Increasing cumulative exposure to volatile anesthetic agents is associated with poorer neurodevelopmental outcomes in children with hypoplastic left heart syndrome

Toward a brighter constellation: multiorgan neuroimaging of neural and vascular dynamics in the spinal cord and brain

Significance

Pain comprises a complex interaction between motor action and somatosensation that is dependent on dynamic interactions between the brain and spinal cord. This makes understanding pain particularly challenging as it involves rich interactions between many circuits (e.g., neural and vascular) and signaling cascades throughout the body. As such, experimentation on a single region may lead to an incomplete and potentially incorrect understanding of crucial underlying mechanisms.

Aim

We aimed to develop and validate tools to enable detailed and extended observation of neural and vascular activity in the brain and spinal cord. The first key set of innovations was targeted to developing novel imaging hardware that addresses the many challenges of multisite imaging. The second key set of innovations was targeted to enabling bioluminescent (BL) imaging, as this approach can address limitations of fluorescent microscopy including photobleaching, phototoxicity, and decreased resolution due to scattering of excitation signals.

Approach

We designed 3D-printed brain and spinal cord implants to enable effective surgical implantations and optical access with wearable miniscopes or an open window (e.g., for one- or two-photon microscopy or optogenetic stimulation). We also tested the viability for BL imaging and developed a novel modified miniscope optimized for these signals (BLmini).

Results

We describe "universal" implants for acute and chronic simultaneous brain-spinal cord imaging and optical stimulation. We further describe successful imaging of BL signals in both foci and a new miniscope, the "BLmini," which has reduced weight, cost, and form-factor relative to standard wearable miniscopes.

Conclusions

The combination of 3D-printed implants, advanced imaging tools, and bioluminescence imaging techniques offers a coalition of methods for understanding spinal cord-brain interactions. Our work has the potential for use in future research into neuropathic pain and other sensory disorders and motor behavior.

[Formula: see text] The multifaceted role of neuropsychology in pediatric solid organ transplant: preliminary guidelines and strategies for clinical practice

The incidence of pediatric solid organ transplantation (SOT) has increased in recent decades due to medical and surgical advances as well as improvements in organ procurement. Survival rates for pediatric kidney, liver, and heart transplantation are above 85% but patients continue to experience complex healthcare needs over their lifetime. Long-term developmental and neuropsychological sequelae are becoming increasingly recognized in this population, although preliminary work is limited and deserves further attention. Neuropsychological weaknesses are often present prior to transplantation and may be related to underlying congenital conditions as well as downstream impact of the indicating organ dysfunction on the central nervous system. Neuropsychological difficulties pose risk for functional complications, including disruption to adaptive skill development, social-emotional functioning, quality of life, and transition to adulthood. The impact of cognitive dysfunction on health management activities (e.g., medication adherence, medical decision-making) is also an important consideration given these patients' lifelong medical needs. The primary aim of this paper is to provide preliminary guidelines and clinical strategies for assessment of neuropsychological outcomes across SOT populations for pediatric neuropsychologists and the multidisciplinary medical team, including detailing unique and shared etiologies and risk factors for impairment across organ types, and functional implications. Recommendations for clinical neuropsychological monitoring as well as multidisciplinary collaboration within pediatric SOT teams are also provided.

Sevoflurane Exposure Induces Neuronal Cell Ferroptosis Initiated by Increase of Intracellular Hydrogen Peroxide in the Developing Brain via ER Stress ATF3 Activation

Neuronal cell death is acknowledged as the primary pathological basis underlying developmental neurotoxicity in response to sevoflurane exposure, but the exact mechanism remains unclear. Ferroptosis is a form of programmed cell death characterized by iron-dependent lipid peroxidation that is driven by hydrogen peroxide (H2O2) and ferrous iron through the Fenton reaction and participates in the pathogenesis of multiple neurological diseases. As stress response factor, activating transcription factor 3 (ATF3) can be activated by the PERK/ATF4 pathway during endoplasmic reticulum (ER) stress, followed by increased intracellular H2O2, which is involved in regulation of apoptosis, autophagy, and ferroptosis. Here, we investigated whether ferroptosis and ATF3 activation were implicated in sevoflurane-induced neuronal cell death in the developing brain. The results showed that sevoflurane exposure induced neuronal death as a result of iron-dependent lipid peroxidation damage secondary to H2O2 accumulation and ferrous iron increase, which was consistent with the criteria for ferroptosis. Furthermore, we observed that increases in iron and H2O2 induced by sevoflurane exposure were associated with the upregulation and nuclear translocation of ATF3 in response to ER stress. Knockdown of ATF3 expression alleviated iron-dependent lipid peroxidation, which prevented sevoflurane-induced neuronal ferroptosis. Mechanistically, ATF3 promoted sevoflurane-induced H2O2 accumulation by activating NOX4 and suppressing catalase, GPX4, and SLC7A11 expression. Additionally, an increase in H2O2 was accompanied by the upregulation of TFR and TF and downregulation of FPN, which linked iron overload to ferroptosis induced by sevoflurane. Taken together, our results demonstrated that ER stress-mediated ATF3 activation contributed to sevoflurane-induced neuronal ferroptosis via H2O2 accumulation and the resultant iron overload.

Towards a Brighter Constellation: Multi-Organ Neuroimaging of Neural and Vascular Dynamics in the Spinal Cord and Brain

Significance

Pain is comprised of a complex interaction between motor action and somatosensation that is dependent on dynamic interactions between the brain and spinal cord. This makes understanding pain particularly challenging as it involves rich interactions between many circuits (e.g., neural and vascular) and signaling cascades throughout the body. As such, experimentation on a single region may lead to an incomplete and potentially incorrect understanding of crucial underlying mechanisms.

Aim

Here, we aimed to develop and validate new tools to enable detailed and extended observation of neural and vascular activity in the brain and spinal cord. The first key set of innovations were targeted to developing novel imaging hardware that addresses the many challenges of multi-site imaging. The second key set of innovations were targeted to enabling bioluminescent imaging, as this approach can address limitations of fluorescent microscopy including photobleaching, phototoxicity and decreased resolution due to scattering of excitation signals.

Approach

We designed 3D-printed brain and spinal cord implants to enable effective surgical implantations and optical access with wearable miniscopes or an open window (e.g., for one- or two-photon microscopy or optogenetic stimulation). We also tested the viability for bioluminescent imaging, and developed a novel modified miniscope optimized for these signals (BLmini).

Results

Here, we describe novel 'universal' implants for acute and chronic simultaneous brain-spinal cord imaging and optical stimulation. We further describe successful imaging of bioluminescent signals in both foci, and a new miniscope, the 'BLmini,' which has reduced weight, cost and form-factor relative to standard wearable miniscopes.

Conclusions

The combination of 3D printed implants, advanced imaging tools, and bioluminescence imaging techniques offers a new coalition of methods for understanding spinal cord-brain interactions. This work has the potential for use in future research into neuropathic pain and other sensory disorders and motor behavior.

Anesthesia and Sedation Exposure and Neurodevelopmental Outcomes in Infants Undergoing Congenital Cardiac Surgery: A Retrospective Cohort Study

BACKGROUND

Children undergoing complex cardiac surgery are exposed to substantial cumulative doses of sedative medications and volatile anesthetics and are more frequently anesthetized with ketamine, compared with healthy children. This study hypothesized that greater exposure to sedation and anesthesia in this population is associated with lower neurodevelopmental scores at 18 months of age.

METHODS

A secondary analysis was conducted of infants with congenital heart disease who participated in a prospective observational study of environmental exposures and neurodevelopmental outcomes to assess the impact of cumulative volatile anesthetic agents and sedative medications. Cumulative minimum alveolar concentration hours of exposure to volatile anesthetic agents and all operating room and intensive care unit exposures to sedative and anesthesia medications were collected before administration of Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley III), at 18 months of age.

RESULTS

The study cohort included 41 (37%) single-ventricle and 69 (63%) two-ventricle patients. Exposures to volatile anesthetic agents, opioids, benzodiazepines, and dexmedetomidine were not associated with abnormal Bayley III scores. At 18-month follow-up, after adjusting for confounders, each mg/kg increase in ketamine exposure was associated with a 0.34 (95% CI, -0.64 to -0.05) point decrease in Bayley III motor scores (P = 0.024).

CONCLUSIONS

Total cumulative exposures to volatile anesthetic agents were not associated with neurodevelopmental impairment in infants with congenital heart disease undergoing various imaging studies and procedures, whereas higher ketamine doses were associated with poorer motor performance.

EDITOR’S PERSPECTIVE

Hypoplastic Left Heart Syndrome: A Review

Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.

The Genetics of Neurodevelopment in Congenital Heart Disease

Congenital heart disease (CHD) is the most common birth anomaly, affecting almost 1% of infants. Neurodevelopmental delay is the most common extracardiac feature in people with CHD. Many factors may contribute to neurodevelopmental risk, including genetic factors, CHD physiology, and the prenatal/postnatal environment. Damaging variants are most highly enriched among individuals with extracardiac anomalies or neurodevelopmental delay in addition to CHD, indicating that genetic factors have an impact beyond cardiac tissues in people with CHD. Potential sources of genetic risk include large deletions or duplications that affect multiple genes, such as 22q11 deletion syndrome, single genes that alter both heart and brain development, such as CHD7, and common variants that affect neurodevelopmental resiliency, such as APOE. Increased use of genome-sequencing technologies in studies of neurodevelopmental outcomes in people with CHD will improve our ability to detect relevant genes and variants. Ultimately, such knowledge can lead to improved and more timely intervention of learning support for affected children.

Bioethics for Neonatal Cardiac Care

BACKGROUND

Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications.

METHODS

Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice.

RESULTS

We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions.

CONCLUSIONS

We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.

Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease

Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.

General anesthesia in children and long-term neurodevelopmental deficits: A systematic review

Background

Millions of children experienced surgery procedures requiring general anesthesia (GA). Any potential neurodevelopmental risks of pediatric anesthesia can be a serious public health issue. Various animal studies have provided evidence that commonly used GA induced a variety of morphofunctional alterations in the developing brain of juvenile animals.

Methods

We conducted a systematic review to provide a brief overview of preclinical studies and summarize the existing clinical studies. Comprehensive literature searches of PubMed, EMBASE, CINAHL, OVID Medline, Web of Science, and the Cochrane Library were conducted using the relevant search terms “general anesthesia,” “neurocognitive outcome,” and “children.” We included studies investigating children who were exposed to single or multiple GA before 18, with long-term neurodevelopment outcomes evaluated after the exposure(s).

Results

Seventy-two clinical studies originating from 18 different countries published from 2000 to 2022 are included in this review, most of which are retrospective studies (n = 58). Two-thirds of studies (n = 48) provide evidence of negative neurocognitive effects after GA exposure in children. Neurodevelopmental outcomes are categorized into six domains: academics/achievement, cognition, development/behavior, diagnosis, brain studies, and others. Most studies focusing on children <7 years detected adverse neurocognitive effects following GA exposure, but not all studies consistently supported the prevailing view that younger children were at greater risk than senior ones. More times and longer duration of exposures to GA, and major surgeries may indicate a higher risk of negative outcomes.

Conclusion

Based on current studies, it is necessary to endeavor to limit the duration and numbers of anesthesia and the dose of anesthetic agents. For future studies, we require cohort studies with rich sources of data and appropriate outcome measures, and carefully designed and adequately powered clinical trials testing plausible interventions in relevant patient populations.

Outcomes of Gastrostomy Tubes in Newborns With Congenital Heart Disease and Comparison of Techniques

INTRODUCTION

Gastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population.

METHODS

The Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score-matched analysis was performed among newborns with or without CHD using > 100 covariates.

RESULTS

Seven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P < 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P < 0.001).

CONCLUSIONS

Compared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.

The impact of early exposure to general anesthesia on visual and neurocognitive development

Every year millions of children are exposed to general anesthesia while undergoing surgical and diagnostic procedures. In the field of ophthalmology, 44,000 children are exposed to general anesthesia annually for strabismus surgery alone. While it is clear that general anesthesia is necessary for sedation and pain minimization during surgical procedures, the possibility of neurotoxic impairments from its exposure is of concern. In animals there is strong evidence linking early anesthesia exposure to abnormal neural development. but in humans the effects of anesthesia are debated. In humans many aspects of vision develop within the first year of life, making the visual system vulnerable to early adverse experiences and potentially vulnerable to early exposure to general anesthesia. We attempt to address whether the visual system is affected by early postnatal exposure to general anesthesia. We first summarize key mechanisms that could account for the neurotoxic effects of general anesthesia on the developing brain and review existing literature on the effects of early anesthesia exposure on the visual system in both animals and humans and on neurocognitive development in humans. Finally, we conclude by proposing future directions for research that could address unanswered questions regarding the impact of general anesthesia on visual development.

Nonapoptotic caspases in neural development and in anesthesia-induced neurotoxicity

Apoptosis, classically initiated by caspase pathway activation, plays a prominent role during normal brain development as well as in neurodegeneration. The noncanonical, nonlethal arm of the caspase pathway is evolutionarily conserved and has also been implicated in both processes, yet is relatively understudied. Dysregulated pathway activation during critical periods of neurodevelopment due to environmental neurotoxins or exposure to compounds such as anesthetics can have detrimental consequences for brain maturation and long-term effects on behavior. In this review, we discuss key molecular characteristics and roles of the noncanonical caspase pathway and how its dysregulation may adversely affect brain development. We highlight both genetic and environmental factors that regulate apoptotic and sublethal caspase responses and discuss potential interventions that target the noncanonical caspase pathway for developmental brain injuries.

Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis

IMPORTANCE

Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results.

OBJECTIVE

To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children.

DATA SOURCES

PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021.

STUDY SELECTION

Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded.

DATA EXTRACTION AND SYNTHESIS

Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model.

MAIN OUTCOMES AND MEASURES

The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses.

RESULTS

A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002).

CONCLUSIONS AND RELEVANCE

These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.

Neuroplacentology in congenital heart disease: placental connections to neurodevelopmental outcomes

Children with congenital heart disease (CHD) are living longer due to effective medical and surgical management. However, the majority have neurodevelopmental delays or disorders. The role of the placenta in fetal brain development is unclear and is the focus of an emerging field known as neuroplacentology. In this review, we summarize neurodevelopmental outcomes in CHD and their brain imaging correlates both in utero and postnatally. We review differences in the structure and function of the placenta in pregnancies complicated by fetal CHD and introduce the concept of a placental inefficiency phenotype that occurs in severe forms of fetal CHD, characterized by a myriad of pathologies. We propose that in CHD placental dysfunction contributes to decreased fetal cerebral oxygen delivery resulting in poor brain growth, brain abnormalities, and impaired neurodevelopment. We conclude the review with key areas for future research in neuroplacentology in the fetal CHD population, including (1) differences in structure and function of the CHD placenta, (2) modifiable and nonmodifiable factors that impact the hemodynamic balance between placental and cerebral circulations, (3) interventions to improve placental function and protect brain development in utero, and (4) the role of genetic and epigenetic influences on the placenta-heart-brain connection. IMPACT: Neuroplacentology seeks to understand placental connections to fetal brain development. In fetuses with CHD, brain growth abnormalities begin in utero. Placental microstructure as well as perfusion and function are abnormal in fetal CHD.

The Current Status of Neuroprotection in Congenital Heart Disease

Neurological deficits are a serious and common sequelae of congenital heart disease (CHD). While their underlying mechanisms have not been fully characterized, their manifestations are well-known and understood to persist through adulthood. Development of therapies to address or prevent these deficits are critical to attenuate future morbidity and improve quality of life. In this review, we aim to summarize the current status of neuroprotective therapy in CHD. Through an exploration of present research in the pre-operative, intra-operative, and post-operative phases of patient management, we will describe existing clinical and bench efforts as well as current endeavors underway within this research area.

Long-term neurodevelopmental effects of intraoperative blood pressure during surgical closure of a septal defect in infancy or early childhood

BACKGROUND

Many children born with congenital heart defects are faced with cognitive deficits and psychological challenges later in life. The mechanisms behind are suggested to be multifactorial and are explained as an interplay between innate and modifiable risk factors. The aim was to assess whether there is a relationship between mean arterial pressure during surgery of a septal defect in infancy or early childhood and intelligence quotient scores in adulthood.

METHODS

In a retrospective study, patients were included if they underwent surgical closure of a ventricular septal defect or an atrial septal defect in childhood between 1988 and 2002. Every patient completed an intelligence assessment upon inclusion, 14-27 years after surgery, using the Wechsler Adult Intelligence Scale Version IV.

RESULTS

A total of 58 patients met the eligibility criteria and were included in the analyses. No statistically significant correlation was found between blood pressure during cardiopulmonary bypass and intelligence quotient scores in adulthood (r = 0.138; 95% CI-0.133-0.389). Although amongst patients with mean arterial pressure < 40 mmHg during cardiopulmonary bypass, intelligence quotient scores were significantly lower (91.4; 95% CI 86.9-95.9) compared to those with mean arterial pressure > 40 mmHg (99.8; 95% CI 94.7-104.9).

CONCLUSIONS

Mean arterial pressure during surgery of ventricular septal defects or atrial septal defects in childhood does not correlate linearly with intelligence quotient scores in adulthood. Although there may exist a specific cut-off value at which low blood pressure becomes harmful. Larger studies are warranted in order to confirm this, as it holds the potential of partly relieving CHD patients of their cognitive deficits.

An introduction to and review of cardiac neurodevelopment: the risks and recommended approaches

PURPOSE OF REVIEW

To introduce the reader to the current understanding of the neurocognitive profile of congenital heart disease (CHD) survivors, the risk factors that may influence outcomes, and to the recommendations for cardiac neurodevelopmental care.

RECENT FINDINGS

A growing body of literature has shown that survivors of CHD are at increased risk for neurodevelopmental impairments. Multiple elements influence each patient's risk, which likely begins in utero and extends to perioperative management, surgical considerations, and long-term clinical care. Additionally, sociodemographic factors may compound these risks. Serial developmental follow-up is recommended for children with critical CHD.

SUMMARY

Though there are some clinical factors that increase risk, based on the high rate of developmental impairments for children with CHD, serial evaluations are recommended. Multidisciplinary and multicenter collaboration is ongoing and will facilitate moving this field forward to improve neurodevelopmental outcomes for children with CHD.

Exposure to general anaesthesia in childhood and the subsequent risk of attention-deficit hyperactivity disorder: A meta-analysis of cohort studies

BACKGROUND

The evidence for a relationship between general anaesthesia induced in childhood and the risk of attention-deficit hyperactivity disorder (ADHD) in later life is inconsistent. We systematically assessed whether such an association existed.

METHODS

We searched the PubMed and EMBASE databases for relevant cohort studies. Relative risks (RRs) and 95 % confidence intervals (CIs) were calculated to determine the relationship between induction of childhood general anaesthesia and the risk of ADHD in later life.

RESULTS

Seven studies (eight publications) on developmental outcomes after the induction of childhood general anaesthesia met our inclusion criteria but not our exclusion criteria. Repeat childhood general anaesthesia (RR = 1.84, 95 CI% 1.14-2.97; P < 0.001; I² = 74.8 %), but not one-off general anaesthesia (RR = 1.09, 95 CI% 0.93-1.27; P = 0.301; I² = 0%), was associated with an increased risk of ADHD in later life. The association was evident only when the total general anaesthesia exposure exceeded 90 min.

CONCLUSIONS

Our meta-analysis indicated that the effect of general anaesthesia on the risk of ADHD is dose- or duration-dependent.

[Inhalational anesthetics]

Inhalational anesthetics have been used for induction and maintenance of general anesthesia for more than 150 years. All of the currently used inhalational anesthetics are chlorinated and fluorinated derivatives of ether. Dosing is carried out using the minimal alveolar concentration (MAC) concept. The pharmacokinetic properties of the various inhalational anesthetics are governed by the specific distribution coefficients. Mechanisms of action include specific modulations of various receptors of the central nervous system as well as an unspecific interaction with the cell membrane. Organ toxicity of modern inhalational anesthetics is considered to be minimal. The role of inhalational anesthetics in the context of postoperative nausea and vomiting (PONV) has been reassessed in recent years. The superiority of inhalational anesthetics over intravenous hypnotics with respect to intraoperative awareness is undisputed. The organ protective mechanism of preconditioning is an exclusive property of inhalational anesthetics among all the currently available hypnotics.

Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome

OBJECTIVES

Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates.

DESIGN

Single-center, retrospective cohort study.

SETTING

A total of 259-bed, quaternary, pediatric referral center.

PATIENTS

Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04).

CONCLUSIONS

Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.

Expression Signature of lncRNAs and mRNAs in Sevoflurane-Induced Mouse Brain Injury: Implication of Involvement of Wide Molecular Networks and Pathways

Sevoflurane, one of the most commonly used pediatric anesthetics, was found to cause developmental neurotoxicity. To understand specific risk groups and develop countermeasures, a better understanding of its mechanisms is needed. We hypothesize that, as in many other brain degeneration pathways, long non-coding RNAs (lncRNAs) are involved in the sevoflurane-induced neurotoxicity. Postnatal day 7 (PD7) mice were exposed to 3% sevoflurane for 6 h. To quantify neurotoxicity in these mice, we (1) detected neural apoptosis through analysis of caspase 3 expression level and activity and (2) assessed long-term learning ability via the Morris water maze at PD60. To elucidate specific mechanisms, profiles of 27,427 lncRNAs and 18,855 messenger RNAs (mRNAs) in mouse hippocampi were analyzed using microarray assays. Sevoflurane-induced abnormal lncRNA and mRNA expression-associated function pathways were predicted by bioinformatic analysis. We found that sevoflurane induced significant neurotoxicity, causing acute neuroapoptosis and abnormal expression of 148 mRNAs and 301 lncRNAs on PD7 in mouse hippocampus. Additionally, exposed mice exhibited impaired memory on PD60. Bioinformatic analysis predicted that the dysregulated mRNAs, which are highly correlated with their co-expressed dysregulated lncRNAs, might be involved in 34 neurodegenerative signaling pathways (e.g., brain cell apoptosis and intellectual developmental disorder). Our study reveals for the first time that neonatal exposure to 3% sevoflurane induces abnormal lncRNA and mRNA expression profiles. These dysregulated lncRNAs/mRNAs form wide molecular networks that might contribute to various functional neurological disease pathways in the hippocampus, resulting in the observed acute apoptosis and impaired long-term memory.

Antenatal and Perioperative Mechanisms of Global Neurological Injury in Congenital Heart Disease

Congenital heart defects (CHD) is one of the most common types of birth defects. Thanks to advances in surgical techniques and intensive care, the majority of children with severe forms of CHD survive into adulthood. However, this increase in survival comes with a cost. CHD survivors have neurological functioning at the bottom of the normal range. A large spectrum of central nervous system dysmaturation leads to the deficits seen in critical CHD. The heart develops early during gestation, and CHD has a profound effect on fetal brain development for the remainder of gestation. Term infants with critical CHD are born with an immature brain, which is highly susceptible to hypoxic-ischemic injuries. Perioperative blood flow disturbances due to the CHD and the use of cardiopulmonary bypass or circulatory arrest during surgery cause additional neurological injuries. Innate patient factors, such as genetic syndromes and preterm birth, and postoperative complications play a larger role in neurological injury than perioperative factors. Strategies to reduce the disability burden in critical CHD survivors are urgently needed.

Sevoflurane Exposure Induces Neuronal Cell Parthanatos Initiated by DNA Damage in the Developing Brain via an Increase of Intracellular Reactive Oxygen Species

The safety of volatile anesthetics in infants and young children has been drawing increasing concern due to its potential neurotoxicity in the developing brain. Neuronal death is considered a major factor associated with developmental neurotoxicity after exposure to volatile anesthetics sevoflurane, but its mechanism remains elusive. Parthanatos, a new type of programmed cell death, resulting from poly (ADP-ribose) polymerase 1 (PARP-1) hyperactivation in response to DNA damage, was found to account for the pathogenesis of multiple neurological disorders. However, the role of Parthanatos in sevoflurane-induced neonatal neuronal cell death has not been investigated. To test it, neuronal cells treated with 2, 4, and 8% sevoflurane for 6, 12, and 24 h and postnatal day 7 rats exposed to 2.5% sevoflurane for 6 h were used in the present study. Our results found sevoflurane exposure induced neuronal cell death, which was accompanied by PARP-1 hyperactivation, cytoplasmic polymerized ADP-ribose (PAR) accumulation, mitochondrial depolarization, and apoptosis-inducing factor (AIF) nuclear translocation in the neuronal cells and hippocampi of rats. Pharmacological or genetic inhibition of PAPR-1 significantly alleviated sevoflurane-induced neuronal cell death and accumulation of PAR polymer and AIF nuclear translocation, which were consistent with the features of Parthanatos. We observed in vitro and in vivo that sevoflurane exposure resulted in DNA damage, given that 8-hydroxydeoxyguanosine (8-OHdG) and phosphorylation of histone variant H2AX (γH2AX) were improved. Moreover, we detected that sevoflurane exposure was associated with an overproduction of intracellular reactive oxygen species (ROS). Inhibition of ROS with antioxidant NAC markedly alleviated DNA damage caused by sevoflurane, indicating that ROS participated in the regulation of sevoflurane-induced DNA damage. Additionally, sevoflurane exposure resulted in upregulation of Parthanatos-related proteins and neuronal cell death, which were significantly attenuated by pretreatment with NAC. Therefore, these results suggest that sevoflurane exposure induces neuronal cell Parthanatos initiated by DNA damage in the developing brain via the increase of intracellular ROS.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures

BACKGROUND

Children frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear.

METHODS

Children undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI.

RESULTS

Of 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d.

CONCLUSIONS

The type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

Induced pluripotent stem cells as a platform to understand patient-specific responses to opioids and anaesthetics

Recent advances in human induced pluripotent stem cell (iPSC) technology may provide unprecedented opportunities to study patient-specific responses to anaesthetics and opioids. In this review, we will (1) examine the advantages and limitations of iPSC technology, (2) summarize studies using iPSCs that have contributed to our current understanding of anaesthetics and opioid action on the cardiovascular system and central nervous system (CNS), and (3) describe how iPSC technology can be used to further develop personalized analgesic and sedative pharmacotherapies with reduced or minimal detrimental cardiovascular effects.

Changes in Cortical Thickness Are Associated With Cognitive Ability in Postoperative School-Aged Children With Tetralogy of Fallot

In children with tetralogy of Fallot (TOF), there is a risk of brain injury even if intracardiac deformities are corrected. This population follow-up study aimed to identify the correlation between cerebral morphology changes and cognition in postoperative school-aged children with TOF. Resting-state functional magnetic resonance imaging (rs-fMRI) and the Wechsler Intelligence Scale for Children–Chinese revised edition (WISC-CR) were used to assess the difference between children with TOF and healthy children (HCs). Multiple linear regression showed that the TOF group had a lower verbal intelligence quotient (VIQ, 95.000 ± 13.433, p = 0.001) than the HC group and that VIQ had significant positive correlations with the cortical thickness of both the left precuneus (p < 0.05) and the right caudal middle frontal gyrus (p < 0.05) after adjustment for preoperative SpO2, preoperative systolic blood pressure (SBP), preoperative diastolic blood pressure (DBP) and time of aortic override (AO). Our results suggested that brain injury induced by TOF would exert lasting effects on cortical and cognitive development at least to school age. This study provides direct evidence of the relationship between cortical thickness and VIQ and of the need for strengthened verbal training in school-aged TOF patients after corrective surgery.

Cognitive flexibility in critical CHD: a target for intervention

Most children born with even the most critical forms of CHD are now surviving well into adulthood. However, with increased survival has come increased recognition of the diverse neurobehavioural and psychosocial challenges these children experience. Among these challenges are deficits in executive function skills, including inhibitory control, working memory, and cognitive flexibility. Over the past several years, whereas inhibitory control and working memory deficits have garnered particular attention among clinicians and interventionists, relatively less attention has been paid to cognitive flexibility. This is unfortunate given both the high prevalence of cognitive flexibility deficits observed in children and adolescents with critical CHD, and also the far-reaching relevance of cognitive flexibility in helping individuals achieve optimal quality of life across the lifespan. This paper reviews the construct of cognitive flexibility, including its definition, development, measurement, and neuroanatomical basis, provides a summary of how cognitive flexibility is affected by CHD, and offers evidence-based recommendations to systematically support the development of cognitive flexibility within the context of CHD.

Voltage dependent allosteric modulation of IPSCs by benzodiazepines

GABA_A receptors (GABA_AR) are inhibitory ion channels ubiquitously expressed in the central nervous system and play critical roles in brain development and function. Benzodiazepines are positive allosteric modulators of GABA_AR, enhancing channel opening frequency when GABA is bound to the receptor. Midazolam is a commonly used benzodiazepine. It is frequently used for premature infants, but the long-term consequences of its use in this patient population are not well established. Here, we studied the acute effects of midazolam on immature synapses. Using a rodent organotypic hippocampal slice preparation, we evaluated how midazolam affects inhibitory synaptic transmission onto CA1 pyramidal neurons. We found that 1 μM midazolam enhances evoked inhibitory post synaptic currents (eIPSCs) at a holding potential of -60 mV. Similarly, 1 μM midazolam enhances miniature IPSCs (mIPSCs) in CA1 pyramidal neurons at holding potentials of -60 mV and -30 mV. At depolarized holding potentials, however, midazolam no longer enhances mIPSCs. Depolarization of the postsynaptic cell by itself increases mIPSC decay, which occludes the allosteric effects of midazolam. These results provide insight into how a benzodiazepine and membrane voltage may modulate GABA_AR function in developing circuits.

Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities

Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.

Neurologic Injury in Neonates Undergoing Cardiac Surgery

Neurodevelopmental outcomes after neonatal congenital heart surgery are significantly influenced by brain injury detectable by MRI imaging techniques. This brain injury can occur in the prenatal and postnatal periods even before cardiac surgery. Given the significant incidence of new MRI brain injury after cardiac surgery, much work is yet to be done on strategies to detect, prevent, and treat brain injury in the neonatal period in order to optimize longer-term neurodevelopmental outcomes.

Neurodevelopmental outcomes of children with congenital heart disease: A review

Congenital heart defects are the most common birth anomaly affecting approximately 1% of births. With improved survival in this population, there is enhanced ability to assess long-term morbidities including neurodevelopment. There is a wide range of congenital heart defects, from those with minimal physiologic consequence that do not require medical or surgical intervention, to complex structural anomalies requiring highly specialized medical management and intricate surgical repair or palliation. The impact of congenital heart disease on neurodevelopment is multifactorial. Susceptibility for adverse neurodevelopment increases with advancing severity of the defect with initial risk factors originating during gestation. Complex structural heart anomalies may pre-dispose the fetus to abnormal circulatory patterns in utero that ultimately impact delivery of oxygen rich blood to the fetal brain. Thus, the brain of a neonate born with complex congenital heart disease may be particularly vulnerable from the outset. That vulnerability is compounded during the newborn period and through childhood, as this population endures a myriad of medical and surgical interventions. For each individual patient, these factors are likely cumulative and synergistic with progression from fetal life through childhood. This review discusses the spectrum of risk factors that may impact neurodevelopment in children with congenital heart disease, describes current recommendations and practices for neurodevelopmental follow-up of children with congenital heart disease and reviews important neurodevelopmental trends in this high risk population.

Comparison of Intranasal Dexmedetomidine and Oral Pentobarbital Sedation for Transthoracic Echocardiography in Infants and Toddlers: A Prospective, Randomized, Double-Blind Trial

BACKGROUND

Acquisition of transthoracic echocardiographic (TTEcho) images in children often requires sedation. The optimal sedative for TTEcho has not been determined. Children with congenital heart disease are repeatedly exposed to sedatives and anesthetics that may affect brain development. Dexmedetomidine, which in animals alters brain structure to a lesser degree, may offer advantages in this vulnerable population.

METHODS

A prospective, randomized, double-blind trial enrolled 280 children 3-24 months of age undergoing outpatient TTEcho, comparing 2.5 µg·kg intranasal dexmedetomidine to 5 mg·kg oral pentobarbital. Rescue sedation, for both groups, was intranasal dexmedetomidine 1 µg·kg. The primary outcome was adequate sedation within 30 minutes without rescue sedation, assessed by blinded personnel. Secondary outcomes included number of sonographer pauses, image quality in relation to motion artifacts, and parental satisfaction.

RESULTS

Success rates with a single dose were not different between sedation techniques; 85% in the pentobarbital group and 84% in the dexmedetomidine group (P = .8697). Median onset of adequate sedation was marginally faster with pentobarbital (16.5 [interquartile range, 13-21] vs 18 [16-23] minutes for dexmedetomidine [P = .0095]). Time from drug administration to discharge was not different (P = .8238) at 70.5 (64-83) minutes with pentobarbital and 70 (63-82) minutes with dexmedetomidine. Ninety-five percent of sedation failures with pentobarbital and 100% of dexmedetomidine failures had successful rescue sedation with intranasal dexmedetomidine.

CONCLUSIONS

Intranasal dexmedetomidine was comparable to oral pentobarbital sedation for TTEcho sedation in infants and did not increase the risk of clinically important adverse events. Intranasal dexmedetomidine appears to be an effective "rescue" sedative for both failed pentobarbital and dexmedetomidine sedation. Dexmedetomidine could be a safer option for repeated sedation in children, but further studies are needed to assess long-term consequence of repeated sedation in this high-risk population.

Neurotoxicity of general anesthetics in children: evidence and uncertainties

PURPOSE OF REVIEW

Compelling evidence in animal models that, under some conditions, general anesthetics and sedatives produce changes in the brain and persistent impairments in learning, memory, and behavior. The present review summarizes recent clinical studies investigating whether the use of these agents in children causes similar neurotoxicities.

RECENT FINDINGS

Although the results of retrospective studies are somewhat mixed, multiple exposures to general anesthesia were generally found to confer greater risk than single exposures with regard to learning disability, attention deficit hyperactivity disorder, school readiness, and academic achievement. Recent clinical studies, including a large randomized controlled trial, are consistent in confirming that a single exposure in infancy to general anesthesia lasting less than 1 h is not associated with neurodevelopmental impairments in later childhood. These studies do not, however, clarify the potential impacts of longer exposures or multiple exposures.

SUMMARY

Given that approximately half of the anesthetic exposures in young US children are 1 h or less in duration, the results of the recent clinical studies are reassuring. Because of the clinical necessity of administering general anesthetics and sedatives for longer periods for many surgical, procedural, or diagnostic purposes, the identification of adjuvants that prevent or reduce the potential neurotoxicity of these agents is an area of active research.

Visual-spatial processing style is associated with psychopathology in adolescents with critical congenital heart disease

OBJECTIVE

To determine whether visual-spatial processing style is associated with psychopathology in a large sample of adolescents with critical congenital heart disease (CHD). Local (part-oriented) style was hypothesized to increase risk for internalizing (but not externalizing) forms of psychopathology.

METHOD

Participants included 278 adolescents with critical CHD (dextro-transposition of the great arteries = 134, tetralogy of Fallot = 58, single-ventricle cardiac anatomy requiring the Fontan procedure = 86). Visual-spatial processing style was indexed using Copy Style Ratings from the Rey-Osterrieth Complex Figure-Developmental Scoring System. The Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present & Lifetime Version was used to determine presence/absence of diagnosable DSM-IV psychiatric disorder(s). Processing style and psychopathology were assessed concurrently.

RESULTS

Thirty-three percent of the sample had a part-oriented processing style. In multivariable binary logistic regression models, part-orientation was associated with more than twice the odds of having an anxiety disorder (lifetime: OR = 2.2, p = .02, 95% CI = 1.1-4.1; current: OR = 2.7, p = .03, 95% CI = 1.1-6.5) but was not associated with an increased risk for ADHD, disruptive behavior, or mood disorders (ps > .05).

CONCLUSIONS

Adolescents with critical CHD who approach complex visual-spatial materials in a local, part-oriented fashion are more likely to meet criteria for an anxiety disorder than those who approach complexity more holistically. Part-orientation may make it more difficult for individuals to judge the relative importance of isolated details and engage in more adaptive perspective-taking.

Percutaneous endoscopic gastrostomy vs surgical gastrostomy in infants with congenital heart disease

BACKGROUND

Infants with congenital heart disease often require feeding tube placement to supplement oral intake. Gastrostomy tubes may be placed by either surgical or percutaneous endoscopic methods, but there is currently no data comparing outcomes of these procedures in this population.

AIMS

The aim of our retrospective study was to investigate the perioperative outcomes between the 2 groups to determine if there are clinically significant differences.

METHODS

We reviewed the charts of all infants with congenital heart disease at a single academic institution having isolated surgical or percutaneous endoscopic gastrostomy tube placement from January 2011 to December 2015. Anesthetic time, defined by cumulative minimum alveolar concentration hours of exposure to volatile anesthetic, was the primary outcome. Operative time, intraoperative complications, and postoperative intensive care admissions were secondary outcomes.

RESULTS

One hundred and one infants with congenital heart disease were included in this study. Anesthetic exposure was shorter in the endoscopic group than the surgical group (0.20 MAC-hours vs 0.56 MAC-hours, 95% confidence interval 0.23, 0.49, P < .001). Average operative times were also shorter in the endoscopic gastrostomy vs the surgical group (8 ± 0.7 minutes vs 35 ± 1.3 minutes, 95% confidence interval 23.7, 31.0, P < .001). Adjusting for prematurity and preoperative risk category, the surgical group was associated with a 3.45 fold increase in the likelihood of a higher level of care postoperatively (95% confidence interval 1.20, 9.90, P = .02).

CONCLUSION

In infants with congenital heart disease, percutaneous endoscopic gastrostomy placement is associated with reduced anesthetic exposure and fewer postoperative intensive care unit admissions compared to surgical gastrostomy.

Neuroprotective Anesthesia Regimen and Intensive Management for Pediatric Cardiac Surgery with Cardiopulmonary Bypass: a Review and Initial Experience

This article describes our proposal for routine anesthesia, intraoperative medical management, cerebral and physiological monitoring during pediatric cardiac surgery with cardiopulmonary bypass that intend to provide appropriate anesthesia (analgesia, hypnosis), neuroprotection, adequate cerebral and systemic oxygen supply, and preventing against drugs neurotoxicity. A concise retrospective data is presented.

Elevated cranial ultrasound resistive indices are associated with improved neurodevelopmental outcomes one year after pediatric cardiac surgery: A single center pilot study

OBJECTIVE

To determine if a non-invasive, repeatable test can be used to predict neurodevelopmental outcomes in patients with congenital heart disease.

METHODS

This was a prospective study of pediatric patients less than two months of age undergoing congenital heart surgery at the Children's Health Children's Medical Center at Dallas. Multichannel near-infrared spectroscopy (NIRS) was utilized during the surgery, and ultrasound (US) resistive indices (RI) of the major cranial vessels were obtained prior to surgery, immediately post-operatively, and prior to discharge. Pearson's correlation, Fischer exact t test, and Fischer r to z transformation were used where appropriate.

RESULTS

A total of 16 patients were enrolled. All had US data. Of the sixteen patients, two died prior to the neurodevelopmental testing, six did not return for the neurodevelopmental testing, and eight patients completed the neurodevelopmental testing. There were no significant correlations between the prior to surgery and prior to discharge US RI and neurodevelopmental outcomes. The immediate post-operative US RI demonstrated a strong positive correlation with standardized neurodevelopmental outcome measures. We were able to demonstrate qualitative differences using multichannel NIRS during surgery, but experienced significant technical difficulties implementing consistent monitoring.

CONCLUSIONS

A higher resistive index in the major cerebral blood vessels following cardiac surgery in the neonatal period is associated with improved neurological outcomes one year after surgery. Obtaining an ultrasound with resistive indices of the major cerebral vessels prior to and after surgery may yield information that is predictive of neurodevelopmental outcomes.

Neurodevelopmental Abnormalities and Congenital Heart Disease: Insights Into Altered Brain Maturation

In the past 2 decades, it has become evident that individuals born with congenital heart disease (CHD) are at risk of developing life-long neurological deficits. Multifactorial risk factors contributing to neurodevelopmental abnormalities associated with CHD have been identified; however, the underlying causes remain largely unknown, and efforts to address this issue have only recently begun. There has been a dramatic shift in focus from newly acquired brain injuries associated with corrective and palliative heart surgery to antenatal and preoperative factors governing altered brain maturation in CHD. In this review, we describe key time windows of development during which the immature brain is vulnerable to injury. Special emphasis is placed on the dynamic nature of cellular events and how CHD may adversely impact the cellular units and networks necessary for proper cognitive and motor function. In addition, we describe current gaps in knowledge and offer perspectives about what can be done to improve our understanding of neurological deficits in CHD. Ultimately, a multidisciplinary approach will be essential to prevent or improve adverse neurodevelopmental outcomes in individuals surviving CHD.

The benefits of youth are lost on the young cardiac arrest patient

Children and young adults tend to have reduced mortality and disability after acquired brain injuries such as trauma or stroke and across other disease processes seen in critical care medicine. However, after out-of-hospital cardiac arrest (OHCA), outcomes are remarkably similar across age groups. The consistent lack of witnessed arrests and a high incidence of asphyxial or respiratory etiology arrests among pediatric and young adult patients with OHCA account for a substantial portion of the difference in outcomes. Additionally, in younger children, differences in pre-hospital response and the activation of developmental apoptosis may explain more severe outcomes after OHCA. These require us to consider whether present practices are in line with the science. The present recommendations for compression-only cardiopulmonary resuscitation in young adults, normothermia as opposed to hypothermia (33°C) after asphyxial arrests, and paramedic training are considered within this review in light of existing evidence. Modifications in present standards of care may help restore the benefits of youth after brain injury to the young survivor of OHCA.

From Drug-Induced Developmental Neuroapoptosis to Pediatric Anesthetic Neurotoxicity-Where Are We Now?

The fetal and neonatal periods are critical and sensitive periods for neurodevelopment, and involve rapid brain growth in addition to natural programmed cell death (i.e., apoptosis) and synaptic pruning. Apoptosis is an important process for neurodevelopment, preventing redundant, faulty, or unused neurons from cluttering the developing brain. However, animal studies have shown massive neuronal cell death by apoptosis can also be caused by exposure to several classes of drugs, namely gamma-aminobutyric acid (GABA) agonists and N-methyl-d-aspartate (NMDA) antagonists that are commonly used in pediatric anesthesia. This form of neurotoxic insult could cause a major disruption in brain development with the potential to permanently shape behavior and cognitive ability. Evidence does suggest that psychoactive drugs alter neurodevelopment and synaptic plasticity in the animal brain, which, in the human brain, may translate to permanent neurodevelopmental changes associated with long-term intellectual disability. This paper reviews the seminal animal research on drug-induced developmental apoptosis and the subsequent clinical studies that have been conducted thus far. In humans, there is growing evidence that suggests anesthetics have the potential to harm the developing brain, but the long-term outcome is not definitive and causality has not been determined. The consensus is that there is more work to be done using both animal models and human clinical studies.