[size=20px]You are consulted for an inguinal hernia in a 6 month old former 30 week premature boy in the NICU. He has intermittent periods of being fussy, but has not had incarceration of the hernia. The family expresses concern over general anesthesia and potential effects on neurodevelopmental outcomes. Based on data from prospective trials in humans, when should you suggest the ideal time to repair this hernia would be with regards to neurologic outcomes?

 

A At diagnosis

 

B 6 months

 

C 12 months

 

D 24 months

 

E 36 months[/size]

(Untitled)

 

A

A

correct answer

A At diagnosis

 

In 2015, the FDA announced a ‘black box’ warning with regards to the effects of GA on the developing brain and suggested that efforts should be made to limit (wherever possible) the use within the first three years of life. This warning was made based on pre-clinical animal studies which convincingly demonstrated that EVERY GA agent tested in any class resulted in a pervasive neurodevelopmental change and this was in part based on accelerated apoptosis in various area of the developing brain. Some epidemiologic studies had also suggested an increased incidence of developmental problems in humans who underwent GA and surgery in the first year of life compared to controls, however these studies were not adjusted for the need for surgery – while others noted no difference with one or even multiple episodes of GA. These data resulted in much concern due to the number of GA episodes in the US every year. The GAS (General Anesthesia vs. Spinal) trial and the PANDA study of paired twins found no difference in neurodevelopmental outcome for a brief anesthetic event in the first 36 months of life when specific prospective testing was performed. These patients all had undergone an inguinal hernia repair in these studies, and the conclusion was to not delay an operation that was necessary in this age group. Therefore, in an infant or neonate with a potentially symptomatic inguinal hernia, the recommendation would be to undergo repair at the earliest convenient time point.