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Paul L, Greve S, Hegemann J, Gienger S, Löffelhardt VT, Della Marina A, Felderhoff-Müser U, Dohna-Schwake C, Bruns N. Association of bilaterally suppressed EEG amplitudes and outcomes in critically ill children. Front Neurosci 2024; 18:1411151. [PMID: 38903601 PMCID: PMC11188580 DOI: 10.3389/fnins.2024.1411151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Background and objectives Amplitude-integrated EEG (aEEG) is used to assess electrocortical activity in pediatric intensive care if (continuous) full channel EEG is unavailable but evidence regarding the meaning of suppressed aEEG amplitudes in children remains limited. This retrospective cohort study investigated the association of suppressed aEEG amplitudes in critically ill children with death or decline of neurological functioning at hospital discharge. Methods Two hundred and thirty-five EEGs derived from individual patients <18 years in the pediatric intensive care unit at the University Hospital Essen (Germany) between 04/2014 and 07/2021, were converted into aEEGs and amplitudes analyzed with respect to age-specific percentiles. Crude and adjusted odds ratios (OR) for death, and functional decline at hospital discharge in patients with bilateral suppression of the upper or lower amplitude below the 10th percentile were calculated. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were assessed. Results The median time from neurological insult to EEG recording was 2 days. PICU admission occurred due to neurological reasons in 43% and patients had high overall disease severity. Thirty-three (14%) patients died and 68 (29%) had a functional decline. Amplitude suppression was observed in 48% (upper amplitude) and 57% (lower amplitude), with unilateral suppression less frequent than bilateral suppression. Multivariable regression analyses yielded crude ORs between 4.61 and 14.29 and adjusted ORs between 2.55 and 8.87 for death and functional decline if upper or lower amplitudes were bilaterally suppressed. NPVs for bilaterally non-suppressed amplitudes were above 95% for death and above 83% for pediatric cerebral performance category Scale (PCPC) decline, whereas PPVs ranged between 22 and 32% for death and 49-52% for PCPC decline. Discussion This study found a high prevalence of suppressed aEEG amplitudes in critically ill children. Bilaterally normal amplitudes predicted good outcomes, whereas bilateral suppression was associated with increased odds for death and functional decline. aEEG assessment may serve as an element for risk stratification of PICU patients if conventional EEG is unavailable with excellent negative predictive abilities but requires additional information to identify patients at risk for poor outcomes.
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Affiliation(s)
- Luisa Paul
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Pediatric Cardiology/Congenital Cardiology, Heidelberg University Medical Center, Heidelberg, Germany
| | - Sandra Greve
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Johanna Hegemann
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sonja Gienger
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Verena Tamara Löffelhardt
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Adela Della Marina
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, Pediatric Neurology, and Pediatric Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- C-TNBS, Centre for Translational Neuro-and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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You S, Xu F, Zhu X, Qin S, Zheng X, Tao C, Wu Y, Chen Y, Shu B, Huang H, Duan G. Effect of intraoperative noise on postoperative pain in surgery patients under general anesthesia: evidence from a prospective study and mouse model. Int J Surg 2023; 109:3872-3882. [PMID: 37598384 PMCID: PMC10720791 DOI: 10.1097/js9.0000000000000672] [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: 06/09/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Most patients are in a noisy environment during abdominal surgery under general anesthesia. This study included patients who underwent abdominal surgery under general anesthesia and established an animal model to determine whether intraoperative noise affects postoperative pain. MATERIALS AND METHODS This prospective study included 200 patients who underwent abdominal surgery under general anesthesia. Intraoperative noise and electroencephalograms were continuously recorded, and the mean level and time proportion of noise intensity of greater than 70 dB were calculated. Maximum postoperative pain was assessed using a numerical rating scale at 0-12 h and 12-24 h after surgery, and postoperative analgesia consumption in patients receiving patient-controlled intravenous analgesia was recorded. Postoperative pain intensity and electroencephalogram amplitude were compared between patients with high-noise exposure (time proportion of noise intensity greater than 70 dB ≥40%) and low-noise exposure (<40%). Mechanical pain sensitivity was tested in two groups of mice with plantar incisions exposed to 40 dB or 70-100 dB. RESULTS The time proportion of noise intensity greater than 70 dB was identified as an independent risk factor for postoperative pain intensity ( P <0.001). P ain numerical rating scale 0-12 h (4.5±1.5 vs. 3.7±1.3, P =0.001) and 12-24 h (3.9±1.5 vs. 3.2±1.1, P =0.004) after surgery in patients with high-noise exposure was significantly higher than in patients with low-noise exposure. The electroencephalogram amplitude of patients with high-noise exposure was significantly lower than that of patients with low-noise exposure ( P <0.05). In the mouse model, mechanical hyperalgesia in the 70-100 dB group was significantly greater than that in the 40 dB group ( P <0.001). CONCLUSION High-level intraoperative noise exposure aggravates the degree of postoperative pain and analgesic needs of patients undergoing abdominal surgery, which may be related to the impact of noise on the neurophysiological activity of the brain and postoperative hyperalgesia.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, People’s Republic of China
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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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Schultz B, Schultz M, Boehne M, Dennhardt N. EEG monitoring during anesthesia in children aged 0 to 18 months: amplitude-integrated EEG and age effects. BMC Pediatr 2022; 22:156. [PMID: 35346111 PMCID: PMC8962600 DOI: 10.1186/s12887-022-03180-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The amplitude-integrated EEG (aEEG) is a widely used monitoring tool in neonatology / pediatric intensive care. It takes into account the amplitudes, but not the frequency composition, of the EEG. Advantages of the aEEG are clear criteria for interpretation and time compression. During the first year of life, the electroencephalogram (EEG) during sedation / anesthesia changes from a low-differentiated to a differentiated EEG; higher-frequency waves develop increasingly. There are few studies on the use of aEEG during pediatric anesthesia. A systematic evaluation of the aEEG in defined EEG stages during anesthesia / sedation is not yet available. Parameters of pediatric EEGs (power, median frequency, spectral edge frequency) recorded during anesthesia and of the corresponding aEEGs (upper and lower value of the aEEG trace) should be examined for age-related changes. Furthermore, it should be examined whether the aEEG can distinguish EEG stages of sedation / anesthesia in differentiated EEGs.
Methods
In a secondary analysis of a prospective observational study EEGs and aEEGs (1-channel recordings, electrode positions on forehead) of 50 children (age: 0–18 months) were evaluated. EEG stages: A (awake), Slow EEG, E2, F0, and F1 in low-differentiated EEGs and A (awake), B0–2, C0–2, D0–2, E0–2, F0–1 in differentiated EEGs.
Results
Median and spectral edge frequency increased significantly with age (p < 0.001 each). In low-differentiated EEGs, the power of the Slow EEG increased significantly with age (p < 0.001). In differentiated EEGs, the power increased significantly with age in each of the EEG stages B1 to E1 (p = 0.04, or less), and the upper and lower values of the aEEG trace increased with age (p < 0.001). A discriminant analysis using the upper and lower values of the aEEG showed that EEG epochs from the stages B1 to E1 were assigned to the original EEG stage in only 19.3% of the cases. When age was added as the third variable, the rate of correct reclassifications was 28.5%.
Conclusions
The aEEG was not suitable for distinguishing EEG stages above the burst suppression range. For this purpose, the frequency composition of the EEG should be taken into account.
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Bruns N, Felderhoff‐Müser U, Dohna‐Schwake C. aEEG as a useful tool for neuromonitoring in critically ill children - Current evidence and knowledge gaps. Acta Paediatr 2021; 110:1132-1140. [PMID: 33210762 DOI: 10.1111/apa.15676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/06/2020] [Accepted: 11/16/2020] [Indexed: 12/28/2022]
Abstract
AIM Amplitude-integrated electroencephalography (aEEG) is used in children beyond neonatal age, but systematic investigations have been lacking. This mini-review summarised aEEG studies on children aged one month to 18 years, evaluated the usefulness of aEEG and identified knowledge gaps or limitations. METHODS We searched the PubMed database for articles published in English up to September 2020, and 23 papers were identified. RESULTS aEEG was frequently used to compensate for the absence of continuous full-channel EEG monitoring, particularly for detecting seizures. Interpreting background patterns was based on neonatal classifications, as reference values for older infants and children are lacking. It is possible that aEEG could predict outcomes after paediatric cardiac arrests and other conditions. Gaps in our knowledge exist with regard to normal values in healthy children and the effects of sedation on aEEG background patterns in children. CONCLUSION The main application of aEEG was detecting and treating paediatric seizures. Further research should determine reference values and investigate the potential to predict outcome after critical events or in acute neurological disease. It is likely that aEEG will play a role in paediatric critical care in the future.
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Affiliation(s)
- Nora Bruns
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Ursula Felderhoff‐Müser
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
| | - Christian Dohna‐Schwake
- Department of Paediatrics I University Hospital Essen University of Duisburg‐Essen Essen Germany
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6
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Affiliation(s)
- Rossella Garra
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Carmela Riso
- Institute of Anesthesia and Intensive Care, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
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A Prospective Study of Age-dependent Changes in Propofol-induced Electroencephalogram Oscillations in Children. Anesthesiology 2017; 127:293-306. [PMID: 28657957 DOI: 10.1097/aln.0000000000001717] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In adults, frontal electroencephalogram patterns observed during propofol-induced unconsciousness consist of slow oscillations (0.1 to 1 Hz) and coherent alpha oscillations (8 to 13 Hz). Given that the nervous system undergoes significant changes during development, anesthesia-induced electroencephalogram oscillations in children may differ from those observed in adults. Therefore, we investigated age-related changes in frontal electroencephalogram power spectra and coherence during propofol-induced unconsciousness. METHODS We analyzed electroencephalogram data recorded during propofol-induced unconsciousness in patients between 0 and 21 yr of age (n = 97), using multitaper spectral and coherence methods. We characterized power and coherence as a function of age using multiple linear regression analysis and within four age groups: 4 months to 1 yr old (n = 4), greater than 1 to 7 yr old (n = 16), greater than 7 to 14 yr old (n = 30), and greater than 14 to 21 yr old (n = 47). RESULTS Total electroencephalogram power (0.1 to 40 Hz) peaked at approximately 8 yr old and subsequently declined with increasing age. For patients greater than 1 yr old, the propofol-induced electroencephalogram structure was qualitatively similar regardless of age, featuring slow and coherent alpha oscillations. For patients under 1 yr of age, frontal alpha oscillations were not coherent. CONCLUSIONS Neurodevelopmental processes that occur throughout childhood, including thalamocortical development, may underlie age-dependent changes in electroencephalogram power and coherence during anesthesia. These age-dependent anesthesia-induced electroencephalogram oscillations suggest a more principled approach to monitoring brain states in pediatric patients.
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Cornelissen L, Bergin AM, Lobo K, Donado C, Soul JS, Berde CB. Electroencephalographic discontinuity during sevoflurane anesthesia in infants and children. Paediatr Anaesth 2017; 27:251-262. [PMID: 28177176 DOI: 10.1111/pan.13061] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deep anesthesia in adults may be associated with electroencephalographic (EEG) suppression and higher rates of postoperative complications. Little is known about the impact of anesthetic depth on short- or long-term outcomes in pediatrics. Brain activity monitoring may complement clinical signs of anesthetic depth. This prospective observational study aimed to assess the frequency and degree of profound EEG suppression using multichannel EEG in children during sevoflurane general anesthesia. METHODS Children aged 0-40 months who required general anesthesia for elective surgery were included. Continuous EEG recordings were performed starting from when anesthesia began and until recovery. Discontinuity was defined as EEG amplitude <25 uV, lasting ≥2 s, and observed in all electrodes across the scalp. Frequency, duration, and inter-event interval of discontinuity events were measured. Relationships between discontinuity events and postnatal age, endtidal sevoflurane concentration (etSEVO), and multiple clinical parameters were analyzed. RESULTS Discontinuity events were observed in 35/68 children, with a median duration of 10 s (95%CI: 8-12) and a median of 4 events per patient (95%CI: 2-7). Children who had discontinuity events were younger (5.5 months, 95%CI: 3.6-6.5) compared to children who did not have discontinuity events (10.2 months, 95%CI: 6.1-14); (difference between medians, 4.7 months, 95%CI: 2.3-8, P = 0.0002). Younger infants exhibited a higher number of discontinuity events, and the incidence decreased with postnatal age (r68 = -0.53, P < 0.0001). The majority of discontinuity events were observed during the first 30 min of anesthesia (66.4% total events), where etSEVO was >3%. Few discontinuity events were observed during maintenance and none during emergence. Blood pressure, heart rate, tissue oxygen saturation, and endtidal CO2 partial pressure did not change during these events. CONCLUSIONS Electroencephalographic monitoring may complement clinical signs in providing information about brain homeostasis during general anesthesia. The impact of discontinuity events on immediate and long-term outcomes merits further study.
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Affiliation(s)
- Laura Cornelissen
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Ann M Bergin
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Kimberly Lobo
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Carolina Donado
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Charles B Berde
- Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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Baarslag MA, Allegaert K, Van Den Anker JN, Knibbe CAJ, Van Dijk M, Simons SHP, Tibboel D. Paracetamol and morphine for infant and neonatal pain; still a long way to go? Expert Rev Clin Pharmacol 2016; 10:111-126. [PMID: 27785937 DOI: 10.1080/17512433.2017.1254040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pharmacologic pain management in newborns and infants is often based on limited scientific data. To close the knowledge gap, drug-related research in this population is increasingly supported by the authorities, but remains very challenging. This review summarizes the challenges of analgesic studies in newborns and infants on morphine and paracetamol (acetaminophen). Areas covered: Aspects such as the definition and multimodal character of pain are reflected to newborn infants. Specific problems addressed include defining pharmacodynamic endpoints, performing clinical trials in this population and assessing developmental changes in both pharmacokinetics and pharmacodynamics. Expert commentary: Neonatal and infant pain management research faces two major challenges: lack of clear biomarkers and very heterogeneous pharmacokinetics and pharmacodynamics of analgesics. There is a clear call for integral research addressing the multimodality of pain in this population and further developing population pharmacokinetic models towards physiology-based models.
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Affiliation(s)
- Manuel A Baarslag
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Karel Allegaert
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,b Department of development and regeneration , KU Leuven , Leuven , Belgium
| | - John N Van Den Anker
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,c Division of Clinical Pharmacology , Children's National Health System , Washington , DC , USA.,d Division of Pediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Catherijne A J Knibbe
- e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands.,f Division of Pharmacology, Leiden Academic Center for Drug Research , Leiden University , Leiden , the Netherlands
| | - Monique Van Dijk
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands.,g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Sinno H P Simons
- g Department of Pediatrics, division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Dick Tibboel
- a Intensive Care and department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , the Netherlands
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Sabir H, Wood T, Gill H, Liu X, Dingley J, Thoresen M. Xenon depresses aEEG background voltage activity whilst maintaining cardiovascular stability in sedated healthy newborn pigs. J Neurol Sci 2016; 363:140-4. [PMID: 27000239 DOI: 10.1016/j.jns.2016.02.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/25/2016] [Accepted: 02/19/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Changes in electroencephalography (EEG) voltage range are used to monitor the depth of anaesthesia, as well as predict outcome after hypoxia-ischaemia in neonates. Xenon is being investigated as a potential neuroprotectant after hypoxic-ischaemic brain injury, but the effect of Xenon on EEG parameters in children or neonates is not known. This study aimed to examine the effect of 50% inhaled Xenon on background amplitude-integrated EEG (aEEG) activity in sedated healthy newborn pigs. METHODS Five healthy newborn pigs, receiving intravenous fentanyl sedation, were ventilated for 24 h with 50%Xenon, 30%O2 and 20%N2 at normothermia. The upper and lower voltage-range of the aEEG was continuously monitored together with cardiovascular parameters throughout a 1 h baseline period with fentanyl sedation only, followed by 24 h of Xenon administration. RESULTS The median (IQR) upper and lower aEEG voltage during 1 h baseline was 48.0 μV (46.0-50.0) and 25.0 μV (23.0-26.0), respectively. The median (IQR) aEEG upper and lower voltage ranges were significantly depressed to 21.5 μV (20.0-26.5) and 12.0 μV (12.0-16.5) from 10 min after the onset of 50% Xenon administration (p=0.002). After the initial Xenon induced depression in background aEEG voltage, no further aEEG changes were seen over the following 24h of ventilation with 50% xenon under fentanyl sedation. Mean arterial blood pressure and heart rate remained stable. CONCLUSION Mean arterial blood pressure and heart rate were not significantly influenced by 24h Xenon ventilation. 50% Xenon rapidly depresses background aEEG voltage to a steady ~50% lower level in sedated healthy newborn pigs. Therefore, care must be taken when interpreting the background voltage in neonates also receiving Xenon.
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Affiliation(s)
- Hemmen Sabir
- School of Clinical Sciences, University of Bristol, St Michael's Hospital, Bristol, United Kingdom; Departments of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Düsseldorf, Heinrich-Heine University Düsseldorf, Germany
| | - Thomas Wood
- Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Hannah Gill
- School of Clinical Sciences, University of Bristol, St Michael's Hospital, Bristol, United Kingdom
| | - Xun Liu
- School of Clinical Sciences, University of Bristol, St Michael's Hospital, Bristol, United Kingdom
| | - John Dingley
- College of Medicine, Swansea University, United Kingdom
| | - Marianne Thoresen
- School of Clinical Sciences, University of Bristol, St Michael's Hospital, Bristol, United Kingdom; Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.
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Akeju O, Pavone KJ, Thum JA, Firth PG, Westover MB, Puglia M, Shank ES, Brown EN, Purdon PL. Age-dependency of sevoflurane-induced electroencephalogram dynamics in children. Br J Anaesth 2015; 115 Suppl 1:i66-i76. [PMID: 26174303 DOI: 10.1093/bja/aev114] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND General anaesthesia induces highly structured oscillations in the electroencephalogram (EEG) in adults, but the anaesthesia-induced EEG in paediatric patients is less understood. Neural circuits undergo structural and functional transformations during development that might be reflected in anaesthesia-induced EEG oscillations. We therefore investigated age-related changes in the EEG during sevoflurane general anaesthesia in paediatric patients. METHODS We analysed the EEG recorded during routine care of patients between 0 and 28 yr of age (n=54), using power spectral and coherence methods. The power spectrum quantifies the energy in the EEG at each frequency, while the coherence measures the frequency-dependent correlation or synchronization between EEG signals at different scalp locations. We characterized the EEG as a function of age and within 5 age groups: <1 yr old (n=4), 1-6 yr old (n=12), >6-14 yr old (n=14), >14-21 yr old (n=11), >21-28 yr old (n=13). RESULTS EEG power significantly increased from infancy through ∼6 yr, subsequently declining to a plateau at approximately 21 yr. Alpha (8-13 Hz) coherence, a prominent EEG feature associated with sevoflurane-induced unconsciousness in adults, is absent in patients <1 yr. CONCLUSIONS Sevoflurane-induced EEG dynamics in children vary significantly as a function of age. These age-related dynamics likely reflect ongoing development within brain circuits that are modulated by sevoflurane. These readily observed paediatric-specific EEG signatures could be used to improve brain state monitoring in children receiving general anaesthesia.
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Affiliation(s)
- O Akeju
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - K J Pavone
- Department of Anesthesia, Critical Care and Pain Medicine
| | - J A Thum
- Harvard Medical School, Boston, MA, USA Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology
| | - P G Firth
- Department of Anesthesia, Critical Care and Pain Medicine Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - M B Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA
| | - M Puglia
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - E S Shank
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA
| | - E N Brown
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science Harvard-Massachusetts Institute of Technology Division of Health Sciences and Technology Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - P L Purdon
- Department of Anesthesia, Critical Care and Pain Medicine Harvard Medical School, Boston, MA, USA Department of Brain and Cognitive Science
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12
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Cornelissen L, Kim SE, Purdon PL, Brown EN, Berde CB. Age-dependent electroencephalogram (EEG) patterns during sevoflurane general anesthesia in infants. eLife 2015; 4:e06513. [PMID: 26102526 PMCID: PMC4502759 DOI: 10.7554/elife.06513] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 06/22/2015] [Indexed: 12/31/2022] Open
Abstract
Electroencephalogram (EEG) approaches may provide important information about developmental changes in brain-state dynamics during general anesthesia. We used multi-electrode EEG, analyzed with multitaper spectral methods and video recording of body movement to characterize the spatio-temporal dynamics of brain activity in 36 infants 0-6 months old when awake, and during maintenance of and emergence from sevoflurane general anesthesia. During maintenance: (1) slow-delta oscillations were present in all ages; (2) theta and alpha oscillations emerged around 4 months; (3) unlike adults, all infants lacked frontal alpha predominance and coherence. Alpha power was greatest during maintenance, compared to awake and emergence in infants at 4-6 months. During emergence, theta and alpha power decreased with decreasing sevoflurane concentration in infants at 4-6 months. These EEG dynamic differences are likely due to developmental factors including regional differences in synaptogenesis, glucose metabolism, and myelination across the cortex. We demonstrate the need to apply age-adjusted analytic approaches to develop neurophysiologic-based strategies for pediatric anesthetic state monitoring.
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Affiliation(s)
- Laura Cornelissen
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, United States
| | - Seong-Eun Kim
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Patrick L Purdon
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, United States
| | - Emery N Brown
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, United States
| | - Charles B Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, United States
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13
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Tu B, Assassi N, Bazil CW, Hamberger MJ, Hirsch LJ. Quantitative EEG is an objective, sensitive, and reliable indicator of transient anesthetic effects during Wada tests. J Clin Neurophysiol 2015; 32:152-8. [PMID: 25580802 PMCID: PMC4385440 DOI: 10.1097/wnp.0000000000000154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The intracarotid amobarbital or Wada procedure is a component of the presurgical evaluation for refractory epilepsy, during which monitoring the onset and offset of transient anesthetic effects is critical. In this study, the authors characterized changes of 8 quantitative measures during 26 Wada tests, which included alpha, beta, theta, and delta powers, alpha/delta power ratio, beta/delta power ratio, median amplitude-integrated EEG, and 90% spectral edge frequency (SEF90), and correlated them with contralateral hemiplegia. The authors found that on the side of injection, delta and theta powers, alpha/delta power ratio, beta/delta power ratio, and SEF90 peaked within 1 minute after injection of 70 to 150 mg amobarbital or 4 to 7 mg methohexital. When contralateral arm strength returned to 3/5, delta power and amplitude-integrated EEG decayed on average 24% and 19%, respectively, for amobarbital, similar to that of methohexital (27% and 18%). Because delta power resolution most closely mirrored that of the hemiplegia and amplitude-integrated EEG had the highest signal/noise ratio, these quantitative values appear to be the best measures for decay of anesthetic effects. Increase in alpha power persisted longest, and therefore may be the best measure of late residual anesthetic effects.
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Affiliation(s)
- Bin Tu
- Columbia University Comprehensive Epilepsy Center, New York, NY 10032
| | - Nadege Assassi
- New York University Pre-Medicine Neural Science Program, New York, NY 10003
| | - Carl W. Bazil
- Columbia University Comprehensive Epilepsy Center, New York, NY 10032
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14
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McKeever S, Johnston L, Davidson AJ. Sevoflurane-induced changes in infants' quantifiable electroencephalogram parameters. Paediatr Anaesth 2014; 24:766-73. [PMID: 24612073 DOI: 10.1111/pan.12366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Electroencephalogram (EEG) based depth of anesthesia algorithms developed in the adult population have not demonstrated the same reliability when applied to infants. This may be due to frequency changes occurring in the EEG during development. Amplitude-integrated EEG (aEEG) is based primarily in the time domain and hence may have greater utility in infants. OBJECTIVE To investigate the relationship between age adjusted Minimal Alveolar Concentration (MAC) multiples and aEEG in children under 2 years of age. METHODS The aEEG, Spectral Edge Frequency 90% (SEF90) and Bispectral Index™ (BIS) were investigated in a prospective study of children <2 years of age. After anesthetic induction, and caudal block administration, EEG data were collected simultaneously with BrainZ BRM2™ and BIS™ monitors. Using a randomized crossover design, children received up to three age adjusted concentrations of sevoflurane: 0.75, 1 and 1.25 MAC. After 15 min of stable anesthetic delivery EEG readings were obtained. Prediction Probability (Pk ) and correlation coefficients were calculated for each EEG parameter. RESULTS From 51 children 102 stable anesthetics concentrations were obtained. For all age groups Pk of aEEG to multiple of age adjusted MAC was <0.72 indicating a poor predictive power for aEEG. In contrast for the SEF90 and BIS there was evidence for better predictive properties in children aged between 6 months and 2 years, with a Pk >0.81. CONCLUSION The aEEG is unlikely to be a useful measure of anesthesia depth in young children.
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Affiliation(s)
- Stephen McKeever
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Vic., Australia; Murdoch Childrens Research Institute, Melbourne, Vic., Australia; Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Vic., Australia
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15
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Abstract
Applying scalp sensors in the operating theater, intensive care, or resuscitation scenarios to detect and monitor brain function is achievable, practical, and affordable. The modalities are complex and the output of the monitor needs careful interpretation. The monitor may have technical problems, and a single reading must be considered with caution. These monitors may have a use for monitoring trends in specific situations, but evidence does not support their widespread use. Nevertheless, research should continue to investigate their role. Future techniques and treatments may show that these monitors can monitor brain function and prevent harm.
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Affiliation(s)
- Michael Sury
- Department of Anaesthesia, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.
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