complicated by HELLP-syndrome. We recall the specific pathophysiology of polyuric-polydipsic syndrome during pregnancy and summarize its various causes. Finally, we discuss the indications, in case of isolated gestational diabetes insipidus, of treatment by dDAVP.

For several years, total intravenous anaesthesia (TIVA) has demonstrated many advantages that allow considering propofol anaesthesia as an interesting alternative in pediatric anaesthesia. TCI in children requires calculation and validation of pharmacokinetic (PK) models specifically adapted to the paediatric population. Several PK models based on a 3-compartement approach have been proposed in children: all these models, which integrate only weight as covariable, show increased distribution volumes with a wide interindividual variability. The particular importance to include physiological covariables, as age and lean body mass, to describe metabolic processes during growth and maturation in pediatric PKPD models is in agreement with recent allometric scaling works in children. However, as pharmacodynamic (PD) parameters are still debated in children, there is up to now, no PKPD model currently available for paediatric anaesthesia. Schnider et al.'s model, a model described in adults that includes numerous covariables, may be adapted and more efficient than the classical paediatric models to describe propofol-PKPD relationship in children over 5years. Whatever the model, a pharmacodynamic feedback such as the bispectral index may be useful to counteract interindividual variability in the paediatric population.

Summary Background Analgesia and nociception can not be specifically monitored during general anesthesia. Movement of the patient or hemodynamic variations are usually considered as symptoms of insufficient analgesia. The measure of skin conductance (SC) allows an assessment of peripheral sympathetic activity. The analgesia-nociception index (ANI) provides an evaluation of the parasympathetic activity based on heart rate variability. These two non-invasive monitors might allow a better assessment of perioperative nociception. Objectives Describe the profiles of SC and ANI after a standardized nociceptive stimulation, in anesthetized children, at different infusion rates of remifentanil. Materials/Methods For this pilot study, 12 children (8.4 ± 5 years) scheduled for middle-ear surgery were anesthetized with desflurane to maintain a bispectral index at 50. Remifentanil was used for analgesia, at an initial infusion rate of 0.2 μg·kg−1·min−1. Remifentanil infusion rate was then decreased: Five steady-state periods of 10 min were obtained at 0.2, 0.16, 0.12, 0.08, and 0.04 μg·kg−1·min−1. At the end of each period, a standardized tetanic stimulation was applied to the patient. Variations in heart rate, blood pressure, SC, and ANI were recorded before and after each stimulation. Results After the stimulation, ANI was significantly decreased compared with prestimulation values for all remifentanil infusion rates. This decrease was greater at 0.04 μg·kg−1·min−1 than at the other infusion rates. SC, heart rate, and blood pressure were not modified by the stimulations, whatever the dose of remifentanil. Conclusion ANI might provide a more sensitive assessment of nociception in anesthetized children than hemodynamic parameters or skin conductance.

The accurate assessment of the depth of anesthesia, allowing a more accurate adaptation of the doses of hypnotics, is an important end point for the anesthesiologist. It is a particularly crucial issue in pediatric anesthesia, in the context of the recent controversies about the potential neurological consequences of the main anesthetic drugs on the developing brain. The electroencephalogram signal reflects the electrical activity of the neurons in the cerebral cortex. It is thus the key to assessment of the level of hypnosis. Beyond visual analysis, several monitoring devices allow an automated treatment of the electroencephalographic (EEG) signal, combining time and frequency domain analysis. Each of these monitors focuses on a specific combination of characteristics of the signal and provides the clinician with useful information that remains, however, partial. For a comprehensive approach of the EEG-derived indices, the main features of the normal EEG, in adults and children, will be presented in the awake state and during sleep. Age-related modifications accompanying cerebral maturation during infancy and childhood will be detailed. Then, this review will provide an update on how anesthetic drugs, particularly hypnotics, influence the EEG signal, and how the main available monitors analyze these drug-induced modifications. The relationships between pain, memory, and the EEG will be discussed. Finally, this review will focus on some specific EEG features such as the electrical epileptoid activity observed under sevoflurane anesthesia. The EEG signal is the best window we have on cortical brain activity and provides a fair pharmacodynamic feedback of the effects of hypnotics. However, the cortex is only one of several targets of anesthesia. Hypnotics and opiates, have also subcortical primary targets, and the EEG performances in the evaluation or prediction of nociception are poor. Monitoring subcortical structures in combination with the EEG might in the future allow a better evaluation and a more precise adaptation of balanced anesthesia.

In children, sevoflurane is the most commonly used anaesthetic. Its excellent haemodynamic tolerance gives it a wide therapeutic index. This halogenated agent can abolish movement [minimal alveolar concentration (MAC)] or haemodynamic responses (MACBAR) to noxious stimulus in children as in adults. Reflex pupillary dilatation (RPD) has been demonstrated as a very sensitive measure of noxious stimulation. In order to investigate the effect of sevoflurane on the RPD, a subcortical reflex, we determined the MAC of sevoflurane inhibiting the RPD in 50% of the subjects in response to skin incision (MACpup) in pre- and post-pubertal subjects.We included 30 pre-pubertal children and 19 post-pubertal subjects. Patients received sevoflurane at preselected concentrations according to an 'up and down' design, and after a steady-state period, skin incision was performed. The RPD was considered as significant when the pupillary diameter increased by more than 100%. Heart rate (HR) and bispectral index (BIS) changes were analysed according to the pupillary response.The MACpup of sevoflurane was 4.8% (95% confidence interval, 4.6-5.1%) in pre-pubertal children vs 3.4% (3.5-3.3%) in post-pubertal subjects (P0.001). Inhibition of RPD was always associated with lack of significant HR response. In pre-pubertal children receiving high concentrations of sevoflurane, RPD in response to noxious stimulation was frequently associated with lack of HR response and low BIS values.MACpup was higher than MAC and close to the MACBAR. Inhibition of RPD in pre-pubertal children required higher sevoflurane concentrations compared with post-pubertal subjects, suggesting that the relationship between the brain structure sensitivities may differ with brain maturation.

The practice of paediatric anaesthesia has changed during the last 25 years, with a noticeable reduction of mortality and serious morbidity. This improvement results in part from the use of new anaesthetic agents which large therapeutic interval regarding cardiovascular effects. Parallel to this advance and following experimental or clinical studies in neurosciences, some new concerns have emerged regarding short and long time consequences of anaesthesia. Indeed, postoperative hyperalgesia due to opioids, emergence agitation and postoperative maladaptive behavioural changes are widely described in children, in the same way the potential epileptogenic effect of sevoflurane is demonstrated. Thus the hypothetical cerebral toxicity leads us to reconsider our practice. Basically, monitoring of cerebral cortical effects of hypnotics is now possible from automated devices based on EEG, allowing us to control the administration of hypnotic agents. The therapeutic interval of these agents, previously determined between movement at incision and deleterious cardiovascular effect, may be revisited with a cerebral approach, with the risk of memorisation for the lower limit and the risk of cerebral over dosage for the upper limit. Lastly, further experimental and clinical studies are required to analyse the effects of the anaesthetic agents on the brain of the neonate, and the interest of the cerebral monitoring in this population.

Resume La gestion perianesthesique des voies aeriennes chez l’enfant presente certaines particularites liees aux specificites anatomiques et physiologiques pediatriques. Ce texte decrit l’equipement classiquement utilisable dans ce contexte. Les recentes evolutions des dispositifs impliques dans la gestion des voies aeriennes ainsi que leur disponibilite pediatrique sont abordees. Par ailleurs, les principales evolutions actuelles dans les principes d’utilisation de ces dispositifs sont discutees.

This paper presents several experimental and simulation results on silicon integrated inductors. Measurements and 3D electromagnetic simulations highlight the efficiency of different layout techniques and technological choices to improve integrated inductor Q factor. Different kinds of pattern ground shields and different substrate configurations are measured and studied. Electromagnetic phenomena involved in such passive integrated devices are described thanks to the complementary measurement/simulation approach. Pattern ground shields have to be carefully used: this layout solution can degrade the integrated inductor quality depending on substrate characteristics of the integration technology.

Resume La surveillance de la profondeur de lˈanesthesie par lˈelectroencephalogramme (EEG) a ete proposee pour completer la surveillance clinique et guider lˈajustement des doses. Cette revue decrit les principales caracteristiques de lˈEEG spontane et les techniques dˈanalyse automatique du trace. Elle reprend les effets de chaque classe dˈagent anesthesique sur lˈEEG et sur les parametres calcules par lˈanalyse automatique, chez lˈadulte et chez lˈenfant, ainsi que les correlations entre ces parametres et les signes cliniques attendus au cours dˈune anesthesie generale (perte de conscience et de memorisation, absence de mouvement et stabilite neurovegetative malgre les stimulations chirurgicales). A ce jour, la technique dˈanalyse offrant la meilleure correlation est lˈanalyse bispectrale, dont le resultat final dans les moniteurs commercialises est lˈindex bispectral ou BIS™. Les interets, indications cliniques et limites du BIS™ en anesthesie et en reanimation, sont detailles et commentes en se basant sur une analyse des publications recentes.

In this paper investigations are performed in order to understand the source of sodium contamination in clean-room environments and to find different cleaning processes able to limit or suppress sodium deposition. In a clean-room environment, the human being has been identified as one of the major sources of sodium. The airborne sodium contamination is essentially transmitted in particle form. In order to limit sodium deposition from the air, the wafers awaiting subsequent processing need to be stored in a protective box or placed far from the human environment and should not be left for much more than 1 week in a class 1 clean room. Also, wet chemistries could cause sodium contamination on wafers particularly during the deionized water rinse. In order to limit the possible contamination, the sodium deposition mechanisms have been studied: they show the typical characteristics of Langmuir adsorption. Temperature and ionic concentration are both parameters which influence the deposition. In water, sodium deposition can be avoided by introducing acid or alkaline solutions or increasing the temperature: it can be drastically reduced by adding traces of HCl (0.01%). Finally, other cleaning chemistries such as SC1 (NH4 OH-H2 O2 -H2 O) in 0.25:1:5 proportion, SC2 (HCl-H2 O2 -H2 O) in 1:1:5 proportion, 0.1% HF and SPM (H2 SO4 -H2 O2 ) in 3:1 proportion reduce the contamination as well.

We studied prospectively the effects of the technique of tracheal extubation on arterial haemoglobin oxygen saturation (SpO2) in 120 ASA I-III children, mean age 5.3 (range 0.25-16.9) yr. At completion of surgery, tracheal extubation was performed when spontaneous ventilation had resumed, children were fully awake and SpO2 was 99-100%. Children were allocated randomly to receive a single lung inflation manoeuvre with 100% oxygen before tracheal extubation (group I; n = 59) or to have the tracheal tube removed while applying suction through the tube (group S; n = 61). SpO2 was monitored during the first 5 min after tracheal extubation in the operating room. Supplementary oxygen was given if SpO2 decreased to less than 92%. The time between tracheal extubation and decrease in SpO2 to 92% (T92) was recorded. Children in group S required oxygen administration more frequently after tracheal extubation than those in group I (65.6% vs 45.8%; P = 0.04), and had a three-fold shortening of T92 (mean 25 (SD 19) s vs 85 (63) s; P = 0.0001). These effects were more pronounced in children less than 4 yr of age compared with older children. We conclude that tracheal extubation greatly impaired oxygenation and therefore administration of oxygen was appropriate. This impairment was more marked when suction was used, and in young children. Lung inflation with 100% oxygen before removal of the tracheal tube is advised before routine tracheal extubation in children.

The objective of the present study was to investigate whether increased beta-human chorionic gonadotrophin (beta HCG) plasma concentrations in an unselected population of nulliparas could predict the occurrence of complicated pregnancy-induced hypertension (PIH). The design was that of a prospective population study. It was conducted at the obstetric departments of Amiens University Hospital and Creil General Hospital on 434 consecutive nulliparas with singleton pregnancies after natural fertilization who accepted the systematic offer of trisomy 21 screening but for whom this disorder was finally estimated. Measurement of plasma concentration of beta HCG (ELISA method) was carried out between 14 and 20 weeks (mean: 17 weeks) of amenorrhea, and measurement of blood pressure and proteinuria (300 mg/24 h or Albustix +2) during the first, second and third term and 2-3 months after the delivery, as well as measurement of birth weight for determination of small for gestational age (SGA) babies, 37 women developed PIH, 10 without other complication, 16 with proteinuria (5 of which with SGA babies) and 11 with SGA babies. Furthermore 2 patients presented abruptio placentae without PIH. 395 women did not develop PIH including 389 normotensive women and 6 chronic hypertensive patients without superimposed toxemia. Only 1 was diabetic. None had chronic renal disease. Mean (+/- SD) levels of beta HCG were higher in PIH than in controls: 46,805 +/- 19,068 versus 23,479 +/- 13,463 IU. A pathologic threshold was chosen as the mean for the whole population + 1 SD: 25,613 + 15,479 = 41,082 IU. Elevated levels (above this value) were significantly associated with isolated PIH or PIH complicated with proteinuria and/or with SGA babies. The positive predictive value of this criterion was respectively 11, 15 and 12% for each of these complications. The relative risk (and 95% confidence limit) of women with elevated beta HCG for each of these complications was 20 (6-79), 11 (4-43) and 22 (7-93). Elevated plasma beta HCG found around 17 weeks of amenorrhea predicts PIH complicated with either proteinuria or SGA babies with a positive predictive value comparable to that of the best and earliest test proposed up to now to select nulliparas at high risk of preeclampsia, namely the abnormalities of the Doppler waveforms of the uterine arteries. Since this test is simpler to perform, it represents the most convenient method to screen a population of nulliparas for evaluation of the benefits of low-dose aspirin.

For several years, total intravenous anaesthesia (TIVA) has demonstrated many advantages that allow considering propofol anaesthesia as an interesting alternative in pediatric anaesthesia. TCI in children requires calculation and validation of pharmacokinetic (PK) models specifically adapted to the paediatric population. Several PK models based on a 3-compartement approach have been proposed in children: all these models, which integrate only weight as covariable, show increased distribution volumes with a wide interindividual variability. The particular importance to include physiological covariables, as age and lean body mass, to describe metabolic processes during growth and maturation in pediatric PKPD models is in agreement with recent allometric scaling works in children. However, as pharmacodynamic (PD) parameters are still debated in children, there is up to now, no PKPD model currently available for paediatric anaesthesia. Schnider et al.'s model, a model described in adults that includes numerous covariables, may be adapted and more efficient than the classical paediatric models to describe propofol-PKPD relationship in children over 5years. Whatever the model, a pharmacodynamic feedback such as the bispectral index may be useful to counteract interindividual variability in the paediatric population.

Gestational diabetes insipidus is an uncommon clinical disease whose prevalence is approximately two to three pregnancies per 100,000. It may be isolated or associated with preeclampsia. We report a case of gestational diabetes insipidus in a twin pregnancy, originally isolated during two months, and secondarily complicated by HELLP-syndrome. We recall the specific pathophysiology of polyuric-polydipsic syndrome during pregnancy and summarize its various causes. Finally, we discuss the indications, in case of isolated gestational diabetes insipidus, of treatment by dDAVP.

Summary Objective This article presents the Clinical Practice Guidelines for Pediatric Tonsillectomy of the French Society of ENT and Head and Neck Surgery (SFORL), entitled “Amygdalectomie de l’enfant : Recommandation pour la pratique clinique” (SFORL, 2009). Method The French Society of ENT (SFORL), in partnership with the French Association for Ambulatory Surgery (AFCA) and French Society for Anaesthesia and Intensive Care (SFAR), set up a representative panel in the fields of anesthesiology, ENT and head-and-neck surgery, pediatrics, sleep medicine and general medicine. Following the literature analysis reported in the Presentation of the Guidelines, recommendations were drawn up taking account of risk/benefit ratios, levels of evidence, feasibility in pediatric tonsillectomy and baseline risk assessment in the relevant population. Results Around 50,000 pediatric tonsillectomies, with or without associated adenoidectomy, are performed in France each year. Postoperative morbidity and mortality are non-negligible, despite progress in peri-operative management. The present guidelines address the following questions: 1) What are the indications for tonsillectomy, notably in case of obstructive sleep disorder; 2) What pre-operative assessment is required? 3) What are the technical principles involved? 4) What are the selection criteria for ambulatory tonsillectomy? 5) How should postoperative follow-up be organized? 6) How should complications be managed? Conclusion The present Clinical Practice Guidelines for pediatric tonsillectomy in France should improve clinical and organizational practices to enhance patient safety. They seek to ensure optimal conditions of care for all children undergoing tonsillectomy.

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N(2)O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7-8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.

International audience; The ability of near-infrared spectroscopy to trace cow feeding systems and farming altitude was tested on 486 bulk milk samples from France and northwestern Italy. Milks were grouped into feeding systems according to the main forage in the diet. Partial least square discriminant analysis correctly classified 95.5, 91.5, and 93.3% of pasture versus maize silage, hay, and fermented herbage feeding systems, respectively. Discrimination was slightly less successful when diets with large proportions of the nondominant forage were included in each group. Near-infrared spectroscopy correctly discriminated no-pasture from pasture milk, even with only 30% of pasture in the diet (5.4% cross-validation error), and the error stabilized when pasture exceeded 70% (2.5% error). Near-infrared spectroscopy did not reliably trace milk geographic origin when the feeding system effect was isolated from the altitude effect. These findings may be usefully exploited for the authentication of dairy products.

Acute burn is a more or less profound destruction of the skin envelope. The depth of the injury determines the severity of functional and aesthetic sequelae. Local care prevents the infection, factor of deepening of the burn. Currently the dressing used in most Burns centers is a bandage covering a bacterial product applied to the burn. The advantage of this dressing is to prevent the occurrence of local infection. In contrast, open-air method of treatment is based on the notions that the wound is infected. His purpose is to reduce the effects of infection by creating an unfavourable environment to the growth and multiplication of bacteria. The principle of this method is the formation over the burned area of an eschar. The eschar acts as a natural dressing to protect the injured area against infection. The residual skin islets are preserved. The surgical cleavage of the eschar is easy; the deep surface of the crust defines the surgical plan. Deep tangential excisions are not necessary. The implementation of this technique is easy and it is particularly well suited to pediatrics. Treatment is not painful and the child's activities are not hampered by bandages. Respect of the children's quality of life and medical-economic efficiency of this method give it a prominent place in the treatment of burns in children.

The practice of paediatric anaesthesia has changed during the last 25 years, with a noticeable reduction of mortality and serious morbidity. This improvement results in part from the use of new anaesthetic agents which large therapeutic interval regarding cardiovascular effects. Parallel to this advance and following experimental or clinical studies in neurosciences, some new concerns have emerged regarding short and long time consequences of anaesthesia. Indeed, postoperative hyperalgesia due to opioids, emergence agitation and postoperative maladaptive behavioural changes are widely described in children, in the same way the potential epileptogenic effect of sevoflurane is demonstrated. Thus the hypothetical cerebral toxicity leads us to reconsider our practice. Basically, monitoring of cerebral cortical effects of hypnotics is now possible from automated devices based on EEG, allowing us to control the administration of hypnotic agents. The therapeutic interval of these agents, previously determined between movement at incision and deleterious cardiovascular effect, may be revisited with a cerebral approach, with the risk of memorisation for the lower limit and the risk of cerebral over dosage for the upper limit. Lastly, further experimental and clinical studies are required to analyse the effects of the anaesthetic agents on the brain of the neonate, and the interest of the cerebral monitoring in this population.

The differences between a child's airway and an adult's, dictate differences in anaesthetic management techniques. Techniques and principles to assist in this management are reviewed in this article. Paediatric specificities of airway devices and other materials required for endotracheal intubation are described. In addition, recent development of equipment and current trends in management of paediatric airway are discussed.

Continuous blood pressure (BP) measurement provides instantaneous information on hemodynamic status, and allows for assessment of sympathetic modulation of vasomotor tone using spectral analysis. As an alternative to intraarterial blood pressure (IABP) measurement, the Finapres, a photoplethysmographic device, allows for non-invasive continuous measurement of finger blood pressure (FBP). This study was designed to evaluate the accuracy of spectral measurements of FBP variability in children during anesthesia and recovery. For this purpose, reliability of BP measurement and short-term BP variability assessed by FBP were calculated and compared with IABP.Finger blood pressure was compared with IABP from the ipsilateral radial artery, in 14 children undergoing major surgery. Sixty-seven simultaneous recordings of both signals were performed during anesthesia and 32 during recovery period. The accuracy of the FBP was determined by measuring its bias and precision according to the Bland and Altman method. To assess the ability of the FBP to follow short term BP variability, bias of total spectral power and bias of the 3 main spectral components (LF, MF, HF) were calculated. Transfer functions between invasive and non-invasive signals were calculated.The average bias of SBP measurement was 3.8 +/- 7.4 mmHg during anesthesia and 2.2 +/- 6.7 mmHg during recovery. During anesthesia overall variability and spectral components of FBP and IABP were similar with both techniques; while during recovery, a selective amplification of the low frequencies (0.15 Hz) of FBP was observed. Frequency response analysis of the pressure waveform, showed a high coherence between both signal with a gain of 0.96 +/- 0.52 mmHg FBP/ mmHg IABP under anesthesia, and of 0.74 mmHg FBP/ mmHg IABP during recovery.The differences evidenced between FBP and IABP spectral profiles might result from specific physiological properties of digital arteries, which are sympathetic effectors. This study supports the use of FBP in children to assess non-invasively the vascular sympathetic component of the autonomic nervous system during anesthesia and recovery.

Spontaneous EEG has been proposed for monitoring depth of anaesthesia and adjusting anesthetic drugs doses. This review describes the main features of spontaneous EEG, the principles of EEG signal analysis used in anaesthesia, and the EEG effects of the different anesthetic drugs in adults and children. Then, the correlations between EEG parameters changes and clinical signs of anesthesia (loss of consciousness and memory, lack of movement and haemodynamic stability despite noxious stimulations) are analyzed. The best signal analysis technique available today for routine use seems to be bispectral analysis, which returns, in the available monitors, a single number called bispectral index or BIS. Based upon the recent literature, clinical uses, performances and limits of use of BIS are described and discussed.

Summary Angiotensin-converting enzyme (ACE) inhibitors are widely used as antihypertensive drugs, and serious complications have been described in adults, particularly in the perioperative period. This report concerns a 14-months-old infant who developed prolonged hypotension and reversible renal failure during major surgery for neuroblastoma removal. He was treated for 4 months by the long-acting ACE inhibitor, enalapril, that had been continued until the morning of surgery. This observation, as well as others in adults, suggests that consideration should be given to discontinue the administration of long-acting ACE inhibitors preoperatively in children scheduled to undergo extensive surgical procedure involving large blood or fluid shifts.

Introduction Chez l’enfant, l’anesthesie locoregionale (ALR) est rarement utilisee sans anesthesie generale (AG) (environ 0,04 % des procedures) [1] . Le niveau d’anxiete des enfants et des parents en perioperatoire, la peur de la realisation de l’ALR ou de la douleur pendant la chirurgie ainsi que la necessaire immobilite, sont les principales causes de rejet des techniques d’ALR seule. L’utilisation de techniques de distraction a demontre son efficacite dans la diminution de l’anxiete et de la douleur dans la realisation de soins douloureux chez l’enfant. L’objectif de cette etude etait d’evaluer l’utilisation de la distraction par video 3D, en termes de faisabilite et d’interet, chez des enfants operes d’une chirurgie sous ALR seule. Materiel et methodes Etude prospective observationnelle approuvee par le CPP de Saint-Antoine. La possibilite de realiser l’intervention chirurgicale sous ALR sans AG avec une distraction par casque video 3D, etait proposee en consultation d’anesthesie, a tous les enfants âges d’au moins 6 ans (et leurs parents) programmes pour une chirurgie peripherique adaptee. Apres obtention du consentement eclaire de l’enfant et des parents, l’acceptation de cette technique et le choix du film 3D etaient confirmes lors de la visite preanesthesique. Les enfants etaient premediques par de l’hydroxyzine per os, la pose de la voie veineuse et l’ALR etait realisees sous N2O ou hypnose conversationnelle, avec un reperage nerveux sous echographie. Un monitorage peranesthesique standard etait mis en place. Un interrogatoire de l’enfant sur son ressenti de la technique etait realise a j0 et a j8. Les criteres evalues etaient : l’anxiete avant la realisation de l’ALR, la douleur pendant la pose de voie veineuse (VVP), pendant la realisation de l’ALR, pendant la chirurgie et a la sortie de SSPI, la satisfaction de l’enfant apres l’intervention, la satisfaction du chirurgien apres l’intervention, les raisons du choix cette technique, par l’enfant. Les echecs de cette technique etaient definis par les echecs d’ALR, la necessite de complements anesthesiques par voie generale, les signes de mauvaise tolerance (plainte, pleur, agitation). Resultats Trente et un enfants, âges en moyenne de 12,4 ± 3,3 ans (moyenne ± SD) ont ete inclus. Un patient sur 31, a ete considere comme un echec de la technique (echec de l’ALR) et donc exclu de l’analyse. Vingt-trois enfants etaient operes d’une chirurgie du membre superieur, et 8 du membre inferieur. La duree moyenne de la chirurgie etait de 35 ± 27 min. Soixante-cinq pour cent des patients presentaient une score d’anxiete > 4 avant l’ALR. Les valeurs medianes de l’EVA douleur etaient de 0 (VVP), 2,5 (ALR) et 0 (CHIR). Tous les enfants presentaient des scores de satisfaction > 7 a j0 et j8. La satisfaction des chirurgiens etait excellente (mediane EN a 10). Concernant les raisons du choix de cette technique, 25 % des enfants souhaitaient eviter l’AG, alors que 75 % etaient motives par le visionnage d’un film 3D ( Fig. 1 ). Discussion Lors d’une chirurgie sous ALR, l’utilisation d’un casque video 3D induit une immersion dans une realite virtuelle permettant a l’enfant d’eviter l’anesthesie generale et ses complications potentielles. Cette technique basee sur l’utilisation ludique du multimedia est particulierement attractive chez les enfants d’âge scolaire.

Introduction Dans une maternite de type 3 de plus de 3000 naissances, la presence d’un IADE poste en salle de naissance (SDN) joue un role important dans la surveillance et l’optimisation de l’analgesie peridurale (APD) obstetricale. Les reinjections peridurales par l’IADE, apres evaluation clinique, doivent etre faites sous couvert de prescription medicale [1] . Le but de cette etude est l’evaluation d’un protocole de prise en charge par les IADE d’une APD obstetricale non optimale, sous forme d’un arbre decisionnel ( Fig. 1 ). Materiel et methodes Enquete prospective observationnelle menee d’avril 2013 a mars 2014 sous forme d’EPP. Apres chaque intervention par l’IADE en SDN pour APD non optimale, sur la base du protocole, une fiche descriptive sous forme de questionnaire a ete remplie par l’IADE. L’objectif principal du questionnaire etait d’evaluer le pourcentage d’analgesie optimisee apres intervention de l’IADE. Les objectifs secondaires etaient l’analyse des echecs d’analgesie (niveau symetrique insuffisant (NSI), defaut de puissance (DP), niveau asymetrique (NA)), l’evaluation du suivi conforme au protocole, les situations eventuelles non prevues par ce dernier et le taux d’interventions secondaires sous anesthesie generale (AG). Resultats Sur une periode de 11 mois, 85 questionnaires ont ete remplis a la suite d’appels pour APD non satisfaisante. Dans 84 % des cas la premiere intervention par l’IADE sur la base du protocole a ete efficace et suffisante, tandis que dans 16 % des cas une seconde intervention a ete necessaire apres appel du MAR. Les causes retrouvees d’APD inefficace etaient par ordre de frequence decroissante un DP (76 %), un NSI (13 %), un NA (11 %). L’intervention etait en adequation avec le protocole dans 81 % des cas et l’administration inadaptee de clonidine etait l’erreur de suivi du protocole la plus frequente dans les autres cas. Le protocole etait applicable a toutes les situations rencontrees. Une seconde pose d’APD a ete realisee avec succes chez trois patientes. Une cesarienne a ete necessaire en cours de travail pour 13 patientes (15 %) dont 12 sous APD et 1 sous AG. Discussion La surveillance reguliere et l’optimisation de l’APD obstetricale permet de limiter les echecs et d’eviter le recours a l’AG dans certains cas [2] . La mise a disposition d’un protocole d’evaluation et de reinjection en cas d’APD inefficace permet a l’IADE de jouer un role important dans le depistage et la prise en charge de la plupart des APD inefficaces permettant une meilleure optimisation de l’APD et limitant ainsi le recours a l’AG en cas d’echec.