Best practice & research. Clinical anaesthesiology
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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
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
ReviewNeuroprotective strategies in anesthesia-induced neurotoxicity.
Over the past 20 years, hundreds of preclinical studies of the developing central nervous system have been published concluding that the common γ-aminobutryic acid and N-methyl-d-aspartate binding anesthetic agents cause neuroapoptosis and other forms of neurodegeneration. Some clinical studies, including controlled trials, both prospective and ambidirectional in design, indicate an association between any exposure (single or multiple) to anesthesia and surgery at a young age, generally less than 3-4 years, and later behavioral and neurodevelopmental problems. A consideration of neuroprotective strategies is important, as scientists and clinicians alike ponder methods to potentially improve the neurodevelopmental outcomes of the millions of infants and children who undergo surgery and anesthesia annually around the world. This review will address plausible neuroprotective strategies and include alternative anesthetics, neuroprotective nonanesthetic drugs, and physiologic neuroprotection.
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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
ReviewClinical investigations on anesthesia-induced developmental neurotoxicity: The knowns, the unknowns and future prospects.
Pre-clinical experimental evidence, along with a plausible biological rational suggests that exposure of neonates and young children to anesthesia may harm brain development. However, the translational relevance of these observations remains unsolved. While a variety of lasting morpho-functional effects can be attributed to early life exposure to anesthetics in laboratory animals, we do not have a convincing human phenotype that reflects any causal effects of general anesthetic exposure on brain development and functional outcome. This review is aimed to provide a comprehensive description of the current state of clinical research alongside exploring future challenges in this field by focusing on the critical appraisal of methodological approaches applied in clinical research into developmental anesthesia neurotoxicity.