title: Controversies in pediatric anesthesia: sevoflurane and fluid management.
abstract: OBJECTIVE
  To explore the interrelationships among the pharmacokinetics of sevoflurane, epileptiform electroencephalographic (EEG) activity and awareness in children. To also describe the revised perioperative fluid management strategy espoused by Holliday and Segar and noninvasive measures that may predict who will respond positively to fluid loading.
  
  
  RESULTS
  The depth of anesthesia during the early washin period with sevoflurane 8% is one-third less than during halothane. Eight percent sevoflurane rarely causes clinical seizures; more commonly, it causes epileptiform EEG activity that only weakly portends seizure activity. When preceded by nitrous oxide, midazolam or normocapnia, the risk of inducing epileptiform activity during spontaneous respiration is exceedingly small. Decreasing the inspired concentration of sevoflurane upon loss of the eyelash reflex to prevent epileptiform activity has not been shown to reduce the risk of clinical seizures, but more importantly, it may increase the risk of awareness if the child is stimulated. Isotonic intravenous solutions should be infused in volumes of 20-40 ml/kg over 2-4 h in children undergoing elective surgery. Postoperatively, these infusions may be continued at rates of 2/1/0.5 ml/kg/h; serum sodium concentration should be measured periodically. Noninvasive measures currently do not reliably identify those children who will respond positively to fluid boluses.
  
  
  CONCLUSIONS
  Sevoflurane is a well tolerated induction agent that rarely causes seizures in children, but may cause awareness if the inspired concentration is prematurely reduced. Perioperative isotonic fluids should be infused at 20-40 ml/kg over 2-4 h during elective surgery. Noninvasive metrics do not predict a child's responsiveness to fluid loading.
authors.affiliation: Department of Anesthesia, State University of New York at Buffalo and Women and Children's Hospital of Buffalo, Buffalo, New York, USA.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Gueli
authors.forename: Jerrold
authors.initials: J
authors.lastname: Lerman
mesh_terms: D000293:Adolescent; D000758:Anesthesia / Q000379:methods*; D018685:Anesthetics, Inhalation / Q000009:adverse effects*; D002648:Child; D002675:Child, Preschool; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D007010:Hyponatremia / Q000139:chemically induced / Q000628:therapy; D007223:Infant; D007231:Infant, Newborn; D008738:Methyl Ethers / Q000009:adverse effects* / Q000493:pharmacokinetics / Q000494:pharmacology; D010372:Pediatrics / Q000379:methods*; D019990:Perioperative Care; D011237:Predictive Value of Tests; D012640:Seizures / Q000139:chemically induced; D000077149:Sevoflurane; D014882:Water-Electrolyte Balance / Q000187:drug effects; D014883:Water-Electrolyte Imbalance / Q000139:chemically induced / Q000628:therapy
chemical_list: D018685:Anesthetics, Inhalation; D008738:Methyl Ethers; D000077149:Sevoflurane