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Zhou H, Sun W, Ning L, Kang J, Jin Y, Dong C. Early exposure to general anesthesia may contribute to later attention-deficit/hyperactivity disorder (ADHD): A systematic review and meta-analysis of cohort studies. J Clin Anesth 2024; 98:111585. [PMID: 39153353 DOI: 10.1016/j.jclinane.2024.111585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/16/2024] [Accepted: 08/13/2024] [Indexed: 08/19/2024]
Abstract
STUDY OBJECTIVE The association between early childhood exposure to general anesthesia and subsequent risk of developing attention-deficit/hyperactivity disorder remains unknown. DESIGN A systematic review and meta-analysis of cohort studies. PATIENTS Children undergoing general anesthesia. INTERVENTIONS A comparison of any type of general anesthesia exposure, including total intravenous anesthesia, inhalation general anesthesia, and combined intravenous and inhaled anesthesia, with non-anesthetic exposures, which did not receive any exposure to anesthetic drugs, including general anesthetics as well as local anesthetics. MEASUREMENTS The primary outcome measure was the risk of developing attention-deficit/hyperactivity disorder after general anesthesia exposure. MAIN RESULTS The results of the overall meta-analysis showed an increased risk of subsequent attention-deficit/hyperactivity disorder in children exposed to general anesthesia (RR = 1.26, 95% CI, 1.16-1.38; P < 0.001; I2 = 44.6%). Subgroup analysis found that a single exposure to general anesthesia in childhood was associated with an increased risk of developing attention-deficit/hyperactivity disorder (RR = 1.29, 95% CI, 1.19-1.40, P < 0.001; I2 = 2.6%), and the risk of attention-deficit/hyperactivity disorder was further increased after multiple general anesthesia exposures (RR = 1.61, 95% CI, 1.32-1.97, P < 0.001; I2 = 57.6%). Exposure to general anesthesia lasting 1-60 min during childhood is associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD) (RR: 1.38, 95% CI: 1.26-1.51, P < 0.001; I2 = 0.0%). Moreover, with longer durations of exposure (61-120 min), the risk further rises (RR: 1.55, 95% CI: 1.21-1.99, P = 0.001; I2 = 37.8%). However, no additional increase in ADHD risk was observed with exposures exceeding 120 min (RR: 1.55, 95% CI: 1.35-1.79, P < 0.001; I2 = 0.0%). CONCLUSIONS Exposure to general anesthesia during early childhood increases the risk of developing attention-deficit/hyperactivity disorder. In particular, multiple general anesthesia exposures and exposures longer than 60 min significantly increase the risk of developing ADHD.
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Affiliation(s)
- Hao Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Wenyi Sun
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Liuxian Ning
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Jie Kang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yadong Jin
- International School, Jinan University, Guangzhou, Guangdong, China
| | - Chaoxuan Dong
- Department of Anesthesiology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China.
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Salimi-Jazi F, Sabapaty A, Santos Dalusag K, Abrajano C, Nguyen J, Robinson B, Caruso TJ, Rodriguez S, Hartman G, Chao SD. Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population. J Pediatr Surg 2024; 59:992-996. [PMID: 38307749 PMCID: PMC11031342 DOI: 10.1016/j.jpedsurg.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 12/18/2023] [Accepted: 01/03/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children. METHODS A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. RESULTS A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. CONCLUSION VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Fereshteh Salimi-Jazi
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Akanksha Sabapaty
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kyla Santos Dalusag
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Claire Abrajano
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Jackie Nguyen
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Blaine Robinson
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas Jon Caruso
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Samuel Rodriguez
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary Hartman
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephanie D Chao
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Yang R, Zhao R, Chaudry F, Wang T, Brunton P, Khurshid Z, Ratnayake J. Modern sedative agents and techniques used in dentistry for patients with special needs: A review. J Taibah Univ Med Sci 2024; 19:153-163. [PMID: 38047240 PMCID: PMC10692720 DOI: 10.1016/j.jtumed.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/24/2023] [Accepted: 10/18/2023] [Indexed: 12/05/2023] Open
Abstract
According to the World Health Organisation, approximately 1.3 billion people worldwide experience substantial disability due to physical, mental or sensory impairment. People with special needs require special consideration and more time or altered delivery methods when receiving dental treatments. Various factors, such as patients' lack of cooperation, cognitive impairment and complex medical status, may lead dental practitioners to recommend conscious sedation. Several pharmacological agents and administrative routes are available, which achieve varying levels of sedation ranging from minimal to deep. Pre-operative assessment and careful case selection are necessary to determine the appropriate sedative agent, route of administration and level of sedation for each patient. Thus, a thorough understanding of the pharmacokinetics, risks and benefits, and implications of various sedatives available for PSN is essential to achieve the desired clinical outcomes. This review critically presents the considerations associated with the use of various sedative agents for PSN in dentistry. Considerations include patients' pre-anaesthesia medical comorbidities, cardiorespiratory adverse effects and cooperativeness, and the viable alternative treatment modalities.
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Affiliation(s)
- Ruijia Yang
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Rusin Zhao
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Fatima Chaudry
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Tao Wang
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
| | - Paul Brunton
- Department of Prosthodontics and Dental Implantology, Curtin University, Bentley, Australia
| | - Zohaib Khurshid
- Department of Prosthodontics and Dental Implantology, College of Dentistry, King Faisal University, Al-Ahsa, KSA
| | - Jithendra Ratnayake
- Department of Oral Science, Faculty of Dentistry, University of Otago, Dunedin, New Zealand
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4
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Skakum M, Katako A, Mitchell-Dueck J, Ricci MF, Russell K. Risk of attention deficit hyperactivity disorder diagnosis following multiple exposures to general anesthesia in the paediatric population: A systematic review and meta-analysis. Paediatr Child Health 2024; 29:29-35. [PMID: 38332968 PMCID: PMC10848114 DOI: 10.1093/pch/pxad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 10/13/2023] [Indexed: 02/10/2024] Open
Abstract
Objectives The risk of attention deficit hyperactivity disorder (ADHD) following multiple exposures to anesthesia has been debated. Our objective was to systematically review the literature to examine the association between multiple exposures to general anesthesia before age 5 and subsequent diagnosis of ADHD. Methods A systematic search of EMBASE, PubMed, and SCOPUS was performed using key search terms in February 2022. We included studies that: were published after 1980, included only otherwise healthy children who experienced two or more exposures to general anesthetic before age 5, diagnosed ADHD by a medical professional before age 19 years after exposure to general anesthetic, were cross-sectional, case-control, or cohort study, and were published in English. The results (expressed as hazard ratios [HR] and associated 95% confidence intervals [CI]) were pooled using meta-analytic techniques. Studies which did not present their results as HR and 95% CI were analyzed separately. GRADE was used to determine the certainty of the findings. PRISMA guidelines were followed at each stage of the review. Results Eight studies (196,749 children) were included. Five reported HR and 95% CI and were subsequently pooled for meta-analysis. Multiple exposures to anesthesia were associated with diagnosis of ADHD before the 19th year of life (HR: 1.71; 95% CI: 1.59, 1.84). Two of the three studies not used in the meta-analysis also found an increased risk of ADHD diagnosis following multiple anesthetic exposures. Conclusions There was an association between multiple early exposures to general anesthesia and later diagnosis of ADHD.
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Affiliation(s)
- Megan Skakum
- University of Manitoba Master of Physician Assistant Studies Program, Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audrey Katako
- University of Manitoba Master of Physician Assistant Studies Program, Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - M Florencia Ricci
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Specialized Services for Children and Youth (SSCY) Centre, Winnipeg, Manitoba, Canada
| | - Kelly Russell
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
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Butt MN, Shamim N, Faraz A. Anesthetic Challenges for a Pediatric Leukemia Patient Undergoing Total Body Irradiation (TBI): A Case Report. Cureus 2024; 16:e53535. [PMID: 38445113 PMCID: PMC10912886 DOI: 10.7759/cureus.53535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/07/2024] Open
Abstract
Radiotherapy of the whole body is called total body irradiation (TBI). It is a well-established component of conditioning regimens before stem cell transplantation in juvenile leukemia. The patient was a three-year-old child with a diagnosis of B-cell acute lymphoblastic leukemia and planned for stem cell transplantation. He was given TBI under anesthesia for three consecutive days prior to the bone marrow transplantation under general anesthesia. The important concerns were related to neutropenia/immune suppression, parental consent for repeated anesthesia, nothing per oral guidelines for the TBI treatment, the possibility of high-grade fever, high chance of respiratory tract infections with repeated anesthesia exposure, etc. Proper preparation, teamwork, and collaborative efforts and the child's parents made this treatment possible with intended success.
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Affiliation(s)
- Mohsin N Butt
- Department of Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | - Nazia Shamim
- Department of Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
| | - Asma Faraz
- Department of Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
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Alrimy T, Alhalabi W, Malibari A, Alzahrani F, Alrajhi S, Yamani A, Ahmed H, Abduljawad A, Nasser E, ALattar S, Alharby B, Khalid H, Alhalabi M, Hoffman HG, Mason KP. Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study. J Clin Med 2023; 12:4985. [PMID: 37568388 PMCID: PMC10419830 DOI: 10.3390/jcm12154985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.
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Affiliation(s)
- Taima Alrimy
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Wadee Alhalabi
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Immersive Virtual Reality Research Group, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Areej Malibari
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatma Alzahrani
- Paediatric Department, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sharifah Alrajhi
- Statistics Department, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ayman Yamani
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Halah Ahmed
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Amro Abduljawad
- Department of Plastic Surgery and Burn, Alnoor Specialist Hospital, Makka 24241, Saudi Arabia
| | - Essam Nasser
- Burn Unit, King Abdulaziz Hospital, Jeddah 22421, Saudi Arabia
| | - Samar ALattar
- Burn Unit, King Abdulaziz Hospital, Jeddah 22421, Saudi Arabia
| | | | - Hasna Khalid
- Plastic Surgery Department, International Medical Center, Jeddah 23214, Saudi Arabia
| | - Mohammed Alhalabi
- Immersive Virtual Reality Research Group, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hunter G. Hoffman
- Computer Science Department, Faculty of Computing and Information Technology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Mechanical Engineering HPL, University of Washington, Seattle, WA 98195, USA
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children’s Hospital, Boston, MA 02115, USA
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7
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Kimball H, Cobham VE, Sanders M, Douglas T. Procedural anxiety among children and adolescents with cystic fibrosis and their parents. Pediatr Pulmonol 2023. [PMID: 37097054 DOI: 10.1002/ppul.26419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 03/13/2023] [Accepted: 04/10/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Procedural anxiety involves acute distress around medical procedures and may lead to avoidance or resistance behaviors that interfere with effective cystic fibrosis (CF) care and health outcomes. While individuals with CF commonly endure uncomfortable and/or distressing medical procedures, procedural anxiety among children and adolescents with CF has received little research attention. This study investigated the prevalence and correlates of procedural anxiety among individuals with CF aged 6-18 and their parents. METHOD Eighty-nine parents of children with CF completed surveys examining child procedural anxiety, anxiety, and health behaviors (including treatment adherence); and parent vicarious procedural anxiety. RESULTS Seventy-five percent of participants rated at least one CF-related procedure as "extremely" anxiety-inducing for their child. Parental vicarious procedural anxiety was reported in 80.9% of participants. Procedural anxiety significantly correlated with child anxiety, treatment-resistive behaviors, and parent-vicarious procedural anxiety. Procedural anxiety was associated with younger age and frequency of distressing procedures, but not with forced expiratory volume in 1 s, body mass index, hospitalizations, or exposure to general anesthesia. CONCLUSION Procedural anxiety is common among children, adolescents, and caregivers, and is associated with child anxiety and treatment resistance, emphasizing the importance of screening and interventions for procedural anxiety as part of routine CF care from early childhood. Implications for screening and intervention are discussed.
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Affiliation(s)
- Hayley Kimball
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, Australia
- Children's Hospital Foundation, Brisbane, Queensland, Australia
| | - Vanessa E Cobham
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, Australia
- Child and Youth Mental Health Service (CYMHS), Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Matthew Sanders
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, Australia
| | - Tonia Douglas
- Cystic Fibrosis Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
- School of Medicine Clinical Unit, The University of Queensland, Herston, Brisbane, Queensland, Australia
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Bleeser T, Devroe S, Lucas N, Debels T, Van de Velde M, Lemiere J, Deprest J, Rex S. Neurodevelopmental outcomes after prenatal exposure to anaesthesia for maternal surgery: a propensity-score weighted bidirectional cohort study. Anaesthesia 2023; 78:159-169. [PMID: 36283123 DOI: 10.1111/anae.15884] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 01/11/2023]
Abstract
Up to 1% of pregnant women undergo anaesthesia for non-obstetric surgery. This study investigated neurodevelopmental outcomes after prenatal anaesthesia for maternal surgery. A bidirectional cohort study of children born between 2001 and 2018 was performed: neurodevelopmental outcomes of children who had received prenatal anaesthesia for maternal surgery were prospectively compared with unexposed children, with exposure status being assessed retrospectively. Children exposed to anaesthesia for obstetric and fetal surgery were excluded. The primary outcome was the global executive composite of the behaviour rating inventory of executive function score. Our secondary outcomes were: total problems; internalising problems and externalising problems derived from the child behaviour checklist; psychiatric diagnoses; and learning disorders. In 90% of exposed children, there was a single mean (SD) antenatal anaesthesia exposure lasting 91(94) min. There was a broad spectrum of indications, with abdominal surgery being most frequent. Parents of 129 exposed (response rate 68%) and 453 unexposed (response rate 63%) children participated. There were no arguments for non-response bias. After propensity weighting, there were no statistically significant differences in primary outcome, with a weighted mean difference (95%CI) of exposed minus unexposed children of 1.9 (-0.4-4.2), p = 0.10; or any of the secondary outcomes. Sensitivity analyses confirmed the robustness. Exploratory analyses, however, showed significant differences in certain subgroups for the primary outcome, (e.g. for intra-abdominal surgery, exposure duration > 1 h) and some cognitive subdomains (e.g. working memory and attention). This bidirectional cohort study, the largest investigation on the subject to date, has found no evidence in the general population for an association between prenatal exposure to anaesthesia and impaired neurodevelopmental outcomes.
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Affiliation(s)
- T Bleeser
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - S Devroe
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - N Lucas
- Department of Anaesthesia, Northwick Park Hospital, Harrow, UK
| | - T Debels
- Faculty of Medicine, KU Leuven, Belgium
| | - M Van de Velde
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
| | - J Lemiere
- Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Belgium
| | - S Rex
- Department of Anaesthesiology, University Hospitals Leuven, Belgium
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The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review. J Clin Med 2023; 12:jcm12030843. [PMID: 36769490 PMCID: PMC9917582 DOI: 10.3390/jcm12030843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 01/24/2023] Open
Abstract
Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.
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Kaji AA, Torii M, Ishii S. Caspase-3 Inhibition toward Perinatal Protection of the Developing Brain from Environmental Stress. Dev Neurosci 2023; 45:66-75. [PMID: 36642064 PMCID: PMC10521911 DOI: 10.1159/000529125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023] Open
Abstract
Throughout our lives, we are exposed to a variety of hazards, such as environmental pollutants and chemical substances that affect our health, and viruses and bacteria that cause infectious diseases. These external factors that are undesirable to an organism are called environmental stress. During the perinatal period, when neural networks are drastically reorganized and refined, the tolerance of the developing brain to various environmental stresses is lower than in adulthood. Thus, exposure to environmental stress during this vulnerable period is strongly associated with cognitive and behavioral deficits in later life. Recent studies have uncovered various mechanisms underlying the adverse impacts of environmental stress during the perinatal period on brain development. In this mini-review, we will present the findings from these studies, focusing on caspase-mediated apoptotic and nonapoptotic effects of environmental stress, and discuss several compounds that mitigate these caspase-mediated effects as examples of potential therapeutic approaches.
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Affiliation(s)
- Anna Arjun Kaji
- Center for Neuroscience Research, Children’s Research Institute, Children’s National Hospital, Washington, D.C., United States
| | - Masaaki Torii
- Center for Neuroscience Research, Children’s Research Institute, Children’s National Hospital, Washington, D.C., United States
- Department of Pediatrics, Pharmacology and Physiology, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., United States
| | - Seiji Ishii
- Department of Anatomy, Keio University School of Medicine, Tokyo, Japan
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Jacobs Sariyar A, van Pesch V, Nassogne MC, Moniotte S, Momeni M. Usefulness of serum neurofilament light in the assessment of neurologic outcome in the pediatric population: a systematic literature review. Eur J Pediatr 2023; 182:1941-1948. [PMID: 36602623 DOI: 10.1007/s00431-022-04793-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/14/2022] [Accepted: 11/24/2022] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Aurélie Jacobs Sariyar
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium.
| | - Vincent van Pesch
- Department of Neurology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Marie-Cécile Nassogne
- Department of Pediatrics, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Stéphane Moniotte
- Department of Pediatrics, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
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Xiao A, Feng Y, Yu S, Xu C, Chen J, Wang T, Xiao W. General anesthesia in children and long-term neurodevelopmental deficits: A systematic review. Front Mol Neurosci 2022; 15:972025. [PMID: 36238262 PMCID: PMC9551616 DOI: 10.3389/fnmol.2022.972025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMillions of children experienced surgery procedures requiring general anesthesia (GA). Any potential neurodevelopmental risks of pediatric anesthesia can be a serious public health issue. Various animal studies have provided evidence that commonly used GA induced a variety of morphofunctional alterations in the developing brain of juvenile animals.MethodsWe conducted a systematic review to provide a brief overview of preclinical studies and summarize the existing clinical studies. Comprehensive literature searches of PubMed, EMBASE, CINAHL, OVID Medline, Web of Science, and the Cochrane Library were conducted using the relevant search terms “general anesthesia,” “neurocognitive outcome,” and “children.” We included studies investigating children who were exposed to single or multiple GA before 18, with long-term neurodevelopment outcomes evaluated after the exposure(s).ResultsSeventy-two clinical studies originating from 18 different countries published from 2000 to 2022 are included in this review, most of which are retrospective studies (n = 58). Two-thirds of studies (n = 48) provide evidence of negative neurocognitive effects after GA exposure in children. Neurodevelopmental outcomes are categorized into six domains: academics/achievement, cognition, development/behavior, diagnosis, brain studies, and others. Most studies focusing on children <7 years detected adverse neurocognitive effects following GA exposure, but not all studies consistently supported the prevailing view that younger children were at greater risk than senior ones. More times and longer duration of exposures to GA, and major surgeries may indicate a higher risk of negative outcomes.ConclusionBased on current studies, it is necessary to endeavor to limit the duration and numbers of anesthesia and the dose of anesthetic agents. For future studies, we require cohort studies with rich sources of data and appropriate outcome measures, and carefully designed and adequately powered clinical trials testing plausible interventions in relevant patient populations.
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Affiliation(s)
- Aoyi Xiao
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yingying Feng
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Yu
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chunli Xu
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jianghai Chen
- Department of Hand Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Wang
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
- Tingting Wang
| | - Weimin Xiao
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Weimin Xiao
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13
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Wong-Kee-You AMB, Loveridge-Easther C, Mueller C, Simon N, Good WV. The impact of early exposure to general anesthesia on visual and neurocognitive development. Surv Ophthalmol 2022; 68:539-555. [PMID: 35970232 DOI: 10.1016/j.survophthal.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022]
Abstract
Every year millions of children are exposed to general anesthesia while undergoing surgical and diagnostic procedures. In the field of ophthalmology, 44,000 children are exposed to general anesthesia annually for strabismus surgery alone. While it is clear that general anesthesia is necessary for sedation and pain minimization during surgical procedures, the possibility of neurotoxic impairments from its exposure is of concern. In animals there is strong evidence linking early anesthesia exposure to abnormal neural development. but in humans the effects of anesthesia are debated. In humans many aspects of vision develop within the first year of life, making the visual system vulnerable to early adverse experiences and potentially vulnerable to early exposure to general anesthesia. We attempt to address whether the visual system is affected by early postnatal exposure to general anesthesia. We first summarize key mechanisms that could account for the neurotoxic effects of general anesthesia on the developing brain and review existing literature on the effects of early anesthesia exposure on the visual system in both animals and humans and on neurocognitive development in humans. Finally, we conclude by proposing future directions for research that could address unanswered questions regarding the impact of general anesthesia on visual development.
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Affiliation(s)
| | - Cam Loveridge-Easther
- Smith-Kettlewell Eye Research Institute, San Francisco, CA, USA; University of Auckland, Auckland, New Zealand
| | - Claudia Mueller
- Sutter Health, San Francisco, CA, USA; Stanford Children's Health, Palo Alto, CA, USA
| | | | - William V Good
- Smith-Kettlewell Eye Research Institute, San Francisco, CA, USA.
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14
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Ing C, Bellinger DC. Long-term cognitive and behavioral outcomes following early exposure to general anesthetics. Curr Opin Anaesthesiol 2022; 35:442-447. [PMID: 35788121 DOI: 10.1097/aco.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Caleb Ing
- Departments of Anesthesiology and Epidemiology, Columbia University Vagelos College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
| | - David C Bellinger
- Departments of Neurology and Psychiatry, Harvard Medical School
- Departments of Neurology and Psychiatry, Boston Children's Hospital
- Department of Environmental Health, Harvard T.H. Can School of Public Health, Boston, Massachusetts, USA
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15
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Reighard C, Junaid S, Jackson WM, Arif A, Waddington H, Whitehouse AJO, Ing C. Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2217427. [PMID: 35708687 PMCID: PMC9204549 DOI: 10.1001/jamanetworkopen.2022.17427] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Charles Reighard
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Shaqif Junaid
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - William M. Jackson
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ayesha Arif
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Hannah Waddington
- Faculty of Education, Victoria University of Wellington, Wellington, New Zealand
| | | | - Caleb Ing
- Department of Anesthesiology and Epidemiology, Columbia University Vagelos College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
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Sozbilen MC, Evren Sahin K. Long-term efficacy and safety of repeated botulinum toxin a applications based on function and anesthesia type in children with cerebral palsy. J Orthop 2021; 29:22-27. [PMID: 35027815 PMCID: PMC8731691 DOI: 10.1016/j.jor.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/27/2021] [Accepted: 12/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE This study evaluates the motor development of patients undergoing three or more repeated Botulinum toxin A (BoNT-A) applications in a tertiary pediatric hospital as well as the safety of three different types of anesthesia. METHODS Seventy-five children who underwent BoNT-A applications at least three consecutive times at six-month intervals and a total of 320 procedures were examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. The three anesthesia methods (sedation analgesia, anesthesia with larengeal mask [LMA] and inhalation mask) were compared in terms of sedation, procedure, recovery, and total operation room time. RESULTS Following the procedures, significant motor development was observed in 60 (80%) patients. In sedation analgesia group during the first three procedures, the recovery time was seen to be significantly shorter, while there was no difference between the anesthesia methods of any procedures following the fourth. Regardless of the type of anesthesia, the recovery times of those having undergone six or more procedures were longer than those with less than six procedures. CONCLUSIONS As repeated BoNT-A application provides motor step progress, it can be applied safely and effectively under anesthesia. Sedation analgesia provides an easier recovery compared to LMA and mask only within the first three applications. However, recovery time increases with four or more repeated applications, specifically increasing as the number of applications increases. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Murat Celal Sozbilen
- Department of Orthopaedic Surgery, School of Medicine Hospital, Ege University, Bornova, Izmir, Turkey,Corresponding author.
| | - Kubra Evren Sahin
- Department of Anesthesiology and Reanimation, Dr Behcet Uz Child Diseases and Surgery Research and Training Hospital, Konak, Izmir, Turkey
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Schüttler C, Münster T, Gall C, Trollmann R, Schüttler J. General Anesthesia in the First 36 Months of Life–a Study of Cognitive Performance in Children Aged 7-11 Years (ANFOLKI-36). DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:835-841. [PMID: 34743788 DOI: 10.3238/arztebl.m2021.0355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 03/28/2021] [Accepted: 10/04/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Experimental data have shown that the developing brain is especially vulnerable to exogenous noxious substances. The potential effects of anesthetic drugs on brain growth and development are a matter of concern. Clinical studies of children who underwent general anesthesia in their earliest years can make a major contribution to our understanding of the effects of anesthetic drugs on infants and toddlers (i.e., children under age 5). METHODS Children born at term during the years 2007-2011 who were exposed to general anesthesia before their third birthday were included in the study. Data on general anesthesia were retrospectively evaluated, and the overall intelligence quotient (IQ) was determined prospectively as the primary target parameter. Children who had not been exposed to general anesthesia were recruited as a control group. The non-inferiority threshold was set at a difference of 5 IQ points out of a consideration of clinical relevance. RESULTS 430 complete data sets were available from exposed children and 67 from members of the control group. The exposed group achieved a mean IQ score of 108.2, with a 95% confidence interval of [107; 109.4]; the corresponding values in the control group were 113 [110; 116.1]. Both groups achieved a mean score that was higher than the expected 100 points. After adjustment for age, socioeconomic status, and sex, the difference between the two groups was 2.9 points [0.2; 5.6], indicating a significantly better outcome in the control group than in the exposed group. The non-inferiority threshold of 5 IQ points was within the confidence interval; thus, non-inferiority was not demonstrated. CONCLUSION The fact that both groups achieved a higher IQ score than the expected 100 points may be attributable, at least in part, to the restriction of the study to children born at term. The results indicate that general anesthesia in early childhood is not associated with markedly reduced intelligence in later years, although non-inferiority could not be demonstrated.
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18
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Kim J, Byun SH, Kim JW, Kim JY, Kim YJ, Choi N, Lee BS, Yu S, Kim E. Behavioral changes after hospital discharge in preschool children experiencing emergence delirium after general anesthesia: A prospective observational study. Paediatr Anaesth 2021; 31:1056-1064. [PMID: 34309126 DOI: 10.1111/pan.14259] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Emergence delirium is well known as early postoperative behavioral change after general anesthesia. However, it is unclear whether children with emergence delirium have negative behavioral changes after hospital discharge. AIM This observational study investigated the association between emergence delirium and posthospital behavioral changes. METHODS One-hundred preschoolers aged 2-7 years undergoing elective surgery were enrolled in 2 tertiary university hospitals. Preoperative anxiety level was assessed using modified Yale preoperative anxiety scale. Emergence delirium was defined via pediatric anesthesia emergence delirium score ≥12 at any time in the recovery room. We divided the delirium score into a delirium-specific score (the sum of the first 3 items: eye contact, purposeful movement, and awareness of surrounding) and a pain-related score (the sum of the last 2 items: restlessness and inconsolability). High delirium scores represent severe emergence delirium. Posthospital behavioral changes were assessed by a change in Child Behavior Checklist 1.5-5 scores before and 1 week after surgery. The primary outcome was the total behavior checklist scores 1 week after surgery. Multiple linear regression was performed to identify risk factors for posthospital behavioral changes. RESULTS Children with emergence delirium (n = 58) had higher postoperative behavior checklist scores than children without emergence delirium (n = 42) [mean (SD), 22.8 (17.5) vs. 14.0 (12.1); mean difference (95% CI), 8.8 (1.5-16.2)]. Increases in preoperative anxiety level [regression coefficient (b) (95% CI) =0.241 (0.126-0.356)] and peak delirium-specific score [b = 0.789 (0.137-1.442)] were associated with an increase in behavior checklist score 1 week after surgery, while pain-related score, type of surgery, premedication, and age were not. CONCLUSION Children with emergence delirium developed more severe behavior changes 1 week after surgery than those without emergence delirium. High preoperative anxiety level and emergence delirium scores were associated with posthospital behavioral changes.
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Affiliation(s)
- Jonghae Kim
- Department of Anesthesiology and Pain Medicine, Daegu Catholic University Medical Center, School of Medicine, Daegu Catholic University, Daegu, Korea
| | - Sung Hye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University, Daegu, Korea
| | - Jun Won Kim
- Department of Psychiatry, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Yun Jin Kim
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Nayeon Choi
- Biostatistical Consulting and Research Lab, Medical Research Collaborating Center, Hanyang University, Seoul, Korea
| | - Bong Soo Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Seungcheol Yu
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Eugene Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Medical Center, College of Medicine, Hanyang University, Seoul, Korea
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Tennant M, Anderson N, Youssef GJ, McMillan L, Thorson R, Wheeler G, McCarthy MC. Effects of immersive virtual reality exposure in preparing pediatric oncology patients for radiation therapy. Tech Innov Patient Support Radiat Oncol 2021; 19:18-25. [PMID: 34286115 PMCID: PMC8274338 DOI: 10.1016/j.tipsro.2021.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Procedural anxiety in children undergoing radiation therapy (RT) is common and is associated with poor procedural compliance and an increased used of general anaesthesia (GA). There is emerging evidence that Virtual Reality (VR) technology may reduce medical procedural distress through realistic and educative exposure to actual procedures via virtual simulation. OBJECTIVE To examine the feasibility, acceptability and efficacy of an Immersive VR exposure intervention aimed at reducing anxiety and enhancing preparedness for pediatric patients undergoing radiation therapy, and their parents. METHOD A convenience sample of patients (6-18 years) scheduled for RT, and their parent caregivers, were recruited consecutively over a 14-month period. Patients were exposed to a virtual simulation of both CT Simulation (Phase 1) and RT (Phase 2), prior to these procedures occurring. Pre-and-post VR intervention measures (anxiety, health literacy) were administered across multiple time points. GA requirement following VR intervention was also recorded. RESULTS Thirty children and adolescents were recruited (88% participation rate). High VR acceptability and satisfaction was reported by patients, parents and radiation therapists. There were minimal adverse effects associated with VR. The VR intervention was found to improve children's understanding of the RT procedures (health literacy) and lower pre-procedural child and parental anxiety. Only one child in the study required GA (3.33%). CONCLUSIONS This study provides novel and preliminary support for utilizing VR to prepare children and families for RT. Subsequent implementation of VR into routine paediatric RT has the potential to improve clinical and operational outcomes.
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Affiliation(s)
- Michelle Tennant
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria 3052, Australia
- School of Psychology, Faculty of Health, Deakin University, Geelong, Victoria 3220, Australia
- Children’s Cancer Centre, The Royal Children’s Hospital, Parkville, Victoria 3052, Australia
| | - Nigel Anderson
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - George J. Youssef
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria 3052, Australia
- Centre for Adolescent Health, Murdoch Children’s Research Institute, Parkville, Victoria 3052, Australia
| | - Laura McMillan
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria 3052, Australia
| | - Renae Thorson
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
| | - Greg Wheeler
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria 3000, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria 3010, Australia
| | - Maria C. McCarthy
- Clinical Sciences, Murdoch Children’s Research Institute, Parkville, Victoria 3052, Australia
- Children’s Cancer Centre, The Royal Children’s Hospital, Parkville, Victoria 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria 3052, Australia
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Tran J, Chen JW, Trapp L, McCormack L. An Investigation of the Long and Short Term Behavioral Effects of General Anesthesia on Pediatric Dental Patients With Autism. FRONTIERS IN ORAL HEALTH 2021; 2:679946. [PMID: 35048025 PMCID: PMC8757844 DOI: 10.3389/froh.2021.679946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The purpose of this study was to compare the incidence of short and long term adverse behavioral effects of general anesthesia (GA) in healthy vs. moderate to severe autistic (ASD) children. Methods: Forty healthy and 37 ASD children, aged 3–17 years, undergoing GA for dental surgery participated in this study. Their anesthesia records were reviewed, and their parents answered telephone surveys to assess activity level, sleep disturbances, gastrointestinal disturbances, central nervous system effects, and respiratory depression. Three follow-up surveys were taken 8 h, 24 h, and 3 months post-surgery. Results: Four hundred fifty-five incidences of adverse behavioral effects occurred within 8 h post-surgery. Significantly more ASD patients had difficulty walking (P = 0.016) and nausea (P = 0.030), while more healthy children snored in the car ride home (P = 0.036) and talked about the dental surgery (P = 0.027). Three months post-discharge, sixASD patients acted in a way that concerned caregivers compared to 0 healthy patients, (P = 0.008). Incidence of adverse behavioral effects significantly decreased from 8 to 24 h overall. Conclusions: Most behavioral effects occur within 8 h post-surgery. There are potential long term adverse behavioral effects in ASD children from GA, but the chance is low and generally not long lasting.
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Affiliation(s)
- Janine Tran
- Dental Resident, Pediatric Dentistry, Loma Linda, CA, United States
| | - Jung-Wei Chen
- Pediatric Dentistry, Loma Linda, CA, United States
- *Correspondence: Jung-Wei Chen
| | - Larry Trapp
- Dental Anesthesiologist, Loma Linda, CA, United States
| | - Laura McCormack
- Private Practice Dentist, Pediatric Dentistry, Irvine, CA, United States
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21
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Sun JJ, Zhu CY, Jiang HY. Exposure to general anaesthesia in childhood and the subsequent risk of attention-deficit hyperactivity disorder: A meta-analysis of cohort studies. Asian J Psychiatr 2021; 62:102708. [PMID: 34052708 DOI: 10.1016/j.ajp.2021.102708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/10/2021] [Accepted: 05/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The evidence for a relationship between general anaesthesia induced in childhood and the risk of attention-deficit hyperactivity disorder (ADHD) in later life is inconsistent. We systematically assessed whether such an association existed. METHODS We searched the PubMed and EMBASE databases for relevant cohort studies. Relative risks (RRs) and 95 % confidence intervals (CIs) were calculated to determine the relationship between induction of childhood general anaesthesia and the risk of ADHD in later life. RESULTS Seven studies (eight publications) on developmental outcomes after the induction of childhood general anaesthesia met our inclusion criteria but not our exclusion criteria. Repeat childhood general anaesthesia (RR = 1.84, 95 CI% 1.14-2.97; P < 0.001; I2 = 74.8 %), but not one-off general anaesthesia (RR = 1.09, 95 CI% 0.93-1.27; P = 0.301; I2 = 0%), was associated with an increased risk of ADHD in later life. The association was evident only when the total general anaesthesia exposure exceeded 90 min. CONCLUSIONS Our meta-analysis indicated that the effect of general anaesthesia on the risk of ADHD is dose- or duration-dependent.
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Affiliation(s)
- Ji-Jun Sun
- No.3 Psychiatry Department, Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.
| | - Chun-Yan Zhu
- No.6 Psychiatry Department, Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Hai-Yin Jiang
- Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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22
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Abstract
AIMS Aneurysmal bone cysts (ABCs) are locally aggressive lesions typically found in the long bones of children and adolescents. A variety of management strategies have been reported to be effective in the treatment of these lesions. The purpose of this review was to assess the effectiveness of current strategies for the management of primary ABCs of the long bones. METHODS A systematic review of the published literature was performed to identify all articles relating to the management of primary ABCs. Studies required a minimum 12-month follow-up and case series reporting on under ten participants were not included. RESULTS A total of 28 articles meeting the eligibility criteria were included in this review, and all but one were retrospective in design. Due to heterogeneity in study design, treatment, and outcome reporting, data synthesis and group comparison was not possible. The most common treatment option reported on was surgical curettage with or without a form of adjuvant therapy, followed by injection-based therapies. Of the 594 patients treated with curettage across 17 studies, 86 (14.4%) failed to heal or experienced a recurrence. Similar outcomes were reported for 57 (14.70%) of the 387 patients treated with injection therapy across 12 studies. Only one study directly compared curettage with injection therapy (polidocanol), randomizing 94 patients into both treatment groups. This study was at risk of bias and provided low-quality evidence of a lack of difference between the two interventions, reporting success rates of 93.3% and 84.8% for injection and surgical treatment groups, respectively. CONCLUSION While both surgery and sclerotherapy are widely implemented for treatment of ABCs, there is currently no good quality evidence to support the use of one option over the other. There is a need for prospective multicentre randomized controlled trials (RCTs) on interventions for the treatment of ABCs. Cite this article: Bone Jt Open 2021;2(2):125-133.
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Affiliation(s)
- Luckshman Bavan
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Asanka Wijendra
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alpesh Kothari
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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23
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Ing C, Jackson WM, Zaccariello MJ, Goldberg TE, McCann ME, Grobler A, Davidson A, Sun L, Li G, Warner DO. Prospectively assessed neurodevelopmental outcomes in studies of anaesthetic neurotoxicity in children: a systematic review and meta-analysis. Br J Anaesth 2021; 126:433-444. [PMID: 33250180 PMCID: PMC8040118 DOI: 10.1016/j.bja.2020.10.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/08/2020] [Accepted: 10/18/2020] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Caleb Ing
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, New York, NY, USA.
| | - William M Jackson
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | | | - Terry E Goldberg
- Department of Psychiatry and Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Mary-Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Anneke Grobler
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Andrew Davidson
- Murdoch Children's Research Institute, Melbourne, Australia; Department of Anaesthesia and Pain Management, Royal Children's Hospital, Melbourne, Australia
| | - Lena Sun
- Departments of Anesthesiology and Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, New York, NY, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Lau KTR, John J, Eaton KA, Keightley AJ. Service evaluation of the paediatric dental general anaesthesia service in NHS Lothian. Br Dent J 2020:10.1038/s41415-020-1982-z. [PMID: 32855519 PMCID: PMC7451226 DOI: 10.1038/s41415-020-1982-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective To gain insight into the reasons for children undergoing dental treatment under general anaesthesia in NHS Lothian.Methods This service evaluation was based on a representative sample size of 294 patients, randomly selected from the 1,236 children seen for dental general anaesthesia (DGA) during 2017 in NHS Lothian. Data on patient and treatment descriptors were collected retrospectively from clinical records and analysed to identify significant correlations.Results The data indicated paediatric DGAs were mostly provided due to dental caries (88%, 260/294) and for children from the most deprived areas of Lothian. Most children were referred because they were of a very young age or had needs which precluded treatment under local anaesthesia (LA). Almost every child had teeth extracted under DGA (99%, 290/294) and a third of children received restorations (33%, 96/294).Discussion and conclusion This study highlighted the disproportionate increased risk of dental caries and DGA in children from more deprived backgrounds, despite a nationwide reduction of children with caries experience. There is a need for more holistic, whole-system approaches to reduce child dental caries, with opportunities for collaborative work with local stakeholders to follow-up children who have had DGA. More research is needed locally and nationally to inform the translation of evidence into effective interventions.
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Affiliation(s)
- Kirstie T-R Lau
- Senior House Officer, Oral and Maxillofacial Surgery, Torbay Hospital, Newton Road, Torquay, Devon, TQ2 7AA, UK.
| | - Jeyanthi John
- Consultant, Dental Public Health, Wessex & Thames Valley, Public Health England South East, Wellington House, 133-155 Waterloo Road, Lambeth, London, SE1 8UG, UK
| | - Kenneth A Eaton
- Honorary Professor, University of Kent, Centre for Professional Practice, Compass Centre South, Chatham Maritime, Kent, ME4 4YG, UK
| | - Alexander J Keightley
- Consultant, Paediatric Dentistry, Edinburgh Dental Institute, Lauriston Building, Lauriston Place, Edinburgh, EH2 9HA, UK
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Marquez JL, Wang E, Rodriguez ST, O'Connell C, Munshey F, Darling C, Tsui B, Caruso J, Caruso TJ. A retrospective cohort study of predictors and interventions that influence cooperation with mask induction in children. Paediatr Anaesth 2020; 30:867-873. [PMID: 32452092 DOI: 10.1111/pan.13930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation. AIM The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation. METHODS This retrospective cohort study included patients 2-11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed-effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed-effects logistic regression was used to examine the association between preoperative interventions and cooperation. RESULTS 9692 patients underwent 23 474 procedures during the study period. 3372 patients undergoing 5980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002). CONCLUSION In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.
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Affiliation(s)
- Juan L Marquez
- Department of Preventive Medicine, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Ellen Wang
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Samuel T Rodriguez
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Chloe O'Connell
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Farrukh Munshey
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Curtis Darling
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ban Tsui
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph Caruso
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Thomas J Caruso
- Division of Pediatric Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Foubert R, Devroe S, Foubert L, Van de Velde M, Rex S. Anesthetic neurotoxicity in the pediatric population: a systematic review of the clinical evidence. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
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.
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Diana P, Joksimovic SM, Faisant A, Jevtovic-Todorovic V. Early exposure to general anesthesia impairs social and emotional development in rats. Mol Neurobiol 2020; 57:41-50. [PMID: 31494825 PMCID: PMC6980478 DOI: 10.1007/s12035-019-01755-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 11/25/2022]
Abstract
Several animal and emerging human studies suggest an association between an early exposure to general anesthesia (GA) and long-lasting problems with complex social and emotional behaviors such as inattentiveness, impulsivity, anxiogenic tendencies, as well as difficulties engaging in proper social intercourse, with significant increase in attention deficit and hyperactivity-type behaviors. To further investigate these behaviors, and to examine the potential of presently available rodent behavioral models to guide future assessments of long-term socio-emotional impairments in humans, we examined the long-term effects of GA on anxiety/fear and social behaviors. We exposed male and female Sprague-Dawley infant rats at the peak of their synaptogenesis to either GA containing midazolam (9 mg/kg, i.p.), 70% nitrous oxide (N2O) and 0.75% isoflurane (Iso) administered in 29-30% oxygen (experimental), or air (with 30% oxygen) plus the vehicle, 0.1% dimethyl sulfoxide (Sham) for 6 h. Behavioral experiments were conducted at adolescence (the open-field test) and young adulthood (the open-field test, the elevated plus-maze and the social novelty test). We report that an early exposure to GA during critical stages of brain development results in long-lasting increase in risk-taking tendencies and significant changes in the anxiety-related behaviors when tested in young adult rats. In addition, we noted novelty-seeking tendencies/less guarded behavior with changes in social discrimination. We conclude that early exposure to anesthesia may have lasting influences on emotional and social development. Importantly, our results show that currently used rodent behavioral models could be a good correlate to assess long-term socio-emotional GA-induced impairments observed in humans.
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Affiliation(s)
- Paolo Diana
- Department of Medicine, University of Padua, Padua, Italy
| | - Srdjan M Joksimovic
- Department of Anesthesiology, University of Colorado School of Medicine, 12801 E. 17th Avenue, Rm L18-4100, Aurora, CO, USA
| | - Azra Faisant
- School of Nursing, University of Virginia, Charlottesville, VA, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado School of Medicine, 12801 E. 17th Avenue, Rm L18-4100, Aurora, CO, USA.
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Walkden GJ, Pickering AE, Gill H. Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities. Anesth Analg 2019; 128:681-694. [PMID: 30883414 PMCID: PMC6436726 DOI: 10.1213/ane.0000000000004052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.
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Affiliation(s)
- Graham J Walkden
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Anthony E Pickering
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Hannah Gill
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
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29
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Buckwalter KD, Maxon D, Moody K. Prevention of Medical Trauma in Children With Early Onset Scoliosis and the Use of Mehta Casting. Creat Nurs 2019; 25:103-112. [PMID: 31085662 DOI: 10.1891/1078-4535.25.2.103] [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: 11/25/2022]
Abstract
Despite recent emergence of information about treatment of medical trauma in children, the literature remains sparse regarding prevention of medical trauma. Health-care professionals are in an ideal position to educate about and advocate for ways to prevent the far-reaching consequences of medical trauma, yet policies remain which at times contribute to the problem. This article presents practical approaches intended to reduce the likelihood of medical trauma in children receiving serial casting for treatment of progressive infantile scoliosis (PIS). The majority of the suggestions apply not only to children being treated for PIS, but to children receiving medical treatment for many conditions. The article also provides suggestions for parents who are enduring the stress of their child undergoing repeated surgeries and hospital stays. The authors interviewed a variety of experts in the field and draw on their own experiences as clinical social workers specializing in the treatment of post-traumatic stress disorder and developmental trauma in children.
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30
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General anesthetic neurotoxicity in the young: Mechanism and prevention. Neurosci Biobehav Rev 2019; 107:883-896. [PMID: 31606415 DOI: 10.1016/j.neubiorev.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/27/2019] [Accepted: 10/04/2019] [Indexed: 12/17/2022]
Abstract
General anesthesia (GA) is usually considered to safely induce a reversible unconscious state allowing surgery to be performed without pain. A growing number of studies, in particular pre-clinical studies, however, demonstrate that general anesthetics can cause neuronal death and even long-term neurological deficits. Herein, we report our literature review and meta-analysis data of the neurological outcomes after anesthesia in the young. We also review available mechanistic and epigenetic data of GA exposure related to cognitive impairment per se and the potential preventive strategies including natural herbal compounds to attenuate those side effects. In summary, anesthetic-induced neurotoxicity may be treatable and natural herbal compounds and other medications may have great potential for such use but warrants further study before clinical applications can be initiated.
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31
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The dental health of cleft patients attending the 18-month-old clinic at a specialised cleft centre. Br Dent J 2019; 227:199-202. [DOI: 10.1038/s41415-019-0608-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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32
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Controlled isoflurane anesthesia exposure is required for reliable behavioral testing in murine surgical models. J Pharmacol Sci 2019; 140:106-108. [DOI: 10.1016/j.jphs.2019.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 01/08/2023] Open
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33
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Limb Remote Ischemic Preconditioning Reduces Repeated Ketamine Exposure-Induced Adverse Effects in the Developing Brain of Rats. J Mol Neurosci 2019; 68:58-65. [DOI: 10.1007/s12031-019-01282-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 02/18/2019] [Indexed: 11/26/2022]
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34
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Xu L, Hu Y, Huang L, Liu Y, Wang B, Xie L, Hu Z. The association between attention deficit hyperactivity disorder and general anaesthesia - a narrative review. Anaesthesia 2018; 74:57-63. [PMID: 30511754 DOI: 10.1111/anae.14496] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2018] [Indexed: 11/30/2022]
Affiliation(s)
- L. Xu
- Department of Anesthesiology; Women's Hospital; Zhejiang University School of Medicine; Hangzhou China
| | - Y. Hu
- Department of Cell Biology; Yale University; New Haven CT USA
| | - L. Huang
- Department of Anesthesiology; The Children's Hospital; Zhejiang University School of Medicine; Hangzhou China
| | - Y. Liu
- Department of Anesthesiology; The Children's Hospital; Zhejiang University School of Medicine; Hangzhou China
| | - B. Wang
- Department of Anesthesiology; The Children's Hospital; Zhejiang University School of Medicine; Hangzhou China
| | - L. Xie
- Department of Anesthesiology; The Children's Hospital; Zhejiang University School of Medicine; Hangzhou China
| | - Z. Hu
- Department of Anesthesiology; The Children's Hospital; Zhejiang University School of Medicine; Hangzhou China
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35
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Clausen N, Kähler S, Hansen T. Systematic review of the neurocognitive outcomes used in studies of paediatric anaesthesia neurotoxicity. Br J Anaesth 2018; 120:1255-1273. [DOI: 10.1016/j.bja.2017.11.107] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/22/2017] [Accepted: 11/21/2017] [Indexed: 01/08/2023] Open
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36
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LaBarbera V, García PS, Bliwise DL, Trotti LM. Central Disorders of Hypersomnolence, Restless Legs Syndrome, and Surgery With General Anesthesia: Patient Perceptions. Front Hum Neurosci 2018; 12:99. [PMID: 29615884 PMCID: PMC5869929 DOI: 10.3389/fnhum.2018.00099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 03/05/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction: The importance of obstructive sleep apnea in patients undergoing surgery with general anesthesia is well-defined, but the surgical and anesthetic implications of other sleep disorders are less clear. We sought to evaluate response to surgery with general anesthesia in patients with central disorders of hypersomnolence or restless legs syndrome. Methods: We surveyed patients on their most recent surgical procedure with general anesthesia, querying about procedure, recovery, and any changes in sleep disorder symptomatology following the procedure. Results: Forty-five patients with restless legs syndrome and 57 patients with central disorders of hypersomnolence (15 narcolepsy type 2, 1 narcolepsy type 1, 30 idiopathic hypersomnia, 1 Kleine-Levin syndrome, and 10 subjective sleepiness) completed the survey, with response rates of 45.5 and 53.8%, respectively. While patients in both groups were equally likely to report surgical complications and difficulty awakening from anesthesia, hypersomnolent patients were more likely to report worsened sleepiness (40% of the hypersomnolent group vs. 11% of the RLS group, p = 0.001) and worsening of their sleep disorder symptoms (40% of the hypersomnolent group vs. 9% of the RLS group, p = 0.0001). Conclusion: Patients with sleep disorders other than sleep apnea frequently report surgical or anesthetic complications. Patients with hypersomnolence disorders commonly perceive that their sleep disorder worsened following a procedure; whether this might be related to long term effects of general anesthesia in a particularly vulnerable clinical population requires further study.
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Affiliation(s)
- Vincent LaBarbera
- Sleep Center and Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Paul S García
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, United States.,Research and Anesthesiology Service Lines, Atlanta VA Medical Center, Atlanta, GA, United States
| | - Donald L Bliwise
- Sleep Center and Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Lynn M Trotti
- Sleep Center and Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
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Betulinic acid protects the neuronal damage in new born rats from isoflurane-induced apoptosis in the developing brain by blocking FASL-FAS signaling pathway. Biomed Pharmacother 2017; 95:1631-1635. [PMID: 28950663 DOI: 10.1016/j.biopha.2017.09.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 11/22/2022] Open
Abstract
Betulinic acid (BA) is a naturally occurring pentacyclic lupane group triterpenoid, has reported to protect cerebral ischemia. Present study evaluates the protective effect of betulinic acid on the isoflurane-induced neuronal damage in neonatal mice. All the mice of 7days age were exposed to isoflurane (2%; 2h) for the duration of 3day. At the end of protocol cognitive function was evaluated by Morris water maze (MWM) test. However count of apoptotic cells were estimated by TUNEL staining. Concentration of oxidative stress parameters [superoxide dismutase (SOD); catalase (CAT) and reduced glutathione (GSH)], cytokines [tumor necrosis factor (TNF-α); interlukin-6 (IL-6) and IL-1β] and expressions of caspase 3, FAS and FASL were estimated in the neuronal cells. Result of the study suggested that treatment with betulinic acid significantly reduces the escape latency and enhances platform crossing time than negative control group. Count of apoptotic cells were also found to be reduced in BA treated group of mice than negative control group. Moreover treatment with BA significantly attenuates the concentration of inflammatory cytokines and oxidative stress in isoflurane induced neonatal mice. However expressions of caspase-3, FAS/FASL was found to be significantly reduced in BA treated group of mice than negative control group. Present study concludes the neuroprotective effect of betulinic acid in isoflurane-induced brain damage in developing brain by attenuating the apoptosis through Fas/FASL pathway inhibition.
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Anesthesia, brain changes, and behavior: Insights from neural systems biology. Prog Neurobiol 2017; 153:121-160. [PMID: 28189740 DOI: 10.1016/j.pneurobio.2017.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 02/08/2023]
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39
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Kwok MMK, Paddle P. Median philtrum sinus: a rare presentation and review of management options. BMJ Case Rep 2017; 2017:bcr-2017-219779. [PMID: 28473432 DOI: 10.1136/bcr-2017-219779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Nasal dermoids are rare congenital abnormalities, and there is only one previously reported case of a philtrum sinus tract extending to the skull base. A 2-month-old boy was presented with an incidental finding of a median philtrum sinus with no infective features and no other abnormal clinical findings. MRI demonstrated a sinus tract extending from the philtrum to the crista galli. On multidisciplinary review, a conservative approach was taken due to the asymptomatic nature of the patient. Given the rarity of nasal dermoids, diagnosis requires precise clinical examination and MRI to identify the extent of the tract. Management options require a multidisciplinary case-specific approach and include non-surgical as well as surgical approaches.
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Affiliation(s)
- Matthew Ming Kei Kwok
- Otolaryngology, Head and Neck Surgery, Monash Health, Bentleigh East, Victoria, Australia
| | - Paul Paddle
- Otolaryngology, Head and Neck Surgery, Monash Health, Bentleigh East, Victoria, Australia.,Surgery, Monash University, Clayton, Victoria, Australia
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40
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Almenrader N, Colucci P, De Castro V, Valeri D, Palmery M, Trezza V, Campolongo P. Effects of sevoflurane and clonidine on acid base status and long-term emotional and cognitive outcomes in spontaneously breathing rat pups. PLoS One 2017; 12:e0173969. [PMID: 28319126 PMCID: PMC5358762 DOI: 10.1371/journal.pone.0173969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 03/01/2017] [Indexed: 12/20/2022] Open
Abstract
Background Numerous experiments in rodents suggest a causative link between exposure to general anaesthetics during brain growth spurt and poor long-lasting neurological outcomes. Many of these studies have been questioned with regard of their translational value, mainly because of extremely long anaesthesia exposure. Therefore, the aim of the present study was to assess the impact of a short sevoflurane anaesthesia, alone or combined with clonidine treatment, on respiratory function in spontaneously breathing rat pups and overall effects on long-lasting emotional and cognitive functions. Methods At postnatal day (PND) 7, male Sprague Dawley rat pups were randomized into four groups and exposed to sevoflurane for one hour, to a single dose of intraperitoneal clonidine or to a combination of both and compared to a control group. Blood gas analysis was performed at the end of sevoflurane anaesthesia and after 60 minutes from clonidine or saline injection. Emotional and cognitive outcomes were evaluated in different group of animals at infancy (PND12), adolescence (PND 30–40) and adulthood (PND 70–90). Results Rat pups exposed to either sevoflurane or to a combination of sevoflurane and clonidine developed severe hypercapnic acidosis, but maintained normal arterial oxygenation. Emotional and cognitive outcomes were not found altered in any of the behavioural task used either at infancy, adolescence or adulthood. Conclusions Sixty minutes of sevoflurane anaesthesia in newborn rats, either alone or combined with clonidine, caused severe hypercapnic acidosis in spontaneously breathing rat pups, but was devoid of long-term behavioural dysfunctions in the present setting.
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Affiliation(s)
- Nicole Almenrader
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- Department of Anaesthesia and Intensive Care, Policlinico Umberto I, Rome, Italy
| | - Paola Colucci
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Valentina De Castro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Daniela Valeri
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Maura Palmery
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - Viviana Trezza
- Department of Science, Section of Biomedical Sciences and Technologies, University “Roma Tre”, Rome, Italy
| | - Patrizia Campolongo
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
- * E-mail:
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