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Safeguarding cerebral function is of major importance during pediatric anesthesia. Premature, ex‐premature, and full‐term neonates can be vulnerable to physiological changes that occur during anesthesia and surgery. Data from studies performed during pediatric cardiac surgery and in neonatal/pediatric intensive care units have shown the benefits of near‐infrared spectroscopy (NIRS) monitoring of regional cerebral oxygenation (c‐rSO2). However, NIRS monitoring is seldom used during noncardiac pediatric anesthesia. Despite compelling evidence that blood pressure does not reflect end‐organ perfusion, it is still regarded as the most important determinant of cerebral perfusion and the most relevant hemodynamic management target parameter by most (pediatric) anesthetists. The principle of NIRS monitoring is not self‐explanatory and sometimes seems even counterintuitive, which may explain why many anesthesiologists are reserved regarding its use. The first part of this paper is dedicated to a clinical introduction to NIRS monitoring. Despite scientific efforts, it has not yet been possible to define individual lower limit c‐rSO2 values and it is unlikely this will succeed in the near future. Nonetheless, published treatment algorithms usually specify c‐rSO2 values which may be associated with cerebral hypoxia. Our treatment guideline for maintaining sufficient cerebral oxygenation differs fundamentally from all previously published approaches. We define a baseline c‐rSO2 value, registered in the awake child prior to anesthesia induction, as the lowest acceptable limit during anesthesia and surgery. The cerebral rSO2 is the single target parameter, while blood pressure, heart rate, PaCO2, and SaO2 are major parameters that determine the c‐rSO2. Cerebral NIRS monitoring, interpreted together with its continuously available contributing parameters, may help avoid potentially harmful episodes of cerebral desaturation in anesthetized pediatric patients. [ABSTRACT FROM AUTHOR]

Background The aep EX is a measure of depth of hypnosis (DoH), derived from processed mid-latency auditory evoked potentials. Objectives To evaluate the aep EX as a measure of DoH in children receiving sevoflurane-remifentanil anesthesia. Methods aep EX and bispectral index ( BIS) were recorded simultaneously in 75 children, (1-3, 3-6, and 6-18 years), receiving sevoflurane at endtidal concentrations ( ETsevo) between 1.5 and 0.5 MAC. The ETsevo at which the aep EX and BIS had a value of 50 ( EC50aep EX and EC50 BIS) was calculated by nonlinear regression analysis. The accuracy of aep EX and BIS to predict the DoH was assessed by prediction probability (Pk) and receiver operating characteristics ( ROC) analysis. Results Seventy-four children were included for analysis. The EC50aep EX (2.68%) and EC50 BIS (2.10%) were comparable; the same accounts for the EC50aep EX of the different age groups and the EC50aep EX and EC50 BIS of corresponding age groups. The EC50 BIS in children aged 1-3 years was lower than in the older age groups ( P < 0.05). Pk values of the aep EX (0.32, CI 95% 0.08-0.56) and BIS (0.47, CI 95% 0.19-0.75) were comparable. The area under the ROC curve was 0.72 ( CI 95%: 0.62-0.82) and 0.67 ( CI95%: 0.56-0.77) for the aep EX and BIS, respectively ( P = 0.54). Optimal cutoff values were >60 (aep EX) and >68 ( BIS), with corresponding specificities 91%, CI 95%: 80-97% (aep EX) and 66%, CI 95%: 52-77% ( BIS). Conclusions In this study with children receiving sevoflurane anesthesia, the aep EX outperformed the BIS in distinguishing unconsciousness from consciousness. Both indices performed equally bad in differentiating different levels of DoH. [ABSTRACT FROM AUTHOR]

Background The aep EX Plus monitor (aep EX) utilizes a mid-latency auditory evoked potential-derived index of depth of hypnosis ( Do H). Objective This observational study evaluates the performance of the aep EX as a Do H monitor for pediatric patients receiving propofol-remifentanil anesthesia. Methods aep EX and BIS values were recorded simultaneously during surgery in three groups of 25 children (aged 1-3, 3-6 and 6-16 years). Propofol was administered by target-controlled infusion. The University of Michigan Sedation Scale ( UMSS) was used to clinically assess the Do H during emergence. Prediction probability ( Pk) and receiver operating characteristics ( ROC) analyses were performed to assess the accuracy of both Do H monitors. Nonlinear regression analysis was used to describe the dose-response relationships for the aep EX, the BIS, and propofol plasma concentrations ( Cp). Results The Pk for the aep EX and BIS was 0.36 and 0.21, respectively ( P = 0.010). ROC analysis showed an area under the curve of 0.77 and 0.88 for the aep EX and BIS, respectively ( P = 0.644). At half-maximal effect ( EC50), Cp of 3.13 μg·ml−1 and 3.06 μg·ml−1 were observed for the aep EX and BIS, respectively. The r2 for the aep EX and BIS was 0.53 and 0.82, respectively. Conclusion The aep EX performs comparable to the BIS in differentiating between consciousness and unconsciousness, while performing inferior to the BIS in terms of distinguishing different levels of sedation and does not correlate well with the Cp in children receiving propofol-remifentanil anesthesia. [ABSTRACT FROM AUTHOR]

Background: To assess the thoughts of practicing anaesthesiologists about the use of depth of hypnosis monitors in children. Methods: Members of the European Society for Paediatric Anaesthesiology were invited to participate in an online survey about their thoughts regarding the use, applicability and reliability of hypnosis monitoring in children. Results: The survey achieved a response rate of 30% (N = 168). A total of 138 completed surveys were included for further analysis. Sixty-eight respondents used hypnosis monitoring in children (Users) and 70 did not (Non-users). Sixty-five percent of the Users reported prevention of intra-operative awareness as their main reason to apply hypnosis monitoring. Among the Non-users, the most frequently given reason (43%) not to use hypnosis monitoring in children was the perceived lack or reliability of the devices in children. Hypnosis monitoring is used with a higher frequency during propofol anaesthesia than during inhalation anaesthesia. Hypnosis monitoring is furthermore used more frequently in children > 4 years than in younger children. An ideal hypnosis monitor should be reliable for all age groups and any (combination of) anaesthetic drug. We found no agreement in the interpretation of monitor index values and subsequent anaesthetic interventions following from it. Conclusions: Prevention of intraoperative awareness appears to be the most important reason to use hypnosis monitoring in children. The perceived lack of reliability of hypnosis monitoring in children is the most important reasons not to use it. No consensus currently exists on how to adjust anaesthesia according to hypnosis monitor index values in children. [ABSTRACT FROM AUTHOR]

Background Blood pressure ( BP) is the most commonly applied clinical surrogate parameter for tissue perfusion and cerebral autoregulation. Hypotension during anesthesia may contribute to unfavorable outcome in young children. Hypotension in anesthetized infants can be defined using BP values relative to individual awake baseline or absolute BP values. Aim The aim of this study was to investigate the applicability of the two definitions and to compare the incidences of hypotension. Method This was a prospective observational study in 151 infants <12 months of age. The percentage of successful awake BP measurements was calculated and related to the infant's behavioral state. Hypotension under sevoflurane anesthesia was defined by a decrease of mean arterial pressure ( MAP) relative to awake baseline (>20% in infants <6 months, >40% in infants >6 months) or absolute MAP values (<35 mmHg in infants <6 months, <43 mmHg in infants >6 months). The incidences of hypotension using the two definitions were compared. Results Awake BP values were obtained in 85% of the patients. Calm patients were more likely to allow their BP to be measured than anxious patients. Anxious patients had higher preinduction MAP values than calm patients. The relative BP approach resulted in a higher incidence of postinduction hypotension than using absolute BP values. Conclusions Awake BP values were unobtainable in 15% of our patients, resulting in the necessity to define hypotension under anesthesia using absolute BP values. Definitions of hypotension using either absolute MAP or values relative to awake baseline are not interchangeable. [ABSTRACT FROM AUTHOR]

Background Hypotension during general anesthesia in neonates and infants is considered to contribute to poor neurological outcome. Aim The aim of this retrospective analysis was to determine the incidence of hypotension after induction of anesthesia and sustained hypotension (>10 min) during the anesthesia, and to determine factors contributing to the development of (sustained) hypotension. Method We performed a retrospective analysis of 1091 electronic anesthesia records from children <1 year. Patients were stratified for age (group 1: <1 month, group 2: 1-3 months, group 3: 4-6 months, group 4: >6 months). Hypotension was defined as a mean arterial pressure ( MAP) <35 mmHg in patients ≤6 months and <43 mmHg in patients >6 months. Results The incidence of hypotension after induction was highest in group 1 (25.5%) [ P = 0.009 vs group 2 (13.3%), P < 0.0001 vs groups 3 (3.4%) and 4 (1.0%)], in group 2, it was higher than in groups 3 and 4 ( P < 0.0001), and in group 3, it was higher than in group 4 ( P = 0.033). The incidence of sustained hypotension was highest in group 1 (43.6%) ( P < 0.0001 vs groups 2-4), followed by group 2 (15.7%) [ P < 0.0001 vs group 3 (3.4%) and P = 0.006 vs group 4 (8.8%)] and group 4 ( P = 0.004 vs group 3). Hypotension after induction occurred more often in emergency procedures than in elective procedures in groups 1 ( P = 0.002), 2 ( P = 0.029), and 3 ( P = 0.037). Conclusion Hypotension, both postinduction and sustained during surgery, is a common phenomenon in anesthetized children under 1 year, peaking in neonates. Generally accepted lower limits of MAP in anesthetized infants urgently need to be defined, enabling us to develop anesthesia strategies avoiding cerebral hypoperfusion. [ABSTRACT FROM AUTHOR]

Dipyrone has analgesic, spasmolytic, and antipyretic effects and is used to treat pain. Due to a possible risk of agranulocytosis with the use of dipyrone, it has been banned in a number of countries. The most commonly used data for the use of dipyrone are related to adults. Information relating to the use of dipyrone in children is scarce. Given the potential added value of dipyrone in the treatment of pain, a review of the literature was conducted to obtain more insight into the analgesic efficacy of dipyrone in children as well as the safety of dipyrone in terms of adverse events. A literature search was done for original articles (in English, German, or Spanish language) which met the following criteria: the use of dipyrone for pain and children up to the age of 17 years old. All titles and abstracts retrieved were reviewed, independently, by two of the authors, for their suitability for inclusion. The references of the selected articles were also checked for additional relevant papers. The publications were categorized into case reports, observational studies, or randomized controlled trials. To assess the methodological quality of the studies, the Jadad score was used. In the limited available data, the analgesic efficacy of intravenous dipyrone appears similar to that of intravenous paracetamol. Evidence is lacking to support the claim that dipyrone is equivalent or even superior to Non-Steroid-Anti-Inflammatory-Drugs in pediatric pain. While the absolute risk of agranulocytosis with dipyrone in children, based on available literature, cannot be determined, case reports suggest that this risk is not negligible. [ABSTRACT FROM AUTHOR]