Elective Pediatric Surgery? Think again

[BLADEMDA]

August 28, 2012 — Children exposed to anesthesia before the age of 3 demonstrate signs of long-term language and reasoning deficits at age 10, even when the exposure occurs only on a single occasion, a new study suggests.
A research team led by Caleb Ing, MD, of Columbia University's College of Physicians and Surgeons, evaluated data on 2608 children in the Western Australian Pregnancy Cohort (Raine) Study who were born between 1989 and 1992. Among these children, 321 had been exposed to anesthesia before the age of 3, and 2287 were unexposed.
Neuropsychological assessments at age 10 indicated that children who had been exposed to anesthesia showed significant deficits in receptive and expressive language, as well as abstract reasoning, compared with children in the nonexposed group.
Contrary to previous studies, which have shown cognitive deficits only in relation to 2 or more anesthesia exposures, the new study showed long-term impairment even with a single exposure.
"These results were unexpected since prior studies had not documented deficits with single exposures," Dr. Ing told Medscape Medical News.
This study was published online August 20 and will appear in the September issue of Pediatrics.

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[Planktonmd]

Is it possible to say that children who required surgery before the age of 3 might have had health problems that required repeated doctor visits, medications, exposure to many stressful and traumatic situations that caused them to have these learning disabilities?
I mean before we concede that a single anesthetic causes a learning disability maybe we should do a study taking the other factors surrounding the surgery into consideration.

August 28, 2012 — Children exposed to anesthesia before the age of 3 demonstrate signs of long-term language and reasoning deficits at age 10, even when the exposure occurs only on a single occasion, a new study suggests.
A research team led by Caleb Ing, MD, of Columbia University's College of Physicians and Surgeons, evaluated data on 2608 children in the Western Australian Pregnancy Cohort (Raine) Study who were born between 1989 and 1992. Among these children, 321 had been exposed to anesthesia before the age of 3, and 2287 were unexposed.
Neuropsychological assessments at age 10 indicated that children who had been exposed to anesthesia showed significant deficits in receptive and expressive language, as well as abstract reasoning, compared with children in the nonexposed group.
Contrary to previous studies, which have shown cognitive deficits only in relation to 2 or more anesthesia exposures, the new study showed long-term impairment even with a single exposure.
"These results were unexpected since prior studies had not documented deficits with single exposures," Dr. Ing told Medscape Medical News.
This study was published online August 20 and will appear in the September issue of Pediatrics.

 

[BLADEMDA]

Is it possible to say that children who required surgery before the age of 3 might have had health problems that required repeated doctor visits, medications, exposure to many stressful and traumatic situations that caused them to have these learning disabilities?
I mean before we concede that a single anesthetic causes a learning disability maybe we should do a study taking the other factors surrounding the surgery into consideration.

Do you have a moral and legal obligation to discuss this possible "risk" with the surgeon, patient and family prior to proceeding with an elective anesthetic on a child younger than 3 years of age?

Will you mention this possible risk in the future to surgeons or family members?

 

[Planktonmd]

Do you have a moral and legal obligation to discuss this possible "risk" with the surgeon, patient and family prior to proceeding with an elective anesthetic on a child younger than 3 years of age?

Will you mention this possible risk in the future to surgeons or family members?

I think at this point in time and with the mounting number of studies we certainly need to include some language in the consent for surgery and the consent for anesthesia addressing these issues.
I would give the parents an honest opinion telling them that there is some evidence that exposure to anesthesia could cause a learning disability but i would add that there are other factors involved and it might be the whole surgical experience not simply anesthesia.

 

[BLADEMDA]

I think at this point in time and with the mounting number of studies we certainly need to include some language in the consent for surgery and the consent for anesthesia addressing these issues.
I would give the parents an honest opinion telling them that there is some evidence that exposure to anesthesia could cause a learning disability but i would add that there are other factors involved and it might be the whole surgical experience not simply anesthesia.

If it was MY kid I would NOT want any elective surgery prior to age 3 if at all possible; in addition, I would be ANGRY if my Anesthesiologist and/or surgeon didn't discuss any possible increased risk for learning disability due to the anesthetic. In short, those of you doing kids under 3 for ELECTIVE B.S. cases better think long and hard about a new consent form and a discussion with the parents.

After all, why can't the kid wait until age 3.5/4 for the surgery? For those of you looking for an excuse to get out of the pediatric anesthesia business altogether (under age 3 at least) this study is your ticket.

 

[Planktonmd]

If it was MY kid I would NOT want any elective surgery prior to age 3 if at all possible; in addition, I would be ANGRY if my Anesthesiologist and/or surgeon didn't discuss any possible increased risk for learning disability due to the anesthetic. In short, those of you doing kids under 3 for ELECTIVE B.S. cases better think long and hard about a new consent form and a discussion with the parents.

After all, why can't the kid wait until age 3.5/4 for the surgery? For those of you looking for an excuse to get out of the pediatric anesthesia business altogether (under age 3 at least) this study is your ticket.

The problem: Do you know for a fact that waiting to 3.5 or 4 Y/O makes any difference?
Further, do you know for a fact that anesthesia is the only cause?

 

[deleted126335]

Define "elective" surgery in a less than three year old.

Do you not fix an inguinal hernia?
How about a cleft lip?
Not biopsy a mass?
repair a club foot?
ear tubes and tonsils in a kid with recurrent infections?

There aint alot of completely elective stuff in this population.

 

[cincincyreds]

If it was MY kid I would NOT want any elective surgery prior to age 3 if at all possible; in addition, I would be ANGRY if my Anesthesiologist and/or surgeon didn't discuss any possible increased risk for learning disability due to the anesthetic. In short, those of you doing kids under 3 for ELECTIVE B.S. cases better think long and hard about a new consent form and a discussion with the parents.

After all, why can't the kid wait until age 3.5/4 for the surgery? For those of you looking for an excuse to get out of the pediatric anesthesia business altogether (under age 3 at least) this study is your ticket.

Man, I can do 10-15 tonsil cases in a day at my place in this age group easily.

 

[imfrankie]

As we caution the surgeons, let's not be too quick to implicate "anesthesia."
This is, and has been, an extremely active area of investigation.

 

[BLADEMDA]

Define "elective" surgery in a less than three year old.

Do you not fix an inguinal hernia?
How about a cleft lip?
Not biopsy a mass?
repair a club foot?
ear tubes and tonsils in a kid with recurrent infections?

There aint alot of completely elective stuff in this population.

1. Can the hernia wait until age 3?
2. Discuss the possible increased risk and proceed
3. Does Ketamine and IV anesthesia have the same risks as GA in Kids under 3?
4. Can the Tonsillectomy wait until age 3? Most of the time the answer is yes.

Avoiding the subject entirely with the family and surgeon about elective surgery in children under age 3 may make your life a lot easier but it isn't the right thing to do.

 

[BLADEMDA]

Man, I can do 10-15 tonsil cases in a day at my place in this age group easily.

Reschedule them all for age 3. Temporary glitch in your business model.

 

[BLADEMDA]

Define "elective" surgery in a less than three year old.

Do you not fix an inguinal hernia?
How about a cleft lip?
Not biopsy a mass?
repair a club foot?
ear tubes and tonsils in a kid with recurrent infections?

There aint alot of completely elective stuff in this population.

When we have discussions like this I am glad that Malpractice ****** are out there to keep the greed in check. No doubt there will be lawsuits about this topic in the future once the word gets out about this increased risk. Family members deserve to know that Surgery can wait until age 3 and an honest discussion with an appropriate consent should be required.

Perhaps, Family members should get second and third opinons before proceeding with that surgery before age 3 in their child.

 

[Consigliere]

I greatly doubt this will be the death knell for pediatric anesthesiology. It may give some more educated individuals pause prior to ELECTIVE surgeries but most likely will have no impact on non-elective procedures. What will come next is a dissection of this study revealing the multitude of flaws contained within. I mean, why pick 3 as the arbitrary age? What happens when 4 year olds under go GA? 5 year olds? I don't have an answer, just proposing the question.

 

[BLADEMDA]

I greatly doubt this will be the death knell for pediatric anesthesiology. It may give some more educated individuals pause prior to ELECTIVE surgeries but most likely will have no impact on non-elective procedures. What will come next is a dissection of this study revealing the multitude of flaws contained within. I mean, why pick 3 as the arbitrary age? What happens when 4 year olds under go GA? 5 year olds? I don't have an answer, just proposing the question.

It has to do with the developing Brain. We know that by age 5 many parts of the brain are not as placid as age 3. Look at language for example. Yes, at age 5 the brain is still developing but perhaps not as fast as at age 3 and not as easily "damaged" by exposure to a single anesthetic.

 

[BLADEMDA]

http://synapse.princeton.edu/~brain...eventive_medicine_glucose-use-child-brain.pdf

This study points out that the Child's brain uses DOUBLE the amount of Glucose compared to an adult until age 4.

So, the evidence does seem to implicate a RAPIDLY developing brain is more susceptible to injury from anesthesia even a single exposure. So is age 3 the right age or should it be age 4?

 

[BLADEMDA]

Evidence of Rapid Ongoing Brain Development Beyond 2 Years of Age Detected by Fiber Tracking

1. X.-Q. Dinga,b,
2. Y. Suna,
3. H. Braaßa,
4. T. Illiesa,
5. H. Zeumera,
6. H. Lanfermannb and
7. J. Fiehlera

+ Author Affiliations

1. aDepartment of Neuroradiology, University Medical Center Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany

bInstitute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany

1. Please address correspondence to: Xiao-Qi Ding, PhD, MD, Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Carl-Neuberg-Str 1, 30625 Hannover, Germany; e-mail: [email protected]

Next Section

Abstract


BACKGROUND AND PURPOSE:
Development of callosal fibers is important for psychomotor and cognitive functions. We hypothesized that brain maturation changes are detectable beyond 2 years of age by using diffusion tensor imaging (DTI) of the corpus callosum (CC).

MATERIALS AND METHODS:
T2 and fractional anisotropy (FA) maps of the brain of 55 healthy subjects between 0.2 and 39 years of age were obtained. Quantitative T2 and FA values were measured at the genu and splenium of the CC (gCC and sCC). Fiber tracking, volumetric determination, and the fiber density calculations of the CC were related to age. A paired t test was used for significant differences between the values at the gCC and sCC.

RESULTS:
T2 relaxation times at gCC and sCC decrease fast in the first months of life and very little after 2 years of age. The ***CC increases until 5 years of age and remains nearly constant thereafter; it showed a significant increase from 0 to 2 years versus 2–5 years, whereas there was no difference in the other age groups. FAsCC values showed no significant changes after 2 years of age. The fiber density of the CC shows a tendency of inverse age dependence from childhood to adulthood.

CONCLUSION:
Rapid ongoing changes in brain maturation (increase in ***CC) are detectable until 5 years of age. DTI reveals more information about brain maturation than T2 relaxometry.

 

[BLADEMDA]

http://www.wisspd.org/htm/atpracguides/training/progmaterials/ch980-09/bdca.pdf

More evidence that points to age 3-5. A single short exposure to an anesthetic sholuld be safe at some point in a child. The exact age? Unknown. But, best available evidence does suggest age 3-5.

 

[Consigliere]

It has to do with the developing Brain. We know that by age 5 many parts of the brain are not as placid as age 3. Look at language for example. Yes, at age 5 the brain is still developing but perhaps not as fast as at age 3 and not as easily "damaged" by exposure to a single anesthetic.

Thanks for the knowledge.

 

[deleted162650]

Me pyloric stenosis surgery had when as infant. Me language skills good with problems not.

 

[somedumbDO]

1. Can the hernia wait until age 3?
2. Discuss the possible increased risk and proceed
3. Does Ketamine and IV anesthesia have the same risks as GA in Kids under 3?
4. Can the Tonsillectomy wait until age 3? Most of the time the answer is yes.

Avoiding the subject entirely with the family and surgeon about elective surgery in children under age 3 may make your life a lot easier but it isn't the right thing to do.

actually ketamine has been ID'd as one of the biggest cultprits with possible DD secondary to anesthesia. There has also been twin retrospective studies with one twin undergoing anesthesia while the other is naive. No increased risk in this population. Its to hard to tell at this point if this is a real concern. Most peds surgeries are not elective. I personally do not tell my parents unless they ask specifically about cognitive difficulties. It is my IMHO, as in much with anesthesia, we just dont know.

 

[Bertelman]

1. Can the hernia wait until age 3?
2. Discuss the possible increased risk and proceed
3. Does Ketamine and IV anesthesia have the same risks as GA in Kids under 3?
4. Can the Tonsillectomy wait until age 3? Most of the time the answer is yes.

Avoiding the subject entirely with the family and surgeon about elective surgery in children under age 3 may make your life a lot easier but it isn't the right thing to do.

So the right thing to do is to tell them a few studies suggest that the procedure they are about to undergo may lead to developmental disorders, of the type and severity we could not determine precisely? But that's if you only read certain studies, because other studies say there is no increased risk. Maybe they should come back in a year to take care of this when their kid is 45 months old, because the handful of studies we have so far seem to tell us that age group is safe, but hey, who knows?

For me, in the absence of very clear findings, I would choose not to confuse a parent already anxious about a surgery for their child. Popping this on a parent in pre-op is not my idea of a good morning, or frankly a good future relationship with my surgeon.

 

[dhb]

For me, in the absence of very clear findings, I would choose not to confuse a parent already anxious about a surgery for their child. Popping this on a parent in pre-op is not my idea of a good morning, or frankly a good future relationship with my surgeon.

👍 Some large retrospective studies showed no difference (i think it was in Scandinavia) so no reason to freak out.

 

[imfrankie]

👍 Some large retrospective studies showed no difference (i think it was in Scandinavia) so no reason to freak out.

There is a large and growing literature on this. Some twin studies from the Mayo Rochester suggested a double hit in infancy was necessary. People are looking at this in and out. The conclusions that have been bandied about in this forum are beer talk.

 

[Planktonmd]

It is too early for any conclusions on this matter.
We don't really know what causes these problems and we really don't know at what age they stop happening.
But I partially agree with Balde that the parents should be informed about the presence of data suggesting that SURGERY at a young age could cause a learning disability.

 

[imfrankie]

I'm not sure there is much information in that statement except--I'd rather you worry mom rather than me worry about you suing me later.

How about this: kids that need surgery in childhood could be ones that are setups to develop learning disabiltiies later.

I think I'll wait for more reasoned conclusions before scaring parents the morning of surgery.

 

[Planktonmd]

I'm not sure there is much information in that statement except--I'd rather you worry mom rather than me worry about you suing me later.

How about this: kids that need surgery in childhood could be ones that are setups to develop learning disabiltiies later.

I think I'll wait for more reasoned conclusions before scaring parents the morning of surgery.

The problem though with the pediatric population the statute of limitations is different and the kid can sue you 18 years later for his learning disability.
So, if you neglected to mention the current concerns about surgery in young children you might be considered negligent.

 

[urge]

Now they got to repeat the study at 4, 5, 6 7, 8, 9,.........100 y/o to see what the optimal age for surgery is.....

People who need anesthesia at that age have bad DNA most likely... What is the suprise?

 

[IveGotTwins]

Children that need myringotomy/tympanostomy at <36 months of age have bad genes?

 

[EW1779]

This study (the one done by Ing) is seriously flawed, so much so that when he presented it at SPA last year he was basically heckled. The animal model studies also have fatal flaws in their methods. I think we're going to find that anesthetic neurotoxicity in the developing brain is much less significant than we thought, at least as it is currently being studied.

 

[pgg]

OK. This retrospective study looks at
- group A, kids exposed to anesthesia
- group B, kids not exposed to anesthesia
and finds a difference?

So all those premature NICU kids who had surgery for NEC or gastroschisis or even 'benign' deformities grew up to be included in the 'exposed' group and score poorly in school.

Must've been the anesthesia.


If we exclude the 'elective' and 'boring' stuff like hernias, myringotomies, tonsils, dental, etc, and add up the 'whoa there might be something else screwed up in this kid' kind of surgeries, my semi-arbitrary list of 'kids that might not have been totally normal in the first place' looks like:

Gastric and bowel repair and resection 10 (2.2)
Cardiac catheterization 5 (1.1)
Open heart procedure 4 (0.9)
Kidney and urinary tract procedure 4 (0.9)
Tracheostomy 4 (0.9)
Laparotomy and laparoscopy 3 (0.7)
Laryngoscopy, tracheoscopy, and bronchoscopy 2 (0.4)
Repair of aortic coarctation 2 (0.4)
Craniectomy 1 (0.2)
Patent ductus arteriosus closure 1 (0.2)
Bone marrow biopsy 1 (0.2)
Tenckhoff catheter placement and peritoneal dialysis 1 (0.2)
Diaphragmatic hernia repair 1 (0.2)

Close to 10% of these ghastly 'exposures' to anesthesia were in kids who might have had some serious issues to begin with.

And some of the other surgeries listed were likely treatments for part of a constellation of symptoms. Odds are some of those orchiopexies or hernias were in syndrome kids too.


I didn't read the article that carefully, but it appears that the authors weren't concerned that a bunch of kids who got tracheostomies, or dialysis, or had a Fontan, or some other congenital anomoly fixed might have had a NON-ANESTHESIA reason to blow the curve for the rest of the 'exposed' cohort?

And they don't actually know anything about the actual anesthetics, but they surmise that it was probably halothane.


I think maybe I'll do a study involving kids who've spent time on an oncology ward. I'll divide it into two groups: kids who were patients, and kids who were visitors. And then I'll compare 5 year mortality rates. And if there's a difference, I'll attribute it to the fact that group A spent most of their time in the bed, while group B spent most of their time in the chair. Then I can blame the bed.


Ugh.

 

[MRW]

And if there's a difference, I'll attribute it to the fact that group A spent most of their time in the bed, while group B spent most of their time in the chair. Then I can blame the bed.
Ugh.

Probably the non-allergenic pillow...

 

[Bertelman]

This study (the one done by Ing) is seriously flawed, so much so that when he presented it at SPA last year he was basically heckled. The animal model studies also have fatal flaws in their methods. I think we're going to find that anesthetic neurotoxicity in the developing brain is much less significant than we thought, at least as it is currently being studied.

To be fair, there have been some pretty remarkable discoveries that were heckled at first presentation.

 

[RussianJoo]

I was recently at a Desflurane Drug dinner and they had some studies that showed reduced cognitive ability after the use of Isoflurane vs. Desflurane in adults, I believe this was measured a few weeks after surgery, but I might be wrong.. So maybe the type of anesthesia we use is just as important?

 

[Bertelman]

I was recently at a Desflurane Drug dinner and they had some studies that showed reduced cognitive ability after the use of Isoflurane vs. Desflurane in adults, I believe this was measured a few weeks after surgery, but I might be wrong.. So maybe the type of anesthesia we use is just as important?

They would love for you to believe that.

 

[michigangirl]

OK. This retrospective study looks at
- group A, kids exposed to anesthesia
- group B, kids not exposed to anesthesia
and finds a difference?

So all those premature NICU kids who had surgery for NEC or gastroschisis or even 'benign' deformities grew up to be included in the 'exposed' group and score poorly in school.

Must've been the anesthesia.


If we exclude the 'elective' and 'boring' stuff like hernias, myringotomies, tonsils, dental, etc, and add up the 'whoa there might be something else screwed up in this kid' kind of surgeries, my semi-arbitrary list of 'kids that might not have been totally normal in the first place' looks like:

Gastric and bowel repair and resection 10 (2.2)
Cardiac catheterization 5 (1.1)
Open heart procedure 4 (0.9)
Kidney and urinary tract procedure 4 (0.9)
Tracheostomy 4 (0.9)
Laparotomy and laparoscopy 3 (0.7)
Laryngoscopy, tracheoscopy, and bronchoscopy 2 (0.4)
Repair of aortic coarctation 2 (0.4)
Craniectomy 1 (0.2)
Patent ductus arteriosus closure 1 (0.2)
Bone marrow biopsy 1 (0.2)
Tenckhoff catheter placement and peritoneal dialysis 1 (0.2)
Diaphragmatic hernia repair 1 (0.2)

Close to 10% of these ghastly 'exposures' to anesthesia were in kids who might have had some serious issues to begin with.

And some of the other surgeries listed were likely treatments for part of a constellation of symptoms. Odds are some of those orchiopexies or hernias were in syndrome kids too.


I didn't read the article that carefully, but it appears that the authors weren't concerned that a bunch of kids who got tracheostomies, or dialysis, or had a Fontan, or some other congenital anomoly fixed might have had a NON-ANESTHESIA reason to blow the curve for the rest of the 'exposed' cohort?

And they don't actually know anything about the actual anesthetics, but they surmise that it was probably halothane.


I think maybe I'll do a study involving kids who've spent time on an oncology ward. I'll divide it into two groups: kids who were patients, and kids who were visitors. And then I'll compare 5 year mortality rates. And if there's a difference, I'll attribute it to the fact that group A spent most of their time in the bed, while group B spent most of their time in the chair. Then I can blame the bed.


Ugh.

Thank you. You just saved me a lot of time writing a post and read my mind. 👍

 

[BLADEMDA]

PGG,

Nice response and I did see that study had a lot of holes/issues.


Summary

A great deal of concern has recently arisen regarding the safety of anaesthesia in infants and children. There is mounting and convincing preclinical evidence in rodents and non-human primates that anaesthetics in common clinical use are neurotoxic to the developing brain in vitro and cause long-term neurobehavioural abnormalities in vivo. An estimated 6 million children (including 1.5 million infants) undergo surgery and anaesthesia each year in the USA alone, so the clinical relevance of anaesthetic neurotoxicity is an urgent matter of public health. Clinical studies that have been conducted on the long-term neurodevelopmental effects of anaesthetic agents in infants and children are retrospective analyses of existing data. Two large-scale clinical studies are currently underway to further address this issue. The PANDA study is a large-scale, multisite, ambi-directional sibling-matched cohort study in the USA. The aim of this study is to examine the neurodevelopmental effects of exposure to general anaesthesia during inguinal hernia surgery before 36 months of age. Another large-scale study is the GAS study, which will compare the neurodevelopmental outcome between two anaesthetic techniques, general sevoflurane anaesthesia and regional anaesthesia, in infants undergoing inguinal hernia repair. These study results should contribute significant information related to anaesthetic neurotoxicity in children.

 

[BLADEMDA]

The age of vulnerability in children cannot be extrapolated easily from the clinical studies because cross-species translation of brain development is still an area of ongoing study. The vulnerable period of injury has been consistently demonstrated to be during peak synaptogenesis.7103050 Therefore, our current understanding of human brain development may be informative in choosing the age most likely to be at risk for anaesthetic neurotoxicity. In the human brain, there are significant regional differences in the timing for peak synaptogenesis. The earliest is in the primary sensorimotor cortex, occurring around birth. This is followed by the parietal and temporal association cortex, important in language and spatial attention, where peak synaptogenesis occurs at around 9 months. The last region to peak in synaptogenesis is in the prefrontal cortex, which occurs at age 2&#8211;3 yr. The prefrontal cortex is key in executive function and integrative and modulatory brain function. Since peak synaptogenesis occurs between birth and 2&#8211;3 yr of age,656768 the vulnerability period for anaesthetic-induced neurotoxicity might be up to 36 months of age in the developing human brain.


http://bja.oxfordjournals.org/content/105/suppl_1/i61.full

 

[BLADEMDA]

http://www.pac.chla-accm.org/Abstracts/48thPDFs/48thMaxwellNeuro.pdf

Complete summary of the literature. This author does not believe the current evidence warrants telling the parents that exposure to a single anesthetic causes any harm to a child under age 3.

 

[BLADEMDA]

Dr. Ing, the lead author from Columbia University notes in his interview with CNN Health "that "we can't determine if the cause is due to anesthesia, surgical stimulus, or the medical condition. We just know there's a difference."
The researchers warn that parents should not decline a surgery if there is a real benefit.
There is always a risk benefit discussion that happens with every surgery. A surgeon will not want to perform surgery on an infant and/or toddler unless it is medically necessary. Dr. Ing notes that is important for parents to know that these potential risks are present, and they should be part of the pre-operative discussions with the surgeon and the anesthesiologist.

 

[IlDestriero]

OK. This retrospective study looks at
- group A, kids exposed to anesthesia
- group B, kids not exposed to anesthesia
and finds a difference?

So all those premature NICU kids who had surgery for NEC or gastroschisis or even 'benign' deformities grew up to be included in the 'exposed' group and score poorly in school.

Must've been the anesthesia.


If we exclude the 'elective' and 'boring' stuff like hernias, myringotomies, tonsils, dental, etc, and add up the 'whoa there might be something else screwed up in this kid' kind of surgeries, my semi-arbitrary list of 'kids that might not have been totally normal in the first place' looks like:

Gastric and bowel repair and resection 10 (2.2)
Cardiac catheterization 5 (1.1)
Open heart procedure 4 (0.9)
Kidney and urinary tract procedure 4 (0.9)
Tracheostomy 4 (0.9)
Laparotomy and laparoscopy 3 (0.7)
Laryngoscopy, tracheoscopy, and bronchoscopy 2 (0.4)
Repair of aortic coarctation 2 (0.4)
Craniectomy 1 (0.2)
Patent ductus arteriosus closure 1 (0.2)
Bone marrow biopsy 1 (0.2)
Tenckhoff catheter placement and peritoneal dialysis 1 (0.2)
Diaphragmatic hernia repair 1 (0.2)

Close to 10% of these ghastly 'exposures' to anesthesia were in kids who might have had some serious issues to begin with.

And some of the other surgeries listed were likely treatments for part of a constellation of symptoms. Odds are some of those orchiopexies or hernias were in syndrome kids too.


I didn't read the article that carefully, but it appears that the authors weren't concerned that a bunch of kids who got tracheostomies, or dialysis, or had a Fontan, or some other congenital anomoly fixed might have had a NON-ANESTHESIA reason to blow the curve for the rest of the 'exposed' cohort?

And they don't actually know anything about the actual anesthetics, but they surmise that it was probably halothane.


I think maybe I'll do a study involving kids who've spent time on an oncology ward. I'll divide it into two groups: kids who were patients, and kids who were visitors. And then I'll compare 5 year mortality rates. And if there's a difference, I'll attribute it to the fact that group A spent most of their time in the bed, while group B spent most of their time in the chair. Then I can blame the bed.


Ugh.

👍
Ugh is right.
There's no conclusive evidence in humans. That's what I tell the parents that ask. And I add that the drugs that we use now are not the same as were used in the past, that I tightly control their child's breathing and blood pressure, and that I only give the amount of medication necessary for the procedure. I also explain that there is a great deal of research going on now in humans, and the data is unclear, but they obviously don't have the massive neurological damage shown in some initial animal studies. It seems to make them feel better.
Not a lot of surgeries done on babies at my institution are really elective. Circs are one that comes to mind. Ear tubes, tonsils, hernias, urology-plastics-ortho reconstructive stuff, it all needs to be done, maybe not today or even next month, but it can't wait a year or three.

 

[Mman]

👍
Ugh is right.
There's no conclusive evidence in humans. That's what I tell the parents that ask. And I add that the drugs that we use now are not the same as were used in the past, that I tightly control their child's breathing and blood pressure, and that I only give the amount of medication necessary for the procedure. I also explain that there is a great deal of research going on now in humans, and the data is unclear, but they obviously don't have the massive neurological damage shown in some initial animal studies. It seems to make them feel better.
Not a lot of surgeries done on babies at my institution are really elective. Circs are one that comes to mind. Ear tubes, tonsils, hernias, urology-plastics-ortho reconstructive stuff, it all needs to be done, maybe not today or even next month, but it can't wait a year or three.

Agree whole heartedly. The answer is that we don't know if there is a risk or what the risk is. There might be. It be meaningful or it might be insignificant. More human studies are needed. But as you point out, very few pediatric surgeries are completely elective. I'm guessing data would quickly show that untreated sleep apnea from adenotonsillar hypertrophy in a 2 or 3 year old is a bigger risk to long term development of their CNS than 30 minutes of 1 MAC of sevoflurane.

I'm also not entirely clear of how much discussion should take place before every anesthetic in every kid detailing the potential risk of things we don't even completely understand and may or may not even be relevant. Medicolegally we are under no obligation to describe every potential complication that could ever happen to a patient as a result of a procedure. So if somebody wanted to sue you 18 years later for some kid not getting into an Ivy League school because they had ear tubes at 8 months age, they wouldn't have much legal ground to stand on.

 

[Impromptu]

This looks like something that a prospective study could evaluate. Randomly divide a group and put a bunch of babies under anesthesia for an hour and the other group not. The babies won't remember. Take them to recovery and give them back to their parents once they have "fully awakened". Very low risk given the current data. You just need to wait 10 years to get the final results.

 

[Bertelman]

This looks like something that a prospective study could evaluate. Randomly divide a group and put a bunch of babies under anesthesia for an hour and the other group not. The babies won't remember. Take them to recovery and give them back to their parents once they have "fully awakened". Very low risk given the current data. You just need to wait 10 years to get the final results.

Totally. My neighbor just had a baby. I'll gas him down tomorrow morning.

Here's to hoping you don't really think this is a viable study protocol.

 

[Planktonmd]

This looks like something that a prospective study could evaluate. Randomly divide a group and put a bunch of babies under anesthesia for an hour and the other group not. The babies won't remember. Take them to recovery and give them back to their parents once they have "fully awakened". Very low risk given the current data. You just need to wait 10 years to get the final results.

 

[imfrankie]

I think this study is in the German literature.

 

[Mman]

I think this study is in the German literature.

 

[pgg]

This looks like something that a prospective study could evaluate. Randomly divide a group and put a bunch of babies under anesthesia for an hour and the other group not. The babies won't remember. Take them to recovery and give them back to their parents once they have "fully awakened". Very low risk given the current data. You just need to wait 10 years to get the final results.

I don't think that's ambitious enough. There could be a third arm:

1) No procedure, no anesthesia
2) No procedure, anesthesia
3) No procedure, anesthesia by solo CRNA

I think this study is in the German literature.

Yeah, but it was probably with ether.