INFORMATION FOR PARENTS OF CHILDREN HAVING AN ANAESTHETIC
It is important to read this information carefully before seeing your child's anaesthetist. The purpose of this website is to help you to understand your child's anaesthetic and to assist you in making informed decisions about your child's care. It contains a lot of information and you may need to read it more than once. Unfortunately, this amount of information is necessary to have you well informed. If you would like to, it is a good idea to discuss this information with a member of your family or a friend. The information provided is of a general nature and does not take your child's individual circumstances into account. It cannot replace specific advice about your child given to you by your child's own anaesthetist. If you have any questions or concerns, or there is anything you don't understand, talk to your child's anaesthetist. In Australia, most anaesthetics are provided by specialist anaesthetists or trainee anaesthetists under the supervision of specialist anaesthetists. However, this is not always the case. You should feel welcome to ask about the qualifications of the person anaesthetising your child.
WHAT IS AN ANAESTHETIC? The purpose of an anaesthetic is to remove the pain or awareness of an operation or procedure. There are a number of ways in which your child's anaesthetist can do this. Your child's anaesthetist will provide the type of anaesthetic most suited to your child's needs. This decision is based on a balance between your child's state of health, the specific risks and benefits for your child, the type and length of procedure and your input. In addition to removing the pain or awareness of an operation, your child's anaesthetist looks after your child's general well being during and after the procedure. This may include giving intravenous fluids and, when required, blood transfusions to replace bloodloss caused by the surgery or the use of drugs to maintain optimal levels for blood pressure, heart rate and rhythm and breathing. Your child's anaesthetist also manages your child's postoperative pain relief. A general anaesthetic is given using a combination of drugs that are injected into your child and gases that your child breathes. It is used to make your child unconscious in a carefully controlled way. Your child's body has a number of reflex responses to the painful stimulus caused by the surgery, even when your child is not aware of the pain. These responses include changes in blood pressure, raising or lowering of heart rate and alteration of breathing. As well as making your child unconscious, the anaesthetist also controls changes in your child's blood pressure, heart rate and breathing that are caused by the surgery. For some larger operations, drugs are used to weaken your child's muscles and a machine called a ventilator is used to do the beathing for your child. Muscle relaxing drugs are used in long procedures or to make it possible for the surgeon to do a particular operation. For most procedures, your child is asleep and able to breathe alone without the assistance of a machine. Sedation is the use of drugs to make your child sleepy, but not as deeply asleep as a general anaesthetic. Sedation is usually used for shorter, less painful procedures in adults and less frequently in children. It may be used in combination with a local anaesthetic block. It has advantages over a general anaesthetic in that it may be safer, causes less nausea or vomiting, and allows quicker recovery. It is not unusual for patients receiving sedation to wake up during the procedure and to be aware of what is going on around them. After the procedure, most patients do not remember being awake, but some patients do recall what has happened. This is not an unpleasant experience and should not be of concern. If you have any concerns about this, you should talk to your anaesthetist. Local anaesthetic blocks involve the injection of special drugs that make specific parts of the body go numb. This can range from making a single finger go numb to making half of your body numb. These blocks are particularly safe when small parts of the body are made numb. Larger blocks, such as epidural or spinal anaesthetic, can also be safer than a general anaesthetic. Local anaesthetic blocks provide better pain relief following surgery and are often combined with a general anaesthetic. They can also be used with sedation.
TYPES OF LOCAL ANAESTHETIC BLOCKS
Local anaesthetics may be injected directly at the site of surgery, or to block a single nerve or even whole groups of nerves to make parts of the body go numb and prevent pain. Intravenous limb block. Although this type of block is commonly used in adults, it requires the cooperation of the patient and is less frequently used in children. For this type of block, your child's anaesthetist puts a tourniquet around your child's upper arm or leg and injects a local anaesthetic drug into a vein in your child's hand or foot. This is a very reliable block for making the arm numb, particularly for short procedures and is less commonly used in the leg. However, there can be some discomfort from the tourniquet and for this reason it is common for the anaesthetist to give sedation as well.
Nerve plexus blocks. Nerves are grouped together in some parts of the body. Such a group of nerves is called a plexus. The whole upper limb and parts of the lower limb can be made numb by injecting a local anaesthetic drug near the groups of nerves that supply the limbs. For the upper limb, this is most commonly done by injecting the local anaesthetic into the armpit. For the lower limb, this can be done in the upper thigh or behind the knee. It is usual in children to give a general anaesthetic or sedation when the block is put in. This technique is best used for longer, larger operations on the limbs.
Individual nerve blocks. Individual nerves in the face, mouth and limbs can be blocked by injecting the local anaesthetic near the individual nerve that supplies the area of the body where the procedure will take place. These blocks are particularly safe. Because smaller doses of local anaesthetic are required there are less potential complications. This type of block is most useful for dentistry or surgery on the hand or fingers. Spinal and epidural anaesthetics. An epidural or spinal anaesthetic is an injection of local anaesthetic, often with other pain-relieving drugs, into the lower back. Your child's anaesthetist uses this type of block to make a large region of your child's body go numb. Your anaesthetist may recommend this type of block, because it may provide better safety, quicker recovery and better postoperative pain relief than a general anaesthetic alone. Running down the middle of the backbones (spine) there is a sac of fluid called the dural sac. A spinal anaesthetic is an injection of local anaesthetic through the back, into the fluid inside the dural sac. An epidural anaesthetic is an injection of local anaesthetic through the back, into the area outside of the dural sac. Nerves travel both inside and outside the dural sac and the local anaesthetic is used to block these nerves and make parts of the body go numb.
Epidural anaesthetics are usually used for treating postoperative pain following large operations. Epidurals can also be used to treat long-term pain. This is because a plastic tube, called an epidural catheter, can be threaded into the epidural space and left there for ongoing doses of local anaesthetic until pain relief is no longer required. An epidural may be used for several days. Spinal anaesthetics are usually used as a single injection of local anaesthetic for an operation. The single injection lasts for 2-3 hours Sometimes a combined epidural/spinal technique is used and can offer the benefits of both techniques Another common local anaesthetic block is a caudal anaesthetic. This is like an epidural anaesthetic, but given lower down in the back. Caudal anaesthetics have been shown to be particularly safe and useful in children.
WHAT SHOULD I DO BEFORE MY CHILD'S ANAESTHETIC? • You will need to follow the instructions your surgeon gives you. • Your child will need to fast before the anaesthetic. This means no food or drink, not even water, lollies or chewing gum. If your child doesn't fast, there is a risk your child will vomit while under the anaesthetic and that material from the stomach will go into the lungs and cause serious lung infections. It is usual for your child to be allowed to eat up to six hours before the anaesthetic, have milk up to four hours before the anaesthetic and drink water up to two hours before the anaesthetic. Your surgeon will let you know exactly how long your child needs to fast. • Keep giving your child regular, prescribed medications, but remember to let your child's surgeon or anaesthetist know what your child is taking. It is especially important to continue taking medication to control asthma or epilepsy on the day of the anaesthetic. If your child is diabetic you will need to adjust your child's medications because of the surgery and must ask your surgeon or anaesthetist what to do before the day of your child's operation or procedure. • Do not give your child herbal or alternative products for at least two weeks before the anaesthetic, as some of these products may interfere with the anaesthetic, blood clotting and blood pressure. • If your child has a cough or cold in the week before the procedure contact your surgeon or anaesthetist. • If you object to blood transfusions you should let your surgeon know. Donated blood is carefully screened, but the risks of infection or reactions cannot be totally eliminated. Your doctors will only consider giving your child a blood transfusion if they believe the benefits to your child outweigh the risks. • Your anaesthetist will usually see your child on the day of the operation, if you have any concerns or questions you would like to discuss before this, you should contact your anaesthetist prior to the day of the procedure. • If your child has any serious health problems, let your child's anaesthetist know before the operation Your child's anaesthetist is especially interested in lung or heart problems; problems with blood clotting; or if your child or anyone in your family has had problems with anaesthetics in the past. Your child will receive better care, if your child's anaesthetist has all the information.
WHEN MY CHILD SEES THE ANAESTHETIST• When you see your child's anaesthetist on the day of the operation, you will be asked a number of questions about your child's general health, medications and allergies, past medical problems, family medical problems, teeth and problems with past anaesthetics. You will also be asked about the procedure or operation your child is about to have and how long since your child last ate or drank. Bring all the medications your child is taking with you to show your anaesthetist. It is helpful if you bring a list of the medications and doses your child takes as well. • Let your anaesthetist know before the operation, if your child has any health problems, especially asthma or bronchitis, other lung or heart problems, problems with blood clotting or if your child or anyone else in the family has had problems with anaesthetics in the past. You will receive better care if your anaesthetist has all the information. • Your anaesthetist will also collect personal details about you and your child such as name, date of birth, address, and health fund, Medicare and motor vehicle accident details, if required. • The personal information collected by your child's anaesthetist is used for the purposes of providing your child with anaesthetic care, referral and discussion with other health care providers looking after your child, billing and medical indemnity purposes. Government Privacy Legislation protects all the information collected. • Your child's anaesthetist will also perform a physical examination, concentrating on your child's heart and lungs. • Your child's anaesthetist will discuss the anaesthetic with you, including the associated risks; the usual side effects your child may experience and planned pain relief after the procedure. You will have the opportunity to ask questions and are encouraged to do so. • Your child's anaesthetist may order a medication to relax or calm your child before the procedure or operation; this will usually be in the form of a drink. Usually this type of medication is not necessary, especially when your child is having day surgery, as this type of medication may keep your child drowsy for longer and may delay you taking your child home. It is common for your child to be given paracetamol before the anaesthetic to help with pain relief after the surgery. DURING MY CHILD'S ANAESTHETICWhen it is time for the procedure, your child will be taken to the anaesthetic room or operating theatre. For children over one year of age one parent may be able to stay with your child until he or she is asleep. Although watching your child drift off to sleep may be stressful for some parents, having mum or dad present is often very reassuring for your child. The anaesthetic may be started by giving your child an injection or by giving your child special gases to breathe through a facemask. Sometimes your child will be given oxygen to breathe through a facemask before the anaesthetic starts. When an injection is given, local anaesthetic cream is usually used on the skin first so that your child will not feel the injection. Anaesthetic drugs given by injection work very quickly and your child may suddenly become floppy and unconscious. This may surprise parents but is of no concern. When gases are used your child may take a minute or two to go to sleep. During this time your child may become restless. This is expected and is usually not remembered by the child. Your child's anaesthetist routinely uses an intravenous line (drip), a pulse oximeter, blood pressure monitor and an ECG during your child's anaesthetic. Intravenous Line. An intravenous line or drip is a small plastic tube or cannula that is inserted into a vein. A vein is a blood vessel that carries blood back to the heart. Your child's anaesthetist uses the drip to give your child drugs or fluids during and after the anaesthetic. Risks associated with an intravenous drip include pain and bruising at the insertion site that usually resolves in a few days and infection. Pulse Oximeter. A pulse oximeter is a small peg that the anaesthetist places on your child's finger, toe or earlobe to monitor your child's pulse and the oxygen level in your blood. Blood Pressure Monitor. Your child's blood pressure is monitored via a cuff placed around the upper arm. The cuff can be inflated either manually or automatically in order to measure your child's blood pressure. ECG. An ECG, or electrocardiograph, monitors the electrical activity of your child's heart. It is not invasive and small electrodes or leads are connected to sticky patches that are placed on your child's chest and limbs. Your anaesthetist uses the ECG to monitor the rate and rhythm of your child's heart. An ECG also provides information about whether enough oxygen is getting to the heart, past damage to the heart and how well your child's heart is functioning. The only side effect of an ECG may be some skin irritation from the sticky patches. Your child's anaesthetist understands the importance of looking after your child's wellbeing very carefully during the procedure and remains with your child during the whole anaesthetic. In Australia an aneasthetist only cares for one patient at a time. Your child's anaesthetist uses sophistocated equipment to monitor your child during the anaesthetic. This equipment is used to measure your child's breathing, oxygen level, blood pressure, heart rate, heart rhythm and the level of anaesthetic. Your child's anaesthetist adjusts the anaesthetic according to your child's needs. For large operations or for sicker patients, your child's anaesthetist may use some of the following procedures to monitor your child more closely and provide your child with optimal care. These procedures are not used routinely for most operations. Arterial Line. Arteries are blood vessels that carry blood away from the heart. An arterial line is a plastic tube or cannula that is inserted into an artery, usually at the wrist. The anaesthetist uses an arterial line to measure blood pressure very accurately or to collect blood samples. Arterial lines are used with some anaesthetics or in Intensive Care Units. Risks associated with arterial lines include pain and bruising that can be more severe than that caused by an intravenous line, but which still resolves within a few days, or infection. There is an extremely small risk that the artery will become blocked and cut off the blood supply to part of the hand. This would not normally cause a problem as two arteries carry blood to the hand in most people. However, in a small number of people only one artery supplies the hand and this type of blockage may cause permanent damage to the hand. Central Line. A central line is a plastic tube inserted into a major vein in the neck, or below the collarbone. This is a larger tube than an intravenous drip and the anaesthetist uses this for measuring pressures in the veins, giving fluids and drugs and assessing how much fluid is in your body. A central line is more likely to be used in association with larger operations or to closely monitor more seriously ill patients and does not need to be changed as often as intravenous drips do. Risks associated with Central Lines include pain; bruising and infection as with other lines into blood vessels, however because of the position of a central line there are also some other potential risks. It is possible to damage nearby structures when a central line is being inserted, these structures include the lung or the carotid artery (the main artery in the neck) or the subclavian artery (main artery to the upper limb). Nasogastric tube. A nasogastric tube is a plastic tube that goes from the nose down into the stomach to help empty the contents from the stomach. Even when your child hasn't been eating the stomach still makes acid and the surgeon may ask the anaesthetist to insert a nasogastric tube, especially if your child is having surgery on the intestines. There is a very small risk of damage to the nose, throat or oesophagus when the tube is inserted. All needles, syringes, drugs for injection, intravenous equipment and fluids are sterile items that are used for one patient only. Other items of anaesthetic equipment are either single patient use, are sterilized before each use in accordance with Australian Standards, or are protected by viral and bacterial filters. These measures have been shown to be extremely effective in preventing cross infection.
AFTER MY CHILD'S ANAESTHETICWhen the operation or procedure is finished, your child will be taken to the Post Anaesthetic Care Unit. The anaesthetist hands your child's care over to specially trained recovery nurses in the Post Anaesthetic Care Unit. Once your child has woken up, you may be called to come and wait with your child until he or she is ready to be moved from this specialized area. It is standard for children to be given oxygen to breathe and for monitoring of the pulse, heart rate, breathing and oxygen level to continue while your child recovers from the anaesthetic. The effectiveness of pain relief is also assessed. Postoperative pain. The anaesthetist aims to have your child as comfortable as possible following the operation or procedure and will order pain relief for your child. However, it is not always possible to have your child totally free of any discomfort. The use of local anaesthetic blocks, with or without general anaesthetic best reduces postoperative pain, but other methods include: tablets, mixtures, suppositories (medicine via the back passage), injections into muscles or veins or combinations of these. A method for delivering postoperative pain relief following larger operations is to use an electronic pump to deliver doses of pain reliving medicines through the intravenous drip. The pain relief can be given to your child at a steady rate from the pump, or be available to some older children as small doses when your child pushes a button attached to the pump, or both. Your child's need for pain relief will depend on the type of procedure your child has. While your child is in the Post Anaesthetic Care Unit, the recovery nurses will assess your child's pain level. Different children need different amounts of pain relief and the nurses are used to assessing your child's requirements. If you have concerns about postoperative pain, you should discuss them with your child's anaesthetist. SIDE EFFECTSDizziness, drowsiness, headache and blurred vision occur in about 20% of children and usually wear off quickly. Shivering is common during the first fifteen minutes following a general anaesthetic but is of no medical concern. Occasionally muscle weakness can be noticed immediately after the anaesthetic, and may briefly cause difficulty with breathing. Children often wake up feeling confused, frightened or teary. Your child may appear to be distressed but these problems recover quickly and usually your child has no memory of them. Swelling, bruising and tenderness at injection sites are common and recover within a few days. Nausea and vomiting are the most common side effects of general anaesthetics, up to 50% of children experience some nausea and 35% of children may have vomiting. They are more likely to occur with longer and larger operations, abdominal surgery- including laparoscopy, and surgery on the ear. They are less likely to occur when sedation or local anaesthetic techniques are used. There is a lot of individual variation, with some children more likely to experience these side effects. If your child has had problems with nausea and vomiting after anaesthetics in the past, tell your anaesthetist, as there are ways to tackle this problem. Once your child is fully asleep, it is common for your anaesthetist to place a tube in the airway to help maintain your child's breathing during the anaesthetic. This may occasionally cause a sore throat or hoarse voice, which usually recovers within 24 hours. After surgery on the mouth or face, it is possible to have black eyes or a nosebleed. Muscle aches and pains are uncommon, but can occur when certain anaesthetic drugs are used. These are more likely to occur after emergency surgery, but usually recover within three days. These aches and pains are usually controlled with paracetamol. RISKS AND COMPLICATIONSAnaesthetics in Australia are among the safest in the world. For a fit and healthy person, general anaesthetic and local anaesthetic blocks are no more hazardous than a couple of short trips in the car. This level of safety is because, in addition to being a fully trained medical practitioner, your anaesthetist has spent an additional five years completing a high level of specialist training in anaesthetics, pain relief and treating emergencies and participates in continuous education and professional development.. The newer anaesthetic drugs and modern anaesthetic equipment make having an anaesthetic the safest it has ever been. However, as with driving a car, it is not possible to totally eliminate risk. Although very uncommon, anaesthetic complications do occur and these complications may be serious. These risks may be higher for children who are less healthy, especially for those with heart or lung disease and those undergoing longer, more complex procedures.
Awareness. During a general anaesthetic, it is possible to be awake, unable to move and aware of what is happening around you. This is called awareness and only occurs during general anaesthetics where muscle-relaxing drugs are used. Most general anaesthetics do not require muscle-relaxing drugs. It is also possible to dream of being aware, without it actually happening. Where muscle-relaxing drugs are used, awareness may occur in up to 1% of adults, but is very uncommon in children. For children who are given sedation rather than a general anaesthetic, being aware and comfortable is expected and is not of concern. Death or serious complication. This may include conditions such as: heart attack; stroke; brain damage; fitting; pneumonia; DVT (blood clot in the leg) and pulmonary embolus (blood clot in the lungs); major allergic reaction; irregular heart beat; kidney, lung or liver failure; permanent nerve damage; permanent damage to voice; eye damage; and infections or reactions to blood transfusions. Even though many parents are worried about this, the chance of your child dying or having a serious complication because of an anaesthetic is extremely low. For a young healthy person, the chance is so low that it is not possible to measure it accurately. For those with poor general health, especially heart or lung disease, the risks may be greater. You should discuss your child's individual risks with your anaesthetist. Damage to teeth. Every care is taken by your anaesthetist not to damage teeth. Children between the ages of 5 and 10 often have loose teeth. Although dental damage is uncommon, it is important to understand that with any general anaesthetic there is a small risk that teeth may be damaged or loosened. Although very uncommon, injury may also occur to the larynx (voice box), vocal chords, lips, throat or tongue. Incidental injury. Very rarely, a child who is unconscious or drowsy is injured accidentally. For example, falls from operating table, eye damage, pressure injury, stretching injury, or unintentional burns. Very rarely, a child who is unconscious develops a nerve injury, which may result in an area or region of numbness or weakness, despite the best positioning or padding.
RISKS ASSOCIATED WITH LOCAL ANAESTHETIC BLOCKS.
For children it is common to use local anaesthetic blocks in combination with a general anaesthetic or sedation. Local anaesthetic blocks provide better postoperative pain relief and may lead to quicker recovery. The local anaesthetic blocks last for several hours, but your child may need additional pain relief when the block wears off. As with general anaesthetics, there are risks associated with local anaesthetic blocks. Pain at injection site. Pain and bruising at the injection site are common but are expected to resolve within 2 weeks Inadequate block. Different types of local anaesthetic blocks vary in their reliability. If a block is inadequate for postoperative pain relief, it may be possible to repeat the block or give other pain relief. Death or serious complications. These are the same types of risks as those discussed for general anaesthesia. Although these risks are often lower with a local anaesthetic block than with general anaesthesia, they still exist and cannot be totally eliminated. Post spinal headache. A headache can occur after spinal or epidural injection in up to 1% of healthy young people. This headache can be mild or severe and usually resolves spontaneously over 1-3 weeks. It can be cured more quickly using an epidural injection of the child's own blood. If your child has a persistent headache following an epidural or spinal anaesthetic you should contact your child's anaesthetist. It is also possible to have temporary deafness following a spinal anaesthetic. Infection. Infections are extremely rare, so rare that it is not possible to give an accurate incidence. All of the needles, catheters, local anaesthetics, intravenous drips, syringes, tubing and fluids are sterile and used for one patient only. Your child's anaesthetist uses a sterile technique to insert a local anaesthetic block. However, it is not possible to totally eliminate the risk of infection at the injection site. With epidurals and spinal anaesthetics it is possible to develop an infection around the spinal cord, causing meningitis or an abscess. This extremely rare type of infection may have serious consequences and result in brain damage, paraplegia or death. Infection may require antibiotic treatment, or very rarely surgery. Nerve Damage. Nerve damage is uncommon and usually only temporary, but rarely may be permanent. The type and extent of damage depends on where the block is placed. Nerve damage may range from causing a very small area of numbness, pain or weakness to, in extremely rare cases, paraplegia or quadriplegia. Once again, these risks are usually lower than those of a general anaesthetic. WHEN YOU TAKE YOUR CHILD HOME
• Anaesthetic drugs can remain in your child's system for 24 hours after an anaesthetic and may make your child drowsy. Take your child home by car or taxi; do not use public transport. • Local anaesthetic blocks take time to wear off. If part of your child's body is still numb, take care that your child doesn't injure him or herself • You may be told to give your child paracetamol every 4 hours for the first 24 hours after the operation. Paracetamol works best if it is given regularly. • If your child has ongoing nausea, vomiting or pain, or if you have any other concerns call your anaesthetist, surgeon or the facility at which your child was treated.
OUT OF POCKET COSTS
If your child is treated as a private patient, there will be an out of pocket cost with most anaesthetic services. There are no standard charges, each anaesthetist sets his or her own fees. The level of the ‘gap' or out of pocket cost will also depend on whether or not your family has Private Health Insurance, the type of insurance you have, the type of procedure your child is undergoing and how long the procedure takes. You should ask your child's surgeon or anaesthetist about the cost of your child's anaesthetic.
This information has been prepared by Dr G Eastaugh, Dr L Eastaugh and Dr J Waters to give you a better understanding of you child's anaesthetic, but cannot replace professional advice regarding your child's individual circumstances. It is important that you are satisfied that you understand the information regarding both your child's procedure and the anaesthetic. If you are unsure or concerned about any of this information you should talk to your anaesthetist. Your anaesthetist can assess your child and discuss your child's risks at the pre anaesthetic visit or earlier if required.
Copyright. © Tellwave Pty Ltd 2003 (Revised July 2007). All Rights Reserved.
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