Marzena Zielińska

Pro–con debate: intravenous vs inhalation induction of anesthesia in children

IntroductionInduction of anesthesia in a child can often be arelaxed event, but this is not always the case. Theselection of approach and technique has some basisin scientific evidence and published data, but in real-ity the procedure is more complex. Induction ofanesthesia is not simply a technical exercise. Itinvolves a variety of rapid individual evaluations andjudgements relating to both child and parent, the sit-uation and to some extent the experience and prefer-ences of the individual anesthetic team on aparticular day.It is clear from the outset that one mode of induc-tion may be indicated over the other in particular clini-cal situations, but that in more general terms, it is nota case of one or the other. Most pediatric anesthetistsuse both induction methods at different times but usu-ally have a preference. The articles below thereforereflect the personal opinions of two experienced pediat-ric anesthetists who have kindly agreed to put a casefor each method. They have addressed the sciencewhere possible but also have given personalizedaccounts which will stimulate individual reflection onpractice and rationale.In support of intravenous induction of anesthesiaDr Marzena ZielinskaFor many children, the induction of anesthesia can behighly stressful and current estimations, indicate thatmore than 60% of children suffer anxiety in the pre-operative period (1). The reasons of this are complex:first, children are afraid of being separated from theirparents and home environment and this is com-pounded by unfamiliar routines, new strange people,frightening equipment such as anesthetic machine andsurgical instruments which all contribute to the processof building high levels of anxiety.Not surprisingly then, the method of induction canplay a crucial role in generation of perioperative anxi-ety. Pediatric anesthesiologists make a choice betweentwo recommended methods: inhalational or intra-venous. Traditionally, the inhalational method ofinduction of anesthesia is thought to be less harmfulfor children (2–4). In many textbooks of pediatricanesthesia, the potential fear of a needle among pediat-ric patients is stressed. But it is clear to experiencedanesthesiologists working with children that childrenare not only afraid of a needle but also a mask. Usu-ally, children struggle to accept the presence of anyforeign body on their face and they start to expresstheir dissatisfaction immediately after placing the maskclose to their face. This then becomes even less accept-able if the mask is then kept against their face despitetheir protests. Volatile agents have an unfamiliar andoften pungent smell causing even the most well-pre-pared child to lose composure when the concentrationof anesthetic gas is increased.

The current place of nitrous oxide in clinical practice An expert opinion-based task force consensus statement of the European Society of Anaesthesiology

Nitrous oxide (N2O) has been used for years as an essential part of general anaesthesia. During the past few decades, however, its use in general anaesthesia has steadily declined. Parallel to this evolution, we witness a growing interest in the use of N2O by nonanaesthesiologists, mainly as a sedative and adjuvant for pain therapy during procedural interventions.1–4 In line with this paradigm shift, heated debates, frequently blurred by strong emotional viewpoints, are questioning the current place of N2O during anaesthesia and during procedural sedation.5 In an attempt to search for up-to-date answers to these issues, the European Society of Anaesthesiology (ESA) convened a number of clinical experts to debate specifically on the following questions. 1. What is the place of N2O in todays perioperative anaesthesia management? 2. What is the place of N2O in procedural analgesia and sedation? 3. Is administration of N2O associated with a health risk for patients and/or providers? Members of the task force consisted of the chairs of the ESA Scientific Committee and Research Committee, and the chairs of the scientific subcommittees on Pharmacology, Paediatrics, and Monitoring, Ultrasound and Equipment. In addition, Western and Eastern European key opinion leaders on the use and place of N2O in adult and paediatric anaesthesia were asked to join the task force. The present consensus statement is the result of an intensive debate based on the available literature and the expert opinion of the task force members.

Pharmacokinetics of sufentanil during long‐term infusion in critically ill pediatric patients

The aim of this study was to develop a population pharmacokinetic model of sufentanil and to assess the influence of covariates in critically ill children admitted to a pediatric intensive care unit. After institutional approval, 41 children were enrolled in the study. Blood samples for pharmacokinetic (PK) assessment were collected from routinely placed arterial catheters during and after discontinuation of infusion. Population nonlinear mixed‐effects modeling was performed using NONMEM. A 2‐compartment model described sufentanil PK sufficiently. Typical values of the central and peripheral volume of distribution and the metabolic and intercompartmental clearance for a theoretical patient weighing 70 kg were VC = 7.90 l, VT = 481 L, Cl = 45.3 L/h, and Q = 38.3 L/h, respectively. High interindividual variability of all PK parameters was noted. Allometric/isometric principles to scale sufentanil PK revealed that to achieve the same steady‐state sufentanil concentrations in plasma for pediatric patients of different body weights, the infusion rate should follow the formula (infusion rate for a 70‐kg adult patient, μg/h) × (body weight/70 kg)0.75. Severity of illness described by PRISM score, the monitored physiological and laboratory parameters, and coadministered drugs such as vasopressors were not found to be significant covariates.

Do we really know the pharmacodynamics of anaesthetics used in newborns, infants and children? A review of the experimental and clinical data on neurodegeneration.

The practices of anaesthesiology and intensive therapy are difficult to imagine without sedation or general anaesthesia, regardless of whether the patient is a newborn, baby, child or adult. The relevant concerns for children are distinct from those for adults, primarily due to the effects of anatomical, physiological and pharmacokinetic-pharmacodynamic (PK/PD) differences, which become increasingly important in the brains of children as they develop. The process of central nervous system maturation in humans lasts for years, but its greatest activity (myelination and synaptogenesis) occurs during the fetal period and the first two years of life. Many experimental studies have demonstrated that exposure to anaesthetic drugs during this period can induce neurodegenerative changes in the central nervous systems of animals. The extrapolation of these results directly to humans must be performed with great caution, but anaesthesiologists around the world must begin to debate the safety of general anaesthesia in humans. Prospective trials should continue being carried out, and anaesthesia and surgery, delayed if possible among the smallest patients. The simultaneous use of different anaesthetics with the same potential neurotoxicities should also be avoided, potentially in favour of regional anaesthesia techniques, in this group of patients.

The use of nalbuphine in paediatric anaesthesia.

Nalbuphine is an agonist-antagonist opioid. It causes analgesic and sedative effect and because of ceiling effect it does not cause a respiratory depression. In a perioperative therapy of paediatric patients it may be used for premedication, sedation during diagnostic procedures as well as for postoperative pain treatment. It reverses adverse reactions of other opioids such as itch or urinary retention, not significantly influencing its analgetic properties. After sevoflurane anaesthesia of small children, it reduces the incidences of emergence agitation. Nalbuphine is considered a safe drug, which causes nausea and vomiting less frequently than other opioids. Analgesic effect, the ability to provide moderate sedation and a large margin of safety make that analgesic often used for paediatric patients.

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

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Beneficial effects of inhaled nitric oxide with intravenous steroid in an ischemia–reperfusion model involving aortic clamping

This study evaluated the effects of inhaled nitric oxide (iNO) therapy combined with intravenous (IV) corticosteroids on hemodynamics, selected cytokines, and kidney messenger RNA toll-like receptor 4 (mRNA TLR4) expression in ischemia–reperfusion injury animal model. The primary endpoint was the evaluation of circulatory, respiratory, and renal function over time. We also investigated the profile of selected cytokines and high-mobility group box 1 (HMGB1) protein, as well as renal mRNA TLR4 activation determined by quantitative real-time polymerase chain reaction analysis. Pigs (n = 19) under sevoflurane AnaConDa anesthesia/sedation were randomized and subjected to abdominal laparotomy and alternatively suprarenal aortic cross-clamping (SRACC) for 90 min or sham surgery: Group 1 (n = 8) iNO (80 ppm) + IV corticosteroids (25 mg ×3) started 30 min before SRACC and continued 2 h after SRACC release, followed with decreased iNO (30 ppm) until the end of observation, Group 2 (n = 8) 90 min SRACC, Group 3 (n = 3)—sham surgery. Renal biopsies were sampled 1 hr before SRACC and at 3 and 20 h after SRACC release. Aortic clamping increased TLR4 mRNA expression in ischemic kidneys, but significant changes were recorded only in the control group (P = 0.016). Treatment with iNO and hydrocortisone reduced TLR4 mRNA expression to pre-ischemic conditions, and the difference observed in mRNA expression was significant between control and treatment group after 3 h (P = 0.042). Moreover, animals subjected to treatment with iNO and hydrocortisone displayed an attenuated systemic inflammatory response and lowered pulmonary vascular resistance plus increased oxygen delivery. The results indicated that iNO therapy combined with IV corticosteroids improved central and systemic hemodynamics, oxygen delivery, and diminished the systemic inflammatory response and renal mRNA TLR4 expression.

Organic mononitrites of 1,2-propanediol act as an effective NO-releasing vasodilator in pulmonary hypertension and exhibit no cross-tolerance with nitroglycerin in anesthetized pigs

Purpose Clinically available intravenous (IV) nitric oxide (NO) donor drugs such as nitroglycerin (GTN) cause systemic hypotension and/or tolerance development. In a porcine model, novel NO donor compounds – the organic mononitrites of 1,2-propanediol (PDNO) – were compared to GTN with regard to pulmonary selectivity and tolerance development. The vasodilatory effects of inorganic nitrite were investigated. Materials and methods In anesthetized piglets, central hemodynamics were monitored. At normal pulmonary vascular resistance (PVR), IV infusions of PDNO (15–60 nmol kg−1 min−1), GTN (13–132 nmol kg−1 min−1), and inorganic nitrite (dosed as PDNO) were administered. At increased PVR (by U46619 IV), IV infusions of PDNO (60–240 nmol kg−1 min−1) and GTN (75–300 nmol kg−1 min−1) before and after a 5 h infusion of GTN (45 nmol kg−1 min−1) were given. Results At normal PVR, PDNO (n=12) and GTN (n=7) caused significant dose-dependent decreases in mean systemic and pulmonary arterial pressures, whereas inorganic nitrite (n=13) had no significant effect. At increased PVR, PDNO (n=6) and GTN (n=6) significantly decreased mean systemic and pulmonary pressures and resistances, but only PDNO reduced the ratio between pulmonary and systemic vascular resistances significantly. After the 5 h GTN infusion, the hemodynamic response to GTN infusions (n=6) was significantly suppressed, whereas PDNO (n=6) produced similar hemodynamic effects to those observed before the GTN infusion. Conclusion PDNO is a vasodilator with selectivity for pulmonary circulation exhibiting no cross-tolerance to GTN, but GTN causes non selective vasodilatation with substantial tolerance development in the pulmonary and systemic circulations. Inorganic nitrite has no vasodilatory properties at relevant doses.

Toxic epidermal necrolysis in an 8-year-old girl successfully treated with cyclosporin A, intravenous immunoglobulin and plasma exchange

Address for correspondence: Iwona Chlebicka MD, Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, 1 Chałubińskiego St, 50-638 Wroclaw, Poland, phone: +48 509 689 147, +48 509 689 147, fax: +48 509 689 147, e-mail: iwonak4wsk@interia.pl Received: 21.01.2017, accepted: 25.03.2017. Toxic epidermal necrolysis in an 8-year-old girl successfully treated with cyclosporin A, intravenous immunoglobulin and plasma exchange