Mari-Liis Ilmoja SA Tallinna Lastehaigla

Transcription

1 Mari-Liis Ilmoja SA Tallinna Lastehaigla

2 24,165 anaesthesias 724 adverse events; 31: % respiratory Risk factors: infancy, higher ASA status, ENT surgery Perioperative anaesthetic morbidity in children: a database of anaesthetics over a 30-month period I Murat, I Constant, H Maud'huy Pediatric Anesthesia, Vol 14:2, , 2004

3 35190 anesteesiat 1214 ebasoodsat juhtumit s.o. 34 : ,5% hingamisteedega seotud Riskifaktorid: ASA III-IV, alla 1-aastased, erakorralised protseduurid Anesthesia-related critical incidents in the perioperative period in children; a proposal for an anesthesia-related reporting system for critical incidents in children. de Graaff JC 1, Paediatr Anaesth 2015

4 Prospective study anaesthesias No cardiac surgery (except PDA ligation) Ilmoja ML Baltic Congress of Anesthesiology and Intensive Care, 2010

5 No of patients Respiratory events 64% Ilmoja ML Baltic Congress of Anesthesiology and Intensive Care, 2010

6 Respiratory infections and adverse events inf AE 0 sept oct nov dec jan feb mar apr may june july aug 0 Ilmoja ML Baltic Congress of Anesthesiology and Intensive Care, 2010

7 Risk factors for adverse events: ASA status III-V AE per 1000 anaesthesias I-II III-V ASA III-IV OR 7,98 (95%CI 5,38 11,84) Ilmoja ML Baltic Congress of Anesthesiology and Intensive Care, 2010

8 Risk factors for adverse events: age < 1 year 140 AE per 1000 anaesthesias resp cardiac vomiting CNS medication other regional 0 < 1 mo 1mo-1 yr 1-5 yr 6-12 yr > 12 yr Age < 1 year OR 3,87 (95%CI 2,72 5,39) Ilmoja ML Baltic Congress of Anesthesiology and Intensive Care, 2010

9 APRICOT: Anaesthesia PRactice In Children Observational Trial: European prospective multicenter observational study: Epidemiology of severe critical events NECTARINE: NEonate-Children audit of Anaesthesia practice IN Europe. Epidemiology of morbidity and mortality in neonatal anaesthesia: A European prospective multicentre observational audit of practice

10 Käitumuslikud ja autonoomsed vastused valule Maksa ensüümsüsteemid ja ravimite metabolism Ravimite ja nende metaboliitide renaalne kliirens Ravimite omastamise ja ümberjaotumise vanuselised aspektid Ravimite famakodünaamika vanuselised aspektid Nasr V, Davis J; Pediatric Research 2015

11 Opiaatide toime hingamissüsteemile Opiaatretseptorite, transporterite ja teiste ensüümsüsteemide geneetiline polümorfism erinev vastus anesteesia ravimitele Neuronite tundlikkus apoptoosi suhtes nii ravimid kui haigusseisundid Hemodünaamika muutused üld-, spinaal või epiduraalanalgeesias Hormonaalne vastus haigusele või kirugiale Ravimite koostoime Nasr V, Davis J; Pediatric Research 2015

12 GAS study sevofluraan vs spinaalanalgeesia songa operatsiooniks

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14 NMDA glutamaat retseptorite inhibeerimine Ketamiin, N2O GABA retseptorite aktivatsioon Neuroapoptoos Neurokognitiivne defitsiit Bensodiasepiinid, barbituraadid, propofool, sevofluraan Anesthetics and sedatives: Toxic or protective for the developing brain? C Ward, A Loepke Pharmacological Research, 2011,

15 7 p rotid Midasolaam+N2O+isofluraan 6 tundi Tulemused: widespread apoptotic neurodegeneration in the developing brain, deficits in hippocampal synaptic function, persistent memory/learning impairments. Jevtovic-Todorovic et al. J. Neurosci. 2003

16 Gleich S, Nemergut M, Flick R Curr Opin Anesthesiol 2013

17 Gleich S, Nemergut M, Flick R Curr Opin Anesthesiol 2013

18 1. How does the anesthetic exposure in preclinical studies compare with pediatric anesthesia practice? 2. Is the maturational state of the brain in experimental models comparable to that of patients undergoing pediatric anesthesia? 3. Are there any detectable clinical markers of neurodegeneration in children after exposure to anesthetics? Loepke A, et al; ANESTHESIA & ANALGESIA, 2008

19 Concurrent noxious stimulation with CFA attenuates ketamine-induced caspase-3 activation Concurrent noxious stimulation attenuates ketamine-induced increase in cyclin D1 expression. Data are presented as mean ± SE. CFA = complete Freund's adjuvant; KET = ketamine. Liu J, et al; Anesthesiology, 2012 Date of download: 5/21/2015 Copyright 2015 American Society of Anesthesiologists. All rights reserved.

20 Shih J, et al; Anesthesiology. 2012

21 I have no wish, nor the skill, to embark upon a philosophical discussion of the meaning of 'causation'. Meeting January, 1965

22 Gleich S, Nemergut M, Flick R Curr Opin Anesthesiol 2013

23 Mayo Clinic 8548 last(s ) Anesteesia alla 2 aasta vanuses 350 vs 700 Flick R, et al; Pediatrics 2011

24 Hazard ratio: Korstnapühkija ja skrootumi vähk 200 Salitsülaadid ja Reye sündroom 26 Kõhuli magamine ja SIDS 12,6 Gleich,2013; Bell 1965

25 Anesthetic-related neurotoxicity in young children Gleich et al. Curr Opin Anesthesiol 2013, 26:

26 Summary Although the evidence from nonhuman primates and humans is overtly concerning, it lacks clinical verification. There are, at present, no data that would dictate a change in clinical practice in the anesthetic management of infants and children. Anesthetic-related neurotoxicity in young children Gleich et al. Curr Opin Anesthesiol 2013, 26:

27 Anesteesia tüsistuste esinemissagedus Eestis on võrreldav teiste riikidega Anesteesia mõju arenevale ajule vajab täpsustamist