The effect of regional anaesthesia versus general anaesthesia on behavioural functions in children

Effect of nerve block combined with superficial general anaesthesia on anaesthetic dosage and anaesthetic awakening in paediatric surgery

BACKGROUND

To compare the effects of nerve block composite general anesthesia and general anesthesia on the dosage of anesthetics and anesthesia awakening in pediatric orthopedic injury patients under anesthesia depth monitoring.

METHODS

Forty pediatric patients with external humerus condylar fractures were randomly distributed into general anesthesia (GA) and nerve block combined with general anesthesia (GNA) groups. Patients in the GA group had induction of anesthesia with propofol at 2.5 mg/kg and remifentanil at 0.6 ug/kg. The Angel-6000D EEG anesthesia depth multi-parameter monitor maintained the EEG awareness index (IOC1) between 40 and 60 and the injury sensitivity index (IOC2) between 30 and 50.

RESULTS

Both intraoperative propofol maintenance in the GA group (6.74 ± 0.93) and propofol maintenance in the GNA group (5.16 ± 0.76) were significantly different upon comparison between the groups (p < 0.05). Intraoperative remifentanil maintenance differed significantly (p < 0.05) between the GA group (0.26 ± 0.04) and the GNA group (0.10 ± 0.04). Comparison of awakening time: the time of eyelid opening, time of completion order, extubation time, and time of recovery of positioning function in the GNA group were markedly shorter than that of the GA group (p < 0.01) with a high level of significance.

CONCLUSION

Nerve block composite general anesthesia under multi-parameter monitoring of depth of anesthesia by Angel-6000D electroencephalogram can lead to a significant reduction in the dosage of propofol and remifentanil, advancement of awakening and extubation time and an increase in the safety of anesthesia in pediatric surgery patients.

Pediatric Anesthesia Exposure: Decoding Its Neurodevelopmental Implications and Navigating the Nuances

General anesthesia is fundamental in pediatric medical interventions, but its potential neurodevelopmental impact on children has raised concerns, necessitating a thorough investigation. This systematic review aimed to assess the association between pediatric anesthesia exposure and neurodevelopmental outcomes, focusing on dosage effects and identifying high-risk groups. The study involved an extensive literature search across PubMed, Medline, and Google Scholar, selecting 40 relevant studies from an initial pool of 2,000, based on inclusion criteria that focused on children under 18 years exposed to anesthesia, excluding those with major comorbidities or perioperative physiological insults. It was observed that while a single exposure to anesthesia had minimal impact on general neurodevelopment, repeated or prolonged exposures posed greater concerns. Despite these findings, the study identified gaps in certain areas like adaptive behavior and sensory cognition due to limited data. The conclusion drawn is that although the evidence on anesthesia-induced neurotoxicity in children remains inconclusive, the implications of pediatric anesthesia exposure are significant enough to warrant careful consideration by healthcare professionals, who should balance the procedural benefits against the risks. This study also calls for future research to standardize methodologies and employ consistent, validated neurodevelopmental measurement tools.

Comparison of Postoperative Outcome in Children Undergoing Inguinal Hernia Repair Using Regional With General Versus General Anesthesia Alone: A Single Center Study

BACKGROUND

Inguinal hernia repair is one of the most common general surgical procedures. It has been performed under local, regional, or general anesthesia. We hypothesized that using regional plus general anesthesia rather than general anesthesia alone would improve outcomes in neonates and pediatric patients undergoing hernia repair.

METHODS

This is a retrospective cohort study, including all pediatric patients who underwent inguinal hernia repair from 2015-2021. We divided patients into two groups. The first group was labeled "general anesthesia" (GA), while the second group was labeled "combined general and regional anesthesia" (GA+RA). We compared both groups in terms of demographic data, intraoperative outcome variables, and postoperative outcome variables.

RESULTS

 212 children fulfilled the study criteria, with 57 in the GA group and 155 in the GA+RA group. Demographic and preoperative data were comparable between both groups except for age, which was 60.3±49.4 months in the GA group versus 26.7±33.13 months in the GA+RA group (p<.0001). Outcome variables demonstrated statistically significant improvement in postoperative pain occurrence, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation in the GA+RA group in comparison to the GA group with P values of 0.031, 0.02, 0.005, and 0.02, respectively.

CONCLUSION

Using regional and general anesthesia techniques rather than general anesthesia alone is associated with a decrease in postoperative pain, length of hospital stay, incidence of bradycardia, and need for mechanical ventilation. Further studies are still warranted to validate our conclusions.

Usefulness of serum neurofilament light in the assessment of neurologic outcome in the pediatric population: a systematic literature review

Children undergoing general anesthesia and surgery in the early years of life are exposed to the possible neurotoxicity of anesthetic agents. Prospective studies have shown deficits in behavior, executive function, social communication, and motor function in children undergoing anesthesia and surgery. Different biomarkers of neuronal injury have been evaluated neuronal injury in the pediatric population, among which neurofilaments represent a significant advantage as they are proteins exclusively expressed in neuronal tissue. Our aim was to evaluate the utility of serum neurofilament light (NfL) as a prognostic biomarker of neuronal injury in the pediatric population. A literature search was performed on PubMed, Embase, and Cochrane Databases in November 2022 for studies concerning serum NfL in the pediatric population in addition to a neurological assessment. Inclusion criteria were as follows: (1) prospective or retrospective studies, (2) studies including pediatric population until the age of 18 years, (3) serum NfL sampling, and (4) evaluation of neurological outcome. Data collection regarding study design, pediatric age, serum NfL levels, and results for neurological assessment were extracted from each study. Four manuscripts met the inclusion criteria and evaluated the prognostic utility of serum NfL in neonatal encephalopathy in correlation with the neurodevelopmental outcome that was assessed by the Bayley Scales of Infant Development until the age of 2 years. Children with neonatal encephalopathy showed significantly higher serum NfL vs. healthy controls and high serum NfL levels predicted an adverse neurological outcome. The decrease of serum NfL to a nadir point between 10 and 15 years old reflects the brain growth in healthy controls. No studies were available in the perioperative period.  Conclusions: Serum NfL is a valuable biomarker in evaluating neuronal injury in the pediatric population. Further studies with perioperative serial sampling of serum NfL combined with standardized neurodevelopmental tests should be conducted to evaluate the neurotoxicity of anesthetic agents and monitor the effectiveness of specific neuroprotective strategies in pediatric patients undergoing anesthesia and surgery. What is Known: • Preclinical animal data have shown neurotoxicity of the anesthetic agents in the developing brain. • Data regarding anesthetic neurotoxicity in humans show limitations and no objective tools are available. What is New: • This systematic review showed that serum NfL is a valuable biomarker of neuronal injury in the pediatric population. • Perioperative use of serum NfL may be considered in future trials evaluating anesthetic neurotoxicity in the pediatric population and in monitoring neuroprotective strategies.

Long-term cognitive and behavioral outcomes following early exposure to general anesthetics

PURPOSE OF REVIEW

Nearly 100 clinical studies have been published evaluating neurodevelopmental outcomes in children following surgery and anesthesia. These studies have reported mixed results, likely attributable at least in part to significant heterogeneity in their study designs, types and numbers of exposures, patient populations evaluated, and most importantly, the outcomes that were assessed. This review aims to summarize the results from clinical studies evaluating behavioral outcomes in children exposed to surgery and anesthesia.

RECENT FINDINGS

Children with early exposure to surgery and anesthesia were found to have limited to no differences in intelligence when compared with unexposed children. However, several studies have reported more behavioral problems in children exposed to general anesthesia. An increased incidence of attention-deficit hyperactivity disorder has also been reported in anesthetic exposed children, particularly after multiple exposures.

SUMMARY

Nearly all clinical studies of anesthetic neurotoxicity are observational in nature, so the associations between anesthetic exposure and behavioral deficits cannot yet be directly attributed to the anesthetic medication. However, the finding of deficits in some neurodevelopmental domains and not others will help guide the selection of appropriate outcomes in future studies of anesthetic neurotoxicity that can further evaluate whether anesthetic medications have an impact on neurodevelopment in children.

Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis

Importance

Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results.

Objective

To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children.

Data Sources

PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021.

Study Selection

Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded.

Data Extraction and Synthesis

Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model.

Main Outcomes and Measures

The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses.

Results

A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002).

Conclusions and Relevance

These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.

Prospectively assessed neurodevelopmental outcomes in studies of anaesthetic neurotoxicity in children: a systematic review and meta-analysis

BACKGROUND

Whether exposure to a single general anaesthetic (GA) in early childhood causes long-term neurodevelopmental problems remains unclear.

METHODS

PubMed/MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library were searched from inception to October 2019. Studies evaluating neurodevelopmental outcomes and prospectively enrolling children exposed to a single GA procedure compared with unexposed children were identified. Outcomes common to at least three studies were evaluated using random-effects meta-analyses.

RESULTS

Full-scale intelligence quotient (FSIQ); the parentally reported Child Behavior Checklist (CBCL) total, externalising, and internalising problems scores; and Behavior Rating Inventory of Executive Function (BRIEF) scores were assessed. Of 1644 children identified, 841 who had a single exposure to GA were evaluated. The CBCL problem scores were significantly higher (i.e. worse) in exposed children: mean score difference (CBCL total: 2.3 [95% confidence interval {CI}: 1.0-3.7], P=0.001; CBCL externalising: 1.9 [95% CI: 0.7-3.1], P=0.003; and CBCL internalising problems: 2.2 [95% CI: 0.9-3.5], P=0.001). Differences in BRIEF were not significant after multiple comparison adjustment. Full-scale intelligence quotient was not affected by GA exposure. Secondary analyses evaluating the risk of these scores exceeding predetermined clinical thresholds found that GA exposure was associated with increased risk of CBCL internalising behavioural deficit (risk ratio [RR]: 1.47; 95% CI: 1.08-2.02; P=0.016) and impaired BRIEF executive function (RR: 1.68; 95% CI: 1.23-2.30; P=0.001).

CONCLUSIONS

Combining results of studies utilising prospectively collected outcomes showed that a single GA exposure was associated with statistically significant increases in parent reports of behavioural problems with no difference in general intelligence.

Conditions requiring hospitalisations, more than general anaesthesia itself, are associated with diagnosis of learning disorders in children

BACKGROUND

Anaesthesia is neurotoxic in developing primates. Retrospective clinical studies show a correlation between exposure to anaesthesia during infancy and the occurrence of learning disorders (LD). Prospective studies failed to detect any influence of a single exposure to anaesthesia on neurodevelopment. We hypothesised that some specific populations of children were electively sensitive to anaesthesia-related neurotoxicity.

METHODS

Using a case-control design, we analysed the medical histories of children with LD, compared to those of their normally reading siblings. Interviews were conducted and medical records were reviewed. The numbers of hospitalisations and anaesthesia exposures before the age of five years were determined.

RESULTS

Four hundred fourteen dyslexic children were screened over a one-year period. Two hundred and seventy patients were excluded due to confounding variables (single child, all siblings showing LD or any condition placing the neurological prognosis at risk (N = 107/414 for the latter)) or inability to accurately collect evaluation criteria. In the 144 case-control pairs studied, the mean number of hospitalisations was significantly different (N = 1.097 ± 0 .135/case versus 0.667 ± 0.097/control, p = 0.0052), as was the proportion of hospitalised patients (54.2% versus 38.9%, p = 0.0031). The mean number of anaesthesia exposures per individual was not statistically different (N = 0.958 ± 0.183/case versus 0.569 ± 0.107/control, p =  0.0732), but the proportion of children anaesthetised at least once was (43.8% (cases) versus 33.3% (controls), p =  0.0301).

DISCUSSION

One or more hospitalisation(s) may reflect a health status and/or have an iatrogenic effect disrupting the normal setting up of learning abilities. Anaesthesia may play a role, but a correlation between LD and anaesthesia is of a lower magnitude than between LD and hospitalisation.

Anesthetic neurotoxicity in the pediatric population: a systematic review of the clinical evidence

Background: Exposure to general anesthesia (GA) in early life is known to be neurotoxic to animals. Objectives: To evaluate the risk of GA inducing long-term neurodevelopmental deficits in human children. Design: Systematic review. Methods: We included observational and randomized studies that compared the long-term neurodevelopment of postnatal children exposed to GA to the long-term neurodevelopment of children not exposed to GA. We searched MEDLINE, Embase and Web of Science for relevant studies published in the year 2000 or later. We screened all the identified studies on predetermined inclusion and exclusion criteria. A risk of bias assessment was made for each included study. We identified 9 neurodevelopmental domains for which a sub-analysis was made: intelligence; memory; learning; language/speech; motor function; visuospatial skills; development/emotions/behavior; ADHD/attention; autistic disorder. Results: We included 26 studies involving 605.391 participants. Based on AHRQ-standards 11 studies were of poor quality, 7 studies were of fair quality and 8 studies were of good quality. The major causes of potential bias were selection and comparability bias. On 2 neurodevelopmental domains (visuospatial skills and autistic disorder), the available evidence showed no association with exposure to GA. On 7 other neurodevelopmental domains, the available evidence showed mixed results. The 4 studies that used a randomized or sibling-controlled design showed no association between GA and neurodevelopmental deficits in their primary endpoints. Limitations: The absence of a meta-analysis and funnel plot. Conclusions: Based on observational studies, we found an association between GA in childhood and neuro-developmental deficits in later life. Randomized and sibling-matched observational studies failed to show the same association and therefore no evidence of a causal relationship exists at present. Since GA seems to be a marker, but not a cause of worse neurodevelopment, we argue against delaying or avoiding interventional or diagnostic procedures requiring GA in childhood based on the argument of GA-induced neurotoxicity.