Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

It's Time to Talk About Pediatric General Anesthesia for Children (Part 2 of 2)

3/31/2015 12:18:08 PM | 3 comments

In my previous post, I discussed some of the evidence linking general anesthesia in childhood to cognitive problems later in life. To recap, both humans and animals who received a general anesthetic early in their development appear to have trouble with recollection, the act of retrieving events and information from the past.
 
Experts and professional societies are sufficiently concerned to recommend these risks be discussed with parents and caregivers. However, this creates a bind for pediatric anesthesiologists. For one thing, we don't want to cause undue alarm to families who are already anxious about a child's surgery. Second, we're constrained by gaps in the existing evidence. We think there could be a link between general anesthesia and cognitive deficits, but we can't yet say so for certain. Nor can we promise that any of the available alternatives won't cause the same issues.
 
Still, enough concerns have been raised that we can no longer remain silent. This realization hit home when my young daughter was diagnosed with enlarged tonsils. Suddenly it didn't matter that the studies were small or that certain research findings hadn't been replicated. I was going to explore every possible alternative to giving her a general anesthetic.
 
This experience definitely changed the way I practice. After all, I can't in good conscience recommend care that I wouldn't feel one hundred percent comfortable giving my own child. And this has definitely moved me to go the extra mile when it comes to communicating with parents and exploring alternatives.
 
Unfortunately, there aren't many resources out there on how to address this important topic. So in this post, I'll share how we've handled the issue in my own anesthesia practice. I'll also touch on some promising research avenues that may yield new hope for the near future.

What Parents Should Know

Unfortunately, many pediatric surgeries are unavoidable. Young children rarely have an operation unless there's a serious medical problem that can't wait. So when providing informed consent about general anesthesia, it's important to keep the risks in perspective.
 
Parents may find it helpful to know that:
  • While all anesthetics carry risks, they've also made it possible for millions of children to receive lifesaving and life-enhancing care. In many cases, the benefits of anesthesia clearly outweigh the drawbacks.
  • The fact that we are now worried about the effects of anesthesia on a child's brain is a luxurious problem to have. Some decades ago, we were more worried about how to keep kids alive during a general anesthetic. The specialty of pediatric anesthesia has come a very long way in ensuring patient safety. Yet there are new frontiers. Anesthetic neurotoxicity in kids is the next frontier.
  • All that being said, it may be wise to consider delaying elective procedures and surgeries until the child is older and the brain is more developed.
  • If an operation or procedure can't be postponed, it may be possible to use an alternative anesthetic. Certain anesthetics don't seem to cause the same cognitive problems in young animals that we've observed with traditional general anesthetics. Unfortunately, we don't yet have enough data to say whether this will also be true in human children.
  • When an anesthetic is needed, parents may have the option of enrolling the child in a clinical trial. The anesthesiologist can help them explore available options as well as the potential benefits and drawbacks. 

What Alternatives Can We Offer?

Our pediatric anesthesia practice currently offers parents two alternatives to general anesthesia when possible. Both of these involve a promising, relatively new drug called dexmedetomidine, which provides sedation and some pain relief. Unlike many other sedatives and anesthetics, dexmedetomidine has not been implicated in cognitive problems in animals.
 
Our two current alternatives:

Regional anesthesia. This involves numbing an area of the body by injecting a local anesthetic around an associated nerve cluster under ultrasound guidance. Prior to the injection, the patient is sedated with dexmedetomidine, and sedation is maintained throughout the procedure. Regional anesthesia blocks pain and relaxes the muscles without the use of general anesthesia. It's so gentle, my group was able to use it during the hand surgery of a three-pound premature baby.  

Neuraxial anesthesia (including epidural, caudal and spinal anesthesia) are other examples of regional techniques that can be combined with dexmedetomidine sedation to avoid a general anesthetic. The major drawback: these methods only work for procedures on certain parts of the body.

Procedural sedation with dexmedetomidine. In the past, most young children were given a general anesthetic to keep them still during imaging procedures like MRI. Fortunately, our group has found that in about 60 percent of cases, the same benefits can be achieved via procedural sedation with dexmedetomidine. When that isn't enough, we add a very small dose of general anesthetic (about one-fourth of what would be used for surgery) that puts them out for less than five minutes. We follow this with another period of dexmedetomidine sedation.

Creating Bright Futures

While these alternative anesthetics are promising, they're not appropriate for all patients or procedures. Fortunately, researchers are working hard to find new options.
 
The future of pediatric anesthesia may actually lie in its past. Beginning in the 1940s, anesthesiologists began administering a combination of sedatives, muscle relaxants and opiate painkillers to their pediatric surgical patients. This approach, known as the Liverpool technique, effectively controlled pain and prevented movement without putting the patient into a deep coma. Complication rates were much lower than for inhaled anesthetics, and children woke up faster after surgery. Eventually the Liverpool technique fell out of favor due to concerns around surgical awareness, and children began receiving the same inhaled anesthetics given to adults.
 
We are now investigating whether a modified version of the Liverpool technique might provide a safer alternative to general anesthesia. The proposed procedure would involve sedation with dexmedetomidine, administration of muscle relaxants, and infusion of powerful, short-acting painkillers. After surgery, paralysis would be reversed and the patient would be transitioned to longer-acting painkillers to manage post-operative pain.
 
A second option under investigation is the use of dexmedetomidine in conjunction with a traditional inhaled anesthetic. In one study, baby rats anesthetized using this technique showed no signs of brain cell death. Nor did they demonstrate any cognitive deficits down the road. If these findings (which are admittedly quite preliminary and seem a bit too good to be true!) can be replicated in humans, we could have an incredibly simple solution to the general anesthesia dilemma.

Parting Thoughts

It's difficult for pediatric anesthesiologists to acknowledge that our current practice might have some adverse effects. After all, we chose this specialty because we care deeply about kids. The fact that some concerns are now being raised doesn't make us bad doctors, and it doesn't negate the fact that general anesthetics have helped to save and improve millions of young lives.
 
I totally understand physicians' reluctance to take action based on incomplete evidence. But at the end of the day, we must do what's best for our patients — even if bringing up the subject with caregivers, colleagues and hospital administrators feels awkward. Throughout history, medicine has been about change and continuous improvement. By opening the lines of communication, exploring alternatives and supporting research efforts, we do our part to help patients and keep great care moving forward. 


Comments
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12/7/2016 9:49:38 AM

Sarah Maurer - Blog Editor
Thanks for taking the time to read, Dr. Ryon. Wishing your son a successful procedure and speedy recovery.
11/15/2016 3:49:59 PM

david ryon
my 4 year old son is to have a marginally indicated MRI tomorrow under general anesthesia. Many thanks for taking the time to post these data..loftusdenis
11/10/2016 7:41:09 PM