REVIEW

CURRENT
OPINION Pediatric neuroanesthesia
Anna Clebone

Purpose of review
A series of recent studies have changed the practice of pediatric neuroanesthesia, improving outcomes and
making children’s quality of life better.
Recent findings
Potential long-term neurologic effects in infants and young children undergoing surgery and anesthesia
have been recognized for over a decade. Several recent, well performed studies suggest that hypotension
Downloaded from https://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3ZRPSXgVoeNmk/yYblKMeKnWl7IdMtDYbiTNeMckJeBg= on 08/17/2020

may also be a major contributor to postoperative neurologic impairment in children. Craniosynostosis

surgery has also been the subject of extensive study, both related to decreasing blood loss and to
optimizing postoperative outcomes.
Summary
Although neurosurgical anesthesia research in the pediatric population can be ethically and logistically
complex, resolving questions such as the optimal blood pressure during surgery and best management of
infants undergoing repair of craniosynostosis will improve patient outcomes.
Keywords
craniosynostosis, neonatal intracranial perfusion, NIRS

INTRODUCTION neuroapoptosis occurs, it is not significant enough

The study of pediatric neurosurgical anesthesia is
unique because the brain of the infant and child is
uniquely susceptible to injury, and also exhibits the
capacity for significant recovery. Prolonged episodes
of hypotension can cause ischemic injury, whereas
sustained hypertension can rapidly injure the
cerebral vasculature, causing intraventricular hem-
orrhage and possibly lifelong disability. An intra-
cranial arterio-venous malformation can produce
congestive heart failure in the neonate, possibly
leading to death. The entire skull can be recon-
structed, piece by piece, in toddlers with craniosy-
nostosis, relieving pressure on the brain, allowing
the brain to grow normally, and giving these chil-
dren an outstanding cosmetic result. Procedures
once reserved for adults, such as deep brain stimu-
lation, have been modified and adapted for children
with dystonia, restoring function.
Children also have a remarkable potential for
recovery. Half of the brain can be completely
resected in children with intractable seizures, spar-
ing the healthy part of the brain from years of
hypoxia, and in some cases leaving these children
indistinguishable from their peers. Although potent
volatile anesthetics and N-methyl-D-aspartate
(NMDA) antagonists have been associated with neu-
roapoptosis, some of these studies have recently
been refuted, whereas other studies suggest that if
to impact intellectual outcomes later in life.
Quantity of life has been extended greatly through
these advances, and the focus is now also on improv-
ing quality of life by decreasing pain after cranio-
tomy.
The present study will review the perils and
progress made over the past year in research into
pediatric neuroanesthesia.
NEONATAL INTRACRANIAL PERFUSION
Over the past decade, multiple studies have sug-
gested that potent volatile anesthetics and NMDA
antagonists may cause neuroapoptosis. Although
the choice of anesthetic agents might increase this
possibility [1], maintaining adequate brain per-
fusion by avoiding hypotension during anesthesia
and surgery may be more important to neurologic
outcome. At the same time, abrupt episodes of
Department of Anesthesia and Critical Care, University of Chicago,
Chicago, IL, USA
Correspondence to Anna Clebone, MD, Assistant Professor of Anes-
thesiology and Pediatrics, Case Western Reserve University School of
Medicine, 11100 Euclid Ave, LKS 5007, Cleveland, OH 44106, USA.
Tel: +1 2168443777; e-mail: aclebone@gmail.com
Curr Opin Anesthesiol 2015, 28:494–497
DOI:10.1097/ACO.0000000000000241

www.co-anesthesiology.com Volume 28  Number 5  October 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Cognitive impairment after neonatal anesthesia may be
related more to impaired cerebral perfusion than to the
specific anesthetic agent used.
 Recent studies suggest that a minimum mean blood
pressure of 35 mmHg or within 20% of baseline is
needed to ensure cerebral perfusion in healthy full-
term neonates.
 Prophylactic use of fresh frozen plasma in pediatric
craniosynostosis surgery did not lead to a decrease
in total blood loss, a decreased need for blood
transfusion, or less total time in the hospital or
pediatric ICU.
hypertension may cause rupture of fragile blood
vessels, leading to intracranial hemorrhage [2].
Unlike adult patients, in whom computed tomo-
graphy (CT) or MRI is required to detect hemor-
rhage, intracranial bleeding can be detected in
neonates by ultrasound examination of the fonta-
nelle. This allows noninvasive determination of the
status of the neonatal brain and determination of
the integrity of the intracranial blood vessels [3].
Both intraventricular and cerebellar hemorrhage
can be detected using transfontanelle ultrasound
imaging [4]. This information is critical for both
neonatologists and parents because the degree of
intraventricular hemorrhage is one factor that cor-
relates with later neurodevelopmental outcomes [5].
It is possible to determine if cerebral blood vessels
are ruptured. A potential for cerebral hemorrhage
certainly exists during the perioperative period,
during which significant shifts in blood pressure
can occur.
Although it is important to maintain normal
hemodynamic parameters, the ideal neonatal blood
pressure is unclear. The blood pressure must be
sufficient to maintain cerebral perfusion, yet not
high enough to cause rupture of fragile neonatal
&&
intracranial blood vessels. Rhondali et al. [6 ] pub-
lished one of the first studies of brain perfusion as a
function of blood pressure in 180 healthy infants
who were younger than 6 months of age and under-
going elective procedures. Regional saturation of
oxygen (rSO2c) was measured with near infared
spectometry (NIRS), and cerebral blood flow vel-
ocities (CBFV) were determined using transcranial
Doppler. In healthy full-term neonates undergoing
elective procedures, cerebral blood flow velocity
decreases when the MAP falls below 45 mmHg
&&
[6 ]. Interestingly, rSO2c increases as MAP falls to
35 mmHg, because the oxygen supply is sufficient
&&
to meet cerebral metabolic demand [6 ]. Below
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Pediatric neuroanesthesia Clebone
35 mmHg, CBFV decreases, and rSO2c shows
&&
decreased brain perfusion [6 ]. Michelet et al. [7 ]
&&
reported similar findings in a study of changes in
NIRS in response to variations in blood pressure in a
study of 60 infants undergoing anesthesia and
surgery who were younger than 3 months of age.
These studies suggest that a minimum mean blood
&&
pressure of 35 mmHg (Rhondali et al. [6 ]) or within
&&
20% of baseline (Michelet et al. [7 ]) is needed to
ensure cerebral perfusion in healthy full-term neo-
nates, but the data are not conclusive. Reliably
monitoring NIRS is challenging in unstable infants,
because NIRS values also vary with anemia and
pH status.
Additional topics for future research include the
impact of intraoperative hypotension on long-term
neurocognitive outcomes, similar to the current
studies of outcomes and choice of anesthetic agent.
The ideal intraoperative blood pressure is unknown
for preterm neonates and more research is needed in
this area. Indeed, the rate of meaningful survival
without major disability was 3.4% of infants born at
22 weeks’ gestational age in one large study encom-
passing 24 hospitals [8]. Many preterm infants will
need a surgical procedure during their initial hos-
pital stay. Intracranial vessels are most fragile in
preterm neonates, so additional information in this
subpopulation has the potential to improve neuro-
cognitive outcomes.
CRANIOSYNOSTOSIS
Once a major neurologic and cosmetic deformity, the
premature fusion of skull sutures in the infant can
now be repaired safely and effectively [9], with good
long-term outcomes [10]. Surgical blood loss can be
significant, however, often approaching more than
one blood volume and necessitating transfusion with
accompanying immunologic, infectious, and aller-
genic risks [11]. A recent systematic review found that
of almost 700 studies, only 18 were either random-
ized controlled trials or case-control studies [12].
Despite these studies, however, only recent
studies offer evidence that blood conservation
strategies lead to improved overall outcomes. A
10-year retrospective study at Boston Children’s
Hospital examined cardiorespiratory and hemorrha-
&
gic complications, as well as ICU admission [13 ]. In
this study, it was shown that the use of tranexamic
acid decreases blood loss, as had been shown pre-
viously [14], and also decreases the risk of a signifi-
cant cardiorespiratory or hemorrhagic incident that
would have required ICU admission. Of note, this is
an off-label use of tranexamic acid.
Some principles of damage-control resuscitation
have been applied to pediatric craniosynostosis
www.co-anesthesiology.com 495
Neuroanesthesia
surgery, but the value of fresh frozen plasma (FFP) is
unclear. Pieters et al. [15] studied prophylactic trans-
fusion of clotting factors and suggested the value of
looking ’beyond the numbers’. In a prospective trial
of approximately 80 patients, patients receiving
prophylactic FFP were compared with those given
FFP only if needed. Although the group given pro-
phylactic FFP had better coagulation values, the
clinical outcome was not improved. The prophylac-
tic FFP group did not have a decrease in total blood
loss, need for blood transfusion, or total time in the
hospital or pediatric ICU [15].
The decision as to whether the patient can be
transferred to the postanesthesia care unit and a
regular bed or must receive ICU management is
guided by clinical decisions made during the surgi-
cal procedure. An algorithm created in one study
&
was used to predict postoperative disposition [13 ].
Factors that made patients more likely to be admit-
ted to the ICU included low patient weight (<10 kg),
American Society of Anesthesiologists status (3),
large volume transfusion (>60 ml/kg Packed Red
Blood Cells), any FFP, platelet, or cryoprecipitate
transfusion, or major complications during the
&
surgery [13 ].
The number of craniosynostosis procedures per-
formed annually has almost doubled since 2003
[16], and children with increasingly complex
comorbidities are considered to be reasonable can-
didates for these procedures. For example, patients
with both craniosynostosis and congenital heart
disease may benefit from having the craniosynos-
tosis repair performed first [17]. Venous air embolus,
a potentially fatal complication, is more common in
patients with right to left cardiac shunts. In a surgery
with a potential for large-volume fluid transfusion,
such as craniosynostosis surgery, transesophageal
echocardiography can facilitate detection of venous
air embolus in these patients [17]. Fortunately, the
majority of craniosynostosis repairs are performed at
major teaching hospitals [16], where, presumably,
more resources such as a full service blood bank, an
ICU, and experienced physicians from a variety
of subspecialties are available to optimize care
throughout the perioperative period.
Potential complications of craniosynostosis
surgery extend beyond intraoperative blood loss.
Edema and fluid shifts must also be managed
throughout the perioperative period. Intravenous
steroids are commonly administered and most likely
offer some benefit. In a large meta-analysis of peri-
operative administration of steroids for craniosynos-
tosis surgery, the group receiving steroids had a
decreased total postoperative hospital stay, less
edema, and quicker eye opening; however, the
authors did stress the need for further research in
496 www.co-anesthesiology.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
this area, and rated the level of evidence as only a III
[18]. Fluid shifts may also lead to hypoalbuminemia,
as was the case for all 114 patients in a small retro-
spective study at Oxford Children’s Hospital [19].
Implications of hypoalbuminemia include altered
metabolism of medications. This can be especially
pernicious in the population undergoing craniosy-
nostosis surgery, who may require seizure medicine,
as was the case in the patient that prompted that
study [19].
Perioperative imaging for patients undergoing
craniosynostosis repair includes several CT scans,
often under general anesthesia, which carries the
risk of significant levels of radiation exposure.
Advances in imaging technology limit the total dose
to both child and caretakers. Kaasalainen et al. [20]
evaluated ‘ultra low dose’ protocols for CT scanning,
and found that radiation dose could be decreased by
over 80% in both the newborn and 5-year-old imag-
ing models. This is consistent with the national
‘image lightly’ campaign, which seeks to decrease
the total radiation dose in pediatric patients who
require radiographic studies. This initiative has suc-
ceeded in achieving a statistically significant overall
decrease in radiation dose at the 13 North American
pediatric hospitals in the study [21].
Early detection of craniosynostosis, combined
with an increasing knowledge of associated syn-
dromes and prompt intervention, can make pre-
viously fatal or disabling conditions manageable.
Early detection and timely intervention improve out-
comes in multiple types of craniosynostosis [22].
Several syndromes, including Crouzon, Pfeiffer,
and Apert syndromes, involve craniosynostosis,
and awareness of the associated syndrome improves
management [23] throughout the perioperative
period. One very recent example is a possible associ-
ation of craniosynostosis with Williams syndrome.
Although only a small number of patients have been
studied so far, advanced genetic and imaging tech-
niques show a possible association [24], suggesting a
possible benefit of screening for craniosynostosis in
patients with Williams syndrome.
CONCLUSION
Over the past decade, the potential for long-term
neurologic effects in infants and young children
undergoing surgery and anesthesia have been rec-
ognized. Several well designed studies have begun to
look at the possibility that hypotension may also be
a major contributor to postoperative neurologic
impairment in children. Craniosynostosis surgery,
which offers a significantly improved quality of life,
has also been the subject of extensive study, both
related to decreasing blood loss and to optimizing
Volume 28  Number 5  October 2015

postoperative outcomes. Although neurosurgical
anesthesia research in pediatric patients can be ethi-
cally and logistically complex, the impact and
importance constantly increases, as highlighted in
these studies from 2015.
Acknowledgements
I would like to thank Dr Keith J. Ruskin for his assistance
with this article.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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READING
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& of special interest
&& of outstanding interest
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