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Clonidine and dexmedetomidine Both drugs are alpha-2 agonists that may cause hypotension, bradycardia and somnolence in high doses. Regarding pediatric patients, seizures in association with moderate hyperventilation was observed in a very high percentage of patients receiving sevoflurane [ 34 ]. We need to do the same when the airway, a classical tunnel for the passage of air, has to be examined for possible damage. The Association of Paediatric Anaesthetists limits membership to consultants who have a major commitment to paediatric anaesthesia, but trainees may attend meetings as guests of a member. All inhalational agents except N 2 O are contraindicated in icteric ictal? The danger of PRIS is present today.
Because of this, many consultants currently working in paediatric intensive care obtained their skills overseas. A similar committee exists for adult intensive care medicine. Application has been made for intensive care medicine to be recognised as a specialty, but currently it is necessary to obtain a CCST in the parent specialty. It is proposed that specialist training in paediatric intensive care medicine could be undertaken by trainees from paediatrics, anaesthesia, or paediatric surgery. Trainees will need to have spent some time in other relevant specialties, depending on their parent specialty.
Doctors interested in these and similar posts should check with the relevant royal college and postgraduate dean about approval for the CCST and keeping the NTN. At present consultants in paediatric intensive care generally have as their base specialty paediatrics or anaesthesia, and many maintain sessions in the primary specialty.
Neonatal services are almost exclusively the domain of paediatricians, and there is little overlap with intensive care provision for older children. Courses such as APLS advanced paediatric life support or PALS paediatric advanced life support are recommended for anyone who will have to deal with paediatric emergencies. Meetings of relevant societies are always a good place to meet others in the field and perhaps learn something new. The Association of Paediatric Anaesthetists limits membership to consultants who have a major commitment to paediatric anaesthesia, but trainees may attend meetings as guests of a member.
The Paediatric Intensive Care Society is a multidisciplinary organisation and holds regular meetings. Paediatric anaesthesia and paediatric intensive care represent challenging areas of practice. Training programmes, particularly in intensive care, have still to develop in Britain, and a period overseas is likely to prove valuable.
There are many opportunities at consultant level, both in specialist units and general hospitals, for doctors with training in paediatric anaesthesia or intensive care. The Royal College of Anaesthetists maintains a website www. The Intensive Care Society, which is largely concerned with adult intensive care, has a website which has some information about progress being made in the training of intensivists http: The Pediatric Critical Care Medicine website pedsccm.
An email discussion list for those interested in paediatric intensive care may be joined from this site. Many children's hospitals in North America have a presence on the internet and some include details of their residency and fellowship programmes. For example, Boston Children's Hospital web1. The Hospital for Sick Children's site also has an email discussion list for paedaitric anaesthetists. Those interested in training in the United States may wish to check the site of the Educational Commission for Foreign Medical Graduates http: The Royal Children's Hospital, Melbourne, Australia, has a website with general information about the hospital and an email directory www.
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Previous situation Anaesthetic training has involved rotations through a variety of subspecialty areas, such as cardiac, neurosurgical, and paediatric anaesthesia, often in specialist centres, as well as more general experience of anaesthesia and intensive care. Training requirements for consultant appointments in paediatric intensive care 4 Paediatric intensive care unit in lead centre: Lead consultant with two years' approved training in paediatric intensive care Consultants providing sessional commitment or on call coverage with approved training in paediatric intensive care Major acute general hospitals providing paediatric intensive care: Lead consultant with approved training in paediatric intensive care with major sessional input to unit Cover by consultants with training and continuing experience in paediatric intensive care while children are cared for in the unit All consultants to have advanced paediatric life support APLS or paediatric advanced life support PALS certification Single specialty hospitals: Cover by consultants with training and continuing experience in paediatric intensive care while children are cared for in the unit All consultants to have APLS or PALS certification.
Overseas training Specialist training in paediatric anaesthesia and intensive care in North America is normally undertaken after completing a residency programme. Paediatric intensive care Training in paediatric intensive care medicine in Britain has been hampered by the lack of organised training programmes and the plethora of small centres. Appendix Links to sites of interest on the world wide web The Royal College of Anaesthetists maintains a website www.
UK reviews intensive care and emergency services. BMJ ; The view from the specialist hospital. Scientifically proven advantages of sevoflurane remain the reasons for its use in arrhythmic patients and in those requiring subcutaneous adrenaline injections in plastic surgery. Whether children with congenital heart defects and cyanosis do profit from sevoflurane in comparison with halothane remains questionable since the study supporting this opinion [ 44 ] used up to 4.
All inhalational agents except N 2 O are contraindicated in icteric ictal? Children, whereas N 2 O is the best choice of inhalational analgesia if there is difficulty obtaining i. Inhalational anesthesia in pediatrics needs experienced anesthesiologists with a high awareness of the side effects of any anaesthetics currently available on the market. More detailed, epidemiological investigations are necessary to determine if sevoflurane has long term effects on the brain, in particular after a series of anesthetics. Desflurane is infrequently used in pediatric anesthesia despite a very low blood-gas partition of 0.
Due to a high incidence of restlessness during emergence from anesthesia [ 45 ] and the difficulty in using it for mask induction, have kept many pediatric anesthesiologists from using it. However, airway events after desflurane anesthesia can be reduced considerably when children are extubated when they are awake [ 46 ]. Remifentanil, the newest opioid marketed since , is unique because an ester linkage allows rapid degradation by blood and tissue esterases. The very short half-life permits a rapid recovery, within 10 minutes, independent of hepatic or renal function [ 47 ].
Unlike all other opioids, the duration of action is independent of the administered dose and the duration of infusion, keeping the context sensitive half-life constant. This makes it an ideal agent for neonatal and infant anesthesia. There is no other drug than remifentanil with a greater clearance in neonates compared to older children [ 48 ].
Since remifentanil needs to be administered by continuous infusion, every interruption of the infusion or kinking of the intravenous line will quickly cause pain and possibly awareness. Postoperatively, pain management must be taken care of by regional blocks or other pain relieving medication. Overdosing in the sense of toxicity is not possible; however, high doses cause bradycardia and hypotension, in particular when a bolus is given - which should therefore be avoided [ 49 ].
Chest rigidity, a typical opioid-related side effect that can prevent proper ventilation, is rarely encountered when bolus-injections are avoided. Chest wall rigidity seems to be related to dosing of remifentanil and appears to be a rare event. Acute tolerance is suspected to occur during remifentanil infusion. In volunteers, analgesia was only one fourth of the initial peak level after three hours of continuous infusion [ 52 ].
This indicates that the dose needs to be increased during anesthesia according to the pain reactions of the patient. Remifentanil alone is not sufficient as a sole anesthetic, even when given in higher doses, since it has no hypnotic effect. Propofol as a sole hypnotic is a good partner for remifentanil for short procedures and for diagnostic interventions without postoperative pain as after endoscopies.
Propofol, a pure hypnotic agent, was released on the European market rather late in in in the USA! A great disadvantage of propofol for children is frequently appearing intense pain when it is injected intravenously, which can be reliably prevented only by inhalational induction. Significant drops in blood pressure with propofol induction or co-induction remain an important clinical problem today [ 54 , 55 ].
Due to its "popularity" it was uncritically used in high doses, often for long periods in intensive care units despite strict warnings based on pharmacokinetic data [ 56 ]. The result was the unnecessary, deplorable death of dozens of children and adults from propofol infusion syndrome PRIS. Only a small fraction of these cases were reported in the literature according to my own experience [ 57 ]. The danger of PRIS is present today. These extremely dangerous side effects are practically all preventable by avoiding too high doses and by reacting immediately to early symptoms [ 60 ].
Both drugs are alpha-2 agonists that may cause hypotension, bradycardia and somnolence in high doses. However, their sedative, anxiolytic, analgesic effects and the absence of respiratory depression make alpha-2 agonists very helpful drugs in pediatric anesthesia.
Alpha-2 agonists, being used as analgesics and sedatives, are associated with an opioid sparing effect - typical opioid side effects such as respiratory depression, pruritus and urinary retention do not occur. For this reason, clonidine is frequently used as an adjunct to neuraxial block, with advantageous clinical results [ 61 ]. Clonidine is an old drug. Its analgesic properties have been used in pediatrics since [ 62 ]. Dexmedetomidine was released on the market in in the USA for adult use.
Initial experiences with this drug in children, still being used off label, were published in [ 63 ]. Dexmedetomidine differs from clonidine by a greater alpha-2 receptor affinity, which results in shorter sedation times after ending an intravenous infusion, a more pronounced anti-shivering effect postoperatively, and a higher degree of arousability during long term sedation. The most frequent side effects are hypotension, bradycardia, nausea and significant hypertension when an initial dose is administered too rapidly [ 64 ]. The elimination half life of dexmedetomidine is about 2 hr, while it about 9 hr for clonidine [ 65 , 66 ].
Differentiating between these two similar drugs in order to provide the best clinical effects in any given case, cannot be done yet since convincing direct comparisons between the two drugs are missing. Dexmedetomidine as a new drug is far more intensely marketed than clonidine with arguments derived mainly from case reports. We as clinicians are in a conflict, as always, when being confronted with promising new drugs that are not well investigated in children.
We would like to find a scientifically based, independent point of view. However, due to a lack of data we are prone to make mistakes, and in general, we should choose a careful approach to new drugs. This classical conflict has been described by well known pediatric anesthesiologists, possibly helping us to make appropriate decisions and not over-eagerly resort to new drugs [ 67 - 69 ].
The well known "old" drugs might have the same if not a better safety record. At this point it seems that dexmedetomidine might have some advantages in short interventions in day care, and clonidine might have some advantages as an additive to regional blocks and long term sedation where easy arousability is not needed. Flumazenil, an antagonist used in diazepine overdoses, has had an established place in pediatric anesthesia for about 20 years.
Using it as routine antagonist in midazolam-supported anesthesia for target controlled anesthesia is rarely done anymore with the advent of propofol and remifentanil.
However, it remains a safe mode of anesthesia. Suggamadex, an antagonist of the long acting muscle relaxant rocuronium, is a very helpful new tool on the market since in pediatric anesthesia. It reverses even an immediately administered relaxant without permitting a rebound effect. A high dose of rocuronium can be used for rapid sequence induction and be reversed within about one minute with a dose of 4. Suggamadex is still very expensive.
Therefore, it is used only for well founded indications. Dealing with delicate airways in infants and children is a very important part of pediatric anesthesia!
A large body of literature and many presentations at international meetings have dealt with this problem. Unfortunately, the discussions are presently narrowed to the entirely unscientific slogan: There is no "versus" position between different tubes per se, but an intense interest in identifying the least traumatic side effects of different brands and designs of tracheal tubes. This question was not convincingly answered by the above quoted studies since their outcome measure was simply inadequate.
These sometimes dangerous injuries are not accessible to direct view and need to be evaluated by simple optical instruments Hopkins or Bonfils lenses in order to prevent the development of granulation tissue and later scarring and stenoses. Stridor cannot differentiate between benign injuries temporary edema or injuries needing an immediate surgical intervention. Endoscopy is needed for studying the effects of tracheal tubes in vivo; otherwise we will lose the most important information we need, a detailed description of possible injuries, whether they cause stridor or not.
In addition, an indispensable prerequisite for comparing tracheal tubes in humans was the design of the tubes same outer diameters, cuffs of identical shape and position on the shaft. They had to be standardized before comparing tracheal tubes, which was not the case in any of the above mentioned studies. If damage in a tunnel is suspected, specialists with good light sources are sent out to make visible what has happened to the walls or floor of the tunnel and to give a report.
We need to do the same when the airway, a classical tunnel for the passage of air, has to be examined for possible damage. The inadequacy of outcome measures for assessing airway injury was already addressed in They recommended airway endoscopy to initiate preventive treatment, e. In , five children with subglottic stenosis due to intubation trauma were described.
In it was noticed that not a single one of the studies designed to compare the incidence of airway trauma between children intubated with cuffed or un-cuffed tubes addressed subglottic stenosis, the worst side effect of airway injury. Since this is the worst complication of intubation, appearing late after the trauma, without the symptom of stridor, it should be the center of our concerns! This observation shows the inadequacy of all studies using stridor only as the only outcome measure!
There is no rational reason for assuming that the absence of immediate post-extubation stridor excludes late subglottic stenosis [ 77 ].
The differences between paediatric and adult anaesthetic practice are generally need IPPV during anaesthesia and would benefit from a higher respiratory. Pediatric Anesthesia; First published: 12 September . articles with audio and video files as part of our History of Pediatric Anesthesia Timeline series.
This observation was supported in by two studies with an unusually large number of endoscopic documents, demonstrating that the mechanisms of airway injury were due to intubation and late scar development and were not accompanied by stridor [ 78 , 79 ]. However, this ample evidence of the insufficiency of stridor as an outcome measure has not prevented further publications which still do not use the indispensable optical instruments Such studies make comparisons between differently designed tracheal tubes impossible, and they thus prevent the acquisition of convincing results.
It is not easy to answer the question why so many scientists in pediatric anesthesia are reluctant to use simple instruments to detect airway trauma as early as possible, in order to prevent late consequences for the patient. Is it a general fear of embarking on new technologies? Is it too difficult to imagine the value of endoscopic interventions, not having been exposed to airway endoscopy previously? It is all the more remarkable that since the beginning of , several departments of pediatric anesthesia in ASEAN countries have embarked on using airway endoscopy to check for injuries on a regular basis.
Lectures by external instructors and training in the operating rooms were part of this program. Lectures combined with training in the operating room show astounding immediate results. Practically all airway complications and injuries reported in the literature could be documented within a short time by endoscopy, such as injuries due to too large cuffed or uncuffed tubes, mucosal trauma by malpositioned cuffs, or folds of uninflated cuffs. Inflammation of ulcers or abrasions could be documented as evidence of older injuries that could not be detected without endoscopes.
Unexpected malformations and narrowing of the airway could be detected early and expert help for intubation obtained. Thinking about advances in any medical field will always show progress accompanied by adverse effects that were not known before the advances. Knowing this rule, we have to be aware of unknown side effects when new drugs or techniques are introduce into clinical practice and we must use the novelties with great care. National Center for Biotechnology Information , U. Journal List Korean J Anesthesiol v. Published online May Find articles by Josef Holzki. Received Sep 7; Accepted Oct This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License http: Abstract Writing about advances in a field of medicine normally includes some pride about progress which one was witness to or even a participant in.
Advances pediatric regional intravenous anesthesia. Recent Guidelines in Pediatric Cardiopulmonary Resuscitation CPR Cardiac arrest algorithms are of particular importance in pediatric anaesthesia since they are life saving when cardiac arrest occurs in otherwise healthy children during anesthesia due to unexpected adverse events.
What is new in the guidelines of ? Interruption of chest compressions during CPR must be minimized!! Main differences from older CPR-models Children over eight years of age are treated like adults. A compression - ventilation ratio of In newborns and infants a In children, the lower third of the sternum should be used for chest compression since it may generate a higher blood pressure than the usual compression of the middle of the chest. After one defibrillation, CPR should be continued immediately without rhythm analysis, to prevent longer no-flow times.
After two minutes of CPR, the next shock should be applied. Despite lack of scientific evidence in human studies, the routine use of vasopressors adrenaline is recommended. A fold higher dose of i. Sodium bicarbonate is not recommended for routine use but might be considered for life-threatening hyperkalemia or cardiac arrest associated with hyperkalemia or for pre-existing severe metabolic acidosis or tricyclic antidepressant overdose. Recent guidelines in neonatal resuscitation Resuscitation Guidelines for term and preterm infants were included in the ILCOR guidelines of Regional Anesthesia Probably the most important general achievement in pediatric anesthesia during the last few years, one influencing all areas of pediatric anesthesia, was the re-introduction of regional techniques in the late s.
Inhalational Anesthesia Halothane was introduced into clinical practice in as the first non-inflammable anesthetic. Open in a separate window. Table 2 Output of Halothane-vaporizers and Compared to Sevoflurane-vaporizers. Intravenous Agents Remifentanil, the newest opioid marketed since , is unique because an ester linkage allows rapid degradation by blood and tissue esterases. Clonidine and dexmedetomidine Both drugs are alpha-2 agonists that may cause hypotension, bradycardia and somnolence in high doses. Recently Developed Antagonists Flumazenil, an antagonist used in diazepine overdoses, has had an established place in pediatric anesthesia for about 20 years.
Airway Care in Pediatric Anesthesia Dealing with delicate airways in infants and children is a very important part of pediatric anesthesia! A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. Critical Care for infants and children. High-dose epinephrine improves outcome from pediatric arrest. Quality of chest compressions during 10 min of single-rescuer basic life support with different compression: Vento M, Saugstad OD. Resuscitation of the term and preterm infant.
Semin Fetal Neonatal Med. Regional anesthesia in pediatrics. Ann Fr Anesth Reanim. Recent advances in the pharmacokinetics of local anesthetics. Long-acting amide enantiomers and continuous infusion. A Practice of Anesthesia for Infants and Children. Accidents following extradural anesthesia in children. The results of a retrospective study. Epidemiology and morbidity of regional anesthesia in children: Innovative approaches to neuraxial blockade in children: Tsui BC, Suresh S. Ultrasound imaging for regional anesthesia in infants, children and adolescents: Minimum alveolar anesthetic concentration: Paul M, Fisher DM.
Are estimates of MAC reliable?
Pharmacokinetics and Pharmakology of Drugs Used in Children. Slow induction with sevoflurane was associated with complete atrioventricular block in a child with hypertension, renal dysfunction, and impaired cardiac conduction. Severe myocardial ischaemia during mask induction of anaesthesia in an infant with unknown critical supravalvular aortic stenosis.
Induction and recovery characteristics and hemodynamic responses to sevoflurane and halothane in children. High concentration versus incremental induction of anesthesia with sevoflurane in children: Comparison of intubating condition under sevoflurane and halothane anesthesia in pediatric patients. Clinical characteristics of sevoflurane in children: Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery: Rapid inhalation induction in children: Holzki J, Kretz FJ.
Changing aspects of sevoflurane in paediatric anaesthesia: Anesthesia-related cardiac arrest in children: Comparison of sevoflurane and halothane for outpatient dental anaesthesia in children. Comparative hemodynamic depression of sevoflurane versus halothane in infants: Anesthetic induction of children with high concentrations of sevoflurane. Epileptiform electroencephalogram during mask induction of anesthesia with sevoflurane. Epileptiform discharges during 2 MAC sevoflurane anesthesia in two healthy volunteers.
Sevoflurane mask induction of anaesthesia is associated with epileptiform EEG in children.