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Handlogten K. Pediatric regional anesthesiology: a narrative review and update on outcome-based advances. Int Anesthesiol Clin 2024; 62:69-78. [PMID: 38063039 DOI: 10.1097/aia.0000000000000421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Kathryn Handlogten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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2
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Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
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Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
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3
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Areias J, Sola C, Chastagnier Y, Pico J, Bouquier N, Dadure C, Perroy J, Szabo V. Whole-brain characterization of apoptosis after sevoflurane anesthesia reveals neuronal cell death patterns in the mouse neonatal neocortex. Sci Rep 2023; 13:14763. [PMID: 37679476 PMCID: PMC10484929 DOI: 10.1038/s41598-023-41750-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023] Open
Abstract
In the last two decades, safety concerns about general anesthesia (GA) arose from studies documenting brain cell death in various pharmacological conditions and animal models. Nowadays, a thorough characterization of sevoflurane-induced apoptosis in the entire neonatal mouse brain would help identify and further focus on underlying mechanisms. We performed whole-brain mapping of sevoflurane-induced apoptosis in post-natal day (P) 7 mice using tissue clearing and immunohistochemistry. We found an anatomically heterogenous increase in cleaved-caspase-3 staining. The use of a novel P7 brain atlas showed that the neocortex was the most affected area, followed by the striatum and the metencephalon. Histological characterization in cortical slices determined that post-mitotic neurons were the most affected cell type and followed inter- and intracortical gradients with maximal apoptosis in the superficial layers of the posterodorsal cortex. The unbiased anatomical mapping used here allowed us to confirm sevoflurane-induced apoptosis in the perinatal period, neocortical involvement, and indicated striatal and metencephalic damage while suggesting moderate hippocampal one. The identification of neocortical gradients is consistent with a maturity-dependent mechanism. Further research could then focus on the interference of sevoflurane with neuronal migration and survival during development.
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Affiliation(s)
- Julie Areias
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Chrystelle Sola
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
- Montpellier University Hospital, 191 Av. du Doyen Gaston Giraud, 34295, Montpellier Cedex 05, France
| | - Yan Chastagnier
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Julien Pico
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
- Montpellier University Hospital, 191 Av. du Doyen Gaston Giraud, 34295, Montpellier Cedex 05, France
| | | | - Christophe Dadure
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
- Montpellier University Hospital, 191 Av. du Doyen Gaston Giraud, 34295, Montpellier Cedex 05, France
| | - Julie Perroy
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Vivien Szabo
- IGF, University of Montpellier, CNRS, INSERM, Montpellier, France.
- Montpellier University Hospital, 191 Av. du Doyen Gaston Giraud, 34295, Montpellier Cedex 05, France.
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4
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Yılmaz H, Şengelen A, Demirgan S, Paşaoğlu HE, Çağatay M, Erman İE, Bay M, Güneyli HC, Önay-Uçar E. Acutely increased aquaporin-4 exhibits more potent protective effects in the cortex against single and repeated isoflurane-induced neurotoxicity in the developing rat brain. Toxicol Mech Methods 2022; 33:279-292. [PMID: 36127839 DOI: 10.1080/15376516.2022.2127389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Damage to hippocampus, cerebellum, and cortex associated with cognitive functions due to anesthetic-induced toxicity early in life may cause cognitive decline later. Aquaporin 4 (AQP4), a key protein in waste clearance pathway of brain, is involved in synaptic plasticity and neurocognition. We investigated the effects of single and repeated isoflurane (Iso) anesthesia on AQP4 levels and brain damage. Postnatal-day (P)7 Wistar albino rats were randomly assigned to Iso or Control (C) groups. For single-exposure, pups were exposed to 1.5% Iso in 30% oxygenated-air for 3-h at P7 (Iso1). For repeated-exposure, pups were exposed to Iso for 3 days, 3-h each day, at 1-day intervals (P7 + 9+11) starting at P7 (Iso3). C1 and C3 groups received only 30% oxygenated-air. Based on HE-staining and immunoblotting (Bax/Bcl-2, cleaved-caspase3 and PARP1) analyses, Iso exposures caused a higher degree of apoptosis in hippocampus. Anesthesia increased 4HNE, oxidative stress marker; the highest ROS accumulation was determined in cerebellum. Increased inflammation (TNF-α, NF-κB) was detected. Multiple Iso-exposures caused more significant damage than single exposure. Moreover, 4HNE and TNF-α contributed synergistically to Iso-induced neurotoxicity. After anesthesia, higher expression of AQP4 was detected in cortex than hippocampus and cerebellum. There was an inverse correlation between increased AQP4 levels and apoptosis/ROS/inflammation. Correlation analysis indicated that AQP4 had a more substantial protective profile against oxidative stress than apoptosis. Remarkably, acutely increased AQP4 against Iso exhibited a more potent neuroprotective effect in cortex, especially frontal cortex. These findings promote further research to understand better the mechanisms underlying anesthesia-induced toxicity in the developing brain.
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Affiliation(s)
- Habip Yılmaz
- Department of Public Hospital Services, Istanbul Health Directorate, Istanbul, Turkey
| | - Aslıhan Şengelen
- Department of Molecular Biology and Genetics, Institute of Graduate Studies in Sciences, Istanbul University, Istanbul, Turkey
| | - Serdar Demirgan
- Department of Molecular Biology and Genetics, Institute of Graduate Studies in Sciences, Istanbul University, Istanbul, Turkey.,Clinic of Anesthesiology and Reanimation, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Hüsniye Esra Paşaoğlu
- Department of Pathology, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Melike Çağatay
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - İbrahim Emre Erman
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Bay
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Hasan Cem Güneyli
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Evren Önay-Uçar
- Department of Molecular Biology and Genetics, Faculty of Science, Istanbul University, Istanbul, Turkey
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5
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Wong-Kee-You AMB, Loveridge-Easther C, Mueller C, Simon N, Good WV. The impact of early exposure to general anesthesia on visual and neurocognitive development. Surv Ophthalmol 2022; 68:539-555. [PMID: 35970232 DOI: 10.1016/j.survophthal.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Cam Loveridge-Easther
- Smith-Kettlewell Eye Research Institute, San Francisco, CA, USA; University of Auckland, Auckland, New Zealand
| | - Claudia Mueller
- Sutter Health, San Francisco, CA, USA; Stanford Children's Health, Palo Alto, CA, USA
| | | | - William V Good
- Smith-Kettlewell Eye Research Institute, San Francisco, CA, USA.
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Lin EE, Fazal FZ, Pearsall MF, Talwar D, Chang H, Shah AS. Local Anesthetic Injection Before Incision Decreases General Anesthesia Requirements in Pediatric Trigger Thumb Release: A Randomized Controlled Trial. J Pediatr Orthop 2022; 42:e285-e289. [PMID: 34967805 DOI: 10.1097/bpo.0000000000002042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Animal studies have shown evidence of neurotoxicity from inhalational anesthesia, yet clinical studies have been less conclusive. While ongoing studies investigate the clinical significance of anesthesia-associated neurodevelopmental changes in young children, reducing anesthetic exposure in pediatric orthopaedic surgery is prudent. The primary objective of this study is to determine if local anesthetic injection before surgical incision versus after surgical release decreased inhalational anesthetic exposure in children undergoing unilateral trigger thumb release. The secondary objectives were to determine if the timing of local anesthetic injection affected postoperative pain or length of stay. METHODS This was a single-center randomized controlled trial of pediatric patients (4 y and below) undergoing unilateral trigger thumb release. Subjects were randomized into preincision or postrelease local anesthesia injection groups. The surgeon was aware of the treatment group, while the anesthesiologist was blinded. Patient demographics, operative times, cumulative sevoflurane dose, and postoperative anesthesia care unit recovery characteristics were collected. The χ2, Fisher exact, and Mann-Whitney U tests were conducted. RESULTS A total of 24 subjects were enrolled, with 13 randomized to the preincision injection group and 11 to the postprocedure injection group. There was no significant difference in age, sex, operative time, or tourniquet time between groups. There was a significant difference in the cumulative sevoflurane dose between the preincision injection group (23.2 vol%; interquartile range: 21.7 to 27.6) and the postprocedure injection group (28.1 vol%; interquartile range: 27 to 30) (P=0.03), with a 21% reduction in cumulative dose. There were no significant differences in postoperative pain scores, use of rescue pain medications, the incidence of nausea, or time to discharge between groups. CONCLUSIONS Administering local anesthesia before incision versus at the end of the procedure significantly decreased cumulative sevoflurane dose for unilateral trigger thumb release. The results of this study suggest that local anesthetic injection before the incision is a low risk, easy method to reduce general anesthesia requirements during trigger thumb release and could decrease sevoflurane exposure more substantially in longer procedures and mitigate risks of neurotoxicity. Preincision injection with local anesthetic should be incorporated into routine clinical practice. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Elaina E Lin
- Department of Anesthesiology and Critical Care Medicine
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Faris Z Fazal
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Matthew F Pearsall
- Department of Anesthesiology and Critical Care Medicine
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Divya Talwar
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Hannah Chang
- Division of Orthopaedics, Children's Hospital of Philadelphia
| | - Apurva S Shah
- Division of Orthopaedics, Children's Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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7
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Wang C, Liu S, Liu F, Bhutta A, Patterson TA, Slikker W. Application of Nonhuman Primate Models in the Studies of Pediatric Anesthesia Neurotoxicity. Anesth Analg 2022; 134:1203-1214. [PMID: 35147575 DOI: 10.1213/ane.0000000000005926] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Numerous animal models have been used to study developmental neurotoxicity associated with short-term or prolonged exposure of common general anesthetics at clinically relevant concentrations. Pediatric anesthesia models using the nonhuman primate (NHP) may more accurately reflect the human condition because of their phylogenetic similarity to humans with regard to reproduction, development, neuroanatomy, and cognition. Although they are not as widely used as other animal models, the contribution of NHP models in the study of anesthetic-induced developmental neurotoxicity has been essential. In this review, we discuss how neonatal NHP animals have been used for modeling pediatric anesthetic exposure; how NHPs have addressed key data gaps and application of the NHP model for the studies of general anesthetic-induced developmental neurotoxicity. The appropriate application and evaluation of the NHP model in the study of general anesthetic-induced developmental neurotoxicity have played a key role in enhancing the understanding and awareness of the potential neurotoxicity associated with pediatric general anesthetics.
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Affiliation(s)
- Cheng Wang
- From the Division of Neurotoxicology, National Center for Toxicological Research/FDA, Jefferson, Arkansas
| | - Shuliang Liu
- From the Division of Neurotoxicology, National Center for Toxicological Research/FDA, Jefferson, Arkansas
| | - Fang Liu
- From the Division of Neurotoxicology, National Center for Toxicological Research/FDA, Jefferson, Arkansas
| | - Adnan Bhutta
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Tucker A Patterson
- Office of the Director, National Center for Toxicological Research/FDA, Jefferson, Arkansas
| | - William Slikker
- Office of the Director, National Center for Toxicological Research/FDA, Jefferson, Arkansas
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8
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Early Development of the GABAergic System and the Associated Risks of Neonatal Anesthesia. Int J Mol Sci 2021; 22:ijms222312951. [PMID: 34884752 PMCID: PMC8657958 DOI: 10.3390/ijms222312951] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/19/2021] [Accepted: 11/25/2021] [Indexed: 12/30/2022] Open
Abstract
Human and animal studies have elucidated the apparent neurodevelopmental effects resulting from neonatal anesthesia. Observations of learning and behavioral deficits in children, who were exposed to anesthesia early in development, have instigated a flurry of studies that have predominantly utilized animal models to further interrogate the mechanisms of neonatal anesthesia-induced neurotoxicity. Specifically, while neonatal anesthesia has demonstrated its propensity to affect multiple cell types in the brain, it has shown to have a particularly detrimental effect on the gamma aminobutyric acid (GABA)ergic system, which contributes to the observed learning and behavioral deficits. The damage to GABAergic neurons, resulting from neonatal anesthesia, seems to involve structure-specific changes in excitatory-inhibitory balance and neurovascular coupling, which manifest following a significant interval after neonatal anesthesia exposure. Thus, to better understand how neonatal anesthesia affects the GABAergic system, we first review the early development of the GABAergic system in various structures that have been the focus of neonatal anesthesia research. This is followed by an explanation that, due to the prolonged developmental curve of the GABAergic system, the entirety of the negative effects of neonatal anesthesia on learning and behavior in children are not immediately evident, but instead take a substantial amount of time (years) to fully develop. In order to address these concerns going forward, we subsequently offer a variety of in vivo methods which can be used to record these delayed effects.
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Park SH, Lu Y, Shao Y, Prophete C, Horton L, Sisco M, Lee HW, Kluz T, Sun H, Costa M, Zelikoff J, Chen LC, Cohen MD. Longitudinal impact on rat cardiac tissue transcriptomic profiles due to acute intratracheal inhalation exposures to isoflurane. PLoS One 2021; 16:e0257241. [PMID: 34648499 PMCID: PMC8516213 DOI: 10.1371/journal.pone.0257241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Isoflurane (ISO) is a widely used inhalation anesthetic in experiments with rodents and humans during surgery. Though ISO has not been reported to impart long-lasting side effects, it is unknown if ISO can influence gene regulation in certain tissues, including the heart. Such changes could have important implications for use of this anesthetic in patients susceptible to heart failure/other cardiac abnormalities. To test if ISO could alter gene regulation/expression in heart tissues, and if such changes were reversible, prolonged, or late onset with time, SHR (spontaneously hypertensive) rats were exposed by intratracheal inhalation to a 97.5% air/2.5% ISO mixture on two consecutive days (2 hr/d). Control rats breathed filtered air only. On Days 1, 30, 240, and 360 post-exposure, rat hearts were collected and total RNA was extracted from the left ventricle for global gene expression analysis. The data revealed differentially-expressed genes (DEG) in response to ISO (compared to naïve control) at all post-exposure timepoints. The data showed acute ISO exposures led to DEG associated with wounding, local immune function, inflammation, and circadian rhythm regulation at Days 1 and 30; these effects dissipated by Day 240. There were other significantly-increased DEG induced by ISO at Day 360; these included changes in expression of genes associated with cell signaling, differentiation, and migration, extracellular matrix organization, cell-substrate adhesion, heart development, and blood pressure regulation. Examination of consistent DEG at Days 240 and 360 indicated late onset DEG reflecting potential long-lasting effects from ISO; these included DEG associated with oxidative phosphorylation, ribosome, angiogenesis, mitochondrial translation elongation, and focal adhesion. Together, the data show acute repeated ISO exposures could impart variable effects on gene expression/regulation in the heart. While some alterations self-resolved, others appeared to be long-lasting or late onset. Whether such changes occur in all rat models or in humans remains to be investigated.
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Affiliation(s)
- Sung-Hyun Park
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
- * E-mail:
| | - Yuting Lu
- Departments of Population Health & Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Yongzhao Shao
- Departments of Population Health & Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Colette Prophete
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Lori Horton
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Maureen Sisco
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Hyun-Wook Lee
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Thomas Kluz
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Hong Sun
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Max Costa
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Judith Zelikoff
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Lung-Chi Chen
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Mitchell D. Cohen
- Department of Environmental Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
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Gascoigne DA, Drobyshevsky A, Aksenov DP. The Contribution of Dysfunctional Chloride Channels to Neurovascular Deficiency and Neurodegeneration. Front Pharmacol 2021; 12:754743. [PMID: 34671264 PMCID: PMC8520995 DOI: 10.3389/fphar.2021.754743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/21/2021] [Indexed: 01/11/2023] Open
Affiliation(s)
- David A. Gascoigne
- Department of Radiology, NorthShore University HealthSystem, Evanston, IL, United States
| | - Alexander Drobyshevsky
- Department of Pediatrics, NorthShore University HealthSystem, Evanston, IL, United States
| | - Daniil P. Aksenov
- Department of Radiology, NorthShore University HealthSystem, Evanston, IL, United States,Department of Anesthesiology, NorthShore University HealthSystem, Evanston, IL, United States,*Correspondence: Daniil P. Aksenov,
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11
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Unchiti K, Leurcharusmee P, Samerchua A, Pipanmekaporn T, Chattipakorn N, Chattipakorn SC. The potential role of dexmedetomidine on neuroprotection and its possible mechanisms: Evidence from in vitro and in vivo studies. Eur J Neurosci 2021; 54:7006-7047. [PMID: 34561931 DOI: 10.1111/ejn.15474] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/24/2022]
Abstract
Neurological disorders following brain injuries and neurodegeneration are on the rise worldwide and cause disability and suffering in patients. It is crucial to explore novel neuroprotectants. Dexmedetomidine, a selective α2-adrenoceptor agonist, is commonly used for anxiolysis, sedation and analgesia in clinical anaesthesia and critical care. Recent studies have shown that dexmedetomidine exerts protective effects on multiple organs. This review summarized and discussed the current neuroprotective effects of dexmedetomidine, as well as the underlying mechanisms. In preclinical studies, dexmedetomidine reduced neuronal injury and improved functional outcomes in several models, including hypoxia-induced neuronal injury, ischaemic-reperfusion injury, intracerebral haemorrhage, post-traumatic brain injury, anaesthetic-induced neuronal injury, substance-induced neuronal injury, neuroinflammation, epilepsy and neurodegeneration. Several mechanisms are associated with the neuroprotective function of dexmedetomidine, including neurotransmitter regulation, inflammatory response, oxidative stress, apoptotic pathway, autophagy, mitochondrial function and other cell signalling pathways. In summary, dexmedetomidine has the potential to be a novel neuroprotective agent for a wide range of neurological disorders.
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Affiliation(s)
- Kantarakorn Unchiti
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prangmalee Leurcharusmee
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Artid Samerchua
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tanyong Pipanmekaporn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Neurophysiology Unit, Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.,Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
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12
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Aksenov DP. Normal Development of Local Neurovascular Interactions and the Diagnostic Value of Resting State Functional MRI in Neurovascular Deficiency Based on the Example of Neonatal Anesthesia Exposure. Front Neurol 2021; 12:664706. [PMID: 33995262 PMCID: PMC8116565 DOI: 10.3389/fneur.2021.664706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/08/2021] [Indexed: 01/25/2023] Open
Affiliation(s)
- Daniil P Aksenov
- Department of Radiology, NorthShore University HealthSystem, Evanston, IL, United States.,Department of Anesthesiology, NorthShore University HealthSystem, Evanston, IL, United States
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13
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Li X, Jiang X, Zhao P. Effects of Pregnancy Anesthesia on Fetal Nervous System. Front Pharmacol 2021; 11:523514. [PMID: 33597861 PMCID: PMC7883872 DOI: 10.3389/fphar.2020.523514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 12/09/2020] [Indexed: 11/13/2022] Open
Abstract
The effects of general anesthesia on the developing brain remain a great concern in the medical field and even in the public, and most researches in this area focus on infancy and childhood. In recent years, with the continuous development of medical technology, the number of operations during pregnancy is increasing, however, studies on general anesthesia during pregnancy are relatively lacking. The mid-trimester of pregnancy is a critical period, and is regarded as a safe period for surgery, but it is a fragile period for the development of the central nervous system and is particularly sensitive to the impact of the environment. Our research group found that general anesthesia may have adverse effects on fetal neurodevelopment during the mid-trimester. Therefore, in this review, we summarize the characteristics of anesthesia during pregnancy, and the related research of the anesthesia’s impacts on the development of central nervous system were introduced.
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Affiliation(s)
- Xingyue Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xi Jiang
- Department of Neurosurgery, Shenyang Chest Hospital, Shenyang, China
| | - Ping Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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14
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Slupe AM, Villasana L, Wright KM. GABAergic neurons are susceptible to BAX-dependent apoptosis following isoflurane exposure in the neonatal period. PLoS One 2021; 16:e0238799. [PMID: 33434191 PMCID: PMC7802958 DOI: 10.1371/journal.pone.0238799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/27/2020] [Indexed: 12/18/2022] Open
Abstract
Exposure to volatile anesthetics during the neonatal period results in acute neuron death. Prior work suggests that apoptosis is the dominant mechanism mediating neuron death. We show that Bax deficiency blocks neuronal death following exposure to isoflurane during the neonatal period. Blocking Bax-mediated neuron death attenuated the neuroinflammatory response of microglia following isoflurane exposure. We find that GABAergic interneurons are disproportionately overrepresented among dying neurons. Despite the increase in neuronal apoptosis induced by isoflurane exposure during the neonatal period, seizure susceptibility, spatial memory retention, and contextual fear memory were unaffected later in life. However, Bax deficiency alone led to mild deficiencies in spatial memory and contextual fear memory, suggesting that normal developmental apoptotic death is important for cognitive function. Collectively, these findings show that while GABAergic neurons in the neonatal brain undergo elevated Bax-dependent apoptotic cell death following exposure to isoflurane, this does not appear to have long-lasting consequences on overall neurological function later in life.
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Affiliation(s)
- Andrew M. Slupe
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Laura Villasana
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Kevin M. Wright
- Vollum Institute, Oregon Health & Science University, Portland, Oregon, United States of America
- * E-mail:
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15
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Tong D, Ma Z, Su P, Wang S, Xu Y, Zhang LM, Wu Z, Liu K, Zhao P. Sevoflurane-Induced Neuroapoptosis in Rat Dentate Gyrus Is Activated by Autophagy Through NF-κB Signaling on the Late-Stage Progenitor Granule Cells. Front Cell Neurosci 2020; 14:590577. [PMID: 33384584 PMCID: PMC7769878 DOI: 10.3389/fncel.2020.590577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/12/2020] [Indexed: 12/20/2022] Open
Abstract
Objective The mechanisms by which exposure of the late-stage progenitor cells to the anesthesia sevoflurane alters their differentiation are not known. We seek to query whether the effects of sevoflurane on late-stage progenitor cells might be regulated by apoptosis and/or autophagy. Methods To address the short-term impact of sevoflurane exposure on granule cell differentiation, we used 5-bromo-2-deoxyuridine (BrdU) to identify the labeled late-stage progenitor granule cells. Male or female rats were exposed to 3% sevoflurane for 4 h when the labeled granule cells were 2 weeks old. Differentiation of the BrdU-labeled granule cells was quantified 4 and 7 days after exposure by double immunofluorescence. The expression of apoptosis and autophagy in hippocampal dentate gyrus (DG) was determined by western blot and immunofluorescence. Western blot for the expression of NF-κB was used to evaluate the mechanism. Morris water maze (MWM) test was performed to detect cognitive function in the rats on postnatal 28–33 days. Results Exposure to sevoflurane decreased the differentiation of the BrdU-labeled late-stage progenitor granule cells, but increased the expression of caspase-3, autophagy, and phosphorylated-P65 in the hippocampus of juvenile rats and resulted in cognitive deficiency. These damaging effects of sevoflurane could be mitigated by inhibitors of autophagy, apoptosis, and NF-κB. The increased apoptosis could be alleviated by pretreatment with the autophagy inhibitor 3-MA, and the increased autophagy and apoptosis could be reduced by pretreatment with NF-κB inhibitor BAY 11-7085. Conclusion These findings suggest that a single, prolonged sevoflurane exposure could impair the differentiation of late-stage progenitor granule cells in hippocampal DG and cause cognitive deficits possibly via apoptosis activated by autophagy through NF-κB signaling. Our results do not preclude the possibility that the affected differentiation and functional deficits may be caused by depletion of the progenitors pool.
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Affiliation(s)
- Dongyi Tong
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhongliang Ma
- Department of Otolaryngology Head and Neck Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Su
- Medical Research Center, Shengjing Hospital of China Medical University, Benxi, China
| | - Shuai Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Xu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Li Min Zhang
- Department of Anesthesiology, Cangzhou Central Hospital, Cangzhou, China
| | - Ziyi Wu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Kun Liu
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ping Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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16
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Arana Håkanson C, Fredriksson F, Engstrand Lilja H. Attention deficit hyperactivity disorder and educational level in adolescent and adult individuals after anesthesia and abdominal surgery during infancy. PLoS One 2020; 15:e0240891. [PMID: 33085711 PMCID: PMC7577494 DOI: 10.1371/journal.pone.0240891] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 10/05/2020] [Indexed: 11/18/2022] Open
Abstract
AIM Several studies in animal models have found that exposure to anesthetics in early life can cause cognitive dysfunction. Human studies show conflicting results and studies of cognitive function after anesthesia and neonatal surgery are scarce. The aim of this study was to investigate whether exposure to anesthesia and abdominal surgery during infancy was associated with cognitive dysfunction from the perspective of educational level, disposable income and attention deficit hyperactivity disorders (ADHD) in adolescent and adult individuals. METHODS A cohort study with patients born 1976 to 2002 that underwent abdominal surgery during infancy at a pediatric surgical center were matched by age, sex, and gestational age to ten randomly selected individuals from the Swedish Medical Birth Register. Individuals with chromosomal aberrations were excluded. Data on highest level of education and annual disposable income were attained from Statistics Sweden and the diagnosis of ADHD were retrieved from the Swedish National Patient Register. RESULTS 485 individuals and 4835 controls were included. Median gestational age was 38 weeks (24-44) and median age at surgery was seven days (0-365). Three hundred sixty-six individuals (70.0%) underwent surgery during the neonatal period (< 44 gestational weeks). Median operating time was 80 minutes (10-430). The mean age at follow-up was 28 years. Fisher's exact test for highest level of education for the exposed and unexposed groups were respectively: university 35% and 33%, upper secondary 44% and 47%, compulsory 21% and 20% (p = 0.6718). The median disposable income was 177.7 versus 180.9 TSEK respectively (p = 0.7532). Exposed individuals had a prevalence of ADHD of 5.2% and unexposed 4.4% (p = 0.4191). CONCLUSIONS This study shows that exposure to anesthesia and abdominal surgery during infancy is not associated with cognitive dysfunction from the perspective of educational level, disposable income and ADHD in adolescent and adult individuals. Further studies in larger cohorts at earlier gestational ages are needed to verify these findings.
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Affiliation(s)
- Cecilia Arana Håkanson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- * E-mail:
| | - Fanny Fredriksson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | - Helene Engstrand Lilja
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
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17
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Perkins SE, Hankenson FC. Nonexperimental Xenobiotics: Unintended Consequences of Intentionally Administered Substances in Terrestrial Animal Models. ILAR J 2020; 60:216-227. [PMID: 32574354 DOI: 10.1093/ilar/ilaa003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 12/17/2019] [Accepted: 01/10/2020] [Indexed: 11/13/2022] Open
Abstract
Review of the use of nonexperimental xenobiotics in terrestrial animal models and the potential unintended consequences of these compounds, including drug-related side effects and adverse reactions.
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Affiliation(s)
- Scott E Perkins
- Tufts Comparative Medicine Services, Tufts University, Boston, Massachusetts; and Department of Environmental and Population Health, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts
| | - F Claire Hankenson
- Campus Animal Resources, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
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18
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Aksenov DP, Miller MJ, Dixon CJ, Drobyshevsky A. Impact of anesthesia exposure in early development on learning and sensory functions. Dev Psychobiol 2020; 62:559-572. [PMID: 32115695 DOI: 10.1002/dev.21963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
Each year, millions of children undergo anesthesia, and both human and animal studies have indicated that exposure to anesthesia at an early age can lead to neuronal damage and learning deficiency. However, disorders of sensory functions were not reported in children or animals exposed to anesthesia during infancy, which is surprising, given the significant amount of damage to brain tissue reported in many animal studies. In this review, we discuss the relationship between the systems in the brain that mediate sensory input, spatial learning, and classical conditioning, and how these systems could be affected during anesthesia exposure. Based on previous reports, we conclude that anesthesia can induce structural, functional, and compensatory changes in both sensory and learning systems. Changes in myelination following anesthesia exposure were observed as well as the neurodegeneration in the gray matter across variety of brain regions. Disproportionate cell death between excitatory and inhibitory cells induced by anesthesia exposure can lead to a long-term shift in the excitatory/inhibitory balance, which affects both learning-specific networks and sensory systems. Anesthesia may directly affect synaptic plasticity which is especially critical to learning acquisition. However, sensory systems appear to have better ability to compensate for damage than learning-specific networks.
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Affiliation(s)
| | | | - Conor J Dixon
- NorthShore University HealthSystem, Evanston, IL, USA
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19
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Hypoxia, hypercarbia, and mortality reporting in studies of anaesthesia-related neonatal neurodevelopmental delay in rodent models. Eur J Anaesthesiol 2020; 37:70-84. [DOI: 10.1097/eja.0000000000001105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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20
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Yang ZY, Zhou L, Meng Q, Shi H, Li YH. An appropriate level of autophagy reduces emulsified isoflurane-induced apoptosis in fetal neural stem cells. Neural Regen Res 2020; 15:2278-2285. [PMID: 32594049 PMCID: PMC7749471 DOI: 10.4103/1673-5374.285004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Autophagy plays essential roles in cell survival. However, the functions and regulation of the autophagy-related proteins Atg5, LC3B, and Beclin 1 during anesthetic-induced developmental neurotoxicity remain unclear. This study aimed to understand the autophagy pathways and mechanisms that affect neurotoxicity, induced by the anesthetic emulsified isoflurane, in rat fetal neural stem cells. Fetal neural stem cells were cultured, in vitro, and neurotoxicity was induced by emulsified isoflurane treatment. The effects of pretreatment with the autophagy inhibitors 3-methyladenine and bafilomycin and the effects of transfection with small interfering RNA against ATG5 (siRNA-Atg5) were observed. Cell viability was determined using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, and apoptosis was assessed using flow cytometry. Ultrastructural changes were analyzed through transmission electron microscopy. The levels of the autophagy-related proteins LC3B, Beclin 1, Atg5, and P62 and the pro-apoptosis-related protein caspase-3 were analyzed using western blot assay. The inhibition of cell proliferation and that of apoptosis rate increased after treatment with emulsified isoflurane. Autophagolysosomes, monolayer membrane formation due to lysosomal degradation, were observed. The autophagy-related proteins LC3B, Beclin 1, Atg5, and P62 and caspase-3 were upregulated. These results confirm that emulsified isoflurane can induce toxicity and autophagy in fetal neural stem cells. Pre-treatment with 3-methyladenine and bafilomycin increased the apoptosis rate in emulsified isoflurane-treated fetal neural stem cells, which indicated that the complete inhibition of autophagy does not alleviate emulsified isoflurane-induced fetal neural stem cell toxicity. Atg5 expression was decreased significantly by siRNA-Atg5 transfection, and cell proliferation was inhibited. These results verify that the Atg5 autophagy pathway can be regulated to maintain appropriate levels of autophagy, which can inhibit the neurotoxicity induced by emulsified isoflurane anesthetic in fetal neural stem cells.
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Affiliation(s)
- Ze-Yong Yang
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Embryo Original Disease, Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Lei Zhou
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Qiong Meng
- Department of Anesthesiology, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Embryo Original Disease, Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Hong Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Yuan-Hai Li
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
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21
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Clausen NG, Hansen TG, Disma N. Anesthesia Neurotoxicity in the Developing Brain: Basic Studies Relevant for Neonatal or Perinatal Medicine. Clin Perinatol 2019; 46:647-656. [PMID: 31653300 DOI: 10.1016/j.clp.2019.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Diagnostic and invasive procedures in premature infants may require general anesthesia. General anesthetics interfere with the development of the immature animal brain. Accelerated apoptosis, disturbed synaptogenesis, and cytoarchitecture are among the mechanisms suspected to underlie this phenomenon. The implications for humans are unknown. This article presents current suspected mechanisms of anesthesia-induced neurotoxicity and elaborates on the difficulties in translating results from animal research to human. Ethical considerations limit the conduct of such experiments in human neonates, but the use of animal models is still considered feasible. Vulnerable periods in brain development need further identification as do neurotoxic and neuroprotective interventions.
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Affiliation(s)
- Nicola Groes Clausen
- Department of Anesthesiology and Intensive Care, Odense University Hospital, J.B. Winsløwsvej 4, Odense C 5000, Denmark
| | - Tom G Hansen
- Department of Anesthesiology and Intensive Care - Pediatrics, Odense University Hospital, J.B. Winsløwsvej 4, Odense C 5000, Denmark; Department of Clinical Research - Anesthesiology, University of Southern Denmark, Odense C 5000, Denmark
| | - Nicola Disma
- Department of Anesthesia, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, Genoa 16100, Italy.
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22
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Early Developmental Exposure to Repetitive Long Duration of Midazolam Sedation Causes Behavioral and Synaptic Alterations in a Rodent Model of Neurodevelopment. J Neurosurg Anesthesiol 2019; 31:151-162. [PMID: 30767941 DOI: 10.1097/ana.0000000000000541] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a large body of preclinical literature suggesting that exposure to general anesthetic agents during early life may have harmful effects on brain development. Patients in intensive care settings are often treated for prolonged periods with sedative medications, many of which have mechanisms of action that are similar to general anesthetics. Using in vivo studies of the mouse hippocampus and an in vitro rat cortical neuron model we asked whether there is evidence that repeated, long duration exposure to midazolam, a commonly used sedative in pediatric intensive care practice, has the potential to cause lasting harm to the developing brain. We found that mice that underwent midazolam sedation in early postnatal life exhibited deficits in the performance on Y-maze and fear-conditioning testing at young adult ages. Labeling with a nucleoside analog revealed a reduction in the rate of adult neurogenesis in the hippocampal dentate gyrus, a brain region that has been shown to be vulnerable to developmental anesthetic neurotoxicity. In addition, using immunohistochemistry for synaptic markers we found that the number of presynaptic terminals in the dentate gyrus was reduced, while the number of excitatory postsynaptic terminals was increased. These findings were replicated in a midazolam sedation exposure model in neurons in culture. We conclude that repeated, long duration exposure to midazolam during early development has the potential to result in persistent alterations in the structure and function of the brain.
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23
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McCann ME, de Graaff JC, Dorris L, Disma N, Withington D, Bell G, Grobler A, Stargatt R, Hunt RW, Sheppard SJ, Marmor J, Giribaldi G, Bellinger DC, Hartmann PL, Hardy P, Frawley G, Izzo F, von Ungern Sternberg BS, Lynn A, Wilton N, Mueller M, Polaner DM, Absalom AR, Szmuk P, Morton N, Berde C, Soriano S, Davidson AJ. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet 2019; 393:664-677. [PMID: 30782342 PMCID: PMC6500739 DOI: 10.1016/s0140-6736(18)32485-1] [Citation(s) in RCA: 370] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 09/27/2018] [Accepted: 10/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND In laboratory animals, exposure to most general anaesthetics leads to neurotoxicity manifested by neuronal cell death and abnormal behaviour and cognition. Some large human cohort studies have shown an association between general anaesthesia at a young age and subsequent neurodevelopmental deficits, but these studies are prone to bias. Others have found no evidence for an association. We aimed to establish whether general anaesthesia in early infancy affects neurodevelopmental outcomes. METHODS In this international, assessor-masked, equivalence, randomised, controlled trial conducted at 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand, we recruited infants of less than 60 weeks' postmenstrual age who were born at more than 26 weeks' gestation and were undergoing inguinal herniorrhaphy, without previous exposure to general anaesthesia or risk factors for neurological injury. Patients were randomly assigned (1:1) by use of a web-based randomisation service to receive either awake-regional anaesthetic or sevoflurane-based general anaesthetic. Anaesthetists were aware of group allocation, but individuals administering the neurodevelopmental assessments were not. Parents were informed of their infants group allocation upon request, but were told to mask this information from assessors. The primary outcome measure was full-scale intelligence quotient (FSIQ) on the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III), at 5 years of age. The primary analysis was done on a per-protocol basis, adjusted for gestational age at birth and country, with multiple imputation used to account for missing data. An intention-to-treat analysis was also done. A difference in means of 5 points was predefined as the clinical equivalence margin. This completed trial is registered with ANZCTR, number ACTRN12606000441516, and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 4023 infants were screened and 722 were randomly allocated: 363 (50%) to the awake-regional anaesthesia group and 359 (50%) to the general anaesthesia group. There were 74 protocol violations in the awake-regional anaesthesia group and two in the general anaesthesia group. Primary outcome data for the per-protocol analysis were obtained from 205 children in the awake-regional anaesthesia group and 242 in the general anaesthesia group. The median duration of general anaesthesia was 54 min (IQR 41-70). The mean FSIQ score was 99·08 (SD 18·35) in the awake-regional anaesthesia group and 98·97 (19·66) in the general anaesthesia group, with a difference in means (awake-regional anaesthesia minus general anaesthesia) of 0·23 (95% CI -2·59 to 3·06), providing strong evidence of equivalence. The results of the intention-to-treat analysis were similar to those of the per-protocol analysis. INTERPRETATION Slightly less than 1 h of general anaesthesia in early infancy does not alter neurodevelopmental outcome at age 5 years compared with awake-regional anaesthesia in a predominantly male study population. FUNDING US National Institutes of Health, US Food and Drug Administration, Thrasher Research Fund, Australian National Health and Medical Research Council, Health Technologies Assessment-National Institute for Health Research (UK), Australian and New Zealand College of Anaesthetists, Murdoch Children's Research Institute, Canadian Institutes of Health Research, Canadian Anesthesiologists Society, Pfizer Canada, Italian Ministry of Health, Fonds NutsOhra, UK Clinical Research Network, Perth Children's Hospital Foundation, the Stan Perron Charitable Trust, and the Callahan Estate.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Jurgen C de Graaff
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, Netherlands; Department of Anaesthesiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Liam Dorris
- Paediatric Neurosciences, Royal Hospital for Children, Glasgow, Scotland, UK; Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola Disma
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Davinia Withington
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anaesthesia, McGill University, Montreal, QC, Canada
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Robyn Stargatt
- Child Neuropsychology, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Psychological Science, La Trobe University, Melbourne, Victoria, Australia
| | - Rodney W Hunt
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Suzette J Sheppard
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Gaia Giribaldi
- Department of Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; School of Behavioural and Health Sciences, Australian Catholic University, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Francesca Izzo
- Department of Anaesthesiology and Paediatric Intensive Care, Ospedale Pediatrico Vittore Buzzi, Milan, Italy
| | - Britta S von Ungern Sternberg
- Medical School, The University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia; Telethon Kid's Institute, Perth, WA, Australia
| | - Anne Lynn
- Department of Anesthesiology and Pain Medicine, and Pediatrics University of Washington, Seattle, WA, USA; Department of Anaesthesia and Pain Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Martin Mueller
- Department of Anaesthesia, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - David M Polaner
- Department of Anaesthesiology, Children's Hospital Colorado, Denver, CO, USA; Department of Anaesthesiology, University of Colorado, Denver, CO, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Peter Szmuk
- Department of Anesthesiology and Pain Management, University of Texas Southwestern and Children's Medical Centre Dallas, Dallas, TX, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Neil Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, Scotland, UK; Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Charles Berde
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sulpicio Soriano
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia.
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Anesthesia affects excitatory/inhibitory synapses during the critical synaptogenic period in the hippocampus of young mice: Importance of sex as a biological variable. Neurotoxicology 2019; 70:146-153. [DOI: 10.1016/j.neuro.2018.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/17/2018] [Accepted: 11/27/2018] [Indexed: 11/18/2022]
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25
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Chen P, Shang A, Wang W, Yang J. Astragaloside suppresses tumor necrosis factor receptor‐associated factor 5 signaling pathway and alleviates neurodegenerative changes in retinal pigment epithelial cells induced by isoflurane. J Cell Biochem 2018; 120:1028-1037. [PMID: 30277612 DOI: 10.1002/jcb.27599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/08/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Pei‐Jun Chen
- Department of Anesthesiology The First Affiliated Hospital of Soochow University Suzhou China
- Department of Anesthesiology The Sixth People’s Hospital of Yancheng City Yancheng China
| | - An‐Quan Shang
- Department of Laboratory Medicine Tongji Hospital of Tongji University School of Medicine Shanghai China
| | - Wei‐Wei Wang
- Department of Pathology The Sixth People’s Hospital of Yancheng City Yancheng China
| | - Jian‐Ping Yang
- Department of Anesthesiology The First Affiliated Hospital of Soochow University Suzhou China
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Shibuta S, Morita T, Kosaka J. Intravenous anesthetic-induced calcium dysregulation and neurotoxic shift with age during development in primary cultured neurons. Neurotoxicology 2018; 69:320-329. [PMID: 30107222 DOI: 10.1016/j.neuro.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 07/29/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
Anesthetic-induced neurotoxicity in the developing brain is a concern. This neurotoxicity is closely related to anesthetic exposure time, dose, and developmental stages. Using calcium imaging and morphological examinations in vitro, we sought to determine whether intravenous anesthetic-induced direct neurotoxicity varies according to different stages of the days in vitro (DIV) of neurons in primary culture. Cortical neurons from E17 Wistar rats were prepared. On DIV 3, 7, and 13, cells were exposed to the intravenous anesthetics thiopental sodium (TPS), midazolam (MDZ), or propofol (PPF), to investigate direct neurotoxicity using morphological experiments. Furthermore, using calcium imaging, the anesthetic-induced intracellular calcium concentration ([Ca2+]i) elevation was monitored in cells on DIV 4, 8, and 13. All anesthetics elicited significant [Ca2+]i increases on DIV 4. While TPS (100 μM) and MDZ (10 μM) did not alter neuronal death, PPF (10 μM and 100 μM) decreased the survival ratio (SR) significantly. On DIV 8, TPS and MDZ did not elicit [Ca2+]i elevation or SR decrease, while PPF still induced [Ca2+]i elevation (both at 10 μM and 100 μM) and significant SR decrease at 100 μM (0.76 ± 0.03; P < 0.05), but not at 10 μM (0.91 ± 0.03). Such anesthetic-induced [Ca2+]i elevation and SR decrease were not observed on DIV 13-14 for any of the anesthetic drugs. Our study indicates that more caution may be exercised when using PPF compared to TPS or MDZ during development.
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Affiliation(s)
- Satoshi Shibuta
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare, Narita, Chiba, Japan; Department of Anesthesiology and Intensive Care Medicine, Osaka University, Suita, Osaka, Japan.
| | - Tomotaka Morita
- Department of Anesthesiology and Intensive Care Medicine, Osaka University, Suita, Osaka, Japan.
| | - Jun Kosaka
- Department of Anatomy, International University of Health and Welfare, Narita, Chiba, Japan.
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Mayer S, Peukert N, Gnatzy R, Gosemann JH, Lacher M, Suttkus A. Physiologic Changes in a Small Animal Model for Neonatal Minimally Invasive Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:912-917. [PMID: 29782214 DOI: 10.1089/lap.2018.0075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS) has gained increasing importance in neonatal surgery but the effects on neonatal physiology remain unclear. We aimed to characterize the impact of capnoperitoneum on physiologic parameters in a small animal model for neonatal MIS. MATERIAL AND METHODS Twenty-four 10-day-old Sprague Dawley rats underwent inhalative anesthesia (1% isoflurane in 100% O2 250 mL/minutes) and were allowed to breathe spontaneously. CO2 was insufflated into the abdominal cavity for 1 hour via a 24G cannula. Anesthetized litter mates without insufflation served as sham controls, those without any treatment as external controls. Continuous monitoring included O2-saturation, heart and respiration rate, pulse and breath distension. After euthanasia, blood gas analysis was performed. RESULTS All animals survived the experiment. Capnoperitoneum was best tolerated at a pressure of 2 mmHg and a flow of 0.5 L/minutes. A significant decrease in heart rate was observed within the first 30 minutes of insufflation comparing the CO2 and sham group (P < .05). In both, the CO2 and sham group, postmortem pH-levels were lower and pCO2 levels were higher compared to external controls (P < .05). Additionally, levels of pCO2 were higher but pH levels remained unchanged in the CO2 compared to sham group (P < .05). CONCLUSION We established a small animal model for neonatal laparoscopy. A pressure of 2 mmHg and flow of 0.5 L/minutes induced physiologic alterations but was well tolerated by the animals. These settings can be used in future studies on the impact of the capnoperitoneum in neonatal MIS.
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Affiliation(s)
- Steffi Mayer
- Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany
| | - Nicole Peukert
- Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany
| | - Richard Gnatzy
- Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany
| | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany
| | - Anne Suttkus
- Department of Pediatric Surgery, University of Leipzig , Leipzig, Germany
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Nitrogen narcosis induced by repetitive hyperbaric nitrogen oxygen mixture exposure impairs long-term cognitive function in newborn mice. PLoS One 2018; 13:e0196611. [PMID: 29698458 PMCID: PMC5919656 DOI: 10.1371/journal.pone.0196611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/15/2018] [Indexed: 01/07/2023] Open
Abstract
Human beings are exposed to compressed air or a nitrogen-oxygen mixture, they will produce signs and symptoms of nitrogen narcosis such as amnesia or even loss of memory, which may be disappeared once back to the normobaric environment. This study was designed to investigate the effect of nitrogen narcosis induced by repetitive hyperbaric nitrogen-oxygen mixture exposure on long-term cognitive function in newborn mice and the underlying mechanisms. The electroencephalogram frequency was decreased while the amplitude was increased in a pressure-dependent manner during 0.6, 1.2, 1.8 MPa (million pascal) nitrogen-oxygen mixture exposures in adult mice. Nitrogen narcosis in postnatal days 7-9 mice but not in adult mice induced by repetitive hyperbaric exposure prolonged the latency to find the platform and decreased the number of platform-site crossovers during Morris water maze tests, and reduced the time in the center during the open field tests. An increase in the expression of cleaved caspase-3 in the hippocampus and cortex were observed immediately on the first day after hyperbaric exposure, and this lasted for seven days. Additionally, nitrogen narcosis induced loss of the dendritic spines but not of the neurons, which may mainly account for the cognitive dysfunction. Nitrogen narcosis induced long-term cognitive and emotional dysfunction in the postnatal mice but not in the adult mice, which may result from neuronal apoptosis and especially reduction of dendritic spines of neurons.
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29
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Perez-Zoghbi J, Zhu W, Grafe M, Brambrink A. Dexmedetomidine-mediated neuroprotection against sevoflurane-induced neurotoxicity extends to several brain regions in neonatal rats. Br J Anaesth 2017; 119:506-516. [DOI: 10.1093/bja/aex222] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2017] [Indexed: 12/21/2022] Open
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Kang E, Jiang D, Ryu YK, Lim S, Kwak M, Gray CD, Xu M, Choi JH, Junn S, Kim J, Xu J, Schaefer M, Johns RA, Song H, Ming GL, Mintz CD. Early postnatal exposure to isoflurane causes cognitive deficits and disrupts development of newborn hippocampal neurons via activation of the mTOR pathway. PLoS Biol 2017; 15:e2001246. [PMID: 28683067 PMCID: PMC5500005 DOI: 10.1371/journal.pbio.2001246] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 06/02/2017] [Indexed: 12/18/2022] Open
Abstract
Clinical and preclinical studies indicate that early postnatal exposure to anesthetics can lead to lasting deficits in learning and other cognitive processes. The mechanism underlying this phenomenon has not been clarified and there is no treatment currently available. Recent evidence suggests that anesthetics might cause persistent deficits in cognitive function by disrupting key events in brain development. The hippocampus, a brain region that is critical for learning and memory, contains a large number of neurons that develop in the early postnatal period, which are thus vulnerable to perturbation by anesthetic exposure. Using an in vivo mouse model we demonstrate abnormal development of dendrite arbors and dendritic spines in newly generated dentate gyrus granule cell neurons of the hippocampus after a clinically relevant isoflurane anesthesia exposure conducted at an early postnatal age. Furthermore, we find that isoflurane causes a sustained increase in activity in the mechanistic target of rapamycin pathway, and that inhibition of this pathway with rapamycin not only reverses the observed changes in neuronal development, but also substantially improves performance on behavioral tasks of spatial learning and memory that are impaired by isoflurane exposure. We conclude that isoflurane disrupts the development of hippocampal neurons generated in the early postnatal period by activating a well-defined neurodevelopmental disease pathway and that this phenotype can be reversed by pharmacologic inhibition. The United States Food and Drug Administration has recently warned that exposure to anesthetic and sedative drugs during the third trimester of prenatal development and during the first 3 years of life may cause lasting impairments in cognitive function. The mechanisms by which this undesirable side effect occurs are unknown. In this manuscript, we present evidence in mice that early developmental exposure to isoflurane, a canonical general anesthetic, disrupts the appropriate development of neurons in the hippocampus, a brain region associated with learning and memory. Isoflurane also causes up-regulation of the mechanistic target of rapamycin (mTOR) pathway, a signaling system that has been associated with other neurodevelopmental cognitive disorders. Treatment with an inhibitor of the mTOR pathway after isoflurane exposure normalizes neuronal development and also ameliorates the impairments in learning induced by isoflurane. We conclude that early exposure to isoflurane can cause learning deficits via actions on the mTOR pathway, and that this mechanism represents a potentially druggable target to minimize the side effects of anesthetics on the developing brain.
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Affiliation(s)
- Eunchai Kang
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Danye Jiang
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Yun Kyoung Ryu
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sanghee Lim
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Minhye Kwak
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Christy D. Gray
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michael Xu
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jun H. Choi
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Sue Junn
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jieun Kim
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Jing Xu
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michele Schaefer
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Roger A. Johns
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Hongjun Song
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Solomon Snyder Department of Neuroscience, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Guo-Li Ming
- Institute for Cell Engineering, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- The Solomon Snyder Department of Neuroscience, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - C. David Mintz
- Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Álvarez Escudero J, Paredes Esteban RM, Cambra Lasaosa FJ, Vento M, López Gil M, de Agustín Asencio JC, Moral Pumarega MT. More than 3 hours and less than 3 years old. Safety of anesthetic procedures in children under 3 years of age, subject to surgeries of more than 3 hours. ACTA ACUST UNITED AC 2017. [PMID: 28641810 DOI: 10.1016/j.redar.2017.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- J Álvarez Escudero
- Presidente de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), jefe del Servicio de Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela, catedrático de Anestesiología, director del Departamento de Cirugía y especialidades Médico Quirúrgicas, Facultad de Medicina y Odontología, Universidad de Santiago de Compostela.
| | - R M Paredes Esteban
- Presidente de la Sociedad Española de Cirugía Pediátrica (SECP), presidente de la Sociedad Andaluza de Cirugía Pediátrica (ACPA), directora de la Unidad de Gestión Clínica de Cirugía Pediátrica, jefa del Servicio de Cirugía Pediátrica, Hospital Universitario Reina Sofía, Córdoba, España
| | - F J Cambra Lasaosa
- Presidente de la Sociedad Española de Cuidados Intensivos Pediátricos (SECIP), jefe del Servicio Unidad de Cuidados Intensivos Pediátricos Hospital Universitario Sant Joan de Déu, Barcelona, profesor asociado de Pediatría, Facultad de Medicina, Universidad de Barcelona
| | - M Vento
- Presidente de la Sociedad Española de Neonatología (SENeo), coordinador nacional de la Retic, Red de Salud Materno Infantil y del Desarrollo SAMID RD16/0022, Instituto Carlos III, Ministerio de Economía, Industria y Competitividad, Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - M López Gil
- Vicepresidenta de la Sección Anestesia Pediátrica, Sociedad Española de Anestesiología Reanimación y Terapéutica del Dolor (SEDAR), jefa del Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, profesora asociada del Departamento de Farmacología, Facultad de Medicina, Universidad Complutense de Madrid
| | - J C de Agustín Asencio
- Vicepresidente de la Sociedad Española de Cirugía Pediátrica (SECP), jefe del Servicio de Cirugía Pediátrica, coordinador de Especialidades Quirúrgicas en Pediatría, Hospital Materno Infantil, Hospital General Universitario Gregorio Marañón, Madrid, profesor asociado de Pediatría, Facultad de Medicina, Universidad Complutense de Madrid
| | - M T Moral Pumarega
- Sociedad Española de Neonatología (SENeo), jefa de Sección, Servicio de Neonatología, Hospital Universitario 12 de Octubre, Madrid, colaboradora de la REDSAMID, profesora asociada de Pediatría y Ciencias de la Salud, Facultad de Medicina, Universidad Complutense de Madrid
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32
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Whitaker EE, Zheng CZ, Bissonnette B, Miller AD, Koppert TL, Tobias JD, Pierson CR, Christofi FL. Use of a Piglet Model for the Study of Anesthetic-induced Developmental Neurotoxicity (AIDN): A Translational Neuroscience Approach. J Vis Exp 2017. [PMID: 28654034 PMCID: PMC5608378 DOI: 10.3791/55193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Anesthesia cannot be avoided in many cases when surgery is required, particularly in children. Recent investigations in animals have raised concerns that anesthesia exposure may lead to neuronal apoptosis, known as anesthesia-induced developmental neurotoxicity (AIDN). Furthermore, some clinical studies in children have suggested that anesthesia exposure may lead to neurodevelopmental deficits later in life. Nonetheless, an ideal animal model for preclinical study has yet to be developed. The neonatal piglet represents a valuable model for preclinical study, as they share a striking number of developmental similarities with humans. The anatomy and physiology of piglets allow for implementation of rigorous human perioperative conditions in both survival and non-survival procedures. Femoral artery catheterization allows for close monitoring, thus enabling prompt correction of any deviation of the piglet's vital signs and chemistries. In addition, there are multiple developmental similarities between piglets and human neonates. The techniques required to use piglets for experimentation will require experience to master. A pediatric anesthesiologist is a critical member of the investigative team. We describe, in a general sense, the appropriate use of a piglet model for neurodevelopmental study.
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Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital;
| | | | - Bruno Bissonnette
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital; Department of Anaesthesia and Critical Care Medicine, University of Toronto
| | - Andrew D Miller
- Department of Biomedical Sciences, Section of Anatomic Pathology, Cornell University College of Veterinary Medicine
| | - Tanner L Koppert
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Joseph D Tobias
- Department of Anesthesiology, Ohio State University College of Medicine; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Christopher R Pierson
- Department of Pathology and Anatomy, Ohio State University College of Medicine; Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital
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Vutskits L, Xie Z. Lasting impact of general anaesthesia on the brain: mechanisms and relevance. Nat Rev Neurosci 2017; 17:705-717. [PMID: 27752068 DOI: 10.1038/nrn.2016.128] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
General anaesthesia is usually considered to safely induce a reversible brain state allowing the performance of surgery under optimal conditions. An increasing number of clinical and experimental observations, however, suggest that anaesthetic drugs, especially when they are administered at the extremes of age, can trigger long-term morphological and functional alterations in the brain. Here, we review available mechanistic data linking general-anaesthesia exposure to impaired cognitive performance in both young and mature nervous systems. We also provide a critical appraisal of the translational value of animal models and highlight the important challenges that need to be addressed to strengthen the link between laboratory work and clinical investigations in the field of anaesthesia-neurotoxicity research.
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Affiliation(s)
- Laszlo Vutskits
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospitals of Geneva, 4 rue Gabrielle-Perret-Gentil, 1205 Geneva 4, Switzerland.,Department of Basic Neuroscience, University of Geneva Medical School, 1 rue Michel Servet, 1211 Geneva 4, Switzerland
| | - Zhongcong Xie
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, 149 13th Street, Room 4310, Charlestown, Massachusetts 02129, USA
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34
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Broad KD, Kawano G, Fierens I, Rocha-Ferreira E, Hristova M, Ezzati M, Rostami J, Alonso-Alconada D, Chaban B, Hassell J, Fleiss B, Gressens P, Sanders RD, Robertson NJ. Surgery increases cell death and induces changes in gene expression compared with anesthesia alone in the developing piglet brain. PLoS One 2017; 12:e0173413. [PMID: 28355229 PMCID: PMC5371291 DOI: 10.1371/journal.pone.0173413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 02/19/2017] [Indexed: 11/24/2022] Open
Abstract
In a range of animal species, exposure of the brain to general anaesthesia without surgery during early infancy may adversely affect its neural and cognitive development. The mechanisms mediating this are complex but include an increase in brain cell death. In humans, attempts to link adverse cognitive development to infantile anaesthesia exposure have yielded ambiguous results. One caveat that may influence the interpretation of human studies is that infants are not exposed to general anaesthesia without surgery, raising the possibility that surgery itself, may contribute to adverse cognitive development. Using piglets, we investigated whether a minor surgical procedure increases cell death and disrupts neuro-developmental and cognitively salient gene transcription in the neonatal brain. We randomly assigned neonatal male piglets to a group who received 6h of 2% isoflurane anaesthesia or a group who received an identical anaesthesia plus 15 mins of surgery designed to replicate an inguinal hernia repair. Compared to anesthesia alone, surgery-induced significant increases in cell death in eight areas of the brain. Using RNAseq data derived from all 12 piglets per group we also identified significant changes in the expression of 181 gene transcripts induced by surgery in the cingulate cortex, pathway analysis of these changes suggests that surgery influences the thrombin, aldosterone, axonal guidance, B cell, ERK-5, eNOS and GABAA signalling pathways. This suggests a number of novel mechanisms by which surgery may influence neural and cognitive development independently or synergistically with the effects of anaesthesia.
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MESH Headings
- Aldosterone/genetics
- Aldosterone/metabolism
- Anesthesia, General/adverse effects
- Anesthetics, Inhalation/administration & dosage
- Anesthetics, Inhalation/adverse effects
- Animals
- Animals, Newborn
- B-Lymphocytes/immunology
- B-Lymphocytes/metabolism
- Cell Death/drug effects
- Gene Expression Profiling
- Gene Expression Regulation, Developmental/drug effects
- Gyrus Cinguli/drug effects
- Gyrus Cinguli/metabolism
- Gyrus Cinguli/pathology
- Hernia, Inguinal/complications
- Hernia, Inguinal/surgery
- Herniorrhaphy/adverse effects
- Isoflurane/administration & dosage
- Isoflurane/adverse effects
- Male
- Mitogen-Activated Protein Kinase 7/genetics
- Mitogen-Activated Protein Kinase 7/metabolism
- Nerve Net/drug effects
- Nerve Net/metabolism
- Nerve Net/pathology
- Nitric Oxide Synthase Type III/genetics
- Nitric Oxide Synthase Type III/metabolism
- Receptors, GABA-A/genetics
- Receptors, GABA-A/metabolism
- Sequence Analysis, RNA
- Signal Transduction
- Swine
- Thrombin/genetics
- Thrombin/metabolism
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Affiliation(s)
- Kevin D. Broad
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Go Kawano
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Igor Fierens
- Institute for Women’s Health, University College London, London, United Kingdom
| | | | - Mariya Hristova
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Mojgan Ezzati
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Jamshid Rostami
- Institute for Women’s Health, University College London, London, United Kingdom
| | | | - Badr Chaban
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Jane Hassell
- Institute for Women’s Health, University College London, London, United Kingdom
| | - Bobbi Fleiss
- Centre for the Developing Brain, Kings College, St Thomas Campus, London, United Kingdom
- Inserm, U1141, Paris, France
- University Paris Diderot, Sorbonne Paris Cite, UMRS 1141, Paris, France
| | - Pierre Gressens
- Centre for the Developing Brain, Kings College, St Thomas Campus, London, United Kingdom
- Inserm, U1141, Paris, France
- University Paris Diderot, Sorbonne Paris Cite, UMRS 1141, Paris, France
| | - Robert D. Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Nicola J. Robertson
- Institute for Women’s Health, University College London, London, United Kingdom
- * E-mail:
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35
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J. K, Durga P, Ramachandran G. Inhalational agents in anesthesia induced developmental neurotoxicity – Recent advances. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2016. [DOI: 10.1016/j.tacc.2016.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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36
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Lin EP, Lee JR, Lee CS, Deng M, Loepke AW. Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies. Neurotoxicol Teratol 2016; 60:117-128. [PMID: 27793659 DOI: 10.1016/j.ntt.2016.10.008] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/09/2016] [Accepted: 10/24/2016] [Indexed: 11/28/2022]
Abstract
Anesthetics that permit surgical procedures and stressful interventions have been found to cause structural brain abnormalities and functional impairment in immature animals, generating extensive concerns among clinicians, parents, and government regulators regarding the safe use of these drugs in young children. Critically important questions remain, such as the exact age at which the developing brain is most vulnerable to the effects of anesthetic exposure, whether a particular age exists beyond which anesthetics are devoid of long-term effects on the brain, and whether any specific exposure duration exists that does not lead to deleterious effects. Accordingly, the present analysis attempts to put the growing body of animal studies, which we identified to include >440 laboratory studies to date, into a translational context, by integrating the preclinical data on brain structure and function with clinical results attained from human neurocognitive studies, which currently exceed 30 studies. Our analysis demonstrated no clear exposure duration threshold below which no structural injury or subsequent cognitive abnormalities occurred. Animal data did not clearly identify a specific age beyond which anesthetic exposure did not cause any structural or functional abnormalities. Several potential mitigating strategies were found, however, no general anesthetic was identified that consistently lacked neurodegenerative properties and could be recommended over other anesthetics. It therefore is imperative, to expand efforts to devise safer anesthetic techniques and mitigating strategies, even before long-term alterations in brain development are unequivocally confirmed to occur in millions of young children undergoing anesthesia every year.
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Affiliation(s)
- Erica P Lin
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Jeong-Rim Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul 120-752, Republic of Korea
| | - Christopher S Lee
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States
| | - Meng Deng
- Department of Anesthesiology, Huashan Hospital of Fudan University, Shanghai, China
| | - Andreas W Loepke
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States; Department of Anesthesiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, United States; Neuroscience Program, University of Cincinnati, Cincinnati, OH 45267, United States.
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Biomarkers, Genetics, and Epigenetic Studies to Explore the Neurocognitive Effects of Anesthesia in Children. J Neurosurg Anesthesiol 2016; 28:384-388. [PMID: 27564554 DOI: 10.1097/ana.0000000000000351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Exposure to commonly used anesthetic agents causes widespread neuronal degeneration in the developing mammalian brain and has been shown to impair neurodevelopment in a variety of newborn vertebrate animal species. Although retrospective studies have suggested an association between anesthesia exposure in childhood and subsequent neurodevelopmental abnormalities, a causal relationship in humans has yet to be demonstrated. Unfortunately, translation of findings from bench to bedside is limited by several factors and histologic assessment in healthy children following exposure to anesthesia is not possible. Therefore, to prove that anesthesia-induced neurotoxicity occurs in humans, alternative approaches are necessary. Here we present the summary of a focus group discussion regarding the utility of biomarkers in translational studies of anesthetic neurotoxicity as part of The 2016 Pediatric Anesthesia NeuroDevelopmental Assessment (PANDA) Symposium at Columbia University Medical Center. The experts agreed that defining intermediate phenotypes using advanced neuroimaging as a biomarker is a highly feasible and reasonable modality to provide new insights into the deleterious effects of anesthetic exposure in the developing human brain and could illuminate a viable investigative path forward. Ultimately, well-defined intermediate phenotypes may allow us to fully understand the neurodevelopmental impact of anesthesia-induced neurotoxicity and permit us to develop the safest and most effective anesthetic strategies for the infants and children we care for.
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Wang LY, Tang ZJ, Han YZ. Neuroprotective effects of caffeic acid phenethyl ester against sevoflurane‑induced neuronal degeneration in the hippocampus of neonatal rats involve MAPK and PI3K/Akt signaling pathways. Mol Med Rep 2016; 14:3403-12. [PMID: 27498600 DOI: 10.3892/mmr.2016.5586] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 06/24/2016] [Indexed: 11/06/2022] Open
Abstract
Millions of infants and children are exposed to anesthesia every year during medical care. Sevoflurane is a volatile anesthetic that is frequently used for pediatric anesthesia. However, previous reports have suggested that the administration of sevoflurane promotes neurodegeneration, raising concerns regarding the safety of its usage. The present study aimed to investigate caffeic acid phenethyl ester (CAPE) and its protective effect against sevoflurane‑induced neurotoxicity in neonatal rats. Rat pups were administered with CAPE at 10, 20 or 40 mg/kg body weight from postnatal day 1 (P1) to P15. The P7 rats were exposed to sevoflurane (2.9%) for 6 h. Control group rats received no sevoflurane or CAPE. Neuronal apoptosis was determined by terminal deoxynucleotidyl transferase dUTP nick‑end labeling assay. The expression levels of caspases (caspase‑3, ‑8 and ‑9), apoptotic pathway proteins [Bcl‑2‑associated X protein (Bax), B cell CCL/lymphoma 2 (Bcl‑2), Bcl‑2‑like 1 (Bcl‑xL), Bcl‑2‑associated agonist of cell death (Bad) and phosphorylated (p)‑Bad], mitogen‑activated protein kinases (MAPK) signaling pathway proteins [c‑Jun N‑terminal kinase (JNK), p‑JNK, extracellular signal‑regulated kinase (ERK)1/2, p‑ERK1/2, p38, p‑p38 and p‑c‑Jun] and the phosphoinositide 3‑kinase (PI3K)/Akt cascade were evaluated by western blotting following sevoflurane and CAPE treatment. In addition, the expression of cleaved caspase‑3 was analyzed by immunohistochemistry. CAPE significantly reduced sevoflurane‑induced apoptosis, downregulated the expression levels of caspases and pro‑apoptotic proteins (Bax and Bad) and elevated the expression levels of Bcl‑2 and Bcl‑xL when compared with sevoflurane treatment. Furthermore, CAPE appeared to modify the expression levels of MAPKs and activate the PI3K/Akt signaling pathway. Thus, the present study demonstrated that CAPE effectively inhibited sevoflurane‑induced neuroapoptosis by modulating the expression and phosphorylation of apoptotic pathway proteins and MAPKs, and by regulating the PI3K/Akt pathway.
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Affiliation(s)
- Li-Yan Wang
- Department of Pediatric Surgery, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Zhi-Jun Tang
- Department of Orthopedics in Repair and Reconstruction, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
| | - Yu-Zeng Han
- Department of Pediatric Internal Medicine, Linyi People's Hospital, Linyi, Shandong 276003, P.R. China
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Nyman Y, Fredriksson A, Lönnqvist PA, Viberg H. Etomidate exposure in early infant mice (P10) does not induce apoptosis or affect behaviour. Acta Anaesthesiol Scand 2016; 60:588-96. [PMID: 26763687 DOI: 10.1111/aas.12685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/30/2015] [Accepted: 12/08/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Numerous animal studies have shown that all commonly used intravenous anaesthetic drugs and volatile agents may cause neuronal apoptosis following exposure in early life. Most studies have focussed on detecting increased apoptosis but their methods are not always readily transferrable to humans. The lipid formulation of etomidate represents an alternative to the currently established intravenous anaesthetic agents but there is no animal or human data on apoptosis or long-term behavioural changes. The aim of our study was to investigate the effects of etomidate on cerebral neuronal apoptosis and long-term behavioural effects using an established mouse model that represents the clinically relevant period of anaesthesia during early infancy in humans. METHODS Six groups of 10 day old mice (P10) were injected with either etomidate 0.3, 3 or 10 mg/kg, propofol 60 mg/kg, ketamine 50 mg/kg or placebo only. Apoptosis in the cerebral cortex and hippocampus was assessed 24 h after treatment (activated caspase-3). Late behavioural effects were tested at 2 months of age (spontaneous activity in a new environment). RESULTS No evidence was found of differences in activated caspase 3-concentrations among the study groups. Significant late behavioural changes were only observed in the ketamine group. CONCLUSION A single dose of etomidate in early infant mice at P10 did not produce evidence of cerebral apoptosis or impaired adult motor behaviour.
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Affiliation(s)
- Y. Nyman
- Department of Paediatric Anaesthesia and Intensive Care; Astrid Lindgrens Children's Hospital/Karolinska University Hospital; Stockholm Sweden
| | - A. Fredriksson
- Department of Neuroscience, Psychiatry; Uppsala University; Uppsala Sweden
| | - P.-A. Lönnqvist
- Department of Paediatric Anaesthesia and Intensive Care; Astrid Lindgrens Children's Hospital/Karolinska University Hospital; Stockholm Sweden
| | - H. Viberg
- Department of Environmental Toxicology; Uppsala University; Uppsala Sweden
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Bodolea C. Anaesthesia in early childhood - is the development of the immature brain in danger? Rom J Anaesth Intensive Care 2016; 23:33-40. [PMID: 28913475 DOI: 10.21454/rjaic.7518.231.chd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Experimental studies performed on immature animal brains had demonstrated a neurotoxic effect following sedation and general anaesthetics administration. The same magnitude of neurotoxicity has been suggested but not been proven to neonates, infants and small children who have undergone anaesthesia. There is a justified and increasing inquiry regarding the administration of general anaesthesia to paediatric patients.
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Affiliation(s)
- Constantin Bodolea
- Department of Anaesthesia and Intensive Care, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Cheng Y, He L, Prasad V, Wang S, Levy RJ. Anesthesia-Induced Neuronal Apoptosis in the Developing Retina: A Window of Opportunity. Anesth Analg 2016; 121:1325-35. [PMID: 26465931 DOI: 10.1213/ane.0000000000000714] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anesthetics cause widespread apoptosis in the developing brain, resulting in neurocognitive abnormalities. However, it is unknown whether anesthesia-induced neurotoxicity occurs in humans because there is currently no modality to assess for neuronal apoptosis in vivo. The retina is unique in that it is the only portion of the central nervous system that can be directly visualized noninvasively. Thus, we aimed to determine whether isoflurane induces apoptosis in the developing retina. METHODS CD-1 male mouse pups underwent 1-hour exposure to isoflurane (2%) or air. After exposure, activated caspase-3, caspase-9, and caspase-8 were quantified in the retina, cytochrome c release from retinal mitochondria was assessed, and the number and types of cells undergoing apoptosis were identified. Retinal uptake and the ability of fluorescent-labeled annexin V to bind to cells undergoing natural cell death and anesthesia-induced apoptosis in the retina were determined after systemic injection. RESULTS Isoflurane activated the intrinsic apoptosis pathway in the inner nuclear layer (INL) and activated both the intrinsic and extrinsic pathways in the ganglion cell layer. Immunofluorescence demonstrated that bipolar and amacrine neurons within the INL underwent physiologic cell death in both cohorts and that amacrine cells were the likely targets of isoflurane-induced apoptosis. After injection, fluorescent-labeled annexin V was readily detected in the INL of both air-exposed and isoflurane-exposed mice and colocalized with activated caspase-3-positive cells. CONCLUSIONS These findings indicate that isoflurane-induced neuronal apoptosis occurs in the developing retina and lays the groundwork for development of a noninvasive imaging technique to detect anesthesia-induced neurotoxicity in infants and children.
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Affiliation(s)
- Ying Cheng
- From the *Division of Anesthesiology and Pain Medicine, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, DC; and †Department of Biostatistics, Columbia University, Mailman School of Public Health, New York, New York
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Davidson AJ, Disma N, de Graaff JC, Withington DE, Dorris L, Bell G, Stargatt R, Bellinger DC, Schuster T, Arnup SJ, Hardy P, Hunt RW, Takagi MJ, Giribaldi G, Hartmann PL, Salvo I, Morton NS, von Ungern Sternberg BS, Locatelli BG, Wilton N, Lynn A, Thomas JJ, Polaner D, Bagshaw O, Szmuk P, Absalom AR, Frawley G, Berde C, Ormond GD, Marmor J, McCann ME. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016; 387:239-50. [PMID: 26507180 PMCID: PMC5023520 DOI: 10.1016/s0140-6736(15)00608-x] [Citation(s) in RCA: 593] [Impact Index Per Article: 74.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial. METHODS In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks' gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600. FINDINGS Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awake-regional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-per-protocol analysis, the cognitive composite score (mean [SD]) was 98.6 (14.2) in the awake-regional group and 98.2 (14.7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0.169, 95% CI -2.30 to 2.64). The median duration of anaesthesia in the general anaesthesia group was 54 min. INTERPRETATION For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia. FUNDING Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).
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Affiliation(s)
- Andrew J Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Melbourne Children's Trials Centre, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Davinia E Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, Canada; Department of Anesthesia, McGill University, Montreal, Canada
| | - Liam Dorris
- Mental Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Graham Bell
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK
| | - Robyn Stargatt
- School of Psychological Science, La Trobe University, Victoria, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Sarah J Arnup
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Pollyanna Hardy
- National Perinatal Epidemiology Unit, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Rodney W Hunt
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Neonatal Medicine, The Royal Children's Hospital, Melbourne, Australia
| | - Michael J Takagi
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Child Neuropsychology, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Gaia Giribaldi
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Penelope L Hartmann
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Ida Salvo
- Department of Anesthesiology and Pediatric Intensive Care, Ospedale Pediatrico 'Vittore Buzzi', Milan, Italy
| | - Neil S Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK; University of Glasgow, Glasgow, UK
| | - Britta S von Ungern Sternberg
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children, Perth, WA, Australia
| | | | - Niall Wilton
- Department of Paediatric Anaesthesia and Operating Rooms, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Anne Lynn
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Joss J Thomas
- Department of Anesthesia, University of Minnesota, Minneapolis, MN, USA
| | - David Polaner
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA
| | - Oliver Bagshaw
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK
| | - Peter Szmuk
- Department of Anesthesiology, Children's Medical Centre Dallas, Dallas, TX, USA
| | - Anthony R Absalom
- Department of Anaesthesiology, University Medical Centre Groningen, Groningen University, Groningen, Netherlands
| | - Geoff Frawley
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Charles Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gillian D Ormond
- Anaesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Jacki Marmor
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Disma N, Mondardini MC, Terrando N, Absalom AR, Bilotta F. A systematic review of methodology applied during preclinical anesthetic neurotoxicity studies: important issues and lessons relevant to the design of future clinical research. Paediatr Anaesth 2016; 26:6-36. [PMID: 26530523 DOI: 10.1111/pan.12786] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 12/19/2022]
Abstract
UNLABELLED Preclinical evidence suggests that anesthetic agents harm the developing brain thereby causing long-term neurocognitive impairments. It is not clear if these findings apply to humans, and retrospective epidemiological studies thus far have failed to show definitive evidence that anesthetic agents are harmful to the developing human brain. AIM The aim of this systematic review was to summarize the preclinical studies published over the past decade, with a focus on methodological issues, to facilitate the comparison between different preclinical studies and inform better design of future trials. METHOD The literature search identified 941 articles related to the topic of neurotoxicity. As the primary aim of this systematic review was to compare methodologies applied in animal studies to inform future trials, we excluded a priori all articles focused on putative mechanism of neurotoxicity and the neuroprotective agents. Forty-seven preclinical studies were finally included in this review. RESULTS Methods used in these studies were highly heterogeneous-animals were exposed to anesthetic agents at different developmental stages, in various doses and in various combinations with other drugs, and overall showed diverse toxicity profiles. Physiological monitoring and maintenance of physiological homeostasis was variable and the use of cognitive tests was generally limited to assessment of specific brain areas, with restricted translational relevance to humans. CONCLUSION Comparison between studies is thus complicated by this heterogeneous methodology and the relevance of the combined body of literature to humans remains uncertain. Future preclinical studies should use better standardized methodologies to facilitate transferability of findings from preclinical into clinical science.
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Affiliation(s)
- Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Maria C Mondardini
- Department of Pediatric Anesthesia and Intensive Care Unit, University Hospital Policlinico S.Orsola-Malpighi, Bologna, Italy
| | - Niccolò Terrando
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Federico Bilotta
- Section of Neuroanesthesia and Neurocritical Care, Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Rome, Rome, Italy
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Manjeri GR, Rodenburg RJ, Blanchet L, Roelofs S, Nijtmans LG, Smeitink JA, Driessen JJ, Koopman WJH, Willems PH. Increased mitochondrial ATP production capacity in brain of healthy mice and a mouse model of isolated complex I deficiency after isoflurane anesthesia. J Inherit Metab Dis 2016; 39:59-65. [PMID: 26310962 PMCID: PMC4710641 DOI: 10.1007/s10545-015-9885-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 12/19/2022]
Abstract
We reported before that the minimal alveolar concentration (MAC) of isoflurane is decreased in complex I-deficient mice lacking the NDUFS4 subunit of the respiratory chain (RC) (1.55 and 0.81% at postnatal (PN) 22-25 days and 1.68 and 0.65% at PN 31-34 days for wildtype (WT) and CI-deficient KO, respectively). A more severe respiratory depression was caused by 1.0 MAC isoflurane in KO mice (respiratory rate values of 86 and 45 at PN 22-25 days and 69 and 29 at PN 31-34 days for anesthetized WT and KO, respectively). Here, we address the idea that isoflurane anesthesia causes a much larger decrease in brain mitochondrial ATP production in KO mice thus explaining their increased sensitivity to this anesthetic. Brains from WT and KO mice of the above study were removed immediately after MAC determination at PN 31-34 days and a mitochondria-enriched fraction was prepared. Aliquots were used for measurement of maximal ATP production in the presence of pyruvate, malate, ADP and creatine and, after freeze-thawing, the maximal activity of the individual RC complexes in the presence of complex-specific substrates. CI activity was dramatically decreased in KO, whereas ATP production was decreased by only 26% (p < 0.05). The activities of CII, CIII, and CIV were the same for WT and KO. Isoflurane anesthesia decreased the activity of CI by 30% (p < 0.001) in WT. In sharp contrast, it increased the activity of CII by 37% (p < 0.001) and 50% (p < 0.001) and that of CIII by 37% (p < 0.001) and 40% (p < 0.001) in WT and KO, respectively, whereas it tended to increase that of CIV in both WT and KO. Isoflurane anesthesia increased ATP production by 52 and 69% in WT (p < 0.05) and KO (p < 0.01), respectively. Together these findings indicate that isoflurane anesthesia interferes positively rather than negatively with the ability of CI-deficient mice brain mitochondria to convert their main substrate pyruvate into ATP.
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Affiliation(s)
- Ganesh R Manjeri
- Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 286 Biochemistry, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
- Department of Pediatrics, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 804 Pediatrics, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Richard J Rodenburg
- Department of Pediatrics, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 804 Pediatrics, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Lionel Blanchet
- Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 286 Biochemistry, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Suzanne Roelofs
- Department of Anesthesiology, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 549 Anesthesiology, P.O Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Leo G Nijtmans
- Department of Pediatrics, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 804 Pediatrics, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Jan A Smeitink
- Department of Pediatrics, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 804 Pediatrics, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Jacques J Driessen
- Department of Anesthesiology, Nijmegen Centre for Mitochondrial Disorders, Radboud University Medical Centre, 549 Anesthesiology, P.O Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Werner J H Koopman
- Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 286 Biochemistry, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands
| | - Peter H Willems
- Department of Biochemistry, Radboud Institute for Molecular Life Sciences, Radboud University Medical Centre, 286 Biochemistry, P.O. Box 9101, NL-6500 HB, Nijmegen, The Netherlands.
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Isoflurane Damages the Developing Brain of Mice and Induces Subsequent Learning and Memory Deficits through FASL-FAS Signaling. BIOMED RESEARCH INTERNATIONAL 2015; 2015:315872. [PMID: 26609525 PMCID: PMC4644536 DOI: 10.1155/2015/315872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 09/28/2015] [Indexed: 11/17/2022]
Abstract
Background. Isoflurane disrupts brain development of neonatal mice, but its mechanism is unclear. We explored whether isoflurane damaged developing hippocampi through FASL-FAS signaling pathway, which is a well-known pathway of apoptosis. Method. Wild type and FAS- or FASL-gene-knockout mice aged 7 days were exposed to either isoflurane or pure oxygen. We used western blotting to study expressions of caspase-3, FAS (CD95), and FAS ligand (FASL or CD95L) proteins, TUNEL staining to count apoptotic cells in hippocampus, and Morris water maze (MWM) to evaluate learning and memory. Result. Isoflurane increased expression of FAS and FASL proteins in wild type mice. Compared to isoflurane-treated FAS- and FASL-knockout mice, isoflurane-treated wild type mice had higher expression of caspase-3 and more TUNEL-positive hippocampal cells. Expression of caspase-3 in wild isoflurane group, wild control group, FAS/FASL-gene-knockout control group, and FAS/FASL-gene-knockout isoflurane group showed FAS or FASL gene knockout might attenuate increase of caspase-3 caused by isoflurane. MWM showed isoflurane treatment of wild type mice significantly prolonged escape latency and reduced platform crossing times compared with gene-knockout isoflurane-treated groups. Conclusion. Isoflurane induces apoptosis in developing hippocampi of wild type mice but not in FAS- and FASL-knockout mice and damages brain development through FASL-FAS signaling.
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Short TG, Leslie K, Chan MTV, Campbell D, Frampton C, Myles P. Rationale and Design of the Balanced Anesthesia Study: A Prospective Randomized Clinical Trial of Two Levels of Anesthetic Depth on Patient Outcome After Major Surgery. Anesth Analg 2015; 121:357-65. [PMID: 25993386 DOI: 10.1213/ane.0000000000000797] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND An association between relatively deep anesthesia, as guided by the bispectral index (BIS), and increased postoperative mortality has been demonstrated in 6 of 8 published observational studies, but association does not necessarily mean causality. Small clinical trials of anesthetic depth have demonstrated increased delirium and postoperative cognitive dysfunction in patients who were relatively deeply anesthetized, but have been inadequately powered to study mortality. A large-scale randomized study is required to determine whether causality exists. METHODS The primary hypothesis of our study is that "light" anesthesia, defined as a BIS target of 50, will reduce all-cause mortality within 1 year of surgery in comparison with "deep" anesthesia, defined as a BIS target of 35, in patients aged ≥60 years presenting for major surgery under general anesthesia. The trial is an international multicenter, randomized, parallel-group, double-blind (patients and investigators) prospective, intention-to-treat, safety and efficacy study. The relative reduction in mortality in the light anesthesia group is expected to be 20%, giving an absolute risk reduction from 10% to 8%. Power analysis using a = 0.049 and b = 0.2 indicates that 3250 patients are required in each group. RESULTS The study is underway, and 1325 patients have been recruited in 40 centers in 5 countries. It is anticipated that the study will be completed in 3 years. CONCLUSIONS This randomized controlled trial should definitively answer the question of whether titrating anesthetic depth makes a difference to patient outcome in a vulnerable patient group.
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Affiliation(s)
- Timothy G Short
- From the *Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand; †Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Victoria, Australia; ‡Anaesthesia, Perioperative and Pain Medicine Unit, Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia; §Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; ∥Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, People's Republic of China; ¶Department of Statistics, University of Otago, Christchurch, New Zealand; #Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; and **Academic Board of Anaesthesia and Perioperative Medicine, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Leslie K, Short TG. Anesthetic depth and long-term survival: an update. Can J Anaesth 2015; 63:233-40. [DOI: 10.1007/s12630-015-0490-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 05/20/2015] [Accepted: 09/10/2015] [Indexed: 01/12/2023] Open
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Toxic and protective effects of inhaled anaesthetics on the developing animal brain: systematic review and update of recent experimental work. Eur J Anaesthesiol 2015; 31:669-77. [PMID: 24922049 DOI: 10.1097/eja.0000000000000073] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accumulating preclinical data indicate that neonatal exposure to general anaesthetics is detrimental to the central nervous system. Some studies, however, display potential protective effects of exactly the same anaesthetic agents on the immature brain. The effects of inhaled anaesthetics on the developing brain have received close attention from researchers, clinicians and the public in recent decades. OBJECTIVES To summarise the preclinical evidence reported in the last 5 years on both the deleterious effects and the neuroprotective potential in special indications, of inhaled anaesthetics on the developing brain. DESIGN A systematic review. DATA SOURCES PubMed search performed in June 2013. ELIGIBILITY CRITERIA Search terms included brain, development, inhaled anaesthetic, toxicity and protection within the scope of the last 5 years with animals. The reference lists of relevant articles and recent reviews were also hand-searched for additional studies. The type, dose and exposure duration of anaesthetics, species and age of animals, histopathologic indicators, outcomes and affected brain areas, neuro developmental test modules and outcomes, as well as other outcomes and comments were summarised. RESULTS Two hundred and nineteen relevant titles were initially revealed. In total, 81 articles were identified, with 68 articles assessing the detrimental effects induced by inhaled anaesthetics in the immature brain along with possible treatments. The remaining 13 articles focused on the protective profile of inhaled anaesthetics on perinatal hypoxic-ischaemic brain injury. Administration of inhaled anaesthetic agents to the immature brain was shown to be deleterious in several preclinical studies. In perinatal hypoxic-ischaemic brain injury models, pre- and postconditioning of inhalational anaesthetics exerted neuroprotective effects. CONCLUSION The majority of studies have linked inhaled anaesthetics to toxic effects in the neonatal brain of rodents, piglets and primates. Only a few studies, however, could demonstrate long-lasting cognitive impairment. The results of inhalational anaesthetic-induced neuroprotection in perinatal hypoxic-ischaemic brain injury are a promising basis for more research in this field. In general, prospective clinical trials are needed to further differentiate the effects of inhaled anaesthetics on the immature brain.
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Systemic physiology and neuroapoptotic profiles in young and adult rats exposed to surgery: A randomized controlled study comprising four different anaesthetic techniques. Int J Dev Neurosci 2015; 45:11-8. [PMID: 25916972 DOI: 10.1016/j.ijdevneu.2015.04.351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/08/2015] [Accepted: 04/23/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Experimental evidence indicates that general anaesthetics can induce apoptotic neurodegeneration in the developing brain. The majority of these studies have been performed in the absence of surgery and it currently remains unclear how the presence of surgical stimuli would influence neuroapoptosis as well as systemic homeostasis. Here we explored this possibility by performing dorsal skin flap surgery in young and adult rats under four distinct currently used anaesthesia regimens. METHODS Young (21-days) and adult (2 months) male Sprague-Dawley rats were randomized to 150 min exposure to one of four anaesthetics regimens: (i) sevoflurane/dexmedetomidine, (ii) sevoflurane/fentanyl; (iii) propofol/dexmedetomidine, and (iv) propofol/fentanyl. Animals underwent a dorsal skin flap procedure while physiologic, metabolic and biochemical parameters were closely monitored. Neuroapoptotic profiles were evaluated in the cortex, thalamus and hippocampus (CA1 and CA3) at the end of the procedure in each experimental group. RESULTS Significant perturbations of systemic homeostasis were found under all anaesthetic regimens. Hyperglycemia and decreased heart rate were particularly relevant in experimental groups receiving dexmedetomidine, while propofol administration was associated with increased systemic lactate levels and metabolic acidosis. A substantial difference in anaesthesia/surgery-induced neuroapoptosis was found between young and adult rats in several brain regions. Combination of sevoflurane and dexmedetomidine resulted in the highest number of caspase-3 positive cells, although the extent of cell death remained relatively low in all experimental groups. CONCLUSION Combination of anaesthesia and surgery induces significant perturbations of physiological parameters in both young and adult spontaneously breathing rats undergoing surgery. These observations further enlighten the need for detailed physiological monitoring under these experimental conditions. Although some statistically significant differences in activated caspase-3 profiles were detected between experimental groups, the overall extent of neuronal cell death remained very low under all conditions questioning, thereby, the physiological significance of apoptotic neurodegeneration in the context of anaesthesia and surgery.
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