Wondering what you all are doing for anesthesia for appendectomy in the pregnant woman. We used to do SAB. Then the procedure went laparoscopic so we moved to GA. Now we have the scary literature on CNS damage in developing brains. Do any of you force the surgeons to do the procedure open (the old way) so you can do it under SAB?
This is an area of huge controversy in the pediatric anesthesia community. There is a large and increasing amount of research on apoptosis in the developing brain.
Here is a good place to start (from last months A&A). Check the references.
Anesth Analg. 2010 Feb;110(2):442-8. Epub 2009 Dec 2.
The young: neuroapoptosis induced by anesthetics and what to do about it.
Creeley CE, Olney JW.O
Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri 63110, USA.
Comment in:
Anesth Analg. 2010 Feb;110(2):291-2.
Millions of human fetuses, infants, and children are exposed to anesthetic drugs every year in the United States and throughout the world. Anesthesia administered during critical stages of neurodevelopment has been considered safe and without adverse long-term consequences. However, recent reports provide mounting evidence that exposure of the immature animal brain to anesthetics during the period of rapid synaptogenesis, also known as the brain growth spurt period, triggers widespread apoptotic neurodegeneration, inhibits neurogenesis, and causes significant long-term neurocognitive impairment. Herein, we summarize currently available evidence for anesthesia-induced pathological changes in the brain and associated long-term neurocognitive deficits and discuss promising strategies for protecting the developing brain from the potentially injurious effects of anesthetic drugs while allowing the beneficial actions of these drugs to be realized.
The only real conclusions are that most of our anesthetics are bad for the developing brain of mice. Some new literature suggests that there is evidence of damage and impairment in macaques, which is concerning, though it appears to be related to duration. The human studies are really weak and inconclusive. If you want to be conservative, keep it simple and clean and avoid multiple agents (N2O, ketamine, midaz, etc). And get it done as quickly as possible, ie attending driving vs 2 residents w/ minimal supervision. Or, do it open with a spinal. I would also recommend Doppler or US before and after to confirm that the fetus is still alive. Tight BP control, etc, etc.
The next few years should be interesting.
