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Br J Anaesth ; 108(4): 648-54, 2012 Apr.
Article in English | MEDLINE | ID: mdl-22265901

ABSTRACT

BACKGROUND: In children, sevoflurane is the most commonly used anaesthetic. Its excellent haemodynamic tolerance gives it a wide therapeutic index. This halogenated agent can abolish movement [minimal alveolar concentration (MAC)] or haemodynamic responses (MACBAR) to noxious stimulus in children as in adults. Reflex pupillary dilatation (RPD) has been demonstrated as a very sensitive measure of noxious stimulation. In order to investigate the effect of sevoflurane on the RPD, a subcortical reflex, we determined the MAC of sevoflurane inhibiting the RPD in 50% of the subjects in response to skin incision (MACpup) in pre- and post-pubertal subjects. METHODS: We included 30 pre-pubertal children and 19 post-pubertal subjects. Patients received sevoflurane at preselected concentrations according to an 'up and down' design, and after a steady-state period, skin incision was performed. The RPD was considered as significant when the pupillary diameter increased by more than 100%. Heart rate (HR) and bispectral index (BIS) changes were analysed according to the pupillary response. RESULTS: The MACpup of sevoflurane was 4.8% (95% confidence interval, 4.6-5.1%) in pre-pubertal children vs 3.4% (3.5-3.3%) in post-pubertal subjects (P<0.001). Inhibition of RPD was always associated with lack of significant HR response. In pre-pubertal children receiving high concentrations of sevoflurane, RPD in response to noxious stimulation was frequently associated with lack of HR response and low BIS values. CONCLUSIONS: MACpup was higher than MAC and close to the MACBAR. Inhibition of RPD in pre-pubertal children required higher sevoflurane concentrations compared with post-pubertal subjects, suggesting that the relationship between the brain structure sensitivities may differ with brain maturation.


Subject(s)
Anesthetics, Inhalation/pharmacology , Dermatologic Surgical Procedures , Methyl Ethers/pharmacology , Pulmonary Alveoli/metabolism , Reflex, Pupillary/drug effects , Adolescent , Age Factors , Analysis of Variance , Anesthesia, General , Anesthetics, Inhalation/pharmacokinetics , Child , Child, Preschool , Cross-Over Studies , Dose-Response Relationship, Drug , Electroencephalography/drug effects , Heart Rate/drug effects , Humans , Infant , Methyl Ethers/pharmacokinetics , Monitoring, Intraoperative/methods , Prospective Studies , Sevoflurane
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