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This chapter, provides an overview on the concerns centered on neurotoxicity from anesthetics in children following the FDA warning from 2016 and 2017. The authors provide a background for both clinical and basic science evidence on the effects of commonly used anesthetics on neural development. After review of the landmark studies in both animals and humans, the chapter provides suggestions for reducing exposure as well as addressing parental concerns.
Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level.
We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient’s autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure.
A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual’s peak autoregulation and biomarker values (p=0.01).
Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.
The significant increase in complex anaesthetic care for infants, children, adolescents, and adults with CHD has given rise to specialized fellowship training programs. Specialized paediatric cardiac anaesthesia training for residents and fellows has advanced significantly since the 1970’s, when there a handful of programs. With the advent of formal paediatric anaesthesia fellowship programs in the U.S., more specialized training became available in the 1990’s and early 2000’s. In the past decade, increasing numbers of second year advanced fellowships in paediatric cardiac anaesthesia have been organized; today in North America there are 18 programs with 25 positions. Standardized recommendations for case numbers and curriculum have been devised and are widely available via journal publications.