Annales françaises d'anesthèsie et de rèanimation
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The initial management of severely head-injured patients, including infants and children, is aimed at preventing and treating secondary brain damage, which mainly result from systemic insults (hypoxaemia, hypercarbia, arterial hypotension). Orotracheal intubation, followed by continuous sedation-analgesia, is mandatory when the Glasgow Coma Scale score (GCS) is less than or equal to 8 (crush induction is recommended). The goal of mechanical ventilation is to maintain normoxaemia and normocarbia. ⋯ However, it should be noted, that severe head trauma is frequently associated with extra-cranial traumatic injuries, which may be responsible for (avoidable) deaths if the diagnosis is not made or delayed. Therefore, infants and small children presenting with severe head trauma should be considered as multiple injured and treated accordingly. Adequate initial management of severely head-injured children may participate to improved neurological outcome.
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The symptomatic treatment of hydrocephalus remains cerebrospinal fluid (CSF) drainage to an external reservoir (external CSF drainage) or to an internal cavity mainly the peritoneum or the right atrium via a unidirectional valve (internal CSF drainage) and finally by endoscopic ventriculocisternostomy. Local anaesthesia is adequate for external CSF drainage in adults and children above 10 years while general anaesthesia is required in all other cases. The main problems encountered in these patients are difficult intubation and full stomach associated with increased intracranial pressure. ⋯ Complications (infectious, mechanical and bleeding kinds) are frequent and are often the cause of reinterventions or revisions of the device, exposing the patients to iterative anaesthesia. Furthermore, patients with shunts are at risk of malfunction of the device when exposed to situations like pregnancy, magnetic resonance imaging, or laparoscopy. Under these circumstances, it is recommended to associate the neurosurgical team in the management of these patients and to verify that the shunt is working well before and after the procedure or event.
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Cerebral stereotaxy is an old methodology allowing an accurate approach of a lesion or a function, in constant renewal with the introduction of computers and robotic. There is a natural complementarity with recent neuroradiological investigations and together, it is possible to reach cerebral deep-seated or functional structures with inocuity and fiability for diagnosis and/or therapy. ⋯ The development of functional stereotaxy is associated with the interest of the neurosurgical treatment of involuntary abnormal movements, without forgetting different aspects of surgery of chronic pain and intractable epilepsies. Moreover, the stereotactic methodology leads the concept of radiosurgery, which is in some indications a true alternative to open surgery (arteriovenous malformations, vestibular schwannoma, metastasis) under the control of accurate selection in a multidisciplinary approach.
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Ann Fr Anesth Reanim · Feb 2002
Review[Infections of cerebrospinal fluid shunts in the child: prevention and treatment].
Cerebrospinal fluid (CSF) shunting has developed into the mean method of treatment in children with hydrocephalus. Until the last decade, shunt infection was the most important cause of morbidity with a mean rate of 10%. Most of shunt infection (> 90%) are diagnosed within six months after surgery supporting a basic premise of direct contamination at the time of surgery. ⋯ The small sample sizes of prospective controlled clinical trials precluded sufficient statistical power. The conclusions of the meta-analyses are not sufficiently robust to resolve the controversy and it is not possible to make recommendations either for or against the use of prophylaxis in shunt surgery. The management of shunt infection is examined with emphasis on antibiotic therapy.
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Pain management in paediatric neurosurgery must be a daily concern for surgeons and anaesthetists. Pain assessment in infants and small children is difficult to perform because of limitations associated with these patients. The association of safe and effective analgesics allows good pain relief together with good safety conditions. However, neuropathic pain, which may occur following neurosurgical procedures, will require further studies.