Archives de pédiatrie : organe officiel de la Sociéte française de pédiatrie
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The development of patient controlled analgesia (PCA) in children is the result of a search for an analgesia being both maximally efficient and secure, in the management of severe pain. The technique is based on self infusions of an analgesic, mainly morphine, by the child, through a special pump. ⋯ PCA is applicable to children older than 5 years. The main indications are post-operative and oncological pains.
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This article describes the most current and effective means for providing sedation and analgesia for the pediatric patient. Three basic levels for sedation can be defined: conscious sedation, deep sedation and general anesthesia. ⋯ Providing safe and effective sedation and analgesia to children requires appropriate selection of drugs and dosage, proper monitoring, knowledge of potential side effects, and adequate airway management equipment and personnel. Agents available for sedation and analgesia of children and therapeutic options according to different clinical situations are described.
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Perioperative fasting aims at decreasing the incidence of gastric content inhalation during anesthesia. Current knowledge concerning gastric emptying and the epidemiology of pulmonary aspiration authorizes new perioperative fasting guidelines. ⋯ On the other hand, after surgery, the mandatory intake of water significantly increases the incidence of postoperative vomiting. Therefore new guidelines may be applied for children operated in ambulatory surgery settings: 1) clear fluids may be allowed until 2-3 hours before operation, 10 ml.kg-1, or even ad libitum for some authors (by clear fluids one means water, tea, coffee, apple juice, syrup with water); 2) drinking is not absolutely necessary before discharge from day care surgery unit and should be left to the child's own assessment.
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Intraosseous vascular access is a simple and very efficient technique for fluid and drug administration in any pediatric emergencies where the intravenous route is impossible or inadequate. Yet it remains unrecognized in France. ⋯ Provided that the technique is performed with careful asepsis, the risk of infectious complications is very low. However the intraosseous route must remain a transitory vascular access, and has to be stopped as soon as possible, its use never exceeding 24 hours.
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Children under 6 often show marked anxiety and physical pain during laceration repair. If locally infiltrated anesthetics usually give a good control of physical pain, they have no effect on anxiety and restlessness for which several medications are available for conscious sedation. Continuous nitrous oxide, intramuscular sedative "cocktail" with meperidine-promethazine-chlorpromazine or intravenous fentanyl have various inconveniences and therefore are not ideal for this purpose. By contrast, Midazolam, a short acting watersoluble benzodiazepine with anxiolitic, hypnotic and anterograde amnestic effect, appears to be a safe and effective treatment when given orally or intranasally for alleviating anxiety in under 6 year-old out-patient in emergency department; its rectal administration appears less effective and needs further studies before to be routinely used.