国际麻醉学与复苏杂志   2017, Issue (7): 10-10
    
全身麻醉药发育神经毒性的机制及其防治研究进展
张森, 郑吉建1()
1.上海交通大学医学院附属上海儿童医学中心
Developmental neurotoxicity of general anesthesia: underlying mechanisms, prevention, and treatment
 全文:
摘要:

背景 越来越多的动物研究显示全身麻醉药能够导致发育神经元的凋亡,流行病学研究亦表明,患儿在3岁前接受长时间或/和多次全身麻醉发生术后认知功能障碍的风险明显增加;然而,全身麻醉药导致发育神经元毒性的机制尚未阐明,临床上也缺乏有效的防治措施。 目的 通过综述全身麻醉药导致发育神经元毒性的可能机制,探讨可能的防治措施。 内容 全身麻醉药通过不同的分子途经调控发育神经元并能够启动或加速神经元的凋亡。首先,由于发育神经元内Cl-的浓度较高,全身麻醉药激活γ-氨基丁酸A(γ-aminobutyric acid A, GABAA)受体后可促进Cl-由胞内流向胞外,进而导致神经元兴奋性中毒。其次,氯胺酮上调能够渗透钙离子的N-甲基-D天冬氨酸(N-methyl-D-aspanate, NMDA)受体可能会导致钙超载。第三,全身麻醉药抑制前体脑源性神经营养因子(brain derived neurotrophic factor, BDNF)向成熟BDNF(mBDNF)的转化,进而通过P75神经营养因子受体(p75 neurotrophin receptor, p75NTR)通路诱导神经元凋亡。第四,一些全身麻醉药也能够造成活性氧自由基(reactive oxygen species, ROS)的积聚,在钙超载和ROS的共同作用下可导致线粒体功能障碍。全身麻醉药物引起神经网络活动的紊乱也可以导致神经元凋亡和认知功能障碍。越来越多的研究发现靶向相关的离子通道、控制钙超载、减少ROS产物以及减轻神经元凋亡可有效保护全身麻醉药物导致的神经元变性。 趋向 全身麻醉药可通过不同的分子途经导致发育神经元凋亡,将这些分子或分子途经作为潜在的靶标可以对全身麻醉药诱发的功能障碍进行防治。

关键词: 神经毒性; 麻醉,全身; 发育; 凋亡; 防治措施
Abstract:

Background More and more animal studies have demonstrated that general anesthesia can cause apoptosis in developing neurons. Epidemiological studies also demonstrate that long time or repetitive general anesthesia significantly increases the risk of postoperative cognitive dysfunction in young children less than 3 years old. However, the mechanisms of general anesthesia-induced developmental neurotoxicity is still unclear, meanwhile, no effective strategy for prevention and treatment has been found. Objective To explore the potential strategies for prevention and treatment by reviewing the mechanisms underlying developmental neurotoxicity of general anesthetics. Content General anesthetics modulate a variety of molecules in developing neurons and initiate or exacerbate apoptosis. First, as developing neurons contain high concentrations of Cl-, enhancement of γ-aminobutyric acid (GABA) A receptors by general anesthetics strengthens efflux of Cl- upon GABA stimulation, and subsequently leads to excitotoxicity of neurons. Second, upregulation of calcium-permeable N-methyl-D-aspanate(NMDA) receptors by ketamine may result in calcium overload. Third, general anesthetics inhibit the transformation of brain derived neurotrophic factor(BDNF) from prototype to mature one, which may induce apoptosis through p75 neurotrophin receptor(P75NTR) pathway. Fourth, some general anesthetics also cause accumulation of reactive oxygen species(ROS). Together with calcium overload, ROS induces mitochondrial malfunction. The neuronal apoptosis after general anesthesia can be followed by dysfunction of neural network and confer cognitive deficits. Accumulating studies found that targeting related ion channels, controlling calcium overload, reducing ROS production, and attenuating apoptosis can effectively protect neurons from degeneration following general anesthesia. Trend General anesthesia can cause apoptosis in developing neurons by targeting a variety of molecules, and these molecules or processes involving these molecules can be potential targets to prevent and treat general anesthesia-induced malfunctions.

Key words: Neurotoxicity; Anesthesia general; Development; Apoptosis; Prevention and treatment