Pediatric Anesthesia and Pediatric Pain Management at Hospital for Special Surgery
Members of the Department of Anesthesiology at Hospital for Special Surgery (HSS) recognize that pediatric patients have special needs. We work with your surgeons, pediatricians, and nurses to make your child’s experience a positive one. By using this multi-disciplinary team approach, we will care for your child - and for you - during your child’s surgery and throughout your family’s stay with us. The anesthesiologists at HSS who care for children have specialized training in pediatric anesthesiology and pediatric pain management, and they possess many years of experience treating children before, during, and after surgery.
Our anesthetic techniques are tailored to address the special needs of children with a variety of medical and orthopedic problems such as club feet, cerebral palsy, scoliosis, deformities of the extremities, muscular dystrophy, spina bifida and a variety of other orthopedic conditions. We use a variety of blood-sparing techniques for major surgical procedures (like scoliosis surgery) that reduce the need for blood transfusions.
Pediatric Regional Anesthesia
The Department of Anesthesiology at HSS offers a unique approach to anesthesia and pain management. It is called “regional anesthesia,” and it is used for many types of operations and procedures; a familiar example is an epidural for a pregnant woman in labor. Regional anesthesia is especially good for orthopedic surgery because we can temporarily “block” sensation to the extremity that is being repaired by the surgeons, as opposed to using “general anesthesia,” which affects the entire body and prolongs recovery. You may hear the term “block” used to mean regional anesthesia. At HSS, we perform over 25,000 regional anesthetics a year.
For example, children undergoing clubfoot surgery will have a popliteal fossa nerve block after they are asleep in the operating room. This is done by injecting a long lasting local anesthetic behind the knee---usually under ultrasound guidance--providing pain relief for up to 24-36 hours. We have had children who have not required any pain medicine for 24 hours after this usually painful procedure.
And just like an adult, a child who has an operation on his/her hip or leg may receive a spinal for anesthesia and an epidural catheter to be used for pain management after surgery. Or if your child has a broken arm, her entire arm may be “numbed up” with an infraclavicular block. For children we use smaller needles to place the blocks, and anesthesia medications are dosed based on weight in kilograms.
There are many advantages to using regional anesthesia, including a lower anesthetic requirement, superior pain control and fewer side effects such as nausea and drowsiness. Regional anesthesia also reduces the amount of narcotic pain medications required after surgery. Not all patients are candidates for regional anesthesia, and your anesthesiologist will discuss this with you before surgery. For example, general anesthesia is required for spine surgery.
Day of Surgery
The Pre-op Area
The day of surgery, you will go to the admitting office and then to the pre-operative holding area. Here your child will get ready for surgery: Nurses take vital signs, your child changes into a gown, and your surgeon will come and write his/her initials on the site of surgery. You will meet your anesthesiologist and at this time the full plan for the anesthesia will be discussed and explained.
Televisions are available, and patients are welcome to bring a favorite toy, book, video with portable DVD player, or selection of music to use while they are waiting.
A nurse will place "numbing cream" on the child's hands for IV placement. Some patients will receive pre-medication to help with anxiety. The majority of patients aged five years and older receive an IV by the nurse in the holding area, after the cream has made the skin numb.
The Operating Room (OR)
Many parents are concerned that their child will remember something from the surgery, or that the procedures we perform in the operating room will cause their child unnecessary discomfort. Our job as anesthesiologists is to keep our patients safe and asleep during surgery. If your child is having regional anesthesia, she will be asleep before we start the block. Regardless of what type of surgery or anesthesia they have, the vast majority of patients do not remember being in the OR. Your anesthesiologist will be with your child the entire time, until she is settled in the recovery room.
The Recovery Room (PACU)
As soon as the surgery is finished and your child is brought to the recovery room (PACU), you will join your child. Your child will be attached to monitors for vital signs and will have a PACU nurse taking care of him/her. Two adults are allowed with the child in the PACU.
Depending on what type of procedure your child had, he will stay in the PACU for a minimum of one hour before going to the hospital room. Some patients go home the day of surgery (ambulatory surgery) and some spend the night in the PACU for observation and pain management. If your child spends the night in the hospital, one adult is permitted to stay with him/her.
Pain Management After Surgery
After surgery, there will always be some discomfort. We may not be able to keep your child completely pain-free, but we use a variety of techniques to keep the pain under control during your child’s recuperation. Our goal is to keep your child comfortable using safe and effective methods. It is important to keep on top of the pain by treating it early; it is much easier to treat mild pain than waiting until the pain is severe.
Most children staying overnight in the hospital receive “pain pumps” in addition to oral pain medications. These pumps are called PCAs. The pump administers pain medication via a "no-needles" system, either through an IV, an epidural catheter, or a catheter placed near a nerve in the arm or leg. The pain pump administers medication when a button is pushed. For the safety of the child, parents are not allowed to push the pain button. If the patient cannot use the button, the nurse will push it for him/her.
There are many factors that we consider when we order pain medications for children, including the patient’s size, previous experience with pain medication, and whether or not the child is able to take medication orally (by mouth). After surgery, the Acute Pain Service will see your child every day while he/she is on the PCA.
The pediatricians will assist with oral pain medications, and other medications that are prescribed to minimize side effects that may occur, such as nausea or itching. If your child needs extra help with pain control after-hours, there is an anesthesiologist in the hospital available 24 hours a day, 7 days a week. Before you are discharged from the hospital, the staff will ensure that your child is comfortable on oral pain medications alone. Your surgeons will write prescriptions for these pain medicines.
It is always a good idea to use a multi-modal approach to pain management. “Multi-modal” means that we use different therapies at the same time. These therapies include different types of medications to attack pain from different angles, and it also means that pain can be treated by other ways besides medication. Your nurses will show you how to position your child in the hospital bed to relieve some pain. For some surgeries, ice packs are helpful.
You are encouraged to touch your child, and it is sometimes helpful to use breathing exercises and guided imagery (focusing and relaxing the imagination) to help your child cope with the discomfort.
Anesthesia for MRI
Most children cannot tolerate staying still for the length of an MRI examination. If your surgeon orders an MRI with anesthesia, an Anesthesiologist will provide enough sedation so that your child sleeps for the entire exam. For MRI, anesthesia is administered with an IV catheter. When your child arrives, the nurse in the holding area will apply numbing cream to her hands and/or feet, depending on the age of your child and on which area of the body is being evaluated by the MRI. Most children go home within an hour or two of MRI completion.
Children with Cerebral Palsy (CP)
Children with cerebral palsy sometimes require surgery of the extremities to relieve abnormalities of posture or gait. These children have special requirements related to breathing, sensitivity to pain medications, seizures, and other associated medical conditions. We use anesthetic techniques designed to minimize these risks.
Postoperative pain relief is a major concern because pain medication may result in significant breathing problems in these children. In addition, muscle spasticity in children with cerebral palsy results in muscle spasms postoperatively, which are often difficult to treat. For surgery in the lower body, we routinely use narcotic-free epidural infusions to treat pain. These are very effective in treating pain and reducing muscle spasms. For arm surgery, we use long lasting nerve blocks for both anesthesia and postoperative pain relief. Many children with cerebral palsy may not need general anesthesia for arm surgery.
Definitions
Acute Pain Service: a team of an Anesthesiologist and a Pain Management Nurse who see patients after surgery to keep pain well-controlled
Ambulatory Surgery: also called “Day Surgery,” patients go home the same day they have surgery
Anesthesiologist: the doctor who provides anesthesia and keeps the child asleep and safe during surgery
Analgesics: medicines to treat pain (can be oral, IV, rectal, injected)
Anti-emetic: medication used to treat nausea or vomiting
Epidural: a catheter in the back that delivers medication to help with pain after surgery, or is used to numb a patient’s legs during surgery
Holding area/pre-op area: the area where patients prepare for surgery
Infraclavicular block: a regional anesthesia technique commonly used for hand or arm surgery; an injection placed under the collar bone to numb the entire arm
IV catheter: a thin, flexible tube placed in a vein, used for medicine and fluid
Narcotics: pain medications that have a morphine or morphine-like compound; these medications require a prescription
Nausea: the sensation of needing to vomit, it is a side effect of some medications
NPO: in Latin: non per os, or nil per os, which means the patient is not allowed to eat or drink
Numbing Cream: brand names are EMLA or LMAX, a local anesthetic cream that is placed on skin before IV placement or blood-drawing to make skin numb
Oral: by mouth
PACU: recovery room or “post-anesthesia care unit”
PCA: the “pain pump” that gives medication in an IV, epidural catheter, or a catheter near a nerve
Peripheral catheter: a catheter placed near a nerve in an arm or leg that delivers local anesthetic to minimize pain after an operation
Popliteal catheter: a peripheral catheter placed behind the knee that is commonly used at HSS for pain-control after extensive foot surgery
Pre-med: medication that is given before surgery by mouth or IV to help calm and relax the patient
Regional Anesthesia: epidurals, spinals, “nerve blocks” that localize the anesthetic effects, minimizing side effects and recovery time, as opposed to general anesthesia, which numbs the entire body
Side Effects: an undesired effect on the body that can occur with medications; examples are nausea, constipation, drowsiness
Spinal: an injection in the back that numbs a patient’s legs during surgery; the sensation returns completely in the recovery room
Please let us know:
-What name your child prefers to be called.
-If your child has special needs: for example, does he/she have problems hearing or seeing?
-How your child lets others know when he/she is hurting.
-If your child has had surgery or anesthesia in the past, let us know if something in particular did or did not work for him/her.
Keep in mind:
Every child is different and every surgical experience is unique. If your child has had previous experiences with surgery or anesthesia, she may not react the same way this time.
Ask questions if there is something you do not understand or have not been told.
Children often mirror their parents’ reactions, and children who are calm and relaxed before surgery have a better chance of feeling better after surgery.
The medical staff will take good care of your child!
A Word About Upper Respiratory Infections
It is common for children to have a “cold” or an upper respiratory infection during the winter months. If your anesthesiologist is concerned about these symptoms on the day of surgery, the procedure will be delayed until your child is better. It is very important for your child’s safety to call your surgeon and the pediatrician before the day of the operation if you have any concerns or questions about a possible cold before the surgery.
