Anesthesia in children
Anesthesia in children
Maria I. Dalamagka
Chapter 1
Review: International Journal of Science and Research Archive, 2024, 12(01), 2924–2927.
Article DOI: 10.30574/ijsra.2024.12.1.1179
Corpus ID: 270895971
Anesthesiology complications in children
Maria I. Dalamagka
Abstract
General anesthesia is defined by the American Society of Anesthesiologists as a “drug induced loss of consciousness during which patients are not arousable, even by painful stimulation”. The perioperative period, immediately before, during, and after surgery, is a particularly critical time for pediatric patients. Even though anesthesia today is much safer than it has ever been, all anesthesia has an element of risk. General anesthesia has been safely given to children for many years. Improvements in inhalational and intravenous agents have increased the safety profile of general anesthesia and complication rates are low. General anesthesia has also allowed children to undergo painful or anxiety inducing procedures. General anesthesia is a complete loss of consciousness with amnesia, analgesia and neuromuscular blockade. It can be divided into three phases: induction, maintenance and emergence. Induction usually occurs with inhalational anesthetic in children until intravenous access occurs. Propofol, etomidate and ketamine are often used for induction. Maintenance of anesthesia occurs with inhalational or intravenous medications. Common inhalational anesthetics include nitrous oxide, sevoflurane or desflurane. Common intravenous medications used for maintenance are propofol and remifentanil. Typical complications in pediatric anesthesia are respiratory problems, medication errors, difficulties with the intravenous puncture and pulmonal aspiration. In the postoperative setting, nausea and vomiting, pain, and emergence delirium can be mentioned as typical complications. Side effects of anesthesia may include nausea, vomiting, drowsiness, muscle soreness and sore throat. Rare but more serious complications include adverse reactions that affect breathing, allergic reactions and irregular heart rhythms. Airway and respiratory events are the most common perioperative complications in pediatric patients. Several studies have reported on the incidence of pediatric airway-related complications. Consistently reported risk factors for serious airway complications include very young age and multiple intubation attempts. Laryngospasm was the most common cause of respiratory related arrests. Other etiologies included airway obstruction, difficult intubation, esophageal intubation, and aspiration.
https://www.researchgate.net/publication/382428764_ebookpdf.
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Chapter 2
SURGERYMEET2022. International Meet on Surgery and Surgical Techniques. albedo. 2022.
Eurotoxicology2023, Naples, Italy, 6-8/11/2023. https://www.signatureconferences.com/eurotoxi2023/
Citation: Dalamagka MI (2022) Combination of Ketamine, Corticosteroids and Sevoflurane Inhibits the Risk of Bronchospasm in Intubated Children under General Anesthesia. SunText Rev Med Clin Res 3(2): 154
GSC Advanced Research and Reviews, 2022, 11(01), 165–166. Article DOI: 10.30574/gscarr.2022.11.1.0108
10.5281/zenodo.6769670
https://doi.org/10.5281/zenodo.6769670
Combination of ketamine, corticosteroids and sevoflurane inhibits the risk of bronchospasm in intubated children under general anesthesia
Maria I Dalamagka
Abstract
Asthma in children is associated with significant morbidity. Children with severe asthma are at increased risk for adverse outcomes including medication-related side effects, life-threatening exacerbations, and impaired quality of life. In the study, an asthmatic child with a recent cold, received general anesthesia for emergency surgery centered on sevoflurane, corticosteroids and ketamine. The purpose of this study is to demonstrate the beneficial effects of the combination of sevoflurane, ketamine and corticosteroids in asthmatic children and to prevent complications when they are given general anesthesia for emergency surgery.
Asthma is a chronic respiratory disease that affects people of all ages and is characterized by episodic and reversible attacks of wheezing, chest tightness, shortness of breath, and coughing. According to the ATS/ERS guideline, severe asthma is defined as asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller (and/or systemic corticosteroid) to prevent it from becoming “uncontrolled” or remains “uncontrolled“despite this therapy [1-7].
A 6-year-old child weighing 30 kg with a recent cold, nasal congestion and hearing of both amphibians and with a known history of frequent asthma attacks underwent emergency appendectomy. It was given intravenously before the introduction of anesthesia solu medrol 60 mg, Dexaton 3 mg, onda 3 mg. Introduction to anesthesia was by intravenous administration of Fentanyl 60 mcg, Propofol 120 mg, Esmeron 30 mg. After intubation, intrabronchial aspiration was performed, intrabronchial Flixotide 50 mcg και Aerolin 100 mcg was given and mechanically ventilated with 50% N2O and 2% sevoflurane. Ketamine 6 mg was given intravenously, plus 30 mcg Fentanyl, Apotel 350 mg, and morphine 1.5 mg. The monitoring included ECG, NBP, SpO2 and the ventilation model in Drager machine was Volune Control. Towards the end of the operation and with pure inhaled oxygen he was put in a Pressure Control model and the awakening was done smoothly after intravenous Bridion 60 mg.
The common denominator underlined in all forms of asthma is bronchial hyperresponsiveness to various stimuli. Inhaled glucocorticoids have long been used as a first-line treatment for persistent pediatric asthma, as they are the most effective intervention for the treatment of asthma. Thus, Solu medrol (kg x 2), Dexaton (up to 0.1x kg) and Flixotide 50 mcg and Aerolin 100 mcg were administered intravenously. Ketamine also causes bronchodilation and was administered at its appropriate titrated dose (0.2 x kg), as anesthesia was maintained with sevoflurane which does not irritate the respiratory system.
Corticosteroids have inhibitory properties in many effects on many stem cells and inflammatory cells, which are activated in asthma. Inhaled steroids reduce the number and activation of inflammatory cells in the epithelium and submucosa by clogging the damaged epithelium and, potentially, inhibiting the production of proinflammatory cytokines, and reducing the survival time of the epithelium. This action of corticosteroids in combination with the ketamine which has a bronchodilator effect and the property of sevoflurane as it does not irritate the airway, they eliminate bronchospasm and prevent possible laryngospasm.
In conclusion, the combination of Ketamine, corticosteroids and sevoflurane has been shown to inhibit possible complications such as bronchospasm when asthmatic children implied in general anesthesia.
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Chapter 3
R Discovery
Articles published on Anesthetic Agents In Children. https://discovery.researcher.life/topic/anesthetic-agents-in-children/25561753?page=1&topic_name=Anesthetic%20Agents%20In%20Children
https://zenodo.org/records/13636095
Review Article: GSC Advanced Research and Reviews, 2024, 20(01), 001–004.
Article DOI: 10.30574/gscarr.2024.20.1.0238
DOI:10.30574/gscarr.2024.20.1.0238
Corpus ID: 271011003
Remifentanil as anaesthetic agent in children
Maria I. Dalamagka
Abstract
Remifentanil hydrochloride is an ultra-short-acting opioid that undergoes rapid metabolism by tissue and plasma esterases. Remifentanil is increasingly used as an adjuvant to general anaesthesia in neonates undergoing surgery because of its favourable haemodynamic and respiratory effects compared with other agents. The pharmacokinetic profile of remifentanil appears well suited for use in the sedation of children for short, day case procedures and remifentanil has been demonstrated to be an attractive drug for this purpose. Owing to higher clearances, younger children will require higher infusion rates of remifentanil than older children and adults to achieve equivalent plasma concentrations. Propofol and remifentanil appear to be gaining popularity for short procedures in children. Together they provide sedation, anxiolysis and analgesia, possibly best provided by separate continuous infusions. They also promote haemodynamic stability, minimal respiratory depression, with a rapid recovery profile. The use of remifentanil in neonates and young infants is increasing despite the difficulties in obtaining high standard objective evidence in this age group. Remifentanil’s pharmacokinetic and pharmacodynamic profile in this age group is similar to that of older children, which may have several theoretical advantages. Reports of a rapid development of µ-receptor tolerance with remifentanil are in conflict; activity at δ-opioid receptors may contribute. Remifentanil produce a fall in blood pressure and cardiac index, mainly as a result of a fall in heart rate. Although atropine is able to reduce the fall in heart rate, is not able to prevent completely the reduction in cardiac index. Remifentanil has been described as a titratable opioid. It has been reported to be ideally suited to the sedation of selected neurosurgical patients who require frequent neurological examinations. It may also provide suitable analgesia based sedation in mechanically ventilated children postoperatively.
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Chapter 4
GSC Advanced Research and Reviews, 2024, 19(01), 001–003. Article DOI: 10.30574/gscarr.2024.19.1.0125
DOI:10.30574/gscarr.2024.19.1.0125
Corpus ID: 269002239
12 References
R Discovery
https://explore.openaire.eu/search/publication?pid=10.30574/gscarr.2024.19.1.0125
Etomidate as Anesthetic Agent in Asthmatic Child with Food Allergy
Maria I. Dalamagka
Abstract
Children with bronchial asthma and respiratory infections have significant peri-operative implications for the anaesthesiologists. With improvements in medical knowledge and anaesthesia techniques, morbidity and mortality associated with an asthmatic child undergoing surgery have come down. Etomidate is an intravenous anesthetic agent whose clinical effects are the result of potentiation of the gamma-amino butyric acid inhibitory neurotransmitter system with the alteration of transmembrane chloride conductance. Physicians commonly use etomidate for adult rapid-sequence intubation, but the manufacturer does not recommend its use for children under 10 years of age due to a lack of data. Ketamine has been suggested as an alternative agent given its limited effects on hemodynamic function related to the release of endogenous catecholamines. A child aged 11 years and weighing 40 kg, with egg allergy and a more general allergic predisposition, with a history of asthma treated with inhalants and a recent respiratory infection with antibiotics, came with a diagnosis of acute abdomen. Etomidate was used as an anesthetic agent in combination with ketamine, using rocuronium and sevoflurane. Corticosteroids and aminophylline were given to prevent bronchospasm. Ketamine and etomidate, both of which provide effective sedation with limited effects on hemodynamic function, have become increasingly popular as induction agents.
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Chapter 5
Review: International Journal of Science and Research Archive, 2024, 12(02), 1577–1581.
Article DOI: 10.30574/ijsra.2024.12.2.1408
R Discovery
https://discovery.researcher.life/article/emergence-delirium-in-children/b418693e77503fe69d957577cb9544b7
What are the most common risk factors associated with emergence agitation in children after general anesthesia? Insight from top 5 papers
https://typeset.io/questions/what-are-the-most-common-risk-factors-associated-with-3yaz2larvu
https://typeset.io/papers/emergence-delirium-in-children-56pix2thu7ey
Emergence Delirium in children
Maria I. Dalamagka
Abstract
Delirium after anesthesia, also known as emergence delirium (ED) is a clinical condition in which patients have alterations to their attention, awareness, and perceptions. In children, this often results in behavioral disturbances such as crying, sobbing, thrashing and disorientation. Emergence Agitation (EA) and Emergence Delirium (ED) are commonly used interchangeably, they describe two distinct conditions with emergence delirium being described in the anesthesia literature as a state of mental confusion, agitation, and dis-inhibition marked by some degree of hyper-excitability during recovery from general anesthesia. The commonly reported incidence of emergence delirium is about 10% to 30% of paediatric patients. Risk factors associated with emergence delirium are age, preexisting behaviours, types of surgery and the use of volatile anaesthesia. Transient agitation - delirium from sevoflurane anesthesia can lead to a variety of adverse events, such as airway spasm, shedding or displaced tracheal tube, dehiscence, or bleeding. Volatile anaesthetics may affect brain activity by interfering with the balance between neuronal synaptic inhibition and excitation in the central nervous system. Elevated postoperative pain has been suggested to underlie ED. But given that ED is seen in patients undergoing MRI, pain cannot be the sole cause. Treatment options include the use of premedication, analgesic adjuvants, single dose of propofol at the conclusion of the case. Midazolam premedication, intraoperative dexmedetomidine and fentanyl were associated with lower incidence of ED. The incidence of ED in patients receiving propofol is markedly lower than those receiving sevoflurane, despite the similar rapid emergence profile of both agents. Paediatric Assessment of Emergence Delirium (PAED) scale, developed specifically for children, is a valid and reliable scale. Watcha score is a simpler, reliable tool to measure emergence behaviour. There has been considerable progress in the neuroscience of anaesthesia and the application of new pharmacological agents, but the mystery behind the exact mechanism of ED is elusive. ED is a diagnosis of exclusion once other causes have been dismiss. There is no strong evidence of long-term effects and outcomes in children who developed emergence delirium after anesthesia. Prevention may be the best treatment but no one medication is entirely effective.
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Chapter 6
Review Article: GSC Advanced Research and Reviews, 2024, 19(01), 161–164.
Article DOI: 10.30574/gscarr.2024.19.1.0153
Corpus ID: 269464862
Acute Pain and Analgesia in children
Maria I. Dalamagka
Abstract
Acute pain is a complex process involving activation of nociceptors, chemical mediators and inflammation. All the major children’s hospitals now have dedicated pain services to provide evaluation and immediate treatment of pain in any child. Children experience pain in a similar way to adults. Pain intensity in children depends on the surgical procedure itself but also on numerous other factors such as age, emotional state or the level of anxiety associated with the hospital stay. The perception and communication of the child’s pain depends on his or her intellectual and social development. Expression of pain therefore relies on the child’s ability to understand, quantitate and communicate it. Previous pain experiences or chronic diseases that required many medical procedures may significantly change the pain threshold in paediatric patients. Moreover, genetic predispositions and environmental effects are significant. The American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The total number of behaviors that are present in the child are used to estimate his/her pain at the time of assessment. Pain assessment is important to facilitate effective postoperative pain management in these vulnerable children. The purpose of this study is to investigate acute pain as well as analgesia and availability of the used analgesic drugs in children. A multimodal approach to preventing and treating pain is usually used.
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Chapter 7
Obesity in Children and General Anesthesia. 2024. doi: 10.5281/ZENODO.10894783.
https://commons.datacite.org/doi.org/10.5281/zenodo.10894783
https://zenodo.org/records/6628053
https://doi.org/10.5281/zenodo.6628052
Citation: Dalamagka MI. Obestity in Children and General Anesthesia. Mega J Case Rep. 2024;7(02):2001-2003.
https://megajournalofcasereports.com/wp-content/uploads/2024/02/MJCR-72-2158.pdf
Dalamagka, M. Obesity in children and general anesthesia. GSC Biol. Pharm. Sci. 2022, 19, 308–309, https://doi.org/10.30574/gscbps.2022.19.2.0206.
Scilit
https://www.scilit.net/publications/df2192fb4e8217ced5bdd9b28eaf3f64
Abstract
Childhood obesity has reached epidemic levels in developed as well as in developing countries. Overweight and obesity in childhood are known to have significant impact on both physical and psychological health. Obese 10-year-old boy undergoes general anesthesia for emergency peritonitis surgery. The purpose of this study was to study the intraoperative behavior of obese children as they are accompanied by respiratory and metabolic disorders
The Greek e-Journal of perioperative Medicine. Supplement Issue 2022;21(c) | https://e-journal.gr (p.173)
Purpose
Childhood obesity has reached epidemic levels in both developed and developing countries. Childhood overweight and obesity are known to have a significant impact on both physical and psychological health. The World Health Organization (WHO) has recognized childhood obesity as "one of the most serious public health challenges of the 21st century". In 2016, the WHO found that worldwide, the number of overweight
of children under 5 exceeded 41 million and the number between the ages of 5 and 19 was 340 million. Sociocultural factors have also been found to influence the development of obesity. Our society tends to use food as a reward, as a means of controlling others and as part of socialization. Almost 30% of obese children suffer from asthma. Obese children are more likely to suffer from respiratory infections that may require rescheduling of scheduled surgery. Patients with bronchial asthma have an increased risk of developing intraoperative bronchospasm, especially if they receive general anesthesia with an endotracheal tube. Bronchospasm occurs as bronchoconstriction becomes more severe and it takes progressively longer for the alveoli to empty carbon dioxide during exhalation. An obese 10-year-old boy underwent general anesthesia for emergency peritonitis surgery. The purpose of this work was to study the intraoperative behavior of obese children as they are accompanied by respiratory and metabolic disorders.
Case report
A 10-year-old, 60-kg child presented with an acute abdomen for appendectomy. The child had allergic bronchial asthma, with known allergic predisposition, known egg allergy and frequent asthma attacks two years ago. Preoperative administration of Solu medrol 120 mg, Dexaton 4 mg and Onda 4 mg was performed. Anesthesia was induced with Dormicum 1 mg, Ketamine 10 mg, Fentanyl 0.1 mg, Hypnomidate 18 mg, Esmeron 50 mg. After intubation, he was placed on mechanical ventilation, with a Primus Drager volume control ventilator model. Maintenance of anesthesia was achieved with Sevoflurane 2.5%, additional Fentanyl 0.1 mg and morphine 3 mg were administered. The duration of the surgery was one hour. At the end of the operation, Bridion 200 mg was administered with pure inhaled oxygen and awakening was delayed for half an hour. The concept of cross-reactivity between drugs used in the perioperative environment and food is often mentioned but usually not supported by evidence. Preexisting allergic diseases and other nonallergic but relevant clinical entities should be carefully considered during the preoperative evaluation, as they may lead to life-threatening perioperative conditions. for this reason Dormicum, Ketamine and Hypnomidate were administered, instead of Propofol, although studies have shown that it can be used. Awakening was delayed due to recirculation of drugs and drugs were not calculated based on ideal body weight because the child was in acute pain and anxiety and this would lead to complications in the induction of anesthesia. Intravenous Solu Medrol and Dexaton which prevents sensitization was also given. Expiratory reserve volume is reduced in obesity. Total lung capacity is usually preserved except in conditions such as morbid obesity, excessive central obesity, or obesity-hypoventilation syndrome. Obese patients have a reduced FRC that can lead to atelectasis. Atelectasis means incomplete dilatation. Obesity leads to an increased metabolic rate, increased oxygen demand, increased CO2 production and increased alveolar ventilation. This is a reduced compliance of the chest wall due to the fatty tissue that lies above the chest. Lung volumes are reduced as the increased abdominal mass pushes the diaphragm cephalad. For this reason Bridion was given in the awakening phase, as the remaining muscle wasting would lead to life-threatening situations for the patient.
Conclusion
Obese children have special anesthesia needs in emergency surgery and the metabolic and respiratory disorders that may occur as a result of obesity should be considered.
https://www.researchgate.net/publication/383400837_Anesthesia_in_children
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