Anesthesia and neurodevelopment after 20 years: where are we now and where to next?

Excerpt

Since an initial publication in 2003 that described widespread neurodegeneration and persistent learning deficits in neonatal rats with early exposure to isoflurane,¹ the anesthesia community has seen an explosion of nonclinical and clinical studies trying to quantify the effects of anesthetic exposure on neurodevelopment in human infants, including preterm neonates. The results have been conflicting and many confounders have been identified, including degree of prematurity, presence of comorbidities such as intraventricular hemorrhage (IVH) and congenital heart disease, indication for surgical procedure, exposure to multiple anesthetics/sedatives, duration of exposure, and degree of hemodynamic and physiologic stability (both perioperatively and in the neonatal intensive care [NICU]). In 2016, the United States Food and Drug Administration (FDA) issued a black box warning on the administration of several anesthetic and sedative medications to pregnant women and children less than three years of age, including volatile anesthetics, propofol, ketamine, benzodiazepines, pentobarbital, and etomidate. Opioids were notably excluded from this warning. Health Canada issued a similar warning in December 2017. …