Low-neurotoxicity anesthesia

Eizaga Rebollar, R.; García Palacios, M.V.; Morales Guerrero, J.; Torres Morera, L.M.

doi:10.1016/j.redare.2017.12.012

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"apellidos" => "Torres Morera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Anestesia baja en neurotoxicidad" ] ] "textoCompleto" => "We would like to submit our comments on the article “More than 3hours and less than 3 years old. Safety of anaesthetic procedures in children under 3 years of age, subject to surgeries of more than 3hours”, published in the December 2017 issues of the Revista Española de Anestesiología y Reanimación.<a class="elsevierStyleCrossRef" href="#bib0035">1</a> First of all, we must congratulate the authors for their clarity and concision in interpreting and stating their position regarding the warning issued by the US Food and Drug Administration (FDA) about the use of anaesthetics in young children.<a class="elsevierStyleCrossRef" href="#bib0040">2</a> This stems from a topic that has generated much controversy in the last 20 years, starting with the first experimental studies in animal models, followed by retrospective studies in humans, and finally the latest ambispective studies, some of which are still awaiting the final results.The warning issued by the FDA a year ago caused a considerable stir in the international anaesthesiology community, and led to several publications in 2017, ranging from consensus documents drawn up by international societies and editorials in high impact journals, to opinion articles written by working clinicians.<a class="elsevierStyleCrossRefs" href="#bib0045">3–5</a> These articles were prompted by the need to take a position on an issue that can, as the authors mention, have both legal and ethical connotations, particularly in the light of the results of the promising PANDA and GAS studies, and the upcoming MASK study. Despite their limitations (the PANDA study recruited patients exclusively from high-income families, and in the GAS study sevoflurane was the only anaesthetic agent used) these trials found no significant differences between single and short-term anaesthetic procedures.<a class="elsevierStyleCrossRef" href="#bib0055">5</a>Our purely clinical opinion is based on the fact that there is currently no clear evidence that general anesthetics can induce neurotoxicity in humans, and that undelayable procedures in young children include not only surgical emergencies (gastroschisis or oesophageal atresia), but also scheduled procedures in which delay increases the risk of poor outcome (cleft palate or hypospadias) or even potential emergency situations (inguinal hernia or cryptorchidism).We would propose a new term, “low neurotoxicity anaesthesia” (similar to low carbohydrate or low-fat diets), which would mitigate anaesthetic-induced neurotoxicity (drugs), surgical stress-induced neurotoxicity (pain and inflammation), and anaesthesiologist-induced neurotoxicity (anaesthetic management). This mainly involves controlling the following factors: Duration–reduce the duration of surgery as much as possible, weighing up the risk-benefit ration of a single prolonged procedure against the several consecutive surgeries; Stimulus/dose balance–separately monitor pain (perfusion index or “new born parasympathetic evaluation”) and anaesthetic depth (bispectral index or entropy) and on this basis independently and accurately determine the best analgesic and anaesthetic dosage (minimising the latter); Adjuvants–with sedative, analgesic and/or neuroprotective properties (dexmedetomidine, magnesium sulfate or vitamin C); Regional anaesthesia–this should be prioritised, as it avoids or reduces the administration of anaesthetic agents, controls pain, and inhibits the neuroendocrine response; Anaesthetic management–this must of the highest quality and should meet the standards of perioperative care in young children recommended by the “Safe Anaesthesia for Every Tot Initiative” (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.safetots.org/">www.safetots.org</a>).<a class="elsevierStyleCrossRefs" href="#bib0055">5,6</a>We take note of the interesting ethical and legal considerations the authors put forward in their article, and await the consensus document. We would also thank the authors for their commitment to such a widely though inconclusively debated topic that is so important to the health of our children." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. Anestesia baja en neurotoxicidad. Rev Esp Anestesiol Reanim. 2018;65:299–300." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Más de 3 horas y menos de 3 años. Seguridad de procedimientos anestésicos en niños menores de 3 años, sometidos a cirugías de más de 3 horas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Álvarez Escudero" 1 => "R.M. Paredes Esteban" 2 => "F.J. Cambra Lasaosa" 3 => "M. Vento" 4 => "M. López Gil" 5 => "J.C. de Agustín Asencio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2017.04.002" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2017" "volumen" => "64" "paginaInicial" => "577" "paginaFinal" => "584" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28641810" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "US, Food, Drug administration FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women; 2016. Avaiable from: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-drugs-gen/documents/document/ucm533197.pdf">http://www.fda.gov/ucm/groups/fdagov-public/@fdagov-drugs-gen/documents/document/ucm533197.pdf</a> [acccessed 14.12.16]." ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of anaesthetics in young children: consensus statement of the European Society of Anaesthesiology, the European Society for Paediatric Anaesthesiology, the European Association of Cardiothoracic Anaesthesiology and the European Safe Tots Anaesthesia Research Initiative" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.G. Hansen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/EJA.0000000000000629" "Revista" => array:6 [ "tituloSerie" => "Eur J Anaesthesiol" "fecha" => "2017" "volumen" => "34" "paginaInicial" => "327" "paginaFinal" => "328" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28459783" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anesthesia and developing brains – implications of the FDA warning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.B. Andropoulos" 1 => "M.F. Greene" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMp1700196" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2017" "volumen" => "376" "paginaInicial" => "905" "paginaFinal" => "907" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28177852" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurotoxicity versus neuroprotection of anesthetics: young children on the ropes?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R. Eizaga Rebollar" 1 => "M.V. García Palacios" 2 => "J. Morales Guerrero" 3 => "L.M. Torres Morera" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s40272-017-0230-8" "Revista" => array:6 [ "tituloSerie" => "Paediatr Drugs" "fecha" => "2017" "volumen" => "19" "paginaInicial" => "271" "paginaFinal" => "275" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28466422" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safe anesthesia for every tot – the SAFETOTS initiative" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Weiss" 1 => "L. Vutskits" 2 => "T.G. Hansen" 3 => "T. Engelhardt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACO.0000000000000186" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Anaesthesiol" "fecha" => "2015" "volumen" => "28" "paginaInicial" => "302" "paginaFinal" => "307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25887194" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000005/v1_201805120427/S2341192918300453/v1_201805120427/en/main.assets" "Apartado" => array:4 [ "identificador" => "74420" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter sto the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000005/v1_201805120427/S2341192918300453/v1_201805120427/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300453?idApp=UINPBA00004N"]

ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 5.