Sunday, April 2, 2017

Anesthesia- Do we know the risk in a child?

Recently, there has been much discussion regarding anesthesia in the child.  The concern is appropriately about safety- do we know when it is 'safe' to allow anesthesia for children.  There have been a large number of studies on this topic and recently the FDA voiced concerns.  I will try to summarize the issues and our understanding (at least the understanding of an informed surgeon).

1) Anesthesia has more risk in children compared to adults.  There are many reasons for this including simple concepts such as the small size of the windpipe in the very young child.  Cardiac events and even death are risks in any anesthesia and these are higher in young children- however, remember that anesthesia is very, very safe but the risks are somewhat higher in young children compared to adults.

2) One of the concerns is the risk of learning delays or 'cognitive' difficulties for children that have surgery at a young age.  This is very difficult to study for some obvious reasons including only young children with serious issues have major or repeated surgeries at a young age.  There really is very limited know risk to simple, short surgeries such as ear tubes or short orthopedic surgeries.  A very good study was published from Sweden on this topic.

This study showed very minimal differences in academic performance based on exposure to anesthesia and it showed things like maternal education and season of birth (i.e., winter vs summer) had an even bigger effect.  Other studies, such as the 'PANDA' and the 'GAS' study did not find evidence for an association with single brief exposures to anesthesia.

3) The anesthesia provider matters.  I have blogged previously that I believe experience matters in the care of your child.  An experienced surgeon is, I strongly believe, better able to give your child the care he/ she needs for the best possible outcome.  The literature also strongly supports that the anesthesia team matters to the safety of your child.  A busy children's hospital is a safer place for surgery than the anesthesia provided by those who only occasionally take care of kids.  One study showed a risk of 7 complications/ 1000 surgeries for an anesthesia team that performed less than 100 surgeries a year compared to 1.3 complications/ 1000 surgeries for teams that performed more than 200 surgeries/ year.

The FDA recently provided some thoughts.  The link to the entire statement is provided HERE.   The first two paragraphs are key:

The U.S. Food and Drug Administration (FDA) is warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children’s brains.

Consistent with animal studies, recent human studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development.

Additionally there are two websites that have received publicity.
1. Smarttots.org Link  This site discusses some of the ongoing research
2. Safetots.org Link  This site discusses some of the general concepts I have shared and the importance of an experienced pediatric anesthesiologist.

The bottom line is that we should carefully consider anesthesia in anyone, especially a young child.  Lengthy and repeated surgeries may carry some risk and anesthesia by non pediatric providers does have some risk.  Every decision for surgery is a serious one.  However, after reviewing the literature, I feel that surgeries for problems that are affecting a child's hand or arm (typically shorter surgeries and unlikely to require second surgeries in a short interval) have very low risk in the appropriate hands.

Charles A. Goldfarb, MD
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congenitalhand@wudosis.wustl.edu