Anestesia pediátrica / Pediatric anesthesia

Octubre 3, 2016. No. 2467

Propofol. Revisión de su papel en anestesia y sedación pediátrica Propofol: a review of its role in pediatric anesthesia and sedation. Chidambaran V1, Costandi A, D'Mello A. CNS Drugs. 2015 Jul;29(7):543-63. doi: 10.1007/s40263-015-0259-6. Abstract Propofol is an intravenous agent used commonly for the induction and maintenance of anesthesia, procedural, and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially the gamma-aminobutyric acid A receptor. Approved for use in the USA by the Food and Drug Administration in 1989, its use for induction ofanesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not "little adults", in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exists despite the Food and Drug Administration mandating addition of antimicrobial preservative, calling for manufacturers' directions to discard open vials after 6 h. While propofol has advantages over inhalation anesthesia such as less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol-induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research. PDF Inducción con barbituratos para prevenir agitación en la emergencia anestésica con sevoflurano Barbiturate Induction for the Prevention of Emergence Agitation after Pediatric Sevoflurane Anesthesia. Use T1, Nakahara H1, Kimoto A1, Beppu Y1, Yoshimura M1, Kojima T2, Fukano T1. J Pediatr Pharmacol Ther. 2015 Sep-Oct;20(5):385-92. doi: 10.5863/1551-6776-20.5.385. Abstract OBJECTIVES: Emergence agitation (EA) is a common and troublesome problem in pediatric patients recovering from general anesthesia. The incidence of EA is reportedly higher after general anesthesia maintained with sevoflurane, a popular inhalational anesthetic agent for pediatricpatients. We conducted this prospective, randomized, double-blind study to test the effect of an intravenous ultra-short-acting barbiturate, thiamylal, administered during induction of general anesthesia on the incidence and severity of EA in pediatric patients recovering from Sevoflurane anesthesia. METHODS: Fifty-four pediatric patients (1 to 6 years of age) undergoing subumbilical surgeries were randomized into 2 groups. Patients received either intravenous thiamylal 5mg/kg (Group T) or inhalational Sevoflurane 5% (Group S) as an anesthetic induction agent. Following induction, general anesthesia was maintained with Sevoflurane and nitrous oxide (N2O) in both groups. To control the intra- and post-operative pain, caudal block or ilioinguinal/iliohypogastric block was performed. The incidence and severity of EA were evaluated by using the Modified Objective Pain Scale (MOPS: 0 to 6) at 15 and 30 min after arrival in the post-anesthesia care unit (PACU). RESULTS: Fifteen minutes after arrival in the PACU, the incidence of EA in Group T (28%) was significantly lower than in Group S (64%; p = 0.023) and the MOPS in Group T (median 0, range 0 to 6) was significantly lower than in Group S (median 4, range 0 to 6; p = 0.005). The interval from discontinuation of Sevoflurane to emergence from anesthesia was not significantly different between the 2 groups. CONCLUSIONS: Thiamylal induction reduced the incidence and severity of EA in pediatric patients immediately after Sevoflurane anesthesia. KEYWORDS: Sevoflurane; anesthesia recovery period; pediatrics; psychomotor agitation; thiamylal PDF Comparación entre sevoflorano y tiopental como inductores y agitación postanestésica en pacientes pediátricos A comparison of postoperative emergence agitation between sevoflurane and thiopental anesthesia induction in pediatric patients. Son JS1, Jang E1, Oh MW1, Lee JH1, Han YJ1, Ko S1. Korean J Anesthesiol. 2015 Aug;68(4):373-8. doi: 10.4097/kjae.2015.68.4.373. Epub 2015 Jul 28. Abstract BACKGROUND: This study was performed to compare the incidence of emergence agitation (EA) between inhalation and intravenous anesthesiainduction in children after sevoflurane anesthesia. METHODS: In this prospective and double-blind study, 100 children aged 3 to 7 years were enrolled. Subjects were randomly assigned to the sevoflurane (Group S) or thiopental (Group T) anesthesia induction groups. Anesthesia was induced using 8% sevoflurane and 4-6 mg/kg thiopental in Groups S and T, respectively. Anesthesia was maintained with nitrous oxide and sevoflurane. The children were evaluated at 5 and 20 min after arrival in the postanesthesia care unit (PACU) with a four-point agitation scale and the Pediatric Anesthesia Emergence Delirium scale. The incidence of EA and administration of the rescue agent were recorded. RESULTS: The incidence of EA was significantly lower in Group T compared to Group S at 5 min after PACU arrival (3/49 patients, 6% vs. 12/47 patients, 26%, P = 0.019). However, there was no difference between the two groups at 20 min after PACU arrival (23/49 vs. 19/47 patients in Group T vs. Group S, P = 0.425). The overall incidence of EA was 60% (28/47 patients) in Group S and 41% (20/49 patients) in Group T (P = 0.102). The number of children who received propofol as a rescue agent was significantly lower in Group T (Group S: 14/47 vs. Group T: 5/49, P = 0.031). CONCLUSIONS: Intravenous anesthesia induction with thiopental reduced the incidence of EA in the early PACU period compared to inhalation induction with sevoflurane in 3- to 7-year-old children undergoing sevoflurane anesthesia. KEYWORDS: Agitation; Pediatrics; Sevoflurane; Thiopental PDF XIII Congreso Virtual Mexicano de Anestesiología Octubre a Diciembre 2016 Información / Information

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Trauma pediátrico / Pediatric trauma

Octubre 4, 2016. No. 2468

Manejo del trauma pediátrico Management of Pediatric Trauma. COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, COUNCIL ON INJURY; VIOLENCE, AND POISON PREVENTION, SECTION ON CRITICAL CARE, SECTION ON ORTHOPAEDICS, SECTION ON SURGERY, SECTION ON TRANSPORT MEDICINE, PEDIATRIC TRAUMA SOCIETY, AND SOCIETY OFTRAUMA NURSES PEDIATRIC COMMITTEE. Pediatrics. 2016 Aug;138(2). pii: e20161569. doi: 10.1542/peds.2016-1569. Abstract Injury is still the number 1 killer of children ages 1 to 18 years in the United States (http://www.cdc.gov/nchs/fastats/children.htm). Children who sustain injuries with resulting disabilities incur significant costs not only for their health care but also for productivity lost to the economy. The families of children who survive childhood injury with disability face years of emotional and financial hardship, along with a significant societal burden. The entire process of managing childhood injury is enormously complex and varies by region. Only the comprehensive cooperation of a broadly diverse trauma team will have a significant effect on improving the care of injured children. PDF XIII Congreso Virtual Mexicano de Anestesiología Octubre a Diciembre 2016 Información / Information

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Medicamentos y obesidad / Medicines and obesity

Septiembre 29, 2016. No. 2463

El retorno de las píldoras dietéticas arcoiris The return of rainbow diet pills. Cohen PA, Goday A, Swann JP. Am J Public Health. 2012;102(9):1676-86. Author information Abstract The US Food and Drug Administration (FDA) has recently warned consumers about the risks of weight loss supplements adulterated with multiple pharmaceutical agents. Some of these supplements combine potent anorectics, such as amphetamines derivatives, with benzodiazepines, beta-blockers, and other medications to suppress the anorectics' adverse effects. These weight loss supplements represent the most recent generation of rainbow diet pills, named for their bright and varied colors, which date back more than 70 years. Beginning in the 1940s, several US pharmaceutical firms aggressively promoted rainbow pills to physicians and patients. By the 1960s the pills had caused dozens of deaths before the FDA began removing them from the US market. We used a variety of original resources to trace these deadly pills from their origins in the United States to their popularity in Spain and Brazil to their reintroduction to the United States as weight loss dietary supplements. PDF Opciones para sedación para el obeso mórbido en terapia intensiva Sedation options for the morbidly obese intensive care unit patient: a concise survey and an agenda for development. Aantaa R1, Tonner P2, Conti G3, Longrois D4, Mantz J5, Mulier JP6. Multidiscip Respir Med. 2015 Mar 7;10(1):8. doi: 10.1186/s40248-015-0007-2. eCollection 2015. Abstract BACKGROUND: We offer some perspectives and commentary on the sedation of obese patients in the intensive care unit (ICU). DISCUSSION: Sedation in morbidly obese patients should conform to the same broad principles now current in ICU practice. These include a general presumption against benzodiazepines as first-line agents. Opioids should be avoided in any situation where spontaneous breathing is required. Remifentanil is the preferred agent where continuous stable opioid levels using an infusion are required, because of its lack of context-sensitive accumulation. Volatile anaesthetics may be an option for the same reason but there are no substantial, controlled demonstrations of effectiveness/safety in short-term use in the ICU setting. Propofol is a valuable resource in the morbidly obese patients but the duration of continuous sedation should not exceed 6 days, in order to avoid propofol infusion syndrome. Alpha-2 agonists offer a range of theoretically positive features for the sedation of morbidly obese patients, but at present there is a lack of pharmacokinetic data and a critical mass of high-grade clinical data. Dexmedetomidine has the attraction of not causing respiratory depression or obstructive breathing during sedation and its sympatholytic effects should help deliver stable blood pressure and heart rate. Ketamine has a poor tolerability profile in adults so its use in the ICU context is largely confined to paediatrics. CONCLUSION: None of the agents currently available is ideal for every situation encountered in the management of morbidly obese patients. This article identifies additional research needed to place sedation practice of obese patients on a more systematic footing. KEYWORDS: Benzodiazepines; Clonidine; Dexmedetomidine; Intensive care; Ketamine; Obesity; Opioids; Propofol; Sedation; Volatile anaesthetics PDF La farmacocinética del midazolam, un sustrato de CYP3A en pacientes con obesidad mórbida antes y un año después de la cirugía bariátrica. The pharmacokinetics of the CYP3A substrate midazolam in morbidly obese patients before and one year after bariatric surgery.  Brill MJ, van Rongen A, van Dongen EP, van Ramshorst B, Hazebroek EJ, Darwich AS, Rostami-Hodjegan A, Knibbe CA. Pharm Res. 2015 Dec;32(12):3927-36. Abstract Bariatric surgery is nowadays commonly applied as treatment for morbid obesity. As information about the effects of this procedure on a drug's pharmacokinetics is limited, we aimed to evaluate the pharmacokinetics of CYP3A probe substrate midazolam after oral and intravenous administration in a cohort of morbidly obese patients that was studied before and 1 year post bariatric surgery. CONCLUSIONS: In this cohort study in morbidly obese patients, systemic clearance was 1.7 times higher 1 year after bariatric surgery, which may potentially result from an increase in hepatic CYP3A activity per unit of liver weight. Although MTT was found to be faster, oral bioavailability remained unchanged, which considering the increased systemic clearance implies an increase in the fraction escaping intestinal first pass metabolism. KEYWORDS:CYP3A; bariatric surgery; midazolam; pharmacokinetics PDF XIII Congreso Virtual Mexicano de Anestesiología Octubre a Diciembre 2016 Información / Information

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015