Bradycardia During Induction of Anesthesia with

Sevoflurane in Children with Down Syndrome

Wickham Kraemer,et al.

Presented by
Michael Aritonang, MD
Anesthesia Rotator
PCMC

INTRODUCTION

Down syndrome is one of the most common

genetic disorders in children with an
incidence of 1 in 800
Up to 50% of children with this syndrome
have congenital cardiac defects

INTRODUCTION

Anesthesia in children including down

syndrome often induced by inhale potent
anesthetics
Inhalation anesthetics have well-described
cardiovascular depressant effects

REVIEW OF LITERATURE

Borland et al. in 2004. The incidence of

severe bradycardia associated with inhaled
anesthetic induction in children with Down
syndrome was reported as being 3.7%. This
study focused on patients receiving halothane
and isoflurane.

REVIEW OF LITERATURE

Murat et al. reported an incidence of

bradycardia of 0.3% in a pediatric population
of 24,165.
There is greater hemodynamic stability during
induction with sevoflurane than with the older
drugs halothane and isoflurane.

OBJECTIVES

1. To compare the incidence and

characteristics of bradycardia after induction
with sevoflurane in children with Down
syndrome and control
2. To determine the factors associated with
bradycardia, including the presence of
congenital heart disease (CHD).

METHODOLOGY

Review Automated
electronic anesthesia
record-keeping system for
anesthetic procedures
Between July 1, 1998, and
November 15, 2006.

DATA EXTRACTED

METHODOLOGY

METHODOLOGY

Power analysis was performed

Univariate analysis was performed
Multivariate analysis was performed

RESULTS
Total of 477 anesthetic record were reviewed:
209 subjects with Down syndrome and 268 controls.

RESULTS

The overall incidence of bradycardia and

hypotension was significantly higher in the
Down syndrome group than in the control
group for all ages
57% vs 12%
odds ratio [OR] 9.56, 95% confidence interval
[CI] 6.06 to 15.09

DISCUSSION

RESULTS

More patients with Down syndrome received

anticholinergic drugs after induction in
comparison with the control group
24% vs. 0%; P 0.001
with 14%, 5%, and 5% receiving IV atropine,
IM atropine, and IV glycopyrrolate,

DISCUSSIONS

The threshold of intervention with anticholinergic

dx is variable among individuals anesthesiologist
Clinical importance is whether pharmacological
intervention are required or not
Investigation of strategies such as anticholinergic
premedication to prevent this phenomenon of
bradycardia on induction may be warranted.

RESULTS

RESULTS

RESULTS

Down syndrome patients were more likely to

have an oxyhemoglobin saturation of 90%
during the induction period
23/209 vs. 2/268
OR 16.5, 95% CI 4.3 to 63.8

Discussion

Bradycardia during induction with sevoflurane

was common in children with Down
syndrome, with and without a history of
congenital heart disease.
This suggests that the bradycardia on
induction phenomenon occurs independently
of overtly manifest structural heart defects
and that other factors are responsible.

 Increased susceptibility of pediatric patients

those with Down syndrome to bradycardia
during induction with sevoflurane.
The clinical implication
anesthesiologists should be aware and
attenuate its occurrence by a judicious
reduction in the concentration of inhaled drug
and to treat this condition quickly