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Hosokawa M, Takahashi Y, Ueno T, Oe K, Masui K. Remimazolam anesthesia in pediatric patients undergoing cardiac catheterization for congenital heart disease: a retrospective observational study. J Anesth 2024:10.1007/s00540-024-03395-5. [PMID: 39153037 DOI: 10.1007/s00540-024-03395-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Benzodiazepines are used in pediatric patients with congenital heart disease (CHD) because of their mild hemodynamic depressant effects. A novel short-acting benzodiazepine, remimazolam, is expected to be suitable for these patients. We examined the characteristics of remimazolam anesthesia in pediatric patients with CHD undergoing cardiac catheterization. METHODS This single-center retrospective study included pediatric patients undergoing cardiac catheterization for CHD. The primary outcome was the remimazolam dose for loss of consciousness. Secondary outcomes included the mean maintenance remimazolam dose, recovery time from anesthesia, predicted remimazolam concentration at emergence, decrease in blood pressure and heart rate, vasopressor administration during anesthesia, electroencephalogram index (bispectral index: BIS or patient state index: PSI), and life-threatening adverse events. RESULTS Thirty-nine patients, aged 2 months to 16 years, were included. Thirty-three patients received a median [interquartile] midazolam dose of 0.10 [0.10-0.10] mg.kg-1 in the pre-anesthesia room. The remimazolam dose for loss of consciousness was 0.34 [0.26-0.45] mg.kg-1. The mean maintenance dose was 1.0 [0.8-1.4] mg.kg-1.h-1. The recovery time was 15 [12-17] min. The predicted remimazolam concentration at emergence was 0.4-1.2 µg.ml-1 in 3-6-year-old patients. Blood pressure and heart rate decreased by 30% in 15 and 6 patients, respectively. Vasopressors were administered as a bolus in 8 patients. The BIS or PSI did not fall ≤ 60 or ≤ 50, respectively, in 51% of patients before tracheal intubation. No life-threatening adverse events were reported. CONCLUSIONS Remimazolam is a good alternative anesthetic agent for pediatric patients undergoing cardiac catheterization for CHD.
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Affiliation(s)
- Maiko Hosokawa
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Yurie Takahashi
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Takahiro Ueno
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Katsunori Oe
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Kenichi Masui
- Department of Anesthesiology, Yokohama City University School of Medicine, Fukuura 3-9, Kanazawa-Ku, Yokohama, 236-0004, Japan.
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Albertz M, Ing RJ, Schwartz L, Navaratnam M. Error traps in patients with congenital heart disease undergoing noncardiac surgery. Paediatr Anaesth 2024. [PMID: 39092610 DOI: 10.1111/pan.14971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.
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Affiliation(s)
- Megan Albertz
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, California, USA
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Hamilton ARL, Odegard KC, Yuki K. Exploring Noncardiac Surgical Needs From Infancy to Adulthood in Patients With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2022; 36:4364-4369. [PMID: 36216687 DOI: 10.1053/j.jvca.2022.09.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/04/2022] [Accepted: 09/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES As life expectancy for patients born with congenital heart disease (CHD) continues to rise, these patients will present increasingly for noncardiac surgery during childhood and adolescence. This study aimed to map the lifespan of noncardiac surgical needs among patients with CHD and explore how these needs may change over time. DESIGN All patients with CHD presenting for noncardiac surgery between 2008 and 2014 were selected for review. SETTING The study was conducted at a single urban academic tertiary pediatric hospital. PARTICIPANTS All patients with CHD presenting for noncardiac surgery during the study period were included and grouped by cardiac diagnosis. INTERVENTIONS Descriptive analysis included patient demographics, CHD diagnosis, procedures performed, and clinical data, including baseline saturation and underlying cardiac function. MEASUREMENTS AND MAIN RESULTS A total of 3,011 noncardiac surgical procedures were performed on patients with CHD during the study period. The most common CHD diagnoses were patent ductus arteriosus (27.6%), ventricular septal defects (24.7%), and patent foramen ovale (24.3%). The median age was 4 years, 87% of all the patients were ≤10 years, and 41% had associated syndromes. Of the patients, 76% underwent a preoperative echocardiogram, and 10% had depressed cardiac function at the time of surgery. The most common procedures performed were ear, nose, and throat (20%), general surgery (14%), and radiology (11%). Intraoperative events were reported in 488 out of 3,010 encounters (16.2%), with the highest rates reported in patients with single-ventricle physiology (55/179; 30.7%). CONCLUSIONS These findings suggested a greater burden of noncardiac surgery in lower age groups, with ear, nose, and throat and general surgery most common in young children and orthopedic and dental procedures increasing in adolescence.
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Affiliation(s)
- A Rebecca L Hamilton
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA; Department of Cell and Molecular Biology, Karolinska Institute, Stockholm, Sweden.
| | - Kirsten C Odegard
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA
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Kaufmann J, Schindler E. [Safe and Appropriate Pharmacotherapy in Paediatric Anaesthesia]. Anasthesiol Intensivmed Notfallmed Schmerzther 2022; 57:523-535. [PMID: 36049737 DOI: 10.1055/a-1690-5603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Safe and appropriate pharmacotherapy in children requires knowledge of age-group-specific features regarding pharmacology and drug dosing. In addition, aspects of medication safety must be considered. This review highlights basic principles and discusses key facts; further research in paediatric databases is recommended (www.kinderformularium.de).
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Sebastian R, Ullah S, Motta P, Das B, Zabala L. Anesthetic Considerations in Pediatric Patients With Acute Decompensated Heart Failure. Semin Cardiothorac Vasc Anesth 2021; 26:41-53. [PMID: 34730043 DOI: 10.1177/10892532211044977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute decompensated heart failure (ADHF) in pediatrics is a significant cause for morbidity and mortality in children. Congenital heart disease and cardiomyopathy are the leading etiologies of ADHF. It is common for these children to undergo diagnostic, therapeutic, or surgical procedure under anesthesia, which may be associated with significant morbidity and mortality. The importance of preanesthetic multidisciplinary planning with all involved teams, including anesthesia, cardiology, intensive care, perfusion, and cardiac surgery, cannot be emphasized enough. In order to safely manage these patients, it is imperative for the anesthesiologist to understand the complex pathophysiological interactions between cardiopulmonary systems and anesthesia during these procedures. This review discusses the etiology, pathophysiology, clinical manifestations, and perioperative management of these patients.
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Affiliation(s)
- Roby Sebastian
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
| | - Sana Ullah
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
| | - Pablo Motta
- Perioperative and Pain Medicine, 3989Baylor College of Medicine Houston, TX, USA.,Texas Children's Hospital, Arthur S. Keats Division of Pediatric Cardiovascular Anesthesiology, Houston, TX, USA
| | - Bibhuti Das
- Department of Pediatrics, Department of Pediatric Cardiology, 3989Baylor College of Medicine, Austin, TX, USA.,Texas Children's Hospital Austin Specialty Center, Austin, TX, USA
| | - Luis Zabala
- Department of Anesthesiology and Pain Management, 248024University of Texas Southwestern, Dallas, TX, USA.,Children's Medical Center of Dallas, Anesthesiology and Pain Management, Dallas, TX, USA
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Vernamonti J, Gadepalli SK. Non-cardiac surgical considerations in pediatric patients with congenital heart disease. Semin Pediatr Surg 2021; 30:151036. [PMID: 33992307 DOI: 10.1016/j.sempedsurg.2021.151036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jack Vernamonti
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA.
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Luo RY, Luo C, Zhong F, Shen WY, Li H, Zhang YL, Dai RP. Early-Life Multiple Sevoflurane Exposures Alleviate Long-term Anxiety-Like Behaviors in Mice via the proBDNF/ERK Pathway. Mol Neurobiol 2021; 58:170-183. [PMID: 32910421 DOI: 10.1007/s12035-020-02113-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
Early-life multiple anesthetics exposure causes neurotoxicity and hence cognitive dysfunction on developing brain. However, the effects of early-life multiple sevoflurane exposures on emotional changes, especially upon stress, are far beyond understood. In young male C57BL6/J mice, the present study showed that 3% sevoflurane inhalation for 2 h in three consecutive days did not influence anxiety-like behaviors as measured by open field test, light dark transition, and elevated plus maze test. In addition, foot shocks stress induced both the short- and long-term anxiety-like behaviors. However, triple sevoflurane exposures ameliorated the long-term anxiety-like behaviors induced by the foot shocks. In parallel, foot shocks stress upregulated the expression of phosphorylated extracellular signal-regulated kinase (p-ERK) and brain-derived neurotrophic factor precursor (proBDNF) in the anterior cingulate cortex (ACC), which were significantly inhibited by triple sevoflurane exposures. Immunofluorescence further indicated that the increased p-ERK was mainly expressed in the proBDNF-positive staining cells. Intra-ACC injection of recombinant proBDNF protein upregulated the p-ERK expression and blocked the anxiolytic effect of sevoflurane exposure on long-term anxiety-like behaviors. Therefore, our study demonstrated that multiple sevoflurane exposures alleviate long-term anxiety-like behaviors upon acute stress in young mice by inhibiting proBDNF-ERK signaling in the ACC.
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Affiliation(s)
- Ru-Yi Luo
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China
- Anesthesia Medical Research Center, Central South University, Changsha, China
| | - Cong Luo
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China.
- Anesthesia Medical Research Center, Central South University, Changsha, China.
| | - Feng Zhong
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China
- Anesthesia Medical Research Center, Central South University, Changsha, China
| | - Wei-Yun Shen
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China
- Anesthesia Medical Research Center, Central South University, Changsha, China
| | - Hui Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China
- Anesthesia Medical Research Center, Central South University, Changsha, China
| | - Yan-Ling Zhang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China
- Anesthesia Medical Research Center, Central South University, Changsha, China
| | - Ru-Ping Dai
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Central Ren-Min Road No. 139, Changsha, 410011, Hunan Province, China.
- Anesthesia Medical Research Center, Central South University, Changsha, China.
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Schure A. Anaesthesia risks for non-cardiac procedures in cardiac patients. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s2.2515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The number of patients with complex congenital heart disease (CHD) presenting for non-cardiac procedures is steadily increasing and more and more anaesthesiologists will be asked to participate in their care. This can be a very challenging task and will require adequate planning and preparation, but also some basic scientific inquiries.
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Dennhardt N, Elfgen-Schiffner FD, Keil O, Beck CE, Heiderich S, Sümpelmann R, Nickel K. Effect of etomidate on systemic and regional cerebral perfusion in neonates and infants with congenital heart disease: A prospective observational study. Paediatr Anaesth 2020; 30:984-989. [PMID: 32767521 DOI: 10.1111/pan.13977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/15/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonates and infants with congenital heart disease undergoing general anesthesia have an increased risk for critical cardiovascular events. Etomidate produces very minimal changes in hemodynamic parameters in older children with congenital heart disease. There is a lack of studies evaluating the effect of etomidate on systemic and regional cerebral perfusion in neonates and infants with congenital heart disease. AIM The aim of this prospective observational study was to evaluate the effect of etomidate on systemic and regional cerebral perfusion in neonates and infants with congenital heart disease. METHODS In fifty infants aged 0-11 months (24% neonates n = 12) with congenital heart disease, mean arterial blood pressure, cardiac index using electrical cardiometry, and regional cerebral oxygen saturation using near-infrared spectroscopy were measured at baseline and 1, 3, 5, and 10 minutes after induction by 0.4 mg kg-1 etomidate. Hypotension was defined as a mean arterial blood pressure under 35 mm Hg and cerebral desaturation as a regional cerebral oxygen saturation of less than 80% of baseline. RESULTS Mean arterial blood pressure, cardiac index, and regional cerebral oxygen saturation remained stable above the predefined limits. Mean arterial blood pressure decreased slightly within a physiological range after 3 minutes (P = .005, 95% CI:-5.9 to -1.0). No significant change in cardiac index could be observed. CONCLUSION Etomidate 0.4mg kg-1 does not impair systemic or regional cerebral perfusion in neonates or infants with congenital heart disease.
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | | | - Oliver Keil
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Christiane E Beck
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Sebastian Heiderich
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Robert Sümpelmann
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
| | - Katja Nickel
- Clinic for Anesthesiology and Intensive Care Medicine, Hanover Medical School, Hanover, Germany
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Loomba RS, Gray SB, Flores S. Hemodynamic effects of ketamine in children with congenital heart disease and/or pulmonary hypertension. CONGENIT HEART DIS 2018; 13:646-654. [DOI: 10.1111/chd.12662] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Rohit S. Loomba
- Department of Pediatrics The Heart Institute, Advocate Children’s Hospital Oak Lawn Illinois
| | - Seth B. Gray
- Department of Pediatrics, Division of Cardiology The Hospital for Sick Children Toronto Ontario Canada
| | - Saul Flores
- Department of Pediatrics, Section of Critical Care and Cardiology Texas Children’s Hospital, Baylor College of Medicine Houston Texas
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