Effects of hypotension and/or hypocapnia during sevoflurane anesthesia on perfusion and metabolites in the developing brain of piglets-a blinded randomized study

End-tidal carbon dioxide measurements as a surrogate to arterial carbon dioxide during pediatric laparoscopic surgeries: a prospective observational cohort study

BACKGROUND

Maintaining normocapnia during mechanical ventilation in anesthetized children during laparoscopic surgeries is highly recommended. There is a debate regarding the use of capnography (ETCO2) as a trend monitor for evaluation of arterial carbon dioxide levels (PaCO2). We analyzed the relationship between ETCO2 and PaCO2 with time in elective pediatric laparoscopic surgeries.

METHODS

This study was a prospective observational cohort analysis of 116 paired comparisons between PaCO2 and ETCO2 computed from 29 children (ASA I, 12...72 months). Arterial blood samples were withdrawn before, at 15...minutes and 30...minutes during pneumoperitoneum and 1...minute after deflation. ETCO2 value was recorded simultaneously, while arterial blood was withdrawn. PaCO2...ETCO2 relationship was evaluated by Pearson's correlation coefficients and Bland Altman Method of agreement.

RESULTS

Out of the 116 comparisons analyzed, a PaCO2...ETCO2 difference beyond 0 to ..± 5...mmHg was recorded in 71 comparisons (61.2%) with negative difference in 34 comparisons (29.3%). A positive significant correlation between PaCO2 and ETCO2 was recorded before (r...=...0.617, p...=...0.000) and at 15...minutes (r...=...0.582, p...=...0.001), with no significant correlation at 30 minutes (r...=...0.142, p...=...0.461), either after deflation (r...=...0.108, p...=...0.577). Bland-Altman plots showed agreement between ETCO2 and PaCO2 before inflation with mean PaCO2-ETCO2 difference 0.14........5.6...mmHg (limits of 95% agreement -10.84...11.2, simple linear regression testing p-value 0.971), with no agreement at 15...minutes (0.51........7.15, -13.5...14.5, p...=...0.000), 30...minutes. (2.62........7.83, -12.73...17.97, p...=...0.000), or after deflation (1.81........6.56, -10.93...14.55, p...=...0.015).

CONCLUSION

Usage of capnography as a trend monitor in pediatric laparoscopic surgeries may not be a reliable surrogate for PaCO2 levels.

TRIAL REGISTRATION

Clinical Trials. gov (Identifier: NCT03361657).

Assessment of Autoregulation of the Cerebral Circulation during Acute Lung Injury in a Neonatal Porcine Model

In neonates with acute lung injury (ALI), targeting lower oxygenation saturations is suggested to limit oxygen toxicity while maintaining vital organ function. Although thresholds for cerebral autoregulation are studied for the management of premature infants, the impact of hypoxia on hemodynamics, tissue oxygen consumption and extraction is not well understood in term infants with ALI. We examined hemodynamics, cerebral autoregulation and fractional oxygen extraction, as measured by near-infrared spectroscopy (NIRS) and blood gases, in a neonatal porcine oleic acid injury model of moderate ALI. We hypothesized that in ALI animals, cerebral oxygen extraction would be increased to a greater degree than kidney or gut oxygen extraction as indicative of the brain's adaptive efforts to increase cerebral oxygen extraction at the expense of splanchnic end organs. Fifteen anesthetized, ventilated 5-day-old neonatal piglets were divided into moderate lung injury by treatment with oleic acid or control (sham injection). The degree of lung injury was quantified at baseline and after establishment of ALI by blood gases, ventilation parameters and calculated oxygenation deficit, hemodynamic indices by echocardiography and lung injury score by ultrasound. PaCO2 was maintained constant during ventilation. Cerebral, renal and gut oxygenation was determined by NIRS during stepwise decreases in inspired oxygen from 50% to 21%, correlated with PaO2 and PvO2; changes in fractional oxygen extraction (ΔFOE) were calculated from NIRS and from regional blood gas samples. The proportion of cerebral autoregulation impairment attributable to blood pressure, and to hypoxemia, was calculated from autoregulation nomograms. ALI manifested as hypoxemia with increasing intrapulmonary shunt fraction, decreased lung compliance and increased resistance, and marked increase in lung ultrasound score. Brain, gut and renal NIRS, obtained from probes placed over the anterior skull, central abdomen and flank, respectively, correlated with concurrent SVC (brain) or IVC (gut, renal) PvO2 and SvO2. Cerebral autoregulation was impaired after ALI as a function of blood pressure at all FiO2 steps, but predominantly by hypoxemia at FiO2 < 40%. Cerebral ΔFOE was higher in ALI animals at all FiO2 steps. We conclude that in an animal model of neonatal ALI, cerebrovascular blood flow regulation is primarily dependent on oxygenation. There is not a defined oxygenation threshold below which cerebral autoregulation is impaired in ALI. Cerebral oxygen extraction is enhanced in ALI, reflecting compensation for exhausted cerebral autoregulation due to the degree of hypoxemia and/or hypotension, thereby protecting against tissue hypoxia.

[Perioperative Complications in Pediatric Anesthesia]

Perioperative complications are more frequent in younger children, especially under the age of 3 years and in infants. The anatomy and physiology of children cause more respiratory adverse events compared to adult patients. Respiratory adverse events account for 60% of all anesthetic complications. Main risk factors for respiratory adverse events are upper respiratory tract infections. Keeping the airway management as noninvasive as possible helps prevent major complications.Perioperative hypotension can compromise cerebral oxygenation, especially when hypocapnia and anemia are present. Congenital heart disease leads to a higher cardiovascular adverse event rate and should be diagnosed preoperatively whenever possible.Venous and arterial cannulation is more challenging in children and complications are more frequent even for experienced practitioners. Ultrasound is an essential tool for peripheral venous access as well as for central venous catheterization.Medication errors are more common in pediatric than in adult patients. Charts and electronic calculation of dosing can increase safety of prescriptions. Standardized storage of medications at all workplaces, avoiding look-alike medications in the same compartment and storing high-risk medications separately help prevent substitution errors.Emergence delirium and postoperative nausea and vomiting (PONV) are the most frequent postoperative adverse events. For diagnosing emergence delirium, the PAED scale is a helpful tool. Prevention of emergence delirium by pharmacological and general measures plays a key role for patient outcome. Routine prophylaxis of PONV above the age of 3 years is recommended.Frequency and severity of perioperative adverse events in pediatric anesthesia can be reduced by using algorithms and defined processes to allow for structured actions. Efficient communication and organization are mainstays for utilizing all medical options to reduce the risk of complications.

Systemic and regional cerebral perfusion in small infants undergoing minor lower abdominal surgery under awake caudal anaesthesia: An observational study

BACKGROUND

Infants undergoing general anaesthesia have an increased risk of severe respiratory and cardiovascular critical events. Awake caudal anaesthesia is an alternative for small infants undergoing minor lower abdominal surgery. While clinical experience has shown stable intra-operative haemodynamic conditions, there are no studies evaluating systemic and regional cerebral perfusion during such a procedure.

OBJECTIVES

The purpose of this study was to evaluate the effects of awake caudal anaesthesia on systemic and regional cerebral perfusion in small infants.

DESIGN

A prospective observational cohort study.

SETTING

Clinic of Anaesthesiology, University Children's Hospital, between November 2017 and June 2018.

PATIENTS

Twenty small infants (postmenstrual age 36 to 54 weeks, weight 1800 to 5700 g) scheduled for lower abdominal surgery under awake caudal anaesthesia were enrolled in this study.

INTERVENTION

Standard monitoring was expanded to include cardiac index using electrical velocimetry and regional cerebral oxygen saturation using near infrared spectroscopy. The caudal block was performed with 0.3% ropivacaine 1 ml kg Hypotension was defined as mean arterial blood pressure (BP) less than 35 mmHg and regional cerebral desaturation as regional cerebral oxygen saturation less than 80% of baseline.

MAIN OUTCOMES

Mean arterial BP, cardiac index and regional cerebral oxygen saturation parameters under awake caudal anaesthesia.

RESULTS

Mean arterial BP, cardiac index and regional cerebral oxygen saturation remained above the predefined lower limits. No episodes of hypotension or regional cerebral desaturation were observed. Operation time was 35 ± 13 (range 20 to 71) min. The infants were discharged to the neonatal ward after the end of surgery, and milk was fed 22 ± 15 (range 6 to 55) min thereafter. Five preterm infants experienced self-limiting episodes of apnoea intra-operatively.

CONCLUSION

The current study shows that awake caudal anaesthesia does not impair systemic and regional cerebral perfusion in small infants.

TRIAL REGISTRATION

German registry of clinical studies (DRKS-ID: 800015742).

[Near-infrared spectroscopy : Technique, development, current use and perspectives]

Near-infrared spectroscopy (NIRS) has been available in research and clinical practice for more than four decades. Recently, there have been numerous publications and substantial developments in the field. This article describes the clinical application of NIRS in relation to current guidelines, with a focus on pediatric and cardiac anesthesia. It discusses technical and physiological principles, pitfalls in clinical use and presents (patho)physiological influencing factors and derived variables, such as fractional oxygen extraction (FOE) and the cerebral oxygen index (COx). Recommendations for the interpretation of NIRS values in connection with influencing factors, such as oxygen transport capacity, gas exchange and circulation as well as an algorithm for cardiac anesthesia are presented. Limitations of the method and the lack of comparability of values from different devices as well as generally accepted standard values are explained. Technical differences and advantages compared to pulse oxymetry and transcranial Doppler sonography are illuminated. Finally, the prognostic significance and requirements for future clinical studies are discussed.

Effects of moderate and severe hypocapnia on intracerebral perfusion and brain tissue oxygenation in piglets

BACKGROUND

Hypocapnia is a common alteration during anesthesia in neonates.

AIM

To investigate the effects of hypocapnia and hypocapnia combined with hypotension (HCT) on cerebral perfusion and tissue oxygenation in anesthetized piglets.

METHOD

Thirty anesthetized piglets were randomly allocated to groups: moderate hypocapnia (mHC), severe hypocapnia (sHC), and HCT. Cerebral monitoring comprised a tissue oxygen partial pressure and a laser Doppler probe inserted into the brain tissue as well as a near-infrared spectroscopy (NIRS) sensor placed on the skin, measuring regional oxygen saturation. Hypocapnia was induced by hyperventilation (target PaCO₂ mHC: 3.7-4; sHC: 3.1-3.3 kPa) and hypotension by blood withdrawal and nitroprusside infusion (mean blood pressure: 35-38 mm Hg). Data were analyzed at baseline, during (Tr20, Tr40, Tr60) and after (Post20, Post40, Post60) treatment.

RESULTS

Compared to baseline, tissue oxygen partial pressure decreased significantly and equally during all treatments (mean [SD] at baseline: mHC 35.7 [32.45]; sHC: 28.1 [20.24]; HCT 25.4 [10.3] and at Tr60: mHC: 29.9 [27.36]; sHC: 22.2 [18.37]; HCT: 18.4 [9.5] mm Hg). Decreased laser Doppler flow was detected with all treatments at Tr20 (mHC: 0.9 [0.18]; sHC: 0.88 [0.15]; HCT: 0.97 [0.13] proportion from baseline). Independently of group, regional oxygen saturation varied only after reverting and not during treatment. Blood lactate, pH, HCO₃^- , and PaO₂ increased during treatment with no differences between groups.

CONCLUSION

This animal model revealed reduced cerebral blood flow and brain tissue oxygenation during hypocapnia without detectable changes in regional oxygen saturation as measured by NIRS. Changes occurred as early as during moderate hypocapnia.

Effects of moderate and severe arterial hypotension on intracerebral perfusion and brain tissue oxygenation in piglets

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.

Effects of isoflurane, sevoflurane, propofol and alfaxalone on brain metabolism in dogs assessed by proton magnetic resonance spectroscopy (1H MRS)

Background

The purpose of this study was to determine the effects of isoflurane, sevoflurane, propofol and alfaxalone on the canine brain metabolite bioprofile, measured with single voxel short echo time proton magnetic resonance spectroscopy at 3 Tesla. Ten adult healthy Beagle dogs were assigned to receive isoflurane, sevoflurane, propofol and alfaxalone at 3 different dose rates each in a randomized cross-over study design. Doses for isoflurane, sevoflurane, propofol and alfaxalone were F_E’Iso 1.7 vol%, 2.1 vol%, 2.8 vol%, F_E’Sevo 2.8 vol%, 3.5 vol% and 4.7 vol%, 30, 45 and 60 mg kg^− 1 h^− 1 and 10, 15 and 20 mg kg^− 1 h^− 1 respectively. A single voxel Point Resolved Spectroscopy Sequence was performed on a 3 T MRI scanner in three brain regions (basal ganglia, parietal and occipital lobes). Spectral data were analyzed with LCModel. Concentration of total N-acetylaspartate (tNAA), choline, creatine, inositol and glutamine and glutamate complex (Glx) relative to water content was obtained. Plasma concentration of lactate, glucose, triglycerides, propofol and alfaxalone were determined. Statistics were performed using repeated measures ANOVA or Wilcoxon Sign Rank test with alpha = 5%.

Results

Plasma glucose increased with isoflurane, sevoflurane and alfaxalone but decreased with propofol. Plasma lactate increased with all anesthetics (isoflurane > sevoflurane > propofol > alfaxalone). Cerebral lactate could not be detected. Only minor changes in cerebral metabolite concentrations of tNAA, choline, inositol, creatine and Glx occurred with anesthetic dose changes.

Conclusion

The metabolomic profile detected with proton magnetic resonance spectroscopy at 3 Tesla of canine brain showed only minor differences between doses and anesthetics related to tNAA, choline, creatine, inositol and Glx.