+ What is a Pediatric Anesthesiologist?

A Pediatric Anesthesiologist is a physician who has trained in the medical specialty of anesthesiology and who has also received additional training, usually as a fellowship, to develop proficiency in meeting the special needs of pediatric patients. Many aspects of pediatric anesthesia are unique from the adult population and require a skilled pediatric anesthesiologist to insure safe delivery of that care. A residency in anesthesiology includes four years of training after medical school. A fellowship takes an additional year of training after residency. Subspecialty training is usually between six and twelve months.

+ What type of anesthetic will my child receive?

There are three main types of anesthesia: general, regional and IV sedation or MAC (monitored anesthesia care). General anesthesia means that the child will "go to sleep" with medicine through an intravenous (IV) line or by breathing a combination of anesthetic gases through a mask, then remain asleep during the procedure while continuing to breathe through the mask or through a breathing tube in the airway. The child may have breathing controlled by a ventilator during the procedure. Regional anesthesia includes spinal, epidural and caudal blocks, which are injections given near the spinal nerves in the back or tailbone, to "numb" the area undergoing surgery; or peripheral nerve blocks, which are injections given to the nerve closer to the surgical site, to also "numb" the surgical area. These injections will provide anesthesia for surgery, and in children are usually combined with a general anesthetic, as well as provide postoperative pain relief. IV sedation (with or without local anesthetic directly to the surgical site) is usually done for brief or minor procedures, which would be too painful or dangerous to perform without sedation. Small amounts of sedative and/or pain medications are injected through an IV to make the child immobile and unable to recall the procedure.

+ How will my child go to sleep?

Most young children (roughly age 10 or younger) will receive a "mask induction" for general anesthesia. This means that they will breathe a combination of anesthetic gases through a mask until they are asleep. Most children do very well with this. Others may be upset for a short period until they get sleepy. This method allows the child to be asleep before anything painful or stimulating (such as starting an intravenous line) is done. Older children will usually get an IV started before going to sleep, with medicine through the IV used to get them to sleep. They may be offered the option of breathing oxygen and nitrous oxide (laughing gas) while the IV is being placed to decrease any anxiety. Some cases (such as true emergency surgery and some other procedures) and some children with special medical problems require an IV be placed prior to going to sleep. Your anesthesiologist will discuss the plan for your child to allow for the safest anesthetic to be provided.

+ Will I be able to be present while my child goes to sleep?

Most children (especially very young and older children) do very well without a parent being present for the induction of anesthesia. Some children who are extremely anxious may require an oral premedication of an anti-anxiety medication to ease the transition to the operating room. The issue of parental presence during induction of general anesthesia is a topic of considerable discussion among pediatric anesthesiologists. Recent studies have shown no benefit in reducing anxiety in a premedicated child undergoing anesthesia when a parent is present for induction. Reasons for parents not routinely being allowed to be present for induction of anesthesia include patient safety (the induction of anesthesia is a critical time in the anesthetic delivery), concern about possible parental adverse reactions (such as fainting or anxiety which would distract care being given to the child), and possible increased anxiety in the child with an anxious parent. Due to these factors, we at CHKD do not routinely invite parents back in the operating room. At the same time, we do recognize that there are some patients for whom parental presence during induction of anesthesia is beneficial. Thus the decision regarding parental presence must be made by the anesthesiologist, he or she being the individual primarily responsible for the safety of the patient during the process of going to sleep.

+ What are the most common side effects of anesthesia?

Postoperative nausea and vomiting are common side effects and can also be related to certain types of surgical procedures, including tonsillectomy, eye surgery and laparoscopic surgery. Patients who are intubated (have a breathing tube placed for surgery) frequently have a sore throat or hoarse voice for one to two days after surgery. Other possible side effects will be discussed by the anesthesiologist.

+ What are the risks of anesthesia?

As with any procedure, anesthesia is not without risk. However, anesthesia is safer now than it has ever been. This is a due to a number of reasons, including safer medications and better monitoring equipment during anesthesia. Minor complications, including such things as injury to the mouth, sore throat and nausea/vomiting are occasionally seen. The incidence of major complications, including dental injury, major drug reaction, cardiac rhythm disturbances, breathing difficulties and aspiration of stomach contents, is extremely rare, especially in healthy patients. A recent study listed the risk of death from anesthesia for a pediatric patient as 1 in 40,000. This is a 75% decrease in risk over the past 10 years. Your anesthesiologist will discuss specific risks during the preanesthesia visit.

+ How will my child's pain be managed after surgery?

There are a variety of methods which can be used to manage postoperative pain. For procedures that do not require an intravenous (IV) line, oral medication, such as ibuprofen or acetaminophen, can be given. This is usually done for very brief and less painful procedures, such as ear tubes. IV pain medication can be given on an intermittent basis or via a continuous infusion. A PCA (Patient Controlled Analgesia) can be utilized for older children. This device allows the patient to deliver doses of pain medication themselves, as their pain needs dictate. The settings are ordered by the anesthesiologist so that adequate pain control can be obtained but to prevent any overdosing of medication by the patient. Regional blocks, which include peripheral nerve blocks, caudal blocks and epidural analgesia, can be utilized for a variety of surgical procedures and can provide pain relief for anywhere from a few hours to a few days, depending on the method used and the medication utilized.

+ What is a caudal block?

A caudal block is a form of regional anesthesia used for procedures involving the abdomen or lower extremities. It provides for excellent pain relief after surgery for six to eighteen hours, depending on the medication used. After the child is asleep, they are turned onto their side, the area over the tailbone is cleaned with sterile, antiseptic solution and an injection is given into an opening at the base of the tailbone. The child will wake up with the abdomen and legs feeling "numb", but will still be able to move them. The procedure is very safe, with the most common complications (which are very rare) being infection at the injection site, itching (if a narcotic is injected with the block) and a failed block. Other options are available if a caudal block is not desired or the block fails, including local injection at the surgical site and intravenous pain medication.

+ What is an epidural block?

An epidural block is a type of regional anesthesia in which an injection of local anesthetic is given into the epidural space (an area in the spine between the vertebrae and outside the area of the spinal cord and fluid). A small catheter can be inserted into this space to allow for longer term anesthesia and pain management, with local anesthetic and narcotic pain medication infused continuously through the catheter. This type of anesthesia works well for procedures involving the abdomen and lower extremities. It can also be used for thoracic (chest) surgery.

+ What is pectus excavatum and what type of anesthetic is used for this surgery?

Pectus excavatum is a condition involving the anterior chest and sternum (breast bone) in which the area is sunken or curved inward. Patients often experience shortness of breath or chest pains with activity. A procedure for correction of the deformity, which does not involve removing any ribs or breaking the sternum, has been developed by Dr. Donald Nuss, a pediatric general surgeon (now retired) at Children's Hospital of The King's Daughters.

The anesthetic for this procedure is general anesthesia. Some patients will also have a regional anesthetic, which consists of ultrasound guided paravertebral catheters for intraoperative and especially postoperative pain. The catheters are placed after the patient is asleep. They are placed in the midthoracic area and remain in place (with local anesthetic infusing through a pump) for two to three days after surgery to provide postoperative pain relief. The pain management is monitored by the anesthesiologist and surgeon until the catheters are removed, at which time pain control is maintained with oral or intravenous medication. Patients who do not receive the catheters will be placed on pain pumps called PCAs to help with postoperative pain.