Hemodynamic response to ketamine in children with pulmonary hypertension.

Published on Jan 1, 2016in Pediatric Anesthesia2.311
· DOI :10.1111/PAN.12799
Robert H. Friesen23
Estimated H-index: 23
 (University of Colorado Denver), Mark D. Twite13
Estimated H-index: 13
 (University of Colorado Denver)+ 7 AuthorsD. Dunbar Ivy71
Estimated H-index: 71
 (University of Colorado Denver)
Sources
Abstract
Summary Background The safety of ketamine in children with pulmonary hypertension has been debated because of conflicting results of prior studies in which changes in mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) have been widely variable. The goal of this prospective study was to quantitate the effects of ketamine on pulmonary hemodynamics in a cohort of children with pulmonary hypertension under conditions in which variables such as airway/ventilatory management, FiO2, and use of vasodilating anesthetics were controlled. Methods The IRB approved this study of 34 children undergoing cardiac catheterization for pulmonary hypertension studies. Following anesthetic induction with sevoflurane and tracheal intubation facilitated by the administration of rocuronium 0.7–1 mg·kg−1 iv, sevoflurane was discontinued and anesthesia was maintained with midazolam 0.1 mg·kg−1 iv (or 0.5 mg·kg−1 po preoperatively) and remifentanil iv infusion 0.5–0.7 mcg·kg−1·min−1. Ventilation was mechanically controlled to maintain PaCO2 35–40 mmHg. When endtidal sevoflurane was 0% and FiO2 was 0.21, baseline heart rate (HR), mean arterial pressure (MAP), mPAP, right atrial pressure (RAP), pulmonary artery occlusion pressure (PAOP), right ventricular end-diastolic pressure (RVEDP), cardiac output, and arterial blood gases were measured, and indexed systemic vascular resistance (SVRI), indexed pulmonary vascular resistance (PVRI), and cardiac index (CI) were calculated. Each child then received a bolus of ketamine 2 mg·kg−1 infused over 2 min. Measurements and calculations were repeated 2 min after the conclusion of the infusion. Results The mean (95% CI) increase in mPAP following ketamine was 2 mmHg (0.2, 3.7), which was statistically significant but clinically insignificant. PVRI and PVRI/SVRI did not change significantly. Hemodynamic changes did not differ among subjects with differing severity of pulmonary hypertension or between subjects chronically treated with pulmonary vasodilators or not. Conclusion Ketamine is associated with minimal, clinically insignificant hemodynamic changes in sedated, mechanically ventilated children with pulmonary hypertension.
📖 Papers frequently viewed together
2009Acta Medica Scandinavica
3 Authors (Arne M. Abrahamsen, ..., Carsten Müller)
4 Citations
2015The American review of respiratory disease
5 Authors (David V. Tuxen, ..., E. J. Moran Campbell)
1 Citations
1987
7 Authors (Asher Kimchi, ..., H. J. C. Swan)
4 Citations
References19
Newest
#1Mark D. Twite (University of Colorado Denver)H-Index: 13
#2Robert H. Friesen (University of Colorado Denver)H-Index: 23
1 CitationsSource
Feb 1, 2015·Anesthesia & Analgesia4.30
#1Katherine TaylorH-Index: 11
#2Dagmar MoultonH-Index: 1
Last. Peter C. LaussenH-Index: 76
view all 4 authors...
BACKGROUND: Pulmonary hypertension (PHT) is a significant risk factor for major adverse events during anesthesia, with a reported incidence of 5% to 7%, secondary to acute pulmonary hypertensive crises or right ventricular ischemia. Newer therapies for treating PHT have reduced mortality. In this single-center study, we investigated the frequency of major and minor events during anesthesia under the current strategies to manage PHT. METHODS: We reviewed the records of children with PHT who under...
14 CitationsSource
Jun 1, 2014·Journal of Anesthesia1.63
#1Koji Watanabe (Juntendo University)H-Index: 2
#2Kunitomo Kashiwagi (Juntendo University)H-Index: 2
Last. Yoichiro Kamiyama (Juntendo University)H-Index: 3
view all 7 authors...
Purpose Although laparoscopic surgery is minimally invasive, it produces stress responses to an extent similar to that of conventional laparotomy. Both epidural anesthesia and remifentanil intravenously (i.v.), combined with general anesthesia, provide stable hemodynamics during laparoscopic surgery. However, it has not been elucidated whether epidural anesthesia and remifentanil are associated with suppression of autonomic and neuroendocrine stress responses. This study aimed to clarify whether...
27 CitationsSource
Aug 19, 2013·Anesthesia & Analgesia4.30
#1Robert H. Friesen (CU: University of Colorado Boulder)H-Index: 23
#2Christopher S. NicholsH-Index: 3
Last. D. Dunbar IvyH-Index: 71
view all 10 authors...
The pulmonary vascular effects of many anesthetic drugs have been inadequately investigated. The lack of knowledge of these effects can create uncertainty in the delivery of clinical anesthetic care, particularly in children with congenital heart disease and/or pulmonary hypertension, who frequently require anesthesia or sedation for diagnostic or therapeutic procedures. Dexmedetomidine, an α-2 and imidazole receptor agonist, is widely used in pediatrics for procedural and therapeutic sedation a...
41 CitationsSource
Nov 1, 2012·Pediatric Anesthesia2.31
#1Glyn D. Williams (Lucile Packard Children's Hospital)H-Index: 21
#2Robert H. Friesen (University of Colorado Denver)H-Index: 23
8 CitationsSource
Jan 1, 2010·Pediatric Anesthesia2.31
#1Glyn D. Williams (Lucile Packard Children's Hospital)H-Index: 21
#2Harjot Maan (Dartmouth–Hitchcock Medical Center)H-Index: 1
Last. Jeffrey A. Feinstein (Lucile Packard Children's Hospital)H-Index: 53
view all 9 authors...
Summary Background: Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications in children, including pulmonary hypertensive crisis and cardiac arrest. Uncertainty remains about the safety of ketamine anesthesia in this patient population. Aim: Retrospectively review the medical records of children with PAH to ascertain the nature and frequency of peri-procedural complications and to determine whether ketamine administration was associated wit...
59 CitationsSource
Dec 1, 2007·Anesthesia & Analgesia4.30
#1Glyn D. Williams (Stanford University)H-Index: 21
#2Bridget M. PhilipH-Index: 2
Last. Chandra RamamoorthyH-Index: 32
view all 10 authors...
BACKGROUND:The use of ketamine in children with increased pulmonary vascular resistance is controversial. In this prospective, open label study, we evaluated the hemodynamic responses to ketamine in children with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg).METHODS:Children aged
109 CitationsSource
Mar 1, 2006·Seminars in Cardiothoracic and Vascular Anesthesia
#1J. G. Bovill (LEI: Leiden University)H-Index: 2
#1J. G. Bovill (LEI: Leiden University)H-Index: 1
Patients with heart failure have a diminished cardiac reserve capacity that may be further compromised by anesthesia. In addition to depression of sympathetic activity, most anaesthetics interfere with cardiovascular performance, either by a direct myocardial depression or by modifying cardiovascular control mechanisms. Etomidate causes the least cardiovascular depression. It is popular for induction of anesthesia in cardiac-compromised patients; however, it is not suitable for maintenance of an...
80 CitationsSource
Mar 1, 2004·Anesthesiology7.07
#1Alexandre OuattaraH-Index: 32
#2Gilles BoccaraH-Index: 7
Last. Pierre CoriatH-Index: 73
view all 9 authors...
Background: To assess intrinsic vascular effects of remifentanil, increased concentrations were infused in critically ill patients with a total artificial heart. Methods: In the early postoperative period after implantation of a total artificial heart, nine ventilated patients requiring short general anesthesia were included in this study. After anesthesia was induced with 0.3 mg/kg intravenous etomidate, the artificial heart settings were modified to render cardiac output preload-independent. w...
33 CitationsSource
Dec 1, 2003·Journal of Cardiothoracic and Vascular Anesthesia2.26
#1E Öklü (KHU: Kadir Has University)H-Index: 1
#2Füsun Bulutçu (KHU: Kadir Has University)H-Index: 5
Last. Osman Bayindir (KHU: Kadir Has University)H-Index: 7
view all 6 authors...
Abstract Objective To compare the effects of propofol and ketamine on systemic and pulmonary circulations in pediatric patients scheduled for elective cardiac catheterization. Design Prospective, randomized, and blinded. Setting University hospital. Participants Children (n = 41) undergoing cardiac catheterization. Interventions All children were premedicated with oral midazolam 60 minutes before the procedure. Patients were separated into 3 groups according to shunts diagnosed by transthoracic ...
90 CitationsSource
12
Cited By13
Newest
Apr 1, 2021·BJA: British Journal of Anaesthesia6.88
#1Laura C. Price (NIH: National Institutes of Health)H-Index: 21
#2Guillermo Martinez (Papworth Hospital)H-Index: 9
Last. Stephen J. Wort (NIH: National Institutes of Health)H-Index: 30
view all 34 authors...
Abstract Background The risk of complications, including death, is substantially increased in patients with pulmonary hypertension (PH) undergoing anaesthesia for surgical procedures, especially in those with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). Sedation also poses a risk to patients with PH. Physiological changes including tachycardia, hypotension, fluid shifts, and an increase in pulmonary vascular resistance (PH crisis) can precipitate acute right ventr...
1 CitationsSource
Feb 28, 2021·Journal of Cardiothoracic and Vascular Anesthesia2.26
#1Rajeev Wadia (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 3
#2Meghan Bernier (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 6
Last. Jochen Steppan (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 22
view all 6 authors...
Abstract Pediatric pulmonary hypertension is a disease that has many etiologies and can present anytime during childhood. Its newly revised hemodynamic definition follows that of adult pulmonary hypertension: a mean pulmonary artery pressure > 20 mmHg. However, the pediatric definition stipulates that the elevated pressure must be present after the age of 3 months. The definition encompasses many different etiologies, and diagnosis often involves a combination of noninvasive and invasive testing...
Source
Jan 8, 2021·Clinics in Chest Medicine2.67
#1Jochen Steppan (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 22
#1Jochen Steppan
Last. Paul M. Heerdt
view all 2 authors...
The incidence of pulmonary hypertension (PH) in patients undergoing noncardiac surgery has increased steadily over the past decade. Patients with known PH have significantly higher perioperative morbidity and mortality than those without PH. Moreover, a substantial number of patients may have occult disease. It, therefore, is of paramount importance for perioperative providers to recognize high-risk patients and treat them appropriately. This review first provides an overview of PH pathophysiolo...
1 CitationsSource
#1Anuradha P. MenonH-Index: 2
#2Yoke Hwee ChanH-Index: 9
Source
May 1, 2019·Pediatric Anesthesia2.31
#1Gregory J. Latham (UW: University of Washington)H-Index: 10
#2Delphine Yung (UW: University of Washington)H-Index: 12
: Pediatric pulmonary hypertension is a complex disease with multiple, diverse etiologies affecting the premature neonate to the young adult. Pediatric pulmonary arterial hypertension, whether idiopathic or associated with congenital heart disease, is the most commonly discussed form of pediatric pulmonary hypertension, as it is progressive and lethal. However, neonatal forms of pulmonary hypertension are vastly more frequent, and while most cases are transient, the risk of morbidity and mortali...
7 CitationsSource
Source
Sep 1, 2018·Congenital Heart Disease1.66
#1Rohit Loomba (Boston Children's Hospital)H-Index: 91
#2Seth B. GrayH-Index: 2
Last. Saul Flores (BCM: Baylor College of Medicine)H-Index: 5
view all 3 authors...
INTRODUCTION: Ketamine is a drug often used for procedural sedation or as adjunct agent for general sedation in children with congenital heart disease. In the clinical realm, there is often confusion regarding the effects of ketamine on hemodynamics, particularly pulmonary vascular resistance and systemic vascular resistance. We performed a meta-analysis of studies investigating the effects of ketamine on hemodynamics. METHODS: A systematic review was conducted to identify studies characterizing...
7 CitationsSource
May 29, 2018·Circulation23.60
#1Sébastien J. Dumas (French Institute of Health and Medical Research)H-Index: 3
#2Gilles Bru-Mercier (French Institute of Health and Medical Research)H-Index: 1
Last. Sylvia Cohen-Kaminsky (French Institute of Health and Medical Research)H-Index: 11
view all 17 authors...
Background —Excessive proliferation and apoptosis resistance in pulmonary vascular cells underlie vascular remodeling in pulmonary arterial hypertension (PAH). Specific treatments for PAH exist, mostly targeting endothelial dysfunction, but high pulmonary arterial pressure still causes heart failure and death. Pulmonary vascular remodeling may be driven by metabolic reprogramming of vascular cells to increase glutaminolysis and glutamate production. The N-methyl-D-aspartate receptor (NMDAR), a m...
38 CitationsSource
Source
Jan 1, 2018·Pulmonary circulation2.21
#1Meghan Bernier (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 6
#2Ariel I. Jacob (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 1
Last. Chinwe UnegbuH-Index: 2
view all 6 authors...
Prior limited research indicates that children with pulmonary hypertension (PH) have higher rates of adverse perioperative outcomes when undergoing non-cardiac procedures and cardiac catheterizations. We examined a single-center retrospective cohort of children with active or pharmacologically controlled PH who underwent cardiac catheterization or non-cardiac surgery during 2006–2014. Preoperative characteristics and perioperative courses were examined to determine relationships between the seve...
16 CitationsSource
12