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PEDIATRIC ANESTHESIAUPDATE 2014
RitaAgarwal MD, FAAPProfessor ofAnesthesiologyUniversity of ColoradoChildren’s Hospital Colorado
Disclosures
Nothing, except for my desire to usegratuitous photos of my family
Death or Neurologic Injury AfterTonsillectomy in Children with a Focus onObstructive Sleep Apnea: Houston, We Havea Problem!
SPA survey andASA closed Claims
Charles J. Coté, MD,* Karen L. Posner, PhD,†and Karen B. Domino, MD, MPH AnesthAnalg.2013 Jul 10
Coté et.al
“Tonsillectomy relatedmalpracticesettlements occur against anesthesiologistsmore commonly than against surgeons andsettle for nearly 5 fold larger awards becauseof the devastating outcomes”
Death or Neurologic injury
111 patients identifiedDeath or neurologic injury in 77%63 (57%) hadOSAPts withOSA incidence of obesity +/ comorbiditiesPts withOSA > events attributed to apnea
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Houston………
Race and Ethnicity
AfricanAmerican childenmay have:4x incidence ofOSASGreater in oxygen saturation? pharmacogenetics
Morphine andPharmacogenetics
AfricanAmerican children have > clearance ofMorphine to M3GAfricanAmerican children have > painCaucasian children have > side effectLatino children compared to non LatinoCaucasian children had a higher incidence of sideeffects
PruritusPOV
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Pediatrics.2012 May;129(5):832–838
Pediatrics 2012 et.al
After similar uses of intraoperativemorphinefor tonsillectomy, there was an unequalburden of increased pain inAfricanAmericanchildren and increased opioid adverse effectsin Caucasian children in the recovery room.ThoughCaucasian children received relativelyless opioids perioperatively, they had higherincidences of opioid related adverse effectsthanAfricanAmerican children.
Latino versus Non Latinochildren
Paediatr Anaesth.2012 Jul;22(7):66975. Jimenez N,AndersonGD,Shen DD, NielsenSS, Farin FM,Seidel K, LynnAM.
Latino vs Non Latino:SideEffects
Houston………
15 deaths in the first 24 hours after surgerydue to apnea
10 at home2 in PACU3 on floor
Need better monitoring/guidelines
Charles J. Coté, MD,* Karen L. Posner,PhD,† and Karen B. Domino, MD,MPH Anesth Analg. 2013 Jul 10
> 4000 consecutive tonsillectomy7.2 %with persistent desat post op
Trisomy 21,Weight,Cardiac diseaseSyndromesOSANeurologic issuesPulmonary disease
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
STBUR
Snoring
Trouble Breathing
UnRefreshed
STBURSnoresmore than ½ the timeSnores LoudlyTrouble breathing/strugglesStops breathingWakes up un refreshed
3 = 3x risk or perioperative respiratoryadverse events5 = 10x risk,
So what should we do for painmanagement?
NSAID?Steroids?
NSAIDs and Tonsillectomy ?
15 studies, 1101 childrenInsufficient data regarding bleeding vomiting
Cochrane Database July 2013
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
36 studies 1747 children + 1446 adultsNo increase in bleedingNo increase in severe bleedingNo increase need for readmission or reoperation
Our surgeons have started using ibuprofen inpost op period
Steroids and Tonsillectomy?
YES
215 children4 groups: 0. 0.05, 0.15, 0.5 mg/kg dexHigher incidence of bleeding with higherdoses
No Increased bleeding
Absolutely, positively NO!(Jane you ignorant…….)
314 children 3 18Placebo or dex 0.5mg/kgNo difference in sign bleedUnable to determine if bleeding by parentreport was increased
Our surgeons are nervous
Many have started using lower doses ofsteroidsOther things to consider
Local anesthesia infiltrationKetamineTramadol
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Anesthesia and Neurotoxicity Volatile and Other Anesthetics
Young rodents and other animals have shownapoptosis and cell death during critical periods
of brain developmentMost anesthetics and sedatives increaseinhibitionFine balance between neuronal excitation andinhibition:
crucial for neuronal survivalproper maturation and functioning
Volatile and Other Anesthetics
Over inhibitionmay be toxicMay agents are both neuroprotective andneurotoxicAll volatile anesthetics, midazolam, propofoland ketamine have been implicatedMany species including primatesSo far opioids seem to beOK
Of Mice and Men
MiceBrain Growth Spurt: first 1-2 weeks of lifeAnesthetized for 5-6 hoursMany unmonitored Pain and surgical stress are harmful
• Humans• Brain Growth
Spurt: prenatal-24 months
• Equivalent to several days-months
• Monitored• Pain and surgical
stress are harmful
Table 1. Characteristics of eligible studies for meta analysis.
Wang X, Xu Z, Miao C H (2014) Current Clinical Evidence on the Effect of General Anesthesia on Neurodevelopment in Children: An UpdatedSystematic Review with Meta Regression. PLoS ONE 9(1): e85760. doi:10.1371/journal.pone.0085760http://www.plosone.org/article/info:doi/10.1371/journal.pone.0085760
PLoSOne. 2014 Jan 20;9(1):e85760.
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
All children undergoing pyloric stenosis b/w1986 1990 in DenmarkComparedwith 5% agematched sample9th grade standardized educational testSmall % of Danish children do NOT take thesetestsVariables: sex, birth weight, parental educationand age.Exclusions: congenital malformation,hyperbilirubinemia, neonatal jaundice
RSI: Sux +thiopentalHalothane or isofluraneNo info on acid base orABG24 48 hours of fluid resuscitation pre op
Results
Pyloric Stenosis No Pyloric Stenosis
%male 80 51.6
Parental Age similar similar
Parental Education slightly lower
Mean BirthWeight (g) 3345 3434
Age at time of surgery 40 days
Congenitalmalformations
6.8% 4.4%
Non attainment boys 22% 16%
Non attainment girls 13% 10%OR=1.37
Conclusion
Mean test scores similar once low birthweight and congenital malformatin areexcludedHigher incidence of test Non Attainment inexposed patients boys > girls
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
100 children who had surgery < 1yr of age106 controlPerformance on “high stakes” test at age 12Diagnosis of “learning disability”Phone surveys
Figure 2
Figure 2. Frequency of distribution ofPrimary School Leaving Examination(PSLE) aggregate scores between subjectsand controls with and without learningdisability. LD = learning disability
Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams &Wilkins. 44
The Effects of Exposure to General Anesthesia in Infancy on Academic Performance at Age 12
Bong, Choon Looi; Allen, John Carson; Kim, Josephine Tan Swee
Anesthesia & Analgesia. 117(6):1419 1428, December 2013.
Table 2
Table 2. Summary of Multivariate Analysison Primary School Leaving Examination(PSLE) Aggregate Score
Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams &Wilkins. 45
The Effects of Exposure to General Anesthesia in Infancy on Academic Performance atAge 12
Bong, Choon Looi; Allen, John Carson; Kim, Josephine Tan Swee
Anesthesia & Analgesia. 117(6):1419 1428, December 2013.
Table 3
Table 3. Learning Disability Profiles forExposed and Control Groups
Copyright © 2014 International Anesthesia Research Society. Published by Lippincott Williams &Wilkins. 46
The Effects of Exposure to General Anesthesia in Infancy on Academic Performance at Age 12
Bong, Choon Looi; Allen, John Carson; Kim, Josephine Tan Swee
Anesthesia & Analgesia. 117(6):1419 1428, December 2013.
doi: 10.1213/ANE.0b013e318299a7c2
Problems with the Study
SmallRetrospectiveGA group was 90%maleMaternal educationslightly lowerLearning disabilitiesnot defined
Abstracts
ASA 2013
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
MultimodalAssessment of CognitiveOutcomesAssociatedWith Exposure toAnesthesia in EarlyChildhood Caleb H. Ing, M.D., Charles DiMaggio, Ph.D et.al.
WesternAustralian PregnancyCohort117/847 pts had surgery/anesthesia < 3yrsAt 10 year of age
Higher incidence of language problems and ICD9diagnosisNo difference in standardized tests Caffeine Potentiates Neurotoxicity of Isoflurane in the Fetal Macaque Brain
Ansgar M. Brambrink, M.D.,Ph.D., GregA. Dissen, Ph.D., Lauren D. Martin,V.M.D., StephenA. Johnson, No Degree, JohnW.Olney, M.D.Oregon Health & Sciences University, Portland, Oregon, United States
Prenatal Exposure to Propofol Induces Synaptic Loss and Long Term BehavioralDeficits in theOffspring Rats
Ming Xiong, M.D.,Ph.D., Jing Li, M.D.,Ph.D., H M.Alhashem, M.D., SergeyPisklakov, M.D., Steve Shulman, M.D., Jiang H.Ye, M.D., M.S., Alex Bekker,M.D.,Ph.D.UMDNJ, Newark, New Jersey, United States
Longer In UteroAnesthetic Exposure at Peak Cortical Neurogenesis ImpairsBehavior in Rats
VickoGluncic, M.D.,Ph.D., Jeffrey S. Kroin, Ph.D., Mario Moric, M.S., Amanda L.Persons, Ph.D., Leo Kelly, B.A., Kenneth J. Tuman, M.D.Rush University Medical Center, Chicago, Illinois, United States
Comparison of Neurodegeneration andCognitive Impairment in Neonatal MiceExposed to Propofol or Isoflurane
Soorena Khojasteh, M.D., Grace Liang, M.D., ZhenWu, Ph.D., HuafengWei,M.D.,Ph.D.University of Pennsylvania, Philadelphia, Pennsylvania, United States
Isoflurane Exposure in Neonatal Rats Is Not AssociatedWith Social Avoidance inEarly Adulthood
Jacqueline S. Lagoy, M.D., Meredith M. Pace, M.D., Michael G. Holmes, M.D.,Jennifer M.O'Donnell, Student, Christine D. Bub, Student, Kyle Jenks, B.S.,Michael L. Beach, M.D., Gregory L. Holmes, M.D., Rod Scott, M.D.,Ph.D., SimonC. Hillier, M.D.Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, United States
Should we wait?
What should we tellfamilies?Informed consent?
And now for something completelydifferent………
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Continuous nerve blocks
> 12oo patients254 with 2 catheters98.9% placed after general anesthesiaFull barrier protectionLow conc of ropivacaine for homePain service followed up with 1 2 phone callsper day
Pts with 2 catheters
Our Data
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Ketorolac
Trend towards lower clearance inyounger patients
Trend towards more rapid clearanceSmall #’sAppears safe
In 30 /300 critically ill infants 3 16 months old,IO was successfully used in emergencysurgeryMinor side effects extravasation and cellulitis
Children aged 2 6EMLA and rectal midazolam premedIV induction with 4mg/kg propofol + 2 ug/kgfentanyl +/ mivacuriumLess Heart rate variability with NMB thanwithout
Sevo inductionCaudal with bup 0.25% 1ml/lkgLMADixon up and downmethodologyED50 for airway removal 3.4%ED90 for airway removal 4.13%
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014
Come back next year
Agarwal, Rita, MD, FAAP Pediatric Anesthesia Update 2014