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Yuan I, Georgostathi G, Zhang B, Hodges A, Kurth CD, Kirschen MP, Huh JW, Topjian AA, Lang SS, Richter A, Abend NS, Massey SL. Quantitative electroencephalogram in term neonates under different sleep states. J Clin Monit Comput 2024; 38:591-602. [PMID: 37851153 DOI: 10.1007/s10877-023-01082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023]
Abstract
Electroencephalogram (EEG) can be used to assess depth of consciousness, but interpreting EEG can be challenging, especially in neonates whose EEG undergo rapid changes during the perinatal course. EEG can be processed into quantitative EEG (QEEG), but limited data exist on the range of QEEG for normal term neonates during wakefulness and sleep, baseline information that would be useful to determine changes during sedation or anesthesia. We aimed to determine the range of QEEG in neonates during awake, active sleep and quiet sleep states, and identified the ones best at discriminating between the three states. Normal neonatal EEG from 37 to 46 weeks were analyzed and classified as awake, quiet sleep, or active sleep. After processing and artifact removal, total power, power ratio, coherence, entropy, and spectral edge frequency (SEF) 50 and 90 were calculated. Descriptive statistics were used to summarize the QEEG in each of the three states. Receiver operating characteristic (ROC) curves were used to assess discriminatory ability of QEEG. 30 neonates were analyzed. QEEG were different between awake vs asleep states, but similar between active vs quiet sleep states. Entropy beta, delta2 power %, coherence delta2, and SEF50 were best at discriminating awake vs active sleep. Entropy beta had the highest AUC-ROC ≥ 0.84. Entropy beta, entropy delta1, theta power %, and SEF50 were best at discriminating awake vs quiet sleep. All had AUC-ROC ≥ 0.78. In active sleep vs quiet sleep, theta power % had highest AUC-ROC > 0.69, lower than the other comparisons. We determined the QEEG range in healthy neonates in different states of consciousness. Entropy beta and SEF50 were best at discriminating between awake and sleep states. QEEG were not as good at discriminating between quiet and active sleep. In the future, QEEG with high discriminatory power can be combined to further improve ability to differentiate between states of consciousness.
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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, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Georgia Georgostathi
- Vagelos Integrated Program in Energy Research, University of Pennsylvania, Philadelphia, PA, USA
| | - Bingqing Zhang
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ashley Hodges
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - C Dean Kurth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam Richter
- Vagelos Integrated Program in Energy Research, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Nicholas S Abend
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia. Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shavonne L Massey
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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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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Chao JY, Simpao AF, Yuan I. A Window into the Developing Brain: Toward a Deeper Understanding of Pediatric Anesthesia. Anesthesiology 2024; 140:863-864. [PMID: 38592355 PMCID: PMC11006386 DOI: 10.1097/aln.0000000000004937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Jerry Y Chao
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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de Heer IJ, Raab HAC, Krul S, Karaöz-Bulut G, Stolker RJ, Weber F. Electroencephalographic density spectral array monitoring during propofol/sevoflurane coadministration in children, an exploratory observational study. Anaesth Crit Care Pain Med 2024; 43:101342. [PMID: 38142866 DOI: 10.1016/j.accpm.2023.101342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Propofol and sevoflurane have a long history in pediatric anesthesia. Combining both drugs at low dose levels offers new opportunities. However, monitoring the hypnotic effects of this drug combination in children is challenging, because the currently available processed EEG-based systems are insufficiently validated in young children and the co-administration of anesthetics. This study investigated electroencephalographic density spectral array monitoring during propofol/sevoflurane coadministration with fixed sevoflurane- and variable propofol dosages. PATIENTS AND METHODS We analyzed the density spectral array pattern recorded during propofol/sevoflurane anesthesia in pediatric patients from birth to 11 years of age. Data from 78 patients were suitable for analysis. The primary outcome parameter of this study was the correlation between variable propofol dosages and the expression of the four electroencephalogram frequency bands β, α, θ, and δ. The main secondary outcome parameters were the intra-operative total EEG power and the prevalence of burst suppression. RESULTS In patients above the age of 1 year, a dose-dependent correlation between the propofol dosage and the relative percentage of β (-12.2%, p < 0.001) and δ (5.1%, p < 0.001) was found. There was an age-dependent trend toward increasing mean EEG power, with the most significant increase in the first year of life. In 14.1% of our patients, at least one episode of burst suppression occurred. CONCLUSION DSA-guided augmentation of propofol anesthesia with sevoflurane provides sufficient depth of anesthesia at doses usually considered sub-anesthetic in children, leading to less anesthetic drug exposure for the individual child.
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Affiliation(s)
- Iris J de Heer
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Hannah A C Raab
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Stephan Krul
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Gulhan Karaöz-Bulut
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan Stolker
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank Weber
- Department of Pediatric Anesthesiology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Jones Oguh S, Iyer RS, Yuan I, Missett R, Daly Guris RJ, Johnson G, Babus LW, Massa CB, McClung-Pasqualino H, Garcia-Marcinkiewicz AG, Sequera-Ramos L, Kurth CD. Implementation of an electroencephalogram-guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project. Paediatr Anaesth 2024; 34:160-166. [PMID: 37962837 DOI: 10.1111/pan.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/12/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Propofol-based total intravenous anesthesia is gaining popularity in pediatric anesthesia. Electroencephalogram can be used to guide propofol dosing to the individual patient to mitigate against overdosing and adverse events. However, electroencephalogram interpretation and propofol pharmacokinetics are not sufficiently taught in training programs to confidently deploy electroencephalogram-guided total intravenous anesthesia. AIMS We conducted a quality improvement project with the smart aim of increasing the percentage of electroencephalogram-guided total intravenous anesthesia cases in our main operating room from 0% to 80% over 18 months. Balancing measures were number of total intravenous anesthesia cases, emergence times, and perioperative emergency activations. METHODS The project key drivers were education, equipment, and electronic health record modifications. Plan-Do-Study-Act cycles included: (1) providing journal articles, didactic lectures, intraoperative training, and teaching documents; (2) scheduling electroencephalogram-guided total intravenous anesthesia teachers to train faculty, staff, and fellows for specific cases and to assess case-based knowledge; (3) adding age-based propofol dosing tables and electroencephalogram parameters to the electronic health record (EPIC co, Verona, WI); (4) procuring electroencephalogram monitors (Sedline, Masimo Inc). Electroencephalogram-guided total intravenous anesthesia cases and balancing measures were identified from the electronic health record. The smart aim was evaluated by statistical process control chart. RESULTS After the four Plan-Do-Study-Act cycles, electroencephalogram-guided total intravenous anesthesia increased from 5% to 75% and was sustained at 72% 9 months after project completion. Total intravenous anesthesia cases/mo and number of perioperative emergency activations did not change significantly from start to end of the project, while emergence time for electroencephalogram-guided total intravenous anesthesia was greater statistically but not clinically (total intravenous anesthesia without electroencephalogram [16 ± 10 min], total intravenous anesthesia with electroencephalogram [18 ± 9 min], sevoflurane [17 ± 9 min] p < .001). CONCLUSION Quality improvement methods may be deployed to adopt electroencephalogram-guided total intravenous anesthesia in a large academic pediatric anesthesia practice. Keys to success include education, in operating room case training, scheduling teachers with learners, electronic health record modifications, and electroencephalogram devices and supplies.
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Affiliation(s)
- Sheri Jones Oguh
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rajeev S Iyer
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Ian Yuan
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Richard Missett
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Rodrigo J Daly Guris
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Gregory Johnson
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Lenard W Babus
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Christopher B Massa
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Heather McClung-Pasqualino
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Annery G Garcia-Marcinkiewicz
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Luis Sequera-Ramos
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - C Dean Kurth
- Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Gao Z, Zhang J, Zhang X, Wang L, Huang Y, Yu J. A Retrospective Study of the Patient State Index During General Anesthesia in Infants and Young Children. Clin Pediatr (Phila) 2024; 63:249-256. [PMID: 37042054 DOI: 10.1177/00099228231168475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
This study described electroencephalogram (EEG) parameters in children under general anesthesia, which could monitor patient-specific brain responses to anesthetics and assess the effects of anesthesia. The objective was to detect the patient state index (PSI) and associated factors. We analyzed EEG parameters in patients in the age range 1 to 36 months. Patients were stratified into 2 groups as those aged 1 to 12 months and 13 to 36 months. Sixty-two patients were involved. Spectral edge frequency (SEF), PSI, and blood pressure were lower, and burst suppression rate (BSR) and heart rate were higher in the 1 to 12 months group. The SEF was associated with PSI in both groups. Age and blood pressure were positively associated with PSI, and BSR was negatively related to PSI in children under 1 year of age. Blood pressure was not associated with PSI in the 13 to 36 months age group. We found that the PSI levels did not accurately assess the depth of anesthesia in children under 1 year of age.
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Affiliation(s)
- Zhengzheng Gao
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jianmin Zhang
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xuemei Zhang
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liya Wang
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yao Huang
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Yu
- Department of Anaesthesiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Ricci Z, Robino C, Rufini P, Cumbo S, Cavallini S, Gobbi L, Brocchi A, Serio P, Romagnoli S. Monitoring anesthesia depth with patient state index during pediatric surgery. Paediatr Anaesth 2023; 33:855-861. [PMID: 37334678 DOI: 10.1111/pan.14711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Monitoring anesthesia depth in children is challenging. Pediatric anesthesiologists estimate general anesthesia depth using indirect methods such as pharmacokinetic models and neurovegetative reflexes. The application of processed electroencephalography may help to identify the correct anesthesia depth (i.e., patient state index between 25 and 50). AIMS To determine the median values of patient state index and spectral edge frequency 95% in children undergoing general anesthesia conducted according to indirect evaluation of depth. The relationships between patient state index and spectral edge frequency 95% and indirect monitoring of anesthesia depth, type of anesthesia, age subgroups, and postoperative delirium were also assessed. METHODS A prospective observational study on children (aged 1-18 years) undergoing surgery longer than 60 min. The SedLine monitor and the novel SedLine pediatric sensors (Masimo Inc., Irvine California) were applied. Patient state index levels were recorded for the duration of the anesthesia until the discharge to the ward at predefined time points. RESULTS In the 111 enrolled children, median patient state index level at the end of anesthesia induction was 25 (22-32) and ranged from 26 (23-34) to 28 (25-36) in the maintenance phase. Patient state index at extubation was 48 (35-60) and 69 (62-75) at discharge from the operatory room. Median right/left spectral edge frequency 95% values at the end of induction were 10 (6-14)/9 (5-14) Hz and median right/left spectral edge frequency 95% values in the maintenance phase ranged from 10 (6-14) to 12 (11-15) Hz in both hemispheres. At extubation, right/left spectral edge frequency 95% levels were 18 (15-21)/17 (15-21) Hz. We observed 39 episodes of burst suppression in 20 patients (19%). Median patient state index levels were not different between patients undergoing inhalational and intravenous anesthesia and between those undergoing general anesthesia and general anesthesia added to locoregional anesthesia. Children <2 years displayed significantly higher patient state index levels than older patients (p = .0004). The presence of a burst suppression episode was not associated with PAED levels (OR 1.58, 95% CI 0.14-16.74, p` = .18). CONCLUSIONS NonpEEG-guided anesthesia in children led to median patient state index levels at the low range of recommended unconsciousness values with frequent episodes of burst suppression. Patient state index levels were generally higher in children below 2 years.
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Affiliation(s)
- Zaccaria Ricci
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Chiara Robino
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Paolo Rufini
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Silvia Cumbo
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Sara Cavallini
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Lorenzo Gobbi
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Agata Brocchi
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
| | - Paola Serio
- Department of Anesthesia and Critical Care, Meyer Children's University Hospital, IRCCS, Florence, Italy
| | - Stefano Romagnoli
- Department of Health Sciences, Section of Anesthesiology and Intensive Care, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, AOU Careggi, Florence, Italy
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Jöhr M. A new view on old problems in paediatric anaesthesia: premedication, postoperative agitation and dosing. Curr Opin Anaesthesiol 2023; 36:311-317. [PMID: 36745083 DOI: 10.1097/aco.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss recent developments in paediatric anaesthesia, which have evolved in an undulating fashion. RECENT FINDINGS The role and efficacy of pharmacological premedication is reevaluated. The anxiolytic and sedative properties of midazolam and α 2 -agonists have now been defined more precisely. Both classes of drugs have their unique profile, and there is no reason to condemn one or the other. Midazolam is an excellent anxiolytic, whereas dexmedetomidine is superior in the postoperative period and for sedation during diagnostic imaging.A total intravenous technique with propofol is often considered to be the standard for the prevention of emergence agitation; but alternatives do exist, such as a co-medication with dexmedetomidine or opioids. In clinical reality, a multimodal approach may often be advisable.The theoretical basis for propofol dosing has recently been adapted. In contrast to previous beliefs, the context-sensitive half-life of propofol seems to be quite short beyond the first year of life. SUMMARY Midazolam and dexmedetomidine are not interchangeable; each compound has its pros and cons. As an anxiolytic drug, midazolam indisputably deserves its place, whereas dexmedetomidine is a better sedative and particularly beneficial in the postoperative period. New data will allow more precise age-adapted dosing of propofol.
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Affiliation(s)
- Martin Jöhr
- Paediatric Anaesthesia, Luzerner Kantonsspital, Luzern Switzerland
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Köditz H, Drouche A, Dennhardt N, Schmidt M, Schultz M, Schultz B. Depth of anesthesia, temperature, and postoperative delirium in children and adolescents undergoing cardiac surgery. BMC Anesthesiol 2023; 23:148. [PMID: 37131120 PMCID: PMC10152600 DOI: 10.1186/s12871-023-02102-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND After pediatric cardiosurgical interventions, postoperative delirium can occur, which can be associated with undesirable consequences during and after the hospital stay. It is therefore important to avoid any factors causing delirium as far as possible. Electroencephalogram (EEG) monitoring can be used during anesthesia to individually adjust dosages of hypnotically acting drugs. It is necessary to gain knowledge about the relationship between intraoperative EEG and postoperative delirium in children. METHODS In a dataset comprising 89 children (53 male, 36 female; median age: 0.99 (interquartile range: 0.51, 4.89) years) undergoing cardiac surgery involving use of a heart-lung machine, relationships between depth of anesthesia as measured by EEG (EEG index: Narcotrend Index (NI)), sevoflurane dosage, and body temperature were analyzed. A Cornell Assessment of Pediatric Delirium (CAP-D) score ≥ 9 indicated delirium. RESULTS The EEG could be used in patients of all age groups for patient monitoring during anesthesia. In the context of induced hypothermia, EEG monitoring supported individually adjusted sevoflurane dosing. The NI was significantly correlated with the body temperature; decreasing temperature was accompanied by a decreasing NI. A CAP-D score ≥ 9 was documented in 61 patients (68.5%); 28 patients (31.5%) had a CAP-D < 9. Delirious patients with an intubation time ≤ 24 h showed a moderate negative correlation between minimum NI (NImin) and CAP-D (rho = -0.41, 95% CI: -0.70 - -0.01, p = 0.046), i.e., CAP-D decreased with increasing NImin. In the analysis of all patients' data, NImin and CAP-D showed a weak negative correlation (rho = -0.21, 95% CI: -0.40 - 0.01, p = 0.064). On average, the youngest patients had the highest CAP-D scores (p = 0.002). Patients with burst suppression / suppression EEG had a longer median intubation time in the intensive care unit than patients without such EEG (p = 0.023). There was no relationship between minimum temperature and CAP-D score. CONCLUSIONS The EEG can be used to individually adjust sevoflurane dosing during hypothermia. Of the patients extubated within 24 h and classified as delirious, patients with deeper levels of anesthesia had more severe delirium symptoms than patients with lighter levels of anesthesia.
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Affiliation(s)
- H Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - A Drouche
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - N Dennhardt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schmidt
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - M Schultz
- Medical University of Vienna, Vienna, Austria
| | - Barbara Schultz
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
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Zhang Y, Zhang Q, Xu S, Zhang X, Gao W, Chen Y, Zhu Z. Association of volatile anesthesia exposure and depth with emergence agitation and delirium in children: Prospective observational cohort study. Front Pediatr 2023; 11:1115124. [PMID: 37033193 PMCID: PMC10076635 DOI: 10.3389/fped.2023.1115124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/09/2023] [Indexed: 04/11/2023] Open
Abstract
Background Sevoflurane anesthesia is widely used in pediatric ambulatory surgery. However, emergency agitation (EA) and emergency delirium (ED), as major complications following sevoflurane anesthesia in children, pose risks to surgery and prognosis. Identifying the high risk of EA/ED, especially anesthesia exposure and the depth of anesthesia, may allow preemptive treatment. Methods A total of 137 patients were prospectively enrolled in this single-center observational cohort study to assess the incidence of EA or ED. Multivariable logistic regression analyses were used to test the association between volatile anesthesia exposure and depth with EA or ED. The Richmond Agitation and Sedation Scale (RASS), Pediatric Anesthesia Emergence Delirium Scale (PAED) and Face, Legs, Activity, Cry, and Consolability (FLACC) behavioural pain scale was used to assess the severity of EA or ED severity and pain. Bispectral index (BIS) to monitor the depth of anesthesia, as well as TimeLOW-BIS/TimeANES %, EtSevo (%) and EtSevo-time AUC were included in the multivariate logistic regression model as independent variables to analyze their association with EA or ED. Results The overall prevalence of EA and ED was 73/137 (53.3%) and 75/137 (54.7%) respectively, where 48/137 (35.0%), 19/137 (13.9%), and 6/137 (4.4%) had mild, moderate, and severe EA. When the recovery period was lengthened, the prevalence of ED and extent of FLACC decreased and finally normalized within 30 min in recovered period. Multivariable logistic regression demonstrated that intraoperative agitation [2.84 (1.08, 7.47) p = 0.034], peak FLACC [2.56 (1.70, 3.85) p < 0.001] and adverse event (respiratory complications) [0.03 (0.00, 0.29) p = 0.003] were independently associated with higher odds of EA. Taking EtSevo-time AUC ≤ 2,000 as a reference, the incidence of EA were [15.84 (2.15, 116.98) p = 0.002] times and 16.59 (2.42, 113.83) p = 0.009] times for EtSevo-time AUC 2,500-3,000 and EtSevo-time AUC > 3,000, respectively. Peak FLACC [3.46 (2.13, 5.62) p < 0.001] and intraoperative agitation [5.61 (1.99, 15.86) p = 0.001] were independently associated with higher odds of developing ED. EtSevo (%), intraoperative BIS value and the percentage of the duration of anesthesia at different depths of anesthesia (BIS ≤ 40, BIS ≤ 30, BIS ≤ 20) were not associated with EA and ED. Conclusions For pediatrics undergoing ambulatory surgery where sevoflurane anesthesia was administered, EA was associated with surgical time, peak FLACC, respiratory complications, and "EtSevo-time AUC" with a dose-response relationship; ED was associated with peak FLACC and intraoperative agitation.
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Affiliation(s)
- Yinan Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Translational Neurology Laboratory, Affiliated Hospital of ZunYi Medical University, Zunyi, China
| | - Qiuying Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Translational Neurology Laboratory, Affiliated Hospital of ZunYi Medical University, Zunyi, China
| | - Shan Xu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Translational Neurology Laboratory, Affiliated Hospital of ZunYi Medical University, Zunyi, China
| | - Xiaoxi Zhang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Translational Neurology Laboratory, Affiliated Hospital of ZunYi Medical University, Zunyi, China
| | - Wenxu Gao
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yu Chen
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zhaoqiong Zhu
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Translational Neurology Laboratory, Affiliated Hospital of ZunYi Medical University, Zunyi, China
- Correspondence: Zhaoqiong Zhu
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Klučka J, Klabusayová E, Vafek V, Musilová T, Kratochvíl M, Kosinová M, Štourač P. Year 2022 in review - Paediatric anesthesia and intensive care. ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA 2022. [DOI: 10.36290/aim.2022.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
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Andropoulos DB, Dunbar BS. Neuroprotective Strategies in Anesthesia-Induced Neurotoxicity. Best Pract Res Clin Anaesthesiol 2022. [DOI: 10.1016/j.bpa.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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