L’échographie cardiaque trans-thoracique permet d’avoir une bonne évaluation du débit cardiaque mais sans évaluation du retentissement sur les organes (31). Cet outil est utilisé en néonatalogie comme outil diagnostique de défaillances cardiovasculaires, mais sans amélioration significative du pronostic (45). Son utilisation au bloc opératoire ne peut être faite en pratique courante, en effet il n’existe que peu de personnel qualifié avec une variabilité interindividuelle forte (45). Par ailleurs le monitorage continu n’est pas réalisable en peropératoire chez le nourrisson en raison des difficultés d’accessibilité à l’enfant.
c – Autres
Chez l’adulte il existe de très nombreux moyens de monitorage évalués chez l’enfant dans une méta-analyse effectuée en 2013. La pression veineuse centrale, la pression d’occlusion de l’artère pulmonaire, les volumes obtenus par thermodilution et ceux obtenus par échodoppler ne permettent pas de prédire la réponse au remplissage (46). Seules les variations respiratoires du pic de vélocité aortique permettraient de prédire la réponse au remplissage chez l’enfant. Mais chez le nourrisson l’ensemble de ces outils de monitorage est difficile à mettre en place en pratique. En dehors des chirurgies lourdes le monitorage à l’aide du NIRS semble être une bonne alternative à la mesure non invasive de la pression artérielle.
Conclusion
Chez le nourrisson de moins de 6 mois, les mesures de la pression artérielle réalisées en visite pré-anesthésique ou après l’induction ne peuvent être utilisées comme valeurs de référence à la place de la mesure réalisée avant l’induction. Les limites de pression artérielle fixées en pourcentage ne sont prises en compte en peropératoire que lorsque la valeur de référence est la mesure réalisée avant l’induction anesthésique. Lorsque que cette mesure n’est pas réalisable et afin d’éviter la méconnaissance d’une hypotension artérielle, la prise en compte de la valeur absolue de la pression artérielle ou l’utilisation d’autres moyens de monitorage hémodynamique, telle que l’oxygénation cérébrale par spectroscopie proche de l’infrarouge, devraient être associés.
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