Annales françaises d'anesthèsie et de rèanimation
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A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. ⋯ In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.
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Ann Fr Anesth Reanim · Jun 2007
Review[Nociceptive cancer pain in adult patients: statement about guidelines related to the use of antinociceptive medicine].
The World Health Organization (WHO) published guidelines to improve cancer pain control which allow to relieve noceptive cancer pain in 80% of adult patients. Nevertheless WHO recommendations do not include: various ways to start morphine treatment, how to manage opioids adverse effects, severe cancer pain management, postoperative pain and procedure-relatived pain. The goal of this review is to discuss these issues. ⋯ Oral immediate or controlled release morphine is the most common and effective pain treatment for most patients with nociceptive cancer pain but rotation with other opioids or alternative routes of administration must be discussed quickly if pain persits or if adverse effects occur.
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Ann Fr Anesth Reanim · Jun 2007
Review[Steroids in the critical care children with septic shock and other conditions].
Steroids are indicated in paediatric intensive care as anti-inflammatory drugs or for substitutive treatment. During septic shock, the incidence of adrenal insufficiency (AI) varies between 18 à 52%, depending on the relative or absolute nature of the AI. Contrary to adults, for whom long courses of low doses of corticosteroids were shown to reduce mortality and increased shock reversibility, particularly in those with a negative synacthene test, no study provided sufficient evidence to show a benefit of steroids in terms of outcome in children with septic shock. ⋯ However the high incidence of side effects, particularly on the central nervous system, makes steroids currently not recommended for bronchopulmonary dysplasia. At last, steroids are indicated for severe asthma and for bacterial meningitis. In this latter indication, dexamethasone was shown to improve neurological outcome, indeed mortality in Haemophilus influenzae and Streptococcus pneumoniae meningitis.
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The real place of tramadol in the armatarium of postoperative analgesics in children remains to be defined. This paper presents a synthetic review of the present knowledge regarding the efficacy, dosage and possible routes of administration of tramadol to children in the postoperative period. ⋯ The perinervous routes (epidural, around peripheral nerves, skin infiltration) are controversial. Tramadol is a good alternative to NSAIDs and to morphine for moderate pain but its efficacy is variable due to the genetic polymorphism of its metabolism and possible drug interactions.
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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. ⋯ 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.