Anesthesia-related mortality in pediatric patients: a systematic review

This systematic review of the Brazilian and worldwide literature aimed to evaluate the incidence and causes of perioperative and anesthesia-related mortality in pediatric patients. Studies were identified by searching EMBASE (1951-2011), PubMed (1966-2011), LILACS (1986-2011), and SciElo (1995-2011). Each paper was revised to identify the author(s), the data source, the time period, the number of patients, the time of death, and the perioperative and anesthesia-related mortality rates. Twenty trials were assessed. Studies from Brazil and developed countries worldwide documented similar total anesthesia-related mortality rates (<1 death per 10,000 anesthetics) and declines in anesthesia-related mortality rates in the past decade. Higher anesthesia-related mortality rates (2.4-3.3 per 10,000 anesthetics) were found in studies from developing countries over the same time period. Interestingly, pediatric perioperative mortality rates have increased over the past decade, and the rates are higher in Brazil (9.8 per 10,000 anesthetics) and other developing countries (10.7-15.9 per 10,000 anesthetics) compared with developed countries (0.41-6.8 per 10,000 anesthetics), with the exception of Australia (13.4 per 10,000 anesthetics). The major risk factors are being newborn or less than 1 year old, ASA III or worse physical status, and undergoing emergency surgery, general anesthesia, or cardiac surgery. The main causes of mortality were problems with airway management and cardiocirculatory events. Our systematic review of the literature shows that the pediatric anesthesia-related mortality rates in Brazil and in developed countries are similar, whereas the pediatric perioperative mortality rates are higher in Brazil compared with developed countries. Most cases of anesthesia-related mortality are associated with airway and cardiocirculatory events. The data regarding anesthesia-related and perioperative mortality rates may be useful in developing prevention strategies

Incidência de parada cardíaca e mortalidade durante anestesia em hospital universitário de atendimento terciário no período de 2005 a 2012

Introdução. A parada cardíaca (PC) e o óbito são os piores desfechos clínicos. A investigação das incidências dessas complicações é difícil devido à diferença metodológica encontrada na literatura. Assim, comparações das incidências e causas entre os estudos devem ser feitas com ressalvas. Nos últimos anos, melhorias técnicas na prática anestesiológica podem ter contribuído para a diminuição na incidência de PC e de óbito no Hospital das Clínicas da Faculdade de Medicina de Botucatu, Universidade Estadual Paulista. Objetivou-se com este estudo reavaliar a incidência, as causas e os fatores desencadeantes de PC e de óbito em pacientes anestesiados em hospital universitário de atendimento terciário no período de 2005 a 2012. Método. Os casos de PC e óbito em 55.002 anestesias consecutivas foram identificados em banco de dados de complicações anestésicas. A incidência de PC e de óbito foi calculada em relação aos atributos: faixa etária, sexo, classificação do estado físico da American Society of Anesthesiologists (ASA), tipo de atendimento, técnica anestésica, especialidade cirúrgica e fatores desencadeantes. Uma comissão classificou todas as PC e os óbitos, de acordo com os seguintes fatores desencadeantes: 1) totalmente relacionada à doença/condição do paciente; 2) totalmente relacionada à cirurgia; 3) totalmente relacionada à anestesia; e 4) parcialmente relacionada à anestesia. As incidências foram expressas para 10.000 anestesias, juntamente com o intervalo de confiança (IC) de 95%. Resultados. Ocorreram 139 PC (25,1 por 10.000 anestesias; IC 95%: 21,4 – 29,8) e 88 óbitos (16,0 por 10.000 anestesias; IC 95%: 13,0 – 19,7). Maiores incidências de PC e de óbito ocorreram em crianças menores que um ano e idosos (p = 0,03 e p = 0,028, respectivamente), com estado físico ASA ? III (p = 0,01 e p = 0,001, respectivamente), em atendimento de ...Background. Cardiac arrest (CA) and death are the worst outcomes in medicine. To survey these complications is difficult because of the methodological variation in literature. As a result, the comparison of incidence and triggering factors between studies should be made sparingly. Technical improvement in our institutional anesthesia care may have declined the CA and death incidences in the last years. Then we intended to reexamine the CA and mortality incidence, causes and triggering factors in a Brazilian tertiary teaching hospital from 2005 to 2012. Methods. Cardiac arrest and death were identified from an anesthetics complications database. Cardiac arrest and death incidence was calculated for the following characteristics: age, sex, ASA physical status classification, surgical procedure, anesthesia technique, surgery specialty, and triggering factors. All CA and death were reviewed and classified into following four groups of triggering factors: 1) totally patient disease/condition-related; 2) totally surgery-related; 3) totally anesthesia-related; or 4) partially anesthesia-related. The incidences were expressed per 10,000 anesthetics with 95% confidence interval (95% CI). Results. A total of 139 CA (25.1 per 10,000; 95% CI: 21.4 – 29.8) and 88 deaths (16.0 per 10,000; 95% CI: 13.0 – 19.7) were counted. The major CA and death incidence occurred in neonates and elderly (p = 0.03 and p = 0.028, respectively), ASA physical status ? III (p = 0.01 and p = 0.028, respectively), emergency surgery (p = 0.023 and p = 0.03, respectively), general anesthesia (p = 0.03 and p = 0.001, respectively), and multispecialty, cardiac and vascular surgery (p = 0.04 and p = 0.01, respectively). Patient disease/condition was the main triggering factor of CA and deaths (p = 0.01 and p = 0.02, respectively), with sepsis and multiple organ dysfunction syndrome, ruptured aneurysms and trauma the main causes. Anesthesia-related cardiac arrest ...Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES

Efeitos antinociceptivos, cardiorrespiratórios e gastrointestinais da detomidina associada ou não à metadona em equinos

Apesar de doses relativamente elevadas de opioides produzirem maior intensidade de efeito analgésico, tais doses também estão associadas a efeitos adversos que podem limitar seu emprego em equinos. No presente estudo, hipotetizou-se que uma dose baixa de metadona (0,2 mg/kg), a qual não produz analgesia consistente quando administrada isoladamente em modelos de dor experimental, potencializaria a analgesia induzida pela detomidina, sem resultar em efeitos adversos como excitação/depressão cardiorrespiratória importante ou potencializar a hipomotilidade intestinal induzida pelo agonista α2-adrenérgico. Seis equinos (415 ± 20 kg) receberam dois tratamentos intravenosos com intervalo mínimo de uma semana em um delineamento aleatorizado duplo-cego: 0,01 mg/kg de detomidina administrada isoladamente (tratamento DET) ou em associação a 0,2 mg/kg de metadona (tratamento DET/MET). A analgesia foi avaliada através dos limiares nociceptivos térmico (LNT) e elétrico (LNE). O LNT consistiu no tempo para retirada do membro torácico em resposta à lâmpada de projeção de calor aplicada sobre a banda coronária. O LNE consistiu na voltagem (aplicada via eletrodos sobre a banda coronária) mais elevada capaz de induzir a retirada do membro torácico. A sedação foi avaliada pela distância queixo-solo e pelo interesse por alimento (feno de alfafa). A analgesia, sedação e parâmetros cardiorrespiratórios (eletrocardiografia, pressão arterial e gasometria arterial) foram avaliados antes e durante 120 min após os a administração dos tratamentos. Os escores de auscultação intestinal foram determinados durante 12 horas após a administração dos tratamentos. Tanto o LNE como o LNT se elevaram significativamente em relação aos valores basais durante 15 min após a DET. No tratamento DET/MET, a administração dos fármacos resultou em elevação significativamente...Although relativelly high doses of opioids result in greater analgesic effect, these doses also cause adverse effects that may limit its clinical usefullness in horses. In the present study it was hipothesized that a dose of methadone that does not induce a consistent analgesic effect when administered alone (0.2 mg/kg) in experimental pain models would potentialize detomidine’s analgesic effect without resulting in adverse side effects such as excitation / important cardiorespiratory depression or potentialization of the intestinal hypomotility induced by the alpha-2 agonist. A total of six horses (415 ± 20 kg) received 2 intravenous treatments in a randomized double-blinded study design: 0.01 mg/kg of detomidine administered alone (DET treatment) or combined with 0.2 mg/kg of methadone (DET/MET treatment). The analgesia was evaluated by assessing the thermal (TNT) and electrical nociceptive thresholds (ENT). The TNT was assessed by measuring time for limb withdrawal (thoracic limb) in response to a heat projection lamp applied to the coronary band. The ENT was recorded as the highest voltage (applied via electrodes placed in the coronary band of the thoracic limb) that induced limb withdrawal. Sedation was assessed by the chin-to-floor distance and by the interest for food (alfalfa hay). The nociceptive testing, sedation and cardiorespiratory data (electrocardiography, direct arterial pressures, and arterial blood gases) were recorded before and during 120 minutes after drug injection. The intestinal auscultation scores were recorded for 12 hours after treatment administration.Both the ENT and the TNT significantly increased from baseline during 15 minutes after DET. In the DET/MET treatment, drug injection resulted in significantly greater and more prolonged (30 minutes increases in ENT and TNT in comparison to the DET treatment. The chin-to-floor distance was significantly... (Complete abstract click electronic access below)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Agreement between direct, oscillometric and Doppler ultrasound blood pressures using three different cuff positions in anesthetized dogs

Objective To evaluate the agreement between invasive blood pressure (IBP) and Doppler ultrasound blood pressure (DUBP) using three cuff positions and oscillometric blood pressure (OBP) in anesthetized dogs.Study design Prospective study. Animals Nine adult dogs weighing 14.5-29.5 kg.Methods The cuff was placed above and below the tarsus, and above the carpus with the DUBP and above the carpus with the OBP monitor. Based on IBP recorded via a dorsal pedal artery catheter, conditions of low, normal, and high systolic arterial pressures [SAP (mmHg) 140, respectively] were induced by changes in isoflurane concentrations and/or dopamine administration. Mean biases +/- 2 SD (limits of agreement) were determined.Results At high blood pressures, regardless of cuff position, SAP determinations with the DUBP under-estimated invasive SAP values by more than 20 mmHg in most instances. With the DUBP, cuff placement above the tarsus yielded better agreement with invasive SAP during low blood pressures (0.2 +/- 16 mmHg). The OBP underestimated SAP during high blood pressures (-42 +/- 42 mmHg) and yielded better agreement with IBP for mean (MAP) and diastolic (DAP) arterial pressure measurements [overall bias: 2 +/- 15 mmHg (MAP) and 0.2 +/- 16 mmHg (DAP)].Conclusions Agreement of SAP determinations with the DUBP is poor at SAP > 140 mmHg, regardless of cuff placement. Measurement error of the DUBP with the cuff placed above the tarsus is clinically acceptable during low blood pressures. Agreement of MAP and DAP measurements with this OBP monitor compared with IBP was clinically acceptable over a wide pressure range.Clinical relevance With the DUBP device, placing the cuff above the tarsus allows reasonable agreement with IBP obtained via dorsal pedal artery catheterization. Only MAP and DAP provide reasonable estimates of direct blood pressure with the OBP monitor evaluated.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Cardiorespiratory and neuroendocrine changes induced by methadone in conscious and in isoflurane anaesthetised dogs

The aim of this study was to compare the cardiorespiratory and neurohormonal effects of methadone in conscious and in isoflurane anaesthetised dogs. Six mature dogs (28.0 +/- 3.8 kg bodyweight) received intravenous (IV) methadone (1 mg/kg) three times, once when conscious and twice during isoflurane anaesthesia (with a wash-out period of 1 week). The vasopressin antagonist relcovaptan (0.1 mg/kg IV) was administered before the methadone either during the first or second (selected randomly) isoflurane anaesthesia to evaluate the contribution of vasopressin to methadone-associated vasoconstriction. Cardiorespiratory data, plasma catecholamines and serum vasopressin were recorded before (baseline) and for 90 min after methadone.Methadone induced dysphoria in all conscious dogs and significantly (P < 0.05) increased mean arterial pressure (MAP), catecholamines, and vasopressin concentrations. During anaesthesia, in addition to significantly greater decreases in heart rate (HR) and cardiac index (Cl) than during the conscious state, methadone induced apnoea and mechanical ventilation was necessary in all dogs. In anaesthetised animals, methadone administration significantly increased vasopressin concentrations and systemic vascular resistance index (SVRI), while MAP did not differ from baseline. Relcovaptan administration did not modify the increase in SVRI associated with methadone injection during anaesthesia. Increases in plasma catecholamines may account for the slight decreases in HR and Cl seen after methadone administration in conscious dogs. In contrast, isoflurane enhanced the intensity of the cardiorespiratory changes induced by methadone. Vasoconstrictive responses associated with methadone did not appear to be induced by vasopressin.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

Eletroacupuntura e morfina sobre parâmetros cardiorrespiratórios em gatas submetidas à ovariosalpingohisterectomia eletiva Electroacupuncture and morphine on cardiorespiratory parameters on cat elective ovariohysterectomy

Objetivou-se avaliar os efeitos da morfina e da eletroacupuntura sobre parâmetros cardiorrespiratórios e consumo do anestésico isofluorano em gatas submetidas à ovariosalpingohisterectomia eletiva. Foram utilizadas 18 gatas hígidas, adultas, distribuídas em três grupos: Eletroacupuntura, Morfina e Controle, as quais receberam acepromazina, propofol e isoflurano. Nos animais dos grupos Controle e Morfina foram introduzidas agulhas em acupontos falsos, e nos do grupo Eletroacupuntura nos pontos Zusanli e Yanglingquan. A eletroestimulação no grupo submetido a Eletroacupuntura foi realizada na frequência de 2 e 100Hz. Nos animais do grupo Morfina, administrou-se a dose de 0,3mg/kg por via intramuscular e no grupo Controle não foi realizado tratamento. O registro das variáveis foi obtido anteriormente à administração da acepromazina; 10 minutos após a aplicação desse fármaco; após indução e estabilização anestésica; decorridos 30 minutos do início da eletroestimulação ou aplicação da morfina; e a cada 10 minutos, durante 60 minutos. Foram estudadas temperatura retal, frequência respiratória e cardíaca, saturação parcial de oxiemoglobina, pressão arterial média, volume total de isoflurano consumido e volume inspirado de isoflurano. Os dados foram submetidos a Análise de Perfil. Somente os animais do grupo Eletroacupuntura (GE) não apresentaram diferença significativa entre os momentos para a pressão arterial média, e observou-se melhor estabilidade cardíaca nos animais do grupo Eletroacupuntura e Morfina. O volume inspirado de isoflurano foi 58,33% menor no grupo Eletroacupuntura e 22,02% no grupo Morfina quando comparados ao grupo Controle. Pode-se concluir que eletroestimulação dos acupontos Zusanli e Yanglingquan, diminui o volume inspirado de isoflurano e promove estabilidade cardiorrespiratória, sendo superior ao uso da morfina.<br>The aim of this work was to evaluate the morphine and electroacupuncture effects on cardiorespiratory parameters and isoflurane consumption in cats submitted to elective ovariohysterectomy. Eighteen healthy cats were equally distributed in three groups: Electroacupunture, Morphine and Control. Animals were anestethized with acepromazine, propofol and isoflurane. Needles were introduced in false acupoints on animals from Control and Morphine groups, and on Zusanli and Yanglingquan acupoints on Electroacupunture group animals. Electroacupuncture was performed with 2 and 100Hz, square wave. Animals from Morphine group received morphine (0.3mg/kg/im) and Control animals received no treatment. Data were recorded just before acepromazine administration; 10 minutes after acepromazine; after anesthetic induction and stabilization; 30 minutes after electrostimulation beginning or morphine injection; and every 10 minutes for 60 minutes. Variables recorded were: rectal temperature; respiratory frequency; heart rate; oxyhemoglobin partial saturation; mean arterial pressure; total volume of consumed isoflurane; and inspired isoflurane volume. Data were analyzed by MANOVA. Only Electroacupunture animals did not show significant difference between moments for mean arterial pressure, while Electroacupunture and Morphine animals presented better cardiac stability. Compared to Control, the inspired isoflurane volume was decreased in 58.33% on Electroacupunture and 22.01% on GM. It is concluded that electrostimulation of Zusanli and Yanglingquan acupoints in cats submitted to elective ovariohysterectomy decreases the inspired isoflurane volume, leading to cardiorespiratory stability, being superior to morphine

Methadone Increases and Prolongs Detomidine-Induced Arterial Hypertension in Horses, but These Effects Are Not Mediated by Increased Plasma Concentrations of Arginine Vasopressin or Serum Concentrations of Catecholamines

Catecholamines and arginine vasopressin (AVP) release can affect arterial blood pressure (ABP) and hemodynamic stability in standing, sedated horses. Six mature horses were included in this prospective, randomized, crossover, blinded, experimental study. All the horses were sedated with detomidine (DET) alone (0.01 mg/kg, IV) or combined with methadone (MET) (0.01 mg/kg DET and 0.2 mg/kg MET, IV). Cardiopulmonary data and blood samples were collected 30 minutes before (prebaseline and baseline) and for 120 minutes postinjection. The combination DET/MET produced a significant increase (31%) in mean ABP (MAP) 5 minutes after drug administration which lasted for 120 minutes. Detomidine alone induced only a short-term increase in MAP (15%) at 5 minutes compared with baseline. There were significant differences between groups at 5, 15, and from 60 to 120 minutes. Plasma AVP concentrations were higher in horses receiving the treatment DET from 60 to 120 minutes than those in the combination group, for the same period. There were no significant differences in norepinephrine and epinephrine serum concentrations respect to baseline and between treatments. Detomidine induces a short-term MAP increase, and this effect was prolonged and potentiated by MET association. There is no evidence of AVP, norepinephrine, and epinephrine involvement in this effect. (C) 2016 Elsevier Inc. All rights reserved.Sao Paulo Research Foundation (FAPESP)UNESP Univ Estadual Paulista, Sch Med, Dept Anesthesiol, Sao Paulo, BrazilUNESP Univ Estadual Paulista, Sch Vet Med & Anim Sci, Dept Vet Surg & Anesthesiol, Dist Rubiao Jr S-N, BR-18618970 Sao Paulo, BrazilUniv Fed Sao Paulo, Dept Biochem, Escola Paulista Med, Sao Paulo, BrazilUniv Fed Sao Paulo, Dept Biochem, Escola Paulista Med, Sao Paulo, BrazilFAPESP: 2008/56362-0Web of Scienc

Antinociceptive and Behavioral Effects of Methadone Alone or in Combination with Detomidine in Conscious Horses

The antinociceptive and behavioral effects of methadone (MET) alone or combined with detomidine (DET) were studied in horses. Intravenous treatments were randomly administered in a two-phase crossover study. In phase 1, six horses were treated with saline (control) or 0.2 or 0.5 mg/kg methadone (MET0.2; MET0.5, respectively). In phase 2, six horses were treated with 0.01 mg/kg DET alone or with DET combined with 0.2 mg/kg MET (DET/MET0.2). Thermal nociceptive threshold (TNT) and electrical nociceptive thresholds (ENT) were recorded by using a heat projection lamp and electrodes placed in the coronary band of the thoracic limbs, respectively. Spontaneous locomotor activity (SLA) was studied by movement sensors in the stall (phase 1). Chin-to-floor distance was assessed in phase 2. In phase 1, the TNT increased significantly for 30 minute after MET0.5 but not after saline or MET0.2. Hyperesthesia and ataxia were observed in 2 of 6 and 6 of 6 horses after MET0.2 and MET0.5, respectively. SLA increased significantly for 120 minutes after MET in a dose-dependent way, but not after placebo. In phase 2, DET and DET/MET0.2 significantly increased the TNT and ENT above baseline for 15 and 30 minutes, respectively; thresholds were significantly higher with DET/MET0.2 than with DET at the same times. Chin-to-floor distance decreased significantly from baseline for 30 minutes, and no excitatory behavior was observed in both treatments. Although the higher dose of MET induced short-acting antinociception, the associated adverse effects may contraindicate its clinical use. The lower dose of MET potentiated DET-induced antinociception without adverse effects, which might be useful under clinical circumstances. © 2013 Elsevier Inc. All rights reserved