Background Dental procedures under general anesthesia (DGA) was found to improve the oral health-related quality of children’s life. However, some parents and pediatricians expressed concern about the neurotoxicity of general anesthesia. The purpose of this trial was to whether DGA in children has an adverse effect on neurocognition. Methods In this prospective, assessor-masked, controlled, equivalence trial, we recruited 340 children younger than 7 years who were undergoing caries treatment between Feb 1, 2019, and Aug 31, 2019, without factors affecting neurodevelopment. They received either sevoflurane-based general anesthesia or awake-local anesthesia. The Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition was used to evaluate the neurocognitive function of children at 6 months after surgery, and the Full-Scale IQ (FSIQ) was selected as the primary outcome. The predefined clinical equivalence margin was 5 (1/3 SD of FSIQ score). If the 95% CI of the difference between the average FSIQ score of the two groups is within − 5 to + 5, then the two groups are equivalent. Results The outcome data were obtained from 129 children in the general anesthesia group and 144 in the local anesthesia group. The median length of general anesthesia was 130 min (IQR 110–160). The mean FSIQ score in the general anesthesia group was 103·12 (SD 8.94), and the mean of the local anesthesia group was 103·58 (SD 8.40). There was equivalence in means of FSIQ score between the two groups (local minus general anesthesia 0.46, 95% CI − 2.35 to 1.61). There was no significant difference in FSIQ scores between different age groups and different anesthesia durations. Only the mother’s education could affect the primary outcome. Conclusions In this trial, prolonged DGA with a sevoflurane-only anesthetic in preschool children, does not adversely affect neurocognitive function at 6 months after surgery compared with awake-local anesthesia. Trial registration Chinese Clinical Trial Registry, ChiCTR1800015216. Registered Mar 15 2018.
The anterior cingulate cortex (ACC) plays a key role in regulating mood in animals, especially anxiety, and is also a brain region that is indispensable to pain perception. Postoperative anxiety is closely related to the experience of pain. Remifentanil is a commonly used surgical analgesic. The mechanism of supraspinal hyperalgesia caused by remifentanil remains unclear. We used animal models to simulate postoperative hyperalgesia and studied the GluR1 AMPA receptor subunit in the ACC using western blots and immunocytochemistry. Behavioral tests were used to estimate anxiety levels. We found no significant change in GluR1 levels before and after hyperalgesia, whereas phosphorylation of GluR1 was significantly increased after hyperalgesia. Double staining for c-Fos, widely used as a marker of neural activation, and Arc, which facilitates GluR1 endocytosis, revealed that neural activation increased and the expression of Arc decreased after hyperalgesia. Local injection of a protein kinase A inhibitor (H89) in the ACC effectively blocked the phosphorylation of GluR1 and alleviated the hyperalgesia and anxiety shown in the behavioral tests. Double staining revealed no significant change in c-Fos or Arc levels after the administration of H89. Local injection of ibotenic acid caused damage to the ACC, following which remifentanil did not induce hyperalgesia or anxiety. These results lead us to conclude that the ACC is a critical hub for remifentanil-induced hyperalgesia (RIH) and RIH-related anxiety and that regulating the phosphorylation of GluR1 may modulate RIH and anxiety. Anxiety may be an influential factor contributing to individual differences in RIH occurrence.
The safety and efficacy of selective antegrade cerebral perfusion (SACP) in children undergoing aortic arch surgery are unclear. In this retrospective analysis, we compared moderate hypothermic circulatory arrest (MHCA; n = 61) plus SACP vs deep hypothermic circulatory arrest (DHCA; n = 53) in children undergoing aortic arch surgery during a period from January 2008 to December 2017. Demographic characteristics and the underlying anomalies were comparable between the two groups. The MHcA + SACP group had shorter cardiopulmonary bypass (CPB) time (146.9 ± 40.6 vs 189.6 ± 41.2 min for DHCA; p < 0.05) and higher nasopharyngeal temperature (26.0 ± 2.1 vs 18.9 ± 1.6 °C; p < 0.01). the MHcA + SACP group had lower rate of neurologic complications (3/61 vs 10/53 for DHCA; p < 0.05) but not complications in other organ systems. The MHCA + SACP group also had less 24-hour chest drainage (median, interquartile rage: 28.9, 12.6-150.0 vs 47.4, 15.2-145.0 ml/kg for DHCA; p < 0.05), shorter duration of postoperative mechanical ventilation (35.0, 15.4-80.3 vs 94.0, 42.0-144.0 h; p < 0.01), and shorter stay in intensive care unit (3.9, 3.0-7.0 vs 7.7, 5.0-15.0 d; p < 0.05). In regression analysis, in-hospital mortality was associated with longer CPB time. In conclusion, MHCA + SAcp is associated with better short-term outcomes in children receiving aortic arch surgery under CPB. Coarctation of the aorta (CoA) and interrupted aortic arch (IAA) are the most common congenital large vascular malformations 1. Surgery should be performed as early as possible. Minimally invasive surgery is recommended for simple CoA/IAA. Patients with other comorbid abnormalities, however, may require open surgery under cardiopulmonary bypass (CPB). Deep hypothermic circulatory arrest (DHCA) is routinely used in aortic arch surgeries that require CPB to minimize cerebral metabolism and to provide clean surgical field 2 , but may lead to hypothermia-induced coagulopathy, capillary leak syndrome, microvasculature endothelial dysfunction, elevated systemic inflammatory response and multiple organ dysfunctions 3. Meanwhile, the time of DHCA is limited by the temperature. Selective antegrade cerebral perfusion (SACP) is designed to supply regional cerebral perfusion through the circle of Willis, and allow longer CPB time than DHCA 4,5. More recently, SACP has been increasingly used with mild hypothermia or normothermia in aortic arch surgery 6. Several studies suggested that SACP in combination with mild hypothermia (core temperature at 30 °C) could provide sufficient cerebral protection in aortic arch surgery that typically lasted for at least 90 minutes 7,8. However, SACP at higher core temperatures has been associated with spinal cord injury and even cerebral thrombosis in some cases. As a result, the use of SACP with normothermia in young children remains controversial 9. In the current retrospective analysis, we used relatively larger number of cases to compare moderate hypothermic circulatory arrest (MHCA) in combination with SACP versus DHCA alone in ...
BackgroundHigh-flow nasal oxygenation (HFNO) has been suggested as an alternative oxygenation method during procedural sedation. This randomized, non-inferiority trial evaluated the safety and efficacy of HFNO compared with laryngeal mask airway (LMA) in pediatric ambulatory oral surgery under deep sedation.MethodsIn total, 120 children aged 2–7 years (weight: 10–30 kg) were equally assigned into two groups, namely, HFNO with propofol total intravenous anesthesia infusion (HFNO-IV) or LMA with propofol total intravenous anesthesia infusion (LMA-IV). The primary objective was to monitor carbon dioxide (CO2) accumulation during perioperative surgery. Secondary objectives included monitoring transcutaneous oxygen saturation, grade exposure to the surgical field, perioperative adverse events, or other events. The predefined non-inferiority margin was 7 mmHg. During the COVID-19 pandemic, a novel WeChat applet was implemented to gather follow-up data after discharge.ResultsNon-inferiority could be declared for HFNO relative to LMA (mean difference in transcutaneous CO2 (TcCO2) = −1.4 mmHg, 95% CI: −2.9, 0.1 mmHg; P > 0.05). The pre-surgical TcCO2 of the HFNO-IV group (45.4 ± 4.5 mmHg) was similar to that of the LMA-IV group (44.0 ± 3.5 mmHg), within the clinically acceptable normal range. All the children maintained SpO2 levels of >97%. The surgical field exposure score of the HFNO group was significantly better than that of the LMA group. There was no significant difference between the two groups regarding risk or adverse events.ConclusionHFNO was not inferior to LMA for maintaining oxygenation and ventilation in patients undergoing pediatric ambulatory oral surgery under deep sedation under strict isolation from the oral cavity to the upper airway.
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