Are there still limitations for the use of target-controlled infusion in children?

Abstract

Target controlled infusion (TCI) devices are gaining popularity among paediatric anaesthesia practitioners because propofol and short-acting opioids allow rapid onset and offset of action, reduce postoperative nausea and vomiting, reduce emergence delirium, lessen exposure to atmospheric pollutants and can be used in peripheral locations. Widespread use remains limited and this review examines reasons why children do not yet enjoy such benefits. There is no integrated pharmacokinetic/pharmacodynamic analysis that can supply parameter estimates to be programmed into pumps for either plasma or effect-site concentration determination over the broad paediatric age range. The six pharmacokinetic parameter sets available for children out of infancy all differ. Validation studies are few. Estimates in neonates and infants are dependent on maturation and size considerations that have not yet been elucidated. There remains a need for specific neonate-derived algorithms if electroencephalogram (EEG)-derived anaesthesia depth monitors are to be used for neonates or infants. End-tidal breath analysis of propofol offers a useful tool for central compartment monitoring. Hardware limitations, a lack of integrated pharmacokinetic/pharmacodynamic studies and target monitoring issues restrict use. Intravenous induction remains a hurdle, but increasing familiarity with the technique guarantees continued use for maintenance anaesthesia.