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A-1440
2004
Remifentanil and Delayed Intubation Improve Glucose Control in Children with Hyperinsulinism during an Interventional Procedure
Scott D. Markowitz, M.D., Mehernoor F. Watcha, M.D., Giovanni Cucchiaro, M.D., Ronald S. Litman, D.O., Laura A. Wanner, R.N., M.S.N., C.R.N.P.
Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Congenital hyperinsulinism, the most frequent cause of persistent, severe hypoglycemia in infancy, is amenable to surgical resection of focal hypersecreting pancreatic lesions, but localization of such tumors is difficult if <2cm in diameter. The most sensitive and specific technique is the arterial stimulation and venous sampling (ASVS) test where the diagnosis is established if a >2-fold rise in insulin levels in pancreatic veins occurs following selective arterial injections of calcium. In pediatric patients this test is performed under general anesthesia, but catecholamine secretion during stress can cause a marked variability in blood glucose (BG) levels under anesthesia. Wide changes in the BG levels during ASVS can induce insulin secretion from normal pancreatic tissue, making it difficult to interpret test data. This retrospective study examined the effect of anesthetic interventions on BG levels in children undergoing ASVS testing in order to devise an anesthetic management protocol for the procedure.

Methods: Data were abtracted from the medical records of 68 children receiving general anesthesia during the ASVS test. Demographics, anesthetic interventions and drug doses were recorded along with all adjustments of glucose infusion rates, insulin administration, and all BG levels. The effect of the following anesthetic related factors on the mean, peak and range of glucose values were examined: (a) induction anesthetics inhalation (sevoflurane), intravenous (propofol, thiopentone), (b) maintenance inhalation anesthetics (sevo-, iso- or desflurane), (c) supplemental regional anesthesia with caudal bupivacaine, (d) continuous infusions of remifentanil and (e) the time between induction and tracheal intubation. P<0.05 was considered statistically significant.

Results: There were 30 males and 38 females, mean age of 11±21 months. Remifentanil infusions were used on 42 occasions, and 5 patients received caudal epidural bupivacaine The choice of IV drug for induction of anesthesia or the inhalation agent for maintenance did not cause significant differences in the mean BG levels during the ASVS test. The use of caudal epidural bupivacaine did not result in significant differences in BG values compared to patients who did not receive supplemental regional anesthesia. The mean BG readings during ASVS testing were lower in the remifentanil group (80±19 vs. 100±43 mg/dl, p=0.01). The percentage change in BG values from preintubation baseline were greater in patients who underwent early tracheal intubation (<10 min after induction) compared to those in whom tracheal intubation was delayed > 10 min (32±51% vs. 5±24%, P<0.01).

There were no clinically important cardiovascular changes during ASVS testing in any patient. There were also no significant differences in the time from the end of the procedure to tracheal extubation in patients who did or did not receive remifentanil infusions during anesthesia.

Conclusion: The anesthetic interventions that helped maintain stability of BG were the concomitant use of remifentanil infusion and delaying tracheal intubation for 10 min after induction.

Ref:1)Doppman et al. Localization of insulinomas to regions of the pancreas by intra-arterial stimulation with calcium.Ann Intern Med 1995;123:269-73.

2)Srinivasan et al. Glucose homeostasis during anesthesia and surgery in infants. J Pediatr Surg 1986;21:718-21.

Anesthesiology 2004; 101: A1440