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Lee AJ, Prager JD, Mandler TN, Chatterjee D, Wine TM, Janosy NR. Anesthesia for laryngotracheal reconstruction in children: A narrative review. Paediatr Anaesth 2023; 33:883-893. [PMID: 37408495 DOI: 10.1111/pan.14716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 07/07/2023]
Abstract
Laryngotracheal stenosis, congenital or acquired, is a common cause of pediatric airway obstruction. Acquired subglottic stenosis frequently results from prolonged neonatal intubation. The clinical presentation of subglottic stenosis is variable, ranging from biphasic stridor and frequent upper respiratory infections to acute airway compromise. Optimal patient care requires clinical coordination within a multidisciplinary subspecialty team. Medical management includes optimizing respiratory status, gastroesophageal reflux, speech, feeding, nutrition therapies, and providing psychosocial support. If surgical intervention is required, the otolaryngologist, anesthesiologist, and perioperative team must collaborate closely to ensure successful operative outcomes. This narrative review of laryngotracheal stenosis will discuss the pathophysiology, clinical evaluation, medical management, and surgical interventions, and focus on the perioperative anesthetic considerations for children undergoing laryngotracheal reconstruction.
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Affiliation(s)
- Amy J Lee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeremy D Prager
- Department of Otolaryngology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tessa N Mandler
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Debnath Chatterjee
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Todd M Wine
- Department of Otolaryngology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Norah R Janosy
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Maroda AJ, Coca KK, McLevy-Bazzanella JD, Wood JW, Grissom EC, Sheyn AM. Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery. Otolaryngol Clin North Am 2020; 53:819-830. [PMID: 32622548 DOI: 10.1016/j.otc.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.
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Affiliation(s)
- Andrew J Maroda
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kimberly K Coca
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer D McLevy-Bazzanella
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua W Wood
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Erica C Grissom
- Department of Anesthesiology, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Anthony M Sheyn
- Department of Pediatric Otolaryngology, Le Bonheur Children's Hospital, Memphis, TN, USA; Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 400, Memphis, TN 38163-2242, USA; Department of Pediatric Otolaryngology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Perez-Zoghbi JF, Zhu W, Neudecker V, Grafe MR, Brambrink AM. Neurotoxicity of sub-anesthetic doses of sevoflurane and dexmedetomidine co-administration in neonatal rats. Neurotoxicology 2020; 79:75-83. [DOI: 10.1016/j.neuro.2020.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 03/09/2020] [Accepted: 03/25/2020] [Indexed: 12/14/2022]
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Bowe SN, Colaianni CA, Yamasaki A, Cummings BM, Hartnick CJ. Reevaluating a Standardized Sedation Weaning Protocol for Pediatric Laryngotracheal Reconstruction for Continuous Quality Improvement. JAMA Otolaryngol Head Neck Surg 2019; 145:321-327. [PMID: 30763412 DOI: 10.1001/jamaoto.2018.4348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation. Objective Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR). Design, Setting, and Participants A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients. Main Outcomes and Measures The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission. Results The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS. Conclusions and Relevance Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.
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Affiliation(s)
- Sarah N Bowe
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - C Alessandra Colaianni
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - Alisa Yamasaki
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts
| | - Brian M Cummings
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts.,Department of Otology & Laryngology, Harvard Medical School, Boston, Massachusetts
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Fauman KR, Durgham R, Duran CI, Vecchiotti MA, Scott AR. Sedation after airway reconstruction in children: A protocol to reduce withdrawal and length of stay. Laryngoscope 2015; 125:2216-9. [PMID: 26152806 DOI: 10.1002/lary.25176] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/19/2014] [Accepted: 01/05/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Karen R Fauman
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Rashed Durgham
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Carlos I Duran
- Department of Pediatrics-Critical Care Medicine, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Mark A Vecchiotti
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
| | - Andrew R Scott
- Department of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children, Boston, Massachusetts, U.S.A
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Kozin ED, Cummings BM, Rogers DJ, Lin B, Sethi R, Noviski N, Hartnick CJ. Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction. JAMA Otolaryngol Head Neck Surg 2015; 141:27-33. [PMID: 25356601 PMCID: PMC4465249 DOI: 10.1001/jamaoto.2014.2694] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol. OBJECTIVE To standardize and decrease length of sedation wean in pediatric patients undergoing LTR. DESIGN, SETTING, AND PARTICIPANTS Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation. INTERVENTIONS Implementation of a standardized sedation protocol. MAIN OUTCOMES AND MEASURES Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge. RESULTS The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02). CONCLUSIONS AND RELEVANCE We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.
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Affiliation(s)
- Elliott D Kozin
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
| | - Brian M Cummings
- Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Derek J Rogers
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
| | - Brian Lin
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
| | - Rosh Sethi
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
| | - Natan Noviski
- Department of Pediatrics, Massachusetts General Hospital, Boston
| | - Christopher J Hartnick
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston
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McCormick ME, Johnson YJ, Pena M, Wratney AT, Pestieau SR, Zalzal GH, Preciado DA. Dexmedetomidine as a Primary Sedative Agent after Single-Stage Airway Reconstruction. Otolaryngol Head Neck Surg 2013; 148:503-8. [DOI: 10.1177/0194599812471784] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To examine the outcomes of children receiving dexmedetomidine after single-stage airway reconstruction. Study Design Historical cohort study. Setting Tertiary care children’s hospital. Subjects and Methods Of 61 eligible patients, 50 children undergoing single-stage airway reconstruction were included in the study. Thirty children received dexmedetomidine (Dex) as a primary sedative agent, and 20 received a more traditional sedation protocol (no Dex). Primary outcomes included complications, intubation lengths, and lengths of pediatric intensive care unit (PICU)/hospital admission. Secondary analysis incorporating polypharmacy and age was performed using multivariate linear regression models. Results Median age was 18.0 months. Age, sex, and weight were similar between the groups. Intubation length was equal in the 2 groups, and there were no statistical differences between lengths of PICU or hospital stay after extubation. Similarly, overall and individual complications were all similar, and there was no difference between the 2 groups in the amount of polypharmacy administered. On multivariate analysis, polypharmacy and younger age were independently correlated with an increase in overall complications, and polypharmacy alone was correlated with an increased length of stay after extubation. Conclusion The use of dexmedetomidine as a primary sedation agent after single-stage airway surgery does not appear to improve outcomes or decrease the need for additional pharmacologic agents. Polypharmacy was associated with an increase in overall complications and an increased length of stay after extubation. Although success can be expected in greater than 90% of these surgical patients, the optimal postoperative sedation management remains challenging.
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Affiliation(s)
- Michael E. McCormick
- Division of Pediatric Otolaryngology, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Yewande J. Johnson
- Division of Anesthesiology and Pain Medicine, Children’s National Medical Center, Washington, DC
| | - Maria Pena
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Angela T. Wratney
- Critical Care Medicine Department, Children’s National Medical Center, Washington, DC
| | - Sophie R. Pestieau
- Division of Anesthesiology and Pain Medicine, Children’s National Medical Center, Washington, DC
| | - George H. Zalzal
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
| | - Diego A. Preciado
- Division of Pediatric Otolaryngology, Children’s National Medical Center, Washington, DC
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Boettcher M, Göttler S, Stoffel L, Schwab K, Berger S, Mérat M. Schmerzmanagement bei Kindern in der Schweiz. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2680-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gupta P, Tobias JD, Goyal S, Kuperstock JE, Hashmi SF, Shin J, Hartnick CJ, Noviski N. Perioperative care following complex laryngotracheal reconstruction in infants and children. Saudi J Anaesth 2011; 4:186-96. [PMID: 21189858 PMCID: PMC2980667 DOI: 10.4103/1658-354x.71577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Laryngotracheal reconstruction (LTR) involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR) or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (singlestage LTR). With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Protocol-driven sedation: Will both the patient and physician be more comfortable?*. Crit Care Med 2011; 39:887-8. [DOI: 10.1097/ccm.0b013e31820a4dd8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Silver AL, Yager P, Purohit P, Noviski N, Hartnick CJ. Dexmedetomidine use in pediatric airway reconstruction. Otolaryngol Head Neck Surg 2010; 144:262-7. [PMID: 21493428 DOI: 10.1177/0194599810391397] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Assess the postoperative use of dexmedetomidine (Precedex) in pediatric patients following airway reconstruction. STUDY DESIGN Historical cohort study. SETTING Tertiary medical center. SUBJECTS AND METHODS A retrospective review of 24 children undergoing laryngotracheal reconstruction (LTR) or laryngeal cleft repair (LCR) was conducted. Twelve children were treated with standard sedation protocols where dexmedetomidine was administered in lieu of propofol (Diprivan); 12 age-, gender-, and procedure-matched controls were selected. Subjects were divided into groups based on duration of postoperative intubation for cross-comparison; group 1 was intubated <24 hours, group 2 was intubated 2 to 6 days, and group 3 was intubated 7 days or longer. Baseline heart rate and blood pressure measurements were compared to hourly measurements for the first 6 hours following initiation of dexmedetomidine or mechanical ventilation in the control group. Number of supportive respiratory interventions, adverse events, self-extubations, premature termination of dexmedetomidine, amount of muscle relaxants, agents to treat withdrawal, and length of stay were evaluated. RESULTS Ten patients undergoing LTR and 2 patients undergoing LCR receiving dexmedetomidine were compared to 10 LTR and 2 LCR control patients. Overall, dexmedetomidine was well tolerated and without significant adverse effects, particularly in cases of short-term intubation or as a bridge to extubation. CONCLUSION In cases requiring short-term intubation following airway reconstruction, dexmedetomidine may offer a safe alternative to propofol by providing readily reversible sedation during the periextubation period. Further studies are needed to determine the safety, efficacy, dosing, and potential complications of longer term dexmedetomidine administration in pediatric airway reconstruction.
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Affiliation(s)
- Amanda L Silver
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, and Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts 02114, USA
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Developmental neurotoxicity of sedatives and anesthetics: a concern for neonatal and pediatric critical care medicine? Pediatr Crit Care Med 2010; 11:217-26. [PMID: 19770789 DOI: 10.1097/pcc.0b013e3181b80383] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the currently available evidence for the deleterious effects of sedatives and anesthetics on developing brain structure and neurocognitive function. DESIGN A computerized, bibliographic search of the literature regarding neurodegenerative effects of sedatives and anesthetics in the developing brain. MEASUREMENTS AND MAIN RESULTS A growing number of animal studies demonstrate widespread structural damage of the developing brain and long-lasting neurocognitive abnormalities after exposure to sedatives commonly used in neonatal and pediatric critical care medicine. These studies reveal a dose and exposure time dependence of neuronal cell death, characterize its molecular pathways, and suggest a potential early window of susceptibility in humans. Several clinical studies document neurologic abnormalities in neonatal intensive care unit graduates, usually attributed to comorbidities. Emerging human epidemiologic data, however, do not exclude prolonged or repetitive exposure to sedatives and anesthetics in early childhood as contributing factors to some of these abnormalities. CONCLUSIONS Neuronal cell death after neonatal exposure to sedatives and anesthetics has been clearly demonstrated in developing animal models. Although the relevance for human medicine remains speculative, the phenomenon's serious implications for public health necessitate further preclinical and clinical studies. Intensivists using sedatives and anesthetics in neonates and infants need to stay informed about this rapidly emerging field of research.
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