Exposure to Operative Anesthesia in Childhood and Subsequent Neurobehavioral Diagnoses
A Natural Experiment Using Appendectomy
Anesthesiology
Submitted November 2024 by Dr Eamonn Upperton
Read by 111 Journal Watch subscribers
Overview:
This retrospective study looks at the risk of developing a neurobehavioural diagnosis in two parallel groups of children aged between 3 and 15 years:
- Those who underwent appendicectomy
- Those admitted to hospital for a medical condition (pneumonia, cellulitis, and gastroenteritis)
The diagnoses in question were:
- Behavioural disorders (conduct, impulse control, oppositional defiant, attention-deficit hyperactivity disorder)
- Mood or anxiety disorders (depression, anxiety, or bipolar disorder)
The finding was that both groups showed an increased risk of being diagnosed with one of these disorders compared with their matched controls; the medical group moreso than the appendicectomy group.
Exposure to anaesthesia occurred in 100% of the appendicectomy group, and only 8% of the medical group. In the absence of an excess in the primary outcome in the group with higher anaesthesia exposure, this study supports the conclusion that a neurobehavioural diagnosis after hospital admission is likely due to factors other than anaesthesia.
Study design:
Medicaid data from across the United States of America was extracted to include patients between age 3 to 15, between 2001 to 2013. ICD codes were used to determine the diagnoses of interest.
The groups were:
- 134,388 healthy children who underwent appendicectomy; matched with healthy controls 1:5 (671,940 controls)
- 154,887 healthy children admitted for pneumonia, cellulitis or gastroenteritis; matched with healthy controls 1:5 (774,435 controls)
Each cohort was analysed for the primary outcome compared with its matched controls.
Interpretation:
This is a data-driven study, where some of its limitations are partially overcome by the sheer number of participants. This helps it achieve its impressive P values, which indicates that the appendicectomy and medical groups are likely to be truly different from the matched controls in terms of neurobehavioural diagnoses. While many confounders may give rise to this difference, this paper does not need to exclude these – it only aims to show that the cohorts’ dissimilarity in exposure to anaesthesia is not matched by a dissimilarity in primary outcome.
Interestingly, both appendicectomy and medical groups showed higher rates of dental or ophthalmology care compared with their matched controls. These outcomes were intentionally chosen to have no plausible link to anaesthesia, and the result suggests that some other factor (perhaps a propensity to higher healthcare utilisation) is responsible for the observed increased risk of neurobehavioural diagnosis for both cohorts.
Take-home message:
This study uses an enormous dataset to demonstrate that if anaesthesia exposure does influence neurobehavioural outcomes, its impact is far overshadowed by other factors – such as hospital admission.
