Lancet Correspondence from Weiss M, Becke K, Hansen TG, Engelhardt T.
This letter represents a consensus response study from the Safe Anesthesia For Every Tot (SAFETOTS) initiative which addresses the need for teaching, training, education, supervision, and research into the safe conduct of paediatric anaesthesia.1
The hypothesis of anaesthesia-induced neurotoxic effects in young patients assumes that anaesthetic drugs are correctly administered and the conduct of anaesthesia is always perfect. However, the fact that children suffer from intraoperative cardiac arrest, brain damage, and death due to inappropriate anaesthesia care worldwide is often ignored.
Young children undergoing general anaesthesia regularly suffer from hypotension, hypoglycaemia or hyperglycaemia, hypoxia or hyperoxia, hypocapnia, or hyponatraemia with the latter due to inadequate perioperative fluid treatment. Each of these entities can lead to serious perioperative cerebral damage or even death. These effects are highly likely to be responsible for minor cerebral lesions that are not immediately apparent postoperatively. Years later the consequences are detected using highly sophisticated neurocognitive testing, which are then wrongly attributed to anaesthetic drugs in some but not all human cohort studies.
The latest interim report of the GAS study is to be applauded because it is the first and only prospective randomised controlled clinical trial that indicates that there is no discernible effect on neurocognitive function in very young children undergoing either regional or general (sevoflurane) anaesthesia for inguinal herniorrhaphy. Even though this finding is only a secondary outcome of the study, it is of note that this result is possibly due to the provision of high quality paediatric anaesthesia clinical care in the participating specialised centres. Importantly, this finding is also consistent with present large-scale cohort studies. The GAS study highlights the need to move from preclinical animal studies of anaesthesia-induced neurotoxic effects to defining the safe conduct of perioperative anaesthesia care in very young children. This should include research into pharmacokinetics and pharmacodynamics of frequently used anaesthetic drugs and techniques as well as investing in proper training and education of paediatric anaesthesia care providers. Other non-anaesthesia related factors, such as those intrinsic to the patient as well as socioeconomic and environmental factors (e.g., parental age and education), need recognition and further investigation into patients undergoing prolonged or repeated exposures to general anaesthesia.