Does my child need general anesthesia?
Does my child need general anesthesia?
Usually, yes. Here’s why.
Children are not small adults:
Encounters in a health-care setting can be stressful for even the most informed patients. Children may be especially overwhelmed because of their age, cognitive and emotional development, and inexperience. Their understanding of a condition or treatment is often limited, and they may feel anxiety from several sources: an unfamiliar environment, evaluation or procedure, separation from parents, and loss of control. Children may be unable to verbalize their concerns and instead revert to behavioral changes to express objection, apprehension, and helplessness.
One of the foremost differences between pediatric and adult patients is observed in the procedural setting. The ability to follow directions, tolerate discomfort, and remain immobile is often necessary to perform a procedure safely and efficiently. Understandably, this behavior may be unrealistic for many children.
Sedation is used frequently to facilitate a variety of procedures throughout the hospital. It is administered to ease anxiety, minimize physical discomfort and control behavior. Many variables influence how much sedation a patient requires including the type of procedure, anticipated discomfort and need for cooperation or absence of movement; in addition to these, a patient’s age is one of the most important considerations.
Sedation and general anesthesia:
The American Society of Anesthesiologists defines sedation and analgesia (pain relief) as a continuum of states ranging from minimal sedation through general anesthesia. The depth of sedation is defined by a patient’s response to a stimulus – verbal, tactile, or painful. At any level of sedation other than general anesthesia, a patient must demonstrate a purposeful response.
Gross, JB et al., 2002. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 1004-17.
In the operating room, most surgical procedures in children and many in adults are performed under general anesthesia because a patient must be unconscious and immobile for maximum comfort and safety. Other factors related to a procedure such as the surgical site, technique, exposure, or duration of an operation may be unsafe or intolerable for any patient using a different anesthetic technique.
Outside of the operating room, most painful procedures in children, or painless ones requiring immobility, are tolerated best by a patient who is generally unresponsive. Examples of these procedures include MRI, central line placement and lumbar puncture among others. Children are unlikely to cooperate with any lesser degree of sedation and may interfere with a procedure or compromise safety. For this reason, sedation in children is often an all-or-nothing experience.
It’s not the same for everyone:
Common features of patients under general anesthesia are unconsciousness, amnesia, and lack of purposeful movement. However, general anesthesia is not necessarily administered the same way to every patient.
For instance, medications may be given to breathe or injected through an intravenous line. Patients may breathe on their own or with assistance using a mask or breathing tube, but one is not required to be completely anesthetized. The topic of airway management in anesthesia is critically important and depends on several factors. The anesthesiologist will choose the technique that is most appropriate for a given patient and procedure.
Consider the examples below of pediatric patients undergoing common procedures under general anesthesia.They do not all “look” the same.
1. A two-year-old child with recurrent ear infections undergoes myringotomy and placement of pressure equalization tubes:
Anesthesia is induced and maintained with inhaled anesthetic by mask
No intravenous access is placed
The patient breathes spontaneously through the mask with a natural airway
2. A five-year-old child with abdominal pain and vomiting undergoes laparoscopic appendectomy:
An intravenous line is placed in the emergency department
Anesthesia is induced with intravenous medication
A breathing tube is placed in the airway and a ventilator is used to breathe for the patient during the procedure
3. An eight-year-old child with bone pain and abnormal blood counts undergoes MRI, lumbar puncture, and bone marrow biopsy:
Anesthesia is induced with inhaled anesthetic by mask
An intravenous line is placed, and anesthesia is maintained with intravenous medications
The patient breathes spontaneously with a natural airway and oxygen is administered by nasal cannula
Additional options:
With certain exceptions, children receive general anesthesia for surgery. This anesthetic choice is usually more practical and comfortable for patients and provides optimal conditions for surgeons. However, regional anesthetic techniques including spinal, epidural, and peripheral nerve block are frequently used in addition to general anesthesia for pediatric patients.
The practice of regional anesthesia is widely employed in children to relieve post-operative pain and reduce the need for opioid medication during and after surgery. These methods prevent pain signals from reaching the spinal cord and brain, and effectively isolate the surgical site from the patient’s central nervous system. The quality and duration of pain relief often improves the immediate recovery from surgery and extends well into the post-operative period.
While regional anesthetic blocks are usually performed awake or with mild sedation in adults and may serve as the primary anesthetic for a procedure, they are usually performed after the induction of general anesthesia in children. This approach has been studied extensively, maintains patient safety, and minimizes complications. Regional anesthesia is infrequently the sole anesthetic technique for procedures in children and not necessarily appropriate for every patient or procedure. However, it is an essential component of pediatric anesthesia practice and provides a clear and immediate benefit to our patients.
Gross, JB et al., 2002. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 1004-17.
Kain ZN, Fortier MA and Mayes LC. Perioperative Behavior Stress in Children. In: Cote, CJ, Lerman J, and Anderson BJ. A Practice of Anesthesia for Infants and Children. 5th ed., Elsevier; 2013. pp 21-29.
Kaplan RF, Cravero JP, Yaster M et al. Sedation for Diagnostic and Therapeutic Procedures Outside the Operating Room. In: Cote, CJ, Lerman J, and Anderson BJ. A Practice of Anesthesia for Infants and Children. 5th ed., Elsevier; 2013. pp 993-1013.
Polaner, DM et al., 2012. Pediatric Regional Anesthesia Network (PRAN) A Multi-Institutional Study of the Use and Incidence of Complications of Pediatric Regional Anesthesia. Anesth Analg, 115(6), pp. 1353-1364.