Specialty Spotlight with Siva: Demystifying Pediatric Anesthesia

May 31, 2024

Transcript

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric healthcare information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. Today’s segment is Specialty Spotlight with Siva where we delve into the complexities of pediatric medical and surgical subspecialties with pediatric otolaryngologist and facial plastic surgeon Dr. Siva Chinnadurai.

Dr. Siva Chinnadurai: Welcome to Specialty Spotlight. Today we’re going to be demystifying pediatric anesthesia and I’m delighted to have our guest, Dr. Megan Clinton. She’s a pediatric anesthesiologist with 14 years of experience. I’ve had the pleasure of working with her clinically for many years, but in addition to being a fantastic anesthesiologist, she’s also the associate chief of surgery here at Children’s Minnesota and was the medical director for pediatric anesthesia on our St. Paul campus for many years.

In these roles, she has helped shape the way that children are cared for in the operating rooms at Children’s Minnesota. Welcome to the podcast Dr. Clinton.

Dr. Megan Clinton: Thank you Dr. Chinnadurai, I’m happy to be here. The operating room and anesthesia can sometimes be a mystery to physicians and providers doing the hard work of primary care, so hopefully today we can demystify that a little bit.

Dr. Siva Chinnadurai: Let’s start with the basics. I think most people familiar with the health care system know that anesthesiologists are the people in the hospital who are responsible for getting kids safely through surgery, getting them safely off to sleep, keeping them safe during the operations, and then waking them up in a safe way afterwards. But the job is so much more involved and so much more complicated than that. Could you give the listeners an idea of all of the things that you’re responsible for, what you think about when you meet a new patient or are taking care of a patient during surgery?

Dr. Megan Clinton: Anesthesiologists are perioperative physicians, so our job includes getting the patient through the entire perioperative period, which would be pre-op assessment and management, intraoperative management, and post-op management. That’s probably the best way to break it down.

Dr. Siva Chinnadurai: And then before the surgery, when you’re meeting kids and their families, maybe for the first time, maybe these are people you’ve taken care of or your colleagues have taken care of in the past, how do you approach that session before surgery to get everything teed up for a successful day?

Dr. Megan Clinton: From a pre-operative standpoint, we review the history and do a thorough assessment interview and examination of each patient. Of course, we’re always concerned about things like NPO status and allergies, but we’re also paying attention to chronic health problems, family history, current health. This information coupled with a surgical procedure helps us figure out an anesthetic plan for every patient.

Pediatric anesthesiologists are also very attuned to various common and uncommon syndromes. Some of those can strike fear in our hearts, even the most seasoned of us. We pay a lot of attention to the patient’s anxiety level preoperatively as well to assess the best plan for induction of anesthesia.

Dr. Siva Chinnadurai: When you get into the operating room, there’s a lot of different types of things that can happen, different types of anesthetics, different types of things that you have to watch out for. What do you guys look for in the operating room?

Dr. Megan Clinton: The operating room is kind of I think where people think of anesthesiologists working and we’re basically facilitating a smooth surgical process for the patient. So we are going to induce anesthesia, manage the airway, handle IV access. A big part of our job is managing hemodynamics and maintaining the anesthesia as long as it takes for you to do your surgeries.

Many anesthetics cause hemodynamic changes, so we’re managing blood pressure, titrating fluids, medications to keep the patient normotensive, and we’re thinking about how the patient’s going to be postoperatively, implementing the analgesics, opioid and non-opioid medications, and other things that we can do for pain such as local anesthetic by the surgeon, nerve blocks, epidurals are all part of our intraoperative management as well.

Dr. Siva Chinnadurai: How do you decide who’s appropriate for those different types of things? Say deep sedation or general anesthetic, who gets an inhalational induction? Who gets an IV induction?

Dr. Megan Clinton: Most pediatric patients will get an inhalational induction just because it’s the easiest and least stressful for them and for their families. It’s a lot easier to do an inhalational induction on a toddler than hold them down to place an IV, for example.

Most patients will get an IV after induction of anesthesia and older children will get an IV prior to induction of anesthesia and we’ll use that IV to put them to sleep. That’s all part of the things that we figure out as we’re assessing the patient.

Dr. Siva Chinnadurai: In the postoperative period, of course your care doesn’t stop. You have to think about how to wake them up safely but also smoothly. I know a lot of families and providers are concerned about children being aware of their surroundings when they wake up, having anxiety when they wake up, disorientation. We hear a lot about emergence delirium. Can you talk to us a little bit about what emergence delirium is and how you manage that or any other postoperative considerations?

Dr. Megan Clinton: Emergence delirium is a complication of anesthesia that we see most frequently in kids that are between the ages of two and five, and it’s a result of the anesthetic, not totally understood, but seems to have something to do with a developing brain waking up from anesthesia.

Children that experience emergence delirium are typically inconsolable. They have purposeless movements and it can be a pretty distressing thing for families. I typically warn patient’s families that this is a possibility, particularly in patients in those age groups, and we do have some medications that we give prophylactically to smooth out the wake up and medications that we use that can treat emergence agitation or emergence delirium.

Dr. Siva Chinnadurai: If families have had tough experiences with emergence delirium with one of their kids, is it likely that that child might have that same problem again if they’re anesthetized in that same age timeframe or that other children in the same family might have the same thing?

Dr. Megan Clinton: It’s more of an age-related phenomena than a family-related phenomena and highly likely that a child who’s experienced emergence delirium with one anesthetic will have that a second time around. So we do titrate our anesthetic, keeping that in mind, we would give medications like Precedex while the patient is still under general anesthesia to help smooth out that emergence.

Dr. Siva Chinnadurai: Yeah, and it sounds like those are all part of that very important but quick time that you have to meet with the families beforehand, understand the risk, understand their previous experiences, build that relationship and build that care plan right before surgery.

In addition to doing all of those many things, I know the anesthesiologist play a very critical role in other areas of the hospital, not just the operating room. Can you talk about some of those places where the anesthesiologists are needed elsewhere in the hospital?

Dr. Megan Clinton: We are sometimes asked to help with difficult airways or airway management in the PICU and the NICU. At Children’s, we run the sedation unit, which is a big out of the operating room area in which we work. In the sedation unit, patients that are having imaging procedures or other procedures that don’t necessarily need to be done in the operating room or under general anesthesia, receive sedation that is typically done with propofol in a native airway, but we have other options that we can use as well.

And then there are procedures in the hospital that we’re occasionally asked to do. For example, we do get requests for epidural blood patches for postural puncture headaches every once in a while and various things like that.

Dr. Siva Chinnadurai: The support that we get from the anesthesiologist and the sedation unit is really important to a lot of our specialists, myself included. I know there’s a lot of things like post-operative injections, suture removals, laceration repairs, those kind of things that we can do in the sedation units without having to work around the scheduling restrictions or all of the bells and whistles of the operating room. Just having that resource available and knowing that we still have the support of the skilled anesthesiologist is really important to our ability to deliver care.

Dr. Megan Clinton: It’s definitely a nice thing for patients and families

Dr. Siva Chinnadurai: When we look into anesthesia, there’s a lot of confusing terms for folks who aren’t anesthesiologists or CRNAs. When we talk about general anesthetics versus conscious sedation versus deep sedation, can you break down what some of those terms mean? And when parents ask their pediatricians about those things, what do those terms mean and who might be suitable for one versus the other?

Dr. Megan Clinton: General anesthesia typically means that a patient is not responsive to surgical stimuli and oftentimes they need support of their airway while they’re unconscious. Sedation is a less deep anesthetic where they will respond potentially to some painful stimulation.

But anesthesia is really a spectrum, and so patients undergoing different procedures require different depths of anesthesia, and a lot of what we do is monitoring how much anesthesia is going in the patient’s vital signs to determine if they are experiencing pain, if they need more anesthesia or less anesthesia. And we titrate everything specific to patients.

Dr. Siva Chinnadurai: And general anesthetic, you said that this is a patient who is not aware of their surroundings, they’re generally not receptive to surgical stimulation, maybe with the addition of some local anesthetic or some additional sedation medications, but how do general anesthetic medications work? How do they achieve that effect?

Dr. Megan Clinton: General anesthetics seem to work by acting on the GABA system in the brain and neurotransmitter release, and that’s how volatile anesthetics or inhalational anesthetics work. Propofol has the same mechanism. Other adjuncts that we use have different mechanisms. For example, ketamine at the NMDA receptor and local anesthetics at sodium channel receptors and things like that. But mostly they work by depressing the brain.

Dr. Siva Chinnadurai: When children are coming in for their preoperative physicals or sometimes on the day of, of course taking care of small kids who are in daycare, in the school settings, we see lots of kids who come in with upper respiratory tract infections or they have the sniffles or they’ve gotten sick having the flu or RSV, and a lot of things that might interfere with the plans for surgery. What are the risk factors for having a child with a routine illness undergo an elective anesthetic, and when do you think about tolerable risk or when should a case be canceled because of a routine illness?

Dr. Megan Clinton: In general, kids that have an anesthetic while they have an active upper respiratory infection have an increased risk of perioperative adverse events. Those are mostly airway events, things like laryngospasm, bronchospasm, or maybe they just need some oxygen postoperatively for longer than expected, but this can cause patients to need intervention, it can cause them to need an unexpected admission and them at risk.

So in general, if a patient has an upper respiratory infection, it’s best if they wait about two weeks after resolutions of symptoms if they’re an otherwise healthy child. But children with asthma or chronic lung disease should really wait a longer period of time after an upper respiratory infection, usually four to six weeks is what we recommend. But we always have to weigh risks and benefits and take into account the urgency of the surgical procedure. So like everything in medicine, there’s a bit of an art to figuring out when the child should undergo anesthesia.

Dr. Siva Chinnadurai: I know a problem that our pediatricians face a lot is that people may come into their preoperative assessment having a sibling who has a cold, and so they’re worried about the child who needs surgery developing that cold. Or maybe the family has questions of what happens if my kid gets sick between my physical and the day of surgery? What advice would you give to pediatricians when they’re counseling families about what to do if your kid gets sick before a scheduled surgery?

Dr. Megan Clinton: I think families need to know that there is a possibility of surgery postponement due to upper respiratory symptoms. Frequently the anesthesiologist can evaluate the child on the day of surgery with some of these unknown things, and if it needs to be canceled, it will be canceled in the best interest of the child. We’re going to do what’s the best and safest thing for every child having care at Children’s.

Dr. Siva Chinnadurai: I know something that comes up a lot in my practice, and I’m sure for many of our general pediatricians is when we talk about surgical treatment, there’s a lot of concern about some of the potential long-term effects of receiving general anesthetic in children.

And in 2016, the US Food and Drug Administration issued a safety announcement regarding potential adverse effects of anesthetic, particularly in children under the age of three. And this, I think, gave a lot of traction and a lot of voice to some of the concerns people have had. There have been a number of studies addressing this, but I’d love to hear it straight from an expert. How do you think about these risks and how do you counsel families with regards to them?

Dr. Megan Clinton: To give a little bit of background, about 20 years ago, there were animal studies in which animals were exposed to anesthetics for long durations of time, and they found when they studied these animals’ brains that there was evidence of neuroapoptosis. And then there was thought that maybe children undergoing anesthesia at this developmental time could also have some adverse effects on their brain development. So there were some retrospective studies done that showed potentially there were some behavioral concerns in patients that had had multiple anesthetics, and the anesthesia world decided that we actually needed to try to get an answer for this.

So some very elegant prospective studies were designed that looked at this issue, most notably the GAS study. And what these studies have found, looking at patients that had a single short exposure to anesthesia in that timeframe of one to two years old or less than two years old, there has not been shown to be an association between a singular anesthetic exposure early in life and adverse cognitive outcomes.

Now it’s hard to really study this, of course, and there is still some concern that children having many anesthetics at that early age may have some effects from the anesthesia, but ultimately the Society of Anesthesia’s position on this is that clinicians should assess the risks and benefits of both anesthetic and surgical procedures requiring anesthesia because the likelihood that neurotoxicity exists for routine surgical procedures is low. And I do get this question quite a bit from parents.

Dr. Siva Chinnadurai: So it sounds like the data that’s driving a lot of that concern initially was retrospective, but when we look at it going forward, for your otherwise healthy kid who has a time-sensitive but maybe limited need for surgical intervention, they need one surgery or two surgeries in their early years of life that are short periods of time, that the best prospective data from the society is that that’s not of risk, but there’s a little bit of unknown area still in children who need a lot of intervention in that time. Is that correct?

Dr. Megan Clinton: That’s correct. We do recommend that if a child is needing a purely elective procedure that may be delayed if possible until age two rather than doing it at six months old. But there’s so many procedures that we do. I mean, a perfect example for someone like you, Siva, is ear tubes, a procedure that really affects a child’s development and health, and those things shouldn’t be delayed because the risk of a singular brief anesthetic really is low.

Dr. Siva Chinnadurai: This is a big topic we could talk about probably all day, but if the listeners want to get more information or they want to dive deep into this topic of neurodevelopment, do you have some resources that you’d recommend that they look at?

Dr. Megan Clinton: I think that the SmartTots website is a great resource for answering a lot of the questions that we frequently get as clinicians. It’s smarttots.org, and it really gives a good overview of some of the studies that have been done and ways to think about if a case should proceed based on patient risk factors and surgical implications.

Dr. Siva Chinnadurai: Another thing that comes up a lot as we think about surgery in the NT world, but also management of risk is the role of obesity and overweight in children and how that affects anesthesia management, airway management.

The prevalence of childhood obesity has grown in the last 20, 30 years from about 4% to about 10%, and in North America, about 30% of our school-age children are overweight or obese. This has a big impact on how you deliver care. Can you talk more about how you weigh that in terms of delivering the safest care for patients?

Dr. Megan Clinton: Obesity does have a significant effect on the anesthetic management. Patients are still kids and they still need mask inductions, but a mask induction in an obese child is more risky than in a child that is not obese. Obese patients have more episodes of desaturation because they have a decreased functional residual capacity. They have more episodes of airway obstruction just because they have more tissue affecting their airway. And so those are things that we think of from a respiratory standpoint, and then just basic little things are harder in obese patients, for example, it’s harder to achieve IV access in a morbidly obese patient, and that’s something that we really struggle with. Thank goodness we have ultrasound these days.

Dr. Siva Chinnadurai: Another question we get a lot in my office, and I know our primary care colleagues do a lot too, particularly when kids are having their first anesthetic, is can parents be with their kids when they go to sleep and why and why not? I know different hospitals have different policies about this, so what are the ups and downs?

Dr. Megan Clinton: It depends. Most healthy children coming in for an elective procedure can have parental presence at induction. Can be a helpful thing for both the patient and the family. When you think about an adult who’s having surgery, they typically have an IV and get some sort of anxiolytic medication like Versed in their IV prior to their surgery.

Well, most kids don’t have an IV, and so what I tell parents is that if they’re going to come back to the operating room while their child goes to sleep, that they are acting as that anti-anxiety medicine for their child.

As you have seen, some parents don’t handle this as well as other parents, and so I always ask the family to choose the parent who’s going to project the most calm for the child, because really the anxiety of the parent can transfer to the child and complicate the induction.

We can use oral medications as pre-medications for anxiolysis. There are also situations in which we wouldn’t have parents present, in emergencies and small babies. And I never want parents to feel like they have to come back for induction because it is a hard thing to watch. It can be traumatic for parents. Children go limp with anesthesia, they can have strange eye movements, limb movements, they breathe loudly, and so I try to prepare parents for these things beforehand, but it’s often pretty shocking to them if they are not ready for it.

Dr. Siva Chinnadurai: We’ve talked about a lot of things and if these questions come up in pre-op physicals or in general visits with kids pediatricians and the pediatrician has a question or a concern, an uncertainty about how to proceed, maybe the child has a URI or any of the other things we’ve talked about today, what resources are available for pediatricians to address some of these concerns before the day of surgery?

Dr. Megan Clinton: The easiest way to address those concerns is to have the pediatrician get in touch with our pre-op call center. That is a group of nurses who are taking these preoperative phone calls and also doing some pre-op assessments over the phone of patients in the days before surgery. They’re always able to connect the pediatrician with an anesthesiologist if it’s a more complicated question that can’t be answered just based on our standard protocols.

Dr. Siva Chinnadurai: This has been a lot of great information.

My guest today has been Dr. Megan Clinton, and thank you so much for joining us today, Dr. Clinton. Your insight in the world of pediatric anesthesia has been very enlightening. It’s clear that the care and precision you bring to your patients ensures their safety.

Today, we learned a bit about how anesthetic medications work, how anesthesia teams work together. We looked at some of the ways that you manage risk in the operating room and in the hospital and the science behind the great work you do. We learned the primary care providers can look for more information about some of the questions about neurodevelopment on the smarttots.org web page, and if they need some real-time advice to call the pre-op call center.
It was great to have you on the podcast, and thank you so much for your time, Dr. Clinton.

Dr. Megan Clinton: Thanks for having me, Siva.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.