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The Practice of Pediatric Anesthesia
IN THIS CHAPTER, WE outline the basis of our collective practice of pediatric anesthesia. These basic principles of practice can be applied regardless of the circumstances; they provide the foundation for safe anesthesia.
Preoperative Evaluation and Management
Parents and Child
Anesthesiologists must assume an active role in the preoperative assessment of children. Ideally, the same anesthesiologist who performs the preoperative evaluation will anesthetize the child. The preoperative evaluation should include a complete review of the birth, medical, surgical and family histories; a review of the medical record; evaluation and review of laboratory, radiologic, and other investigations; and physical examination of every child who is to be anesthetized (see Chapter 4 ). When appropriate, the child should receive preoperative medical therapy to optimize his or her medical conditions (e.g., a child with reactive airway disease) before receiving anesthesia. In addition, the emotional state of the child and family must be considered and appropriate psychological and, if necessary, pharmacologic support provided. The anesthesia team, working in concert with surgical colleagues, nursing, and child-life specialists (e.g., the use of iPad, movies, play therapy, or games) should find appropriate and creative techniques to prepare the child and family for the surgical experience (e.g., using videotapes, booklets, hospital tours, and/or trained paramedical personnel). The marked increase in the number of outpatient surgical procedures has reduced the time available for the anesthesiologist to interact with the family and the child preoperatively. Despite the reduced contact time, these support strategies should continue to be included in the preoperative assessment.
Familiarity with a child's clinical and psychological status as well as the parental concerns is essential to delivering quality anesthesia care. To achieve the very best outcome for each child, it is essential to meet with the child and the parents (or caregiver or legal guardian) together and establish rapport preoperatively. If the family speaks a different language than the anesthesiologist, then a medical interpreter should be sought.
Many developmental issues are related to the hospital experience. For example, toddlers fear separation from their parents, younger children fear mutilation from their surgery, and teenagers fear loss of control, awareness, and pain (see Chapter 3 ). When conducting the preoperative interview, speak directly to the child (who is old enough to understand [usually age 5 years and older]) and explain what anesthesia involves and what will transpire when they enter the operating room in terms that are age appropriate. Children at the age of reason have the same fears as adults but may have greater difficulty articulating them. For example, identify the key elements that distinguish “sleep” from anesthesia medicine from the sleep they experience at home. Explain that even if children undergo anesthesia for hours, they will feel as if they were unconscious for only a few minutes. Children should be reassured that unlike sleep at home, the anesthetic prevents them from feeling anything during surgery, that they will not wake up during the procedure, and that they will awaken after the surgery.
How anesthesia will be induced should be explained to the child in terms that are appropriate for the child's developmental level. For young children, one can describe that he/she will breathe “laughing gas” through a flavored mask, with a flavor that he/she chooses. Older children can be given the option to receive anesthesia either intravenously (IV) with nitrous oxide by mask, topical local anesthesia cream (e.g., eutectic mixture of local anesthetics [EMLA]) or vapocoolant such as Pain Ease (Gebauer Chemicals, Cleveland, OH) to establish IV access painlessly; or if they are afraid of needles, they may choose to receive anesthesia by an inhalational induction. Child-life specialists can be particularly helpful in demonstrating the anesthesia mask and circuit, illustrating that an IV is just a plastic tubing and not a needle and even decorating the mask with stickers and picking flavored scents.
If the parents will be present at induction of anesthesia, it is preferable that they attend a preoperative instructional session during which a typical induction is described along with the child's responses, perhaps complemented by a video of an induction. The parents should be instructed on how they might assuage their child's concerns, and questions from the parents should be answered. It is challenging to expect parents to cope with their child's induction without providing any preoperative instruction and teaching. Specific changes that might be observed in their child during anesthetic induction can be addressed as follows:
- 1.
As your child is anesthetized, his or her eyes may roll up: “You might see your child's eyes roll up and this might be disturbing to you, but this is completely normal and expected; it happens to all of us when we fall asleep; it is just that we are not looking for it.”
- 2.
“As children fall asleep the structures in the neck relax so they may snore or make other noises from their throat; if your child does this, it is completely normal.”
- 3.
“As the anesthetic reaches the brain, the brain sometimes gets excited and causes movements of the arms and legs that are without purpose, or it may cause them to turn their head from side to side. This means the anesthetic is having its effect and even though your child appears to be partly awake, he or she has received enough anesthesia to ensure that he or she does not remember this.”
- 4.
“If your child becomes frightened, we will increase the amount of the anesthesia medicine rapidly and calm your child as quickly as possible.”
- 5.
If anesthesia is induced intravenously, the parents should be informed that their child might suddenly become limp, stop moving and breathing, and appear pale. These are all normal reactions.
At the same time, parents should not be pressured to be present for induction of anesthesia. If the parents are present at induction, it must be clear that they may be asked to leave the operating room if a new or additional risk to the child surfaces during the induction. Parents should be informed that their presence at induction is for their child's benefit and that their presence is a privilege, not a right. Moreover, in some circumstances it may not be in the child's best interest for parents to be present at induction, such as when the health care team could be distracted when everyone's attention should be focused on the child.
A simple explanation of the monitors to be used during anesthesia can be interesting to children and reassuring to parents. For example, the pulse oximeter can be described as a “Band-Aid–like device” that lights up red and measures the oxygen in the bloodstream during anesthesia and recovery. It is very helpful as an early warning indicator of low oxygen levels in the perioperative period. The blood pressure cuff can be characterized as an “arm hugger” or “muscle tester”; and the electrocardiogram leads can be called “little sticky things that let us watch your heart beat but don't hurt at all.” Simple descriptions of the measurements may also be soothing. For example, “We measure the amount of oxygen you (your child) are (is) breathing, we measure the amount of the anesthesia medicines you (your child) are (is) breathing, and we measure the carbon dioxide you (your child) are (is) breathing out to ensure that your (your child's) breathing is just right throughout the anesthesia.” Sometimes asking teenagers if they have studied carbon dioxide in school science class helps them to better understand the monitors and provides reassurance, as well as making it more interesting.
These preemptive discussions are meant to attenuate the parents' anxiety at a time when we need to focus on the child. It is common for parents to decline to be present during induction after hearing these explanations.
To prepare children for recovery from anesthesia, it is useful to describe our strategies to minimize emesis and pain after surgery. In emetogenic surgery and in children who are prone to emesis, prophylactic antiemetic therapy will be administered during anesthesia. If pain is anticipated during recovery, analgesics will be administered during anesthesia either in the form of a regional block and/or parenteral analgesics and supplemented in the recovery room should the child experience further pain. Anesthesiologists can provide valuable assistance in this respect because of their knowledge of the pharmacology of sedative and opioid medications (see Chapter 7 ), as well as their ability to perform neuraxial and peripheral nerve blocks (see Chapter 42, Chapter 43, Chapter 44 ). If special monitoring is required in the operating room or postoperatively, this should be explained and the child assured that the IV catheters, airway devices, and all invasive monitoring devices will be placed after induction of anesthesia to avoid causing discomfort and will be removed as soon as the child's postoperative condition permits. The possible need for postoperative intensive care, including assisted ventilation, should be anticipated and fully discussed with the parents and child (if the child is of an appropriate age) in circumstances that warrant such discussion.
The anesthesiologist who sits down with the family, who speaks slowly and clearly while answering questions, and who is neither distracted nor in a rush to leave, presents a much more sincere and caring impression to both the child and parents than the anesthesiologist who stands tapping his or her toes while interviewing the family, who speaks quickly, and whose body language points toward the door as if he or she is looking to exit the interview as quickly as possible. The detail with which this information is presented will vary from child to child and family to family, as well as with the anesthesiologist's understanding of the needs of the child and family. The anesthetic prescription should not be recited in a cold and technical manner, but rather with communication that addresses the parents' and the child's questions and concerns. This dialogue is frequently afforded too little time, leaving the parents and child insecure and apprehensive, their questions unanswered. Body language is especially important during this preoperative interview. But by the end of the interview, the child and parents should understand that you will be providing the quality of care that ensures the child's safety during anesthesia, thus reducing the child's and parents' anxiety.
The Anesthesiologist
Anesthesiologists must fully understand the proposed surgical, medical, or investigative procedure to facilitate the planning of an appropriate level of monitoring and selection of anesthetic drugs and technique. They must anticipate the needs of the surgeon or proceduralist in terms of positioning the child, the need for or avoidance of muscle relaxants, considerations regarding specific procedures (e.g., the surgeon's need to monitor motor and sensory evoked potentials may influence choices of anesthetic technique), IV fluids and blood products (see Chapters 9 and 12 ), as well as the need to alleviate perioperative anxiety and pain. For complex cases, the anesthesiologist and surgeon should formulate a plan and convey it to the parents and child preoperatively. Any important medical issues that require clarification should be investigated during the preoperative evaluation by consulting appropriate medical consultants as indicated. Consultant recommendations must be carefully reviewed and should reflect the consultant's understanding of the anesthesia process and what you require regarding the child's medical condition to assist you in the delivery of anesthesia (see Chapter 11, Chapter 13, Chapter 16, Chapter 24, Chapter 27, Chapter 28, Chapter 30 ).
All children should fast preoperatively. Infants must receive special consideration; prolonged abstinence may lead to dehydration or hypoglycemia (see Chapters 4 and 9 ). Children may surreptitiously circumvent the preoperative fasting orders, especially if the period of fasting is prolonged or other children in the vicinity have food. One must always be prepared for the possibility of a full stomach and its sequelae. For example, the risk of pulmonary aspiration of gastric contents is increased in some children (e.g., those who ate a meal just before a trauma, those who had previous esophageal surgery, or those with a hiatus hernia). In these children, the anesthetic management should be modified to minimize the risk of regurgitation and aspiration. Preoperative consideration must be given to proper psychological support, appropriate premedication, and the timing of the premedication (see Chapters 3 and 4 ). Psychological support of the child and parents must never be neglected, no matter how calm they might appear. Premedication may be administered on the ward or in the waiting area; however, in children at risk for desaturation or cardiorespiratory compromise, the child may require monitoring and/or close observation. Critically ill children must be accompanied by skilled staff who will ensure continued infusions of vasoactive medications and who are skilled in the management of any emergencies that could arise during transport (see Chapter 39 ). In some, premedication may be omitted because of the critical nature of a child's illness or because a child is especially cooperative.
Informed Consent
The benefits and risks of the anesthetic procedure must be presented in clear, easily understood terms. At the same time, it is important not to present this information in a manner that unduly frightens the child or parents. The details of such a presentation will depend, in part, on the severity of the underlying medical and surgical conditions and how these affect anesthetic management and the planned procedure. Thus, risk can be presented in general terms, such as the following:
- ■
“The risks of anesthesia depend on the health of the child. For example, if a child has a heart, lung, or kidney disorder, or so on, then the risk from anesthesia is increased. In your child's case, these are our concerns” (and then elaborate the particular patient's issues, such as reactive airway disease, apnea of prematurity, etc.). “Knowing these problems ahead of time makes it easier for us and reduces the anesthetic risk for your child because we can modify our anesthetic prescription according to your child's specific needs. However, there is always the possibility of allergic or unusual responses to anesthetic medications that we cannot predict even if your child has had anesthesia before, and that is why we shall carefully observe and monitor your child throughout the anesthetic as I have described.”
We are designing the “anesthetic prescription” specifically for the particular needs of their child, and this notion should be described exactly this way to the parents. We are physicians and not technicians, and just as the pediatrician writes a prescription for antibiotics, anesthesiologists write the treatment prescription for anesthesia and administer it.
If a child is critically ill or has a disease process that is an immediate threat to his or her life, then this must be explained to the family. If a parent asks about the mortality risk, then all one can say is that the mortality related to anesthesia in most advanced countries is very small—less risky than crossing a busy thoroughfare on foot. Statistically, the incidence varies from one in several hundred thousand for healthy children undergoing routine procedures to a much greater rate for those who are critically ill. Nonetheless, the mortality for any specific child cannot be predicted with certainty. Recent concerns regarding possible anesthetic agent–induced neurotoxicity in young children (see Chapter 25 ) have been expressed by parents of young children during the preoperative visit. We should remind parents that the decision to proceed with anesthesia and surgery is a balance of the benefits and risks of both anesthesia and surgery and that the absence of substantive human data that anesthetics cause harm to young children combined with the sensitivity of our monitors to detect untoward events and our experience should allay their concerns.
Operating Room and Monitoring
For the anesthesiologist to successfully carry out a proposed anesthetic plan, the child's medical record must be examined for pertinent information before induction of anesthesia. For children who have already been assessed preoperatively, the record should be reviewed again for new information that may have been added since the initial evaluation. It is most important that the child's identification bracelet is checked, especially if the anesthetizing team is different from the preoperative evaluation team. A “time-out” and checklist for nurses, surgeon, and anesthesiologist to confirm the child's name, the planned surgical procedure, and the site of the surgical procedure (right or left side or bilateral); airway concerns; the need for prophylactic antibiotics; allergies and anaphylaxis; and availability of special equipment and large bore IV access are also reviewed. It is also important to confirm whether antibiotics were administered on the ward or in the ICU to avoid double-dosing of antibiotics. This review constitutes a vital safety net in the operating room ( Fig. 1.1 ). All equipment for induction and maintenance of anesthesia, including suction and all necessary monitoring devices, must be checked by the anesthetic team and operational before induction of anesthesia (see Chapters 4 and 52 ).
Monitoring should be appropriate for the child's clinical condition and the surgical procedure. In every situation, basic monitoring is essential; to this are added special monitoring devices as they become necessary. The basic monitors are the anesthesiologist's eyes, ears, and hands, which confer the ability to observe a child's color and chest movements, to listen for heart tones and breath sounds, and to palpate the arterial pulse and temperature of the skin. A precordial or esophageal stethoscope is a very useful and simple device to monitor heart sounds and the quality of breath sounds, even when our attention is focused away from physiologic monitors. All children, except those undergoing the briefest noninvasive procedures, should have IV access to allow for fluid administration and to provide a route for rapid and predictable drug administration. If IV access is already in place, its patency should be checked preoperatively. The size of the catheter should be confirmed in case a larger cannula is required to administer large volumes of fluid or blood during surgery. If so, the new catheter should be placed after induction of anesthesia. A balanced salt solution is an appropriate fluid to infuse in most children undergoing elective surgery, although glucose-containing solutions may be preferred in specific circumstances (see Chapter 9 ). Continuous monitoring of the electrocardiogram, temperature, inspired oxygen concentration, oxygen saturation, expired carbon dioxide, and serial blood pressure determination are considered routine. Expired carbon dioxide monitors (especially those that display the waveform) and pulse oximetry are extremely important in the early detection of potential anesthetic-related events that, if undetected, could result in serious morbidity or mortality. Identifying the anesthetic agent and monitoring its concentration breath by breath is also helpful but not mandatory. The role of wakefulness-monitoring devices in children remains unestablished, especially in children younger than 2 years of age (see Chapters 7 and 52 ). Near-infrared spectroscopy is being used increasingly during cardiac surgery; it provides a useful monitor of cerebral (i.e., organ) oxygenation. The routine use of noninvasive continuous cardiac output monitors will likely provide the next generation of operating room monitoring (see Chapter 52 ), providing an early warning of evolving adverse hemodynamic events and the response to corrective measures (e.g., the administration of blood, crystalloid, vasopressor, vagolytic).
Invasive hemodynamic monitoring (e.g., direct arterial blood pressure, central venous pressure) may be required for major surgery if extensive blood loss or major fluid shifts are anticipated, or if a child is medically unstable. Urine output provides indirect data of the intravascular volume and organ perfusion in the presence of normal renal function. Monitoring urinary output is particularly useful for prolonged operations, for procedures involving major blood loss, when there is the potential for rapid or massive blood loss, when wide variations in blood pressure and fluid balance can be anticipated, or during induced hypotensive anesthesia. In general, if a particular variable would be monitored in an adult, then the same approach should be adopted for a child.
Invasive monitors are sometimes forsaken in a child because the pediatric anesthesiologist considers that the risk/benefit ratio does not justify their use. However, when the benefits outweigh the risks, these monitors provide an accurate estimate of blood pressure, cardiac output, filling pressures, and cardiac and pulmonary function. In turn, they provide a safe mechanism for assessing the response to pharmacologic interventions, as well as the responses to administration of blood products, fluids, and vasoactive medications (see Chapter 52 ).
A cautionary note: As monitoring has become more sophisticated, anesthesiologists have become more distanced than ever from their patients. Relying totally on monitoring devices to detect clinical abnormalities is dangerous. The focus must always be on the child and the surgical field. Electronic monitors may fail, and if the anesthesiologist focuses too much attention on the monitor in an effort to interpret it, rather than attending directly to the child, the child may suffer. This is the reason a precordial stethoscope is so useful; strong heart sounds in the face of failed monitors provide some degree of assurance that the child is not in severe trouble. The tone of the pulse oximeter should be audible by everyone in the operating room to identify a decreasing oxygen saturation. Silencing the monitor and its alarms for an extended period of time is a serious breach of safety and practice standards. One of the editors is aware of a child for whom all monitor alarms and sounds were disabled during anesthesia who was discovered dead at the conclusion of the procedure after an unrecognized, unintended tracheal extubation. All monitors should be functioning and their alarms audible at all times during anesthesia of infants and children.
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