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Naguib AN, Bozych M, McNally K, Galantowicz M, Tobias J. Achieving Neuroprotection in the Setting of Early Extubation During Infant Cardiac Surgery: A Prospective, Randomized, and Blinded Study. Cardiol Res 2025; 16:178-188. [PMID: 40370628 PMCID: PMC12074690 DOI: 10.14740/cr2029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2025] [Accepted: 04/10/2025] [Indexed: 05/16/2025] Open
Abstract
Background This study aimed to investigate the impact of early extubation on stress response and neurodevelopmental outcomes after pediatric cardiac surgery utilizing cardiopulmonary bypass (CPB). Methods In this single-center prospective pilot study, we attempted to study the impact of using dexmedetomidine as an adjunct to facilitate early extubation after pediatric cardiac surgery requiring CPB during the first year of life. The study was conducted between May 2014 and January 2020. Perioperative data and stress hormone levels were collected at different points during the perioperative period. In addition, neurodevelopmental outcome measures including cognitive composite score, language (expressive and receptive) and motor (fine and gross) composites were evaluated at five time points including prior to surgery and up to 1 year after the procedure. Two-sample t-tests and Kruskal-Wallis tests were used to compare continuous parametric and non-parametric outcomes, respectively. Fisher's exact or Chi-squared tests were used to compare categorical outcomes. Results A total of 30 subjects were included in the final cohort of patients. Of the 30 subjects, 14 patients were randomized to the dexmedetomidine group (dexmedetomidine plus fentanyl) (DEX group) and 16 patients were randomized to the no dexmedetomidine group (fentanyl only) (no DEX group). With few exceptions, both groups demonstrated appropriate blunting of the stress response. There was a significant increase in the ratio of the pro-inflammatory interleukin-10 (IL-10) to the anti-inflammatory interleukin-6 (IL-6) for the no DEX group at the end of the procedure when compared to the DEX group (10 ± 9 vs. 5 ± 4, P = 0.04). When looking at the Bayley cognitive composite score, the DEX group scored better than the no DEX group during the second visit (102 ± 11 vs. 88 ± 17, P = 0.023). By the fifth visit, the two groups scored similarly (94 ± 12 vs. 94 ± 12, P = 0.9 for the no DEX and DEX groups, respectively). Conclusion When looking at the neurodevelopmental outcome, both groups had no significant changes in their Bayley scores from baseline with blunting of most stress markers. This study offers possible evidence of the safety of early extubation after pediatric cardiac surgery while maintaining the goal of neuroprotection.
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Affiliation(s)
- Aymen N. Naguib
- Departments of Anesthesiology and Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Marc Bozych
- Departments of Anesthesiology and Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kelly McNally
- Department of Pediatric Psychology and Neuropsychology, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mark Galantowicz
- The Heart Center, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Departments of Anesthesiology and Pediatrics, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
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Elhoff JJ, Acosta S, Flores S, LaSalle J, Loomba R, McGetrick M, McKinney C, Ostrom M, Pande CK, Schlosser R, Schwab S, Savorgnan F. Parental holding of infants improves haemodynamics in the cardiac ICU. Cardiol Young 2024; 34:1004-1009. [PMID: 38014584 DOI: 10.1017/s1047951123003931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.
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Affiliation(s)
- Justin J Elhoff
- Department of Pediatrics, Pediatrix Medical Group, Sunrise Children's Hospital, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
| | - Sebastian Acosta
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | - Rohit Loomba
- Department of Pediatrics, Advocate Children's Hospital, Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Molly McGetrick
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Chetna K Pande
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Fabio Savorgnan
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Tamvaki E, Giannakopoulou M, Bozas E, Zachpoulou D. Use of Biomarkers to Objectively Evaluate Pain in Critically Ill Children: A Scoping Review. Crit Care Nurse 2024; 44:55-66. [PMID: 38295869 DOI: 10.4037/ccn2024257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Many studies have been conducted recently to identify biomarkers that could potentially be used to objectively evaluate pain. OBJECTIVE To synthesize and critically analyze primary studies of endogenous biomarkers and their associations with pain to identify suitable biomarkers for the objective evaluation of pain in critically ill children. METHODS PubMed, Scopus, and Ovid databases were searched; searches were restricted by publication date, language, species, and participant age. Critical appraisal tools and the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used to evaluate quality of evidence. RESULTS All included articles were coded according to methods and findings. Saliva, blood, cerebrospinal fluid, and gingival crevicular fluid were used to detect biomarkers. Enzyme-linked immunosorbent assays were used in most studies (64%). Appropriate statistical analyses were performed at a significance level of P < .05 in included studies. Cytokines, peptides, and hormones were associated with pain, stress, and inflammatory response, suggesting that they can be used to screen for pain in children during painful conditions. Only 1 study in neonates did not show any correlation between saliva biomarkers and pain. CONCLUSION According to this literature review, various biomarkers that are easily obtained and measured in a clinical setting are associated with pain in children. Further investigation of these biomarkers through observational studies is suggested to evaluate their suitability for pain assessment in critically ill children.
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Affiliation(s)
- Eleni Tamvaki
- Eleni Tamvaki is a registered nurse in pediatric intensive care and a clinical researcher in inherited and rare diseases, Great Ormond Street Hospital for Children, London, England
| | - Margarita Giannakopoulou
- Margarita Giannakopoulou is a professor in the Department of Nursing and the Director of the Clinical Nursing Applications Laboratory, National and Kapodistrian University of Athens, Greece
| | - Evangelos Bozas
- Evangelos Bozas is a biologist in the Department of Nursing, National and Kapodistrian University of Athens
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Bashiryan BA, Gadzhieva OA, Satanin LA, Mazerkina NA, Khukhlaeva EA, Lavrenyuk EA, Tere VA, Kwan OK, Roginsky VV. [Prospective assessment of surgical stress response in patients with craniosynostosis: comparison of clinical and laboratory data]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2024; 88:62-70. [PMID: 39169583 DOI: 10.17116/neiro20248804162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
BACKGROUND Highly traumatic surgical correction of craniosynostosis (CS) is usually followed by severe postoperative period and high risk of complications. Surgical stress response (SSR) is an important and often neglected cause of severe early postoperative period. OBJECTIVE To compare clinical and laboratory parameters of SSR in children who underwent various surgeries for CS. MATERIAL AND METHODS The study included 63 patients aged 7.02±4.12 months. All ones underwent surgery for CS between October 2021 and June 2022. We analyzed clinical and laboratory markers of SSR, as well as correlation with severity of surgical stress. RESULTS No surgical complications were observed. There were postoperative complications in 12 (19.0%) cases including febrile fever in 9 (14.3%) patients, severe pain and edematous syndromes with prolonged hospital-stay in 3 (4.8%) cases. Significant correlations were revealed between severity of surgical stress and certain laboratory markers (CRP, ACTH, T3, insulin, HOMA-IR). The last ones characterized SSR severity. Patients with high scores of stress response demonstrated more severe course of early postoperative period. CONCLUSION Surgical stress scale makes it possible to predict early postoperative period and optimize patient management. Lower severity of surgical stress response following endoscopic interventions is another reason for the wider use of low-traumatic surgical methods in pediatric neurosurgery.
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Affiliation(s)
| | | | - L A Satanin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - V A Tere
- Burdenko Neurosurgical Center, Moscow, Russia
| | - O K Kwan
- Burdenko Neurosurgical Center, Moscow, Russia
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Kesumarini D, Widyastuti Y, Boom CE, Dinarti LK. Dexmedetomidine as a myocardial protector in pediatric heart surgery using cardiopulmonary bypass: a systematic review. Ann Med Surg (Lond) 2023; 85:5075-5084. [PMID: 37811026 PMCID: PMC10553181 DOI: 10.1097/ms9.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023] Open
Abstract
Background In recent years, dexmedetomidine has been studied as a cardioprotective agent. However, studies on its application in pediatric heart surgery using cardiopulmonary bypass (CPB) remain limited. This systematic review aimed to provide information on the cardioprotective effect of dexmedetomidine in children undergoing heart surgery using CPB. Methods The authors searched several databases (MEDLINE, Embase, Cochrane Library, etc.) to identify all trials comparing the levels of myocardial injury via biomarkers, including pediatric patients undergoing heart surgery using CPB who received dexmedetomidine versus placebo or other anesthetic agents. Literatures from non-primary studies were excluded. Two reviewers independently screened studies for eligibility and extracted data. The Cochrane Risk-of-Bias tool was implemented to evaluate any potential biases. Information from eligible studies was summarized and correspondingly reviewed based on any quantitative outcomes. Results We identified six trials composed of 419 participants, three of which (n=241) showed significantly reduced interleukin-6 (IL-6) levels in the dexmedetomidine group, while one study (n=40) showed no IL-6 difference between groups. Cardiac troponin I (cTnI) and creatinine kinase-myocardial band (CK-MB), as myocardial injury biomarkers, were found to be lower in two trials (n=180). Despite several limitations hindering this review from pooling the data objectively, the majority of published studies indicated that dexmedetomidine is a seemingly efficacious agent protecting against cardiac injury during bypass. Conclusions These studies suggest that dexmedetomidine has cardioprotective effects through the lowering of cardiac injury biomarkers while improving its clinical outcomes after heart surgery using bypass.
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Affiliation(s)
- Dian Kesumarini
- Department of Anesthesia and Intensive Therapy, National Cardiovascular Center Harapan Kita, Jakarta
- Doctoral Programme, Faculty of Medicine and Public Health University of Gadjah Mada
| | - Yunita Widyastuti
- Department of Anesthesia and Intensive Therapy, University of Gadjah Mada/Dr. Sardjito Hospital
| | - Cindy E. Boom
- Department of Anesthesia and Intensive Therapy, National Cardiovascular Center Harapan Kita, Jakarta
| | - Lucia K. Dinarti
- Department of Cardiology and Vascular Medicine, University of Gadjah Mada/Dr. Sardjito Hospital, Yogyakarta, Indonesia
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Scharoun J, Rong LQ. The evolving role of dexmedetomidine in pediatric cardiac surgery: Beyond anxiolysis. J Card Surg 2022; 37:4243-4245. [PMID: 35748296 PMCID: PMC9789201 DOI: 10.1111/jocs.16706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Jacques Scharoun
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
| | - Lisa Q. Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY, USA
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Kaushik J, Vijayakumar R, Soundaravalli B, Shoba M, Jenit O, Anisha S. One-year experience after adoption of an on-table extubation protocol following pediatric cardiac surgery. Ann Card Anaesth 2022; 25:422-428. [PMID: 36254905 PMCID: PMC9732950 DOI: 10.4103/aca.aca_58_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 06/16/2023] Open
Abstract
OBJECTIVE To report our initial experience with on-table extubation following cardiac surgery for congenital heart disease, assessing its efficacy and safety, and the potential for fast-tracking these patients through the intensive care unit (ICU). METHODS We decided to implement a multidisciplinary protocol aiming toward on-table extubation following congenital cardiac surgery at our hospital. Between December 2018 and January 2020, 376 patients underwent congenital cardiac surgery. The management strategy involved choosing the patients preoperatively, a specific anesthetic technique, application of a standard extubation protocol, multidisciplinary team approach, and perioperative echocardiogram for assessment of surgical repair. Relevant data were collected and analyzed. RESULTS Out of the 376 patients who underwent congenital cardiac surgery during the study period, 44 patients were extubated on-table. Although a majority of these patients belonged to Risk Adjustment for Congenital Heart Surgery-1 score (RACHS-1) 1 and 2 categories, 18% of the patients who were extubated on-table were of RACHS-3 category. This included a wide spectrum of anatomical substrates such as endocardial cushion defects, pulmonary venous anomalies, single ventricle physiology, valvular defects, and others such as cor triatriatum and sinus of Valsalva aneurysm. There was no in-hospital mortality related to on-table extubation. Only one patient was reintubated following on-table extubation resulting in a reintubation rate of 2.27% among those patients extubated on-table. The patients extubated on-table had a shorter ICU stay (25.89 ± 7.20 h) compared with those patients who underwent delayed extubation (59.30 ± 6.80 h). The duration of the hospital stay was also significantly reduced in these patients (91.09 ± 20.40 h) leading to an earlier discharge compared with those patients who underwent delayed extubation (134.40 ± 16.20 h). CONCLUSION On-table extubation is an attractive alternative in limited-resource environments to enhance recovery in patients following congenital cardiac malformations. Owing to the lack of significant comorbidities such as Chronic Obstructive Pulmonary Disease (COPD) in this patient population, corrective surgery for cardiac malformation usually optimizes the cardiorespiratory status. This results in more chances of successful extubation immediately following surgery. However, this requires proper perioperative planning, a careful discussion about the choice of patients, adoption of an extubation protocol, and most importantly, a multidisciplinary team approach. It is associated with low morbidity and mortality, with reduced length of stay in the ICU and hospital. This preliminary study demonstrated that on-table extubation is feasible following congenital cardiac surgery at our center and greatly reduces the intensive care requirements. This article focuses mainly on the decision-making process which determines the ideal candidates for on-table extubation and the anesthetic protocol implemented in a low-resource environment to enable the same.
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Affiliation(s)
- Jothinath Kaushik
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Raju Vijayakumar
- Department of Cardiac Anesthesiology, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | | | - Menon Shoba
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
| | - Osborn Jenit
- Department of Community Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Shajan Anisha
- Department of Cardiac Surgery, G Kuppuswamy Naidu Memorial Hospital, Coimbatore, Tamil Nadu, India
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Gil D, Aljiffry A, Dryer R, Rao N, Figueroa J, Downey L, Shaw FR, Beshish AG. Extubation delays and the associated prostaglandin and opiate dose following coarctation of the aorta repair. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
BACKGROUND The usefulness of ultra-fast track cardiac anaesthesia may give great benefits to patients; however, its usefulness has not been completely evaluated in infants and toddlers, who are generally considered the most difficult group for ultra-fast track cardiac anaesthesia. METHOD A total of 130 children were allocated randomly into to a ultra-fast track cardiac anaesthesia group (Group D) or a conventional anaesthesia group (Group C) (each n = 65). In Group D, dexmedetomidine was administrated at a dosage of 1 µg/kg/hour after induction. The patient- controlled intravenous analgesia was dexmedetomidine and sufentanil. In Group C, patients were infused with of the same volume of normal saline, and sufentanil alone for patient-controlled intravenous analgesia. The dosages of sufentanil, extubation time, haemodynamic parameters, postoperative hospitalisation conditions, pain and sedation scores, blood gas analysis, and inotropic scores were all recorded. RESULTS The dosage of sufentanil (1.49 ± 0.05 vs. 3.81 ± 0.04 µg, p < 0.001) and extubation time (2.63 ± 0.52 vs. 436.60 ± 22.19 minutes, p < 0.001) in Group D were all significantly lower than those in Group C. Moreover, cardiac intensive care unit stay time, total hospital stay, hospitalisation costs, postoperative lactate levels, and inotropic scores were also significantly lower in Group D. CONCLUSIONS Using of ultra-fast track cardiac anaesthesia in infants and toddlers is effective, it not only reduce the perioperative requirement for opioids and shorten the extubation time but also decreases the inotrope requirement and provide a better postoperative condition for young children.
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Abstract
The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7AS, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
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Zhou W, Wang J, Yang D, Tian S, Tan C, Yang Y, Sui W, Sun J, Zhang Z. Effects of dexmedetomidine on glucose-related hormones and lactate in non-diabetic patients under general anesthesia: a randomized controlled trial. Minerva Anestesiol 2021; 88:8-15. [PMID: 34709010 DOI: 10.23736/s0375-9393.21.15734-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To explore the effects of dexmedetomidine on glucose-related hormones and lactate levels in non-diabetic patients undergoing malignant gastrointestinal tumor radical resection. METHODS Groups D1 and D2 received dexmedetomidine loading dose 1 μg/kg and maintenance dose 0.25 and 0.5 μg/kg/h, respectively. Group C received saline solution. Glucose, lactate, insulin, glucagon, cortisol, epinephrine, norepinephrine and dopamine levels were measured before dexmedetomidine infusion (T1), 1 h after surgery beginning (T2), at surgery ending (T3), and 1 h after transfer to the post-anesthesia care unit (T4). RESULTS Compared with group C, glucose levels increased in group D2 at T2 and reduced in groups D1 and D2 at T4. Lactate levels reduced in groups D1 and D2 at T4. A positive correlation between glucose and lactate levels was found in all groups. Compared with group C, insulin level reduced in group D2 at T2; glucagon levels reduced in groups D1 and D2 at T4; cortisol levels reduced in group D1 at T4 and in group D2 at T3 and T4; epinephrine and norepinephrine levels reduced in group D1 at T4 and in group D2 at T2 and T4; and dopamine level reduced in group D2 at T4. CONCLUSIONS Dexmedetomidine loading dose 1 μg/kg and maintenance dose 0.25 μg/kg/h produces a stable insulin level and significant postoperative decreases in glucagon, cortisol, epinephrine and norepinephrine secretion with stable maintenance of intraoperative and postoperative blood glucose levels and decreased postoperative lactate levels in non-diabetic patients under general anesthesia.
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Affiliation(s)
- Wei Zhou
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Jiahua Wang
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China.,School of Medicine, Yangzhou University, Yangzhou, China
| | - Dawei Yang
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Shunping Tian
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Chao Tan
- School of Medicine, Yangzhou University, Yangzhou, China
| | - Yang Yang
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Wei Sui
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Jianhong Sun
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Zhuan Zhang
- Department of Anesthesiology, The Affiliated Hospital of Yangzhou University, Yangzhou, China -
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12
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Erector spinae plane blocks for postoperative pain control after single ventricle Norwood palliation: A case report. J Clin Anesth 2021; 75:110505. [PMID: 34509959 DOI: 10.1016/j.jclinane.2021.110505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/26/2021] [Accepted: 09/04/2021] [Indexed: 11/20/2022]
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13
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Reinert JP, Lang A, Veronin M. Dexmedetomidine as an adjunctive analgaesic in the perioperative setting: A review of the literature. J Perioper Pract 2021; 31:223-229. [PMID: 33906497 DOI: 10.1177/1750458920971108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Though arguably past the initial phase of the opioid epidemic, opioid-sparing or opioid-eliminating pain management regimens remain beneficial for patients and practitioners alike. Providing adequate analgaesia without relying on opioids is especially advantageous in the operative setting, as patients may be able to recover without deep levels of sedation or the need for a high amount of opioid medications. Despite being used primarily as a sedative over the past 20 years, dexmedetomidine, a centrally acting alpha2-agonist, possesses analgaesic properties, though its use has been limited by its well-described cardiovascular suppressive effects. The objective of this review was to determine the efficacy and safety of adjunctive dexmedetomidine for the purposes of analgaesia in the perioperative setting.
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Affiliation(s)
- Justin P Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Andrew Lang
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Michael Veronin
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
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Frankel WC, Maul TM, Chrysostomou C, Wearden PD, Lowry AW, Baker KN, Nelson JS. A Minimal Opioid Postoperative Management Protocol in Congenital Cardiac Surgery: Safe and Effective. Semin Thorac Cardiovasc Surg 2020; 34:262-272. [PMID: 33333164 DOI: 10.1053/j.semtcvs.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022]
Abstract
There is evidence that reducing opioid exposure in children undergoing cardiac surgery may enhance postoperative recovery. We aimed to describe a minimal opioid postoperative management protocol in children undergoing cardiac surgery and our early outcomes with this strategy. We reviewed the medical records of children (6 months-18 years) who underwent elective cardiac surgery through a median sternotomy with cardiopulmonary bypass at our institution between 2016 and 2018. All patients were managed postoperatively using a standardized protocol. 101 children (median age 5 years) were included and 85% were extubated in the operating room. Although most patients (96%) received opioids postoperatively, opioid requirements decreased steadily over time, with 88%, 58%, and 18% of children receiving opioids on postoperative day 1, 2, and 3, respectively; 41% received no opioids after postoperative day 1. The median cumulative opioid exposure was 0.25 morphine milligram equivalents per kg (interquartile range, 0.10-0.75). Greater than mild pain was rare (<10%) at each time point. The rates of operative mortality and major complication were 0% and 3%, respectively. The median postoperative length of stay was 3 days, and 13% required readmission within 30 days. Age, cardiopulmonary bypass time, and number of benzodiazepine doses were independently associated with cumulative opioid exposure. Any complication, chest tube time, and higher STAT Category were independently associated with prolonged postoperative length of stay. A minimal opioid postoperative management protocol can be safe and effective in children undergoing cardiac surgery. Future prospective studies are needed to determine optimal practice and patient selection.
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Affiliation(s)
| | - Timothy M Maul
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Constantinos Chrysostomou
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Memorial Care Miller Children's & Women's Hospital, Long Beach, California
| | - Peter D Wearden
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Adam W Lowry
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Kimberly N Baker
- Division of Cardiac Critical Care, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Jennifer S Nelson
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida; Department of Surgery, University of Central Florida College of Medicine, Orlando, Florida.
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Rogozov V, Vaněk T. The importance and options of peroperative evaluation of nociception. ANESTEZIOLOGIE A INTENZIVNI MEDICINA 2020. [DOI: 10.36290/aim.2020.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Lisanti AJ, Demianczyk AC, Costarino A, Vogiatzi MG, Hoffman R, Quinn R, Chittams JL, Medoff-Cooper B. Skin-to-Skin Care is Associated with Reduced Stress, Anxiety, and Salivary Cortisol and Improved Attachment for Mothers of Infants With Critical Congenital Heart Disease. J Obstet Gynecol Neonatal Nurs 2020; 50:40-54. [PMID: 33181093 DOI: 10.1016/j.jogn.2020.09.154] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the effect of skin-to-skin care (SSC) on biobehavioral measures of stress (anxiety and salivary cortisol) and attachment (attachment scores and salivary oxytocin) of mothers before and after their infants' neonatal cardiac surgery. DESIGN A prospective interventional, baseline response-paired pilot study. SETTING Cardiac center of a large, metropolitan, freestanding children's hospital. PARTICIPANTS Thirty women whose infants were hospitalized for neonatal cardiac surgery. METHODS Participants acted as their own controls before, during, and after SSC at two time points: once before and once after surgery. We measured the stress response of mothers, as indicated by self-reported scores of anxiety and maternal salivary cortisol, and maternal-infant attachment, as indicated by self-reported scores and maternal salivary oxytocin. RESULTS Significant reductions in self-reported scores of anxiety and salivary cortisol were found as a result of SSC at each time point, as well as increased self-reported attachment. No significant differences were found in oxytocin. CONCLUSION Our findings provide initial evidence of the benefits of SSC as a nurse-led intervention to support maternal attachment and reduce physiologic and psychological stress responses in mothers of infants with critical congenital heart disease before and after neonatal cardiac surgery.
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Skin-to-Skin Care Is a Safe and Effective Comfort Measure for Infants Before and After Neonatal Cardiac Surgery. Pediatr Crit Care Med 2020; 21:e834-e841. [PMID: 32740179 PMCID: PMC8865053 DOI: 10.1097/pcc.0000000000002493] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery. DESIGN A baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2). SETTING Cardiac ICU and step-down unit in a large metropolitan freestanding children's hospital. SUBJECTS Convenience sample of 30 infants admitted preoperatively for critical congenital heart disease. INTERVENTIONS Eligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2. MEASUREMENTS AND MAIN RESULTS Measurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 μg/dL) versus lower (≤ 0.3 μg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group. CONCLUSIONS Skin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.
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Changes in Anesthetic and Postoperative Sedation-Analgesia Practice Associated With Early Extubation Following Infant Cardiac Surgery: Experience From the Pediatric Heart Network Collaborative Learning Study. Pediatr Crit Care Med 2019; 20:931-939. [PMID: 31169762 PMCID: PMC6776694 DOI: 10.1097/pcc.0000000000002005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Heart Network sponsored the multicenter Collaborative Learning Study that implemented a clinical practice guideline to facilitate early extubation in infants after repair of isolated coarctation of the aorta and tetralogy of Fallot. We sought to compare the anesthetic practice in the operating room and sedation-analgesia management in the ICU before and after the implementation of the guideline that resulted in early extubation. DESIGN Secondary analysis of data from a multicenter study from January 2013 to April 2015. Predefined variables of anesthetic, sedative, and analgesia exposure were compared before and after guideline implementation. Propensity score weighted logistic regression analysis was used to determine the independent effect of intraoperative dexmedetomidine administration on early extubation. SETTING Five children's hospitals. PATIENTS A total of 240 study subjects who underwent repair of coarctation of the aorta or tetralogy of Fallot (119 preguideline implementation and 121 postguideline implementation). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical practice guideline implementation was accompanied by a decrease in the median total intraoperative dose of opioids (49.7 vs 24.0 µg/kg of fentanyl equivalents, p < 0.001) and benzodiazepines (1.0 vs 0.4 mg/kg of midazolam equivalents, p < 0.001), but no change in median volatile anesthetic agent exposure (1.3 vs 1.5 minimum alveolar concentration hr, p = 0.25). Intraoperative dexmedetomidine administration was associated with early extubation (odds ratio 2.5, 95% CI, 1.02-5.99, p = 0.04) when adjusted for other covariates. In the ICU, more patients received dexmedetomidine (43% vs 75%), but concomitant benzodiazepine exposure decreased in both the frequency (66% vs 57%, p < 0.001) and cumulative median dose (0.5 vs 0.3 mg/kg of ME, p = 0.003) postguideline implementation. CONCLUSIONS The implementation of an early extubation clinical practice guideline resulted in a reduction in the dose of opioids and benzodiazepines without a change in volatile anesthetic agent used in the operating room. Intraoperative dexmedetomidine administration was independently associated with early extubation. The total benzodiazepine exposure decreased in the early postoperative period.
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Effect of Dexmedetomidine on Lactate Clearance in Patients With Septic Shock: A Subanalysis of a Multicenter Randomized Controlled Trial. Shock 2019; 50:162-166. [PMID: 29117063 DOI: 10.1097/shk.0000000000001055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lactate clearance is useful to guide initial resuscitation of patients with septic shock. We conducted this study to evaluate whether dexmedetomidine increases lactate clearance in patients with septic shock. This was a randomized controlled trial that involved a post hoc subgroup analysis. Adult patients with septic shock under ventilation were randomized to receive sedation strategy with or without dexmedetomidine (60 in the dexmedetomidine and 51 in the nondexmedetomidine groups). The primary outcome was the lactate clearance at 6 h, defined as the percent decrease in lactate from randomization to 6 h after. The median Acute Physiology and Chronic Health Evaluation II score was 25 (interquartile range 19-31). The median serum lactate value at randomization was lower in the dexmedetomidine group than in the nondexmedetomidine group (4.0 mmol/L vs. 4.8 mmol/L; P = 0.053). The lactate clearance at 6 h was higher in the dexmedetomidine group, although this was not statistically significant (23.3 ± 29.8 vs. 11.1 ± 54.4, mean difference 12.2, 95% confidence interval (CI), -4.4 to 28.8). After adjusting for the lactate level at randomization, lactate clearance at 6 h was significantly higher in the dexmedetomidine group (adjusted mean difference 18.5, 95% CI, 2.2-34.9). There was no statistically significant difference in the 28-day mortality between the dexmedetomidine and the nondexmedetomidine groups (13 [22%] vs. 18 [35%] patients, P = 0.11). In conclusion, among mechanically ventilated patients with septic shock, sedation with dexmedetomidine resulted in increased lactate clearance compared with sedation without dexmedetomidine.
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Ding M, Chen Y, Luan H, Zhang X, Zhao Z, Wu Y. Dexmedetomidine reduces inflammation in traumatic brain injury by regulating the inflammatory responses of macrophages and splenocytes. Exp Ther Med 2019; 18:2323-2331. [PMID: 31410183 PMCID: PMC6676199 DOI: 10.3892/etm.2019.7790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 05/09/2019] [Indexed: 12/20/2022] Open
Abstract
Traumatic brain injury (TBI) affects people in all demographics, since it is associated with a variety of chronic degenerative diseases, such as Alzheimer's and Parkinson's disease. In TBI, the central nervous system elicits an immune response involving various immune cells that is necessary for healing and defending the body against pathogens, but can also cause secondary damage to the brain if the response is prolonged. In our clinical practice, it has been identified that administration of dexmedetomidine was associated with reduced production of inflammatory cytokines in patients with TBI, which led to the hypothesis that dexmedetomidine may regulate certain inflammatory responses. To test this hypothesis, the roles of dexmedetomidine in the immune system of mice were investigated. Different biological assays were used to assess the influence of dexmedetomidine on the production of inflammatory cytokines, including tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-8 and IL-1β. To understand how dexmedetomidine affects different types of immune cells, the influence of dexmedetomidine on splenocytes was also investigated. Finally, the effects of dexmedetomidine on macrophage activation and inflammatory functions were studied. In the present study, clinical observations and in vivo results using a mouse model of TBI revealed the regulatory functions of dexmedetomidine in TBI-associated immune response.
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Affiliation(s)
- Mengyao Ding
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
| | - Ying Chen
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
| | - Hengfei Luan
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
| | - Xiaobao Zhang
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
| | - Zhibin Zhao
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
| | - Yong Wu
- Department of Anesthesiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu 222002, P.R. China
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22
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Liu RZ, Li BT, Zhao GQ. Efficacy of different analgesic or sedative drug therapies in pediatric patients with congenital heart disease undergoing surgery: a network meta-analysis. World J Pediatr 2019; 15:235-245. [PMID: 31016566 DOI: 10.1007/s12519-019-00252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/27/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgery is an effective therapy for congenital heart disease (CHD) and the management after surgery poses challenges for the clinical workers. We performed this network meta-analysis to enhance the corresponding evidence with respect to the relative efficacy of different drug treatments applied after the CHD surgery. METHODS Embase and PubMed were systematically retrieved to identify all published controlled trials investigating the effectiveness of drugs for patients up to 25 August, 2018. Mean differences (MD), odds ratios and their 95% credible intervals (CrIs) were used to evaluate multi-aspect comparisons. Surface under cumulative ranking curve (SUCRA) was used to analyze the relative ranking of different treatments in each endpoint. RESULTS Compared to saline, all the drugs achieved better preference under the efficacy endpoints except fentanyl in JET. As for ventilator time, all drugs were more effective than saline while only the difference of dexmedetomidine was statistically obvious (MD = 6.92, 95% CrIs 1.77-12.54). Under the endpoint of ICU time, dexmedetomidine was superior to saline as well (MD = 1.26, 95% CrIs 0.11-2.45). When all the endpoints were taken into consideration and with the help of ranking probabilities and SUCRA values, fentanyl combined with dexmedetomidine was one of the recommended drugs due to its shorter time on ventilator and stay in hospital as well as lower mortality. CONCLUSIONS Overall, based on the comprehensive consideration of all the endpoints, fentanyl combined with dexmedetomidine was considered to be the best-recommended clinical interventions among all the methods.
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Affiliation(s)
- Rui-Zhu Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130000, China
| | - Bing-Tong Li
- Department of Rheumatology and Immunology, China-Japan Union Hospital of Jilin University, Changchun 130000, China
| | - Guo-Qing Zhao
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun 130000, China.
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Chaparro H, Abeldaño-Zuñiga RA. Factors associated with early extubation of patients after corrective tetralogy of Fallot. ENFERMERIA INTENSIVA 2018; 30:154-162. [PMID: 30509876 DOI: 10.1016/j.enfi.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/29/2018] [Accepted: 08/20/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess surgical management and postoperative results associated with early extubation in patients undergoing tetralogy of Fallot corrective surgery at a public hospital in Argentina. METHODS A retrospective review was made from clinical records from patients who underwent corrective surgery for tetralogy of Fallot. A total of 38 clinical records that met the inclusion criteria for the retrospective review were included in the analysis. RESULTS 16% were extubated early. Milrinone was the only drug that showed differences in patients who were extubated early (p=0.01). Extracorporeal circulation time, aortic clamping time, transfusion with cryoprecipitates, saturation of oxygen pressure, and haematocrit at the end of the surgical procedure showed no differences (p>.05). In the postoperative period, the ICU stay was shorter for the patients who were extubated early (p=0.0007), but there were no differences in the total hospital stay (p=0.26). CONCLUSIONS Early extubation in the institution, although found to be low frequency, has proved as a safe and effective alternative to shorten these patients' stay in ICU.
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Affiliation(s)
- H Chaparro
- Hospital de Pediatría SAMIC, Juan P. Garrahan, Buenos Aires, Argentina
| | - R A Abeldaño-Zuñiga
- División de Estudios de Posgrado, Universidad de la Sierra Sur, Oaxaca, México.
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Gong Z, Li J, Zhong Y, Guan X, Huang A, Ma L. Effects of dexmedetomidine on postoperative cognitive function in patients undergoing coronary artery bypass grafting. Exp Ther Med 2018; 16:4685-4689. [PMID: 30542420 PMCID: PMC6257246 DOI: 10.3892/etm.2018.6778] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 09/04/2018] [Indexed: 11/23/2022] Open
Abstract
Effects of dexmedetomidine on postoperative cognitive function in patients undergoing coronary artery bypass grafting were investigated. Eighty patients undergoing systemic anesthesia with extracorporeal coronary artery bypass grafting in The People's Hospital of Guangxi Zhuang Autonomous Region from January 2015 to August 2017 were selected and randomly divided into the observation group (n=40) and control group (n=40). The two groups were treated with dexmedetomidine and equal volume of normal saline, respectively. Moreover, safety indexes including EEG bispectral index (BIS) at 30 min before induction of anesthesia (T0), immediately after intubation (T1), when incision was made (T2), when chest was closed (T3), when operation was completed (T4) and at 6 h after operation (T5), intraoperative circulatory system-related complications, cortisol, epinephrine and norepinephrine levels at the end of surgery as well as anesthesia recovery time and postoperative mechanical ventilation time were recorded and compared. All the patients were followed up for 1 week. Mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA) were administered at 1, 3 and 7 days after operation, and the incidence of intraoperative awareness and postoperative cognitive dysfunction was recorded. BIS value in the observation group was lower than that in the control group (P<0.05) at T1-T4 time points, and the BIS value in the observation group was higher than that in the control group (P<0.05) at T5. Incidence rates of intraoperative arrhythmia, hypertension and hypotension in the observation group was significantly lower than those in the control group (P<0.05). At the end of operation, levels of cortisol, epinephrine and norepinephrine in the observation group were significantly lower than those in the control group (P<0.05). Anesthesia recovery time and postoperative mechanical ventilation time in the observation group was significantly shorter than the time in the control group (P<0.05). MMSE and MoCA scores of the observation group were better than those of the control group (P<0.05). The incidence of cognitive impairment and postoperative cognitive impairment in the observation group was significantly lower than those in the control group (P<0.05). Therefore, it is concluded that dexmedetomidine can effectively reduce the incidence of postoperative cognitive impairment in patients undergoing coronary artery bypass grafting, and it is of high safety for circulatory function.
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Affiliation(s)
- Zheng Gong
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Jun Li
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Yuling Zhong
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Xuehai Guan
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Ailan Huang
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Li Ma
- Department of Anesthesiology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
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Garisto C, Ricci Z, Tofani L, Benegni S, Pezzella C, Cogo P. Use of low-dose dexmedetomidine in combination with opioids and midazolam in pediatric cardiac surgical patients: randomized controlled trial. Minerva Anestesiol 2018. [DOI: 10.23736/s0375-9393.18.12213-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Epstein HM. Postoperative Patient-Controlled Analgesia in the Pediatric Cardiac Intensive Care Unit. Crit Care Nurse 2018; 37:55-61. [PMID: 28148615 DOI: 10.4037/ccn2017724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND High rates of uncontrolled pain in critically ill patients remain common. Patient-controlled analgesia is more effective than traditional intravenous as-needed dosing regimens for managing postoperative pain in older children and adults. OBJECTIVE To determine whether pain-related clinical outcomes in patients from age 10 years to adult following cardiac surgery are improved by using patient-controlled analgesia as a pain management strategy. METHODS Using the plan-do-study-act method of quality improvement, a process was instituted to have both staff and patients' families support the use of patient-controlled analgesia postoperatively as opposed to traditional pain control with as-needed analgesics. Use of as-needed medications and pain scores were retrospectively compared from before to after initiation of patient-controlled analgesia. RESULTS The cumulative mean pain score from the time of extubation through the following 24 hours decreased from 4.14 (on a scale from 0 to 10) when strictly as-needed medications were used to 2.8 with patient-controlled analgesia. Further, the mean amount of opioid consumed decreased from 14.98 mg of morphine and 22.27 mg of oxycodone to 13.58 mg of morphine and 3.33 mg of oxycodone after implementation of patient-controlled analgesia. CONCLUSIONS Standardized use of patient-controlled analgesia for postoperative pain management in patients 10 years of age through adulthood is efficient and effective, as evidenced by less medication being consumed by patients and lower mean pain scores.
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Affiliation(s)
- Hanna M Epstein
- Hanna Epstein is a graduate of the Doctor of Nursing Practice program at the Medical University of South Carolina in Charleston, South Carolina. She is credentialed as a pediatric nurse practitioner and is currently practicing inpatient pediatric palliative care.
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Sedation and Analgesia Following Pediatric Heart Surgery-Less May Be More. Crit Care Med 2018; 46:170-172. [PMID: 29252950 DOI: 10.1097/ccm.0000000000002841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pollak U, Serraf A. Pediatric Cardiac Surgery and Pain Management: After 40 Years in the Desert, Have We Reached the Promised Land? World J Pediatr Congenit Heart Surg 2018; 9:315-325. [PMID: 29692232 DOI: 10.1177/2150135118755977] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
Abstract
Pain prevention in the pediatric population is mandatory and an integrative aspect of medical practice. Optimal pain management is the right of all patients and the responsibility of all health professionals. The key to adequate pain management is assessing its presence and severity, identifying those who require intervention, and appreciating treatment efficacy. The population of pediatric patients undergoing cardiac surgery is unique in both clinical severity and hemodynamic response to painful stimuli, thus making pain management even more challenging. In this review, we will describe the different pain assessment tools as well as intra- and postoperative regimens of pain management.
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Affiliation(s)
- Uri Pollak
- 1 Pediatric Cardiac Intensive Care Unit, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- 2 Pediatric Cardiology, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- 3 Pediatric Sedation Service, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- 4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alain Serraf
- 4 The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- 5 Pediatric and Congenital Cardiac Surgery, The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Quinonez ZA, Downey L, Abbasi RK, Kuan C, Asija R, McElhinney DB, Hanley FL, Mainwaring RD, Wise-Faberowski L. Anesthetic Management During Surgery for Tetralogy of Fallot With Pulmonary Atresia and Major Aortopulmonary Collateral Arteries. World J Pediatr Congenit Heart Surg 2018; 9:236-241. [DOI: 10.1177/2150135118754522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collaterals (TOF/PA/MAPCAs) is a heterogeneous disease with varying degrees of severity, requiring complex anesthetic management. Our institution has adopted the approach of early complete repair with incorporation of all lung segments, extensive lobar and branch segmental pulmonary artery reconstruction, and ventricular septal defect closure. While the surgical management of TOF/PA/MAPCAs has been extensively described and varies depending on the institution, there is a paucity of literature on the anesthetic management for such procedures. Herein, we describe our anesthetic management based on our own institution’s surgical approach at Lucile Packard Children’s Hospital/Stanford University.
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Affiliation(s)
- Zoel A. Quinonez
- Division of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Laura Downey
- Division of Anesthesiology, Egleston Children’s Hospital/Emory University, Atlanta, GA, USA
| | - Rania K. Abbasi
- Division of Anesthesiology, Riley Hospital for Children/Indiana University, Indianapolis, IN, USA
| | - Calvin Kuan
- Division of Anesthesiology, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Ritu Asija
- Division of Pediatrics, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Doff B. McElhinney
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Frank L. Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Richard D. Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Lisa Wise-Faberowski
- Division of Anesthesiology, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
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Liu Y, Bian W, Liu P, Zang X, Gu X, Chen W. Dexmedetomidine improves the outcomes in paediatric cardiac surgery: a meta-analysis of randomized controlled trials. Interact Cardiovasc Thorac Surg 2018. [PMID: 29522148 DOI: 10.1093/icvts/ivy043] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Yang Liu
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Weishuai Bian
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Ping Liu
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xuefeng Zang
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xuyun Gu
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wei Chen
- Department of Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Postoperative opioids, endocrine changes, and immunosuppression. Pain Rep 2018; 3:e640. [PMID: 29756086 PMCID: PMC5902248 DOI: 10.1097/pr9.0000000000000640] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/02/2017] [Indexed: 12/18/2022] Open
Abstract
Opioids are among most effective drugs for managing acute postoperative pain. This article discusses the potential effects of perioperative opioids on endocrine and immune function.
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McGauran M, Jordan B, Beijers R, Janssen I, Franich-Ray C, de Weerth C, Cheung M. Long-term alteration of the hypothalamic-pituitary-adrenal axis in children undergoing cardiac surgery in the first 6 months of life. Stress 2017; 20:505-512. [PMID: 28720027 DOI: 10.1080/10253890.2017.1349748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Children with congenital heart disease (CHD) have poorer neurodevelopmental and psychological outcomes. The mechanisms underlying this remain unclear. One mechanism could be that the stressful experience of cardiac surgery early in life influences long-term hypothalamic-pituitary-adrenal (HPA) axis regulation. Dysregulation of the HPA axis has been linked to poorer neurocognitive and psychological outcomes in other study populations. This case-control study aims to compare HPA-axis regulation (circadian rhythm and reactivity) using salivary cortisol in 3- to 5-year-olds with CHD who did and did not have cardiac surgery prior to 6 months of age. Saliva samples for cortisol analysis were collected from preschoolers with CHD (N = 28, Males = 18, Females = 10) over two weekend days, and before and after an echocardiogram. Caregiver education, child age, sex, and cardiac disease severity score were included as confounders. Multilevel analysis (hierarchical linear modeling) was used to analyze the data. The analysis for the cortisol circadian rhythm shows that the early surgery group has a flatter diurnal slope secondary to lower mean weekend morning waking cortisol levels than controls but similar mean bed time values. Multilevel analysis of the stress response to an echocardiogram indicates that the early surgery group has an increased response when compared to the control group. This is the first study to show that cardiac surgery prior to 6 months of age is associated with a different pattern of HPA-axis regulation at 3-5 years of age.
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Affiliation(s)
- Monica McGauran
- a Social & Mental Health Research Group, Murdoch Children's Research Institute , Royal Children's Hospital , Parkville , VIC , Australia
- b Department of Paediatrics , University of Melbourne , Melbourne , Australia
| | - Brigid Jordan
- a Social & Mental Health Research Group, Murdoch Children's Research Institute , Royal Children's Hospital , Parkville , VIC , Australia
- b Department of Paediatrics , University of Melbourne , Melbourne , Australia
- c Department of Social Work , Royal Children's Hospital , Melbourne , Australia
| | - Roseriet Beijers
- d Department of Developmental Psychology, Behavioural Science Institute , Radboud University , Nijmegen , The Netherlands
| | - Irma Janssen
- d Department of Developmental Psychology, Behavioural Science Institute , Radboud University , Nijmegen , The Netherlands
| | - Candice Franich-Ray
- a Social & Mental Health Research Group, Murdoch Children's Research Institute , Royal Children's Hospital , Parkville , VIC , Australia
- b Department of Paediatrics , University of Melbourne , Melbourne , Australia
| | - Carolina de Weerth
- d Department of Developmental Psychology, Behavioural Science Institute , Radboud University , Nijmegen , The Netherlands
| | - Michael Cheung
- b Department of Paediatrics , University of Melbourne , Melbourne , Australia
- e Cardiac Research Group, Murdoch Children's Research Institute , Parkville , VIC , Australia
- f Department of Cardiology , Royal Children's Hospital , Melbourne , Australia
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Schwartz LI, Twite M, Gulack B, Hill K, Kim S, Vener DF. The Perioperative Use of Dexmedetomidine in Pediatric Patients with Congenital Heart Disease: An Analysis from the Congenital Cardiac Anesthesia Society-Society of Thoracic Surgeons Congenital Heart Disease Database. Anesth Analg 2017; 123:715-21. [PMID: 27167685 DOI: 10.1213/ane.0000000000001314] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Dexmedetomidine is a selective α-2 receptor agonist with a sedative and cardiopulmonary profile that makes it an attractive anesthetic for pediatric patients with congenital heart disease (CHD). Although several smaller, single-center studies suggest that dexmedetomidine use is gaining traction in the perioperative setting in children with CHD, there are limited multicenter data, with little understanding of the variation in use across age ranges, procedural complexity, and centers. The aim of this study was to use the Congenital Cardiac Anesthesia Society-Society of Thoracic Surgeons (CCAS-STS) registry to describe patient- and center-level variability in the use of dexmedetomidine in the perioperative setting in children with heart disease. METHODS To describe the use of dexmedetomidine in patients for CHD surgery, we analyzed all index cardiopulmonary bypass operations entered in the CCAS-STS database from 2010 to 2013. Patient and operative characteristics were compared between those who received intraoperative dexmedetomidine and those who did not. Selective outcomes associated with dexmedetomidine use were also described. RESULTS Of the 12,142 operations studied, 3600 (29.6%) received perioperative dexmedetomidine (DEX) and 8542 did not receive the drug (NoDEX). Patient characteristics were different between the 2 groups with the DEX group generally exhibiting both lower patient and procedural risk factors. Patients who received dexmedetomidine were more likely to have a lower level of Society of Thoracic Surgeons mortality complexity than patient who did not receive it. Consistent with their overall lower risk profile, children in the DEX group also demonstrated improved outcomes compared with patients who did not receive dexmedetomidine. CONCLUSIONS We described the growing use of dexmedetomidine in children anesthetized for surgical repair of CHD. Dexmedetomidine appears to be preferentially given to older and larger children who are undergoing less complex CHD surgery. We believe that the data provided in this study are the largest investigating the use of an anesthetic drug in CHD patients. It is also the first analysis of the anesthesia data in the CCAS-STS Congenital Heart Disease database.
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Affiliation(s)
- Lawrence I Schwartz
- From the *Department of Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado; †Department of Surgery, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina; ‡Department of Pediatrics, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina; §Department of Biostatistics, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina; and ‖Department of Anesthesiology, Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Abstract
BACKGROUND Etomidate potently suppresses adrenocortical steroid synthesis with potentially deleterious consequences by binding to 11β-hydroxylase and inhibiting its function. The authors hypothesized that other sedative-hypnotics currently in clinical use or under development (or their metabolites) might bind to the same site at clinically relevant concentrations. The authors tested this hypothesis by defining etomidate's affinity for this site and the potencies with which other sedative-hypnotics (and their metabolites) inhibit etomidate binding. METHODS H-etomidate's binding to adrenal membranes from Sprague-Dawley rats was characterized with a filtration assay, and its dissociation constant was defined using saturation and homologous ligand competition approaches. Half-inhibitory concentrations of sedative-hypnotics and metabolites were determined from the reduction in specific H-etomidate binding measured in the presence of ranging sedative-hypnotic and metabolite concentrations. RESULTS Saturation and homologous competition studies yielded H-etomidate dissociation constants of 40 and 21 nM, respectively. Half-inhibitory concentrations of etomidate and cyclopropyl methoxycarbonyl metomidate (CPMM) differed significantly (26 vs. 143 nM, respectively; P < 0.001), and those of the carboxylic acid (CA) metabolites etomidate-CA and CPMM-CA were greater than or equal to 1,000× higher than their respective parent hypnotics. The half-inhibitory concentration of dexmedetomidine was 2.2 µM, whereas those of carboetomidate, ketamine, and propofol were greater than or equal to 50 µM. CONCLUSION Etomidate's in vitro dissociation constant for 11β-hydroxylase closely approximates its in vivo adrenocortical half-inhibitory concentration. CPMM produces less adrenocortical suppression than etomidate not only because it is metabolized faster but also because it binds to 11β-hydroxylase with lower affinity. Other sedative-hypnotics and metabolites bind to 11β-hydroxylase and inhibit etomidate binding only at suprahypnotic concentrations.
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Wald EL, Backer CL, Dearani JA, Li Z, Oliver WC, Crow SS. Total and free cortisol responses and their relation to outcomes after cardiopulmonary bypass in infants. J Thorac Cardiovasc Surg 2016; 153:1155-1163. [PMID: 28024808 DOI: 10.1016/j.jtcvs.2016.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 10/07/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. METHODS We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-μg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. RESULTS Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 μg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. CONCLUSIONS We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 μg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.
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Affiliation(s)
- Eric L Wald
- Divisions of Critical Care and Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Joseph A Dearani
- Division of Cardiothoracic Surgery, Mayo Clinic, Rochester, Minn
| | - Zhuo Li
- Division of Statistics, Mayo Clinic, Rochester, Minn
| | | | - Sheri S Crow
- Division of Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minn
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Mahle WT, Nicolson SC, Hollenbeck-Pringle D, Gaies MG, Witte MK, Lee EK, Goldsworthy M, Stark PC, Burns KM, Scheurer MA, Cooper DS, Thiagarajan R, Sivarajan VB, Colan SD, Schamberger MS, Shekerdemian LS. Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med 2016; 17:939-947. [PMID: 27513600 PMCID: PMC5053873 DOI: 10.1097/pcc.0000000000000918] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery. DESIGN Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites). SETTING Ten children's hospitals. PATIENTS Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites. INTERVENTIONS Development and application of early extubation clinical practice guideline. MEASUREMENTS AND MAIN RESULTS After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068). CONCLUSIONS A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.
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Affiliation(s)
- William T Mahle
- 1Department of Pediatrics, Emory University, Atlanta, GA.2Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, PA.3New England Research Institutes, Watertown, MA.4Department of Pediatrics, University of Michigan, Ann Arbor, MI.5Department of Pediatrics, University of Utah, Salt Lake City, UT.6Industrial Engineering Department, Georgia Institute of Technology, Atlanta, GA.7Department of Pediatrics, Baylor College of Medicine, Houston, TX.8National Heart, Lung, and Blood Institute, Bethesda, MD.9Department of Pediatrics, Medical University of South Carolina, Charleston, SC.10Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH.11Cardiology Department, Boston Children's Hospital, Boston, MA.12Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.13Department of Pediatrics, Riley Children's Hospital, Indianapolis, IN
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Karuppiah S, Mckee C, Hodge A, Galantowicz M, Tobias J, Naguib A. Perioperative Management of a Child with Hypoplastic Left Heart Syndrome of the Jehovah's Witness Faith Presenting for Hybrid Comprehensive Stage II Procedure. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2016; 48:141-147. [PMID: 27729708 PMCID: PMC5056685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/09/2016] [Indexed: 06/06/2023]
Abstract
Over the years, there has been a growing recognition of the potential negative sequelae of allogeneic blood products on postoperative outcomes following cardiac surgery. In addition, followers of the Jehovah's Witness (JW) faith have a religious restriction against receiving blood or blood components. Advances in perioperative care, cardiopulmonary bypass (CPB), and surgical technique have minimized the need for allogeneic blood products. Specific blood conservation strategies include maximizing the preoperative hematocrit and coagulation function as well as intraoperative strategies, such as acute normovolemic hemodilution and adjustments of the technique of CPB. We report a 7-month-old patient whose parents were of the JW faith who underwent a comprehensive stage II procedure for hypoplastic left heart syndrome without exposure to blood or blood products during his hospital stay. Perioperative techniques for blood avoidance are discussed with emphasis on their application to infants undergoing surgery for congenital heart disease.
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Affiliation(s)
- Sathappan Karuppiah
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Christopher Mckee
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ashley Hodge
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Mark Galantowicz
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio
- Department of Cardiothoracic, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
| | - Aymen Naguib
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio
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Wang XW, Cao JB, Lv BS, Mi WD, Wang ZQ, Zhang C, Wang HL, Xu Z. Effect of perioperative dexmedetomidine on the endocrine modulators of stress response: a meta-analysis. Clin Exp Pharmacol Physiol 2016; 42:828-36. [PMID: 26016707 DOI: 10.1111/1440-1681.12431] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 05/06/2015] [Accepted: 05/19/2015] [Indexed: 11/30/2022]
Abstract
This study examined the effects of perioperative dexmedetomidine treatment on physiological modulators of surgical stress response. The quality of the included studies was assessed prior to performing meta-analyses of the weighted mean differences in the changes from baseline of stress hormones and interpreted in the light of statistical heterogeneity between the studies. Nineteen studies (844 surgical subjects) data were used for this meta-analysis. Dexmedetomidine administration significantly decreased blood cortisol levels (μg/dL) postoperatively (mean difference with 95% confidence interval (CI) from controls: -18.78 (-28.45, -9.10); P < 0.05). In the subgroup analysis, the mean difference between dexmedetomidine-treated and saline-treated subjects in the changes from baseline of the cortisol levels was -20.10 (-30.96, -9.25; P < 0.05) but, between dexmedetomidine- and comparator-treated subjects, it was not statistically significantly different (-15.13 (-49.78, 19.52); P < 0.05). Compared with controls, dexmedetomidine treatment also decreased adrenaline and noradrenaline levels significantly (mean difference in the percent changes from baseline: -90.41 (-145.79, -35.03)%; P < 0.05 and -62.82 (-85.47, -0.40.17)%; P < 0.05, respectively). Dexmedetomidine also decreased prolactin levels with a mean difference of -19.42 (-39.37, 0.52) μg/L (P = 0.06). In conclusion, perioperative use of dexmedetomidine reduces serum catecholamine and cortisol levels but the decrease in cortisol levels was not statistically different from the comparator anaesthetics. More data will be required to assess the effects of dexmedetomidine on corticotropin, prolactin, and growth hormone.
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Affiliation(s)
- Xian-wang Wang
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China.,Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Jiang-bei Cao
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Bao-sheng Lv
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Wei-dong Mi
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhuo-qiang Wang
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Changsheng Zhang
- Anaesthesia and Operation Centre, Chinese PLA General Hospital, Beijing, China
| | - Heng-lin Wang
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
| | - Zhen Xu
- Department of Anaesthesiology, The 309th Hospital of PLA, Beijing, China
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Peng W, Zhang T, Wang Y. Comparison of propofol-hydromorphone and propofol-dexmedetomidine in patients with intubation after maxillofacial plastic surgery. Ther Clin Risk Manag 2016; 12:373-7. [PMID: 27022268 PMCID: PMC4789838 DOI: 10.2147/tcrm.s99262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To compare the sedation and analgesic effects between propofol–hydromorphone and propofol–dexmedetomidine in patients with postoperative intubation after maxillofacial plastic surgery. Methods Forty-two patients undertaking maxillofacial plastic surgery with intubation were randomly assigned into propofol plus hydromorphone (P–H) group or propofol plus dexmedetomidine (P–D) group, receiving intravenous infusion of P–H or P–D, respectively. Cerebral state index, Ramsay sedation score, arterial blood gas analysis, and physiology indices were recorded before admission (T0), 30 minutes (T1), 1 hour (T2), 2 hours (T3), 6 hours (T4), and 12 hours after admission (T5) to intensive care unit, and 10 minutes after extubation (T6). Blood interleukin-6 was measured with enzyme-linked immunosorbent assay. Results There was no significant difference in arterial blood gas analysis, oxygen saturation, mean arterial pressure, and respiratory rate between two groups at all time-points (P>0.05). The changes of heart rate (at T4, T5, and T6), cerebral state index (T1, T2, T3, T4, and T5), and Ramsay score (at T3) in P–H group were significantly different from that in P–D group (P<0.05). The plasma interleukin-6 at T4 in P–H group was significantly lower than that in P–D group (P<0.05). Conclusion The P–H approach takes advantages over P–D approach in relieving the pain and discomfort, reducing the overstimulation of sympathetic nerve and the stress level, and enhancing the tolerance of postoperative intubation after maxillofacial plastic surgery.
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Affiliation(s)
- Wei Peng
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China; Department of Anesthesiology, School and Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Tiejun Zhang
- Department of Anesthesiology, School and Hospital of Stomatology, Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Yanlin Wang
- Department of Anesthesiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, People's Republic of China
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Pan W, Wang Y, Lin L, Zhou G, Hua X, Mo L. Outcomes of dexmedetomidine treatment in pediatric patients undergoing congenital heart disease surgery: a meta-analysis. Paediatr Anaesth 2016; 26:239-48. [PMID: 26612740 DOI: 10.1111/pan.12820] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dexmedetomidine decreases cardiac complications in adults undergoing cardiovascular surgery. This systematic review assessed whether perioperative dexmedetomidine improves congenital heart disease (CHD) surgery outcomes in children. METHODS The PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials (RCTs) or observational studies that were published until 16 April 2015 and compared dexmedetomidine with placebo or an alternative anesthetic agent during pediatric CHD surgery. The assessed outcomes included hemodynamics, ventilation length, intensive care unit (ICU) and hospital stays, blood glucose and serum cortisol levels, postoperative analgesia requirements, and postoperative delirium. RESULTS Five RCTs and nine observational studies involving 2229 patients were included. In pooled analyses, dexmedetomidine was associated with shorter length of mechanical ventilation (mean difference: -93.36, 95% CI: -137.45, -49.27), lower postoperative fentanyl (mean difference: -24.11, 95% CI: -36.98, -11.24) and morphine (mean difference: -0.07, 95% CI: -0.14, 0.00) requirements, reduced stress response (i.e., lower blood glucose and serum cortisol levels), and lower risk of delirium (OR: 0.39, 95% CI: 0.21, 0.74). The hemodynamics of dexmedetomidine-treated patients appeared more stable, but there were no significant differences in the ICU or hospital stay durations. Dexmedetomidine may increase the bradycardia and hypotension risk (OR: 3.14, 95% CI: 1.47, 6.69). CONCLUSIONS Current evidence indicates that dexmedetomidine improves outcomes in children undergoing CHD surgery. However, this finding largely relies on data from observational studies; high-quality RCTs are warranted because of the potential for subject selection bias.
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Affiliation(s)
- Wanying Pan
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yueting Wang
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lin Lin
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ge Zhou
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoxiao Hua
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liqiu Mo
- Department of Anaesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care: Sedation, Analgesia and Muscle Relaxant. Pediatr Crit Care Med 2016; 17:S3-S15. [PMID: 26945327 DOI: 10.1097/pcc.0000000000000619] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This article reviews pharmacotherapies currently available to manage sedation, analgesia, and neuromuscular blockade for pediatric cardiac critical patients. DATA SOURCES The knowledge base of an expert panel of pharmacists, cardiac anesthesiologists, and a cardiac critical care physician involved in the care of pediatric cardiac critical patients was combined with a comprehensive search of the medical literature to generate the data source. STUDY SELECTION The panel examined all studies relevant to management of sedation, analgesia, and neuromuscular blockade in pediatric cardiac critical patients. DATA EXTRACTION Each member of the panel was assigned a specific subset of the studies relevant to their particular area of expertise (pharmacokinetics, pharmacodynamics, and clinical care) to review and analyze. DATA SYNTHESIS The panel members each crafted a comprehensive summary of the literature relevant to their area of expertise. The panel, as a whole, then collaborated to cohesively summarize all the available, relevant literature. CONCLUSIONS In the cardiac ICU, management of the cardiac patient requires an individualized sedative and analgesic strategy that maintains hemodynamic stability. Multiple pharmacological therapies exist to achieve these goals and should be selected based on the patient's underlying physiology, hemodynamic vulnerabilities, desired level of sedation and analgesia, and the projected short- or long-term recovery trajectory.
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Palermo NE, Gianchandani RY, McDonnell ME, Alexanian SM. Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications. Curr Diab Rep 2016; 16:33. [PMID: 26957107 DOI: 10.1007/s11892-016-0721-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.
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Affiliation(s)
- Nadine E Palermo
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Suite 381, Boston, MA, 02115, USA.
| | - Roma Y Gianchandani
- Department of Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Health Systems, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48109, USA.
| | - Marie E McDonnell
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Ave, Suite 381, Boston, MA, 02115, USA.
| | - Sara M Alexanian
- Department of Medicine, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston University School of Medicine, 732 Harrison Ave, 5th Floor, Suite 511, Boston, MA, 02118, USA.
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Du Y, Chen YJ, He B, Wang YW. The Effects of Single-Dose Etomidate Versus Propofol on Cortisol Levels in Pediatric Patients Undergoing Urologic Surgery: A Randomized Controlled Trial. Anesth Analg 2016; 121:1580-5. [PMID: 26496368 DOI: 10.1213/ane.0000000000000981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of general anesthetics on the hypothalamus-pituitary-adrenal axis and cortisol release in children are poorly characterized. Normal, daily fluctuation of cortisol levels complicates assessment of these effects. This study aimed to characterize the effects of etomidate compared with propofol on the normal cortisol secretory pattern in children undergoing urologic surgery by using a salivary cortisol assay. METHODS In this prospective, randomized, double-blind, controlled study, we recruited 80 children aged 3 to 12 years assigned ASA physical status I who were scheduled for urologic surgery and 11 healthy child volunteers. Before surgery, cortisol levels of the 11 volunteers and 15 study patients were tested from 7:00 AM to 9:00 PM every hour for 1 day. The study patients were then randomly allocated into an etomidate group and a propofol group, receiving etomidate 0.3 mg/kg (n = 38) or propofol 2 mg/kg (n = 39) and midazolam 0.1 mg/kg, fentanyl 2 μg/kg, and rocuronium 0.6 mg/kg for induction, respectively. The cortisol levels of the patients were assessed continuously for 2 days postoperatively. RESULTS The cortisol levels of the etomidate group were continuously and significantly lower than those of the propofol group from the time of discharge from the postanesthesia care unit (approximately 2:00 PM) until 8:00 AM the next morning (all P < 0.0001) and were significantly lower than before surgery at the same time points (all P < 0.0001). Except at 11:00 AM just before the operation, no significant differences in cortisol levels were detected before and after the operation in the propofol group (P max = 0.476, P min = 0.002). Also, no significant differences in clinical outcomes were detected between the 2 groups undergoing surgery (all P > 0.070). CONCLUSIONS Compared with propofol, a single induction dose of etomidate suppressed postoperative cortisol levels in healthy children undergoing urologic surgery. This suppression lasted approximately 24 hours and was not associated with any changes in clinical outcomes.
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Affiliation(s)
- Yi Du
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Schwartz LI, Miyamoto SD, Stenquist S, Twite MD. Cardiac Arrest in a Heart Transplant Patient Receiving Dexmedetomidine During Cardiac Catheterization. Semin Cardiothorac Vasc Anesth 2015; 20:175-8. [DOI: 10.1177/1089253215624765] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dexmedetomidine is an α-2 agonist with a sedative and cardiopulmonary profile that makes it an attractive anesthetic in pediatric cardiac patients. Cardiac transplant patients may suffer from acute cellular rejection of the cardiac conduction system and, therefore, are at an increased risk of the electrophysiological effect of dexmedetomidine. We present such a patient who had a cardiac arrest while receiving dexmedetomidine during cardiac catheterization. Because acute cellular rejection of the cardiac conduction system is difficult to diagnose, dexmedetomidine should be used with caution in pediatric heart transplant patients.
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Affiliation(s)
| | - Shelley D. Miyamoto
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Denver, Aurora, CO, USA
| | - Scott Stenquist
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Denver, Aurora, CO, USA
| | - Mark David Twite
- Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado, Denver, Aurora, CO, USA
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Riveros R, Riveros-Perez E. Perioperative Considerations for Children With Right Ventricular Dysfunction and Failing Fontan. Semin Cardiothorac Vasc Anesth 2015; 19:187-202. [PMID: 26287019 DOI: 10.1177/1089253215593178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The survival of patients with congenital heart diseases (CHD) has increased in the past decades, resulting in the identification of new characteristics of chronic comorbidities observed in pediatric and adults with CHD. Patients with CHD can present with a broad clinical spectrum of manifestations of congestive heart failure (CHF) at any point throughout their lives that may be related to anatomical or surgical variables. This article focuses on the perioperative assessment of patients with CHD and CHF, with an emphasis on pathophysiologic, diagnostic, and therapeutic alternatives in patients with right ventricular failure and failing Fontan circulation. We also provide descriptions of the effects of sedatives and anesthetics commonly used in this population in diagnostic or invasive procedures.
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Li B, Li Y, Tian S, Wang H, Wu H, Zhang A, Gao C. Anti-inflammatory Effects of Perioperative Dexmedetomidine Administered as an Adjunct to General Anesthesia: A Meta-analysis. Sci Rep 2015. [PMID: 26196332 PMCID: PMC4508837 DOI: 10.1038/srep12342] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The aim of this meta-analysis is to examine the effects of dexmedetomidine on serum inflammatory markers when administered perioperatively. We searched multiple electronic databases for relevant research papers, and carried out meta-analyses of weighted mean differences and interpreted in the light of statistical heterogeneity (I2). Fifteen RCTs recruiting 641 patients were included. Dexmedetomidine treatment significantly decreased interleukin-6 (IL-6), IL-8 and tumor necrosis factor-alpha (TNF-α) levels with mean differences [95% CI] in the changes from baseline between dexmedetomidine treated and controls of −25.14 [−35.29, −15.00]; P < 0.00001 (for IL-6), −5.69 [−10.77, −0.60]; P < 0.04 (for IL-8), and −20.30 [−30.93, −9.67]; P < 0.0002 (for TNF-α) immediately after surgery; and −41.55 [−57.41, −25.70]; P < 0.00001 (IL-6), −6.46 [−10.83, −2.08]; P < 0.005 (IL-8), and −14.67 [−22.61, −6.73]; P < 0.0003 (TNF-α) on postoperative day 1 (random effects). IL-10 levels were found to increase significantly a day after surgery (8.33 [3.31, 13.36]; P = 0.001). Subgroup analyses did not reveal significant differences. In conclusion, perioperative adjunctive use of dexmedetomidine substantially decreases serum IL-6, IL-8 and TNF-α levels.
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Affiliation(s)
- Bo Li
- Department of Anesthesiology, Jinan General Hospital, PLA Jinan Military Area Command, Jinan 250031, Shandong, China
| | - Yalan Li
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong, China
| | - Shushi Tian
- Department of Radiology, No. 261 Hospital of PLA, Beijing, China
| | - Huixia Wang
- Department of Anesthesiology, Jinan General Hospital, PLA Jinan Military Area Command, Jinan 250031, Shandong, China
| | - Hui Wu
- Department of Anesthesiology, The People's Hospital of Zhangqiu, Zhangqiu 250200, Henan, China
| | - Aihua Zhang
- Department of Anesthesiology, Yancheng City No.1 People's Hospital, Yancheng 224005, Jiangsu, China
| | - Chengjie Gao
- Department of Anesthesiology, Jinan General Hospital, PLA Jinan Military Area Command, Jinan 250031, Shandong, China
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Intranasal Dexmedetomidine on Stress Hormones, Inflammatory Markers, and Postoperative Analgesia after Functional Endoscopic Sinus Surgery. Mediators Inflamm 2015. [PMID: 26199465 PMCID: PMC4496499 DOI: 10.1155/2015/939431] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background. A strong ongoing intraoperative stress response can cause serious adverse reactions and affect the postoperative outcome. This study evaluated the effect of intranasally administered dexmedetomidine (DEX) in combination with local anesthesia (LA) on the relief of stress and the inflammatory response during functional endoscopic sinus surgery (FESS). Methods. Sixty patients undergoing FESS were randomly allocated to receive either intranasal DEX (DEX group) or intranasal saline (Placebo group) 1 h before surgery. Stress hormones, inflammatory markers, postoperative pain relief, hemodynamic variables, blood loss, surgical field quality, body movements, and satisfaction were assessed. Results. Plasma epinephrine, norepinephrine, and blood glucose levels were significantly lower in DEX group as were the plasma IL-6 and TNF-α levels (P < 0.05). The weighted areas under the curve (AUCw) of the VAS scores were also significantly lower in DEX group at 2–12 h after surgery (P < 0.001). Furthermore, hemodynamic variables, blood loss, body movements, discomfort with hemostatic stuffing, surgical field quality, and satisfaction scores of patients and surgeons were significantly better (P < 0.05) in DEX group. Conclusions. Patients receiving intranasal DEX with LA for FESS exhibited less perioperative stress and inflammatory response as well as better postoperative comfort with hemostatic stuffing and analgesia.
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Wajekar AS, Shetty AN, Oak SP, Jain RA. Anaesthetic management for drainage of frontoparietal abscess in a patient of uncorrected Tetralogy of Fallot. Indian J Anaesth 2015; 59:244-6. [PMID: 25937652 PMCID: PMC4408654 DOI: 10.4103/0019-5049.155003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anjana S Wajekar
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Anita N Shetty
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Shrikanta P Oak
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
| | - Ruchi A Jain
- Department of Anaesthesia, KEM Hospital, Mumbai, Maharashtra, India
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Naguib AN, Winch PD, Tobias JD, Simsic J, Hersey D, Nicol K, Preston T, Gomez D, McConnell P, Galantowicz M. A single-center strategy to minimize blood transfusion in neonates and children undergoing cardiac surgery. Paediatr Anaesth 2015; 25:477-86. [PMID: 25581204 DOI: 10.1111/pan.12604] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The transfusion of blood products in the setting of uncontrolled bleeding is unquestionably lifesaving. However, in many instances, the decision to transfuse is based on physician gestalt rather than medical evidence. When indications for transfusion are unclear, the benefits of blood products must be balanced against their significant risks and associated costs. As our institution is a referral center for patients of Jehovah's Witness faith, this population has pushed our development of techniques to achieve the goal of bloodless surgery. Our practices in caring for this population have become our standard practice for managing all patients undergoing congenital cardiac surgery. OBJECTIVES To evaluate our success in minimizing the use of blood products during pediatric cardiac surgery. METHODS After IRB approval, we retrospectively reviewed all patients who underwent cardiac surgery utilizing cardiopulmonary bypass (CPB), for biventricular repair procedures. The study was conducted at a single institution (Nationwide Children's Hospital (NCH)) during the period: January 1, 2013 and December 31, 2013. RESULTS A total of 209 patients were included. Overall, 81 patients (38.8%) and 81 of 136 (59.6%) weighing more than 6 kg received no blood products (bloodless) during their entire hospital stay. Bloodless surgery was most successful in patients weighing more than 18 kg, followed by patients weighing 6-18 kg. All 73 patients who weighed <6 kg received blood transfusion during their hospitalization. CONCLUSION The techniques that we have developed to initially care for our Jehovah's Witness families may be applied to other pediatric and adult surgical procedures.
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Affiliation(s)
- Aymen N Naguib
- Department of Anesthesia and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA; The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
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