Neurotoxicity versus Neuroprotection of Anesthetics: Young Children on the Ropes?

Abstract

Normal brain development in young children depends on a balance between excitation and inhibition of neurons, and alterations to this balance may cause apoptosis. During the perioperative period, both surgical stimuli and anesthetics can induce neurotoxicity. This article attempts to expand the perspective of a topical issue-anesthetic-induced neurotoxicity-by also considering the protective effect of general anesthetics against surgery-induced neurotoxicity, all of which may generate some controversy in the current literature. The "new" major factor influencing neurotoxicity-nociceptive stimulus-is discussed together with other factors to develop clinical and research strategies to obtain a balance between neurotoxicity and neuroprotection.

Pediatric spinal anesthesia at a tertiary care hospital: Eleven years after

“…Pending further scientific evidence on this issue, spinal block could be considered a very suitable option in children under 3 years of age, as long as the site and duration of the surgical procedure allow it, and bearing in mind the specific risks of spinal blockade such as needle trauma, PDPH, perimedullar/subdural/epidural hematoma, meningitis, or drug error. 20,10,15,8 Regarding indications for spinal block, they were initially made for the target patient and target surgery of spinal anesthesia: the expremature infant undergoing inguinal herniotomy. Given the positive outcomes, indications were subsequently extended to other types of patients (i.e., congenital heart diseases, metabolic disorders, or risk of malignant hyperthermia) and procedures (i.e., pyloromyotomy or muscle biopsy).…”

“…However, spinal block did not become popular again until 1980s, when Abajian first described the high-risk infant (subsequently defined as the ex-premature infant whose postmenstrual age [PMA] at surgery is <60 weeks) as a target patient for this technique, and over the last few years, due to the growing concern about the potential general anesthetic-induced neurotoxicity in young children. [4][5][6][7][8] While its current use is not so widespread, this technique has various advantages compared to general anesthesia, by reducing the risk of cardiorespiratory events (hypoxemia, bradycardia, and hypotension) associated with general anesthesia, especially in neonates and infants. The main limitation is the duration of the anesthetic block, which reduces the number of surgical procedures to be undertaken under this technique to those lasting less than 90 min.…”

Opioid-free anesthesia with interfascial dexmedetomidine in a high-risk infant

“…It therefore represents a cornerstone of “low-neurotoxicity anesthesia” and OFA, being a technique of choice in high-risk infants. [ 10 11 12 ]…”

“…It also reduces pain and postoperative analgesia needs by >50%, and extends the duration of analgesia by >50% in the first 24 hours. [ 12 13 14 15 ]…”

Conflicting Actions of Inhalational Anesthetics, Neurotoxicity and Neuroprotection, Mediated by the Unfolded Protein Response

“…Exposure to sevoflurane has also been shown to improve cognitive function in both young (8-10 weeks) and aged rats (19 months) [13]. The general mechanism responsible for these conflicting effects, neurotoxicity and neuroprotection, remains unelucidated [14][15][16].…”