Pediatric Anesthesia and Pain Management

Members of the Department of Anesthesiology, Critical Care & Pain Management at HSS recognize that pediatric patients have special needs. We work with your surgeons, pediatricians, and nurses to make your child’s experience a positive one. By using this multidisciplinary team approach, we will care for your child – and for you – during your child’s surgery and throughout your family’s stay with us. The anesthesiologists at HSS who care for children have highly specialized training in all aspects of pediatric anesthesiology and the management of pediatric pain. These dedicated and caring physicians have many years of experience treating children before, during, and after surgery.

Learn more about FDA guidelines for young children and general anesthesia.

Pediatric Regional Anesthesia

The Department of Anesthesiology offers a unique approach to anesthesia and pain management called regional anesthesia. It is used for many types of operations and procedures; a familiar example is an epidural for a pregnant woman in labor. Regional anesthesia is especially good for orthopedic surgery because we can temporarily “block” sensation to the extremity that is being repaired by the surgeons. You may hear the term “block” used to mean regional anesthesia. At HSS, we perform over 60,000 regional anesthetics a year in the operating room (OR).

Just like an adult, a child who has an operation on their hip or leg may receive a spinal for anesthesia and an epidural catheter to be used for pain management after surgery. Sometimes patients having foot or ankle surgery have a small catheter placed in the back of the knee to provide pain-relief during their hospital stay. We call these techniques “nerve blocks.” With the advances of modern science, we now use ultrasound to guide the majority of our nerve blocks. In children, the blocks are performed in the operating room after they are asleep.

There are many advantages to using regional anesthesia, including a lower anesthetic requirement, better pain control, and fewer side effects such as nausea and drowsiness. Regional anesthesia also reduces the amount of narcotic pain medications required after surgery. Not all patients are candidates for regional anesthesia, and your anesthesiologist will discuss this with you before surgery. For example, general anesthesia is required for spine surgery.

Pain Management After Surgery

After surgery, there will always be some discomfort. We may not be able to keep your child completely pain-free but we use a variety of techniques to keep the pain under control during your child’s recuperation. Our goal is to keep your child comfortable using safe and effective methods. It is important to keep on top of the pain by treating it early. It is much easier to treat mild pain than waiting until the pain is severe.

Most children staying overnight in the hospital receive “pain pumps,” in addition to oral pain medications. The pump administers pain medication via a “no-shots” system, either through an IV, an epidural catheter, or a catheter placed near a nerve in the arm or leg. The pain pump will be activated by a button, either Patient-Controlled Analgesia (PCA) or Nurse-Controlled Analgesia (NCA,) depending on the patient’s developmental age. For the safety of the child, parents are not allowed to push the pain button. If the patient cannot use the button, the nurse will push it for him/her.

Opioid Use After Surgery

Opioids can be important for managing pain, but they should be given to children and teens with careful supervision.

Children may mistake opioid pills for candy. They should be stored out of reach or in a lockbox and only given to children as prescribed.

Adolescents have a higher risk of addiction than adults because their brains are still developing, some face peer pressure or experiment with drugs or alcohol, and many face mental health issues, such as anxiety or depression. Adolescents may believe that opioids are safer to abuse than recreational drugs. It is important to discuss opioid safety with your teen, ensure that medicine is being taken as prescribed, and safely dispose of pills when they are no longer needed.

But despite the risks, opioids are often important for managing post-surgical pain in children and adolescents when other pain-relief methods fall short.

Watch our video to learn how to keep your child or teen safe when they’re using opioid pain medications.

Day of Surgery

The day of surgery, you will go to the admitting office and then to the pre-operative holding area. There your child will get ready for surgery: nurses will take vital signs; your child will change into a gown; your surgeon will write his/her initials on the site of surgery.

You will meet your anesthesiologist and at this time the full plan for the anesthesia will be discussed and explained. Televisions are available and patients are welcome to bring a favorite toy, book, video with portable DVD player, or music to use while they are waiting. For most patients, the nurse will place a “numbing cream” on the child’s hands for IV placement. Some patients will receive pre-medication to help with anxiety. The majority of patients age 5 years and older receive an IV by the nurse in the holding area, after the cream has made the skin numb.

The Operating Room

Many parents are concerned that their child will remember something from the surgery, or that the procedures we do in the OR will cause their child unnecessary discomfort. We recognize and appreciate your concerns. Our job as anesthesiologists is to keep our patients safe and asleep during surgery. If your child is having regional anesthesia, he/she will be asleep before we start the block. Regardless of what type of surgery or anesthesia they have, the vast majority of patients do not remember being in the OR. Your anesthesiologist will be with your child at all times until he/she is settled in the recovery room.

The Recovery Room

When the surgery is finished, your anesthesiologist takes your child to the Post Anesthesia Care Unit (PACU.) It is important for your child’s recovery to have you nearby when he/she wakes up from surgery, so as soon as the nurses in the PACU obtain their initial assessment, they will call for you. While you are in the PACU, please follow the nurse’s instructions regarding touching, feeding and waking your child.

Depending on what type of procedure your child had, he/she will stay in the PACU for a minimum of one hour before going to the hospital room. Some patients go home the day of surgery and some spend the night in the PACU for observation and pain management. If your child spends the night in the hospital, one adult is permitted to stay with him/her.

Please Let Us Know

• By what name your child prefers to be called.
• If your child has special needs: for example, does he/she have problems hearing or seeing?
• How your child lets others know when he/she is hurting.
• If your child has had surgery or anesthesia in the past, let us know if something in particular did or did not work.

Keep in Mind

• Every child is different and every surgical experience is different. If your child has had previous experiences with surgery or anesthesia, he/she may not react the same way this time.
• Ask questions if there is something you do not understand or have not been told.
• Children often mirror their parents’ reactions. Children who are calm and relaxed before surgery have a better chance of feeling better after surgery.
• The medical staff will take good care of your child!

A Word About Upper Respiratory Infections, Colds and Flu

It is common for children to have a “cold,” or an upper respiratory infection during the winter months. Flu strains and/or other viruses may be present in the environment throughout the seasons and may cause problems with breathing, or result in more serious infections. If your anesthesiologist is concerned about your child having any symptoms of a cold, flu, infection, or breathing problem on the day of surgery, the procedure will be delayed until your child is better.

If you have any concerns or questions about your child’s present or recent health, please call your surgeon and pediatrician to discuss them before the day of the operation.

Anesthesia for MRI

Most children cannot tolerate staying still for the length of an MRI examination. If your surgeon orders an MRI with anesthesia, an anesthesiologist will provide enough sedation so that your child sleeps for the entire exam. For MRI, anesthesia is administered with an IV catheter. When your child arrives, the nurse in the holding area will apply numbing cream to her hands and/or feet, depending on the age of your child and on which area of the body is being evaluated by the MRI. Most children go home within an hour or two of MRI completion.

You can watch our video below to learn more about the process.

Safety and Pediatric Anesthesia

It is natural for parents to be concerned about the effects of anesthesia on their child. Our number one priority is your child’s safety, and this principle is the basis for everything that we do and every decision that we make regarding your child’s anesthesia. On the day of surgery, you will have time to discuss your concerns with your child’s anesthesiologist. There are a few things that you can do to maximize your child’s safety: follow the instructions given to you about feeding your child on the day of surgery, answer all questions honestly, bring a list of your child’s medications, and let the doctor know if your child has had a recent cold or an episode of croup.

Research and Pediatric Patients

HSS prides itself on being a leader in all aspects of orthopedics, including research. Occasionally we want to gather information about your child’s anesthetic and postoperative pain management to assess our own performance. We need your permission to do so, so if we plan on collecting data from your child’s medical record, we will ask you before surgery. All proposed research projects are extensively reviewed by an IRB (Investigational Review Board), a group of experienced scientists, doctors, and other patient advocates. When conducting research on children, the review process is especially stringent because children are considered a “vulnerable population.” Your participation is always voluntary, and if you agree to participate in a project, all of your medical information remains confidential.

Helpful Definitions

• Acute Pain Service: A team consisting of an anesthesiologist and a pain management nurse who see patients after surgery to keep pain under control.
• Analgesics: Medication to treat pain (can be oral, IV, rectal, subcutaneous).
• Anesthesiologist: The doctor who provides anesthesia, keeping the child asleep and safe during surgery.
• Epidural: A catheter in the back that delivers medication to help with pain after surgery, or used to numb a patient’s legs during surgery.
• Holding Area/Pre-Op Area: Where patients prepare for surgery.
• IV: A thin, flexible tube placed in a vein, used for medicine and fluid.
• Narcotics: Also known as opioids, these are pain medications that have a morphine or morphine-like compound. They require a prescription.
• Numbing Cream: A local anesthetic cream that is placed on skin before IV placement or blood-drawing to make skin numb.
• NPO: In Latin this is non per os meaning nothing by mouth. This means the patient is not allowed to eat or drink.
• PACU: The recovery room where nurses take care of patients after surgery.
• PCA: The “pain pump” that gives medication in an IV, epidural catheter, or a catheter near a nerve.
• Peripheral Catheter: A catheter placed near a nerve in an arm or leg that delivers local anesthetic to minimize pain after an operation.
• Pre-Med: Medication that is given before surgery by mouth or IV to help calm and relax the patient.
• Regional Anesthesia: Epidurals, spinals, “nerve blocks.”