Enfant de 3 ans 13 kg amygdalectomie

En consultation pour une amygdalectomie programmeacutee en ambulatoire

1 Quels sont les deux risques principaux que vous allez chercher agrave eacutevaluer pendant la consultation

Risque respiratoire SAOS (anamnegravese ORL PSG SpO2 nocturne Comorbiditeacute obeacutesiteacute malformation faciale trisomie dreacutepanocytosehellip Hyperreacuteactiviteacute des VAS

Risque heacutemorragique

ATCD personnels ou familiaux

En consultation pour une amygdalectomie programmeacutee Comment eacutevaluez vous le risque heacutemorragique

Enfant de 3 ans 13 kg amygdalectomie

Lrsquoeacutevaluation preacuteopeacuteratoire du risque heacutemorragique repose sur un interrogatoire preacutecis agrave la recherche drsquoanteacuteceacutedents personnels etou familiaux suggeacuterant une anomalie de lrsquoheacutemostase et sur un examen clinique recherchant une symptomatologie heacutemorragique [Accord fort] ndash En cas drsquoanteacuteceacutedents personnels ou familiaux drsquoheacutemorragie connus ou suspecteacutes ou lorsque lrsquoeacutevaluation preacuteopeacuteratoire ne peut ecirctre consideacutereacutee comme fiable notamment chez lrsquoenfant de moins de trois ans une eacutetude de lrsquoheacutemostase doit ecirctre reacutealiseacutee [Accord fort] ndash Les reacutesultats de cette eacutetude initiale srsquoils restent anormaux apregraves controcircle doivent ecirctre discuteacutes avec un speacutecialiste de lrsquoheacutemostase afin de deacuteterminer lrsquoopportuniteacute drsquoune eacutetude plus approfondie [Accord fort] ndash Si des examens drsquoheacutemostase sont prescrits le temps de ceacutephaline avec activateur et la numeacuteration plaquettaire sont les tests les plus utiles [Accord fort] ndash Chez lrsquoenfant de plus de trois ans lorsque lrsquoeacutevaluation clinique preacuteopeacuteratoire ne deacutepiste pas de risque heacutemorragique anormal lrsquoeacutetude systeacutematique de lrsquoheacutemostase ne srsquoimpose pas [Accord fort]

ndash OUI

ndash Midazolam sublingual ou intrarectal 03-05 mgkg

ndash Hydroxyzine per os 1 mgkg

ndash Clonidine 4 microgkg

Enfant de 3 ans 13 kg amygdalectomie

Prescrivez-vous une preacutemeacutedication si oui laquelle

bull Apregraves une visite preacuteanestheacutesique sans particulariteacute lrsquoenfant arrive au bloc ndash Quelle strateacutegie anestheacutesique envisagez-vous

ndash Induction controcircle des voies aeacuteriennes

ndash Entretien peropeacuteratoire

ndash Extubation critegraveres

Induction par inhalation ou IV

IOT sonde agrave ballonnet preacuteformeacutee ndeg4

Morphinique peropeacuteratoire pas de desflurane

Extubation apregraves ouverture des yeux spontaneacutee

Enfant de 3 ans 13 kg amygdalectomie

Quelles sont vos prescriptions concernant lrsquoanalgeacutesie postopeacuteratoire

ndash En SSPI

ndash A la sortie agrave domicile

Enfant de 3 ans 13 kg amygdalectomie

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

En consultation pour une amygdalectomie programmeacutee Comment eacutevaluez vous le risque heacutemorragique

Enfant de 3 ans 13 kg amygdalectomie

Lrsquoeacutevaluation preacuteopeacuteratoire du risque heacutemorragique repose sur un interrogatoire preacutecis agrave la recherche drsquoanteacuteceacutedents personnels etou familiaux suggeacuterant une anomalie de lrsquoheacutemostase et sur un examen clinique recherchant une symptomatologie heacutemorragique [Accord fort] ndash En cas drsquoanteacuteceacutedents personnels ou familiaux drsquoheacutemorragie connus ou suspecteacutes ou lorsque lrsquoeacutevaluation preacuteopeacuteratoire ne peut ecirctre consideacutereacutee comme fiable notamment chez lrsquoenfant de moins de trois ans une eacutetude de lrsquoheacutemostase doit ecirctre reacutealiseacutee [Accord fort] ndash Les reacutesultats de cette eacutetude initiale srsquoils restent anormaux apregraves controcircle doivent ecirctre discuteacutes avec un speacutecialiste de lrsquoheacutemostase afin de deacuteterminer lrsquoopportuniteacute drsquoune eacutetude plus approfondie [Accord fort] ndash Si des examens drsquoheacutemostase sont prescrits le temps de ceacutephaline avec activateur et la numeacuteration plaquettaire sont les tests les plus utiles [Accord fort] ndash Chez lrsquoenfant de plus de trois ans lorsque lrsquoeacutevaluation clinique preacuteopeacuteratoire ne deacutepiste pas de risque heacutemorragique anormal lrsquoeacutetude systeacutematique de lrsquoheacutemostase ne srsquoimpose pas [Accord fort]

ndash OUI

ndash Midazolam sublingual ou intrarectal 03-05 mgkg

ndash Hydroxyzine per os 1 mgkg

ndash Clonidine 4 microgkg

Enfant de 3 ans 13 kg amygdalectomie

Prescrivez-vous une preacutemeacutedication si oui laquelle

bull Apregraves une visite preacuteanestheacutesique sans particulariteacute lrsquoenfant arrive au bloc ndash Quelle strateacutegie anestheacutesique envisagez-vous

ndash Induction controcircle des voies aeacuteriennes

ndash Entretien peropeacuteratoire

ndash Extubation critegraveres

Induction par inhalation ou IV

IOT sonde agrave ballonnet preacuteformeacutee ndeg4

Morphinique peropeacuteratoire pas de desflurane

Extubation apregraves ouverture des yeux spontaneacutee

Enfant de 3 ans 13 kg amygdalectomie

Quelles sont vos prescriptions concernant lrsquoanalgeacutesie postopeacuteratoire

ndash En SSPI

ndash A la sortie agrave domicile

Enfant de 3 ans 13 kg amygdalectomie

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

ndash OUI

ndash Midazolam sublingual ou intrarectal 03-05 mgkg

ndash Hydroxyzine per os 1 mgkg

ndash Clonidine 4 microgkg

Enfant de 3 ans 13 kg amygdalectomie

Prescrivez-vous une preacutemeacutedication si oui laquelle

bull Apregraves une visite preacuteanestheacutesique sans particulariteacute lrsquoenfant arrive au bloc ndash Quelle strateacutegie anestheacutesique envisagez-vous

ndash Induction controcircle des voies aeacuteriennes

ndash Entretien peropeacuteratoire

ndash Extubation critegraveres

Induction par inhalation ou IV

IOT sonde agrave ballonnet preacuteformeacutee ndeg4

Morphinique peropeacuteratoire pas de desflurane

Extubation apregraves ouverture des yeux spontaneacutee

Enfant de 3 ans 13 kg amygdalectomie

Quelles sont vos prescriptions concernant lrsquoanalgeacutesie postopeacuteratoire

ndash En SSPI

ndash A la sortie agrave domicile

Enfant de 3 ans 13 kg amygdalectomie

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

bull Apregraves une visite preacuteanestheacutesique sans particulariteacute lrsquoenfant arrive au bloc ndash Quelle strateacutegie anestheacutesique envisagez-vous

ndash Induction controcircle des voies aeacuteriennes

ndash Entretien peropeacuteratoire

ndash Extubation critegraveres

Induction par inhalation ou IV

IOT sonde agrave ballonnet preacuteformeacutee ndeg4

Morphinique peropeacuteratoire pas de desflurane

Extubation apregraves ouverture des yeux spontaneacutee

Enfant de 3 ans 13 kg amygdalectomie

Quelles sont vos prescriptions concernant lrsquoanalgeacutesie postopeacuteratoire

ndash En SSPI

ndash A la sortie agrave domicile

Enfant de 3 ans 13 kg amygdalectomie

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

Quelles sont vos prescriptions concernant lrsquoanalgeacutesie postopeacuteratoire

ndash En SSPI

ndash A la sortie agrave domicile

Enfant de 3 ans 13 kg amygdalectomie

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

Analgeacutesie postopeacuteratoire

La posologie de la morphine

doit ecirctre reacuteduite en cas de

SAOS grave (nadir Sp

O2lt85)

Confeacuterence drsquoexperts SFAR 2005 (Annales Franccedilaises drsquoAnestheacutesie et Reacuteanimation 272008)

Recommandations Pratique Clinique SFORL 2009 (Eur Ann Otorhinolaryngol Head Neck Dis 129 2012)

1 Analgeacutesie postopeacuteratoire immeacutediate morphine

2 Analgeacutesie postopeacuteratoire relai

codeacuteine + paraceacutetamol hellip

Mais ccedila crsquoeacutetait avant hellip

La codeacuteine est une prodrogue

80 de la codeacuteine est

meacutetaboliseacutee en meacutetabolites

inactifs

Lrsquoeffet analgeacutesique reacutesulte de la transformation en morphine (CYP2D6) et morphine 6G

Le CYP2D6 a une activiteacute tregraves variable due agrave son polymorphisme geacuteneacutetique et agrave la freacutequence de ses duplications

Le meacutetabolisme de la codeacuteine (et donc son activiteacute clinique) est tregraves variable selon les individus

MORPHINE

CYP2D6

ELIMINATIONRENALE

Preacutevalence des PM et des UM

Groupe Etnique Freacutequence des PM

()

Freacutequence des UM

()

Europe du nord

(caucasiens) 5-10 15-35

Espagne 5 7-10

Asiatiques 1 0-2

Afro-ameacutericains 1-2 2

Afrique-Ethiopie 1-4 29

Moyen orient 1-2 21

Mexicains 3 1

Codeacuteine

inefficace Codeacuteine

dangereuse

Voronov et al Pediatr Anesth 2007

2 ans 14 kg AVG SAOS 12-24 mg x 4 24h RECUP UM or EM

Ciszkowski et al NEJM 2009

2 ans 13 kg AVG SAOS 13 mg x 4-6 36h DECES UMd 30 ngml

Kelly et al Pediatrics 2012

4 ans 28 kg AVG SAOS 8 mg x 5 24h DECES UMd 18 ngml

3 ans 14 kg AVG SAOS 15 mg x4-6 30h RECUP EMd 17 ngml

5 ans 29 kg AVG ronfl 12 mg x 4-6 24h DECES UMp 30 ngml

Le contexte postopeacuteratoire (amygdalectomie)

Intervalle theacuterapeutique = 45plusmn21 ngml

Deacutepression respiratoire = 20 ngml

Lynn et al AA 1993

Pourquoi les accidents sont ils survenus chez des

enfants nord-ameacutericains avec des troubles

obstructifs du sommeil

ALERTE FDA EMA ANM hellip

CODEINE INTERDITE CHEZ LrsquoENFANT

DE MOINS DE 12 ANS

COMMENT LA REMPLACER

AINS

CORTICOIDES

TRAMADOL

MORPHINE PER OS

Faut il encore utiliser la codeacuteine

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Preacutevalence des PM et des UM

Groupe Etnique Freacutequence des PM

()

Freacutequence des UM

()

Europe du nord

(caucasiens) 5-10 15-35

Espagne 5 7-10

Asiatiques 1 0-2

Afro-ameacutericains 1-2 2

Afrique-Ethiopie 1-4 29

Moyen orient 1-2 21

Mexicains 3 1

Codeacuteine

inefficace Codeacuteine

dangereuse

Voronov et al Pediatr Anesth 2007

2 ans 14 kg AVG SAOS 12-24 mg x 4 24h RECUP UM or EM

Ciszkowski et al NEJM 2009

2 ans 13 kg AVG SAOS 13 mg x 4-6 36h DECES UMd 30 ngml

Kelly et al Pediatrics 2012

4 ans 28 kg AVG SAOS 8 mg x 5 24h DECES UMd 18 ngml

3 ans 14 kg AVG SAOS 15 mg x4-6 30h RECUP EMd 17 ngml

5 ans 29 kg AVG ronfl 12 mg x 4-6 24h DECES UMp 30 ngml

Le contexte postopeacuteratoire (amygdalectomie)

Intervalle theacuterapeutique = 45plusmn21 ngml

Deacutepression respiratoire = 20 ngml

Lynn et al AA 1993

Pourquoi les accidents sont ils survenus chez des

enfants nord-ameacutericains avec des troubles

obstructifs du sommeil

ALERTE FDA EMA ANM hellip

CODEINE INTERDITE CHEZ LrsquoENFANT

DE MOINS DE 12 ANS

COMMENT LA REMPLACER

AINS

CORTICOIDES

TRAMADOL

MORPHINE PER OS

Faut il encore utiliser la codeacuteine

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Voronov et al Pediatr Anesth 2007

2 ans 14 kg AVG SAOS 12-24 mg x 4 24h RECUP UM or EM

Ciszkowski et al NEJM 2009

2 ans 13 kg AVG SAOS 13 mg x 4-6 36h DECES UMd 30 ngml

Kelly et al Pediatrics 2012

4 ans 28 kg AVG SAOS 8 mg x 5 24h DECES UMd 18 ngml

3 ans 14 kg AVG SAOS 15 mg x4-6 30h RECUP EMd 17 ngml

5 ans 29 kg AVG ronfl 12 mg x 4-6 24h DECES UMp 30 ngml

Le contexte postopeacuteratoire (amygdalectomie)

Intervalle theacuterapeutique = 45plusmn21 ngml

Deacutepression respiratoire = 20 ngml

Lynn et al AA 1993

Pourquoi les accidents sont ils survenus chez des

enfants nord-ameacutericains avec des troubles

obstructifs du sommeil

ALERTE FDA EMA ANM hellip

CODEINE INTERDITE CHEZ LrsquoENFANT

DE MOINS DE 12 ANS

COMMENT LA REMPLACER

AINS

CORTICOIDES

TRAMADOL

MORPHINE PER OS

Faut il encore utiliser la codeacuteine

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Pourquoi les accidents sont ils survenus chez des

enfants nord-ameacutericains avec des troubles

obstructifs du sommeil

ALERTE FDA EMA ANM hellip

CODEINE INTERDITE CHEZ LrsquoENFANT

DE MOINS DE 12 ANS

COMMENT LA REMPLACER

AINS

CORTICOIDES

TRAMADOL

MORPHINE PER OS

Faut il encore utiliser la codeacuteine

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

ALERTE FDA EMA ANM hellip

CODEINE INTERDITE CHEZ LrsquoENFANT

DE MOINS DE 12 ANS

COMMENT LA REMPLACER

AINS

CORTICOIDES

TRAMADOL

MORPHINE PER OS

Faut il encore utiliser la codeacuteine

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Conclusions These results suggest that

NSAIDs can be considered as a safe

method of analgesia among children

undergoing tonsillectomy

LES AINS hellip

en 2013 hellip

Le doute

persiste hellip

2003

Anesthesiology Marret et al

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Corticoiumldeshellip JAMA 2008 Czarnetzki C et al Randomized prospective study (n=215)

Conclusion In this study of children undergoing tonsillectomy dexamethasone decreased the risk of PONV dose

dependently but was associated with an increased risk of postoperative bleeding

JAMA 2012 Gallagher multicenter study Randomized prospective study (n=314)

Conclusion Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with

excessive clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5

Increased subjective (level I) bleeding events caused bydexamethasone could not be excluded because the

noninferiority threshold was crossed

Laryngoscope 2012 Shargorodsky et al Meta-analysis 12 studies 1180 patients

Conclusion There was no overall association between dexamethasone administration and postoperative bleeding in

children undergoingtonsillectomy or adenotonsillectomy However this study cannot exclude the possibility of an

association between specific dexamethasone doses and increased odds of bleeding The results underscore the need

for more dedicated prospective studies of this very common intervention

BMJ 2012 Plante et al Meta-analysis 29 studies and 2674 patients

Conclusions Although systemic steroids do not appear to increase bleeding events after tonsillectomy their use is

associated with a raised incidence of operative reinterventions for bleeding episodes which may be related to increased

severity of bleeding events Systemic steroids should be used with caution and the risks and benefits weighed for the

prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their

condition of use

ORL J Otorhinolaryngol Relat Spec 2013 Keller et al

The steroid controversy where are we

Ultimately the body of evidence that currently exists appears to support the concept that a single dose of perioperative

dexamethasone is not associated with undue risk A decision to withdraw dexamethasone from use in pediatric

tonsillectomy needs to be weighed against the potential of causing increased postoperative nausea vomiting pain and

resultant hospital readmission At this point surgeons and anesthesiologists should feel comfortable giving perioperative

dexamethasone but must remain vigilant for bleeding complications

Le doute srsquoinstalle hellip

Le Tramadol

Analgeacutesique central Deux meacutecanismes daction synergiques

une activiteacute morphinique faible

une activiteacute drsquoinhibiteur de la recapture de la noradreacutenaline et de la

seacuterotonine

2 eacutenantiomegraveres et un meacutetabolite actif M1 (CYP2D6)

Effets secondaires

Nauseacutees vomissements

Seacutedation

Pas (peu) de deacutepression respiratoire aux doses cliniques

Convulsions possibles si overdose

bull Efficaciteacute correcte en post amygdalectomie

bull Mecircme meacutetabolisme que la codeacuteine mecircme risques probables

Au total Le risque nul nrsquoexiste pas hellip

Saignements Vomissements Douleur Deacutepression

respiratoire AMM

Corticoides 3 mois

AINS 3 mois

Tramadol 3 ans

Morphine

per os

6 mois

Codeacuteine 1 an

La reacuteflexion est en cours hellip RPC SFORL

Au total Le risque nul nrsquoexiste pas hellip

Saignements Vomissements Douleur Deacutepression

respiratoire AMM

Corticoides 3 mois

AINS 3 mois

Tramadol 3 ans

Morphine

per os

6 mois

Codeacuteine 1 an

La reacuteflexion est en cours hellip RPC SFORL