Impact of anesthetic agents on cerebrovascular physiology in children

Szabó, Elöd Z.; Luginbuehl, Igor; Bissonnette, Bruno

doi:10.1111/j.1460-9592.2008.02826.x

Cited by 41 publications

(33 citation statements)

References 165 publications

(191 reference statements)

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“…This is associated with a fall in cerebral blood flow, metabolic demand for oxygen and any pre-existing cerebral edema [88, 89]. However cerebral autoregulation and cerebrovascular reactivity to CO 2 appear unaffected [90].…”

Section: ) Effects On Different Organ Systemsmentioning

confidence: 99%

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

2015

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Propofol is an intravenous agent used commonly for induction and maintenance of anesthesia, procedural and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially gamma-aminobutyric acid A receptor. Approved for use in the United States by the Federal Drugs and Administration (FDA) in 1989, its use for induction of anesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not “little adults”, in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exist despite the FDA mandating addition of antimicrobial preservative, calling for manufacturers’ directions to discard open vials after six hours. While propofol has advantages over inhalation anesthesia like less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research.

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Section: ) Effects On Different Organ Systemsmentioning

confidence: 99%

Propofol: A Review of its Role in Pediatric Anesthesia and Sedation

2015

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“…28 Though CBF is expected to be greater in younger children, 29, 30 there was no significant difference in CBF between (younger) sedated and (older) awake subjects, likely because propofol reduces CBF. 15, 31 As a result, MTT (CBV/CBF) was also greater in younger sedated subjects, though MTT is expected to be greater in older children. 32 We speculate that propofol-induced decreases in CBF could lead to compensatory dilatation of precapillary pial vessels, increasing CBV and prolonging MTT and resulting in diffusely increased SSI, as occurs asymmetrically in patients with Moyamoya and temporary ICA balloon occlusion.…”

Section: Discussionmentioning

confidence: 98%

“…Patients receiving other anesthetic agents or opioids were ineligible due to potential confounding effects on cerebral perfusion. 15 Two subjects who had intravenous contrast within 48 hours before the graded scan, 16 and six subjects with remote documented or suspected leptomeningeal disease not captured in our database search, were subsequently excluded, yielding 42 total subjects ranging in age from 1.2 to 18 years (mean 9.66 ± 4.92 years, 48% male). Of these, 25 subjects (1.2 to 18 years, mean 10.3 ± 4.60 years, 36% male) had technically adequate supraventricular PWI.…”

Section: Methodsmentioning

confidence: 99%

“…11 The appearance is also similar to the leptomeningeal “ivy sign” in Moyamoya patients, found to correlate with cerebral perfusion, dilated pial vessels and decreased cerebrovascular reserve. 12–14 We hypothesized that cerebral perfusion, known to be altered by anesthesia 15 , may contribute to diffuse FLAIR SSI. The purpose of this study was to investigate whether cerebral perfusion and enhancing pial vessels contribute to diffuse SSI in a relatively homogeneous pediatric neuro-oncology cohort and, if contributory, to explore the relative contributions of supplemental oxygen, cerebral perfusion and anesthesia to SSI on T2-weighted FLAIR imaging.…”

Section: Introductionmentioning

confidence: 99%

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Elevated Cerebral Blood Volume Contributes to Increased FLAIR Signal in the Cerebral Sulci of Propofol-Sedated Children

Harreld¹,

Sabin²,

Rossi

et al. 2014

American Journal of Neuroradiology

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Background and Purpose Hyperintense FLAIR signal in the cerebral sulci (SSI) of anesthetized children is attributed to supplemental oxygen (FiO2), but resembles FLAIR hypersignal associated with perfusion abnormalities in Moyamoya and carotid stenosis. We investigated whether cerebral perfusion, known to be altered by anesthesia, contributes to diffuse SSI in children, and explored the relative contributions of supplemental oxygen, cerebral perfusion and anesthesia to SSI. Methods Supraventricular SSI on pre- and post-contrast T2-FLAIR images of 24 propofol-sedated (6.20 ± 3.28 years) breathing supplemental oxygen and 18 non-sedated (14.28 ±2.08 years) children breathing room air was graded from 0 to 3. Spearman correlation of SSI with FiO2 and age in 42 subjects, and with DSC measures of cortical CBF, CBV and MTT available in 25 subjects, were evaluated overall and compared between subgroups. Factors most influential on SSI were identified by stepwise logistic regression. Results CBV was more influential on non-contrast FLAIR SSI than FiO2 or age in propofol-sedated children (CBV: r=0.612, p=0.026; FiO2: r=−0.418, p=0.042; Age: r=0.523, p=0.009) and overall (CBV: r=0.671, p=0.0002; FiO2: r=0.442, p=0.003; Age: r=−0.374, p=0.015); MTT (CBV/CBF) was influential in the overall cohort (r=0.461, p=0.020). SSI increased with contrast in 45% of subjects, decreased in none, and was greater (p<0.0001) in younger propofol-sedated subjects, in whom SSI increased with age post-contrast (r=0.600, p=0.002). Conclusion Elevated cortical CBV appears to contribute to increased SSI on non-contrast FLAIR in propofol-sedated children. Effects of propofol on age-related cerebral perfusion and vascular permeability may play a role.

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“…No single technique is superior to others. [319] Isoflurane, sevoflurane, and continuous intravenous infusion of propofol and opioids have all been used safely. [20] However, the total intravenous anesthesia technique is gaining popularity, especially during neurosurgical procedures.…”

Section: Intraoperative Managementmentioning

confidence: 99%