REVIEW

CURRENT
OPINION Current state of noninvasive, continuous monitoring
modalities in pediatric anesthesiology
Jan J. van Wijk a, Frank Weber a, Robert J. Stolker b, and Lonneke M. Staals a

Purpose of review
The last decades, anesthesia has become safer, partly due to developments in monitoring. Advanced
monitoring of children under anesthesia is challenging, due to lack of evidence, validity and size
constraints. Most measured parameters are proxies for end organ function, in which an anesthesiologist is
Downloaded from http://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/07/2020

actually interested. Ideally, monitoring should be continuous, noninvasive and accurate. This present review
summarizes the current literature on noninvasive monitoring in noncardiac pediatric anesthesia.
Recent findings
For cardiac output (CO) monitoring, bolus thermodilution is still considered the gold standard. New noninvasive
techniques based on bioimpedance and pulse contour analysis are promising, but require more refining in
accuracy of CO values in children. Near-infrared spectroscopy is most commonly used in cardiac surgery
despite there being no consensus on safety margins. Its place in noncardiac anesthesia has yet to be
determined. Transcutaneous measurements of blood gases are used mainly in the neonatal intensive care unit,
and is finding its way to the pediatric operation theatre. Especially CO2 measurements are accurate and useful.
Summary
New techniques are available to assess a child’s hemodynamic and respiratory status while under
anesthesia. These new monitors can be used as complementary tools together with standard monitoring in
children, to further improve perioperative safety.
Keywords
bioimpedance, near-infrared spectroscopy, noninvasive monitoring, transcutaneous measurements

INTRODUCTION of some parameters, while goal directed monitoring

Patient safety is the number one issue in anesthesi- in adults has already been established.
ology. At present, anesthesia is absolutely safe in Due to rapid hemodynamic and respiratory
uncomplicated patients undergoing low-risk pro- changes under anesthesia, continuous and nonin-
cedures, as improvement of monitoring modalities vasive monitoring would be favorable. Most param-
and anesthetics, and the preparation of the peri- eters daily used in anesthesia are only proxies for
operative process have led to optimization of care. end organ function. The brain is perhaps the most
In general, intraoperative mortality has dramati- vulnerable, but also the least monitored organ. Due
cally decreased in the last decades [1]. This overall
safety has led to a change of the paradigm of a
Department of Anesthesiology, Erasmus MC Sophia Children’s Hospital
anesthesia, from survival of the surgery and avoid- and bDepartment of Anesthesiology, Erasmus MC, University Medical
ing direct side effects into concepts based on qual- Center Rotterdam, Rotterdam, The Netherlands
ity of life and value-based health care. This Correspondence to Jan J. van Wijk, MD, Department of Anesthesiology,
requires a new view on monitoring to optimize Erasmus MC Sophia Children’s Hospital, University Medical Center
organ preservation by controlling local oxygen- Rotterdam, Dr Molewaterplein 40, 3015 GD Rotterdam, The
Netherlands. Tel: +31 0 10 7042289;
ation and metabolism.
e-mail: [email protected]
In perioperative monitoring of pediatric patients,
Curr Opin Anesthesiol 2020, 33:781–787
we face specific challenges, which postponed the
DOI:10.1097/ACO.0000000000000927
development of appropriate age and size-related
pediatric monitors. First, it is not always possible to This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
get baseline measurements and some equipment is (CCBY-NC-ND), where it is permissible to download and share the work
not validated for children or has size limitations. provided it is properly cited. The work cannot be changed in any way or
Moreover, there is no consensus on safety margins used commercially without permission from the journal.

0952-7907 Copyright ß 2020 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-anesthesiology.com
Technology, education and safety

constant volume and varying the counter pressure

KEY POINTS [9,10]. With the Nexfin monitor (Table 1), FINAP is
Noninvasive continuous blood pressure measurements reconstructed into a brachial arterial pulse pressure
are available for children, and show good agreement, waveform. In children, the FINAP was reliable, with a
however with some underestimation of SBP. good level of agreement for DBP and mean arterial
pressure between the Nexfin and IABP. However,
For noninvasive measurement of CO in children,
underestimation of Nexfin SBP was observed [11,12].
bioimpedance techniques seem promising, although
further refinement in accuracy during anesthesia The CNAP monitor (Table 1) provides beat-to-
is needed. beat noninvasive pressure readings. In pediatric
patients, the continuous BP readings were clinically
Near-infrared spectroscopy is at present the best useful. However, there is some variation in accuracy,
available monitor to measure regional tissue-
especially with SBPs. Cuff placement was sometimes
oxygenation and tissue-perfusion.
problematic, so further development in finger cuffs
Transcutaneous measurement of carbon dioxide is for children is necessary [14,15].
complementary to blood sampling and capnography.

CARDIAC OUTPUT MEASUREMENTS

to the development of encephalopathy in (ex)pre- CO is the product of cardiac stroke volume (SV) and
term neonates requiring multiple surgeries, pediat- heart rate (HR). CO is measured by transpulmonary
ric anesthesiologists are especially interested in dilution techniques, requiring central venous cathe-
brain perfusion [2]. We know that a short anesthetic terization [16,17]. Bolus thermodilution is still the
in healthy children is harmless, but if this is still the most accepted reference method [18]. Less invasive
case in high-risk neonates and infants undergoing techniques have become available, such as pulse con-
&&
multiple procedures remains unknown [3 ]. It is tour cardiac output analysis, arterial pressure curve-
unclear what exactly happens within the brain dur- based CO measurements, transesophageal Doppler
ing anesthesia, due to changes in fluid status, cere- (TED) and partial rebreathing of CO2. Transthoracic
bral perfusion pressure, CO2 pressure and unknown echocardiography or ultrasonic monitors are nonin-
local factors. vasive, but noncontinuous measures [16,17,19–21].
The current review focuses on recent develop- Pulse contour analysis (PCA) of IABP waveforms
ments and current evidence on noninvasive moni- can estimate CO continuously [17]. PCA can be
toring in noncardiac pediatric anesthesia. We will measured noninvasively with devices such as the
concentrate on cardiac output (CO), near-infrared Nexfin monitor or Mobil-O-Graph (Table 1). Pediat-
spectroscopy (NIRS) and transcutaneous blood gas ric studies using this method are limited. The PCA-
analysis as monitors that may guide our interven- derived CO values of the Mobil-O-Graph were mea-
tions to optimize end organ function of our patients. sured in awake adults and children at least 10 years
of age, and showed to be comparable with two-
dimensional echocardiography CO values; however,
HEMODYNAMIC MONITORING &&
the values were not interchangeable [22 ]. At low
Blood pressure (BP) measured noninvasively with the CO values, PCA-derived data were higher than data
oscillometry technique (NIBP) has a good correlation from echocardiography. This type of CO measure-
with intra-arterial BP (IABP), also in infants and neo- ment needs further refining in accuracy and preci-
nates [4]. However, changing the site of measurement sion, before it can be used in pediatric anesthesia.
from the arm to another location may provide less Another technique of measuring CO continu-
reliable information. Large deviations are common ously is based on the bioimpedance method. Bio-
when NIBP is measured from the leg or forearm in impedance cardiography measures changes in
children under anesthesia, compared with arm NIBP. thoracic electrical bioimpedance during the cardiac
Leg NIBPs are usually lower than arm measurements cycle via electrodes on the skin, from which SV, and
in children, in contrast to higher leg NIBPs in adults. subsequently CO can be calculated [23]. Several
In children the soft, compliant pediatric arteries pro- devices are on the market measuring bioimpedance,
duce less augmentation of the signal than stiffer adult electrical velocimetry or bioreactance (Table 1).
arteries. Also a reduced sympathetic tone and a rela- Electrical velocimetry relates the maximum rate
tively reduced blood volume in the lower limbs of of change of impedance to peak aortic blood accel-
&
small children may play a role [5 ,6–8]. eration during the cardiac cycle. The change in
Continuous noninvasive BP can be measured with orientation of the red blood cells in the aorta, from
a finger cuff, measuring noninvasive finger arterial random during diastole (high-impedance state) to
pressure (FINAP) by clamping the finger artery to a an aligned or parallel orientation during systole

782 www.co-anesthesiology.com Volume 33 Number 6 December 2020

Current state of noninvasive, continuous monitoring modalities Wijk et al.

Table 1. Devices for noninvasive hemodynamic measurements

Measurement Device name Use in pediatric patients

of (manufacturer) Technology (literature) Method

Cardiac output Mobil-O-Graph (I.E.M. PCA Zocalo et al. [22 ] Oscillometric cuff placed around
&&

GmbH, Stolberg, Only investigated in the arm, measures peripheral

Germany) children of 10 years and BP, determines central BP
older waveform and quantifies
several parameters including
CO
Cardiac output ICON (Cardiotronic/ Thoracic King et al. [28] In neonates and small infants: 4
Osypka Medical, Inc, La bioimpedance/ Coté et al. [24] EKG electrodes placed on the
Jolla, California, USA) Electrical Observational studies in left leg, left chest, left neck and
cardiometry children 1 day to forehead or cheek. Older
19 years old patients: 2 EKG electrodes on
the left chest and 2 on the left
side of the neck
Cardiac output Aesculon (Osypka Medical Thoracic Absolute CO values in 2 EKG electrodes on the left chest
GmbH, Berlin, Germany) bioimpedance/ children not reliable and 2 on the left side of the
Electrical (Tomaske et al. [25]) neck
velocimetry
Cardiac output NICOM (Cheetah Medical, Transthoracic Not feasible in children A current injecting device (high
Wilmington, Delaware, bioreactance <10 kg (Dubost et al. frequency, 75 kHz alternating
USA) [31]; Sun et al. [30]) current) and 4 dual sensing
electrodes, placed on the
thorax
Cardiac output IQ, model 101 Thoracic Martin et al. [13] Prewired hydrogen electrodes on
(Noninvasive Medical bioimpedance the skin, and 3 EKG electrodes
Technologies LLC, on the precordium and each
Auburn Hills, Michigan, shoulder. A 100 kHz, 4 mA
USA) alternating current is passed
through the thorax by the outer
pairs of electrodes and the
voltage is sensed by the inner
pairs
Cardiac output USCOM (USCOM Ltd, Doppler ultrasound, Intermittent measurement. Transducer/probe placed on the
Sydney, New South transthoracic Reliable measurement in chest in suprasternal position
Wales, Australia) children, when operated
by trained user (Dhanani
et al. [21]; Cattermole
et al. [20])
Cardiac output NICO (Novametrix Partial rebreathing Less accurate in patients Via an ETT without leak
Medical Systems Inc, of CO2, ventilated with <300 ml
Wallingford, determines CO tidal volume (Levy et al.
Connecticut, USA) via the Fick [19])
principle
Continuous BP Nexfin HD monitor FINAP; finger Accurate for continuous Finger cuff with infrared
(BMEYE, Amsterdam, the volume clamp measurement of MAP in photoplethysmography. Built-in
Netherlands) method children, but sometimes physiological calibration
difficult placement of method (Physiocal; BMEYE) to
finger cuff in small check and adjust the set point
children (Lemson et al. of the clamped artery every 80
[12]; Garnier et al. [11]) heartbeats. Also measures CO
with PCA
Continuous BP CNAP monitor 500 CNAP values Studies in children 20 kg. Cuff around 2 adjacent fingers on
(CNSystems represent the Sometimes difficult the same side as an arm cuff;
Medizintechnik, Graz, arterial pressure placement of finger cuff calibration with upper-arm
Austria) at the brachial (Tobias et al. [15]; Kako oscillometric measurements
artery et al. [14])

BP, blood pressure; CO, cardiac output; ETT, endotracheal tube; FINAP, finger arterial pressure; MAP, mean arterial pressure; PCA, pulse contour analysis.

0952-7907 Copyright ß 2020 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-anesthesiology.com 783
Technology, education and safety

(low-impedance state), causes changes in electrical Despite significant scientific efforts during the
conductivity and electrical impedance [24]. In pedi- last two decades aiming at the definition of normal
atric patients studies showed agreement, but not ranges [36,37] and lower safety margins [38–41] of
consistently [25–27]. Observational studies with cerebral r-SO2 in children, consensus regarding
the ICON monitor in 402 children, ranging from these important targets has not yet been reached.
preterm neonates to teenagers, showed that contin- Many pediatric anesthesiologists have adopted com-
uous cardiovascular parameter assessment was fea- mon adult patient intervention limits like baseline r-
sible during anesthesia for patients of all sizes and SO2 20% or an absolute value less than 55% [35].
&&
that it provided useful, real-time information Gómez-Pesquera et al. [42 ] recently demonstrated
regarding adverse hemodynamic changes and the the association of a decrease in cerebral r-SO2 of less
response to interventions [24,28]. than 20% and negative behavioral changes on post-
Bioreactance is the analysis of the variation in the operative day 7 in noncardiac pediatric patients.
&
frequency spectra of a delivered oscillating current Kamata et al. [43 ] reported a decrease in cerebral
that occurs when the current traverses the thoracic r-SO2 values during laparoscopic surgery in children,
cavity. It is less susceptible to interference than bio- not reaching awake baseline levels, while hemody-
impedance [17,29]. NICOM CO values showed a namic and respiratory parameters remained
&
good correlation and agreement with echocardiogra- unchanged. Costerus et al. [44 ] reported decreases
phy during anesthesia in pediatric patients with nor- in cerebral r-SO2 (10% from baseline) during neo-
mal heart anatomy, but no agreement in pediatric natal thoracoscopic surgery and favorable neuro-
patients with a cardiac defect [30]. In children under- developmental outcome within 24 months despite
going major abdominal surgery, the NICOM showed severe intraoperative acidosis.
poor correlation between confidence interval values Two recent studies conducted in infants found
&
obtained by bioreactance and TED [31]. no evidence of an effect of awake caudal [45 ] and
A meta-analysis of CO monitoring devices in spinal [46] anesthesia on cerebral r-SO2.
adults found that no noninvasive device or technol-
ogy was interchangeable with bolus thermodilu-
tion; the percentage of error was 42% for RECENT DEVELOPMENTS IN NEAR-
bioimpedance and 45% for noninvasive PCA, where INFRARED SPECTROSCOPY MONITORING
a maximum of 30% percentage of error is considered The list of new applications of NIRS monitoring in
acceptable [32]. Still, the noninvasive CO monitors pediatric anesthesiology is continuously growing.
could be interesting bedside monitors, as the per- Combined cerebral and peripheral (muscle)
centage of error was similar to that of minimally NIRS monitoring is a new trend, with some initial
invasive CO monitors, such as FloTrac (Edward Life- evidence of its capability to detect early stage cen-
sciences Corp., Irvine, California, USA). tralization [47].
The calculation of fractional regional tissue oxy-
gen extraction [FTOE ¼ (SaO2 rSO2)/SaO2] [48], a
NEAR-INFRARED SPECTROSCOPY composite parameter reflecting the regional oxygen
Almost 30 years after the introduction of the first delivery/consumption balance is also becoming
commercially available NIRS monitor the value of increasingly used.
&
NIRS and its applicability in pediatric anesthesia are Jildenstål et al. [49 ] found an acceptable level of
still a matter of debate. agreement between frontal and occipital recordings
NIRS is still misunderstood while a short intro- of cerebral rSO2, introducing the possibility to apply
duction to its technical background would help to NIRS during surgical procedures where the forehead
use it in the best interest of patients at risk of is not available for sensor placement.
&
inadequate tissue oxygenation [33,34 ,35]. NIRS Neunhoeffer et al. [50] found a positive effect of
provides blood flow independent real time informa- red blood cell transfusion on FTOE and cerebral r-
tion regarding regional tissue oxygenation (r-SO2), SO2 in postsurgical infants, suggesting the feasibility
and the oxygen uptake/consumption balance. It of both parameters as transfusion triggers.
&
should not be confused with pulse oximetry. Smarius et al. [51 ] observed a significant reduc-
Cerebral NIRS monitoring has become a stan- tion in cerebral r-SO2 induced by hyperextension of
dard monitoring tool in many pediatric cardiac the neck during positioning for cleft palate repair
centers and neonatal ICUs. In noncardiac pediatric surgery in children.
&
anesthesiology, however, NIRS has not yet become Lang et al. [52 ] found initial evidence of addi-
part of the standard monitoring equipment, and the tional value of perioperative cerebral NIRS monitor-
price of the disposables certainly requires careful ing as a measure of intracranial pressure in
patient selection. symptomatic pediatric hydrocephalus patients.

784 www.co-anesthesiology.com Volume 33 Number 6 December 2020

Current state of noninvasive, continuous monitoring modalities Wijk et al.

NEAR-INFRARED SPECTROSCOPY hemodynamics or fluid status and anesthetic agents

DIRECTED HEMODYNAMIC MANAGEMENT as well as vasoactive medication could have effect on
We recently developed a hemodynamic manage- transcutaneous measurements by influencing the
ment algorithm using cerebral r-SO2 as the single microcirculation, so doubts remain about the peri-
target parameter, using BP, PaCO2, HR and SaO2 as operative validity of measurements.
&
major contributing parameters [34 ]. A preinduction
awake baseline r-SO2 is defined as the lowest accept-
RECENT FINDINGS
able value during the anesthetic. Our experience
from several hundred patients has confirmed the Only few studies have been published on this sub-
feasibility of this approach. ject. Nosovitch et al. [59] performed the first periop-
erative study in children in 2002. They concluded
that of noninvasive measurements of CO2, transcu-
TRANSCUTANEOUS BLOOD GAS taneous values were slightly more accurate than
ANALYSIS end-tidal measurements. Dullenkopf et al. [60] com-
The principles of transcutaneous blood gas analysis pared end-tidal and transcutaneous measurements
have already been described in the late fifties by Clark of CO2 in 60 children under general anesthesia and
and Stow-Severinghaus [53,54]. Although continu- found no significant difference in accuracy between
ous and noninvasive, it was prone to errors compared the two methods. Karlsson et al. [61] concluded on a
with simpler techniques such as pulse oximetry. As relatively small group of neonates under general
the introduction of user-friendly transcutaneous sen- anesthesia that measurements where technically
sors, their use is increasing. Especially, measurement possible but not yet accurate.
&&
of CO2 is reliable. This is particularly important due to Recently, Chandrakantan et al. [62 ] compared
the increase of video-assisted procedures. Insufflation end-tidal and transcutaneous CO2 to venous blood
of CO2 could lead to an increase in arterial CO2, gas values in children under 10 kg and showed that
which is a highly vasoactive substance. This is espe- transcutaneous measured CO2 has good correlation
cially the case in neonates, whose brains are very to venous values which are slightly better than
&
sensitive for changes in CO2 [55]. However, arterial standard end-tidal CO2. May et al. [63 ] reported
blood gas analysis, despite the risks of invasive arterial similar results comparing single CO2 values simul-
lines, and capnography remain the gold standard. taneously obtained during arterial, venous, transcu-
Transcutaneous CO2 measurement could also be use- taneous and end-tidal analysis in 47 children (mean
ful during endoscopic airway procedures or in spon- age 13.4 7.8 years old) with cystic fibrosis during
taneously breathing children without a definitive anesthesia. Transcutaneous monitoring was more
airway during procedural sedation. Therefore, further accurate and closer to PaCO2 than capnography.
developments on the use of continuous and nonin-
vasive measurements would be favorable.
DISCUSSION
The ultimate monitor should be easy to set up and
TECHNIQUE should provide the pediatric anesthesiologist of con-
Transcutaneous sensors locally heat the skin tinuous, noninvasive, accurate, reproducible and
improving diffusion of oxygen and CO2 through real-time measurements. Ideally, this would display
the skin [56]. This results in a close approximation end organ function.
of arterial values, although accuracy on oxygen So far, this monitor has not yet been available.
measurements is restricted due to limited diffusion Some techniques, however, seem very promis-
capacity and due to increasing skin thickness with ing. Regarding BP measurements and CO monitor-
&
age [57 ,58]. It is mostly used on neonatal and ing improvements are being made with regard to
pediatric ICUs. However, its use in the pediatric availability and accuracy in children. Further devel-
operation theatre is limited and concerns still opment of finger cuffs for smaller children is neces-
remain on the accuracy of measured oxygen values sary. Although the bioimpedance technique seems
and its usability. Membranes of the device must be very promising, drawbacks are that in young chil-
switched carefully and calibration has to be taken dren the electrodes may be difficult to place, elec-
into account afterwards. Furthermore, a short equil- trocautery induces loss of data, and arrhythmia or
ibration time of 10 min after skin attachment is pleural effusion may limit its use [24,29,31]. Most
necessary, before measurements can be interpreted importantly, more research needs to be conducted
safely. Nevertheless, due to improvements in sensor on the accuracy of the absolute CO values of these
&
application [57 ], its use perioperatively has devices before it can be applied routinely during
increased. During an operation, changes in anesthesia in pediatric patients.

0952-7907 Copyright ß 2020 The Author(s). Published by Wolters Kluwer Health, Inc. www.co-anesthesiology.com 785
Technology, education and safety

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just as for blood pressure. ments of CO2 are more accurate than capnography.

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