|
|
DOI Prefix 10.20431 |
Information
Journal Policies
ARC Journal of Anesthesiology
Volume-3 Issue-2, 2018, Page No: 5-7
Anesthesia Management for Pediatric Cardiac Catheterization
Ayse Ulgey1*, Aynur Mustafayeva1, Ersin Sonmez1, Buket Kapcak1
1.Department of Anesthesiology and Intensive Care, Erciyes University Medical Faculty, 38039 Kayseri, Turkey.
Citation : Ayse Ulgey, Aynur Mustafayeva, Ersin Sonmez, Buket Kapcak, "Anesthesia Management for Pediatric Cardiac Catheterization" ARC Journal of Anesthesiology. 2018; 3(2) : 5-7.
Copyright : © 2018 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Pediatric cardiac catheterization, sedation, anesthetic agents, Anesthesiology
Cardiac Catheterizations done for therapeutic and diagnostic purpose are vastly used in children with CHD. Anesthetic techniques in these children are more likely challenging for anesthesiologist and requires a capable and experienced team. Therefore, the aim of the technique is to maintain adequate sedation, analgesia, anxiolysis, immobility of patient and in addition to secure the respiratory and cardiovascular system. Techniques done for the cardiac catheterization are either deep sedation or general anesthesia. Depending on cardiac defect, clinical appearance of a patient and experience of a cardiologist, various anesthetic techniques may be applied, furthermore, the ideal one does not exist. Moreover, taking in consideration that children are very vulnerable to hypoxia, so that, oxygenation of a child is very crucial within the procedure. It should be noted that hypercapnia may lead to pulmonary vasoconstriction, hence deteriorating the condition may bring up to undesireable findings like bradycardia, even cardiac arrest and brain damage. Hyperoxia and hypoxia may affect the pressure levels as well. Wrong measurements of carbon dioxide should also be mentioned. In many studies, the drugs and their combinations that are widely used for sedation are ketamine, propofol, fentanyl, midazolam, dexmedetomidine.
Pediatric cardiac catheterization, sedation, anesthetic agents, Anesthesiology
1. Introduction
Currently, the amount of children surviving from congenital heart disease (CHD) rises fundamentally [1]. Deep sedation is one of the most important requirements in pediatric cardiac catheterization lab. Main factors of sedation in cardiac catheterization are prevention of respiratory depression and hemodynamic instability [2-5].
Ketamine as a NMDA (N-methyl-D-aspartate glutamate) receptor antagonist may provide sedation and deep analgesia with less side effects. Airway reflexes, spontaneous ventilation, and cardiovascular stability are actually preserved in patients [6]. Producing cortical dissociation that clinically shows up nystagmic gaze and cataleptic appearance, creating deep analgesia, sedation and amnesia are characteristics of Ketamine [7].
Fentanyl being 80 times as potent as morphine is a frequently used opioid agent in cardiac catheterization [8]. Fentanyl provides only analgesia, thus is used with the combination of other anesthetic drugs [9].
Midazolam the most commonly used benzodiazepine for anesthetic techniques may provide sedation, hypnosis, amnesia, muscle relaxation and anticonvulsive effects [10].
Propofol is vastly used in cardiac catheterization for its quick onset, short duration of action, short recovery time and antiemetic properties [11]. However, side effects like cardiovascular and respiratory depression must be kept in mind for instable patient [12].
Dexmedetomidine as a selective a2-adrenoreceptor agonist drug provides sedative, anxiolytic and analgesic effects. Minimal risk of respiratory and hemodynamic depression are the advantages of dexmedetomidine, however it must be avoided in patients with preexisting bradyarrhytmias and/or atrioventricular blocks. Side effects like bradycardia and hypotension may easily be prevented by decreasing the infusion rate [13].
Ülgey et al.[14]in the study that 46 children undergoing transcatheter closure of atrial septal defect divided into two groups receiving either dexmedetomidine-propofol, or ketamine-propofol combination revealed that, ketamine-propofol combination provided excellent circumstances for the procedure and was less likely to create hemodynamic instability. Tosun et al. in the study that44 children undergoing cardiac catheterization were divided into two groups receiving dexmedetomidine-ketamine and propofol-ketamine combination, showed that, dexmedetomidine -ketamine group was not superior to the second one.
Kristin et al. [15] reported that administration of only dexmedetomidine as a primary sedative drug for the invasive procedure in six spontaneously breathing children at the age of 3 days-29 months with congenital heart defect, may provide sufficient sedation.
Mester et al. [3] in their cohort study included 16 infants undergoing cardiac catheterization revealed that ketamine and dexmedetomidine combination may provide efficacious sedation creating less cardiovascular and respiratory changes because of covering the side effects of each other.
Munro et al. [4]showed that the only dexmedetomidine infusion with the dose of 1μg/kg perhour titrated up to 2 μg/kg per hour was not effective thus 25% of patients moved in the procedure and 60% needed propofol administration.
Ulgey et al. [16]in the study where 60 children were randomly chosen to receive the sedation either with ketamine-propofol or ketamine-propofol-dexmedetomidine combination. Both groups received 1 mg/kg ketamine and 1 mg/kg propofol for induction, however the second group received dexmedetomidine infusion. The results showed that none of the patients was intubated in both groups. Adding dexmedetomidine for sedation decreased the requirements for respiratory intervention, reduced the patient΄s movement and shortened recovery time.
Lebovic et al. [17] in a study of 20 patients divided into two groups where 10 patients received ketamine and 10 received propofol concluded that propofol is superior to ketamine in order to the shorter recovery time.
Akin et al. [18] in a randomized double-blind study enrolled 60 children at the age of from one month till 13 years old undergoing cardiac catheterization revealed that propofol and low dose of ketamine combination excellently preserves mean arterial pressure and does not affect the recovery time at all.
Koruk et al.[19]in order to compare propofol- dexmedetomidine and propofol-ketamine combination effects in two groups of patients undergoing transcatheter ASD closure determined that ketamine significantly prolonged the recovery time.
Kogan et al [20] in a clinical study where 45 patients with the age of 6 months till 16 years old undergoing cardiac catheterization received propofol and ketamine infusion. The doses of infusion and extra doses were arranged according the depth of anesthesia. Study concluded that propofol-ketamine combination is appropriate enough to achieve proper sedation in spontaneously breathing patients through the procedure.
Jobier et al. [21]in a retrospective study where 154 patients were chosen for cardiac catheterization received either ketamine, or midazolam or both. Study showed that low dose of ketamine and midazolam may safely be administered in pediatric patients.
Kaynar et al. [22]showed in a research work where 60 children undergoing cardiac catheterization were divided into two groups according to the infusion dose of remifentanil, whereas the first group received 0.1 μg/kg/min and the second one received 0.2 μg/kg/min of infusion dose. Study concluded that premedication with midazolam and administration of 0.2 μg/kg/min remifentanil infusion provided effective sedation with proper hemodynamic stability.
In cardiac catheterization spontaneous breathing with no oxygen supplement and immobility are highly important for the excellent quality of the procedure. [18,23,24] Main goals for the anesthesiologist are the reduction of pain and anxiety, maintaining respiratory and hemodynamic stability and providing appropriate recovery time in pediatric patients. [4,25] Various combinations of drugs are used for the sedation in cardiac catheterization however results are mostly focused on ventilation and hemodynamic effects like spontaneous breathing, saturation, pulse and blood pressure. The aim of using the drug combination is covering the side effects of each other.
Currently, the amount of children surviving from congenital heart disease (CHD) rises fundamentally [1]. Deep sedation is one of the most important requirements in pediatric cardiac catheterization lab. Main factors of sedation in cardiac catheterization are prevention of respiratory depression and hemodynamic instability [2-5].
Ketamine as a NMDA (N-methyl-D-aspartate glutamate) receptor antagonist may provide sedation and deep analgesia with less side effects. Airway reflexes, spontaneous ventilation, and cardiovascular stability are actually preserved in patients [6]. Producing cortical dissociation that clinically shows up nystagmic gaze and cataleptic appearance, creating deep analgesia, sedation and amnesia are characteristics of Ketamine [7].
Fentanyl being 80 times as potent as morphine is a frequently used opioid agent in cardiac catheterization [8]. Fentanyl provides only analgesia, thus is used with the combination of other anesthetic drugs [9].
Midazolam the most commonly used benzodiazepine for anesthetic techniques may provide sedation, hypnosis, amnesia, muscle relaxation and anticonvulsive effects [10].
Propofol is vastly used in cardiac catheterization for its quick onset, short duration of action, short recovery time and antiemetic properties [11]. However, side effects like cardiovascular and respiratory depression must be kept in mind for instable patient [12].
Dexmedetomidine as a selective a2-adrenoreceptor agonist drug provides sedative, anxiolytic and analgesic effects. Minimal risk of respiratory and hemodynamic depression are the advantages of dexmedetomidine, however it must be avoided in patients with preexisting bradyarrhytmias and/or atrioventricular blocks. Side effects like bradycardia and hypotension may easily be prevented by decreasing the infusion rate [13].
2. Results And Discussion
Ülgey et al.[14]in the study that 46 children undergoing transcatheter closure of atrial septal defect divided into two groups receiving either dexmedetomidine-propofol, or ketamine-propofol combination revealed that, ketamine-propofol combination provided excellent circumstances for the procedure and was less likely to create hemodynamic instability. Tosun et al. in the study that44 children undergoing cardiac catheterization were divided into two groups receiving dexmedetomidine-ketamine and propofol-ketamine combination, showed that, dexmedetomidine -ketamine group was not superior to the second one.
Kristin et al. [15] reported that administration of only dexmedetomidine as a primary sedative drug for the invasive procedure in six spontaneously breathing children at the age of 3 days-29 months with congenital heart defect, may provide sufficient sedation.
Mester et al. [3] in their cohort study included 16 infants undergoing cardiac catheterization revealed that ketamine and dexmedetomidine combination may provide efficacious sedation creating less cardiovascular and respiratory changes because of covering the side effects of each other.
Munro et al. [4]showed that the only dexmedetomidine infusion with the dose of 1μg/kg perhour titrated up to 2 μg/kg per hour was not effective thus 25% of patients moved in the procedure and 60% needed propofol administration.
Ulgey et al. [16]in the study where 60 children were randomly chosen to receive the sedation either with ketamine-propofol or ketamine-propofol-dexmedetomidine combination. Both groups received 1 mg/kg ketamine and 1 mg/kg propofol for induction, however the second group received dexmedetomidine infusion. The results showed that none of the patients was intubated in both groups. Adding dexmedetomidine for sedation decreased the requirements for respiratory intervention, reduced the patient΄s movement and shortened recovery time.
Lebovic et al. [17] in a study of 20 patients divided into two groups where 10 patients received ketamine and 10 received propofol concluded that propofol is superior to ketamine in order to the shorter recovery time.
Akin et al. [18] in a randomized double-blind study enrolled 60 children at the age of from one month till 13 years old undergoing cardiac catheterization revealed that propofol and low dose of ketamine combination excellently preserves mean arterial pressure and does not affect the recovery time at all.
Koruk et al.[19]in order to compare propofol- dexmedetomidine and propofol-ketamine combination effects in two groups of patients undergoing transcatheter ASD closure determined that ketamine significantly prolonged the recovery time.
Kogan et al [20] in a clinical study where 45 patients with the age of 6 months till 16 years old undergoing cardiac catheterization received propofol and ketamine infusion. The doses of infusion and extra doses were arranged according the depth of anesthesia. Study concluded that propofol-ketamine combination is appropriate enough to achieve proper sedation in spontaneously breathing patients through the procedure.
Jobier et al. [21]in a retrospective study where 154 patients were chosen for cardiac catheterization received either ketamine, or midazolam or both. Study showed that low dose of ketamine and midazolam may safely be administered in pediatric patients.
Kaynar et al. [22]showed in a research work where 60 children undergoing cardiac catheterization were divided into two groups according to the infusion dose of remifentanil, whereas the first group received 0.1 μg/kg/min and the second one received 0.2 μg/kg/min of infusion dose. Study concluded that premedication with midazolam and administration of 0.2 μg/kg/min remifentanil infusion provided effective sedation with proper hemodynamic stability.
3. Conclusion
In cardiac catheterization spontaneous breathing with no oxygen supplement and immobility are highly important for the excellent quality of the procedure. [18,23,24] Main goals for the anesthesiologist are the reduction of pain and anxiety, maintaining respiratory and hemodynamic stability and providing appropriate recovery time in pediatric patients. [4,25] Various combinations of drugs are used for the sedation in cardiac catheterization however results are mostly focused on ventilation and hemodynamic effects like spontaneous breathing, saturation, pulse and blood pressure. The aim of using the drug combination is covering the side effects of each other.
References
- Welke KF, Diggs BS, Karamlou T, et al. Comparison of pediatric cardiac surgical mortality rates from national administrative data to contemporary clinical standards. AnnThoracSurg 2009; 87:216–23.
- Gayatri P, Suneel PR, Sinha PK (2007) Evaluation of propofol–ketamine anesthesia for children undergoing cardiac catheterization procedures. J IntervCardiol 20:158–163
- Mester R, Easley B, Brady KM, Chilson K, Tobias JD (2008) Monitoredanesthesia care with a combination of ketamine and dexmedetomidine during cardiac catheterization. Am J Ther 15:24–30
- Munro HM, Tirotta JF, Felix DE, Lagueruela RG, Madril DR, Zahn EM, Nykanen DG (2007) Initial experience with dexmedetomidine for diagnostic and interventional cardiac catheterizationin children. PediatrAnesth 17: 109–112
- Tosun Z, Akın A, Guler G, Esmaoglu A, Boyacı A (2006) Dexmedetomidine–ketamine and propofol ketamine combination for anesthesia in spontaneously breathing pediatric patient undergoing cardiac catheterization. J CardiothoracVascAnesth 20:515–519
- White PF, Way WL, Trevor AJ. Ketamine – its pharmacology and therapeutic uses. Anesthesiology 1982; 56:119–36.
- Stoelting RK, Hillier SC. Nonbarbiturate intravenous anesthetic drugs. In: Stoelting RK, Hiller SC, editors. Pharmacology and physiology in anesthetic practice.4th edition. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 115–78
- Reisine T, Pasternak G. Opioid analgesics and antagonists. In: Hardman JG, Limbird LE, editors. Goodman &Gilman’s the pharmacological basis of therapeutics.9th edition. New York: McGraw-Hill Health Professions Division; 1996. p. 521–55.
- Bailey PL, Pace NL, Ashburn MA, et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990; 73(5):826–30.
- Yildirim SV, Guc BU, Bozdogan N, et al. Oral versus intranasal midazolam premedication for infants during echocardiographic study. AdvTher 2006; 23:719–24.
- Borgeat A, Wilder-Smith OH, Suter PM. The nonhypnotic therapeutic applications of propofol. Anesthesiology 1994; 80:642–56.
- Williams GD, Jones TK, Hanson KA, et al. The hemodynamic effects of propofol in children with congenital heart disease. AnesthAnalg 1999; 89:1411–6.
- Hammer GB, Drover DR, Cao H, et al. The effects of dexmedetomidine on cardiac electrophysiology in children. AnesthAnalg 2008; 106:79–83.
- Ayşe Ü, Adnan B, Işın G, et al. Sedation for pediatric transcatheter atrial septal defect closure: comparison of two sedation protocols. Cardiology in the Young (09 Sep 2013), 24(5), 880-885
- Dexmedetomidine as the primary sedative during invasive procedures in infants and toddlers with congenital heart disease. Kristin P etal. PediatrCrit Care Med 2008 Vol 9, No 6
- Ayşe Ülgey et al Is the Addition of Dexmedetomidine to a Ketamine–Propofol Combination in Pediatric Cardiac Catheterization Sedation Useful? Ped. Cardiol. 2012 33; 770-774
- Saul Lebovic, David L. et al Comparison of Propofol Versus Ketarnine for Anesthesia in Pediatric Patients Undergoing Cardiac Catheterization AnesthAnalg 1992; 74;490-4
- A. Akin, A. Esmaoglu et al Propofol and Propofol–Ketamine in Pediatric Patients Undergoing Cardiac CatheterizationPediatr Cardiol 26:553–557, 2005
- SenemKoruk, AyseMizrak et al Propofol/Dexmedetomidine and Propofol/ Ketamine Combinations for Anesthesia in Pediatric Patients Undergoing Transcatheter AtrialSeptalDefectClosure:A ProspectiveRandomized Study; Clinical Therapeutics/Volume 32, Number 4, 2010
- Kogan A, Rachel E, Propofol-Ketamine Mixture for Anesthesia in Pediatric Patients Undergoing Cardiac Catheterization Journal of Cardioth and VascAnesth, Vol 17, No 6 (December), 2003; 691-693
- Jobeir A, Galal M, Bulbul Z et al Use of Low-Dose Ketamine and/or Midazolam for Pediatric Cardiac Catheterization: Is an Anesthesiologist Needed? Pediatr Cardiol 24:236–243, 2003
- Kaynar A, Kelsaka E et al. Effects of Different Doses of Remifentanil Infusion on Hemodaynamic and recovery in Children Undergoing Pediatric Diagnostic Cardiac Catheterization. Journal of Cardioth and Vascular Anesthesia, Vol 25, No 4 (August), 2011; 660-664
- Hollinger, I., Mittnacht, A. Cardiac catheterization and other radiographic examination. In:C.L. Lake, P.D. Booker (Eds.) Pediatric Cardiac Anesthesia. (ed 4).Lippincot Williams & Wilkins, Philadelphia, PA; 2005:112–136.
- Andropoulos, D.B., Stayer, S.A. An anesthesiologist for all pediatric cardiac catheterizations: Luxury or necessity? J CardiothoracVascAnesth. 2003; 17:683–685.
- Oklü, E., Bulutcu, F.S., Yalcin, Y. et al, Which anesthetic agent alters the hemodynamic status during pediatric catheterization? (Comparison of propofol versus ketamine). J CardiothoracVascAnesth. 2003; 17:686–690.