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Gorsky K, Cuninghame S, Jayaraj K, Slessarev M, Francoeur C, Withington DE, Chen J, Cuthbertson BH, Martin C, Chapman M, Ganesan SL, McKinnon N, Jerath A. Inhaled Volatiles for Status Asthmaticus, Epilepsy, and Difficult Sedation in Adult ICU and PICU: A Systematic Review. Crit Care Explor 2024; 6:e1050. [PMID: 38384587 PMCID: PMC10881088 DOI: 10.1097/cce.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. STUDY SELECTION Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021. DATA EXTRACTION Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case-control studies, and risk-of-bias framework for clinical trials. DATA SYNTHESIS Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1-2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89-95%, pediatric: 80-97%), SE (adults: 54-100%, pediatric: 60-100%), and DS (adults: 60-90%, pediatric: 62-90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol. CONCLUSIONS Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.
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Affiliation(s)
- Kevin Gorsky
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Sean Cuninghame
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Kesikan Jayaraj
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marat Slessarev
- Department of Medicine, University of Western Ontario, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
| | - Conall Francoeur
- Department of Pediatrics, Laval University Faculty of Medicine, QC, Canada
| | - Davinia E Withington
- Department of Anesthesiology, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Jennifer Chen
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Martin Chapman
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Saptharishi Lalgudi Ganesan
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Nicole McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Cardiovascular Program, ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Withington DE, Mujallid R, Al Sabaa Z. Sedation and neurodevelopmental outcomes in PICU: Identification of study groups. Paediatr Anaesth 2019; 29:175-179. [PMID: 30472750 DOI: 10.1111/pan.13558] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/12/2018] [Accepted: 11/20/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND/AIMS As little as 30 minutes of exposure to anesthetic and sedative agents may adversely affect the developing brain. Safe, humane management of critically ill infants requires the use of sedative agents, often for prolonged periods. We sought to identify two comparable groups of critical care patients who did or did not receive sedatives, with the aim of designing a long-term neurodevelopment follow-up study. This feasibility study aimed to determine if two comparable groups could be found. METHODS Infants with respiratory diagnoses having noninvasive ventilation without sedation (Group C) or intubation and ventilation with sedation (Group S) were identified by chart review. Charts of patients fulfilling the above inclusion criteria were searched for exclusion criteria including neurological disease, extreme prematurity, congenital cardiac disease, and genetic anomalies. Data were extracted to score pediatric severity of illness scores (PRISM and PELOD) for each patient. These scores were then compared using the absolute scores and by risk strata. RESULTS Group S included 33 patients and Group C had 39. The absolute PRISM and PELOD scores were different between groups. Comparing the groups in three risk strata (PRISM greater or less than 5 or 10), there were no significant differences between groups. CONCLUSION It is not possible to randomize infants to sedation or no sedation to investigate neurodevelopmental outcomes. This phase of the project aimed to determine the comparability of two groups of PICU patients. These findings indicate that these groups could be enrolled as exposed and control subjects in an outcomes study.
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Affiliation(s)
- Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Razaz Mujallid
- Department of Anesthesiology, Maternity and Children's Hospital, Jeddah, Saudi Arabia
| | - Zainab Al Sabaa
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
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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.
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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
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McCann ME, Withington DE, Arnup SJ, Davidson AJ, Disma N, Frawley G, Morton NS, Bell G, Hunt RW, Bellinger DC, Polaner DM, Leo A, Absalom AR, von Ungern-Sternberg BS, Izzo F, Szmuk P, Young V, Soriano SG, de Graaff JC. Differences in Blood Pressure in Infants After General Anesthesia Compared to Awake Regional Anesthesia (GAS Study-A Prospective Randomized Trial). Anesth Analg 2017; 125:837-845. [PMID: 28489641 DOI: 10.1213/ane.0000000000001870] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT). CONCLUSIONS RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.
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Affiliation(s)
- M E McCann
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; †Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada; ‡Department of Anesthesia, McGill University, Montreal, Canada; §Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ‖Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ¶Department of Anaesthesia and Pain Management, the Royal Children's Hospital, Melbourne, Victoria, Australia; #Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; **Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy; ††Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, United Kingdom; ‡‡Department of Anaesthesia, Royal Hospital for Sick Children, Glasgow, United Kingdom; §§Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia; ‖‖Neonatal Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; ¶¶Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; ##Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; ***Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; †††Departments of Anesthesiology and Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado; ‡‡‡Department of Anaesthesia, Royal Children's Hospital, Melbourne, Australia; §§§University Medical Center Groningen, Groningen University, the Netherlands; ‖‖‖Pharmacology, Pharmacy, Anaesthesiology Unit, School of Medicine and Pharmacology, the University of Western Australia, Perth, Western Australia, Australia; ¶¶¶Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, Western Australia, Australia; ###Department of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit Children Hospital 'Vittore Buzzi', Milano, Italy; ****Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Health Medical Center, Dallas, Texas; ††††Outcome Research Consortium, Cleveland, Ohio; ‡‡‡‡Department of Anaesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands; §§§§Brain Center Rudolph Magnus, University Medical Centre Utrecht, the Netherlands; and ‖‖‖‖Department of Anesthesia, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, the Netherlands
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Withington DE. Comment on: Z-Z Peng 'The agreement between oscillometric and intra-arterial technique for blood pressure monitoring in the lower extremities of infants undergoing aortic coarctation repair'. Paediatr Anaesth 2017; 27:552. [PMID: 28383192 DOI: 10.1111/pan.13117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Davinia E Withington
- Department of Anesthesia and Division of Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
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Davidson AJ, Disma N, de Graaff JC, Withington DE, McCann ME. Outcomes in the trial registry should match those in the protocol - Authors' reply. Lancet 2016; 388:341. [PMID: 27477161 DOI: 10.1016/s0140-6736(16)30964-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Andrew J Davidson
- Murdoch Childrens Research Institute, Royal Children's Hospital and University of Melbourne, Parkville, VIC 3052, Australia.
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Andrew J Davidson
- Murdoch Childrens Research Institute, Royal Children's Hospital and University of Melbourne, Parkville, VIC 3052, Australia.
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, Stargatt R, Bellinger DC, Schuster T, Arnup SJ, Hardy P, Hunt RW, Takagi MJ, Giribaldi G, Hartmann PL, Salvo I, Morton NS, von Ungern Sternberg BS, Locatelli BG, Wilton N, Lynn A, Thomas JJ, Polaner D, Bagshaw O, Szmuk P, Absalom AR, Frawley G, Berde C, Ormond GD, Marmor J, McCann ME. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016; 387:239-50. [PMID: 26507180 PMCID: PMC5023520 DOI: 10.1016/s0140-6736(15)00608-x] [Citation(s) in RCA: 585] [Impact Index Per Article: 73.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial. METHODS In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98.6 (14.2) in the awake-regional group and 98.2 (14.7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0.169, 95% CI -2.30 to 2.64). The median duration of anaesthesia in the general anaesthesia group was 54 min. INTERPRETATION For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia. FUNDING Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).
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Affiliation(s)
- Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Melbourne Children's Trials Centre, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada; Department of Anesthesia, McGill University, Montreal, Canada
| | - Liam Dorris
- Mental Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK
| | - Robyn Stargatt
- School of Psychological Science, La Trobe University, Victoria, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Sarah J Arnup
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Rodney W Hunt
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Michael J Takagi
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Gaia Giribaldi
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Ida Salvo
- Department of Anesthesiology and Pediatric Intensive Care, Ospedale Pediatrico 'Vittore Buzzi', Milan, Italy
| | - Neil S Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - Britta S von Ungern Sternberg
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia
| | | | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Anne Lynn
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Joss J Thomas
- Department of Anesthesia, University of Minnesota, Minneapolis, MN, USA
| | - David Polaner
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Oliver Bagshaw
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK
| | - Peter Szmuk
- Department of Anesthesiology, Children's Medical Centre Dallas, Dallas, TX, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Charles Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gillian D Ormond
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Withington DE, Fontela PS, Harrington KP, Tchervenkov C, Lands LC. A comparison of three dose timings of methylprednisolone in infant cardiopulmonary bypass. Springerplus 2014; 3:484. [PMID: 25221738 PMCID: PMC4161735 DOI: 10.1186/2193-1801-3-484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 08/15/2014] [Indexed: 11/25/2022]
Abstract
Although commonly used in pediatric cardiopulmonary bypass (CPB) optimal dose and timing of steroid administration is unclear. We hypothesized that early administration of a commonly used dose of methylprednisolone given the evening before surgery (ultra-early) would be more effective in decreasing CPB-related inflammatory response than when given at induction of anesthesia (early) or in pump prime (standard). This was a triple-arm, parallel, active control, superiority RCT including 54 infants <2 years old who were randomised to receive 30 mg/kg methylprednisolone at one of the 3 time points. Outcomes included alveolar-arterial oxygen gradient (AaDO2) during, 24, 48 and 72 hours post-CPB, IL-6, IL-8 and reduced (GSH) to oxidized (GSSG) glutathione ratio (pre-ultrafiltration on CPB, end-CPB and 24 hours), PICU length of stay (LOS) and ventilator days. Data were analysed using descriptive statistics and a random effects regression model. The ultra-early group had higher Risk Adjusted Congenital Heart Surgery Score, lower age and longer CPB times than the other groups. No significant differences in AaDO2, IL-8, PICU LOS and ventilator days were observed between groups. Compared to the ultra-early group, the overall rise in IL-6 in the early and standard groups was lower, -27.8 pg/ml (95% CI -52.7,-2.9) and -35.3 pg/ml (95% CI -64.3,-6.34), respectively. GSH:GSSG was significantly lower in the standard group (-35.9; 95% CI -63.31,-8.5) at 24 hours post-CPB. Ultra-early administration of methylprednisolone does not improve AaDO2 post-CPB, nor diminish cytokine release. Lower GSH:GSSG in the standard group suggests less oxidative stress. However despite statistical adjustments conclusions are limited by the unbalanced randomisation of the groups.
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Affiliation(s)
- Davinia E Withington
- Department of Pediatric Anesthesia, McGill University Health Center/Montreal Children's Hospital, 2300 Tupper Street, Room C-1118, Montreal, Quebec Canada ; Department of Pediatrics, McGill University Health Center/Montreal Children's Hospital, Montreal, Canada
| | - Patricia S Fontela
- Department of Pediatrics, McGill University Health Center/Montreal Children's Hospital, Montreal, Canada ; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University Montreal, Montreal, Canada
| | - Karen P Harrington
- Department of Critical Care, Centre Hospitalier Universitaire Ste Justine, Montreal, Canada
| | - Christo Tchervenkov
- Division of Pediatric Cardiothoracic Surgery, McGill University Health Center/Montreal Children's Hospital, Montreal, Canada
| | - Larry C Lands
- Department of Pediatrics, McGill University Health Center/Montreal Children's Hospital, Montreal, Canada
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10
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11
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Abstract
We describe a case of severe pain associated with extensive lower limb injures in a 5-year old, complicated by profound anemia in a Jehovah's Witness family. The study was carried out in a pediatric intensive care unit of a tertiary level university hospital. The patient was 5-year-old girl, with multiple open fractures and extensive soft tissue loss on her left foot and ankle due to a lawnmower injury leading to severe pain and profound anemia with management of the latter complicated by family beliefs. The interventions given were multi-modal pain management and treatment of severe anemia with avoidance of transfusion. A drop in hemoglobin from 11.6 g.dl(-1) at admission to a nadir of 4.3 g.dl(-1) on day 7 was observed. Effective pain control was achieved with nurse- and then patient-controlled analgesia plus adjuncts. Effective pain management and control of anxiety can be achieved by a multi-modal approach in young children. Profound anemia was treated without transfusion and without compromise of tissue healing.
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Affiliation(s)
- Giuliana Rizzo
- Departments of Pediatric Anesthesia, Montreal Childrens' Hospital and McGill University, Montreal, QC, Canada.
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12
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Hill SJ, Withington DE. Too clever by half? Can bilateral or unilateral NIRS monitoring improve neurological outcome from pediatric cardiopulmonary bypass? Paediatr Anaesth 2006; 16:709-11. [PMID: 16879512 DOI: 10.1111/j.1460-9592.2006.01988.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Abstract
BACKGROUND Exhaled nitric oxide (eNO) is elevated in inflammatory airway conditions, e.g. asthma. We measured eNO levels in normal preschool children for whom there is little data available and in whom the prevalence of asthma is high. SUBJECTS AND METHODS Fifty children, 2-7 years old, undergoing elective surgery, excluding airway procedures, were recruited. Children with known respiratory disease or acute viral infections were excluded. Gas for eNO measurement was collected in a non-diffusion bag via 1) the mask after inhalation induction of anesthesia, 2) endotreacheal tube (ETT) or laryngeal mask airway (LMA), and 3) during emergence. Measurement was off-line by chemiluminescent analyzer. RESULTS Mean eNO level by mask was 10.23 ppb (mean value+/-SD of 8.8-11.1 ppb) after induction and 8.35 ppb (mean value+/-SD of 5.9-10.8 ppb) on emergence. Mean eNO for the intubated group (n=25) was 0.75 ppb (mean value+/-SD of 0.4-1 ppb) (P<0.0001 vs mask); mean eNO for the LMA group (n=25) was 2.6 ppb (mean value+/-SD of 2-3.2 ppb), which differed from the mask (P<0.0001), and from ETT values (P<0.0001). CONCLUSIONS Most eNO is produced by the upper airway in healthy pre-school children. The lower airway constitutive eNO production is very low. The LMA does not completely isolate the upper airway and current mask collection techniques allow significant contamination of samples by sino-nasal eNO production in young children.
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Affiliation(s)
- Tareq M Al-Ayed
- Department of Critical Care, Montreal Children's Hospital, Montreal, Quebec, Canada.
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14
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Abstract
A 5-month-old boy required sedation after a cleft lip repair. He was sedated with propofol and intermittent fentanyl, requiring escalating doses over the subsequent 48 h. On the second post-operative day he developed a metabolic acidosis followed by multiple cardiac dysrhythmias, hepatic and renal failure. Propofol was stopped. His multisystem organ failure gradually resolved after initiation of charcoal haemoperfusion. Further investigation demonstrated an abnormality in acylcarnitine metabolism, similar to that found in one previous case report.
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Affiliation(s)
- Davinia E Withington
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, Quebec, Canada.
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15
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Affiliation(s)
- DE Withington
- Department of Anaesthesia, Montreal Children's Hospital/McGill University and Faculte de Pharmacie, Universite de Montreal, Montreal, Quebec, Canada
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16
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Abstract
OBJECTIVE To describe the use of inhaled nitric oxide in the management of refractory postoperative chylothorax. DESIGN Case report. SETTING A pediatric intensive care unit of a tertiary care children's hospital. PATIENT A neonate with refractory chylothoraces complicated by moderate pulmonary hypertension after a complicated arterial switch operation. INTERVENTIONS Administration of inhaled nitric oxide through a ventilator circuit. MEASUREMENTS AND MAIN RESULTS The institution of inhaled nitric oxide at 20 ppm resulted in a marked reduction in chest tube drainage and a decrease in echocardiographically estimated pulmonary artery pressure from 50%-75% systemic to 30%-50% systemic. Chest tube drainage doubled when the nitric oxide was decreased to 10 ppm and, again, dramatically decreased after raising nitric oxide back to 20 ppm. After 8 days of nitric oxide therapy, the chest tube drainage ceased. Nitric oxide therapy was successfully discontinued 19 days after initiation, with no recurrence of chylothorax. There was no effect of nitric oxide on systemic blood pressure. Methemoglobin levels while on NO remained <1.7%. CONCLUSION Consideration may be given to the use of inhaled nitric oxide in the therapy of refractory chylothoraces complicated by central venous hypertension.
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Affiliation(s)
- J W Berkenbosch
- Department of Pediatric Critical Care, Montreal Children's Hospital, McGill University, Quebec, Canada
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17
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Abstract
Residual neuromuscular blockade is a major risk factor for respiratory insufficiency. We examined the relationship between neuromuscular and respiratory function in 18 ASA I or II children aged 2-4 years. Lung function was measured by pneumotachography and transpulmonary pressure, neuromuscular transmission by first twitch response ratio (T1:T1) and train-of-four ratio (TOFR), before and at specific points in recovery from vecuronium paralysis. The tidal volume was directly related to maximal inspiratory pressure at occlusion (PIOCC), P < 0.001, whereas the minute ventilation (VE) was related to the respiratory drive (P0.1), P < 0.001. The best predictors of minute ventilation were the P0.1 (r = 0.57), and the TOFR (r = 0.62). PIOCC and P0.1 correlated closely (r = 0.889, P = 0.002) but TOFR and T1:T1 did not correlate with either. Our results show that the occlusion pressure measurements, P0.1 and PIOCC, were good predictors of both VE.kg-1 and respiratory work.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Montreal Children's Hospital, Québec, Canada
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18
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Fitzsimmons CL, Withington DE. Use of adenosine in multiple doses for supraventricular tachycardia in an infant. Pediatr Cardiol 1997; 18:432-3. [PMID: 9326690 DOI: 10.1007/s002469900222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/05/2023]
Abstract
The treatment of recurrent supraventricular tachycardia in a 3-week-old infant is described. Multiple doses of adenosine were used successfully to convert the dysrhythmia, without adverse effects or apparent tachyphylaxis.
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Affiliation(s)
- C L Fitzsimmons
- Department of Pediatrics, McGill University, Montreal Children's Hospital, 2300 Tupper Street, Montreal, Quebec H3H 1P3, Canada
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19
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Abstract
PURPOSE Histamine release has been previously documented in adults and children during cardiopulmonary bypass (CPB). It has not been studied in neonates nor during deep hypothermic circulatory arrest (DHCA). Histamine effects could explain many perioperative complications of congenital cardiac surgery such as dysrhythmias and massive oedema. Therefore, documentation of histamine release in the perioperative period is of clinical importance. The source of histamine can be determined by measurement of tryptase which is released with histamine from mast cells but not basophils. METHODS Blood samples for histamine and tryptase were taken before and after specific events eg. cross-clamp removal, during anaesthesia and CPB in 14 infants and seven neonates undergoing complex congenital heart repairs and were analysed by commercial radioimmunoassays. Haemodynamic variables and pre and post-op weights were recorded to look for correlation between pathophysiological events and histamine release. RESULTS Histamine concentration decreased at the start of bypass (0.69 to 0.38 ng.ml-1 at five minutes, (P < .005). There were no changes associated with DHCA and a small rise with reventilation (P < 0.02). Histamine concentration was lower in neonates than in infants (P < 0.05) during CPB. Plasma histamine and tryptase concentrations did not correlate, suggesting histamine release was from basophils and not from mast cells. Haemodynamic variables did not correlate with histamine concentrations. CONCLUSION There was no major histamine release during CPB in infants and neonates. There was no relationship between histamine concentrations and clinical variables. Histamine released during CPB appears to come from basophils and may be a function of age.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Montréal Children's Hospital, Québec.
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20
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Withington DE, Aranda JV. Measurement of plasma histamine by high performance liquid chromatography and radioimmunoassay. Inflamm Res 1997; 46 Suppl 1:S77-8. [PMID: 9098774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- D E Withington
- Department of Anaesthesia, Montréal Children's Hospital, Canada
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21
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Withington DE, Aranda JV. Measurement of plasma histamine by high performance liquid chromatography and radioimmunoassay. Inflamm Res 1997; 46:77-8. [PMID: 27518012 DOI: 10.1007/s000110050091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- D E Withington
- Department of Anaesthesia, C-1119, Montréal Children's Hospital, 2300 Tupper Street, Montréal, Canada, , , , , , CA
| | - J V Aranda
- Department of Developmental Pharmacology, Lady Davis Institute, Jewish General Hospital, 3755 Côte Ste Catherine, Montréal, Québec H3T 1EZ, Canada, , , , , , CA
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22
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23
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Abstract
The use of epidural analgesia has become so widespread in recent years that many women are now requesting repeat epidural analgesia for their second or subsequent labour. This study examines the incidence of problems at insertion and of inadequate block in 71 multiparae having second epidurals compared with 150 primiparae having their first epidural. Unilateral block occurred in 6.66% of primiparae and 18.3% of multiparae (P < 0.02). There was no association between difficulty of insertion of catheter, blood in needle/catheter or paraesthesia and unilateral blockade. Epidurals were inserted at a greater dilatation (P < 0.05) and there was a shorter time to delivery (P < 0.01) in the multiparous group. We conclude that unilateral block is thus more common in women receiving repeat epidurals.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Royal Victoria Hospital, Montreal, Quebec
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24
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van der Wal M, Lang SA, Yip RW, Chow FL, Duncan PG, Perverseff RA, Crone LAL, Verity RA, Flath J, Twist DL, Code WE, Thornhill J, Wang L, Hong M, Milne B, Jhamandas K, Shannon JL, Gerard M, Takeuchi L, Puchalski SA, Roberts R, Law V, Bell R, Dunn GL, Eger RP, McLeod BA, Asenjo F, Blaise G, Normandin D, Naguib M, Abdulatif M, Hung OR, Mezei M, Varvel JR, Whynot SC, McKenzie W, Bands C, Shafer SL, Neumeister MW, Hall RI, Li G, Dawe G, O’Regan N, Hall R, Gardner M, El-Beheiry H, Shelley ES, Frcpc S, Freeman DJ, Gelb AW, Orser BA, Wang LY, MacDonald JF, Derdemezi J, Britt BA, Hyperthermia M, Doyle DJ, Chau TCY, Guay J, Crochètiere C, Gaudreault P, Lortie L, Varin F, Bevan DR, Plourde RG, Zaharia F, Knox JWD, Belo S, Warriner CB, Cannon JE, Watson JB, Byrick RJ, Mullen JBM, Wigglesworth DF, Klinck JR, Ortiz F, Pedersen J, Smith MF, Hayman GA, Buckingham C, Nebbia SP, Un V, Chung FF, Theodorou-Michaloliakou C, Baylon GJ, Chua JG, Sharma S, Cruise C, McGuire G, Chan VWS, Patel N, Pinchak AC, Smith CE, Hancock DE, Tessler MJ, Grillas BH, Gioseffini S, Grillas B, Desparmet JF, MacArthur C, MacArthur A, Carpenter RD, Bissonnette B, Fear DW, Lerman J, Spahr-Schopfer IA, Sikich N, Hagen JF, Fuller JG, Taylor M, Fisgus J, Petz C, Hagen J, Forrest JB, Buckley DN, Beattie WS, Beattie AE, Clairoux M, Katz J, Kavanagh B, Roger S, Nierenberg H, Sandler A, Baxter AD, Samson B, Laganière S, Stewart J, Hull KA, Goernart L, Sosis MB, Braverman B, Toppses A, Lipov E, Ivankovich AD, Rose DK, Cohen MM, Cheng DCH, Asokumar B, Caballero AC, Wong D, Maltby JR, Eagle CJ, Müller HG, Teasdale SJ, Karski JM, Carroll JA, Van Luven S, Zulys VJ, Davies A, Norman PN, Cuddihy P, Kavanagh B, Caballero A, Sandier A, Peniston C, Sandler AN, Boylan JF, Feindel CM, Sandier AN, Boylen P, Ries CR, Puil E, Hickey DR, Scott A, Doblar DD, Frenette L, Boyo G, Poplawski S, Ranjan D, Godley MB, Saprunoff S, Vincent D, Yee D, Goodall D, Zawacki J, Withington DE, Davis M, Vallinis P, Bevan JC, Sapin-Leduc A, Plourde G, Fosset N, Symes JF, Morin JE, De Varennes B, Latter D, Kantor GS, Smyth RJ, Glynn M, McLean RF, Phillips AA, Fremes SE, Bunting P, Joy L, Hamilton C, Searle NR, Roy M, Perrault J, Roof J, Hermanns CC, Courtemanche M, Demers C, Cartier R, Boudreault D, Couture P, To Q, Parent M, Badner NH, Komar WE, Murkin JM, Martzke JB, Buchan AM, Bentley C, Mazer CD, Byrick RJ, Tong J, Carroll JA, Van Kessel K, Glynn MF, Martin R, Jourdain S, Tétrault JP, Javery KB, Colclough GW, Sutterlin J, Witt WO, Rolbin S, Levinton C, Sayeed YG, Ward ME, Campbell D, Douglas MJ, Merrick P, Sandier A, Baxter A, Samson B, Katz J, Friedlander M, Donnelly M, Pagenkopf DS, Bagdan BL, Davies JM, Parsons LM, Roth L, Garnett RL, MacIntyre A, Lindsay MP, Yogendran S, Little D, Lena J, Halpern SH, Lin S, Bell DD, Ostryzniuk P, Roberts E, Roberts D, Gauthier JE, Perreault C, Tomasa G, Sosis NB, Matta BF, Eng CC, Mayberg TS, Lam AM, Mathisen TL, Kitts J, Martineau R, Miller D, Lindsay P, Curran M, Betcher JG, Kirpalani H, Gray S, Lung KE, Multari J, Stewart RD, Forward SP, McGrath PJ, Finley GA, McNeill G, Biddle NL, Gelb AW, Hamilton JT, Sharpe MD, Vanelli T, Craen RA, Brodkin I, Le D, Lok P, Rose DK, Yee DA, Layon AJ, White SE, Gibby GL, Greig PD, Nierenberg H, Sheiner PA, Levytam S, Arellano R, Glynn MFX, Purday JP, Reichert CC, Reimer EJ, Bevan JC, Montgomery CJ, Blackstock D, Reichert C, Byers GF, Muir JG, Levine MF, Kleinman S, Sarner J, Davis P, Motoyaraa E, Cook DR, Sessler DI, Foster JMT, Burrows FA, Haig M, Poitras B, Reid CW, Slinger P, Lenis S, Wilkes P, Henderson SM, Zhang C, Zulys V, Bradwell J, Mabuchi N, Carroll J, Harley P, Doblar D, Boyd G, Singer D, Gelman S, Devitt JH, Wenstone R, Noel AG, O’Donnell MP, Pytka S, Murphy MF, Launcelott GO, Morris IR, Stevens SC, Cooper RM, Irish JC, Brown DH, Donen N, White IWC, Snidal L, Sanmartin C, Knox MG, Roper F, Gornall W, Fisk JD, Ritvo P, Stanish W. Abstract. Can J Anaesth 1993. [DOI: 10.1007/bf03020692] [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: 10/20/2022] Open
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25
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Abstract
Histamine release is part of the general inflammatory response and occurs during surgery and cardiopulmonary bypass (CPB) in adults. Few data are available for children. Histamine release was studied in 23 children undergoing CPB with standard anaesthetic and CPB techniques. Blood sampling was performed in relation to specific anaesthetic and surgical events, e.g., start of CPB, removal of aortic clamps, reventilation of the lungs. Plasma histamine was determined by a single isotope radioenzymatic technique. There was no consistent histamine release in the study population although there was an increase in plasma histamine concentration in some subjects after initiation of CPB (P < 0.05) and on removal of the aortic cross-clamp (P < 0.05). No correlation was demonstrated between histamine concentration and systolic arterial pressure, temperature, duration of CPB or cross-clamp time. Histamine concentration was positively correlated with heart rate.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, St. Thomas' Hospital, London, U.K
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26
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Abstract
Intravenous morphine and diamorphine are routinely used for postoperative analgesia but the relative histamine releasing abilities of these drugs have not been compared in man. Thirty-eight patients were randomly allocated to receive morphine (0.16 mg.kg-1) or diamorphine (0.08 mg.kg-1) after abdominal surgery. Blood samples for histamine were taken before, and at timed intervals after, opioid administration and analysed by an isotopic radioenzymatic technique. Haemodynamic parameters and pain scores were recorded before and after analgesic administration, and a series of eight basophil histamine release studies was also performed. Significant histamine release (plasma concentration > 2 ng.ml-1 or rise of > 700% baseline) occurred in 23.5% of the morphine group and 21.1% of the diamorphine group. Histamine was released earlier in those receiving diamorphine, but no significant change in haemodynamic parameters occurred, and no histamine release was demonstrated in the basophil histamine release studies. These findings suggest that morphine and diamorphine release histamine from mast cells rather than basophils.
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Withington DE. Pulse oximetry in the postcardiopulmonary bypass period. Anaesthesia 1991; 46:517-8. [PMID: 2048696 DOI: 10.1111/j.1365-2044.1991.tb11731.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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28
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Abstract
Histamine release occurs during paediatric cardiopulmonary bypass at the time of removal of the aortic cross-clamp. Left atrial histamine levels are significantly (p less than 0.02) higher than right atrial levels at the time of reventilation of the lungs. These results suggest that histamine is released from the pulmonary vasculature following reperfusion.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Hospital for Sick Children, London, UK
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29
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Abstract
This study was designed to determine the time required for potentiation of atracurium neuromuscular blockade after the introduction of enflurane. Ten ASA physical status I and II adults anesthetized with thiopental, nitrous oxide, and alfentanil were given 0.4 mg/kg atracurium besylate. The force of contraction of the adductor pollicis muscle in response to train-of-four stimulation of the ulnar nerve was recorded. When the first twitch (T1) of the train-of-four recovered to 10% of control, an atracurium infusion was started and adjusted to keep the level of blockade constant. After 15 min of stable blockade, 1.6%-1.7% end-tidal enflurane was started and maintained for up to 2 h. Venous blood samples were drawn and plasma atracurium concentrations were measured 15 min before and 0, 5, 10, 15, 30, 45, 60, 90, and 120 min after the introduction of enflurane. Atracurium plasma concentrations were 730 +/- 127 (SEM) ng/mL at time 0. During the first 30 min, no significant decrease in plasma levels occurred; but at 45 min, concentrations were only 67% +/- 8% of their initial value (P less than 0.01) and 48% +/- 2% at 120 min (P less than 0.01). This suggests that the interaction between enflurane and atracurium is time-dependent. Clinically, the interaction between atracurium and enflurane is negligible during procedures of less than 45 min.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Royal Victoria Hospital, Montreal, Quebec, Canada
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30
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Withington DE. The laryngeal mask airway in paediatric anaesthesia. Anaesthesia 1991; 46:321-2. [PMID: 2024759 DOI: 10.1111/j.1365-2044.1991.tb11518.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Withington DE, Ramsay JG, Saoud AT, Bilodeau J. Weaning from ventilation after cardiopulmonary bypass: evaluation of a non-invasive technique. Can J Anaesth 1991; 38:15-9. [PMID: 1899203 DOI: 10.1007/bf03009157] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [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: 12/29/2022] Open
Abstract
Weaning of patients from IPPV after cardiopulmonary bypass (CPB) is usually monitored by frequent arterial blood gas analysis. Non-invasive monitoring has the advantage of providing continuous and instantaneous information and could reduce the frequency of arterial blood gas sampling. Twenty patients were studied to determine the reliability of capnometry and pulse oximetry in this situation. The effects of hypothermia and moderate haemodynamic instability were examined. A further 40 patients were then weaned using non-invasive monitoring. Correlation between PaCO2 and PETCO2 was 0.64-0.79 for the mass spectrometer and 0.67-0.81 for the infra-red analyser. No clinical problems arose. The detection rate for mild hypercarbia was 78.6 per cent and 50 per cent for hypoxia. Possible reasons for this are discussed. Once CO2 and O2 gradients are established, pulse oximetry and capnometry provide sufficiently reliable monitoring to enable weaning from IPPV, with the advantage of continuous display, and allow a reduction in the use of arterial blood gas analyses.
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Affiliation(s)
- D E Withington
- Department of Anaesthesia, Royal Victoria Hospital, Montreal, Canada
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Withington DE. Relevance of histamine to the anaesthetist. Br J Hosp Med (Lond) 1988; 40:264, 266, 268-70. [PMID: 3228658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Histamine is a widely distributed amine with many functions, both physiological and pathological. The anaesthetist may encounter histamine in several of these roles, many of which require further elucidation. Histamine research is involved in the investigation of release mechanisms and their modification, both having implications for the clinical situation.
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Abstract
Propofol (2,6-diisopropylphenol) has recently been introduced into clinical practice as an induction agent. This study evaluated the effect of propofol on basophil histamine release in 13 healthy subjects. No release was demonstrated in 11 subjects. Two subjects released histamine at the highest drug concentration, one also releasing at lower concentrations. Both subjects whose basophils released histamine in response to propofol were anaesthetists using the drug during the course of their practice.
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Abstract
A patient who suffered a severe hypotensive episode after induction of anaesthesia, was subsequently found to show positive skin-test responses to suxamethonium. Investigation revealed that suxamethonium induced basophils from the patient to release histamine to an extent comparable to that found after exposure to anit-IgE. Basophils from control subjects showed no such response. Basophil histamine release may offer a useful approach to the investigation of adverse drug reactions.
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35
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Abstract
A case is described in which administration of intravenous metoclopramide was twice followed by cardiac dysrhythmias. The literature is reviewed.
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