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Bratke S, Schmid S, Sabharwal V, Jungwirth B, Becke-Jakob K. [Intraoperative hypotension in children-Measurement and treatment]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01461-x. [PMID: 39331070 DOI: 10.1007/s00101-024-01461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/28/2024]
Abstract
Intraoperative hypotension is a common perioperative complication in pediatric anesthesia. Oscillometric blood pressure measurement is therefore an essential part of standard perioperative monitoring in pediatric anesthesia. The optimum measurement site is the upper arm. Attention must be paid to the correct cuff size. Blood pressure should be measured before induction. In children undergoing major surgery or in critically ill children, invasive blood pressure measurement is still the gold standard. Continuous noninvasive measurement methods could be an alternative in the future.Threshold values to define hypotension remain unknown, even in awake children. There are also little data on hypotension thresholds in the perioperative setting. The most reliable measurement parameter for estimating hypotension is the mean arterial pressure. The threshold values for intraoperative hypotension are 40 mm Hg in newborns, 45 mm Hg in infants, 50 mm Hg in young children and 65 mm Hg in adolescents. Treatment should be initiated at a deviation of 10% and intensified at a deviation of 20%.Bolus administration of isotonic balanced crystalloid solutions, vasopressors and/or catecholamines are used as treatment options. Consistent and rapid intervention in the event of hypotension appears to be crucial. So far there is no evidence as to whether this leads to an improvement in outcome parameters.
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Affiliation(s)
- Sebastian Bratke
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - Sebastian Schmid
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - Vijyant Sabharwal
- Anästhesie und Intensivmedizin, Cnopfsche Kinderklinik - Klinik Hallerwiese, Diakoneo, Nürnberg, Deutschland
| | - Bettina Jungwirth
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - Karin Becke-Jakob
- Anästhesie und Intensivmedizin, Cnopfsche Kinderklinik - Klinik Hallerwiese, Diakoneo, Nürnberg, Deutschland
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Kubo Y, Itosu Y, Kubo T, Saito H, Okada K, Ito YM, Morimoto Y. Cerebral oxygenation saturation in childhood: difference by age and comparison of two cerebral oximetry algorithms. J Clin Monit Comput 2024; 38:639-648. [PMID: 38310594 DOI: 10.1007/s10877-023-01124-z] [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: 10/01/2023] [Accepted: 12/28/2023] [Indexed: 02/06/2024]
Abstract
Few reports are available on the monitoring of regional cerebral oxygen saturation (rSO2) in pediatric patients undergoing non-cardiac surgical procedures. In addition, no study has examined the rSO2 levels in children of a broad age range. In this study, we aimed to assess and compare rSO2 levels in pediatric patients of different age groups undergoing non-cardiac surgery. We used two oximeters, tNIRS-1, which uses time-resolved spectroscopy, and conventional INVOS 5100C. Seventy-eight children-26 infants, 26 toddlers, and 26 schoolchildren-undergoing non-cardiac surgery were included. We investigated the differences in the rSO2 levels among the age groups and the correlation between the models and physiological factors influencing the rSO2 values. rSO2 measured by INVOS 5100C was significantly lower in infants than those in other patients. rSO2 measured by tNIRS-1 was higher in the toddler group than those in the other groups. The rSO2 values of tNIRS-1 and INVOS 5100C were moderately correlated (r = 0.41); however, those of INVOS 5100C were approximately 20% higher, and a ceiling effect was observed. The values in INVOS 5100C and tNIRS-1 were affected by blood pressure and the minimum alveolar concentration of sevoflurane, respectively. In pediatric patients undergoing non-cardiac surgery, rSO2 values differed across the three age groups, and the pattern of these differences varied between the two oximeters employing different algorithms. Further research must be conducted to clarify cerebral oxygenation in children.
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Affiliation(s)
- Yasunori Kubo
- Department of Anesthesiology, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan.
| | - Yusuke Itosu
- Department of Anesthesiology, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
| | - Tomonori Kubo
- Department of Anesthesiology, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
| | - Hitoshi Saito
- Department of Anesthesiology, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
| | - Kazufumi Okada
- Promotion Unit, Data Science Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
| | - Yoichi M Ito
- Promotion Unit, Data Science Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, N14 W5, Kita-ku, Sapporo, 0608648, Japan
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, N15 W7, Kita-ku, Sapporo, 0608638, Japan
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Szostek AS, Saunier C, Elsensohn MH, Boucher P, Merquiol F, Gerst A, Portefaix A, Chassard D, De Queiroz Siqueira M. Effective dose of ephedrine for treatment of hypotension after induction of general anaesthesia in neonates and infants less than 6 months of age: a multicentre randomised, controlled, open label, dose escalation trial. Br J Anaesth 2023; 130:603-610. [PMID: 36639328 DOI: 10.1016/j.bja.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/18/2022] [Accepted: 12/10/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The recommended dose of ephedrine in adults (0.1 mg kg-1) frequently fails to treat hypotension after induction of general anaesthesia in neonates and infants less than 6 months of age. The aim of this study was to determine the optimal dose of ephedrine in this population for the treatment of hypotension after induction of general anaesthesia with sevoflurane. METHODS We conducted a multicentre, prospective, randomised, open-label, controlled, dose-escalation trial. Subjects were randomised if presenting a >20% change from baseline in MAP. Six cohorts of 20 subjects each were enrolled. Ten subjects in the first cohort received 0.1 mg kg-1 i. v. (reference dose). For each subsequent cohort, 10 subjects were assigned to the next higher dose (consecutively 0.6, 0.8, 1, 1.2, and 1.4 mg kg-1 i. v.), and the other subjects were assigned to one or more doses already investigated in previous cohorts. The primary outcome was the return of MAP to >80% of baseline at least once within 10 min after ephedrine administration. RESULTS A total of 119 infants (25% females), with a mean age (standard deviation) of 2.7 (1.3) months, received their allocated dose of ephedrine. The optimal dose of ephedrine was 1.2 mg kg-1, with a percentage of success of 65.5% (95% confidence interval, 35.6-86.4). The doses of ephedrine investigated did not induce adverse events. CONCLUSIONS Doses of ephedrine much higher (∼10-fold) than those used in adults are necessary in neonates and infants for the treatment of hypotension after induction of general anaesthesia with sevoflurane. CLINICAL TRIAL REGISTRATION NCT02384876.
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Affiliation(s)
- Anne-Sara Szostek
- Department of Paediatric Anaesthesia, Hospices Civils de Lyon, Bron, France
| | - Clarisse Saunier
- Department of Epidemiology, Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Bron, France
| | - Mad-Hélénie Elsensohn
- Department of Biostatistics, Hospices Civils de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Pierre Boucher
- Department of Paediatric Anaesthesia, Hospices Civils de Lyon, Bron, France
| | - Fanette Merquiol
- Department of Anaesthesia, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Adeline Gerst
- Department of Anaesthesia, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélie Portefaix
- Department of Epidemiology, Hospices Civils de Lyon, EPICIME-CIC 1407 de Lyon, Inserm, Bron, France; Department of Biostatistics, Hospices Civils de Lyon, Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Dominique Chassard
- Department of Anaesthesia, Hospices Civils de Lyon, Université Lyon 1, Bron, France.
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Zipfel J, Wikidal B, Schwaneberg B, Schuhmann MU, Magunia H, Hofbeck M, Schlensak C, Schmid S, Neunhoeffer F. Identifying the optimal blood pressure for cerebral autoregulation in infants after cardiac surgery by monitoring cerebrovascular reactivity-A pilot study. Paediatr Anaesth 2022; 32:1320-1329. [PMID: 36083106 DOI: 10.1111/pan.14555] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/13/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Advances in the treatment of pediatric congenital heart disease have increased survival rates. Despite efforts to prevent neurological injury, many patients suffer from impaired neurodevelopmental outcomes. Compromised cerebral autoregulation can increase the risk of brain injury following pediatric cardiac surgery with cardiopulmonary bypass. Monitoring autoregulation and maintaining adequate cerebral blood flow can help prevent neurological injury. AIMS Our objective was to evaluate autoregulation parameters and to define the optimal blood pressure as well as the lower and upper blood pressure limits of autoregulation. METHODS Autoregulation was monitored prospectively in 36 infants after cardiopulmonary bypass surgery for congenital heart defects between January and December 2019. Autoregulation indices were calculated by correlating invasive arterial blood pressure, cortical oxygen saturation, and relative tissue hemoglobin levels with near-infrared spectroscopy parameters. RESULTS The mean patient age was 4.1 ± 2.8 months, and the mean patient weight was 5.2 ± 1.8 kg. Optimal mean arterial pressure could be identified in 88.9% of patients via the hemoglobin volume index and in 91.7% of patients via the cerebral oxygenation index, and a lower limit of autoregulation could be found in 66.7% and 63.9% of patients, respectively. No significant changes in autoregulation indices at the beginning or end of the monitoring period were observed. In 76.5% ± 11.1% and 83.8% ± 9.9% of the 8 and 16 h monitoring times, respectively, the mean blood pressure was inside the range of intact autoregulation (below in 21.5% ± 25.4% and 11.3% ± 16.5% and above in 8.7% ± 10.4% and 6.0% ± 11.0%, respectively). The mean optimal blood pressure was 57.4 ± 8.7 mmHg and 58.2 ± 7.9 mmHg and the mean lower limit of autoregulation was 48.8 ± 8.3 mmHg and 45.5 ± 6.7 mmHg when generated via the hemoglobin volume index and cerebral oxygenation index, respectively. CONCLUSIONS Postoperative noninvasive autoregulation monitoring after cardiac surgery in children can be reliably and safely performed using the hemoglobin volume index and cerebral oxygenation index and provides robust data. This monitoring can be used to identify individual hemodynamic targets to optimize autoregulation, which differs from those recommended in the literature. Further evaluation of this subject is needed.
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Affiliation(s)
- Julian Zipfel
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Berit Wikidal
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Bernadett Schwaneberg
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Martin U Schuhmann
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Harry Magunia
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Michael Hofbeck
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Tuebingen, Germany
| | - Simon Schmid
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Felix Neunhoeffer
- Paediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen, Germany
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Isoelectric Electroencephalography in Infants and Toddlers During Anesthesia for Surgery-an International Observational Study. Anesthesiology 2022; 137:187-200. [PMID: 35503999 DOI: 10.1097/aln.0000000000004262] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Intraoperative isoelectric electroencephalography (EEG) has been associated with hypotension and postoperative delirium in adults. This international prospective observational study sought to determine the prevalence of isoelectric EEG in young children during anesthesia. We hypothesized that the prevalence of isoelectric events would be common worldwide and associated with certain anesthetic practices and intraoperative hypotension. METHODS. Fifteen hospitals enrolled patients age ≤ 36 months for surgery using sevoflurane or propofol anesthetic. Frontal 4-channel EEG was recorded for isoelectric events. Demographics, anesthetic, emergence behavior, and Pediatric Quality of Life (PedsQL) variables were analyzed for association with isoelectric events. RESULTS. Isoelectric events occurred in 32% (206/648) of patients, varied significantly among sites (9-88%), and were most prevalent during pre-incision (117/628, 19%) and surgical maintenance (117/643, 18%). Isoelectric events were more likely with [odds ratio-OR (95% confidence interval-CI)] infants < 3 months [4.4 (2.57-7.4) p<0.001], endotracheal tube use [1.78 (1.16-2.73) p=0.008], propofol bolus for airway placement after sevoflurane induction [2.92 (1.78-4.8) p<0.001], and less likely with use of muscle relaxant for intubation [0.67 (0.46-0.99) p=0.046]. Expired sevoflurane was higher in patients with isoelectric events [mean difference (95% CI)] during pre-incision [0.2% (0.1, 0.4) p=0.005] and surgical maintenance [0.2% (0.1, 0.3) p=0.002]. Isoelectric events were associated with moderate (8/12, 67%) and severe hypotension (11/18, 61%) during pre-incision [OR: 4.6 (1.30-16.1) p=0.018; 3.54 (1.27, 9.9) p=0.015] and surgical maintenance [OR: 3.64 (1.71-7.8) p=0.001; 7.1 (1.78- 28.1) p=0.005], and lower PedsQL scores [median of differences (95% CI)] at baseline in patients 0-12 [-3.5 (-6.2, -0.7) p=0.008] and 25-36 months [-6.3 (-10.4, -2.1) p=0.003] and 30-day follow-up in 0-12 months [-2.8 (-4.9, 0) p=0.036]. Isoelectric events were not associated with emergence behavior or anesthetic (sevoflurane vs propofol). CONCLUSIONS. Isoelectric events were common worldwide in young children during anesthesia and associated with age, specific anesthetic practices, and intraoperative hypotension.
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Dahmani S, Laffargue A, Dadure C, De Queiroz M, Julien-Marsollier F, Michelet D, Veyckemans F, Amory C, Ludot H, Bert D, Godart J, Laffargue A, Dupont H, Urbina B, Baujard C, Roulleau P, Staiti G, Bordes M, Nouette Gaulain K, Hamonic Y, Semjen F, Jacqmarcq O, Lejus-Bourdeau C, Magne C, Petry L, Ros L, Zang A, Bennis M, Coustets B, Fesseau R, Constant I, Khalil E, Sabourdin N, Audren N, Descarpentries T, Fabre F, Legrand A, Druot E, Orliaguet G, Sabau L, Uhrig L, De La Briere F, Jonckheer K, Mission JP, Scordo L, Couchepin C, Dadure C, De La Arena P, Hertz L, Pirat P, Sola C, Bellon M, Depret-Donatien V, Lesage A. Epidemiology and complications of anaesthesia in the French centres that participated to NECTARINE: A secondary analysis. Anaesth Crit Care Pain Med 2022; 41:101036. [PMID: 35181529 DOI: 10.1016/j.accpm.2022.101036] [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: 05/30/2021] [Revised: 11/08/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Neonatal and infant anaesthesia are associated with a high risk of perioperative complications. The aim of the current study was to describe those risks in France using the French data from the NECTARINE study. MATERIAL AND METHODS Data from the French centres that participated to the NECTARINE study were analysed. The primary goal of the study was the description of patients' characteristics, procedures and perioperative management and their comparison with the results of the European NECTARINE study. Secondary outcomes were the description of major perioperative complications and death. RESULTS Overall, 926 procedures collected in 15 centres (all teaching hospitals) were analysed. Comparison between the French and European NECTARINE cohorts found few differences related to patients' characteristics and procedures. The rate of interventions for critical events (respiratory, haemodynamic, and metabolic) was similar between the two cohorts. Near-infrared spectroscopy monitoring was used in 12% of procedures. Nearly none of the thresholds for these interventions met the published standards. By day 30, complications (respiratory, haemodynamic, metabolic, renal, and liver failure) and death were observed in 14.4% [95% CI 11.6 - 16.4] % and 1.8% [95 % CI 1.1 - 2.9] of cases, respectively. DISCUSSION Although the health status of the patients in the French cohort was less severe, procedures, management and postoperative complications and mortality rates were similar to the European cohort. However, thresholds for interventions were often inadequate in both cohorts. Efforts should be undertaken to improve the knowledge and use of new monitoring devices in this population.
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Affiliation(s)
- Souhayl Dahmani
- French NECTARINE Trial Group, France; Paris Diderot University (Paris VII), Paris, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; FHU I2-D2, INSERM U1141, Robert Debré University Hospital, Paris, France.
| | - Anne Laffargue
- Department of Anaesthesia and Intensive Care, Jeanne de Flandre University Hospital, Lille, France
| | - Christophe Dadure
- Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France; Institut de Neurosciences de Montpellier, Unité INSERM U1051, Montpellier, France
| | - Mathilde De Queiroz
- Department of Anaesthesia and Intensive Care, University Hospital of Lyon, Lyon, France
| | - Florence Julien-Marsollier
- French NECTARINE Trial Group, France; Paris Diderot University (Paris VII), Paris, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; FHU I2-D2, INSERM U1141, Robert Debré University Hospital, Paris, France
| | - Daphné Michelet
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Department of Anaesthesia and Intensive Care, University Hospital of Reims, Reims, France
| | - Francis Veyckemans
- Department of Anaesthesia and Intensive Care, Jeanne de Flandre University Hospital, Lille, France
| | - Catherine Amory
- French NECTARINE Trial Group, France; American Memorial Hospital CHU Reims, Reims, France
| | - Hugues Ludot
- French NECTARINE Trial Group, France; American Memorial Hospital CHU Reims, Reims, France
| | - Dina Bert
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Jeanne de Flandre University Hospital, Lille, France
| | - Juliette Godart
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Jeanne de Flandre University Hospital, Lille, France
| | - Anne Laffargue
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Jeanne de Flandre University Hospital, Lille, France
| | - Hervé Dupont
- French NECTARINE Trial Group, France; CHU Amiens Picardie, Amiens, France
| | - Benjamin Urbina
- French NECTARINE Trial Group, France; CHU Amiens Picardie, Amiens, France
| | - Catherine Baujard
- French NECTARINE Trial Group, France; CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Philippe Roulleau
- French NECTARINE Trial Group, France; CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Giuseppe Staiti
- French NECTARINE Trial Group, France; CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Maryline Bordes
- French NECTARINE Trial Group, France; CHU de Bordeaux, Bordeaux, France
| | | | - Yann Hamonic
- French NECTARINE Trial Group, France; CHU de Bordeaux, Bordeaux, France
| | - François Semjen
- French NECTARINE Trial Group, France; CHU de Bordeaux, Bordeaux, France
| | | | | | - Cécile Magne
- French NECTARINE Trial Group, France; CHU de Nantes, Nantes, France
| | - Léa Petry
- French NECTARINE Trial Group, France; CHU Nancy, Nancy, France
| | - Lilica Ros
- French NECTARINE Trial Group, France; CHU Nancy, Nancy, France
| | - Aurélien Zang
- French NECTARINE Trial Group, France; CHU Nancy, Nancy, France
| | - Mehdi Bennis
- French NECTARINE Trial Group, France; CHU Toulouse, Toulouse, France
| | - Bernard Coustets
- French NECTARINE Trial Group, France; CHU Toulouse, Toulouse, France
| | - Rose Fesseau
- French NECTARINE Trial Group, France; CHU Toulouse, Toulouse, France
| | - Isabelle Constant
- French NECTARINE Trial Group, France; Hôpital Armand-Trousseau AP-HP, Paris, France
| | - Eliane Khalil
- French NECTARINE Trial Group, France; Hôpital Armand-Trousseau AP-HP, Paris, France
| | - Nada Sabourdin
- French NECTARINE Trial Group, France; Hôpital Armand-Trousseau AP-HP, Paris, France
| | - Noémie Audren
- French NECTARINE Trial Group, France; Hôpital couple enfant, CHU Grenoble Alpes, Grenoble, France
| | - Thomas Descarpentries
- French NECTARINE Trial Group, France; Hôpital couple enfant, CHU Grenoble Alpes, Grenoble, France
| | - Fanny Fabre
- French NECTARINE Trial Group, France; Hôpital couple enfant, CHU Grenoble Alpes, Grenoble, France
| | - Aurélien Legrand
- French NECTARINE Trial Group, France; Hôpital couple enfant, CHU Grenoble Alpes, Grenoble, France
| | - Emilie Druot
- French NECTARINE Trial Group, France; Hôpital Universitaire Necker Enfants Malades, Paris, France
| | - Gilles Orliaguet
- French NECTARINE Trial Group, France; Hôpital Universitaire Necker Enfants Malades, Paris, France
| | - Lucie Sabau
- French NECTARINE Trial Group, France; Hôpital Universitaire Necker Enfants Malades, Paris, France
| | - Lynn Uhrig
- French NECTARINE Trial Group, France; Hôpital Universitaire Necker Enfants Malades, Paris, France
| | - François De La Briere
- French NECTARINE Trial Group, France; Fondation Lenval - Hôpital pour enfants, Nice, France
| | - Karin Jonckheer
- French NECTARINE Trial Group, France; Fondation Lenval - Hôpital pour enfants, Nice, France
| | - Jean-Paul Mission
- French NECTARINE Trial Group, France; Fondation Lenval - Hôpital pour enfants, Nice, France
| | - Lucia Scordo
- French NECTARINE Trial Group, France; Fondation Lenval - Hôpital pour enfants, Nice, France
| | - Caroline Couchepin
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Christophe Dadure
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Pablo De La Arena
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Laurent Hertz
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Philippe Pirat
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Chrystelle Sola
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Lapeyronie University Hospital, Montpellier, France
| | - Myriam Bellon
- French NECTARINE Trial Group, France; Department of Anaesthesia and Intensive Care, Robert Debré University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Anne Lesage
- French NECTARINE Trial Group, France; Teaching Hospital of Caen, Caen, France
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Karlsson J, Lönnqvist PA. Blood pressure and flow in pediatric anesthesia: An educational review. Paediatr Anaesth 2022; 32:10-16. [PMID: 34741785 DOI: 10.1111/pan.14328] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 01/01/2023]
Abstract
During recent years, a lot of interest has been focused on blood pressure in the context of pediatric anesthesia, trying to define what is normal in relation to age and what numeric values that should be regarded as hypotension, needing active intervention. However, blood pressure is mainly measured as a proxy for flow, that is, cardiac output. Thus, just focusing on specific blood pressure numbers may not necessarily be very useful or appropriate. The aim of this educational review is to put the issue of intraoperative blood pressure in the context of pediatric anesthesia in further perspective.
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Affiliation(s)
- Jacob Karlsson
- Karolinska Institute Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group - Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Per-Arne Lönnqvist
- Karolinska Institute Department of Physiology and Pharmacology (FYFA), C3, Per-Arne Lönnqvist Group - Section of Anesthesiology and Intensive Care, Anestesi- och Intensivvårdsavdelningen, Stockholm, Sweden.,Pediatric perioperative medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Grasso C, Marchesini V, Disma N. Applications and Limitations of Neuro-Monitoring in Paediatric Anaesthesia and Intravenous Anaesthesia: A Narrative Review. J Clin Med 2021; 10:jcm10122639. [PMID: 34203942 PMCID: PMC8232784 DOI: 10.3390/jcm10122639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 12/26/2022] Open
Abstract
Safe management of anaesthesia in children has been one of the top areas of research over the last decade. After the large volume of articles which focused on the putative neurotoxic effect of anaesthetic agents on the developing brain, the attention and research efforts shifted toward prevention and treatment of critical events and the importance of peri-anaesthetic haemodynamic stability to prevent negative neurological outcomes. Safetots.org is an international initiative aiming at raising the attention on the relevance of a high-quality anaesthesia in children undergoing surgical and non-surgical procedures to guarantee a favourable outcome. Children might experience hemodynamic instability for many reasons, and how the range of normality within brain autoregulation is maintained is still unknown. Neuro-monitoring can guide anaesthesia providers in delivering optimal anaesthetic drugs dosages and also correcting underling conditions that can negatively affect the neurological outcome. In particular, it is referred to EEG-based monitoring and monitoring for brain oxygenation.
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Affiliation(s)
- Chiara Grasso
- Unit for Research & Innovation, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy;
| | - Vanessa Marchesini
- Paediatric Intensive Care Unit, Royal Melbourne Children’s Hospital, Parkville 3052, Australia;
| | - Nicola Disma
- Unit for Research & Innovation, Department of Paediatric Anaesthesia, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy;
- Correspondence:
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9
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Effect of Permissive Mild Hypercapnia on Cerebral Vasoreactivity in Infants: A Randomized Controlled Crossover Trial. Anesth Analg 2021; 133:976-983. [PMID: 33410612 DOI: 10.1213/ane.0000000000005325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Mechanical ventilation interferes with cerebral perfusion via changes in intrathoracic pressure and/or as a consequence of alterations in CO2. Cerebral vascular vasoreactivity is dependent on CO2, and hypocapnia can potentially lead to vasoconstriction and subsequent decrease in cerebral blood flow. Thus, we aimed at characterizing whether protective ventilation with mild permissive hypercapnia improves cerebral perfusion in infants. METHODS Following ethical approval and parental consent, 19 infants were included in this crossover study and randomly assigned to 2 groups for which the initial ventilation parameters were set to achieve an end-tidal carbon dioxide (Etco2) of 6.5 kPa (group H: mild hypercapnia, n = 8) or 5.5 kPa (group N: normocapnia, n = 11). The threshold was then reversed before going back to the initial set value of normo- or hypercapnia. At each step, hemodynamic, respiratory, and near-infrared spectroscopy (NIRS)-derived parameters, including tissue oxygenation index (TOI) and tissue hemoglobin index (THI), concentration of deoxygenated hemoglobin (HHb) and oxygenated hemoglobin (O2Hb), were collected. Concomitantly, sevoflurane maintenance concentration, ventilatory (driving pressure) and hemodynamic parameters, as mean arterial pressure (MAP), were recorded. RESULTS Targeting an Etco2 of 5.5 kPa resulted in significantly higher mean driving pressure than an Etco2 of 6.5 kPa (P < .01) with no difference between the groups in end-tidal sevoflurane, MAP, and heart rate. A large scatter was observed in NIRS-derived parameters, with no evidence for difference in Etco2 changes between or within groups. A mild decrease with time was observed in THI and MAP in infants randomly assigned to group N (P < .036 and P < .017, respectively). When pooling all groups together, a significant correlation was found between the changes in MAP and TOI (r = 0.481, P < .001). CONCLUSIONS Allowing permissive mild hypercapnia during mechanical ventilation of infants led to lower driving pressure and comparable hemodynamic, respiratory, and cerebral oxygenation parameters than during normocapnia. Whereas a large scatter in NIRS-derived parameters was observed at all levels of Etco2, the correlation between TOI and MAP suggests that arterial pressure is an important component of cerebral oxygenation at mild hypercapnia.
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10
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Costerus SA, Hendrikx D, IJsselmuiden J, Zahn K, Perez-Ortiz A, Van Huffel S, Flint RB, Caicedo A, Wijnen R, Wessel L, de Graaff JC, Tibboel D, Naulaers G. Cerebral Oxygenation and Activity During Surgical Repair of Neonates With Congenital Diaphragmatic Hernia: A Center Comparison Analysis. Front Pediatr 2021; 9:798952. [PMID: 34976902 PMCID: PMC8718750 DOI: 10.3389/fped.2021.798952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background and aim: Neonatal brain monitoring is increasingly used due to reports of brain injury perioperatively. Little is known about the effect of sedatives (midazolam) and anesthetics (sevoflurane) on cerebral oxygenation (rScO2) and cerebral activity. This study aims to determine these effects in the perioperative period. Methods: This is an observational, prospective study in two tertiary pediatric surgical centers. All neonates with a congenital diaphragmatic hernia received perioperative cerebral oxygenation and activity measurements. Patients were stratified based on intraoperatively administrated medication: the sevoflurane group (continuous sevoflurane, bolus fentanyl, bolus rocuronium) and the midazolam group (continuous midazolam, continuous fentanyl, and continuous vecuronium). Results: Intraoperatively, rScO2 was higher in the sevoflurane compared to the midazolam group (84%, IQR 77-95 vs. 65%, IQR 59-76, p = < 0.001), fractional tissue oxygen extraction was lower (14%, IQR 5-21 vs. 31%, IQR 29-40, p = < 0.001), the duration of hypoxia was shorter (2%, IQR 0.4-9.6 vs. 38.6%, IQR 4.9-70, p = 0.023), and cerebral activity decreased more: slow delta: 2.16 vs. 4.35 μV 2 (p = 0.0049), fast delta: 0.73 vs. 1.37 μV 2 (p = < 0.001). In the first 30 min of the surgical procedure, a 3-fold increase in fast delta (10.48-31.22 μV 2) and a 5-fold increase in gamma (1.42-7.58 μV 2) were observed in the midazolam group. Conclusion: Sevoflurane-based anesthesia resulted in increased cerebral oxygenation and decreased cerebral activity, suggesting adequate anesthesia. Midazolam-based anesthesia in neonates with a more severe CDH led to alarmingly low rScO2 values, below hypoxia threshold, and increased values of EEG power during the first 30 min of surgery. This might indicate conscious experience of pain. Integrating population-pharmacokinetic models and multimodal neuromonitoring are needed for personalized pharmacotherapy in these vulnerable patients. Trial Registration: https://www.trialregister.nl/trial/6972, identifier: NL6972.
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Affiliation(s)
- Sophie A Costerus
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dries Hendrikx
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - Joen IJsselmuiden
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Katrin Zahn
- Department of Paediatric Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Alba Perez-Ortiz
- Neonatal Intensive Care Unit, University Hospital Mannheim, Mannheim, Germany
| | - Sabine Van Huffel
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Division of Neonatology, Department of Paediatrics, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pharmacy, Erasmus Medical Center, Rotterdam, Netherlands
| | - Alexander Caicedo
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - René Wijnen
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Lucas Wessel
- Department of Paediatric Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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11
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Clausen NG, Filipovic M, Pater GH, Zickerman C, Ydemann M. Blood pressure in Danish children during general anaesthesia: Hypotension in a paediatric population observational (HIPPO) study. Acta Anaesthesiol Scand 2020; 64:1453-1459. [PMID: 32589795 DOI: 10.1111/aas.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Denmark, thousands of infants and children require general anaesthesia annually. Hypotension during general anaesthesia might reduce cerebral blood flow and oxygen delivery to the brain. Safe lower limits of blood pressure are ill defined. The Hypotension in Paediatric Populations Observational study objective was to assess blood pressure in Danish children during general anaesthesia. METHODS This study is a prospective observational multicentre study. Primary outcomes were mean arterial blood pressures in children aged 0-12 years. Lowest mean arterial blood pressure, intervention thresholds to increase blood pressure and type of intervention were secondary outcomes. Premature infants and children scheduled for cardio-thoracic surgery were excluded. Blood pressures were measured by oscillometry or invasively. RESULTS In total, 726 patients were included. In children < 1 year, median arterial pressure was 51 mm Hg, (interquartile range; 43-58) and increased to 58 mm Hg (interquartile range; 52-65) for 12-year-old children. In 32 patients, 49 actions were taken to modulate blood pressure. Pre-induction blood pressures were recorded for 29%. CONCLUSION This study presents pragmatic, multicentre, prospectively collected observations of blood pressure in children undergoing general anaesthesia in usual practice. In the youngest infants, variability in blood pressure appears to be large. Measurement of blood pressure is recommended during every general anaesthesia and in children of all ages. Safe ranges of blood pressure remain to be defined.
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Affiliation(s)
- Nicola G. Clausen
- Anaesthesiology and Intensive Care Section Paediatric Anaesthesia Odense University Hospital Odense Denmark
| | - Maja Filipovic
- Department of Neuroanesthesiology and intensive careRigshospitalet Copenhagen Denmark
| | - Gerrit H. Pater
- Department of Anesthesiology and Intensive Care Haukeland University Hospital Bergen Norway
| | - Caroline Zickerman
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care MedicineUmeå University Umeå Sweden
| | - Mogens Ydemann
- Department of Neuroanesthesiology and intensive careRigshospitalet Copenhagen Denmark
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12
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Fideler F, Walker M, Grasshoff C. Effects of awake caudal anesthesia on mean arterial blood pressure in very low birthweight infants. BMC Anesthesiol 2020; 20:175. [PMID: 32689935 PMCID: PMC7370478 DOI: 10.1186/s12871-020-01094-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 07/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Intraoperative blood pressure is a relevant variable for postoperative outcome in infants undergoing surgical procedures. It is therefore important to know whether the type of anesthesia has an impact on intraoperative blood pressure management in very low birth weight infants. Here, we retrospectively analyzed intraoperative blood pressure in very low birthweight infants receiving either awake caudal anesthesia without sedation, or caudal block in combination with general anesthesia, both for open inguinal hernia repair. Methods Ethical approval was provided by the University of Tuebingen Ethical Committee on 05/29/2018 with the project number 403/2018BO2. Patient records of infants admitted by the neonatologist (median age at birth 31.1 ± 3.5 weeks, median weight at birth 1240 ± 521 g) which were scheduled for inguinal hernia repair were retrospectively evaluated for the course of mean arterial blood pressure and perioperative interventions to stabilize blood pressure. A total of 42 patients were included, 16 patients (11 boys, 5 girls) received awake caudal anesthesia, 26 patients (22 boys, 4 girls) a combination of general anesthesia and caudal block. Results Approximately 3% of the measured mean arterial blood pressure values in the caudal anesthesia group were below a critical margin of 35 mmHg, in contrast to 47% in the combined anesthesia group (p < 0.001). Patients in the latter group showed a significantly larger drop of mean arterial blood pressure below 35 mmHg (4.7 ± 2.7 mmHg vs. 1.9 ± 1.6 mmHg; p < 0.005) and a significantly longer time of mean arterial blood pressure below 35 mmHg (25.6 ± 26.0 min vs. 0.9 ± 2.3 min; p < 0.001), although they received more volume and vasopressor boluses for stabilization (27 ± 14.8 ml vs. 10 ± 4.1 ml; p < 0.01 and 0.15 ± 0.06 ml vs. 0 ml of cafedrine/theoadrenaline; p < 0.001). Conclusions The study indicates that the use of caudal block as stand alone procedure for inguinal hernia repair in very low birthweight infants might be advantageous in preventing critical blood pressure drops compared to a combination of caudal block with general anesthesia.
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Affiliation(s)
- Frank Fideler
- Departmnt of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Tübingen, Germany.
| | - Michael Walker
- Clinic for Anesthesiology, Intensive, Emergency- and Pain-Therapy, Ludwigsburg, Germany
| | - Christian Grasshoff
- Departmnt of Anesthesiology and Intensive Care Medicine, University Hospital Tuebingen, Tübingen, Germany
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13
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Shrimpton AJ, Gill H. Perioperative management of oral cleft repair: A retrospective chart review. Paediatr Anaesth 2020; 30:710-712. [PMID: 32275794 DOI: 10.1111/pan.13871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/22/2020] [Accepted: 04/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Andrew James Shrimpton
- School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences Building, University of Bristol, Bristol, UK
| | - Hannah Gill
- School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences Building, University of Bristol, Bristol, UK.,Bristol Anaesthesia, Pain & Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, UK.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK
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14
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Zhang W, Xie S, Han D, Ou-Yang C, Lu J, Huang J. Effect of End-Tidal Carbon Dioxide on Cerebral Dynamics in Infants With Ventricular Septal Defect: A Comparison Between Sevoflurane and Intravenous Anesthetics. J Cardiothorac Vasc Anesth 2020; 34:1558-1564. [PMID: 32139343 DOI: 10.1053/j.jvca.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The primary aim was to compare the changes in regional cerebral oxygen saturation (rSO2) and cerebral blood flow velocity (CBFV) during sevoflurane and intravenous anesthesia when the end-tidal carbon dioxide partial pressure (PETCO2) changed in infants undergoing ventricular septal defect (VSD) repair. DESIGN Prospective, observational study. SETTING Tertiary care hospital. PARTICIPANTS Patients younger than 6 months with VSDs. INTERVENTIONS End-tidal carbon dioxide was increased by decreasing tidal volume or respiratory rate. MEASUREMENTS AND MAIN RESULTS The infants were randomly assigned to receive either sevoflurane (SA group) or midazolam-sufentanil based intravenous anesthesia (IA group). PETCO2 levels of 30 mmHg (T1), 35 mmHg (T2), 40 mmHg (T3), or 45 mmHg (T4) were obtained by adjusting the tidal volume and respiratory rate. There were no significant intergroup differences in rSO2. In the SA group, as PETCO2 increased from T1 to T4, rSO2 increased significantly from 68.8% ± 5.9% to 76.4% ± 6.0% (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). In the IA group, rSO2 showed a significant increase from 68.6% ± 4.6% to 76.1% ± 6.2% with the change in PETCO2 from T1 to T4 (p < 0.001). CBFV increased linearly, whereas the pulsatility index and resistance index decreased linearly from T1 to T4 (p < 0.001). CONCLUSION Cerebrovascular response to different PETCO2 levels was preserved and similar during clinically relevant doses of sevoflurane anesthesia and midazolam-sufentanil based intravenous anesthesia in infants younger than 6 months old undergoing VSD repair.
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Affiliation(s)
- Weizhi Zhang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Siyuan Xie
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Ding Han
- Anesthesia Department, Capital Institute of Pediatrics affiliated Children's Hospital, Beijing, China
| | - Chuan Ou-Yang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
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15
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Weber F, Scoones GP. A practical approach to cerebral near-infrared spectroscopy (NIRS) directed hemodynamic management in noncardiac pediatric anesthesia. Paediatr Anaesth 2019; 29:993-1001. [PMID: 31437328 DOI: 10.1111/pan.13726] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/10/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Abstract
Safeguarding cerebral function is of major importance during pediatric anesthesia. Premature, ex-premature, and full-term neonates can be vulnerable to physiological changes that occur during anesthesia and surgery. Data from studies performed during pediatric cardiac surgery and in neonatal/pediatric intensive care units have shown the benefits of near-infrared spectroscopy (NIRS) monitoring of regional cerebral oxygenation (c-rSO2 ). However, NIRS monitoring is seldom used during noncardiac pediatric anesthesia. Despite compelling evidence that blood pressure does not reflect end-organ perfusion, it is still regarded as the most important determinant of cerebral perfusion and the most relevant hemodynamic management target parameter by most (pediatric) anesthetists. The principle of NIRS monitoring is not self-explanatory and sometimes seems even counterintuitive, which may explain why many anesthesiologists are reserved regarding its use. The first part of this paper is dedicated to a clinical introduction to NIRS monitoring. Despite scientific efforts, it has not yet been possible to define individual lower limit c-rSO2 values and it is unlikely this will succeed in the near future. Nonetheless, published treatment algorithms usually specify c-rSO2 values which may be associated with cerebral hypoxia. Our treatment guideline for maintaining sufficient cerebral oxygenation differs fundamentally from all previously published approaches. We define a baseline c-rSO2 value, registered in the awake child prior to anesthesia induction, as the lowest acceptable limit during anesthesia and surgery. The cerebral rSO2 is the single target parameter, while blood pressure, heart rate, Pa CO2 , and SaO2 are major parameters that determine the c-rSO2. Cerebral NIRS monitoring, interpreted together with its continuously available contributing parameters, may help avoid potentially harmful episodes of cerebral desaturation in anesthetized pediatric patients.
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Affiliation(s)
- Frank Weber
- Department of Anesthesia, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gail P Scoones
- Department of Anesthesia, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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16
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Marsac L, Michelet D, Sola C, Didier-Vidal A, Combet S, Blanc F, Orliaguet G, Aubineau JV, Julien-Marsollier F, Brasher C, Dahmani S. A survey of the anesthetic management of pediatric kidney transplantation in France. Pediatr Transplant 2019; 23:e13509. [PMID: 31168909 DOI: 10.1111/petr.13509] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Renal transplantation is the best available therapeutic option for end-stage renal failure in both children and adults. However, little is known about anesthetic practice during pediatric renal transplantation. MATERIAL AND METHODS The study consisted of a national survey about anesthetic practice during pediatric renal transplantation in France. French tertiary pediatric centers performing renal transplants were targeted, and one physician from each team was asked to complete the survey. The survey included patient data, preoperative assessment and optimization data, and intraoperative anesthesia data (drugs, ventilation, and hemodynamic interventions). RESULTS Twenty centers performing kidney transplantation were identified and contacted to complete the survey, and eight responded. Surveyed centers performed 96 of the 122 pediatric kidney transplantations performed in France in 2017 (79%). Centers consistently performed echocardiography and ultrasound examinations of the great veins preoperatively and consistently employed esophageal Doppler cardiac output estimation and vasopressors intraoperatively. All other practices were found to be heterogeneous. Central venous pressure was monitored in six centers, and dopamine was administered perioperatively in two centers. CONCLUSIONS The current study provides a snapshot of the perioperative management of pediatric kidney transplantation in France. Results emphasize the need for both standardization of practice and awareness of recent evidence against the use of CVP monitoring and dopamine infusions.
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Affiliation(s)
- Lucile Marsac
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris, France.,PRES Paris Sorbonne Cité, Paris Diderot University (Paris VII), Paris, France
| | - Daphné Michelet
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris, France.,PRES Paris Sorbonne Cité, Paris Diderot University (Paris VII), Paris, France
| | - Chrystelle Sola
- Pediatric Anesthesia Unit, Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier University, Montpellier, France.,IGF, Montpellier University, CNRS, INSERM, Montpellier, France
| | - Anne Didier-Vidal
- Department of Anesthesia and Intensive Care, Hôpital des Enfants, Groupe Hospitalier Pellegrin, Bordeaux Cedex, France
| | - Sylvie Combet
- Department of Anesthesia and Intensive Care, Hospices Civils de Lyon, Hopital Femme Mere Enfant, Bron, France
| | - Frederic Blanc
- Department of Anesthesia and Intensive Care, Assistance Publique Hôpitaux de Marseille, Timone Enfants Hospital, Aix-Marseille University, Marseille, France
| | - Gilles Orliaguet
- Department of Anesthesia and Intensive Care, Necker-Enfant Malades Hospital, Paris, France.,EA08, Pharmacologie et Évaluation des Thérapeutiques Chez L'enfant et la Femme Enceinte, Paris-Descartes and Paris Descartes University (Paris V), PRES Paris Sorbonne Cité, Paris, France
| | | | - Florence Julien-Marsollier
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris, France.,PRES Paris Sorbonne Cité, Paris Diderot University (Paris VII), Paris, France
| | - Christopher Brasher
- Department of Anesthesia & Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia.,Anaesthesia and Pain Management Research Group, Murdoch Childrens' Research Institute, Parkville, Victoria, Australia
| | - Souhayl Dahmani
- Department of Anesthesia, Intensive care and Pain Management, Robert Debré University Hospital, Paris Diderot University, Paris, France.,PRES Paris Sorbonne Cité, Paris Diderot University (Paris VII), Paris, France.,DHU PROTECT, INSERM U1141, Robert Debré University Hospital, Paris, France
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17
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Zens TJ, Rogers A, Cartmill R, Ostlie D, Muldowney BL, Nichol P, Kohler JE. Age-dependent outcomes in asymptomatic umbilical hernia repair. Pediatr Surg Int 2019; 35:463-468. [PMID: 30430281 DOI: 10.1007/s00383-018-4413-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Umbilical hernias are common in young children. Many resolve spontaneously by age four with very low risk of symptoms or incarceration. Complications associated with surgical repair of asymptomatic umbilical hernias have not been well elucidated. We analyzed data from one hospital to test the hypothesis that repair at younger ages is associated with increased complication rates. METHODS A retrospective chart review of all umbilical hernia repairs performed during 2007-2015 was conducted at a tertiary care children's hospital. Patients undergoing repairs as a single procedure for asymptomatic hernia were evaluated for post-operative complications by age, demographics, and co-morbidities. RESULTS Of 308 umbilical hernia repairs performed, 204 were isolated and asymptomatic. Postoperative complications were more frequent in children < 4 years (12.3%) compared to > 4 years (3.1%, p = 0.034). All respiratory complications (N = 4) and readmissions (N = 1) were in children < 4 years. CONCLUSIONS Age of umbilical hernia repair in children varied widely even within a single institution, demonstrating that timing of repair may be a surgeon-dependent decision. Patients < 4 years were more likely to experience post-operative complications. Umbilical hernias often resolve over time and can safely be monitored with watchful waiting. Formal guidelines are needed to support delayed repair and prevent unnecessary, potentially harmful operations.
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Affiliation(s)
- Tiffany J Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue Madison, Madison, WI, 53792-7375, USA
| | - Andrew Rogers
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue Madison, Madison, WI, 53792-7375, USA
| | - Randi Cartmill
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue Madison, Madison, WI, 53792-7375, USA
| | - Daniel Ostlie
- Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Bridget L Muldowney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peter Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue Madison, Madison, WI, 53792-7375, USA
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue Madison, Madison, WI, 53792-7375, USA.
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18
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Zens TJ, Cartmill R, Muldowney BL, Fernandes-Taylor S, Nichol P, Kohler JE. Practice Variation in Umbilical Hernia Repair Demonstrates a Need for Best Practice Guidelines. J Pediatr 2019; 206:172-177. [PMID: 30448274 PMCID: PMC6389373 DOI: 10.1016/j.jpeds.2018.10.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/08/2018] [Accepted: 10/24/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate and better understand variations in practice patterns, we analyzed ambulatory surgery claims data from 3 demographically diverse states to assess the relationship between age at umbilical hernia repair and patient, hospital, and geographic characteristics. STUDY DESIGN We performed a cross-sectional descriptive study of uncomplicated hernia repairs performed as a single procedure in 2012-2014, using the State Ambulatory Surgery and Services Database for Wisconsin, New York, and Florida. Age and demographic characteristics of umbilical hernia repair patients are described. RESULTS The State Ambulatory Surgery and Services Database analysis included 6551 patients. Across 3 states, 8.2% of hernia repairs were performed in children <2 years, 18.7% in children age 2-3 years, and 73.0% in children age ≥4 years, but there was significant variability (P < .001) in practice patterns by state. In regression analysis, race, Medicaid insurance and rural residence were predictive of early repair, with African American patients less likely to have a repair before age 2 (OR 0.62, P = .046) and rural children (OR 1.53, P = .009) and Medicaid patients (OR 2.01, P < .001) more likely to do so. State of residence predicted early repair even when holding these variables constant. CONCLUSIONS The age of pediatric umbilical hernia repair varies widely. As hernias may resolve over time and can be safely monitored with watchful waiting, formal guidelines are needed to support delayed repair and prevent unnecessary operations.
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Affiliation(s)
- Tiffany J Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Randi Cartmill
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Bridget L Muldowney
- Division of Pediatric Anesthesiology, Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sara Fernandes-Taylor
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Peter Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI; Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Zens T, Nichol P, Leys C, Haines K, Brinkman A. Fractured pediatric central venous catheters - Repair or replace? J Pediatr Surg 2019; 54:165-169. [PMID: 30466713 DOI: 10.1016/j.jpedsurg.2018.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/01/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Central venous catheter (CVC) fracture is a common complication. The aim of this study is to examine risk factors resulting in CVC fracture and compare outcomes of children undergoing CVC repair versus replacement. METHODS A retrospective chart review was conducted from 2000 to 2016 for children with tunneled CVCs. Children with CVC fractures were compared to those without to identify risk factors resulting in fracture. Children with fractured CVCs were divided into repair or replacement treatment groups and outcomes compared. A logistic regression model determined independent predictors of CVC-associated bloodstream infections (CLABSI) after fracture. RESULTS In the 236 children with CVCs, the fracture rate was 29.2%. Fractured CVCs were more common with double lumen CVC (p = 0.040) and children whose indication was total parenteral nutrition (p = 0.003). Given children often underwent multiple repairs or replacements. 98 CVC repairs and 41 replacements were analyzed. CVC replacements had longer durability than repair (181.98 vs. 98.9 days, p = 0.038). There were no differences in CLABSI incidence for repair vs. replacement (OR 0.5 CI 0.05-4.97) after controlling for other factors. CONCLUSIONS CVC fracture is a frequent complication in children with tunneled CVCs. CVC repair has no increased incidence of CLABSI but eliminates the intraoperative and anesthetic risks of CVC replacement. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tiffany Zens
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Peter Nichol
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Charles Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Krista Haines
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Adam Brinkman
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Division of General Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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20
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Effects of moderate and severe arterial hypotension on intracerebral perfusion and brain tissue oxygenation in piglets. Br J Anaesth 2018; 121:1308-1315. [PMID: 30442258 DOI: 10.1016/j.bja.2018.07.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/29/2018] [Accepted: 07/24/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypotension is common in anaesthetised children, and its impact on cerebral oxygenation is unknown. The goal of the present study was to investigate the effects of moderate systemic arterial hypotension (mHT) and severe hypotension (sHT) on cerebral perfusion and brain tissue oxygenation in piglets. METHODS Twenty-seven anaesthetised piglets were randomly allocated to a control group, mHT group, or sHT group. Cerebral monitoring comprised a tissue oxygen partial pressure ( [Formula: see text] ) and laser Doppler (LD) perfusion probe advanced into the brain tissue, and a near-infrared spectroscopy sensor placed over the skin measuring regional oxygen saturation (rSO2). Arterial hypotension was induced by blood withdrawal and i.v. nitroprusside infusion [target MAP: 35-38 (mHT) and 27-30 (sHT) mm Hg]. Data were analysed at baseline, and every 20 min during and after treatment. RESULTS Compared with control, [Formula: see text] decreased equally with mHT and sHT [mean (SD) after 60 min: control: 17.1 (6.4); mHT: 6.4 (3.6); sHT: 7.2 (4.3) mm Hg]. No differences between groups were detected for rSO2 and LD during treatment. However, in the sHT group, rSO2 increased after restoring normotension [from 49.3 (9.5) to 58.9 (8.9)% Post60]. sHT was associated with an increase in blood lactate [from 1.5 (0.4) to 2.4 (0.9) mmol L-1], and a decrease in bicarbonate [28 (2.4) to 25.8 (2.6) mmol L-1] and base excess [4.7 (1.9) to 2.0 (2.7) mmol L-1] between baseline and 60 min after the start of the experiment. CONCLUSIONS Induction of mHT and sHT by hypovolaemia and nitroprusside infusion caused alterations in brain tissue oxygenation in a piglet model, but without detectable changes in brain tissue perfusion and regional oxygen saturation.
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21
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An International, Multicenter, Observational Study of Cerebral Oxygenation during Infant and Neonatal Anesthesia. Anesthesiology 2017; 128:85-96. [PMID: 29019815 DOI: 10.1097/aln.0000000000001920] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND General anesthesia during infancy is associated with neurocognitive abnormalities. Potential mechanisms include anesthetic neurotoxicity, surgical disease, and cerebral hypoxia-ischemia. This study aimed to determine the incidence of low cerebral oxygenation and associated factors during general anesthesia in infants. METHODS This multicenter study enrolled 453 infants aged less than 6 months having general anesthesia for 30 min or more. Regional cerebral oxygenation was measured by near-infrared spectroscopy. We defined events (more than 3 min) for low cerebral oxygenation as mild (60 to 69% or 11 to 20% below baseline), moderate (50 to 59% or 21 to 30% below baseline), or severe (less than 50% or more than 30% below baseline); for low mean arterial pressure as mild (36 to 45 mmHg), moderate (26 to 35 mmHg), or severe (less than 25 mmHg); and low pulse oximetry saturation as mild (80 to 89%), moderate (70 to 79%), or severe (less than 70%). RESULTS The incidences of mild, moderate, and severe low cerebral oxygenation were 43%, 11%, and 2%, respectively; mild, moderate, and severe low mean arterial pressure were 62%, 36%, and 13%, respectively; and mild, moderate, and severe low arterial saturation were 15%, 4%, and 2%, respectively. Severe low oxygen saturation measured by pulse oximetry was associated with mild and moderate cerebral desaturation; American Society of Anesthesiology Physical Status III or IV versus I was associated with moderate cerebral desaturation. Severe low cerebral saturation events were too infrequent to analyze. CONCLUSIONS Mild and moderate low cerebral saturation occurred frequently, whereas severe low cerebral saturation was uncommon. Low mean arterial pressure was common and not well associated with low cerebral saturation. Unrecognized severe desaturation lasting 3 min or longer in infants seems unlikely to explain the subsequent development of neurocognitive abnormalities.
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22
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Devroe S, Meeusen R, Gewillig M, Cools B, Poesen K, Sanders R, Rex S. Xenon as an adjuvant to sevoflurane anesthesia in children younger than 4 years of age, undergoing interventional or diagnostic cardiac catheterization: A randomized controlled clinical trial. Paediatr Anaesth 2017; 27:1210-1219. [PMID: 28872734 DOI: 10.1111/pan.13230] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Xenon has repeatedly been demonstrated to have only minimal hemodynamic side effects when compared to other anesthetics. Moreover, in experimental models, xenon was found to be neuroprotective and devoid of developmental neurotoxicity. These properties could render xenon attractive for the anesthesia in neonates and infants with congenital heart disease. However, experience with xenon anesthesia in children is scarce. AIMS We hypothesized that in children undergoing cardiac catheterization, general anesthesia with a combination of sevoflurane with xenon results in superior hemodynamic stability, compared to sevoflurane alone. METHODS In this prospective, randomized, single-blinded, controlled clinical trial, children with a median age of 12 [IQR 3-36] months undergoing diagnostic/interventional cardiac catheterization were randomized to either general anesthesia with 50-65vol% xenon plus sevoflurane or sevoflurane alone. The primary outcome was the incidence of intraprocedural hemodynamic instability, defined as the occurrence of: (i) a heart rate change >20% from baseline; or (ii) a change in mean arterial blood pressure >20% from baseline; or (iii) the requirement of vasopressors, inotropes, chronotropes, or fluid boluses. Secondary endpoints included recovery characteristics, feasibility criteria, and safety (incidence of emergence agitation and postoperative vomiting. RESULTS After inclusion of 40 children, the trial was stopped as an a priori planned blinded interim analysis revealed that the overall rate of hemodynamic instability did not differ between groups [100% in both the xenon-sevoflurane and the sevoflurane group. However, the adjuvant administration of xenon decreased vasopressor requirements, preserved better cerebral oxygen saturation, and resulted in a faster recovery. Xenon anesthesia was feasible (with no differences in the need for rescue anesthetics in both groups). CONCLUSION Our observations suggest that combining xenon with sevoflurane in preschool children is safe, feasible, and facilitates hemodynamic management. Larger and adequately powered clinical trials are warranted to investigate the impact of xenon on short- and long-term outcomes in pediatric anesthesia.
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Affiliation(s)
- Sarah Devroe
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Roselien Meeusen
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Pediatric and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Bjorn Cools
- Department of Pediatric and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Koen Poesen
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Robert Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Changes of Cerebral Oxygenation in Sequential Glenn and Fontan Procedures in the Same Children. Pediatr Cardiol 2017; 38:1215-1219. [PMID: 28589407 DOI: 10.1007/s00246-017-1647-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 05/30/2017] [Indexed: 01/24/2023]
Abstract
Recently, it is common to perform the Fontan procedure after the Glenn procedure as surgical repair for the univentricular heart. How the brain oxygen saturation (rSO2) values change with the cardiac restoration and the process of growth during these procedures in individual children remains unknown. In this study, we retrospectively studied rSO2 data as well as the perioperative clinical records of 30 children who underwent both Glenn and Fontan procedures by the same surgeon in the same institute. The rSO2 was measured at the beginning and end of each procedure with an INVOS 5100C. Cerebral perfusion pressure was calculated by subtracting central venous pressure from mean arterial pressure. Arterial oxygen saturation (SaO2) and the hemoglobin concentration were obtained as candidates affecting rSO2 changes at the start and the end of both procedures. The rSO2 increased during the Glenn procedure, but this increase was slight and insignificant. On the other hand, the rSO2 significantly increased during the Fontan procedure. Significant increases in SaO2 were observed only between the beginning and end of the Fontan procedure. Correlation coefficients determined by linear regression analysis were more than 0.5 between rSO2 and SaO2 in both procedures. Multiple linear regression analysis showed that SaO2 was the key determinant of the rSO2. The rSO2 increases step by step from the Glenn to the Fontan procedure in the same patient. Within each procedure, SaO2 is the key determinant of the rSO2. The significance of rSO2 monitoring in these procedures should be further evaluated.
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24
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Neunhoeffer F, Warmann SW, Hofbeck M, Müller A, Fideler F, Seitz G, Schuhmann MU, Kirschner HJ, Kumpf M, Fuchs J. Elevated intrathoracic CO 2 pressure during thoracoscopic surgery decreases regional cerebral oxygen saturation in neonates and infants-A pilot study. Paediatr Anaesth 2017; 27:752-759. [PMID: 28544108 DOI: 10.1111/pan.13161] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intraoperative hypercapnia and acidosis are risk factors during thoracoscopy in neonates and infants. METHODS In a prospective pilot study, we evaluated the effects of thoracoscopy in neonates and infants on cerebral microcirculation, oxygen saturation, and oxygen consumption. Regional cerebral oxygen saturation and blood flow were measured noninvasively using a new device combining laser Doppler flowmetry and white light spectrometry. Additionally, cerebral fractional tissue oxygen extraction and approximated oxygen consumption were calculated. Fifteen neonates and infants undergoing thoracoscopy were studied using the above-mentioned method. The chest was insufflated with carbon dioxide with a pressure of 2-6 mm Hg. Single lung ventilation was not used. As control group served 15 neonates and infants undergoing abdominal surgery. RESULTS Data are presented as median and range. The 95% confidence intervals for differences of means (95% CI) are given for the mean difference from baseline values. We observed a correlation between intrathoracic pressure exceeding 4 mm Hg and transient decrease in regional cerebral oxygen saturation of 12.7% (95% CI: 9.7-17.2, P<.001). Peripheral oxygen saturation was normal at the same time. Intraoperative increase in arterial paCO2 (median maximum value: 48.8 mm Hg, range: [36.5-65.4]; 95% CI: -16.0 to -3.0, P=.002) and decrease in arterial pH (median minimum value: 7.3, range: [7.2-7.4]; 95% CI: 0.04-0.12, P=.008) were observed during thoracoscopy with both parameters recovering at the end of the procedure. Periods of regional cerebral oxygen saturation below 20% from baseline were significantly more frequent during thoracoscopy as compared to the control group (median maximum value: 1.3%min/h, range: [0.0-66.2] vs median maximum value: 0.0%min/h, range: [0.0-4.0]; 95% CI: -16.6 to -1.1, P=.028). CONCLUSION We suggest that thoracoscopic surgery in neonates and infants, although generally safe, may be associated with a decrease in regional cerebral oxygen saturation correlating with the applied intrathoracic pressure. According to our data an inflation pressure >4 mm Hg should be avoided during thoracoscopic surgery.
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Affiliation(s)
- Felix Neunhoeffer
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Steven W Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Alisa Müller
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tuebingen, Germany
| | - Guido Seitz
- Department of Pediatric Surgery, University Hospital Giessen/Marburg, Marburg, Germany
| | - Martin U Schuhmann
- Department of Pediatric Neurosurgery, University Hospital, Tuebingen, Germany
| | - Hans-Joachim Kirschner
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmology and Pediatric Intensive Care Medicine, University Children's Hospital, Tuebingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
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Pelizzo G, Carlini V, Iacob G, Pasqua N, Maggio G, Brunero M, Mencherini S, De Silvestri A, Calcaterra V. Pediatric Laparoscopy and Adaptive Oxygenation and Hemodynamic Changes. Pediatr Rep 2017; 9:7214. [PMID: 28706621 PMCID: PMC5494445 DOI: 10.4081/pr.2017.7214] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 06/02/2017] [Accepted: 06/03/2017] [Indexed: 11/23/2022] Open
Abstract
Adaptive changes in oxygenation and hemodynamics are evaluated during pediatric laparoscopy. The children underwent laparoscopy (LAP Group, n=20) or open surgery (Open Group, n=10). Regional cerebral (rScO2) and peripheral oxygen saturation (SpO2), heart rate (HR), diastolic (DP) and systolic pressure (SP) were monitored at different intervals: basal (T0); anesthesia induction (T1); CO2PP insufflation (T2); surgery (T3); CO2PP cessation (T4); before extubation (T5). At T1, in both the LAP and Open groups significant changes in rScO2, DP and SP were recorded compared with T0; a decrease in SatO2 was also observed at T5. In the LAP group, at T2, changes in HR related to CO2PP pressure and in DP and SP related to IAP were noted; at T4, a SP change associated with CO2PP desufflation was recorded. Open group, at T3 and T5 showed lower rScO2 values compared with T1. Pneuperitoneum and anesthesia are influent to induce hemodynamics changes during laparoscopy.
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Affiliation(s)
- Gloria Pelizzo
- Pediatric Surgery Unit, Children's Hospital, Istituto Mediterraneo di Eccellenza Pediatrica, Palermo
| | - Veronica Carlini
- Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia
| | - Giulio Iacob
- Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia
| | - Noemi Pasqua
- Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia
| | - Giuseppe Maggio
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Marco Brunero
- Pediatric Surgery Unit, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia
| | - Simonetta Mencherini
- Anesthesiology and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Annalisa De Silvestri
- Biometry and Clinical Epidemiology, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Valeria Calcaterra
- Pediatric Unit, Department of Maternal and Child Health Fondazione IRCCS Policlinico San Matteo Pavia, Italy.,Department of Internal Medicine an Therapeutics, University of Pavia, Italy
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Michelet D, Brasher C, Kaddour HB, Diallo T, Abdat R, Malbezin S, Bonnard A, Dahmani S. Postoperative complications following neonatal and infant surgery: Common events and predictive factors. Anaesth Crit Care Pain Med 2017; 36:163-169. [DOI: 10.1016/j.accpm.2016.05.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 01/10/2023]
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Waurick K, Sauerland C, Goeters C. Dexmedetomidine sedation combined with caudal anesthesia for lower abdominal and extremity surgery in ex-preterm and full-term infants. Paediatr Anaesth 2017; 27:637-642. [PMID: 28256096 DOI: 10.1111/pan.13110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Awake caudal anesthesia is a potentially attractive option, because the administration of general anesthesia is associated with a high rate of respiratory complications and hemodynamic disturbances and potential neurotoxic effects. To facilitate the caudal puncture and subsequent surgical intervention, additional sedatives are commonly administered. AIM We aimed to establish a new, safe, and effective anesthetic procedure for very young children with comorbidities. METHODS We retrospectively analyzed 23 children who underwent lower abdominal or lower extremity surgery with dexmedetomidine sedation and caudal anesthesia from January 2015 to August 2015. Dexmedetomidine was initiated with a total bolus infusion of 0.7-1.1 μg·kg-1 followed by a continuous infusion of 1 μg·kg-1 ·h-1 . Bupivacaine (2.5 mg·kg-1 ) was supplemented with 5-10 μg·kg-1 epinephrine to strengthen and prolong motor block. According to maturity at birth, two groups were defined: ex-preterm and full-term infants. RESULTS There were 12 ex-preterm and 10 full-term infants available for analysis. The median postmenstrual age was 44 (38-52) weeks in ex-preterm and 46.5 (40-72) weeks in full-term infants. Without any additional intervention, surgery was successfully accomplished in 82% of all cases. While respiratory complications were not a problem, hemodynamic disturbances commonly occurred. Maximum decreases in heart rate (HR) of 30% were accompanied by maximum decreases in mean arterial pressure (MAP) of 38%. No infant had a heart rate below 100 bpm. MAP declined in one ex-preterm infant to a minimum value of 32 mmHg. CONCLUSION Caudal anesthesia combined with dexmedetomidine sedation is an effective anesthetic technique for lower abdominal and extremity surgery in ex-preterm and full-term infants with severe comorbidities.
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Affiliation(s)
- Katrin Waurick
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Münster, Münster, Germany
| | - Cristina Sauerland
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Christiane Goeters
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Münster, Münster, Germany
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28
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Weber F, Koning L, Scoones GP. Defining hypotension in anesthetized infants by individual awake blood pressure values: a prospective observational study. Paediatr Anaesth 2017; 27:377-384. [PMID: 28244242 DOI: 10.1111/pan.13091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Blood pressure (BP) is the most commonly applied clinical surrogate parameter for tissue perfusion and cerebral autoregulation. Hypotension during anesthesia may contribute to unfavorable outcome in young children. Hypotension in anesthetized infants can be defined using BP values relative to individual awake baseline or absolute BP values. AIM The aim of this study was to investigate the applicability of the two definitions and to compare the incidences of hypotension. METHOD This was a prospective observational study in 151 infants <12 months of age. The percentage of successful awake BP measurements was calculated and related to the infant's behavioral state. Hypotension under sevoflurane anesthesia was defined by a decrease of mean arterial pressure (MAP) relative to awake baseline (>20% in infants <6 months, >40% in infants >6 months) or absolute MAP values (<35 mmHg in infants <6 months, <43 mmHg in infants >6 months). The incidences of hypotension using the two definitions were compared. RESULTS Awake BP values were obtained in 85% of the patients. Calm patients were more likely to allow their BP to be measured than anxious patients. Anxious patients had higher preinduction MAP values than calm patients. The relative BP approach resulted in a higher incidence of postinduction hypotension than using absolute BP values. CONCLUSIONS Awake BP values were unobtainable in 15% of our patients, resulting in the necessity to define hypotension under anesthesia using absolute BP values. Definitions of hypotension using either absolute MAP or values relative to awake baseline are not interchangeable.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Laurens Koning
- Department of Anaesthesia, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gail P Scoones
- Department of Anaesthesia, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
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29
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Dennhardt N, Beck C, Huber D, Sümpelmann R. Reply to Greenstein, Alan; Morton, Neil; Patil, Vinodkumar, regarding their comment on "Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study". Paediatr Anaesth 2017; 27:325-326. [PMID: 28220671 DOI: 10.1111/pan.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology, Hanover Medical School, Hanover, Germany
| | - Dirk Huber
- Clinic for Anesthesiology, Hanover Medical School, Hanover, Germany
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Dix LML, van Bel F, Lemmers PMA. Monitoring Cerebral Oxygenation in Neonates: An Update. Front Pediatr 2017; 5:46. [PMID: 28352624 PMCID: PMC5348638 DOI: 10.3389/fped.2017.00046] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/24/2017] [Indexed: 11/13/2022] Open
Abstract
Cerebral oxygenation is not always reflected by systemic arterial oxygenation. Therefore, regional cerebral oxygen saturation (rScO2) monitoring with near-infrared spectroscopy (NIRS) is of added value in neonatal intensive care. rScO2 represents oxygen supply to the brain, while cerebral fractional tissue oxygen extraction, which is the ratio between rScO2 and systemic arterial oxygen saturation, reflects cerebral oxygen utilization. The balance between oxygen supply and utilization provides insight in neonatal cerebral (patho-)physiology. This review highlights the potential and limitations of cerebral oxygenation monitoring with NIRS in the neonatal intensive care unit.
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Affiliation(s)
- Laura Marie Louise Dix
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands; Monash Newborn, Monash Medical Centre, Melbourne, VIC, Australia
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht , Utrecht , Netherlands
| | - Petra Maria Anna Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht , Utrecht , Netherlands
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31
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Pelizzo G, Bernardi L, Carlini V, Pasqua N, Mencherini S, Maggio G, De Silvestri A, Bianchi L, Calcaterra V. Laparoscopy in children and its impact on brain oxygenation during routine inguinal hernia repair. J Minim Access Surg 2017; 13:51-56. [PMID: 27251842 PMCID: PMC5206840 DOI: 10.4103/0972-9941.181800] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The systemic impact of intra-abdominal pressure (IAP) and/or changes in carbon dioxide (CO2) during laparoscopy are not yet well defined. Changes in brain oxygenation have been reported as a possible cause of cerebral hypotension and perfusion. The side effects of anaesthesia could also be involved in these changes, especially in children. To date, no data have been reported on brain oxygenation during routine laparoscopy in paediatric patients. PATIENTS AND METHODS Brain and peripheral oxygenation were investigated in 10 children (8 male, 2 female) who underwent elective minimally invasive surgery for inguinal hernia repair. Intraoperative transcranial near-infrared spectroscopy to assess regional cerebral oxygen saturation (rScO2), peripheral oxygen saturation using pulse oximetry and heart rate (HR) were monitored at five surgical intervals: Induction of anaesthesia (baseline T1); before CO2insufflation induced pneumoperitoneum (PP) (T2); CO2PP insufflation (T3); cessation of CO2PP (T4); before extubation (T5). RESULTS rScO2decreases were recorded immediately after T1 and became significant after insufflation (P = 0.006; rScO2decreased 3.6 ± 0.38%); restoration of rScO2was achieved after PP cessation (P = 0.007). The changes in rScO2were primarily due to IAP increases (P = 0.06). The HR changes were correlated to PP pressure (P < 0.001) and CO2flow rate (P = 0.001). No significant peripheral effects were noted. CONCLUSIONS The increase in IAP is a critical determinant in cerebral oxygenation stability during laparoscopic procedures. However, the impact of anaesthesia on adaptive changes should not be underestimated. Close monitoring and close collaboration between the members of the multidisciplinary paediatric team are essential to guarantee the patient's safety during minimally invasive surgical procedures.
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Affiliation(s)
- Gloria Pelizzo
- Department of Maternal and Child Health, Pediatric Surgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Luciano Bernardi
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Veronica Carlini
- Department of Maternal and Child Health, Pediatric Surgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Noemi Pasqua
- Department of Maternal and Child Health, Pediatric Surgery Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Italy
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Simonetta Mencherini
- Department of Anesthesiology and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Maggio
- Department of Anesthesiology and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Annalisa De Silvestri
- Department of Biometry and Clinical Epidemiology, Scientific Direction, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Lucio Bianchi
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Valeria Calcaterra
- Department of Internal Medicine, University of Pavia, Pavia, Italy
- Department of Maternal and Children's Health, Pediatric Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
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Simpao AF, Ahumada LM, Gálvez JA, Bonafide CP, Wartman EC, Randall England W, Lingappan AM, Kilbaugh TJ, Jawad AF, Rehman MA. The timing and prevalence of intraoperative hypotension in infants undergoing laparoscopic pyloromyotomy at a tertiary pediatric hospital. Paediatr Anaesth 2017; 27:66-76. [PMID: 27896911 DOI: 10.1111/pan.13036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraoperative hypotension may be associated with adverse outcomes in children undergoing surgery. Infants and neonates under 6 months of age have less autoregulatory cerebral reserve than older infants, yet little information exists regarding when and how often intraoperative hypotension occurs in infants. AIMS To better understand the epidemiology of intraoperative hypotension in infants, we aimed to determine the prevalence of intraoperative hypotension in a generally uniform population of infants undergoing laparoscopic pyloromyotomy. METHODS Vital sign data from electronic records of infants who underwent laparoscopic pyloromyotomy with general anesthesia at a children's hospital between January 1, 1998 and October 4, 2013 were analyzed. Baseline blood pressure (BP) values and intraoperative BPs were identified during eight perioperative stages based on anesthesia event timestamps. We determined the occurrence of relative (systolic BP <20% below baseline) and absolute (mean arterial BP <35 mmHg) intraoperative hypotension within each stage. RESULTS A total of 735 full-term infants and 82 preterm infants met the study criteria. Relative intraoperative hypotension occurred in 77%, 72%, and 58% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Absolute intraoperative hypotension was seen in 21%, 12%, and 4% of infants in the 1-30, 31-60, and 61-90 days age groups, respectively. Intraoperative hypotension occurred primarily during surgical prep and throughout the surgical procedure. Preterm infants had higher rates of absolute intraoperative hypotension than full-term infants. CONCLUSIONS Relative intraoperative hypotension was routine and absolute intraoperative hypotension was common in neonates and infants under 91 days of age. Preterm infants and infants under 61 days of age experienced the highest rates of absolute and relative intraoperative hypotension, particularly during surgical prep and throughout surgery.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luis M Ahumada
- Data Analytics and Enterprise Reporting, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher P Bonafide
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elicia C Wartman
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William Randall England
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arul M Lingappan
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abbas F Jawad
- Department of Biostatistics in Pediatrics, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mohamed A Rehman
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Razlevice I, Rugyte DC, Strumylaite L, Macas A. Assessment of risk factors for cerebral oxygen desaturation during neonatal and infant general anesthesia: an observational, prospective study. BMC Anesthesiol 2016; 16:107. [PMID: 27793105 PMCID: PMC5086037 DOI: 10.1186/s12871-016-0274-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/20/2016] [Indexed: 12/03/2022] Open
Abstract
Background Cerebral oxygen saturation (rSO2c) decrease from baseline greater than 20 % during infant cardiac surgery was associated with postoperative neurologic changes and neurodevelopmental impairment at 1 year of age. So far, there is no sufficient evidence to support the routine monitoring of rSO2c during general surgical procedures in children. We aimed to find out the frequency of cerebral desaturation 20 % or more from baseline and to identify possible predictors of change in cerebral oxygen saturation during neonatal and infant general surgery. Methods Forty-four infants up to 3 months of age were recruited. Before induction of anesthesia, two pediatric cerebral sensors were placed bilaterally to the forehead region and monitoring of regional cerebral saturation of oxygen was started and continued throughout the surgery. Simultaneously, mean arterial blood pressure (MAP), pulse oximetry (SpO2), heart rate (HR), endtidal CO2, expired fraction of sevoflurane and rectal temperature were recorded. The main outcome measure was rSO2c value drop-off ≥20 % from baseline. Mann-Whitney U-test, chi-squared test, simple and multiple linear regression models were used for statistical analysis. Results Forty-three infants were analyzed. Drop-off ≥20 % in rSO2c from baseline occurred in 8 (18.6 %) patients. There were no differences in basal rSO2c, SpO2, HR, endtidal CO2, expired fraction of sevoflurane and rectal temperature between patients with and without desaturation 20 % or more from baseline. But the two groups differed with regard to gestation, preoperative mechanical ventilation and the use of vasoactive medications and red blood cell transfusions during surgery. Simple linear regression model showed, that gestation, age, preoperative mechanical ventilation and mean arterial pressure corresponding to minimal rSO2c value during anesthesia (MAPminrSO2c) were associated with a change in rSO2c values. Multiple regression model including all above mentioned variables, revealed that only MAPminrSO2c was predictive for a change in rSO2c values (β (95 % confidence interval) -0.28 (−0.52–(−0.04)) p = 0.02). Conclusions Cerebral oxygen desaturation ≥20 % from baseline occurred in almost one fifth of patients. Although different perioperative factors can predispose to cerebral oxygenation changes, arterial blood pressure seems to be the most important. Gestation as another possible risk factor needs further investigation. Trial registration The international registration number NCT02423369. Retrospectively registered on April 2015. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0274-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ilona Razlevice
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania.
| | - Danguole C Rugyte
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania
| | - Loreta Strumylaite
- Neuroscience Institute, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Eiveniu str. 2, Kaunas, LT-50009, Lithuania
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Weber F, Honing GHM, Scoones GP. Arterial blood pressure in anesthetized neonates and infants: a retrospective analysis of 1091 cases. Paediatr Anaesth 2016; 26:815-22. [PMID: 27218872 DOI: 10.1111/pan.12924] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hypotension during general anesthesia in neonates and infants is considered to contribute to poor neurological outcome. AIM The aim of this retrospective analysis was to determine the incidence of hypotension after induction of anesthesia and sustained hypotension (>10 min) during the anesthesia, and to determine factors contributing to the development of (sustained) hypotension. METHOD We performed a retrospective analysis of 1091 electronic anesthesia records from children <1 year. Patients were stratified for age (group 1: <1 month, group 2: 1-3 months, group 3: 4-6 months, group 4: >6 months). Hypotension was defined as a mean arterial pressure (MAP) <35 mmHg in patients ≤6 months and <43 mmHg in patients >6 months. RESULTS The incidence of hypotension after induction was highest in group 1 (25.5%) [P = 0.009 vs group 2 (13.3%), P < 0.0001 vs groups 3 (3.4%) and 4 (1.0%)], in group 2, it was higher than in groups 3 and 4 (P < 0.0001), and in group 3, it was higher than in group 4 (P = 0.033). The incidence of sustained hypotension was highest in group 1 (43.6%) (P < 0.0001 vs groups 2-4), followed by group 2 (15.7%) [P < 0.0001 vs group 3 (3.4%) and P = 0.006 vs group 4 (8.8%)] and group 4 (P = 0.004 vs group 3). Hypotension after induction occurred more often in emergency procedures than in elective procedures in groups 1 (P = 0.002), 2 (P = 0.029), and 3 (P = 0.037). CONCLUSION Hypotension, both postinduction and sustained during surgery, is a common phenomenon in anesthetized children under 1 year, peaking in neonates. Generally accepted lower limits of MAP in anesthetized infants urgently need to be defined, enabling us to develop anesthesia strategies avoiding cerebral hypoperfusion.
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Affiliation(s)
- Frank Weber
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gijsbert H M Honing
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Gail P Scoones
- Department of Anaesthesia, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Dennhardt N, Beck C, Huber D, Sander B, Boehne M, Boethig D, Leffler A, Sümpelmann R. Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study. Paediatr Anaesth 2016; 26:838-43. [PMID: 27291355 DOI: 10.1111/pan.12943] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND In pediatric anesthesia, preoperative fasting guidelines are still often exceeded. OBJECTIVE The objective of this noninterventional clinical observational cohort study was to evaluate the effect of an optimized preoperative fasting management (OPT) on glucose concentration, ketone bodies, acid-base balance, and change in mean arterial blood pressure (MAP) during induction of anesthesia in children. METHODS Children aged 0-36 months scheduled for elective surgery with OPT (n = 50) were compared with peers studied before optimizing preoperative fasting time (OLD) (n = 50) who were matched for weight, age, and height. RESULTS In children with OPT (n = 50), mean fasting time (6.0 ± 1.9 h vs 8.5 ± 3.5 h, P < 0.001), deviation from guideline (ΔGL) (1.2 ± 1.4 h vs 3.7 ± 3.1 h, P < 0.001, ΔGL>2 h 8% vs 70%), ketone bodies (0.2 ± 0.2 mmol·l(-1) vs 0.6 ± 0.6 mmol·l(-1) , P < 0.001), and incidence of hypotension (MAP <40 mmHg, 0 vs 5, P = 0.022) were statistically significantly lower and MAP after induction was statistically significantly higher (55.2 ± 9.5 mmHg vs 50.3 ± 9.8 mmHg, P = 0.015) as compared to children in the OLD (n = 50) group. Glucose, lactate, bicarbonate, base excess, and anion gap did not significantly differ. CONCLUSION Optimized fasting times improve the metabolic and hemodynamic condition during induction of anesthesia in children younger than 36 months of age.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Christiane Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dirk Huber
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Bjoern Sander
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Martin Boehne
- Clinic for Pediatric Cardiology and Pediatric Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Andreas Leffler
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Changes in Cerebral Blood Flow and Oxygenation During Induction of General Anesthesia with Sevoflurane Versus Propofol. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 876:479-484. [DOI: 10.1007/978-1-4939-3023-4_60] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Michelet D, Arslan O, Hilly J, Mangalsuren N, Brasher C, Grace R, Bonnard A, Malbezin S, Nivoche Y, Dahmani S. Intraoperative changes in blood pressure associated with cerebral desaturation in infants. Paediatr Anaesth 2015; 25:681-8. [PMID: 25929346 DOI: 10.1111/pan.12671] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intraoperative hypotension has been linked to poor postoperative neurological outcomes. However, the definition of hypotension remains controversial in children. We sought to determine arterial blood pressure threshold values associated with cerebral desaturation in infants. METHODS After ethics committee approval, infants younger than 3 months were included in this prospective observational study. Cerebral saturation was assessed using near-infrared spectroscopy. The primary goal of the study was to determine percentage reductions in intraoperative systolic blood pressure (SBP) and mean blood pressure (MBP) associated with decreases in cerebral blood oxygen saturation of >20%, when compared to baseline. Analyses were performed using a bootstrap receiving operator characteristic (ROC) curves with determination of the gray zone. RESULTS Sixty patients were recruited and 960 measurement points were recorded. Fifty-nine data points (6.1%) recorded cerebral desaturation of >20% when compared to baseline. The areas under the ROC curves were 0.79 (0.74-0.84) and 0.67 (0.6-0.75) for percentage decreases in SBP and MBP, respectively. Gray zone values with false-positive and negative rates <10% were SBP decreases of 20.5% and 37.5%, respectively, and MBP decreases of 15.5% and 44.5%, respectively. CONCLUSION Our results indicate that falls in noninvasive systolic blood pressure of <20% from baseline are associated with a <10% chance of cerebral desaturation in neonates and infants <3 months of age undergoing noncardiac surgery. As such, maintaining systolic blood pressure above this threshold value appears a valid clinical target.
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Affiliation(s)
- Daphné Michelet
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Ozkan Arslan
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Julie Hilly
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Nyamjargal Mangalsuren
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Christopher Brasher
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Robert Grace
- Department of Anesthesia, Intensive Care and Peri-operative Medicine, Cairns Hospital, Cairns, Qld, Australia
| | - Arnaud Bonnard
- Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France.,Department of General and Urological Surgery, AP-HP, Robert Debré University Hospital, Paris Diderot University, Paris, France
| | - Serge Malbezin
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Yves Nivoche
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France
| | - Souhayl Dahmani
- Department of Anesthesia, Intensive Care and Pain Management, AP-HP, Robert Debré University Hospital, Paris, France.,Paris Diderot University (Paris VII), Pres Paris Sorbonne Cité, Paris, France.,Department of Anesthesia, Intensive Care and Peri-operative Medicine, Cairns Hospital, Cairns, Qld, Australia.,University and Hospital Department PROTECT, Robert Debré University Hospital, Paris, France
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Abstract
As in adult anesthesia, morbidity and mortality could be significantly reduced in pediatric anesthesia in recent decades. This fact cannot conceal the fact that the incidence of anesthetic complications in children is still much more common than in adults and sometimes with a severe outcome. Newborns and infants in particular but also children with emergency interventions and severe comorbidities are at increased risk of potential complications. Typical complications in pediatric anesthesia are respiratory problems, medication errors, difficulties with the intravenous puncture and pulmonal aspiration. In the postoperative setting, nausea and vomiting, pain, and emergence delirium can be mentioned as typical complications. In addition to the systematic prevention of complications in pediatric anesthesia, it is important to quickly recognize disturbances of homeostasis and treat them promptly and appropriately. In addition to the expertise of the performing anesthesia team, the institutional structure in particular can improve quality and safety in pediatric anesthesia.
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Affiliation(s)
- K Becke
- Abteilung für Anästhesie und Intensivmedizin, Klinik Hallerwiese/Cnopf'sche Kinderklinik, Diakonie Neuendettelsau, St. Johannis-Mühlgasse 19, 90419, Nürnberg, Deutschland,
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Rhondali O, André C, Pouyau A, Mahr A, Juhel S, De Queiroz M, Rhzioual-Berrada K, Mathews S, Chassard D. Sevoflurane anesthesia and brain perfusion. Paediatr Anaesth 2015; 25:180-5. [PMID: 25224780 DOI: 10.1111/pan.12512] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/AIM To assess the impact of sevoflurane and anesthesia-induced hypotension on brain perfusion in children younger than 6 months. BACKGROUND Safe lower limit of blood pressure during anesthesia in infant is unclear, and inadequate anesthesia can lead to hypotension, hypocapnia, and low cerebral perfusion. Insufficient cerebral perfusion in infant during anesthesia is an important factor of neurological morbidity. In two previous studies, we assessed the impact of sevoflurane anesthesia on cerebral blood flow (CBF) by transcranial Doppler (TCD) and on brain oxygenation by NIRS, in children ≤2 years. As knowledge about consequences of anesthesia-induced hypotension on cerebral perfusion in children ≤6 months is scarce, we conducted a retrospective analysis to compare the data of CBF and brain oxygenation, in this specific population. METHODS We performed a retrospective analysis of data collected from our two previous studies. Baseline values of TCD or NIRS were recorded and then during sevoflurane anesthesia. From a database of 338 patients, we excluded all patients older than 6 months. Then, we compared physiological variables of TCD and NIRS population to ensure that the two groups were comparable. We compared rSO2 c and TCD measurements variation according to MAP value during sevoflurane anesthesia, using anova and Student-Newman-Keuls for posthoc analysis. RESULTS One hundred and eighty patients were included in the analysis. TCD and NIRS groups were comparable. CBF velocities (CBFV) or rSO2 c reflects a good cerebral perfusion when MAP is above 45 mmHg. When MAP is between 35 and 45 mmHg, CBFV variation reflects a reduction of CBF, but rSO2 c increase is the consequence of a still positive balance between CMRO2 and O2 supply. Below 35 mmHg of MAP during anesthesia, CBFV decrease and rSO2 c variation from baseline is low. For each category of MAP and for the two groups, etCo2 and expired fraction of sevoflurane (FeSevo) were comparable (anova P > 0.05). CONCLUSION In a healthy infant without dehydration, with normal PaCO2 and hemoglobin value, scheduled for short procedures, MAP is a good proxy of cerebral perfusion as we found that CBF assessed by CBFV and rSO2 c decreased proportionally with cerebral perfusion pressure. During 1 MAC sevoflurane anesthesia, maintaining MAP beyond 35 mmHg during anesthesia is probably safe and sufficient. But when MAP decreases below 35 mmHg, CBF decreases and rSO2 c variation from baseline is low despite CMRO2 reduction. In this situation, cerebral metabolic reserve is low and further changes of systemic conditions may be poorly tolerated by the brain.
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Affiliation(s)
- Ossam Rhondali
- Department of Pediatric Anesthesia, Hôpital Mère-Enfant, Lyon, France; Department of Pediatric Anesthesia, Hôpital Sainte Justine, Montréal, QC, Canada
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Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
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