The importance of maintaining normal perioperative physiological parameters in children during anaesthesia
1Department of Anesthesia, McGill University, Montreal Children's Hospital, Montreal, Canada
Online publish date: 07 April 2021
Every year, millions of neonates, infants and young children need general anesthesia for a variety of procedures. As pediatric anesthesia remains at high risk of perioperative morbidity and mortality, attention has been directed towards the anesthesia training and the anesthetics safety. We are now reassured about the relatively safeness of the anesthetic drugs, but the safest intraoperative conduct has still to be determined. In the absence of clear evidence, it appears logical to prevent perturbations of the child “baseline”, by avoiding preoperative distress, maintaining normal intraoperative parameters and preventing postoperative discomfort. Recently, ten “N” principles (no fear/awareness, normovolemia, normotension, normal heart rate, normoxemia, normocapnia, normonatremia, normoglycemia, normotermia and no pain/nausea/vomiting/emergence delirium) have been proposed as the base of a safer anesthesia care. The current paper aims to summarize the current evidence behind the “10-Ns” rational and to help guide anesthesiologists in their practice.
Safetots; Pediatric anesthesia; Pediatric homeostasis
Is'haq Al Aamri,Gianluca Bertolizio. The importance of maintaining normal perioperative physiological parameters in children during anaesthesia. Signa Vitae. 2021.doi:10.22514/sv.2021.058.
 Weiss M, Vutskits L, Hansen TG, Engelhardt T. Safe anesthesia for every tot - the SAFETOTS initiative. Current Opinion in Anaesthesiology. 2015; 28: 302-307.
 Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics. Anesthesia and Analgesia. 1997; 84: 234-235.
 Habre W, Disma N, Virag K, Becke K, Hansen TG, Jöhr M, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. The Lancet Respiratory Medicine. 2017; 5: 412-425.
 McCann ME, Lee JK, Inder T. Beyond anesthesia toxicity. Anesthesia & Analgesia. 2019; 129: 1354-1364.
 Weiss M, Bissonnette B, Engelhardt T, Soriano S. Anesthetists rather than anesthetics are the threat to baby brains. Pediatric Anesthesia. 2013; 23: 881-882.
 Kain ZN, Caldwell-Andrews AA. Preoperative psychological preparation of the child for surgery: an update. Anesthesiology Clinics of North America. 2005; 23: 597-614.
 Rosenbaum A, Kain ZN, Larsson P, Lönnqvist P, Wolf AR. The place of premedication in pediatric practice. Pediatric Anesthesia. 2009; 19: 817-828.
 Davidson A, McKenzie I. Distress at induction: prevention and consequences. Current Opinion in Anaesthesiology. 2011; 24: 301-306.
 Manyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children. The Cochrane Database of Systematic Reviews. 2015; CD006447.
 Chow CHT, Van Lieshout RJ, Schmidt LA, Dobson KG, Buckley N. Systematic review: audiovisual interventions for reducing preoperative anxiety in children undergoing elective surgery. Journal of Pediatric Psychology. 2016; 41: 182-203.
 Evans C, Moonesinghe R. Virtual reality in pediatric anesthesia: a toy or a tool. Pediatric Anesthesia. 2020; 30: 386-387.
 Anderson BJ, Exarchos H, Lee K, Brown TC. Oral premedication in children: a comparison of chloral hydrate, diazepam, alprazolam, midazolam and placebo for day surgery. Anaesthesia and Intensive Care. 1990; 18: 185-193.
 Sury MRJ. Accidental awareness during anesthesia in children. Pediatric Anesthesia. 2016; 26: 468-474.
 Lopez U, Habre W, Van der Linden M, Iselin-Chaves IA. Intra-operative awareness in children and post-traumatic stress disorder. Anaesthesia. 2008; 63: 474-481.
 Beekoo D, Yuan K, Dai S, Chen L, Di M, Wang S, et al. Analyzing electroencephalography (EEG) waves provides a reliable tool to assess the depth of sevoflurane anesthesia in pediatric patients. Medical Science Monitor. 2019; 25: 4035-4040.
 Sury M. Brain monitoring in children. Anesthesiology Clinics. 2014; 32: 115-132.
 Fahy BG, Chau DF. The technology of processed electroencephalogram monitoring devices for assessment of depth of anesthesia. Anesthesia and Analgesia. 2018; 126: 111-117.
 Sümpelmann R, Becke K, Brenner S, Breschan C, Eich C, Höhne C, et al. Perioperative intravenous fluid therapy in children: guidelines from the Association of the Scientific Medical Societies in Germany. Paediatric Anaesthesia. 2017; 27: 10-18.
 Sümpelmann R, Becke K, Zander R, Witt L. Perioperative fluid management in children: can we sum it all up now? Current Opinion in Anaesthesiology. 2019; 32: 384-391.
 Frykholm P, Schindler E, Sümpelmann R, Walker R, Weiss M. Preoperative fasting in children: review of existing guidelines and recent developments. British Journal of Anaesthesia. 2018; 120: 469-474.
 Soriano SG, McCann ME. Is Anesthesia Bad for the Brain? Current knowledge on the impact of anesthetics on the developing brain. Anesthesiology Clinics. 2020; 38: 477-492.
 Shalish W, Olivier F, Aly H, Sant’Anna G. Uses and misuses of albumin during resuscitation and in the neonatal intensive care unit. Seminars in Fetal & Neonatal Medicine. 2017; 22: 328-335.
 Milford EM, Reade MC. Resuscitation fluid choices to preserve the endothelial glycocalyx. Critical Care. 2019; 23: 77.
 Williams M, Lee JK. Intraoperative blood pressure and cerebral perfusion: strategies to clarify hemodynamic goals. Pediatric Anesthesia. 2014; 24: 657-667.
 McCann ME, Schouten ANJ. Beyond survival; influences of blood pressure, cerebral perfusion and anesthesia on neurodevelopment. Paediatric Anaesthesia. 2014; 24: 68-73.
 de Graaff JC, Pasma W, van Buuren S, Duijghuisen JJ, Nafiu OO, Kheterpal S, et al. Reference values for noninvasive blood pressure in children during anesthesia: a multicentered retrospective observational cohort study. Anesthesiology. 2016; 125: 904-913.
 Rhondali O, André C, Pouyau A, Mahr A, Juhel S, De Queiroz M, et al. Sevoflurane anesthesia and brain perfusion. Paediatric Anaesthesia. 2015; 25: 180-185.
 van Wijk JJ, Weber F, Stolker RJ, Staals LM. Current state of noninvasive, continuous monitoring modalities in pediatric anesthesiology. Current Opinion in Anaesthesiology. 2020; 33: 781-787.
 Eyre ELJ, Duncan MJ, Birch SL, Fisher JP. The influence of age and weight status on cardiac autonomic control in healthy children: a review. Autonomic Neuroscience: Basic & Clinical. 2014; 186: 8-21.
 Stricker PA, Lin EE, Fiadjoe JE, Sussman EM, Jobes DR. Absence of tachycardia during hypotension in children undergoing craniofacial reconstruction surgery. Anesthesia and Analgesia. 2012; 115: 139-146.
 Murat I, Constant I, Maud’huy H. Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period. Paediatric Anaesthesia. 2004; 14: 158-166.
 Numa A, Aneja H, Awad J, Ravindranathan H, Singh P, Swil K, et al. Admission hyperoxia is a risk factor for mortality in pediatric intensive care. Pediatric Critical Care Medicine. 2018; 19: 699-704.
 Wakimoto M, Miller R, Chenault K, Tobias JD. Inadvertent hyperoxia during intraoperative care in neonates: a case-series study. Journal of Anesthesia. 2020; 34: 149-152.
 Akça O. Optimizing the intraoperative management of carbon dioxide concentration. Current Opinion in Anaesthesiology. 2006; 19: 19-25.
 Brown MK, Poeltler DM, Hassen KO, Lazarus DV, Brown VK, Stout JJ, et al. Incidence of hypocapnia, hypercapnia, and acidosis and the associated risk of adverse events in preterm neonates. Respiratory Care. 2018; 63: 943-949.
 Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. Journal of Perinatology. 1995; 15: 470-479.
 Oh GJ, Sutherland SM. Perioperative fluid management and postopera-tive hyponatremia in children. Pediatric Nephrology. 2016; 31: 53-60.
 Baumgart S, Langman CB, Sosulski R, Fox WW, Polin RA. Fluid, electrolyte, and glucose maintenance in the very low birth weight infant. Clinical Pediatrics. 1982; 21: 199-206.
 Howell HB, Lin M, Zaccario M, Kazmi S, Sklamberg F, Santaniello N, et al. The impact of hypernatremia in preterm infants on neurodevel-opmental outcome at 18 months of corrected age. American Journal of Perinatology. 2020.
 Wu Y, Lai W, Pei J, Zhao Y, Wang Q, Xiang B. Hyperglycemia and its association with clinical outcomes in postsurgical neonates and small infants in the intensive care unit. Journal of Pediatric Surgery. 2016; 51: 1142-1145.
 Moga M, Manlhiot C, Marwali EM, McCrindle BW, Van Arsdell GS, Schwartz SM. Hyperglycemia after pediatric cardiac surgery: impact of age and residual lesions. Critical Care Medicine. 2011; 39: 266-272.
 Riegger LQ, Leis AM, Golmirzaie KH, Malviya S. Risk factors for intraoperative hypoglycemia in children: a multicenter retrospective cohort study. Anesthesia & Analgesia. 2021; 132: 1075-1083.
 Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, et al. Clinical practice guideline: maintenance intravenous fluids in children. Pediatrics. 2018; 142: e20183083.
 Sessler DI. Complications and treatment of mild hypothermia. Anesthe-siology. 2001; 95: 531-543.
 McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews. 2018; 2: CD004210.
 Oguz F, Yildiz I, Varkal MA, Hizli Z, Toprak S, Kaymakci K, et al. Axillary and tympanic temperature measurement in children and normal values for ages. Pediatric Emergency Care. 2018; 34: 169-173.
 Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W, Sadana N, et al. The impact of ambient operating room temperature on neonatal and maternal hypothermia and associated morbidities: a randomized controlled trial. American Journal of Obstetrics and Gynecology. 2016; 214: 505.e1-505.e7.
 Schroeck H, Lyden AK, Benedict WL, Ramachandran SK. Time trends and predictors of abnormal postoperative body temperature in infants transported to the intensive care unit. Anesthesiology Research and Practice. 2016; 2016: 7318137.
 Don Paul JM, Perkins EJ, Pereira-Fantini PM, Suka A, Farrell O, Gunn JK, et al. Surgery and magnetic resonance imaging increase the risk of hypothermia in infants. Journal of Paediatrics and Child Health. 2018; 54: 426-431.
 Buisson P, Bach V, Elabbassi EB, Chardon K, Delanaud S, Canarelli J, et al. Assessment of the efficiency of warming devices during neonatal surgery. European Journal of Applied Physiology. 2004; 92: 694-697.
 Kim P, Taghon T, Fetzer M, Tobias JD. Perioperative hypothermia in the pediatric population: a quality improvement project. American Journal of Medical Quality. 2013; 28: 400-406.
 Harpin VA, Rutter N. Sweating in preterm babies. The Journal of Pediatrics. 1982; 100: 614-619.
 Asakura H. Fetal and neonatal thermoregulation. Journal of Nippon Medical School. 2004; 71: 360-370.
 Tander B, Baris S, Karakaya D, Ariturk E, Rizalar R, Bernay F. Risk factors influencing inadvertent hypothermia in infants and neonates during anesthesia. Paediatric Anaesthesia. 2005; 15: 574-579.
 Dobson G, Chow L, Flexman A, Hurdle H, Kurrek M, Laflamme C, et al. Guidelines to the practice of anesthesia - revised edition 2019. Canadian Journal of Anesthesia. 2019; 66: 75-108.
 Boselli E, Bouvet L, Bégou G, Dabouz R, Davidson J, Deloste J, et al. Pre-diction of immediate postoperative pain using the analgesia/nociception index: a prospective observational study. British Journal of Anaesthesia. 2014; 112: 715-721.
 Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews. Neuroscience. 2013; 14: 502-511.
 Tavare AN, Perry NJS, Benzonana LL, Takata M, Ma D. Cancer recurrence after surgery: direct and indirect effects of anesthetic agents. International Journal of Cancer. 2012; 130: 1237-1250.
 Schneider J, Duerden EG, Guo T, Ng K, Hagmann P, Bickle Graz M, et al. Procedural pain and oral glucose in preterm neonates: brain development and sex-specific effects. Pain. 2018; 159: 515-525.
 Si H, Yang T, Zeng Y, Zhou Z, Pei F, Lu Y, et al. Correlations between inflammatory cytokines, muscle damage markers and acute postoperative pain following primary total knee arthroplasty. BMC Musculoskeletal Disorders. 2017; 18: 265.
 Vittinghoff M, Lönnqvist P, Mossetti V, Heschl S, Simic D, Colovic V, et al. Postoperative pain management in children: guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Paediatric Anaesthesia. 2019; 28: 493-506.
 Sherman M, Sethi S, Hindle AK, Chanza T. Multimodal pain management in the perioperative setting. Open Journal of Anesthesiology. 2020; 10:47-71.
 Mason KP. Paediatric emergence delirium: a comprehensive review and interpretation of the literature. British Journal of Anaesthesia. 2017; 118:335-343.
 Voepel-Lewis T, Malviya S, Tait AR. A prospective cohort study of emergence agitation in the pediatric postanesthesia care unit. Anesthesia and Analgesia. 2003; 96: 1625-1630.
 Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesthesia and Analgesia. 2007; 104: 84-91.
 Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal D, Mayes LC, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesthesia and Analgesia. 2004; 99: 1648-1654.
 Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia & Analgesia. 2020; 131: 411-448.
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