1
|
Cloesmeijer ME, van Esdonk MJ, Lynn AM, Smits A, Tibboel D, Daali Y, Olkkola KT, Allegaert K, Mian P. Impact of enantiomer-specific changes in pharmacokinetics between infants and adults on the target concentration of racemic ketorolac: A pooled analysis. Br J Clin Pharmacol 2020; 87:1443-1454. [PMID: 32901947 PMCID: PMC9328374 DOI: 10.1111/bcp.14547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/26/2022] Open
Abstract
Aims Ketorolac is a nonsteroidal anti‐inflammatory racemic drug with analgesic effects only attributed to its S‐enantiomer. The aim of this study is to quantify enantiomer‐specific maturational pharmacokinetics (PK) of ketorolac and investigate if the contribution of both enantiomers to the total ketorolac concentration remains equal between infants and adults or if a change in target racemic concentration should be considered when applied to infants. Methods Data were pooled from 5 different studies in adults, children and infants, with 1020 plasma concentrations following single intravenous ketorolac administration. An allometry‐based enantiomer‐specific population PK model was developed with NONMEM 7.3. Simulations were performed in typical adults and infants to investigate differences in S‐ and R‐ketorolac exposure. Results S‐ and R‐ketorolac PK were best described with a 3‐ and a 2‐compartment model, respectively. The allometry‐based PK parameters accounted for changes between populations. No maturation function of ketorolac clearance could be identified. All model parameters were estimated with adequate precision (relative standard error <50%). Single dose simulations showed that a previously established analgesic concentration at half maximal effect in adults of 0.37 mg/L, had a mean S‐ketorolac concentration of 0.057 mg/L, but a mean S‐ketorolac concentration of 0.046 mg/L in infants. To match the effective adult S‐ketorolac‐concentration (0.057 mg/L) in typical infants, the EC50‐racemic should be increased to 0.41 mg/L. Conclusion Enantiomer‐specific changes in ketorolac PK yield different concentrations and S‐ and R‐ketorolac ratios between infants and adults at identical racemic concentrations. These PK findings should be considered when studies on maturational pharmacodynamics are considered.
Collapse
Affiliation(s)
- Michael E Cloesmeijer
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Hospital Pharmacy - Clinical Pharmacology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Michiel J van Esdonk
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands
| | - Anne M Lynn
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Anne Smits
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - Klaus T Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Clinical Pharmacy, Erasmus MC Rotterdam, Rotterdam, the Netherlands
| | - Paola Mian
- Intensive Care and Department of Paediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, the Netherlands
| |
Collapse
|
2
|
Holmer N, Artola E, Christianson E, Lynn AM, Whitlock KB, Norton S. Feasibility of Acupuncture to Induce Sleep for Brainstem Auditory Evoked Response Testing. Am J Audiol 2019; 28:895-907. [PMID: 31747523 DOI: 10.1044/2019_aja-19-0069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Purpose Brainstem auditory evoked response (BAER) testing is often performed under general anesthesia for children unable to complete behavioral audiologic evaluation. Alternatively, acupuncture treatment may be considered appropriate for BAER. Reports of acupuncture treatment in pediatric patients are scarce but are needed to demonstrate effectiveness. This study had 2 main objectives: (a) to examine the feasibility and effectiveness of acupuncture to achieve sleep to perform diagnostic BAER testing in medically complex (Cohort I) and nonmedically complex (Cohort II) children and (b) to assess acceptability to parents and audiologists of acupuncture as an alternative to anesthesia for BAER testing. Method A prospective feasibility study at Seattle Children's Hospital Outpatient Audiology Clinic from August 2015 through December 2018 was performed. A total of 31 pediatric patients were included. The median age for Cohort I was 29 months (interquartile range: 19-37 months), and the median age for Cohort II was 25.5 months (interquartile range: 16-32 months). Variables included number of BAER thresholds obtained, sleep indicators, and acceptability. The cost of BAER with acupuncture and the cost of BAER under anesthesia were compared. Results Acupuncture treatment effectively contributed to an adequate sleep state to obtain BAER results for most patients in both cohorts. Across cohorts, most patients (81%) fell asleep after acupuncture treatment. Complete test results were obtained in 48% of patients. Audiologists and parents reported high satisfaction rates with this procedure (87%). There were no adverse safety effects. Acupuncture treatment was less costly than anesthesia for BAER testing. Conclusions Acupuncture to induce sleep for BAER testing is effective, safe, and cost-efficient in small samples of medically and nonmedically complex pediatric patients. This procedure allowed earlier detection of hearing status and avoided potential adverse effects of anesthesia. Audiologists and parents reported that acupuncture treatment was an acceptable alternative to anesthesia for the BAER procedure.
Collapse
Affiliation(s)
- Nicole Holmer
- Division of Audiology, Seattle Children's Hospital, WA
| | - Elizabeth Artola
- Department of Anesthesia and Pain Medicine, Seattle Children's Hospital, WA
| | | | - Anne M. Lynn
- Department of Anesthesia and Pain Medicine, Seattle Children's Hospital, WA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Kathryn B. Whitlock
- Department of Otolaryngology–Head and Neck Surgery, Seattle Children's Hospital, WA
- Center for Clinical and Translational Research, Seattle Children's Hospital, WA
| | - Susan Norton
- Division of Audiology, Seattle Children's Hospital, WA
- Childhood Communication Center, Seattle Children's Hospital, WA
- Department of Otolaryngology–Head and Neck Surgery, Seattle Children's Hospital, WA
- Department of Speech & Hearing Sciences, University of Washington, Seattle
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
| |
Collapse
|
3
|
Kullmann AF, Truschel ST, Wolf-Johnston AS, McDonnell BM, Lynn AM, Kanai AJ, Kessler TM, Apodaca G, Birder LA. Acute spinal cord injury is associated with mitochondrial dysfunction in mouse urothelium. Neurourol Urodyn 2019; 38:1551-1559. [PMID: 31102563 DOI: 10.1002/nau.24037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/11/2019] [Accepted: 04/25/2019] [Indexed: 12/16/2022]
Abstract
AIM To characterize the effects of acute spinal cord injury (SCI) on mitochondrial morphology and function in bladder urothelium and to test the therapeutic efficacy of early treatment with the mitochondrially targeted antioxidant, MitoTempo. METHODS We used a mouse model of acute SCI by spinal cord transection between the T8-T9 vertebrae with or without MitoTempo delivery at the time of injury followed by tissue processing at 3 days after SCI. Control, SCI, and SCI-MitoTempo-treated mice were compared in all experimental conditions. Assessments included analysis of markers of mitochondrial health including accumulation of reactive oxygen species (ROS), morphological changes in the ultrastructure of mitochondria by transmission electron microscopy, and Western blot analysis to quantify protein levels of markers for autophagy and altered mitochondrial dynamics. RESULTS SCI resulted in an increase in oxidative stress markers and ROS production, confirming mitochondrial dysfunction. Mitochondria from SCI mice developed large electron-dense inclusions and these aberrant mitochondria accumulated throughout the cytoplasm suggesting an inability to clear dysfunctional mitochondria by mitophagy. SCI mice also exhibited elevated levels of dynamin-related protein 1 (DRP1), consistent with a disruption of mitochondrial dynamics. Remarkably, treatment with MitoTempo reversed many of the SCI-induced abnormalities that we observed. CONCLUSIONS Acute SCI negatively and severely affects mitochondrial health of bladder urothelium. Early treatment of SCI with MitoTempo may be a viable therapeutic agent to mitigate these deleterious effects.
Collapse
Affiliation(s)
- Aura F Kullmann
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steven T Truschel
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amanda S Wolf-Johnston
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bronagh M McDonnell
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - A M Lynn
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anthony John Kanai
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Gerard Apodaca
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Cell Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lori A Birder
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
4
|
Lynn AM, McRorie TI, Slattery JT, Calkins D, Opheim KE. Pharmacokinetics and Pharmacodynamics of Morphine in
Infant Monkeys. ACTA ACUST UNITED AC 2019. [DOI: 10.1159/000480554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
5
|
Gentry KR, Arnup SJ, Disma N, Dorris L, de Graaff JC, Hunyady A, Morton NS, Withington DE, McCann ME, Davidson AJ, Lynn AM. Enrollment challenges in multicenter, international studies: The example of the GAS trial. Paediatr Anaesth 2019; 29:51-58. [PMID: 30375133 DOI: 10.1111/pan.13522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Randomized trials are important for generating high-quality evidence, but are perceived as difficult to perform in the pediatric population. Thus far there has been poor characterization of the barriers to conducting trials involving children, and the variation in these barriers between countries remains undescribed. The General Anesthesia compared to Spinal anesthesia (GAS) trial, conducted in seven countries between 2007 and 2013, provides an opportunity to explore these issues. METHODS We undertook a descriptive analysis to evaluate the reasons for variation in enrollment between countries in the GAS trial, looking specifically at the number of potential subjects screened, and the subsequent application of four exclusion criteria that were applied in a hierarchical order. RESULTS A total of 4023 patients were screened by 28 centers in seven countries. Australia and the USA screened the most subjects, accounting for 84% of all potential trial participants. The percentage of subjects eliminated from the screened pool by each exclusion criterion varied between countries. Exclusion due to a predefined condition (H1) eliminated only 5% of potential subjects in Italy and the UK, but 37% in Canada. Exclusions due to a contraindication or a physician's refusal most impacted enrollment in Australia and the USA. The patient being "too large for spinal anesthesia" was the most commonly cited by anesthetists who refused to enroll a patient (64% of anesthetist refusals). The majority of surgeon refusals came from the USA, where surgeons preferred the patient to receive a general anesthetic. The percentage of approached parents refusing to consent ranged from a low of 3% in Italy to a high of 70% in the USA and Netherlands. The most frequently cited reason for parent refusal in all countries was a preference for general anesthesia (median: 43%, range: 32%-67%). However, a sizeable proportion of parents in all countries had a contrasting preference for spinal anesthesia (median: 25%, range: 13%-31%), and 23% of U.S. parents expressed concern about randomization. CONCLUSION The GAS trial highlights enrollment challenges that can occur when conducting multicenter, international, pediatric studies. Investigators planning future trials should be aware of potential differences in screening processes across countries, and that exclusions by anesthetists and surgeons may vary in reason, in frequency, and by country. Furthermore, investigators should be aware that the U.S. centers encountered particularly high surgeon and parental refusal rates and that U.S. parents were uniquely concerned about randomization. Planning trials that address these difficulties should increase the likelihood of successfully recruiting subjects in pediatric trials.
Collapse
Affiliation(s)
- Katherine R Gentry
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Sarah J Arnup
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Liam Dorris
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Anesthesia, Erasmus MC Sophia's Children Hospital Rotterdam, Rotterdam, The Netherlands
| | - Agnes Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Neil S Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK
| | | | - Mary Ellen McCann
- Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Andrew J Davidson
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anne M Lynn
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | | |
Collapse
|
6
|
Walco GA, Kopecky EA, Weisman SJ, Stinson J, Stevens B, Desjardins PJ, Berde CB, Krane EJ, Anand KJS, Yaster M, Dampier CD, Dworkin RH, Gilron I, Lynn AM, Maxwell LG, Raja S, Schachtel B, Turk DC. Clinical trial designs and models for analgesic medications for acute pain in neonates, infants, toddlers, children, and adolescents: ACTTION recommendations. Pain 2018; 159:193-205. [PMID: 29140927 PMCID: PMC5949239 DOI: 10.1097/j.pain.0000000000001104] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clinical trials to test the safety and efficacy of analgesics across all pediatric age cohorts are needed to avoid inappropriate extrapolation of adult data to children. However, the selection of acute pain models and trial design attributes to maximize assay sensitivity, by pediatric age cohort, remains problematic. Acute pain models used for drug treatment trials in adults are not directly applicable to the pediatric age cohorts-neonates, infants, toddlers, children, and adolescents. Developmental maturation of metabolic enzymes in infants and children must be taken into consideration when designing trials to test analgesic treatments for acute pain. Assessment tools based on the levels of cognitive maturation and behavioral repertoire must be selected as outcome measures. Models and designs of clinical trials of analgesic medications used in the treatment of acute pain in neonates, infants, toddlers, children, and adolescents were reviewed and discussed at an Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) Pediatric Pain Research Consortium consensus meeting. Based on extensive reviews and continuing discussions, the authors recommend a number of acute pain clinical trial models and design attributes that have the potential to improve the study of analgesic medications in pediatric populations. Recommendations are also provided regarding additional research needed to support the use of other acute pain models across pediatric age cohorts.
Collapse
Affiliation(s)
- Gary A. Walco
- University of Washington, Seattle, WA, USA
- Seattle Children’s Hospital, Seattle, WA, USA
| | - Ernest A. Kopecky
- Collegium Pharmaceutical, Inc., Canton, MA, USA
- Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | | | | | - Elliot J. Krane
- Stanford University School of Medicine, Stanford, CA, USA
- Stanford Children’s Health, Palo alto, CA, USA
| | - Kanwaljeet JS Anand
- Stanford University School of Medicine, Stanford, CA, USA
- Stanford Children’s Health, Palo alto, CA, USA
| | - Myron Yaster
- Johns Hopkins University Hospital, Baltimore, MA, USA
| | | | | | - Ian Gilron
- Queen’s University, Kingston, ON, Canada
| | - Anne M. Lynn
- University of Washington, Seattle, WA, USA
- Seattle Children’s Hospital, Seattle, WA, USA
| | | | | | | | | |
Collapse
|
7
|
Krekels EHJ, DeJongh J, van Lingen RA, van der Marel CD, Choonara I, Lynn AM, Danhof M, Tibboel D, Knibbe C. Predictive Performance of a Recently Developed Population Pharmacokinetic Model for Morphine and its Metabolites in New Datasets of (Preterm) Neonates, Infants and Children. Clin Pharmacokinet 2017; 50:51-63. [PMID: 27975238 DOI: 10.2165/11536750-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Model validation procedures are crucial when models are to be used to develop new dosing algorithms. In this study, the predictive performance of a previously published paediatric population pharmacokinetic model for morphine and its metabolites in children younger than 3 years (original model) is studied in new datasets that were not used to develop the original model. METHODS Six external datasets including neonates and infants up to 1 year were obtained from four different research centres. These datasets contained postoperative patients, ventilated patients and patients on extracorporeal membrane oxygenation (ECMO) treatment. Basic observed versus predicted plots, normalized prediction distribution error analysis, model refitting, bootstrap analysis, subpopulation analysis and a literature comparison of clearance predictions were performed with the new datasets to evaluate the predictive performance of the original morphine pharmacokinetic model. RESULTS The original model was found to be stable and the parameter estimates were found to be precise. The concentrations predicted by the original model were in good agreement with the observed concentrations in the four datasets from postoperative and ventilated patients, and the model-predicted clearances in these datasets were in agreement with literature values. In the datasets from patients on ECMO treatment with continuous venovenous haemofiltration (CVVH) the predictive performance of the model was good as well, whereas underprediction occurred, particularly for the metabolites, in patients on ECMO treatment without CVVH. CONCLUSION The predictive value of the original morphine pharmacokinetic model is demonstrated in new datasets by the use of six different validation and evaluation tools. It is herewith justified to undertake a proof-of-principle approach in the development of rational dosing recommendations - namely, performing a prospective clinical trial in which the model-based dosing algorithm is clinically evaluated.
Collapse
Affiliation(s)
- Elke H J Krekels
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands.,Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joost DeJongh
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands.,LAP&P Consultants BV, Leiden, The Netherlands
| | - Richard A van Lingen
- Princess Amalia Department of Pediatrics, Division of Neonatology, Isala Clinics, Zwolle, The Netherlands
| | - Caroline D van der Marel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Anne M Lynn
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington, USA
| | - Meindert Danhof
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Catherijne Knibbe
- Division of Pharmacology, Leiden/Amsterdam Center for Drug Research, Leiden, The Netherlands. .,Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands. .,Department of Clinical Pharmacy, St Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, The Netherlands.
| |
Collapse
|
8
|
Abstract
This review focuses on pharmacokinetics and pharmacodynamics of opioid and non-opioid analgesics in neonates and infants. The unique physiology of this population differs from that of adults and impacts drug handling. Morphine and remifentanil are described as examples of older versus recently developed opiates to compare and contrast pharmacokinetics and pharmacodynamics in infants. Exploration of genetics affecting both pharmacokinetics and pharmacodynamics of opiates is an area of active research, as is the investigation of a new class of mu-opiate-binding agents which seem selective for analgesic pathways while having less activity in pathways linked to side effects. The kinetics of acetaminophen and of ketorolac as examples of parenteral non-steroidal analgesics in infants are also discussed. The growth in regional anesthesia for peri-operative analgesia in infants can fill an important role minimizing intra-operative anesthetic exposure to opioids and transitioning to post-operative care. Use of multi-modal techniques is recommended to decrease undesirable opiate-related side effects in this vulnerable population.
Collapse
Affiliation(s)
- Lizabeth D Martin
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Nathalia Jimenez
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Anne M Lynn
- University of Washington School of Medicine, Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| |
Collapse
|
9
|
Martin L, Jimenez N, Lynn AM. Developmental pharmacokinetics and pharmacodynamics of parenteral opioids and nonsteroidal anti-nflammatory drugs in neonates and infants. Colombian Journal of Anesthesiology 2017. [DOI: 10.1016/j.rcae.2016.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
10
|
Martin L, Jimenez N, Lynn AM. Farmacología del desarrollo de analgésicos opioides y no esteroideos en neonatos e infantes. Revista Colombiana de Anestesiología 2017. [DOI: 10.1016/j.rca.2016.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
11
|
Ralston-Wilson J, Artola E, Lynn AM, Doorenbos AZ. The Feasibility of Developing an Inpatient Acupuncture Program at a Tertiary Care Pediatric Hospital. J Altern Complement Med 2016; 22:458-64. [PMID: 27203737 DOI: 10.1089/acm.2015.0347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Use of complementary and integrative health approaches has increased significantly in recent decades, with hospital-based acupuncture programs becoming more common. This article presents the feasibility of developing an inpatient acupuncture program at a pediatric hospital. DESIGN AND SETTING In January 2014, Seattle Children's Hospital, a tertiary care pediatric hospital serving patients from a five-state region, began a 6-month pilot project offering inpatient acupuncture. During the pilot, inpatient acupuncture and related manual therapies were provided to pediatric patients age 0-23 years who were admitted to Seattle Children's Hospital or were seen for an outpatient surgical procedure. MEASURES The following data were collected: the reason for the acupuncture consult, type and number of treatments provided, any reported response to treatment, and any reported adverse events. Patients and referring providers gave feedback via questionnaires. RESULTS During the pilot program, 338 treatments were provided to 87 patients. High interest, demand, and positive feedback from hospital providers, patients, and families led to the development of a full-time inpatient acupuncture program. CONCLUSIONS The positive response to Seattle Children's inpatient acupuncture program with feasibility and acceptability demonstrated by increasing consults and patient and provider questionnaire data suggest that similar programs may be of interest to other pediatric hospitals.
Collapse
Affiliation(s)
- Jaime Ralston-Wilson
- 1 Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital , Seattle, WA
| | - Elizabeth Artola
- 1 Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital , Seattle, WA
| | - Anne M Lynn
- 1 Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital , Seattle, WA.,2 Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington , Seattle, WA
| | - Ardith Z Doorenbos
- 2 Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington , Seattle, WA.,3 Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington , Seattle, WA
| |
Collapse
|
12
|
Jimenez N, Song K, Lynn AM. Hemodynamic instability during prone spine surgery in a patient with merosin-deficient congenital muscular dystrophy. Paediatr Anaesth 2013; 23:294-6. [PMID: 23279697 DOI: 10.1111/pan.12101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2012] [Indexed: 11/26/2022]
Abstract
Trans-esophageal echocardiography (TEE) and/or central venous pressure (CVP) monitoring are important in the anesthetic management of spine fusion of pediatric patients with severe muscular weakness. This case highlights an unusual situation of apparent acute right ventricular mechanical obstruction after prone positioning and its prompt recognition with CVP monitoring. The anesthetic management of a patient with congenital muscular dystrophy, an uncommon neuromuscular disorder, is presented. Good communication and planning between the anesthesiology and surgical teams allowed completion of the procedure using a lateral approach.
Collapse
Affiliation(s)
- Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, University of Washington, USA.
| | | | | |
Collapse
|
13
|
Jimenez N, Anderson GD, Shen DD, Nielsen SS, Farin FM, Seidel K, Lynn AM. Is ethnicity associated with morphine's side effects in children? Morphine pharmacokinetics, analgesic response, and side effects in children having tonsillectomy. Paediatr Anaesth 2012; 22:669-75. [PMID: 22486937 PMCID: PMC3366036 DOI: 10.1111/j.1460-9592.2012.03844.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES/AIMS To examine whether morphine pharmacokinetics (PK) and/or genetic polymorphisms in opioid-related genes, underlie differences in analgesic response and side effects to morphine in Latino (L) vs non-Latino Caucasian (NL) children. BACKGROUND Morphine has high interindividual variability in its analgesic response and side effects profile. Earlier studies suggest that morphine response may vary by race and ethnicity. METHODS Prospective cohort study in L and NL children, 3-17 years of age comparing pain scores, occurrence of side effects, plasma morphine, morphine-6- and morphine-3-glucuronide concentrations measured after a single morphine IV bolus administration. Noncompartmental pharmacokinetic analysis and genotyping for 28 polymorphisms in eight genes (UGT1A8, UGT2B7, ABCB1, COMT, STAT6, MC1R, OPRM1, and ARRB2) were performed. RESULTS We enrolled 68 children (33 L, 35 NL). There were no differences in pain scores or need for rescue analgesia. Statistically significant differences in the occurrence of side effects were documented: While 58% of L children experienced at least one side effect only 20% of NL did (P = 0.001). Pruritus was four times (P = 0.006) and emesis seven times (P = 0.025) more frequent in L compared with NL. PK parameters were similar between groups. None of the assessed polymorphisms mediated the association between ethnicity and side effects. CONCLUSIONS We found statistically significant differences in the occurrence of side effects after morphine administration between L and NL children. Neither differences in morphine or metabolite concentrations, nor the genetic polymorphisms examined explain these findings. Studies are needed to further investigate reasons for the increase in morphine side effects by Latino ethnicity.
Collapse
Affiliation(s)
- Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
| | | | - Danny D. Shen
- Department of Pharmacy; University of Washington, Seattle, WA
| | | | - Federico M. Farin
- Environmental and Occupational Health Sciences, University of Washington, Seattle, WA
| | - Kristy Seidel
- Biostatistical Services Seattle Children's Hospital, Seattle, WA
| | - Anne M. Lynn
- Department of Anesthesiology and Pain Medicine; University of Washington, Seattle, WA
| |
Collapse
|
14
|
Abstract
OBJECTIVES/AIMS The aim of this retrospective review was to determine the feasibility, safety, and potential therapeutic effects of acupuncture in an inpatient infant population and to obtain data that would support the design of a randomized, controlled trial of acupuncture in infants. BACKGROUND Hospitalized infants are often exposed to sedative and analgesic medications to facilitate intensive and invasive medical care. With increasing concern about the potential neurotoxic effects of common analgesic and sedative medications, minimizing an infant's exposure to such agents is desirable. Acupuncture can be therapeutic in adults and children, but data in infants are lacking. METHODS/MATERIALS We performed a retrospective chart review of infants who received acupuncture during hospitalizations between 2008 and 2010. Demographic data, diagnoses, reason for acupuncture consult, ventilator settings, sedative/analgesic medication regimens, details of acupuncture therapy, and adverse effects were among data collected. RESULTS Ten infants were identified in this review, seven of whom had agitation issues, two of whom had feeding difficulties, and one had both symptoms. Six of the eight infants with agitation had a decrease in the use of sedative and analgesic medications over the acupuncture therapy period, and four of five initially requiring mechanical ventilation were successfully weaned. One of the three infants with oral aversion transitioned rapidly to oral intake. Acupuncture therapy was well tolerated, and there were no complications observed. CONCLUSIONS In this small group of hospitalized infants, acupuncture was found to be safe, well tolerated, and therapeutic. More studies are warranted to define the role of acupuncture in this population.
Collapse
Affiliation(s)
- Katherine R Gentry
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA 98105, USA.
| | | | | | | |
Collapse
|
15
|
Abstract
We describe 14 consecutive children who received computed tomography-guided percutaneous lung biopsy (CT-PLB) under general anesthesia over an 18-month period at our institution. Pulmonary hemorrhage (occurring in 36%) and pneumothorax (29%) were the two most common complications; the overall complication rate was 64%. When complications did occur, immediate airway management was facilitated by the presence of an endotracheal tube (ETT). We conclude as follows: (i) CT-PLB in our series is associated with a high risk of both overall and severe complications; (ii) risk of complications is increased by both patient and procedure-related factors; (iii) airway management with ETT may be preferable should a complication arise; (iv) severe complications may necessitate ICU admission, which should be available before proceeding.
Collapse
Affiliation(s)
- Heather Naumann
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, Seattle, WA 98105, USA
| | | | | | | |
Collapse
|
16
|
Lynn AM, Bradford H, Kantor ED, Andrew M, Vicini P, Anderson GD. Ketorolac tromethamine: stereo-specific pharmacokinetics and single-dose use in postoperative infants aged 2-6 months. Paediatr Anaesth 2011; 21:325-34. [PMID: 21199130 PMCID: PMC3078765 DOI: 10.1111/j.1460-9592.2010.03484.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We determined the postoperative pharmacokinetics (PK), safety, and analgesic effects of ketorolac in 14 infants (aged <6 months) receiving a single intravenous (IV) administration of racemic ketorolac or placebo. BACKGROUND Information on the PK of ketorolac in infants is limited. Unblinded studies suggest ketorolac may be useful in infants. METHODS This double-blinded, placebo-controlled study enrolled 14 infants (aged <6 months) postoperatively. At 6-18 h after surgery, infants were randomized to receive placebo, 0.5 mg·kg(-1), or 1 mg·kg(-1) ketorolac IV. All infants received morphine sulfate as needed for pain control. Blood was collected up to 12-h postdosing. Analysis used noncompartmental and compartmental population modeling methods. RESULTS In addition to noncompartmental and empirical Bayes PK modeling, data were integrated with a previously studied data set comprising 25 infants and toddlers (aged 6-18 months). A two-compartmental model described the comprehensive data set. The population estimates of the R (+) isomer were (%CV): central volume of distribution 1130 (10%) ml, peripheral volume of distribution 626 (25%) ml, and clearance from the central compartment 7.40 (8%) ml·min(-1). Those of the S (-) isomer were 1930 (15%) ml, 319 (58%) ml, and 39.5 (13%) ml·min(-1). Typical elimination half-lives were 191 and 33 min, respectively. There was a trend for increased clearance and central volume with increasing age and weight. The base model suggested that clearance of the S (-) isomer was weakly related to age; however, when body size adjustment was added to the model, no covariates were significant. Safety assessment showed no changes in renal or hepatic function tests, surgical drain output, or continuous oximetry between groups. Cumulative morphine administration showed large inter-patient variability and was not different between groups. CONCLUSION Stereo-isomer-specific clearance of ketorolac in infants (aged 2-6 months) shows rapid elimination of the analgesic S (-) isomer as reported in infants aged 6-18 months. No adverse effects were seen after a single IV ketorolac dose.
Collapse
Affiliation(s)
- Anne M. Lynn
- Departments of Anesthesia & Pain Management, Seattle Children’s Hospital and University of Washington School of Medicine
| | - Heidi Bradford
- Departments of Anesthesia & Pain Management, Seattle Children’s Hospital and University of Washington School of Medicine
| | - Eric D. Kantor
- Department of Pharmacy, University of Washington School of Pharmacy
| | - Marilee Andrew
- Department of Bioengineering, University of Washington Schools of Engineering and Medicine Seattle, Washington,Applied Physics Laboratory, University of Washington, Seattle, Washington
| | - Paolo Vicini
- Department of Bioengineering, University of Washington Schools of Engineering and Medicine Seattle, Washington
| | - Gail D. Anderson
- Department of Pharmacy, University of Washington School of Pharmacy
| |
Collapse
|
17
|
Rowell J, Lynn AM, Filardi TZ, Celix J, Ojemann JG. Acute unilateral enlargement of the parotid gland immediately post craniotomy in a pediatric patient: a case report. Childs Nerv Syst 2010; 26:1239-42. [PMID: 20512498 DOI: 10.1007/s00381-010-1186-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Accepted: 05/11/2010] [Indexed: 11/26/2022]
Abstract
A temporary acute unilateral enlargement of the parotid gland or "anesthesia mumps" has been described in both surgical and anesthesia literature. It has been described in elderly, dehydrated, poorly nourished, and post-operative patients. We present a 5-year-old patient who underwent a left temporal craniotomy for seizure focus resection and quadriceps muscle biopsy. Immediately post procedure, he was noted to have an acute unilateral enlargement of the right parotid gland. We report acute unilateral parotitis as a possible, but uncommon, complication of positioning in the pediatric population and to discuss possible pathophysiology and prevention, as well as a review of the available literature.
Collapse
Affiliation(s)
- Jonathan Rowell
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | | | | | | | | |
Collapse
|
18
|
Jimenez N, Seidel K, Martin LD, Rivara FP, Lynn AM. Perioperative analgesic treatment in Latino and non-Latino pediatric patients. J Health Care Poor Underserved 2010; 21:229-36. [PMID: 20173265 DOI: 10.1353/hpu.0.0236] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE Adult studies suggest pain treatment is influenced by patient's race/ ethnicity. The present study aims to evaluate the effect of the patient's race/ethnicity on pain treatment in children. METHODS Retrospective cohort study comparing perioperative analgesic administration for tonsillectomy and adenoidectomy (T&A) surgery in Latino and Caucasian patients younger than 18 years of age. RESULTS Ninety-four (94) patients were included (47 Latino, 47 Caucasian), mean age 8.44 yrs (SD 3.45), 43% female. Administration of non-opioid analgesics and intraoperative opioids was similar in both groups. Early post-operative administration of opioid analgesics was significantly different between groups. Latino subjects received 30% less opioid analgesics than Caucasians; median amount in morphine equivalents was 0.05 (0-0.14) vs. 0.07 (0-0.90) mg/kg for Latino and Caucasian patients respectively (p5.02). CONCLUSION This study suggests that perioperative pain treatment in children is correlated with the patient's ethnicity. The cause of this difference is unknown and prospective studies are necessary to elucidate the reasons.
Collapse
Affiliation(s)
- Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
| | | | | | | | | |
Collapse
|
19
|
Abstract
Many physiologic differences between children and adults can result in age-related differences in pharmacokinetics. Understanding the effects of age on bioavailability, volume of distribution, protein binding, hepatic metabolic isoenzymes, and renal elimination can provide insight into optimizing doses for pediatric patients. We performed a search of English-language literature using the MEDLINE database regarding age and pharmacokinetics (1979-July 2008). We then evaluated the literature with an emphasis on drugs with one primary elimination pathway, such as renal clearance or a pathway involving a single metabolic isoenzyme. Our mechanistic-based analysis revealed that children need weight-corrected doses that are substantially higher than adult doses for drugs that are metabolically eliminated solely by the specific cytochrome P450 (CYP) isoenzymes CYP1A2, CYP2C9, and CYP3A4. In contrast, weight-corrected doses for drugs eliminated by renal excretion or metabolism involving CYP2C19, CYP2D6, N-acetyltransferase 2, or uridine diphosphate glucuronosyltransferases are similar in children and adults. In children, bioavailability of drugs with high first-pass metabolism is decreased for drugs metabolized by CYP1A2, CYP2C9, and CYP3A4. Limited data suggest that by age 5 years, bioavailability of drugs affected by efflux transporters should be equivalent to that of adults. Using a pharmacokinetics-based approach, rational predictions can be made for the effects of age on drugs that undergo similar pathways of elimination, even when specific pharmacokinetic data are limited or unavailable.
Collapse
Affiliation(s)
- Gail D Anderson
- Department of Pharmacy, University of Washington, Seattle, Washington 98195, USA.
| | | |
Collapse
|
20
|
Lynn AM, Bradford H, Kantor ED, Seng KY, Salinger DH, Chen J, Ellenbogen RG, Vicini P, Anderson GD. Postoperative Ketorolac Tromethamine Use in Infants Aged 6–18 Months: The Effect on Morphine Usage, Safety Assessment, and Stereo-Specific Pharmacokinetics. Anesth Analg 2007; 104:1040-51, tables of contents. [PMID: 17456651 DOI: 10.1213/01.ane.0000260320.60867.6c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Nonsteroidal antiinflammatory drugs have been useful for treating postoperative pain in children. The only parenteral nonsteroidal antiinflammatory drug currently available in the United States is ketorolac tromethamine with cyclooxygenase-1 and cyclooxygenase-2 effects. Information on the pharmacokinetics of ketorolac in infants is sparse, making dosing difficult. Ketorolac is administered as a racemic mixture with the S(-) isomer responsible for the analgesic effect. In this study, we describe the population pharmacokinetics of ketorolac in a group of 25 infants and toddlers who received a single IV administration of racemic ketorolac and evaluate the potential influence of patient covariates on ketorolac disposition. METHODS In this double-blind, placebo-controlled study, ketorolac pharmacokinetic, safety, and analgesic effects were studied in 37 infants and toddlers (aged 6-18 mo) postoperatively. On postoperative day 1, infants were randomized to receive placebo, 0.5, or 1 mg/kg ketorolac as a 10-min IV infusion. Blood samples were collected up to 12-h after dosing. The data were analyzed using noncompartmental and compartmental (nonlinear mixed-effects model) means. The patient covariates, including body weight, age, and surgical procedure, were analyzed in a stepwise fashion to identify their potential influence on ketorolac pharmacokinetics. RESULTS The data were best described by a two-compartmental model. Inclusion of covariates did not significantly decrease the nonlinear mixed-effects model objective function values and between-subject variability in the pharmacokinetic parameters of nested models. The mean and standard error of the estimates of the R(+) isomer were central volume of distribution 1200 +/- 163 mL (coefficient of variation of interindividual variability, 13.6%), peripheral volume of distribution 828 +/- 108 mL (13.0%), clearance from the central compartment 7.52 +/- 0.7 mL/min (9.3%), and extrapolated elimination half-life 238 +/- 48 min. Those of the S(-) isomer were 2320 +/- 34 (14.6%), 224 +/- 193 mL (86.2%), 45.3 +/- 5.5 mL/min (12.1%), and 50 +/- 42 min respectively. Dosing simulations, using population pharmacokinetic parameters, showed no accumulation of S(-) ketorolac but steady increases in R(+) ketorolac. Safety assessment showed no adverse effects on renal or hepatic function tests, surgical drain output, or continuous oximetry between placebo and ketorolac groups. Cumulative morphine administration showed large interpatient variability and was not different between groups. CONCLUSION The stereo-isomer-specific clearance of ketorolac in infants and toddlers (aged 6-18 mo) shows rapid elimination of the analgesic S(-) isomer. No adverse effects on surgical drain output, oximetry measured saturations, renal or hepatic function tests were seen. Simulation of single dosing at 0.5 or 1 mg/kg every 4 or 6 h does not lead to accumulation of S(-) ketorolac, the analgesic isomer, but does result in increases in R(+) ketorolac. Shorter dose intervals may be needed in infants older than 6 mo.
Collapse
Affiliation(s)
- Anne M Lynn
- Department of Anesthesia and Pain Management, Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, Washington 98105, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
Baclofen is used for the treatment of spasticity. Small doses administered intrathecally achieve high cerebrospinal fluid concentrations with reduced side-effects. Pediatric anesthesiologists are often reluctant to consider epidural analgesia in children receiving baclofen via an intrathecal catheter and subcutaneous pump. This reluctance is based on concerns for damaging the intrathecal catheter and introducing infection. In addition, the acute cessation of intrathecal baclofen can precipitate a life-threatening withdrawal state. We report a case of successful epidural analgesia in a patient receiving intrathecal baclofen and discuss the steps we took to minimize the chance of harm with this technique. We conclude that an intrathecal catheter and subcutaneous pump to deliver baclofen should not preclude the use of an epidural catheter for perioperative analgesia.
Collapse
Affiliation(s)
- Natalia A Piper
- Department of Anesthesiology and Pain Medicine, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
| | | | | | | |
Collapse
|
22
|
Abstract
BACKGROUND Historically, the use of anesthetics and analgesics in neonates and infants has been based on extrapolations from studies performed in adults and older children. Over the past 20 years, there has been a growing body of research on the clinical pharmacology and clinical outcomes of these agents in neonates and infants. OBJECTIVE This article summarizes clinical pharmacology and clinical outcomes studies of opioids, opioid antagonists, sedative-hypnotics, nonsteroidal anti-inflammatory drugs and acetaminophen, and local anesthetics in neonates and infants to highlight gaps in the available knowledge, review some concerns about study design, and identify drugs that should receive high priority for future study. METHODS Relevant studies were identified through a search of MEDLINE and a review of textbooks, conference proceedings, and abstracts. The available literature was subjected to expert committee-based review. CONCLUSIONS There is a growing body of information on analgesic and anesthetic pharmacokinetics, pharmacodynamics, and clinical outcomes in neonates and infants, permitting safe and effective use in some clinical settings. Major gaps in knowledge persist, however. Future research may involve a combination of clinical trials and preclinical studies in suitable infant animal surrogate models.
Collapse
Affiliation(s)
- Charles B Berde
- Department of Anaesthesia, Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | | | | | | | | | | |
Collapse
|
23
|
Anand KJS, Aranda JV, Berde CB, Buckman S, Capparelli EV, Carlo W, Hummel P, Johnston CC, Lantos J, Tutag-Lehr V, Lynn AM, Maxwell LG, Oberlander TF, Raju TNK, Soriano SG, Taddio A, Walco GA. Summary proceedings from the neonatal pain-control group. Pediatrics 2006; 117:S9-S22. [PMID: 16777824 DOI: 10.1542/peds.2005-0620c] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent advances in neurobiology and clinical medicine have established that the fetus and newborn may experience acute, established, and chronic pain. They respond to such noxious stimuli by a series of complex biochemical, physiologic, and behavioral alterations. Studies have concluded that controlling pain experience is beneficial with respect to short-term and perhaps long-term outcomes. Yet, pain-control measures are adopted infrequently because of unresolved scientific issues and lack of appreciation for the need for control of pain and its long-term sequelae during the critical phases of neurologic maturation in the preterm and term newborn. The neonatal pain-control group, as part of the Newborn Drug Development Initiative (NDDI) Workshop I, addressed these concerns. The specific issues addressed were (1) management of pain associated with invasive procedures, (2) provision of sedation and analgesia during mechanical ventilation, and (3) mitigation of pain and stress responses during and after surgery in the newborn infant. The cross-cutting themes addressed within each category included (1) clinical-trial designs, (2) drug prioritization, (3) ethical constraints, (4) gaps in our knowledge, and (5) future research needs. This article provides a summary of the discussions and deliberations. Full-length articles on procedural pain, sedation and analgesia for ventilated infants, perioperative pain, and study designs for neonatal pain research were published in Clinical Therapeutics (June 2005).
Collapse
Affiliation(s)
- Kanwaljeet J S Anand
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Jimenez N, Bradford H, Seidel KD, Sousa M, Lynn AM. A comparison of a needle-free injection system for local anesthesia versus EMLA for intravenous catheter insertion in the pediatric patient. Anesth Analg 2006; 102:411-4. [PMID: 16428534 DOI: 10.1213/01.ane.0000194293.10549.62] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Placement of IV catheters is a painful and stressful procedure for children. J-Tip is a needle-less Food and Drug Administration approved injection system that can be used for delivery of local anesthetic before IV cannulation. In this study, we compared the effectiveness of J-Tip versus eutectic mixture of local anesthetics (EMLA) to facilitate IV cannulation and provide adequate analgesia before IV placement. Children 7-19 years of age (n = 116) were randomized to receive 0.25 mL of 1% buffered lidocaine with J-Tip (n = 57) or 2.5 g of EMLA (n = 59) before IV cannulation. Measurements of success of cannulation (number of attempts for IV placement) and pain (0-10 visual analog scale) at application of local anesthetic and at cannulation were performed. There was a significant (P = 0.0001) difference in pain ratings during IV cannulation between EMLA (median = 3) and the J-Tip (median = 0). Eighty-four percent of patients reported no pain at the time of J-Tip lidocaine application compared to 61% in the EMLA group at the time of dressing removal (P = 0.004). We did not find differences in the number of attempts for IV cannulation. J-Tip application of 1% buffered lidocaine before IV cannulation is not painful and has better anesthetic effectiveness compared with EMLA.
Collapse
Affiliation(s)
- Nathalia Jimenez
- Department of Anesthesiology and Pain Medicine, Children's Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, WA 98105, USA.
| | | | | | | | | |
Collapse
|
25
|
Anand KJS, Aranda JV, Berde CB, Buckman S, Capparelli EV, Carlo WA, Hummel P, Lantos J, Johnston CC, Lehr VT, Lynn AM, Maxwell LG, Oberlander TF, Raju TNK, Soriano SG, Taddio A, Walco GA. Analgesia and anesthesia for neonates: Study design and ethical issues. Clin Ther 2005; 27:814-43. [PMID: 16117988 DOI: 10.1016/j.clinthera.2005.06.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this article is to summarize the clinical, methodologic, and ethical considerations for researchers interested in designing future trials in neonatal analgesia and anesthesia, hopefully stimulating additional research in this field. METHODS The MEDLINE, PubMed, EMBASE, and Cochrane register databases were searched using subject headings related to infant, newborn, neonate, analgesia, anesthesia, ethics, and study design. Cross-references and personal files were searched manually. Studies reporting original data or review articles related to these topics were assessed and critically evaluated by experts for each topical area. Data on population demographics, study characteristics, and cognitive and behavioral outcomes were abstracted and synthesized in a systematic manner and refined by group members. Data synthesis and results were reviewed by a panel of independent experts and presented to a wider audience including clinicians, scientists, regulatory personnel, and industry representatives at the Newborn Drug Development Initiative workshop. Recommendations were revised after extensive discussions at the workshop and between committee members. RESULTS Designing clinical trials to investigate novel or currently available approaches for analgesia and anesthesia in neonates requires consideration of salient study designs and ethical issues. Conditions requiring treatment include pain/stress resulting from invasive procedures, surgical operations, inflammatory conditions, and routine neonatal intensive care. Study design considerations must define the inclusion and exclusion criteria, a rationale for stratification, the confounding effects of comorbid conditions, and other clinical factors. Significant ethical issues include the constraints of studying neonates, obtaining informed consent, making risk-benefit assessments, defining compensation or rewards for participation, safety considerations, the use of placebo controls, and the variability among institutional review boards in interpreting federal guidelines on human research. For optimal study design, investigators must formulate well-defined study questions, choose appropriate trial designs, estimate drug efficacy, calculate sample size, determine the duration of the studies, identify pharmacokinetic and pharmacodynamic parameters, and avoid drug-drug interactions. Specific outcome measures may include scoring on pain assessment scales, various biomarkers and their patterns of response, process outcomes (eg, length of stay, time to extubation), intermediate or long-term outcomes, and safety parameters. CONCLUSIONS Much more research is needed in this field to formulate a scientifically sound, evidence-based, and clinically useful framework for management of anesthesia and analgesia in neonates. Newer study designs and additional ethical dilemmas may be defined with accumulating data in this field.
Collapse
Affiliation(s)
- K J S Anand
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Previous studies show that the age of an infant affects morphine clearance but that ventilatory effects from morphine infusions are similar at the same morphine steady-state concentration in infants and children after surgery. The presence of cyanotic heart disease in infants receiving postoperative morphine infusions was studied for its potential effect on ventilatory effort. METHODS Twenty infants under 90 days of age (10 cyanotic, 10 acyanotic) received morphine intravenous infusions following thoracotomy. PaCO2 during spontaneous breathing, CO2 rebreathing trials during morphine infusions and time to wean from assisted mechanical ventilation after decreasing infusion rates were compared. Analgesia scoring in the first postoperative 24 h was also compared between cyanotic and acyanotic infants. RESULTS PaCO2 during spontaneous breathing and CO2 response curve slopes were not different between groups. The time to wean from assisted mechanical ventilation after decreasing morphine infusion rates was not statistically different (median 6.9 h versus 5.8 h in cyanotic and acyanotic, respectively). Median morphine concentrations were higher in cyanotic infants at the time of ventilatory testing (32 versus 20.5 ng x ml-1 in cyanotic versus acyanotic infants, respectively, P = NS). Both groups had good pain relief. Steady-state morphine clearance rates showed two- to three-fold variability between infants. They were not statistically different in cyanotic versus acyanotic infants but tended to be lower in the cyanotic. Morphine clearance increased significantly with increasing age. CONCLUSIONS Morphine i.v. infusions given to infants following thoracotomy show the same ventilatory effects in infants with cyanotic heart disease as in acyanotic infants. Age is the more important determinant of morphine response by its effect on morphine clearance than cyanosis in infants aged less than 3 months.
Collapse
Affiliation(s)
- Anne M Lynn
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington, USA.
| | | | | | | |
Collapse
|
27
|
Davis PJ, Galinkin J, McGowan FX, Lynn AM, Yaster M, Rabb MF, Krane EJ, Kurth CD, Blum RH, Maxwell L, Orr R, Szmuk P, Hechtman D, Edwards S, Henson LG. A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. I. Emergence and recovery profiles. Anesth Analg 2001; 93:1380-6, table of contents. [PMID: 11726411 DOI: 10.1097/00000539-200112000-00006] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after. IMPLICATIONS The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.
Collapse
Affiliation(s)
- P J Davis
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213-2583, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Galinkin JL, Davis PJ, McGowan FX, Lynn AM, Rabb MF, Yaster M, Henson LG, Blum R, Hechtman D, Maxwell L, Szmuk P, Orr R, Krane EJ, Edwards S, Kurth CD. A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. II. Perioperative breathing patterns in neonates and infants with pyloric stenosis. Anesth Analg 2001; 93:1387-92, table of contents. [PMID: 11726412 DOI: 10.1097/00000539-200112000-00007] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic. IMPLICATIONS Abnormal breathing patterns can follow anesthesia in infants after surgical repair of pyloric stenosis. Occasionally, these patterns can be associated with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.
Collapse
Affiliation(s)
- J L Galinkin
- Department of Anesthesiology, Children's Hospital of Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- G H Meakin
- University Department of Anaesthesia, Royal Manchester Children's Hospital, Pendlebury, United Kingdom.
| | | | | | | | | | | | | |
Collapse
|
30
|
Lynn AM, Jain CK, Kosalai K, Barman P, Thakur N, Batra H, Bhattacharya A. An automated annotation tool for genomic DNA sequences using GeneScan and BLAST. J Genet 2001; 80:9-16. [PMID: 11910119 DOI: 10.1007/bf02811413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Genomic sequence data are often available well before the annotated sequence is published. We present a method for analysis of genomic DNA to identify coding sequences using the GeneScan algorithm and characterize these resultant sequences by BLAST. The routines are used to develop a system for automated annotation of genome DNA sequences.
Collapse
Affiliation(s)
- A M Lynn
- Bioinformatics Centre, Jawaharlal Nehru University, New Delhi 110 067, India
| | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
Both the aqueous and lipid-induced structure of Kassinin, a dodecapeptide of amphibian origin, has been studied by two-dimensional proton nuclear magnetic resonance (2D 1H-NMR) spectroscopy and distance geometry calculations. Unambiguous NMR assignments of protons have been made with the aid of correlation spectroscopy (DQF-COSY and TOCSY) experiments and nuclear Overhauser effect spectroscopy (NOESY and ROESY) experiments. The distance constraints obtained from the NMR data have been utilized in a distance geometry algorithm to generate a family of structures, which have been refined using restrained energy minimization and dynamics. These data show that, while in water Kassinin prefers to be in an extended chain conformation, in the presence of perdeuterated dodecylphosphocholine (DPC) micelles, a membrane model system, helical conformation is induced in the central core and C-terminal region (K4-M12) of the peptide. N-terminus though less defined also displays some degree of order and a possible turn structure. The conformation adopted by Kassinin in the presence of DPC micelles is consistent with the structural motif typical of neurokinin-1 selective agonists and with that reported for Eledoisin in hydrophobic environment.
Collapse
Affiliation(s)
- R C Grace
- Department of Physics, Indian Institute of Science, Bangalore
| | | | | |
Collapse
|
32
|
Abstract
Eighty-three infants received i.v. morphine following surgery as a continuous infusion to a targeted morphine concentration of 20 ng ml(-1) (n = 56) or as intermittent bolus doses as needed (n = 27). Ventilation was compared in the two groups by continuous pulse oximetry, by venous blood gases on postoperative day 1 (POD 1) and by CO2 response curves. Infant pain scores were done to assess analgesia every 4 h. Both groups achieved pain scores consistent with analgesia but the bolus group showed a higher percentage of pain scores indicating distress (32 vs. 13%, P < 0.001). Room air saturations of < 90% were seen for 2.3% of POD1 in infusion-treated infants and for 2.5% of POD1 in bolus-treated infants. Mean venous PCO2S were normal in the two groups. Four infants showed ventilatory effects in the infusion group (4/ 56 = 7%); venous hypercarbia in two (2 days, 36 days), oximetry desaturation in one (240 days), both effects in one (6 days). Ventilatory effects were not statistically different between the intermittent bolus-treated and infusion-treated infants but may be clinically important. Monitoring with continuous oximetry is necessary. Morphine clearance increased with age. Infants with detectable morphine also had measurable morphine-6-glucuronide in both groups. Oral intake began at 16 h in both groups and other side effects were infrequent.
Collapse
Affiliation(s)
- Anne M Lynn
- Department of Anesthesiology, University of Washington Schools of Medicine and Pharmacy, Seattle, WA, USA Department of Anesthesia and Critical Care, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA Department of Pharmaceutics, University of Washington Schools of Medicine and Pharmacy, Seattle, WA, USA
| | | | | | | |
Collapse
|
33
|
Davis PJ, Finkel JC, Orr RJ, Fazi L, Mulroy JJ, Woelfel SK, Hannallah RS, Lynn AM, Kurth CD, Moro M, Henson LG, Goodman DK, Decker MD. A randomized, double-blinded study of remifentanil versus fentanyl for tonsillectomy and adenoidectomy surgery in pediatric ambulatory surgical patients. Anesth Analg 2000; 90:863-71. [PMID: 10735790 DOI: 10.1097/00000539-200004000-00017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We compared, in a double-blinded manner, the anesthetic maintenance and recovery properties of remifentanil with a clinically comparable fentanyl-based anesthetic technique in pediatric ambulatory surgical patients. Anesthesia was induced with either halothane or sevoflurane and nitrous oxide and oxygen. Patients were randomized (computer generated) to receive either remifentanil or fentanyl in a blinded syringe with nitrous oxide and oxygen in one of four possibilities: halothane/remifentanil, halothane/fentanyl, sevoflurane/remifentanil or sevoflurane/fentanyl. In patients receiving remifentanil, a placebo bolus was administered, and a continuous infusion (0.25 microg. kg(-1). min(-1)) was begun. In patients receiving fentanyl, a bolus (2 microg/kg) was administered followed by a placebo continuous infusion. The time from discontinuation of the anesthetic to extubation, discharge from the postanesthesia care unit (PACU), and discharge to home, as well as pain scores, were assessed by a blinded nurse observer. Systolic blood pressure and heart rate were noted at selected times, and adverse events were recorded. Remifentanil provided faster extubation times and higher pain-discomfort scores. PACU and hospital discharge times were similar. There were no statistical differences among the groups for adverse events. There were statistically, but not clinically, significant differences in hemodynamic variables. We noted that continuous infusions of remifentanil were intraoperatively as effective as bolus fentanyl. Although patients could be tracheally extubated earlier with remifentanil, this did not translate to earlier PACU or hospital discharge times. In addition, remifentanil was associated with higher postoperative pain scores. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children. IMPLICATIONS This is a study designed to examine the efficacy and safety of a short-acting opioid, remifentanil, when used in pediatric patients. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children.
Collapse
Affiliation(s)
- P J Davis
- Departments of Anesthesiology and Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213-2583, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Davis PJ, Finkel JC, Orr RJ, Fazi L, Mulroy JJ, Woelfel SK, Hannallah RS, Lynn AM, Kurth CD, Moro M, Henson LG, Goodman DK, Decker MD. A Randomized, Double-Blinded Study of Remifentanil Versus Fentanyl for Tonsillectomy and Adenoidectomy Surgery in Pediatric Ambulatory Surgical Patients. Anesth Analg 2000. [DOI: 10.1213/00000539-200004000-00017] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
35
|
|
36
|
Affiliation(s)
- C Ramamoorthy
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
| | | | | |
Collapse
|
37
|
Abstract
UNLABELLED We measured the ventilatory response to CO2 as an indicator of respiratory control dysfunction in children with obstructive sleep apnea (OSA) scheduled for adenotonsillectomy. Measurements were performed in unpremedicated children via an endotracheal tube under 0.4%-0.5% end-tidal halothane anesthesia. Mean ventilatory CO2 response slopes for 11 children with OSA requiring adenotonsillectomy (Group I) were compared with those for 14 children without OSA requiring adenotonsillectomy (Group II) and 15 children without OSA requiring nonairway surgery (Group III). The mean ventilatory slope corrected for body surface area for Groups I, II, and III were 539 +/- 338, 828 +/- 234, and 850 +/- 380 mL.min-1.mm Hg ETCO2(-1).m-2, respectively (P < 0.05, Group I versus Groups II and III). Historical data--including snoring, apneic episodes > 10 s, daytime hypersomnolence, and nocturnal enuresis--defined those with OSA. Obesity occurred more frequently in patients with OSA and with depressed ventilatory responses (P < 0.001). Children with OSA from adenotonsillar hypertrophy have a diminished ventilatory response to CO2 stimulation, compared with those without OSA symptoms. The depressed response may account, in part, for the reported increased risk of perioperative respiratory complications in this population. IMPLICATIONS Children with obstructive sleep apnea undergoing adenotonsillar surgery are at risk of postoperative respiratory compromise. We found that patients with a clinical history suggesting obstructive sleep apnea have a diminished ventilatory response to CO2 rebreathing, compared with controls.
Collapse
Affiliation(s)
- S G Strauss
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
| | | | | | | |
Collapse
|
38
|
Strauss SG, Lynn AM, Bratton SL, Nespeca MK. Ventilatory Response to CO2 in Children with Obstructive Sleep Apnea from Adenotonsillar Hypertrophy. Anesth Analg 1999. [DOI: 10.1213/00000539-199908000-00015] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
39
|
Mukhopadhyay S, Cowsik SM, Lynn AM, Welsh WJ, Howlett AC. Regulation of Gi by the CB1 cannabinoid receptor C-terminal juxtamembrane region: structural requirements determined by peptide analysis. Biochemistry 1999; 38:3447-55. [PMID: 10079092 DOI: 10.1021/bi981767v] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A CB1 cannabinoid receptor peptide fragment from the C-terminal juxtamembrane region autonomously inhibits adenylyl cyclase activity in a neuroblastoma membrane preparation. The cannabinoid receptor antagonist, SR141716A, failed to block the response. The peptide was able to evoke the response in membranes from Chinese hamster ovary (CHO) cells that do not express the CB1 receptor. These studies are consistent with a direct activation of Gi by the peptide. To test the importance of a BXBXXB sequence, Lys403 was acetylated, resulting in a peptide having similar affinity but reduced efficacy. N-Terminal truncation of Arg401 resulted in a 6-fold loss of affinity, which was not further reduced by sequential truncation of up to the first seven amino acids, four of which are charged. N-Terminal-truncated peptides exhibited maximal activity, suggesting that Gi activation can be conferred by the remaining amino acids. Truncation of the C-terminal Glu417 or substitution of Glu417 by a Leu or of Arg401 by a Norleucine reduced activity at 100 microM. The C-terminal juxtamembrane peptide was constrained to a loop peptide by placement of Cys residues at both terminals and disulfide coupling. This modification reduced the affinity 3-fold but yielded near-maximal efficacy. Blocking the Cys termini resulted in a loss of efficacy. Circular dichroism spectropolarimetry revealed that all C-terminal juxtamembrane peptide analogues exist in a random coil conformation in an aqueous environment. A hydrophobic environment (trifluoroethanol) failed to induce alpha-helix formation in the C-terminal juxtamembrane peptide but did so in less active peptides. The anionic detergent sodium dodecyl sulfate induced alpha-helix formation in all analogues except the loop peptide, where it induces a left-handed PII conformation. It is concluded that alpha-helix formation is not required for Gi activation.
Collapse
Affiliation(s)
- S Mukhopadhyay
- Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, Missouri 63104, USA
| | | | | | | | | |
Collapse
|
40
|
Abstract
We describe the use of remifentanil in three infants with complex medical issues (hepatic failure, cyanotic heart disease and renal compromise). The short duration of opioid effect even after a long period of drug infusion (18 h) suggests this drug may be useful in some infants. Continued study is warranted.
Collapse
Affiliation(s)
- J B Eck
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
| | | |
Collapse
|
41
|
Affiliation(s)
- C Ramamoorthy
- Department of Anesthesiology, University of Washington School of Medicine, Seattle 98105, USA
| | | |
Collapse
|
42
|
Abstract
UNLABELLED We investigated the pharmacokinetics and side effects of milrinone in infants and children (< or = 13 yr) after open heart surgery in this prospective, open-label study. Milrinone binding to cardiopulmonary bypass (CPB) circuitry was also examined in out two groups. Children in the small dose group (n = 11) received two 25-microg/kg boluses with a final infusion rate of 0.5 microg kg(-1) x min(-1); those in the large dose group (n = 8) received a 50-microg/kg bolus and a 25-microg/kg bolus with a final infusion rate of 0.75 microg x kg(-1) x min(-1). Blood samples for milrinone concentration were drawn 30 min after each bolus, at steady state, and after discontinuing the milrinone infusion. Pharmacokinetics were evaluated using traditional and nonlinear mixed effects modeling analysis. Milrinone kinetics best fit a two-compartment model. Steady-state plasma levels in the small and large dose groups were within the adult therapeutic range (113 +/- 39 and 206 +/- 74 ng/mL, respectively). The volumes of distribution (Vbeta) in infants (0.9 L/kg) and children (0.7 L/kg) were not different, but infants had significantly lower milrinone clearance (3.8 vs 5.9 mL x kg(-1) x min(-1)). Thrombocytopenia (defined as platelet count < or = 100,000 mm(-3)) occurred in 58%, and the risk increased significantly with duration of infusion. Tachyarrythmias were noted in two patients. Milrinone did not bind to CPB circuitry. We conclude that milrinone is cleared more rapidly in children than in adults. The major complication was thrombocytopenia. IMPLICATIONS Most pediatric dosing is based on data published for adults. Infants and children have kinetics that differ from adults. We studied the distribution of I.V. milrinone in infants and children after open heart surgery. Milrinone had a larger volume of distribution and a faster clearance in infants and children than in adults, and dosing should be adjusted accordingly.
Collapse
Affiliation(s)
- C Ramamoorthy
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA.
| | | | | | | |
Collapse
|
43
|
Ramamoorthy C, Anderson GD, Williams GD, Lynn AM. Pharmacokinetics and Side Effects of Milrinone in Infants and Children After Open Heart Surgery. Anesth Analg 1998. [DOI: 10.1213/00000539-199802000-00011] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
44
|
Brogan TV, Bratton SL, Lynn AM. Thyroid function in infants following cardiac surgery: comparative effects of iodinated and noniodinated topical antiseptics. Crit Care Med 1997; 25:1583-7. [PMID: 9295836 DOI: 10.1097/00003246-199709000-00029] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Cardiopulmonary bypass has profound effects on thyroid hormone metabolism. These effects may be exacerbated in infants because they are able to absorb large quantities of iodine transcutaneously. The purpose of this study was to test the hypothesis that preoperative povidone-iodine contributes to postoperative thyroid depression in infants who undergo cardiac surgery. DESIGN Prospective, randomized, controlled trial. SETTING Children's Hospital and Medical Center, Seattle, WA. PATIENTS Thirty-seven infants undergoing repair of congenital cardiac defects. INTERVENTIONS Infants requiring cardiopulmonary bypass were divided into two groups: Group 1 received povidone-iodine; group 2 received chlorhexidine as a topical preoperative antiseptic. Group 3 did not require cardiopulmonary bypass for repair of cardiac defects and received povidone-iodine as a preoperative antiseptic. MEASUREMENTS AND MAIN RESULTS Thyrotropin (TSH), total triiodothyronine (T3), and thyroxine (T4) were measured at four intervals: a) before preparation for surgery; b) immediately after surgery; c) at 2 days after surgery; and d) at 5 to 8 days after surgery. There was a significant decrease in TSH concentrations immediately after surgery in the two bypass groups. This change was significantly greater than in the change in TSH concentration in the thoracotomy group. Total T3 and T4 concentrations decreased by postoperative day 2 in both groups 1 and 2, and the changes were significant compared with group 3. Total T3 and T4 concentrations increased significantly in all groups after postoperative day 2, with no significant difference between the three groups. CONCLUSION Cardiopulmonary bypass has a more significant effect on thyroid hormone metabolism than does the preoperative antiseptic.
Collapse
Affiliation(s)
- T V Brogan
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
| | | | | |
Collapse
|
45
|
Affiliation(s)
- G A Talbott
- University of North Carolina at Chapel Hill, Department of Pediatrics 27599-7220, USA
| | | | | | | |
Collapse
|
46
|
Geiduschek JM, Lynn AM, Bratton SL, Sanders JC, Levy FH, Haberkern CM, O'Rourke PP. Morphine pharmacokinetics during continuous infusion of morphine sulfate for infants receiving extracorporeal membrane oxygenation. Crit Care Med 1997; 25:360-4. [PMID: 9034277 DOI: 10.1097/00003246-199702000-00027] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine a) if serum morphine concentration changes during the first 3 hrs of extracorporeal membrane oxygenation (ECMO); and b) if absorption of morphine onto the membrane oxygenator is responsible for these changes. Also, morphine clearance during the first 5 days of ECMO was studied. DESIGN Prospective, open-label study with consecutive patient enrollment. SETTING Neonatal intensive care unit at a university-affiliated, children's hospital. SUBJECTS Eleven neonates with severe persistent pulmonary hypertension of the newborn receiving continuous intravenous infusions of morphine sulfate and requiring ECMO. INTERVENTIONS Blood samples were obtained from the subjects and ECMO circuits at predetermined time intervals. MEASUREMENTS AND MAIN RESULTS Serum morphine concentration was determined using high-performance liquid chromatography. Morphine concentrations were no different from baseline at 5 mins, 1 hr, or 3 hrs after beginning ECMO. There was no significant difference in morphine concentration from samples taken immediately proximal and distal to the membrane oxygenator at 5 mins, 1 hr, and 3 hrs after the start of ECMO. Morphine clearance was calculated on days 1, 3, and 5 of ECMO. The mean value for morphine clearance was 11.7 +/- 9.3 (SD) ml/min/kg (range 2.6 to 34.5). CONCLUSIONS The initiation of ECMO does not lead to a significant decrease in serum morphine concentration and there is no uptake of morphine onto the membrane oxygenator of the ECMO circuit. Morphine clearance for infants receiving ECMO is variable.
Collapse
Affiliation(s)
- J M Geiduschek
- Department of Anesthesiology, University of Washington School of Medicine, Children's Hospital and Medical Center, Seattle 98105, USA
| | | | | | | | | | | | | |
Collapse
|
47
|
Haberkern CM, Lynn AM, Geiduschek JM, Nespeca MK, Jacobson LE, Bratton SL, Pomietto M. Epidural and intravenous bolus morphine for postoperative analgesia in infants. Can J Anaesth 1996; 43:1203-10. [PMID: 8955967 DOI: 10.1007/bf03013425] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To compare two doses of bolus epidural morphine with bolus iv morphine for postoperative pain after abdominal or genitourinary surgery in infants. METHODS Eighteen infants were randomly assigned to bolus epidural morphine (0.025 mg.kg-1 or 0.050 mg.kg-1) or bolus iv morphine (0.050-0.150 mg.kg-1). Postoperative pain was assessed and analgesia provided, using a modified infant pain scale. Monitoring included continuous ECG, pulse oximetry, impedance and nasal thermistor pneumography. The CO2 response curves and serum morphine concentrations were measured postoperatively. RESULTS Postoperative analgesia was provided within five minutes by all treatment methods. Epidural groups required fewer morphine doses (3.8 +/- 0.8 for low dose [LE], 3.5 +/- 0.8 for high dose epidural [HE] vs. 6.7 +/- 1.6 for iv, P < 0.05) and less total morphine (0.11 +/- 0.04 mg.kg-1 for LE, 0.16 +/- 0.04 for HE vs 0.67 +/- 0.34 for iv, P < 0.05) on POD1. Dose changes were necessary in all groups for satisfactory pain scores. Pruritus, apnoea, and haemoglobin desaturation occurred in all groups. CO2 response curve slopes, similar preoperatively (range 36-41 ml.min-1.mmHg ETCO2-1.kg-1) were generally depressed (range, 16-27 ml.min-1.mmHg ETCO2-1.kg-1) on POD1. Serum morphine concentrations, negligible in LE (< 2 ng.ml-1), were similar in the HE and iv groups (peak 8.5 +/- 12.5 and 8.6 +/- 2.4 ng.ml-1, respectively). CONCLUSION Epidural and iv morphine provide infants effective postoperative analgesia, although side effects are common. Epidural morphine gives satisfactory analgesia with fewer doses (less total morphine); epidural morphine 0.025 mg.kg-1 is appropriate initially. Infants receiving epidural or iv morphine analgesia postoperatively need close observation in hospital with continuous pulse oximetry.
Collapse
Affiliation(s)
- C M Haberkern
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA.
| | | | | | | | | | | | | |
Collapse
|
48
|
Brutocao D, Bratton SL, Thomas JR, Schrader PF, Coles PG, Lynn AM. Comparison of hetastarch with albumin for postoperative volume expansion in children after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996; 10:348-51. [PMID: 8725415 DOI: 10.1016/s1053-0770(96)80095-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Hetastarch has been studied as a volume expander in adults after cardiopulmonary bypass (CPB) and in recommended dosages has not altered coagulation studies or increased clinical bleeding. Hetastarch was compared with albumin in children after CPB to determine whether hetastarch use was associated with increased clinical bleeding or alteration of coagulation studies. DESIGN Randomized double-blinded study. SETTING University-affiliated children's hospital. PARTICIPANTS Forty-seven children age 1 year or greater (mean 72.8 months; range 12 months to 15.5 years) scheduled for repair of congenital heart disease with moderate hypothermia were randomized to receive hetastarch or albumin as a postoperative volume expander during the first 24 hours after surgery. INTERVENTIONS Thirty-eight children required colloid replacement therapy. Blood pressure, central venous pressure, urine output, and chest tube drainage were used to determine colloid requirement. MEASUREMENTS AND MAIN RESULTS Clinical bleeding and laboratory studies of coagulation were evaluated as were requirements for colloid, crystalloid, and blood products. Twenty children received 6% hetastarch, and 18 received 5% albumin. No differences were found in the amount of replacement fluids required, or in coagulation parameters in children receiving 20 mL/kg or less of either colloid replacement therapy. An increase in prothrombin time was demonstrated in children who received greater than 20 mL/kg of 6% hetastarch (p = 0.006); however, no difference in clinical bleeding or blood product requirement was demonstrated between the hetastarch or albumin groups receiving more than 20 mL/kg. CONCLUSION This study demonstrated that 6% hetastarch is safe and an effective plasma volume expander in the postoperative management of children, using volumes up to 20 mL/kg. Close laboratory monitoring and careful evaluation of clinical bleeding are suggested when larger doses of hetastarch are administered because of prolongation of the prothrombin time with more than 20 mL/kg of hetastarch.
Collapse
Affiliation(s)
- D Brutocao
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, USA
| | | | | | | | | | | |
Collapse
|
49
|
Abstract
After Fontan repair in children, we performed a prospective, open-label study to evaluate the effect of amrinone on pulmonary vascular resistance (PVRI). Eight patients who underwent the Fontan repair had baseline arterial pressure, left atrial pressure, central venous pressure, and cardiac output measured postoperatively. Hemodynamic measurements were repeated after amrinone 4.5 mg/kg. The PVRI tended to decrease, but the change was not statistically significant. Although the systemic vascular resistance decreased to 802 +/- 222 from 941 +/- 191 dynes.s.cm-5.m-2 (P < 0.05), mean arterial blood pressure was unchanged. Cardiac index (3.8 +/- 1.2 to 4.7 +/- 1.6 L.min-1.m-2) and stroke volume index (23.6 +/- 6.7 to 30.5 +/- 8.1 mL.beat-1.m-2) increased, and heart rate decreased (160 +/- 21 to 151 +/- 24 bpm) (P < 0.05). Colloid transfusion during amrinone bolus administration was 13.9 mL/kg. The mean serum amrinone concentration was 4.2 micrograms/mL at the end of bolus and clearance was 2.24 mL.kg-1.min-1. Arrhythmias and thrombocytopenia were not noted. We conclude that amrinone administration is effective in increasing cardiac output in children who have undergone a Fontan repair.
Collapse
Affiliation(s)
- G K Sorensen
- Division of Pediatric Anesthesiology, Children's Hospital and Medical Center, Seattle, WA 98105, USA
| | | | | | | | | |
Collapse
|
50
|
Sorensen GK, Ramamoorthy C, Lynn AM, French J, Stevenson JG. Hemodynamic Effects of Amrinone in Children After Fontan Surgery. Anesth Analg 1996. [DOI: 10.1213/00000539-199602000-00004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|