If your child develops a cough or cold, or is developing fever prior to an elective procedure, make sure to notify their primary care physician. They may be able to initiate treatment possibly decreasing your child's anesthesia risk. An active or recent upper respiratory or other type illness may pose increased risks of breathing and other problems during and after the procedure. This tends to be more frequent in the winter months when children have more of these types of problems, but is nonetheless important year round.
Can my child still have elective surgery? Every situation is unique. You, along with your surgeon and the anesthesiologist need to weigh the risks and benefits of proceeding versus waiting for a respiratory infection to clear.
Most pediatric anesthetics are conducted by Anesthesia Associates of Boise under a “Care Team Model”. This means that there is both an anesthesiologist (physician) and a certified nurse anesthetist (CRNA) involved in your child’s care. You will meet your child’s CRNA during the pre-operative process. One or both of the anesthesia care team members will be with your child in the Operating Room at all times.
General anesthesia is the most common type for children. Unless your child already has an IV in place, this involves inhalation of “sleepy gases” through a mask in the procedure room. Child Life Specialists will frequently help children place a scent in the mask to cover the strange smell of these gases. After your child falls “asleep”, an IV is placed and the airway is protected. If your child has an IV, then the initial anesthetic will be delivered through the IV. This is the process for almost all surgeries or procedures in children, with the exception of a limited few. Your child will remain anesthetized and pain free for the duration of the procedure. Vital signs and depth of anesthesia are monitored throughout the procedure by the anesthesia care team. Upon completion of the procedure, your child will be awakened, and will be transported to the recovery room where the family will reunite.
Regional anesthesia involves making “regions” of the body numb. The injections are placed near nerve bundles and are performed by the anesthesiologist. Regional anesthesia in children is typically used in conjunction with general anesthesia. Regional anesthesia is mainly used to help control post-operative pain (after the surgery). Regional anesthetics can provide hours of post-operative comfort for the child by rendering the site of surgery numb to painful sensation. Regional anesthesia can also help to decrease the amount of IV pain medicines needed to make your child comfortable following surgery. In infants and young children, these regional anesthesia injections are placed after the patients are anesthetized, and after an IV has been started in the operating room.
MAC anesthesia (Monitored Anesthetic Care) involves injection of local anesthetics in the skin around the operative site by the surgeon. IV sedation is administered by the anesthesia care team. Although the child is not so deeply asleep that we need to place an airway, she tends to be sedated to the point that she will remember little-to-none of the operating room. This type of anesthetic is typically reserved for older children undergoing minor procedures.
After waking from anesthesia, your child will be taken by the anesthesia care team to the PACU or “recovery room”. There parents and caregivers can reunite with their children. The most common side effects of surgery and anesthesia that your child may experience are pain and nausea. Treatment of these requires a team approach with parent participation greatly encouraged. You and your child will be presented with an illustrated pain scale which can help determine the degree of your child’s pain. Because parents know their child best, we actively involve them in helping with this. Pain and nausea are treated with medicine and comfort measures, and we will treat both promptly.
Also common to children undergoing anesthesia is emergence delirium (ED) or emergence agitation. This is a brief period (5-15 minutes) immediately following the conclusion of anesthesia. Children are kept comfortable and safe through this episode, treated with pain medicine, and kept protected. This is most common in children 1-7 years of age, and most commonly after ear, nose, and throat procedures (i.e., ear tubes or tonsillectomy). If this type of reaction occurs with your child, it is important to remember that this can be very common, it is impossible to predict, there is no method to prevent it, and that there are otherwise no long-term consequences to your child’s health or well-being.
After about 1 hour, your child will likely be ready for discharge either to home or to an in-patient hospital unit, when they are comfortable and when their vital signs are stable. If you are going home, we would like to see your child drink and/or eat prior to leaving us. Babies can breast or bottle feed when awake and alert.
Having a procedure done in the hospital can be an anxiety-provoking experience for both children and their parents. When pre-operative sedative medicines are not included in the anesthesia plan, we will often allow a parent to join their child to the anesthetizing location. This is done to help prevent anxiety for the procedure, and also helps to prevent separation anxiety from parents or caregivers. The parent who wishes to accompany us will be provided an OR gown and bonnet. You will then be allowed to walk back to the procedure room with us and comfort your child as they breathe “sleepy gas” through a flavor-scented mask. Providing calm words of encouragement and holding hands reassures patients as they drift off to sleep. Remember that children and infants have a keen ability to detect anxiety in their parent, so it is important for the guardian to remain calm and encouraging through the process. Once your child is asleep, you will be escorted out of the anesthetizing location to the waiting area. When the procedure is finished, you will be able to rejoin your child in the pediatric recovery room.
Parental presence for induction of anesthesia is at the discretion of the anesthesia care team and may not be provided under certain circumstances. Some of these include:
- Older kids who tolerate a pre-operative IV
- Young babies and premature infants
- Previously sedated children
- Emergencies and very ill children
- MRI procedures
It is important to remember that the primary concern of the anesthesia care team is your child’s safety. If we feel that a guardian’s presence may interfere with our safe delivery of anesthesia, we will ask you to give “hugs and kisses” in the POHA and will proceed without parental presence. Additionally, if your child’s medical condition changes in the anesthetizing location or a parent became an obstruction to the safe delivery of anesthesia, we reserve the right to show you to the waiting room.
It is completely normal for you or your child to feel anxiety in the days leading up to a surgery or imaging procedure. Parents and caregivers are invaluable in helping in the preparation of their child by letting them know that it’s okay to be nervous, and by explaining what to expect on procedure day. In describing some of the events that will take place, try to avoid terms like “cutting” and “being put out” as these can carry negative connotations to children. Phrases like “fix your arm” and “take a nap” are less likely to promote anxiety. It may be helpful to bring your child’s favorite small toy to the hospital (i.e., stuffed animal, pacifier, etc.), as this may help comfort your child in a strange place.
Concern has been raised about the potential adverse effects of anesthetics and sedatives on the developing infant brain. A recent FDA warning suggested that repeated or lengthy use of general anesthetics and sedative drugs during surgeries or procedures in children younger than 3 years of age may be associated with an increased incidence of learning and behavior disabilities later in life. The FDA also reported that single relatively short anesthetic and sedative exposures are unlikely to have adverse effects. Based on inconsistent results and difficulty applying animal to human studies, no firm conclusions can be drawn at this time. What we can say is that many anesthetics are safely carried out on children in the U.S. each year for surgeries and procedures which, if not performed, carry inherent risk to the child. It is reassuring that the most recent well-designed large-scale studies do not demonstrate an increased risk of cognitive impairment in infants exposed to general anesthesia. There is also no evidence to support a long term cognitive benefit of one type of anesthetic over another.
In light of the current lack of conclusive data, the Anesthesia Associates of Boise care team continues to provide services to infants and toddlers for those maladies that are felt by the patient’s care providers to carry risk to the child if left untreated. It is also our policy to limit the frequency and duration of anesthetic exposure children to the best of our abilities.
For patients and parents with questions, www.smarttots.org, a collaborative effort between the International Anesthesia Research Society and the FDA, is an informative website.