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Colori A, Ackwerh R, Chang YC, Cody K, Dunlea C, Gains JE, Gaunt T, Gillies CMS, Hardy C, Lalli N, Lim PS, Soto C, Gaze MN. Paediatric radiotherapy in the United Kingdom: an evolving subspecialty and a paradigm for integrated teamworking in oncology. Br J Radiol 2024; 97:21-30. [PMID: 38263828 PMCID: PMC11027255 DOI: 10.1093/bjr/tqad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 01/25/2024] Open
Abstract
Many different malignancies occur in children, but overall, cancer in childhood is rare. Survival rates have improved appreciably and are higher compared with most adult tumour types. Treatment schedules evolve as a result of clinical trials and are typically complex and multi-modality, with radiotherapy an integral component of many. Risk stratification in paediatric oncology is increasingly refined, resulting in a more personalized use of radiation. Every available modality of radiation delivery: simple and advanced photon techniques, proton beam therapy, molecular radiotherapy, and brachytherapy, have their place in the treatment of children's cancers. Radiotherapy is rarely the sole treatment. As local therapy, it is often given before or after surgery, so the involvement of the surgeon is critically important, particularly when brachytherapy is used. Systemic treatment is the standard of care for most paediatric tumour types, concomitant administration of chemotherapy is typical, and immunotherapy has an increasing role. Delivery of radiotherapy is not done by clinical or radiation oncologists alone; play specialists and anaesthetists are required, together with mould room staff, to ensure compliance and immobilization. The support of clinical radiologists is needed to ensure the correct interpretation of imaging for target volume delineation. Physicists and dosimetrists ensure the optimal dose distribution, minimizing exposure of organs at risk. Paediatric oncology doctors, nurses, and a range of allied health professionals are needed for the holistic wrap-around care of the child and family. Radiographers are essential at every step of the way. With increasing complexity comes a need for greater centralization of services.
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Affiliation(s)
- Amy Colori
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Raymond Ackwerh
- Department of Anaesthetics, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Yen-Ch’ing Chang
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Kristy Cody
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Cathy Dunlea
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Jennifer E Gains
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Trevor Gaunt
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Callum M S Gillies
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Claire Hardy
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Narinder Lalli
- Department of Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Pei S Lim
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
| | - Carmen Soto
- Department of Paediatric Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2BU, United Kingdom
| | - Mark N Gaze
- Department of Oncology, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, United Kingdom
- Department of Oncology, UCL Cancer Institute, University College London, London, WC1E 6DD, United Kingdom
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Hansen TG, Vieri J, Børke WB, Castellheim AG. Outcome following anaesthesia in infancy in the Nordic countries: Subgroup analysis of the NECTARINE study. Acta Anaesthesiol Scand 2023; 67:714-723. [PMID: 36918742 DOI: 10.1111/aas.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/16/2023]
Abstract
INTRODUCTION The neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective observational study reported an incidence of 35.2% of critical events requiring intervention during 6542 anaesthetics in 5609 infants up to 60 weeks postmenstrual age (PMA) from 165 centres in 31 European countries. METHODS Sub-analysis of the cohort from the Nordic countries (8% of the entire cohort) was conducted. Secondary aims were to describe the Nordic countries' anaesthetic practices and compare morbidity and mortality with the overall European cohort. RESULTS Eleven Nordic centres recruited 447 infants (66% males, 37.3% born preterm and 45% had congenital anomalies) undergoing anaesthesia for 530 surgical or non-surgical procedures at 25-60 weeks PMA. Perioperative critical events triggered interventions in 228/530 (43%) cases. Hypotension (12.6%) or hypoxaemia (11.7%) were more common in younger patients and those with co-morbidities. Hypo/hypercapnia occurred in 1.5%/4.7% of cases. More than two attempts for intubation were required in 13 (2.9%) infants (max three attempts). Distribution of ASA-Physical Status Scores was similar to the total European cohort (40% was ASA > 2). A total of 236/530 (44.5%) patients were admitted to the postoperative intensive care unit. Thirty-day morbidity (complications in 87/447 = 19.5%) and mortality (8/447, 1.8%) did not differ from the overall European cohort. Hospital re-admissions were significant up to 90 days (98/447 = 21.9%). CONCLUSIONS In Nordic countries, anaesthesia in young infant children is resource-demanding, and perioperative critical events and co-morbidities are common. Thirty-day morbidity and mortality data in the Nordic countries did not differ from the overall European cohort.
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Affiliation(s)
- Tom G Hansen
- Department of Anaesthesiology and Intensive Care - Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jenny Vieri
- Department of Prehospital Emergency Care, Pain Management and Anaesthesiology, Tampere University Hospital, Tampere, Finland
| | - Wenche Bakken Børke
- Division of Emergencies and Critical Care Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Albert Gyllencreutz Castellheim
- Department of Anaesthesiology and Intensive Care Medicine, Queen Silvia Children Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Olbrecht VA, Engelhardt T, Tobias JD. Beyond mortality: definitions and benchmarks of outcome standards in paediatric anaesthesiology. Curr Opin Anaesthesiol 2023; 36:318-323. [PMID: 36745075 DOI: 10.1097/aco.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review the evolution of safety and outcomes in paediatric anaesthesia, identify gaps in quality and how these gaps may influence outcomes, and to propose a plan to address these challenges through the creation of universal outcome standards and a paediatric anaesthesia designation programme. RECENT FINDINGS Tremendous advancements in the quality and safety of paediatric anaesthesia care have occurred since the 1950 s, resulting in a near absence of documented mortality in children undergoing general anaesthesia. However, the majority of data we have on paediatric anaesthesia outcomes come from specialized academic institutions, whereas most children are being anaesthetized outside of free-standing children's hospitals. SUMMARY Although the literature supports dramatic improvements in patient safety during anaesthesia, there are still gaps, particularly in where a child receives anaesthesia care and in quality outcomes beyond mortality. Our goal is to increase equity in care, create standardized outcome measures in paediatric anaesthesia and build a verification system to ensure that these targets are accomplished. The time has come to benchmark paediatric anaesthesia care and increase quality received by all children with universal measures that go beyond simply mortality.
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Affiliation(s)
- Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Thomas Engelhardt
- Department of Paediatric Anaesthesia, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and the Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine
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McGregor K, McConnell C. Principles of anaesthesia for term neonates. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Harmonising paediatric anaesthesia training in Europe: Proposal of a roadmap. Ugeskr Laeger 2022; 39:642-645. [PMID: 35822223 DOI: 10.1097/eja.0000000000001694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Neonates have a high risk of perioperative morbidity and mortality. The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) investigated the anesthesia practice, complications and perioperative morbidity and mortality in neonates and infants <60 weeks post menstrual age requiring anesthesia across 165 European hospitals. The goal of this review is to highlight recent publications in the context of the NECTARINE findings and subsequent changes in clinical practice. RECENT FINDINGS A perioperative triad of hypoxia, anemia, and hypotension is associated with an increased overall mortality at 30 days. Hypoxia is frequent at induction and during maintenance of anesthesia and is commonly addressed once oxygen saturation fall below 85%.Blood transfusion practices vary widely variable among anesthesiologists and blood pressure is only a poor surrogate of tissue perfusion. Newer technologies, whereas acknowledging important limitations, may represent the currently best tools available to monitor tissue perfusion. Harmonization of pediatric anesthesia education and training, development of evidence-based practice guidelines, and provision of centralized care appear to be paramount as well as pediatric center referrals and international data collection networks. SUMMARY The NECTARINE provided new insights into European neonatal anesthesia practice and subsequent morbidity and mortality.Maintenance of physiological homeostasis, optimization of oxygen delivery by avoiding the triad of hypotension, hypoxia, and anemia are the main factors to reduce morbidity and mortality. Underlying and preexisting conditions such as prematurity, congenital abnormalities carry high risk of morbidity and mortality and require specialist care in pediatric referral centers.
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Otte A, Schindler E, Neumann C. [Hemodynamic monitoring in pediatric anesthesia]. DIE ANAESTHESIOLOGIE 2022; 71:417-425. [PMID: 35925144 DOI: 10.1007/s00101-022-01125-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Perioperative mortality and morbidity in childhood essentially depend on the quality of the anesthesia. The Safe Anesthesia for every Tot (SafeTots) initiative takes this into account and has defined normotension, normovolemia and normal heart rate as quality criteria in pediatric anesthesia. Appropriate monitoring of pediatric hemodynamics is necessary to fulfil these criteria. This article provides an overview of currently used methods and techniques for instrumental and non-instrumental cardiovascular monitoring in children. The current study situation, recommendations and guidelines on the application as well as practical aspects of the measurement methods are explained as far as possible. For a better understanding, procedures not routinely used in clinical practice are described in more detail.
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Affiliation(s)
- Andreas Otte
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland.
| | - Ehrenfried Schindler
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Claudia Neumann
- Klinik für Anästhesiologie und operative Intensivmedizin (KAI), Universitätsklinikum Bonn (UKB), Venusberg-Campus 1, 53127, Bonn, Deutschland
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Patient- and Physician-Reported Outcome of Combined Fractional CO2 and Pulse Dye Laser Treatment for Hypertrophic Scars in Children. Ann Plast Surg 2021; 85:237-244. [PMID: 32349082 DOI: 10.1097/sap.0000000000002377] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypertrophic scars are commonly seen in children and associated with pruritus, pain, functional impairment, and aesthetic disfigurement. Ablative fractional CO2 and pulse dye laser are emerging techniques to improve scar quality. Only limited data are available on children, nonburn scars, and patient-reported outcome. We aimed to investigate safety and outcome of repeated laser therapy for hypertrophic scars originating from burns and other conditions by means of patient- and physician-reported outcome measures. METHODS This was a retrospective before-after analysis of laser treatments in children with hypertrophic scars. Outcome was measured using Patient and Observer Scar Assessment Scale, Vancouver Scar Scale and Itch Man Scale. With respect to safety, laser- and anesthesia-related complications were analyzed. RESULTS Seventeen patients, aged 11.37 ± 4.82 years with 27 scars, underwent 102 distinct laser treatments, mainly combined CO2 and pulse dye laser (94%), with few CO2 only (6%). Vancouver Scar Scale total score before the first and after the first session decreased significantly from 7.65 ± 2.12 to 4.88 ± 1.73; Patient and Observer Scar Assessment Scale observer overall opinion also dropped from 5.88 ± 1.57 to 4.25 ± 1.70. Pruritus improved significantly. Patient age and timing of laser intervention did not have an impact on treatment response. Complications related to laser treatment were seen in 2% (wound infection, n = 2) and to anesthesia in 4% (insignificant n = 2, minor n = 1). CONCLUSIONS Combined laser therapy significantly improves quality, pain, and pruritus of hypertrophic scars in children. When provided by experienced laser and anesthesia teams, it is safe with a low rate of complications.
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Waspe J, Chico TJA, Hansen TG. Applying the adverse outcome pathway concept to questions in anaesthetic neurotoxicity. Br J Anaesth 2021; 126:1097-1102. [PMID: 33888301 DOI: 10.1016/j.bja.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/04/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Jennifer Waspe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK; The University of Sheffield, Sheffield, UK.
| | - Timothy J A Chico
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK
| | - Tom G Hansen
- Department of Anaesthesia and Intensive Care, University Hospital Odense, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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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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Shen AH, Tevlin R, Kwan MD, Ho OH, Fox PM. Neonatal Compartment Syndrome and Compound Presentation at Birth. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:166-170. [PMID: 35415493 PMCID: PMC8991503 DOI: 10.1016/j.jhsg.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/06/2020] [Indexed: 11/07/2022] Open
Abstract
Neonatal compartment syndrome is a rare condition. Early diagnosis and timely surgical intervention are paramount to optimize outcome. Time to fasciotomy is the most important prognostic factor. The purposes of this study were to describe a case presentation of neonatal compartment syndrome associated with a compound birth presentation and to perform a literature review. In this case, the neonate’s fingers were noted to be present on maternal cervical examination 24 hours before delivery. The patient then was noted to have a sentinel skin lesion. A diagnosis of neonatal compartment syndrome was suspected, and she underwent urgent fasciotomy. Literature review identified a total of 60 patients from 26 studies. Most patients were managed operatively. All patients presented with a sentinel skin lesion, emphasizing the importance of this clinical sign in diagnosis. Manometry is not routinely performed and no standards are available for acceptable pressure gradients.
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Manley OWG, Wormald JCR, Furniss D. The changing shape of hand trauma: an analysis of Hospital Episode Statistics in England. J Hand Surg Eur Vol 2019; 44:532-536. [PMID: 30764703 DOI: 10.1177/1753193419828986] [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] [Indexed: 02/03/2023]
Abstract
Hospital Episode Statistics (HES) include freely accessible records of all hospital episodes in England. We analysed HES from 1998-1999 to 2014-2015 for diagnoses of hand fractures, tendon injuries, nerve injuries, blood vessel injuries, traumatic amputations and nail bed injuries. Population data were used to calculate the incidence. The overall incidence of the injuries increased from 70 to 110 per 100,000. There were especially large increases in the incidence of fractures in the over 75 years age group and nail bed injuries in the 0-14 years age group. The incidence of nerve injuries also increased. We conclude from this study that HES is a useful tool. The information from HES may help plan service provision and also highlight important clinical problems that may benefit from further research.
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Affiliation(s)
- Oliver W G Manley
- 1 Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Justin C R Wormald
- 1 Department of Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK.,2 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Dominic Furniss
- 2 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Hansen TG, Børke WB, Isohanni MH, Castellheim A. Incidence of severe critical events in paediatric anaesthesia in Scandinavia: Secondary analysis of Anaesthesia PRactice In Children Observational Trial (APRICOT). Acta Anaesthesiol Scand 2019; 63:601-609. [PMID: 30729498 DOI: 10.1111/aas.13333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/07/2018] [Accepted: 01/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Anaesthesia PRactice In Children Observational Trial (APRICOT) in 261 European hospitals revealed a 5.2% incidence of severe critical events in the perioperative period and wide variability in practice. METHODS A sub-analysis of the Scandinavian data was undertaken to investigate differences from the rest of Europe in the incidence and nature of perioperative severe critical events and to attempt to identify areas for quality improvement. FINDINGS In the Scandinavian cohorts of 1520 paediatric patients out of 31 127 patients, the overall incidence of perioperative severe critical events was lower than the rest of Europe (4.4% (95% CI [3.5-5.6]) vs 5.2% (95% CI [5.0-5.5]); RR 0.57), albeit the incidence varied across countries. There was a lower rate of bronchospasm (0.9%), stridor (1.1%) and cardiovascular instability (0.9%) than the rest of Europe. The proportion of bronchospasm events occurring at induction was 0.13% in Scandinavian cohort which was less than the rest of Europe (1.2%). The proportion of sicker patients where less experienced teams were managing the care was notably lower in Scandinavia than in the rest of Europe (14.4% vs 20.4% of the American Society of Anesthesiologists Physical Status Classification System Score (ASA-PS III and 8.3% vs 12.8% of the ASA-PS IV. Cardiovascular instability was lower in Scandinavia (0.92%) compared to Europe (1.9%). The incidence of drug errors was low in both the overall APRICOT (0.2%) and in Scandinavia (0.3%). There were no deaths. INTERPRETATION This sub-analysis shows that current Scandinavia paediatric perioperative clinical practice compares favourably with the rest of Europe. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk groups of patients in Scandinavia. Whether this cohort of anaesthetized children is truly representative of the entire Scandinavia countries is unknown. Areas for quality improvement include: standardisation of the definition of severe critical events, increased reporting, development of evidence-based protocols for the management of severe critical events, development and rational implementation of paediatric perioperative risk assessment scores, implementation of current best practice in the provision of competent paediatric anaesthesia service in Europe, development of specific training and ensuring maintenance skills in paediatric anaesthesia. Furthermore, based on data from the original Apricot paper children under the age of 3 years and ASA-PS III and IV patients should not be anaesthetised without direct supervision of a specialist in paediatric anaesthesia. Given the sample size of the Scandinavian cohort this conclusion cannot be investigated further.
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Affiliation(s)
- Tom G. Hansen
- Department of Anaesthesiology & Intensive Care—Paediatric SectionOdense University Hospital Odense Denmark
- Department of Clinical Research—Anaesthesiology University of Southern Denmark Odense Denmark
| | - Wenche Bakken Børke
- Division of Emergencies and Critical Care Medicine Oslo University Hospital Rikshospitalet Oslo Norway
| | - Mika H. Isohanni
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Division of Anaesthesiology, Eye and Ear Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Albert Castellheim
- Department of Anaesthesiology and Intensive Care Medicine, Queen Silvia Children Hospital Sahlgrenska University Hospital Gothenburg Sweden
- Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
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Incidence of peri-operative paediatric cardiac arrest and the influence of a specialised paediatric anaesthesia team. Eur J Anaesthesiol 2019; 36:55-63. [DOI: 10.1097/eja.0000000000000863] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Engelhardt T, Ayansina D, Bell GT, Oshan V, Rutherford JS, Morton NS. Incidence of severe critical events in paediatric anaesthesia in the United Kingdom: secondary analysis of the anaesthesia practice in children observational trial (APRICOT study). Anaesthesia 2018; 74:300-311. [PMID: 30536369 DOI: 10.1111/anae.14520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 12/20/2022]
Abstract
The anaesthesia practice in children observational trial of 31,127 patients in 261 European hospitals revealed a high (5.2%) incidence of severe critical events in the peri-operative period and wide variability in practice. A sub-analysis of the UK data was undertaken to investigate differences compared with the non-UK cohort in the incidence and nature of peri-operative severe critical events and to attempt to identify areas for quality improvement. In the UK cohort of 7040 paediatric patients from 43 hospitals, the overall incidence of peri-operative severe critical events was lower than in the non-UK cohort (3.3%, 95%CI: 2.9-3.8 vs. 5.8%, 95%CI: 5.5-6.1, RR 0.57, p < 0.001). There was a lower rate of bronchospasm (RR 0.22, 95%CI: 0.14-0.33; p < 0.001), stridor (RR 0.42, 95%CI: 0.28-0.65; p < 0.001) and cardiovascular instability (RR 0.69, 95%CI: 0.55-0.86; p = 0.001) than in the non-UK cohort. The proportion of sicker patients where less experienced teams were managing care was lower in the UK than in the non-UK cohort (10.4% vs. 20.4% of the ASA physical status 3 and 9% vs. 12.9% of the ASA physical status 4 patients). Differences in work-load between centres did not affect the incidence and outcomes of severe critical events when stratified for age and ASA physical status. The lower incidence of cardiovascular and respiratory complications could be partly attributed to more experienced dedicated paediatric anaesthesia providers managing the higher risk patients in the UK. Areas for quality improvement include: standardisation of serious critical event definitions; increased reporting; development of evidence-based protocols for management of serious critical events; development and rational use of paediatric peri-operative risk assessment scores; implementation of current best practice in provision of competent paediatric anaesthesia services in Europe; development of specific training in the management of severe peri-operative critical events; and implementation of systems for ensuring maintenance of skills.
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Affiliation(s)
- T Engelhardt
- Department of Anaesthesia, Royal Aberdeen Children's Hospital, Aberdeen, UK.,Institute of Education for Medical and Dental Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - D Ayansina
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - G T Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK
| | - V Oshan
- Department of Anaesthesia, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - J S Rutherford
- Designated Paediatric Anaesthetist, Dumfries and Galloway Royal Infirmary, Dumfries, Scotland, UK
| | - N S Morton
- Department of Paediatric Anaesthesia and Pain Management, University of Glasgow, Glasgow, Scotland, UK
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Ziegler B, Becke K, Weiss M. [Reduction the risk in pediatric anesthesia-what should we know-what should we do]. Wien Med Wochenschr 2018; 169:56-60. [PMID: 30229333 DOI: 10.1007/s10354-018-0651-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/27/2018] [Indexed: 11/28/2022]
Abstract
Pediatric anesthesia has always been conjuncted with higher risk than anesthesia for adults (JP Morray; Pediatric Anesthesia 2011;21:722-9). Not only the imminent critical events, but also, caused by recently published data, the theoretical neurotoxicity of anesthetic agents and a potencial negative influence of anesthetics on braindevelopement, are in the spotlight.Concerns about the neurodevelopement and the general warnings from the U.S. Food and Drug Administration (FDA) for anesthesia in young children led to a worldwide discussion about safety in pediatric anesthesia (FDA Safety Anouncement 2017).Beside these theoretical risks, which are based only on animal research, we have to pay much more attention to the widely spread out poor quality of anesthesia in children.The following article should summarize the state of science about the risks and the opportunities to minimize them.
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Affiliation(s)
- Bernhard Ziegler
- Univ. Klinik f. Anästhesie, perioperative Medizin und allgemeine Intensivmedizin, Salzburger Landeskliniken, Paracelsus Medizinische Privatuniversität, Strubergasse 22, 5020, Salzburg, Österreich.
| | - Karin Becke
- Abteilung für Anästhesie und Intensivmedizin, Klinik Hallerwiese/Cnopf'sche Kinderklinik, Nürnberg, Deutschland
| | - Markus Weiss
- Anästhesieabteilung, Universitäts-Kinderspital Zürich, Zürich, Schweiz.,Extraordinarius für Kinderanästhesie, Universität Zürich, Zürich, Schweiz
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18
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Raviraj D, Engelhardt T, Giedsing Hansen T. Safe anesthesia for neonates, infants and children. Minerva Pediatr 2018; 70:458-466. [PMID: 30035504 DOI: 10.23736/s0026-4946.18.05336-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This review provides an overview of the perioperative safety concerns in pediatric anesthesia and exploration of strategies to minimize these risks through education and training in pediatric anesthesia. There is increasing human data on the effects of general anesthesia for surgery and procedures on later neurodevelopment. However, the magnitude and relevance of this remains unclear while the long-term outcomes from recent human studies are awaited. The current known and established risks associated with pediatric anesthesia can be minimized by establishing a robust and safe conduct of anesthesia. This not only includes maintenance of normal physiological variables but also other aspects such as reduction of preoperative fear and anxiety and postoperative care. This can be achieved through effective multidisciplinary team working, cross specialty training and further development of fellowships and secondments.
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Affiliation(s)
- Divya Raviraj
- Royal Aberdeen Children's Hospital and School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK -
| | - Thomas Engelhardt
- Royal Aberdeen Children's Hospital and School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - Tom Giedsing Hansen
- Pediatric Section, Department of Anesthesia and Intensive Care, Odense University Hospital, Odense, Denmark.,Clinical Institute of Anesthesiology, University of Southern Denmark, Odense, Denmark
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19
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Becke K, Eich C, Höhne C, Jöhr M, Machotta A, Schreiber M, Sümpelmann R. Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA). Paediatr Anaesth 2018; 28:588-596. [PMID: 29851190 DOI: 10.1111/pan.13383] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/13/2022]
Abstract
Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.
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Affiliation(s)
- Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Christoph Eich
- Department of Anaesthesia, Paediatric Intensive Care and Emergency Medicine, Auf der Bult Children's Hospital, Hannover, Germany
| | - Claudia Höhne
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Martin Jöhr
- Department of Anaesthesia, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Andreas Machotta
- Department of Anaesthesiology, Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands
| | - Markus Schreiber
- Department of Anaesthesiology, University Hospital Ulm, Ulm, Germany
| | - Robert Sümpelmann
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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20
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Affiliation(s)
- Marjory Ruth Graham
- Department of Anesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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21
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Clausen N, Kähler S, Hansen T. Systematic review of the neurocognitive outcomes used in studies of paediatric anaesthesia neurotoxicity. Br J Anaesth 2018; 120:1255-1273. [DOI: 10.1016/j.bja.2017.11.107] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/22/2017] [Accepted: 11/21/2017] [Indexed: 01/08/2023] Open
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23
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Clinical update regarding general anesthesia-associated neurotoxicity in infants and children. Curr Opin Anaesthesiol 2017; 30:682-687. [DOI: 10.1097/aco.0000000000000520] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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24
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Alyami FA, Koyle MA, Bowlin PR, Gleason JM, Braga LH, Lorenzo AJ. Side-to-Side Refluxing Nondismembered Ureterocystotomy: A Novel Strategy to Address Obstructed Megaureters in Children. J Urol 2017; 198:1159-1167. [DOI: 10.1016/j.juro.2017.05.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Fahad A. Alyami
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Martin A. Koyle
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Paul R. Bowlin
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Urology, University of Kansas Medical Center and Children’s Mercy Hospital, Kansas City, Kansas
| | - Joseph M. Gleason
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Urology, University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, Memphis, Tennessee
| | - Luis H. Braga
- Division of Urology, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Armando J. Lorenzo
- Division of Urology, The Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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25
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Abstract
Normal brain development in young children depends on a balance between excitation and inhibition of neurons, and alterations to this balance may cause apoptosis. During the perioperative period, both surgical stimuli and anesthetics can induce neurotoxicity. This article attempts to expand the perspective of a topical issue-anesthetic-induced neurotoxicity-by also considering the protective effect of general anesthetics against surgery-induced neurotoxicity, all of which may generate some controversy in the current literature. The "new" major factor influencing neurotoxicity-nociceptive stimulus-is discussed together with other factors to develop clinical and research strategies to obtain a balance between neurotoxicity and neuroprotection.
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26
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27
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Hansen TG. Use of anesthetics in young children Consensus statement of the European Society of Anaesthesiology (ESA), the European Society for Paediatric Anaesthesiology (ESPA), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Safe Tots Anaesthesia Research Initiative (EuroSTAR). Paediatr Anaesth 2017; 27:558-559. [PMID: 28474809 DOI: 10.1111/pan.13160] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tom G Hansen
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
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28
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Bjur KA, Payne ET, Nemergut ME, Hu D, Flick RP. Anesthetic-Related Neurotoxicity and Neuroimaging in Children: A Call for Conversation. J Child Neurol 2017; 32:594-602. [PMID: 28424007 PMCID: PMC5407309 DOI: 10.1177/0883073817691696] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Each year millions of young children undergo procedures requiring sedation or general anesthesia. An increasing proportion of the anesthetics used are provided to optimize diagnostic imaging studies such as magnetic resonance imaging. Concern regarding the neurotoxicity of sedatives and anesthetics has prompted the US Food and Drug Administration to change labeling of anesthetics and sedative agents warning against repeated or prolonged exposure in young children. This review aims to summarize the risk of anesthesia in children with an emphasis on anesthetic-related neurotoxicity, acknowledge the value of pediatric neuroimaging, and address this call for conversation.
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Affiliation(s)
- Kara A Bjur
- 1 Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric T Payne
- 2 Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | | | - Danqing Hu
- 4 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Randall P Flick
- 3 Division of Pediatric Anesthesiology, Mayo Clinic, Rochester, MN, USA
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Hu HH, Li Z, Pokorney AL, Chia JM, Stefani N, Pipe JG, Miller JH. Assessment of cerebral blood perfusion reserve with acetazolamide using 3D spiral ASL MRI: Preliminary experience in pediatric patients. Magn Reson Imaging 2016; 35:132-140. [PMID: 27580517 DOI: 10.1016/j.mri.2016.08.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/03/2016] [Accepted: 08/20/2016] [Indexed: 01/04/2023]
Abstract
PURPOSE To demonstrate the clinical feasibility of a new non-Cartesian cylindrically-distributed spiral 3D pseudo-continuous arterial spin labeling (pCASL) magnetic resonance imaging (MRI) pulse sequence in pediatric patients in quantifying cerebral blood flow (CBF) response to an acetazolamide (ACZ) vasodilator challenge. MATERIALS AND METHODS MRI exams were performed on two 3 Tesla Philips Ingenia systems using 32 channel head coil arrays. After local institutional review board approval, the 3D spiral-based pCASL technique was added to a standard brain MRI exam and evaluated in 13 pediatric patients (average age: 11.7±6.4years, range: 1.4-22.2years). All patients were administered ACZ for clinically indicated reasons. Quantitative whole-brain CBF measurements were computed pre- and post-ACZ to assess cerebrovascular reserve. RESULTS 3D spiral pCASL data were successfully reconstructed in all 13 cases. In 11 patients, CBF increased 2.8% to 93.2% after administration of ACZ. In the two remaining patients, CBF decreased by 2.4 to 6.0% after ACZ. The group average change in CBF due to ACZ was approximately 25.0% and individual changes were statistically significant (p<0.01) in all patients using a paired t-test analysis. CBF perfusion data were diagnostically useful in supporting conventional MR angiography and clinical findings. CONCLUSION 3D cylindrically-distributed spiral pCASL MRI provides a robust approach to assess cerebral blood flow and reserve in pediatric patients.
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Affiliation(s)
- Houchun H Hu
- Department of Medical Imaging and Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA.
| | - Zhiqiang Li
- Keller Center for Imaging Innovation, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Amber L Pokorney
- Department of Medical Imaging and Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | | | | | - James G Pipe
- Keller Center for Imaging Innovation, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jeffrey H Miller
- Department of Medical Imaging and Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Creeley CE. From Drug-Induced Developmental Neuroapoptosis to Pediatric Anesthetic Neurotoxicity-Where Are We Now? Brain Sci 2016; 6:brainsci6030032. [PMID: 27537919 PMCID: PMC5039461 DOI: 10.3390/brainsci6030032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 08/05/2016] [Accepted: 08/12/2016] [Indexed: 01/02/2023] Open
Abstract
The fetal and neonatal periods are critical and sensitive periods for neurodevelopment, and involve rapid brain growth in addition to natural programmed cell death (i.e., apoptosis) and synaptic pruning. Apoptosis is an important process for neurodevelopment, preventing redundant, faulty, or unused neurons from cluttering the developing brain. However, animal studies have shown massive neuronal cell death by apoptosis can also be caused by exposure to several classes of drugs, namely gamma-aminobutyric acid (GABA) agonists and N-methyl-d-aspartate (NMDA) antagonists that are commonly used in pediatric anesthesia. This form of neurotoxic insult could cause a major disruption in brain development with the potential to permanently shape behavior and cognitive ability. Evidence does suggest that psychoactive drugs alter neurodevelopment and synaptic plasticity in the animal brain, which, in the human brain, may translate to permanent neurodevelopmental changes associated with long-term intellectual disability. This paper reviews the seminal animal research on drug-induced developmental apoptosis and the subsequent clinical studies that have been conducted thus far. In humans, there is growing evidence that suggests anesthetics have the potential to harm the developing brain, but the long-term outcome is not definitive and causality has not been determined. The consensus is that there is more work to be done using both animal models and human clinical studies.
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Affiliation(s)
- Catherine E Creeley
- Department of Psychology, State University of New York at Fredonia, Fredonia, NY 14063, USA.
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