1
|
Jackson SS, Lee JJ, Jackson WM, Price JC, Beers SR, Berkenbosch JW, Biagas KV, Dworkin RH, Houck CS, Li G, Smith HAB, Ward DS, Zimmerman KO, Curley MAQ, Horvat CM, Huang DT, Pinto NP, Salorio CF, Slater R, Slomine BS, West LL, Wypij D, Yeates KO, Sun LS. Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop. Pediatr Crit Care Med 2024; 25:e193-e204. [PMID: 38059739 DOI: 10.1097/pcc.0000000000003426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.
Collapse
Affiliation(s)
- Shawn S Jackson
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer J Lee
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - William M Jackson
- Department of Anesthesiology, Montefiore Medical Center, New York, NY
| | - Jerri C Price
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Sue R Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - John W Berkenbosch
- Department of Pediatrics, University of Louisville, Norton Children's Hospital, Louisville, KY
| | - Katherine V Biagas
- Department of Pediatrics, The Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Robert H Dworkin
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | - Constance S Houck
- Departments of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Heidi A B Smith
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Denham S Ward
- Departments of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Martha A Q Curley
- School of Nursing, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher M Horvat
- Departments of Critical Care Medicine, Pediatrics and Biomedical Informatics, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - David T Huang
- Departments of Critical Care Medicine, Emergency Medicine, Clinical and Translational Science, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Neethi P Pinto
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cynthia F Salorio
- Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebeccah Slater
- Department of Paediatric Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Beth S Slomine
- Center for Brain Injury Recovery, Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leanne L West
- International Children's Advisory Network, Atlanta, GA
| | - David Wypij
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Keith O Yeates
- Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Lena S Sun
- Departments of Pediatrics and Anesthesiology, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
2
|
Finkel GG, Sun LS, Jackson WM. Children with Congenital Heart Disease Show Increased Behavioral Problems Compared to Healthy Peers: A Systematic Review and Meta-Analysis. Pediatr Cardiol 2023; 44:116-123. [PMID: 35661236 DOI: 10.1007/s00246-022-02940-x] [Citation(s) in RCA: 1] [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: 01/18/2022] [Accepted: 05/16/2022] [Indexed: 02/08/2023]
Abstract
Millions of children and adults are living with congenital heart disease (CHD). Their risk for behavioral problems has not been the subject of a meta-analysis. We performed a systematic review and meta-analysis of measures of behavioral problems in people born with CHD compared to peers without CHD. We searched Pubmed, CINAHL, Embase, PsycInfo, and the Cochrane Library from January 1, 1986 to November 15, 2021. We included studies that reported a measure of behavioral problems in patients with CHD in children and adults older than 3 years of age. We screened 26,343 search results, and 24 studies met inclusion criteria. The quality of evidence was generally low. Subjects with CHD had a small increase in internalizing problems [standardized mean difference (SMD): 0.198, p = 0.02] and total behavior problems (SMD: 0.287, p = 0.013), but no difference in externalizing behavioral problems. There was significant heterogeneity in all three domains of behavior problems analyzed, and it could not be explained by variables such as age, severity, assessor, or assessment tool. There are small increases in parent- and self-reported overall behavioral problems and internalizing problems in patients with CHD compared to healthy controls. Wide confidence intervals in the meta-analyses leave open the possibility that certain factors may increase the risk of behavioral problems in this group, and future studies with important attention paid to potential confounders may help identify risk factors.
Collapse
Affiliation(s)
- Grace G Finkel
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 W. 168th St., PH5-505, New York, NY, 10032, USA
| | - Lena S Sun
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 W. 168th St., PH5-505, New York, NY, 10032, USA
| | - William M Jackson
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 W. 168th St., PH5-505, New York, NY, 10032, USA.
| |
Collapse
|
3
|
Eisler L, Jackson WM, Sun LS, Sands SA. Impact of Anesthetic Exposures on the Neurocognitive Profiles of Pediatric Brain Tumor Survivors: A New Direction for Research and Multidisciplinary Collaboration. J Neurosurg Anesthesiol 2023; 35:133-135. [PMID: 36745177 PMCID: PMC9902741 DOI: 10.1097/ana.0000000000000882] [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] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Primary brain tumors are the most commonly diagnosed solid tumors in children, and pediatric brain tumor survivors experience lasting, pervasive deficits of neurocognitive functioning. Repeated exposure to anesthetic drugs is a necessary component not only of surgical resection but also of multimodal cancer care for the youngest patients with brain tumors. The potential for anesthetic neurotoxicity to worsen neurocognitive outcomes in this vulnerable group, therefore, warrants our attention and further study through multi-disciplinary collaboration. This review discusses neurocognitive functioning in pediatric brain tumor survivors, highlighting the findings of a recent study of children with tumors of the posterior fossa which identified treatment-related risk factors for neurocognitive difficulties, with those undergoing multimodal therapies (eg, chemotherapy and irradiation) experiencing the greatest deficits compared with healthy controls. The role of anesthetic neurotoxicity in long-term outcomes among pediatric brain tumor survivors is also reviewed.
Collapse
Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - William M. Jackson
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephen A. Sands
- Psychology, Memorial Sloan Kettering Cancer Center, New York, NY
| |
Collapse
|
4
|
Jackson WM, Price JC, Eisler L, Sun LS, Lee JJ. COVID-19 in Pediatric Patients: A Systematic Review. J Neurosurg Anesthesiol 2022; 34:141-147. [PMID: 34870638 DOI: 10.1097/ana.0000000000000803] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 08/21/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The coronavirus disease (COVID)-19 pandemic has been an enormous global health burden, resulting in hundreds of millions of documented infections and more than 3 million deaths. Increasing reports characterizing the effects of COVID-19 in pediatric populations have been published during the course of the pandemic. We performed a systematic review to assess the scope of diagnosis, treatment, and management of COVID-19 in pediatric patients. MATERIALS AND METHODS We searched the Cochrane Database of Systematic Reviews, PubMed, CINAHL, and Embase for studies published between January 1, 2020, and May 1, 2021. Each result was screened by 2 authors independently, and discordant findings were adjudicated by a third party. Data extracted included demographic data, symptom data, and clinical data including mortality, severe illness, laboratory data, radiologic data, and treatment. Bias assessment was performed using the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies. RESULTS We found a total of 16,266 search results, and we accepted 63 manuscripts into the review. The quality of evidence was low. It was difficult to estimate the risk of mortality in pediatric patients with COVID-19 given the quality of the evidence, but overall it is likely below 1%. The most common symptoms in symptomatic pediatric COVID-19 patients were fever (58%) and cough (50%). There was a high proportion of asymptomatic infection (65%). DISCUSSION Pediatric COVID-19 infection is mild and frequently asymptomatic. There is a low risk of severe illness or death in children who contract COVID-19. High-quality studies should be conducted to develop best practices for prevention, diagnosis, and management of symptomatic illness.
Collapse
Affiliation(s)
| | | | | | - Lena S Sun
- Departments of Anesthesiology
- Pediatrics, Columbia University, New York, NY
| | | |
Collapse
|
5
|
Price JC, Lee JJ, Ing C, Li G, Narula J, Clark MK, Stylianos S, Whittington RA, Levy RJ, Sun LS. Prevalence of SARS-CoV-2 Positivity in Pediatric Surgical Patients Amid the First Wave of the COVID-19 Pandemic in New York City. J Neurosurg Anesthesiol 2022; 34:132-135. [PMID: 34870636 DOI: 10.1097/ana.0000000000000805] [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: 11/26/2022]
Abstract
INTRODUCTION New York State implemented an 11-week elective surgery ban in response to the coronavirus disease-2019 (COVID-19) pandemic, during which pediatric patients from the 10 New York Presbyterian network hospitals requiring urgent or emergent surgical procedures were cared for at Morgan Stanley Children's Hospital (MSCH). MATERIALS AND METHODS Data was abstracted from the electronic medical record of all patients aged 0 to 20 years who had surgery at MSCH from March 23, 2020 to June 7, 2020. Comparative analysis of demographic and clinical data elements between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive and negative cohorts was conducted using the Fisher exact tests. RESULTS A total of 505 surgical procedures were performed in 451 patients, with 32 procedures (6.3%) performed in 21 SARS-CoV-2-positive children. The prevalence of SARS-CoV-2 positivity in Medicaid beneficiaries was more than twice the prevalence in commercially insured (6.8% vs. 2.6%, P=0.04) children. SARS-CoV-2-positive patients were more likely to undergo multiple surgical procedures (23.8% vs. 7.2%, P=0.02), and to have higher American Society of Anesthesiologists (ASA) class designations (69.8% III to V vs. 47.4% I to II, P=0.03). There was no significant difference in the prevalence of SARS-CoV-2 positivity across sex, age, race, or ethnicity groups, or in emergent case status or surgical procedure type. Thirty-day mortality rate was <0.1% overall, with no deaths in the SARS-CoV-2-positive group. CONCLUSIONS During the first wave of the COVID-19 pandemic in New York City, we found a higher prevalence of SARS-CoV-2 positivity in urgent/emergent pediatric surgical patients compared with other institutions in the United States. SARS-CoV-2-positive patients were more likely to be Medicaid beneficiaries, were clinically more complex, and had more surgical procedures.
Collapse
Affiliation(s)
| | | | | | - Guohua Li
- Departments of Anesthesiology
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | | | | | | | | | | | | |
Collapse
|
6
|
Eisler L, Chihuri S, Lenke LG, Sun LS, Faraoni D, Li G. Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion. Transfusion 2022; 62:100-115. [PMID: 34761400 PMCID: PMC8758528 DOI: 10.1111/trf.16722] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Children undergoing spinal fusion often receive blood products. The goal of this study was to develop a preoperative score to help physicians identify those who are at risk of allogeneic red blood cell (RBC) transfusion. STUDY DESIGN AND METHODS This retrospective study of children undergoing spinal fusion in the ACS-NSQIP Pediatric database (2016-2019) aimed at identifying risk factors associated with allogeneic RBC transfusion. Univariable logistic regression and multivariable logistic regression were performed using preoperative patient characteristics and aided in the creation of a simplified scoring system. RESULTS Out of 13,929 total patients, 2990 (21.5%) were transfused. We created a risk score based on 10 independent predictors of transfusion: age, sex, race, weight < 3rd percentile, American Society of Anesthesiologists physical status classification, cardiac risk factors, hematologic disease, preoperative anemia, deformity type, and number of spinal levels to be fused. Patients in both the training and testing cohorts were assigned a score ranging from 0 (lowest risk) to 21 (highest risk). The developed transfusion risk score showed 77% accuracy in distinguishing patients who did not receive a transfusion during or soon after surgery (AUROC 0.7736 [95% CI, 0.7619-0.7852]) in the training cohort and 77% accuracy (AUROC 0.7732 [95% CI, 0.7554-0.7910]) in the testing cohort. DISCUSSION Our score, based on routinely available preoperative data, accurately estimates the risk of allogeneic RBC transfusion in pediatric patients undergoing spinal fusion. Future studies will inform whether patient blood management interventions targeted to high-risk patients can help reduce the need for transfusion and improve outcomes.
Collapse
Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stanford Chihuri
- Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lawrence G. Lenke
- Orthopedic Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - David Faraoni
- Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Guohua Li
- Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons, New York, NY
| |
Collapse
|
7
|
Lee JJ, Price JC, Gewandter J, Kleykamp BA, Biagas KV, Naim MY, Ward D, Dworkin RH, Sun LS. Design and reporting characteristics of clinical trials investigating sedation practices in the paediatric intensive care unit: a scoping review by SCEPTER (Sedation Consortium on Endpoints and Procedures for Treatment, Education and Research). BMJ Open 2021; 11:e053519. [PMID: 34649849 PMCID: PMC8522672 DOI: 10.1136/bmjopen-2021-053519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To conduct a scoping review of sedation clinical trials in the paediatric intensive care setting and summarise key methodological elements. DESIGN Scoping review. DATA SOURCES PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and grey references including ClinicalTrials.gov from database inception to 3 August 2021. STUDY SELECTION All human trials in the English language related to sedation in paediatric critically ill patients were included. After title and abstract screening, full-text review was performed. 29 trials were eligible for final analysis. DATA EXTRACTION A coding manual was developed and pretested. Trial characteristics were double extracted. RESULTS The majority of trials were single centre (22/29, 75.9%), parallel group superiority (17/29, 58.6%), double-blinded (18/29, 62.1%) and conducted in an academic setting (29/29, 100.0%). Trial enrolment (≥90% planned sample size) was achieved in 65.5% of trials (19/29), and retention (≥90% enrolled subjects) in 72.4% of trials (21/29). Protocol violations were reported in nine trials (31.0%). The most commonly studied cohorts were mechanically ventilated patients (28/29, 96.6%) and postsurgical patients (11/29, 37.9%) with inclusion criteria for age ranging from 0±0.5 to 15.0±7.3 years (median±IQR). The median age of enrolled patients was 1.7 years (IQR=4.4 years). Patients excluded from trials were those with neurological impairment (21/29, 72.4%), complex disease (20/29, 69.0%) or receipt of neuromuscular blockade (10/29, 34.5%). Trials evaluated drugs/protocols for sedation management (20/29, 69.0%), weaning (3/29, 10.3%), daily interruption (3/29, 10.3%) or protocolisation (3/29, 10.3%). Primary outcome measures were heterogeneous, as were assessment instruments and follow-up durations. CONCLUSIONS There is substantial heterogeneity in methodological approach in clinical trials evaluating sedation in critically ill paediatric patients. These results provide a basis for the design of future clinical trials to improve the quality of trial data and aid in the development of sedation-related clinical guidelines.
Collapse
Affiliation(s)
| | - Jerri C Price
- Anesthesiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Jennifer Gewandter
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Bethea A Kleykamp
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine V Biagas
- Pediatrics, Stony Brook University Renaissance School of Medicine, Stony Brook, New York, USA
| | - Maryam Y Naim
- Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Denham Ward
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert H Dworkin
- Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Lena S Sun
- Anesthesiology and Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
8
|
Ward DS, Absalom AR, Aitken LM, Balas MC, Brown DL, Burry L, Colantuoni E, Coursin D, Devlin JW, Dexter F, Dworkin RH, Egan TD, Elliott D, Egerod I, Flood P, Fraser GL, Girard TD, Gozal D, Hopkins RO, Kress J, Maze M, Needham DM, Pandharipande P, Riker R, Sessler DI, Shafer SL, Shehabi Y, Spies C, Sun LS, Tung A, Urman RD. Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III. Crit Care Med 2021; 49:1684-1693. [PMID: 33938718 PMCID: PMC8439670 DOI: 10.1097/ccm.0000000000005049] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.
Collapse
Affiliation(s)
- Denham S Ward
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Anthony R Absalom
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Leanne M Aitken
- School of Health Sciences, University of London, London, United Kingdom
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia
| | - Michele C Balas
- Center of Healthy Aging, Self-Management, and Complex Care, The Ohio State University, College of Nursing, Columbus, OH
| | | | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Elizabeth Colantuoni
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Douglas Coursin
- Departments of Anesthesiology and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Talmage D Egan
- Department of Anesthesiology, University of Utah, Salt Lake City, UT
| | - Doug Elliott
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pamela Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Gilles L Fraser
- Department of Medicine, Tufts University School of Medicine, Maine Medical Center, Portland, ME
| | - Timothy D Girard
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - David Gozal
- Division of Anesthesiology and CCM, Hadassah Medical Center, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ramona O Hopkins
- Psychology Department and Neuroscience Center, Brigham Young University, Provo, UT
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, UT
| | - John Kress
- Department of Medicine, Section of Pulmonary and Critical Care, The University of Chicago, Chicago, IL
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Pratik Pandharipande
- Department of Anesthesiology and the Critical Illness, Vanderbilt University Medical Center, Nashville, TN
| | - Richard Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Steven L Shafer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences - Department of Intensive Care Medicine - Critical Care Research, Melbourne, VIC, Australia
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Charité Mitte & Campus Virchow-Klinikum, Berlin, Germany
| | - Lena S Sun
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Avery Tung
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
9
|
Haché M, Sun LS, Gadi G, Busse J, Lee AC, Lorinc A, Rampersad S. Outcomes from wake up safe, the pediatric anesthesia quality improvement initiative. Paediatr Anaesth 2020; 30:1348-1354. [PMID: 33078514 DOI: 10.1111/pan.14044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Received: 11/15/2019] [Revised: 09/14/2020] [Accepted: 10/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related. AIMS Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable. METHODS This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed. RESULTS Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable. CONCLUSIONS The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.
Collapse
Affiliation(s)
- Manon Haché
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Lena S Sun
- Department of Anesthesiology and Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Ghadah Gadi
- Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Jennifer Busse
- Department of Anesthesiology, Lucille Packard Children's Hospital, Stanford, CA, USA
| | - Angela C Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, Washington, DC, USA
| | - Amanda Lorinc
- Department of Anesthesiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Sally Rampersad
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
10
|
Stylianos S, Mesa-Jonassen AE, Albanese CT, Bacha EA, Stark N, Guida SJ, Goffman D, Saiman L, Kernie SG, Lalwani AK, Cassai M, Sun LS. The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City. Ann Surg 2020; 272:e199-e203. [PMID: 32452952 PMCID: PMC7467048 DOI: 10.1097/sla.0000000000004104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Steven Stylianos
- Departments of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Amy E Mesa-Jonassen
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Craig T Albanese
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Emile A Bacha
- Departments of Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Natalya Stark
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Sarah Jane Guida
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Dena Goffman
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Obstetrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Saiman
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Steven G Kernie
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Anil K Lalwani
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Otolaryngology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Mary Cassai
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
| | - Lena S Sun
- NewYork Presbyterian-Morgan Stanley Children's Hospital, New York, New York
- Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| |
Collapse
|
11
|
Eisler LD, Lenke LG, Sun LS, Li G, Kim M. Do Antifibrinolytic Agents Reduce the Risk of Blood Transfusion in Children Undergoing Spinal Fusion?: A Propensity Score-matched Comparison Using a National Database. Spine (Phila Pa 1976) 2020; 45:1055-1061. [PMID: 32675611 PMCID: PMC8120993 DOI: 10.1097/brs.0000000000003455] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate the effectiveness and safety of antifibrinolytic (AF) agents in reducing perioperative blood transfusion in pediatric patients undergoing spinal fusion. SUMMARY OF BACKGROUND DATA The potential for AF to decrease bleeding and reduce exposure to allogenic transfusions has led to widespread off-label use in a number of major pediatric surgical procedures. Recent reviews call for improving the body of evidence for their effectiveness and safety in pediatric spinal fusion. METHODS Children undergoing spinal fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) 2016 and 2017 databases. Univariate analyses of patient and perioperative characteristics informed the creation of a propensity score model predicting treatment with AF, followed by 1:1 matching to allow comparison of allogenic red blood cell transfusion rates and secondary outcomes between treated and untreated patients. RESULTS Of 6626 total patients, 5434 (81%) received AF and 1533 (23%) received a blood transfusion. Analysis of data for 1192 propensity score-matched pairs revealed that treatment with AF was associated with a statistically nonsignificant 16% reduction in perioperative transfusion (OR 0.84, 95% confidence interval 0.68-1.05, P = 0.119) and a statistically significant 43% reduction in postoperative transfusion (OR 0.57, 95% confidence interval 0.39-0.81, P = 0.002). No differences in the incidences of postoperative seizure or thrombosis were observed, with overall rates of 7.5 and 22.5 events per 10,000 patients, respectively. CONCLUSION AF agents appear to reduce postoperative allogenic transfusion in children undergoing spinal fusion surgery. Adverse drug effects such as thromboembolic complications and seizure were extremely rare and warrant continued monitoring, though this is the largest study to date providing evidence for the safety profile of these drugs. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Lisa D. Eisler
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | | | - Lena S. Sun
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Guohua Li
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Minjae Kim
- Anesthesiology, Columbia University Medical Center, New York, NY, USA
- Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
12
|
Taylor WM, Lu Y, Wang S, Sun LS, Li G, Ing C. Long-term Healthcare Utilization by Medicaid Enrolled Children with Neonatal Abstinence Syndrome. J Pediatr 2020; 221:55-63.e6. [PMID: 32446493 PMCID: PMC9112831 DOI: 10.1016/j.jpeds.2020.02.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 10/20/2019] [Revised: 02/07/2020] [Accepted: 02/27/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate healthcare utilization in Medicaid enrolled children with neonatal abstinence syndrome (NAS) in the first 2 years of life. STUDY DESIGN A retrospective, longitudinal cohort study evaluating Medicaid enrolled children born in New York (1999-2011) and Texas (1999-2010) was performed. Healthcare utilization, including inpatient days, emergency department and outpatient visits, and filled prescriptions in children after birth hospitalization was assessed. A tapered propensity-matching methodology was used, matching each child with NAS with 5 children without NAS, first on demographics, then on both demographics and clinical covariates (clinical diagnoses and congenital anomalies at birth). Poisson and negative binomial regression were used to calculate healthcare utilization ratios (HUR). RESULTS In the first 2 years of life, children with NAS (n = 3799) had increased healthcare utilization with more inpatient days and emergency department visits than demographically similar children without NAS. This increased utilization however did not persist after matching on clinical covariates and performing multiple comparisons adjustment (inpatient days [HUR, 1.01; 95% CI, 0.88-1.16; P = .89], total emergency department visits [HUR, 1.06; 95% CI, 1.01-1.11; P = .02]). Children with NAS conversely had 9% fewer outpatient office visits (HUR, 0.91; 95% CI, 0.87-0.95; P < .0001). CONCLUSIONS A diagnosis of NAS does not appear to be an independent predictor of increased healthcare utilization in the first 2 years of life. These results differ from some other published studies, but may suggest that the increased healthcare utilization observed in children with NAS is due to higher incidences of perinatal complications and congenital anomalies in children with prenatal drug exposures.
Collapse
Affiliation(s)
- Walter M Taylor
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY; University of Colorado School of Medicine, Aurora, CO
| | - Yewei Lu
- University of Colorado School of Medicine, Aurora, CO
| | - Shuang Wang
- Department of Biostatistics, Mailman School of Public Health, New York, NY
| | - Lena S Sun
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Caleb Ing
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY.
| |
Collapse
|
13
|
Chinn GA, Pearn ML, Vutskits L, Mintz CD, Loepke AW, Lee JJ, Chen J, Bosnjak ZJ, Brambrink AM, Jevtovic-Todorovic V, Sun LS, Sall JW. Standards for preclinical research and publications in developmental anaesthetic neurotoxicity: expert opinion statement from the SmartTots preclinical working group. Br J Anaesth 2020; 124:585-593. [PMID: 32145876 PMCID: PMC7424895 DOI: 10.1016/j.bja.2020.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 01/06/2020] [Accepted: 01/24/2020] [Indexed: 12/16/2022] Open
Abstract
In March 2019, SmartTots, a public-private partnership between the US Food and Drug Administration and the International Anesthesia Research Society, hosted a meeting attended by research experts, anaesthesia journal editors, and government agency representatives to discuss the continued need for rigorous preclinical research and the importance of establishing reporting standards for the field of anaesthetic perinatal neurotoxicity. This group affirmed the importance of preclinical research in the field, and welcomed novel and mechanistic approaches to answer some of the field's largest questions. The attendees concluded that summarising the benefits and disadvantages of specific model systems, and providing guidance for reporting results, would be helpful for designing new experiments and interpreting results across laboratories. This expert opinion report is a summary of these discussions, and includes a focused review of current animal models and reporting standards for the field of perinatal anaesthetic neurotoxicity. This will serve as a practical guide and road map for novel and rigorous experimental work.
Collapse
Affiliation(s)
- Gregory A Chinn
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Matthew L Pearn
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | - Laszlo Vutskits
- Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Cyrus D Mintz
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas W Loepke
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer J Lee
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Jerri Chen
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Zeljko J Bosnjak
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Lena S Sun
- Department of Anesthesiology, Columbia University, New York, NY, USA
| | - Jeffrey W Sall
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.
| |
Collapse
|
14
|
Abstract
BACKGROUND Unplanned postoperative intubation is an important quality indicator, and is associated with significantly increased mortality in children. Infant patients are more likely than older pediatric patients to experience unplanned postoperative intubation, yet the literature provides few characterizations of this outcome in our youngest patients. The objective of this study was to identify risk factors for unplanned postoperative intubation and to develop a scoring system to predict this complication in infants undergoing major surgical procedures. METHODS In this retrospective cohort study, The National Surgical Quality Improvement Program-Pediatric database was surveyed for all infants who underwent noncardiac surgery between January 1, 2012 and December 31, 2015 (derivation cohort, n = 56,962) and between January 1 and December 31, 2016 (validation cohort, n = 20,559). Demographic and perioperative clinical characteristics were examined in association with our primary outcome of unplanned postoperative intubation within 30 days of surgery. Risk factors were analyzed in the derivation cohort (2012-2015 data) using multivariable logistic regression with stepwise selection. Parameters from the final model were used to create a scoring system for predicting unplanned postoperative intubation. Data from the validation cohort were utilized to assess the performance of the scoring system using the area under the receiver operating characteristic curve. RESULTS In the derivation cohort, 2.2% of the infants experienced unplanned postoperative intubation within 30 days of surgery. Of the 14 risk factors identified in multivariable analysis, 10 (age, prematurity, American Society of Anesthesiologists physical status, inpatient status, operative time >120 minutes, cardiac disease, malignancy, hematologic disorder, oxygen supplementation, and nutritional support) were included in the final multivariable logistic regression model to create the risk score. The area under the receiver operating characteristic curve of the final model was 0.86 (95% CI, 0.85-0.87) for the derivation cohort and 0.83 (95% CI, 0.82-0.85) for the validation cohort. CONCLUSIONS About 1 in 50 infants undergoing major surgical procedures experiences unplanned postoperative intubation. Our scoring system based on routinely collected perioperative assessment data can predict risk in infants with good accuracy. Further investigation should assess the clinical utility of the scoring system for risk stratification and improvement in perioperative care quality and patient outcomes.
Collapse
Affiliation(s)
- Lisa D. Eisler
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
| | - May Hua
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Guohua Li
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lena S. Sun
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Minjae Kim
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| |
Collapse
|
15
|
Abstract
OBJECTIVE To investigate the BRAF gene mutations in ameloblastic fibroma (AF), and to further analyze the relationship between the BRAF mutation and clinical characteristics so as to provide new reference to the study of AF's molecular pathology. METHODS Sixteen cases diagnosed as AF at the Department of Oral Pathology, Peking University School of Stomatology between January 1990 and December 2017 were collected. Genomic DNA was extracted from formalin-fixed, paraffin embedded tissues using the QIAamp DNA Mini Kit (Qiagen, Germany) according to the manufacturer's instructions. Polymerase chain reaction (PCR) and direct sequencings were used to detect the BRAF gene mutations. The clinicopathological data, such as the age, location of the lesion, symptoms and treatments were retrospectively analyzed. RESULTS The sixteen cases of AF involved nine women and seven men aged 2-67 years. Three lesions occurred in the maxilla and thirteen in the mandible. The most common presenting symptom of AF was a painless slowly enlarging mass with swelling. Ten patients received conservative treatment and the other six patients received radical surgery. Three cases relapsed during the study period. BRAF gene mutation was found in sixteen of all the sixteen samples analyzed (100%). The BRAF mutation was a point mutation with a thymine-adenine transversion at nucleotide 1 799 of 15 exons, resulting in a change at residue 600 that substituted glutamine for valine. This mutation was the strongest activator of the downstream RAS/RAF/MEK/ERK-MAPK signaling pathway. This helped to bring about a gain-of-function mutation due to a V600E substitution. Many studies identified that BRAF regulated survival, apoptosis, and proliferation of cells by inducing MAPK pathways activation. For the existing cases, none of the age, sex, location, recurrence and treatments had a statistically significant correlation with BRAF mutation. CONCLUSION Our findings demonstrated high prevalence of BRAF V600E mutation in AF. The pathogenic role remains to be clarified..
Collapse
Affiliation(s)
- Z You
- Department of Central Laboratory, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China.,Department of Oral and Maxillofacial Surgery, School of Stomatology, Shandong University, Jinan 250012, China
| | - L L Xu
- Second Clinical Division, Peking University School and Hospital of Stomatology, Beijing 100081, China
| | - X F Li
- Department of Central Laboratory, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
| | - J Y Zhang
- Department of Oral Pathology, Peking University School and Hospital of Stomatology, Beijing 100081, China
| | - J DU
- Department of Oral and Maxillofacial Surgery, School of Stomatology, Shandong University, Jinan 250012, China
| | - L S Sun
- Department of Central Laboratory, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
| |
Collapse
|
16
|
Ing C, Hegarty MK, Perkins JW, Whitehouse AJO, DiMaggio CJ, Sun M, Andrews H, Li G, Sun LS, von Ungern-Sternberg BS. Duration of general anaesthetic exposure in early childhood and long-term language and cognitive ability. Br J Anaesth 2019; 119:532-540. [PMID: 28969309 DOI: 10.1093/bja/aew413] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 12/31/2022] Open
Abstract
Background The anaesthetic dose causing neurotoxicity in animals has been evaluated, but the relationship between duration of volatile anaesthetic (VA) exposure and neurodevelopment in children remains unclear. Methods Data were obtained from the Western Australian Pregnancy Cohort (Raine) Study, with language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E] and Total [CELF-T]) and cognition (Coloured Progressive Matrices [CPM]) assessed at age 10 yr. Medical records were reviewed, and children divided into quartiles based on total VA exposure duration before age three yr. The association between test score and exposure duration quartile was evaluated using linear regression, adjusting for patient characteristics and comorbidity. Results Of 1622 children with available test scores, 148 had documented VA exposure and were split into the following quartiles: ≤25, >25 to ≤35, >35 to ≤60 and >60 min. Compared with unexposed children, CELF-T scores for children in the first and second quartiles did not differ, but those in the third and fourth quartiles had significantly lower scores ([3 rd quartile - Unexposed] -5.3; 95% confidence interval [CI], (-10.2 - -0.4), [4 th quartile - Unexposed] -6.2; 95% CI, (-11.6 - -0.9). CELF-E showed similar findings, but significant differences were not found in CELF-R or CPM for any quartile. Conclusions Children with VA exposures ≤35 min did not differ from unexposed children, but those with exposures >35 min had lower total and expressive language scores. It remains unclear if this is a dose-response relationship, or if children requiring longer exposures for longer surgeries have other clinical reasons for lower scores.
Collapse
Affiliation(s)
- C Ing
- Departments of Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY, USA
| | - M K Hegarty
- Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, Australia
| | - J W Perkins
- Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, Australia
| | - A J O Whitehouse
- Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - C J DiMaggio
- Departments of Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY, USA
| | - M Sun
- Departments of Anesthesiology and Biostatistics, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY, USA
| | - H Andrews
- Department of Biostatistics, Mailman School of Public Health, New York, NY, USA
| | - G Li
- Departments of Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY, USA
| | - L S Sun
- Departments of Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - B S von Ungern-Sternberg
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia and Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, Australia
| |
Collapse
|
17
|
Lee JJ, Sun LS, Levy RJ. Report on the Sixth Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium, "Anesthesia and Neurodevelopment in Children". J Neurosurg Anesthesiol 2019; 31:103-107. [PMID: 30767931 PMCID: PMC6383795 DOI: 10.1097/ana.0000000000000538] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
On April 14 and 15, 2018, the Sixth Biennial Pediatric Anesthesia Neurodevelopmental Assessment (PANDA) Symposium convened at Columbia University Medical Center and New York Presbyterian/Morgan Stanley Children's Hospital of New York. Since its inception over 10 years ago, the PANDA Symposium has served as a key forum for clinicians, researchers, and other major stakeholders to gather and review the current state of preclinical and clinical research related to anesthetic neurotoxicity in the developing brain. It has also served as an important venue for participants to gain insight and leverage support from various public and private regulatory bodies. Goals of this year's meeting included assessments of how current knowledge has evolved, endeavors to develop common outcome measures, and formulations of future directions for research and policy. The Symposium program highlighted a diverse body of cutting-edge work, from results of preclinical and clinical studies to updates in clinical practice and policymaking.
Collapse
Affiliation(s)
- Jennifer J Lee
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | | | | |
Collapse
|
18
|
Affiliation(s)
- Susan Lei
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Riva Ko
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA
| | - Lena S Sun
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Columbia University Medical Center, New York, NY, USA; Department of Pediatrics, Columbia University Medical Center, New York, NY 01132, USA.
| |
Collapse
|
19
|
Disma N, O'Leary JD, Loepke AW, Brambrink AM, Becke K, Clausen NG, De Graaff JC, Liu F, Hansen TG, McCann ME, Salorio CF, Soriano S, Sun LS, Szmuk P, Warner DO, Vutskits L, Davidson AJ. Anesthesia and the developing brain: A way forward for laboratory and clinical research. Paediatr Anaesth 2018; 28:758-763. [PMID: 30117228 DOI: 10.1111/pan.13455] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [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] [Received: 01/10/2018] [Revised: 04/20/2018] [Accepted: 07/04/2018] [Indexed: 12/15/2022]
Abstract
All commonly used general anesthetics have been shown to cause neurotoxicity in animal models, including nonhuman primates. Opinion, however, remains divided over how cumulative evidence from preclinical and human studies in this field should be interpreted and its translation to current practices in pediatric anesthesia and surgery. A group of international experts in laboratory and clinical sciences recently convened in Genoa, Italy, to evaluate the current state of both laboratory and clinical research and discuss future directions for basic, translational, and clinical studies in this field. This paper describes those discussions and conclusions. A central goal identified was the importance of continuing to pursue laboratory research efforts to better understand the biological pathways underlying anesthesia neurotoxicity. The distinction between basic and translational experimental designs in this field was highlighted, and it was acknowledged that it will be important for future animal research to try to causally link structural changes with long-term cognitive abnormalities. While inherent limitations will continue to affect the ability of even large observational cohorts to determine if anesthesia impacts neurodevelopment or behavioral outcomes, the importance of conducting further large well-designed cohort studies was also emphasized. Adequately powered cohorts could clarify which populations are at increased risk, provide information on environmental and healthcare-related risk modifiers, and guide future interventional trials. If anesthetics cause structural or functional adverse neurological effects in young children, alternative or mitigating strategies need to be considered. While protective or mitigating strategies have been repeatedly studied in animals, there are currently no human data to support alternative anesthetic strategies in clinical practice. Lastly, it was noted that there is still considerable debate over the clinical relevance of anesthesia neurotoxicity, and the need to evaluate the impact of other aspects of perioperative care on neurodevelopment must also be considered.
Collapse
Affiliation(s)
- Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy.,Department of Anesthesia, Great Ormond Street Hospital, London, UK
| | - James D O'Leary
- Department of Anesthesia, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andreas W Loepke
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ansgar M Brambrink
- Department of Anesthesiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - Karin Becke
- Department of Anesthesia and Intensive Care, Cnopf Children's Hospital, Nürnberg, Germany
| | - Nicola G Clausen
- Department of Anesthesia, Children's Hospital Zurich, Zurich, Switzerland.,Department of Anesthesia & Intensive Care, University Hospital Odense, Odense, Denmark
| | - Jurgen C De Graaff
- Department of Anesthesia, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Fang Liu
- Division of Neurotoxicology, National Center for Toxicological Research/Food and Drug Administration, Jefferson, Arkansas
| | - Tom G Hansen
- Department of Anesthesia & Intensive Care, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mary E McCann
- Department of Anesthesia, Perioperative Pain and Critical Care Medicine, Boston, Massachusetts
| | - Cynthia F Salorio
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland.,Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sulpicio Soriano
- Department of Anesthesia, Perioperative Pain and Critical Care Medicine, Boston, Massachusetts
| | - Lena S Sun
- Division of Pediatric Anesthesia, Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Health Medical Centre, Dallas, Texas.,Outcome Research Consortium, Cleveland, Ohio
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
| | - Andrew J Davidson
- Department of Anesthesia and Pain Management, Royal Children's Hospital, Melbourne, Victoria, Australia.,The Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
20
|
Yan XC, Sun LS, Dong ZW, You Z, Dong Q. [Research advances in the v-raf murine sarcoma viral oncogene homolog gene mutation in ameloblastoma]. Zhonghua Kou Qiang Yi Xue Za Zhi 2018; 53:500-502. [PMID: 29996373 DOI: 10.3760/cma.j.issn.1002-0098.2018.07.016] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
V-raf murine sarcoma viral oncogene homolog B1 (BRAF) is a pro-oncogene, which is one member of the RAF family. Mutated BRAF is found in approximately 8% of human tumors. BRAF gene mutations lead to continuous activation of the mitogen-activatd protein kinase (MAPK) pathway, which resulting in abnormal cell proliferation and tumorigenesis. In recent years, recurrent MAPK signaling mutations were identified in ameloblastoma, among which BRAF-V600E is the most prominent type. This provides new strategies for the targeted treatment of ameloblastoma. This paper reviewed the latest advances in BRAF gene mutation associated with ameloblastoma and its potential clinical significance.
Collapse
Affiliation(s)
- X C Yan
- Department of Pediatric Dentistry, School of Stomatology, North China University of Science and Technology, Tangshan 063000, China
| | - L S Sun
- Central Laboratory, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
| | - Z W Dong
- Department of Pediatric Dentistry, School of Stomatology, North China University of Science and Technology, Tangshan 063000, China
| | - Z You
- Central Laboratory, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, China
| | - Q Dong
- Department of Pediatric Dentistry, School of Stomatology, North China University of Science and Technology, Tangshan 063000, China
| |
Collapse
|
21
|
Eisler L, Huang G, Lee KEM, Busse JA, Sun M, Lin AY, Sun LS, Ing C. Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data. Paediatr Anaesth 2018; 28:218-225. [PMID: 29341336 PMCID: PMC6427906 DOI: 10.1111/pan.13319] [Citation(s) in RCA: 10] [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: 12/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Perioperative aspiration is a rare but potentially devastating complication, occurring in 1-10 per 10 000 anesthetics based on studies of quality assurance databases. Quality assurance reporting is known to underestimate the incidence of adverse outcomes, but few large studies use supplementary data sources. This study aims to identify the incidence of and risk factors for perioperative aspiration in children using quality assurance data supplemented by administrative billing records, and to examine the utility of billing data as a supplementary data source. METHODS Aspiration events for children receiving anesthesia at a tertiary care pediatric hospital between 2008 and 2014 were identified using (i) a perioperative quality assurance database and (ii) hospital administrative billing records with International Classification of Diseases, Ninth Revision Clinical Modification coded diagnoses of aspiration. Records were subject to review by pediatric anesthesiologists. Following identification of all aspiration events, the incidence of perioperative aspiration was calculated and risk factors were assessed. RESULTS 47 272 anesthetic cases were evaluated over 7 years. The quality assurance database identified 20 cases of perioperative aspiration occurring in surgical inpatients, same-day admissions, and outpatients. Using hospital administrative data (which excludes outpatients with shorter than a 24-hour stay), 9 cases of perioperative aspiration were identified of which 6 had not been found through quality assurance data. Overall, International Classification of Diseases, Ninth Revision coding demonstrated a positive predictive value of 94.5% for any aspiration event; however, positive predictive value was <4% for perioperative aspiration. A total incidence of 5.5 perioperative aspirations per 10 000 (95% CI: 3.7-8.0 per 10 000) anesthetics was found. CONCLUSION Quality assurance data offer an efficient way to measure the incidence of rare events, but may underestimate perioperative complications. International Classification of Diseases, Ninth Revision codes for aspiration used as a secondary data source were nonspecific for perioperative aspiration, but when combined with record review yielded a 30% increase in identified cases of aspiration over quality assurance data alone. The use of administrative data therefore holds potential for supplementing quality assurance studies of rare complications.
Collapse
Affiliation(s)
- Lisa Eisler
- Anesthesiology, Columbia University, New York, NY, USA
| | - Grace Huang
- Anesthesiology, Columbia University, New York, NY, USA
| | - Ka-Eun M. Lee
- Anesthesiology, Columbia University, New York, NY, USA
| | | | - Ming Sun
- Biostatistics, Mailman School of Public Health, New York, NY, USA
| | - Albert Y. Lin
- Anesthesiology, Columbia University, New York, NY, USA
| | - Lena S. Sun
- Anesthesiology and Pediatrics, Columbia University, New York, NY, USA
| | - Caleb Ing
- Anesthesiology, Columbia University, New York, NY, USA,Epidemiology, Mailman School of Public Health, New York, NY, USA
| |
Collapse
|
22
|
Ing C, Sun M, Olfson M, DiMaggio CJ, Sun LS, Wall MM, Li G. Age at Exposure to Surgery and Anesthesia in Children and Association With Mental Disorder Diagnosis. Anesth Analg 2017; 125:1988-1998. [PMID: 28857799 PMCID: PMC5856466 DOI: 10.1213/ane.0000000000002423] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Animals exposed to anesthetics during specific age periods of brain development experience neurotoxicity, with neurodevelopmental changes subsequently observed during adulthood. The corresponding vulnerable age in children, however, is unknown. METHODS An observational cohort study was performed using a longitudinal dataset constructed by linking individual-level Medicaid claims from Texas and New York from 1999 to 2010. This dataset was evaluated to determine whether the timing of exposure to anesthesia ≤5 years of age for a single common procedure (pyloromyotomy, inguinal hernia, circumcision outside the perinatal period, or tonsillectomy and/or adenoidectomy) is associated with increased subsequent risk of diagnoses for any mental disorder, or specifically developmental delay (DD) such as reading and language disorders, and attention deficit hyperactivity disorder (ADHD). Exposure to anesthesia and surgery was evaluated in 11 separate age at exposure categories: ≤28 days old, >28 days and ≤6 months, >6 months and ≤1 year, and 6-month age intervals between >1 year old and ≤5 years old. For each exposed child, 5 children matched on propensity score calculated using sociodemographic and clinical covariates were selected for comparison. Cox proportional hazards models were used to measure the hazard ratio of a mental disorder diagnosis associated with exposure to surgery and anesthesia. RESULTS A total of 38,493 children with a single exposure and 192,465 propensity score-matched children unexposed before 5 years of age were included in the analysis. Increased risk of mental disorder diagnosis was observed at all ages at exposure with an overall hazard ratio of 1.26 (95% confidence interval [CI], 1.22-1.30), which did not vary significantly with the timing of exposure. Analysis of DD and ADHD showed similar results, with elevated hazard ratios distributed evenly across all ages, and overall hazard ratios of 1.26 (95% CI, 1.20-1.32) for DD and 1.31 (95% CI, 1.25-1.37) for ADHD. CONCLUSIONS Children who undergo minor surgery requiring anesthesia under age 5 have a small but statistically significant increased risk of mental disorder diagnoses and DD and ADHD diagnoses, but the timing of the surgical procedure does not alter the elevated risks. Based on these findings, there is little support for the concept of delaying a minor procedure to reduce long-term neurodevelopmental risks of anesthesia in children. In evaluating the influence of age at exposure, the types of procedures included may need to be considered, as some procedures are associated with specific comorbid conditions and are only performed at certain ages.
Collapse
Affiliation(s)
- Caleb Ing
- From the Departments of Anesthesiology
- Epidemiology
| | - Ming Sun
- From the Departments of Anesthesiology
- Biostatistics, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
| | - Mark Olfson
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York
| | - Charles J DiMaggio
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Lena S Sun
- From the Departments of Anesthesiology
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Melanie M Wall
- Biostatistics, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York
| | - Guohua Li
- From the Departments of Anesthesiology
- Epidemiology
| |
Collapse
|
23
|
Jerome EH, Sun LS. Letter Concerning SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice in the Cardiac Catheterization Laboratory. Anesth Analg 2017; 125:1078. [DOI: 10.1213/ane.0000000000002285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
24
|
Ing C, Wall MM, DiMaggio CJ, Whitehouse AJO, Hegarty MK, Sun M, von Ungern-Sternberg BS, Li G, Sun LS. Latent Class Analysis of Neurodevelopmental Deficit After Exposure to Anesthesia in Early Childhood. J Neurosurg Anesthesiol 2017; 29:264-273. [PMID: 27077892 PMCID: PMC5757537 DOI: 10.1097/ana.0000000000000303] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Although some studies have reported an association between early exposure to anesthesia and surgery and long-term neurodevelopmental deficit, the clinical phenotype of children exposed to anesthesia is still unknown. METHODS Data were obtained from the Western Australian Pregnancy Cohort Study (Raine) with neuropsychological tests at age 10 years measuring language, cognition, motor function, and behavior. Latent class analysis of the tests was used to divide the cohort into mutually exclusive subclasses of neurodevelopmental deficit. Multivariable polytomous logistic regression was used to evaluate the association between exposure to surgery and anesthesia and each latent class, adjusting for demographic and medical covariates. RESULTS In our cohort of 1444 children, latent class analysis identified 4 subclasses: (1) Normal: few deficits (n=1135, 78.6%); (2) Language and Cognitive deficits: primarily language, cognitive, and motor deficits (n=96, 6.6%); (3) Behavioral deficits: primarily behavioral deficits, (n=151, 10.5%); and (4) Severe deficits: deficits in all neuropsychological domains (n=62, 4.3%). Language and cognitive deficit group children were more likely to have exposure before age 3 (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.17-3.81), whereas a difference in exposure was not found between Behavioral or Severe deficit children (aOR, 1.00; 95% CI, 0.58-1.73, and aOR, 0.85; 95% CI, 0.34-2.15, respectively) and Normal children. CONCLUSIONS Our results suggest that in evaluating children exposed to surgery and anesthesia at an early age, the phenotype of interest may be children with deficits primarily in language and cognition, and not children with broad neurodevelopmental delay or primarily behavioral deficits.
Collapse
Affiliation(s)
- Caleb Ing
- Departments of *Anesthesiology ††Anesthesiology and Pediatrics, Columbia University College of Physicians and Surgeons Departments of †Psychiatry and Biostatistics ‡Anesthesiology and Epidemiology ¶Anesthesiology and Biostatistics **Anesthesiology and Epidemiology, Columbia University College of Physicians and Surgeons and Mailman School of Public Health, New York, NY §Telethon Kids Institute #School of Medicine and Pharmacology, The University of Western Australia ∥Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Ing C, Sun LS, Friend AF, Kim M, Berman MF, Paganelli W, Li G, Williams RK. Differences in intraoperative hemodynamics between spinal and general anesthesia in infants undergoing pyloromyotomy. Paediatr Anaesth 2017; 27:733-741. [PMID: 28419639 PMCID: PMC5461197 DOI: 10.1111/pan.13156] [Citation(s) in RCA: 17] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hypotension and bradycardia are known side effects of spinal anesthesia in pregnant women undergoing cesarean section and adults undergoing other surgical procedures. Whether children experience similar hemodynamic changes is unclear. AIMS The purpose of this study is to evaluate hemodynamic effects of spinal anesthesia compared to general anesthesia in a cohort of healthy infants. METHODS The University of Vermont Medical Center almost exclusively used spinal anesthesia for infant pyloromyotomy surgery between 2008 and 2013, while Columbia University Medical Center relied on general anesthesia. The primary outcome assessed was the percentage change in intraoperative heart rate and blood pressure (systolic [SBP] and mean [MAP] blood pressure) from baseline. Analysis was performed using t-tests for continuous variables, followed by linear regression to account for differences in demographic and clinical covariates. RESULTS The study sample consisted of 51 infants with spinal anesthesia at the University of Vermont and 52 infants with general anesthesia at Columbia University. The decrease from baseline for mean intraoperative SBP was -8.2 ± 16.8% for spinal anesthesia and -24.2 ± 17.2% for general anesthesia (difference between means: 16.2% [95% confidence interval (CI), 9.5-22.9]), while the decrease from baseline for mean intraoperative MAP was -16.3 ± 19.9% for spinal anesthesia and -24.6 ± 19.3% for general anesthesia (difference between means: 8.4% [95% CI, 0.8-16]). Spinal anesthesia patients also had smaller drops in minimum intraoperative MAP and SBP. These blood pressure differences persisted even after adjusting for covariates. No differences in heart rate were seen between spinal and general anesthesia. DISCUSSION Our findings show that spinal anesthesia performed in healthy infants undergoing pyloromyotomy results in reduced intraoperative blood pressure changes from baseline, significantly higher blood pressure readings, and no increased bradycardia compared to general anesthesia. Further research is needed to assess whether any clinical impact of these hemodynamic differences between spinal and general anesthesia exists.
Collapse
Affiliation(s)
- Caleb Ing
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, New York, NY, USA
| | - Lena S. Sun
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Alexander F. Friend
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, VT, USA
| | - Minjae Kim
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, New York, NY, USA
| | - Mitchell F. Berman
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - William Paganelli
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, VT, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA,Department of Epidemiology, Mailman School of Public Health, New York, NY, USA
| | - Robert K. Williams
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, VT, USA,Department of Pediatrics, University of Vermont Medical Center, Burlington, VT, USA
| |
Collapse
|
26
|
Sun LS, Li G, Miller TLK, Salorio C, Byrne MW, Bellinger DC, Ing C, Park R, Radcliffe J, Hays SR, DiMaggio CJ, Cooper TJ, Rauh V, Maxwell LG, Youn A, McGowan FX. Association Between a Single General Anesthesia Exposure Before Age 36 Months and Neurocognitive Outcomes in Later Childhood. JAMA 2016; 315:2312-20. [PMID: 27272582 PMCID: PMC5316422 DOI: 10.1001/jama.2016.6967] [Citation(s) in RCA: 534] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Exposure of young animals to commonly used anesthetics causes neurotoxicity including impaired neurocognitive function and abnormal behavior. The potential neurocognitive and behavioral effects of anesthesia exposure in young children are thus important to understand. OBJECTIVE To examine if a single anesthesia exposure in otherwise healthy young children was associated with impaired neurocognitive development and abnormal behavior in later childhood. DESIGN, SETTING, AND PARTICIPANTS Sibling-matched cohort study conducted between May 2009 and April 2015 at 4 university-based US pediatric tertiary care hospitals. The study cohort included sibling pairs within 36 months in age and currently 8 to 15 years old. The exposed siblings were healthy at surgery/anesthesia. Neurocognitive and behavior outcomes were prospectively assessed with retrospectively documented anesthesia exposure data. EXPOSURES A single exposure to general anesthesia during inguinal hernia surgery in the exposed sibling and no anesthesia exposure in the unexposed sibling, before age 36 months. MAIN OUTCOMES AND MEASURES The primary outcome was global cognitive function (IQ). Secondary outcomes included domain-specific neurocognitive functions and behavior. A detailed neuropsychological battery assessed IQ and domain-specific neurocognitive functions. Parents completed validated, standardized reports of behavior. RESULTS Among the 105 sibling pairs, the exposed siblings (mean age, 17.3 months at surgery/anesthesia; 9.5% female) and the unexposed siblings (44% female) had IQ testing at mean ages of 10.6 and 10.9 years, respectively. All exposed children received inhaled anesthetic agents, and anesthesia duration ranged from 20 to 240 minutes, with a median duration of 80 minutes. Mean IQ scores between exposed siblings (scores: full scale = 111; performance = 108; verbal = 111) and unexposed siblings (scores: full scale = 111; performance = 107; verbal = 111) were not statistically significantly different. Differences in mean IQ scores between sibling pairs were: full scale = -0.2 (95% CI, -2.6 to 2.9); performance = 0.5 (95% CI, -2.7 to 3.7); and verbal = -0.5 (95% CI, -3.2 to 2.2). No statistically significant differences in mean scores were found between sibling pairs in memory/learning, motor/processing speed, visuospatial function, attention, executive function, language, or behavior. CONCLUSIONS AND RELEVANCE Among healthy children with a single anesthesia exposure before age 36 months, compared with healthy siblings with no anesthesia exposure, there were no statistically significant differences in IQ scores in later childhood. Further study of repeated exposure, prolonged exposure, and vulnerable subgroups is needed.
Collapse
Affiliation(s)
- Lena S Sun
- Morgan Stanley Children's Hospital-New York Presbyterian, Columbia University Medical Center, New York, New York
| | - Guohua Li
- Mailman School of Public Health and College of Physicians and Surgeons, Columbia University, New York, New York
| | - Tonya L K Miller
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cynthia Salorio
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary W Byrne
- School of Nursing and College of Physicians and Surgeons, Columbia University, New York, New York
| | - David C Bellinger
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caleb Ing
- Morgan Stanley Children's Hospital-New York Presbyterian, Columbia University Medical Center, New York, New York
| | - Raymond Park
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerilynn Radcliffe
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen R Hays
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Timothy J Cooper
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Virginia Rauh
- Mailman School of Public Health, Columbia University, New York, New York
| | - Lynne G Maxwell
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahrim Youn
- Mailman School of Public Health, Columbia University, New York, New York
| | - Francis X McGowan
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
27
|
Ward CG, Hines SJ, Maxwell LG, McGowan FX, Sun LS. Neurotoxicity, general anesthesia in young children, and a survey of current pediatric anesthesia practice at US teaching institutions. Paediatr Anaesth 2016; 26:60-5. [PMID: 26559907 DOI: 10.1111/pan.12814] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent articles in both scholarly journals and the lay press about the topic of anesthetic related neurotoxicity have increased the awareness and discussion of this topic with parents and other pediatric medical specialties (i.e., surgeons, radiologists, and pediatricians). AIM The purpose of the present study was to survey how a subset of pediatric anesthesia departments in the US have responded to the issue of anesthetic related neurotoxicity in terms of clinical practice, training and communication with other medical specialties, and the frequency and timing of discussions with families. METHODS A survey consisting of 22 questions was sent to PALC (Pediatric Anesthesia Leadership Council) & PAPDA (Pediatric Anesthesia Program Directors Association) via SurveyMonkey. The survey was divided into sections on Anesthesia Faculty/Trainees, Parents and Non-Anesthesia Providers. Responses to the survey were solicited via email to PALC and PAPDA, and then followed up with reminders to individual emails using the mailing lists of both organizations. RESULTS The results of this survey demonstrate that pediatric anesthesia programs around the US do not have a consistent approach in managing the topic of anesthesia-related neurotoxicity with pediatric anesthesiologists, anesthesiology residents, pediatric anesthesiology fellows and their non-anesthesia medical and surgical colleagues, as well as the discussion of this topic with parents. CONCLUSION A significant need exists to provide information to other pediatric professionals and parents. A consistent message from all providers that includes what is known, and indeed more importantly what is not known may be a useful approach.
Collapse
Affiliation(s)
- Christopher G Ward
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott J Hines
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lena S Sun
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
28
|
Abstract
OBJECTIVES To report the epidemiology of obesity in a pediatric surgical population and determine whether obesity is a risk factor for longer anesthesia duration. BACKGROUND Childhood obesity is a significant public health problem in the United States. Epidemiologic studies on pediatric surgical populations have been limited to states with very high prevalence of adult obesity (Michigan, Texas). Data from other states and more recent data since 2006 are unavailable. METHODS We examined anesthesia records for surgical patients age 2-18 years at Columbia University Medical Center from January 2009 to December 2010. Patients undergoing bariatric surgery or those with records missing preoperative height or weight data were excluded. Body mass index (BMI) was calculated as weight (kg)/height (m(2) ). BMI ≥95th percentile according to national growth charts were considered obese. RESULTS We reviewed 9522 patients of which 1639 were obese (17.2%). The sex-age category interaction on obesity was not significant using logistic regression (P = 0.11). Among surgical groups, the otolaryngology (ENT) cohort had the highest obesity rate (21.7%, 360/1656). Obese children who had tonsillectomy, adenoidectomy, or both did not have a prolonged anesthetic (P = 0.33) or surgical duration (P = 0.61) compared with nonobese children, adjusting for surgeon, season, surgical procedure code, and ASA status. CONCLUSION Children presenting for surgery, particularly the ENT cohort, have a high prevalence of obesity. Obese and nonobese children who had tonsillectomy, adenoidectomy, or both had comparable durations of anesthesia. Therefore, obesity did not lead to longer anesthetic duration.
Collapse
Affiliation(s)
- Jennifer J Lee
- Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | |
Collapse
|
29
|
Sun LS. Introduction to the Proceedings of the Third PANDA Symposium on “Anesthesia and Neurodevelopment in Children”. J Neurosurg Anesthesiol 2012; 24:356. [DOI: 10.1097/ana.0b013e31826a0312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
30
|
Abstract
Experimental evidence of anesthesia-induced neurotoxicity has caused serious concern about the long-term effect of commonly used volatile anesthetic agents on young children. Several observational studies based on existing data have been conducted to address this concern with inconsistent results. We conducted a meta-analysis to synthesize the epidemiologic evidence on the association of anesthesia/surgery with neurodevelopmental outcomes in children. Using Bayesian meta-analytic approaches, we estimated the synthesized odds ratios (OR) and 95% credible interval (CrI) as well as the predictive distribution of a future study given the synthesized evidence. Data on 7 unadjusted and 6 adjusted measures of association were abstracted from 7 studies. The synthesized OR based on the 7 unadjusted measures for the association of anesthesia/surgery with an adverse behavioral or developmental outcome was 1.9 (95% CrI, 1.2-3.0). The most likely unadjusted OR from a future study was estimated to be 2.2 (95% CrI, 0.6-6.1). The synthesized OR based on the 6 adjusted measures for the association of anesthesia/surgery with an adverse behavioral or developmental outcome was 1.4 (95% CrI, 0.9-2.2). The most likely adjusted OR from a future study was estimated to be 1.5 (95% CrI, 0.5-4.0). We conclude that existent epidemiologic evidence suggests a modestly elevated risk of adverse behavioral or developmental outcomes in children who were exposed to anesthesia/surgery during early childhood. The evidence, however, is considerably uncertain.
Collapse
Affiliation(s)
- Charles DiMaggio
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
31
|
Ing C, DiMaggio C, Whitehouse A, Hegarty MK, Brady J, von Ungern-Sternberg BS, Davidson A, Wood AJJ, Li G, Sun LS. Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 2012; 130:e476-85. [PMID: 22908104 DOI: 10.1542/peds.2011-3822] [Citation(s) in RCA: 428] [Impact Index Per Article: 35.7] [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: 01/22/2023] Open
Abstract
BACKGROUND Over the past decade, the safety of anesthetic agents in children has been questioned after the discovery that immature animals exposed to anesthesia display apoptotic neurodegeneration and long-term cognitive deficiencies. We examined the association between exposure to anesthesia in children under age 3 and outcomes in language, cognitive function, motor skills, and behavior at age 10. METHODS We performed an analysis of the Western Australian Pregnancy Cohort (Raine) Study, which includes 2868 children born from 1989 to 1992. Of 2608 children assessed, 321 were exposed to anesthesia before age 3, and 2287 were unexposed. RESULTS On average, exposed children had lower scores than their unexposed peers in receptive and expressive language (Clinical Evaluation of Language Fundamentals: Receptive [CELF-R] and Expressive [CELF-E]) and cognition (Colored Progressive Matrices [CPM]). After adjustment for demographic characteristics, exposure to anesthesia was associated with increased risk of disability in language (CELF-R: adjusted risk ratio [aRR], 1.87; 95% confidence interval [CI], 1.20-2.93, CELF-E: aRR, 1.72; 95% CI, 1.12-2.64), and cognition (CPM: aRR, 1.69; 95% CI, 1.13-2.53). An increased aRR for disability in language and cognition persisted even with a single exposure to anesthesia (CELF-R aRR, 2.41; 95% CI, 1.40-4.17, and CPM aRR, 1.73; 95% CI, 1.04-2.88). CONCLUSIONS Our results indicate that the association between anesthesia and neuropsychological outcome may be confined to specific domains. Children in our cohort exposed to anesthesia before age 3 had a higher relative risk of language and abstract reasoning deficits at age 10 than unexposed children.
Collapse
Affiliation(s)
- Caleb Ing
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 W 168th St, BHN 4-440, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Fan LY, He DY, Wang Q, Zong M, Zhang H, Yang L, Sun LS. Citrullinated vimentin stimulates proliferation, pro-inflammatory cytokine secretion, and PADI4 and RANKL expression of fibroblast-like synoviocytes in rheumatoid arthritis. Scand J Rheumatol 2012; 41:354-8. [PMID: 22765310 DOI: 10.3109/03009742.2012.670263] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We aimed to investigate the possible effects of vimentin (Vim) and citrullinated Vim (cVim) on proliferation capacity, pro-inflammatory cytokine secretion, and the expression of peptidylarginine deiminase type 4 (PADI4) and receptor activator of nuclear factor kappa B ligand (RANKL) in cultured fibroblast-like synoviocytes (FLSs) from rheumatoid arthritis (RA) and osteoarthritis (OA) patients. METHOD Human native Vim was citrullinated with rabbit PAD in vitro and detected using a Western blot assay with anti-modified citrulline antibody (anti-MC Ab). FLSs from RA or OA synovial samples were stimulated with Vim or cVim. Cell proliferation capacity was determined using the Celltiter 96 AQueous cell proliferation assay. The concentrations of tumour necrosis factor (TNF)-α, interleukin (IL)-1, and IL-17 were measured by enzyme-linked immunosorbent assay (ELISA). The expression of PADI4 and RANKL was measured by real-time polymerase chain reaction (RT-PCR) and a Western blot assay. RESULTS Our Western blot assay with anti-MC Ab indicated that the amount of cVim increased significantly after Vim had been incubated with rabbit PAD in vitro. The proliferation capacity and secretion of TNF-α and IL-1 were significantly enhanced in the FLSs of RA patients when treated with cVim. However, when treated with Vim, an inhibitory effect on the proliferation capacity was noted in the FLSs from RA and also from OA patients. cVim significantly increased the expression of PADI4 and RANKL in the FLSs from RA patients. CONCLUSION cVim seems to have remarkable biological effects on RA as confirmed by the stimulation of proliferation capacity, pro-inflammatory cytokine secretion, and PADI4 and RANKL expression in the FLSs of RA patients.
Collapse
Affiliation(s)
- L Y Fan
- Department of Clinical Laboratory, Shanghai East Hospital, School of Medicine, Tong Ji University, 150 Ji Mo Road, Shanghai, China.
| | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
BACKGROUND Case reports have linked malignant hyperthermia (MH) to several genetic diseases. OBJECTIVE/AIM The objective of this study was to quantitatively assess excess comorbidities associated with MH diagnosis in pediatric hospital discharge records. PATIENTS AND METHODS Data for this study came from the Kids' Inpatient Database (KID) for the years 2000, 2003, and 2006. The KID contains an 80% random sample of patients under the age of 21 discharged from short-term, non-Federal hospitals in the United States, with up to 19 diagnoses recorded for each patient. Using all pediatric inpatients as the reference, we calculated the standardized morbidity ratios (SMRs) and 95% confidence intervals (CIs) for children with MH diagnosis according to major disease groups and specific medical conditions. RESULTS Of the 5,916,989 nonbirth-related hospital discharges studied, 175 had a recorded diagnosis of MH. Compared with the general pediatric inpatient population, children with MH diagnosis were significantly more likely to be diagnosed with diseases of the musculoskeletal system and connective tissue (SMR 5.7; 95% CI: 3.9-7.9), diseases of the circulatory system (SMR 3.3; 95% CI: 2.1-4.8), and congenital anomalies (SMR 3.2; 95% CI: 2.3-4.4). The specific diagnosis that was most strongly associated with MH was muscular dystrophies (SMR 31.3; 95% CI 12.6-64.6). CONCLUSIONS Diseases of the musculoskeletal system and connective tissue are significantly associated with MH diagnosis in children. Further research is warranted to determine the clinical utility of these comorbidities in assessing MH susceptibility in children.
Collapse
Affiliation(s)
- Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
34
|
DiMaggio C, Sun LS, Li G. Early childhood exposure to anesthesia and risk of developmental and behavioral disorders in a sibling birth cohort. Anesth Analg 2011; 113:1143-51. [PMID: 21415431 DOI: 10.1213/ane.0b013e3182147f42] [Citation(s) in RCA: 382] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In vitro and in vivo studies of anesthetics have demonstrated serious neurotoxic effects on the developing brain. However, the clinical relevance of these findings to children undergoing anesthesia remains unclear. Using data from a sibling birth cohort, we assessed the association between exposure to anesthesia in the setting of surgery in patients younger than 3 years and the risk of developmental and behavioral disorders. METHODS We constructed a retrospective cohort of 10,450 siblings who were born between 1999 and 2005 and who were enrolled in the New York State Medicaid program. The exposed group was 304 children without a history of developmental or behavioral disorders who underwent surgery when they were younger than 3 years. The unexposed group was 10,146 children who did not receive any surgical procedures when they were younger than 3 years. Exposed children were entered into analysis at the date of surgery. Unexposed children were entered into analysis at age 10 months (the mean age at which exposed children underwent surgery). Both exposed and unexposed children were followed until diagnosis with a developmental or behavioral disorder, loss to follow-up, or the end of 2005. The association of exposure to anesthesia with subsequent developmental and behavioral disorders was assessed with both proportional hazards modeling, and pair-matched analysis. RESULTS The incidence of developmental and behavioral disorders was 128.2 diagnoses per 1000 person-years for the exposed cohort and 56.3 diagnoses per 1000 person-years for the unexposed cohort. With adjustment for sex and history of birth-related medical complications, and clustering by sibling status, the estimated hazard ratio of developmental or behavioral disorders associated with any exposure to anesthesia when they were younger than 3 years was 1.6 (95% confidence interval [CI]: 1.4, 1.8). The risk increased from 1.1 (95% CI: 0.8, 1.4) for 1 operation to 2.9 (94% CI: 2.5, 3.1) for 2 operations and 4.0 (95% CI: 3.5, 4.5) for ≥3 operations. The relative risk in a matched analysis of 138 sibling pairs was 0.9 (95% CI: 0.6, 1.4). CONCLUSION The risk of being subsequently diagnosed with developmental and behavioral disorders in children who were enrolled in a state Medicaid program and who had surgery when they were younger than 3 years was 60% greater than that of a similar group of siblings who did not undergo surgery. More tightly matched pairwise analyses indicate that the extent to which the excess risk is causally attributable to anesthesia or mediated by unmeasured factors remains to be determined.
Collapse
Affiliation(s)
- Charles DiMaggio
- Department of Anesthesiology, Columbia University, 622 West 168 St., New York, NY 10032, USA.
| | | | | |
Collapse
|
35
|
Lo SS, Sobol JB, Mallavaram N, Carson M, Chang C, Grieve PG, Emerson RG, Stark RI, Sun LS. Anesthetic-specific electroencephalographic patterns during emergence from sevoflurane and isoflurane in infants and children. Paediatr Anaesth 2009; 19:1157-65. [PMID: 19708912 DOI: 10.1111/j.1460-9592.2009.03128.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Devices that monitor the depth of anesthesia are increasingly used to titrate sedation and avoid awareness during anesthesia. Many of these monitors are based upon electroencephalography (EEG) collected from large adult reference populations and not pediatric populations (Anesthesiology, 86, 1997, 836; Journal of Anaesthesia, 92, 2004, 393; Anesthesiology, 99, 2003, 34). We hypothesized that EEG patterns in children would be different from those previously reported in adults and that they would show anesthetic-specific characteristics. METHODS This prospective observational study was approved by the Institutional Review Board, and informed written consent was obtained. Patients were randomized to receive maintenance anesthesia with isoflurane or sevoflurane. EEG data collection included at least 10 min at steady-state maintenance anesthesia. The EEG was recorded continuously through emergence until after extubation. A mixed model procedure was performed on global and regional power by pooled data analysis and by analyzing each anesthetic group separately. Statistical significance was defined as P < 0.05. RESULTS Thirty-seven children completed the study (ages 22 days-3.6 years). Isoflurane and sevoflurane had different effects on global and regional EEG power during emergence from anesthesia, and frontal predominance patterns were significantly different between these two anesthetic agents. CONCLUSIONS The principal finding of the present study was that there are anesthetic-specific and concentration-dependent EEG effects in children. Depth-of-anesthesia monitors that utilize algorithms based on the EEGs of adult reference populations therefore may not be appropriate for use in children.
Collapse
Affiliation(s)
- Sansan S Lo
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
BACKGROUND Significant intraprocedural adverse events (AE) are reported in children who receive anesthesia for procedures outside the Operating Rooms (NORA). No study, so far, has characterized AE in children who receive anesthesia in the operating rooms (ORA) and NORA when anesthesia care is provided by the same team in a consistent manner. OBJECTIVE/AIM We used the same patient-specific Quality Assurance questionnaires (QAs), to elucidate incidences of intraoperative reported AE for children receiving anesthesia in NORA and ORA locations. Through multivariate logistic regression analysis, we assessed the association between patient's AE risk and procedure's location while adjusting for American Society of Anesthesiologists (ASA) status, age, and unscheduled nature of the procedure. METHODS/MATERIALS After Institutional Review Board approval, we used returned QAs of patients under 21 years, who received anesthesia from our pediatric anesthesia faculty from May 1 2006 through September 30, 2007. We analyzed QA data on: service location, unscheduled/scheduled procedure, age, ASA status, presence, and type of AE. We excluded QAs with incomplete information on date, location, age, and ASA status. RESULTS We included 8707 cases, with 3.5% incidence of reported AE. We had 1898 NORA and 6808 ORA cases with AE incidence of 2.5% and 3.7%, respectively. Multivariate regression analysis revealed that patients with higher ASA status or younger age had higher incidence of reported AE, irrespective of location or unscheduled nature of the procedure. The most common AE type, for both sites, was respiratory related (1.9%). CONCLUSIONS Pediatric reported AE incidence was comparable for NORA and ORA locations. Younger age or higher ASA status are associated with increased risk of AE.
Collapse
Affiliation(s)
- Athina Kakavouli
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
BACKGROUND Previous research on anesthesia-related mortality in the United States was limited to data from individual hospitals. The purpose of this study was to examine the epidemiologic patterns of anesthesia-related deaths at the national level. METHODS The authors searched the International Classification of Diseases, 10th Revision manuals for codes specifically related to anesthesia/anesthetics. These codes were used to identify anesthesia-related deaths from the US multiple-cause-of-death data files for the years 1999-2005. Rates from anesthesia- related deaths were calculated based on population and hospital surgical discharge data. RESULTS The authors identified 46 anesthesia/anesthetic codes, including complications of anesthesia during pregnancy, labor, and puerperium (O29.0 -O29.9, O74.0-74.9, O89.0-O89.9), overdose of anesthetics (T41.0 -T41.4), adverse effects of anesthetics in therapeutic use (Y45.0, Y47.1, Y48.0 - Y48.4, Y55.1), and other complications of anesthesia (T88.2- T88.5, Y65.3). Of the 2,211 recorded anesthesia-related deaths in the United States during 1999-2005, 46.6% were attributable to overdose of anesthetics; 42.5% were attributable to adverse effects of anesthetics in therapeutic use; 3.6% were attributable to complications of anesthesia during pregnancy, labor, and puerperium; and 7.3% were attributable to other complications of anesthesia. Anesthesia complications were the underlying cause in 241 (10.9%) of the 2,211 deaths. The estimated rates from anesthesia-related deaths were 1.1 per million population per year (1.45 for males and 0.77 for females) and 8.2 per million hospital surgical discharges (11.7 for men and 6.5 for women). The highest death rates were found in persons aged 85 yr and older. CONCLUSION Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.
Collapse
Affiliation(s)
- Guohua Li
- Center for Health Policy and Outcomes in Anesthesia and Critical Care, Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
| | | | | | | | | |
Collapse
|
38
|
Voskresenskiy AM, Sun LS. The housekeeping gene (GA3PDH) and the long interspersed nuclear element (LINE) in the blood and organs of rats treated with cocaine. Ann N Y Acad Sci 2008; 1137:309-15. [PMID: 18837965 DOI: 10.1196/annals.1448.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Housekeeping genes are necessary for maintenance of the vital activity of the cells of any phylum of organisms. Transposons or mobile genetic elements are eurysynusic in nature. Thus, the role of these and other genes in the pathogenesis of many diseases and of drug addiction in particular is being investigated. The goal of the work is to determine the influence of cocaine on the activity of GA3PDH and on a representative of the LINE family (L1Rn) in plasma, and in a pellet of blood cells, and in the organs of rats. Gene expression was evaluated by RT-PCR. The GA3PDH (452-bp fragment) was predictably found in plasma, in a pellet of blood cells, and in organs. Its quantity in plasma was greater in the experimental groups than in the control. In a pellet of blood cells and in organs, the GA3PDH activity between the different groups of animals essentially did not differ. The L1Rn fragment (319 bp) in plasma was not found. The expression of L1Rn was much higher in a pellet of blood cells and in organs of experimental animals. These experiments have shown the presence of GA3PDH in the plasma of the controls and an increase in quantity in the plasma of experimental animals. The activation of LINE in a pellet of blood cells of rats and in organs under the influence of cocaine has been demonstrated. Apparently, a recruitment phenomenon of housekeeping genes and transposons is possible in the pathogenesis of drug addiction.
Collapse
Affiliation(s)
- Anatoliy M Voskresenskiy
- Albert Einstein College Cancer Center, and Department of Oncology, Montefiore Medical Center, Bronx, New York, USA.
| | | |
Collapse
|
39
|
Abstract
OBJECTIVE Serum cardiac troponin-I (cTn-I) is a marker for myocardial injury in adults that undergoes developmental isoform change. To determine its utility as a myocardial injury marker in neonates, the authors examined the perioperative pattern of cTn-I elevation in neonates undergoing surgical repair for hypoplastic left-heart syndrome (HLHS) and transposition of great arteries (TGA). DESIGN A prospective cohort study. SETTING The study was performed in a tertiary teaching hospital that is a major referral center for congenital cardiac surgery. PATIENTS Forty-five neonates were enrolled, 17 with HLHS, 15 with TGA with intact septum (TGA + IVS), 8 with TGA with ventricular septal defect (TGA + VSD), and 5 neonates undergoing extracardiac surgery who did not require cardiopulmonary bypass (CPB). INTERVENTIONS None. RESULTS Preoperative cTn-I was elevated in all neonates undergoing cardiac surgery with CPB. Increases in postoperative cTn-I correlated with duration of aortic cross-clamp application and CPB. Peak elevation in serum cTn-I occurred between 6 and 24 hours postoperatively in all neonates after cardiac surgery. The perioperative pattern of cTn-I was different in TGA + VSD (peak cTn-I = 10.9 +/- 5.9 ng/mL) compared with HLHS (peak cTn-I = 4.62 +/- 3.4 ng/mL) and TGA + IVS (peak cTn-I = 4.46 +/- 3.5 ng/mL). CONCLUSION It was found that perioperative elevations in serum cTn-I in neonates with TGA and HLHS were influenced by duration of aortic cross-clamp application, CPB, and the presence of VSD.
Collapse
Affiliation(s)
- Neeta R Saraiya
- Department of Anesthesiology, Columbia University, New York, NY 10032, USA
| | | | | | | | | |
Collapse
|
40
|
Affiliation(s)
- Edmund H Jooste
- Department of Anesthesiology; Pediatric Anesthesiology Division; College of Physicians and Surgeons; Columbia University; New York, NY;
| | | | | |
Collapse
|
41
|
Abstract
OBJECTIVE To examine whether children with univentricular defects have intrinsic dysfunction in the natriuretic peptide system. METHODS We compared plasma levels of the fluid-regulating hormone vasopressin (antidiuretic hormone), aldosterone, atrial natriuretic peptide, and brain natriuretic peptide in children with congenital univentricular and biventricular defects. We enrolled 27 patients with univentricular defects and 27 patients with biventricular cardiac defects. Children who underwent Fontan and Glenn procedures were considered as patients with univentricular cardiac defects; children who underwent repair of tetralogy of Fallot or subaortic stenosis were considered as controls with biventricular defects. RESULTS Preoperative plasma atrial natriuretic peptide, brain natriuretic peptide, antidiuretic hormone, and aldosterone were comparable in both groups. Although plasma cyclic guanosine monophosphate levels were comparable between groups, there was a significant correlation between molar concentrations of plasma cyclic guanosine monophosphate and plasma atrial natriuretic peptide ( r = 0.42) and brain natriuretic peptide ( r = 0.44) in the biventricular group, but not in the univentricular group ( r = 0.19 for atrial natriuretic peptide; r = 0.13 for brain natriuretic peptide). All patients had a significant postoperative increase in plasma antidiuretic hormone. A significant postoperative increase in plasma brain natriuretic peptide was found in the patients with biventricular, but not univentricular, defects. In contrast, a significant increase in plasma aldosterone was observed only in the patients with univentricular defects. CONCLUSIONS There were distinct differences between univentricular and biventricular groups in their perioperative plasma fluid-regulating hormone responses. Specifically, patients with univentricular defects may have abnormal natriuretic peptide secretion and function. The natriuretic dysfunction may be on the basis of hypoplastic ventricular development.
Collapse
Affiliation(s)
- Lena S Sun
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
| | | | | | | |
Collapse
|
42
|
Abstract
Prenatal exposure to cocaine has been shown to induce an increase in the myocardial expression and activation of the cAMP response binding protein (CREB), a transcriptional factor that has been shown to regulate gene expression. Several different kinases, including protein kinase A, calcium calmodulin kinase II, and mitogen-activated protein kinase can induce phosphorylation of CREB at serine 133, a necessary step for CREB activation. We examined whether the mitogen-activated protein kinase-extracellular receptor kinase (ERK) pathway may be involved in mediating the serine 133 CREB phosphorylation in cardiac nuclei after perinatal cocaine exposure. Pregnant rats were treated daily with saline or cocaine at 60 mg/kg (C60) by intragastric administration during the entire gestational period, and treatment was continued in the nursing dams after delivery until the time of the study. Nuclear extracts were isolated from hearts of 1-d- and 7-d-old neonatal rats. We performed immunoblotting experiments using an antibody that recognized CREB with phosphorylation specifically at the serine 133 site and an antibody that recognized both the phosphorylated and the unphosphorylated forms of CREB, as well as antibodies for total ERK, phospho-ERK, total ribosomal S6 kinase 1 (RSK1), RSK2, and phospho-RSK. We assessed the interaction of RSK with CREB or CREB-binding protein by performing co-immunoprecipitation experiments. We found that perinatal cocaine exposure increased both phospho-ERK and phospho-RSK expression, indicative of an increased activity of these two enzymes. Furthermore, we demonstrated that phospho-RSK was immunoprecipitated with CREB in all neonatal cardiac nuclei and that the greatest interaction was found in day 7 hearts after perinatal cocaine exposure. Our results thus illustrate that the ERK-RSK pathway was active in the postnatal rat heart at 1 and 7 d of age and that this pathway may mediate the increase in myocardial CREB activation after perinatal cocaine exposure in the day 7 hearts.
Collapse
Affiliation(s)
- Lena S Sun
- College of Physicians & Surgeons, Columbia University, Department of Anesthesiology, New York, NY 10032, USA.
| | | |
Collapse
|
43
|
Alexianu D, Skolnick ET, Pinto AC, Ohkawa S, Roye DP, Solowiejczyk DE, Hyman JE, Sun LS. Severe Hypotension in the Prone Position in a Child with Neurofibromatosis, Scoliosis and Pectus Excavatum Presenting for Posterior Spinal Fusion. Anesth Analg 2004; 98:334-335. [PMID: 14742365 DOI: 10.1213/01.ane.0000096187.58714.b6] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED A 34-mo-old boy with neurofibromatosis, scoliosis, and pectus excavatum developed severe hypotension when positioned prone. A magnetic resonance image study revealed neurofibromas encircling the great vessels. During the next anesthetic the patient was placed in the prone position on transverse bolsters and hypotension ensued again. A transesophageal echocardiogram (TEE) revealed compression of the right ventricle by the sternum. When the child was turned supine, the blood pressure returned to baseline. The patient was returned to the prone position, this time with bolsters placed longitudinally, without problem. This case supports a cardiac evaluation, possible intraoperative TEE, and avoidance of sternal pressure in patients with chest wall deformities requiring prone positioning. IMPLICATIONS A child with neurofibromatosis, scoliosis, and a chest wall deformity presenting for spinal fusion developed severe hypotension while prone. This was due to compression of the heart by the sternum, not compression of the great vessels by neurofibromas. Sternal pressure in prone patients with chest wall deformities should be avoided. Unique management included the use of transesophageal echocardiography to determine the cause of the hypotension.
Collapse
Affiliation(s)
- Daniela Alexianu
- From the Departments of Anesthesiology, Pediatrics, Orthopaedic Surgery and Division of Pediatric Cardiology, Columbia University College of Physicians & Surgeons and The Children's Hospital of the New York-Presbyterian, New York, New York
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Patberg KW, Plotnikov AN, Quamina A, Gainullin RZ, Rybin A, Danilo P, Sun LS, Rosen MR. Cardiac memory is associated with decreased levels of the transcriptional factor CREB modulated by angiotensin II and calcium. Circ Res 2003; 93:472-8. [PMID: 12893738 DOI: 10.1161/01.res.0000088785.24381.2f] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [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] [Indexed: 11/16/2022]
Abstract
Cardiac memory (CM) has short- (STCM) and long-term (LTCM) components modulated by calcium and angiotensin II. LTCM is associated with reduced Ito and Kv4.3 mRNA levels. Because the cAMP response element binding protein, CREB, contributes to CNS memory transcription, we hypothesized that it might be a transcriptional factor in CM, influenced by calcium and angiotensin II. We studied STCM in dogs that were AV sequentially paced (AVP) for 2 hours or sham-operated. STCM was evaluated with ECG and vectorcardiogram (VCG), and subepicardial biopsies were taken at 5 to 120 minutes and investigated for CREB. LTCM was studied in dogs paced for 3 weeks and in sham controls. At 3 weeks the heart was excised, biopsies obtained, and CRE binding tested. STCM induction occurred in AVP dogs but not in sham or AVP dogs treated with saralasin or nifedipine. Nuclear CREB was significantly decreased at 2 hours in the AVP no-drug group only. LTCM dogs manifested reduced binding of nuclear proteins to CRE, and CRE binding activity in the promoter region of Kv4.3. In conclusion, there is an association between STCM induction and decreased nuclear CREB that is angiotensin-modulated and calcium-dependent. Moreover, the decreased CRE binding after 3 weeks of AVP combined with CRE binding activity in the Kv4.3 promoter can explain the Kv4.3 mRNA and Ito downregulation that characterize LTCM.
Collapse
Affiliation(s)
- Kornelis W Patberg
- Department of Pharmacology, Center for Molecular Therapeutics, College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Abstract
Fetal cocaine exposure has been associated with a variety of cardiovascular dysfunctions in humans. We treated pregnant rats with either saline or cocaine at 60 mg/kg by gastric lavage for the entire gestational period and for 14 days after parturition. We then performed high-frequency transthoracic echocardiography to determine whether cocaine exposure affected neonatal cardiac contractile function in vivo in 7- and 14-day-old neonatal rats. All studies were performed in the unsedated, conscious state. Heart rate (HR) and systolic function, expressed as fractional area of change at the midpapillary muscle level, were calculated from two-dimensional images. Resting HR was faster in the cocaine-exposed group at both ages, but baseline contractile function was not different between control (CTL) and cocaine-exposed (COC) neonatal rats. Dobutamine induced a significant increase in HR in all groups at only the largest dose tested (Day 7 CTL HR increased from 438 +/- 3 bpm to 462 +/- 10 bpm; Day 7 COC HR increased from 466 +/- 3 bpm to 493 +/- 7 bpm; Day 14 CTL HR increased from 443 +/- 4 bpm to 487 +/- 4 bpm; Day 14 COC HR increased from 477 +/- 4 bpm to 501 +/- 5 bpm). Dobutamine elicited a significant increase in contractile response at both Day 7 (from 76.6% +/- 0.6% to 81.5% +/- 0.7%) and Day 14 in CTL (from 78.2% +/- 0.7% to 81.9% +/- 0.7%), but not in COC, animals (from 76.7% +/- 0.8% to 78.9% +/- 0.8% at Day 7 and from 76.8% +/- 1.1% to 79.3% +/- 0.8% at Day 14). Epinephrine induced a significant increase in contractile response in CTL, but not in COC, rats at Day 7 and had no effect on fractional area of change at 14 days of age in either CTL or COC animals. Our results indicate that perinatal cocaine exposure does not modify resting contractile function but attenuates the contractile response to beta-adrenoceptor stimulation in the neonatal rat. These results suggest that perinatal cocaine exposure may lead to decreased responsiveness to inotropic drugs during the early neonatal period.
Collapse
Affiliation(s)
- Lena S Sun
- Departments of *Anesthesiology, †Pediatrics, and ‡Medicine, College of Physicians and Surgeons of Columbia University, New York, New York
| | | | | | | |
Collapse
|
46
|
Abstract
cAMP response binding protein (CREB) is a transcriptional factor known to regulate gene expression. Phosphorylation of CREB at serine 133 is necessary for CREB activation, and quantification of phospho-CREB (p-CREB) expression is an index of CREB activation. Because CREB expression and activation in specific brain regions are modified after chronic cocaine administration, we sought to determine whether chronic perinatal cocaine exposure affects the expression of CREB and p-CREB in the postnatal rat heart. Pregnant rats were treated daily with saline (control) or cocaine at 20 mg/kg (C20) or 60 mg/kg (C60) by intragastric administration throughout gestation. The expression of total CREB and p-CREB was quantified in nuclear extracts isolated from 1- and 7-d-old neonatal rat hearts. Cardiac nuclear p-CREB was increased in the C20 and C60 groups on d 1 and 7 of age compared with their respective age-matched control groups. The increase in p-CREB expression corresponded to an increase in cAMP response element binding activity. We also assayed nuclear protein kinase A activity, which was up-regulated in d 1 animals with prenatal cocaine exposure, but was comparable in all groups at d 7. Our results suggest that perinatal cocaine exposure stimulates CREB activation in the neonatal heart, and it may be mediated by different mechanisms at d 1 and d 7. The changes in myocardial CREB activation induced by perinatal cocaine exposure are likely to result in modified gene expression in the neonatal heart that may account for the cardiac dysfunction reported in human neonates born to cocaine-abusing mothers.
Collapse
Affiliation(s)
- Lena S Sun
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
| | | |
Collapse
|
47
|
Schwarzenberger JC, Sun LS, Pesce MA, Heyer EJ, Delphin E, Almeida GM, Wood M. Sex-based differences in serum cardiac troponin I, a specific marker for myocardial injury, after cardiac surgery. Crit Care Med 2003; 31:689-93. [PMID: 12626970 DOI: 10.1097/01.ccm.0000055442.84685.4d] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prevalence and causes of sex-based differences in morbidity and mortality secondary to cardiovascular disease remain controversial. Cardiac troponin I (cTnI) is a sensitive and specific marker for myocardial injury. Serial cTnI measurements have been used to identify perioperative myocardial cell injury. OBJECTIVE To determine whether sex influences the extent of myocardial injury during cardiac surgery, we measured perioperative cTnI in male and female patients. DESIGN A total of 17 male and 17 female patients were prospectively studied in an age- and case-matched manner. Arterial cTnI were obtained preinduction, 30 mins after the application of the aortic cross-clamp, at arrival to the intensive care unit, and on postoperative day 1. SETTING Tertiary cardiac surgery center at a major teaching hospital. RESULTS There was no difference between men and women in body mass index (kg/m2), duration of cardiopulmonary bypass, and aortic cross-clamp times. Preoperative cTnI measurements were similar in men (0.24 +/- 0.15 ng/mL) and women (0.25 +/- 0.13 ng/mL, mean +/- sem). The maximum serum cTnI occurred on postoperative day 1 in all patients, and it was 3-fold higher in men (18.5 +/- 5.7 ng/mL) compared with women (6.4 +/- 1.0 ng/mL). CONCLUSIONS Men had markedly higher serum cTnI compared with women, although they were case matched with respect to age and cardiac risk factors. Our results may suggest there may be sex-related differences in the myocardial response to ischemia and reperfusion injury or intrinsic differences between the male and female myocardium.
Collapse
Affiliation(s)
- J C Schwarzenberger
- College of Physicians and Surgeons of Columbia University, New York, NY 10032, USA
| | | | | | | | | | | | | |
Collapse
|
48
|
Joshi S, Hartl R, Sun LS, Libow AD, Wang M, Pile-Spellman J, Young WL, Connolly ES, Hirshman CA. Despite in vitro increase in cyclic guanosine monophosphate concentrations, intracarotid nitroprusside fails to augment cerebral blood flow of healthy baboons. Anesthesiology 2003; 98:412-9. [PMID: 12552201 DOI: 10.1097/00000542-200302000-00022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During cerebral angiography, intracarotid infusion of sodium nitroprusside (SNP), an endothelium-independent nitric oxide donor, fails to increase cerebral blood flow (CBF) of human subjects. A confounding effect of intracranial pathology or that of radiocontrast could not be ruled out in these experiments. The authors hypothesized that, if nitric oxide was a significant regulator of CBF of primates, then intracarotid SNP will augment CBF of baboons. METHODS In studies, CBF (intraarterial (133)Xe technique) was measured in healthy baboons during isoflurane anesthesia at (1) baseline and during (2) induced hypertension with intravenous phenylephrine, (3) concurrent infusions of intravenous phenylephrine and intracarotid SNP, and (4) intracarotid verapamil (positive control drug). In studies, the authors measured tissue cyclic guanosine monophosphate (cGMP) by radioimmunoassay after incubating vascular rings obtained from freshly killed baboons (1) with increasing concentrations of SNP and (2) after SNP exposure following preincubation with the radiocontrast agent, iohexhol. RESULTS In the studies, coinfusion of intravenous phenylephrine and intracarotid SNP did not increase CBF. However, intracarotid verapamil significantly increased CBF (from 26 +/- 7 to 43 +/- 11 ml x 100 g(-1) x min(-1); P < 0.0001) without a change in mean arterial pressure. In the studies, incubation of intracranial arterial rings in SNP resulted in dose-dependent increases in cGMP concentrations. A similar increase in cGMP content was evident despite iohexhol preincubation. CONCLUSIONS Collectively, these results suggest that, in healthy baboons, intracarotid SNP does not decrease arteriolar resistance, although SNP could affect proximal arterial tone, as demonstrated by the increase in cGMP content of these vessels.
Collapse
Affiliation(s)
- Shailendra Joshi
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York 10032, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
We have previously demonstrated that both basal and isoproterenol-stimulated activities of myocardial adenylyl cyclase were greater in cyanotic patients with tetralogy of Fallet (TOF) than those in acyanotic patients. However, it was not determined whether increased enzyme activity was related to a similar increase in adenylyl cyclase protein and mRNA expression. In the current study, we examined the mRNA and protein expression of cardiac adenylyl cyclase, types V and VI, in cyanotic and acyanotic patients with TOF. Ribonuclease protection assays and immunoblotting were performed on myocardial specimens obtained from cyanotic patients with TOF and acyanotic patients with TOF or ventricular septal defect. We demonstrated that in both cyanotic and acyanotic patients, there was more type V adenylyl cyclase mRNA than type VI. Types V and VI cardiac adenylyl cyclase mRNA were significantly increased in myocardium of the cyanotic group compared to the acyanotic group. Protein expression of both V and VI adenylyl cyclases was correspondingly upregulated in cyanotic patients compared to acyanotic patients. Our results indicate that gene and protein expression of cardiac adenylyl cyclases, types V and VI, is increased in the cyanotic myocardium. These results suggest that chronic hypoxemia may regulate the expression of adenylyl cyclase enzymes.
Collapse
Affiliation(s)
- Y Zhao
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | | | | | | | | |
Collapse
|
50
|
Adams DC, Heyer EJ, Simon AE, Delphin E, Rose EA, Oz MC, McMahon DJ, Sun LS. Incidence of atrial fibrillation after mild or moderate hypothermic cardiopulmonary bypass. Crit Care Med 2000; 28:309-11. [PMID: 10708158 DOI: 10.1097/00003246-200002000-00003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Atrial fibrillation remains a significant source of morbidity after coronary artery bypass grafting (CABG). Whether cardiopulmonary bypass (CPB) temperature influences the occurrence of postoperative atrial fibrillation in CABG patients has not been specifically examined. In the present study, we reviewed postoperative data from patients who were prospectively randomized to mild or moderate hypothermic CPB for elective CABG to determine the incidence of postoperative atrial fibrillation. DESIGN Randomized, single center, observational study. SETTING Tertiary university medical center. PATIENTS Adults undergoing elective CABG surgery. INTERVENTIONS Enrolled patients were prospectively randomized to mild (34 degrees C [93.2 degrees F]) or moderate (28 degrees C [82.4 degrees F]) hypothermic CPB. MEASUREMENTS AND MAIN RESULTS The incidence of postoperative atrial fibrillation was determined by review of ICU and hospital records. There was a significantly higher incidence of atrial fibrillation in the moderate compared with the mild hypothermic CPB group. Patients who had postoperative atrial fibrillation were significantly older than those without atrial fibrillation. Furthermore, a significant increase in the relative risk of developing postoperative atrial fibrillation was found for both age and CPB temperature. CONCLUSIONS Our results indicate that the temperature of systemic cooling during CPB is an important factor in the development of atrial fibrillation after CABG surgery. In addition, this study confirms that increasing age is a significant determinant of postoperative atrial fibrillation.
Collapse
Affiliation(s)
- D C Adams
- Department of Anesthesiology, Columbia-Presbyterian Medical Center, Columbia University New York, NY, USA
| | | | | | | | | | | | | | | |
Collapse
|