General anesthesia adds to the cognitive sequelae of childhood cancer

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The impact of the total number of administrations and the cumulative dosage of anesthetics and sedatives on the developing brain is not a new topic for readers of The Journal (J Pediatr 2019;204:285–90). In this volume, Jacola et al report the effects of anesthesia exposure in 111 children with medulloblastoma from a retrospective, secondary analysis of patients at St. Jude Children’s Research Hospital enrolled on a multisite clinical trial (https://clinicaltrials.gov/ct2/show/NCT00085202). The children were all treated with surgical resection of tumor, followed by radiotherapy and chemotherapy. This patient population is already well known to be vulnerable to adverse long-term neurocognitive outcomes resulting from these therapies as well as underlying young age and a developing brain. Over 12 months these children were exposed to general anesthesia an average of 19 times for an average cumulative 21 hours. At 3 years after diagnosis, anesthesia exposure significantly and negatively affected intelligence, attention, working memory, processing speed, and reading, independent of other aforementioned risk factors.

The negative effect of general anesthesia on intellectual dysfunction has previously been given little consideration in these children. Yet, anesthesia is deployed over and over again for myriad procedures, such as lumbar puncture, bone marrow sampling, and placement of central venous catheter; administration of daily radiotherapy in younger children; and years of surveillance imaging with MRI or CT. These experiences are not unique to children with medulloblastoma and brain tumors, but rather routine to other children with cancer and even some with other complex or chronic diseases. Although this study was retrospective and limited to only those anesthesia exposures in the first 12 months following medulloblastoma diagnosis, the results should be concerning to all children with complex disease, their families, and their providers. Have we gone too far in the omnipresence of anesthesia to streamline or even escalate the care of children with complex disease, or to spare them any physical pain or psychological trauma? Prospective collection of anesthesia exposure in childhood illnesses is certainly warranted, as the authors suggest, but such an effort will take many years. Perhaps here and now we should reconsider how many procedures are truly required and management-altering in pediatric patients, minimize those procedures, and ask when is anesthesia truly a must.

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