Five Questions to Ask About Pediatric Anesthesia

Each year, about 6 million children in the United States undergo general anesthesia, according to the National Institutes of Health. Last year, roughly 27,000 anesthesia cases took place at Arkansas Children's Hospital (ACH) in Little Rock and Arkansas Children's Northwest in Springdale.  

The trust it takes for a parent or caregiver to allow medical experts to administer anesthesia to their child is something the pediatric anesthesiology team takes to heart, explained John Whitmore Robben, M.D., pediatric anesthesiologist and medical informatics officer at Arkansas Children’s and associate professor of anesthesiology and pediatrics at the University of Arkansas for Medical Sciences. 

"When a parent hands over their child to you to care for, there's nothing more special. That's a huge responsibility. They're giving you the most important part of their life to take care of. That's our job," Dr. Robben said. "Nothing we do is in a vacuum. We have a large care team, and it sets us apart. If there is ever a problem, the resources we can bring to that problem are dramatically different than most other hospitals. We can bring in unmatched resources in our state with the amount of pediatric, multidisciplinary experts ready to assist."  

The skills, approach and medical training required to put a child under general anesthesia are different than those of an adult. At Arkansas Children's, pediatric anesthesiologists are fellowship-trained, which means:  

• A completed residency  
• Certified in anesthesiology and pediatric anesthesiology by the American Board of Anesthesiology  

The team prioritizes a culture of safety, which means close work behind the scenes with a child’s medical care team before a child has surgery to create a complete care plan.  

Dr. Robben said parents' most common question about anesthesia is whether it is safe. While there are risks with any medical procedure, pediatric-trained experts keep safety at the center of patient care.  

"We follow evidence-based medicine to ensure the safest possible anesthesia care for children. Our approach is guided by the latest research on both the safety and timing of anesthesia," Dr. Robben said. "When surgery is necessary, delaying or avoiding treatment can pose risks. Our goal is to provide expert care with highly trained pediatric anesthesiologists, prioritizing your child's safety at every step."  

Dr. Robben discussed the following five questions parents should ask about pediatric anesthesia:  

1. What is anesthesia?

There are several types of anesthesia, and general anesthesia is the most common given to children. General anesthesia uses medications (that are breathed in or given through an IV) to help a patient fall asleep and enter an unconscious state to have no memory or feeling of a procedure.  

If a child is under 10 years old, most general anesthesia is delivered via a mask first to help them reach unconsciousness. Once the patient is asleep, a pediatric anesthesiologist, certified registered nurse anesthetist (CRNA) or a registered nurse starts an IV for medications and fluids typically needed to treat pain, medical conditions (like heart issues and diabetes) and to decrease nausea. Starting an IV after a child is asleep creates less stress for pediatric patients. For shorter procedures, like ear tube placement, an IV is not necessary.  

The medication they breathe through the mask is called a volatile anesthetic. Sevoflurane is used most at Arkansas Children's, along with a combination of nitrous oxide and laughing gas. Arkansas Children's uses medications, like Propofol, for IV medication, that can be used with the inhaled anesthetic to keep a child asleep through the procedure. The team uses multiple medications from different drug classes to improve pain relief and minimize side effects like nausea. The combination of medications improves recovery and reduces complications after surgery. 

Other types of anesthesia include:  

• Local anesthesia: Numbing a small area for a procedure, like tooth removal. The patient is awake.  
• Sedation: Putting a patient under a mild, moderate or deep sleep where they are still aware of their surroundings, but pain-free. A combination of sedation and local or regional anesthesia is also known as monitored anesthesia care (MAC).  
• Regional anesthesia: Numbing a larger portion of the body, like an arm or the abdomen. The patient is awake when the medication is used on its own. Arkansas Children’s does not typically use regional anesthesia on its own.  
  
  

Along with general anesthesia, Arkansas Children's uses regional anesthesia in most patients to help with pain control during and after surgery. An acute pain team comprised of anesthesiologists, physicians, nurses and nurse practitioners administers it. After a patient is under general anesthesia, the team uses an ultrasound to safely perform the nerve block injection so there is less pain at the surgery site for four to six hours. Because of the nerve block, patients typically require less pain medication after surgery and there are fewer side effects from the pain medication such as nausea and drowsiness. It also can help patients wake up faster and go home sooner.  

A child could wake up from anesthesia happy, with no or mild side effects like nausea. However, for some children, there is a chance of emergence delirium, which causes temporary confusion, lack of focus and irritability that can last a few minutes or up to an hour. Pain management and shortened anesthesia time help reduce these side effects.  

2. What is a pre-anesthesia testing appointment?

Some medically complex pediatric patients or those undergoing complicated surgery may need to come to the hospital for a pre-anesthesia testing appointment. At these appointments, pediatric anesthesiologists or a nurse practitioner review a patient's medical history and perform additional testing, which can include bloodwork, X-rays, breathing tests, ultrasounds, etc., to safely develop the best anesthesia surgery plan for that child.  

3. How is the proper anesthesia dosage determined?

The most common way anesthesia doses are determined is by a patient’s weight. In adults, dosing is more generic. At Arkansas Children’s, pediatric experts are trained to know the difference in dosing for the smallest patients, from premature newborns that might fit in the palm of a hand to a teenager. The team is also expertly trained to anesthetize adult patients with congenital medical conditions, like patients in the Arkansas Children’s Heart Institute Adult Congenital Heart Disease Program.  

4. What kind of anesthesia monitoring happens during surgery?  

The initial dosage of anesthesia to get a patient to fall asleep is called induction of anesthesia. To keep a patient unconscious, they continue to receive either breathing medications or a combination of medications through an IV, typically a lesser amount than initially. The medication dosage, brain waves and heart rate are monitored by the pediatric anesthesiologist, along with an extensively trained anesthesia care team constantly present with the patient, including:  

• A medical fellow (a doctor who has completed their residency and is doing additional training to become a pediatric anesthesiologist.)  
• Medical residents still in training  
• Certified nurse anesthetists  

5. Can parents be in the room when a child is receiving anesthesia or when they wake up?

This is allowed on a case-by-case basis, with the child’s safety as the deciding factor. Pre-op rooms in the new outpatient surgery center currently being built as part of the expansion of Arkansas Children’s, are designed with all preparation needs in mind, allowing parents to be present as a child is being given anesthesia in most cases. If a child does not need extra care after surgery, like additional X-rays, the care team tries to get the family back to the patient’s bedside as they are waking up.  

This article was written by the Arkansas Children’s content team and medically reviewed by John Whitmore Robben, M.D.