General anesthesia in children
In young children, general anesthesia is usually unavoidable for important operations. It is used to temporarily switch off the child's consciousness in order to relieve him of the emotional stress and to calm him down so that the surrounding tissue is not injured during the procedure. Immobilization for longer periods of time is only possible with general anesthesia.
Even with interventions that are normally carried out in adults while awake, such as. a gastroscopy, general anesthesia may be indicated for young children, as it is not possible to explain to them exactly what will happen to them in advance. Thus, primarily emotional trauma should be avoided.
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Should a young child undergo a procedure that requires general anesthesia, there are a few things to be aware of. Infants are not "little adults", i.e. Compared to the adult, the toddler has a different metabolism, a different body composition (higher relative water content) and has not yet completed organ maturity.
In addition, it has a significantly larger body surface in relation to its body volume, so that it cools down much faster. These are all factors that doctors must take into account during anesthesia. This is one of the reasons why it is advisable to have interventions in small children performed in specialized centers, which often deal with this group of patients.
Preparation for general anesthesia
Before the procedure, the anesthetist clarifies a few questions with the parents. Important things to be recorded are the child's previous illnesses, allergies and current colds. If possible, a child should not be exposed to anesthesia for up to six weeks after an infection, as this increases the risk of respiratory complications.
If vaccinations have been given beforehand, an anesthetic should be at least two weeks apart (Vaccination with live vaccine) or at least three days (Vaccination with dead vaccine) be respected. In emergencies or other interventions that cannot be postponed, the anesthesia is initiated anyway. Furthermore, the sobriety requirements are clarified in the conversation. Infants must not consume solid food up to six hours before the procedure and no clear liquids (water, apple juice, tea) up to two hours before the procedure. Newborns and infants may be breastfed or bottle-fed up to four hours before induction of anesthesia. Small children from the age of 12 months are usually given an anxiety-relieving, calming drug before the anesthetic is started. Midazolam (Dormicum®) in the form of a juice is used for this purpose.
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However, calm parents are particularly important to calm the child. They should treat their child as normally and informally as possible in order not to make them unnecessarily nervous.
General anesthesia procedure in children
The anesthesia can now be initiated.There are two different ways of doing this: on the one hand, the Induction of anesthesia using a mask, on the other hand the Initiation by means of medicationthat are injected directly into the vein. Mask induction is usually reserved for younger children, venous induction is reserved for older children. Since children are more sensitive to pain, with the second variant a pain reliever plaster can be applied in advance near the puncture site so that the child does not feel the puncture.
When introducing the mask, the child breathes in a mixture of anesthetic gas and oxygen through a mask placed on him. The anesthetic gas sevoflurane, which has a pleasant odor, is usually used here. As soon as the child is asleep, a venous access can be made, through which further medication (pain relievers, muscle relaxants (medication to relax the muscles)) can be administered. The substances administered depend on the type and extent of the planned intervention. Usually the parents are allowed to stay with them until their child falls asleep. Sometimes, however, this is prohibited for hygienic reasons. Subsequent anesthetic induction steps are then carried out in any case without the parents being present.
Since the child does not breathe independently during general anesthesia, it has to be mechanically ventilated. A hose, so-called Tube, inserted into the windpipe (intubation). This is only possible when the anesthesia is deep enough and the child's muscles are relaxed. The oxygen saturation of the blood can then be continuously monitored using special adhesive electrodes. After successful intubation, the child is also connected to an electrocardiogram (EKG) to measure heart activity and to a blood pressure monitor.
During the operation, the child is placed on heated blankets. Disinfectants and other required solutions are warmed up if possible to prevent the child from losing heat unnecessarily. The child's body temperature can be continuously monitored using a probe placed either in the rectum or in the nasopharynx. In addition, the child will be given infusions of nutrient solutions and electrolytes during the operation. In the event that major blood loss occurs during the procedure, blood reserves that have been matched to the child are available in advance.
After the operation is completed, the child is taken to the recovery room, where they can sleep in in the presence of their parents and wake up again in peace. Adequate pain therapy is part of it in advance so that it is also pain-free after the operation. Paracetamol suppositories, which can be given to the child when the anesthetic is initiated, have proven to be effective. For example, diclofenac (Voltaren®) can be used for moderate pain following the procedure or piritramide (Dipidolor®) for even more severe pain. A so-called caudal block can also be performed for operations below the navel. The child is injected with a local anesthetic just above the coccyx between the vertebral bodies, so that the nerves running in this region are numbed. The advantage of this regional anesthetic is that the child needs less anesthetic during the procedure and also remains pain-free for a few hours afterwards. It is carried out while the child is already under anesthesia so that it does not notice anything.
Overall, anesthesia in children is a very safe procedure these days. Complications can of course never be ruled out, but have become rare overall. After waking up from anesthesia, the child may complain of nausea or vomit (10% of the time). Some children also have a sore throat, which can be caused by minor injuries from the breathing tube. Last but not least, some children are agitated, restless and tearful after anesthesia. This can be caused by the after-effects of the medication and is initially not a cause for concern. As a rule, there is no need to fear permanent damage from today's methods and drugs. Nevertheless, procedures should only be performed under general anesthesia if absolutely necessary.
The latest findings from US studies have shown that gas anesthesia in the first year of life can have a lasting effect on memory performance.
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How dangerous is general anesthesia in children?
Reports of complications and accidents related to general anesthesia keep appearing. General anesthesia for children in particular has been a hot topic for some time and many parents have concerns about exposing their child to general anesthesia. It is entirely appropriate to pay sufficient attention to this issue. For this reason, some studies have now been commissioned.
An interim balance can hardly be drawn up to now, as the few studies that have been published so far are partly contradicting or have been heavily criticized. For example, an American study that apparently shows that general anesthesia causes lifelong damage to the brains of children. However, since only a very small group of children with very different underlying diseases were examined, this study can hardly be used as an argument.
This is in contrast to the results of several German, Dutch and American studies, which show that the brain of children, in contrast to the brain of adults, is more sensitive, but also has a much greater ability to repair. General anesthesia in children is therefore quite justifiable.
The next question is what side effects a child can suffer from directly after general anesthesia. It should be said that anesthesia has developed into a very safe procedure in recent decades. Thanks to newly developed, very well-tolerated drugs and uninterrupted medical technology monitoring, the rate of serious complications is very low nowadays. Nevertheless, minor side effects can often not be avoided.
It should be noted that worries about the well-being of your own child are by no means inappropriate. “The best operation is always the one that can be avoided,” is an old medical wisdom. However, it should always be assessed how important an operation is for the child's later development. Hardly any doctor will expect a child to undergo surgery that he does not consider urgent. However, it is not only about emergency operations, but also about minor interventions. For example, the undescended testicle, which is often underestimated, can lead to permanent damage if it is left untreated. In this case, a single general anesthetic is preferable to a lifelong increased risk of testicular cancer or the risk of permanent infertility.
Read more about this under: Risks of general anesthesia.
Immediately after a general anesthetic, the children are often very sleepy and confused because the anesthetic drugs are still in the body and are only gradually broken down. Some children also react tearfully and aggressively after the operation. These states of restlessness, in which the children sometimes lash around, usually occur in children between the ages of three and seven and usually only last a maximum of a quarter of an hour. Sometimes it is necessary to give the children a sedative. Common after-effects of general anesthesia include a sore throat and hoarseness. This comes from the ventilation tube that is pushed into the windpipe in most general anesthesia and can irritate the glottis. Furthermore, some children react with nausea and sometimes with vomiting. Most of the time, this aftereffect is directly due to the anesthetic drugs, but the nausea can also be caused by irritation of the throat during ventilation. Another reason for the nausea can be swallowed blood during throat and oral surgery, which is later vomited again. Since the children can still be confused and inattentive a few hours after the anesthesia, they should not ride bicycles or travel alone even after outpatient operations.
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General anesthesia in children despite having a cold
A mild to moderate cold is usually not a reason to cancel an operation in adults. With children, however, it looks a little different.
The airways of children are much more sensitive, which is why they are generally more likely to have problems with the airways. The mucous membranes of your airways have a higher tendency to swell. If the mucous membranes are also attacked by a viral infection (colloquially known as a cold or runny nose), the risk of complications increases.
A cold causes the lining of the patient's large and small bronchi to swell, causing the airways to narrow. At the same time, the small gland cells of the bronchial mucous membrane produce more mucus in order to fight off the pathogens. In any case, this often leads to the fact that we get bad air with colds and have an increased urge to cough. This makes intubation, i.e. the placement of a ventilation tube, noticeably more difficult in preparation for general anesthesia, especially in children, as their airways are smaller. In the worst case, this can even lead to a convulsive airway obstruction, Bronchospasm called, come.
General anesthesia in children despite a cold is by no means to be taken lightly. For this reason, it is important to inform pediatric surgery before the day of admission or operation that your child is sick so that the anesthetist in charge can decide whether an operation is still possible or not. The condition of your child should in no way be played down. Only if the anesthetist can get an exact picture of the condition of your child is it possible to make an appropriate decision on how to proceed.
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General anesthesia at the dentist
Visits to the dentist are very uncomfortable and sometimes painful for many adults. In addition, especially for small children under four years of age, it is often difficult to understand how important dental treatment is. The bright light of the treatment room, the strange noises made by the instruments and the absence of their parents therefore quickly frighten them. For this reason, general anesthesia is often indispensable for the success of the treatment in the context of major dental treatments in children.
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Indications for this are usually extensive damage to the milk teeth, if local anesthesia is not sufficient due to inflammatory processes or in children who are still very small and unwilling to be treated. General anesthesia has great advantages here. The treatment can be done much more efficiently and the child will not develop any negative associations with dental visits in the future. In recent years, however, there have been increasing reports of complications and even deaths, particularly as a result of general anesthesia. First of all: overall, complications during such dental treatments in children under general anesthesia are rare. However, it can't hurt to think in advance about how you can recognize good anesthetic staff or professional handling of the little patients.
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As a rule, parents can tell from their first impression of the dental practice whether the doctors are trained in treating children. If, on the other hand, the practice gives the impression that the treatment of children is more likely to disrupt the practice than to be seamlessly integrated into it, this is not a good sign. To be on the safe side, you can ask how often children are treated here. Apart from this, there are children's dental practices in which the anesthetists specialize in anesthetizing young children. In any case, the anesthetist should be able to take enough time in the preliminary discussion to be able to answer all of your questions. A detailed information sheet should be available and discussed with the parents. It is also imperative that the anesthetist get an overview of your child's health through basic examinations such as listening to the lungs and heart.
A healthy trust in their gut feeling cannot harm the child's parents in any case. If the practice and the team do not inspire confidence, your child should be treated in another practice.
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