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Bong CL, Balanza GA, Khoo CEH, Tan JSK, Desel T, Purdon PL. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Anesth Analg 2023; 137:108-123. [PMID: 36729437 DOI: 10.1213/ane.0000000000006267] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The major therapeutic end points of general anesthesia include hypnosis, amnesia, and immobility. There is a complex relationship between general anesthesia, responsiveness, hemodynamic stability, and reaction to noxious stimuli. This complexity is compounded in pediatric anesthesia, where clinicians manage children from a wide range of ages, developmental stages, and body sizes, with their concomitant differences in physiology and pharmacology. This renders anesthetic requirements difficult to predict based solely on a child's age, body weight, and vital signs. Electroencephalogram (EEG) monitoring provides a window into children's brain states and may be useful in guiding clinical anesthesia management. However, many clinicians are unfamiliar with EEG monitoring in children. Young children's EEGs differ substantially from those of older children and adults, and there is a lack of evidence-based guidance on how and when to use the EEG for anesthesia care in children. This narrative review begins by summarizing what is known about EEG monitoring in pediatric anesthesia care. A key knowledge gap in the literature relates to a lack of practical information illustrating the utility of the EEG in clinical management. To address this gap, this narrative review illustrates how the EEG spectrogram can be used to visualize, in real time, brain responses to anesthetic drugs in relation to hemodynamic stability, surgical stimulation, and other interventions such as cardiopulmonary bypass. This review discusses anesthetic management principles in a variety of clinical scenarios, including infants, children with altered conscious levels, children with atypical neurodevelopment, children with hemodynamic instability, children undergoing total intravenous anesthesia, and those undergoing cardiopulmonary bypass. Each scenario is accompanied by practical illustrations of how the EEG can be visualized to help titrate anesthetic dosage to avoid undersedation or oversedation when patients experience hypotension or other physiological challenges, when surgical stimulation increases, and when a child's anesthetic requirements are otherwise less predictable. Overall, this review illustrates how well-established clinical management principles in children can be significantly complemented by the addition of EEG monitoring, thus enabling personalized anesthesia care to enhance patient safety and experience.
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Affiliation(s)
- Choon Looi Bong
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Gustavo A Balanza
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charis Ern-Hui Khoo
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Josephine Swee-Kim Tan
- From the Department of Pediatric Anesthesia, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Tenzin Desel
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick Lee Purdon
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Smith HAB, Besunder JB, Betters KA, Johnson PN, Srinivasan V, Stormorken A, Farrington E, Golianu B, Godshall AJ, Acinelli L, Almgren C, Bailey CH, Boyd JM, Cisco MJ, Damian M, deAlmeida ML, Fehr J, Fenton KE, Gilliland F, Grant MJC, Howell J, Ruggles CA, Simone S, Su F, Sullivan JE, Tegtmeyer K, Traube C, Williams S, Berkenbosch JW. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med 2022; 23:e74-e110. [PMID: 35119438 DOI: 10.1097/pcc.0000000000002873] [Citation(s) in RCA: 151] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
RATIONALE A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. OBJECTIVE To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. DESIGN The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. METHODS Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. RESULTS The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. CONCLUSIONS The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.
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Affiliation(s)
- Heidi A B Smith
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
- Division of Pediatric Cardiac Anesthesiology, Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, TN
| | - James B Besunder
- Division of Pediatric Critical Care, Akron Children's Hospital, Akron, OH
- Department of Pediatrics, Northeast Ohio Medical University, Akron, OH
| | - Kristina A Betters
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, OK
- The Children's Hospital at OU Medical Center, Oklahoma City, OK
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anne Stormorken
- Pediatric Critical Care, Rainbow Babies Children's Hospital, Cleveland, OH
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH
| | - Elizabeth Farrington
- Betty H. Cameron Women's and Children's Hospital at New Hanover Regional Medical Center, Wilmington, NC
| | - Brenda Golianu
- Division of Pediatric Anesthesia and Pain Management, Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
| | - Aaron J Godshall
- Department of Pediatrics, AdventHealth For Children, Orlando, FL
| | - Larkin Acinelli
- Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Christina Almgren
- Lucile Packard Children's Hospital Stanford Pain Management, Palo Alto, CA
| | | | - Jenny M Boyd
- Division of Pediatric Critical Care, N.C. Children's Hospital, Chapel Hill, NC
- Division of Pediatric Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michael J Cisco
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA
| | - Mihaela Damian
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Mary L deAlmeida
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA
- Division of Pediatric Critical Care, Emory University School of Medicine, Atlanta, GA
| | - James Fehr
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA
- Department of Anesthesiology, Lucile Packard Children's Hospital, Palo Alto, CA
| | | | - Frances Gilliland
- Division of Cardiac Critical Care, Johns Hopkins All Children's Hospital, St Petersburg, FL
- College of Nursing, University of South Florida, Tampa, FL
| | - Mary Jo C Grant
- Primary Children's Hospital, Pediatric Critical Care Services, Salt Lake City, UT
| | - Joy Howell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | | | - Shari Simone
- University of Maryland School of Nursing, Baltimore, MD
- Pediatric Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD
| | - Felice Su
- Lucile Packard Children's Hospital Stanford at Stanford Children's Health, Palo Alto, CA
- Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Janice E Sullivan
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chani Traube
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, NY
| | - Stacey Williams
- Division of Pediatric Critical Care, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - John W Berkenbosch
- "Just For Kids" Critical Care Center, Norton Children's Hospital, Louisville, KY
- Division of Pediatric Critical Care, University of Louisville School of Medicine, Louisville, KY
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Lee AC, Redding AT, Tjia I, Rana MS, Heitmiller E. Self-reported awareness during general anesthesia in pediatric patients: A study from Wake Up Safe. Paediatr Anaesth 2021; 31:676-685. [PMID: 33709457 DOI: 10.1111/pan.14176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Awareness under general anesthesia occurs rarely, but can result in emotional trauma. Although well-studied in adults, there is a paucity of data on unintentional awareness in children. AIMS This case series examines instances of self-reported awareness registered with Wake Up Safe, a patient safety organization that maintains a database of adverse events in pediatric anesthesia. METHODS Cases of self-reported intraoperative awareness submitted to Wake Up Safe from January 1, 2010 to May 31, 2020 were reviewed for circumstances, causative factors, and level of harm. RESULTS Fourteen cases of self-reported intraoperative awareness out of 555 360 cases in patients aged 5-20 years were noted during the study period. Overall incidence of awareness was 2.52 (95% CI: 1.38-4.23) cases per 100 000 patients, or approximately 1:40 000. Self-reported intraoperative awareness was more frequently associated with cardiac and gastrointestinal endoscopic procedures. Incidence for cardiac procedures was 20.34 (95% CI: 8.18-41.90) cases per 100 000 patients. Incidence for gastrointestinal endoscopic procedures was 7.74 (95% CI: 1.60-22.62) cases per 100 000 patients. Most patients were assessed to have suffered harm. CONCLUSIONS Self-reported intraoperative awareness is a rare complication in pediatric patients that has implications for harm. Compared to awareness cases elicited by a questionnaire method, cases of self-reported awareness during general anesthesia may represent those that have a greater impact. A preoperative discussion of intraoperative awareness should be considered for procedures that carry a higher likelihood of awareness in order to mitigate harm.
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Affiliation(s)
- Angela C Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Amanda Townsend Redding
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Imelda Tjia
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Md Sohel Rana
- Joseph E. Robert, Jr., Center for Surgical Care, Children's National Hospital, Washington, District of Columbia, USA
| | - Eugenie Heitmiller
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine, Washington, District of Columbia, USA
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Lee Y, Banooni A, Yuki K, Staffa SJ, DiNardo JA, Brown ML. Incidence and predictors of postoperative nausea and vomiting in children undergoing electrophysiology ablation procedures. Paediatr Anaesth 2020; 30:147-152. [PMID: 31869854 DOI: 10.1111/pan.13797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative nausea and vomiting remains a significant concern for patients undergoing general anesthesia for percutaneous radiofrequency catheter ablation and cryoablation for tachyarrhythmias. AIM Our objective was to examine the incidence and risk factors for nausea and vomiting in the recovery room. METHODS Children aged > 2 and ≤ 18 years who underwent general anesthesia for a percutaneous radiofrequency catheter ablation or cryoablation for a tachyarrhythmia between January 1, 2013, and January 1, 2016, were retrospectively reviewed. Outcomes included postoperative nausea, vomiting, and a composite of postoperative nausea and vomiting in the recovery room. RESULTS We identified 611 patients with a mean age of 13.3 ± 3.9 years, 54.5% male, and a mean length of anesthesia was 3.9 ± 1.0 hours. Vomiting or retching in the postanesthesia care unit occurred in 7.4% of patients and nausea in an additional 12.4%. A composite of nausea and vomiting occurred in 95 patients (15.5%). On multivariable analysis, a subhypnotic propofol infusion (OR 0.45, 95% CI 0.23-0.88, P = .019) and shorter anesthetic duration (OR 0.81 per 30 minutes, 95% CI 0.70-0.94, P = .006) were independently associated with less vomiting in the recovery room. A history of PONV (OR 2.24, 95% CI 1.24-4.05, P = .007) was independently associated with a composite of nausea and vomiting in the recovery room. CONCLUSIONS A shorter anesthetic time and a subhypnotic propofol infusion were predictive of a lower rate of postoperative vomiting in patients undergoing general anesthesia for electrophysiologic ablation procedures.
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Affiliation(s)
- Ye Lee
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Andrew Banooni
- Department of Anesthesiology, Beaumont Hospital, Royal Oak, MI, USA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Morgan L Brown
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Davis BM, Brenton J, Davis S, Shamsher E, Sisa C, Grgic L, Cordeiro MF. Assessing anesthetic activity through modulation of the membrane dipole potential. J Lipid Res 2017; 58:1962-1976. [PMID: 28818873 PMCID: PMC5625120 DOI: 10.1194/jlr.m073932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 08/09/2017] [Indexed: 12/21/2022] Open
Abstract
There is great individual variation in response to general anesthetics (GAs) leading to difficulties in optimal dosing and sometimes even accidental awareness during general anesthesia (AAGA). AAGA is a rare, but potentially devastating, complication affecting between 0.1% and 2% of patients undergoing surgery. The development of novel personalized screening techniques to accurately predict a patient’s response to GAs and the risk of AAGA remains an unmet clinical need. In the present study, we demonstrate the principle of using a fluorescent reporter of the membrane dipole potential, di-8-ANEPPs, as a novel method to monitor anesthetic activity using a well-described inducer/noninducer pair. The membrane dipole potential has previously been suggested to contribute a novel mechanism of anesthetic action. We show that the fluorescence ratio of di-8-ANEPPs changed in response to physiological concentrations of the anesthetic, 1-chloro-1,2,2-trifluorocyclobutane (F3), but not the structurally similar noninducer, 1,2-dichlorohexafluorocyclobutane (F6), to artificial membranes and in vitro retinal cell systems. Modulation of the membrane dipole provides an explanation to overcome the limitations associated with the alternative membrane-mediated mechanisms of GA action. Furthermore, by combining this technique with noninvasive retinal imaging technologies, we propose that this technique could provide a novel and noninvasive technique to monitor GA susceptibility and identify patients at risk of AAGA.
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Affiliation(s)
| | - Jonathan Brenton
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom
| | - Sterenn Davis
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom
| | - Ehtesham Shamsher
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom
| | - Claudia Sisa
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom
| | - Ljuban Grgic
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom
| | - M Francesca Cordeiro
- University College London Institute of Ophthalmology, London EC1V 9EL, United Kingdom .,Western Eye Hospital, Imperial College Healthcare National Health Service Trust, and Imperial College Ophthalmic Research Group, Imperial College London, London NW1 5QH, United Kingdom
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