Pädiatrische Neuroanästhesie - Physiologie und Pathophysiologie des kindlichen Zerebrums

Klaus U. Klein; Kristin Engelhard; Christian Werner

doi:10.1055/s-2007-984549

AINS - Anästhesiologie · Intensivmedizin · Notfallmedizin · Schmerztherapie, Table of Contents

Anästhesiol Intensivmed Notfallmed Schmerzther 2007; 42(6): 432-438
DOI: 10.1055/s-2007-984549

Fachwissen: Topthema: Pädiatrische Neuroanästhesie

Pädiatrische Neuroanästhesie - Physiologie und Pathophysiologie des kindlichen Zerebrums

Klaus U. Klein, Kristin Engelhard, Christian Werner

Abstract

Wenn es um intrakranielle Pathologien im Kindesalter geht, sind für ein optimales anästhesiologisches Management substanzielle Kenntnisse von Anatomie, Physiologie und Pathophysiologie des kindlichen Zerebrums unverzichtbar. Dieser Beitrag stellt zerebrale Entwicklung und altersabhängige Grundlagen von zerebraler Perfusion, Metabolismus und intrakraniellem Druck dar. Dabei geht er auf den Pathomechanismus einer hypoxisch-ischämischen kindlichen Hirnschädigung mit Exzitotoxizität, Ödembildung und Immunmodulation bis hin zum Zelltod ein.

Kernaussagen

Die erhöhte Vulnerabilität des frühkindlichen Gehirns begründet sich in der besonderen Anatomie des Neurokraniums und dem hohen Metabolismus während der Entwicklung. Reflexprüfungen sind hilfreich für die Beurteilung der Reife des frühkindlichen zentralen Nervensystems.
Die altersabhängigen Unterschiede der intrakraniellen Druck-Volumen-Verhältnisse sind für die Beurteilung einer Kapazitätsänderung des kindlichen Hirngewebekompartiments (80 %), Blutvolumenkompartiments (12 %) und Liquorkompartiments (8 %) von Bedeutung.
Die zerebrale Durchblutung und der Metabolismus sind im Neugeborenenalter vermindert, im Klein- und Schulkindalter im Vergleich zur adulten Situation hingegen erhöht. Die Kopplung von zerebraler Durchblutung und Metabolismus ist vom Alter unabhängig.
Die zerebrovaskuläre Autoregulation zum Erhalt einer konstanten zerebralen Perfusion ist bei Früh- und termingerechten Neugeborenen wahrscheinlich existent, wobei die untere Grenze zu niedrigeren Werten verschoben ist. Analog zum Erwachsenen kann die zerebrovaskuläre Autoregulation beim Vorliegen intrakranieller Läsionen aufgehoben und direkt vom zerebralen Perfusionsdruck abhängig sein. In dieser Situation kann eine Reduktion des zerebralen Perfusionsdruckes zur zerebralen Ischämie bzw. eine Steigerung zum Hirnödem führen.
Mit einer Erhöhung des arteriellen Kohlendioxid-Partialdruckes steigt die kindliche zerebrale Durchblutung linear bzw. exponentiell beim Vorliegen einer arteriellen Hypoxämie (CO₂-Vasoreaktivität). Im Falle einer ausgeprägten arteriellen Hyperoxie kann sie reduziert sein (O2-Vasoreaktivität).
Der Erhalt der Homöostase des kindlichen Flüssigkeitshaushalt ist für eine konstante zerebrale Perfusion und Oxygenierung von wesentlicher Bedeutung (Normotonie, Normovolämie, Normoxämie, Normokapnie, Normoglykämie, Normothermie).
Multiple pathophysiologische Mechanismen führen nach einem hypoxisch-ischämischen Geschehen durch Exzitotoxizität, Ödemformation und Inflammation des Gewebes zum apoptotischen oder nekrotischen Zelltod im ischämischen Hirnareal.

Full Text

References

Literaturverzeichnis

1 Dekaban AS.. Changes in brain weights during the span of human life: relation of brain weights to body heights and body weights. Ann Neurol. 1978; 4 345-56
2 Krane P, Yeh D. Anesthesia for pediatric neurosurgery. In: Anesthesia for infants and children. Philadelphia 2006: 651-684
3 Segar JL.. Ontogeny of the arterial and cardiopulmonary baroreflex during fetal and postnatal life. Am J Physiol. 1997; 273 457-71
4 Friedman WF.. The intrinsic physiologic properties of the developing heart. Prog Cardiovasc Dis. 1972; 1 87-111
5 Baethmann A, Jantzen JP, Piek J, Prange H, Unterberg A.. Physiology and pathophysiology of intracranial pressure. Zentralbl Neurochir. 1997; 1 29-31
6 Jöhr M.. Regionalanästhesie. In: Kinderanästhesie Stuttgart Jena New York: Gustav Fischer Verlag 1995: 132-63
7 Rosman NP.. Increased intracranial pressure in childhood. Pediatr Clin North Am. 1974; 2 483-99
8 Edmond J, Auestad N, Robbins RA, Bergstrom JD.. Ketone body metabolism in the neonate: development and the effect of diet. Fed Proc. 1985; 7 2359-64
9 Nehlig A.. Imaging and the ontogeny of brain metabolism. Baillieres Clin Endocrinol Metab. 1993; 3 627-42
10 Kety SS, Schmidt CF.. The Nitrous Oxide Method for the Quantitative Determination of Cerebral Blood Flow in Man: Theory, Procedure and Normal Values. J Clin Invest. 1948; 4 476-83
11 Lassen NA.. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959; 2 183-238
12 Garfunkel JM, Baird 3rd W H, Ziegler J.. The relationship of oxygen consumption of cerebral functional activity. J Pediatr. 1954; 1 64-72
13 Altman DI, Perlman JM, Volpe JJ, Powers WJ.. Cerebral oxygen metabolism in newborns. Pediatrics. 1993; 1 99-104
14 Elwell CE, Henty JR, Leung TS, Austin T, Meek JH, Delpy DT, Wyatt JS.. Measurement of CMRO₂ in neonates undergoing intensive care using near infrared spectroscopy. Adv Exp Med Biol 2005: 263-8
15 Kennedy C, Sokoloff L.. An adaptation of the nitrous oxide method to the study of the cerebral circulation in children; normal values for cerebral blood flow and cerebral metabolic rate in childhood. J Clin Invest. 1957; 7 1130-7
16 Chiron C, Raynaud C, Maziere B, Zilbovicius M, Laflamme L, Masure MC, Dulac O, Bourguignon M, Syrota A.. Changes in regional cerebral blood flow during brain maturation in children and adolescents. J Nucl Med. 1992; 5 696-703
17 Kehrer M, Blumenstock G, Ehehalt S, Goelz R, Poets C, Schoning M.. Development of cerebral blood flow volume in preterm neonates during the first two weeks of life. Pediatr Res. 2005; 5 927-30
18 Settergren G, Lindblad BS, Persson B.. Cerebral blood flow and exchange of oxygen, glucose ketone bodies, lactate, pyruvate and amino acids in anesthetized children. Acta Paediatr Scand. 1980; 4 457-65
19 Younkin DP, Reivich M, Jaggi J, Obrist W, Delivoria-Papadopoulos M.. Noninvasive method of estimating human newborn regional cerebral blood flow. J Cereb Blood Flow Metab. 1982; 4 415-20
20 Greisen G.. Cerebral blood flow and energy metabolism in the developing brain. In: Fetal and neonatal neurology and neurosurgery. Chatham, UK: Churchill Livingstone 2001: 139-154
21 Greisen G, Pryds O.. Low CBF, discontinuous EEG activity, and periventricular brain injury in ill, preterm neonates. Brain Dev. 1989; 3 164-8
22 Kissack CM, Garr R, Wardle SP, Weindling AM.. Cerebral fractional oxygen extraction is inversely correlated with oxygen delivery in the sick, newborn, preterm infant. J Cereb Blood Flow Metab. 2005; 5 545-53
23 Newfield A. Anesthesia for pediatric neurosurgery. In: Cottrell J (Hrsg). Anesthesia and neurosurgery St. Louis: Mosby 2001: 501-31
24 Ito H, Kanno I, Fukuda H.. Human cerebral circulation: positron emission tomography studies. Ann Nucl Med. 2005; 2 65-74
25 Biagi L, Abbruzzese A, Bianchi MC, Alsop DC, Del A Guerra, Tosetti M.. Age dependence of cerebral perfusion assessed by magnetic resonance continuous arterial spin labeling. J Magn Reson Imaging. 2007; 4 696-702
26 Lassen NA, Christensen MS.. Physiology of cerebral blood flow. Br J Anaesth. 1976; 8 719-34
27 Greisen G, Hellstrom-Vestas L, Lou H, Rosen I, Svenningsen N.. Sleep-walking shifts and cerebral blood flow in stable preterm infants. Pediatr Res. 1985; 11 1156-9
28 Pryds O, Christensen NJ, Friis-Hansen B.. Increased cerebral blood flow and plasma epinephrine in hypoglycemic, preterm neonates. Pediatrics. 1990; 2 172-6
29 Walter B, Bauer R, Kuhnen G, Fritz H, Zwiener U.. Coupling of cerebral blood flow and oxygen metabolism in infant pigs during selective brain hypothermia. J Cereb Blood Flow Metab. 2000; 8 1215-24
30 Purves MJ, James IM.. Observations on the control of cerebral blood flow in the sheep fetus and newborn lamb. Circ Res. 1969; 42 651-67
31 Hernandez MJ, Brennan RW, Bowman GS.. Autoregulation of cerebral blood flow in the newborn dog. Brain Res. 1980; 1 199-202
32 Rogers MC, Nugent SK, Traystman RJ.. Control of cerebral circulation in the neonate and infant. Crit Care Med. 1980; 10 570-4
33 Tweed WA, Cote J, Pash M, Lou H.. Arterial oxygenation determines autoregulation of cerebral blood flow in the fetal lamb. Pediatr Res. 1983; 4 246-9
34 Papile LA, Rudolph AM, Heymann MA.. Autoregulation of cerebral blood flow in the preterm fetal lamb. Pediatr Res. 1985; 2 159-61
35 Pryds A, Tonnesen J, Pryds O, Knudsen GM, Greisen G.. Cerebral pressure autoregulation and vasoreactivity in the newborn rat. Pediatr Res. 2005; 2 294-8
36 Helou S, Koehler RC, Gleason CA, Jones MD, Traystman RJ.. Cerebrovascular autoregulation during fetal development in sheep. Am J Physiol 1994;3 Pt 2:H 1069-74
37 Younkin DP, Reivich M, Jaggi JL, Obrist WD, Delivoria-Papadopoulos M.. The effect of hematocrit and systolic blood pressure on cerebral blood flow in newborn infants. J Cereb Blood Flow Metab. 1987; 3 295-9
38 Greisen G.. Cerebral blood flow in preterm infants during the first week of life. Acta Paediatr Scand. 1986; 1 43-51
39 Greisen G, Trojaborg W.. Cerebral blood flow, PaCO₂ changes, and visual evoked potentials in mechanically ventilated, preterm infants. Acta Paediatr Scand. 1987; 3 394-400
40 Pryds O, Greisen G, Lou H, Friis-Hansen B.. Heterogeneity of cerebral vasoreactivity in preterm infants supported by mechanical ventilation. J Pediatr. 1989; 4 638-45
41 Pryds O, Andersen GE, Friis-Hansen B.. Cerebral blood flow reactivity in spontaneously breathing, preterm infants shortly after birth. Acta Paediatr Scand. 1990; 4 391-6
42 Tyszczuk L, Meek J, Elwell C, Wyatt JS.. Cerebral blood flow is independent of mean arterial blood pressure in preterm infants undergoing intensive care. Pediatrics 1998: 337-41
43 Pryds O, Greisen G, Lou H, Friis-Hansen B.. Vasoparalysis associated with brain damage in asphyxiated term infants. J Pediatr 1990: 119-25
44 Milligan DW.. Failure of autoregulation and intraventricular haemorrhage in preterm infants. Lancet. 1980; 814 896-8
45 Greisen G.. Autoregulation of cerebral blood flow in newborn babies. Early Hum Dev. 2005; 5 423-8
46 Kety SS, Schmidt CF.. The Effects of Altered Arterial Tensions of Carbon Dioxide and Oxygen on Cerebral Blood Flow and Cerebral Oxygen Consumption of Normal Young Men. J Clin Invest. 1948; 4 484-92
47 Jayasinghe D, Gill AB, Levene MI.. CBF reactivity in hypotensive and normotensive preterm infants. Pediatr Res. 2003; 42 848-53
48 Shapiro HM, Greenberg JH, Naughton KV, Reivich M.. Heterogeneity of local cerebral blood flow-PaCO₂ sensitivity in neonatal dogs. J Appl Physiol. 1980; 1 113-8
49 Hansen NB, Brubakk AM, Bratlid D, Oh W, Stonestreet BS.. The effects of variations in PaCO₂ on brain blood flow and cardiac output in the newborn piglet. Pediatr Res. 1984; 11 1132-6
50 Greisen G.. Cerebral blood flow and energy metabolism in the newborn. Clin Perinatol. 1997; 3 531-46
51 Vavilala MS, Lam AM.. CBF reactivity to changes in MAP (cerebral autoregulation) or Cot.
52 Johnston AJ, Steiner LA, Gupta AK, Menon DK.. Cerebral oxygen vasoreactivity and cerebral tissue oxygen reactivity. Br J Anaesth. 2003; 42 774-86
53 Demchenko IT, Oury TD, Crapo JD, Piantadosi CA.. Regulation of the brain's vascular responses to oxygen. Circ Res. 2002; 11 1031-7
54 Omae T, Ibayashi S, Kusuda K, Nakamura H, Yagi H, Fujishima M.. Effects of high atmospheric pressure and oxygen on middle cerebral blood flow velocity in humans measured by transcranial Doppler. Stroke. 1998; 1 94-7
55 Floyd TF, Clark JM, Gelfand R, Detre JA, Ratcliffe S, Guvakov D, Lambertsen CJ, Eckenhoff RG.. Independent cerebral vasoconstrictive effects of hyperoxia and accompanying arterial hypocapnia at 1 ATA. J Appl Physiol. 2003; 42 2453-61
56 Leahy FA, Cates D, MacCallum M, Rigatto H.. Effect of CO₂ and 100 % O2 on cerebral blood flow in preterm infants. J Appl Physiol. 1980; 3 468-72
57 Zander R.. Physiology and clinical relevance of hyperoxygenation. Anasthesiol Intensivmed Notfallmed Schmerzther. 2005; 10 616-23
58 Zander R.. The oxygen status of arterial human blood. Scand J Clin Lab Invest Suppl 1990: 187-96
59 Saugstad OD.. Oxidative stress in the newborn-a 30-year perspective. Biol Neonate. 2005; 3 228-36
60 Wood JH. et al. . Hypervolemic hemodilution in experimental focal cerebral ischemia. Elevation of cardiac output, regional cortical blood flow, and ICP after intravascular volume expansion with low molecular weight dextran. J Neurosurg. 1983; 3 500-9
61 Pulsinelli WA, Levy DE, Sigsbee B, Scherer P, Plum F.. Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus. Am J Med. 1983; 4 540-4
62 Pulsinelli W, Waldman S, Sigsbee B, Rawlinson D, Scherer P, Plum F.. Experimental hyperglycemia and diabetes mellitus worsen stroke outcome. Trans Am Neurol Assoc 1980: 21-4
63 Longstreth WT, Inui TS.. High blood glucose level on hospital admission and poor neurological recovery after cardiac arrest. Ann Neurol. 1984; 1 59-63
64 Woo E, Chan YW, Yu YL, Huang CY.. Admission glucose level in relation to mortality and morbidity outcome in 252 stroke patients. Stroke. 1988; 2 185-91
65 Sieber FE, Traystman RJ.. Special issues: glucose and the brain. Crit Care Med. 1992; 1 104-14
66 Rozance PJ, Hay WW.. Hypoglycemia in newborn infants: Features associated with adverse outcomes. Biol Neonate. 2006; 2 74-86
67 Wangemann BU.. Pädiatrische Neuranästhesie. In: Jantzen, Löffler (Hrsg). Neuroanaesthesie. Stuttgart New York: Thieme 2000: 346-49
68 Phelps DL, Brown DR, Tung B, Cassady G, McClead RE, Purohit DM, Palmer EA.. 28-day survival rates of 6676 neonates with birth weights of 1250 grams or less. Pediatrics. 1991; 1 7-17
69 Brazel CY, Rao MS.. Aging and neuronal replacement. Ageing Res Rev. 2004; 4 465-83
70 Levison SW, Rothstein RP, Romanko MJ, Snyder MJ, Meyers RL, Vannucci SJ.. Hypoxia/ischemia depletes the rat perinatal subventricular zone of oligodendrocyte progenitors and neural stem cells. Dev Neurosci. 2001; 3 234-47
71 Vannucci SJ, Hagberg H.. Hypoxia-ischemia in the immature brain. J Exp Biol 2004: 3149-54
72 Haynes RL, Baud O, Li J, Kinney HC, Volpe JJ, Folkerth DR.. Oxidative and nitrative injury in periventricular leukomalacia: a review. Brain Pathol. 2005; 3 225-33
73 Blumenthal I.. Periventricular leucomalacia: a review. Eur J Pediatr. 2004; 8 435-42
74 Johnston MV.. Neurotransmitters and vulnerability of the developing brain. Brain Dev. 1995; 5 301-6
75 Waters KA, Machaalani R.. NMDA receptors in the developing brain and effects of noxious insults. Neurosignals. 2004; 4 162-74
76 MacManus JP, Linnik MD.. Gene expression induced by cerebral ischemia: an apoptotic perspective. J Cereb Blood Flow Metab. 1997; 8 815-32
77 Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH.. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics. 1981; 5 607-13
78 Adams FH, Landaw EM.. What are healthy blood pressures for children?. Pediatrics. 1981; 2 268-70
79 Settergren G, Lindblad BS, Persson B.. Cerebral blood flow and exchange of oxygen, glucose, ketone bodies, lactate, pyruvate and amino acids in infants. Acta Paediatr Scand. 1976; 3 343-53
80 Meyer JS, Ishihara N, Deshmukh VD, Naritomi H, Sakai F, Hsu MC, Pollack P.. Improved method for noninvasive measurement of regional cerebral blood flow by 133Xenon inhalation. Part I: description of method and normal values obtained in healthy volunteers. Stroke. 1978; 3 195-205
81 Cross KW, Dear PR, Hathorn MK, Hyams A, Kerslake DM, Milligan DW, Rahilly PM, Stothers JK.. An estimation of intracranial blood flow in the new-born infant. J Physiol 1979: 329-45
82 Lou HC, Henriksen L, Bruhn P.. Focal cerebral hypoperfusion in children with dysphasia and/or attention deficit disorder. Arch Neurol. 1984; 8 825-9

Dr. med. Klaus U Klein

Email: kuklein@uni-mainz.de

PD Dr. med. Kristin Engelhard

Email: engelhak@mail.uni-mainz.de

Prof. Dr. med. Christian Werner

Email: werner@anaesthesie.klinik.uni-mainz.de

Supplementary Material

Literaturverzeichnis