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Verma RK, Keller D, Grunt S, Bigi S, Weisstanner C, Wiest R, Gralla J, Hutter D, Wagner B. Decreased oxygen saturation levels in neonates with transposition of great arteries: Impact on appearance of cerebral veins in susceptibility-weighted imaging. Sci Rep 2017; 7:15471. [PMID: 29133891 PMCID: PMC5684390 DOI: 10.1038/s41598-017-15591-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/27/2017] [Indexed: 12/24/2022] Open
Abstract
Purpose of this study was to investigate a potential correlation between the pattern of cerebral veins (CV) on susceptibility-weighted imaging (SWI) and blood oxygen saturation, as well as preoperative brain injury, in neonates with transposition of the great arteries (TGA). Eleven neonates with TGA underwent MRI preoperatively, including SWI, T1- and T2-weighted scans. Images were retrospectively evaluated and appearance of CV was graded from 0 (normal appearance) to 3 (severe prominent appearance). White matter injuries (WMI) and strokes were analysed. Results were correlated with preductal arterial oxygen saturation. As findings one subject showed a normal CV appearance (grade 0) whereas 10 showed pathological prominent CV (grades 1–3); median 2. Mean oxygen saturation ranged between 67.5% and 89.0% (median 81.0%). CV grade and mean oxygen saturation correlated significantly (p = 0.011). WMI were absent in 5 cases, mild in 4, and moderate in 2 cases. We conclude, that SWI has the potential to be used to estimate the current hypoxic burden on brain tissue in TGA newborns by assessing the prominence of the CV.
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Affiliation(s)
- Rajeev Kumar Verma
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland. .,Institute of Radiology and Neuroradiology, Tiefenau Hospital, Division Stadt, Inselgroup, Bern, Switzerland.
| | - Desislava Keller
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Sebastian Grunt
- University Department of Pediatrics, Division of Pediatric Neurology, Development and Rehabilitation, Inselspital, University of Bern, Bern, Switzerland
| | - Sandra Bigi
- University Department of Pediatrics, Division of Pediatric Neurology, Development and Rehabilitation, Inselspital, University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Roland Wiest
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Damian Hutter
- University Department of Pediatrics, Division of Pediatric Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Bendicht Wagner
- University Department of Pediatrics, Division of Pediatric Intensive Care Medicine, Inselspital Bern, University of Bern, Bern, Switzerland
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Kwak HJ, Kim JY, Lee KC, Kim HS, Kim JY. Effect of mild hypocapnia on hemodynamic and bispectral index responses to tracheal intubation during propofol anesthesia in children. J Clin Monit Comput 2014; 29:29-33. [PMID: 24526409 DOI: 10.1007/s10877-014-9564-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Accepted: 02/07/2014] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to investigate the effect of mild hypocapnia on hypertension and arousal response after tracheal intubation in children during propofol anesthesia. Forty-four children, American Society of Anesthesiologists physical status I-II patients, aged 3-9 years were randomly allocated to either the normocapnia group [end-tidal carbon dioxide tension (ETCO2=35 mmHg, n=22)] or the hypocapnia group (ETCO2=25 mmHg, n=22). Anesthesia was induced with propofol 2.5 mg/kg. Five minutes after the administration of rocuronium 0.6 mg/kg, laryngoscopy was attempted. The mean arterial pressure (MAP), heart rate (HR), SpO2 and bispectral index (BIS) were measured during induction and intubation periods. The maximal change in the BIS with tracheal intubation (ΔBIS) was defined as the difference between the baseline value and the maximal value within the first 5 min after intubation. Before tracheal intubation, the change in BIS over time was not different between the groups. After tracheal intubation, the changes in the MAP, HR and BIS over time were not significantly different between the groups. The mean value±SD of ΔBIS was 5.7±5.2 and 7.4±5.5 in the normocapnia and hypocapnia groups, respectively, without any intergroup difference. This study showed that mild hypocapnia did not attenuate hemodynamic and BIS responses to tracheal intubation in children during propofol anesthesia. Our results suggested that hyperventilation has no beneficial effect on hemodynamic and arousal responses to tracheal intubation in children.
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Affiliation(s)
- Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University, Incheon, Korea
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Orliaguet G. [Sedation and analgesia in emergency structure. Paediatry: Which sedation and analgesia for pediatric patients? Pharmacology]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:359-368. [PMID: 22445224 DOI: 10.1016/j.annfar.2012.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- G Orliaguet
- Département d'anesthésie-réanimation, hôpital Necker-Enfants-malades, université Paris Descartes, Paris 5, 149, rue de Sèvres, 75730 Paris cedex 15, France.
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Calvo Vecino JM, Abad Gurumeta A, Garrido Reche E, Chao Novo K, Orts Castro A, Tomás Lachos J. [Transcranial Doppler ultrasound, bispectral index, and electroencephalographic monitoring of entropy during pediatric total intravenous anesthesia]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:621-629. [PMID: 22283014 DOI: 10.1016/s0034-9356(10)70298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND OBJECTIVE Transcranial Doppler ultrasound is a noninvasive technique for monitoring the velocity of blood flow in the main intracranial arteries, particularly those in the circle of Willis. Our aim was to assess whether changes in cerebral arterial blood flow in anesthetized pediatric patients detected by pulsed Doppler ultrasound correlate with changes in the bispectral (BIS) index and electroencephalographic state and response entropy (ES and ER, respectively). MATERIAL AND METHODS Prospective, blinded observational study of 36 pediatric patients (age range, 5 to 11 years) under total intravenous anesthesia for minor surgical procedures. Propofol and fentanyl were used for induction; propofol and remifentanil in continuous perfusion and a single dose of cisatracurium were used for maintenance. In all patients we monitored hemodynamic and respiratory patterns, gases, temperature, and hypnosis (BIS, ES and ER) as well as cerebral blood flow estimated by pulsed Doppler ultrasound in the middle cerebral artery. Raw data were subjected to statistical smoothing. The resistance index, pulsatility index, mean velocity, and estimated baseline cerebral blood flow were calculated from the Doppler sonogram. We then studied the correlations between the Doppler-derived values and BIS, ES, ER, fraction of end-tidal carbon dioxide, and temperature. The variables were entered into logistic regression. RESULTS The pattern at induction indicated high resistance (low mean velocities and high pulsatility indexes) until the lowest BIS and ES values of 31 and 29, respectively, were reached. During maintenance, the Doppler sonogram pattern was slower (normalization of the pulsatility index, the resistance index, and mean velocity). Changes in flow and absolute entropy and BIS values were statistically correlated (Pearson's r values > or = 0.91); there was 95.6% agreement between Doppler values and BIS and agreement between BIS and ES values of 35-45. On awakening, flow velocities approached baseline values when BIS and ES rose to between 90 and 98. The estimated cerebral blood flow underwent fluctuations coinciding with an approximately concomitant increase or decrease in BIS (r > 0.95); the response of BIS was slightly delayed by no more than a minute but there was no corresponding response of entropy measurements. CONCLUSIONS We report Doppler ultrasound patterns during anesthesia with propofol. Systems for monitoring hypnosis could be considered indirect measurements of cerebral blood flow; BIS measurements are more sensitive to flow change. Transcranial Doppler ultrasound facilitates the observation of changes in blood flow that occur at different levels of hypnosis during anesthesia.
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Affiliation(s)
- J M Calvo Vecino
- Servicio de Anestesiología y Reanimación, Complejo Hospitalario de Vallecas, Hospital Infanta Leonor, Vallecas, Madrid.
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Schlünzen L, Vafaee MS, Juul N, Cold GE. Regional cerebral blood flow responses to hyperventilation during sevoflurane anaesthesia studied with PET. Acta Anaesthesiol Scand 2010; 54:610-5. [PMID: 20003126 DOI: 10.1111/j.1399-6576.2009.02181.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Arterial carbon dioxide tension (PaCO(2)) is an important factor controlling cerebral blood flow (CBF) in neurosurgical patients. It is still unclear whether the hypocapnia-induced decrease in CBF is a general effect on the brain or rather linked to specific brain regions. We evaluated the effects of hyperventilation on regional cerebral blood flow (rCBF) in healthy volunteers during sevoflurane anaesthesia measured with positron emission tomography (PET). METHODS Eight human volunteers were anaesthetized with sevoflurane 1 MAC, while exposed to hyperventilation. During 1 MAC sevoflurane at normocapnia and 1 MAC sevoflurane at hypocapnia, one H(2)(15)O scan was performed. Statistical parametric maps and conventional regions of interest analysis were used for estimating rCBF differences. RESULTS Cardiovascular parameters were maintained constant over time. During hyperventilation, the mean PaCO(2) was decreased from 5.5 + or - 0.7 to 3.8 + or - 0.9 kPa. Total CBF decreased during the hypocapnic state by 44%. PET revealed wide variations in CBF between regions. The greatest values of vascular responses during hypocapnia were observed in the thalamus, medial occipitotemporal gyrus, cerebellum, precuneus, putamen and insula regions. The lowest values were observed in the superior parietal lobe, middle and inferior frontal gyrus, middle and inferior temporal gyrus and precentral gyrus. No increases in rCBF were observed. CONCLUSIONS This study reports highly localized and specific changes in rCBF during hyperventilation in sevoflurane anaesthesia, with the most pronounced decreases in the sub cortical grey matter. Such regional heterogeneity of the cerebral vascular response should be considered in the assessment of cerebral perfusion reserve during hypocapnia.
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Affiliation(s)
- L Schlünzen
- Department of Neuroanaesthesiology, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus C, Denmark.
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Sedlacik J, Löbel U, Kocak M, Loeffler RB, Reichenbach JR, Broniscer A, Patay Z, Hillenbrand CM. Attenuation of cerebral venous contrast in susceptibility-weighted imaging of spontaneously breathing pediatric patients sedated with propofol. AJNR Am J Neuroradiol 2010; 31:901-6. [PMID: 20053806 DOI: 10.3174/ajnr.a1960] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE SWI is known for its detailed visualization of the cerebral venous system and seems to be a promising tool for early detection of cerebrovascular pathologies in children, who are frequently sedated for MR imaging. Because sedation influences cerebral hemodynamics, we hypothesized that it would affect cerebral venous contrast in SWI. MATERIALS AND METHODS SWI (125 examinations) of 26 patients (age, 2-16 years) was reviewed in this study. Images were acquired of patients sedated with propofol. Reviewers classified the images by weak or strong venous contrast. Physiologic data, such as etCO(2), BP, age, and CBF by arterial spin-labeling, were monitored and collected during MR imaging. A generalized estimating equation approach was used to model associations of these parameters with venous contrast. RESULTS EtCO(2) and CBF were found to correlate with venous contrast, suggesting that patients with high etCO(2) and CBF have weak contrast and patients with low etCO(2) and CBF have strong contrast. BP was also found to correlate with the venous contrast of SWI, suggesting that patients with high BP have strong venous contrast. No significant correlations were found for any other physiologic parameters. CONCLUSIONS We found that the venous contrast in SWI is affected by propofol sedation in spontaneously breathing patients. We also found that low etCO(2), low CBF, and high BP are associated with strong venous contrast. Reviewing SWI data in light of physiologic measures may therefore help prevent potential misinterpretations of weak venous contrast in SWI examinations under propofol sedation.
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Affiliation(s)
- J Sedlacik
- Department of Radiological Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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Türe H, Mercan A, Koner O, Aykac B, Türe U. The Effects of Propofol Infusion on Hepatic and Pancreatic Function and Acid-Base Status in Children Undergoing Craniotomy and Receiving Phenytoin. Anesth Analg 2009; 109:366-71. [DOI: 10.1213/ane.0b013e3181a89641] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Szabó EZ, Luginbuehl I, Bissonnette B. Impact of anesthetic agents on cerebrovascular physiology in children. Paediatr Anaesth 2009; 19:108-18. [PMID: 19040505 DOI: 10.1111/j.1460-9592.2008.02826.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The role of the pediatric neuroanesthetist is to provide comprehensive care to children with neurologic pathologies. The cerebral physiology is influenced by the developmental stage of the child. The understanding of the effects of anesthetic agents on the physiology of cerebral vasculature in the pediatric population has significantly increased in the past decade allowing a more rationale decision making in anesthesia management. Although no single anesthetic technique can be recommended, sound knowledge of the principles of cerebral physiology and anesthetic neuropharmacology will facilitate the care of pediatric neurosurgical patients.
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Affiliation(s)
- Elöd Z Szabó
- Department of Anaesthesia, University of Toronto, Toronto, ON, Canada.
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Engelhardt T, Chan MK, McCheyne AJ, Karsli C, Luginbuehl I, Bissonnette B. The effect of varying continuous propofol infusions on plasma cyclic guanosine 3',5'-monophosphate concentrations in anesthetized children. Anesth Analg 2007; 105:616-9. [PMID: 17717213 DOI: 10.1213/01.ane.0000275188.56157.a2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The glutamate-nitric oxide-cyclic guanosine 3',5'-monophosphate (cGMP) pathway is potentially an effective target for general anesthetics. Plasma cGMP concentrations are reduced after an increase in predicted plasma propofol concentrations during sedation in healthy adult volunteers. We hypothesized that an increase in measured plasma propofol concentration leads to a reduction in plasma cGMP in anesthetized children. METHODS Eighteen healthy children aged 46.8 (+/-19.6) mo, requiring general anesthesia for lower body surgical procedures were enrolled. After inhaled induction, tracheal intubation and initiation of intermittent positive pressure ventilation, caudal epidural analgesia was performed. Anesthesia was maintained using a continuous propofol infusion adapted from a previously published regimen to achieve predicted propofol plasma concentration of 6, 3, and 1.5 microg/mL after 30, 50, and 70 min, respectively. Samples for propofol and cGMP plasma concentrations were collected and analyzed using high-performance liquid chromatography and an enzyme immunoassay system. RESULTS The plasma cGMP concentrations varied significantly (median [range]) 19.2 [11.8-23.5], 21.3 [14.6-30.8], and 24.9 [15.7-37.8] nmol/L among each predicted plasma propofol concentration, P < 0.0001. The correlation coefficient (r) was -0.62. CONCLUSIONS This study demonstrates that an increase in plasma propofol concentration leads to a decrease in plasma cGMP in healthy children, and could serve as a biochemical marker for depth of propofol anesthesia in children.
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Affiliation(s)
- Thomas Engelhardt
- Department of Anaesthesia and Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW This review assesses whether there is a carbon dioxide concentration range that provides optimum benefit to the patient intraoperatively. It includes the physiological effects of carbon dioxide on various organ systems in awake and anesthetized individuals and its clinical effects in the ischemia/reperfusion setting. This review will present views on end-tidal or arterial carbon dioxide tension management in the perioperative period. RECENT FINDINGS Hypocapnia reduces intracranial pressure and is used by clinicians during acute traumatic brain injury, acute intracranial hemorrhage, and acutely growing brain tumors. There is mounting evidence, however, that hypercapnia improves tissue perfusion and oxygenation. Therefore, clinicians may want to induce mild-to-moderate hypercapnia during reperfusion states such as major vascular surgery, organ transplantation, tissue-graft surgery, and cases managed with low mean arterial pressures to control bleeding. As hypercapnia preserves cerebral blood flow even under relatively low perfusion pressures, it may be beneficial during global reperfusion scenarios. This hypothesis needs to be tested extensively before being considered for clinical applications. From a different perspective, current American Heart Association Guidelines recommend 12-15 breaths/min during cardiopulmonary resuscitation and stress the potential negative role of inadvertent hyperventilation on survival outcome. The importance of this concept is discussed briefly. SUMMARY Overall, the benefits of managing carbon dioxide concentration intraoperatively for the maintenance of cardiac output, tissue oxygenation, perfusion, intracranial pressure, and cerebrovascular reactivity are well defined.
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Affiliation(s)
- Ozan Akça
- Department of Anesthesiology and Perioperative Medicine, OUTCOMES RESEARCH Institute, University of Louisville, Kentucky 40202, USA.
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