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This one is about: Anesthesia for Children with Cleft Lip or Palate


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ANESTHESIA FOR CHILDREN WITH CLEFT LIP OR PALATE
Amy Beth R. Hilton, M.D.

Many parents of cleft-affected children have concerns about anesthesia for the many surgeries their children must have. I would like to address some of those concerns, looking at the process of preoperative preparation, events on the day of surgery, and recovery from anesthesia. Processes and procedures vary from hospital to hospital and doctor to doctor, but I will try and describe the most common approaches and explain the reasons behind them.

PREOPERATIVE PREPARATION:

In some hospitals, most of the preparation is done by the surgeon. Then the anesthesiologist sees the child for the first time right before surgery. In other hospitals, you and your child may be seen in a preoperative assessment clinic by a team consisting of nurses, nurse practitioners or physician assistants, residents training in anesthesiology, nurse anesthetists, and/or anesthesiologists. You and your child will be asked questions about the child's medical history and your child will have a physical exam. You will both have a chance to ask any questions you might have. Some questions about surgery and aftercare may be referred back to the surgeon or cleft palate team coordinator. You should be able to get most of your questions about anesthesia answered at this visit.

Some things, like preoperative sedation (see below) are up to the preference of the individual anesthesiologist. The anesthesiologist you see in the clinic probably will not be the one assigned to take care of your child, but he or she will record all the information obtained during the visit and it will be passed on to the anesthesiologist who does care for your child.

The risks of anesthesia will be discussed with you. Sore throat or hoarseness is a common side effect of anesthesia (20-40% of patients, depending on the type of surgery). Dental damage or minor injury to the mouth or tongue can occur while the breathing tube is being placed or removed (see below) but this is much less common. The anesthesia team will always try to avoid this complication.

About 2% of patients will have a small cut on the lip or tongue. If the teeth are not decayed or loose, dental damage occurs less than 1:1000 patients. If your child has loose or decayed teeth, please report this to the anesthesiologist. He or she needs to know to watch out for these teeth, and may recommend removing a very loose tooth once the child is asleep. This prevents the tooth from being knocked loose accidentally and being swallowed or getting into the lungs during the anesthetic.

Another anesthetic risk is an allergic or adverse reaction to one or more of the anesthetic drugs or gases. This occurs in less than 1 in 10,000 anesthetics.

You should inform the anesthesiologist if the child has any blood relatives who have had a life-threatening reaction to anesthesia or a sudden, unexpected death under anesthesia or immediately after. Some reactions to anesthesia run in families, such as malignant hyperthermia (a rapid rise in temperature and metabolism -- this was once almost always fatal but now can be treated if recognized early and avoided if a family history of this disorder is known) and pseudocholinesterase deficiency (an enzyme deficiency that prevents the breakdown of an anesthetic drug which is usually very short-acting. If it is not broken down, it causes muscle weakness and difficulty breathing. This is usually easy to recognize and is treated by keeping the patient on a ventilator and under sedation until the drug wears off, several hours later.) These disorders are rare.

General anesthesia involves giving anesthetic gases which can be irritating to the airway and often requires insertion of a breathing tube into the trachea which also irritates the airway. Any child or adult can develop spasm of the vocal cords or bronchospasm (asthma-like response) from this irritation. Children and adults who are prone to asthma and those who have had a cold or bronchitis recently are especially prone to this complication. If the spasm is pronounced, it can obstruct the flow of oxygen into the lungs. The anesthesiologist will have emergency drugs available to treat this complication (and other complications that may occur) and the spasm is usually relieved quickly. Rarely (less than 1 in 50,000 anesthetics) this reaction may last long enough to become life-threatening. It is for this reason that your child's surgery may be postponed if s/he has a cold or bronchitis, or is recovering from a respiratory infection. Some anesthesiologists wait two weeks after a cold, but others feel it is safer to wait as much as six weeks. If a child gets frequent colds and the surgery will help with this problem, for example ear tubes or tonsillectomy, the benefits of proceeding with the surgery may outweigh this risk. If a child is feverish, acting sick, having diarrhea or vomiting, coughing up green or yellow mucous, or draining infected mucous from the nose all but emergency surgery should be postponed until the child recovers.

If the child is exposed to chicken pox or other childhood infectious disease and is susceptible (i.e. has not had the disease or been immunized against it), surgery should be postponed until the child either gets the disease and recovers from it or it is clear that s/he will not be infected (30 days from exposure for chicken pox). It is dangerous to anesthetize a child who is coming down with chicken pox or other childhood illnesses, as this may cause liver or brain injury. Also, the child may infect other children in the hospital before s/he looks sick.

You will be given instructions on what your child may eat and drink the night before surgery. Some hospitals allow clear liquids such as water or apple juice up to two-to-four hours before surgery. Others have stricter guidelines.

Some will allow breast milk closer to surgery than they allow formula or cow's milk. Be sure you understand the instructions and follow them carefully. They are meant to prevent a life-threatening pneumonia from aspiration of stomach contents into the lungs. If there is any question about the child's compliance with these rules (if, for example, the child might have found and eaten a cracker while momentarily out of your sight that morning) the child should not have surgery until it is known that his or her stomach is empty. Sometimes the surgery can be postponed to later that day, but usually it must be rescheduled.

Your child may also need blood work or other testing during this visit. Most anesthesiologists are trying to minimize the amount of laboratory testing done preoperatively, especially when it involves drawing blood from kids. Some will require a blood count before palate surgery, and possibly a sample for the blood bank, while others will not. The decision will be based on the size and health of your child (smaller or anemic children cannot tolerate as much blood loss), the expected blood loss for your surgeon performing the planned type of palate repair (some repairs leave more raw surfaces to bleed, some surgeons are better at controlling blood loss than others), and the speed with which banked blood can be processed and brought to the operating room in that hospital. If your child is having more extensive reconstructive surgery you should expect that he or she will have a blood count and a "type and screen" (blood is typed and screened for antibodies against other blood types and subtypes which make crossmatching the blood difficult) or "type and cross" (blood is typed and screened, then units of blood are tested for crossmatch and set aside for your child's use only). A blood count can be done from a finger or heel stick, but the blood bank needs a larger amount of blood which must be drawn from a vein. If you or your family members or friends wish to donate blood for your child, this can be done up to one week before surgery. The blood bank needs at least a week to test and process the blood, and some units may need to be discarded because they are not the right subtype. There are many other factors that must match besides ABO and Rh type.

Some hospitals will provide "play therapy" for children coming for surgery. A specially trained therapist teaches the child what to expect throughout their hospital stay in an age-appropriate way. They show kids anesthesia masks and let them practice with them, let them play with IV tubing and syringes, and show them on dolls what will happen before, during and after surgery. You should ask if this is available at your hospital, since it can help allay the anxiety you and your child naturally feel about surgery.

THE DAY OF SURGERY:

You and your child will check in and then be called back to a changing area.

Your child will be dressed in a hospital gown and booties. If you are allowed to accompany your child to the operating room, you will be given clothes to change into or a jumpsuit to put over your own clothes as well as a cap, mask, and shoe covers. You will be asked the same questions over and over by the nurses and doctors caring for your child. This may seem annoying and unnecessary to you when you have already spent a great deal of time going through your child's history, especially if your child already has a thick hospital chart. Each person who cares for your child must be sure in his or her own mind that nothing has been overlooked. Particularly important are medication allergies and when the child last had anything to eat or drink. Often enough, people will report a drug allergy only after the fourth or fifth person asks about it. Either they didn't remember, or thought it was too long ago to matter, or wasn't serious enough to mention. Likewise, some people will "'fess up" to eating or drinking "just a little" too soon before the time of surgery, after they realize it must be pretty important if everyone keeps asking about it. So be patient with the repetitive questions; they are asked out of concern for your child's well-being.

You will meet the anesthesiologist who will care for your child shortly before the surgery. Some anesthesiologists practice as part of an anesthesia care team. The team consists of the anesthesiologist (an M.D. who has completed residency training in anesthesiology) and either a nurse anesthetist (C.R.N.A.-- a nurse who, after experience in intensive care, has completed additional training in anesthesia and is certified to give anesthesia) or a resident (an M.D. who is currently training to be an anesthesiologist). The anesthesiologist will be present when your child is going to sleep and during other critical parts of the surgery and anesthetic. One member of the team will always be with your child, monitoring him or her closely and adjusting the anesthetic to his or her needs. The anesthesiologist may be supervising other C.R.N.A.'s or residents, but is always available at a moment's notice. In some hospitals, anesthesiologists do not use the "care team" model and administer the anesthetic themselves, without an assistant. In that case, the anesthesiologist will stay with your child continuously (but for a long surgery, another  anesthesiologist might come in to give the primary anesthesiologist a break). In most hospitals which have anesthesia care teams, it is not possible to rearrange the staffing to promise that an anesthesiologist will be with your child continuously. Instead, only the more experienced C.R.N.A.'s and residents are assigned to care for pediatric patients.

Some anesthesiologists allow a parent to be present as the child goes to sleep. This depends on the age of the child, the preference of the anesthesiologist, and the hospital policy. Generally children under six-to-nine months will go easily to a stranger, and then are asleep so quickly that there is no benefit to the child to have the parent present. Older children may be reassured in a strange environment by the presence of a calm parent. A parent who is anxious or easily flustered may have a negative effect on the child and cause the child to be more frightened than if no parent is present. Please do not hesitate to excuse yourself from going into the OR if you are very anxious or think you might faint or cry. There are other ways to make the process easier on your child.

Some anesthesiologists rely on their own rapport with children, with or without parental presence, to keep the child calm and comfortable during the process of getting the child off to sleep. Many anesthesiologists prefer to give the child a sedative premedication to ease the process and to block the memory of anything the child does find upsetting. There are many different medications which can serve this purpose, and these medications can be given by nose drops, under the tongue, in a drink, or by rectum. Shots are avoided, unless the child will not cooperate with the usual methods and is so out-of-control that nothing can be done until the child is sedated. All of the sedative medications will have lingering effects for several hours which may slow the child's recovery from anesthesia. After receiving a sedative, the child should be held by a parent and watched closely as s/he will lose coordination and could, in rare cases, breathe too slowly.

School-age children may be offered a choice between the mask and an IV to go to sleep. The larger a child gets, the longer it takes to go to sleep with the mask. As the child breathes the anesthetic gas, first s/he becomes sleepy or groggy. Then s/he passes through a stage of anesthesia known as "Stage 2" or the excitement phase. The child may become agitated and kick and thrash.

This does not represent a conscious effort to fight the anesthesia, but instead comes from lower parts of the brain, much like the movements seen during sleep. The bigger the child, the harder it is to control these wild movements and the more damage the child can do to him- or herself and others. As the child absorbs more and more of the anesthetic gas, s/he passes through this stage into a relaxed unconsciousness. If you are holding the child during the induction of anesthesia, you may also see the child's eyes cross or diverge during the excitement phase, and then roll upwards as this passes. Seeing the child's eyes move like this and watching the child struggle and then go limp can be very upsetting, even if you have seen it before.

When the child has an IV, medications can be given via the vein which cause the child to become relaxed and unconscious in less than a minute. Sedation can be given in small doses through the IV before going back to the OR. The sedative medication can be carefully adjusted to provide a calming effect with much less chance of slow breathing or a prolonged effect into the recovery period. Inserting the IV can be made easier on the child by the use of sedatives, as described above, and/or by placing a local anesthetic cream on likely IV sites in advance. This cream is called EMLA (eutectic mixture of local anesthetics) and must be kept in contact with the skin for at least one hour to be effective, and works even better if left on for two hours. This numbs the skin, but the child will still feel some pressure and perhaps a very brief sharp/painful "pop" as the IV needle enters the vein. The nurse or anesthesiologist will then hook up the IV catheter to fluid and check to see that the fluid runs well. If it does not, the IV may have to be placed in a different vein. The most important thing for the child to do when having an IV placed is to hold still. Yelling is okay if it makes the child feel better, just don't pull away! Once the IV is working, there will be no more needles. All other medications can be given through the IV. The child may be asked to breathe pure oxygen by mask, but if s/he has a strong fear of the mask, the oxygen can just be blown near the mouth and nose until the child is asleep. Generally, children are offered the choice starting around age seven. Children ten and older should go to sleep with an IV, unless they are very cooperative with breathing the mask. There are certain conditions which may make it safer for your child to have an IV before s/he goes to sleep. The anesthesiologist will do as much as possible to make the insertion of the IV easier on your child, but safety must come before comfort.

After the child is asleep, you will be asked to leave the OR. The anesthesia team will finish connecting the vital sign monitors, which include a blood pressure cuff which measures the blood pressure automatically every few minutes, electrocardiogram patches, and a pulse oximeter which measures the amount of oxygen in the bloodstream by shining a red light through the fingertip. The child's temperature will also be monitored during the operation and the anesthesiologist/anesthetist will listen to the child's breathing through a stethoscope. If the child does not yet have an IV, one is started at this time (except for very short surgery, like ear tubes). It is often hard to find a vein in infants and toddlers. Their arms and legs are chubby and the veins run deep and are naturally quite small. The veins of the hand, foot, ankle, arm, scalp, and even the neck may be tried. The IV is used to replace the fluid the child is not taking by mouth, to replace the volume lost from the bloodstream by bleeding and swelling during the surgery, and to give medications needed to maintain a safe anesthetic.

Once the IV is in place, the child may have a breathing tube (endotracheal tube) inserted through the mouth or nose into the trachea. This makes it easier and safer to assist the child's breathing, and protects the lungs from any blood or other fluids which might drain from the surgical area. Once this breathing tube is secured, the surgeon is able to begin his or her preparations. The child is kept relaxed, unconscious, and free of pain by a combination of anesthetic drugs and gases. The anesthesiologist/anesthetist will watch the heart rate and blood pressure of the child throughout the anesthetic to provide a safe and adequate level of anesthesia. As the surgical procedure is coming to an end, the child will be awakened gradually. When the child is awake enough and strong enough to breathe on his or her own and to cough out any secretions which might get into the lungs, the breathing tube will be removed. It is rare for a child or adult to have any memory of having the breathing tube in place. The child will be observed in the operating room for a few more minutes, and then will be brought to the recovery area. 

In many recovery areas (now called the Post-Anesthetic Care Unit, or PACU) the parent(s) are allowed to come in to comfort the child as soon as the nurses and the anesthesiologist have determined that the child is stable. In some PACU's this is not possible due to lack of space, a hospital policy which protects the privacy of other patients, or the presence of a very sick patient in the PACU who might be upsetting to parents not accustomed to medical procedures such as tracheal intubation or CPR. Every effort will be made to reunite you with your child as soon as this is safe, both for your child and for other patients.

When you first see your child, s/he will be quite pale and may be agitated and confused. S/he may still have a blood pressure cuff, ECG wires, and/or a pulse oximeter attached, and may have an oxygen mask or oxygen tubing on. The child may not recognize you at first, due to the residual effects of the anesthetic, and may be difficult to console until the anesthetic wears off more and the child is awake enough to register that you are there. This is much like "night terrors", where the child may be sitting up crying in bed, but is not really awake, and doesn't calm down until s/he wakes up.

The child may also be "floppy" and have poor motor control from the residual anesthetic. When you hold your child, you should have control of his or her head, just like holding an infant. You may also notice that your child smells strange. Some of this is antiseptic, tape, and other things used in the operating room, but you may also be smelling the anesthetic gases on your child's breath. If you held the child while s/he breathed these gases through a mask, you will recognize the same pungent smell. In the operating room, you might get a strong enough whiff of the gas to make you lightheaded for a moment, but the concentration of gas left on the child's breath afterwards should have no effect.

Anesthetic gases are safe to breathe in the concentrations you would be exposed to in the operating room and the recovery area. There has been some question in the past, based on some poorly-conducted studies, that exposure to anesthetic gases might increase the risk of miscarriage. If you are pregnant or trying to become pregnant, you should discuss this with the anesthesiologist and consider not accompanying your child to the operating room. The minute concentrations on your child's breath after the operation are so low that they are of no concern.

Your child may vomit in the recovery area. Most of the time this will only happen once or twice. If it is more persistent your child can be given medication to prevent nausea. If you are taking your child home the same 
day, bring several changes of clothes in case the child vomits on the way home. You should also bring the child's favorite juice and, for babies and toddlers, the cup or bottle s/he likes best. As long as the child can keep 
down some fluids, s/he will be okay. The vomiting is a side effect of the anesthesia and will go away as the anesthesia wears off, over 2-3 hours for a short, minor procedure like ear tubes, and over 6-12 hours for longer, 
more involved procedures. Narcotic pain medication like codeine and swallowed blood from the surgical site can also cause vomiting. If the child vomits for more than 12 hours after the surgery was completed, contact your surgeon. The child may need a different pain medication or this can be a sign of excessive bleeding from the surgical site, especially after tonsillectomy. Know the signs of dehydration to look for in your child and return to the hospital or your local emergency room or pediatrician if your child appears dehydrated and cannot keep down liquids.

Once liquids are tolerated, try light foods like crackers, and then whatever the child wants to eat. Your child may behave differently for several hours after the anesthetic, being more sleepy, irritable, or even more "hyper". Do not allow your child to climb, run around outside, ride a bike, or participate in other activities that require good motor control or, for older children, good judgment for 24 hours. Subtle effects of the anesthesia on coordination and judgment can last for as much as 24 hours. Narcotic pain medications or other sedatives have similar effects so these precautions should continue as long as the child is on these medications.

Watching your child go through anesthesia and surgery is always stressful, no matter how often you have been through it before, or how much you know. Ask your surgeon and your anesthesiologist any questions that are on your mind.

If you want to discuss the risks of surgery and anesthesia, you may want to find a time when your child is not present. Younger children will not be able to understand the rarity of serious complications and so might worry 
unnecessarily. Teenagers may want their own opportunity to talk to the doctor alone, to ask about their fears without worrying their parents or sounding "stupid" in front of other people.

I have tried to describe here the most common practices in anesthesia today.

There is a wide variety in the way anesthesia can be safely and effectively practiced. Each anesthesiologist and anesthetist chooses from these varied techniques what works best for him or her. Safety must always be the first 
priority. The anesthesia team will do everything possible to make the anesthetic experience easy on your child and on you, but sometimes safety concerns must take precedence over comfort. If there are procedures or policies with which you are not comfortable, ask the anesthesiologist if things can be done in a different way. S/he should be able to comply with your request or explain why it would not be a good idea to do so.


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