51
|
Creeley CE, Dikranian KT, Johnson SA, Farber NB, Olney JW. Alcohol-induced apoptosis of oligodendrocytes in the fetal macaque brain. Acta Neuropathol Commun 2013; 1:23. [PMID: 24252271 PMCID: PMC3893424 DOI: 10.1186/2051-5960-1-23] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/02/2013] [Indexed: 02/08/2023] Open
Abstract
Background In utero exposure of the fetal non-human primate (NHP) brain to alcohol on a single occasion during early or late third-trimester gestation triggers widespread acute apoptotic death of cells in both gray and white matter (WM) regions of the fetal brain. In a prior publication, we documented that the dying gray matter cells are neurons, and described the regional distribution and magnitude of this cell death response. Here, we present new findings regarding the magnitude, identity and maturational status of the dying WM cells in these alcohol-exposed fetal NHP brains. Results Our findings document that the dying WM cells belong to the oligodendrocyte (OL) lineage. OLs become vulnerable when they are just beginning to generate myelin basic protein in preparation for myelinating axons, and they remain vulnerable throughout later stages of myelination. We found no evidence linking astrocytes, microglia or OL progenitors to this WM cell death response. The mean density (profiles per mm3) of dying WM cells in alcohol-exposed brains was 12.7 times higher than the mean density of WM cells dying by natural apoptosis in drug-naive control brains. Conclusions In utero exposure of the fetal NHP brain to alcohol on a single occasion triggers widespread acute apoptotic death of neurons (previous study) and of OLs (present study) throughout WM regions of the developing brain. The rate of OL apoptosis in alcohol-exposed brains was 12.7 times higher than the natural OL apoptosis rate. OLs become sensitive to the apoptogenic action of alcohol when they are just beginning to generate constituents of myelin in their cytoplasm, and they remain vulnerable throughout later stages of myelination. There is growing evidence for a similar apoptotic response of both neurons and OLs following exposure of the developing brain to anesthetic and anticonvulsant drugs. Collectively, this body of evidence raises important questions regarding the role that neuro and oligo apoptosis may play in the human condition known as fetal alcohol spectrum disorder (FASD), and also poses a question whether other apoptogenic drugs, although long considered safe for pediatric/obstetric use, may have the potential to cause iatrogenic FASD-like developmental disability syndromes.
Collapse
|
52
|
Gleich S, Nemergut M, Flick R. Anesthetic-related neurotoxicity in young children. Curr Opin Anaesthesiol 2013; 26:340-7. [DOI: 10.1097/aco.0b013e3283606a37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
53
|
Han BK, Lesser JR. Cardiac CT in the Diagnosis and Postoperative Assessment of Congenital Heart Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
54
|
Sevoflurane anesthesia in pregnant mice induces neurotoxicity in fetal and offspring mice. Anesthesiology 2013; 118:516-26. [PMID: 23314109 DOI: 10.1097/aln.0b013e3182834d5d] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Each year, over 75,000 pregnant women in the United States undergo anesthesia care. The authors set out to assess the effects of the anesthetic sevoflurane on neurotoxicity in pregnant mice and on learning and memory in fetal and offspring mice. METHODS Pregnant mice (gestational day 14) and mouse primary neurons were treated with 2.5% sevoflurane for 2 h and 4.1% sevoflurane for 6 h, respectively. Brain tissues of both fetal and offspring mice (P31) and the primary neurons were harvested and subjected to Western blot and immunohistochemistry to assess interleukin-6, the synaptic markers postsynaptic density-95 and synaptophysin, and caspase-3 levels. Separately, learning and memory function in the offspring mice was determined in the Morris water maze. RESULTS Sevoflurane anesthesia in pregnant mice induced caspase-3 activation, increased interleukin-6 levels (256 ± 50.98% [mean ± SD] vs. 100 ± 54.12%, P = 0.026), and reduced postsynaptic density-95 (61 ± 13.53% vs. 100 ± 10.08%, P = 0.036) and synaptophysin levels in fetal and offspring mice. The sevoflurane anesthesia impaired learning and memory in offspring mice at P31. Moreover, interleukin-6 antibody mitigated the sevoflurane-induced reduction in postsynaptic density-95 levels in the neurons. Finally, environmental enrichment attenuated the sevoflurane-induced increases in interleukin-6 levels, reductions of synapse markers, and learning and memory impairment. CONCLUSIONS These results suggest that sevoflurane may induce detrimental effects in fetal and offspring mice, which can be mitigated by environmental enrichment. These findings should promote more studies to determine the neurotoxicity of anesthesia in the developing brain.
Collapse
|
55
|
Sanders RD, Hassell J, Davidson AJ, Robertson NJ, Ma D. Impact of anaesthetics and surgery on neurodevelopment: an update. Br J Anaesth 2013; 110 Suppl 1:i53-72. [PMID: 23542078 DOI: 10.1093/bja/aet054] [Citation(s) in RCA: 150] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Accumulating preclinical and clinical evidence suggests the possibility of neurotoxicity from neonatal exposure to general anaesthetics. Here, we review the weight of the evidence from both human and animal studies and discuss the putative mechanisms of injury and options for protective strategies. Our review identified 55 rodent studies, seven primate studies, and nine clinical studies of interest. While the preclinical data consistently demonstrate robust apoptosis in the nervous system after anaesthetic exposure, only a few studies have performed cognitive follow-up. Nonetheless, the emerging evidence that the primate brain is vulnerable to anaesthetic-induced apoptosis is of concern. The impact of surgery on anaesthetic-induced brain injury has not been adequately addressed yet. The clinical data, comprising largely retrospective cohort database analyses, are inconclusive, in part due to confounding variables inherent in these observational epidemiological approaches. This places even greater emphasis on prospective approaches to this problem, such as the ongoing GAS trial and PANDA study.
Collapse
Affiliation(s)
- R D Sanders
- Wellcome Department of Imaging Neuroscience, Institute for Women's Health, University College London, London, UK.
| | | | | | | | | |
Collapse
|
56
|
|
57
|
Elective procedures and anesthesia in children: pediatric surgeons enter the dialogue on neurotoxicity questions, surgical options, and parental concerns. J Neurosurg Anesthesiol 2013; 24:396-400. [PMID: 23085786 DOI: 10.1097/ana.0b013e31826a032d] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The Pediatric Anesthesia NeuroDevelopment Assessment research group at Columbia University Medical Center Department of Anesthesiology has conducted biannual national Symposia since 2008 to evaluate study data and invigorate continued thinking about unresolved issues of pediatric anesthesia neurotoxicities. The third Symposium extended the dialogue between pediatric anesthesiologists and surgeons in panel presentations and discussions by four surgical specialists. This paper reports the prevailing opinions expressed by a pediatric general surgeon, urologist, plastic surgeon and ophthalmologist and explores factors related to delayed operative intervention, need for multiple procedures, and parental concerns.
Collapse
|
58
|
|
59
|
Naumann HL, Haberkern CM, Pietila KE, Birgfeld CB, Starr JR, Kapp-Simon KA, Hopper RA, Speltz ML. Duration of exposure to cranial vault surgery: associations with neurodevelopment among children with single-suture craniosynostosis. Paediatr Anaesth 2012; 22:1053-61. [PMID: 22502768 PMCID: PMC3404221 DOI: 10.1111/j.1460-9592.2012.03843.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate associations between neurodevelopment and exposure to surgery and anesthetic agents in children with single-suture craniosynostosis (SSC). BACKGROUND Young children with SSC have unexplained neurodevelopmental delays. The possible contributions of factors related to cranial vault surgery - including anesthesia - have not been previously examined. METHODS/MATERIALS Two anesthesiologists reviewed the surgical records of 89 infants (70 had complete data). Primary exposures were duration of surgery and anesthesia and total duration of inhaled anesthesia (at age 6 months on average). Outcomes were the cognitive and motor scores from the Bayley Scales of Infant Development-II and language scores from the Preschool Language Scale, 3rd edition, given at age 36 months. Linear regression using robust standard error estimates was performed, adjusting for age at surgery and suture site. RESULTS Anesthesia duration ranged from 155 to 547 min. For every 30-min increase in anesthesia duration, the estimated average decrease in developmental test scores ranged from 1.1 to 2.9 (P ranged from <0.001 to 0.30). Similar, but weaker findings were observed with surgery duration and total duration of inhaled anesthesia. Inverse relations between exposure amounts and neurodevelopment were stronger in children with nonsagittal synostosis. CONCLUSIONS Average neurodevelopmental scores were lower among children experiencing longer surgeries and higher exposures to inhaled anesthesia. These associations may be due to anesthesia exposure, nonspecific effects of surgery, or unmeasured variables that correlate with surgery duration. Further study of potential causal mechanisms is warranted.
Collapse
Affiliation(s)
- Heather L. Naumann
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle,Seattle Children's Hospital, Seattle
| | - Charles M. Haberkern
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle,Seattle Children's Hospital, Seattle,Department of Pediatrics, University of Washington, Seattle
| | | | - Craig B. Birgfeld
- Seattle Children's Hospital, Seattle,Department of Surgery, University of Washington, Seattle
| | - Jacqueline R. Starr
- Department of Epidemiology, University of Washington, Seattle,The Forsyth Institute, Cambridge, MA
| | - Kathleen A Kapp-Simon
- Department of Surgery, Northwestern University, Chicago,Shriners Hospital for Children, Chicago
| | - Richard A. Hopper
- Seattle Children's Hospital, Seattle,Department of Surgery, University of Washington, Seattle
| | - Matthew L. Speltz
- Seattle Children's Hospital, Seattle,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle
| |
Collapse
|
60
|
|
61
|
PONTÉN E, VIBERG H, GORDH T, ERIKSSON P, FREDRIKSSON A. Clonidine abolishes the adverse effects on apoptosis and behaviour after neonatal ketamine exposure in mice. Acta Anaesthesiol Scand 2012; 56:1058-65. [PMID: 22694670 DOI: 10.1111/j.1399-6576.2012.02722.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND An increasing amount of both experimental and epidemiological data indicates that neonatal anaesthesia causes disruption of normal brain development in rodents and primates, as manifested by acute increased apoptosis and long-lasting altered behaviour and learning. It is necessary to seek strategies that avoid the possible adverse effects after anaesthesia. Our purpose is to show that increased apoptosis and behavioural alterations after ketamine exposure during this period may be prevented by clonidine, a compound already used by paediatric anaesthetists for sedation. METHODS To investigate the protective properties of clonidine pre-treatment, five groups of 10-day-old mice were injected with either ketamine 50 mg/kg, clonidine 40 μg/kg, ketamine 50 mg/kg 30 min after 10 μg/kg clonidine, ketamine 50 mg/kg 30 min after 40 μg/kg clonidine or saline (control). Apoptosis was measured 24 h after treatment using Flouro-Jade staining. Spontaneous activity in a novel environment was tested at an age of 55 days. RESULTS Pre-treatment with 40 μg/kg clonidine, but not 10 μg/kg clonidine, 30 min before ketamine exposure abolished ketamine-induced apoptosis and the behavioural changes observed in the young adult mice. The mice exposed to clonidine alone showed no differences from the saline-treated (control) mice. CONCLUSION The administration of clonidine eliminated the adverse effects of ketamine in this mouse model, suggesting a possible strategy for protection. Alone, clonidine did not cause any adverse effects in these tests.
Collapse
Affiliation(s)
- E. PONTÉN
- Department of Surgical Sciences, Anaesthesiology and Intensive Care; Uppsala University; Uppsala; Sweden
| | - H. VIBERG
- Department of Environmental Toxicology; Uppsala University; Uppsala; Sweden
| | - T. GORDH
- Department of Surgical Sciences, Anaesthesiology and Intensive Care; Uppsala University; Uppsala; Sweden
| | - P. ERIKSSON
- Department of Environmental Toxicology; Uppsala University; Uppsala; Sweden
| | - A. FREDRIKSSON
- Department of Neuroscience, Psychiatry; Uppsala University; Uppsala; Sweden
| |
Collapse
|
62
|
Walker K, Holland AJA, Halliday R, Badawi N. Which high-risk infants should we follow-up and how should we do it? J Paediatr Child Health 2012; 48:789-93. [PMID: 22970673 DOI: 10.1111/j.1440-1754.2012.02540.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early detection of neurodevelopmental delay and appropriate intervention has been associated with improved academic and social outcomes. Identifying those who are at high risk and might benefit is not straightforward. Approximately 2% of infants are admitted to a neonatal intensive care unit after birth and these babies are known to be at high risk of developmental impairment. While it is well recognised that the extreme preterm infant is at high risk of developmental impairment, there is increasing evidence of a risk in late preterm infants as well as those undergoing major cardiac and non-cardiac surgery. Not all infants are enrolled in multidisciplinary follow-up clinics with easy access to early intervention. These clinics are expensive to run with both limited and conflicting data on their long-term value. This review will concentrate on identifying which infants are at risk, reviewing the aetiology of the risk factors and the efficacy of follow-up clinics.
Collapse
Affiliation(s)
- Karen Walker
- Grace Centre for Newborn Care, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
| | | | | | | |
Collapse
|
63
|
Walker SM, Yaksh TL. Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data. Anesth Analg 2012; 115:638-62. [PMID: 22798528 DOI: 10.1213/ane.0b013e31826253f2] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.
Collapse
Affiliation(s)
- Suellen M Walker
- Portex Unit: Pain Research, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, London, UK.
| | | |
Collapse
|
64
|
Developmental neurotoxicity screening using human embryonic stem cells. Exp Neurol 2012; 237:207-10. [PMID: 22770995 DOI: 10.1016/j.expneurol.2012.06.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 06/11/2012] [Accepted: 06/20/2012] [Indexed: 12/23/2022]
Abstract
Research in the area of stem cell biology and regenerative medicine, along with neuroscience, will further our understanding of drug-induced death of neurons during their development. With the development of an in vitro model of stem cell-derived human neural cell lines investigators can, under control conditions and during intense neuronal growth, examine molecular mechanisms of various drugs and conditions on early developmental neuroapoptosis in humans. If the use of this model will lead to fewer risks, or identification of drugs and anesthetics that are less likely to cause the death of neurons, this approach will be a major stride toward assuring the safety of drugs during the brain development. The ultimate goal would be not only to find the trigger for the catastrophic chain of events, but also to prevent neuronal cell death itself.
Collapse
|
65
|
Abstract
Concerns for toxic effects of anesthesia to the brains of the young and the elderly are mounting. While experimental evidence for such effects in the developing brain is strong, the underlying mechanisms are less well understood and debate continues as to whether young humans are at risk for anesthetic neurotoxicity. The phenomenon of postoperative cognitive deterioration in the elderly remains controversial. Time course, severity, and whether or not it persists long term are under debate. For both patient groups, today's evidence is not sufficient to guide change in clinical practice. Well-designed research is therefore imperative to tackle this critical issue.
Collapse
Affiliation(s)
- Ansgar M Brambrink
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098, USA.
| | | | | |
Collapse
|
66
|
Liu Y, Shangguan Y, Barks JD, Silverstein FS. Bumetanide augments the neuroprotective efficacy of phenobarbital plus hypothermia in a neonatal hypoxia-ischemia model. Pediatr Res 2012; 71:559-65. [PMID: 22398701 PMCID: PMC4721236 DOI: 10.1038/pr.2012.7] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The NaKCl cotransporter NKCC1 facilitates intraneuronal chloride accumulation in the developing brain. Bumetanide (BUM), a clinically available diuretic, inhibits this chloride transporter and augments the antiepileptic effects of phenobarbital (PB) in neonatal rodents. In a neonatal cerebral hypoxia-ischemia (HI) model, elicited by right carotid ligation, followed by 90 min 8% O(2) exposure in 7-d-old (P7) rats, PB increases the neuroprotective efficacy of hypothermia (HT). We evaluated whether BUM influenced the neuroprotective efficacy of combination treatment with PB and HT. METHODS P7 rats underwent HI lesioning; 15 min later, all received PB (30 mg/kg), and 10 min later, half received BUM (10 mg/kg, PB-HT+BUM) and half received saline (PB-HT+SAL). One hour after HI, all were cooled (30 °C, 3 h). Contralateral forepaw sensorimotor function and brain damage were evaluated 1-4 wk later. RESULTS Forepaw functional measures were close to normal in the PB-HT+BUM group, whereas deficits persisted in PB-HT+SAL controls; there were corresponding reductions in right cerebral hemisphere damage (at P35, % damage: PB-HT+BUM, 21 ± 16 vs. 38 ± 20 in controls). DISCUSSION These results provide evidence that NKCC1 inhibition amplifies PB bioactivity in the immature brain and suggest that coadministration of PB and BUM may represent a clinically feasible therapy to augment the neuroprotective efficacy of therapeutic HT in asphyxiated neonates.
Collapse
Affiliation(s)
- YiQing Liu
- Department of Pediatrics, University of Michigan, Ann Arbor, MI,48109,USA
| | - Yu Shangguan
- Department of Pediatrics, University of Michigan, Ann Arbor, MI,48109,USA
| | - John D.E. Barks
- Department of Pediatrics, University of Michigan, Ann Arbor, MI,48109,USA
| | - Faye S. Silverstein
- Department of Pediatrics, University of Michigan, Ann Arbor, MI,48109,USA,Department of Neurology, University of Michigan, Ann Arbor, MI,48109,USA,Address correspondence to: F.S. Silverstein MD, University of Michigan, 1150 W. Medical Center Dr., Ann Arbor, MI 48109-5646, Phone: 734-763-4097, Fax: 734-764-4279,
| |
Collapse
|
67
|
Walker SM, Grafe M, Yaksh TL. Intrathecal clonidine in the neonatal rat: dose-dependent analgesia and evaluation of spinal apoptosis and toxicity. Anesth Analg 2012; 115:450-60. [PMID: 22467896 DOI: 10.1213/ane.0b013e3182501a09] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Neuraxial clonidine is used for perioperative analgesia in children of all ages. Preclinical studies in the postnatal rat allow comparison of the relative toxicity and safety of spinal analgesics throughout postnatal development. METHODS Rat pups aged 3, 7, or 21 postnatal (P) days were briefly anesthetized for intrathecal injections of saline or clonidine. At each age, the maximum tolerated, antinociceptive (increased hindlimb mechanical withdrawal threshold) and antihyperalgesic (hindpaw carrageenan inflammation) doses were determined. Lumbar spinal cord sections were assessed for apoptosis and cell death (histology, activated caspase-3 immunohistochemistry, Fluoro-Jade C staining), histopathology (hematoxylin and eosin staining), and increased glial reactivity (microglial and astrocytic markers). P3 intrathecal ketamine sections served as positive controls. In additional groups, thermal latency and mechanical withdrawal threshold were measured at P35. RESULTS Intrathecal clonidine produces age- and dose-dependent analgesia in rat pups. Maximal doses of clonidine did not alter the degree or distribution of apoptosis or increase glial reactivity in the neonatal spinal cord. No spinal histopathology was seen 1 or 7 days after injection at any age. Intrathecal clonidine did not produce persistent changes in reflex sensitivity to mechanical or thermal stimuli at P35. CONCLUSIONS Intrathecal clonidine in the postnatal rat did not produce signs of spinal cord toxicity, even at doses much larger than required for analgesia. The therapeutic ratio (maximum tolerated dose/antihyperalgesic dose) was >300 at P3, >30 at P7, and >10 at P21. These data provide additional information to inform the clinical choice of spinal analgesic drug in early life.
Collapse
Affiliation(s)
- Suellen M Walker
- Portex Unit: Pain Research, UCL Institute of Child Health and Great Ormond St. Hospital NHS Trust, 30 Guilford St., London WC1N 1EH, United Kingdom.
| | | | | |
Collapse
|
68
|
Whitney N, Raslan AM, Ragel BT. Decompressive craniectomy in a neurologically devastated pregnant woman to maintain fetal viability. J Neurosurg 2012; 116:487-90. [DOI: 10.3171/2011.11.jns11707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. Currently, the ability to treat severe TBI with aggressive management of intracranial pressure (ICP) has led to the possibility of sustaining maternal life until the fetus is of a viable age and can be delivered. The authors present the case of a young woman 21 weeks pregnant with a severe TBI (Glasgow Coma Scale Score 3) in whom safe medical ICP management became ineffective. A decompressive craniectomy was performed to obviate the need for aggressive medical management of elevated ICP using fetal-toxic medications, and thus providing the fetus the best chance of continued in utero development until a viable gestational age was reached.
Collapse
|
69
|
Holtby HM. Neurological injury and anesthetic neurotoxicity following neonatal cardiac surgery: does the head rule the heart or the heart rule the head? Future Cardiol 2012; 8:179-88. [DOI: 10.2217/fca.11.92] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The improvements in care of children with heart disease have resulted in a major decrease in mortality and increased attention to adverse events and quality of survival. There is important neurological morbidity in children with congenital heart disease. Some problems such as stroke or seizure may be immediately apparent, but others, such as learning disability and motor delay emerge over time. The etiology is multifactorial and includes genetic, procedural and social causes. Only some factors are modifiable. Over the last decade, evidence has been presented that anesthetic drugs may be a potential cause of CNS morbidity. Neonates and infants may be particularly vulnerable to this. The purpose of this article is to describe the multiple known causes of neurodevelopmental impairment in children with heart disease, including anesthetic agents, and to explore the relationship between congenital heart disease and its treatment in this regard.
Collapse
Affiliation(s)
- Helen M Holtby
- University of Toronto, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| |
Collapse
|
70
|
Cottrell JE, Hartung J. Developmental Disability in the Young and Postoperative Cognitive Dysfunction in the Elderly After Anesthesia and Surgery: Do Data Justify Changing Clinical Practice? ACTA ACUST UNITED AC 2012; 79:75-94. [DOI: 10.1002/msj.21283] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
71
|
Collins MR, Starr SA, Bishop JT, Baysinger CL. Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States. REVIEWS IN OBSTETRICS & GYNECOLOGY 2012. [PMID: 23483795 DOI: 10.3909/riog0190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nitrous oxide (N2O) is a commonly used labor analgesic in many Western countries, but is used infrequently in the United States. The University of California at San Francisco has been offering N2O for labor analgesia for more than 30 years. Vanderbilt University Medical Center recently began offering N2O as an option for pain relief in laboring women. Many women report that N2O provides effective pain relief during labor and argue that it should be made more widely available in the United States. This article discusses the use of N2O for pain management during labor, including its history, properties, clinical indications, and use and environmental safety issues. Practical issues regarding implementation of N2O service in a medical center setting are also discussed.
Collapse
Affiliation(s)
- Michelle R Collins
- Vanderbilt University School of Nursing, Nurse-Midwifery Specialty, Nashville, TN
| | | | | | | |
Collapse
|
72
|
|
73
|
Transient effects of anesthetics on dendritic spines and filopodia in the living mouse cortex. Anesthesiology 2011; 115:718-26. [PMID: 21768874 DOI: 10.1097/aln.0b013e318229a660] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anesthetics are widely used to induce unconsciousness, pain relief, and immobility during surgery. It remains unclear whether the use of anesthetics has significant and long-lasting effects on synapse development and plasticity in the brain. To address this question, the authors examined the formation and elimination of dendritic spines, postsynaptic sites of excitatory synapses, in the developing mouse cortex during and after anesthetics exposure. METHODS Transgenic mice expressing yellow fluorescence protein in layer 5 pyramidal neurons were used in this study. Mice at 1 month of age underwent ketamine-xylazine and isoflurane anesthesia over a period of hours. The elimination and formation rates of dendritic spines and filopodia, the precursors of spines, were followed over hours to days in the primary somatosensory cortex using transcranial two-photon microscopy. Four to five animals were examined under each experimental condition. Student t test and Mann-Whitney U test were used to analyze the data. RESULTS Administration of either ketamine-xylazine or isoflurane rapidly altered dendritic filopodial dynamics but had no significant effects on spine dynamics. Ketamine-xylazine increased filopodial formation whereas isoflurane decreased filopodial elimination during 4 h of anesthesia. Both effects were transient and disappeared within a day after the animals woke up. CONCLUSION Studies suggest that exposure to anesthetics transiently affects the dynamics of dendritic filopodia but has no significant effect on dendritic spine development and plasticity in the cortex of 1-month-old mice.
Collapse
|
74
|
|
75
|
Abstract
Anesthesia kills neurons in the brain of infantile animals, including primates, and causes permanent and progressive neurocognitive decline. The anesthesia community and regulatory authorities alike are concerned that is also true in humans. In this review, I summarize what we currently know about the risks of pediatric anesthesia to long-term cognitive function. If anesthesia is discovered to cause cognitive decline in humans, we need to know how to prevent and treat it. Prevention requires knowledge of the mechanisms of anesthesia-induced cognitive decline. This review gives an overview of some of the mechanisms that have been proposed for anesthesia-induced cognitive decline and discusses possible treatment options. If anesthesia induces cognitive decline in humans, we need to know what type and duration of anesthetic is safe, and which, if any, is not safe. This review discusses early results of comparative animal studies of anesthetic neurotoxicity. Until we know if and how pediatric anesthesia affects cognition in humans, a change in anesthetic practice would be premature, not guided by evidence of better alternatives, and therefore potentially dangerous. The SmartTots initiative jointly supported by the International Anesthesia Research Society and the Food and Drug Administration aims to fund research designed to shed light on these issues that are of high priority to the anesthesia community and the public alike and therefore deserves the full support of these interest groups.
Collapse
Affiliation(s)
- Greg Stratmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, Box 0464, Room U286, 513 Parnassus Ave., San Francisco, CA 94143, USA.
| |
Collapse
|
76
|
Anesthesia risks associated with pediatric imaging. Pediatr Radiol 2011; 41:949-50. [PMID: 21688064 DOI: 10.1007/s00247-011-2160-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 05/17/2011] [Indexed: 01/03/2023]
|
77
|
Greenberg SB. Rebalancing the risks of Computed Tomography and Magnetic Resonance imaging. Pediatr Radiol 2011; 41:951-2. [PMID: 21626107 DOI: 10.1007/s00247-011-2159-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 04/30/2011] [Accepted: 05/05/2011] [Indexed: 12/29/2022]
Affiliation(s)
- S Bruce Greenberg
- Department of Radiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR 72202, USA.
| |
Collapse
|
78
|
Successful implementation of a pediatric sedation protocol for mechanically ventilated patients. Crit Care Med 2011; 39:683-8. [PMID: 21263324 DOI: 10.1097/ccm.0b013e318206cebf] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of a nursing-driven sedation protocol for mechanically ventilated pediatric patients on duration of use of analgesic and sedative medications. We hypothesized that a protocol would decrease length of sedation use and decrease days of mechanical ventilation and length of stay. DESIGN Retrospective cohort study with historical controls. SETTING Thirty-one-bed tertiary care, medical-surgical-cardiac pediatric intensive care unit in a metropolitan university-affiliated children's hospital. PATIENTS Children requiring mechanical ventilation longer than 48 hrs not meeting exclusion criteria. INTERVENTIONS Before protocol implementation, sedation was managed per individual physician orders. During the intervention period, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol based on a comfort score. MEASUREMENTS AND MAIN RESULTS The observation group included consecutive patients admitted during the 12-month period before protocol education and implementation (n = 153). The intervention group included patients admitted during the 12 months following protocol implementation (n = 166). The median duration of total sedation days (intravenous plus enteral) was 7 days for the observation period and 5 days for the intervention period (p = .026). Specifically, the median duration of morphine infusion was 6 days for the observation period and 5 days for the intervention period (p = .015), whereas the median duration of lorazepam infusion was 2 days for the observation period and 0 days for the intervention period. After adjusting for severity of illness with the pediatric risk of mortality III (PRISM III) score, the Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the intervention group were 23% more likely to be off all sedation (heart rate 0.77, p = .020). Additionally, the intervention group tended to be associated with fewer days of mechanical ventilation (heart rate 0.81, p = .060) and decreased pediatric intensive care unit length of stay (heart rate 0.81, p = .058), although these associations did not quite reach statistical significance. CONCLUSION A pediatric sedation protocol can significantly decrease days of benzodiazepine and opiate administration, which may improve pediatric intensive care unit resource utilization.
Collapse
|
79
|
Wise-Faberowski L, Loepke A. Anesthesia during surgical repair for congenital heart disease and the developing brain: neurotoxic or neuroprotective? Paediatr Anaesth 2011; 21:554-9. [PMID: 21481079 DOI: 10.1111/j.1460-9592.2011.03586.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Lisa Wise-Faberowski
- Department of Anesthesiology, Stanford University Medical Center, Lucile Packard Children’s Hospital, Palo Alto, CA 94305, USA.
| | | |
Collapse
|
80
|
Sun L. Early childhood general anaesthesia exposure and neurocognitive development. Br J Anaesth 2011; 105 Suppl 1:i61-8. [PMID: 21148656 DOI: 10.1093/bja/aeq302] [Citation(s) in RCA: 260] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A great deal of concern has recently arisen regarding the safety of anaesthesia in infants and children. There is mounting and convincing preclinical evidence in rodents and non-human primates that anaesthetics in common clinical use are neurotoxic to the developing brain in vitro and cause long-term neurobehavioural abnormalities in vivo. An estimated 6 million children (including 1.5 million infants) undergo surgery and anaesthesia each year in the USA alone, so the clinical relevance of anaesthetic neurotoxicity is an urgent matter of public health. Clinical studies that have been conducted on the long-term neurodevelopmental effects of anaesthetic agents in infants and children are retrospective analyses of existing data. Two large-scale clinical studies are currently underway to further address this issue. The PANDA study is a large-scale, multisite, ambi-directional sibling-matched cohort study in the USA. The aim of this study is to examine the neurodevelopmental effects of exposure to general anaesthesia during inguinal hernia surgery before 36 months of age. Another large-scale study is the GAS study, which will compare the neurodevelopmental outcome between two anaesthetic techniques, general sevoflurane anaesthesia and regional anaesthesia, in infants undergoing inguinal hernia repair. These study results should contribute significant information related to anaesthetic neurotoxicity in children.
Collapse
Affiliation(s)
- L Sun
- Department of Anesthesiology and Pediatrics, Columbia University, New York, NY 10032, USA.
| |
Collapse
|
81
|
Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys. Neurotoxicol Teratol 2011; 33:220-30. [PMID: 21241795 DOI: 10.1016/j.ntt.2011.01.001] [Citation(s) in RCA: 403] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 12/17/2010] [Accepted: 01/10/2011] [Indexed: 01/30/2023]
Abstract
Previously our laboratory has shown that ketamine exposure (24h of clinically relevant anesthesia) causes significant increases in neuronal cell death in perinatal rhesus monkeys. Sensitivity to this ketamine-induced neurotoxicity was observed on gestational days 120-123 (in utero exposure via maternal anesthesia) and on postnatal days (PNDs) 5-6, but not on PNDs 35-37. In the present study, six monkeys were exposed on PND 5 or 6 to intravenous ketamine anesthesia to maintain a light surgical plane for 24h and six control animals were unexposed. At 7 months of age all animals were weaned and began training to perform a series of cognitive function tasks as part of the National Center for Toxicological Research (NCTR) Operant Test Battery (OTB). The OTB tasks used here included those for assessing aspects of learning, motivation, color discrimination, and short-term memory. Subjects responded for banana-flavored food pellets by pressing response levers and press-plates during daily (M-F) test sessions (50 min) and were assigned training scores based upon their individual performance. As reported earlier (Paule et al., 2009) beginning around 10 months of age, control animals significantly outperformed (had higher training scores than) ketamine-exposed animals for approximately the next 10 months. For animals now over 3 and one-half years of age, the cognitive impairments continue to manifest in the ketamine-exposed group as poorer performance in the OTB learning and color and position discrimination tasks, as deficits in accuracy of task performance, but also in response speed. There are also apparent differences in the motivation of these animals which may be impacting OTB performance. These observations demonstrate that a single 24-h episode of ketamine anesthesia, occurring during a sensitive period of brain development, results in very long-lasting deficits in brain function in primates and provide proof-of-concept that general anesthesia during critical periods of brain development can result in subsequent functional deficits. Supported by NICHD, CDER/FDA and NCTR/FDA.
Collapse
|
82
|
Loeliger M, Shields A, McCurnin D, Clyman RI, Yoder B, Inder TE, Rees SM. Ibuprofen treatment for closure of patent ductus arteriosus is not associated with increased risk of neuropathology. Pediatr Res 2010; 68:298-302. [PMID: 20581742 PMCID: PMC2976654 DOI: 10.1203/pdr.0b013e3181ed1864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ibuprofen is an effective pharmacological intervention for closure of a patent ductus arteriosus (PDA) in preterm infants and is an alternative to surgical ligation; however, it is not certain whether ibuprofen treatment is associated with adverse effects on the brain. Therefore, this study examined neuropathological outcomes of ibuprofen therapy for a PDA. Fetal baboons were delivered at 125 d of gestation (dg; term ∼185 dg) by caesarean section, given surfactant, and ventilated for 14 d with positive pressure ventilation (PPV). Baboons were randomly allocated to receive either ibuprofen (PPV+ ibuprofen, n = 8) or no therapy (PPV, n = 5). Animals were killed on day 14 and brains assessed for cerebral growth, development, and neuropathology. Body and brain weights, the total volume of the brain, and the surface folding index (measure of brain growth) were not different (p > 0.05) between PPV+ ibuprofen-treated and PPV animals. There was no difference (p > 0.05) in the number of myelin basic protein-immunoreactive (IR) oligodendrocytes, glial fibrillary acid protein-IR astrocytes, or Iba1-IR macrophages/microglia in the forebrain. No overt cerebellar alterations were observed in either group. Ibuprofen treatment for PDA closure in the preterm baboon neonate is not associated with any increased risk of neuropathology or alterations to brain growth and development.
Collapse
Affiliation(s)
- Michelle Loeliger
- Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Victoria 3010, Australia.
| | | | | | | | | | | | | |
Collapse
|
83
|
Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
84
|
Effects of intrathecal ketamine in the neonatal rat: evaluation of apoptosis and long-term functional outcome. Anesthesiology 2010; 113:147-59. [PMID: 20526188 DOI: 10.1097/aln.0b013e3181dcd71c] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Systemic ketamine can trigger apoptosis in the brain of rodents and primates during susceptible developmental periods. Clinically, spinally administered ketamine may improve the duration or quality of analgesia in children. Ketamine-induced spinal cord toxicity has been reported in adult animals but has not been systematically studied in early development. METHODS In anesthetized rat pups, intrathecal ketamine was administered by lumbar percutaneous injection. Changes in mechanical withdrawal threshold evaluated dose-dependent antinociceptive and carrageenan-induced antihyperalgesic effects in rat pups at postnatal day (P) 3 and 21. After intrathecal injection of ketamine at P3, 7, or 21, spinal cords were examined for apoptosis (Fluoro-Jade C and activated caspase-3), histopathologic change, and glial responses (ionized calcium-binding adapter molecule 1 and glial fibrillary acid protein). After maximal doses of ketamine or saline at P3 or P21, sensory thresholds and gait analysis were evaluated at P35. RESULTS Intrathecal injection of 3 mg/kg ketamine at P3 and 15 mg/kg at P21 reverses carrageenan-induced hyperalgesia. Baseline neuronal apoptosis in the spinal cord was greater at P3 than P7, predominantly in the dorsal horn. Intrathecal injection of 3-10 mg/kg ketamine in P3 pups (but not 15 mg/kg at P21) acutely increased apoptosis and microglial activation in the spinal cord and altered spinal function (reduced mechanical withdrawal threshold and altered static gait parameters) at P35. CONCLUSIONS Because acute pathology and long-term behavioral change occurred in the same dose range as antihyperalgesic effects, the therapeutic ratio of intrathecal ketamine is less than one in the neonatal rat. This measure facilitates comparison of the relative safety of spinally administered analgesic agents.
Collapse
|
85
|
Durieux M, Davis PJ. The Safety of Key Inhaled and Intravenous Drugs in Pediatrics (SAFEKIDS): an update. Anesth Analg 2010; 110:1265-7. [PMID: 20418291 DOI: 10.1213/ane.0b013e3181d5a656] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
86
|
|