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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.
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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
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Nourmohammadi A, Swift JR, de Pesters A, Guay CS, Adamo MA, Dalfino JC, Ritaccio AL, Schalk G, Brunner P. Passive functional mapping of receptive language cortex during general anesthesia using electrocorticography. Clin Neurophysiol 2023; 147:31-44. [PMID: 36634533 PMCID: PMC10267852 DOI: 10.1016/j.clinph.2022.11.021] [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: 04/18/2022] [Revised: 09/30/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the feasibility of passive functional mapping in the receptive language cortex during general anesthesia using electrocorticographic (ECoG) signals. METHODS We used subdurally placed ECoG grids to record cortical responses to speech stimuli during awake and anesthesia conditions. We identified the cortical areas with significant responses to the stimuli using the spectro-temporal consistency of the brain signal in the broadband gamma (BBG) frequency band (70-170 Hz). RESULTS We found that ECoG BBG responses during general anesthesia effectively identify cortical regions associated with receptive language function. Our analyses demonstrated that the ability to identify receptive language cortex varies across different states and depths of anesthesia. We confirmed these results by comparing them to receptive language areas identified during the awake condition. Quantification of these results demonstrated an average sensitivity and specificity of passive language mapping during general anesthesia to be 49±7.7% and 100%, respectively. CONCLUSION Our results demonstrate that mapping receptive language cortex in patients during general anesthesia is feasible. SIGNIFICANCE Our proposed protocol could greatly expand the population of patients that can benefit from passive language mapping techniques, and could eliminate the risks associated with electrocortical stimulation during an awake craniotomy.
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Affiliation(s)
- Amin Nourmohammadi
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - James R Swift
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Adriana de Pesters
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA.
| | - Christian S Guay
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA.
| | - Anthony L Ritaccio
- Department of Neurology, Albany Medical College, Albany, NY, USA; Department of Neurology, Mayo Clinic, Jacksonville, FL, USA.
| | - Gerwin Schalk
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Chen Frontier Lab for Applied Neurotechnology, Tianqiao and Chrissy Chen Institute, Shanghai, P.R. China.
| | - Peter Brunner
- National Center for Adaptive Neurotechnologies, Washington University School of Medicine, St. Louis, MO, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA; Department of Biomedical Sciences, State University of New York at Albany, Albany, NY, USA; Department of Neurology, Albany Medical College, Albany, NY, USA.
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Schmid W, Marhofer P, Opfermann P, Zadrazil M, Kimberger O, Triffterer L, Marhofer D, Klug W. Brainwave entrainment to minimise sedative drug doses in paediatric surgery: a randomised controlled trial. Br J Anaesth 2020; 125:330-335. [DOI: 10.1016/j.bja.2020.05.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 10/23/2022] Open
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A practical guide for anesthetic management during intraoperative motor evoked potential monitoring. J Anesth 2019; 34:5-28. [PMID: 31630259 DOI: 10.1007/s00540-019-02698-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/05/2019] [Indexed: 12/19/2022]
Abstract
Postoperative motor dysfunction can develop after spinal surgery, neurosurgery and aortic surgery, in which there is a risk of injury of motor pathway. In order to prevent such devastating complication, intraoperative monitoring of motor evoked potentials (MEP) has been conducted. However, to prevent postoperative motor dysfunction, proper understanding of MEP monitoring and proper anesthetic managements are required. Especially, a variety of anesthetics and neuromuscular blocking agent are known to attenuate MEP responses. In addition to the selection of anesthetic regime to record the baseline and control MEP, the measures to keep the level of hypnosis and muscular relaxation at constant are crucial to detect the changes of MEP responses after the surgical manipulation. Once the changes of MEP are observed based on the institutional alarm criteria, multidisciplinary team members should share the results of MEP monitoring and respond to check the status of monitoring and recover the possible motor nerve injury. Prevention of MEP-related adverse effects is also important to be considered. The Working Group of Japanese Society of Anesthesiologists (JSA) developed this practical guide aimed to help ensure safe and successful surgery through appropriate anesthetic management during intraoperative MEP monitoring.
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Wang F, Zhang J, Yu J, Tian M, Cui X, Wu A. Variation of bispectral index in children aged 1-12 years under propofol anesthesia: an observational study. BMC Anesthesiol 2019; 19:145. [PMID: 31390975 PMCID: PMC6686421 DOI: 10.1186/s12871-019-0815-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/29/2019] [Indexed: 11/22/2022] Open
Abstract
Background The use of the bispectral index (BIS) is widespread in pediatric anesthesia, but few studies have attempted to perform a detailed evaluation of how BIS varies according to age in children under propofol anesthesia. This prospective study aimed to explore the exact relationship between BIS value and the age of 1- to 12-year-old children under propofol anesthesia. Methods This study enrolled 165 children (1 < yr. ≤ 12), scheduled for surgery under anesthesia, and divided them into 11 age groups. Of the 165 participants, 157 completed the study protocol. All patients were anesthetized with propofol for over 30 s. An observation period of 4 min followed. BIS values were recorded at 0 (immediately after propofol injection), 30, 40, 50, 60, 90, 120, 180, and 240 s after the injection. BIS values at each time point corresponding to the 11 age groups were compared using repeated measures ANOVA. Results BIS values significantly differed among the nine time points (p < 0.01) as well as among the different age groups (p < 0.01) after propofol administration. Post-hoc Bonferroni tests showed a difference in BIS values between groups 1–4 (1 < yr. ≤ 5) and groups 5–11(5 < yr. ≤ 12). BIS values were lower in the latter than in the former, from 50 to 240 s. The minimum BIS values in group 1 < yr. ≤ 5 and in group 5 < yr. ≤ 12 were recorded at 60 s as 49 ± 17 and 35 ± 14, respectively. Conclusions During propofol anesthesia, the BIS values were closely related to age, which can be divided into two groups: 1 < yr. ≤ 5 and 5 < yr. ≤ 12. BIS values of the older age group were lower than those of the younger age group at the same time points. Trial registration Registration number: chictr-roc-16008630. Registered on 12 June 2016. Retrospectively registered.
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Affiliation(s)
- Fang Wang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Jianmin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Jie Yu
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Muyang Tian
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Xiaohuan Cui
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi Road, Beijing, 100045, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang District, Beijing, 100020, China.
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Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology 2019; 131:164-185. [DOI: 10.1097/aln.0000000000002657] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Abstract
Propofol administered in conjunction with an opioid such as remifentanil is used to provide total intravenous anesthesia for children. Drugs can be given as infusion controlled manually by the physician or as automated target-controlled infusion that targets plasma or effect site. Smart pumps programmed with pharmacokinetic parameter estimates administer drugs to a preset plasma concentration. A linking rate constant parameter (keo) allows estimation of effect site concentration. There are two parameter sets, named after the first author describing them, that are commonly used in pediatric target-controlled infusion for propofol (Absalom and Kataria) and one for remifentanil (Minto). Propofol validation studies suggest that these parameter estimates are satisfactory for the majority of children. Recommended target concentrations for both propofol and remifentanil depend on the type of surgery, the degree of surgical stimulation, the use of local anesthetic blocks, and the ventilatory status of the patient. The use of processed electroencephalographic monitoring is helpful in pediatric total intravenous anesthesia and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.
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Blussé van Oud-Alblas HJ, Brill MJE, Peeters MYM, Tibboel D, Danhof M, Knibbe CAJ. Population pharmacokinetic-pharmacodynamic model of propofol in adolescents undergoing scoliosis surgery with intraoperative wake-up test: a study using Bispectral index and composite auditory evoked potentials as pharmacodynamic endpoints. BMC Anesthesiol 2019; 19:15. [PMID: 30669968 PMCID: PMC6343297 DOI: 10.1186/s12871-019-0684-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In adolescents limited data are available on the pharmacokinetics (PK) and pharmacodynamics (PD) of propofol. In this study we derived a PK-PD model for propofol in adolescents undergoing idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia using both Bispectral Index (BIS) and composite A-line ARX index (cAAI) as endpoints. METHODS Fourteen adolescents (9.8-20.1 years) were evaluated during standardized propofol-remifentanil anesthesia for idiopathic scoliosis surgery with an intraoperative wake-up test with reinduction of anesthesia. BIS and cAAI were continuously measured and blood samples collected. A propofol PKPD model was developed using NONMEM. RESULTS The time courses of propofol concentrations, BIS and cAAI values during anesthesia, intra-operative wakeup and reduction of anesthesia were best described by a two-compartment PK model linked to an inhibitory sigmoidal Emax PD model. For the sigmoidal Emax model, the propofol concentration at half maximum effect (EC50) was 3.51 and 2.14 mg/L and Hill coefficient 1.43 and 6.85 for BIS and cAAI, respectively. The delay in PD effect in relation to plasma concentration was best described by a two compartment effect-site model with a keo of 0.102 min- 1, ke12 of 0.121 min- 1 and ke21 of 0.172 min- 1. CONCLUSIONS A population PKPD model for propofol in adolescents was developed that successfully described the time course of propofol concentration, BIS and cAAI in individuals upon undergoing scoliosis surgery with intraoperative wake-up test and reinduction of anesthesia. Large differences were demonstrated between both monitors. This may imply that BIS and cAAI measure fundamentally different endpoints in the brain.
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Affiliation(s)
- Heleen J Blussé van Oud-Alblas
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Anesthesiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Margreke J E Brill
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Mariska Y M Peeters
- Department of Clinical Pharmacy, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Intensive Care, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Meindert Danhof
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Catherijne A J Knibbe
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands. .,Department of Clinical Pharmacy, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands.
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Intraoperative feasibility of bulbocavernosus reflex monitoring during untethering surgery in infants and children. J Clin Monit Comput 2018. [PMID: 29520678 DOI: 10.1007/s10877-018-0127-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Bulbocavernosus reflex (BCR) monitoring is used to assess the integrity of urinary and bowel function. In this study, we evaluated the feasibility of BCR monitoring during untethering surgery in infants and children to predict postoperative urinary and bowel dysfunction. The records of 22 patients ranging from 4 days to 10 years old (mean 2.7 ± 3.3 years) were reviewed. Anesthesia was maintained by propofol or sevoflurane/opioid without neuromuscular blockade. BCR waveforms induced by electrical stimulation (20-40 mA, train-of-four pulses with 500 Hz) to the penis or clitoris were recorded from bilateral external anal sphincters. To assess the sensitivity and specificity of BCR monitoring, we investigated the association between a significant continuous decrease in BCR amplitude at the end of surgery and postoperative urinary and bowel dysfunction after surgery. Reproducible baseline BCR waveforms were successfully recorded in 20 of 22 patients (90.9%). A significant continuous decrease in BCR amplitude was observed in 8 patients. The results of intraoperative BCR monitoring included three true-positives, twelve true-negatives, five false-positives, and zero false-negatives. Therefore, the sensitivity and specificity of BCR monitoring used to predict postoperative urinary and bowel dysfunction were 100 and 70.6%, respectively. BCR monitoring during untethering surgery in infants and children under general anesthesia was found to be a feasible method to prevent postoperative urinary and bowel dysfunction.
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Dennhardt N, Arndt S, Beck C, Boethig D, Heiderich S, Schultz B, Weber F, Sümpelmann R. Effect of age on Narcotrend Index monitoring during sevoflurane anesthesia in children below 2 years of age. Paediatr Anaesth 2018; 28:112-119. [PMID: 29274102 DOI: 10.1111/pan.13306] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND In older children, different electroencephalogram-based algorithms for measuring depth of anesthesia displayed a similar performance as in adults, but in infants they have not displayed the same reliability so far. According to the individual developmental state, the Narcotrend distinguishes "differentiated" electroencephalograms, which can be classified using the full Narcotrend Index scale, from "undifferentiated" electroencephalograms, which are classified using a scale with fewer stages. OBJECTIVE The objective of this prospective clinical observational study was to assess the feasibility and performance of the Narcotrend monitor in children <2 years within a clinical setting. METHODS Sixty-one children aged 0-24 months undergoing general anesthesia with sevoflurane and remifentanil for elective pediatric surgery were studied. We investigated the percentage of differentiated electroencephalograms and the correlation between multiples of minimal alveolar sevoflurane concentration and the Narcotrend Index according to age groups. Prediction probability was used to evaluate the performance of the Narcotrend Index for differentiation between consciousness and unconsciousness and between different sevoflurane concentrations. RESULTS The percentage of differentiated electroencephalograms increased with increasing age (0-3 months: 23.8%, 4-5 months: 87.5%, 6-11 months: 92.3%, 12-24 months: 100%). The overall prediction probability of Narcotrend Index was 1.0 (SE 0.05) for differentiation between awake and loss of consciousness and 1.0 (SE 0.01) for differentiation between anesthetized and return of consciousness. Spearman correlation analysis revealed a significant negative correlation between sevoflurane concentration and the Narcotrend Index (r = -0.78, P < .0001, 95%CI: -0.81 to -0.74). Overall prediction probability of Narcotrend Index to sevoflurane concentration was 0.8 (95%CI: 0.78-0.82). CONCLUSION The Narcotrend monitor indicated a Narcotrend Index in most infants and young children starting from 4 months with significant correlation to and acceptable prediction probability for minimal alveolar sevoflurane concentration.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Stefanie Arndt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Sebastian Heiderich
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Barbara Schultz
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Frank Weber
- Department of Anesthesia, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Dennhardt N, Boethig D, Beck C, Heiderich S, Boehne M, Leffler A, Schultz B, Sümpelmann R. Optimization of initial propofol bolus dose for EEG Narcotrend Index-guided transition from sevoflurane induction to intravenous anesthesia in children. Paediatr Anaesth 2017; 27:425-432. [PMID: 28213945 DOI: 10.1111/pan.13118] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sevoflurane induction followed by intravenous anesthesia is a widely used technique to combine the benefits of an easier and less traumatic venipuncture after sevoflurane inhalation with a recovery with less agitation, nausea, and vomiting after total intravenous anesthesia (TIVA). Combination of two different anesthetics may lead to unwanted burst suppression in the electroencephalogram (EEG) during the transition phase. OBJECTIVE The objective of this prospective clinical observational study was to identify the optimal initial propofol bolus dose for a smooth transition from sevoflurane induction to TIVA using the EEG Narcotrend Index (NI). METHODS Fifty children aged 1-8 years scheduled for elective pediatric surgery were studied. After sevoflurane induction and establishing of an intravenous access, a propofol bolus dose range 0-5 mg·kg-1 was administered at the attending anesthetist's discretion to maintain a NI between 20 and 64, and sevoflurane was stopped. Anesthesia was continued as TIVA with a propofol infusion dose of 15 mg·kg-1 ·h-1 for the first 15 min, followed by stepwise reduction according to McFarlan's pediatric infusion regime, and remifentanil 0.25 μg·kg-1 ·min-1 . Endtidal concentration of sevoflurane, NI, and hemodynamic data were recorded during the whole study period using a standardized case report form. Propofol plasma concentrations were calculated using the paedfusor dataset and a TIVA simulation program. RESULTS Median endtidal concentration of sevoflurane at the time of administration of the propofol bolus was 5.1 [IQR 4.7-5.9] Vol%. The median propofol bolus dose was 1.2 [IQR 0.9-2.5] mg·kg-1 and median NI thereafter was 33 [IQR 23-40]. Nine children presented with a NI 13-20 and three children with burst suppression in the EEG (NI 0-12); all of them received an initial propofol bolus dose >2 mg·kg-1 . Regression equation demonstrated that NI 20-64 was achieved with a 95% probability when using a propofol bolus dose of 1 mg·kg-1 after sevoflurane induction. Decrease in mean arterial blood pressure correlated significantly with propofol bolus dose (P = 0.038). After 25 min of TIVA, children younger than 2 years had a higher NI (median difference 14.0, 95%CI: 6.0-20.0, P = 0.001), higher deviations from the expected Narcotend Index (median difference 4.1, 95%CI: 3.9-4.2, P < 0.001) and lower calculated propofol plasma concentrations (median difference 0.2 μg·ml-1 , 95% CI: 0.1-0.3 μg·ml-1 , P < 0.001) than older children. CONCLUSION After sevoflurane induction, a reduced propofol bolus dose of 1 mg·kg-1 followed by TIVA according to McFarlan's regime resulted in a NI within the recommended range in children aged 1-8 years. During the course of TIVA, children younger than 2 years displayed higher NI values and more pronounced interindividual variation. Processed EEG monitoring is recommended to find adequate individual age-dependent doses.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Sebastian Heiderich
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Martin Boehne
- Clinic for Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Andreas Leffler
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Barbara Schultz
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Messina AG, Wang M, Ward MJ, Wilker CC, Smith BB, Vezina DP, Pace NL. Anaesthetic interventions for prevention of awareness during surgery. Cochrane Database Syst Rev 2016; 10:CD007272. [PMID: 27755648 PMCID: PMC6461159 DOI: 10.1002/14651858.cd007272.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND General anaesthesia is usually associated with unconsciousness. 'Awareness' is when patients have postoperative recall of events or experiences during surgery. 'Wakefulness' is when patients become conscious during surgery, but have no postoperative recollection of the period of consciousness. OBJECTIVES To evaluate the efficacy of two types of anaesthetic interventions in reducing clinically significant awareness:- anaesthetic drug regimens; and- intraoperative anaesthetic depth monitors. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, ISSUE 4 2016); PubMed from 1950 to April 2016; MEDLINE from 1950 to April 2016; and Embase from 1980 to April 2016. We contacted experts to identify additional studies. We performed a handsearch of the citations in the review. We did not search trial registries. SELECTION CRITERIA We included randomized controlled trials (RCTs) of either anaesthetic regimens or anaesthetic depth monitors. We excluded volunteer studies, studies of patients prior to skin incision, intensive care unit studies, and studies that only randomized different word presentations for memory tests (not anaesthetic interventions).Anaesthetic drug regimens included studies of induction or maintenance, or both. Anaesthetic depth monitors included the Bispectral Index monitor, M-Entropy, Narcotrend monitor, cerebral function monitor, cerebral state monitor, patient state index, and lower oesophageal contractility monitor. The use of anaesthetic depth monitors allows the titration of anaesthetic drugs to maintain unconsciousness. DATA COLLECTION AND ANALYSIS At least two authors independently scanned abstracts, extracted data from the studies, and evaluated studies for risk of bias. We made attempts to contact all authors for additional clarification. We performed meta-analysis statistics in packages of the R language. MAIN RESULTS We included 160 studies with 54,109 enrolled participants; 53,713 participants started the studies and 50,034 completed the studies or data analysis (or both). We could not use 115 RCTs in meta-analytic comparisons because they had zero awareness events. We did not merge 27 of the remaining 45 studies because they had excessive clinical and methodological heterogeneity. We pooled the remaining 18 eligible RCTs in meta-analysis. There are 10 studies awaiting classification which we will process when we update the review.The meta-analyses included 18 trials with 36,034 participants. In the analysis of anaesthetic depth monitoring (either Bispectral Index or M-entropy) versus standard clinical and electronic monitoring, there were nine trials with 34,744 participants. The overall event rate was 0.5%. The effect favoured neither anaesthetic depth monitoring nor standard clinical and electronic monitoring, with little precision in the odds ratio (OR) estimate (OR 0.98, 95% confidence interval (CI) 0.59 to 1.62).In a five-study subset of Bispectral Index monitoring versus standard clinical and electronic monitoring, with 34,181 participants, 503 participants gave awareness reports to a blinded, expert panel who adjudicated or judged the outcome for each patient after reviewing the questionnaires: no awareness, possible awareness, or definite awareness. Experts judged 351 patient awareness reports to have no awareness, 87 to have possible awareness, and 65 to have definite awareness. The effect size favoured neither Bispectral Index monitoring nor standard clinical and electronic monitoring, with little precision in the OR estimate for the combination of definite and possible awareness (OR 0.96, 95% CI 0.35 to 2.65). The effect size favoured Bispectral Index monitoring for definite awareness, but with little precision in the OR estimate (OR 0.60, 95% CI 0.13 to 2.75).We performed three smaller meta-analyses of anaesthetic drugs. There were nine studies with 1290 participants. Wakefulness was reduced by ketamine and etomidate compared to thiopental. Wakefulness was more frequent than awareness. Benzodiazepines reduces awareness compared to thiopental, ketamine, and placebo., Also, higher doses of inhaled anaesthetics versus lower doses reduced the risk of awareness.We graded the quality of the evidence as low or very low in the 'Summary of findings' tables for the five comparisons.Most of the secondary outcomes in this review were not reported in the included RCTs. AUTHORS' CONCLUSIONS Anaesthetic depth monitors may have similar effects to standard clinical and electrical monitoring on the risk of awareness during surgery. In older studies comparing anaesthetics in a smaller portion of the patient sample, wakefulness occurred more frequently than awareness. Use of etomidate and ketamine lowered the risk of wakefulness compared to thiopental. Benzodiazepines compared to thiopental and ketamine, or higher doses of inhaled anaesthetics versus lower doses, reduced the risk of awareness.
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Affiliation(s)
- Anthony G Messina
- School of Management, University of Texas at DallasThe Alliance for Medical Management EducationBox 2331920 N. Coit RoadRichardsonTXUSA75080
| | - Michael Wang
- University of LeicesterClinical Psychology UnitLancaster RoadLeicesterUKLE1 7HA
| | - Marshall J Ward
- Dartmouth‐Hitchcock Medical Center1 Medical Center DrLebanonNHUSA03766
| | - Chase C Wilker
- ARUP LaboratoriesClinical Toxicology IIISalt Lake CityUTUSA
| | - Brett B Smith
- University of UtahUniversity of Utah School of MedicineSalt Lake CityUTUSA84112
| | - Daniel P Vezina
- University of UtahDepartment of Anesthesiology, Department of Internal Medicine, Division of CardiologySalt Lake CityUTUSA
- Veteran's AdministrationEchocardiography LaboratorySalt Lake CityUTUSA
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
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Feasibility of Closed-loop Titration of Propofol and Remifentanil Guided by the Bispectral Monitor in Pediatric and Adolescent Patients. Anesthesiology 2015; 122:759-67. [DOI: 10.1097/aln.0000000000000577] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background:
This study was designed to assess the feasibility of dual closed-loop titration of propofol and remifentanil guided solely by the Bispectral Index (BIS) monitor in pediatric and adolescent patients during anesthesia.
Methods:
Children undergoing elective surgery in this single-blind randomized study were allocated into the closed-loop (auto) or manual (manual) group. Primary outcome was the percentage of time with the BIS in the range 40 to 60 (BIS40–60). Secondary outcomes were the percentage of deep (BIS<40) anesthesia and drug consumption. Data are presented as median (interquartile range) or number (%).
Results:
Twenty-three patients (12 [10 to 14] yr) were assigned to the auto group and 19 (14 [7 to 14] yr) to the manual group. The closed-loop controller was able to provide induction and maintenance for all patients. The percentage of time with BIS40–60 was greater in the auto group (87% [75 to 96] vs. 72% [48 to 79]; P = 0.002), with a decrease in the percentage of BIS<40 (7% [2 to 17] vs. 21% [11 to 38]; P = 0.002). Propofol (2.4 [1.9 to 3.3] vs. 1.7 [1.2 to 2.8] mg/kg) and remifentanil (2.3 [2.0 to 3.0] vs. 2.5 [1.2 to 4.3] μg/kg) consumptions were similar in auto versus manual groups during induction, respectively. During maintenance, propofol consumption (8.2 [6.0 to 10.2] vs. 7.9 [7.2 to 9.1] mg kg−1 h−1; P = 0.89) was similar between the two groups, but remifentanil consumption was greater in the auto group (0.39 [0.22 to 0.60] vs. 0.22 [0.17 to 0.32] μg kg−1 min−1; P = 0.003). Perioperative adverse events and length of stay in the postanesthesia care unit were similar.
Conclusion:
Intraoperative automated control of hypnosis and analgesia guided by the BIS is clinically feasible in pediatric and adolescent patients and outperformed skilled manual control.
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Abstract
Applying scalp sensors in the operating theater, intensive care, or resuscitation scenarios to detect and monitor brain function is achievable, practical, and affordable. The modalities are complex and the output of the monitor needs careful interpretation. The monitor may have technical problems, and a single reading must be considered with caution. These monitors may have a use for monitoring trends in specific situations, but evidence does not support their widespread use. Nevertheless, research should continue to investigate their role. Future techniques and treatments may show that these monitors can monitor brain function and prevent harm.
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Affiliation(s)
- Michael Sury
- Department of Anaesthesia, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
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Choi BM, Koh EH, Kim MG, Kim SH, Ok SY, Noh GJ. Temporal linear mode complexity as a surrogate measure of the anesthetic drug effects during sevoflurane anesthesia. Korean J Anesthesiol 2013; 65:385-96. [PMID: 24363840 PMCID: PMC3866333 DOI: 10.4097/kjae.2013.65.5.385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/08/2013] [Accepted: 05/08/2013] [Indexed: 11/17/2022] Open
Abstract
Background The aims of this study were to compare the stability, correlation with end-tidal sevoflurane, and area below the effect (AUCeffect) vs. time curves of temporal linear mode complexity (TLMC) and approximate entropy (ApEn) during sevoflurane anesthesia. Another study goal was to characterize the time course of the effects of sevoflurane. Methods Electroencephalogram (EEG) parame1ter stability was evaluated using the coefficients of variation (CV) of the median baseline (E0), maximal (Emax), and individual median E0 - Emax values. Correlations between sevoflurane concentration and EEG parameters were tested. AUCeffect vs. time curves of TLMC and ApEn were calculated to quantitate any decrease in central nervous system activities. A sigmoid Emax model was used for pharmacodynamic modeling. Results TLMC and ApEn demonstrated CVs of 8.36 and 7.35 (for E0) and 19.61 and 13.45 (Emax), respectively. The CVs of the individual median E0 - Emax values were 65.16 for TLMC and 59.97 for ApEn. The Spearman correlation coefficient was -0.3103 for TLMC and -0.3410 for ApEn (P < 0.001 for both parameters). The median AUCeffect value was 338.9 for TLMC and 246.5 for ApEn (P = 0.457). The final pharmacodynamic parameters estimated by sigmoid Emax models were described as follows; E0: 0.614, 0.617, Emax: 0.334, 0.287, Ce50: 5.48, 5.07 vol%, γ: 1.88, 2.01, ke0: 0.306, 0.236 min (TLMC, ApEn). Conclusions TLMC is comparable to ApEn according to the univariate EEG descriptors of the effects of sevoflurane. A sigmoid Emax model well described the pharmacodynamics of sevoflurane for TLMC and ApEn.
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Affiliation(s)
- Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Eun-Hyo Koh
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Mun-Gyu Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Sang-Ho Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Si-Young Ok
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Gyu-Jeong Noh
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea. ; Department of Clinical Pharmacology and Therapeutics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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15
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Anderson BJ. La farmacología de la anestesia total intravenosa en pediatría. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1016/j.rca.2013.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Pharmacology of paediatric total intravenous anaesthesia☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2013. [DOI: 10.1097/01819236-201341030-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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18
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Abstract
Anaesthesia dosing in infants (0-2 years) should be based on pharmacokinetic-pharmacodynamic considerations and adverse effects profiles. Disease processes and treatments in this group are distinct from those in adults. Absorption, distribution and clearance change dramatically during this period because of maturation of anatomical and physiological processes as well as behavioural changes. Pharmacogenomic expression also matures in this period. Population-based and physiological-based pharmacokinetic modelling has improved the understanding of maturation and subsequent dose approximation. Postmenstrual, rather than postnatal, age is a reasonable measure for maturation. There remains a need for clinically applicable tools to assess pharmacodynamics which can provide response feedback; this has been achieved for neuromuscular monitoring, but not yet fully for depth of anaesthesia, sedation or pain. Morbidity and mortality associated with paediatric anaesthesia have historically been highest in this age group and continue to be so. Some of this morbidity was attributable to a poor understanding of developmental pharmacology; this facet continues to plague the specialty.
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Abstract
Pharmacokinetics and pharmacodynamics can provide a useful modeling framework for predicting drug activity and can serve as a basis for dose optimization. Determining a suitable biomarker or surrogate measure of drug effect for pharmacodynamic models can be challenging. The electroencephalograph is a widely-available and non-invasive tool for recording brainwave activity simultaneously from multiple brain regions. Certain drug classes (such as drugs that act on the central nervous system) also generate a reproducible electroencephalogram (EEG) effect. Characterization of such a drug-induced EEG effect can produce pharmacokinetic/pharmacodynamic models useful for titrating drug levels and expediting development of chemically-similar drug analogs. This paper reviews the relevant concepts involved in pharmacokinetic/pharmacodynamic modeling using EEG-based pharmacodynamic measures. In addition, examples of such models for various drugs are organized by drug activity as well as chemical structure and presented.
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20
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Hayashi K, Shigemi K, Sawa T. Neonatal electroencephalography shows low sensitivity to anesthesia. Neurosci Lett 2012; 517:87-91. [PMID: 22542892 DOI: 10.1016/j.neulet.2012.04.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 04/05/2012] [Accepted: 04/10/2012] [Indexed: 11/15/2022]
Abstract
This study examined EEG under clinical anesthesia in neonates and infants, to clarify how growth affects EEG during anesthesia. Subjects comprised 62 neonates and infants. Patients were divided into four groups according to age: Group 1 (neonates), <1 month; Group 2, 1-2 months; Group 3, 3-5 months; and Group 4, 6 months to 2 years. Anesthesia was maintained with sevoflurane and fentanyl and/or caudal block. At four points of sevoflurane concentration (0.5%, 1%, 1.5%, and 2%), 90% spectral edge frequency (SEF90), burst suppression ratio (BSR), relative beta ratio (RBR) and approximate entropy (ApEn) were analyzed. In Group 4, SEF90, BSR, RBR and ApEn changes were dependent on the concentration of anesthesia, along with changes in sevoflurane concentration from 0.5% to 2% (from 14.3 (2.7) [mean (SD)] Hz to 8.2 (3.8) Hz, from 0.0 to 0.32 (0.36), from -1.58 (0.14) to -1.10 (0.15), and from 0.56 (0.25) to 0.24 (0.25) respectively; p<0.05 each). Conversely, these processed EEG parameters in Group 1 showed little anesthesia-dependent change under sevoflurane concentrations between 0.5% and 2% (SEF90: 7.3 (1.2) Hz vs. 7.7 (2.1) Hz; BSR: 0.51 (0.20) vs. 0.62 (0.29); RBR: -1.00 (0.17) vs. -1.03 (0.27); ApEn: 0.32 (0.18) vs. 0.25 (0.14), respectively). The unique EEG features of neonates during anesthesia rapidly change to the usual anesthesia-dependent patterns seen in older children, with a boundary of 3-5 months old. In infants younger than 6 months old, neural network regulation reflected in EEG by anesthesia is weak.
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Affiliation(s)
- Kazuko Hayashi
- Department of Anesthesiology, Nantan General Hospital, Japan.
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Silva A, Ferreira D, Venâncio C, Souza A, Antunes L. Performance of electroencephalogram-derived parameters in prediction of depth of anaesthesia in a rabbit model. Br J Anaesth 2011; 106:540-7. [DOI: 10.1093/bja/aeq407] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sury MRJ, Bould MD. Defining awakening from anesthesia in infants: a narrative review of published descriptions and scales of behavior. Paediatr Anaesth 2011; 21:364-72. [PMID: 21324047 DOI: 10.1111/j.1460-9592.2011.03538.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A descriptive tool or validated scale of consciousness is desirable in infants to test the value of any depth of anesthesia monitor. METHODS We have reviewed published descriptions and scales of observed behavior that may be applicable to the study of infants during the transition from anesthesia to wakefulness. RESULTS Potentially useful scales were found that had been developed for the assessment and study of natural sleep, neurological state, arousal, anesthesia, sedation, coma, and pain. Scales or criteria of behavior had been developed for anesthetised children, but there were no agreed definitions or criteria specifically for anesthetised infants or neonates. CONCLUSION Criteria for awakening of infants from anesthesia need to be developed and agreed.
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Affiliation(s)
- Michael R J Sury
- Portex Unit of Anaesthesia, University College London Institute of Child Health, London, UK.
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Anderson BJ, Allegaert K. The pharmacology of anaesthetics in the neonate. Best Pract Res Clin Anaesthesiol 2010; 24:419-31. [DOI: 10.1016/j.bpa.2010.02.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Are there still limitations for the use of target-controlled infusion in children? Curr Opin Anaesthesiol 2010; 23:356-62. [DOI: 10.1097/aco.0b013e32833938db] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
Target-controlled infusion (TCI) pumps currently do not satisfactorily cater for the pediatric population, particularly for those under 5 years. Growth and development are two major aspects of children not readily apparent in adults, and these two aspects influence clearance (CL) and volume of distribution (V). In simple terms, V determines initial dose, and CL determines infusion rate at steady state. Three major covariates (size, age, and organ function) contribute to parameter variability in children. Size can be standardized for clearance in a 70-kg person using the allometric (3/4) power model. Remifentanil, a drug cleared by hydrolysis, can be modeled in all age groups by simple application of this model using a standardized clearance of 2790 ml x min(-1) for a 70-kg person. Allometry alone is insufficient to predict clearance in neonates and infants from adult parameters for most drugs used in anesthesia. The addition of a model describing maturation is required. The sigmoid Emax or Hill model has been found useful for describing this maturation process. Propofol maturation has been described with a mature clearance of 1.83 l x min(-1) x 70 kg(-1), a maturation half-time (TM(50)) of 44 weeks and a Hill coefficient of 4.9. Organ function also affects clearance, and propofol clearance is reduced in neonates and infants after cardiac surgery. Although pharmacokinetics (PK) in children is receiving increasing attention and is eminently programmable into a TCI device, pharmacodynamic (PD) measures in children remain poorly defined, partly because the depth of anesthesia monitoring are inadequate. Both PK and PD are necessary for safe use of TCI pumps.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
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Pharmacokinetic-pharmacodynamic modeling in anesthesia, intensive care and pain medicine. Curr Opin Anaesthesiol 2009; 22:463-8. [PMID: 19412091 DOI: 10.1097/aco.0b013e32832c3c6c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Studies from the anesthesiology literature published in the last 2 years were selected to illustrate the most important developments in the field of pharmacokinetic-pharmacodynamic modeling. RECENT FINDINGS The pharmacokinetic models focused on incorporating covariate, especially age for pediatric-geriatric use, and altered physiological states. The pharmacodynamic models studied the effect of rate of anesthetic administration, age, experimental conditions, and delay within the monitor on estimation of drug concentration in the biophase. Models for the surrogate measure of the components of general anesthesia, hypnosis (bispectral index scale, entropy), immobility (limb tetanic stimulus-induced withdrawal reflex) and antinociception (surgical stress index, skin conductance algesimeter) were developed and validated. Response surface models were used to study drug interactions for important end-points during surgery and also to optimize dosing of anesthetic agents to maximize the desired/undesired effect ratio. The models for target-controlled infusions were improved by incorporating more covariates, and the closed-loop system was refined by using adaptive controllers that individualize the pharmacokinetic/pharmacodynamic parameters to the particular patient by using Bayesian, Kalman filters, fuzzy logic or neural networks. SUMMARY Progress was made by improving population pharmacokinetic/pharmacodynamic models, developing new indexes to measure drug effect and using them in an adaptive delivery system to the individual patient.
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Abstract
PURPOSE OF REVIEW Toxicity concerns and awareness during anesthesia issues continue to concern pediatric anesthesiologists. Most developmental pharmacokinetic, pharmacodynamic and pharmacogenomic changes occur within the first year of life. Understanding these early changes can improve drug use in this cohort. RECENT FINDINGS Growth and development are two major aspects of children not readily apparent in adults. Clearance in the pediatric population should be investigated using models that describe size, maturation and organ function influences. Glucuronide conjugation (hepatic phase II process) mirrors glomerular filtration maturation over the first year of life. Phase 1 processes appear more rapid, and differences attributable to single nuclear polymorphisms may be obvious by the end of the 4-week neonatal period in term infants.Pharmacodynamic differences in infancy remain poorly defined, and neonatal pharmacokinetic-pharmacodynamic analyses that might elucidate such differences are few, partly because of a paucity of effective pharmacodynamic measures. SUMMARY Mechanistic models create a framework for the study of pharmacokinetic changes in infancy. Understanding these changes allows a target concentration approach to therapy and potential for reduced toxicity. The target concentration may be undefined because of a paucity of effect measures.
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Current World Literature. Curr Opin Anaesthesiol 2009; 22:539-43. [DOI: 10.1097/aco.0b013e32832fa02c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abulhasan Y, Buu N, Frigon C. Perioperative use of dexmedetomidine in an infant with familial dysautonomia. Br J Anaesth 2009; 103:413-5. [PMID: 19592408 DOI: 10.1093/bja/aep178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We present a case of a 10-month-old girl with familial dysautonomia, who was scheduled for the insertion of a gastrotomy tube via laparoscopy under general anaesthesia. We used a total i.v. anaesthetic technique including dexmedetomidine and titrated the drug to patients' haemodynamic status and BIS value. Vital signs remained virtually unchanged during the entire procedure, and the tracheal tube was removed at the end of the procedure. Postoperative course was uneventful. Careful planning of the anaesthetic management, understanding the physiological consequences, and being able to titrate the medications utilized are key to the decrease of complications encountered in these patients. We report the safe use of dexmedetomidine in an infant with this extremely rare condition.
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Affiliation(s)
- Y Abulhasan
- Department of Anaesthesiology, McGill University Health Center, Montreal Children's Hospital, 2300 Tupper Street, Room C-1118, Montreal, QC H3H 1P3, Canada
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Jeleazcov C, Ihmsen H, Schmidt J, Ammon C, Schwilden H, Schüttler J, Fechner J. Pharmacodynamic modelling of the bispectral index response to propofol-based anaesthesia during general surgery in children. Br J Anaesth 2008; 100:509-16. [DOI: 10.1093/bja/aem408] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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