Anestesia y el cerebro neonatal/Anesthesia and neonatal brain

Septiembre 6, 2015. No. 2077

En animales inmaduros que son expuestos a los anestésicos generales se ha visto muerte celular, daño neuronal, y deterioro neurocognitivo. Esto ha preocupado a los investigados y a los clínicos sobre los efectos similares que puedan ocurren en los niños pequeños. Aunque los estudios epidemiológicos no son concluyentes por diversos factores, los descubrimientos actuales  sugieren que la anestesia general para un procedimiento quirúrgico en la primera infancia puede estar asociada con la disminución a largo plazo de las habilidades del lenguaje y la cognición, así como alteraciones volumétricas regionales en la estructura del cerebro.   In immature animals exposed to general anesthetics has been demosntrated  cell death, neuronal damage, and neurocognitive impairment. This has worried investigators and clinicians about that similar effects can occur in young children. Although epidemiological studies are inconclusive by several factors, the current findings suggest that general anesthesia for a surgical procedure in early childhood may be associated with long-term decline of language skills and cognition, as well as regional volumetric changes in brain structure   Em animais imaturos são expostos a anestésicos gerais tem sido a morte celular, as lesões neuronais e comprometimento neurocognitivo. Isso tem preocupado investigados e clínicos sobre os efeitos semelhantes podem ocorrer em crianças pequenas. Embora os estudos epidemiológicos são inconclusivos por diversos fatores, os resultados atuais sugerem que a anestesia geral para um procedimento cirúrgico na primeira infância pode estar associada com declínio a longo prazo das competências linguísticas e cognição, bem como mudanças volumétricas regionais na estrutura do cérebro Efectos de la anestesia en el cerebro de niños en desarrollo Effects of Anesthesia on Children's Brain Development Hernández-Cortez E J Anesth Crit Care Open Access 2015; 2(6): 00079. DOI: 10.15406/ jaccoa.2015.02.00079 J Anesth Crit Care Open Access 2015, 2(6): 00079 Abstract Nowadays, the administration of most of the anesthetics is being questioned. The quality of reversibility of these medications is being questioned, especially when administered to children under 3 years old. The administration of isoflurane elevates intracellular calcium levels which are critical for cell damage resulting in apoptosis. The NMDA and GABA receptors are indirectly involved in the effect of immature brains. The immaturity of the central nervous system associated to the administration of anesthetic agents such as inhaled anesthetics, ketamine, midazolam, nitrous oxide, and others, produces important changes in the brain that  have  an  impact  in  the  child's  later  life.  There  are  two  important  elements in the neurotoxicity of anesthetics, dosage and time administration. Repeating anesthetics produces more brain changes. There are two important elements in the neurotoxicity of anesthetics, dosage and time administration. Repeating anesthetics produces more brain changes. These modifications have resulted in serious behavioral and memory changes in experiments. Keywords. Apotosis, anesthesia, children  PDF Asociación entre daño cerebral, exposición perioperatoria a los anestésicos, y el neurodesarrollo a los 12 meses después de cirugía cardiaca neonatal. Estudio retrospectivo de cohortes The association between brain injury, perioperative anesthetic exposure, and 12-month neurodevelopmental outcomes after neonatal cardiac surgery: a retrospective cohort study. Andropoulos DB, Ahmad HB, Haq T, Brady K, Stayer SA, Meador MR, Hunter JV, Rivera C, Voigt RG,Turcich M, He CQ, Shekerdemian LS, Dickerson HA, Fraser CD, Dean McKenzie E, Heinle JS, Blaine Easley R. Paediatr Anaesth. 2014 Mar;24(3):266-74. doi: 10.1111/pan.12350. Abstract BACKGROUND: Adverse neurodevelopmental outcomes are observed in up to 50% of infants after complex cardiac surgery. We sought to determine the association of perioperative anesthetic exposure with neurodevelopmental outcomes at age 12 months in neonates undergoing complex cardiac surgery and to determine the effect of brain injury determined by magnetic resonance imaging (MRI). METHODS: Retrospective cohort study of neonates undergoing complex cardiac surgery who had preoperative and 7-day postoperative brain MRI and 12-month neurodevelopmental testing with Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Doses of volatile anesthetics (VAA), benzodiazepines, and opioids were determined during the first 12 months of life. RESULTS: From a database of 97 infants, 59 met inclusion criteria. Mean ± sd composite standard scores were as follows: cognitive = 102.1 ± 13.3, language = 87.8 ± 12.5, and motor = 89.6 ± 14.1. After forward stepwise multivariable analysis, new postoperative MRI injury (P = 0.039) and higher VAA exposure (P = 0.028) were associated with lower cognitive scores. ICU length of stay (independent of brain injury) was associated with lower performance on all categories of the Bayley-III (P < 0.02). CONCLUSIONS: After adjustment for multiple relevant covariates, we demonstrated an association between VAA exposure, brain injury, ICU length of stay, and lower neurodevelopmental outcome scores at 12 months of age. These findings support the need for further studies to identify potential modifiable factors in the perioperative care of neonates with CHD to improve neurodevelopmental outcomes. PDF Daño perioperatorio del sistema nervioso central en neonatos Perioperative central nervous system injury in neonates. McCann ME, Soriano SG. Br J Anaesth. 2012 Dec;109 Suppl 1:i60-i67. doi: 10.1093/bja/aes424.Author information Abstract Anaesthetic-induced developmental neurotoxicity (AIDN) has been clearly established in laboratory animal models. The possibility of neurotoxicity during uneventful anaesthetic procedures in human neonates or infants has led to serious questions about the safety of paediatric anaesthesia. However, the applicability of animal data to clinical anaesthesia practice remains uncertain. The spectre of cerebral injury due to cerebral hypoperfusion, metabolic derangements, coexisting disease, and surgery itself further muddles the picture. Given the potential magnitude of the public health importance of this issue, the clinician should be cognisant of the literature and ongoing investigations on AIDN, and raise awareness of the risks of both surgery and anaesthesia. PDF Anestesia general en pediatría. Influencias sobre el cerebro en desarrollo General anesthetics in pediatric anesthesia: influences on the developing brain. McCann ME, Soriano SG. Curr Drug Targets. 2012 Jun;13(7):944-51. Abstract Millions of newborn and infants receive anesthetic, sedative and analgesic drugs for surgery and painful procedures on a daily basis. However, recent laboratory reports clearly demonstrate that anesthetic and sedative drugs induced both neuroapoptosis and neurocognitive deficits in laboratory models. This issue is of paramount interest to pediatric anesthesiologists and intensivists because it questions the safety of anesthetics used for fetal and neonatal anesthesia. Most clinically utilized anesthetic drugs have been found to induce neuronal cell death in the developing brain and to potentially cause long-term neurological impairment. Conversely, painful stimuli without analgesia and anesthesia have been implicated in triggering neuro-apoptosis in juvenile mammalian models. Published retrospective reviews demonstrate temporary neurological sequelae after prolonged anesthetic exposure in young children and larger studies identify long-term neurodevelopmental impairment after neonatal surgery and anesthesia. This paper examines the evidence for the effects of commonly used anesthetics on neuronal structure and neurocognitive function in laboratory models and reviews the relevant clinical human epidemiologic data. PDF  Control de dolor neonatal y efectos neurológicos de los anestésicos y sedantes en infantes de pretérmino Neonatal pain control and neurologic effects of anesthetics and sedatives in preterm infants. McPherson C, Grunau RE. Clin Perinatol. 2014 Mar;41(1):209-27. doi: 10.1016/j.clp.2013.10.002. Epub 2013 Dec 17. Abstract Preclinical and clinical studies have demonstrated the adverse consequences of untreated pain and stress on brain development in the preterm infant. Sucrose has widely been implemented as standard therapy for minor procedural pain. Anesthetics are commonly utilized in preterm infants during major surgery. Pharmacologic agents (benzodiazepines and opioids) have been examined in clinical trials of preterm infants requiring invasive mechanical ventilation. Controversy exists regarding the safety and long-term impact of these interventions. Ongoing multidisciplinary research will help define the impact of these agents and identify potential alternative therapies. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Imágen del mes/ Image of the month

Agosto 31, 2015. No. 2071

Imágen del mes/ Image of the month Ver Galerí­a El trauma agudo cumple los criterios de clasificación de enfermedad para una pandemia mundial, siendo esta una fuente recurrente y significativa de morbimortalidad en las últimas décadas en todo el mundo, no obstante un sinnúmero de esfuerzos para disminuir su impacto en la humanidad. El trauma agudo es sin duda alguna la causa más importante de discapacidad y muerte, produciendo más muertes por año que el VIH, el SIDA, la tuberculosis y la malaria juntos. Las lesiones y la violencia son una creciente preocupación de salud pública que representan casi 1 de cada 10 muertes por año. A nivel mundial más de nueve personas mueren cada minuto por lesiones traumáticas; es decir, cada año mueren aproximadamente 5.8 millones de personas por lesiones no intencionales y violencia. El trauma del tórax es una enfermedad que se ha agravado debido a la modernidad que significa incrementos en la violencia y en los accidentes. Se trata de una patología grave, multifacética -que con frecuencia creciente involucra otras regiones anatómicas que ameritan tratamiento simultáneo. El manejo debe de ser multidisciplinario e idealmente iniciarse antes de su arribo al hospital y mantenerlo durante el traslado, en la sala de urgencias, en el quirófano y posteriormente en las unidades de cuidado intensivo. El diagnóstico temprano y el manejo inicial agresivo son claves para abatir su morbimortalidad. El anestesiólogo tiene un sitio vital en el manejo de estos casos en todo el periodo perioperatorio. Acute trauma fulfills the criteria to classify the disease for a global pandemic. Being these a frequent source and substantial contribution to morbidity and mortality in the last decades all over the world. However, it has been a significant effort to diminish its impact on humanity. Acute trauma is without a doubt the largest cause of death, taking more lives than HIV, AIDS, tuberculosis, and malaria combined. Acute trauma and injuries due to violence are a growing public health concern which causes 1 out of 10 deaths each year. On a global scale every minute nine people die from traumatic injuries; approximately 5.8 million people die every year from non-intentional traumatic injuries and violence.Trauma of the chest is a disease that has worsened due to the modernity that means increases in violence and accidents. This is a serious condition, which often multifaceted growing involves other anatomical regions that merit simultaneous treatment. Management should be multidisciplinary and ideally start before their arrival at the hospital and maintain it during transport, in the emergency room, the operating room and then in intensive care units. Early diagnosis and early aggressive management are key to bring down morbidity and mortality. The anesthesiologist has a fundamental role in the treatment of these patients throughout the perioperative period.  La huella digital molecular de inflamación pulmonar después de trauma cerrado del tórax The molecular fingerprint of lung inflammation after blunt chest trauma. Ehrnthaller C, Flierl M, Perl M, Denk S, Unnewehr H, Ward PA, Radermacher P, Ignatius A, Gebhard F, Chinnaiyan A, Huber-Lang M. Eur J Med Res. 2015 Aug 25;20(1):70. doi: 10.1186/s40001-015-0164-y. PDF Los resultados de lesión traumática de la aorta en abordaje quirúrgico abierto. Outcomes of Traumatic Aortic Injury in a Primary Open Surgical Approach Paradigm. Forcillo J, Philie M, Ojanguren A, Le Guillan S, Verdant A, Demers P, Lamarche Y Trauma Mon. 2015 May;20(2):e18198. doi: 10.5812/traumamon.18198. Epub 2015 May 25. PDF  ¿Trauma cardiaco grave o isquemia de miocardio? Errores de tratamiento en pacientes con politraumatismo con elevación del ST después de un traumatismo torácico cerrado. Severe cardiac trauma or myocardial ischemia? Pitfalls of polytrauma treatment in patients with ST-elevation after blunt chest trauma. Özkurtul O, Höch A, Reske A, Hädrich C, Josten C, Böhme J. Ann Med Surg (Lond). 2015 Aug 4;4(3):254-9. doi: 10.1016/j.amsu.2015.07.019. eCollection 2015. PDF Exposición a oxigeno 100% elimina el deterioro de la curación de fracturas costales después de trauma Exposure to 100% Oxygen Abolishes the Impairment of Fracture Healing after Thoracic Trauma. Kemmler J, Bindl R, McCook O, Wagner F, Gröger M, Wagner K, Scheuerle A, Radermacher P,Ignatius A. PLoS One. 2015 Jul 6;10(7):e0131194. doi: 10.1371/journal.pone.0131194. eCollection 2015. PDF Toracostomía con aguja para neumotórax a tensión. Experiencia de la fuerzas de defensa Israelíes Needle thoracostomy for tension pneumothorax: the Israeli Defense Forces experience. Chen J, Nadler R, Schwartz D, Tien H, Cap AP, Glassberg E. Can J Surg. 2015 Jun;58(3 Suppl 3):S118-24. PDF  Determinantes de la mortalidad en pacientes con trauma de tórax Determinants of mortality in chest trauma patients. Ekpe EE, Eyo C. Niger J Surg.2014 Jan;20(1):30-4. doi: 10.4103/1117-6806.127107. PDF Anestesia torácica y ventilación para lesiones traqueobronquiales: un reto para los anestesiólogos Thoracic anesthesia and cross field ventilation for tracheobronchial injuries: a challenge for anesthesiologists. Sehgal S, Chance JC, Steliga MA. Case Rep Anesthesiol. 2014;2014:972762. doi: 10.1155/2014/972762. Epub 2014 Jan 12. PDF Estudio prospectivo de médico anestesiólogos pre-hospitalarios en pacientes traumatizados:intubación esofágica, contaminación excesiva de las vías respiratorias y la evaluación de las vías respiratorias "rápida mirada". A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the 'quick look' airway assessment. Lockey DJ, Avery P, Harris T, Davies GE, Lossius HM. BMC Anesthesiol. 2013 Sep 11;13(1):21. doi: 10.1186/1471-2253-13-21. PDF    Las fracturas costales ocultas diagnosticadas solo con tomografía computarizada siguen siendo un factor de riesgo para lesiones de órganos sólidos. "Occult" rib fractures diagnosed on computed tomography scan only are still a risk factor for solid organ injury. Bhattacharya B, Fieber J, Schuster K, Davis K, Maung A. J Emerg Trauma Shock. 2015 Jul-Sep;8(3):140-3. doi: 10.4103/0974-2700.160706. Articulo/Article

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