Sevoflurane Well-Handled in Children Is Excellent, but in the Wrong Hands Can Be Life-Threatening

This article refers to:

Sevoflurane Inhalation Anesthesia for Uncooperative Pediatric Outpatients in the Treatment of Ankyloglossia: A Retrospective Study of 137 Cases

In this retrospective study, 137 children aged 1–6 with ankyloglossia received lingual frenulum cut under sevoflurane inhalation and local anesthesia. The authors evaluated among other objectives, the efficacy and safety of sevoflurane. The anesthetic procedure was performed by the dentist, who administered a bolus of 2.5 mg/kg intravenous propofol and followed by 8% sevoflurane inhalation, and was maintained by inhalation of 2–3% sevoflurane continuously with nasal cannula. All the children were visited by an anesthesiologist at the anesthesia clinic.

The pediatric patient presents specific physiological and pharmacological characteristics, which determine an anesthesiological management different from an adult’s, mainly in the newborn and the infant. Children under 1 year have a higher chance of complications, in relation to oxygenation, ventilation, airway management and response to anesthetic agents and other drugs. The pediatric population has an increased vagal tone with an easy tendency to bradycardia. The three main causes of bradycardia are hypoxia, vagal stimulation and volatile anesthetic agents [1, 2]. The literature teaches us that halogenated inhalation agents, such as sevoflurane, should be administered by a properly trained health professional, using a specially calibrated vaporizer, so that the concentration released can be controlled exactly. It is essential that the area in which any type of anesthetic procedure is to be carried out is provided with a system which is able to provide oxygen under pressure at a minimum concentration of 90% and a debit of 15 L/min, from a suction source (portable or wall-mounted), of equipment for monitoring according to all minimum standards (ECG, noninvasive pressure, pulse oximetry, capnography) and of drugs and material necessary for airway management and cardiopulmonary resuscitation (ambu, probes, endotracheal tubes, laryngoscope, etc.). If the area in question does not have these minimums, the equipment should be transferred before proceeding to the sedation although this has been planned as a minimum, as it can always fail or complicate. The Food and Drug Administration has already warned of the risks of sedation, which are detailed below [3–5]. First, all sedatives and narcotics have the risk of causing problems even if they are used at the recommended doses. This may be the case of patients exposed for the first time to halogenated who may develop seizures or a malignant hyperthermia syndrome [6]. Second, complications have occurred in all areas of sedation. In addition, children <5 years old are at higher risk, even without basic pathology. Respiratory depression and obstruction of the airway are the most frequent complications [7, 8]. The factors associated with complications during a sedation are the use of multiple drugs, drug errors or overdosage, inadequate patient evaluation, inadequate monitoring and professionals with insufficient training. Who should perform sedation is still a subject of debate in some scientific societies. Should it be an anesthesiologist or can it be other specialist doctors such as the gastroenterologist, the radiologist or the cardiologist? Can it also be the trained nursing staff? The anesthesiologist Blike [9] suggests continued accredited training under the direction of the anesthesiology departments with interdisciplinary collaboration teams between anesthesiologists and non-anesthesiologists. He adds that it must be the anesthesiologist who supervises, supports and leads the anesthetic procedure since it has the greatest capacity to recover the patient from unforeseen adverse events. Sedation has another added risk, the place of observation for patient monitoring after the procedure. Complications can appear after the patient awakens, the most frequent being agitation, respiratory depression, nausea and vomiting.

From the reading of this study [10], another consideration which emerges in the working environment, is the risk of contamination of health personnel resulted from the use of sevoflurane. The authors describe that the halogenated agent is administered by inhalation through a nasal cannula, with high fresh gas flows, in an area where it may not be properly ventilated and where gas extraction systems may not exist. Gas extraction systems collect expired gases and evacuate them passively or actively outside the surgical room. An adequate ventilation system with renewal and treatment of the ambient air is the first link in the fight against pollution and reduces by 50% the environmental concentrations of anesthetic gases in the respiratory zone of the exposed personnel. Ventilation must conserve air sterility in the operative field and should maintain a comfortable environment for the occupants of the operating room [4, 5].

In agreement with the English and American clinical guidelines, I suggest that each institution should create the training routes for professionals who handle any anesthetic agent and who work with pediatric patients. We must also define the documents and certifications of competence of the personnel assigned to the surgical areas, either ambulatory or with hospital admission.

Declaration of interest

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.