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Kortenbout AJ, Costerus S, Dudink J, de Jong N, de Graaff JC, Vos HJ, Bosch JG. Automatic Max-Likelihood Envelope Detection Algorithm for Quantitative High-Frame-Rate Ultrasound for Neonatal Brain Monitoring. Ultrasound Med Biol 2024; 50:434-444. [PMID: 38143187 DOI: 10.1016/j.ultrasmedbio.2023.12.006] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/07/2023] [Accepted: 12/03/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE Post-operative brain injury in neonates may result from disturbed cerebral perfusion, but accurate peri-operative monitoring is lacking. High-frame-rate (HFR) cerebral ultrasound could visualize and quantify flow in all detectable vessels using spectral Doppler; however, automated quantification in small vessels is challenging because of low signal amplitude. We have developed an automatic envelope detection algorithm for HFR pulsed wave spectral Doppler signals, enabling neonatal brain quantitative parameter maps during and after surgery. METHODS HFR ultrasound data from high-risk neonatal surgeries were recorded with a custom HFR mode (frame rate = 1000 Hz) on a Zonare ZS3 system. A pulsed wave Doppler spectrogram was calculated for each pixel containing blood flow in the image, and spectral peak velocity was tracked using a max-likelihood estimation algorithm of signal and noise regions in the spectrogram, where the most likely cross-over point marks the blood flow velocity. The resulting peak systolic velocity (PSV), end-diastolic velocity (EDV) and resistivity index (RI) were compared with other detection schemes, manual tracking and RIs from regular pulsed wave Doppler measurements in 10 neonates. RESULTS Envelope detection was successful in both high- and low-quality arterial and venous flow spectrograms. Our technique had the lowest root mean square error for EDV, PSV and RI (0.46 cm/s, 0.53 cm/s and 0.15, respectively) when compared with manual tracking. There was good agreement between the clinical pulsed wave Doppler RI and HFR measurement with a mean difference of 0.07. CONCLUSION The max-likelihood algorithm is a promising approach to accurate, automated cerebral blood flow monitoring with HFR imaging in neonates.
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Affiliation(s)
- Anna J Kortenbout
- Biomedical Engineering, Department of Cardiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Sophie Costerus
- Department of Pediatric Surgery, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nico de Jong
- Biomedical Engineering, Department of Cardiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands; Department of Imaging Physics, Medical Imaging, Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands; Department of Anesthesiology, Erasmus MC, Goes, The Netherlands; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Hendrik J Vos
- Biomedical Engineering, Department of Cardiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands; Department of Imaging Physics, Medical Imaging, Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands
| | - Johan G Bosch
- Biomedical Engineering, Department of Cardiology, University Medical Center Rotterdam, Erasmus MC, Rotterdam, The Netherlands.
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de Graaff JC, Frykholm P, Engelhardt T, Schindler E, Kovesi T, Simic D, Malagon I, Woodman N, Courtman S, Najafi N, Claussen NG, Karlsson J, Bonhomme F, Laffargue A, Vutskits L. Pediatric anesthesia in Europe: Variations within uniformity. Paediatr Anaesth 2024. [PMID: 38415881 DOI: 10.1111/pan.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 02/29/2024]
Abstract
Organization of healthcare strongly differs between European countries and results in country-specific requirements in postgraduate medical training. Within the European Union (EU), the European Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country-specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3-6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country-specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum.
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Affiliation(s)
- Jurgen C de Graaff
- Department of Anesthesia, Adrz-Erasmus MC, Goes, The Netherlands
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Peter Frykholm
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Engelhardt
- Department of Anesthesia, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tamas Kovesi
- Department of Paediatric Anaesthesia, Department of Anaesthesiology and Intensive Therapy, University of Pecs Medical School, Pécs, Hungary
| | - Dusica Simic
- Medical faculty University of Belgrade, University Children's Hospital, Belgrade, Serbia
| | - Ignacio Malagon
- Department of Anesthesia Radboud UMC, Nijmegen, The Netherlands
| | | | - Simon Courtman
- Department of Anaesthesia, University Hospital Plymouth, Plymouth, UK
| | - Nadia Najafi
- Department of Anesthesiology and Perioperative Medicine, University Hospital of Brussels, Brussels, Belgium
| | - Nicola Groes Claussen
- Pediatric Anesthesia Section, Department of Anesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jacob Karlsson
- Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Fanny Bonhomme
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Anne Laffargue
- Department of Pediatric Anesthesia, University Hospital of Lille, Lille, France
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
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Rondagh M, Kortenbout AJ, de Munck S, van den Bosch GE, Dudink J, Vos HJ, Bosch JG, de Graaff JC. A comparison of ultrafast and conventional spectral Doppler ultrasound to measure cerebral blood flow velocity during inguinal hernia repair in infants. J Clin Anesth 2024; 92:111312. [PMID: 37926064 DOI: 10.1016/j.jclinane.2023.111312] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Ultrafast cerebral Doppler ultrasound enables simultaneous quantification and visualization of cerebral blood flow velocity. The aim of this study is to compare the use of conventional and ultrafast spectral Doppler during anesthesia and their potential to show the effect of anesthesiologic procedures on cerebral blood flow velocities, in relation to blood pressure and cerebral oxygenation in infants undergoing inguinal hernia repair. METHODS A single-center prospective observational cohort study in infants up to six months of age. We evaluated conventional and ultrafast spectral Doppler cerebral ultrasound measurements in terms of number of successful measurements during the induction of anesthesia, after sevoflurane induction, administration of caudal analgesia, a fluid bolus and emergence of anesthesia. Cerebral blood flow velocity was quantified in pial arteries using conventional spectral Doppler and in the cerebral cortex using ultrafast Doppler by peak systolic velocity, end diastolic velocity and resistivity index. RESULTS Twenty infants were included with useable conventional spectral Doppler images in 72/100 measurements and ultrafast Doppler images in 51/100 measurements. Intraoperatively, the success rates were 53/60 (88.3%) and 41/60 (68.3%), respectively. Cerebral blood flow velocity increased after emergence for both conventional (end diastolic velocity, from 2.01 to 2.75 cm/s, p < 0.001) and ultrafast spectral Doppler (end diastolic velocity, from 0.59 to 0.94 cm/s), whereas cerebral oxygenation showed a reverse pattern with a decrease after the emergence of the infant (85% to 68%, p < 0.001). CONCLUSION It is possible to quantify cortical blood flow velocity during general anesthesia using conventional and ultrafast spectral Doppler cerebral ultrasound. Cerebral blood flow velocity and blood pressure decreased, while regional cerebral oxygenation increased during general anesthesia. Ultrafast spectral Doppler ultrasound offers novel insights into perfusion within the cerebral cortex, unattainable through conventional spectral ultrasound. Yet, ultrafast Doppler is curtailed by a lower success rate and a more rigorous learning curve compared to conventional method.
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Affiliation(s)
- Mathies Rondagh
- Department of Anesthesiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Anna J Kortenbout
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Sophie de Munck
- Department of Surgery, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Gerbrich E van den Bosch
- Department of Neonatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jeroen Dudink
- Department of Neonatology, UMC Utrecht University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Hendrik J Vos
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Johan G Bosch
- Department of Biomedical Engineering, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands; Department of Anesthesiology, Adrz - Erasmus MC, Goes, the Netherlands; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States of America.
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Sjauw DJT, Dulfer K, van Hoorn CE, Buijs V, de Bruijn L, Reijtenbagh BWM, Tangel VE, de Graaff JC. The eXpectations of Parents regarding Anesthesiology Study (XPAS) from a parental perspective: a two-phase observational cross-sectional cohort study. Paediatr Anaesth 2023; 33:1034-1074. [PMID: 37650551 DOI: 10.1111/pan.14748] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Uncertainty concerning anesthetic procedures and risks in children requiring anesthesia may cause concerns in parents and caregivers. AIMS To explore parental expectations and experiences regarding their child's anesthesia using questionnaires designed with parental input. METHODS This observational cross-sectional cohort study included parents (including caregivers) of children undergoing anesthesia in a tertiary pediatric referral university hospital. The study consisted of two phases. In Phase 1, we developed three questionnaires with parental involvement through a focus group discussion and individual interviews. The questionnaires focused on parental satisfaction, knowledge, concerns, and need for preparation regarding their child's anesthesia. In Phase 2, independent samples of parents completed the questionnaires at three time points: before the preanesthesia assessment (T1), 2 days after the preanesthesia assessment (T2), and 4 days after the anesthetic procedure (T3). RESULTS In Phase 1, 22 parents were involved in the development of the questionnaires. The three questionnaires contained 43 questions in total, of which 10 had been proposed by parents. In Phase 2, 78% (474 out of 934) parents participated at T1, 36% (610 out of 1705), at T2 and 34% (546 out of 1622) at T3. Parental satisfaction scores were rated on a visual analogue scale for the preanesthesia assessment with a median of 87/100, and with a median of 90/100 for the anesthetic procedure (0: not satisfied and 100: satisfied). Parental concerns were rated with a median of 50/100 (0: no concerns and 100: extremely concerned). Parental answers from the questionnaire at T2 revealed significant knowledge deficits, with only 73% reporting that the anesthesiologist was a physician. Parents preferred to receive more information about the procedure, especially regarding the intended effects and side effects of anesthesia. CONCLUSIONS Overall, parental satisfaction scores regarding the pediatric anesthesiology procedure were high, with a minority expressing concerns. Parents indicated a preference for their child's anesthesiologist to visit them both before and after the anesthetic procedure. Parental expectations regarding anesthesia did not completely correspond with the information provided; more information from the clinician about the intended effects and side effects of anesthesia was desired.
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Affiliation(s)
- Daphne J T Sjauw
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karolijn Dulfer
- Department of Pediatrics and Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Camille E van Hoorn
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Vivi Buijs
- Department of Medical Care Management, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Liesbeth de Bruijn
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bente W M Reijtenbagh
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Virginia E Tangel
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Anesthesiology, Admiraal de Ruyter Ziekenhuis-Erasmus MC, Goes, The Netherlands
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van den Berg J, Johansen M, Disma N, Engelhardt T, Hansen TG, Veyckemans F, Zielinska M, de Graaff JC. Perioperative anaesthetic management and short-term outcome of neonatal repair of oesophageal atresia with or without tracheo-oesophageal fistula in Europe: A sub-analysis of the neonate and children audit of anaesthesia practice in Europe (NECTARINE) prospective multicenter observational study. Eur J Anaesthesiol 2023; 40:936-945. [PMID: 37779460 DOI: 10.1097/eja.0000000000001905] [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] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
BACKGROUND Oesophageal atresia with or without a tracheo-oesophageal fistula is a congenital abnormality that usually requires surgical repair within the first days of life. OBJECTIVE Description of the perioperative anaesthetic management and outcomes of neonates undergoing surgery for oesophageal atresia with or without a tracheo-oesophageal fistula, included in the 'neonate and children audit of anaesthesia practice in Europe' (NECTARINE) database. DESIGN Sub-analyses of prospective observational NECTARINE study. SETTING European multicentre study. PATIENTS Neonates who underwent surgery for oesophageal atresia with or without a tracheo-oesophageal fistula in the NECTARINE cohort were selected. MAIN OUTCOME MEASURES Incidence rates with 95% confidence intervals were calculated for peri-operative clinical events which required a predetermined intervention, postoperative complications, and mortality. RESULTS One hundred and three neonates undergoing a first surgical intervention for oesophageal atresia with or without a tracheo-oesophageal fistula repair were identified. Their median gestational age was 38 weeks with a median birth weight of 2840 [interquartile range 2150 to 3150] grams. Invasive monitoring was used in 66% of the procedures. The incidence of perioperative clinical events was 69% (95% confidence interval 59 to 77%), of 30-day postoperative complications 47% (95% confidence interval 38 to 57%) and the 30- and 90 days mortality rates were 2.1% and 2.6%, respectively. CONCLUSION Oesophageal atresia with or without a tracheo-oesophageal fistula repair in neonates is associated with a high number of perioperative interventions in response to clinical events, a high incidence of postoperative complications, and a substantial mortality rate.
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Affiliation(s)
- Johanneke van den Berg
- From the Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands (M.JVDB), Division of Pediatric Anaesthesia, Montreal Children's Hospital, McGill University Centre, Montreal, Canada (MJ), Unit for Research & Innovation, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy (ND), Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada (TE), Department of Anaesthesia, Akershus University Hospital and Oslo University, Oslo, Norway (TGH), Clinique d'Anesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHU de Lille, Lille, France (FV), Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland (MZ), Department of Anesthesiology, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands, Adrz-EramusMC, Goes, The Netherlands (JCDG)
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Veyckemans F, Sola C, de Graaff JC, Becke-Jakob K, Zielinska M, Hansen TG, Walker SM, Disma N, Habre W. Epidemiology and outcomes of inguinal surgery with or without regional anaesthesia in neonates and small infants: A subanalysis of the NECTARINE database. Eur J Anaesthesiol 2023; 40:956-959. [PMID: 37357905 DOI: 10.1097/eja.0000000000001870] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Affiliation(s)
- Francis Veyckemans
- From the UCLouvain, Brussels, Belgium (FV), Department of Anaesthesia and Critical Care Medicine, Paediatric Anaesthesia Unit, Montpellier University Hospital, Institute of Functional Genomics (IGF), University of Montpellier, CNRS, INSERM, Montpellier, France (CS), Department of Anesthesia, Adrz-Erasmus MC, Goes, The Netherlands (JCdG), Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital - Hospital Hallerwiese, Nürnberg, Germany (KB), Department of Paediaric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland (MZ), Department of Anaesthesia & Intensive Care, Akershus University Hospital and Olso University, Oslo, Norway (TGH), Department of Anaesthesia and Pain Management, Great Ormond Street Hospital NHS Foundation Trust, London, UK (SMW), Unit for Research in Anaesthesia, IRCCS, Istituto G Gaslini, Genova, Italy (ND), and Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland (WH)
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Erdem Ö, de Graaff JC, Hilty MP, Kraemer US, de Liefde II, van Rosmalen J, Ince C, Tibboel D, Kuiper JW. Microcirculatory Monitoring in Children with Congenital Heart Disease Before and After Cardiac Surgery. J Cardiovasc Transl Res 2023; 16:1333-1342. [PMID: 37450208 PMCID: PMC10721654 DOI: 10.1007/s12265-023-10407-4] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023]
Abstract
In this prospective observational study, we investigated whether congenital heart disease (CHD) affects the microcirculation and whether the microcirculation is altered following cardiac surgery with cardiopulmonary bypass (CPB). Thirty-eight children with CHD undergoing cardiac surgery with CPB and 35 children undergoing elective, non-cardiac surgery were included. Repeated non-invasive sublingual microcirculatory measurements were performed with handheld vital microscopy. Before surgery, children with CHD showed similar perfused vessel densities and red blood cell velocities (RBCv) but less perfused vessels (p < 0.001), lower perfusion quality (p < 0.001), and higher small vessel densities (p = 0.039) than children without CHD. After cardiac surgery, perfused vessel densities and perfusion quality of small vessels declined (p = 0.025 and p = 0.032), while RBCv increased (p = 0.032). We demonstrated that CHD was associated with decreased microcirculatory perfusion and increased capillary recruitment. The microcirculation was further impaired after cardiac surgery. Decreased microcirculatory perfusion could be a warning sign for altered tissue oxygenation and requires further exploration.
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Affiliation(s)
- Özge Erdem
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Ulrike S Kraemer
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Inge I de Liefde
- Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan Willem Kuiper
- Intensive Care and department of Pediatric Surgery, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
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Tangel VE, Hoeks SE, White RS, de Graaff JC. Incidence and between-center heterogeneity of anesthesia-related complications in pediatric populations documented in administrative data: A retrospective study. Paediatr Anaesth 2023. [PMID: 37186105 DOI: 10.1111/pan.14681] [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] [Received: 11/24/2022] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Virginia E Tangel
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Sanne E Hoeks
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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de Graaff JC, Frykholm P. Ephedrine to treat intraoperative hypotension in infants: what is the target? Br J Anaesth 2023; 130:510-515. [PMID: 36906461 DOI: 10.1016/j.bja.2023.02.007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 03/11/2023] Open
Abstract
Off-label use of medications in paediatric anaesthesia is common practice, owing to the relative paucity of evidence-based dosing regimens in children. Well-performed dose-finding studies, especially in infants, are rare and urgently needed. Unanticipated effects can result when paediatric dosing is based on adult parameters or local traditions. A recent dose-finding study on ephedrine highlights the uniqueness of paediatric dosing in comparison with adult dosing. We discuss the problems of off-label medication use and the lack of evidence for various definitions of hypotension and associated treatment strategies in paediatric anaesthesia. What is the aim of treating hypotension associated with anaesthesia induction: restoring the MAP to awake baseline values or elevating it above a provisional hypotension threshold?
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Affiliation(s)
| | - Peter Frykholm
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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de Rover I, Wylleman J, Dogger JJ, Bramer WM, Hoeks SE, de Graaff JC. Needle-free pharmacological sedation techniques in paediatric patients for imaging procedures: a systematic review and meta-analysis. Br J Anaesth 2023; 130:51-73. [PMID: 36283870 DOI: 10.1016/j.bja.2022.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 03/22/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sedation techniques and drugs are increasingly used in children undergoing imaging procedures. In this systematic review and meta-analysis, we present an overview of literature concerning sedation of children aged 0-8 yr for magnetic resonance imaging (MRI) procedures using needle-free pharmacological techniques. METHODS Embase, MEDLINE, Web of Science, and Cochrane databases were systematically searched for studies on the use of needle-free pharmacological sedation techniques for MRI procedures in children aged 0-8 yr. Studies using i.v. or i.m. medication or advanced airway devices were excluded. We performed a meta-analysis on sedation success rate. Secondary outcomes were onset time, duration, recovery, and adverse events. RESULTS Sixty-seven studies were included, with 22 380 participants. The pooled success rate for oral chloral hydrate was 94% (95% confidence interval [CI]: 0.91-0.96); for oral chloral hydrate and intranasal dexmedetomidine 95% (95% CI: 0.92-0.97); for rectal, oral, or intranasal midazolam 36% (95% CI: 0.14-0.65); for oral pentobarbital 99% (95% CI: 0.90-1.00); for rectal thiopental 92% (95% CI: 0.85-0.96); for oral melatonin 75% (95% CI: 0.54-0.89); for intranasal dexmedetomidine 62% (95% CI: 0.38-0.82); for intranasal dexmedetomidine and midazolam 94% (95% CI: 0.78-0.99); and for inhaled sevoflurane 98% (95% CI: 0.97-0.99). CONCLUSIONS We found a large variation in medication, dosage, and route of administration for needle-free sedation. Success rates for sedation techniques varied between 36% and 98%.
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Affiliation(s)
- Ingeborg de Rover
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jasper Wylleman
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Anaesthesiology and Perioperative Medicine, UZ Brussel, Brussels, Belgium
| | - Jaap J Dogger
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Sophia Children's Hospital, Rotterdam, the Netherlands.
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Disma N, Engelhardt T, Hansen TG, de Graaff JC, Virag K, Habre W. Neonates undergoing pyloric stenosis repair are at increased risk of difficult airway management: secondary analysis of the NEonate and Children audiT of Anaesthesia pRactice IN Europe. Br J Anaesth 2022; 129:734-739. [PMID: 36085092 DOI: 10.1016/j.bja.2022.07.041] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypertrophic pyloric stenosis in otherwise healthy neonates frequently requires urgent surgical procedure but anaesthesia care may result in respiratory complications, such as hypoxaemia, pulmonary aspiration of gastric contents, and postoperative apnoea. The primary aim was to study whether or not the incidence of difficult airway management and of hypoxaemia in neonates undergoing pyloric stenosis repair was higher than that in neonates undergoing other surgeries. METHODS Data on neonates and infants undergoing anaesthesia and surgery for pyloric stenosis were extracted from the NEonate and Children audiT of Anesthesia pRactice In Europe (NECTARINE) database, for secondary analysis. RESULTS We identified 310 infants who had anaesthesia for surgery for pyloric stenosis. Difficult airway management (more than two attempts at laryngoscopy) was higher in children with pyloric stenosis when compared with the entire NECTARINE cohort (7.9% [95% confidence interval {CI}, 5.22-11.53] vs 4.4% [95% CI, 1.99-6.58]; relative risk [RR]=1.81 [95% CI, 1.21-2.69]; P=0.004), whereas transient hypoxaemia with oxygen saturation <90% was comparable between the two cohorts. Postoperative complications occurred in 16 children (5.6%) within the 30-day follow-up. No mortality was reported at 30 and 90 days. CONCLUSIONS Children undergoing surgery for pyloric stenosis had a higher incidence of difficult intubation compared with the entire NECTARINE cohort. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Unit for Research and Innovation, Department of Anaesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy.
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, Canada
| | - Tom G Hansen
- Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Centre, Rotterdam, the Netherlands
| | - Katalin Virag
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; Unit for Anaesthesiological Research, University of Geneva, Geneva, Switzerland
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12
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Walker SM, Engelhardt T, Ahmad N, Dobby N, Masip N, Brooks P, Hare A, Casey M, De Silva S, Krishnan P, Sogbodjor LA, Walker E, King S, Nicholson K, Quinney M, Stevens P, Blevin A, Giombini M, Goonasekera C, Adil S, Bew S, Bodlani C, Gilpin D, Jinks S, Malarkkan N, Miskovic A, Pad R, Barry JW, Abbott J, Armstrong J, Cooper N, Crate L, Emery J, James K, King H, Martin P, Catenacci SS, Bomont R, Smith P, Mele S, Verzelloni A, Dix P, Bell G, Gordeva E, McKee L, Ngan E, Scheffczik J, Tan LE, Worrall M, Cassar C, Goddard K, Barlow V, Oshan V, Shah K, Bell S, Daniels L, Gandhi M, Pachter D, Perry C, Robertson A, Scott C, Waring L, Barnes D, Childs S, Norman J, Sunderland R, Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Perioperative critical events and morbidity associated with anesthesia in early life: Subgroup analysis of United Kingdom participation in the NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective multicenter observational study. Paediatr Anaesth 2022; 32:801-814. [PMID: 35438209 PMCID: PMC9322016 DOI: 10.1111/pan.14457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE) prospective observational study reported critical events requiring intervention during 35.2% of 6542 anesthetic episodes in 5609 infants up to 60 weeks postmenstrual age. The United Kingdom (UK) was one of 31 participating countries. METHODS Subgroup analysis of UK NECTARINE cases (12.8% of cohort) to identify perioperative critical events that triggered medical interventions. Secondary aims were to describe UK practice, identify factors more commonly associated with critical events, and compare 30-day morbidity and mortality between participating UK and nonUK centers. RESULTS Seventeen UK centers recruited 722 patients (68.7% male, 36.1% born preterm, and 48.1% congenital anomalies) undergoing anesthesia for 876 surgical or diagnostic procedures at 25-60 weeks postmenstrual age. Repeat anesthesia/surgery was common: 17.6% patients prior to and 14.4% during the recruitment period. Perioperative critical events triggered interventions in 300/876 (34.3%) cases. Cardiovascular instability (16.9% of cases) and/or reduced oxygenation (11.4%) were more common in younger patients and those with co-morbidities or requiring preoperative intensive support. A higher proportion of UK than nonUK cases were graded as ASA-Physical Status scores >2 or requiring urgent or emergency procedures, and 39% required postoperative intensive care. Thirty-day morbidity (complications in 17.2%) and mortality (8/715, 1.1%) did not differ from nonUK participants. CONCLUSIONS Perioperative critical events and co-morbidities are common in neonates and young infants. Thirty-day morbidity and mortality data did not demonstrate national differences in outcome. Identifying factors associated with increased risk informs preoperative assessment, resource allocation, and discussions between clinicians and families.
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Affiliation(s)
- Suellen M. Walker
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK,Developmental NeurosciencesUCL GOS Institute of Child HealthLondonUK
| | - Thomas Engelhardt
- Department of AnaesthesiaMontreal Children's HospitalMontrealQCCanada
| | - Nargis Ahmad
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK
| | - Nadine Dobby
- Department of Paediatric AnaesthesiaGreat Ormond St Hospital NHS Foundation TrustLondonUK
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13
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Vlug LE, Verloop MW, Dierckx B, Bosman L, de Graaff JC, Rings EH, Wijnen RM, de Koning BA, Legerstee JS. Cognitive Outcomes in Children With Conditions Affecting the Small Intestine: A Systematic Review and Meta-analysis. J Pediatr Gastroenterol Nutr 2022; 74:368-376. [PMID: 35226646 PMCID: PMC8860224 DOI: 10.1097/mpg.0000000000003368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/09/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of the study was to assess cognitive outcomes in children with intestinal failure (IF) and children at high risk of IF with conditions affecting the small intestine requiring parenteral nutrition. METHODS EMBASE, Cochrane, Web of Science, Google Scholar, MEDLINE, and PsycINFO were searched from inception to October 2020. Studies were included constituting original data on developmental quotient (DQ), intelligence quotient (IQ) and/or severe developmental delay/disability (SDD) rates assessed with standardized tests. We used appropriate standardized tools to extract data and assess study quality. We performed random effects meta-analyses to estimate pooled means of DQ/IQ and pooled SDD rates (general population mean for DQ/IQ: 100, for percentage with SDD: 1.8%) for 4 groups: IF, surgical necrotizing enterocolitis (NEC), abdominal wall defects (AWD), and midgut malformations (MM). Associations of patient characteristics with DQ/IQ were evaluated with meta-regressions. RESULTS Thirty studies met the inclusion criteria. The pooled mean DQ/IQ for IF, NEC, AWD, and MM were 86.8, 83.3, 96.6, and 99.5, respectively. The pooled SDD rates for IF, NEC, AWD and MM were 28.6%, 32.8%, 8.5%, and 3.7%, respectively. Meta-regressions indicated that lower gestational age, longer hospital stay, and higher number of surgeries but not parenteral nutrition duration, were associated with lower DQ/IQ. CONCLUSIONS Adverse developmental outcomes are common in children with IF and NEC, and to a much lesser extent in children with AWD and MM. It is important to monitor cognitive development in children with conditions affecting the small intestine and to explore avenues for prevention and remediation.
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Affiliation(s)
- Lotte E. Vlug
- Division of Gastroenterology, Department of Pediatrics
| | | | - Bram Dierckx
- Department of Child and Adolescent Psychiatry/Psychology
| | - Lotte Bosman
- Department of Child and Adolescent Psychiatry/Psychology
| | - Jurgen C. de Graaff
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam
| | - Edmond H.H.M. Rings
- Division of Gastroenterology, Department of Pediatrics
- Division of Gastroenterology, Department of Pediatrics, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden
| | - René M.H. Wijnen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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14
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Fuchs A, Disma N, Virág K, Ulmer F, Habre W, de Graaff JC, Riva T. Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study. Eur J Anaesthesiol 2022; 39:252-260. [PMID: 34845167 PMCID: PMC8815837 DOI: 10.1097/eja.0000000000001646] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN A multicentre observational study. SETTING The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT02350348.
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Affiliation(s)
- Alexander Fuchs
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (AF, TR), Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy (ND, TR), Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, University of Geneva, Geneva (KV, WH), Department of Paediatrics, Section of Critical Care, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (FU), and Department of Anaesthesiology, Erasmus MC-Sophia Children's Hospital, University Medical Centre, Rotterdam, The Netherlands (JCdG)
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15
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van den Bosch GE, Tibboel D, de Graaff JC, El Marroun H, van der Lugt A, White T, van Dijk M. Neonatal Pain, Opioid, and Anesthetic Exposure; What Remains in the Human Brain After the Wheels of Time? Front Pediatr 2022; 10:825725. [PMID: 35633952 PMCID: PMC9132108 DOI: 10.3389/fped.2022.825725] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To evaluate possible negative long-term effects of neonatal exposure to pain, opioids and anesthetics in children and adolescents. STUDY DESIGN We studied five unique groups of children recruited from well-documented neonatal cohorts with a history of neonatal exposure to pain, opioids or anesthetics at different points along the continuum from no pain to intense pain and from no opioid exposure to very high opioid exposure in the presence or absence of anesthetics. We evaluated children who underwent major surgery (group 1 and 2), extracorporeal membrane oxygenation (group 3), preterm birth (group 4) and prenatal opioid exposure (group 5) in comparison to healthy controls. Neuropsychological functioning, thermal detection and pain thresholds and high-resolution structural and task-based functional magnetic resonance imaging during pain were assessed. In total 94 cases were included and compared to their own control groups. RESULTS Children and adolescents in groups 3 and 5 showed worse neuropsychological functioning after high opioid exposure. A thicker cortex was found in group 1 (pain, opioid and anesthetic exposure) in only the left rostral-middle-frontal-cortex compared to controls. We found no differences in other brain volumes, pain thresholds or brain activity during pain in pain related brain regions between the other groups and their controls. CONCLUSIONS No major effects of neonatal pain, opioid or anesthetic exposure were observed in humans 8-19 years after exposure in early life, apart from neuropsychological effects in the groups with the highest opioid exposure that warrants further investigation. Studies with larger sample sizes are needed to confirm our findings and test for less pronounced differences between exposed and unexposed children.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hanan El Marroun
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Psychology, Education and Child Studies, Erasmus University, Rotterdam, Netherlands
| | | | - Tonya White
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Radiology, Erasmus MC, Rotterdam, Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus Medical Center (MC)-Sophia Children's Hospital, Rotterdam, Netherlands
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16
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van Hoorn CE, de Graaff JC, Vlot J, Wijnen RM, Stolker RJ, Schnater JM. Primary repair of esophageal atresia is followed by multiple diagnostic and surgical procedures. J Pediatr Surg 2021; 56:2192-2199. [PMID: 34229878 DOI: 10.1016/j.jpedsurg.2021.06.004] [Citation(s) in RCA: 3] [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: 12/23/2020] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children born with esophageal atresia (EA) face comorbidities and complications often requiring surgery and anesthesia. We aimed to assess all procedures performed under general anesthesia during their first 12 years of life. METHODS We performed a retrospective cohort study about subsequent surgeries and procedures requiring general anesthesia in children born with type C EA between January 2007 and December 2017, with follow-up to March 2019. RESULTS Of 102 eligible patients, 63 were diagnosed with comorbidities, of whom 18 had VACTERL association. Follow-up time for all patients varied between 14 months and 12 years (median 7 years). The patients underwent total 637 procedures, median 4 [IQR2-7] per patient. In the first year of life, 464 procedures were performed, in the second year 69 and in the third year 29. Thirteen patients underwent no other procedures than primary EA repair. In 57 patients, 228 dilatations were performed. Other frequently performed procedures were esophagoscopy (n=52), urologic procedures (n=44) and abdominal procedures (n=33). CONCLUSIONS Patients with EA frequently require multiple anesthetics for a variety of procedures related to the EA, complications and comorbidities. This study can help care providers when counselling parents of a patient with an EA by giving them more insight into possible procedures they can be confronted with during childhood.
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Affiliation(s)
- Camille E van Hoorn
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands; Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - John Vlot
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rene Mh Wijnen
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Pediatric Intensive Care, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
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17
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Simpao AF, de Graaff JC. Predicting hypotension during pediatric anesthesia: Can we move beyond a definition that is in the eye of the beholder? Paediatr Anaesth 2021; 31:1025-1027. [PMID: 34553451 DOI: 10.1111/pan.14266] [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] [Received: 07/20/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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18
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Dreuning KMA, van Tulder MW, Been JV, Rovers MM, de Graaff JC, Stevens MF, Anema JR, Twisk JWR, van Heurn LWE, Derikx JPM. Contralateral surgical exploration during inguinal hernia repair in infants (HERNIIA trial): study protocol for a multi-centre, randomised controlled trial. Trials 2021; 22:670. [PMID: 34593022 PMCID: PMC8481323 DOI: 10.1186/s13063-021-05606-w] [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] [Received: 04/09/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The incidence of metachronous contralateral inguinal hernia (MCIH) is high in infants with an inguinal hernia (5-30%), with the highest risk in infants aged 6 months or younger. MCIH is associated with the risk of incarceration and necessitates a second operation. This might be avoided by contralateral exploration during primary surgery. However, contralateral exploration may be unnecessary, leads to additional operating time and costs and may result in additional complications of surgery and anaesthesia. Thus, there is no consensus whether contralateral exploration should be performed routinely. METHODS The Hernia-Exploration-oR-Not-In-Infants-Analysis (HERNIIA) study is a multicentre randomised controlled trial with an economic evaluation alongside to study the (cost-)effectiveness of contralateral exploration during unilateral hernia repair. Infants aged 6 months or younger who need to undergo primary unilateral hernia repair will be randomised to contralateral exploration or no contralateral exploration (n = 378 patients). Primary endpoint is the proportion of infants that need to undergo a second operation related to inguinal hernia within 1 year after primary repair. Secondary endpoints include (a) total duration of operation(s) (including anaesthesia time) and hospital admission(s); (b) complications of anaesthesia and surgery; and (c) participants' health-related quality of life and distress and anxiety of their families, all assessed within 1 year after primary hernia repair. Statistical testing will be performed two-sided with α = .05 and according to the intention-to-treat principle. Logistic regression analysis will be performed adjusted for centre and possible confounders. The economic evaluation will be performed from a societal perspective and all relevant costs will be measured, valued and analysed. DISCUSSION This study evaluates the effectiveness and cost-effectiveness of contralateral surgical exploration during unilateral inguinal hernia repair in children younger than 6 months with a unilateral inguinal hernia. TRIAL REGISTRATION ClinicalTrials.gov NCT03623893 . Registered on August 9, 2018 Netherlands Trial Register NL7194. Registered on July 24, 2018 Central Committee on Research Involving Human Subjects (CCMO) NL59817.029.18. Registered on July 3, 2018.
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Affiliation(s)
- Kelly M A Dreuning
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Maurits W van Tulder
- Department of Health Sciences and Amsterdam Movement Science research institute, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physiotherapy & Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Jasper V Been
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Maroeska M Rovers
- Radboud Institute for Health Sciences, Department of Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Markus F Stevens
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes R Anema
- Department of Public and Occupational Health, and the Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jos W R Twisk
- Department of Methodology and Applied Biostatistics, and the Amsterdam Public Health research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - L W Ernest van Heurn
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Joep P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam & Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute and the Amsterdam Public Health Research Institute, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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19
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van Hoorn CE, ten Kate CA, Rietman AB, Toussaint-Duyster LCC, Stolker RJ, Wijnen RMH, de Graaff JC. Long-term neurodevelopment in children born with esophageal atresia: a systematic review. Dis Esophagus 2021; 34:6347567. [PMID: 34378009 PMCID: PMC8597907 DOI: 10.1093/dote/doab054] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/29/2021] [Accepted: 06/27/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although the survival rate of esophageal atresia (EA) has increased to over 90%, the risk of functional long-term neurodevelopmental deficits is uncertain. Studies on long-term outcomes of children with EA show conflicting results. Therefore, we provide an overview of the current knowledge on the long-term neurodevelopmental outcome of children with EA. METHODS We performed a structured literature search in Embase, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google scholar on November 8, 2020 with the keywords 'esophageal atresia', 'long-term outcome', 'motor development', 'cognitive development', and 'neurodevelopment'. RESULTS The initial search identified 945 studies, of which 15 were included. Five of these published outcomes of multiple tests or tested at multiple ages. Regarding infants, one of six studies found impaired neurodevelopment at 1 year of age. Regarding preschoolers, two of five studies found impaired neurodevelopment; the one study assessing cognitive development found normal cognitive outcome. Both studies on motor function reported impairment. Regarding school-agers, the one study on neurodevelopmental outcome reported impairment. Cognitive impairment was found in two out of four studies, and motor function was impaired in both studies studying motor function. CONCLUSIONS Long-term neurodevelopment of children born with EA has been assessed with various instruments, with contrasting results. Impairments were mostly found in motor function, but also in cognitive performance. Generally, the long-term outcome of these children is reason for concern. Structured, multidisciplinary long-term follow-up programs for children born with EA would allow to timely detect neurodevelopmental impairments and to intervene, if necessary.
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Affiliation(s)
- Camille E van Hoorn
- Address correspondence to: Camille E. van Hoorn, Erasmus Medical Centre-Sophia Children’s Hospital, Department of Anaesthesiology, Department of Paediatric Surgery, PO Box: 2060, 3000 CB Rotterdam, The Netherlands. Tel: +31 636400488;
| | - Chantal A ten Kate
- Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands
| | - Andre B Rietman
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands, and
| | - Leontien C C Toussaint-Duyster
- Department of Orthopaedics, Section of Physical Therapy, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands
| | - Robert Jan Stolker
- Department of Anaesthesiology, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC-Sophia Children’s Hospital University Medical Centre, Rotterdam, The Netherlands
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20
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van Hoorn CE, van der Cammen‐van Zijp MHM, Stolker RJ, van Rosmalen J, Wijnen RMH, de Graaff JC. Associations of perioperative characteristics with motor function in preschool children born with esophageal atresia. Paediatr Anaesth 2021; 31:854-862. [PMID: 33998103 PMCID: PMC8362197 DOI: 10.1111/pan.14204] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/04/2021] [Accepted: 05/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children born with esophageal atresia experience long-term neurodevelopmental deficits, with unknown origin. AIMS To find associations between perioperative variables during primary esophageal atresia repair and motor function at age 5 years. METHODS This ambidirectional cohort study included children born with esophageal atresia who consecutively had been operated on in the Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, from January 2007 through June 2013. The perioperative data of this cohort were collected retrospectively; the motor function data prospectively. RESULTS After exclusion of patients with syndromal congenital diseases (n = 8) and lost to follow-up (n = 10), the data of 53 children were included. The mean (SD) total motor function impairment z-score at 5 years of age was -0.66 (0.99), significantly below normal (p < .001). In multivariable linear regression analysis, number of postoperative days endotracheal intubation (B = -0.211, 95% CI: -0.389 to -0.033, p = .021) was negatively associated with motor outcome, whereas high blood pressure (B = 0.022, 95% CI 0.001 to 0.042, p = .038) was positively associated. Preoperative nasal oxygen supplementation versus room air (B = 0.706, 95% CI: 0.132 to 1.280, p = .016) was positively associated with motor outcome, which we cannot explain. CONCLUSIONS Motor function in 5-year-old esophageal atresia patients was impaired and negatively associated with the number of postoperative days of endotracheal intubation and positively associated with high blood pressure. Prospective studies with critical perioperative monitoring and monitoring during stay at the intensive care unit are recommended.
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Affiliation(s)
- Camille E. van Hoorn
- Department of AnesthesiaErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands,Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Monique H. M. van der Cammen‐van Zijp
- Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands,Department of OrthopedicsSection of Physical therapyErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Robert Jan Stolker
- Department of AnesthesiaErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Joost van Rosmalen
- Department of BiostatisticsErasmus MCUniversity Medical CenterRotterdamThe Netherlands,Department of EpidemiologyErasmus MCUniversity Medical CenterRotterdamThe Netherlands
| | - Rene M. H. Wijnen
- Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Jurgen C. de Graaff
- Department of AnesthesiaErasmus MC‐Sophia Children's HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
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21
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Disma N, Veyckemans F, Virag K, Hansen TG, Becke K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE). Br J Anaesth 2021; 126:1157-1172. [PMID: 33812668 DOI: 10.1016/j.bja.2021.02.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/15/2021] [Accepted: 02/21/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. METHODS This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. RESULTS Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). CONCLUSIONS Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants. CLINICAL TRIAL REGISTRATION NCT02350348.
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Affiliation(s)
- Nicola Disma
- Department of Anaesthesia, Unit for Research & Innovation, Istituto Giannina Gaslini, Genova, Italy.
| | - Francis Veyckemans
- Département d'Anaesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Tom G Hansen
- Department of Anaesthesia and Intensive Care -Paediatrics, Odense University Hospital, Odense, Denmark; Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Karin Becke
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Pierre Harlet
- Research Department, European Society of Anaesthesiology, Brussels, Belgium
| | - Laszlo Vutskits
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
| | - Suellen M Walker
- Department of Anaesthesia and Pain Management, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Jurgen C de Graaff
- Department of Anesthesia, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Dusica Simic
- Department of Pediatric Anesthesia and Intensive Care, University Children's Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
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22
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Costerus SA, Kortenbout AJ, Vos HJ, Govaert P, Tibboel D, Wijnen RMH, de Jong N, Bosch JG, de Graaff JC. Feasibility of Doppler Ultrasound for Cortical Cerebral Blood Flow Velocity Monitoring During Major Non-cardiac Surgery of Newborns. Front Pediatr 2021; 9:656806. [PMID: 33829005 PMCID: PMC8019737 DOI: 10.3389/fped.2021.656806] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aim: Newborns needing major surgical intervention are at risk of brain injury and impaired neurodevelopment later in life. Disturbance of cerebral perfusion might be an underlying factor. This study investigates the feasibility of serial transfontanellar ultrasound measurements of the pial arteries during neonatal surgery, and whether perioperative changes in cerebral perfusion can be observed and related to changes in the perioperative management. Methods: In this prospective, observational feasibility study, neonates with congenital diaphragmatic hernia and esophageal atresia scheduled for surgical treatment within the first 28 days of life were eligible for inclusion. We performed transfontanellar directional power Doppler and pulsed wave Doppler ultrasound during major high-risk non-cardiac neonatal surgery. Pial arteries were of interest for the measurements. Extracted Doppler ultrasound parameters were: peak systolic velocity, end diastolic velocity, the resistivity index and pulsatility index. Results: In 10 out of 14 patients it was possible to perform perioperative measurements; the others failed for logistic and technical reasons. In 6 out of 10 patients, it was feasible to perform serial intraoperative transfontanellar ultrasound measurements with directional power Doppler and pulsed wave Doppler of the same pial artery during neonatal surgery. Median peak systolic velocity was ranging between 5.7 and 7.0 cm s-1 and end diastolic velocity between 1.9 and 3.2 cm s-1. In patients with a vasoactive-inotropic score below 12 the trend of peak systolic velocity and end diastolic velocity corresponded with the mean arterial blood pressure trend. Conclusion: Perioperative transfontanellar ultrasound Doppler measurements of the pial arteries are feasible and provide new longitudinal data about perioperative cortical cerebral blood flow velocity. Trial Registration: https://www.trialregister.nl/trial/6972, identifier: NL6972.
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Affiliation(s)
- Sophie A Costerus
- Department of Paediatric Surgery, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Anna J Kortenbout
- Department of Biomedical Engineering, Thorax Centre, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Hendrik J Vos
- Department of Biomedical Engineering, Thorax Centre, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Paul Govaert
- Department of Neonatology, Ziekenhuis Netwerk Antwerp, Middelheim Antwerp, Belgium
| | - Dick Tibboel
- Department of Paediatric Surgery, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - René M H Wijnen
- Department of Paediatric Surgery, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Nico de Jong
- Department of Biomedical Engineering, Thorax Centre, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Johan G Bosch
- Department of Biomedical Engineering, Thorax Centre, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
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23
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Costerus SA, Hendrikx D, IJsselmuiden J, Zahn K, Perez-Ortiz A, Van Huffel S, Flint RB, Caicedo A, Wijnen R, Wessel L, de Graaff JC, Tibboel D, Naulaers G. Cerebral Oxygenation and Activity During Surgical Repair of Neonates With Congenital Diaphragmatic Hernia: A Center Comparison Analysis. Front Pediatr 2021; 9:798952. [PMID: 34976902 PMCID: PMC8718750 DOI: 10.3389/fped.2021.798952] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background and aim: Neonatal brain monitoring is increasingly used due to reports of brain injury perioperatively. Little is known about the effect of sedatives (midazolam) and anesthetics (sevoflurane) on cerebral oxygenation (rScO2) and cerebral activity. This study aims to determine these effects in the perioperative period. Methods: This is an observational, prospective study in two tertiary pediatric surgical centers. All neonates with a congenital diaphragmatic hernia received perioperative cerebral oxygenation and activity measurements. Patients were stratified based on intraoperatively administrated medication: the sevoflurane group (continuous sevoflurane, bolus fentanyl, bolus rocuronium) and the midazolam group (continuous midazolam, continuous fentanyl, and continuous vecuronium). Results: Intraoperatively, rScO2 was higher in the sevoflurane compared to the midazolam group (84%, IQR 77-95 vs. 65%, IQR 59-76, p = < 0.001), fractional tissue oxygen extraction was lower (14%, IQR 5-21 vs. 31%, IQR 29-40, p = < 0.001), the duration of hypoxia was shorter (2%, IQR 0.4-9.6 vs. 38.6%, IQR 4.9-70, p = 0.023), and cerebral activity decreased more: slow delta: 2.16 vs. 4.35 μV 2 (p = 0.0049), fast delta: 0.73 vs. 1.37 μV 2 (p = < 0.001). In the first 30 min of the surgical procedure, a 3-fold increase in fast delta (10.48-31.22 μV 2) and a 5-fold increase in gamma (1.42-7.58 μV 2) were observed in the midazolam group. Conclusion: Sevoflurane-based anesthesia resulted in increased cerebral oxygenation and decreased cerebral activity, suggesting adequate anesthesia. Midazolam-based anesthesia in neonates with a more severe CDH led to alarmingly low rScO2 values, below hypoxia threshold, and increased values of EEG power during the first 30 min of surgery. This might indicate conscious experience of pain. Integrating population-pharmacokinetic models and multimodal neuromonitoring are needed for personalized pharmacotherapy in these vulnerable patients. Trial Registration: https://www.trialregister.nl/trial/6972, identifier: NL6972.
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Affiliation(s)
- Sophie A Costerus
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dries Hendrikx
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - Joen IJsselmuiden
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Katrin Zahn
- Department of Paediatric Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Alba Perez-Ortiz
- Neonatal Intensive Care Unit, University Hospital Mannheim, Mannheim, Germany
| | - Sabine Van Huffel
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - Robert B Flint
- Division of Neonatology, Department of Paediatrics, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pharmacy, Erasmus Medical Center, Rotterdam, Netherlands
| | - Alexander Caicedo
- ESAT-STADIUS Division, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
| | - René Wijnen
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Lucas Wessel
- Department of Paediatric Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Paediatric Surgery, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Gunnar Naulaers
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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24
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de Graaff JC, Johansen MF, Hensgens M, Engelhardt T. Best practice & research clinical anesthesiology: Safety and quality in perioperative anesthesia care. Update on safety in pediatric anesthesia. Best Pract Res Clin Anaesthesiol 2020; 35:27-39. [PMID: 33742575 DOI: 10.1016/j.bpa.2020.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 11/09/2020] [Accepted: 12/03/2020] [Indexed: 12/20/2022]
Abstract
Pediatric anesthesia is large part of anesthesia clinical practice. Children, parents and anesthesiologists fear anesthesia because of the risk of acute morbidity and mortality. Modern anesthesia in otherwise healthy children above 1 year of age in developed countries has become very safe due to recent advance in pharmacology, intensive education, and training as well as centralization of care. In contrast, anesthesia in these children in low-income countries is associated with a high risk of mortality due to lack of basic resources and adequate training of health care providers. Anesthesia for neonates and toddlers is associated with significant morbidity and mortality. Anesthesia-related (near) critical incidents occur in 5% of anesthetic procedures and are largely dependent on the skills and up-to-date knowledge of the whole perioperative team in the specific needs for children. An investment in continuous medical education of the perioperative staff is required and international standard operating protocols for common procedures and critical situations should be defined.
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Affiliation(s)
- Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands.
| | - Mathias Fuglsang Johansen
- Division Pediatric Anesthesia, Montreal Children's Hospital, McGill University Centre, Montreal, Canada
| | - Martinus Hensgens
- Department of Anesthesiology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
| | - Thomas Engelhardt
- Division Pediatric Anesthesia, Montreal Children's Hospital, McGill University Centre, Montreal, Canada
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25
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van Hoorn CE, Flint RB, Skowno J, Davies P, Engelhardt T, Lalwani K, Olutoye O, Ista E, de Graaff JC. Off-label use of dexmedetomidine in paediatric anaesthesiology: an international survey of 791 (paediatric) anaesthesiologists. Eur J Clin Pharmacol 2020; 77:625-635. [PMID: 33119787 PMCID: PMC7935836 DOI: 10.1007/s00228-020-03028-2] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 10/15/2020] [Indexed: 01/02/2023]
Abstract
Purpose The purpose of this international study was to investigate prescribing practices of dexmedetomidine by paediatric anaesthesiologists. Methods We performed an online survey on the prescription rate of dexmedetomidine, route of administration and dosage, adverse drug reactions, education on the drug and overall experience. Members of specialist paediatric anaesthesia societies of Europe (ESPA), New Zealand and Australia (SPANZA), Great Britain and Ireland (APAGBI) and the USA (SPA) were consulted. Responses were collected in July and August 2019. Results Data from 791 responders (17% of 5171 invitees) were included in the analyses. Dexmedetomidine was prescribed by 70% of the respondents (ESPA 53%; SPANZA 69%; APAGBI 34% and SPA 96%), mostly for procedural sedation (68%), premedication (46%) and/or ICU sedation (46%). Seventy-three percent had access to local or national protocols, although lack of education was the main reason cited by 26% of the respondents not to prescribe dexmedetomidine. The main difference in dexmedetomidine use concerned the age of patients (SPA primarily < 1 year, others primarily > 1 year). The dosage varied widely ranging from 0.2–5 μg kg−1 for nasal premedication, 0.2–8 μg kg−1 for nasal procedural sedation and 0–4 μg kg−1 intravenously as adjuvant for anaesthesia. Only ESPA members (61%) had noted an adverse drug reaction, namely bradycardia. Conclusion The majority of anaesthesiologists use dexmedetomidine in paediatrics for premedication, procedural sedation, ICU sedation and anaesthesia, despite the off-label use and sparse evidence. The large intercontinental differences in prescribing dexmedetomidine call for consensus and worldwide education on the optimal use in paediatric practice. Supplementry Information The online version of this article (10.1007/s00228-020-03028-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Camille E van Hoorn
- Department of Anaesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands. .,Department of Paediatric Surgery, Erasmus University Medical Centre -Sophia Children's Hospital, PO Box: 2060, 3000 CB, Rotterdam, The Netherlands.
| | - Robert B Flint
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Justin Skowno
- Department of Anaesthesiology, Children's Hospital at Westmead, University of Sydney, Sydney, Australia
| | - Paul Davies
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Australia
| | - Thomas Engelhardt
- Department of Anaesthesia, Royal Children's Hospital Aberdeen and School of Medicine, University of Aberdeen, Aberdeen, UK.,Department of Anaesthesia, McGill University Health Center, Montreal Children's Hospital, Montreal, QC, Canada
| | - Kirk Lalwani
- Department of Anaesthesiology and Paediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Olutoyin Olutoye
- Department of Anaesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Houston, TX, 77030, USA
| | - Erwin Ista
- Department of Internal Medicine - Nursing Science, Erasmus University Medical Centre, Rotterdam, The Netherlands.,Department of Paediatric Surgery, Paediatric Intensive Care, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus University Medical Centre -Sophia Children's Hospital, Rotterdam, The Netherlands
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26
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Bruijnzeel H, Wammes E, Stokroos RJ, Topsakal V, de Graaff JC. A retrospective cohort study of adverse event assessment during anesthesia-related procedures for cochlear implant candidacy assessment and cochlear implantation in infants and toddlers. Paediatr Anaesth 2020; 30:1033-1040. [PMID: 32506586 PMCID: PMC7590089 DOI: 10.1111/pan.13944] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 05/26/2020] [Accepted: 05/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cochlear implantation in children with sensorineural hearing loss is preferably performed at youngest age because early auditory input is essential to prevent neural plasticity decline. In contrast, the rate of anesthetic adverse events is increased during infancy. Therefore, to provide recommendations regarding an optimal pediatric implantation age, these possible anesthetic risks in infants need to be taken into account. AIMS This study aimed at assessing the relation between the age at cochlear implant surgery and anesthetic and surgical adverse events. Secondary aims were to evaluate anesthetic and surgical adverse events in relation to (a) the number of preoperative anesthesia-related procedures for cochlear implant candidacy assessment and (b) the anesthetic maintenance agent (total intravenous anesthesia versus inhalation anesthesia) during implantation. METHODS We executed a retrospective cohort study to evaluate cochlear implantation performed in infants and toddlers between January 2008 and July 2015 in a tertiary pediatric center. We compared anesthetic and surgical adverse events between age-at-implantation (0-12 and 12-24 months of age) groups. Furthermore, we assessed whether anesthetic adverse events occurred during preoperative anesthesia-related procedures for cochlear implant candidacy assessment. RESULTS Forty-six cochlear implantations were performed in 43 patients requiring 42 preoperative anesthesia-related procedures. Nineteen cochlear implantations (41.3%) were performed during infancy. During implantation, the maintenance agent was either sevoflurane (n = 22) or propofol (n = 24). None of the patients encountered major anesthetic adverse events, whereas minor adverse events occurred during 34 cochlear implantations. Those attributed to surgery occurred following six implantations. Neither the age at implantation nor the anesthetic maintenance agent was significantly related to the occurrence of both types of adverse events. CONCLUSIONS Adverse events occur independent of the age at implantation, the number of anesthetic preoperative procedures, and the type of anesthetic maintenance agent in patients who received a cochlear implant before 24 months of age.
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Affiliation(s)
- Hanneke Bruijnzeel
- Department of Otolaryngology and Head & Neck SurgeryUniversity Medical Centre UtrechtUtrechtThe Netherlands,Brain Center Rudolf MagnusUtrecht UniversityUtrechtThe Netherlands
| | - Emily Wammes
- Department of Otolaryngology and Head & Neck SurgeryUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Robert J. Stokroos
- Department of Otolaryngology and Head & Neck SurgeryUniversity Medical Centre UtrechtUtrechtThe Netherlands,Brain Center Rudolf MagnusUtrecht UniversityUtrechtThe Netherlands
| | - Vedat Topsakal
- Brain Center Rudolf MagnusUtrecht UniversityUtrechtThe Netherlands,Department of Otolaryngology and Head & Neck SurgeryUniversity Hospital AntwerpAntwerpBelgium
| | - Jurgen C. de Graaff
- Department of Anesthesiology, Erasmus MCSophia Children's HospitalRotterdamThe Netherlands
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27
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Muhly WT, Taylor E, Razavi C, Walker SM, Yang L, de Graaff JC, Vutskits L, Davidson A, Zuo Y, Pérez-Pradilla C, Echeverry P, Torborg AM, Xu T, Rawlinson E, Subramanyam R, Whyte S, Seal R, M Meyer H, Yaddanapudi S, Goobie SM, Cravero JP, Keaney A, Graham MR, Ramo T, Stricker PA. A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group. Paediatr Anaesth 2020; 30:1166-1182. [PMID: 32734593 DOI: 10.1111/pan.13981] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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: 05/08/2020] [Accepted: 07/20/2020] [Indexed: 02/05/2023]
Abstract
The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.
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Affiliation(s)
- Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elsa Taylor
- Auckland District Health Board, Pediatric Anesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Cyrus Razavi
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
- Research Department of Targeted Intervention, Centre for Perioperative Medicine, University College London, London, UK
| | - Suellen M Walker
- Clinical Neurosciences (Pain Research), UCL GOS Institute of Child Health, London, UK
- Department of Anaesthesia and Pain Medicine, Great Ormond St Hospital NHS Foundation Trust, London, UK
| | - Lei Yang
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC - Sophia Children's Hospital, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Andrew Davidson
- Department of Anaesthesia, Royal Children's Hospital, Parkville, Vic., Australia; Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia; Anaesthesia Research Group, Murdoch Children's Research Institute, Parkville, Vic, Australia
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | | | - Piedad Echeverry
- Department of Pediatric Anesthesiology, Instituto Roosevelt, Bogotá, Colombia
| | - Alexandra M Torborg
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ting Xu
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Ellen Rawlinson
- Department of Anaesthesia and Pain Medicine, Great Ormond St Hospital NHS Foundation Trust, London, UK
| | - Rajeev Subramanyam
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Simon Whyte
- Department of Anesthesia, British Columbia Children's Hospital, University of Britisch Columbia, Vancouver, Canada
| | - Robert Seal
- Department of Anesthesia and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Heidi M Meyer
- Department of Anaesthesia and Perioperative Medicine, Division of PaediatricAnaesthesia, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sandhya Yaddanapudi
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph P Cravero
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aideen Keaney
- Department of Anaesthesia& Critical Care Medicine, Royal Belfast Hospital for Sick Children, Belfast, Ireland
| | - M Ruth Graham
- Department of Anesthesiology, Perioperative, and Pain Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Tania Ramo
- Department of Nursing, Royal Children's Hospital, Parkville, Vic, Australia
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Costerus SA, Bettink MW, Tibboel D, de Graaff JC, Mik EG. Mitochondrial Oxygen Monitoring During Surgical Repair of Congenital Diaphragmatic Hernia or Esophageal Atresia: A Feasibility Study. Front Pediatr 2020; 8:532. [PMID: 32984226 PMCID: PMC7492594 DOI: 10.3389/fped.2020.00532] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/27/2020] [Indexed: 01/07/2023] Open
Abstract
Current monitoring techniques in neonates lack sensitivity for hypoxia at cellular level. The recent introduction of the non-invasive Cellular Oxygen METabolism (COMET) monitor enables measuring in vivo mitochondrial oxygen tension (mitoPO2), based on oxygen-dependent quenching of delayed fluorescence of 5-aminolevulinic acid (ALA)-enhanced protoporphyrin IX. The aim is to determine the feasibility and safety of non-invasive mitoPO2 monitoring in surgical newborns. MitoPO2 measurements were conducted in a tertiary pediatric center during surgical repair of congenital diaphragmatic hernia or esophageal atresia. Intraoperative mitoPO2 monitoring was performed with a COMET monitor in 11 congenital diaphragmatic hernia and four esophageal atresia neonates with the median age at surgery being 2 days (IQR 1.25-5.75). Measurements were done at the skin and oxygen-dependent delayed fluorescence was measurable after at least 4 h application of an ALA plaster. Pathophysiological disturbances led to perturbations in mitoPO2 and were not observed with standard monitoring modalities. The technique did not cause damage to the skin, and seemed safe in this respect in all patients, and in 12 cases intraoperative monitoring was successfully completed. Some external and potentially preventable factors-the measurement site being exposed to the disinfectant chlorohexidine, purple skin marker, or infrared light-seemed responsible for the inability to detect an adequate delayed fluorescence signal. In conclusion, this is the first study showing it is possible to measure mitoPO2 in neonates and that the cutaneous administration of ALA to neonates in the described situation can be safely applied. Preliminary data suggests that mitoPO2 in neonates responds to perturbations in physiological status.
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Affiliation(s)
- Sophie A Costerus
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Mark Wefers Bettink
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Egbert G Mik
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, Netherlands
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van Hoorn CE, Costerus SA, Lau J, Wijnen RMH, Vlot J, Tibboel D, de Graaff JC. Perioperative management of esophageal atresia/tracheo-esophageal fistula: An analysis of data of 101 consecutive patients. Paediatr Anaesth 2019; 29:1024-1032. [PMID: 31343794 DOI: 10.1111/pan.13711] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 03/11/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The perioperative management of esophageal atresia/tracheo-esophageal fistula by open or thoracoscopic approach can be complicated by metabolic derangements. Little is known, however, about the severity of derangements of vital and metabolic parameters in the perioperative period. AIM The aim of this study is to describe the perioperative courses of vital and metabolic parameters in 101 consecutive neonates undergoing surgical repair of esophageal atresia type C. METHOD In a retrospective cohort study, we extracted all data from the electronic anesthetic and medical charts of patients who underwent esophageal atresia type C repair within 30 days of life (2007-2017). We distinguished three types of surgery: primary open, primary thoracoscopic, and primary thoracoscopic surgery converted to open surgery. Descriptive analysis was applied. RESULTS The charts of 117 patients were reviewed: data of 101 were included. The perioperative anesthetic management was not standardized; various methods and medications were used for anesthesia induction and maintenance. Intraoperative blood gas analysis data of 72 patients were available and showed derangements regardless of type of surgery. The median pH-value decreased to 7.21 [IQR 7.14-7.30] and a pH-value below 7.20 was found in 29 patients; in four cases below 7.0, with the lowest value 6.83. The median PaCO2 reached an upper level of 7.5kPa [IQR 5.8-9.2]; in 13 cases above 10.0kPa, with a peak value of 25.8kPa. These high PaCO2 levels fluctuated with lowest measured PaCO2 of median 5.6 [IQR 4.5-6.6], with the lowest value 2.8kPa. The median PaO2 level reached an upper level of 16.9kPa [IQR 11.8-25.7], in 22 cases above 20.0kPa, with a peak value of 50.0kPa. These high levels fluctuated with lowest measured PaO2 levels of median 8.3kPa [IQR 6.73-10.5]; the lowest PaO2 value was 4.7 kPa. CONCLUSION Open and thoracoscopic correction of esophageal atresia were associated with periods of severe metabolic derangements. These events need to be taken into account for the evaluation of esophageal atresia (surgical) care and in evaluations of short- and long-term outcomes.
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Affiliation(s)
- Camille E van Hoorn
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sophie A Costerus
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jessica Lau
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - John Vlot
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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30
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van den Bosch GE, Dijk MV, Tibboel D, de Graaff JC. Long-term Effects of Early Exposure to Stress, Pain, Opioids and Anaesthetics on Pain Sensitivity and Neurocognition. Curr Pharm Des 2019; 23:5879-5886. [PMID: 28950826 DOI: 10.2174/1381612823666170926150259] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 08/01/2017] [Accepted: 09/21/2017] [Indexed: 11/22/2022]
Abstract
Background Experimental studies have shown that neonatal exposure to stress, pain, opioids and anaesthetics may cause histologic and morphologic changes in the central nervous system with associated functional and behavioural changes in the long term. An important question is whether this holds true for humans also - and in particular for sick neonates who often are exposed to pain and receive anaesthetics and sedatives. Methods In this narrative review, we evaluate the effects of neonatal exposure to stress, pain, opioids and anaesthetics in infancy and childhood in animals and in preterm born and term born humans on pain sensitivity, brain morphology, cognition and behaviour later in life. Results In animals, neonatal exposure to stress, pain, opioids and early exposure to anaesthetics are associated with neurodegeneration and cognitive problems later in life. Human studies mainly focus on pain sensitivity, cognition and behaviour and find contradictory outcomes. Dramatic long-term effects found in animal studies could not be confirmed in human. Conclusion While studies in animals suggest neurotoxic effects of early exposure to stress, pain, opioids and anaesthetics, these effects seem clinically less relevant in humans. A possible reason is that the latter often receive opioids in the presence of pain and opioids and anaesthetics in balanced therapeutic dosages and with adequate monitoring of physiological parameters, in contrast to animal studies.
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Affiliation(s)
- Gerbrich E van den Bosch
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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31
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Yuan I, Olbrecht VA, Mensinger JL, Zhang B, Davidson AJ, von Ungern-Sternberg BS, Skowno J, Lian Q, Song X, Zhao P, Zhang J, Zhang M, Zuo Y, de Graaff JC, Vutskits L, Szmuk P, Kurth CD. Statistical Analysis Plan for "An international multicenter study of isoelectric electroencephalography events in infants and young children during anesthesia for surgery". Paediatr Anaesth 2019; 29:243-249. [PMID: 30664323 DOI: 10.1111/pan.13589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/13/2018] [Revised: 12/17/2018] [Accepted: 01/17/2019] [Indexed: 02/05/2023]
Abstract
This Statistical Analysis Plan details the statistical procedures to be applied for the analysis of data for the multicenter electroencephalography study. It consists of a basic description of the study in broad terms and separate sections that detail the methods of different aspects of the statistical analysis, summarized under the following headings (a) Background; (b) Definitions of protocol violations; (c) Definitions of objectives and other terms; (d) Variables for analyses; (e) Handling of missing data and study bias; (f) Statistical analysis of the primary and secondary study outcomes; (g) Reporting of study results; and (h) References. It serves as a template for researchers interested in writing a Statistical Analysis Plan.
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Affiliation(s)
- Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vanessa A Olbrecht
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Janell L Mensinger
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Bingqing Zhang
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Davidson
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Medical School, The University of Western Australia, Perth, WA, Australia
| | - Justin Skowno
- Department of Anaesthesia, Children's Hospital at Westmead, University of Sydney, Sydney, NSW, Australia
| | - QingQuan Lian
- Department of Anesthesiology, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - XingRong Song
- Department of Anesthesiology, Guangzhou Medical University Affiliated Women and Children Medical Center, Guangzhou, China
| | - Pin Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - JianMin Zhang
- Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - MaZhong Zhang
- Department of Anesthesiology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - YunXia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jurgen C de Graaff
- Department of Anesthesiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Charles D Kurth
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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32
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McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, Grobler A, Stargatt R, Hunt RW, Sheppard SJ, Marmor J, Giribaldi G, Bellinger DC, Hartmann PL, Hardy P, Frawley G, Izzo F, von Ungern Sternberg BS, Lynn A, Wilton N, Mueller M, Polaner DM, Absalom AR, Szmuk P, Morton N, Berde C, Soriano S, Davidson AJ. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet 2019; 393:664-677. [PMID: 30782342 PMCID: PMC6500739 DOI: 10.1016/s0140-6736(18)32485-1] [Citation(s) in RCA: 370] [Impact Index Per Article: 74.0] [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] [Received: 09/19/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND In laboratory animals, exposure to most general anaesthetics leads to neurotoxicity manifested by neuronal cell death and abnormal behaviour and cognition. Some large human cohort studies have shown an association between general anaesthesia at a young age and subsequent neurodevelopmental deficits, but these studies are prone to bias. Others have found no evidence for an association. We aimed to establish whether general anaesthesia in early infancy affects neurodevelopmental outcomes. METHODS In this international, assessor-masked, equivalence, randomised, controlled trial conducted at 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand, we recruited infants of less than 60 weeks' postmenstrual age who were born at more than 26 weeks' gestation and were undergoing inguinal herniorrhaphy, without previous exposure to general anaesthesia or risk factors for neurological injury. Patients were randomly assigned (1:1) by use of a web-based randomisation service to receive either awake-regional anaesthetic or sevoflurane-based general anaesthetic. Anaesthetists were aware of group allocation, but individuals administering the neurodevelopmental assessments were not. Parents were informed of their infants group allocation upon request, but were told to mask this information from assessors. The primary outcome measure was full-scale intelligence quotient (FSIQ) on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III), at 5 years of age. The primary analysis was done on a per-protocol basis, adjusted for gestational age at birth and country, with multiple imputation used to account for missing data. An intention-to-treat analysis was also done. A difference in means of 5 points was predefined as the clinical equivalence margin. This completed trial is registered with ANZCTR, number ACTRN12606000441516, and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 4023 infants were screened and 722 were randomly allocated: 363 (50%) to the awake-regional anaesthesia group and 359 (50%) to the general anaesthesia group. There were 74 protocol violations in the awake-regional anaesthesia group and two in the general anaesthesia group. Primary outcome data for the per-protocol analysis were obtained from 205 children in the awake-regional anaesthesia group and 242 in the general anaesthesia group. The median duration of general anaesthesia was 54 min (IQR 41-70). The mean FSIQ score was 99·08 (SD 18·35) in the awake-regional anaesthesia group and 98·97 (19·66) in the general anaesthesia group, with a difference in means (awake-regional anaesthesia minus general anaesthesia) of 0·23 (95% CI -2·59 to 3·06), providing strong evidence of equivalence. The results of the intention-to-treat analysis were similar to those of the per-protocol analysis. INTERPRETATION Slightly less than 1 h of general anaesthesia in early infancy does not alter neurodevelopmental outcome at age 5 years compared with awake-regional anaesthesia in a predominantly male study population. FUNDING US National Institutes of Health, US Food and Drug Administration, Thrasher Research Fund, Australian National Health and Medical Research Council, Health Technologies Assessment-National Institute for Health Research (UK), Australian and New Zealand College of Anaesthetists, Murdoch Children's Research Institute, Canadian Institutes of Health Research, Canadian Anesthesiologists Society, Pfizer Canada, Italian Ministry of Health, Fonds NutsOhra, UK Clinical Research Network, Perth Children's Hospital Foundation, the Stan Perron Charitable Trust, and the Callahan Estate.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, Netherlands; Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Liam Dorris
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, Scotland, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola Disma
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Davinia Withington
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Robyn Stargatt
- Child Neuropsychology, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Psychological Science, La Trobe University, Melbourne, Victoria, Australia
| | - Rodney W Hunt
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Suzette J Sheppard
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Gaia Giribaldi
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Francesca Izzo
- Department of Anaesthesiology and Paediatric Intensive Care, Ospedale Pediatrico Vittore Buzzi, Milan, Italy
| | - Britta S von Ungern Sternberg
- Medical School, The University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Telethon Kid's Institute, Perth, WA, Australia
| | - Anne Lynn
- Department of Anesthesiology and Pain Medicine, and Pediatrics University of Washington, Seattle, WA, USA; Department of Anaesthesia and Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Martin Mueller
- Department of Anaesthesia, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David M Polaner
- Department of Anaesthesiology, Children's Hospital Colorado, Denver, CO, USA; Department of Anaesthesiology, University of Colorado, Denver, CO, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Medical Centre Dallas, Dallas, TX, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Neil Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK; Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Charles Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sulpicio Soriano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia.
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van Hoorn CE, Hoeks SE, Essink H, Tibboel D, de Graaff JC. A systematic review and narrative synthesis on the histological and neurobehavioral long-term effects of dexmedetomidine. Paediatr Anaesth 2019; 29:125-136. [PMID: 30475445 PMCID: PMC6850292 DOI: 10.1111/pan.13553] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Recent experimental studies suggest that currently used anesthetics have neurotoxic effects on young animals. Clinical studies are increasingly publishing about the effects of anesthesia on the long-term outcome, providing contradictory results. The selective alpha-2 adrenergic receptor agonist dexmedetomidine has been suggested as an alternative nontoxic sedative agent. AIMS The aim of this systematic review was to assess the potential neuroprotective and neurobehavioral effects of dexmedetomidine in young animals and children. METHODS Systematic searches separately for preclinical and clinical studies were performed in Medline Ovid and Embase on February 14, 2018. RESULTS The initial search found preclinical (n = 661) and clinical (n = 240) studies. A total of 20 preclinical studies were included. None of the clinical studies met the predefined eligibility criteria. Histologic injury by dexmedetomidine was evaluated in 11 studies, and was confirmed in three of these studies (caspase-3 activation or apoptosis). Decrease of injury caused by another anesthetic was evaluated in 16 studies and confirmed in 13 of these. Neurobehavioral tests were performed in seven out of the 20 studies. Of these seven rodent studies, three studies tested the effects of dexmedetomidine alone on neurobehavioral outcome in animals (younger than P21). All three studies found no negative effect of dexmedetomidine on the outcome. In six studies, outcome was evaluated when dexmedetomidine was administered following another anesthetic. Dexmedetomidine was found to lessen the negative effects of the anesthetic. CONCLUSION In animals, dexmedetomidine was found not to induce histologic injury and to show a beneficial effect when administered with another anesthetic. No clinical results on the long-term effects in children have been identified yet.
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Affiliation(s)
- Camille E. van Hoorn
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Sanne E. Hoeks
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Heleen Essink
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive CareSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Jurgen C. de Graaff
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
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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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Stricker PA, de Graaff JC, Vutskits L, Muhly WT, Xu T, Torborg AM, Jiang Y, Walker SM. Pediatric perioperative outcomes group: Defining core outcomes for pediatric anesthesia and perioperative medicine. Paediatr Anaesth 2018; 28:314-315. [PMID: 29575457 DOI: 10.1111/pan.13354] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 11/28/2022]
Affiliation(s)
- Paul A Stricker
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jurgen C de Graaff
- Department of Anesthesia, Sophia Children's Hospital, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ting Xu
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Alexandra M Torborg
- Discipline of Anaesthesiology and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Yifei Jiang
- Department of Anesthesiology, The 2nd Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Suellen M Walker
- Developmental Neurosciences Program, UCL Great Ormond Street Institute of Child Health, Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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de Wit M, Peelen LM, van Wolfswinkel L, de Graaff JC. The incidence of postoperative respiratory complications: A retrospective analysis of cuffed vs uncuffed tracheal tubes in children 0-7 years of age. Paediatr Anaesth 2018; 28:210-217. [PMID: 29436138 DOI: 10.1111/pan.13340] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The use of cuffed vs uncuffed endotracheal tubes in pediatric anesthesia is widely debated. This study aimed to investigate whether the use of cuffed vs uncuffed tubes is associated with an increased incidence of acute postoperative respiratory complications. METHODS We retrospectively studied all children aged 0-7 years in which the trachea was intubated between September 28, 2006 and August 26, 2016 in a pediatric university hospital. Logistic regression analysis was performed to estimate the association between tube design (cuffed vs uncuffed) and the incidence of acute postoperative respiratory complications (stridor, wheezing, or dyspnea; desaturations ≤90%) in need of intervention (epinephrine, dexamethasone, nebulizers, supplementary oxygen, or reintubation), adjusting for potential confounders. RESULTS In 5247 of 6796 cases (77%), a cuffed tube was used. Acute postoperative respiratory complications in need of intervention occurred in 334 cases (4.9%) and were less common after cuffed than after uncuffed tubes (N = 236, 4.5% vs N = 98, 6.3%, respectively, odds ratio 0.70; 95%CI 0.55-0.89). Desaturation occurred less often after cuffed tubes (cuffed: N = 1365, 26.0%; uncuffed: N = 512, 33.1%; OR: 0.71 (0.61-0.84)). After adjusting for confounders, there was no difference in acute postoperative respiratory complications between cuffed tubes and uncuffed tubes (OR 0.74; 95%CI 0.55-1.01). Subgroup analyses in various age groups did not show significant differences between the use of cuffed or uncuffed tubes. CONCLUSION After adjustment for multiple confounders, the use of cuffed tubes was not associated with an increased incidence of acute respiratory complications in postanesthesia care unit.
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Affiliation(s)
- Michel de Wit
- Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda M Peelen
- Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Leo van Wolfswinkel
- Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jurgen C de Graaff
- Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Anesthesia, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
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de Graaff JC, Pasma W, van Buuren S, Duijghuisen JJ, Nafiu OO, Kheterpal S, van Klei WA. Reference Values for Noninvasive Blood Pressure in Children during Anesthesia: A Multicentered Retrospective Observational Cohort Study. Anesthesiology 2017; 125:904-913. [PMID: 27606930 DOI: 10.1097/aln.0000000000001310] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Although noninvasive blood pressure (NIBP) monitoring during anesthesia is a standard of care, reference ranges for blood pressure in anesthetized children are not available. We developed sex- and age-specific reference ranges for NIBP in children during anesthesia and surgery. METHODS In this retrospective observational cohort study, we included NIBP data of children with no or mild comorbidity younger than 18 yr old from the Multicenter Perioperative Outcomes Group data set. Sex-specific percentiles of the NIBP values for age were developed and extrapolated into diagrams and reference tables representing the 50th percentile (0 SD), +1 SD, -1 SD, and the upper (+2 SD) and lower reference ranges (-2 SD). RESULTS In total, 116,362 cases from 10 centers were available for the construction of NIBP age- and sex-specific reference curves. The 0 SD of the mean NIBP during anesthesia varied from 33 mmHg at birth to 67 mmHg at 18 yr. The low cutoff NIBP (2 SD below the 50th percentile) varied from 17 mmHg at birth to 47 mmHg at 18 yr old. CONCLUSIONS This is the first study to present reference ranges for blood pressure in children during anesthesia. These reference ranges based on the variation of values obtained in daily care in children during anesthesia could be used for rapid screening of changes in blood pressure during anesthesia and may provide a consistent reference for future blood pressure-related pediatric anesthesia research.
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Affiliation(s)
- Jurgen C de Graaff
- From the Department of Anesthesiology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands (J.C.d.G., W.P., J.J.D., W.A.v.K.); Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands (J.C.d.G.); Department of Anesthesia, Sophia Children's Hospital, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands (J.C.d.G.); Netherlands Organization for Applied Scientific Research TNO, Leiden, The Netherlands (S.v.B.); Department of Methodology and Statistics, FSS, University of Utrecht, Utrecht, The Netherlands (S.v.B.); and Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan (O.O.N., S.K.)
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Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, Leva B, Morton NS, Vermeulen PM, Zielinska M, Boda K, Veyckemans F, Klimscha W, Konecny R, Luntzer R, Morawk-Wintersperger U, Neiger F, Rustemeyer L, Breschan C, Frey D, Platzer M, Germann R, Oeding J, Stoegermüller B, Ziegler B, Brotatsch P, Gutmann A, Mausser G, Messerer B, Toller W, Vittinghoff M, Zangl G, Seidel-Ahyai N, Hochhold C, Kroess R, Paal P, Cnudde S, Coucke P, Loveniers B, Mitchell J, Kahn D, Pirotte T, Pregardien C, Veyckemans F, Coppens M, De Hert S, Heyse B, Neckebroek M, Parashchanka A, Van Limmen J, Van Den Eynde N, Vanpeteghem C, Wyffels P, Lalot M, Lechat JP, Stevens F, Casaer S, De Groote F, De Pooter F, De Villé A, Gerin M, Magasich N, Sanchez Torres C, Van Deenen D, Berghmans J, Himpe D, Roofthooft E, Joukes E, Smitz C, Van Reeth V, Huygens C, Lauweryns J, De Smet K, Najafi N, Poelaert J, Van de Velde A, Van Mossevelde V, Bekavac I, Butkovic D, Heli Litvic D, Kerovec Soric I, Maretic H, Moscatello D, Popovic L, Micici S, Stuck Tus I, Kalagac Fabris L, Simurina T, Sulen N, Kesic-Valpotic G, Djapic D, Žurek J, Jureckova L, Mackova I, Skacel M, Weinlichova S, Divák J, Frelich M, Urbanec R, Biskupova V, Mifsud M, Strachan D, Leva B, Plichon B, Harlet P, Mixa V, Pavlickova J, Afshari A, Bøttger M, Ellekvist MB, Johansen M, Ingeborg Madsen B, Christian Nilsson J, Schousboe BMB, Clausen NG, Hansen TG, Phaff Steen N, Ilmoja ML, Tonise V, Karjagin J, Kikas R, Isohanni M, Lyly A, Takala A, Happo J, Kiviluoma K, Martikainen K, Aantaa R, Manner T, Vilo S, Amory C, Ludot H, Lambotte P, Busche R, Jacqmarcq O, Lejus C, Corouge J, Erb C, Garrigue D, Gillet P, Laffargue A, Lambelin V, Le Freche H, Peresbota D, Richart P, Berton J, Chapotte C, Colbus L, Lehousse T, Monrigal J, Baujard C, Roulleau P, Staiti G, Batoz H, Bordes M, Didier A, Hamonic Y, Lagarde S, Nouette-Gaulain K, Semjen F, Zaghet B, Dekens J, Delcuze A, Dupont H, Legrand A, Raffoflandreur C, Audren N, Camus B, Cartal M, Chazelet C, Davin I, Guillier M, Desjeux L, Larcher C, Grein E, Leclercq M, Levitchi R, Rosu L, Simon D, Zang A, Migeon A, Gagey AC, Bourdaud N, Carre AC, Duflo F, Riche JC, Robert P, Druot E, Maupain O, Orliaguet G, Sabau L, Taright H, Uhrig L, Verchere-Montmayeur J, Debrabant L, Pilla C, Podvin A, Roth B, Dahmani S, Julien-Marsollier F, Sabourdin N, Alexandri B, Brezac G, de la Brière F, Hayem C, Lhubat E, Paul Mission J, Rémond C, Dadure C, Maniora M, Marie A, Pirat P, Saour AC, Sola C, Ecoffey C, Wodey E, Adam C, Standl T, Schindler E, Yamamoto T, Brackhahn M, Eich CB, Guericke H, Kindermann P, Laschat M, Schink C, Wappler F, Hoehne C, Skordou N, Ulrici J, Jetzek-Zader M, Kienbaum P, Meyer-Treschan T, Picker O, Schaefer MS, Mielke G, Baethge S, Ramminger A, Bauer M, Bollinger M, Hinz J, Quintel M, Russo SG, Bauer M, Geil D, Kortgen A, Preussler NP, Hofmann U, Raber M, Reindl D, Becke K, Oppenrieder K, Schierlinger B, Roth J, Funk W, Fischer T, Gernoth C, Wiefelspütz C, Volger H, Zederer N, Diers A, Huber M, Schorer C, Weyland A, Schwarzkopf K, Grau C, Roth W, Holy R, Mader T, Peter L, Supthut H, Kuehhirt T, Milde A, Fiedler F, Isselhorst C, Grundmann U, Pattar A, Reinert J, Ehm B, Fritzsche K, Gaebler R, Meybohm P, Hein M, Guzman I, Jokinen J, Kranke P, Goebel U, Harris S, Eisner C, Ochsenreiter M, Schoeler M, Thil E, Ellerkmann R, Hoeft A, Neumann C, Weber S, Keilhauer J, Kloessing J, Schramm M, Trieschmann U, Knauss K, Sinner B, Steinmann J, Koessler H, Kalliardou E, Malisiova A, Tsiotou A, Chloropoulou P, Chrysi M, Iordanidou D, Ntavlis M, Boda KB, Guerin C, Irwin J, Magner C, Nakhjavani S, O'Hare B, Galvin D, Jamil Y, Lesmes C, Barak Y, Fisher H, Kachko L, Katz J, Kirilov D, Levinzon M, Manevich Y, Nekrasov K, Peled E, Sanko E, Schmain D, Sheinkin O, Simhi E, Tarabikin A, Trabkin E, Yagudaev I, Zeitlin Y, Zunser I, Cerutti E, Maddalena Schellino M, Valzan S, Lucia Pinciroli R, Bortone L, Cerati G, Salici F, Bussolin L, Rizzo G, Rossetti F, Marchesini L, Tesoro S, De Lorenzo B, Guarracino F, Kuppers B, Astuto M, Pitino S, Scalisi R, Scordo L, D'Alessandro S, Dei Giudici L, Farinelli I, Lofino G, Marchetti G, Giuseppe Picardo S, Reali S, Vittori A, Antonio Idone F, Sammartino M, Sbaraglia F, Barbera C, Bevilacqua M, Cento V, Disma N, Kotzeva S, Mameli L, Montobbio G, Passariello L, Punzo C, Sileo R, Viacava R, Volpe C, Zanaboni C, Calderini E, Genco D, Neri S, Ottolina D, Camporesi A, Izzo F, Salvo I, Wolfler A, Sanna A, Sciascia A, Stoia P, Guddo A, Lapi M, Ivani G, Longobardo A, Mossetti V, Pedrotti D, Grazzini M, Meneghini L, Metrangolo S, Michelon S, Minardi C, Tognon C, Zadra N, Busi I, Khotcholava M, Guido Locatelli B, Sonzogni V, Starita G, Almenrader N, Aurilio C, Sansone P, Albarello R, Bracci P, Cecini M, Cristina Mondardini M, Pasini L, Vason M, Zani G, Zoppellari R, Pistidda L, Cortegiani A, Maurizio Raineri S, Hasani A, Hashimi M, Ancupans A, Barzdina A, Straume Z, Zundane A, Chlopin M, Gestautaite D, Lukosiene L, Paliokaite E, Razlevice I, Armoniene I, Bernotiene A, Daugelavicius V, Dockiene I, Gaidelyte L, Saviciene N, Krikstaponiene J, Sidlovskaite-Baltake D, Stasevski V, Vaitoskaite A, Gatt D, Mifsud S, Zammit S, Allison C, Aslami H, Eberl S, van Stijn MFM, Stevens MF, Punt K, van Osch R, Bauwman A, Scholten H, Svircevic V, Adriaens V, Dirckx M, Dogger J, Dons-Sinke I, Machotta A, Moors X, Rad M, Staals L, van der Knijff - van Dortmont A, van der Marel C, Sieben A, van der Zwan T, Veldhuizen M, Alders D, Buhre W, Vermeulen PM, Engel N, Vossen C, Mahadewsing R, Meijer P, Gerling V, van der Schatte Olivier R, van Doorn T, Vons Mark Hendriks K, Lako S, jan Scheffer G, Tielens L, Voet M, Absalom A, Bergsma M, Spanjer V, Spanjersberg R, van de Riet Y, Volkers M, de Graaff JC, Hopman GA, Kappen TH, Hannie J, Megens A, Numan SC, Schouten AN, Turner NM, Van Der Werff DB, Wensing RT, Ephraim E, Nolte C, Reikvam T, Fredrik Lund O, Skaaden L, Marthe Ballovarre K, Bakken Boerke W, Grindheim G, Lindenskov PHH, Beate Solas A, Sponheim S, Ullensvang K, Viken O, Marie Drage I, Gymoese Berthelsen K, Anders Kroken B, Bergland U, Pryzmont M, Talalaj M, Wasiluk M, Zalewska D, Damps M, Siemek-Mitela J, Wieczorek P, Juzwa M, Rosada-Kurasinska J, Bartkowska-Sniatkowska A, Cettler M, Kopycinska R, Rudewicz I, Sobczyk J, Wojciechowski D, Baranowski A, Basiewicz E, Mierzewska-Schmidt M, Retka W, Sawicki P, Checinska M, Zielinska M, Zurawska M, Leal T, Mascarenhas C, Pedro Pina A, Joao Susano M, Moniz A, Teresa Rocha M, Calvao Santos C, Domingas Patuleia M, Pereira R, Roxo H, Amaral R, Guedes I, Gomes C, Gonçalves M, Salgado H, Santos M, Rodrigues S, Sa A, Machado E, Pé d'Arca S, Seabra M, Mihaela Gheorghe L, Ivascu C, Moraru-Draghici L, Suvejan M, Babici R, Eniko K, Hogea C, Mihaela D, Nicoleta D, Barbunc D, Maria Nistor A, Stefan V, Catalina Ionescu G, Davidescu I, Teodora Nastase A, Dumitru Rusu F, Badarau V, Cindea I, Moscaliuc M, Olteanu D, Petrescu L, Ceuca D, Galinescu I, Badeti R, Capusan A, Cucui-Cozma C, Popescu B, Cimpeanu L, Birliba MP, Miulescu M, Balamat S, Gurita A, Ilie L, Mocioiu G, Pick D, Sirghie R, Tabacaru R, Trante I, Gurita A, Horhota L, Bandrabur D, Ciobanu T, Cuciuc V, Munteanu V, Olaru V, Paiu C, Savu A, Trifan O, Elena Malos A, Glazunov A, Ivanov A, Poduskov E, Popov A, Guskov I, Lugovoy A, Nechaev V, Ovezov A, Basov M, Kochkin V, Lazarev V, Chizhov D, Ostreikov I, Tolasov K, Budic I, Marjanovic V, Draskovic B, Pandurov M, Simin J, Dolinaj V, Janjevic D, Mandras A, Mircetic M, Petrovic S, Rebac V, Slavkovic B, Stevanovic V, Velcev A, Knezevic M, Milojevic I, Puric S, Simic I, Stevic M, Stranjanac V, Simic D, Cabanova B, Hanula M, Grynyuk A, Berger J, Cerne U, Nastran A, Pirc D, Popic R, Stupnik S, Rubio P, del Río C, Benito P, Pino G, Gutierrez I, Gutierrez Valcarcel A, León Carsi I, Perez Garcia A, López Galera S, Marco Valls J, Ricol Lainez L, Vallejo Tarrat A, Artes D, Banus E, Chirichiello L, De Abreu L, De Josemaria B, Helena Gaitan M, Garces A, Lazaro JJ, Manen Berga F, Molies D, Monclus E, Navaro M, Pamies C, Perelló M, Prat M, Ribo L, Angeles Sanz M, Serrano S, Sola Ruiz E, Anuncia Escontrela Rodríguez B, Maria Gago Martinez A, Martínez Ruiz A, De La Cruz Benito F, Gabilondo Garcia G, Martinez Maldonado E, Noriega B, Oller Duque L, Olmos Mendez A, Perez- Ferrer A, Reinoso Barbero F, Acevedo Bambaren I, Domínguez F, Franco T, Jiménez A, Melero A, Feliu M, García I, Montferrer N, Munar F, Muro C, Nuño R, Perera R, Schmucker E, Börjesson G, Gillberg L, Castellheim A, Sandström K, Bauer A, Roos T, Hedlund L, Boegli Y, Dolci M, Marcucci C, Spahr-Schopfer I, Habre W, Pellegrini M, Book M, Errass L, Riggenbach C, Casutt M, Hölzle M, Hurni T, Jöhr M, Mauch J, Anselmi L, Anselmi I, Jacomet A, Oberhauser M, Wossner S, Zettl A, Erb T, Mackiewicz T, Simitzes H, Ozer Y, Takil A, Alanoglu Z, Bermede O, Cakar Turhan K, Alkis N, Yildirim Guclu C, Ceyda Meco B, Hatipoglu Z, Ozcengiz D, Begec Z, Ilksen Toprak H, Kendigelen P, Cigdem Tütüncü A, Karadeniz MS, Seyhan Ozkan T, Sivrikoz N, Kemal Arslantas M, Hizal A, Tore Altun G, Umuroglu T, Baris S, Kazak Bengisun Z, Goncharenko G, Khrapak M, Klymenko T, Pavlenko V, Prysiazhniuk D, Rudio O, Varyvoda M, Vodianytskyi S, Boryshkevych I, Kyselova I, Trikash N, Albokrinov A, Perova-Sharonova V, Sklyar V, Surkov D, Abdelaal A, Barber N, Checuti S, Godsiff L, Johanne L, Simpson J, Underhill H, Diwan R, Kelgeri N, Masip N, Ravi R, Roberts S, Cillis A, Marcus R, Merella F, Love D, Baraggia P, Bird V, Hussey J, Alderson P, Bartholomew K, Moncreiff M, Davidson S, Hare A, Kotecha A, Lee C, Liyanage G, Patel S, Samani A, Abou-Samra M, Boyd M, Hullatt L, Levy D, Pauling M, Sharman SJ, Smith N, Rutherford J, Cavalier A, Locke C, Sage F, Bapat S, Hammerschlag J, Ioannou I, King S, Pegg R, Salota V, Sketcher J, Thadsad M, Zeitlin D, Jack E, Lang C, Ahmed S, Ayyash R, Bari F, Bell SJ, Elizabeth Biercamp C, Briggs S, Gabriella Elena Clement M, Dalton M, Ali Eissa Eid M, Gandhi M, Harmen Herrema I, Khaffaf R, Jeng Min Law S, McClintock J, Ireland N, Majid Saleem M, Smith F, Cohen M, Lee CA, O'Donahue L, Powell A, Rawlinson E, Snoek A, Weiss K, Wellesley H, Crawford M, Abdel-Hafiz M, Day A, Rajamani B, Saha R, Wright D, Chee LC, Bew S, Homer R, Malarkkan N, Wolfe Barry J, Angadi P, Cagney B, De Melo E, Dekker E, Helm E, Jones G, Peiris K, Russell W, Slater P, Sodhi P, Browning M, Phillips T, Van Hecke R, Muir V, Singh P, Soskova T, Cumming C, Farquharson P, Pearson K, Shaw N, Whiteside J, Whyte E, Byers G, Davies K, Engelhardt T, Faliszewski I, Johnston G, Kaufmann N, Kusnirikova Z, Wilson G, Carachi P, Makin A, Foster B, Lipczynski D, Mawer R, Rutherford W, Rogerson D, Rushman S, Taylor C, Tomlinson W, Dix P, Woodward T, Bell G, Boyle D, Cloherty M, Cullen J, Cullen P, Fairgrieve R, Ghent R, Glasgow R, Gordeeva E, Harden A, Hivey S, Jerome K, McKee L, Morton N, Pribul V, Sinclair J, Steiner M, Steward H, Sweeney L, Thomson W, Whiteside J, Dalton A, Ross M, Smith C, Allen C, Anders N, Barlow V, Bassett M, Darwin L, Davison R, Diacono J, Hobbs A, Hutchinson A, Lomas B, Lonsdale H, Nasser L, Oshan V, Patel P, Raistrick C, Scott-Warren V, Talbot L, Wai C, Childs S, Dickinson M, Bloomfield T, Garrioch S, Watson K, Gaynor J, Harrison R, Lee J, Blythe E, Dorman T, Eissa A, Ellwood J, Gooch I, Hearn R, Hodgetts V, John R, Kirton C, Ladak N, Morgan J, Plant N, Shepherd E, Short J, Stack C, Steel S, Taylor M, Thomas D, Wilson C, Wilson-Smith E, Bradbury CL, Hussain N, Mayell A, Mesbah A, Qureshi A, Vaidyanath C, Geary T, Hawksworth C, Parasuraman T, Perry N, Banerjee I, Barr K, Butler P, Davies J, Flewin L, Gande R, Montague J, Plumb J, Pratt T, Sutherland P, Taylor M, Vail H, Wilkins A, Hunter C, Russell S, Thomas A. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. The Lancet Respiratory Medicine 2017; 5:412-425. [DOI: 10.1016/s2213-2600(17)30116-9] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 11/24/2022]
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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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de Graaff JC, Sarfo MC, van Wolfswinkel L, van der Werff DBM, Schouten ANJ. Anesthesia-related critical incidents in the perioperative period in children; a proposal for an anesthesia-related reporting system for critical incidents in children. Paediatr Anaesth 2015; 25:621-9. [PMID: 25684322 DOI: 10.1111/pan.12623] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [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] [Accepted: 12/29/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND The incidence, type and severity of anesthesia-related critical incidents during the perioperative phase has been investigated less in children than in adults. AIM The aim of the study was to identify and analyze anesthesia-related critical incidents in children to identify areas to improve current clinical practice, and to propose a specialized anesthesia-related critical incidence registration for children. METHOD All reported pediatric anesthesia-related critical incidents reported on a voluntary reporting based on a 20-item complication list of the Dutch Society of Anesthesiology between January 2007 and August 2013 were analyzed. An anesthesia-related critical incident was defined as 'any incident that affected, or could have affected, the safety of the patient while under the care of an anesthetist'. As the 20-item complications list was too crude for detailed analyses, all critical incidents were reclassified into the more detailed German classification lists with the adjustment of specific items for children (in total 10 categories with 101 different subcategories). RESULTS During the 6-year period, a total of 1214 critical incidents were reported out of 35 190 anesthetics (cardiac and noncardiac anesthesia cases). The most frequently reported incidents (46.5%) were related to the respiratory system. Infants <1 year, children with ASA physical status III and IV, and emergency procedures had a higher rate of adverse incidents. CONCLUSION Respiratory events were the most reported commonly critical incidents in children. Both the Dutch and German existing lists of critical incident definitions appeared not to be sufficient for accurate classification in children. The present list can be used for a new registration system for critical incidents in pediatric anesthesia.
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Affiliation(s)
- Jurgen C de Graaff
- Department of Anesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
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Boerboom SL, Muthukrishnan SM, de Graaff JC, Jonker G. Cuffed or uncuffed endotracheal tubes in pediatric anesthesia: a survey of current practice in the United Kingdom and The Netherlands. Paediatr Anaesth 2015; 25:431-2. [PMID: 25752786 DOI: 10.1111/pan.12594] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [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: 11/29/2022]
Affiliation(s)
- Saskia L Boerboom
- Department of Anaesthesiology, University Medical Centre, Utrecht, The Netherlands
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de Graaff JC, Cuper NJ, van Dijk ATH, Timmers-Raaijmaakers BCMS, van der Werff DBM, Kalkman CJ. Evaluating NIR vascular imaging to support intravenous cannulation in awake children difficult to cannulate; a randomized clinical trial. Paediatr Anaesth 2014; 24:1174-9. [PMID: 25088349 DOI: 10.1111/pan.12501] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Accepted: 07/07/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, various near-infrared vascular imaging devices aimed at facilitating peripheral intravenous cannulation (PIC) were introduced, all claiming to increase success rate of PIC. We evaluated the clinical utility of a near-infrared vascular imaging device (VascuLuminator(®)) in pediatric patients who were referred to the anesthesiologist because of difficult cannulation. METHODS There were 226 consecutive children referred to pediatric anesthesiologists by the treating pediatrician of the in- and outpatient clinic, because of difficulties with intravenous cannulation, were included in this cluster randomized clinical trial. The presence and use of the near-infrared vascular imaging device for PIC was randomized in clusters of 1 week. Success at first attempt (Fisher exact test) and time to successful cannulation (Log-rank test) were assessed to evaluate differences between groups. RESULTS Success at first attempt in the group with the VascuLuminator(®) (59%) was not significantly different from the control group (54%, P = 0.41), neither was the median time to successful cannulation: 246 s and 300 s, respectively (P = 0.54). CONCLUSIONS Visualization of blood vessels with near-infrared light and with near-infrared vascular imaging device did not improve success of PIC in pediatric patients who are known difficult to cannulate.
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Affiliation(s)
- Jurgen C de Graaff
- Department of Pediatric Anesthesia, Wilhelmina Children's Hospital, University Medical Center, Utrecht, the Netherlands
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Vons KMJ, Bijker JB, Verwijs EW, Majoor MHJM, de Graaff JC. Postoperative pain during the first week after adenoidectomy and guillotine adenotonsillectomy in children. Paediatr Anaesth 2014; 24:476-82. [PMID: 24646093 DOI: 10.1111/pan.12383] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [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] [Accepted: 02/10/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adenoidectomy (AD) and adenotonsillectomy (ATE) are frequently occurring and often painful interventions in children. In literature, it is very prevalent that postoperative pain in children following ATE is hard to control. The purpose of this study was to evaluate the prevalence and severity of postoperative pain in children undergoing AD and ATE in the ambulatory setting. METHODS A prospective cohort study was performed including 167 children aged 0-12 years, undergoing AD using an adenotome and ATE using the guillotine technique in day care. Children undergoing AD received acetaminophen pre- and postoperatively. Children undergoing ATE received acetaminophen and diclofenac preoperatively, sufentanyl postoperative and a prescription of around-the-clock treatment with acetaminophen and diclofenac at home. Pain intensity and analgesic consumption were recorded in hospital using the Faces, Legs, Activity, Cry and Consolability-scale (FLACC), as well as during a 1-week follow-up period at home using the Parents' Postoperative Pain Measure (PPPM) and Visual Analogue Scale (VAS) scores. RESULTS All children left the recovery room with adequate pain scores and were discharged with a median VAS of two after ATE and one after AD. The PPPM and VAS scores were highest at the first measurement at home for AD patients (VAS = 2.0 and PPPM = 1.5) and ATE patients (VAS = 4.5 and PPPM = 9). On the second postoperative day, AD patients scored 0.0 points on both VAS and PPPM. ATE patients scored at that time 3.0 point on the VAS and 6.0 points using the PPPM. Despite high adherence to pain treatment, daytime activities normalized after an average of 2 and 7 days after AD and ATE, respectively. CONCLUSION Examination of the PPPM and VAS scores illustrated that children undergoing AD were comfortable with acetaminophen as a single analgesic, whereas children undergoing ATE experience significant pain for up to two postoperative days when treated with acetaminophen and diclofenac.
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Affiliation(s)
- Kristy M J Vons
- Department of Anesthesia, Gelderse Vallei Hospital, Ede, The Netherlands
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Megens JHAM, de Wit M, van Hasselt PM, Boelens JJ, van der Werff DBM, de Graaff JC. Perioperative complications in patients diagnosed with mucopolysaccharidosis and the impact of enzyme replacement therapy followed by hematopoietic stem cell transplantation at early age. Paediatr Anaesth 2014; 24:521-7. [PMID: 24612129 DOI: 10.1111/pan.12370] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [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] [Accepted: 01/22/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mucopolysaccharidoses (MPS) are hereditary storage diseases; airway management typically worsens in these patients with the progression of the disease. OBJECTIVE(S) To assess the incidence of perioperative complications in children with MPS and the impact of enzyme replacement therapy (ERT) followed by hematopoietic stem cell transplantation (HSCT). METHODS The records of patients with MPS treated with ERT followed by HSCT, who received anesthesia at the Wilhelmina Children's Hospital between 2003 and 2012, were reviewed. Data were collected on incidence of perioperative respiratory and cardiovascular complications and the impact of treatment and age. RESULTS Nineteen children with MPS were identified (including 17 Hurler patients), who received ERT treatment followed by HSCT. Median age at start of treatment was 14 (range: 7-43) months. Patients were anesthetized 136 times. The incidence of respiratory and cardiovascular complications was 24% and 4%, respectively. Airway management by face mask was difficult in 7%. There were no problems with the laryngeal mask airway. Tracheal intubation was difficult in 25% and failed in 10%; using a video laryngoscope was most successful (89%), followed by classic laryngoscope (67%) and fiber-optic scope (20%). Multivariate logistic regression analyses showed that the incidence of perioperative respiratory problems did not increase with age or decrease after start of treatment. CONCLUSION Perioperative airway management was most successful using a laryngeal mask airway or video laryngoscope. Treatment with ERT followed by HSCT and patient age did not influence the incidence of perioperative respiratory problems.
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Affiliation(s)
- Johanna H A M Megens
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
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van Waes JAR, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA. Response to letter regarding article, "myocardial injury after noncardiac surgery and its association with short-term mortality". Circulation 2014; 129:e324. [PMID: 24493813 DOI: 10.1161/circulationaha.113.007269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/16/2022]
Affiliation(s)
- Judith A R van Waes
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
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de Graaff JC, Bijker JB, Kappen TH, van Wolfswinkel L, Zuithoff NPA, Kalkman CJ. Incidence of Intraoperative Hypoxemia in Children in Relation to Age. Anesth Analg 2013; 117:169-75. [DOI: 10.1213/ane.0b013e31829332b5] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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van Waes JA, Nathoe HM, de Graaff JC, Kemperman H, de Borst GJ, Peelen LM, van Klei WA, Buhre WF, de Graaff JC, Kalkman CJ, van Klei WA, van Waes JA, van Wolfswinkel L, Doevendans PA, Nathoe HM, Grobben RG, Grobbee DE, Peelen LM, Kemperman H, van Solinge WW, Leiner T, de Borst GJ, Leenen LP, Moll FL. Myocardial Injury After Noncardiac Surgery and its Association With Short-Term Mortality. Circulation 2013; 127:2264-71. [DOI: 10.1161/circulationaha.113.002128] [Citation(s) in RCA: 216] [Impact Index Per Article: 19.6] [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: 12/28/2022]
Abstract
Background—
To identify patients at risk for postoperative myocardial injury and death, measuring cardiac troponin routinely after noncardiac surgery has been suggested. Such monitoring was implemented in our hospital. The aim of this study was to determine the predictive value of postoperative myocardial injury, as measured by troponin elevation, on 30-day mortality after noncardiac surgery.
Methods and Results—
This observational, single-center cohort study included 2232 consecutive intermediate- to high-risk noncardiac surgery patients aged ≥60 years who underwent surgery in 2011. Troponin was measured on the first 3 postoperative days. Log binomial regression analysis was used to estimate the association between postoperative myocardial injury (troponin I level >0.06 μg/L) and all-cause 30-day mortality. Myocardial injury was found in 315 of 1627 patients in whom troponin I was measured (19%). All-cause death occurred in 56 patients (3%). The relative risk of a minor increase in troponin (0.07–0.59 μg/L) was 2.4 (95% confidence interval, 1.3–4.2;
P
<0.01), and the relative risk of a 10- to 100-fold increase in troponin (≥0.60 μg/L) was 4.2 (95% confidence interval, 2.1–8.6;
P
<0.01). A myocardial infarction according to the universal definition was diagnosed in 10 patients (0.6%), of whom 1 (0.06%) had ST-segment elevation myocardial infarction.
Conclusions—
Postoperative myocardial injury is an independent predictor of 30-day mortality after noncardiac surgery. Implementation of postoperative troponin monitoring as standard of care is feasible and may be helpful in improving the prognosis of patients undergoing noncardiac surgery.
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Affiliation(s)
- Judith A.R. van Waes
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik M. Nathoe
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jurgen C. de Graaff
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hans Kemperman
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert Jan de Borst
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M. Peelen
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilton A. van Klei
- From the Departments of Anesthesiology (J.A.R.v.W., J.C.d.G., W.A.v.K.), Cardiology (H.M.N.), Clinical Chemistry and Hematology (H.K.), Surgery (G.J.d.B.), and Epidemiology (L.M.P.), University Medical Center Utrecht, Utrecht, The Netherlands
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van der Woude OCP, Cuper NJ, Getrouw C, Kalkman CJ, de Graaff JC. The Effectiveness of a Near-Infrared Vascular Imaging Device to Support Intravenous Cannulation in Children with Dark Skin Color. Anesth Analg 2013; 116:1266-71. [DOI: 10.1213/ane.0b013e31828e5bde] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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