pediatric anesthesia update 2014 - denver, colorado · pediatric anesthesia update 2014 rita...

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


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


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


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


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.


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


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


The Effects of Exposure to General Anesthesia in Infancy on Academic Performance atAge 12



Table 3

Table 3. Learning Disability Profiles forExposed and Control Groups


The Effects of Exposure to General Anesthesia in Infancy on Academic Performance at Age 12



doi: 10.1213/ANE.0b013e318299a7c2

Problems with the Study

SmallRetrospectiveGA group was 90%maleMaternal educationslightly lowerLearning disabilitiesnot defined

Abstracts

ASA 2013


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………


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


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%


Come back next year


pediatric anesthesia update 2014 - denver, colorado · pediatric anesthesia update 2014 rita...

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