What to Expect Before Pediatric Surgery

What is a Pediatric Anesthesiologist?

A Pediatric Anesthesiologist is a doctor who specializes in providing comfort and safety to children during surgery and other invasive procedures that require stillness or would cause discomfort for an awake child. Though all anesthesiologists are trained to care for kids, these physicians have received advanced training in the anesthetic care of children and in Pediatrics as it relates to anesthetics, surgery, pain management and critical care. Some of our Pediatric Anesthesiologists were practicing Pediatricians. At our hospital the Pediatric Anesthesiologists provide anesthesia for children on a regular and ongoing basis. They take care of children of all ages from premature newborns to teenagers and they are experienced with the special needs of these children (and their families) in relation to surgery and invasive procedures. They evaluate each child to formulate a safe anesthetic plan that addresses the child’s preoperative attitudes and anxieties, intra-operative medical needs and postoperative pain relief. Their goal is to make the hospital experience as easy, pleasant, and stress free as possible for children and their families.

For more information please go to http://www.aap.org/sections/sap/he3003.pdf

Do Pediatric Anesthesiologists only work in the Operating Room (OR)?

Pediatric anesthesiologists may be involved in sedating or anesthetizing your child for many different procedures outside of the OR. Many children can’t lie still or cooperate enough to have a CT Scan or MRI, for example. Bone marrow biopsies and lumbar punctures are procedures that young cancer patients may have to endure. The right kind of anesthesia can make these procedures bearable. Pediatric anesthesiologists may also help prepare your child for surgery if they have complex medical problems. Many pediatric anesthesiologists will be involved with the Pain Service and are experienced with techniques and therapies to manage your child’s pain after surgery.

How Do I Find A Pediatric Anesthesiologist?

Most children’s hospitals have pediatric anesthesiologists, as do many community hospitals and medical centers. Our department currently has seven full time Pediatric Anesthesiologists and several addition Anesthesiologists with extra training and focus on anesthetics for children. If your child is having a procedure at any of our practice locations, please feel free to contact our department or ask your surgeon about our pediatrics team. We look forward to caring for your child.

What are the risks of anesthesia for children?

A natural concern of any parent or guardian is whether anesthetics can cause harm. Even though anesthesia today is much safer than it has ever been, all anesthesia has an element of risk. The anesthetic risk varies depending on the age of the child, whether the anesthesia is for emergency purposes and the child’s medical conditions. Rare, unexpected reactions to anesthetics do occur. In general, though, anesthetics are extremely safe for most children. There is limited evidence about the subtle effects of multiple anesthetic exposures on young children. The significance of this evidence is an area of ongoing research and concern. If your child is facing the need for multiple procedures we recommend discussing it with your surgeon and anesthesiologist and weighing the potential benefit of the procedure against the uncertainties of the anesthetic exposure. Because of the improved safety of today’s anesthetics and the extensive training of physician Anesthesiologists the main risks to pediatric patients involve the actual surgery in the setting of ongoing medical problems.
There are a few specific adverse effects related to anesthesia that are worth noting. These problems are neither intended nor expected. They include: dental trauma, croup (swelling of the windpipe), allergic reactions to drugs or latex products, wheezing, vocal cord spasm or injury, regurgitation of stomach contents with subsequent aspiration pneumonia, injury to arteries, veins or nerves, and irregular heart rhythms. Death and brain damage are the most feared of all anesthetic risks. Fortunately these complications are extremely rare. In the United States, the chance (risk) of a healthy child dying or sustaining a severe injury as a result of anesthesia is far less than the risk of traveling in a car. Temporary, treatable and benign side effects can occur from anesthetics and should not be confused with other more dangerous adverse effects. These potential side effects include: nausea, vomiting, drowsiness, dizziness, sore throat, shivering, aches and pains, discomfort during injection of drugs, and agitation upon awakening from anesthesia. Some side effects of anesthesia drugs and techniques can often be anticipated, but may be unavoidable. Although at times uncomfortable or distressing, most common side effects are not particularly dangerous. They will either wear off or can be treated easily.
The vast majority of children who undergo anesthesia will be comfortable and have no complications. They will often be able to go home the same day as their procedure if the surgery is not too extensive. 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.
Anesthesia takes away the pain and discomfort of surgery and allows a procedure to be accomplished both safely and optimally. These benefits and the need for surgery must be weighed against the collective risks of both the anesthetic and the surgery itself.

When Your Child is Going to Have Surgery

Do children of different ages have different coping skills when faced with surgery? How can I decide what kind of explanation my child needs?
Many parents logically ask, “What should I say to my child before surgery?” While this question has no clear-cut answers, some general principles can be helpful. Overall, be calm, confident and reassuring. Children of all ages are reassured knowing they will be with someone trustworthy such as parents, doctors or nurses, throughout their procedure. When speaking about the procedure, choice of words can make a difference too. For example, let your child know they may have some “soreness” after surgery, rather than “pain.” Calming and reassuring language is generally most effective. On other hand, parents occasionally try to hide from their young child that they will have surgery. This practice is not recommended, as it has been shown to foster mistrust and fear, and increase worries about medical procedures over time.
Young children ages 3-7 may be limited in their capacity to understand or imagine beforehand the process of having a surgery. Using language with which they are comfortable, it is usually acceptable to let these children know they will be with the doctors and nurses for a short time and then come right back to you, the parent. The anesthesiologist may present young children with a face mask or other anesthesia equipment to play with and become familiar before entering the operating room. Additionally, in this age group, anxiety reducing medications are are often used before surgery with good effect.
Elementary school children usually respond well to an upfront and honest explanation about their procedure and what will happen on the day of surgery, with language at their comfort and comprehension level. They generally understand that the surgery needs to be done to fix a problem that won’t go away by itself. Let these children guide most of the discussion by asking questions and try to answer them directly in language that is calming and reassuring.
Adolescents are capable of understanding things in a manner similar to adults. Their procedures can be explained to them openly and honestly to the extent that they are interested. Adolescents at times consider sophisticated concepts such as body disfigurement, pain, needles, diagnosis, prognosis, and even death. Sometimes they may be reluctant to ask questions even when interested and often they will hide their fears. At the same time, adolescents generally like to feel they have some control over events in their lives. Therefore, they may be comforted by participation in the decisions relating to their surgery. It may be helpful to discuss the surgery with an adolescent prior to meeting with the surgeon and anesthesiologist. Encourage and assist them in seeking answers to their concerns throughout the process leading up to surgery and adolescents usually handle their medical experiences very well.”

Should I be concerned about my child having fear or anxiety before surgery?

It is not unusual for a child or parent to be anxious prior to surgery. Reassuring, age-appropriate communication, good interactions with your surgeon and medical professionals, being calm and confident as a parent, play therapy, the use of distracting or familiar objects on the day of surgery, and techniques used by the anesthesiologist and hospital staff including the use sedating medications can all be helpful to decrease a child’s fear of medical or surgical procedures.
Anxiety before surgery will vary from child to child. Studies have shown that children who may be at greatest risk for preoperative anxiety include those with a shy or inhibited personality, a history of previous surgeries and hospitalizations, and parents who have either separated or are very anxious themselves. However, all children, in fact all people, can have normal fears prior to undergoing a procedure. These feelings can be readily apparent, but at times are hard to detect. Young people when anxious before surgery may simply not talk. They may show signs of fearing separation or may seem angry, impatient or agitated. In these situations it is good to be patient, calm and supportive with the understanding that changes in a child’s behavior around or at the time of surgery may be related to the child’s underlying stress and concerns about their procedure even if the child is unable to explain this cause themselves. Preparing your child for surgery can begin in the surgeon’s office. It is beneficial to have good interactions with the surgeon and for you, the parent, to feel comfortable in their care. Ask questions so you feel you understand your child’s procedure. Pamphlets and videos may be available in the surgeons office to further inform you about the procedure. A parent’s calm, trust and understanding will often transfer to the child.
At some hospitals, operating room tours and instruction on coping skills by a Child Life Specialist are offered prior to surgery. In one example of play therapy, a child life specialist allows a child to play with a small anesthesia breathing mask or other medical equipment so that they become comfortable with them prior to entering the operating room. On the day of surgery, a child life specialist, nurses and your child’s anesthesiologist will work to establish trust with your child and may reassure and distract your child from their concerns using similar techniques. In younger children, sedative medications are also often used. Bringing a familiar item from home such as a stuffed toy, blanket, PSP or Gameboy may be comforting, distracting, and also help the process.
Remember, parents can help their child be ready for surgery by being ready themselves. Become informed through research and asking questions. Allow your child the opportunity to ask questions. Do your best to be calm and confident. Give reassurance without going overboard. Being accepting, brave and matter-of-fact is often effective at decreasing frightening uncertainly. Most likely, everything is going to be fine. ”

Can I accompany my child into the operating room?

Hospitals and surgery centers recognize the importance of keeping parents and children together in an atmosphere that keeps everyone feeling calm. At times it can be comforting for a child and helpful for the anesthesiologist to have parents accompany their children into the OR. However, parental accompaniment is not always necessary or beneficial. Studies have shown that, in general, parental anxiety and stress is increased by accompanying their child into the operating room. Also, operating rooms are professional areas where doctors and nurses focus their attention and work on the patient. The period of anesthetic induction (when the patient falls asleep) is a critical part of this process. In many situations it may be best for the patient, your child, to be alone under the focused attention of the nurses and doctors. If for any reason a child needs special care after entering the OR, parents are unable to help, and the medical staff need to be able to focus their attention on the patient even more. Therefore, hospitals and surgery centers have different policies about parents in the operating areas. Anesthesiologists and surgeons also have different rules for this practice. Ultimately, at the time of your child’s procedure, the anesthesiologist will discuss your options and decide what is needed and most beneficial for the child. Please be understanding and cooperative. Many of the doctors and nurses you will meet are also parents and understand the feeling of taking a child to surgery.”

Does my child need an IV?

For most surgical procedures your child will need an IV. For a few cases, like the placement of ear tubes, it is usually not necessary. Importantly, for most children under age ten, IVs are placed after the child is asleep from inhaled anesthesia gases. In the operating room, the child is monitored and gently given anesthetic gases through a breathing mask. Once asleep, the IV is placed. Occasionally it may be necessary to have the IV in place prior to going to sleep. This necessity occurs when there is an acute injury or a medical condition that requires the anesthetic to be given IV. For instance, an IV is absolutely necessary for the patient’s safety if there is increased risk of pulmonary aspiration, the movement of stomach contents out of the stomach and into the lungs. Your anesthesiologist will make that determination when your child is assessed preoperatively. For children 10 years old and above, small IVs are often placed preoperatively just as they are for adults and are usually well tolerated.

My child has a cold. Should surgery be cancelled? What are the risks?

In the past, children with respiratory infections had their anesthesia and surgery cancelled based on concern over increased risk of complications. We now know more about anesthesia during colds and cancellation is much less common. We also know that children frequently get symptomatic viruses and delaying a procedure for every minor infection makes it difficult to reschedule potentially important surgeries.
Regardless, children with colds have slightly more risk of respiratory complications during and after anesthesia than children who are healthy. Studies of children with colds have shown that asthma, intubation, heavy secretions or congestion, airway surgery (e.g. tonsillectomy), tobacco smoke, snoring, and a history of prematurity further increase the likelihood of respiratory problems. The main risk is spasm of the airways that can cause coughing, wheezing and lowering of oxygen in the blood. Fortunately, these complications are usually mild, quickly recognized and easily treated. Studies also show that anesthesia does not prolong or worsen colds in most children. Although there are rare cases of children with colds who developed pneumonia after anesthesia, there has been no evidence to suggest that the anesthetic was the cause.
At the time of your child’s procedure, the surgeon and anesthesiologist will assess them and determine if they are well enough to proceed. If your child has a Cold, the primary concern will be whether or not the cold is likely to cause difficulty breathing during or after anesthesia. Typically, children whose colds are limited to the nose and upper parts of the throat, with clear secretions, no fever, and no lethargy can be safely anesthetized. Children who look sick, have a temperature over 100°F and have thick or heavy secretions, especially if coughing, may benefit from having their surgeries postponed. Other factors may be important, however, including the urgency of the surgery.

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 sometimes recommended to wait 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 surgeon, anesthesiologist and pediatrician. If your child’s surgery was canceled, his or her symptoms were probably 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.

Why is fasting necessary before surgery?

An empty stomach at the time of anesthesia drastically decreases the risk of aspiration pneumonia and associated problems that can be life threatening. Aspiration pneumonia occurs when stomach contents are breathed into the lungs. Stomach acids can directly damage lung tissue and initiate potentially serious inflammation. When patients receive anesthesia, there is relaxation of muscles that normally keep down food and fluids. Therefore, patients are asked not to eat or drink anything prior to anesthesia and surgery. If the stomach is empty, the risk of aspiration is extremely low.

How long does my child have to fast before surgery?

Food and milk empty from the stomach much more slowly than clear liquids (e.g. water, apple juice, Gatorade). Therefore, pediatric patients must fast longer from food or milk but may often continue with clear liquids until 2 hours prior to anesthesia and surgery.
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 It is recommended that you also discuss your child’s fasting requirements with your pediatrician. If emergency surgery is necessary, oral intake of food and liquids is stopped as soon as possible. In general, fluids and nutrients are then given through an IV. If the patient’s stomach is not considered empty and surgery cannot wait, the anesthesiologist will take special precautions to reduce the risk of stomach contents entering the patients lungs. These precautions are effective in almost all situations.

Should my child take his or her medications before surgery?

Medications should be taken or withheld prior to surgery as directed by your pediatrician, surgeon and/or anesthesiologist. If you are unclear which medications to take or hold please discuss it with your child’s doctors as early as possible. In general, medications taken with a sip of water before surgery do not increase the risk of aspiration.

What to Expect During Pediatric Surgery

What happens once my child arrives in the O.R?

When your child arrives in the operating room, we start by applying routine monitors. These monitors are placed on every child. They are in the form of smiley face stickers on the chest, a lighted sticker on a finger or a toe and a small blood pressure cuff that circles an arm or a leg. The staff in the room is trained and experienced keeping your child distracted and entertained. Distracting and comforting techniques are used to get the child to cooperate with the OR process from being placed on the OR table, through placement of monitors and until safely asleep. If your child does not have an intravenous line, we will have him/her fall asleep by breathing anesthetic gases through a mask (often scented like bubble gum or cherry). This can sometimes be done with a parent present in the room. Children are typically asleep after taking just a few breaths. Once the child is asleep, the parent is escorted out of the room. An intravenous line is then started to facilitate the remainder of anesthesia and the operation. For children who come to the OR with an IV in place, intravenous medications are used to send them off to sleep. These medications work rapidly and the child goes to sleep within seconds of these medications being given. Beginning with the initial period in the OR, as your child falls asleep and through the duration of the anesthetic and surgery, the anesthesiologist assesses and maintains your child’s breathing. After monitors, IV access and sleep are established various techniques will be used to continue safe respirations, deliver anesthetics and otherwise care for your child during the surgery itself.

What will my child remember?

Typically children don’t remember any more than being in the holding room and perhaps a brief period after being brought into the operating room. Sometimes children remember talking to the doctors and nurses, hearing a story, playing with the equipment in the OR or giggling as they breathed through a mask. Every effort is made for our pediatric patients to have a calm, easy, comfortable and overall positive experience on the day of their surgery.

How does my child stay asleep?

General anesthesia is typically delivered as a combination of medications given intravenously and through a breathing device. This device, if required is inserted and removed while your child is asleep.

How does my child wake up?

After the operation is finished we turn off the anesthesia being delivered through the breathing device and stop giving additional medications through the IV. The medications wear off quickly and your child wakes up within minutes of the procedure being over.
Occasionally your anesthesiologist will perform a procedure on your child while she is asleep to provide pain relief during the wake up and after surgery. Any such procedure, if necessary, involves a discussion with the parents prior to the child being brought into the operating room.

When am I reunited with my child?

In most instances you will be reunited with your child shortly after their arrival into the Post Anesthesia Care Unit (PACU) also known as the Recovery Room.

What to Expect After Pediatric Surgery

Will I be able to be in the Recovery Room as soon as my child gets there?

In most circumstances, parents are brought into the Recovery Room right away. We believe children generally are comforted and happiest when they awake to find their parents present. Even in those common situations, however, parents are brought in when the anesthesiologist and nurses feel the child is awake enough, will benefit from parents at the bedside and will be safe. There are multiple variables, including length and type of surgery and your child’s medical history that determine how quickly your child awakens from anesthesia. At times a child my need extra care from the doctors and nurses in recovery prior to parental presence. We understand your eagerness in wanting to see your child after surgery and we will bring you to the recovery room absolutely as soon a possible. Please be patient.

Why might my child's legs be weak after surgery?

Certain surgical procedures of the abdomen, legs, buttocks and genitals are appropriately accompanied by a procedure done by your child’s anesthesiologist called a caudal block. Caudal blocks are done to decrease or eliminate pain from these surgeries. If a caudal block is an option for your child, the anesthesiologist will discuss it with you prior to surgery. The medications used for the block may cause your child’s legs to be weak for a few hours. The benefit, however, is excellent pain relief. If you child receives a caudal block, you will be instructed to assess your child’s leg strength and to assist your child with any walking for several hours after the block until their leg strength returns.

Why is my child crying in the recovery room?

Regardless of the surgery performed, it is not unusual for a child, especially pre-school age, to cry after anesthesia and surgery. There are a variety of reasons for this behavior including residual anesthetics, unfamiliar people and environment, a phenomenon called emergence delirium, and pain or discomfort. A conscious effort is made to alleviate surgical pain prior to a child regaining awareness after surgery. Additional pain medicines are given in the Recovery Room if it appears in any way that a child is uncomfortable. Even without pain, however, a child may continue to cry. If the crying persists and is not quickly alleviated by medicines, distraction or parental presence, it is likely the result of emergence delirium, commonly seen in young children after general anesthesia. Typically, this type of delirium lasts about 15 minutes, but can last as long as an hour. At its worst, the delirium can involve a child crying, screaming, and thrashing around inconsolably. It is unpleasant for parents to witness and stressful for hospital staff as well. Fortunately, in most cases it resolves quickly. Creating a dark, quiet environment for the child is helpful. Occasionally sedative medicines are also appropriate and helpful. One of the best ways to prevent emergence delirium is to allow a child to wake up slowly from their anesthetic. This slow process requires caution and is only possible after some types of surger. If a slow wake up is an option, it will be discussed with you by the anesthesiologist. In general, if your child is sleeping when you arrive in the Recovery Room, do not disturb them until you have confirmed with the anesthesiologist or nurse that it is beneficial for the child to do so.

How soon after surgery can my child eat?

Within 1-2 hours after most pediatric surgeries children may begin to have breast milk, formula and solid foods. Whether or not your child can eat depends on the surgery and on the ability to tolerate food after having anesthesia. If the surgery itself limits intake, the surgeon will discuss these limitations with you and provide you with instructions. At times a large meal after anesthesia can cause nausea and vomiting. Therefore, in general, it is important to introduce food slowly after surgery, starting with ice chips, water, and things that are mild and gentle on the stomach.

How long will my child need an IV after surgery?

We understand that IVs bother some children and an effort is made to remove them as early in the recovery period as possible. However, the IV is the quickest and easiest way to treat pain, nausea and any rare or unexpected situation that could arise with your child. It is therefore necessary that your child’s IV remain in place until the doctors and nurses feel your child is safe, recovered sufficiently from anesthesia and unlikely to need further intravenous medications. If your child will be admitted and staying in the hospital after surgery then it is likely that the IV will remain in place for at least part of that stay. If necessary, the nurses and our Child Life support team will attempt distraction and help your child cope with the presence of the intravenous line.

If my child is having same day surgery, how long before I can take her home after she comes out of the OR?

In most cases your child will be ready to go home within 2 hours after arriving in the Recovery Room. After surgery, your child will need to be monitored closely for a minimum of 30 minutes, and often an hour, in the Post Anesthesia Care Unit (PACU). When ready, they will be sent back to the Ambulatory Surgery Unit, observed in a less intensive setting and gotten ready to return home. Before returning home, we want your child to have good pain relief, be free from nausea or vomiting, and able tolerate food and beverages.

How will I manage my child's pain at home?

In most cases, your surgeon will discuss with you the preferred method for managing your child’s pain at home. For some surgeries, over the counter medications are all that is needed. If stronger pain medicine is necessary, a prescription will be written by the surgeon. If your child has or more complex pain management needs, an anesthesiologist and pain management specialist may help develop a strategy for your child’s relief.

Why is the area around my child's eyes red?

While your child is under general anesthesia his or her eyes may be moistened, closed and protected with a variety of different tapes or special eye covers. This care is done to guard the eyes against any accidental injury during the surgery and anesthesia. Tapes or adhesives, though generally mild in the OR, can sometimes cause irritation of the sensitive skin around the eyes in children. This irritation usually rapidly resolves and occasionally can last up to a few hours.