Nghe Marie-Claire, Godier Anne, Shaffii Anoushée, Leblanc Isabelle, Picard Hervé, Blanc Raphaël, Lumbroso-Le Rouic Livia, Devys Jean-Michel
Department of Anesthesiology and Intensive Care, Foundation Adolphe de Rothschild, Paris, France.
INSERM UMR-S1140, Paris Descartes University, Paris, France.
Paediatr Anaesth. 2018 Feb;28(2):120-126. doi: 10.1111/pan.13294. Epub 2017 Dec 5.
Serious adverse cardiorespiratory events complicate super selective ophthalmic artery chemotherapy for retinoblastoma in anesthetized children. Their mechanism remains unclear but may be attributed to an autonomic nervous reflex induced by the catheter close to the ophthalmic artery. Inadequate depth of anesthesia during catheter stimulation might be an aggravating factor. Thus, we tested whether deep general anesthesia reduced the incidence of serious cardiorespiratory events.
Children were prospectively included in this observational study. Standardized deep general anesthesia with sevoflurane, rocuronium, and sufentanil was administered. Sevoflurane MAC was kept between 1.5 and 1.7 and additional sufentanil administered. Serious cardiorespiratory event criteria were predefined and included arterial hypotension, bradycardia, and severe decrease in lung compliance. They were recorded and the factors influencing their occurrence were investigated.
One hundred fifteen procedures were performed on 32 children. The median MAC of sevoflurane was 1.5 and median BIS value was 44. Serious cardiorespiratory events occurred in 20% of procedures and were mainly severe decrease in lung compliance (83% of events). All of them required active treatment. One procedure was aborted due to cardiorespiratory compromise and required an epinephrine infusion. All severe decreases in lung compliance occurred within 2 minutes after catheter insertion in the ophthalmic artery. No recorded demographic and endovascular characteristics were associated with serious cardiorespiratory events.
Serious cardiorespiratory events occur commonly during super selective ophthalmic artery chemotherapy. Standardized deep anesthesia with analgesia did not appear to be protective. No predictive factors were identified, but these events systematically arose within 2 minutes after ophthalmic artery catheter insertion. Anesthetists and neuroradiologists should be prepared to manage these serious complications and parents should be informed of the risks.
在麻醉状态下的儿童中，严重的心肺不良事件使视网膜母细胞瘤的超选择性眼动脉化疗变得复杂。其机制尚不清楚，但可能归因于靠近眼动脉的导管引发的自主神经反射。导管刺激期间麻醉深度不足可能是一个加重因素。因此，我们测试了深度全身麻醉是否能降低严重心肺事件的发生率。
前瞻性纳入儿童进行本观察性研究。采用七氟醚、罗库溴铵和舒芬太尼进行标准化深度全身麻醉。七氟醚的最低肺泡有效浓度（MAC）保持在1.5至1.7之间，并额外给予舒芬太尼。预先定义了严重心肺事件的标准，包括动脉低血压、心动过缓和肺顺应性严重下降。记录这些事件并调查影响其发生的因素。
对32名儿童进行了115例手术。七氟醚的中位MAC为1.5，中位脑电双频指数（BIS）值为44。20%的手术发生了严重心肺事件，主要是肺顺应性严重下降（占事件的83%）。所有这些事件都需要积极治疗。1例手术因心肺功能不全而中止，需要输注肾上腺素。所有肺顺应性严重下降均发生在眼动脉导管插入后2分钟内。记录的人口统计学和血管内特征与严重心肺事件均无关联。
严重心肺事件在超选择性眼动脉化疗期间常见。标准化的深度镇痛麻醉似乎没有保护作用。未发现预测因素，但这些事件均在眼动脉导管插入后2分钟内发生。麻醉师和神经放射科医生应准备好处理这些严重并发症，并应告知家长相关风险。
