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• W2003967560 abstract "Le développement de la cœliochirurgie en pédiatrie conduit à la multiplication des indications chirurgicales et impose de nouvelles contraintes aux anesthésistes. Le retentissement hémodynamique et respiratoire du pneumopéritoine et de la position opératoire diffère peu de celui observé chez l'adulte. L'élévation de la pression artérielle et de la Petco2 est fréquente chez l'enfant âgé de plus de quatre mois, sans rapport avec le niveau de la pression intraabdominale. Chez les enfants plus jeunes, ces modifications n'ont pas été notées, peut-être en raison de la pression intraabdominale maintenue en dessous de 6 mmHg grâce à une suspension pariétale. Les contre-indications retenues incluent l'hypovolémie, les cardiopathies, l'atteinte respiratoire avec distension alvéolaire, telle la bronchodysplasie, et l'hypertension intracrânienne. Certaines indications s'adressent à des enfants atteints d'une affection associée nécessitant une prise en charge spécifique : bronchites récidivantes voire asthme associés à un reflux gastroœsophagien, drépanocytose associée à une lithiase vésiculaire. L'anesthésie doit respecter les règles habituelles de sécurité en anesthésie pédiatrique. Le maintien de la pression artérielle nécessite de limiter la fraction expirée d'halogénés à 1,5 fois la CAM adaptée à l'âge. Les complications rapportées à ce jour sont essentiellement liées à l'acte chirurgical, toutes n'étant pas spécifiques de la cœlioscopie. Les complications en rapport avec l'anesthésie existent vraisemblablement et seront au mieux prévenues par la formation des équipes d'anesthésie pédiatrique dans les centres les plus expérimentés. The increasing use of laparoscopic surgery in children is associated with the enlargement of the spectrum of indications to appendicectomy, extramucosal pylorotomy and cure of œsophageal reflux. It is also linked with new problems, mainly due to physiologic modifications elicited by pneumoperitoneum and patient's posture. Although sufficient data are not yet available, the respiratory and cardiovascular modifications are probably similar to those occurring in adults, at least in children more than 4-month-old, as long as the intra-abdominal pressure remains under 15 mmHg. The use of higher intra-abdominal pressures has not been reported in children. In this case, the cardiovascular changes consist mainly in an increase in arterial pressure. In some children, non specific decreases in heart rate and in blood pressure can be observed. The latter can be elicited by a surgical complication, hypovolaemia, head-elevated position or deep anaesthesia. In the newborn and infant under 6 months, intra-abdominal pressures of 15 mmHg or more carry a risk of low cardiac output due to a decrease in contractility and compliance of the left ventricle. In this group of age it is therefore recommended to establish a pressure not higher than 6 mmHg. Moreover, in these very young children, the risk for reopening of the right-left shunts can result in heart insufficiency and systemic gas embolism. Peroperative respiratory changes include an increase in Petco2 and more rarely a decrease in Sao2. The interpretation of the former depends on the site of gas sampling in the anaesthetic system. It is easily controlled by an increased minute ventilation. Various causes, such as bronchial intubation, inhalation of gastric contents or gas embolism, can decrease Sao2. Contra-indications for laparoscopic surgery include hypovolaemia, heart diseases, increased intracranial pressure and alveolar distension. Therefore newborns are patients at high risk in so far as their foramen ovale or their ductus arteriosus is patent, the pulmonary arterial resistances remain increased and a bronchodysplasia is existing. In some cases a special disease is often associated. As an example recurrent bronchitis or asthma is associated with an œsophageal reflux and a sickle-cell disease in patients with cholelithiasis. These patients require special pre-, per- and postoperative care for prevention of complications. Anaesthesia for laparoscopic surgery does not require a major extension of the usual security regulations. Special attention must be paid to arterial pressure. Therefore end-expiratory concentration of the halogenated anaesthetic agent should not be kept higher than 1.5 times the MAC related to the age during maintenance of anaesthesia. A swift postanaesthetic recovery has to be planned when surgery of the abominal wall is not required at the end of the procedure. Up today the reported complications are related to surgery. However a risk for anaesthetic complications is existing. Their optimal prevention can be obtained by training anaesthetists in centres experienced in paediatric anaesthesia." @default.
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• W2003967560 title "Anesthésie pour cœliochirurgie en pédiatrie" @default.
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