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Ing C, Vutskits L. Unanswered questions of anesthesia neurotoxicity in the developing brain. Curr Opin Anaesthesiol 2023; 36:510-515. [PMID: 37552011 PMCID: PMC10939468 DOI: 10.1097/aco.0000000000001295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW This article reviews recent advances and controversies of developmental anesthesia neurotoxicity research with a special focus on the unanswered questions in the field both from clinical and preclinical perspectives. RECENT FINDINGS Observational cohort studies of prenatal and early childhood exposure to anesthesia have reported mixed evidence of an association with impaired neurodevelopment. Meta-analyses of currently available studies of early childhood exposure to anesthesia suggest that, while limited to no change in general intelligence can be detected, more subtle deficits in specific neurodevelopmental domains including behavior and executive function may be seen. Several studies have evaluated intraoperative blood pressure values and neurocognitive outcomes and have not found an association. Although many animal studies have been performed, taking into consideration other peri-operative exposures such as pain and inflammation may help with translation of results from animal models to humans. SUMMARY Advances have been made in the field of developmental anesthetic neurotoxicity over the past few years, including the recognition that anesthetic exposure is associated with deficits in certain cognitive domains but not others. Although the most important question of whether anesthetic agents actually cause long-term neurodevelopmental effects in children has still not been answered, results from recent studies will guide further studies necessary to inform clinical decision-making in children.
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Affiliation(s)
- Caleb Ing
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons
- Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University Hospitals of Geneva
- Geneva Neuroscience Center, University of Geneva, Geneva, Switzerland
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Bleeser T, Brenders A, Hubble TR, Van de Velde M, Deprest J, Rex S, Devroe S. Preclinical evidence for anaesthesia-induced neurotoxicity. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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van Hoorn CE, Hoeks SE, Essink H, Tibboel D, de Graaff JC. A systematic review and narrative synthesis on the histological and neurobehavioral long-term effects of dexmedetomidine. Paediatr Anaesth 2019; 29:125-136. [PMID: 30475445 PMCID: PMC6850292 DOI: 10.1111/pan.13553] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Recent experimental studies suggest that currently used anesthetics have neurotoxic effects on young animals. Clinical studies are increasingly publishing about the effects of anesthesia on the long-term outcome, providing contradictory results. The selective alpha-2 adrenergic receptor agonist dexmedetomidine has been suggested as an alternative nontoxic sedative agent. AIMS The aim of this systematic review was to assess the potential neuroprotective and neurobehavioral effects of dexmedetomidine in young animals and children. METHODS Systematic searches separately for preclinical and clinical studies were performed in Medline Ovid and Embase on February 14, 2018. RESULTS The initial search found preclinical (n = 661) and clinical (n = 240) studies. A total of 20 preclinical studies were included. None of the clinical studies met the predefined eligibility criteria. Histologic injury by dexmedetomidine was evaluated in 11 studies, and was confirmed in three of these studies (caspase-3 activation or apoptosis). Decrease of injury caused by another anesthetic was evaluated in 16 studies and confirmed in 13 of these. Neurobehavioral tests were performed in seven out of the 20 studies. Of these seven rodent studies, three studies tested the effects of dexmedetomidine alone on neurobehavioral outcome in animals (younger than P21). All three studies found no negative effect of dexmedetomidine on the outcome. In six studies, outcome was evaluated when dexmedetomidine was administered following another anesthetic. Dexmedetomidine was found to lessen the negative effects of the anesthetic. CONCLUSION In animals, dexmedetomidine was found not to induce histologic injury and to show a beneficial effect when administered with another anesthetic. No clinical results on the long-term effects in children have been identified yet.
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Affiliation(s)
- Camille E. van Hoorn
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Sanne E. Hoeks
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Heleen Essink
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive CareSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
| | - Jurgen C. de Graaff
- Department of AnesthesiaSophia Children’s Hospital, Erasmus MCRotterdamThe Netherlands
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Zhang J, Yu Q, Liu Y, Liu H, Sun M, Tian Q, Tu S. [Propofol combined with hypoxia induces cognitive dysfunction in immature rats via p38 pathway]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1294-1299. [PMID: 30514675 PMCID: PMC6744114 DOI: 10.12122/j.issn.1673-4254.2018.11.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVE To investigate the effects of propofol combined with hypoxia on cognitive function of immature rats and the possible role of p38 pathway and tau protein in mediating such effects. METHODS Ninety 7-day-old (P7) SD rats were randomized for daily intraperitoneal injection of propofol (50 mg/kg) or lipid emulsion (5.0 mL/kg) for 7 consecutive days. After each injection, the rats were placed in a warm box (38 ℃) with an oxygen concentration of 18% (hypoxia), 21% (normal air), or 50% (oxygen) until full recovery of the righting reflex. Another 90 P7 rats were similarly grouped and received intraperitoneal injections of p-p38 blocker (15 mg/kg) 30 min before the same treaments. The phosphorylated tau protein, total tau protein and p-p38 content in the hippocampus were detected using Western blotting. The spatial learning and memory abilities of the rats were evaluated with Morris water maze test. RESULTS Compared with lipid emulsion, propofol injection resulted in significantly increased levels of p-p38, phosphorylated tau and total tau proteins in rats with subsequent hypoxic or normal air treatment (P < 0.05), but propofol with oxygen and injections of the blocker before propofol did not cause significant changes in the proteins. Without subsequent oxygenation, the rats receiving injections of propofol, with and without prior blocker injection, all showed significantly prolonged latency time and reduced platform-crossing times and third quadrant residence time compared with the corresponding lipid emulsion groups (P < 0.05). With oxygen treatment, the rats in propofoland blocker-treated groups showed no significant difference in the performance in Morris water maze test from the corresponding lipid emulsion group. The results of Morris water maze test differed significantly between blocker-propofol group and propofol groups irrespective of exposures to different oxygen levels (P < 0.05), but not between the lipid emulsion and blocker group pairs with exposures to different oxygen levels. CONCLUSIONS Propofol combined with hypoxia can affect the expression of tau protein through p38 pathway to impair the cognitive function of immature rats, in which oxygen plays a protective role.
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Affiliation(s)
- Jing Zhang
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing 400014, China
| | - Qing Yu
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Yang Liu
- Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Hui Liu
- Ministry of Education Key Laboratory of Child Development and Critical Disorders, Chongqing 400014, China.,China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China
| | - Mang Sun
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Qin Tian
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Shengfen Tu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
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Olutoye O, Cruz S, Akinkuotu A, Sheikh F, Zamora I, Yu L, Adesina A, Olutoye O. Fetal Surgery Decreases Anesthesia-Induced Neuroapoptosis in the Mid-Gestational Fetal Ovine Brain. Fetal Diagn Ther 2018; 46:111-118. [DOI: 10.1159/000491925] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 07/09/2018] [Indexed: 11/19/2022]
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Estimation of an area between the baseline and the effect curve parameter for lactate levels in the hippocampi of neonatal rats during anesthesia. J Pharm Biomed Anal 2018; 150:327-332. [DOI: 10.1016/j.jpba.2017.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 12/08/2017] [Accepted: 12/09/2017] [Indexed: 11/17/2022]
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Food and Drug Administration warning on anesthesia and brain development: implications for obstetric and fetal surgery. Am J Obstet Gynecol 2018; 218:98-102. [PMID: 28888583 DOI: 10.1016/j.ajog.2017.08.107] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 08/19/2017] [Accepted: 08/31/2017] [Indexed: 11/20/2022]
Abstract
There has been growing concern about the detrimental effects of certain anesthetic agents on the developing brain. Preclinical studies in small animal models as well as nonhuman primates suggested loss or death of brain cells and consequent impaired neurocognitive function following anesthetic exposure in neonates and late gestation fetuses. Human studies in this area are limited and currently inconclusive. On Dec. 14, 2016, the US Food and Drug Administration issued a warning regarding impaired brain development in children following exposure to certain anesthetic agents used for general anesthesia, namely the inhalational anesthetics isoflurane, sevoflurane, and desflurane, and the intravenous agents propofol and midazolam, in the third trimester of pregnancy. Furthermore, this warning recommends that health care professionals should balance the benefits of appropriate anesthesia in young children and pregnant women against potential risks, especially for procedures that may last >3 hours or if multiple procedures are required in children <3 years old. The objective of this article is to highlight how the Food and Drug Administration warning may impact the anesthetic and surgical management of the obstetric patient. Neuraxial anesthesia (epidural or spinal anesthesia) is more commonly administered for cesarean delivery than general anesthesia. The short duration of fetal exposure to general anesthesia during cesarean delivery has not been associated with learning disabilities. However, the fetus can also be exposed to both intravenous and inhalation anesthetics during nonobstetric or fetal surgery in the second and third trimester; this exposure is typically longer than that for cesarean delivery. Very few studies address the effect of anesthetic exposure on the fetus in the second trimester when most nonobstetric and fetal surgical procedures are performed. It is also unclear how the plasticity of the fetal brain at this stage of development will modulate the consequences of anesthetic exposure. Strategies that may circumvent possible untoward long-term neurologic effects of anesthesia in the baby include: (1) use of nonimplicated (nongamma-aminobutyric acid agonist) agents for sedation such as opioids (remifentanil, fentanyl) or the alpha-2 agonist, dexmedetomidine, when appropriate; (2) minimizing the duration of exposure to inhalational anesthetics for fetal, obstetric, and nonobstetric procedures in the pregnant patient, as much as possible within safe limits; and (3) commencing surgery promptly and limiting the interval between induction of anesthesia and surgery start time will help decrease patient exposure to inhalational agents. While the Food and Drug Administration warning was based on duration and repetitive nature of exposure rather than concentration of inhalational agents, intravenous tocolytics can be considered for intraoperative use, to provide uterine relaxation for fetal surgery, in lieu of high concentrations of inhalational anesthetic agents. Practitioners should consider the type of anesthesia that will be administered and the potential risks when scheduling patients for nonobstetric and fetal surgery.
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Lin EP, Lee JR, Lee CS, Deng M, Loepke AW. Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies. Neurotoxicol Teratol 2016; 60:117-128. [PMID: 27793659 DOI: 10.1016/j.ntt.2016.10.008] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/09/2016] [Accepted: 10/24/2016] [Indexed: 11/28/2022]
Abstract
Anesthetics that permit surgical procedures and stressful interventions have been found to cause structural brain abnormalities and functional impairment in immature animals, generating extensive concerns among clinicians, parents, and government regulators regarding the safe use of these drugs in young children. Critically important questions remain, such as the exact age at which the developing brain is most vulnerable to the effects of anesthetic exposure, whether a particular age exists beyond which anesthetics are devoid of long-term effects on the brain, and whether any specific exposure duration exists that does not lead to deleterious effects. Accordingly, the present analysis attempts to put the growing body of animal studies, which we identified to include >440 laboratory studies to date, into a translational context, by integrating the preclinical data on brain structure and function with clinical results attained from human neurocognitive studies, which currently exceed 30 studies. Our analysis demonstrated no clear exposure duration threshold below which no structural injury or subsequent cognitive abnormalities occurred. Animal data did not clearly identify a specific age beyond which anesthetic exposure did not cause any structural or functional abnormalities. Several potential mitigating strategies were found, however, no general anesthetic was identified that consistently lacked neurodegenerative properties and could be recommended over other anesthetics. It therefore is imperative, to expand efforts to devise safer anesthetic techniques and mitigating strategies, even before long-term alterations in brain development are unequivocally confirmed to occur in millions of young children undergoing anesthesia every year.
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Affiliation(s)
- Erica P Lin
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Jeong-Rim Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Andreas W Loepke
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States; Neuroscience Program, University of Cincinnati, Cincinnati, OH 45267, United States.
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Schnitzler S, Kopitz J, Plaschke K. Increased hippocampal CD38 and systemic inflammation after partial hepatectomy does not induce impairment of spatial cognition. Neurol Res 2016; 38:973-980. [DOI: 10.1080/01616412.2016.1242452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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