Anesthesia-induced developmental neurotoxicity in children: past, present, and future

Risk of Neurotoxicity with Multiple General Anaesthetics for Examination Under Anaesthesia in Paediatric Ophthalmology - A Cause for Concern?

Purpose

To evaluate the impact of clinical protocol change via active minimisation on the number of general anaesthetic (GA)/sedation episodes for diagnostic ophthalmic purposes at Children's Health Ireland at Temple Street (CHI-TS), Dublin, Ireland, from 2016 to 2019, inclusive. Change was implemented following published cautionary principles in 2016 by the FDA regarding the potential neurotoxic risk from multiple GA exposure in children.

Methods

Retrospective analysis of electronic operating theatre records was completed using procedure codes "Ophthalmological examination" and "Examination of fundi". Available records for patients undergoing multiple examination under anaesthesia (EUA) procedures were assessed for demographics, indication. Comparison was made regarding overall EUA numbers and breakdown for each year, before and after the new departmental approach. From 2018 onward, a patient-centred, departmental strategy of active minimisation of EUA was adopted, using strategies of "training, technology and patience". A literature review was conducted using online databases.

Results

A total of 450 EUAs were performed over the 4 years investigated. In the former 2 years of the study period, prior to departmental policy change, EUAs represented 32% (304 of 948 total theatre episodes) of the ophthalmic theatre caseload. In the latter 2 years of this study period, this proportion fell to 19% (146 EUAs of 783 theatre episodes). Total theatre case numbers were comparable in both time periods. Eighteen children had multiple EUAs (ie, ≥2 EUAs, mean 6.5, SD 2.9) for life/sight threatening indications, totalling 116 EUAs (25.7%).

Conclusion

A significant reduction in diagnostic EUA volume was accomplished resulting in reduced individual patient risk and increased capacity for surgical interventions. A detailed description of this methodology is included for the purposes of replication at comparable units. EUA will continue to play a crucial role in the management of life/sight threatening conditions but the application of a cautionary principle to reduce EUA, where possible, is appropriate to reduce potential for neurotoxicity.

MFG-E8 Exerts Neuroprotection in Neural Stem Cells Induced by Anesthetic Sevoflurane via Regulating the PI3K/AKT Pathways

MFG-E8 has shown tissue protection effects in various models of organ injury. In this study, the function of MFG-E8 in SEV-induced neural stem cells (NSCs) was studied. The cell viability and apoptosis affected by rhMFG-E8 were tested by MTT and flow cytometry analysis, respectively. Then, the mRNA expression of MFG-E8 was detected by qRT-PCR. The expression of SOD, GSF-Px, and MDA was assessed using ELISA assay. Western blot analysis was applied for assessing the expression of MFG-E8, BCL2, BAX, cleaved caspase-3, GRP-78, XBP-1, ATF-6, ATF-4, CHOP, p-PI3K, PI3K, p-AKT, and AKT. The pharmacological experiments suggested that both mRNA and protein expression of MFG-E8 were significantly decreased after 24 h, 48 h, and 72 h treatment with SEV, and the Western blot results displayed that 50 and 100 μg/ml rhMFG-E8 could evidently promote the expression of MFG-E8 in NSCs induced by SEV. Next, rhMFG-E8 reduced the apoptosis of NSCs induced by SEV through upregulating Bcl-2 and cleaved caspase-3 and downregulating Bax. Moreover, rhMFG-E8 alleviated the endoplasmic reticulum pressure of NSCs induced by SEV through decreasing the expression of GRP-78, XBP-1, ATF-6, ATF-4, and CHOP. In addition, the rhMFG-E8 could promote the expression of SOD and GSH-Px and inhibit the expression of MDA and LDH detected by the ELISA assay and LDH kit. Moreover, rhMFG-E8 elevated the expression of p-PI3K/PI3K and p-AKT/AKT, which were inhibited by SEV in NSCs. The results of this project supported that rhMFG-E8 protects neural activity in neural stem cells induced by anesthetic sevoflurane via regulating the PI3K/AKT pathways.

Atractylenolide III alleviates isoflurane-induced injury in rat hippocampal neurons by activating the PI3K/Akt/mTOR pathway

The use of anesthetics relieves discomfort in patients during operation, but extensive application of anesthetics can cause damage to the nervous system. Atractylenolide III (ATL-III) is an active ingredient derived from Baizhu, which is a kind of traditional Chinese medicines. Recent studies have shown that ATL-III alleviates inflammation and oxidative stress in various tissues by regulating the PI3K/Akt/mTOR signaling pathway. However, whether or not the application of ATL-III could relieve isoflurane-induced damage in rat hippocampal neurons remains unclear. In this study, rats were stimulated with isoflurane and treated with ATL-III (intragastric administration) simultaneously. After rats were sacrificed, apoptosis and autophagy in the hippocampal neurons were assessed using TUNEL assays and western blotting, respectively. Then, the expression of inflammatory factors was determined by q-PCR and ELISA. The levels of p-PI3K, p-Akt, and p-mTOR were quantified by western blotting. We found that ATL-III relieved isoflurane-induced apoptosis, autophagy and inflammation in hippocampal neurons in rats. ATL-III treatment also inhibited the expression of TNF-α, IL-1β, and IL-6 in these cells. Furthermore, ATL-III promoted the expression of p-PI3K, p-Akt, and p-mTOR in the hippocampal neurons. All these results indicated that ATL-III alleviated isoflurane-induced injury in rat hippocampal neurons by activating the PI3K/Akt/mTOR signaling pathway. PRACTICAL APPLICATIONS: Whether or not Atractylenolide III (ATL-III) could alleviate neurotoxicity induced by anesthetics is unclear. In this study, we investigated the effect of ATL-III on anesthetic-induced nervous system damage. The findings from this study could also provide a novel therapy for the treatment of patients with anesthetic-induced nerve injury.