Bogumiła Wołoszczuk-Gębicka

Pharmacokinetic–pharmacodynamic relationship of rocuronium under stable nitrous oxide–fentanyl or nitrous oxide–sevoflurane anesthesia in children

Background:  The aim of this study was to compare pharmacokinetics and pharmacokinetic–pharmacodynamic (PK–PD) relationship of rocuronium in children anesthetized with nitrous oxide (N2O) and fentanyl or with N2O and sevoflurane.

How to limit allogenic blood transfusion in children.

In children as in adults, allogenic blood transfusion may be lifesaving, but blood transfusions are accompanied by a number of risks such as blood incompatibilities, transmission of diseases, as well as immunological sensitization with subsequent early and late complications. The decision to transfuse a pediatric patient must be fully justified because the effects of transfusion complications are more longlasting than in adults, whose median age at transfusion may exceed 70 years (1). Parents’ preferences to avoid transfusions or to direct donor blood should also be taken into account when feasible. Another problem is that while blood transfusions have never been safer, the costs of blood products have never been greater. As data evaluating the efficacy of red blood cell (RBC) transfusion are largely lacking, clinical practice guidelines have been based on the opinion of experts who interpreted animal studies and limited human trials. The decision to transfuse should not rest on the hemoglobin concentration alone but must also be based on changes of the physiological parameters such as heart rate, blood pressure, ST-segment changes, mixed venous oxygen saturation, oxygen consumption and lactate concentration in the serum. In addition, the potential for continued blood loss postoperatively must be factored into the decision to transfuse. Finally, since the safety of blood products varies from country to country in terms of the potential for disease transmission and screening of that blood product, a lower hemoglobin value may be chosen over the marked risk of disease transmission with a transfusion (2).

Sevoflurane increases fade of neuromuscular response to TOF stimulation following rocuronium administration in children. A PK/PD analysis

Background:  Sevoflurane enhances neuromuscular block produced by rocuronium, affecting not only single twitch response but also the response to high‐frequency stimulation, increasing tetanic [or train‐of‐four (TOF)] fade.

Pharmacokinetics of sufentanil administered with 0.2% ropivacaine as a continuous epidural infusion for postoperative pain relief in infants

Our objective was to assess plasma sufentanil concentrations and postinfusion pharmacokinetics in infants receiving 0.2% ropivacaine with sufentanil as a continuous epidural infusion for postoperative pain relief.

Fentanyl with ropivacaine infusion for postoperative pain relief in infants and children. Kinetics of epidural fentanyl

The aim of the study was to evaluate pharmacokinetics of fentanyl administered as continuous epidural infusion with 0.2% ropivacaine for postoperative pain relief in infants and toddlers, and older children undergoing major abdominal and urological procedures.

Stanowisko Sekcji Pediatrycznej Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii w sprawie znieczulenia ogólnego dzieci do 3. roku życia

1Department of Anaesthesiology and Intensive Therapy, Children`s Memorial Health Institute in Warsaw, Poland 2Department of Paediatric Anaesthesiology and Intensive Therapy, Karol Marcinkowski University of Medical Sciences in Poznan, Poland 3Department of Paediatric Anaesthesiology and Intensive Therapy, University Hospital in Wroclaw, Poland 4Department of Anaesthesiology and Intensive Therapy, University Children Hospital in Cracow-Prokocim, Poland 5Department of Intensive Therapy and Anaesthesiology, Medical University in Łodz 6Department of Paediatric and neonatal Anaesthesiology and Intensive Therapy, Regional Medical Centre in Opole, Poland 7Department of Anaesthesiology, Intensive Therapy and Post-operative Care, University Children Hospital in Warsaw, Poland

Perioperative problems and treatment of a teenager with a juvenile angiofibroma refusing blood transfusion

OBJECTIVES Juvenile angiofibroma is a benign, non-encapsulated neoplasm, consisting of vascular and connective tissue. Its main feature is a local malignancy. In its clinical course it destroys adjoining structures, without metastasizing. It appears rarely, and is mainly found in boys at puberty. Among theories about the aetiology of juvenile angiofibroma, we must consider a haematoma-like lesion, an angioma with an extended fibrous component, or type of inflammatory allergic polyp. In the development of the lesion the participation of hormonal disorders on the pituitary gland-gonad axis is also suggested. According to the latest research, juvenile angiofibroma is regarded as a developmental defect, affecting the embryonic vascular network surrounding the sphenoid bone. METHODS If the patient or his/her parents refuse blood transfusion and use of blood products, it is necessary to apply modifications in the routine perioperative treatment. In the case of the patient refusing blood and blood products transfusion because of their beliefs, it is possible to get consent to use different, highly processed products like albumins or a cryoprecipitate, as well as applying some blood-saving techniques. CONCLUSIONS 1. Removal of juvenile angiofibroma with minimal bleeding is possible. 2. Applying erythropoietin and iron preparations prior to surgery increases erythropoiesis and reduces the risks in transfusion. 3. Applying intraoperative normovolaemic haemodilution is a safe method and allows avoidance of transfusion of blood-derived products.

Flip‐Flop Phenomenon in Epidural Sufentanil Pharmacokinetics: A Population Study in Children and Infants

The aims of this study were to develop a population pharmacokinetic model of sufentanil coadministered with 0.2% ropivacaine as an epidural infusion in infants and describe the sufentanil absorption profile from epidural space. Data from 2 previously published studies were merged for analysis—20 infants aged 3–36 months receiving sufentanil as an epidural infusion and 41 children 0–17 years old receiving sufentanil as a long‐term intravenous infusion. A population nonlinear mixed‐effects model was built in NONMEM. Sufentanil pharmacokinetics were described by a 2‐compartment model with first‐order absorption. The effect of body size on all volume and clearance parameters was included in the model according to allometric scaling with theoretical exponents. The maturation process of metabolic clearance was described by the Hill model. During the model‐building process the population was divided into 2 fractions with different typical values of metabolic clearance (CL1 and CL2). The typical values of systemic clearance scaled to a 70‐kg patient for the 2 subpopulations were CL1 = 52.6 L/h and CL2 = 158 L/h. The parameters of the Hill function were 54.9 weeks for the postmenstrual age of 50% clearance maturation and 0.802 for the Hill coefficient. The typical values of distribution clearance and volumes of the central and peripheral compartments for a patient with a weight of 70 kg were Q = 40.5 L/h, VC = 7.63 L, and VT = 473 L, respectively. The value of the absorption rate constant from the epidural space was 0.0459/h, which suggests flip‐flop pharmacokinetics of sufentanil after epidural administration.

Zastosowanie oktreotydu w leczeniu pooperacyjnego chłonkotoku u dzieci

Streszczenie Wstep Chlonkotok jest rzadkim, lecz powaznym powiklaniem zabiegow operacyjnych w obrebie klatki piersiowej. Przedluzający sie wyciek chlonki prowadzi do szeregu powiklan. Obecnie podejmuje sie proby farmakologicznego leczenia chlonkotoku z zastosowaniem somatostatyny lub jej analogow. Cel pracy Przedstawiamy trzy przypadki zastosowania oktreotydu w leczeniu chlonkotoku po zabiegach kardiochirurgicznych u dzieci. Material i metody W okresie od 2006 do 2008 oktreotyd zastosowano w trzech przypadkach chlonkotoku pooperacyjnego. We wszystkich przypadkach chlonkotok byl powiklaniem zabiegu kardiochirugicznego. W dwoch przypadkach zabieg wykonywano z powodu wrodzonej wady serca (mnogie VSD oraz koarktacja aorty), w jednym przypadku z powodu droznego przewodu tetniczego u wcześniaka. Wyniki Wiek dzieci w momencie wlączenia leczenia wynosil od 17, 22 i 80 dni, masa ciala od 870, 2800 i 3400 g. Oktreotyd stosowano we wlewie ciąglym w dawce od 5–10 μ/kg/godz przez 5, 6 i 7 dni. W dwoch przypadkach uzyskano ustąpienie chlonkotoku. W jednym przypadku po wlączeniu leczenia chlonkotok nieznacznie sie zmniejszyl, jednak nadal pozostawal istotny, co spowodowalo, ze dziecko poddano leczeniu operacyjnemu. W zadnym przypadku nie obserwowano skutkow ubocznych leczenia. Wnioski Oktreotyd stanowi nieinwazyjną alternatywe w leczeniu pooperacyjnego chlonkotoku u pacjentow po zabiegach chirurgicznych.