Is it safe for my child to have anesthesia?
“Is it safe when she’s so small? How do you know how much to give? Do you have her current weight? Is my baby going to be OK?!”
These are questions I’m routinely asked by concerned parents. Most parents tell me that they’re much more nervous about the anesthesia than about the surgery itself. As a parent myself, I totally understand. To willingly surrender control over that which you hold most precious can be a terrifying prospect. I know I speak for my entire specialty and subspecialty when I say we understand and do not take that responsibility lightly. I routinely tell parents that I will care for their children like they were my own child, and even after all these years I still mean it every time I say it.
The question of whether or not anesthesia is safe must also be considered within the context of the proposed procedure. Some procedures are purely elective and can be done at any time. Others have a bit more urgency to them, such as a cleft lip or palate to reduce the likelihood of feeding or speech problems, or perhaps an orchiopexy to help lower an undescended testicle into the scrotum to prevent fertility issues or increased risk of testicular cancer later in life. While these procedures are clearly not emergencies, they are not quite elective either. On the other hand, emergency surgery, such as an appendectomy, or pinning for repair of an elbow fracture, must proceed with minimal delay. For these operations, time is of the essence, and to delay the operation may cause even greater harm. Compared to purely elective procedures, emergency surgery carries an increased risk.
Over the years, a number of scientific and pharmaceutical advancements have increased the safety of anesthesia for children undergoing procedures. As Paterson et al noted, in the 1970’s, breathing problems under anesthesia accounted for the majority of intraoperative issues. With the introduction of equipment to monitor oxygen and carbon dioxide levels intraoperatively, those issues declined by about 50%. Furthermore, when this equipment was used together, Cote et al showed that what breathing problems remained were often unavoidable. Improved monitoring had basically eliminated most, if not all, of the preventable adverse respiratory events.
The second advancement was in the area of anesthetic medications. One of the ways in which taking care of kids is different than adults is we typically use inhalational medicine to drift off to sleep. Some kids (and parents) may prefer this way, rather than starting an IV in an awake child. For many years, there was only one viable inhalational option: halothane. It was sweeter smelling than the other inhalational medications, but it also increased the risk of arrhythmias. With advancements in inhalational anesthesia, the risk of cardiac arrhythmias (aka irregular heartbeats) has been reduced.. This dramatically reduced the number of anesthesia-related cardiac arrests.
Though these advancements clearly had a large, positive impact on reducing perioperative risk for anesthetized children, there was still more work to do. More recently, the focus has shifted to trying to identify and quantify risk factors in the hope that we can make pediatric anesthesia even safer. Much of the data studying risk in pediatric anesthesia comes from retrospective studies from single-center reports and self-reporting databases. While this is clearly an invaluable addition to our understanding, it can sometimes be hard to compare those results and make broad, generalized claims. Not every hospital serves the same patient population. In 2008, Wake Up Safe, a patient safety organization founded by The Society for Pediatric Anesthesia, was created with the goals of defining quality measures in pediatric perioperative care and leveraging their data registry of adverse events to devise strategies to reduce risk. This ongoing database also allows participating departments to compare themselves to national norms and find areas for improvement. To date, 37 children’s hospitals participate, and numerous papers have been published highlighting invaluable topics ranging from wrong-sided surgeries to perioperative pediatric cardiac arrests.
Over the last 50- 60 years, there has been a steady decline in morbidity and mortality for children, especially for infants under a year. Improved monitoring, the introduction of safer anesthetic medications, a deeper understanding of pediatric-specific risk, specialized pediatric anesthesia training, and the consolidation of care at high-volume pediatric centers have all contributed to this decline. The most common adverse event for kids of all ages is still typically a respiratory event, while the risk for cardiac events is higher in neonates and infants. Factors conferring a higher risk include younger age, medical co-morbidities, weakened physical condition, and emergency surgery. Clinical experience and pediatric anesthesiologist specialization were both found to reduce risk. While we have not eliminated all the risks associated with anesthesia and surgery, we are coming closer to a clearer understanding, and are fervently looking for ways to eliminate or further reduce that risk for our littlest patients.
For the vast majority of kids having anesthesia, nothing unexpected will happen. For those rare few that do have a reaction while under anesthesia, we are prepared. The evidence is clear that almost all of them will be fine, though we may need to give them a little more TLC and keep an eye on them for a bit little longer. So, while I know time may slow down for you while we care for your child, where an hour or two may feel like an eternity, I can say with almost certainty that we’ll guide your child through their procedure, and give them back to you safely on the other side.
Paterson, N. and Waterhouse, P., 2011. Risk in pediatric anesthesia. Pediatric Anesthesia, 21(8), pp.848-857.
Coté, C.J., Rolf, N., Liu, L.M., Goudsouzian, N.G., Ryan, J.F., Zaslavsky, A., Gore, R., Todres, I.D., Vassallo, S., Polaner, D. and Alifimoff, J.K., 1991. A single-blind study of combined pulse oximetry and capnography in children. The Journal of the American Society of Anesthesiologists, 74(6), pp.980-987.
Morray, J.P., Geiduschek, J.M., Ramamoorthy, C., Haberkern, C.M., Hackel, A., Caplan, R.A., Domino, K.B., Posner, K. and Cheney, F.W., 2000. Anesthesia-related cardiac arrest in children: initial findings of the Pediatric Perioperative Cardiac Arrest (POCA) Registry. The Journal of the American Society of Anesthesiologists, 93(1), pp.6-14.
Ramamoorthy, C., Haberkern, C.M., Bhananker, S.M., Domino, K.B., Posner, K.L., Campos, J.S. and Morray, J.P., 2010. Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry. Anesthesia & analgesia, 110(5), pp.1376-1382.
Habre, W., Disma, N., Virag, K., Becke, K., Hansen, T.G., Jöhr, M., Leva, B., Morton, N.S., Vermeulen, P.M., Zielinska, M. and Boda, K., 2017. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. The Lancet Respiratory Medicine, 5(5), pp.412-425.
von Ungern-Sternberg, B.S., Boda, K., Chambers, N.A., Rebmann, C., Johnson, C., Sly, P.D. and Habre, W., 2010. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. The Lancet, 376(9743), pp.773-783.