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Bruns N, Joist CA, Joist CM, Daniels A, Felderhoff-Müser U, Dohna-Schwake C, Tschiedel E. Correlation of Comfort Score and Narcotrend Index during Procedural Sedation with Midazolam and Propofol in Children. J Clin Med 2024; 13:1483. [PMID: 38592307 PMCID: PMC10932229 DOI: 10.3390/jcm13051483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 04/10/2024] Open
Abstract
Background/Objectives: Precise assessment of hypnotic depth in children during procedural sedation with preserved spontaneous breathing is challenging. The Narcotrendindex (NI) offers uninterrupted information by continuous electrocortical monitoring without the need to apply a stimulus with the risk of assessment-induced arousal. This study aimed to explore the correlation between NI and the Comfort Scale (CS) during procedural sedation with midazolam and propofol and to identify an NI target range for deep sedation. Methods: A prospective observational study was conducted on 176 children (6 months to 17.9 years) undergoing procedural sedation with midazolam premedication and continuous propofol infusion. Statistical analyses included Pearson correlation of NI and CS values, logistic regression, and receiver operating curves. Results: Median NI values varied with CS and age. The correlation coefficient between CS and NI was 0.50 and slightly higher in procedure-specific subgroup analyses. The optimal NI cut-off for deep sedation was between 50 and 60 depending on the analyzed subgroup and displayed high positive predictive values for sufficient sedation throughout. Conclusion: Our study found a moderate correlation between NI and CS, demonstrating reliable identification of adequately sedated patients.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Carolina A. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Constantin M. Joist
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Anna Daniels
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Eva Tschiedel
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany (E.T.)
- Center for Translational Neuro- and Behavioural Sciences (C-TNBS), University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
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Markus M, Nagelsmann H, Schneider M, Rupp L, Spies C, Koch S. Peri- and intraoperative EEG signatures in newborns and infants. Clin Neurophysiol 2021; 132:2959-2964. [PMID: 34715420 DOI: 10.1016/j.clinph.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The electroencephalographic derived indices have been developed for adult patients, however these monitors have not been validated for infants. METHODS Frontal EEGs were recorded in 115 infants aged <1 year [0-3-months (N = 27), 4-6-months (N = 30), 7-9-months (N = 29) and 10-12-months (N = 29)] who received general anaesthesia with sevoflurane. Total power (µV2) and relative β-, α-, θ-, δ-power (%) were analyzed. Additionally, in 20 EEGs event marker were added (baseline, loss of consciousness, intraoperative situation, extubation) to assess perioperative EEG dynamics. RESULTS Newborns show a mean relative δ-power at 80% in intraoperative EEG compared to infants (10-12 months) showing 47.5%. Relative β-power and α-power are low in newborns (mean 3.2% and 4.6%; respectively), with a marked increase in the older infants (4-6 months) (mean 10.9% and 14.4%; respectively). EEG dynamic in newborns from baseline (relative δ-power of 88%) to the intraoperative situation (80.5%) are discrete. In contrast infants >6-months have a strong reduction of relative δ-power from baseline to the intraoperative situation, which corresponds to an increase of faster frequencies. CONCLUSIONS Age dependent perioperative EEG signatures can be demonstrated in infants younger than one year. SIGNIFICANCE We demonstrate significant differences in EEG readouts between newborns and infants which questions our monitoring systems in paediatric anaesthesia.
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Affiliation(s)
- M Markus
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - H Nagelsmann
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - M Schneider
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - L Rupp
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - C Spies
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany
| | - S Koch
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Germany.
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Efune PN, Longanecker JM, Alex G, Saynhalath R, Khan U, Rivera K, Jerome AP, Boone W, Szmuk P. Use of dexmedetomidine and opioids as the primary anesthetic in infants and young children: A retrospective cohort study. Paediatr Anaesth 2020; 30:1013-1019. [PMID: 32510703 DOI: 10.1111/pan.13945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 05/25/2020] [Accepted: 05/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Anesthetic regimens using dexmedetomidine and short-acting opioids have been suggested as potential alternatives to sevoflurane-based anesthesia in children. The primary aim of this study is to compare demographics, intraoperative characteristics, and complications of general anesthetics in which dexmedetomidine and opioids were used without sevoflurane, or in combination with a low sevoflurane concentration, in children 36 months old and younger. The secondary aim is to evaluate intraoperative bispectral index (BIS) values when available in these patients. METHODS General anesthetics performed between January 1, 2017, and May 1, 2018, in children 2 years and younger who received dexmedetomidine and remifentanil, with or without sevoflurane, were identified. Additional anesthetics performed during this time in children 36 months and younger who received dexmedetomidine and opioids and had BIS monitoring were also identified. Charts were reviewed for demographic and intraoperative variables, including drug administration and hemodynamic data. RESULTS A total of 244 patients were identified. All but 22 patients received remifentanil. Ninety-two patients received sevoflurane with a mean end-tidal concentration of 0.84% (SD 0.43). Compared to the sevoflurane group, the nonsevoflurane group received more remifentanil (median dose 0.4 μg/kg/min vs 0.2 μg/kg/min, difference of 0.1 μg/kg/min, 95% CI 0.1-0.3, P < .001) and more dexmedetomidine (median dose 0.9 μg/kg/h vs 0.3 μg/kg/h, difference of 0.6 μg/kg/h, 95% CI 0.4-0.8, P < .001), and had a higher mean arterial pressure (median 53 mm Hg vs 42 mm Hg, difference of 11 mm Hg, 95% CI 8.1-14.8, P < .001). Complications between the two groups were comparable. The median percent intraoperative time with BIS reading <60 was 71.6% (95% CI: 63.3%-79.8%). CONCLUSION Dexmedetomidine and opioids can effectively be used in young children as an alternative total intravenous anesthesia technique with or without <1 minimum alveolar concentration of sevoflurane. Bispectral index monitoring reveals a likely sufficient depth of hypnosis.
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Affiliation(s)
- Proshad N Efune
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | | | - Gijo Alex
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA
| | - Rita Saynhalath
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Umar Khan
- Department of Pediatric Anesthesiology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Kevin Rivera
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA
| | - Aveline P Jerome
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA
| | - Weiwei Boone
- Department of Pediatric Anesthesiology, Children's Medical Center Dallas, Dallas, Texas, USA
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
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Age-related effects of three inhalational anesthetics at one minimum alveolar concentration on electroencephalogram waveform. Aging Clin Exp Res 2020; 32:1857-1864. [PMID: 31650503 DOI: 10.1007/s40520-019-01378-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The characteristics of electroencephalogram (EEG) profiles under general anesthesia may depend on age and type of anesthetic. AIM This study investigated age-related differences in EEG waveforms between three inhalational anesthetics used at the same minimum alveolar concentration (MAC), which indicates the level of analgesia. METHODS Patients with American Society of Anesthesiologists physical status I-II were divided into three groups according to age: pediatric (≦ 15 years); adult (16-64 years); and elderly (≧ 65 years). Each group was divided into three subgroups according to the inhalational anesthetic used: sevoflurane, isoflurane, and desflurane. Anesthesia was maintained at 1 MAC, followed by assessment of 95% spectral edge frequency (SEF95) values and amplitude of EEG waveform. RESULTS The 3 age groups comprised a total of 180 patients. The mean (± SD) EEG waveform amplitude and SEF95 values for sevoflurane in the pediatric, adult, and elderly age groups, respectively, were: 32.9 ± 2.9 µV and 16.7 ± 2.4 Hz; 16.4 ± 3.6 µV and 12.2 ± 1.3 Hz; and 11.0 ± 2.1 µV and 13.6 ± 1.6 Hz. EEG waveform amplitude and SEF95 values were significantly higher in the pediatric group than in the other groups. SEF95 value was higher in the elderly group than in the adult group. Similar results were obtained for isoflurane and desflurane. CONCLUSION The amplitude of the EEG waveform and SEF95 values varied with age, even at the same analgesic state in patients under general anesthesia. This age-dependent change in EEG waveform was observed for all three inhalational anesthetics, and should be considered in procedures requiring general anesthesia.
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Affiliation(s)
- Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Carmela Riso
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
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Morse J, Hannam JA, Cortinez LI, Allegaert K, Anderson BJ. A manual propofol infusion regimen for neonates and infants. Paediatr Anaesth 2019; 29:907-914. [PMID: 31325395 DOI: 10.1111/pan.13706] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/03/2019] [Accepted: 07/06/2019] [Indexed: 01/10/2023]
Abstract
AIMS Manual propofol infusion regimens for neonates and infants have been determined from clinical observations in children under the age of 3 years undergoing anesthesia. We assessed the performance of these regimens using reported age-specific pharmacokinetic parameters for propofol. Where performance was poor, we propose alternative dosing regimens. METHODS Simulations using a reported general purpose pharmacokinetic propofol model were used to predict propofol blood plasma concentrations during manual infusion regimens recommended for children 0-3 years. Simulated steady state concentrations were 6-8 µg.mL-1 in the first 30 minutes that were not sustained during 100 minutes infusions. Pooled clinical data (n = 161, 1902 plasma concentrations) were used to determine an alternative pharmacokinetic parameter set for propofol using nonlinear mixed effects models. A new manual infusion regimen for propofol that achieves a steady-state concentration of 3 µg.mL-1 was determined using a heuristic approach. RESULTS A manual dosing regimen predicted to achieve steady-state plasma concentration of 3 µg.mL-1 comprised a loading dose of 2 mg.kg-1 followed by an infusion rate of 9 mg.kg-1 .h-1 for the first 15 minutes, 7 mg.kg-1 .h-1 from 15 to 30 minutes, 6 mg.kg-1 .h-1 from 30 to 60 minutes, 5 mg.kg-1 .h-1 from 1 to 2 hours in neonates (38-44 weeks postmenstrual age). Dose increased with age in those aged 1-2 years with a loading dose of 2.5 mg.kg-1 followed by an infusion rate of 13 mg.kg-1 .h-1 for the first 15 minutes, 12 mg.kg-1 .h-1 from 15 to 30 minutes, 11 mg.kg-1 .h-1 from 30 to 60 minutes, and 10 mg.kg-1 .h-1 from 1 to 2 hours. CONCLUSION Propofol clearance increases throughout infancy to reach 92% that reported in adults (1.93 L.min.70 kg-1 ) by 6 months postnatal age and infusion regimens should reflect clearance maturation and be cognizant of adverse effects from concentrations greater than the target plasma concentration. Predicted concentrations using a published general purpose pharmacokinetic propofol model were similar to those determined using a new parameter set using richer neonatal and infant data.
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Affiliation(s)
- James Morse
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Jacqueline A Hannam
- Department of Pharmacology & Clinical Pharmacology, Auckland University, Auckland, New Zealand
| | - Luis Ignacio Cortinez
- División Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
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7
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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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Abstract
PURPOSE OF REVIEW To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. RECENT FINDINGS The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0-100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. SUMMARY Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly.
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Weber F, Walhout LC, Escher JC. The impact of Narcotrend™ EEG-guided propofol administration on the speed of recovery from pediatric procedural sedation-A randomized controlled trial. Paediatr Anaesth 2018; 28:443-449. [PMID: 29575232 DOI: 10.1111/pan.13365] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Propofol is often used for procedural sedation in children undergoing gastrointestinal endoscopy. Reliable assessment of the depth of hypnosis during the endoscopic procedure is challenging. Processed electroencephalography using the Narcotrend Index can help titrating propofol to a predefined sedation level. AIMS The aim of this trial was to investigate the impact of Narcotrend Index-guided titration of propofol delivery on the speed of recovery. METHODS Children, aged 12-17 years, undergoing gastrointestinal endoscopy under procedural sedation, had propofol delivered via target controlled infusion either based on Narcotrend Index guidance (group NI) or standard clinical parameters (group C). Sedation was augmented with remifentanil in both study groups. The primary endpoint of this study was to compare the speed of fulfilling discharge criteria from the operating room between study groups. Major secondary endpoints were propofol consumption, discharge readiness from the recovery room, hypnotic depth as measured by the Narcotrend Index, and adverse events. RESULTS Of the 40 children included, data were obtainable from 37. The time until discharge readiness from the operating room was shorter in group NI than in group C, with a difference between medians of 4.76 minutes [95%CI 2.6 to 7.4 minutes]. The same accounts for recovery room discharge times; difference between medians 4.03 minutes [95%CI 0.81 to 7.61 minutes]. Propofol consumption and the percentage of EEG traces indicating oversedation were higher in group C than in group NI. There were no significant adverse events in either study group. CONCLUSION Narcotrend Index guidance of propofol delivery for deep sedation in children aged 12-17 years, underdoing gastrointestinal endoscopy results in faster recovery, less drug consumption, and fewer episodes of oversedation than dosing propofol according to clinical surrogate parameters of depth of hypnosis. The results of this study provide additional evidence in favor of the safety profile of propofol/remifentanil for procedural sedation in adequately selected pediatric patients.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesiology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Laurence C Walhout
- Department of Paediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johanna C Escher
- Department of Paediatrics, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Zhou X, Lu D, Li WD, Chen XH, Yang XY, Chen X, Zhou ZB, Ye JH, Feng X. Sevoflurane Affects Oxidative Stress and Alters Apoptosis Status in Children and Cultured Neural Stem Cells. Neurotox Res 2017; 33:790-800. [PMID: 29071560 DOI: 10.1007/s12640-017-9827-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/16/2017] [Accepted: 10/05/2017] [Indexed: 01/03/2023]
Abstract
Anesthesia-induced neurotoxicity in immature animals has raised concerns about similar effects occurring in young children. Our study investigated two commonly used anesthetics-sevoflurane and propofol-for neurotoxicity in young children. Forty-seven children (aged 12-36 months) undergoing hypospadias repair surgery were randomized to receive sevoflurane (SG, n = 24) or propofol (PG, n = 23) general anesthesia. Venous blood was collected at three different times-immediately after induction, 2 h, and 3 days after surgery. The cellular portion was assessed for antioxidant defense and DNA damage, using enzyme assay kits and qRT-PCR, respectively, while serum was used to treat cultured neural stem cells (NSCs). MTT assay and TUNEL staining were performed, and the mRNA levels of antioxidant enzymes and apoptosis indicators were evaluated by qRT-PCR. Antioxidant defense and apoptosis status in the SG group were significantly higher than in the PG group at 2 h after surgery. Additionally, exposure of NSCs to postoperative serum of the SG group resulted in decreased cell density and viability, increased TUNEL-positive cells, elevated mRNA levels of antioxidant enzymes, and cleaved caspase-3 expression. Our data shows for the first time that in young children, administration of sevoflurane, but not propofol, leads to temporally increased antioxidant defense and apoptosis status as well as damage of NSCs.
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Affiliation(s)
- Xue Zhou
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Dihan Lu
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Wen-da Li
- Department of Hepatobiliary Surgery, The Sun Yat-sen Memorial Hospital, Sun Yat-sen University, No. 107 Yanjiang West Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Xiao-Hui Chen
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, 350001, People's Republic of China
| | - Xiao-Yu Yang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xi Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zhi-Bin Zhou
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jiang-Hong Ye
- Department of Anesthesiology, Rutgers, the State University of New Jersey, New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA.
| | - Xia Feng
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, No. 2nd Zhongshan Road, Guangzhou, 510080, Guangdong, People's Republic of China.
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Stolwijk LJ, Weeke LC, de Vries LS, van Herwaarden MYA, van der Zee DC, van der Werff DBM, Benders MJNL, Toet M, Lemmers PMA. Effect of general anesthesia on neonatal aEEG-A cohort study of patients with non-cardiac congenital anomalies. PLoS One 2017; 12:e0183581. [PMID: 28859124 PMCID: PMC5578644 DOI: 10.1371/journal.pone.0183581] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 08/07/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction The aim of the current study was to determine the effect of general anesthesia on neonatal brain activity using amplitude-integrated EEG (aEEG). Methods A prospective cohort study of neonates (January 2013-December 2015), who underwent major neonatal surgery for non-cardiac congenital anomalies. Anesthesia was administered at the discretion of the anesthetist. aEEG monitoring was started six hours preoperatively until 24 hours after surgery. Analysis of classes of aEEG background patterns, ranging from continuous normal voltage to flat trace in six classes, and quantitative EEG-measures, using spontaneous activity transients (SATs) and interSATintervals (ISI), was performed. Results In total, 111 neonates were included (36 preterm/75 full-term), age at time of surgery was (median (range) 2 (0–32) days. During anesthesia depression of brain activity was seen, with background patterns ranging from flat trace to discontinuous normal voltage. In most patients brain activity was two background pattern classes lower during anesthesia. After cessation of anesthesia, recovery to preoperative brain activity occurred within 24 hours in 86% of the preterm and 96% of the term infants. Gestational age and the dose of sevoflurane were significantly associated with SAT-rate (F(2,68) = 9.288, p < 0.001) and ISI- durations during surgery (F(3,71) = 12.96, p < 0.001). Background pattern and quantitative EEG-values were not associated with brain lesions (χ2(4) = 2.086, ns). Conclusion aEEG shows a variable reduction of brain activity in response to anesthesia in neonates with noncardiac congenital anomalies, with fast recovery after cessation of anesthesia. This reduction is related to gestational age and the dose of sevoflurane. The aEEG offers the opportunity to monitor the depth of anesthesia in the neonate.
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Affiliation(s)
- Lisanne J. Stolwijk
- Department of Neonatology, University Medical Center Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
- Department of Pediatric Surgery, University Medical Center Utrecht, the Netherlands
| | - Lauren C. Weeke
- Department of Neonatology, University Medical Center Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | - Linda S. de Vries
- Department of Neonatology, University Medical Center Utrecht, the Netherlands
- Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands
| | | | - David C. van der Zee
- Department of Pediatric Surgery, University Medical Center Utrecht, the Netherlands
| | | | | | - Mona Toet
- Department of Neonatology, University Medical Center Utrecht, the Netherlands
| | - Petra M. A. Lemmers
- Department of Neonatology, University Medical Center Utrecht, the Netherlands
- * E-mail:
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Sciusco A, Standing JF, Sheng Y, Raimondo P, Cinnella G, Dambrosio M. Effect of age on the performance of bispectral and entropy indices during sevoflurane pediatric anesthesia: a pharmacometric study. Paediatr Anaesth 2017; 27:399-408. [PMID: 28211134 DOI: 10.1111/pan.13086] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bispectral index (BIS) and entropy monitors have been proposed for use in children, but research has not supported their validity for infants. However, effective monitoring of young children may be even more important than for adults, to aid appropriate anesthetic dosing and reduce the chance of adverse consequences. This prospective study aimed to investigate the relationships between age and the predictive performance of BIS and entropy monitors in measuring the anesthetic drug effects within a pediatric surgery setting. METHODS We concurrently recorded BIS and entropy (SE/RE) in 48 children aged 1 month-12 years, undergoing general anesthesia with sevoflurane and fentanyl. Nonlinear mixed effects modeling was used to characterize the concentration-response relationship independently between the three monitor indicators with sevoflurane. The model's goodness-of-fit was assessed by prediction-corrected visual predictive checks. Model fit with age was evaluated using absolute conditional individual weighted residuals (|CIWRES|). The ability of BIS and entropy monitors to describe the effect of anesthesia was compared with prediction probabilities (PK ) in different age groups. Intraoperative and awakening values were compared in the age groups. The correlation between BIS and entropy was also calculated. RESULTS |CIWRES| vs age showed an increasing trend in the model's accuracy for all three indicators. PK probabilities were similar for all three indicators within each age group, though lower in infants. The linear correlations between BIS and entropy in different age groups were lower for infants. Infants also tended to have lower values during surgery and at awakening than older children, while toddlers had higher values. CONCLUSIONS Performance of both monitors improves as age increases. Our results suggest a need for the development of new monitor algorithms or calibration to better account for the age-specific EEG dynamics of younger patients.
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Affiliation(s)
- Alberto Sciusco
- Ospedali Riuniti, Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Joseph F Standing
- Institute of Child Health, University College London (UCL), London, UK
| | - Yucheng Sheng
- Department of Pharmaceutics, UCL School of Pharmacy, London, UK
| | - Pasquale Raimondo
- Ospedali Riuniti, Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Gilda Cinnella
- Ospedali Riuniti, Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Michele Dambrosio
- Ospedali Riuniti, Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
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Valkenburg AJ, de Leeuw TG, van Dijk M, Tibboel D. Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy? Paediatr Drugs 2015; 17:339-48. [PMID: 26076801 PMCID: PMC4768233 DOI: 10.1007/s40272-015-0138-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.
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Affiliation(s)
- Abraham J Valkenburg
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Tom G de Leeuw
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
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14
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Verhoeven MTW, Gerritzen MA, Hellebrekers LJ, Kemp B. Indicators used in livestock to assess unconsciousness after stunning: a review. Animal 2015; 9:320-30. [PMID: 25354537 PMCID: PMC4299535 DOI: 10.1017/s1751731114002596] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/23/2014] [Indexed: 11/30/2022] Open
Abstract
Assessing unconsciousness is important to safeguard animal welfare shortly after stunning at the slaughter plant. Indicators that can be visually evaluated are most often used when assessing unconsciousness, as they can be easily applied in slaughter plants. These indicators include reflexes originating from the brain stem (e.g. eye reflexes) or from the spinal cord (e.g. pedal reflex) and behavioural indicators such as loss of posture, vocalisations and rhythmic breathing. When physically stunning an animal, for example, captive bolt, most important indicators looked at are posture, righting reflex, rhythmic breathing and the corneal or palpebral reflex that should all be absent if the animal is unconscious. Spinal reflexes are difficult as a measure of unconsciousness with this type of stunning, as they may occur more vigorous. For stunning methods that do not physically destroy the brain, for example, electrical and gas stunning, most important indicators looked at are posture, righting reflex, natural blinking response, rhythmic breathing, vocalisations and focused eye movement that should all be absent if the animal is unconscious. Brain stem reflexes such as the cornea reflex are difficult as measures of unconsciousness in electrically stunned animals, as they may reflect residual brain stem activity and not necessarily consciousness. Under commercial conditions, none of the indicators mentioned above should be used as a single indicator to determine unconsciousness after stunning. Multiple indicators should be used to determine unconsciousness and sufficient time should be left for the animal to die following exsanguination before starting invasive dressing procedures such as scalding or skinning. The recording and subsequent assessment of brain activity, as presented in an electroencephalogram (EEG), is considered the most objective way to assess unconsciousness compared with reflexes and behavioural indicators, but is only applied in experimental set-ups. Studies performed in an experimental set-up have often looked at either the EEG or reflexes and behavioural indicators and there is a scarcity of studies that correlate these different readout parameters. It is recommended to study these correlations in more detail to investigate the validity of reflexes and behavioural indicators and to accurately determine the point in time at which the animal loses consciousness.
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Affiliation(s)
- M. T. W. Verhoeven
- Wageningen University and Research Centre, Livestock
Research, PO Box 65, 8200 AB
Lelystad, The Netherlands
- Adaptation Physiology Group, Department of Animal
Sciences, Wageningen University, PO Box
338, 6700 AH Wageningen, The
Netherlands
| | - M. A. Gerritzen
- Wageningen University and Research Centre, Livestock
Research, PO Box 65, 8200 AB
Lelystad, The Netherlands
| | - L. J. Hellebrekers
- Faculty of Veterinary Medicine, Utrecht
University, PO Box 80154, 3508 TD
Utrecht, The Netherlands
| | - B. Kemp
- Adaptation Physiology Group, Department of Animal
Sciences, Wageningen University, PO Box
338, 6700 AH Wageningen, The
Netherlands
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15
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McKeever S, Johnston L, Davidson AJ. Sevoflurane-induced changes in infants' quantifiable electroencephalogram parameters. Paediatr Anaesth 2014; 24:766-73. [PMID: 24612073 DOI: 10.1111/pan.12366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Electroencephalogram (EEG) based depth of anesthesia algorithms developed in the adult population have not demonstrated the same reliability when applied to infants. This may be due to frequency changes occurring in the EEG during development. Amplitude-integrated EEG (aEEG) is based primarily in the time domain and hence may have greater utility in infants. OBJECTIVE To investigate the relationship between age adjusted Minimal Alveolar Concentration (MAC) multiples and aEEG in children under 2 years of age. METHODS The aEEG, Spectral Edge Frequency 90% (SEF90) and Bispectral Index™ (BIS) were investigated in a prospective study of children <2 years of age. After anesthetic induction, and caudal block administration, EEG data were collected simultaneously with BrainZ BRM2™ and BIS™ monitors. Using a randomized crossover design, children received up to three age adjusted concentrations of sevoflurane: 0.75, 1 and 1.25 MAC. After 15 min of stable anesthetic delivery EEG readings were obtained. Prediction Probability (Pk ) and correlation coefficients were calculated for each EEG parameter. RESULTS From 51 children 102 stable anesthetics concentrations were obtained. For all age groups Pk of aEEG to multiple of age adjusted MAC was <0.72 indicating a poor predictive power for aEEG. In contrast for the SEF90 and BIS there was evidence for better predictive properties in children aged between 6 months and 2 years, with a Pk >0.81. CONCLUSION The aEEG is unlikely to be a useful measure of anesthesia depth in young children.
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Affiliation(s)
- Stephen McKeever
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Vic., Australia; Murdoch Childrens Research Institute, Melbourne, Vic., Australia; Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Vic., Australia
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16
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Sury MRJ, Worley A, Boyd SG. Age-related changes in EEG power spectra in infants during sevoflurane wash-out. Br J Anaesth 2013; 112:686-94. [PMID: 24346023 DOI: 10.1093/bja/aet409] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Few electroencephalography (EEG) data are available in anaesthetized infants. This study aimed to identify EEG characteristics that might warn of awakening (AW) from sevoflurane anaesthesia in infants. METHODS Twenty intubated infants [aged 39-77 weeks post-menstrual age (PMA)] were studied after surgery during sevoflurane wash-out. EEG was recorded at the end of surgery and throughout emergence. Changes in EEG time and frequency domains were described. RESULTS At the end of surgery, mean end-tidal sevoflurane concentration was 2.3% (range 1.5-3.5) before wash-out and reduced to 0.3% (0.1-0.6) when AW began. On AW, movement artifacts made signals difficult to interpret. Before awakening, most power was within frequencies ≤4 Hz, but trends over time were variable. Summated power in frequencies between 20 and 70 Hz was almost always <5 µV(2). During anaesthesia, there were two common power spectra: infants >52 weeks PMA had obvious summated power in the frequency range 5-20 Hz (P5-20 Hz) (mean 308, median 320, range 110-542 µV(2)), which decreased before awakening began [mean decrease 252 µV(2) (95% CI 153-351)], whereas younger infants had low P5-20 Hz throughout. P5-20 Hz during anaesthesia increased with age; power in this frequency band of ~100 µV(2) separated infants younger and older than 52 weeks PMA. CONCLUSIONS During sevoflurane wash-out, decreasing P5-20 Hz might warn of impending AW in infants >3 months old, but not in younger infants.
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Affiliation(s)
- M R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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17
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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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18
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Kasdorf E, Engel M, Perlman JM. Amplitude electroencephalogram characterization in preterm infants undergoing patent ductus arteriosus ligation. Pediatr Neurol 2013; 49:102-6. [PMID: 23859855 DOI: 10.1016/j.pediatrneurol.2013.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 02/25/2013] [Accepted: 03/09/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent studies suggest an increased risk of neurodevelopmental impairment following patent ductus arteriosus surgical ligation. The mechanisms are unclear, but intraoperative stress or pain may contribute. The objectives of this study were to determine if pain, evidenced by an increase in heart rate and blood pressure, during patent ductus arteriosus ligation would be accompanied by an increase in amplitude-integrated electroencephalogram (aEEG) voltage. METHODS This was an observational, pilot study of infants born at 22.6-35.1 weeks with patent ductus arteriosus requiring surgical ligation. The aEEG was recorded prior to, during surgery, and for 2 hours following surgery. Mean heart rate, blood pressure, and aEEG voltage were analyzed for each recording period. RESULTS Seventeen preterm infants were studied at a mean postmenstrual age of 26.6 weeks. Following anesthetic induction, aEEG became suppressed and remained suppressed during the postoperative period. Heart rate and blood pressure increased significantly intraoperatively. The aEEG voltage did not increase with an increase in heart rate. Infants received between 3.7-47 μg/kg of fentanyl. CONCLUSIONS There was no correlation between aEEG voltage and vital sign changes. aEEG is not a useful tool as a marker of pain during patent ductus arteriosus ligation, rather a more standardized approach to pain management should be considered.
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Affiliation(s)
- Ericalyn Kasdorf
- Department of Pediatrics, Division of Newborn Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York, USA.
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19
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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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20
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21
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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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22
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Wang J, Ren Y, Zhu Y, Chen JW, Zhu MM, Xu YJ, Tan ZM. Effect of penehyclidine hydrochloride on the incidence of intra-operative awareness in Chinese patients undergoing breast cancer surgery during general anaesthesia. Anaesthesia 2012; 68:136-41. [DOI: 10.1111/anae.12092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2012] [Indexed: 11/30/2022]
Affiliation(s)
- J. Wang
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - Y. Ren
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - Y. Zhu
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - J. W. Chen
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - M. M. Zhu
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - Y. J. Xu
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
| | - Z. M. Tan
- Department of Anaesthesiology; Fudan University; Shanghai Cancer Centre; Shanghai; China
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23
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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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24
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Abstract
There have been a number of recent developments in the practice of anesthesia and intensive care aimed at improving outcome in terms of reducing both morbidity and mortality, as well as other less-defined factors, such as quality of service provision. Significant advances have been made in airway devices such as pediatric tracheal tube designs, Microcuff(®) tracheal tubes, and new laryngoscopes. Noninvasive monitoring devices, including continuous hemoglobin analysis and near infrared spectrometry, are being increasingly used in pediatric anesthesia. Other, 'scaled-down' versions from adult anesthesia care, however, have not universally been shown to result in improved safety and outcomes in pediatric anesthesia.
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Affiliation(s)
- Shane Campbell
- Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK.
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25
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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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26
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Disma N, Tuo P, Astuto M, Davidson AJ. Depth of sedation using Cerebral State Index in infants undergoing spinal anesthesia. Paediatr Anaesth 2009; 19:133-7. [PMID: 19143957 DOI: 10.1111/j.1460-9592.2008.02859.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infants are noted to frequently sleep during spinal anesthesia, with a concomitant fall in Bispectral Index. However, there are suggestions that EEG derived anesthesia depth monitors have inferior performance in infants. The aim of this study was to quantify the degree of sedation during spinal anesthesia in infants using another EEG derived measure of anesthesia effect--the Cerebral State Index (CSI). METHODS Twelve infants, <52 weeks postconceptual menstrual age, scheduled for bilateral inguinal hernia repair under spinal anesthesia were enrolled. Patients received a standard anesthetic protocol with a subarachnoid dose of 1 mg x kg(-1) of levobupivacaine 0.5%. No premedication, sedatives, opioids or anticholinergics were administrated during the perioperative period and patients were left undisturbed during the surgical time, without tactile stimulation or loud auditory stimuli. CSI score (0-100) and bust suppression (BS) (0-100%) were continuously recorded during the surgical time and then statistically re-evaluated. RESULTS In all patients the CSI fell during the procedure and there were significant levels of BS recorded by the CSI monitor. The BS occurred between 12 and 34 min after spinal anesthesia with the peak being at 30 min and mean onset time being 15 (2.6) min after spinal block. A statistical significant difference was found between the lowest mean CSI as well as the highest BS if compared with their baseline values. A negative correlation was found between CSI and BS. CONCLUSIONS The degree of burst suppression detected by the CSI in our study supports the hypothesis that infants may have discontinuous patterns of EEG during spinal anesthesia similar to those seen during emergence from general anesthesia. Moreover, the limitations in the application of the adult algorithms to infant EEG may lead to an overestimation of the degree of sedation.
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Affiliation(s)
- Nicola Disma
- Anaesthesia and Intensive Care, Gaslini Children's Hospital, Genoa, Italy.
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27
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Fuentes R, Cortínez LI, Struys MMRF, Delfino A, Muñoz H. The Dynamic Relationship Between End-Tidal Sevoflurane Concentrations, Bispectral Index, and Cerebral State Index in Children. Anesth Analg 2008; 107:1573-8. [DOI: 10.1213/ane.0b013e318181ef88] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Intraoperative awareness is an anesthesia complication and occurs when a patient becomes conscious during a procedure performed under general anesthesia and subsequently has recall of these events. Awareness is well described phenomenon in adults, with an incidence of 0.1-0.2 % for low-risk surgical procedures. Recent studies have shown that awareness in children is more common than in adults. However, causes and the long-term psychological impact of awareness in children are unknown. We report on two cases of intraoperative awareness in children in an attempt to throw further light on this complex problem.
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Affiliation(s)
- Heleen J Blussé Van Oud-Alblas
- Department of Anaesthesiology and Department of Pediatric Surgery, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
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Abstract
BACKGROUND The aim of this study was to describe ketamine pharmacodynamics (PD) in children. Adult ketamine concentrations during recovery are reported as 0.74 mg.l(-1) (sd 0.24 mg.l(-1)) with an EC(50) for anesthesia of 2 mg.l(-1) (sd 0.5 mg.l(-1)), but pediatric data are few. METHODS Children presenting for painful procedures in an Emergency Department were given ketamine 1-1.5 mg.kg(-1) i.v. Blood was assayed for ketamine on three to six occasions (median 3) over the subsequent 14-152 min (median 28.5). Procedures were videotaped. Level of sedation (0-5; unresponsive - spontaneously awake without stimulus) and a test of memory were recorded. PD was investigated using a variable slope E(max) model (sedation) or logistic regression (arousal time, memory) with nonlinear mixed effects models. RESULTS In total 60 children were enrolled. Pharmacokinetic data were collected in 54 of these children and there were 43 children available for PD study. The mean age was 8.15 years (sd 3.5 years) and weight was 34.9 kg (sd 15.8 kg). The half-time describing equilibration between the effect compartment and central compartment was 11 s (95% CI 0.07-20 s). The EC(50) for arousal was 0.52 (90% CI 0.22-1.17) mg.l(-1). The E(max) model with a baseline (E(0)) of five (spontaneously awake without stimulus) yielded a fractional E(max) 0.939 [coefficient of variability (CV) 24%], an EC(50) 0.56 (CV 136%) mg.l(-1) and a Hill coefficient 3.71. The EC(50) for recall memory was 0.44 (90% CI 0.09-1.70) mg.l(-1). The EC(50) for remembering was 0.38 (90% CI 0.12-1.75) mg.l(-1). CONCLUSIONS Concentrations associated with arousal in children are analogous to adults. The ability to recall and remember occurs at similar concentrations to those associated with arousal. A concentration of 1 mg.l(-1) was associated with a sedation level of three or less (arouses to consciousness with moderate tactile or loud verbal stimulus) in 95% of children while 1.5 mg.l(-1) was associated with a sedation level of two or less (rouses slowly to consciousness with sustained painful stimulus) in 95% of children. These concentrations can be attained for 3-4 min after 1 mg.kg(-1) and 1.5 mg.kg(-1) ketamine IV bolus, respectively. The mean arousal time can be anticipated at approximately 10 min (1 mg.kg(-1)) and 15 min (1.5 mg.kg(-1)).
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Affiliation(s)
- David W Herd
- Department of Paediatrics, Auckland Children's Hospital, Auckland, New Zealand.
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Jeleazcov C, Schmidt J, Schmitz B, Becke K, Albrecht S. EEG variables as measures of arousal during propofol anaesthesia for general surgery in children: rational selection and age dependence. Br J Anaesth 2007; 99:845-54. [DOI: 10.1093/bja/aem275] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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31
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Davidson AJ. Awareness, dreaming and unconscious memory formation during anaesthesia in children. Best Pract Res Clin Anaesthesiol 2007; 21:415-29. [PMID: 17900018 DOI: 10.1016/j.bpa.2007.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Recent studies have reported an incidence of awareness in children of around 1%, while older studies reported incidences varying from 0% to 5%. Measuring awareness in children requires techniques specifically adapted to a child's cognitive development and variations in incidence may be partly explained by the measures used. The causes and consequences of awareness in children remain poorly defined, though a consistent finding is that many children do not seem distressed by their memories. There are, however, some published reports of persistent psychological symptoms after episodes of childhood awareness. Compared to explicit memory, implicit memory is more robust in young children; however there is no evidence yet for implicit memory formation during anaesthesia in children. Children less than 3 years of age do not form explicit memory, although toddlers, infants and even neonates have signs of consciousness and implicit memory formation. In these very young children the relevance of awareness remains largely unknown.
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Affiliation(s)
- Andrew J Davidson
- Department of Anaesthesia, Royal Children's Hospital, Flemington Road, Parkville 3052, Victoria, Australia.
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32
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Barker N, Lim J, Amari E, Malherbe S, Ansermino JM. Relationship between age and spontaneous ventilation during intravenous anesthesia in children. Paediatr Anaesth 2007; 17:948-55. [PMID: 17767630 DOI: 10.1111/j.1460-9592.2007.02301.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Maintaining spontaneous ventilation in children, using total intravenous anesthesia (TIVA), is often desirable, particularly for airway endoscopy. The aim of this study was to evaluate the effect of age on the dose of remifentanil tolerated during spontaneous ventilation under anesthesia maintained with infusions of propofol and remifentanil and to provide guidelines for the administration of remifentanil and propofol to maintain spontaneous ventilation in children. METHODS Forty-five children scheduled for strabismus surgery were divided by age into three groups (group I: 6 months-3 years, group II: 3 years-6 years, and group III: 6 years-9 years). The propofol infusion was titrated using State Entropy as a pharmacodynamic endpoint and remifentanil infused, using a modified up-and-down method, with respiratory rate depression as a pharmacodynamic endpoint. A respiratory rate of just greater than 10, stable for 10 min, determined the final remifentanil infusion rate. The group mean was estimated from the final remifentanil infusion rate tolerated (RD(50)). RESULTS The RD(50) of groups I, II, and III were 0.192 (0.08), 0.095 (0.04), and 0.075 (0.03) microg x kg(-1) x min(-1) respectively. Pair-wise comparisons between the groups for the rate of remifentanil tolerated revealed a statistically significant increase in the RD(50) in children less than 3 years of age compared with older children in groups II and III (P < 0.001). The relationship between remifentanil dose and age, weight or height was not linear. CONCLUSIONS Younger children, especially those aged less than 3 years, tolerate a higher dose of remifentanil while still maintaining spontaneous respiration. TIVA with spontaneous ventilation is readily achieved in younger children and infants.
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Affiliation(s)
- Nigel Barker
- Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, BC, Canada
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Abstract
PURPOSE OF REVIEW There are several commercially available electroencephalogram-derived devices for monitoring anaesthesia depth. This article reviews all published studies describing their use in children; first assessing studies of performance in measuring anaesthesia depth in observational, physiological studies and then describing relevant outcome studies. There is also a brief discussion of why they might be useful, what physiological problems may arise and what the reader should be wary of in the methodology of these studies. The subject is approached from a clinical perspective. RECENT FINDINGS There are several physiological studies suggesting that for older children the bispectral index, entropy, Narcotrend index, cerebral state index and A-line ARX index all change with induction of anaesthesia, and have reasonable correlations with doses of anaesthetic agent. There is consistent evidence that the performances are substantially poorer in infants. Some of these devices have been demonstrated to reduce anaesthesia drug consumption and hasten recovery in older children. SUMMARY The bispectral index is the most widely studied, but at this stage there is no evidence to suggest any one device is substantially superior to any other. There may be a role emerging for their use in older children, but their use in infants cannot be supported.
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Affiliation(s)
- Andrew J Davidson
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia.
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Herd D, Anderson BJ. Ketamine disposition in children presenting for procedural sedation and analgesia in a children's emergency department. Paediatr Anaesth 2007; 17:622-9. [PMID: 17564643 DOI: 10.1111/j.1460-9592.2006.02145.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to describe ketamine pharmacokinetics in children to simulate time-concentration profiles to predict duration of concentrations associated with anesthesia, arousal and analgesia. METHODS Children presenting for painful procedures in the Emergency Dept were given ketamine 1-1.5 mgxkg(-1) i.v. Blood was assayed for ketamine on 3-6 occasions (median 3) over the subsequent 14-152 min (median 28.5). A population pharmacokinetic analysis was undertaken by using nonlinear mixed effects models (NONMEM). Simulation was used to predict time-concentration profiles in this cohort RESULTS There were 188 observations from 54 children (age 8.3 sd 3.5 years, weight 32.5 sd 15.6 kg). A two-compartment (central, peripheral) linear disposition model fitted data better than a one-compartment model. Population parameter estimates and their between subject variability (BSV), standardized to a 70-kg person using allometric models, were central volume (V1) 38.7 (BSV 64%) l.70 kg(-1), peripheral volume of distribution (V2) 102 (51.7%) l.70 kg(-1), clearance (CL) 90 (38.1%) l.h(-1) 70 kg(-1) and intercompartment clearance (Q) 215 (19%) l.h(-1) 70 kg(-1). At 10 min half of the children given 1 mgxkg(-1) will have a serum concentration below 0.75 mgxl(-1). This is a concentration associated with 'awakening' in adults. However, almost all the children will still have a serum concentration above 0.1 mgxl(-1), a level associated with analgesia in adults. CONCLUSIONS Ketamine 1 mgxkg(-1) i.v. provides satisfactory serum concentrations for children undergoing sedation for painful procedures of <5-min duration and produces concentrations associated with analgesic effect for more than 10 min. Clearance increases with decreasing age in children. The relationship between serum concentration and effect is poorly defined in children.
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Affiliation(s)
- David Herd
- Department of Paediatrics, Starship Children's Hospital, Auckland, New Zealand.
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Ironfield CM, Davidson AJ. AEP-monitor/2 derived, composite auditory evoked potential index (AAI-1.6) and bispectral index as predictors of sevoflurane concentration in children. Paediatr Anaesth 2007; 17:452-9. [PMID: 17474952 DOI: 10.1111/j.1460-9592.2006.02155.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Level of anesthesia may be predicted with the auditory evoked potential or with passive processed electroencephalogram (EEG) parameters. Some previous reports suggest the passive EEG does not reliably predict level of anesthesia in infants. The AAI-1.6 is a relatively new index derived from the AEP/2 monitor. It combines auditory evoked potentials and passive EEG parameters into a single index. This study aimed to assess the AAI-1.6 as a predictor of level of anesthesia in infants and children. METHODS Four infants aged less than 1 year, and five older children aged between 2 and 11 years were enrolled. They all had uniform sevoflurane anesthesia for cardiac catheterization. The AAI-1.6 and bispectral index (BIS) were recorded after achieving equilibrium at 1.5%, 2% and 2.5% sevoflurane, and immediately prior to awakening. The prediction coefficient (Pk) for BIS and AAI-1.6 was calculated and compared within each age group. RESULTS The Pk for the AAI-1.6 was low in both 0-1 and 2-11 years age groups. In the 2-12 years group, the Pk for BIS was significantly higher than the Pk for the AAI-1.6 (Pk for BIS: 0.89, Pk for AAI-1.6: 0.53, P < 0.01). In contrast in the 0-1 year age group there was no evidence for a difference between the Pk for BIS and the Pk for the AAI-1.6 (Pk for BIS: 0.74, Pk for AAI-1.6: 0.53, P = 0.25). CONCLUSIONS This preliminary study suggests AAI-1.6 is a poor predictor of sevoflurane concentration in infants and children.
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Affiliation(s)
- Craig M Ironfield
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia
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Disma N, Lauretta D, Palermo F, Sapienza D, Ingelmo PM, Astuto M. Level of sedation evaluation with Cerebral State Index and A-Line Arx in children undergoing diagnostic procedures. Paediatr Anaesth 2007; 17:445-51. [PMID: 17474951 DOI: 10.1111/j.1460-9592.2006.02146.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Monitoring of anesthesia depth is difficult clinically, particularly in children. The aim of this study was to assess the correlation existing between CSI (Cerebral State Index), or AAI (A-line ARX) and a clinical sedation scale such as UMSS (University of Michigan Sedation Scale), during deep sedation with propofol in children undergoing diagnostic procedures. METHODS Twenty ASA I and II children, scheduled to undergo deep sedation for magnetic resonance imaging (MRI) or Esophagogastroduodenoscopy (EGDS), were enrolled. The patients were randomly assigned to receive depth of anesthesia monitoring with CSI or AAI. The anesthetist administered repeated doses of propofol every 10 s to a UMSS score of 3-4. An attending anesthetist, not involved in drug administration, recorded time and doses of sedation medications, vital signs, UMSS score and CSI or AAI score. All the evaluations were recorded at awake state (baseline), every 10 s until an UMSS score of 3-4 and every 3 min until the children were awake. RESULTS We enrolled 13 males and seven females ranging in age from 8 months to 7 years. After induction of anesthesia CSI and AAI scores decreased and from the end of the procedure to emergence the two scores increased. The CSI data showed a strong correlation with the UMSS scores (r = -0.861; P < 0.0001); we found a similar correlation between the AAI data and the UMSS scores (r = -0.823; P < 0.0001). CONCLUSIONS Our study suggests that CSI and AAI may be two, real-time and objective tools to assess induction and emergence during propofol sedation in children undergoing EGDS and MRI.
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Affiliation(s)
- Nicola Disma
- Department of Anesthesia and Intensive Care (Director Prof. A. Gullo), Policlinico University Hospital, Catania, Italy.
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Abstract
Intraoperative awareness has been reported to occur in 0.8-5.0% of paediatric patients undergoing anaesthesia and, therefore, seems to be more common than in adults (incidence 0.1-0.2%). In adult patients, the consequences of intraoperative awareness are well known and can be severe, in children, however, they have not yet been adequately studied. The causes for intraoperative awareness can be divided into three broad categories: First, no or only a light anaesthetic is given on purpose, second, an insufficient dose of an anaesthetic is given inadvertently, third, there is equipment malfunction or the anaesthesiologist makes an error. Unfortunately, especially in young children, painful interventions are still performed without adequate analgesia, e.g. awake intubation or fracture manipulation under midazolam sedation alone. The key issue is, however, that pharmacokinetics and pharmacodynamics change enormously from the 500 g preterm baby to the adolescent patient. Adequate dosing is much more difficult in paediatric patients compared to standard adult surgical patients. Solid knowledge of the pharmacokinetic and pharmacodynamic characteristics of commonly used drugs in different paediatric age groups, as well as aiming for perfection in daily care will help to reduce the incidence of awareness. Methods for monitoring the depth of hypnosis, e.g. the bispectral index, will be used increasingly, at least in children above 1 year of age. In addition to clinical parameters, they will hopefully help to further reduce the incidence of intraoperative awareness.
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Affiliation(s)
- M Jöhr
- Institut für Anästhesie, Kantonsspital, 6000 Luzern 16, Schweiz.
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Wallenborn J, Kluba K, Olthoff D. Comparative evaluation of Bispectral Index and Narcotrend Index in children below 5 years of age. Paediatr Anaesth 2007; 17:140-7. [PMID: 17238885 DOI: 10.1111/j.1460-9592.2006.02036.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The use of electroencephalogram (EEG) monitoring devices for assessing the depth of hypnosis is most difficult in children under 5 years of age. METHODS Forty five children aged 0-60 months were included in a prospective observational study. A direct comparison of the processed EEG variables Bispectral Index (BIS, version 3.4) and Narcotrend Index (NI, version 2.0AF) was to be achieved by simultaneous recording. The ability of these parameters to differentiate between various clinical states was evaluated by using the prediction probability (P(k)). Age-related effects on the BIS and NI were analyzed by dividing the children into three age groups: 0-6, 7-18 and 19-60 months. RESULTS The preanesthesia, conscious children were differentiated from anesthetized patients by the BIS and NI with no overlap (P(k) = 1.0). In the awake period the BIS was superior to the NI (P(k) to differentiate 'end of anesthesia' from 'awakening' was 0.97 vs 0.73 respectively; P = 0.002). Patients aged 7-18 months showed higher BIS and NI values in the course of anesthesia than the younger and older children (P = 0.001). On awakening, children aged 0-6 months showed the lowest mean BIS (n.s.) and NI (P = 0.006) values. CONCLUSIONS The BIS currently seems to be superior to the NI, but age-related processing algorithms of the raw EEG must be implemented in both BIS and NI in order to be useful in children younger than 5 years of age.
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Affiliation(s)
- Jan Wallenborn
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany.
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