Pediatric Anesthesiology

The pediatric anesthesia team cares for newborns, infants, and children undergoing surgery. We reduce post-operative pain with various types of anesthesia and patient-controlled analgesia. Parents are encouraged to be with their children as much as possible before and after surgery.

Can you do anything to help my child feel less anxious on the day of surgery?

Children are often very anxious about having surgery and being separated from their parents, and have not developed the cognitive ability that adults have to "understand" why things have to be done. To help minimize anxiety and unpleasant memories many anesthesiologists will give the child a "pre-medication" 15 to 30 minutes before being separated from their parents. This is usually a liquid form of a short acting medication very similar to Valium. In addition to calming the patient and relieving anxiety, it clouds the memories of going to the operating room. Once in the operating room, most children are put to sleep by allowing them to breath a mixture of oxygen and anesthetic gas via a mask. This allows the anesthesiologist to wait until the patient is completely asleep to start the intravenous catheter (IV), ensuring that the child will not have the unpleasant experience of being stuck with a needle while awake. Make sure you take the opportunity to talk to the staff anesthesiologist that will be caring for your child before your child goes to the OR. They will be happy to discuss the details of their treatment plan for your child and answer any questions you might have.

How do you know how much anesthesia to give my child?

Most medications and fluids are administered according to the child's weight, and this is the principal reason for asking you to note the child's weight before surgery. In addition to weight, we monitor vital signs such as blood pressure, heart rate, and urine output to assess when an appropriate level of anesthesia has been reached.

How safe is anesthesia for pediatrics compared to the adult population?

Anesthesia for pediatrics is extremely safe thanks in large part to improvements in monitoring devices and advances in drug design. The single greatest improvement in monitoring came with the advent of the pulse oximeter. This device measures the percent of oxygen carrying capacity in a child's blood that is being used for carrying oxygen. A pulse oximeter reading of 98% means that the child's blood is carrying 98% of the oxygen it is capable of carrying. Any number over 92% or so is considered good. The reason this monitor contributed so to patient safety is because as long as oxygen is delivered to the lungs and taken up into the blood stream, then vital organ are getting what they need to continue functioning.

Drug design advances as well as an improvement of our understanding of what makes one anesthetic safer than another have resulted in new inhalational agents that are safer than those previously available, even in high doses. For example, most children are anesthetized by an inhalational technique, where the child is asked to breath a mixture of gases containing enriched oxygen and an anesthetic agent called Sevoflurane. Sevoflurane is pleasant smelling (non-pungent) and works very quickly so that the child is unconscious within less than a minute. At the conclusion of the anesthetic, once the sevoflurane has been turned off, the child emerges from anesthesia quickly.

At Penn State Milton S. Hershey Medical Center, we're fortunate enough to have a team of specially trained pediatric anesthesiologists who, in addition to their anesthesiology residency, have all done additional training (called a Fellowship) in providing anesthesia care for infants and children. In tandem with our similarly excellent pediatric surgeons, children receive the highest level of surgical care at our institution.

What are the risks of anesthesia?

A natural concern of any parent or guardian whose child is having an operation is whether the anesthesia will cause any harm. Even though anesthesia today is much safer than it has ever been, all anesthesia has an element of risk. In fact, sometimes it is difficult to separate the risks of anesthesia from the risks of the operation itself. Anesthesia aims to take away the pain and discomfort of surgery and make it easier for a procedure to be accomplished optimally, and these benefits must be weighed against the risks of anesthesia itself.

The specific risks of anesthesia will vary with the type of operation and whether it is an emergency, the age of the child, and any other problems or illnesses that exist. Also, each type of anesthetic has a specific set of risks and side effects associated with it. The anesthesiologist will talk to you about the various types of anesthesia that may be used for your child, and the risks and benefits (advantages and disadvantages) of each.

 

What are the risks of anesthesia?

A natural concern of any parent or guardian whose child is having an operation is whether the anesthesia will cause any harm. Even though anesthesia today is much safer than it has ever been, all anesthesia has an element of risk. In fact, sometimes it is difficult to separate the risks of anesthesia from the risks of the operation itself. Anesthesia aims to take away the pain and discomfort of surgery and make it easier for a procedure to be accomplished optimally, and these benefits must be weighed against the risks of anesthesia itself.

The specific risks of anesthesia will vary with the type of operation and whether it is an emergency, the age of the child, and any other problems or illnesses that exist. Also, each type of anesthetic has a specific set of risks and side effects associated with it. The anesthesiologist will talk to you about the various types of anesthesia that may be used for your child, and the risks and benefits (advantages and disadvantages) of each.

How long does the sedation last? Will my child need to stay in the hospital once the procedure is complete? When can she resume her normal activity?

Depending on the sedative medication used and the child's response, some children may be awake at the end of the procedure and ready to go home soon thereafter once specific discharge criteria are met. Children, however, exhibit varied responses to sedatives. Therefore, it is often hard to predict how sedated or sleepy the child will remain after the procedure. Some children may continue to need monitoring and observation in the recovery room until they are awake. Most children, however, are able to resume their normal activity within a few hours after the procedure.

Is it usual for children to experience anxiety prior to surgery? How can I tell if my child is anxious?

It is not unusual for a child or parent to be anxious prior to surgery. In particular, children who may be at greatest risk for being anxious include those children with a "shy and inhibited" personality, children with a history of previous surgeries and hospitalizations, children of separated parents, and children of very anxious parents. Children may show signs of anxiety in the surgical pre-operative area in various ways such as not talking or fearing separation

How can we reduce the anxiety my child is experiencing about her upcoming surgery?

Preparing your child for surgery should begin in the surgeon's office when you and your child hopefully develop a trust and bond with the surgeon performing the procedure. Many surgeons have pamphlets in their office for you to read and even videos to watch which will inform you about the procedure.

Some hospitals offer operating room tours and instruction on coping skills by a Child Life Specialist prior to surgery. For example, a child life specialist may allow your child to play with a scented facemask and give instructions on how to breathe with it. If time allows and the child shows an interest, other medical tools such as stethoscopes and IV catheters may be shown to the children so that they may be allowed to examine, touch, and play with these items. By becoming familiar with these items, the entire process tends to be less frightening. This and other forms of age-appropriate play therapy greatly aid the process of undergoing surgery.

Your child's anesthesiologist will try to allay these fears by reassuring the child and/or giving the child a sedative medication either through their iv or to drink. Talk to your child's anesthesiologist to determine the best way to help alleviate any associated anxiety that may be present. Bringing a familiar item from home such as a stuffed toy, blanket, or game may be comforting, distracting, and help the process.

Parents can help their child be ready for surgery by being ready themselves. Don't be afraid to discuss any questions or concerns that you have ahead of time with your surgeon and anesthesiologist. If you are anxious, discuss it with your child's doctors, preferably without the presence of your child. When you are comfortable and confident, your child will likely be also. Be careful not to apologize to your child for the decision to undergo surgery or give an excessive amount of reassurance. Instead, be matter of fact about the surgery; this will diminish worry and fear.

Do children of different ages have different coping skills when faced with surgery? How can I decide what kind of explanation my child needs before her surgery?

Children of all ages need to be reassured that someone will be with them at all times. In addition, careful choice of words is important; for example, let your child know that medicine will be given immediately if they feel "sore" after surgery, not that they may have "pain." Similarly, when explaining the surgery, use the phrase "make an opening" instead of "cut." Encourage your child to ask any questions they may have at any time prior to the procedure. If necessary, write them down so they can be answered later.

Adolescents are capable of understanding things in a manner similar to adults. What will happen to them should be explained in detail, both openly and honestly. Adolescents frequently are worried about sophisticated concepts such as body disfigurement, pain, needles, diagnosis, prognosis, and even death. Often they will have such questions without telling anyone and try to hide their fears. It is important to anticipate your adolescent's questions by discussing the surgery prior to meeting with the surgeon and anesthesiologist; you may want to write questions down so that your adolescent's concerns can be answered despite a reluctance to pose the questions in person.

Similarly, elementary school children require an upfront and honest explanation, at a level that is appropriate to their age level. In a direct but simpler way they need to be told that although they will be separated for a while, but they will be reunited when he/she wakes up from sleep. Reassure your child that nothing bad will happen from the surgery and that it needs to be done to fix a problem that won't go away by itself. Let your child guide the discussion by asking what concerns he or she may have, and try to answer them directly.

Young children ages 3-7 are more limited in their capacity to understand but make sure to tell them they will be separated only a short while from you, they will be OK, and someone will be with them to make sure they will be fine. Use age appropriate language (e.g. "booboos" and "band-aids"). As mentioned earlier, instructions on using the facemask and sedation with an anxiety relieving medicine are helpful at this age. Some parents have tried to hide from their young child the fact that they are going to have surgery. This is not a good idea because it fosters distrust and fear later on and serves to increase worries about medical procedures over time.

My child has a cold. Should his/her surgery be cancelled?

In the past, children with colds had their anesthesia and surgery cancelled until they felt better. This practice was based on concerns that the anesthetic made the cold worse and increased the risk of complications during surgery. Nowadays, we know much more about the effects of anesthesia on colds such that cancellation of surgery for children with colds is much less common.

An important role of the anesthesiologist is to ensure that your child breathes freely when asleep for surgery. This is more of a challenge when a child has a cold because they may have a lot of secretions and their air passages may be more sensitive. Sometimes this can result in coughing and spasm of the airways. Although these events, if they occur, are typically mild and easily treated, they can be troublesome.

The decision to cancel surgery for the child with a cold is based on a number of factors. Typically, children whose cold is limited to the nose and upper parts of the throat, whose secretions are clear, who do not have a fever, and who do not feel sleepy or lethargic can be safely anesthetized. Children who look sick, who have a fever (over 100°F) and have yellow or green secretions probably should have their surgery cancelled. Other factors may also be important including the urgency of the surgery. These decisions should be made in consultation with your anesthesiologist and surgeon who can determine whether cancellation of surgery is necessary.

My child's surgery was cancelled because of a cold. How long should I wait to reschedule surgery?

Research has shown that children with colds may have sensitive air passages for several weeks after the symptoms have gone. Because a child with sensitive air passages is more likely to have complications during surgery, it is usually good practice to wait several weeks until the airways have had a chance to fully recover. The length of time that you should wait before rescheduling surgery varies but should be decided in consultation with your anesthesiologist and surgeon. Since your child's surgery was canceled, it is probably because his or her symptoms were severe enough to be worrisome. In these cases the recommended wait time is 4 or more weeks. This should allow the air passages sufficient time to recover. If your child was diagnosed with a bacterial infection of the lungs or airways, he/she should receive antibiotics and surgery postponed for at least 4 weeks.

Will the fact that my child has a cold increase the risk of problems during and after surgery?

Research has shown that children with colds have slightly more complications during anesthesia than children who are healthy. Because children with colds have more secretions and may have more sensitive airways, they are more susceptible to the effects of the anesthetic gas and to the anesthesiologist's contact with their air passages. This can cause coughing, spasm of the airways, and a lowering of oxygen in the blood. It is important to note, however, that these complications are typically mild and can be easily anticipated, recognized, and treated.

Studies of children with colds who require surgery have identified a number of factors that may increase the chance of complications. These include: a history of asthma, children who require a breathing tube for their surgery, children who have a lot of secretions or nasal congestion, surgery that involves the airways (e.g., tonsillectomy), exposure to tobacco smoke, a history of snoring, history of prematurity, and the type of anesthetic gas or drugs used. Although there are rare cases of children with colds who developed pneumonia after anesthesia and surgery, there has been no proof to suggest that the anesthetic was the direct cause. Indeed, studies show that anesthesia does not appear to prolong the cold or make it worse in most children.

Because my child has a cold, will his/her regular anesthetic care be changed in any way?

Regardless of whether your child has a cold or not, he/she will receive the best possible monitoring and care. Children with colds tend to have more secretions and may have more sensitive air passages. Because of this, your child's care may be modified slightly but will still employ standard techniques. Firstly, it will be important to remove as much of the secretions as possible. This can be done by careful suctioning of the nose and air passages and in some cases a drug may be given to dry up the secretions. Also, it will be important to give your child fluids through an IV (catheter in the arm) to prevent their secretions from becoming too thick. As per standard practice, your child will also be monitored continuously to measure the oxygen levels in their blood. If your child requires a breathing tube during surgery, then the anesthesiologist might choose one that limits contact with the sensitive parts of the airway. Sometimes too, the anesthesiologist will select an anesthetic gas or drug that will avoid or reduce irritation of the air passages. Despite all best efforts, complications can and sometimes do occur. It should be noted however that should this happen, anesthesiologists have at their disposal, a host of drugs and techniques available that can simply and effectively treat any problem.

Does my child have to fast before surgery?

Yes.

Why is fasting necessary before surgery?

When patients receive anesthesia for surgery, they become very relaxed and sleepy. When patients are this sleepy, the muscles of the stomach and throat which normally stop food from coming up into the throat, and then going down into the windpipe or trachea, and then into the lungs, are also relaxed. When patients get food or liquid into their lungs from the stomach, this can cause pneumonia or even death. To minimize the risk of this happening, patients are asked not to eat or drink for a certain length of time before surgery. If the stomach is therefore empty, the risk of anything coming up from the stomach and getting into the lungs is extremely low. Anesthesia is therefore much safer.

How long does my child have to fast before surgery?

Food and milk empty from the stomach much slower than clear liquids. To make sure the stomach is as empty as possible by the time anesthesia is started, patients must be fasting longer from food or milk than from clear liquids. You should always check with your doctor to see what they recommend Frequently used recommended fasting times for different types of food and liquids are as follows:

Type of food or liquid
Fasting time before surgery
Fatty or fried food
8 hours
Light meal, milk
6 hours
Breast milk (infants)
4 hours
Clear liquids
2 hours

 

What type of liquids are CLEAR LIQUIDS?

Clear liquids are any type of liquids that, when poured into a clear glass, would allow you to see through them. Some examples are water, electrolyte solutions, apple juice, and carbonated soft drinks or pop. Any liquid that you cannot see through, such as orange juice or milk, empties from the stomach slower, and should be treated as a "light meal" in terms of fasting.

Should my child take his or her medications before surgery?

This is a question you should ask your anesthesiologist ahead of time, because some medications should be continued right up to immediately before surgery, and others may be stopped the day of surgery. In general, medications taken with a sip of water before surgery do not make the stomach "full", and therefore do not increase the risk of anesthesia.

What if the surgery is an emergency?

Emergency surgery cannot be planned ahead of time. When the decision is made that surgery is necessary, the patient will not be allowed to eat or drink before surgery. An intravenous may be started, which will allow the patient to receive fluid through a vein. If the patient's stomach is not considered to be empty but surgery cannot wait, the anesthesiologist will take special precautions to reduce the risk of any stomach contents getting into the patient's lungs. These precautions are very effective.

What are the chances that my child may need a blood transfusion during surgery?

The likelihood of needing a blood transfusion is very small, if your child is otherwise healthy and it is a simple operation. The chances increase if your child is severely anemic or having complex surgery, such as heart surgery. Most surgeries performed in children result in very little blood loss. However, your child may receive a balanced salt solution also known as "crystalloid" through an IV to make up for the lack of drinking prior to the operation and for replacing fluid and minor blood losses during the operation. Crystalloids contain no human or animal tissue.

How would a blood transfusion, if needed, help my child?

A blood transfusion helps to provide enough red blood cells to carry oxygen throughout the body. Without an adequate amount of red blood cells, the body may become starved for oxygen, which if left untreated can have life threatening consequences, such as brain or heart damage. Other components found in blood include coagulation factors, which are needed for clot formation to stop bleeding. It may be necessary to transfuse these coagulation factors during and/or after the operation to help reduce the loss of red blood cells. Lastly, in some cases, colloids, such as 5% albumin, which represent the protein component of blood, may also be used to help increase the blood volume.
 

How soon after my child wakes up can I see them?

Usually, a family member may be with their child shortly after arriving in the pediatric recovery room. We ask that only one family member at a time be present, and that they not come until the pediatric recovery room nurse calls to ask you to come down. Remember, your child may appear upset or confused when first awakening, or may be slow to wake up. This will resolve with time.

Why was my child upset in the recovery room after surgery?

Another area where adults and children are different is in the period immediately after waking up. Some children experience a condition called "emergence delirium". The best analogy we can give is the sensation you get waking up in a hotel room in the middle of the night- for a brief moment you are confused, disoriented, and unsure where you are - it can be a very unsettling experience. A similar thing can happen to children waking up in the recovery area. They find themselves waking up in a strange room, surrounded by strangers, and Mom and Dad are not close by. Although we know from our teenage and adult patients that there is very little, if any, recollection of events in the recovery area, the child can appear very upset. Here at the Hershey Medical Center we have found that the best medicine is bringing a parent to the bedside as soon as the child starts to wake up. Often a familiar face, a soothing voice, and being held in a parents arms is the best medicine. If after trying these conservative measures a child is still upset, we consider the need for additional pain medication or sedation. This not only helps to make the parents an important part of their child's recovery, but also helps to ensure that a child is not over medicated when what is really need is some TLC.

Will any special precautions be needed after my child is sent home?

Depending on the sedative medication used, children may continue to be sleepy and unsteady on their feet for a few hours after the procedure. Therefore, it is recommended that children who are sedated be observed in the car seat during the ride home. Additionally, a responsible adult should stay with the child for a period of 12-24 hours after sedation. Activities that need co-ordination such as swimming, use of playground equipment, climbing, riding a bike, roller blading or skating should be delayed for 12-24 hours or until parents are sure the child is stable on his/her feet.  Under certain circumstances, for example if your baby was premature, we may require him/her to remain in the hospital overnight for observation.

What is MRI?

Magnetic Resonance Imaging or MRI entails obtaining images of the body parts using a powerful magnetic field. It does not involve harmful radiation.

Why might my child need sedation or general anesthesia for MRI scanning?

The MRI scanning is performed in a special room on a special table within a tube. The magnet makes a thumping and a monotonous sound during the scanning. Some patients may also feel really claustrophobic during the procedure if they are awake. Hence, patients may not tolerate the scanning for these reasons. Also, the procedure may take anywhere between 30 minutes to up to 3 hours depending on the body parts to be studied. Any movement on the part of your child may affect the image quality. It is for these reasons that children are referred for administration of sedation or general anesthesia.
 
Is the procedure painful?

No, MRI scanning is not a painful procedure.

Why does my child need to be sedated for her MRI scan? I was told that the procedure is entirely painless.

Procedures such as MRI scans require the child to be completely still to ensure adequate quality of the scans. The scanner is a long tunnel, and during the scan there are loud noises similar to a motorcycle engine. This may present a scary and claustrophobic (closed-in) environment for most young children and even some adults. Scans last for 45 minutes to 2 hours depending on the areas to be scanned. Therefore, many children and even some adults require sedation even though the procedure does not cause any pain. The need for sedation is assessed by nurses and doctors responsible for her care in the MRI scanner based on her age, medical history and experience with past medical procedures. Parents may be asked for important information that will help to determine whether or not the child will need sedation.
 
How will my child be prepared for general anesthesia?

You will be called by the nurse from the MRI area who will explain to you what to expect and also give you instructions regarding fasting for the general anesthesia.

On the day of the procedure, your child will be first seen by a nurse who will complete a check-list. Following this, you and your child will be seen by the anesthesiology team which includes an attending pediatric anesthesiologist along with a resident anesthesiologist or a CRNA (Certified registered nurse anesthetist).  The anesthesia team will perform a detailed history and clinical examination and obtain your permission for anesthesia on a consent form.

How will my child be administered general anesthesia?

Administration of general anesthesia or sedation will be performed in the "induction room". In younger children, anesthesia is usually administered using anesthetic gases via "face mask". This is called ‘gas induction’. Once the child is asleep, an intravenous drip is commenced and anesthesia maintained by either using a gas or using intravenous anesthetic medicines. In some instances the anesthesiologist may insert a "breathing tube" that goes down the throat to help better maintain breathing. However, the tube is removed as the child wakes up. After induction, the child will be moved into the MRI scanner where the anesthetic administration will be continued. Your child will be monitored continuously by our expert pediatric anesthetic team.

In older children, who will tolerate an intravenous line placement, an intravenous anesthetic medicine may be administered for induction instead of a ‘gas induction’. The choice of the technique used is at the discretion of the attending anesthesiologist.

If you decide to be present during induction of anesthesia, you may notice that your child resists the mask, splutters, coughs, makes funny gurgling sound, up rolls eyeballs etc. This is the ‘excitement phase’ of anesthesia and may be seen in most children before they drift off to sleep. Please do not feel distressed when you see that. Also, the anesthesiologist may ask you to step out at anytime during the induction process.

Why can't my child eat or drink before the MRI?

She cannot eat or drink because she is being sedated for the MRI. Sedative medications may cause the muscles of the throat, esophagus and stomach to relax. This may allow food and other stomach contents to come up into the esophagus and throat and these contents may then go into the windpipe and lungs. This can result in severe lung infections that may even require the child to be hospitalized. To minimize this risk, patients should not eat or drink before sedation.
 

What will happen after the scanning procedure is done?

After the scanning, your child will be transferred to the recovery area where a specialized pediatric nurse will monitor your child.

Can I be present during the scanning?

Yes, you can be present with your child during "anesthetic induction" until the child is asleep. We may ask you to leave during the intravenous line placement and during insertion of the ‘breathing tube’ if one is necessary. Once your child is transferred into the scanner, you will be allowed, if you wish, to be present in the scanner room as well as during recovery of your child. There are certain hazards involved if you carry metal objects on your person and the MRI technician will ask you in detail regarding this history.

Can I bring my child’s favorite toy?

Yes, you can bring your child’s favorite toy with you.