Local anesthesia and/or sedation for ambulatory surgical procedures are generally not used in children.
General anesthesia allows for a much more controlled approach to the child’s well-being during his or her surgery. Children tolerate general anesthesia as well as adults and, with few exceptions, pediatric urologic surgery is best performed under general anesthesia.
Healthy full-term infants beyond the age of 3 months can safely undergo outpatient surgery as long as there are no untoward pre-existing conditions.
The physician who specializes in the administration of the anesthesia is the anesthesiologist; and he or she, in addition to the staff in the Operating Room (OR), will administer and monitor the child’s anesthesia. Ambulatory surgical centers devoted to outpatient surgery that cater to infants and children will have state-of-the-art equipment.
The best preparation that the parents can make for their child in anticipation of surgery is to be supportive and to tell the child the truth, in an honest and gentle manner, as to what to expect. Children will then handle surgery a lot better than when given half-truths.
1. Preoperative Testing
Usually preoperative testing in healthy infants and children is not required unless there is a pre-existing concern or a concern from the child’s pediatrician. It is the child’s pediatrician who routinely performs a Preoperative History & Physical and clearance for surgery a day or so prior to the event.
2. Fasting Instructions
Specific instructions will be given to the parents regarding preoperative fasting, and this will vary somewhat depending upon the anesthesiologist that will be administering the anesthesia for surgery, and he or she will advise the parents accordingly. However, numerous studies have documented the safety of drinking clear liquids until 2 hours before surgery.
Parents usually stay with the child until the child is transferred to the Operating Room (OR). It is during this time in the preoperative area that the child will be given a mild sedative. This can be administered orally or by suppository. In this manner, the child is more relaxed on being transferred to the OR.
In addition to normally not requiring blood testing prior to surgery, we usually refrain from starting intravenous (IV) lines until after the child has been masked to sleep, It is only once the child is asleep that the IV line will be started to allow ready access to the bloodstream for various medications as needed.
The most common reason for postponing surgery in a child is the presence of an upper respiratory infection (URI). Children usually average 5-8 URls per year, and a child undergoing anesthesia at that time may be at risk for lung problems.
In the Operating Room, once the child has been masked to sleep and the IV line has been placed, anesthesia can be maintained with a combination of various agents. These agents allow for unconsciousness, amnesia, muscle relaxation, and control of other reflexes; and they allow an operative procedure to take place.
Airway management is paramount during the case, and for short procedures, anesthesia can be administered by mask. For longer or more complicated procedures, the airway may be actually intubated, either through the laryngeal mask airway (LMA) or through an endotracheal tube. The tube is usually placed when performing emergency procedures or in anticipation of long procedures and/or in those patients at risk for aspiration of gastric contents.
The child’s condition during surgery is monitored continuously with such devices as the pulse oximeter and others. Additionally, alarms connected to these and other devices allow an almost fail-safe control of the child’s wellbeing.
3. Adjunctive Measures for Pain Control
In addition to the administration of general anesthesia, post operative pain can be further controlled with the use of adjunctive measures. We have found these to be extremely helpful in the postoperative care of children having undergone urological surgery and one or more agents are routinely administered before the child wakes up from general anesthesia.
a. Analgesic Suppositories.
b. Nerve Blockade. This depends on the site of the wound, but local anesthesia may be administered either through a caudal block, a local nerve block such as the penile nerve block (especially for those children undergoing circumcision) or wound infiltration, in which a local anesthetic is infiltrated in the wound.
c. Topical Anesthetic Agents. These include Xylocaine jelly and Emla cream, which may be administered topically, such as after a circumcision, for additional analgesia.
4. Postoperative Care
Postoperative monitoring is performed in the Recovery Room to ensure normal ventilation and oxygenation as well as stability of blood pressure, heart rate and neurologic status while the patient is recovering from general anesthesia. Furthermore, control of nausea and vomiting is important in addition to adequate pain control.
After uneventful surgery and recovery, most children are discharged with prescriptions for pain medication and possibly also for antibiotics and antiemetics.
With appropriate preparation, anesthesia and surgery, children can have their treatment concluded safely and appropriately, with a minimal amount of physical and emotional stress.
Although most children are fully awake between 10 and 30 minutes after surgery, full recovery from anesthesia can take about 2 hours. Most children will be permitted to go home within 2 hours after surgery.
It is not uncommon for children to be somewhat irritable in the recovery room and on returning home; but after a nap, are usually found to be in a better mood. Some children can complain of wound discomfort, nausea, sore lips, sore throat and/or tenderness of the jaw. Most of these problems are minor, infrequent and self-limiting. A calm and understanding parent is the best sedative for a child.