Children undergoing surgery need special care with anesthesia

07/26/2014 7:39 PM

08/04/2014 2:40 PM

When Joshua Lenchus returned to his Davie home from work the evening of July 7, he was pleased to find his 16-month-old son Samuel happy and eating regularly.

That very morning, Samuel was administered anesthesia before his surgery at the University of Miami at Jackson Memorial Hospital to unblock a tear duct in his right eye, a condition he has had since birth.

Lenchus, a 45-year-old hospitalist, initially had concerns about Samuel undergoing anesthesia for the surgery, which included inserting a stent.

“You are concerned about him having a bad reaction,” Lenchus said, adding Samuel had two previous procedures at another hospital that were unsuccessful. “Are they going to come out of the anesthesia? It is not something you are well prepared for but they did a tremendous job prepping us.”

Lenchus and his wife, Deborah, have three other children, including Samuel’s twin sister, Hannah.

Lenchus spoke with the pediatric anesthesiologist, Jackie Tutiven, a few days before the surgery.

“She allowed me to escort Samuel into the operating room so while she administered the anesthesia, I could be there to console him,” Lenchus said.

Children are usually given a sedative such as a liquid form of midazolam before surgery, which eases stress and induces sedation, said Dr. Lydia Jorge-Reynolds, assistant professor of pediatric anesthesia at the University of Miami at Jackson Memorial Hospital. The children then receive general anesthesia administered through a mask over their face that puts the child into a deep sedation.

Sedations and monitored anesthesia are also used for babies undergoing less invasive procedures such as CT scans and MRIs that require the child to lay motionless, Jorge-Reynolds said.

Cherica Fremond, 4 months old, was administered anesthesia to undergo an MRI of her brachial plexus July 9 at Miami Children’s Hospital. She is due to have surgery in September. Cherica suffers from a brachial plexus injury, which is a loss of movement or weakness of the arm that occurs when the nerves around the shoulder are damaged during birth.

Cherica’s mother, Nadege Jean Michel of West Palm Beach, noted she was initially anxious about anesthesia being given to her child. She talked it through, however, with the medical staff at Miami Children’s Hospital.

“I am OK,” Jean Michel said. “If she doesn’t have the surgery her right hand will not work.”

Whereas adults usually receive pre-dosed anesthesia based upon an ideal body weight, children receive doses based upon their actual weight, said Dr. Sandra Kaufmann, chief of pediatric anesthesia at Joe DiMaggio Children’s Hospital.

“With pediatrics, personality and various sizes in patients causes things to be different,” Kaufmann said.

Children are not small adults, said Dr. Rafael Gonzalez, anesthesiologist and director of pain management at Miami Children’s Hospital. There must be an awareness that a child’s physiology changes during the different stages of development.

“It is a misconception when people think it is a smaller person and you just give smaller doses,” Gonzalez said. “It is a lot more involved than that. You have to understand the physiology and have a plan that addresses that.”

In contrast to adults, children younger than 7 don’t really understand levels of pain, Gonzalez said.

“It’s an abstract thought — if they are going to feel a little or a lot of pain,” Gonzalez said. “They cannot tell the difference.”

There are more risks involved with administering anesthesia to children than adults, said Dr. Maria Forrest, director of pediatric anesthesiology at Kendall Regional Medical Center. Children can respond negatively quicker while under anesthesia but they can be awakened quicker.

“So if their blood pressure drops, it will drop a lot faster than an adult,” Forrest said. “They are smaller and they don’t have the same amount of volume that an adult has.”

Kids are also more likely to have undiagnosed diseases. By the time a person reaches adulthood, they are usually aware of their medical issues.

“Anesthesia is like flying a plane,” said Kaufmann of Joe DiMaggio. “The scariest parts are at the beginning and the end. So everyone is on high alert to look out for dangers.”

One of those dangers could be a child being allergic to a medication, Kaufman said.

“Most of the kids haven’t had anesthesia before so there is a risk of an allergic reaction,” Kaufmann said.

One of the conditions that can become unmasked during anesthesia is malignant hyperthermia, Kaufmann said. It is a rare, inherited condition characterized by a rapid, extreme, and often fatal rise in body temperature following the administering of general anesthesia.

Forrest once treated a 6-year-old boy who was undergoing abdominal surgery after an accident. While under anesthesia, it was discovered he had malignant hyperthermia.

“It was a trauma patient, who tend to get cold,” said Forrest, who treated the condition with dantrolene. “This patient was heating up.”

Patients are unaware that they have the disease unless someone else in their family has already been diagnosed, Kaufmann said.

“It is one of the things adults don’t have to deal with,” Kaufmann said. “Adults usually know what they are allergic to.”

Children can also suffer minor injuries such as the loss of a tooth, lacerations to the tooth or gums, or a sore throat due to general anesthesia being administered with a gas mask, Forrest said. They may also suffer vomiting or nausea.

The most rewarding part about being a pediatric anesthesiologist is the look of relief on the faces of family members after a successful surgery, Kaufmann said.

“They come in terrorized and they leave happy,” Kaufmann said. “We go out of our way to make it as stress free as possible.’’

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