When 2-year-old Lexsea Morgan of Ben Lomond was scheduled for surgery at Lucile Packard Children\u2019s Hospital last February to fix a congenital kidney problem, her mother had an unusual request: Would it be okay if she remained at her daughter\u2019s bedside while the little girl was anesthetized? \u201cI remember when I handed off my oldest daughter for surgery years ago I was just a nervous wreck,\u201d Jennifer Morgan recalls, \u201cso this time I asked if there was any possibility of my being able to come into the operating room with Lexsea and stay with her until she was out.\u201d<\/p>\n
Having mom or dad present during anesthesia induction isn\u2019t always appropriate, particularly if the parent is squeamish or the procedure is complicated. In Lexsea\u2019s case, though, doctors were receptive. After making sure Jennifer was properly suited, they allowed her to sit on the toddler\u2019s gurney and even to hold the anesthesia mask gently over her daughter\u2019s face. \u201cI waited until she was not fully sedated but pretty out of it\u2014to the point she wouldn\u2019t notice that I wasn\u2019t there\u2014and then they took over and did their thing and it was a very successful operation,\u201d Morgan says. \u201cHaving a chance to visualize what was going on gave me a lot of peace of mind.\u201d<\/p>\n
While parent-present induction remains rare in the operating rooms, in other parts of the Hospital it\u2019s almost routine, says anesthesiologist Rebecca Claure, MD. Parents are often present for procedures ranging from MRIs and radiation treatments to colonoscopies and catheterizations. \u201cA lot of the time we need to use \u2018giggle juice\u2019 [short-acting valium] to calm down the smaller kids, but if you have a parent there you often don\u2019t need any,\u201d Claure notes. \u201cI\u2019ve had parents say they don\u2019t want to see their child that way, and we don\u2019t want them to feel guilty about that choice. But for those parents who are interested, we talk through what they can expect to see, and we reassure them.\u201d<\/p>\n
Family-friendly induction isn\u2019t the only thing that people appreciate about the anesthesiology service at Packard Children\u2019s. Unlike adult anesthesiologists, who spend most of their time in the operating room, Packard anesthesiologists are constantly on call, working their bedside magic on kids in widespread units throughout the Hospital. More than half of the 12,000 anesthetic procedures they do each year\u2014from regional blocks and light sedation to general anesthesia\u2014are performed outside the OR, in places like imaging suites, the Cardiac Intensive Care Unit, the Neonatal Intensive Care Unit, and the Bass Center for Childhood Cancer and Blood Diseases.<\/p>\n
Why the traveling roadshow? For one thing, children feel pain more acutely than grownups. They\u2019re also a lot squirmier\u2014particularly when facing strangers armed with needles. As service chief Anita Honkanen, MD, explains, \u201cAdults can typically endure a lumbar puncture without anesthesia, but it\u2019s frightening and they have to hold still. With the aid of an anesthetic, we can get kids to sleep in their parent\u2019s arms in the procedure room, and often they don\u2019t even know that the parent ever left.\u201d<\/p>\n
A U.S. Army veteran and mother of five, Honkanen came to Packard Children\u2019s nine years ago, when there were 15 anesthesiologists on the payroll. Today she oversees 30 staff physicians plus residents and half a dozen hand-picked fellows. Many of them work in teams focusing on complex sub-specialties, such as transplant anesthesia, cardiac anesthesia, neuroanesthesia, and pain management.<\/p>\n
As the anesthesiology staff has evolved over the years, so has the technology. R.J. Ramamurthi, MD, clinical director of operating room management, is especially grateful for four new SonoSite ultrasound machines that assist with placing intravenous lines and nerve blocks. \u201cBefore we got them,\u201d he says, \u201cpeople were using anatomical landmarks and it was a hit-or-miss thing. With ultrasound you actually see the nerves and other structures, so there\u2019s no guesswork involved. Essentially it improves patient safety, with less poking.\u201d<\/p>\n
Another useful new tool is SimBaby, a high-tech mannequin that can mimic breathing, crying, vital signs, and signals of distress. Following scripted scenarios, Packard anesthesiologists wheel the lifelike doll and its attached laptop computer all over the Hospital, acting out emergency situations and complex surgeries with their colleagues. \u201cAnesthesia is like flying an airplane,\u201d Ramamurthi explains. \u201cYou have a takeoff (induction), maintenance, and landing (waking up at the end). So we simulate events just as a pilot would, to get the feel for situations before we\u2019re faced with them in real life. That\u2019s a big thing that we are proud of, because we are the first children\u2019s hospital on the West Coast to do it.\u201d<\/p>\n
On a warm spring afternoon, a mellow golden retriever named Carly is walking her daily rounds on the first floor at Packard Children\u2019s. The certified therapy dog and her owner, clinical nurse specialist Sandy Sentivany-Collins, RN, are relaxed and playful, but their mission is serious: To get children\u2019s minds off their pain and their bodies moving again. \u201cWe get a lot of requests for Carly to come visit; she has a very positive influence on the children\u2019s mood,\u201d says anesthesiologist Elliot Krane, MD, director of Packard\u2019s Pain Management Service.<\/p>\n
Canine therapy is one of several approaches that Krane and his team use to help children deal with post-operative pain, or the pain of injury and disease. Many youngsters benefit from medications like anti-inflammatories, opioids, and nerve blocks. Others find it helpful to talk with a clinical psychologist. Still others find relief in hypnosis, biofeedback, acupuncture, or physical therapy. Sometimes family counseling is necessary as well, to teach parents how to help their children without coddling them.<\/p>\n
Most cases require a combination of tactics. \u201cWe need a multidisciplinary approach because pain is multidisciplinary,\u201d Krane says. \u201cIt affects not just one part of the body but the entire well being of a child, including their mood. And then the mood, in turn, affects how much pain they feel.\u201d<\/p>\n
Over the course of a typical day, Krane and his team of physicians, psychologists, and nurses will evaluate and treat around 25 patients\u2014a five-fold increase from when he arrived at Packard in 1994. He particularly remembers 14-year-old Bailey Deacon, of Los Gatos, who spent six weeks in the Hospital last year suffering from intense burning pain in her feet. The cause was erythromelalgia, a rare, possibly genetic nerve disorder exacerbated by heat and stress. By the time her father carried her into Krane\u2019s office, the girl had lost 35 pounds and was a sleepless wreck.<\/p>\n
\u201cWhen Dr. Krane saw what kind of distress she was in, he put in an epidural so she could finally rest. That was huge,\u201d her grateful father, Troy, recalls. Krane also treated Bailey\u2019s feet with a solution of capsaicin\u2014the same substance that makes peppers hot\u2014to desensitize her nerve endings. Anti-seizure pills also helped to slow her pain response, as did some time with a clinical psychologist, advancing her recovery still further.<\/p>\n
Today Bailey is back at school, enjoying freshman science and algebra classes at Presentation High School in San Jose. \u201cEvery now and then you hit a home run,\u201d Krane acknowledges, smiling. \u201cBut we\u2019re still learning, still in the infancy of pain management, compared to what I hope it will be like in 20 years. We\u2019re still using variations on 2,000-year-old drugs. Even NSAIDS [non-steroidal anti-inflammatory drugs] are basically aspirin, and that\u2019s been around since the time of Hippocrates.\u201d<\/p>\n
Perhaps the biggest challenge in pediatric anesthesia is figuring out how much medication small bodies need. Most painkillers, sedatives, and anesthetics were designed and approved for adults, and scaling down their dosages for an infant or child can be tricky, says Gregory Hammer, MD, director of pediatric anesthesia research. That\u2019s why it\u2019s essential to understand the pharmodynamics and pharmokinetics of various drugs: how they affect the body, and how the body distributes, metabolizes, and eliminates them.<\/p>\n
One of Hammer\u2019s latest clinical studies is looking at morphine and methadone, to understand how these well-known opioids are metabolized in four age groups: babies, toddlers, school age children, and teens. Hammer and his team at Packard Children\u2019s are also investigating etomidate, used for the induction of anesthesia in children with heart failure. \u201cWe like to use etomidate on children with heart failure because it doesn\u2019t tend to lower blood pressure,\u201d Hammer says. \u201cWe\u2019re also looking at promising newer drugs, such as dexmedetomidine, a novel sedative that doesn\u2019t cause respiratory depression.\u201d It\u2019s also less likely to cause delirium, an upsetting side effect that can hamper a child\u2019s recovery.<\/p>\n
Still another research project\u2014one that should be of special interest to parents\u2014involves the long-term effects of anesthesia on the developing brain. Studies in animals suggest that exposure to anesthesia at a very young age might be associated with lower performance on tests of memory, attention, and learning. So cardiac anesthesiologist Lisa Faberowski, MD, is reviewing longitudinal studies to see if there might be similar effects in children.<\/p>\n
In the meantime, service chief Honkanen tells families, \u201cOne of the critical things to remember is that you don\u2019t do a surgical procedure on a child unless you really need to. You have to weigh the risks\u2014a very small chance of a subtle change later on\u2014versus a very real problem at the present moment.\u201d<\/p>\n
Back in Ben Lomond, little Lexsea Morgan is feeling much better now. Free of her chronic urinary tract infections, the brown-eyed toddler is running all over the house, stopping just long enough to catch up on her favorite television show, Dora the Explorer.<\/p>\n
Looking back, her mother is profoundly grateful for the peace that surrounded them both on the day of surgery. \u201cI was surprised because I kept telling everybody that I was going to completely lose it. But by knowing where Lexsea was, and the people who were with her, and the room that she was in, I barely cried,\u201d Jennifer Morgan marvels. \u201cIf this were a normal hospital, that opportunity would have been unlikely, but because it\u2019s Packard, they really were geared to making us comfortable.\u201d<\/p>\n
And her Packard Children\u2019s anesthesiologists couldn\u2019t be more pleased to hear it. As R.J. Ramamurthi likes to say, \u201cCreating a feeling of calm for the family is not just a science, it\u2019s an art.\u201d<\/p>\n
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