Anesthesia Patient Safety
Pediatric Anesthesia in Sparrow Hospital
Obstructive Sleep Apnea Newsletter
Anesthesia has played
an important role in American medical history. The first known use of ether as
an anesthetic was in Georgia on March 30, 1842 by Crawford Long, M.D. In
commemoration of that event, March 30th of each year in the United States is
recognized as Doctor's day. The first public demonstration of ether as an
anesthetic for surgery was at the Massachusetts General Hospital in Boston in
1846 by William T. G. Morton, M.D.
Anesthesiology has come a long way
since then, with the greatest improvements in patient care and safety occurring
since the early to mid 1980's. This is largely due to the explosion of medical
knowledge, biomedical technology, the pharmaceutical industry, and advances by
anesthesiology training programs and societies.
Just as there has been a
tremendous growth in medical knowledge in general, there has been significant
advances in anesthesia related technology. This has greatly increased the safety
of receiving an anesthetic. The advent and subsequent widespread use of the
pulse oximeter and the exhaled carbon dioxide monitors have been the two
greatest advances for anesthesia patient safety in the last 15 years.
The pulse oximeter is a device that utilizes infrared light to analyze
the amount (percent) of hemoglobin that is carrying oxygen. It also detects the
patient's pulse and reads out a (heart) rate. The device allows the early
detection of a decreasing oxygen level. The exhaled carbon dioxide monitor aids
in diagnosing respiratory problems. One of its primary uses is to help confirm
the placement of a breathing tube into the trachea (windpipe). This monitor is
also used to detect changes in breathing during surgery and helps to assure
adequate delivery of oxygen to the lungs. These two devices compliment each
other and allow potential problems to be detected early, thereby helping to
avoid serious problems before they occur.
The pharmaceutical industry
has also contributed to the continuing improvement in anesthesia safety. New
drugs continue to be developed which have fewer side effects and have a shorter
duration of action. For example, developing drugs that have less direct affect
on the heart or lungs allow sicker patients to undergo more complex surgery and
anesthesia with potentially less risk. Using drugs that are metabolized or
excreted from the body more rapidly allows patients to awaken and return to
normal function more quickly.
Two events, both occurring in the mid
1980's also contributed to better care of the surgery patient. Anesthesiology
residency added an additional year of training, going from three to four years
after graduation from an accredited medical school. This was prompted, in part,
by the technological explosion in medicine and surgery allowing more complicated
procedures to be performed on sicker patients. This required more advanced
anesthetic techniques and monitoring devices by better-trained practitioners.
At about the same time, the Anesthesia
Patient Safety Foundation (APSF) came into being. This non-profit
organization dedicates itself to improving the safety of patients undergoing
anesthesia and surgery. The APSF was responsible for disseminating acceptable
minimal monitoring standards, which originated at the Harvard University
Hospitals. These standards were ultimately ratified by the American Society of
Anesthesiologists. The APSF was also helpful in getting the use of pulse
oximeters and carbon dioxide monitors to become the standard of practice in the
United States.
Over the years surgical procedures, and hence,
anesthesia, have become more complicated. However, because of improved
technology, pharmaceuticals, and anesthesiology residency training, the
administration of anesthesia is safer today than ever before. Anesthesiologists
are being trained not only to anesthetize patients for surgery, but also to
effectively manage any co-existing medical conditions.
The risks and
specific choice of anesthetic technique is affected by your underlying medical
illness(es), your specific surgical procedure, and the needs of your surgeon.
The anesthetic plan is ultimately a joint decision between you and your
anesthesiologist. Your anesthesiologist is dedicated to your wellbeing.
The foregoing is not intended to replace an informed discussion with an
anesthesiologist. Therefore, no assurances can be made about any outcome based
upon the information presented here. Any and all questions regarding specific
concerns should be directed to your physician anesthesiologist.
This article is written to introduce the practice of pediatric anesthesia to the medical staff. Pediatric anesthesia, like the rest of anesthesia, has gradually evolved over the last 100 years. The practice of Pediatric Anesthesia has evolved because, early on, differences were noted in the anatomic and physiologic characteristics of infants and small children. With improved prenatal and perinatal care, as well as the development of neonatal and pediatric intensive care units, younger and more critically ill infants and children survive to require surgical care. In fact, pediatric anesthesia care continues to evolve with the care of younger and younger premature infants and the improved survival of many children with metabolic syndromes.
The Anesthesiology Department at Sparrow Hospital has anesthesiologists dedicated to obstetrics, pain management, cardiovascular, and pediatric anesthesia, in addition to general anesthesiology. Call schedules for these anesthesia subspecialties are separate from the routine call schedule of the O.R. Pediatric anesthesia coverage is seven days a week, twenty-four hours a day, three hundred and sixty-five days per year. The current members of Physician Anesthesia Service, P.C. that are on pediatric anesthesia coverage include Dr. Bruce T. Adelman, Dr. Vera F. Barbosa, Dr. Curtis A. Carl, Dr. Mark A. Cook, Dr. John D. Everett, Dr. Joseph J. Kochan III, and Dr. Gail L. Smith, Additionally, all of the PAS anesthesiologists provide routine pediatric anesthesia care for cases such as myringotomies, tonsillectomies, and appendectomies.
Management of the airway, thermoregulation, fluid management, and blood loss are the main differences in caring for neonates, infants, and small children. For example, intubation of the premature infant and newborn is more difficult than in older children because of the more anterior position of the larynx, as well as the larger occiput and epiglottis. Additionally, newborns, premature infants and children with pulmonary disease desaturate much more rapidly than otherwise healthy older children and adults. This necessitates extra expertise in management of the pediatric airway.
Routinely we use an uncuffed endotrachial tube because it allows a larger tube, which has a larger internal diameter. Secretions (which might not even be noticed in an adult) may plug a very small endotrachial tube resulting in airway obstruction. Additionally, the distance from the larynx to the carina is much shorter in a newborn and infant. Therefore, right main stem intubation with associated desaturation is a much more common occurrence. The endotracheal tube size is estimated by taking the age and adding 16, then dividing by four, at least until the age of about six when cuffed endotracheal tubes can be used. Gentle intubation is very important. Post extubation croup is much more common in infants and small children because their airway diameter is much smaller. Therefore, a little bit of swelling in an infant can result in a large reduction in cross-sectional area and, hence, flow.
In infants and small children, maintaining warmth during operations is extremely important. Children, because of their larger body surface area to body mass ratio, are at much more risk for hypothermia during surgery. This is certainly most evident in abdominal surgery and open thoracic cases. For this reason, temperature is monitored more closely. Also, the rooms are kept warmer, and specialized warming lights and forced air warming blankets sized to the particular age and weight of the pediatric patient are utilized.
Fluid balance is also a challenge. One can't simply run two hundred fifty cc's an hour as in an otherwise normal adult case. Rather, fluid replacement is calculated based on weight and type of surgery including basal maintenance rate per hour, plus third space loss per hour, plus blood loss. What might be a minimal 15 or 20 cc blood loss in an adult can be a massive blood loss in a one or two kilogram neonate. Therefore, we keep a much closer eye on blood loss during infant and pediatric cases, which includes weighing sponges, if needed, to estimate blood loss very accurately.
The two biggest advances in Pediatric Anesthesia at Sparrow Hospital over the last ten years has been:
Allowing parents in the operating room on induction in infants older than one year and children younger than twelve years. Most often the type of induction for children is a mask induction using a newer drug called Sevoflurane. Sevoflurane is a pleasant smelling gas that most children tolerate well, usually falling to sleep within about two minutes, often in their parents' laps. The monitoring during induction is similar to that in adults with pulse oximetry, EKG, and blood pressure. For those children that are particularly anxious, oral Versed (approximately 1/2 milligram per kilogram up a maximum of twenty milligrams) has supplanted the use of other tricks such as IM kedamine or rectal Brevital. PO Versed usually will take effect in about ten minutes, peaking in about twenty, and often results in a very cooperative child. This is particularly helpful in children who have had multiple presentations to the O.R. and cannot easily be talked through their mask induction.
The increasing use of regional anesthesia for postoperative pain management. In fact, pain management in children has become similar to that in adults. Caudal and epidural placement is used routinely for urologic procedures, and larger, more painful abdominal and thoracic procedures. The major difference between adult and pediatric post-operative regional analgesia is that the placement of the block in children is after they're asleep, rather than while awake, as we would in adults. Specialized order sheets are available, allowing epidural PCEA dosing as is used often on major abdominal surgery and total joint surgery in adults. Specialized order sheets are also available for intravenous PCA dosing for children.
The "On Call" pediatric anesthesiologist will be called in for surgery in infants less than six months of age, all RNICU patients, premature babies less than 52 weeks post conceptual age, symptomatic congenital heart disease, major abdominal surgery, and intra-cranial surgery in children less than eight years of age. Some of the more interesting cases are pyloric stenosis, usually occurring less than three months of age, and removal of tracheal foreign bodies. It's surprising what infants and young children can manage to get into their esophagus and/or trachea. Erasers, peanuts, pen caps and in one instance, a very expensive coin, have been removed from some of our pediatric patients.
If you have any questions about pediatric anesthesia at Sparrow Hospital, please do not hesitate to contact us in the operating room. Should you feel that one of your pediatric patients needs specialized care, please call the operating room at 364-4022 and ask for the pediatric anesthesiologist on call for that day.