1
|
Yuan I, Bong CL, Chao JY. Intraoperative pediatric electroencephalography monitoring: an updated review. Korean J Anesthesiol 2024; 77:289-305. [PMID: 38228393 PMCID: PMC11150110 DOI: 10.4097/kja.23843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/05/2023] [Accepted: 01/16/2024] [Indexed: 01/18/2024] Open
Abstract
Intraoperative electroencephalography (EEG) monitoring under pediatric anesthesia has begun to attract increasing interest, driven by the availability of pediatric-specific EEG monitors and the realization that traditional dosing methods based on patient movement or changes in hemodynamic response often lead to imprecise dosing, especially in younger infants who may experience adverse events (e.g., hypotension) due to excess anesthesia. EEG directly measures the effects of anesthetics on the brain, which is the target end-organ responsible for inducing loss of consciousness. Over the past ten years, research on anesthesia and computational neuroscience has improved our understanding of intraoperative pediatric EEG monitoring and expanded the utility of EEG in clinical practice. We now have better insights into neurodevelopmental changes in the developing pediatric brain, functional connectivity, the use of non-proprietary EEG parameters to guide anesthetic dosing, epileptiform EEG changes during induction, EEG changes from spinal/regional anesthesia, EEG discontinuity, and the use of EEG to improve clinical outcomes. This review article summarizes the recent literature on EEG monitoring in perioperative pediatric anesthesia, highlighting several of the topics mentioned above.
Collapse
Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Choon L. Bong
- Department of Pediatric Anesthesia, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Singapore
| | - Jerry Y. Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
2
|
Parker J, Hodson N, Young P, Shelton C. How should institutions help clinicians to practise greener anaesthesia: first-order and second-order responsibilities to practice sustainably. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109442. [PMID: 37734908 DOI: 10.1136/jme-2023-109442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/01/2023] [Indexed: 09/23/2023]
Abstract
There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages.
Collapse
Affiliation(s)
- Joshua Parker
- Medical School, Lancaster University Faculty of Health and Medicine, Lancaster, UK
| | - Nathan Hodson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Young
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - Clifford Shelton
- Medical School, Lancaster University Faculty of Health and Medicine, Lancaster, UK
- Department of Anaesthesia, Wythenshawe Hospital, Manchester, UK
| |
Collapse
|
3
|
Doi Y, Ekuni S. Anesthetic management of inguinal hernia in an ex-premature infant with subglottic stenosis: a case report. JA Clin Rep 2023; 9:60. [PMID: 37700065 PMCID: PMC10497473 DOI: 10.1186/s40981-023-00652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND We report the anesthetic management of inguinal hernia repair for an infant with subglottic stenosis. A previously scheduled operation had been cancelled due to unexpected airway trouble during the induction. CASE PRESENTATION A boy was born at 24 weeks of gestation and his trachea was intubated for 45 days. At 16 months old, surgery for inguinal hernia was planned, but cancelled due to unexpected narrow airway, and subglottic stenosis was first suspected. At 17 months old, he was transferred to us for inguinal hernia surgery. After careful discussion between the surgical team and the anesthesiologists, a strategy to manage this patient was developed. He underwent open hernia surgery under spinal anesthesia and diagnostic rigid bronchoscopy under tubeless general anesthesia separately, which revealed low-grade stenosis and some subglottic cysts. The postoperative course was uneventful. CONCLUSION Interdepartmental discussion weighing risks and benefits may deduce the safest and most appropriate anesthesia method.
Collapse
Affiliation(s)
- Yumi Doi
- Department of Anesthesia, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan.
- Pediatric Perioperative Center, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan.
| | - Satoshi Ekuni
- Department of Anesthesia, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka, 5691192, Japan
| |
Collapse
|
4
|
Siegler BH, Dudek M, Müller T, Kessler M, Günther P, Hochreiter M, Weigand MA. Impact of supplemental anesthesia in preterm infants undergoing inguinal hernia repair under spinal anesthesia : A retrospective analysis. DIE ANAESTHESIOLOGIE 2023; 72:175-182. [PMID: 36121460 PMCID: PMC9974706 DOI: 10.1007/s00101-022-01199-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In preterm infants, spinal anesthesia (SpA) is recognized as an alternative to general anesthesia for inguinal hernia repair (IHR); however, some patients require supplemental anesthesia during surgery. The purpose of this study was to investigate the frequency and impact of supplemental anesthesia on perioperative care and adverse respiratory and hemodynamic events. METHODS A retrospective study of preterm infants undergoing IHR at Heidelberg University Hospital within the first year of life between 2009 and 2018 was carried out. RESULTS In total, 230 patients (255 surgeries) were investigated. Among 189 procedures completed using SpA 24 patients received supplemental anesthesia. Reasons for supplemental anesthesia included loss of anesthetic effect, returning motor response, and respiratory complications. Compared to SpA alone, no differences were found concerning hemodynamic parameters; however, patients requiring supplemental anesthesia displayed higher rates of postoperative oxygen supplementation and unexpected admission to the intensive care unit. The rate of perioperative apnea was 2.7%. Apneic events exclusively occurred after supplemental anesthesia. Bilateral IHR and duration of surgery were associated with the need for supplemental anesthesia. CONCLUSION Whereas SpA might be favorable when compared to general anesthesia for IHR, the data indicate that particular caution is required in patients receiving supplemental anesthesia due to the possible risk for adverse respiratory events.
Collapse
Affiliation(s)
- Benedikt Hermann Siegler
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Martha Dudek
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Thomas Müller
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Markus Kessler
- Division of Pediatric Surgery, Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Marcel Hochreiter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany ,Clinic for Anesthesiology and Intensive Care, Essen University Hospital, Hufelandstraße 55, 45147 Essen, Germany
| | - Markus Alexander Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| |
Collapse
|
5
|
Campbell-Yeo M, Eriksson M, Benoit B. Assessment and Management of Pain in Preterm Infants: A Practice Update. CHILDREN (BASEL, SWITZERLAND) 2022; 9:244. [PMID: 35204964 PMCID: PMC8869922 DOI: 10.3390/children9020244] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 12/11/2022]
Abstract
Infants born preterm are at a high risk for repeated pain exposure in early life. Despite valid tools to assess pain in non-verbal infants and effective interventions to reduce pain associated with medical procedures required as part of their care, many infants receive little to no pain-relieving interventions. Moreover, parents remain significantly underutilized in provision of pain-relieving interventions, despite the known benefit of their involvement. This narrative review provides an overview of the consequences of early exposure to untreated pain in preterm infants, recommendations for a standardized approach to pain assessment in preterm infants, effectiveness of non-pharmacologic and pharmacologic pain-relieving interventions, and suggestions for greater active engagement of parents in the pain care for their preterm infant.
Collapse
Affiliation(s)
- Marsha Campbell-Yeo
- School of Nursing, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Pediatrics, Psychology and Neuroscience, Dalhousie University, Halifax, NS B3H 4R2, Canada
- IWK Health, Halifax, NS B3K 6R8, Canada
| | - Mats Eriksson
- School of Health Sciences, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden;
| | - Britney Benoit
- Rankin School of Nursing, St. Francis Xavier University, Antigonish, NS B2G 2N5, Canada;
| |
Collapse
|
6
|
Su MP, Hu PY, Lin JY, Yang ST, Cheng KI, Lin CH. Comparison of laryngeal mask airway and endotracheal tube in preterm neonates receiving general anesthesia for inguinal hernia surgery: a retrospective study. BMC Anesthesiol 2021; 21:195. [PMID: 34289809 PMCID: PMC8293587 DOI: 10.1186/s12871-021-01418-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background Preterm neonates are at higher risk of developing inguinal hernia, and have an increased risk of perioperative adverse events. Laryngeal mask airway (LMA) is claimed to be associated to decreasing perioperative respiratory complications compared to endotracheal tube (ETT) in infants under one year of age receiving minor surgery; thus, we conducted a retrospective survey in former preterm neonates below 5000 g to compare the respiratory complications between LMA and ETT in general anesthesia for inguinal hernia surgeries. Methods The inclusion criteria were: gestational age at birth under 37 weeks, body weight at surgery below 5000 g, and receiving scheduled inguinal hernia repair under general anesthesia with LMA or ETT. Infants who were dependent on mechanical ventilation preoperatively were excluded. The postoperative respiratory complications including delayed extubation, re-intubation, and apnea within postoperative 24 h were compared between groups. Results From July 2014 to December 2017, 72 neonates were enrolled into final analysis. There were 57 neonates managed with LMA, and only 15 neonates intubated with ETT during the study period. The gestational age at birth and post-menstrual age at surgery showed no significant difference between groups, although in the ETT group, the body weight at birth and at surgery were lower, and more infants had history of severe respiratory distress syndrome and had received oxygen therapy within two weeks prior to surgery. Surprisingly, none one of the infants developed delayed extubation, re-intubation, or postoperative apnea in the LMA group. In the ETT group, 40 percent of the neonates could not be successfully extubated in the operation theater. Conclusion In preterm neonates, even in those younger than 52 weeks post-menstrual age who undergoing inguinal hernia repair in their early infancy, LMA appears feasible and safe as the airway device during general anesthesia in specific patient group. However, anesthesiologist might prefer ETT rather than LMA in some complex situation. In neonates with lower body weight at birth and at surgery, and with a history of severe RDS and oxygen-dependence, further prospective study is required.
Collapse
Affiliation(s)
- Miao-Pei Su
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan
| | - Ping-Yang Hu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan
| | - Jao-Yu Lin
- Division of Pediatric Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Ting Yang
- Division of Neonatology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chia-Heng Lin
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Rd, Kaohsiung, Taiwan.
| |
Collapse
|
7
|
Lesher AP, Chess PR. Regional anesthesia may improve cardiorespiratory complications in preterm inguinal hernia surgery. J Perinatol 2021; 41:370-371. [PMID: 32753711 DOI: 10.1038/s41372-020-0763-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/22/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Aaron P Lesher
- Division of Pediatric Surgery, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - Patricia R Chess
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| |
Collapse
|
8
|
Practical approaches to sedation and analgesia in the newborn. J Perinatol 2021; 41:383-395. [PMID: 33250515 PMCID: PMC7700106 DOI: 10.1038/s41372-020-00878-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/06/2020] [Accepted: 11/12/2020] [Indexed: 11/08/2022]
Abstract
The prevention, assessment, and treatment of neonatal pain and agitation continues to challenge clinicians and researchers. Substantial progress has been made in the past three decades, but numerous outstanding questions remain. In this setting, clinicians must establish safe and compassionate standardized practices that consider available efficacy data, long-term outcomes, and research gaps. Novel approaches with limited data must be carefully considered against historic standards of care with robust data suggesting limited benefit and clear adverse effects. This review summarizes available evidence while suggesting practical clinical approaches to pain assessment and avoidance, procedural analgesia, postoperative analgesia, sedation during mechanical ventilation and therapeutic hypothermia, and the issues of tolerance and withdrawal. Further research in all areas represents an urgent priority for optimal neonatal care. In the meantime, synthesis of available data offers clinicians challenging choices as they balance benefit and risk in vulnerable critically ill neonates.
Collapse
|
9
|
Ponde VC, Puri K, Nagdev T. Regional anaesthesia in neonates: a narrative review. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The benefits of regional anaesthesia and the accompanying concerns of general anaesthesia in newborns make the former a safe and valuable addition. Multiple regional anaesthesia techniques, ranging from the central neuraxial blocks, truncal blocks, and peripheral nerve blocks are available. Empowering us to make the case to case decision to choose the most beneficial and safe block for the neonate. The applications of regional anaesthesia, over the period, have encompassed perioperative analgesia and therapeutic uses. With the addition of ultrasonography, neonatal regional anaesthesia has reached a fine amount of objectivity and accuracy. A trend of utilising regional blocks as the sole anaesthetic as against an adjuvant to general anaesthesia is setting in. In this review, we take a look at recent developments in this field in a generalised manner followed by dwelling into most of the commonly used blocks in daily practice. However, a detailed description of each block is beyond the scope of this review.
Collapse
|
10
|
Randriamizao HMR, Rakotondrainibe A, Razafindrabekoto LDE, Ravoaviarivelo PF, Rajaonera AT, Andriamanarivo ML. Use of spinal anaesthesia in neonates and infants in Antananarivo, Madagascar: a retrospective descriptive study. BMC Res Notes 2020; 13:491. [PMID: 33087176 PMCID: PMC7579963 DOI: 10.1186/s13104-020-05330-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022] Open
Abstract
Objective The aim of this study was to present the first cases of spinal anesthesia, in newborns and infants, preterm/ex-prematures, in order to determine its feasibility and its potential harmlessness, in Antananarivo—Madagascar. Indeed, spinal anesthesia is a low cost technique and can limit respiratory complications, postoperative apnea a contrario with pediatric general anesthesia which can lead to perioperative risks. Results In a retrospective, descriptive, 7-year (2013 to 2019) period study, conducted in the University Hospital Joseph Ravoahangy Andrianavalona, 69 patients’ data files planned to have spinal anesthesia were recorded. These pediatric patients were predominantly male (sex ratio = 2.8) and 37 [28–52] days old. The smallest anesthetized child weighed 880 g; the youngest was 4 days old. Twenty-seven (27) of them were premature and 20.3% presented respiratory diseases. They were mostly scheduled for hernia repair (90%). Spinal anesthesia was performed, with a Gauge 25 Quincke spinal needle, after 2 [1–2] attempts with hyperbaric bupivacaine of 4 [3.5–4] mg. Failure rate was 5.8%. The heart rate was stable throughout perioperative period and no complications were observed.
Collapse
Affiliation(s)
| | - Aurélia Rakotondrainibe
- Department of Anesthesia and Intensive Care, University of Antananarivo, Antananarivo, Madagascar. .,Surgical Intensive Care, CHU Joseph Ravoahangy Andrianavalona, BP 4150 - 101, Antananarivo, Madagascar.
| | | | - Prisca F Ravoaviarivelo
- Department of Anesthesia and Intensive Care - Operating Theater, CHU Joseph Ravoahangy Andrianavalona, Antananarivo, Madagascar
| | - Andriambelo T Rajaonera
- Department of Anesthesia and Intensive Care, University of Antananarivo, Antananarivo, Madagascar
| | - Mamy L Andriamanarivo
- Department of Pediatric Surgery, University of Antananarivo, Antananarivo, Madagascar
| |
Collapse
|
11
|
Shin J, Jeon GW. Inguinal Hernia in Preterm Infants: Optimal Timing of Herniorrhaphy to Prevent Preoperative Incarceration and Postoperative Apnea. NEONATAL MEDICINE 2020. [DOI: 10.5385/nm.2020.27.3.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
12
|
Salaün JP, de Queiroz M, Orliaguet G. Development: Epidemiology and management of postoperative apnoea in premature and term newborns. Anaesth Crit Care Pain Med 2020; 39:871-875. [PMID: 32791157 DOI: 10.1016/j.accpm.2020.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/27/2022]
Abstract
Postoperative apnoea (PA) is defined as a respiratory pause of more than 15seconds or as a respiratory pause associated with bradycardia < 120/min, desaturation (Sat02<90%), cyanosis or hypotonia. This is a relatively frequent phenomenon that affects 10% of infants under 60 weeks of post-conceptual age, born prematurely or not, and occurs during the first 12-48h postoperatively. The population exposed to PA is heterogeneous and it is necessary to standardise the management both during the intra- and postoperative period, and to adapt this management according to the risk factors for PA and the status as prematurely born infants or not, based on recent data from the literature.
Collapse
Affiliation(s)
- Jean-Philippe Salaün
- CHU Caen, Department of Anaesthesiology and Critical Care Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France.
| | - Mathilde de Queiroz
- Department of Paediatric Anaesthesia and Intensive Care, Femme Mère Enfant Hospital, 69677 Bron, France
| | - Gilles Orliaguet
- Department of Paediatric Anaesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP, Centre - Université de Paris, France; EA 7323 Université de Paris "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Paris, France
| |
Collapse
|
13
|
Tesoro S, Marchesini V, Fratini G, Engelhardt T, De Robertis E. Drugs for anesthesia and analgesia in the preterm infant. Minerva Anestesiol 2020; 86:742-755. [DOI: 10.23736/s0375-9393.20.14073-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
14
|
Abstract
Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.
Collapse
|
15
|
Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Ehret CB, Berger T, Schälte G. Inguinal hernia repair in preterm neonates: is there evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systematic review and meta-analysis. BMJ Open 2019; 9:e028728. [PMID: 31597647 PMCID: PMC6797401 DOI: 10.1136/bmjopen-2018-028728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Whether spinal anaesthesia (SA) reduces intraoperative and postoperative complications compared with general anaesthesia (GA) was investigated. DESIGN The meta-analysis was structured based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Databases (PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science) were searched, and four randomised controlled trials (RCTs) and two retrospective cohort studies were included. A random-effects model with pooled risk ratios and mean differences with 95% CIs were used. Statistical heterogeneity was evaluated using the I2 statistic. Quality assessment of the studies was performed by assessing the risk of bias according to the Cochrane and GRADE methodology. SETTING Publications from January 1990 to November 2018 were included. PARTICIPANTS AND INTERVENTIONS Our study selection captured information from studies focusing on neonates born before the 37th gestational week who were scheduled for an inguinal hernia repair operation under either SA or GA. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were apnoea, postoperative ventilation and method failure rates according to predefined eligibility criteria. The duration of surgery, desaturation events <80%, hospital stay duration and postoperative bradycardia were secondary outcomes. RESULTS We found significantly fewer events for the outcomes 'any episode of apnoea' and 'mechanical ventilation postoperatively' in the SA group. Bradycardias were significantly less common in the SA group. In total, 7.5% of the SA group were converted to GA. The duration of surgery was significantly shorter in the SA group. No significant differences were found in the outcome measures 'postoperative oxygen supplementation', 'prolonged apnoea', 'postoperative oxygen desaturation <80%' and 'hospital stay'. CONCLUSIONS We consider SA a convenient alternative for hernia repair in preterm infants, providing more safety regarding postoperative apnoea. To the best of our knowledge, this is the first meta-analysis to include studies exclusively comparing SA versus GA. More high-quality RCTs are needed. TRIAL REGISTRATION NUMBER CRD42016048683.
Collapse
Affiliation(s)
- Katharina Dohms
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Marc Hein
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Mark Coburn
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Constanze Barbara Ehret
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Tanja Berger
- Department of Medical Statistics, Univeristy Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| | - Gereon Schälte
- Department of Anesthesiology, University Hospital RWTH Aachen, Medical Faculty, Aachen, Germany
| |
Collapse
|
16
|
Bawazir OA. Delaying surgery for inguinal hernia in neonates: Is it worthwhile? J Taibah Univ Med Sci 2019; 14:332-336. [PMID: 31488964 PMCID: PMC6717073 DOI: 10.1016/j.jtumed.2019.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 12/03/2022] Open
Abstract
Objective The incidence of inguinal hernia is high in premature infants; however, surgical repair is a high-risk procedure for these patients. The timing of hernia repair is still controversial. This study aimed to determine the optimal timing for inguinal herniotomy in neonates in a general hospital. Methods A prospective cohort study was conducted from March 2014 to September 2018. A total of 127 neonates and preterm infants were admitted to the paediatric surgery clinic with uncomplicated inguinal hernia. Herniotomy was performed in all neonates, and the patients were followed up for up to 8 months after surgery for perioperative and postoperative complications. The timing of surgery was based on the surgeon's decision along with the consent of the family to the surgical intervention. Results Of 118 neonates, as many as 53 (45%) underwent early repair and 65 (55%) underwent late repair of inguinal hernia. The demographic data were similar between the 2 groups with no significant difference. There were no significant differences in the incidence of inguinal hernia incarceration and hydrocele formation (p = 0.11 and p = 0.8, respectively); however, there was a higher incidence of inguinal hernia recurrence (p = 0.05) and postoperative apnoea (p = 0.02) in the early repair group. Conclusion Surgical repair of inguinal hernia is feasible with low morbidity in preterm babies. The risk of hernia incarceration and testicular atrophy did not increase with delayed elective hernia repair in neonates. Delayed hernia repair decreased the risk of perioperative and postoperative complications. This study recommends delaying elective hernia repair in neonates and preterm babies.
Collapse
Affiliation(s)
- Osama A Bawazir
- Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah, KSA
| |
Collapse
|
17
|
Abstract
Anaesthesia for neonates is a composite of good knowledge of neonatal and transitional physiology combined with skill in airway maintenance and vascular access. When the newborn is a preterm, the complexities of management increase due to the small size and accompanying issues such as bronchopulmonary dysplasia and apnoea. World over, the number of survivors of preterm birth is on the increase. We searched Pubmed for "Anesthesia, apnea, neonatal, neonates, physiology, preterm, spinal anesthesia", as well as cross references from review articles. These babies have a high incidence of conditions warranting surgery (e.g., tracheoesophaeal fistula, congenital diaphragmatic hernia, anorectal malformations, incarcerated hernia, necrotising enterocolitis). The possibility of neurodevelopmental harm by anaesthetics is currently the topic of active research. In parallel, advances in paediatric anaesthesia equipment, use of regional and neuraxial anaesthesia and availability of monitoring have steadily increased the safety of anaesthesia in these tiny patients.
Collapse
Affiliation(s)
- Rajeshwari Subramaniam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
18
|
Strøm C, Afshari A, Lundstrøm LH, Lohse N. Characteristics of children less than 2 years of age undergoing anaesthesia in Denmark 2005–2015: a national observational study. Anaesthesia 2018; 73:1195-1206. [DOI: 10.1111/anae.14298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- C. Strøm
- Department of Anaesthesia Holbaek Hospital University of Copenhagen Denmark
- Department of Anaesthesia Centre of Head and Orthopaedics Rigshospitalet University of Copenhagen Denmark
| | - A. Afshari
- Department of Anaesthesiology Juliane Marie Centre Rigshospitalet University of Copenhagen Denmark
| | - L. H. Lundstrøm
- Department of Anaesthesiology Hilleroed Hospital University of Copenhagen Denmark
| | - N. Lohse
- Department of Anaesthesia Centre of Head and Orthopaedics Rigshospitalet University of Copenhagen Denmark
| |
Collapse
|
19
|
Tröbs RB, Yilmaz B, Roll C, Alrefai M. Direct bladder hernia after indirect hernia repair in extremely low birth weight babies: two case reports and a review of the literature. J Med Case Rep 2017; 11:15. [PMID: 28088918 PMCID: PMC5238521 DOI: 10.1186/s13256-016-1171-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 12/05/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Inguinal hernia repair is the most common surgical procedure in babies. Despite a meticulous technique, relapses may occur. The occurrence of a direct bladder wall hernia in relapses has never before been reported in the literature. CASE PRESENTATION Here, we report two cases of direct bladder herniation: a white baby boy born after 25 weeks of gestation and a white baby boy born after 26 weeks of gestation. Both of the formerly extremely low birth weight babies were affected after open bilateral hernia repair. Recurrent hernias developed on the right side, and direct bladder herniation was identified intraoperatively. In one case, laparoscopy was applied to identify a supravesical type of hernia. Immaturity and a difficult postnatal course might have contributed to hernia relapse in these cases. CONCLUSIONS Misinterpretation of bladder herniation might have disastrous consequences. Laparoscopy is a helpful tool in comparable cases.
Collapse
Affiliation(s)
- R B Tröbs
- Department of Pediatric Surgery, St. Mary's Hospital Herne, St. Elisabeth Group, Ruhr-University of Bochum, Widumer Str. 8, 44627, Herne, Germany.
| | - B Yilmaz
- Clinic of Surgery and Pediatric Surgery, Friedrich-Ebert-Str. 13, 33699, Bielefeld, Germany
| | - C Roll
- Center of Perinatology, Department of Neonatology and Pediatric Intensive Care, Vest Children's Hospital, University of Witten-Herdecke, Dr.-Friedrich-Steiner Str. 5, 45711, Datteln, Germany
| | - M Alrefai
- Department of Pediatric Surgery, St. Mary's Hospital Herne, St. Elisabeth Group, Ruhr-University of Bochum, Widumer Str. 8, 44627, Herne, Germany
| |
Collapse
|
20
|
Gurria J, Kuo P, Kao A, Christensen L, Holterman A. General endotracheal vs. non-endotracheal regional anesthesia for elective inguinal hernia surgery in very preterm neonates: A single institution experience. J Pediatr Surg 2017; 52:56-59. [PMID: 27863823 DOI: 10.1016/j.jpedsurg.2016.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 10/20/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Very pre-term infants (VP) at <32 weeks post menstrual age PMA have a high incidence of bronchopulmonary dysplasia BPD. BPD places them at risk for pulmonary-related perioperative complications from general endotracheal anesthesia GE during elective inguinal hernia repair. METHODS A retrospective cohort study was done to compare pulmonary-related perioperative risks between VP patients undergoing non-emergent inguinal hernia repair prior to NICU discharge under GE (n=58) vs regional anesthesia RA (n=37). RESULTS Median PMA (RA 26 vs GE 27 weeks), operative weight (RA 2.2 vs GE 2.27 kg), % with BPD, medical and surgical comorbidities, number of concurrent procedures are similar between groups, except for sac laparoscopy (0% RA vs 36% GE). Procedural anesthesia time was 40 minutes for RA vs 69 minutes for GE, (p < 0.001). GE (17%) vs RA (0%) remained intubated post op (p<0.001). Oral feeding was fully tolerated in RA (97%) vs GE (72%, p=0.002) by 48h after surgery. The statistical differences hold after regression analysis controlling for sac laparoscopy and procedure time. No difference in intraoperative or postoperative hernia complications is found. CONCLUSION RA is safe. RA is associated with early resumption of full feed, avoidance of prolonged mechanical intubation. We recommend a randomized controlled trial comparing the safety and efficacy of GE vs RA in VP infants undergoing elective NICU inguinal hernia repair. LEVEL OF EVIDENCE II Retrospective study.
Collapse
Affiliation(s)
- Jean Gurria
- Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria
| | - Phillip Kuo
- Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria
| | - Angie Kao
- Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria
| | - Luisa Christensen
- Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria
| | - AiXuan Holterman
- Children's Hospital of Illinois, University of Illinois College of Medicine at Peoria.
| |
Collapse
|
21
|
Zhong L, Luo F, Zhao W, Feng Y, Wu L, Lin J, Liu T, Wang S, You X, Zhang W. Propofol exposure during late stages of pregnancy impairs learning and memory in rat offspring via the BDNF-TrkB signalling pathway. J Cell Mol Med 2016; 20:1920-31. [PMID: 27297627 PMCID: PMC5020635 DOI: 10.1111/jcmm.12884] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/09/2016] [Indexed: 12/20/2022] Open
Abstract
The brain‐derived neurotrophic factor (BDNF)‐tyrosine kinase B (TrkB) (BDNF‐TrkB) signalling pathway plays a crucial role in regulating learning and memory. Synaptophysin provides the structural basis for synaptic plasticity and depends on BDNF processing and subsequent TrkB signalling. Our previous studies demonstrated that maternal exposure to propofol during late stages of pregnancy impaired learning and memory in rat offspring. The purpose of this study is to investigate whether the BDNF‐TrkB signalling pathway is involved in propofol‐induced learning and memory impairments. Propofol was intravenously infused into pregnant rats for 4 hrs on gestational day 18 (E18). Thirty days after birth, learning and memory of offspring was assessed by the Morris water maze (MWM) test. After the MWM test, BDNF and TrkB transcript and protein levels were measured in rat offspring hippocampus tissues using real‐time PCR (RT‐PCR) and immunohistochemistry (IHC), respectively. The levels of phosphorylated‐TrkB (phospho‐TrkB) and synaptophysin were measured by western blot. It was discovered that maternal exposure to propofol on day E18 impaired spatial learning and memory of rat offspring, decreased mRNA and protein levels of BDNF and TrkB, and decreased the levels of both phospho‐TrkB and synaptophysin in the hippocampus. Furthermore, the TrkB agonist 7,8‐dihydroxyflavone (7,8‐DHF) reversed all of the observed changes. Treatment with 7,8‐DHF had no significant effects on the offspring that were not exposed to propofol. The results herein indicate that maternal exposure to propofol during the late stages of pregnancy impairs spatial learning and memory of offspring by disturbing the BDNF‐TrkB signalling pathway. The TrkB agonist 7,8‐DHF might be a potential therapy for learning and memory impairments induced by maternal propofol exposure.
Collapse
Affiliation(s)
- Liang Zhong
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Foquan Luo
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China.
| | - Weilu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Yunlin Feng
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Liuqin Wu
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Jiamei Lin
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Tianyin Liu
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Shengqiang Wang
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Xuexue You
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Nanchang University, Nancahang, China
| |
Collapse
|
22
|
Andreae MH, Atchabahian A, McCrillis AM, Chao JY, Suzuki S, Shinnar S, Hall CB, Lipton RB. Regional versus general anaesthesia for improved cognitive function after procedures other than cardiac surgery or neurosurgery in adult and paediatric patients. Cochrane Database Syst Rev 2016; 2016:CD008737. [PMID: 27746701 PMCID: PMC5063242 DOI: 10.1002/14651858.cd008737.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: The objective of this review is to compare the effects of regional versus general anaesthesia on cognitive function after procedures other than cardiac surgery or neurosurgery in adult and in paediatric patients.
Collapse
Affiliation(s)
- Michael H Andreae
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arthur Atchabahian
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, NY, USA
| | | | - Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Suzuko Suzuki
- Department of Anesthesiology, NYU Hospital Center, New York, NY, USA
| | - Shlomo Shinnar
- Saul R Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Charles B Hall
- Saul R Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard B Lipton
- Saul R Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|