Medical Info

The role of the anaesthetist

Article originally published in CLAPA News 17, 2005

Dr Mike Sury
Consultant Paediatric Anaesthetist, Great Ormond Street Hospital, London

Dr Agnes Watson
Consultant Paediatric Anaesthetist, St Andrew's Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford

Starting the anaesthetic:

When will I see the anaesthetist?

Either at an assessment clinic or when you come in
for the operation.

How does the anaesthetic begin? Is an injection necessary? What is the difference between gas and an injection?

There are two ways the anaesthetic can begin - either by breathing gas or by an injection, usually in the back of the hand. The "gas" is smelly but not unpleasant and takes a minute to cause unconsciousness. The injection is much quicker and most of the pain can be removed by local anaesthetic skin cream - the drug itself occasionally stings. In terms of safety, there is no difference between the two methods. Generally, small children will have anaesthetic gas to breath. Older children may have a preference. Anaesthesia is maintained with "gas" throughout the operation.

Can I be there?

Almost always yes, but as soon as your child is asleep please leave to allow us to concentrate. Try to appear calm and confident, it will help your child. Infants and toddlers can be cuddled on a lap until they are asleep and you can agree a plan with your anaesthetist.

Will my child be upset? What should I tell my child?

Infants may cry, but are calmed by cuddling. Older children however benefit from appropriate explanations - we favour an honest approach and recommend that they have a simple explanation. For 2 and 3 year olds, tell them about 2 days before and again on the day of admission. Children between 4 and 7 years should be told about a week before admission. Older children will usually be more involved in decision-making and need more discussion "in-advance". Many hospitals have play specialists who are expert at assessing and allaying children's fears, and you can arrange to visit the ward.

Can my child be sedated before the anaesthetic?

Sedatives are sometimes helpful, but not always. Taken by mouth, they are not pleasant to taste, can be spat out, and occasionally cause unexpected excitation. Nevertheless, even though we have emphasised these problems, sedation does calm most children. Sometimes children have sleep and behaviour disturbances after surgery and a sedative premed does help to reduce this problem. Behaviour should normalize within a few days or weeks. As a general rule, sedation is not necessary for infants.

Older uncooperative children need individual attention and will benefit from preparation with play specialists. A premed can be any drug given before the anaesthetic; occasionally painkillers or atropine (this dries secretions) are used.

During the operation:

Who will look after my child during surgery? The anaesthetist. Almost always we set up an intravenous drip and place a tube into the throat to control the breathing. We monitor your child closely and make sure that when they wake up they are as comfortable as possible.

Is it possible for my child to wake up during the operation?

This is extremely unlikely. In a recent study, in adults, the incidence of remembering something of surgery was approximately 1 in 100, but these were situations where the dose of anaesthesia had to be restricted. Further, the chance of remembering pain during surgery is much rarer than this figure.

Recovery and later:

After surgery, children will go to a recovery area until they are awake and comfortable enough to return to the ward. You can be with your child as soon as possible after they wake up.

What about pain?

General points: the pain will depend upon the surgery and age (see Table 1). Crying infants may be in pain or be hungry or both and comforting measures and feeding may help.

Infants having primary lip or palate repair. A combination of simple painkillers such as paracetamol and ibuprofen are not always effective enough and intravenous morphine is often required especially after palate repair. Local anaesthetic injections can "freeze" the lip but not the palate. In our experience infants having palate repair are best managed with intravenous or oral morphine for 12 hours postoperatively together with regular simple painkillers for at least 48 hours.

Secondary or revision surgery in older children is much less painful than primary surgery and opiates are best avoided as they tend to cause nausea and vomiting.

Pharyngoplasty operations cause a sore throat for up to a week and the pain is best treated with regular paracetamol and ibuprofen (or diclofenac).

In alveolar bone graft operations, bone is often taken from the hip and pain is minimised with local anaesthesia.

Pain after rhinoplasty or maxillary osteotomy can be managed with paracetamol and ibuprofen (or diclofenac).

Can my child eat and drink after surgery?

Babies and children can drink immediately after surgery if they wish. Children often fall back to sleep for a while after waking from the anaesthetic and will be ready
for food later on. Milk can comfort an infant although suckling can be painful after surgery to the lip and palate - one of our audits showed that nearly 50% of infants could not feed easily after cleft palate repair. Occasionally nasogastric feeding for a few days is helpful (via a tube passed through the nose into the stomach).

What is a nasal airway?

It is a nasal tube, long enough to sit behind the tongue, and designed to make sure that the tongue or the recently repaired palate does not obstruct breathing. A nasal airway (sometimes called a "prong") is necessary only after primary cleft palate repair and only in a minority of infants - usually those with a small mandible (infants with Pierre Robin sequence for example). The airway may be needed for a few hours and is usually taken out the following day.

How are the stitches removed?

Cleft lip stitches need to be removed between 5 to 7 days after surgery and this is either done under a short general anaesthetic or sedation.

Table 1 - Timing of surgery (These operations will not all be necessary for every child born with a cleft)

Primary cleft lip repair - Around 3 months
Primary cleft palate repair - Around 6 months
Grommets -  6 months at the time of cleft palate repair
Lip and/ or nose revision - Early childhood
Palatal re-repair or pharyngoplasty -  Early childhood
Alveolar bone graft - Around 10 years
Rhinoplasty - 17-18 years old
Maxillary osteotomy - 17-20 years old

Table 2 - Fasting times before surgery

Time before surgery Food/drink allowed:
Up to 6 hours before - Light meal and/ or formula milk
Up to 4 hours before - Breast milk
Up to 2 hours before - Clear fluids

General:

What are the risks of anaesthesia?

Risk is a difficult concept to explain.

First, the risk of death or brain damage due to anaesthesia is fortunately very small. How small? It is estimated to be between 1 in 10,000 to 1 in 100,000 anaesthetics. To put this in context, death or serious injury from an anaesthetic is 100 times less likely than from a road traffic accident. When things go wrong this can be due to unexpected reactions to anaesthetics, faulty equipment or anaesthetist error. It is generally agreed that the risk is least if the anaesthetic team is well trained and experienced: you should know that in the UK only specialist doctors are allowed to give anaesthetics and that paediatric anaesthesia is a subspecialty that requires different skills and knowledge, and further training. The prime aim of anaesthetists is to make anaesthesia as safe as possible and there are recommendations to maintain high standards. For example, routine anaesthesia is not undertaken if monitoring equipment is faulty.

Second, anaesthesia is associated with common minor problems such as nausea and vomiting, headache and sore throat. They occur in approximately 30% of patients and can be reduced but not eliminated. They also depend upon both the operation and anaesthetic technique.

Third, two common problems increase the possibility of chest complications which are not common but can be serious.

The common cold, as defined by a temperature, a runny or blocked nose, or a cough, can progress to pneumonia. If you are in doubt, ring the ward and ask for advice - this may save you a wasted visit.

Vomiting at the start or end of the anaesthetic can allow food to be aspirated into the lungs. This is very dangerous and is the reason why a child needs to be fasted or ‘nil by mouth' beforehand. See Box 2 to check on the fasting times but bear in mind that operation times do change and children may need to be fasted for longer to ensure that everyone can have their operation as planned.

What about my child's syndrome or medical disease?

Fortunately, standard anaesthetic drugs and techniques can be applied to almost all children, whatever their syndromes or medical condition. A few however will need special attention and your surgeon may ask you to see an appropriate specialist - a cardiologist for example. Many centres have an anaesthesia assessment clinic and, there, any potential problems can be dealt with. We need to know about any drugs taken because they will need to be taken both before and after anaesthesia.

Sources of information

(These organisations produce a booklet called ‘Your child's general anaesthetic')