Andersons pediatric cardiology 2300
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (58.53 KB, 3 trang )
EffectsofAnestheticExposureonBrain
Development
Substantialconcernshaverecentlybeenraisedregardingthepotential
deleteriouseffectsofrepeatedorprolongedanestheticexposuresinyoung
childrenontheirbraindevelopment(seealsoChapter76).Anesthetic
neurotoxicity,asitistermed,hasnowbeendemonstratedinmorethan500
animalstudies;brainstructuralabnormalities,suchasaltereddendritic
branching,synapticdegeneration,andwidespreadbraincelldeathhavebeen
observedinawidevarietyofanimalspecies,includingnonhumanprimates,
immediatelyfollowingprolongedexposuretoallroutinelyutilizedgeneral
anesthetics.Alarmingly,long-termcognitiveimpairmentandbehavioraldeficits
havebeendemonstratedinseveralspecies,includingrhesusmonkeys,following
anestheticexposuresearlyinlife(reviewedbyLinetal.94).Whilethehuman
applicabilityoftheseanimaldataremainscontroversial,severalepidemiologic
studieshavefoundbehavioralandcognitiveabnormalitiesinchildren,especially
followingrepeatedexposuresatayoungage.Thishasculminatedinawarning
publishedbytheUSFoodandDrugAdministrationforexposuresofgreaterthan
3hoursinchildrenyoungerthan3years.ChildrenwithcomplexCHDrepresent
agroupofpatientswithdisproportionateexposureburdentoanestheticsand
sedativesatayoungageinordertofacilitaterepeatedsurgeries,interventions
andimagingstudies.Moreover,developmentaldelayandcognitive
abnormalitieshavebeenobservednotinfrequentlyinchildrensufferingfrom
complexCHD.95Recently,exposuretoanestheticsandsedativeshasbeen
independentlyassociatedwithdiminishedcognitiveperformanceinchildren
followingcongenitalheartsurgery.96,97WhiletheFDAacknowledgesthat
medicallynecessaryproceduresshouldnotbedelayedoravoided,itis
imperativethatresearcheffortsareintensifiedtobetterunderstandthe
phenomenon'smechanisms,todevisemitigatingstrategies,andtodevelopsafer
anesthetictechniques.
Animaldatasuggestthatbrainregionsmaybedifferentiallyaffected
dependingontheirmaturationalstageduringtheexposure.98Accordingly,since
anestheticsseemtointerferewithneuronaldevelopmentatanimmaturecellular
stage,99anestheticexposuresatdifferentagescouldpotentiallyaffectdifferent
neurologicdomainsparticularlywhenneurogenesisisincreasedtolearnanew
cognitiveskill.Clearly,additionalresearchbothinhumansandinanimalsis
neededtodeterminehumansusceptibilityandpotentialmitigatingstrategies.
Summary
Insummary,childrenandadultswithmajorCHDrepresentachallengingpatient
populationwhorequirerepeatedanestheticexposurestoundergolife-savingand
quality-of-life–improvingprocedures.Adedicatedanesthesiacareteamdirected
byapediatriccardiacanesthesiologistisbestqualifiedtotakecareofhigh-risk
patients.PatientswithrepairedorpalliatedCHDoflessercomplexitycanbe
caredforbyotheranesthesiaproviders;however,practitionersneedtobe
familiarwiththeirspecificphysiologyandpathophysiology.Giventhe
requirementsforrepeatedandprolongedexposurestoanestheticandsedativesat
ayoungageinthisvulnerablepatientpopulation,concernsforabnormalbrain
developmentneedtobefurtheraddressed.Additionalresearchisurgently
neededtoimprovesafetyandreducemorbidityandmortalityinthiscomplex
andever-evolvingpopulation.
