Anesthetic Agent Exposure New Concerns of Adverse Impact

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Anesthetic Agent Exposure New Concerns of
Adverse Impact
Scott D. Kelley, M.D.
? Conflict of Interest Statement ? Employee and
Officer of Aspect Medical Systems, Inc. Aspect
manufacturers BIS-brand brain monitoring system.
Titration of anesthesia using BIS monitoring has
been demonstrated to reduce anesthetic exposure.
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Anesthetic Agent Exposure

• Additional concerns in pediatric patients
• Preclinical and associative evidence of worrisome
  adverse consequences in adult patients
• Recommendations

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Pediatric Anesthetic ExposureEpileptiform EEG
and Emergence Syndromes
Incidence () during first hour in PACU
Meyer, Pediatric Anesthesia 2007 1756-60
Vakkuri, Acta Anaesthesiol Scand 200145805-11
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Hidden Harm?Anesthetic Exposure Late Outcomes

• Specific Concerns Worrisome Data
• Alzheimers Disease
• Cancer
• Morbidity Mortality
• Important Consideration ?
• Anesthetic exposure may influence patient
  co-morbidities and long-term outcome

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Anesthetics NeurodegenerationPreclinical Not
Limited to Neonatal Animals
12-month-old transgenic tg2576 and nontransgenic
mice Halothane vs Isoflurane (5 Exposures 0.8
MAC x 120 min)
Isoflurane Impairment of cognitive and memory
measures Halothane Increase plague density
measures
Bianchi, Neurobiol Aging. 2007
doi10.1016/j.neurobiolaging.2007.02.009
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Anesthetic Exposure Alzhemiers DiseaseNo
Clinical Association?
It is unlikely that multiple exposures to
general anesthesia Increase the risk of
Alzheimers Disease Bohnen, J Am Geriatr Soc.
199442198-201
(80 power, alpha 0.05)
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Anesthetic Exposure Cancer Preclinical
Evidence Clinical Association

• Murine Model (EL4 Lymphoma) Liver Mets
• Control 15.5 8.7
• Sevoflurane 19.4 5.4
• Sevoflurane Surgery 33.7 8.9
• Sevoflurane Surgery Spinal 19.8 9
• Wada, Anesthesiology. 2007106499-506
• Retrospective Clinical Analysis
• 129 consecutive breast cancer patients
• Mastectomy Axillary Node Dissection
• Non-randomized
• 79 pts GA only
• 50 pts Paravertebral GA
• Follow-up 32 5 months
• Exadaktylos, Anesthesiology. 2006105660-4

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Anesthetic Exposure OutcomeAssociation with
Morbidity Mortality
Time under anesthesia was strikingly correlated
with reinfarction rates in the entire group
Steen. JAMA 1978 2392566-70

• 14,788 pts Lower extremity bypass (GA - 9757
  Spinal - 2848 Epidural - 2183)
• General Anesthesia vs Spinal Anesthesia
• Cardiac events (OR, 1.8 95 CI, 1.32-2.48 P lt
  .0001).
• Postoperative pneumonia (OR 2.2 95CI,
  1.1-4.4 P .034)
• Graft failure (OR, 1.43 95CI, 1.16-1.77 P lt
  .001).
• Return to surgery (OR, 1.40 95CI, 1.20-1.64 Plt
  .001) Singh N,J Vasc Surg. 2006 44964-8
• .

Monk, Anesth Analg 2005 1004-10
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Anesthetic Exposure OutcomeIncreasing Attention
Monk, Anesth Analg 2005 1004-10
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Anesthetic Agent Exposure

• Preclinical and associative evidence of adverse
  effects
• Broad populations at risk
• Developing neonates and pediatric patients
• Elderly patients with co-morbidity
• RECOMMENDATIONS
• Request preclinical and clinical safety studies
  to determine impact of anesthetic exposure on
  late outcomes
• Although the applicability of this to humans and
  our practice is not clear, it has raised concerns
  for the pediatric anesthesiologist and brings an
  added dimension to the Goldilocks conundrum how
  much of our drugs and techniques is "too much,"
  how much is "too little," and how much is "just
  right"? Davis Anesth Analg 2005100650-652
• Engage APSF to alert anesthesia professionals to
  new concerns and to explore clinical options for
  patient care