Paediatric anaesthesia
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Paediatric anaesthesia · Jan 2015
ReviewAnesthesia-related neurotoxicity and the developing animal brain is not a significant problem in children.
A multitude of animal studies have shown that virtually all general anesthetics used in clinical practice possibly during a vulnerable period of brain development (i.e., brain growth spurt, peak of synaptogenesis) may lead to neurodegeneration (particularly apoptosis) and abnormal synaptic development with functional deficits in learning and behavior later in life. Initial studies were mainly performed in immature rodent pups, but more recent studies have included nonhumans primates (rhesus monkeys). Given the number of neonates, infants, and young children anesthetized annually worldwide, these findings could have significant public health implications. ⋯ Multiple anesthetic and surgical exposures on the other hand are different. But there may be other reasons for this than merely the anesthetics. Currently, there is no need to change current anesthetic clinical practice or to postpone or cancel truly urgent surgeries in young children.
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Paediatric anaesthesia · Jan 2015
ReviewAwake caudals and epidurals should be used more frequently in neonates and infants.
The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. ⋯ Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.
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Paediatric anaesthesia · Jan 2015
ReviewBradycardia in perspective-not all reductions in heart rate need immediate intervention.
According to Wikipedia, the word 'bradycardia' stems from the Greek βραδύς, bradys, 'slow', and καρδία, kardia, 'heart'. Thus, the meaning of bradycardia is slow heart rate but not necessarily too slow heart rate. ⋯ In fact, they withstand these episodes without incident, accommodating with a compensatory increase in stroke volume to preserve and maintain cardiac output. With this in mind, it is difficult for the authors to fully understand and agree with the general sentiment amongst many pediatric anesthesiologists that all isolated bradycardia portends impending doom and must be immediately treated with resuscitative measures.
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Paediatric anaesthesia · Jan 2015
ReviewMonitoring depth of anesthesia: from consciousness to nociception. A window on subcortical brain activity.
Anesthesia results from several inhibitor processes, which interact to lead to loss of consciousness, amnesia, immobility, and analgesia. The anesthetic agents act on the whole brain, the cortical and subcortical areas according to their receptor targets. The conscious processes are rather integrated at the level of the cortical neuronal network, while the nonconscious processes such as the nociception or implicit memory require subcortical processing. ⋯ Basically, the skin conductance might be the most adapted to assess the stress in the awake or sedated neonate, while the performances of this method appear disappointing under anesthesia. The surgical pleth index is still poorly investigated in children. The analgesia nociception index showed promising results in adults, which have to be confirmed, especially in children and in infants, and lastly pupillometry, which can be considered as reliable and reactive in children as in adults, but which is still sometimes complicated in its use.
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Paediatric anaesthesia · Jan 2015
ReviewPediatric airway anatomy may not be what we thought: implications for clinical practice and the use of cuffed endotracheal tubes.
One of the long held tenets of pediatric anesthesia has been the notion that the pediatric airway is conical shape with the narrowest area being the cricoid region. However, recent studies using radiologic imaging techniques (magnetic resonance imaging and computed tomography) or direct bronchoscopic observation have questioned this suggesting that the narrowest segment may be at or just below the glottic opening. More importantly, it has been clearly demonstrated that the airway is elliptical in shape rather than circular with the anterior-posterior dimension being greater than the transverse dimension. ⋯ The following article reviews the historical data leading to the assumption that the pediatric airway is conical as well as the more recent imaging and direct bronchoscopic observational studies which refute this tenet. The transition to the use of cuffed ETTs is discussed and potential advantages presented in both the operating room and the intensive care unit. Issues regarding the monitoring of intracuff pressure and techniques to limit potential morbidity related to a high intracuff pressure are outlined.