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Anesthetic Agent Exposure New Concerns of Adverse Impact

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.

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Anesthetic Agent Exposure New Concerns of Adverse Impact

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  1. Anesthetic Agent ExposureNew 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.

  2. Anesthetic Agent Exposure • Additional concerns in pediatric patients • Preclinical and associative evidence of worrisome adverse consequences in adult patients • Recommendations

  3. Pediatric Anesthetic ExposureEpileptiform EEG and Emergence Syndromes Incidence (%) during first hour in PACU Meyer, Pediatric Anesthesia 2007; 17:56-60 Vakkuri, Acta Anaesthesiol Scand 2001;45:805-11

  4. Hidden Harm?Anesthetic Exposure & Late Outcomes • Specific Concerns & Worrisome Data • Alzheimer’s Disease • Cancer • Morbidity & Mortality • Important Consideration  • Anesthetic exposure may influence patient co-morbidities and long-term outcome

  5. 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; doi:10.1016/j.neurobiolaging.2007.02.009

  6. Anesthetic Exposure & Alzhemier’s DiseaseNo Clinical Association? “It is unlikely that multiple exposures to general anesthesia Increase the risk of Alzheimer’s Disease” Bohnen, J Am Geriatr Soc. 1994;42:198-201 (*80% power, alpha = 0.05)

  7. Anesthetic Exposure & CancerPreclinical 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. 2007;106:499-506 • 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. 2006;105:660-4

  8. Anesthetic Exposure & OutcomeAssociation with Morbidity & Mortality 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 < .0001). • Postoperative pneumonia (OR: 2.2; 95%CI, 1.1-4.4; P = .034) • Graft failure (OR, 1.43; 95%CI, 1.16-1.77; P < .001). • Return to surgery (OR, 1.40; 95%CI, 1.20-1.64; P< .001) Singh N,J Vasc Surg. 2006 44:964-8 . “Time under anesthesia was strikingly correlated with reinfarction rates in the entire group” Steen. JAMA 1978; 239:2566-70 Monk, Anesth Analg 2005; 100:4-10

  9. Anesthetic Exposure & OutcomeIncreasing Attention Monk, Anesth Analg 2005; 100:4-10

  10. 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"?”DavisAnesth Analg 2005;100:650-652 • Engage APSF to alert anesthesia professionals to new concerns and to explore clinical options for patient care

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