Anaesthesia and epilepsy

Total intravenous anesthesia will supercede inhalational anesthesia in pediatric anesthetic practice

Inhalational anesthesia has dominated the practice of pediatric anesthesia. However, as the introduction of agents such as propofol, short-acting opioids, midazolam, and dexmedetomidine a monumental change has occurred. With increasing use, the overwhelming advantages of total intravenous anesthesia (TIVA) have emerged and driven change in practice. These advantages, outlined in this review, will justify why TIVA will supercede inhalational anesthesia in future pediatric anesthetic practice.

The preoperative neurological evaluation

Neurological diseases are prevalent in the general population, and the neurohospitalist has an important role to play in the preoperative planning for patients with and at risk for developing neurological disease. The neurohospitalist can provide patients and their families as well as anesthesiologists, surgeons, hospitalists, and other providers guidance in particular to the patient's neurological disease and those he or she is at risk for. Here we present considerations and guidance for the neurohospitalist providing preoperative consultation for the neurological patient with or at risk of disturbances of consciousness, cerebrovascular and carotid disease, epilepsy, neuromuscular disease, and Parkinson disease.

Common medical illnesses that affect anesthesia and their anesthetic management

Patients undergoing an office-based anesthetic require a thorough preoperative evaluation to identify medical illnesses and undertake appropriate investigations or studies. This article addresses common medical illnesses seen in oral surgery offices and provides insight into their anesthetic management, concentrating on open-airway office-based anesthesia.

[Anesthesiological aspects of deep brain stimulation : special features of implementation and dealing with brain pacemaker carriers]

Deep brain stimulation (DBS) provides a very effective treatment for a number of neurological diseases including Parkinson's disease, movement disorders and epilepsy. In DBS microelectrodes are positioned in defined cerebral target areas and connected to a pacemaker. It is most often performed as an awake craniotomy with intraoperative testing. Various anesthesiological regimes are used to protect the patient from surgical stress on the one hand and to achieve ideal test conditions on the other. They include local anesthesia or scalp blocks, intermittent general anesthesia or analgosedation with or without airway protection; however, anesthetic agents interfere with hemodynamic stability and ventilation, with vigilance and cooperation and in addition with the symptoms and microelectrode recording. Guidance and communication have a pivotal impact on patient needs for pharmacological interventions. With increasing numbers of DBS procedures, anesthesiologists are more often faced with patients carrying brain pacemakers. For anesthesia the characteristics of the disease as well as the respective long-term medication have to be considered. In addition, the rules for handling patients with pacemakers need to be followed to avoid both dysfunction of the generator and tissue damage due to overheating of the electrodes.

Phenobarbital induces alterations in the proteome of hepatocytes and mesenchymal cells of rat livers

Preceding studies on the mode of action of non-genotoxic hepatocarcinogens (NGCs) have concentrated on alterations induced in hepatocytes (HCs). A potential role of non-parenchymal liver cells (NPCs) in NGC-driven hepatocarcinogenesis has been largely neglected so far. The aim of this study is to characterize NGC-induced alterations in the proteome profiles of HCs as well as NPCs. We chose the prototypic NGC phenobarbital (PB) which was applied to male rats for a period of 14 days. The livers of PB-treated rats were perfused by collagenase and the cell suspensions obtained were subjected to density gradient centrifugation to separate HCs from NPCs. In addition, HCs and NPC isolated from untreated animals were treated with PB in vitro. Proteome profiling was done by CHIP-HPLC and ion trap mass spectrometry. Proteome analyses of the in vivo experiments showed many of the PB effects previously described in HCs by other methods, e.g. induction of phase I and phase II drug metabolising enzymes. In NPCs proteins related to inflammation and immune regulation such as PAI-1 and S100-A10, ADP-ribosyl cyclase 1 and to cell migration such as kinesin-1 heavy chain, myosin regulatory light chain RLC-A and dihydropyrimidinase-related protein 1 were found to be induced, indicating major PB effects on these cells. Remarkably, in vitro treatment of HCs and NPCs with PB hardly reproduced the proteome alterations observed in vivo, indicating differences of NGC induced responses of cells at culture conditions compared to the intact organism. To conclude, the present study clearly demonstrated that PB induces proteome alterations not only in HCs but also in NPCs. Thus, any profound molecular understanding on the mode of action of NGCs has to consider effects on cells of the hepatic mesenchyme.

Treatment of status epilepticus with ketamine, are we there yet?

Status epilepticus (SE), a neurological emergency both in adults and in children, could lead to brain damage and even death if untreated. Generalized convulsive SE (GCSE) is the most common and severe form, an example of which is that induced by organophosphorus nerve agents. First- and second-line pharmacotherapies are relatively consensual, but if seizures are still not controlled, there is currently no definitive data to guide the optimal choice of therapy. The medical community seems largely reluctant to use ketamine, a noncompetitive antagonist of the N-methyl-d-aspartate glutamate receptor. However, a review of the literature clearly shows that ketamine possesses, in preclinical studies, antiepileptic properties and provides neuroprotection. Clinical evidences are scarcer and more difficult to analyze, owing to a use in situations of polytherapy. In absence of existing or planned randomized clinical trials, the medical community should make up its mind from well-conducted preclinical studies performed on appropriate models. Although potentially active, ketamine has no real place for the treatment of isolated seizures, better accepted drugs being used. Its best usage should be during GCSE, but not waiting for SE to become totally refractory. Concerns about possible developmental neurotoxicity might limit its pediatric use for refractory SE.

Ocular surgery in a child with Coffin Lowry syndrome: Anesthetic concerns

Coffin Lowry syndrome is a rare disease involving multiple organ systems. From the anesthesiologists point of view it involves mental retardation, seizures, difficult airway, cardiac abnormalities (pediatric dilated cardiomyopathy) and skeletal deformities. We share our experience of management of a child with Coffin Lowry syndrome and also discuss the problems faced during perioperative period.