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Klin Padiatr 2013; 225(04): 206-211
DOI: 10.1055/s-0033-1345173
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Observations on the Effects of Inhaled Isoflurane in Long-term Sedation of Critically Ill Children Using a Modified AnaConDa©–System

Erfahrungen mit inhaliertem Isofluran in der Langzeitsedierung von kritisch kranken Kindern mittels eines modifizierten AnaConDa©–Systems
F. Eifinger
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
C. Hünseler
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
B. Roth
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
A. Vierzig
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
A. Oberthuer
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
K. Mehler
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
A. Kribs
1   Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Cologne, Germany
,
C. Menzel
2   Department of Anaesthesiology and Postoperative Intensive Care Medicine, University Hospital of Cologne, Germany
,
U. Trieschmann
2   Department of Anaesthesiology and Postoperative Intensive Care Medicine, University Hospital of Cologne, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
24 June 2013 (online)

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Abstract

Background:

Long-term intravenous sedation may present problems due to dependence and side effects.

Patients:

Medical records of children who were administered isoflurane were reviewed. 15 patients (9 boys, 6 girls) with a mean age of 11.8 month (+2.4) were analysed.

Methods:

Analgesia and sedation was given in mean 9.7+1.1 days before commencing inhalation using a modified application device (AnaConDa©). Administration was given over a period of 7.2+1.4 days. Depth of sedation was monitored by using Comfort- and Hartwig-scores. Observations included continuous monitoring of heart-rate, pulse oxymetry, blood pressure and cerebral tissue oxygenation.

Results:

Within 4 h post administration of isoflurane a satisfactory increase in the depth of sedation was seen and kept till extubation. 6/15 patients received tracheostomies during the observation period. None of the patients observed suffered life-critical events of the modi­fied application of isoflurane proceeded without complications. Ketamine and clonidine infusion rates were significantly reduced (p<0.005) as well as the use and overall infusion rate of midazolam, γ-hydroxy butyrate, fentanyl and morphine (p<0.05).

Conclusion:

Isoflurane inhalation may provide an additional option for long-term sedation in a specific group of critically ill infants but neurodegenerative toxic effects will have to be taken into account when using volatile anesthetics at any time during infancy.

Zusammenfassung

Hintergrund:

Eine lang andauernde intravenöse Sedierung kann durch Abhängigkeit und Nebenwirkungen erheblich erschwert sein.

Patienten:

Alle medizinischen Daten von Kindern, die Isofluran erhalten haben, 15 Patienten (9 Jungen, 6 Mädchen) mit einem mittleren Alter von 11,8 Monaten (+ 2,4), wurden ausgewertet.

Methode:

Vor Beginn der Inhalation mittels eines modifizierten Applikationsgerätes (AnaConDa©) wurden Analgetika und Sedativa im Mittel 9,7+1,1 Tage gegeben. Die Inhalation da­uerte im Mittel 7,2+1,4 Tage an. Die Sedierungstiefe wurde anhand des Comfort- und des Hartwig-Scores gemessen. Die weitere Beobachtung beinhaltete Herzfrequenz, Pulsoxymetrie, Blutdruck und zerebrale Gewebsoxygenierung.

Ergebnisse:

Innerhalb von 4 Stunden nach Beginn der Isofluran-Inhalation wurde eine zufriedenstellende Sedierungstiefe erreicht und bis zur Extubation gehalten. 6/15 Patienten erhielten im Verlauf der Beobachtungszeit ein Tracheostoma. Bei keinem Patienten wurden lebensgefährliche Komplikationen beobachtet. Die technische Durchführung verlief komplikationslos. Sowohl die Ketamin- und Clonidin- Infusionsraten wurden signifikant (p<0,005) reduziert als auch die Gesamtinfusionsmengen von Midazolam, γ-Hydroxy­butyrat, Fentanyl und Morphin (p<0,05).

Schlussfolgerung:

Die Isofluran-Inhalation ist möglicherweise eine ergänzende Option für die Langzeitsedierung kritisch kranker Kinder. Dabei müssen toxisch-neurodegenerative Effekte bei der Verwendung volatiler Anästhetika in jedem Kindesalter berücksichtigt werden.

Key words

prolonged sedation - anesthesia - AnaConDa - pediatric intensive care - isoflurane

Schlüsselwörter

lang anhaltende Sedierung - Anästhesie - AnaConDa - pädiatrische Intensivmedizin - Isofluran
 

  • References

  • 1 Ariyama J, Hayashida M, Shibata K et al. Risk factors for the development of reversible psychomotor dysfunction following prolonged isoflurane inhalation in the general intensive care unit. J Clin Anesth 2009; 21: 567-573
    CrossrefPubMedSearch in Google Scholar
  • 2 Arnold JH, Truog RD, Molengraft JA. Tolerance to isoflurane during prolonged administration. Anesthesiology 1993; 78: 985-988
    CrossrefPubMedSearch in Google Scholar
  • 3 Arnold JH, Truog RD, Rice SA. Prolonged administration of isoflurane to pediatric patients during mechanical ventilation. Anesth Analg 1993; 76: 520-526
    PubMedSearch in Google Scholar
  • 4 Bergman I, Steeves M, Burckart G et al. Reversible neurologic abnormalities associated with prolonged intravenous midazolam and fentanyl administration. J Pediatr 1991; 119: 644-649
    PubMedSearch in Google Scholar
  • 5 Bisonnette B, Leon JE. Cerebrovascular stability during isoflurane anaesthesia in children. Can J Anaesth 1992; 39: 128-134
    PubMedSearch in Google Scholar
  • 6 Bosel J, Purrucker JC, Nowak F et al. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa((R)): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012; 38: 1955-1964
    CrossrefPubMedSearch in Google Scholar
  • 7 Brambrink AM, Back SA, Riddle A et al. Isoflurane-induced apoptosis of oligodendrocytes in the neonatal primate brain. Ann Neurol 2012; 72: 525-535
    CrossrefPubMedSearch in Google Scholar
  • 8 Chen H, Burris M, Fajilan A et al. Prolonged Exposure to Isoflurane Ameliorates Infarction Severity in the Rat Pup Model of Neonatal Hypoxia-Ischemia. Transl Stroke Res 2011; 2: 382-390
    CrossrefPubMedSearch in Google Scholar
  • 9 Haase R, Lieser U, Kramm C et al. Management of oncology patients admitted to the paediatric intensive care unit of a general children’s hospital – a single center analysis. Klin Padiatr 2011; 223: 142-146
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Hartwig S, Roth B, Theisohn M. Clinical experience with continuous intravenous sedation using midazolam and fentanyl in the paediatric intensive care unit. Eur J Pediatr 1991; 150: 784-788
    CrossrefPubMedSearch in Google Scholar
  • 11 Hausdorfer J, Hagemann H, Bell M et al. Isoflurane in pediatric anesthesia. Anaesthesist 1986; 35: 345-352
    PubMedSearch in Google Scholar
  • 12 Hoemberg M, Vierzig A, Roth B et al. Plasma fluoride concentrations during prolonged administration of isoflurane to a pediatric patient requiring renal replacement therapy. Paediatr Anaesth 2012; 22: 412-413
    CrossrefPubMedSearch in Google Scholar
  • 13 Hofmann SR, Stadler K, Heilmann A et al. Stabilisation of cardiopulmonary function in newborns with congenital diaphragmatic hernia using lung function parameters and hemodynamic management. Klin Padiatr 2012; 224: 241-246
    PubMedSearch in Google Scholar
  • 14 Hollmann MW, Liu HT, Hoenemann CW et al. Modulation of NMDA receptor function by ketamine and magnesium. Part II: interactions with volatile anesthetics. Anesth Analg 2001; 92: 1182-1191
    PubMedSearch in Google Scholar
  • 15 Jung C, Granados M, Marsol P et al. Use of sevoflurane sedation by the AnaConDa device as an adjunct to extubation in a pediatric burn patient. Burns 2008; 34: 136-138
    CrossrefPubMedSearch in Google Scholar
  • 16 Loepke AW, Istaphanous GK, McAuliffe III JJ et al. The effects of neonatal isoflurane exposure in mice on brain cell viability, adult behavior, learning, and memory. Anesth Analg 2009; 108: 90-104
    CrossrefPubMedSearch in Google Scholar
  • 17 Lu Y, Wu X, Dong Y et al. Anesthetic sevoflurane causes neurotoxicity differently in neonatal naive and Alzheimer disease transgenic mice. Anesthesiology 2010; 112: 1404-1416
    CrossrefPubMedSearch in Google Scholar
  • 18 Luginbuehl IA, Fredrickson MJ, Karsli C et al. Cerebral blood flow velocity in children anaesthetized with desflurane. Paediatr Anaesth 2003; 13: 496-500
    CrossrefPubMedSearch in Google Scholar
  • 19 Mao J. NMDA and opioid receptors: their interactions in antinociception, tolerance and neuroplasticity. Brain Res Brain Res Rev 1999; 30: 289-304
    CrossrefPubMedSearch in Google Scholar
  • 20 Marx CM, Smith PG, Lowrie LH et al. Optimal sedation of mechanically ventilated pediatric critical care patients. Crit Care Med 1994; 22: 163-170
    PubMedSearch in Google Scholar
  • 21 Matchett GA, Allard MW, Martin RD et al. Neuroprotective effect of volatile anesthetic agents: molecular mechanisms. Neurol Res 2009; 31: 128-134
    CrossrefPubMedSearch in Google Scholar
  • 22 Michel-Behnke I, Rothes A, Hund F et al. Analgosedation with fentanyl/midazolam after correction of congenital heart defects. Klin Padiatr 1995; 207: 341-346
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 Olsson GL. Inhalational anaesthesia at the extremes of age: paediatric anaesthesia. Anaesthesia 1995; 50 (Suppl): 34-36
    CrossrefPubMedSearch in Google Scholar
  • 24 Ostermann ME, Keenan SP, Seiferling RA et al. Sedation in the intensive care unit: a systematic review. JAMA 2000; 283: 1451-1459
    CrossrefPubMedSearch in Google Scholar
  • 25 Prader A. Normal growth and disorders of growth in children and adolescents. Klin Wochenschr 1981; 59: 977-984
    CrossrefPubMedSearch in Google Scholar
  • 26 Revell S, Greenhalgh D, Absalom SR et al. Isoflurane in the treatment of asthma. Anaesthesia 1988; 43: 477-479
    CrossrefPubMedSearch in Google Scholar
  • 27 Sackey PV, Martling CR, Carlsward C et al. Short- and long-term follow-up of intensive care unit patients after sedation with isoflurane and midazolam – a pilot study. Crit Care Med 2008; 36: 801-806
    CrossrefPubMedSearch in Google Scholar
  • 28 Sackey PV, Martling CR, Granath F et al. Prolonged isoflurane sedation of intensive care unit patients with the Anesthetic Conserving Device. Crit Care Med 2004; 32: 2241-2246
    CrossrefPubMedSearch in Google Scholar
  • 29 Sackey PV, Martling CR, Radell PJ. Three cases of PICU sedation with isoflurane delivered by the ‘AnaConDa’. Paediatr Anaesth 2005; 15: 879-885
    CrossrefPubMedSearch in Google Scholar
  • 30 Schifilliti D, Grasso G, Conti A et al. Anaesthetic-related neuroprotection: intravenous or inhalational agents?. CNS Drugs 2010; 24: 893-907
    PubMedSearch in Google Scholar
  • 31 Schmidt B, Adelmann C, Stutzer H et al. Comparison of sufentanil versus fentanyl in ventilated term neonates. Klin Padiatr 2010; 222: 62-66
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Shankar V, Churchwell KB, Deshpande JK. Isoflurane therapy for severe refractory status asthmaticus in children. Intensive Care Med 2006; 32: 927-933
    CrossrefPubMedSearch in Google Scholar
  • 33 Soukup J, Scharff K, Kubosch K et al. State of the art: sedation concepts with volatile anesthetics in critically Ill patients. J Crit Care 2009; 24: 535-544
    CrossrefPubMedSearch in Google Scholar
  • 34 Sponheim S, Skraastad O, Helseth E et al. Effects of 0.5 and 1.0 MAC isoflurane, sevoflurane and desflurane on intracranial and cerebral perfusion pressures in children. Acta Anaesthesiol Scand 2003; 47: 932-938
    CrossrefPubMedSearch in Google Scholar
  • 35 Tobias JD. Therapeutic applications and uses of inhalational anesthesia in the pediatric intensive care unit. Pediatr Crit Care Med 2008; 9: 169-179
    CrossrefPubMedSearch in Google Scholar
  • 36 Wren WS, McShane AJ, McCarthy JG et al. Isoflurane in paediatric anaesthesia. Induction and recovery from anaesthesia. Anaesthesia 1985; 40: 315-323
    PubMedSearch in Google Scholar