Carolinas HealthCare System

The most important thing for parents and families at Levine Children's Hospital to remember is that we will provide your child with all the support he/she needs before, during and after the procedure. Providing anesthesia to infants and children can pose different challenges. Besides the obvious variations in size, we care for pediatric patients differently based on their physical and emotional development as they grow and mature.

Overview: Try to think of anesthesia as a continuum of sedation in which a child can be continuously monitored and evaluated for depth of sedation and appropriateness of response. As children move through each level of sedation there are consistent characteristics physicians can monitor. On one side of the continuum a child is awake, alert and cooperative and on the other side of the continuum a child is in a deep sleep and cannot be aroused with physical stimulation including a surgical incision. Anesthetic medications are the sedatives that allow a child to sleep peacefully during painful procedures. When the procedures are completed, the anesthetic medications are turned off and children gradually return to their alert cooperative state as their bodies metabolize these medications. We will monitor your child carefully while we sedate your child with these medications. The following paragraphs describe commonly used anesthesia terms and concepts.

Types of Anesthesia

Local: Local anesthesia refers to techniques where medications are used to temporarily "numb" or "deaden" nerves. These techniques are frequently used for painful procedures like a tooth extraction in a dental office. The local anesthetic medications can be applied to areas that hurt using a variety of techniques that include creams, injections and occasionally catheter placements (e.g. epidurals) for longer use. A child may require only local anesthesia to complete some procedures. However, in the operating room, the techniques are frequently used to adjuncts to general anesthesia, reducing the body's ability to feel pain during and after the surgical procedure.

Regional: Regional anesthesia refers to a specific technique using local anesthetic medications to "numb" or "deaden" groups of nerves. A common example of a regional anesthetic technique is a lumbar epidural which is used frequently to reduce pain when a pregnant woman labors and delivers a baby. In the operating room, regional anesthesia can be used in conjunction with general anesthesia for certain procedures. Regional anesthetic procedures are performed after the child has fallen asleep using other anesthetic medications they inhale or receive through an intravenous catheter. The effects of the local anesthetic injection often continue to work for a period of time after the child awakens in the recovery room. If an epidural catheter was placed, the local anesthetic medications can be administered for extended periods postoperatively.

General: General anesthesia refers to a deep level of sedation where a patient is unresponsive to any stimulation including the pain associated with a surgical incision. If general anesthesia is needed to complete a procedure/surgery, the child will remain completely unconscious (asleep) throughout the procedure/surgery. The child will not have any awareness that the surgery is taking place and will have no memory of the event afterwards. In children, general anesthesia is administered typically with medications a child can breathe as well as anesthetic medications administered through an intravenous catheter. Under certain circumstances, general anesthesia is administered only with inhaled medications and at other times we may use only medications administered through an intravenous catheter. Children need to be deeply asleep in order to remain motionless while a surgeon completes a painful procedure. Again, because the medications are heavy sedatives, children are closely monitored (see below).

Levels of Sedation

Sedation: The term "sedation" describes a condition created by medications where the patient is sleepy and less responsive to the events around them. In anesthesia we view sedation along a continuum from the point where the patient is awake to the point where the patient will not respond to anything including the pain associated with a surgical incision. Though the level of sedation is truly a continuum, as patients become increasingly "sedated", certain changes take place in the level of responsiveness. We characterize the different levels with the following terms - minimal sedation, moderate sedation, deep sedation and general anesthesia. Our goal at all times is to reduce the stress and discomfort associated with painful procedures while working to ensure the procedures are accomplished safely.

Minimal Sedation: A child is given "minimal sedation" in order to help them relax. With minimal sedation, the child will remain awake and he/she is able to speak to the doctor and answer questions.

Moderate Sedation: A child under moderate sedation will likely sleep through the procedure but if the doctor asks a question or touches the child he/she will respond.

Deep Sedation: A child under deep sedation will be asleep throughout the procedure and not remember the procedure at all. Deep sedation is closely related to general anesthesia and at times patients are "sedated" to the point where they are unresponsive to any stimulation. All patients who receive the anesthetic medications are closely monitored until the effects of these medications wear off. When a procedure is completed, it takes a period of time for each patient to metabolize enough of the medication to return to a point where they are awake and appropriate. This period of time varies but is usually less than one hour. A patient will remain in the recovery room and we will continue to monitor their condition closely until the medications have been metabolized and the patient can be awakened easily.

What to Expect After the Procedure/Surgery

After local anesthesia: If the child received local anesthesia the numbness will most likely wear off within 2-4 hours after the procedure is complete.

After Regional Anesthesia: In children, regional anesthetic procedures are performed in conjunction with general anesthesia. Specifically, the regional blocks are performed after the children are asleep with inhaled or intravenous anesthetic agents. The recovery period for the patient will be similar to the recovery described for general anesthesia above. The length of time that patients experience pain relief from the local anesthetic medication depends on the local anesthetic agent selected, the type of block performed and whether or not a catheter was placed to extend the period of medication administration can be extended postoperatively. The goal of using local/regional anesthesia is to make the surgical incision less painful for the patient. Thus, applying gentle pressure on the incision can often help determine when the effect of the block has dissipated. At that time other intravenous or oral medications would be used to relieve pain.

After General Anesthesia: If the child had general anesthesia, after surgery is completed, the anesthesiologist will turn off the anesthetic gases. As the child begins to wake up the breathing tube will be removed. It usually takes about 45 minutes to an hour for kids to recover completely from general anesthesia. All the medications your child received to keep them asleep are "sedatives". Your child will be transferred to a recovery room where he or she will begin to metabolize the residual medications and gradually awaken. This recovery period is monitored by specially trained nurses in the post-anesthesia care unit (PACU) or recovery room. During recovery, your child is still under the care of the anesthesiologist and he/she will continue to monitor the child and provide pain medication necessary to keep the child comfortable. In most cases parents will be allowed to come to the recovery room to be with their child as he/she wakes up. It is very common for the child to be restless or irritable as they awaken, Parents come to the recovery room to help comfort their children during this time. As your child wakes up, if he/she is in pain the anesthesiology team will administer medication to ease your child's pain.

Analgesic Techniques - How to Relieve Pain

  • Local Anesthetics: medications that "numb" or "deaden" nerves. These medications can be applied to areas of the body that hurt using a number of different techniques. For simple procedures like an intravenous catheter insertion, we commonly use a subcutaneous injection (into the skin directly) or local anesthetic cream applied on skin to ease pain.
    • Single doses of local anesthetic can be given as shots to numb specific nerves or a group of nerves (similar to a dental injection)
    • When longer applications of local anesthetic would be beneficial, a Catheter can be placed - this technique looks similar to an intravenous catheter but instead of inserting the plastic tubing into a vein, the catheter is placed alongside the specific nerves to be "numbed" and local anesthetic drips on the nerves much like a "drip hose' waters a garden
  • Non-narcotic analgesics: Tylenol, Motrin, Toradol (Intravenous non-narcotic medicine similar to ibuprofen)
  • Opioid Narcotics - range from mild to strong
    • Hydrocodone is a mild narcotic because it has a "ceiling effect". The "ceiling effect" implies that at a certain point, giving more hydrocodone will not have more effect on the patient
    • Morphine is a strong narcotic because the more morphine you give to a patient, the stronger the effect that the patient experiences - there is no ceiling effect

Examples of Procedures and Anesthesia/Analgesics Recommended

To complete a painful procedure without using local anesthesia usually requires deep sedation or general anesthesia in order for a child to be able to tolerate the procedure.

  • A child needs an IV - usually performed with local anesthesia alone - no sedation is necessary
  • Endoscopy - typically performed with intravenous moderate or deep sedation
  • Chest tube insertion - typically performed with local anesthesia and IV analgesic medications
  • Abdominal incisions and similar surgical procedures - Requires general anesthesia and a variety of analgesics after surgery including narcotics, non-narcotics, and local anesthetics
  • Magnetic resonance imaging (MRI) - For younger children, this procedure requires deep sedation or general anesthesia to allow the child to remain motionless for the duration of the scan. When children are mature enough to remain still without sedation, the procedure can be performed while the patient is awake. An MRI scan is not painful.