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An Appraisal of Treatment Algorithms in Congenital Hand Reconstruction with Regard to Anesthetic Safety and Motor Development
Michael S. Gart, MD1; Joshua M Adkinson, MD2
1Northwestern University, Chicago, IL, 2Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
Introduction: Each year, millions of infants and toddlers require general anesthesia or sedation for surgery. The potential implications of single or multiple administrations of general anesthesia on neurodevelopment have come under increasing scrutiny in light of recent research. Patients with congenital hand differences (CHD) often require one or more surgical treatments under general anesthesia to optimize their upper extremity function. Moreover, certain conditions must be corrected at a young age before the motor development of the affected structures is completed. We therefore set out to determine: (1) Do the current recommended timelines for correction of CHD align with motor development timelines? (2) What is the available evidence to guide discussions with parents regarding the safety of general anesthesia administration in children with CHD? and (3) Are the proposed timelines for surgical correction of CHD safe from an anesthetic risk perspective?
Materials & Methods: A literature review was conducted to identify the following: (1) Patterns and timing of upper extremity motor development in children; (2) Current practice guidelines and timelines for reconstruction of common CHD, including syndactyly, polydactyly, and thumb hypoplasia; and (3) The most recent evidence regarding anesthetic neurotoxicity in animal models and humans. Timelines of motor development and recommended stages of hand reconstruction were compared for congruency and considered in the context of the available anesthetic neurotoxicity evidence.
Results: (1) Current clinical practice guidelines allow for reconstruction of CHD before motor development of the affected hand anatomy, potentially fostering age-appropriate motor skills following reconstruction. (2) Animal models demonstrate neuronal damage and impaired neurocognitive function following administration of common anesthetic medications during early development. However, there is insufficient data to conclusively state whether or not the administration of general anesthesia early in life has an impact on later neurocognitive function in humans. (3) Insufficient evidence exists to support or refute clinical practice with regard to operative timelines and the safety of general anesthesia administration in developing children.
Conclusion: Current clinical practice guidelines for reconstruction of congenital hand differences are appropriate from a developmental standpoint; however, insufficient data exists regarding the potential implications of general anesthesia administration in developing children. While there is no conclusive evidence that the proposed reconstructive timelines for surgical correction of CHD are not safe, each child must be considered individually and a risk-benefit analysis should be a part of preoperative counseling.
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