RESUMO
BACKGROUND: The General Anesthesia compared to Spinal anesthesia (GAS) study is a prospective randomized, controlled, multisite, trial designed to assess the influence of general anesthesia (GA) on neurodevelopment at 5 years of age. A secondary aim obtained from the blood pressure data of the GAS trial is to compare rates of intraoperative hypotension after anesthesia and to identify risk factors for intraoperative hypotension. METHODS: A total of 722 infants ≤60 weeks postmenstrual age undergoing inguinal herniorrhaphy were randomized to either bupivacaine regional anesthesia (RA) or sevoflurane GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born at <26 weeks of gestation. Moderate hypotension was defined as mean arterial pressure measurement of <35 mm Hg. Any hypotension was defined as mean arterial pressure of <45 mm Hg. Epochs were defined as 5-minute measurement periods. The primary outcome was any measured hypotension <35 mm Hg from start of anesthesia to leaving the operating room. This analysis is reported primarily as intention to treat (ITT) and secondarily as per protocol. RESULTS: The relative risk of GA compared with RA predicting any measured hypotension of <35 mm Hg from the start of anesthesia to leaving the operating room was 2.8 (confidence interval [CI], 2.0-4.1; P < .001) by ITT analysis and 4.5 (CI, 2.7-7.4, P < .001) as per protocol analysis. In the GA group, 87% and 49%, and in the RA group, 41% and 16%, exhibited any or moderate hypotension by ITT, respectively. In multivariable modeling, group assignment (GA versus RA), weight at the time of surgery, and minimal intraoperative temperature were risk factors for hypotension. Interventions for hypotension occurred more commonly in the GA group compared with the RA group (relative risk, 2.8, 95% CI, 1.7-4.4 by ITT). CONCLUSIONS: RA reduces the incidence of hypotension and the chance of intervention to treat it compared with sevoflurane anesthesia in young infants undergoing inguinal hernia repair.
Assuntos
Anestesia por Condução/efeitos adversos , Anestesia Geral/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Vigília/efeitos dos fármacos , Anestesia por Condução/tendências , Anestesia Geral/tendências , Pressão Sanguínea/fisiologia , Pré-Escolar , Humanos , Hipotensão/diagnóstico , Lactente , Recém-Nascido , Estudos Prospectivos , Vigília/fisiologiaRESUMO
Anaesthetic-induced developmental neurotoxicity (AIDN) has been clearly established in laboratory animal models. The possibility of neurotoxicity during uneventful anaesthetic procedures in human neonates or infants has led to serious questions about the safety of paediatric anaesthesia. However, the applicability of animal data to clinical anaesthesia practice remains uncertain. The spectre of cerebral injury due to cerebral hypoperfusion, metabolic derangements, coexisting disease, and surgery itself further muddles the picture. Given the potential magnitude of the public health importance of this issue, the clinician should be cognisant of the literature and ongoing investigations on AIDN, and raise awareness of the risks of both surgery and anaesthesia.
Assuntos
Anestesia Geral/efeitos adversos , Anestésicos/efeitos adversos , Anestésicos/toxicidade , Encéfalo/efeitos dos fármacos , Encéfalo/crescimento & desenvolvimento , Regulação da Temperatura Corporal , Lesões Encefálicas/induzido quimicamente , Lesões Encefálicas/fisiopatologia , Desenvolvimento Infantil/efeitos dos fármacos , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Humanos , Hipocapnia/fisiopatologia , Hipotensão/fisiopatologia , Recém-Nascido , Deficiências da Aprendizagem/etiologia , Período PerioperatórioRESUMO
BACKGROUND AND OBJECTIVES: The aim of this open, non-controlled, multi-centre study was to evaluate the pharmacokinetics and safety of a 24-72 h continuous epidural ropivacaine infusion in children aged 1-9 yr. METHODS: After induction of general anaesthesia, 29 ASA I-II children, scheduled for major surgery in dermatomes below T10 had lumbar epidural catheters placed. A bolus of ropivacaine, 2 mg kg(-1), was given over 4 min, followed immediately by an infusion of 2 mg mL(-1) ropivacaine 0.4 mg kg(-1) h(-1) for the next 24-72 h. RESULTS: Plasma concentrations of total ropivacaine (mean 0.83 and 1.06 mg L(-1) at 16-31 and 59-72 h, respectively) and alpha1-acid-glucoprotein (mean 13 and 25 micromol L(-1) at baseline and 59-72 h) increased over the course of the infusion. Plasma concentrations of unbound ropivacaine were stable throughout the epidural infusion (mean 0.021 range 0.011-0.068 and mean 0.016 range 0.009-0.023 mg L(-1) at 16-31 and 59-72 h, respectively) and were well below threshold levels associated with central nervous system toxicity in adults (0.35 mg L(-1)). Apparent unbound clearance (mean 346, range 86-555 mL min(-1) kg(-1)) showed no age-dependency. No signs of systemic toxicity or cardiovascular effects were observed. All patients received additional analgesics with morphine. CONCLUSION: Following a 24-72 h epidural infusion of ropivacaine 0.4 mg kg(-1) h(-1) in 1-9-yr-old children, the plasma concentrations of unbound ropivacaine were stable over time with no age-dependency.
Assuntos
Amidas/farmacocinética , Analgesia Controlada pelo Paciente , Anestésicos Locais/farmacocinética , Orosomucoide/análise , Dor Pós-Operatória/tratamento farmacológico , Amidas/administração & dosagem , Amidas/sangue , Amidas/urina , Anestésicos Locais/administração & dosagem , Anestésicos Locais/sangue , Anestésicos Locais/urina , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Injeções Epidurais , Masculino , Medição da Dor/métodos , Período Pós-Operatório , Ropivacaina , Estatística como Assunto , Fatores de Tempo , Procedimentos Cirúrgicos UrológicosRESUMO
UNLABELLED: The bispectral index (BIS) correlates with consciousness during adult anesthesia. In this prospective, blinded study of children (n = 24) and infants (n = 25) undergoing elective circumcision, we evaluated BIS and consciousness level during emergence from anesthesia. Anesthesia was maintained with sevoflurane, and a penile nerve block was performed in each patient before surgical stimulation. At the completion of surgery, the sevoflurane was decreased stepwise from 0.9% in increments of 0.2%, and arousal was tested with a uniform auditory stimulus given after a steady state of end-tidal sevoflurane concentration was achieved at each step. The BIS increased significantly as the sevoflurane concentrations decreased in children (0.9%, 62.5 +/- 8.1; 0.7%, 70.8 +/- 7.4; and 0.5%, 74.1 +/- 7.1; P < 0.001 for 0.7% and 0.5% compared with 0.9%), but a similar relationship was not demonstrated in infants. The BIS values at 0.7% and 0.5% sevoflurane were significantly higher in children than infants (P < 0.02 and P < 0.002, respectively). In both children and infants, the BIS increased significantly from pre- to postarousal (children, 73.5 +/- 7 to 83.1 +/- 12, P = 0.01; infants, 67.8 +/- 10 to 85.6 +/- 13.6, P < 0.001). The BIS at which arousal was possible with the stimulus tended to be higher in children than in infants (P = 0.06). IMPLICATIONS: In this study comparing the Bispectral index (BIS) in infants and children undergoing circumcision surgery by use of a standardized surgical and anesthetic technique, a significant decrease in BIS was detected in children during a stepwise decrease in end-tidal sevoflurane concentration. A similar relationship was not demonstrated in infants less than 1 yr old. In both children and infants, BIS increased significantly from pre- to postarousal. Additional studies are necessary to determine changes in BIS with maturational changes in the electroencephalogram.
Assuntos
Anestesia , Circuncisão Masculina , Eletroencefalografia , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Masculino , Estudos ProspectivosRESUMO
The effect of intravenous administration of lipid emulsions enriched with omega-3 (n3) and omega-6 (n6) fatty acids on equine monocyte phospholipid fatty acid composition and the synthesis of inflammatory mediators in vitro was evaluated. In a randomized crossover design, horses were infused intravenously with 20% lipid emulsions containing n3 or n6 fatty acids. Monocytes were isolated from the horses before and 0 h, 8 h, 24 h, and 7 days after lipid infusion. Monocyte fatty acid analysis demonstrated incorporation of the parenteral n3 and n6 fatty acids in monocyte phospholipids immediately after infusion, with changes in the fatty acid composition persisting for up to 7 days after infusion. In vitro production of the inflammatory mediators thromboxane B2/thromboxane B3 (TXB(2/3)) and tumor necrosis factor-alpha (TNFalpha) by peripheral blood monocytes was diminished by n3 lipid infusion and was unchanged or increased by n6 lipid infusion. The results of this study demonstrate that short-term infusions of n3 and n6 fatty acid-enriched lipid emulsions alter the fatty acid composition of equine monocyte phospholipids and modify the inflammatory response of these cells in vitro. These results also support further investigation into the use of parenteral n3 fatty acids as part of the supportive therapy of patients with multiple organ dysfunction (MODS) or systemic inflammatory response syndrome (SIRS).
Assuntos
Ácidos Graxos Ômega-3/farmacologia , Ácidos Graxos Insaturados/farmacologia , Ácidos Graxos/sangue , Monócitos/efeitos dos fármacos , Tromboxano B2/análogos & derivados , Tromboxano B2/biossíntese , Tromboxanos/análogos & derivados , Fator de Necrose Tumoral alfa/biossíntese , Animais , Calcimicina/farmacologia , Células Cultivadas , Estudos Cross-Over , Emulsões , Endotoxemia/metabolismo , Endotoxemia/veterinária , Ácidos Graxos Ômega-3/administração & dosagem , Ácidos Graxos Ômega-6 , Ácidos Graxos Insaturados/administração & dosagem , Feminino , Regulação da Expressão Gênica/efeitos dos fármacos , Doenças dos Cavalos/metabolismo , Cavalos , Infusões Intravenosas , Ionóforos/farmacologia , Lipopolissacarídeos/farmacologia , Masculino , Lipídeos de Membrana/sangue , Monócitos/metabolismo , Fosfolipídeos/sangue , Tromboxano B2/genética , Fator de Necrose Tumoral alfa/genéticaRESUMO
An electrocardiographic artifact was noted on a child under general anaesthesia. The artifact was caused by rhythmic diaphragmatic contractions. A systematic approach to distinguish an artifact from a cardiac electrophysiological event is presented.