Pediatric Anesthesia

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Important Skills for a Pediatric Anesthesiologist

There are skills intrinsic to the management of children that must be acquired by residents prior to independent practice. These skills, once they have been learned, will make the difference between the enjoyment and dread of the care of children. I have listed many, but not all of these skills below. Use this list as a take off point for discussion with the attending in the operating room.

1. The ability to do a mask induction on an infant or child – A part of learning this skill set is losing the anxiety, which often attends anesthetizing someone without an IV. Some of learning this skill is dealing with something small. This is not difficult. Place the mask on the face. Use a non-pungent potent agent in oxygen. Keep your fingers on the mandible and out of the airway. When the infant is still, put an oral airway in to prevent obstruction by the tongue. Allow the infant to breathe spontaneously if an IV is being placed. Control ventilation if you are trying to attain sufficient depth of anesthesia to place an endotracheal tube without muscle relaxants. A shoulder role sufficient to place the infant’s airway in the sniffing position can be very helpful. Be gentle. It’s a baby.

2. The ability to establish rapid intravascular access – Look in places where there are veins – the saphenous, the cubital fossa, the dorsum of the hand. Look for the best vein before you poke the kid. Retract the skin before the cannula goes through. Use a small catheter for a small vein.  Go slowly.

3. The ability to assess volume loss in infants – Think about how long it has been since the infant had anything to drink. We say NPO after five am, but in reality it may have been twelve hours or more since the baby had any fluids. When was the last wet diaper? Is the baby perky or somnolent? Are the mucous membranes wet? Remember that potent inhalational agents severely depress the myocardium and this especially reduces cardiac output in dehydrated infants. Be very careful.

4. The ability to talk to parents – Try to think about what you would feel like if your baby had to go to the operating room and you were putting the baby’s safety in the hands of a complete stranger. Then sit down and calmly talk to the parents about their child and their worries. Play with the baby. Establish rapport. Talk to the parents about your or your attending’s wealth of experience. Be calm.

5. The ability to assess the airway of an infant – All infants have tough airways because of the small mouth, large tongue and large occiput problem. But some have a small chin, a small mouth or a very large tongue. These children can be a real problem if you don’t recognize this until the muscle relaxants are given.  A good rule of thumb is to look up any syndrome that you are unfamiliar with before it becomes a Wednesday Morning Conference.

6. The ability to recognize a sick child – Sick kids look sick. They are listless, somnolent and glassy eyed. They may be mottled or have cold extremities. Their skin will often have a doughy consistency.
   These infants and children respond poorly to the administration of potent anesthetic agents. Extreme caution should be exercised in the conduct of this child’s care. In other words low doses administered slowly. Often these children are dehydrated. It makes sense to assess the need for rehydration in a sick child prior to administering an anesthetic.

7. The ability to manage the pain of surgery in an infant – Infants and children suffer after painful procedures to the same extent as adults. There are many ways to safely control the pain of surgery without added risk. Become familiar with simple blocks that effectively ablate pain after common procedures in children. Discuss the pharmacokinetics and pharmacodynamics of analgesics in infants and older children.

8. The ability to recognize common postoperative problems of infants and children – Laryngospasm, croup and apnea are the three most common life threatening postoperative problems in infants. These can all be predicted with a remarkable degree of certainty by the clinical situation. Laryngospsm rarely occurs in patients with dry airways in which a non-pungent agent has been used. Sevoflurane is very forgiving. In a patient that is somnolent, has a wet airway or has been exposed to Desfluane, the risk of airway obstruction is great after removal of an endotracheal tube.
   Croup is an inflammatory response secondary to a superimposed infectious process or the placement of a large endotracheal tube in a small airway. Croup is tolerated well by children older than three and not at all by infants. This scenario of airway obstruction and respiratory failure can be eliminated by using a small endotracheal tube and leak testing after every intubation in children less than three. Get your attending to demonstrate a leak test if you are uncertain.
   Apnea and/or periodic breathing are uncommon in infants greater than three kgs and fairly common in infants less than 1500 Gms. Be on the look out!

9. The ability to resuscitate a newborn infant in the delivery room – The ability to oxygenate and ventilate the depressed newborn is key to improving survival. In this regard the effective use of the bag-valve-mask can be life saving. It is uncommon for newborn infants to fail to respond to adequate delivery of 100% Oxygen. If this fails consider long-standing acidosis, volume depletion secondary to blood loss, or a central nervous system catastrophe. 

10. The ability to recognize and treat common life threatening problems in newborns – The common life threatening problems in the delivery room include diaphragmatic hernias, severe meconium aspiration, gastroschisis and omphalocoele. Fortunately, with the use of preterm Echo, it is rare for these diagnoses to be made in the delivery room. Because the diagnosis is not in doubt, plans can be made for airway management and other emergent care before the delivery.
    Meconium aspiration represents the end result of stress and hypoxia in a just delivered infant. Aspirated meconium may produce severe airway obstruction and air trapping sometimes leading to respiratory compromise and death. Meconium can be suctioned out of the airway prior to the first breath. This procedure is probably warranted if an infant has had a long hypoxic period or has a large amount of thick meconium in the amniotic fluid. Infants that are vigorous at birth or have thin, non-particulate “pea-soup” meconium do not require direct laryngoscopy before the first breath.

Continued: what do parents need to know?

More about the information that parents should have before their child has a surgical procedure:

Question: Is this facility capable of managing the patient if the unexpected happens?

Largely because of the drive to cut cost, but also because of pressure applied by surgeons and others to do every known case, many facilities are not staffed or equipped to manage infants  and older children that have complex chronic disease. Case in point is the child that has pyloric stenosis. Many small rural medical centers are pressured to take care of these infants without the resources, personnel or equipment, to do so. For most children that are healthy and older than three or four simple surgical procedures can be managed in almost any accredited medical center or ambulatory facility. For the young and the sick, this is not true. Parents have to ask the specific question ” Is this facility prepared to manage my child if there is an untoward event?” Is there a resuscitation plan for children? How many children do you take care of? Be skeptical of the answers if they don’t pass the “sniff”test!

Question: What are the risks of Anesthesia for my child?

After a child is three years old and if the child is healthy the risks of general anesthesia approach those of healthy adults. Over the last twenty years the mortality statistics for anesthetized patients has dropped tremendously. This is because of better training, better technology, and enforcing high standards. So thirty years ago the risk of death for a healthy person was about 1: 100,000 and in 2009 the risks are greater than 1: 2,000,000. Yes we do have a good health system.
For  infants and sick children, the risks are greater, and the statistics will vary with the acuity level of the patient. But this is the issue, the mortality statistics for infants vary with the training and experience of the person that is taking care of them. In my mind, this is not a guarantee of an outcome, but it does suggest that little ones should be taken care of by those that have the specific training to do what needs to be done. Most children’s hospitals and academic medical centers have fellowship trained pediatric anesthesiologists. It makes a difference and if your child is less than two years old or has serious co-morbid conditions, then as a parent you should ask about the training and experience of the people that present themselves to you.

Rae Brown MD

Questions that parents should ask when their children have an operation

The lack of information about what Pediatric Anesthesiologists do and how one defines quality frightens many parents. Moms and Dads often say ” I am more scared about the anesthesia than the surgery.” It is part of my job to explain the risks and benefits and, to the best of my ability, allay some of the anxiety and fear. In this posting, I hope to give some guidance about what parents should want to know before their child goes off with a stranger to the operating room? This may take a couple of postings so put your seat belt on!

1. What experience and training does the practitioner have in the management of infants and children?

Most board certified anesthesiologists have received significant pediatric training during their residencies. After going into practice some develop a niche in managing children; millions of tonsillectomies and hernia repairs are managed by general anesthesiologists safely every year. The overwhelming majority of these practitioners provide high quality and safe care.
Infants, especially newborns, the premature and children with chronic disease require specialized training and should be cared for in centers that have the resources to provide the ancillary support that is required. For these patients, there is a difference in outcomes and parents of these kids should inquire about the training and experience of the person that will be managing the child’s care.

2. Specifically how are Pediatric Anesthesiologists trained?

 Most have five years of graduate training in anesthesiology after medical school including a fellowship in the management of the sickest children. Some have substantially more training – some are board certified in Pediatrics, many have substantial additional training in critical care. Is this necessary? Maybe not, but the more training and experience that a physician has the greater the likelihood that they can ” land this baby in bad weather”, and for some of the sickest infants, the weather is more like landing in a hurricane.

So parents should feel at ease asking about the experience level of the anesthesia practitioner, especially if their child is chronically ill or premature. In the same way that they should investigate the credentials of  a surgeon, parents have a responsibility to ascertain that the person that will manage their most treasured possession meets or exceeds all suitable standards.

More about this in my next posting

Rae

Universal Health Care in the United States

I am a physician and I think that everyone should have the best healthcare that we as a country can provide. I recognize that personal responsibility would have to be a part of the equation – with taxes on sugar, fat, . cigarettes and alcohol. But it is beyond me why we can spend a trillion dollars in Iraq and cannot provide universal healthcare for our citizens. Let’s be clear about this, the United States is the only industrialized country that doesn’t have healthcare for all. In this regard we are the pariahs.

Healthcare is certainly an industry, providing jobs and creating value. When we spend money on medical research or on making people more productive it is an entirely positive thing – the exact opposite of the military industrial complex. When we teach people to be nurse and doctors and technicians, we are creating stable employment opportunities within our economy. As we try to turn the United States from a boom and bust economy to one with steady stable growth, we could do worse than expand the healthcare industry, in a controlled fashion so that every child, every working person and every elderly person could get the same physical and mental health support that is availed of our congressmen and women.

I think that every physician in the United States probably has ten ideas to make healthcare more effective and efficient, reducing costs so that more care could be provided to those that have little or none now. I also know that providing this care will ultimately mean that I will pay more to the government, and I am fine with this. You see, I take care of people every day that wait until a disease process is virtually untreatable to come to the attention of the healthcare system. Many times this is because of the costs involved and the lack of a stable , affordable insurance product for those that are involved in self employment and small business. These are not welfare cheats…these are the working middle class. That everyone else in the industrialized world has recognized this and that we haven’t  makes me sick and it is time for all of us to step up and think about the common good.

Rae Brown, MD

Pyloric Stenosis

They talk about the stroke belt, an area in the southeastern United States where many develop hypertension and diabetes. This is thought to be because of the historically large amount of cholesterol containing fried foods. Well, we live in a pyloric stenosis belt and I don’t think it is because of what babies eat.

Pyloric stenosis represents hypertrophy of a muscular band at the outlet of the stomach. These patients, usually boys, begin to vomit during their first two months of life. Because of the obstruction to outflow from the stomach, these babies become dehydrated and develop a metabolic alkalosis. Most are diagnosed within the first week after they begin to vomit. This reduces the amount of dehydration, but the infants inevitably need substantial IV fluids before coming to the hospital.

The surgical treatment of patients with pyloric stenosis is straight forward. the anesthetic management is not. Infants still die in the United States because of attempts to manage cases in medical centers that have little to no experience with newborns. This is usually because a surgeon feels that they can take care of a child but doesn’t consider the other health care professionals involved in the babies management. This case should only be done in centers that have substantial experience with babies and especially anesthesiologists that take care of infants as a regular part of their practice.

I have written several things on the Infant with Pyloric Stenosis. You can find them at Wildcat Anesthesia.com in the Pediatric Anesthesia Subsection.

Rae Brown, MD

Talking to Parents

I have said this many times, but I think it is worth repeating. Sit down when you go to talk to parents. Take your time and get to know them and their child – your patient. It reduces their anxiety and when that happens the child’s anxieties may be diminished. Parents also respond well to clinicians that can engage children. I find that the best way to do that is to sit at eye level with the child and talk to them in a soft voice. It really doesn’t matter what you say – hence my questions to three year olds about their explanations of complex economic concepts…like credit default swaps. In my mind the three year olds give more intelligent answers than the pundits.
Rae Brown, MD

Mediastinal Masses

Sanjay,
Thanks for looking at the Blog. I hope that you will encourage your friends to post questions and topics that they might be interested in talking about.
Your suggestion that muscle relaxants are not used comes from the experience that decompensation often occurs when patients are paralyzed. The reason is likely multifactorial, but an increase in the mean intrathoracic pressure associated with positive pressure ventilation discourages the return of intravascular volume to the right side of the heart. In the scenario of a large mass that may encapsulate the pericardium, the patient’s ability to maintain cardiac output is limited. In addition, the dynamic forces that maintain a patent airway in the spontaneously ventilating patient are eliminated in a patient that is paralyzed, sometimes producing significant intrathoracic airway obstruction.
Given these issues, what do we need to know about these patients before we put them to sleep?