The importance of maintaining normal perioperative physiological parameters in children during anaesthesia

Abstract

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.

Evaluation of Nociception during Pediatric Surgery: A Topical Review

“…Heart rate and blood pressure poorly correlate with brain and spinal cord nociception [ 2 ]. In children under general anesthesia, maximal tetanic stimulation may lead to an increase in heart rate of only 5% [ 8 ].…”

“…The electrical intensity needed to elicit a spinal polysynaptic withdrawal reflex can be used as surrogate of the level of nociception [ 18 ]. A clinically adequate, opioid-based general anesthesia (absence of somatic and hemodynamic responses to high intensity tetanic stimulations) abolishes only 59% of the spinal cord and brain nociception, which is still detectable with functional magnetic resonance imaging [ 2 ].…”

“…Perioperative pain carries significant morbidity, including cardiovascular complications, immunosuppression, and development of chronic pain [ 1 ]. Intraoperative nociceptive stimuli are still processed centrally even in presence of deep general anesthesia [ 2 ], therefore, optimal nociception control is pivotal in anesthesia practice, as advocated by the Safetots initiative [ 3 ]. Monitoring of intraoperative nociception (neural encoding and the processing of noxious stimuli without conscious perception) has gained popularity in the recent years.…”

Anesthesia for pediatric magnetic resonance imaging: a review of practices and current pathways

“…Second, approximately 1.4-5.7% of the children undergoing sedated MRI experience emergence delirium on awaking [23], a clinical phenomenon that puts the child at risk of self-injury and maladaptive behavioral changes that can persist for weeks [24]. Third, in case of MRI under sedation or general anesthesia, fasting is recommended [22,25], which increases child's discomfort and risk of hypotension [24]. Lastly, the MRI machine works at a room temperature < 218 C, which places small children at risk of hypothermia [26,27].…”

“…Thus, in case of complications (e.g., airway obstruction, cardiac arrest), the availability of emergency equipment, which is often not MRI compatible (e.g., videolaryngoscope, defibrillator), and personnel support are limited [21 ▪ ,22]. Second, approximately 1.4–5.7% of the children undergoing sedated MRI experience emergence delirium on awaking [23], a clinical phenomenon that puts the child at risk of self-injury and maladaptive behavioral changes that can persist for weeks [24]. Third, in case of MRI under sedation or general anesthesia, fasting is recommended [22,25], which increases child's discomfort and risk of hypotension [24].…”