Anesthesia and Pain Control

Pre-Operative Visit with the Anesthesiologist

Preparing for Pediatric Heart Surgery

Look up a term in The Heart Center glossary.

Explanation | Questions for Patients | Family History | Questions for the Anesthesiologist

What does an anesthesiologist do?

The anesthesiologist is the physician responsible for the administration of drugs which will cause a patient to be unaware, or "asleep" during surgery.

The anesthesiologist also provides a secure airway, controls breathing, places various lines used to closely monitor your child during surgery, and administers the fluids and other drugs necessary to get the patient safely through the operation.

Anesthesiology is a big responsibility, and we recognize no two patients are the same. Therefore, it is important that we meet with each family before surgery to discuss a patient's health history, examine the patient and review laboratory tests so we can plan an appropriate anesthetic. At that time, the anesthesiologist can explain what they will do on the first day of surgery and what types of anesthetic drugs they plan to use.

For surgical pstients, most visits will occur in the Same Day Surgery area on the day before surgery. This will be a very busy day, as you will meet with a cardiologist, a nurse practitioner and the anesthesiologist.

Your child will also have a chest X-ray, electrocardiogram (EKG), blood tests and possibly an echocardiogram if needed.

For patients undergoing cardiac catheterization or transesophageal echocardiograms (TEE), most visits will occur on the day of the procedure.

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What types of questions will the anesthesiologist ask?

The anesthesiologist will generally begin by reviewing a patient's health and medication history. Questions will focus on the heart, but other health issues will be addressed as well, including:

Respiratory problems such as asthma or sleep apnea
Problems such as gastro-esophageal reflux or muscle disease
A family history of anesthetic problems.

The anesthesiologist will ask if your child has an active respiratory infection such as a cold or pneumonia or has had a cold or pneumonia in the recent past.

Active respiratory infections can be a reason to postpone the operation until the infection is better. If your child is ill the day you are to come in for the preoperative visit, call the Cardiothoracic Surgery office to discuss the problem. It may save you a trip to the hospital.

You will also be asked about allergies and any family history of problems with anesthetics. Sometimes children react to certain medications in odd ways that are not truly allergic reactions but are labeled as such.

When you report that your child is allergic to a medication, you will be asked to describe the reaction so that we can determine if there is a true allergy. It is unusual for children to be allergic to anesthetic drugs. The most commonly encountered allergies are to antibiotics such as penicillin or amoxicillin.

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What family health problems are important regarding the upcoming operation?

There are some families in which individual family members carry a gene that makes them susceptible to severe reactions to certain anesthetic drugs. The condition is known as malignant hyperthermia (MH).

Malignant hyperthermia is a hereditary condition caused by an abnormality in muscle tissue. This condition is rare but if you know of anyone in the family who developed a very high fever during or shortly after surgery it is important to report this to the anesthesiologist during the pre-operative visit.

Any other unusual events during surgery involving a blood relative should also be reported to the anesthesiologist during the pre-operative visit.

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Questions parents ask the anesthesiologist during the pre-operative visit

The pre-operative visit will give you the chance to discuss your child's anesthetic with the anesthesiologist. It is important to ask questions and receive explanations concerning any phase of the anesthetic process.

Many times parents think of questions after the pre-operative visit the day before surgery. If this happens, write the questions down on paper and bring them with you the day of surgery. We will be happy to answer them for you at that time.

Can I be present as my child goes to sleep? The operating room used for heart surgery does not have an induction room (room where parents can be with their children as they fall to sleep). The primary reason for this is safety.

The child can be more closely monitored in the operating room suite as they go off to sleep. Before the induction of anesthesia, most children have a blood pressure cuff, EKG (heart monitor) leads, and a pulse oximeter placed allowing the anesthesiologist to closely monitor as they go to sleep.
We generally prefer that a child be sedated before coming to the operating room because parents are unable to remain with the child as he /she falls asleep from the anesthetic. The sedative is typically given in the Same Day Surgery examination room.
Why would I want my child to have extra medication before surgery? Preoperative sedatives are designed to make the process of induction of anesthesia (going to sleep) as smooth as possible for the child. It also decreases the anxiety over separation from family members.

Whenever possible, we use liquid medicines taken by mouth. The most commonly used medication is called Versed®.

Preoperative medications are given at a designated time so there is ample time for the medication to take effect.

After receiving Versed®, most children will not remember being taken to the operating room for surgery.
Some children will be fascinated by the whole process and not need a premedication. These children are the exception. We expect most children over the age of one year to be justifiably nervous and unwilling to separate from their parents unless a premedication is given
Will my child experience awareness or pain during surgery? There are two parts to pain. One is a conscious awareness that something hurts and the other is the body's response, which includes increased heart rate and blood pressure as well as the release of various chemicals which increase the breakdown of fats and protein.

The medications used block the conscious awareness. This begins when a child receives Versed® as a premedication. This drug reduces awareness and blocks memory for events after the drug is given.

Anesthesiologists also block awareness and help blunt memory. The combination of inhaled anesthetics and Versed® is very powerful.
Your child may also receive a high dose of narcotic medication as part of the anesthetic. These drugs block pain signals and also block the body's response to painful procedures.

The inhaled anesthetics also help block the body's response to painful stimuli. We adjust the dose based on the child's individual needs.
How do you know how much anesthesia to give?Each child has continuous monitoring of heart rate, blood pressure, exhaled carbon dioxide, and blood oxygen saturation. We use this information as well as the child's age and weight to determine how much anesthetic to give each child.

The anesthetics we use have been well studied and there are ranges of doses that are appropriate for children of given ages and weights. We recognize all children are unique, so the drugs are adjusted to the needs of each child.
Will my child experience pain after surgery?Everything is done to ensure children who have heart surgery are not uncomfortable after surgery. The narcotic medications given during surgery will not wear off as soon as the operation is completed. The pain-killing effect will last for one or more hours after surgery.

Once the child is in the Cardiac Intensive Care Unit, the team there will give additional pain medication as needed.

Some children are placed on continuous infusions of pain medication and many are kept sedated overnight.
Some children have the breathing tube removed immediately after surgery or within the first several hours after surgery.

If they are old enough to give themselves pain medication, a patient-controlled analgesia (PCA) device may be prescribed.

Children who are too young to use a PCA may be given caudal morphine (similar to an epidural). Morphine given by this route provides long periods of pain relief. Another chapter explains details of post-operative pain control options.
Will my child need a blood transfusion during surgery? Every effort is made to avoid transfusion, but in some cases it is necessary for the child's safety.

Infants and children under about 20 pounds are the most likely to need transfusion.

Most infants do not have enough red cells in their circulation to go on the heart-lung bypass machine safely unless red blood cells are added to the bypass pump. This means that they receive a transfusion while on the bypass pump.

Every effort is made to minimize the exposure to extra units of blood. Following bypass, special techniques for concentrating blood are used in order to achieve a safe red blood count in each patient.
In some cases, particularly those involving extensive suturing on large blood vessels in infants, it is necessary to give other blood products such as platelets. Platelets are elements in the blood which help form clots. Platelets are used up or damaged during heart-lung bypass.