Bradycardia During Induction of Anesthesia withSevoflurane in Children with Down Syndrome

Wickham Kraemer,et al.

Presented byMichael Aritonang, MD

Anesthesia RotatorPCMC

INTRODUCTION

• Down syndrome is one of the most common genetic disorders in children with an incidence of 1 in 800

• Up to 50% of children with this syndrome have congenital cardiac defects

INTRODUCTION

• Anesthesia in children including down syndrome often induced by inhale potent anesthetics

• Inhalation anesthetics have well-described cardiovascular depressant effects

REVIEW OF LITERATURE

• Borland et al. in 2004. The incidence of severe bradycardia associated with inhaled anesthetic induction in children with Down syndrome was reported as being 3.7%. This study focused on patients receiving halothane and isoflurane.

REVIEW OF LITERATURE

• Murat et al. reported an incidence of bradycardia of 0.3% in a pediatric population of 24,165.

• There is greater hemodynamic stability during induction with sevoflurane than with the older drugs halothane and isoflurane.

OBJECTIVES

1. To compare the incidence and characteristics of bradycardia after induction with sevoflurane in children with Down syndrome and control

2. To determine the factors associated with bradycardia, including the presence of congenital heart disease (CHD).

METHODOLOGY

• Review Automated electronic anesthesia record-keeping system for anesthetic procedures

• Between July 1, 1998, and November 15, 2006.

DATA EXTRACTED

Demographics

History of Significant

CHD

Heart Rate

Oxygen hemoglobin saturation

Expired sevofluraine

conc

Arterial blood pressure

METHODOLOGY

METHODOLOGY

• Power analysis was performed

• Univariate analysis was performed

• Multivariate analysis was performed

RESULTS

Total of 477 anesthetic record were reviewed: 209 subjects with Down syndrome and 268 controls.

RESULTS

• The overall incidence of bradycardia and hypotension was significantly higher in the Down syndrome group than in the control group for all ages

57% vs 12%odds ratio [OR] 9.56, 95% confidence interval

[CI] 6.06 to 15.09

DISCUSSION

Reasons for this differences of incidences

PREVIOUS STUDIES1. Relied on self-reporting

2. No clear definition of bradycardia and

hypotension

THIS STUDIES1. Electronic anesthesia record-keeping system

2. Well accepted criteria

RESULTS

• More patients with Down syndrome received anticholinergic drugs after induction in comparison with the control group

24% vs. 0%; P 0.001

with 14%, 5%, and 5% receiving IV atropine, IM atropine, and IV glycopyrrolate,

DISCUSSIONS

• The threshold of intervention with anticholinergic dx is variable among individuals anesthesiologist

• Clinical importance is whether pharmacological intervention are required or not

• Investigation of strategies such as anticholinergic premedication to prevent this phenomenon of bradycardia on induction may be warranted.

RESULTS

RESULTS

RESULTS

• Down syndrome patients were more likely to have an oxyhemoglobin saturation of 90% during the induction period

23/209 vs. 2/268 OR 16.5, 95% CI 4.3 to 63.8

Discussion

• Bradycardia during induction with sevoflurane was common in children with Down syndrome, with and without a history of congenital heart disease.

• This suggests that the bradycardia on induction phenomenon occurs independently of overtly manifest structural heart defects and that other factors are responsible.

• Increased susceptibility of pediatric patients those with Down syndrome to bradycardia during induction with sevoflurane.

• The clinical implication anesthesiologists should be aware and attenuate its occurrence by a judicious reduction in the concentration of inhaled drug and to treat this condition quickly