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. 2024 Dec;11(4):241-249.
doi: 10.4274/jpr.galenos.2024.87528. Epub 2024 Dec 10.

Prospective Observational Study of Sympathetic Failure as a Mechanism Associated with Bradycardia During Induction of General Anesthesia in Children with Down Syndrome

Jamie Wingate Sinton  1 , Sarah Marcum  2 , Qing Duan  2 , Kristie Geisler  1 , David Cooper  3 , Lili Ding  4 , Jareen Meinzen-Derr  4 , Susan Wiley  5 , John McAuliffe  6
Affiliations

Prospective Observational Study of Sympathetic Failure as a Mechanism Associated with Bradycardia During Induction of General Anesthesia in Children with Down Syndrome

Jamie Wingate Sinton et al. J Pediatr Res. 2024 Dec.

Abstract

Aim: While bradycardia in children with Down syndrome (DS) during inhalation induction of anesthesia is characteristic, its mechanism is not well understood. This study investigated sympathetic failure as a potential (and modifiable) mechanism of bradycardia.

Materials and methods: Ninety-three children with DS and 102 typically developing (TD) children underwent inhalation induction of anesthesia. These children were monitored for sympathetic activity, exposed to sevoflurane anesthetic and were observed for the development of bradycardia. The primary outcome was sympathetic failure in the context of normoxic bradycardia within the first 300 seconds of induction. Secondary outcome measures included hypotension and parasympathetic excess.

Results: During the first 300 seconds of induction, 54 DS children became bradycardic (54/93, 58%) while 22 TD children became bradycardic (22/102, 22%). In the DS group, 23 experienced hypotension (23/80, 29%). Of those who experienced hypotension, 15 also experienced sympathetic failure (15/28, 54%).

Conclusion: More than half of children with DS undergoing inhalation anesthesia induction with sevoflurane experienced bradycardia. Bradycardia and hypotension were associated with sympathetic failure. Sympathetic activity therefore appears to be a modifiable target in the prevention of bradycardia in children with DS.

Keywords: Down syndrome; autonomic nervous system diseases; pediatric anesthesia; sevoflurane.

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Conflict of interest statement

Conflict of Interest: No conflict of interest was declared by the authors.

Figures

Figure 1.
Figure 1.
Participant flow through the study VU-AMS: Vrije Ambulatory Monitoring System
Figure 2.
Figure 2.
(Panels A and B). Poincare plots of RR Interval during induction. Children with Down syndrome, Panel A, those who became bradycardic had a larger SD1 (standard deviation perpendicular to the long axis of the plot) compared with TD children, Panel B. SD1 comprises the standard deviation of the difference between an RR interval and its predecessor, then the square root of that value. SD2 indicates the square root of the standard deviation of an RR interval TD: Typically developing, SD: Standard deviation
Figure 3.
Figure 3.
Venn Diagram of children with Down syndrome who developed bradycardia during inhalation induction of anesthesia.
Figure 4.
Figure 4.
End tidal sevoflurane concentration over each of the first five minutes of inhalation induction in typically developed versus children with Down syndrome
See this image and copyright information in PMC

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