Paediatric anaesthesia
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Paediatric anaesthesia · Mar 2010
ReviewPediatric models for adult target-controlled infusion pumps.
Target-controlled infusion (TCI) pumps currently do not satisfactorily cater for the pediatric population, particularly for those under 5 years. Growth and development are two major aspects of children not readily apparent in adults, and these two aspects influence clearance (CL) and volume of distribution (V). In simple terms, V determines initial dose, and CL determines infusion rate at steady state. ⋯ Organ function also affects clearance, and propofol clearance is reduced in neonates and infants after cardiac surgery. Although pharmacokinetics (PK) in children is receiving increasing attention and is eminently programmable into a TCI device, pharmacodynamic (PD) measures in children remain poorly defined, partly because the depth of anesthesia monitoring are inadequate. Both PK and PD are necessary for safe use of TCI pumps.
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For several years, total intravenous anesthesia (TIVA) has demonstrated many advantages that allow consideration of propofol anesthesia as an interesting alternative in pediatric anesthesia. TIVA in children requires calculation and validation of pharmacokinetic (PK) models specifically adapted to the pediatric population. Several PK models based on a 3-compartment approach have been proposed in children: all these models, which integrate only weight as covariable, show increased distribution volumes with a wide interindividual variability. ⋯ The particular importance to include physiological covariables, as size and age, to describe metabolic processes during growth and maturation in pediatric PKPD models is in agreement with recent allometric scaling works in children. The Schnider's model, a model described in adults that includes numerous covariables, may be adapted and more efficient than the classical pediatric model to describe propofol-PKPD relationship in children over 5 years. Whatever is the model, a pharmacodynamic feed back such as the bispectral index may be useful to counteract the interindividual variability in the pediatric population.
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The current role of TIVA in children is limited because of hardware limitations, and pharmacokinetic and monitoring issues. Nonetheless, the role of TIVA in children has been increasing in the past decade, in part because of surgical and medical indications. If TIVA is to become more widely used, it must be easy and simple to set up, without serious drawbacks and without added risks. ⋯ If a true TIVA technique is used, i.v. access must be established before induction of anesthesia, which will require a means to establish i.v. access painlessly, e.g., using a topical local anesthetic. This is not a common practice in a number of jurisdictions but must be introduced if TIVA is to expand in its scope in children. Currently, I believe that we deliver a 'partial' TIVA technique in which TIVA occasionally follows an inhalational induction but in the future when the current obstacles have been resolved, I believe that we will be able practice a true TIVA technique ubiquitously in children.
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Paediatric anaesthesia · Feb 2010
Review Meta AnalysisEfficacy of postoperative epidural analgesia in adolescent scoliosis surgery: a meta-analysis.
Scoliosis surgery is one of the most painful operations performed. Postoperative pain management has been historically based on the use of intravenous opioids. Many of the adolescents who undergo these procedures are at increased risk for opioid-related side effects because of underlying medical problems. Epidural analgesia has been demonstrated to provide superior pain control with fewer side effects for chest and abdominal surgery in children as well as adults. We aim to analyze the available literature for sufficient evidence to allow recommendations regarding the use of epidural analgesia with parenteral opioids vs. intravenous opioids only. ⋯ Epidural analgesia is beneficial to patients in terms of improving pain control and reducing side effects. The influence on respiratory depression, length of stay in the intensive care unit, or mortality is not available in the literature at this time.