Paediatric anaesthesia
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Paediatric anaesthesia · Mar 2011
ReviewCircadian rhythms and their development in children: implications for pharmacokinetics and pharmacodynamics in anesthesia.
The influence of time-of-day on the action and toxicity of drugs may be an important factor in the design of pharmacokinetic (PK) and pharmacodynamic (PD) studies, and the interpretation of data resulting from these studies. Time-of-day can have a profound influence on the action of drugs. In some settings (e.g. cancer chemotherapy), the timing of drug administration has been utilized to maximize therapeutic effect and minimize toxicity. ⋯ Circadian rhythms develop over the first months and years of life. Robust rhythms in hormone production (e.g. melatonin and cortisol) are seen at approximately 3 months of age, but it remains unclear as to when daily rhythms in drug PK and PD first appear. Here, we review the evidence for time-of-day effects in anesthetic drugs in adults and children and outline the potential influence this has on pediatric anesthesia.
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Paediatric anaesthesia · Mar 2011
ReviewDevelopmental pharmacology of tramadol during infancy: ontogeny, pharmacogenetics and elimination clearance.
To illustrate the complex interaction between ontogeny, i.e., age-dependent maturation, genetic polymorphisms and renal elimination clearance during infancy, based on developmental disposition of intravenous tramadol during infancy. ⋯ The phenotypic observations might in part explain unanticipated (side-)effects of tramadol. In addition to the compound-specific clinical implications, it is important to stress that the maturational trends in the elimination processes described can be considered for other compounds (e.g., codeine) that undergo similar elimination routes.
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Details of the development of conventional analytical methods for the determination of drugs in pediatric plasma/serum samples via microassays are presented. Examples of the development of small-volume sampling and the use of the newer detection systems such as LC/MS/MS for enhanced detection are presented. Dried blood spot sampling has conventionally been used for the study of inborn errors of metabolism using Guthrie cards. ⋯ The application of the methodology in pharmacokinetic/pharmacodynamic studies is discussed. The utilization of solid-phase microextraction and stir bar sorptive extraction in drug analysis is presented. Clinical applications of these methodologies are reported including the development of in vivo solid-phase microextraction.
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Paediatric anaesthesia · Jan 2011
ReviewBlood transfusion risks and alternative strategies in pediatric patients.
Although the safety of the blood supply has been greatly improved, there still remain both infectious and noninfectious risks to the patient. The incidence of noninfectious transfusion reactions is greater than that of infectious complications. Furthermore, the mortality associated with noninfectious risks is significantly higher. ⋯ In order to decrease the risks associated with transfusion of blood products, various blood-conservation strategies can be utilized. Modalities such as acute normovolemic hemodilution, hypervolemic hemodilution, deliberate hypotension, antifibrinolytics, intraoperative blood salvage, and autologous blood donation are discussed and the pediatric literature is reviewed. A discussion of transfusion triggers, and algorithms as well as current research into alternatives to blood transfusions concludes this review.
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Paediatric anaesthesia · Jan 2011
ReviewCoagulation considerations for infants and children undergoing cardiopulmonary bypass.
Cardiac surgery involving cardiopulmonary bypass imposes a significant pathophysiologic burden on patients. Pediatric patients are especially predisposed to the adverse effects of surgery and bypass on the coagulation system, with resultant bleeding, transfusion, and poor outcomes. ⋯ Conventional measurements of anticoagulation during bypass poorly reflect this incomplete anticoagulation, and alternate methods may improve anticoagulant therapy. Emerging therapies for blocking the effects of bypass on the coagulation system hold promise for decreasing bleeding and related complications, and improving outcomes in congenital heart surgery.