Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2023
ReviewControversies in anesthesia-induced developmental neurotoxicity.
Advances in the field of pediatric anesthesiology have enabled the performance of complex and life-saving procedures with minimal patient discomfort. However, preclinical studies over the past two decades have been reporting substantial neurotoxic potential of general anesthetics in young brain, thus challenging the safety of these agents in pediatric anesthesiology practice. ⋯ The significant degree of anxiety and apprehension surrounding the uncertainty of long-term developmental outcomes following early exposure to anesthesia has prompted numerous studies around the world to investigate the putative mechanisms and translatability of preclinical findings regarding anesthesia-induced developmental neurotoxicity. Guided by the vast preclinical evidence, we aim to highlight relevant human findings presented in the currently available clinical literature.
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Best Pract Res Clin Anaesthesiol · Mar 2023
ReviewPractical and societal implications of the potential anesthesia-induced neurotoxicity: The safetots perspective.
Key elements for safe and high-quality care in pediatric anesthesia are personal and institutional competence, perioperative maintenance of physiological homeostasis, prevention, prompt recognition, and appropriate treatment of critical situations as well as the reassurance of the parents and respecting the children's rights. Training in pediatric anesthesia should take place within the framework of harmonized curricular structures. ⋯ The Safetots.org initiative was established to emphasize the role of the conduct of anesthesia to prevent harm, promote quality in the perioperative period, and provide safe and high-quality clinical care. This initiative considers that the prevention of complications and other well-known risk factors of perioperative care, as well as the quality of anesthesia management, have a far more important impact on outcomes following anesthesia and surgery than anesthetic drugs themselves.
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Best Pract Res Clin Anaesthesiol · Mar 2023
ReviewIntroduction and history of anaesthesia-induced neurotoxicity and overview of animal models.
Brain development is initiated at around 3 weeks of gestation. The peak velocity of brain weight gain occurs around birth, with the neural circuitry subsequently being refined until at least 20 years of age. Antenatal and postnatal general anaesthesia suppresses neuronal firing during this critical period and may therefore impair brain development, referred to as "anaesthesia-induced neurotoxicity". ⋯ In this article, the history of preclinical and clinical research in anaesthesia-induced neurotoxicity will be reviewed, starting from the pioneering preclinical study in 1999 until the most recent systematic reviews. The mechanisms of anaesthesia-induced neurotoxicity are introduced. Finally, an overview of the methods used in preclinical studies will be provided, with a comparison of the different animal models that have been employed to investigate this phenomenon.
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Providing pain relief during labour is a fundamental human right and can benefit both mother and foetus. Epidural analgesia remains the 'gold standard', providing excellent pain relief, as well as the facility to convert to anaesthesia should operative intervention be required. While maternal well-being remains the primary focus, epidural analgesia may also have implications for the foetus. ⋯ Clinically relevant neonatal outcomes such as Apgar score <7 at 5 min, neonatal resuscitation and need for admission to a neonatal unit are reassuring, with the benefits of epidural analgesia for both mother and neonate outweighing any potential risks. Recent concerns regarding an association of epidural with the development of autism spectrum disorder in childhood appear to be unfounded, with several large observational studies refuting this association. This review discusses the evidence relating to maternal neuraxial analgesia in labour, implications for the foetus in utero, and childhood outcomes both in the immediate peripartum period and longer term.
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Best Pract Res Clin Anaesthesiol · Mar 2023
ReviewPreclinical evidence for anaesthesia-induced neurotoxicity.
Preclinical research concerning anaesthesia-induced neurotoxicity was initiated in 1999. A decade later, the earliest clinical observational data showed mixed results in neurodevelopmental outcomes following anaesthesia exposure at a young age. Hence to date, preclinical studies remain the cornerstone of research in this field, primarily because of the vulnerability of clinical observational studies to confounding bias. ⋯ Across all gestational and postnatal ages, there is evidence that all commonly used general anaesthetics induce neuronal injury (e.g. apoptosis) and cause neurobehavioural impairment (e.g. learning and memory deficits). These deficits were more pronounced when animals were subjected to either repeated exposure, prolonged durations of exposure or higher doses of anaesthesia. To interpret these results in the clinical context, the strengths and limitations of each model and experiment should be carefully considered, as these preclinical studies were often biased by supraclinical durations and a lack of control with regard to physiological homeostasis.