Perspective

Round table: Concerns about anesthesia in children not changing management strategies

Use of anesthesia in children is sometimes unavoidable, but limiting the length of exposure and the number of exposures are steps that pediatric ophthalmologists can take to lessen concerns about toxicity.

At the American Association for Pediatric Ophthalmology and Strabismus meeting in Nashville, Tennessee, members of the OSN Pediatrics/Strabismus Editorial Board agreed that their management strategies have not changed much as concerns about dangers of anesthesia in children arise, but they do remain vigilant and look for ways to minimize or avoid each child’s exposure.

In this last installment of the OSN round table series, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, addressed the board: “Our next very important topic has to do with anesthesia in children. There have been several recent publications regarding concerns for possible neurotoxicity and neurodevelopmental issues. So, the question that I have for pediatric ophthalmologists is, has it changed your discussion with parents and/or changed your management of patients you are considering for surgery?”

Roundtable Participants

  • Moderator

  • Robert S. Gold
  • R.V. Paul Chan
  • Kenneth P. Cheng
  • Scott E. Olitsky
  • Rudolph S. Wagner
  • Roberto Warman

Kenneth P. Cheng, MD: There is very clear evidence of potential neurotoxicity of essentially all the pediatric anesthesia agents, but that evidence is in animals. And even though there is a real potential danger, the reality is that the danger is not proven in children. It is the same paradigm we have always dealt with: Do the risks of the procedure outweigh the benefits? I do not think that the concern over anesthesia should be any more than it ever was, just that anesthesia is a potentially risky issue and we should all be aware of that.

However, we should try to minimize the number of exposures to anesthesia because there is evidence to suggest that multiple exposures are potentially deleterious. So if the child is going to need a hernia repair or ear tubes, for example, then by all means take care of their eye issue at the same time. I go out of my way to do that, but if they need surgery, they need surgery.

Gold: Paul, as a pediatric retina specialist, you do more exams under anesthesia on younger children and even on older children. Have you changed the number of exams you do or changed the discussion you have with parents?

R.V. Paul Chan, MD: I don’t think I’ve changed the number of exams that I perform, and I do make sure to take pictures of the anterior segment and retina to use as a reference for future exams. The examinations that I perform under anesthesia are usually done by mask and are relatively quick and not prolonged. Most children are referred to me for a comprehensive exam with a dilated fundus examination using scleral depression. Therefore, in situations when I cannot perform a thorough and complete exam in the office or if my suspicion is high for pathology that may need management, then I will do an exam under anesthesia (EUA). Prior to the EUA, I have a long talk with the family explaining the process and why I feel that the exam is needed. If everything looks good on the EUA, then great. I’ll see the child back in the office and we’ll determine what happens next, maybe another EUA or maybe not.

One important consideration is to minimize how long a child is exposed to anesthesia. And if possible, dilating drops should be administered before going to the operating room.

Scott E. Olitsky, MD: Ken and Paul bring up two key points: One is that the evidence is animal based. The other is concern for longer anesthesia exposures. I agree; minimize the anesthesia. Do a probing at the same time ear tubes are inserted. I would do that anyway, and for the most part, our approach has not changed, but one area where I have seen opinions change is in parent counseling. When debating whether to order an MRI, which needs to be done under general anesthesia, I give parents all the information I can so they can make a better informed decision about what to do.

Cheng: For parents and for clinicians, there is a tremendous organization called Smart Tots whose website — smarttots.org — has all the latest references and papers, as well as a policy statement, which basically says that there is a concern about anesthesia in children, we are not sure exactly what the level of concern should be yet, and we should try to minimize the child’s exposure as well as wait until the children are older, if possible, before exposing them to anesthesia. All these things are basic common sense things that we have always assumed, so I do not think things have changed the way we practice to a great degree.

Roberto Warman, MD: I have said this before, and I say it again here: I am a strong believer in doing probings in the office. Get used to doing them in the office and avoid the need for anesthesia there.

Rudolph S. Wagner, MD: Office probing can be successful only if you have a great deal of experience. It is difficult to develop your probing technique unless you have done many under anesthesia at some point in your training. For years, all of us have worked to be as efficient surgically as we can be and to go to the OR as infrequently as possible. Whether anesthesiologists can make a difference by using different medications or different inducing agents is a good question.

Warman: For those of us who are training residents, for example, placing nasolacrimal tubes in the OR, the amount of time between doing an intubation or teaching a resident to do an intubation significantly increases anesthesia time. This is a rhetorical question, but what are we going to be doing in the future? We still want to train people but anesthesia time will increase.

Cheng: I think that is a question for the anesthesiologists.

Disclosures: The round table participants report no relevant financial disclosures.

Use of anesthesia in children is sometimes unavoidable, but limiting the length of exposure and the number of exposures are steps that pediatric ophthalmologists can take to lessen concerns about toxicity.

At the American Association for Pediatric Ophthalmology and Strabismus meeting in Nashville, Tennessee, members of the OSN Pediatrics/Strabismus Editorial Board agreed that their management strategies have not changed much as concerns about dangers of anesthesia in children arise, but they do remain vigilant and look for ways to minimize or avoid each child’s exposure.

In this last installment of the OSN round table series, OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, addressed the board: “Our next very important topic has to do with anesthesia in children. There have been several recent publications regarding concerns for possible neurotoxicity and neurodevelopmental issues. So, the question that I have for pediatric ophthalmologists is, has it changed your discussion with parents and/or changed your management of patients you are considering for surgery?”

Roundtable Participants

  • Moderator

  • Robert S. Gold
  • R.V. Paul Chan
  • Kenneth P. Cheng
  • Scott E. Olitsky
  • Rudolph S. Wagner
  • Roberto Warman

Kenneth P. Cheng, MD: There is very clear evidence of potential neurotoxicity of essentially all the pediatric anesthesia agents, but that evidence is in animals. And even though there is a real potential danger, the reality is that the danger is not proven in children. It is the same paradigm we have always dealt with: Do the risks of the procedure outweigh the benefits? I do not think that the concern over anesthesia should be any more than it ever was, just that anesthesia is a potentially risky issue and we should all be aware of that.

However, we should try to minimize the number of exposures to anesthesia because there is evidence to suggest that multiple exposures are potentially deleterious. So if the child is going to need a hernia repair or ear tubes, for example, then by all means take care of their eye issue at the same time. I go out of my way to do that, but if they need surgery, they need surgery.

Gold: Paul, as a pediatric retina specialist, you do more exams under anesthesia on younger children and even on older children. Have you changed the number of exams you do or changed the discussion you have with parents?

PAGE BREAK

R.V. Paul Chan, MD: I don’t think I’ve changed the number of exams that I perform, and I do make sure to take pictures of the anterior segment and retina to use as a reference for future exams. The examinations that I perform under anesthesia are usually done by mask and are relatively quick and not prolonged. Most children are referred to me for a comprehensive exam with a dilated fundus examination using scleral depression. Therefore, in situations when I cannot perform a thorough and complete exam in the office or if my suspicion is high for pathology that may need management, then I will do an exam under anesthesia (EUA). Prior to the EUA, I have a long talk with the family explaining the process and why I feel that the exam is needed. If everything looks good on the EUA, then great. I’ll see the child back in the office and we’ll determine what happens next, maybe another EUA or maybe not.

One important consideration is to minimize how long a child is exposed to anesthesia. And if possible, dilating drops should be administered before going to the operating room.

Scott E. Olitsky, MD: Ken and Paul bring up two key points: One is that the evidence is animal based. The other is concern for longer anesthesia exposures. I agree; minimize the anesthesia. Do a probing at the same time ear tubes are inserted. I would do that anyway, and for the most part, our approach has not changed, but one area where I have seen opinions change is in parent counseling. When debating whether to order an MRI, which needs to be done under general anesthesia, I give parents all the information I can so they can make a better informed decision about what to do.

Cheng: For parents and for clinicians, there is a tremendous organization called Smart Tots whose website — smarttots.org — has all the latest references and papers, as well as a policy statement, which basically says that there is a concern about anesthesia in children, we are not sure exactly what the level of concern should be yet, and we should try to minimize the child’s exposure as well as wait until the children are older, if possible, before exposing them to anesthesia. All these things are basic common sense things that we have always assumed, so I do not think things have changed the way we practice to a great degree.

PAGE BREAK

Roberto Warman, MD: I have said this before, and I say it again here: I am a strong believer in doing probings in the office. Get used to doing them in the office and avoid the need for anesthesia there.

Rudolph S. Wagner, MD: Office probing can be successful only if you have a great deal of experience. It is difficult to develop your probing technique unless you have done many under anesthesia at some point in your training. For years, all of us have worked to be as efficient surgically as we can be and to go to the OR as infrequently as possible. Whether anesthesiologists can make a difference by using different medications or different inducing agents is a good question.

Warman: For those of us who are training residents, for example, placing nasolacrimal tubes in the OR, the amount of time between doing an intubation or teaching a resident to do an intubation significantly increases anesthesia time. This is a rhetorical question, but what are we going to be doing in the future? We still want to train people but anesthesia time will increase.

Cheng: I think that is a question for the anesthesiologists.

Disclosures: The round table participants report no relevant financial disclosures.

    Perspective

    While some young people can be more accepting of a procedure, most are not, and they definitely want to be as far away from a procedure room or an operating room as possible. Recently, I have performed procedures, both in the office and in the operating room, with the help of fidget spinners, essentially a modern day stress ball.

    Fidget spinners are a hot new trend that provide hours of entertainment for both adults and children. A fidget spinner is a toy that consists of a ball bearing in the center of a flat structure made of metal or plastic, which spins along its axis with little effort. Fidget spinners have been advertised to help people who have trouble with focusing or fidgeting by relieving nervous energy or psychological stress. There are claims that spinners can help calm people with anxiety, attention deficit disorders and autism.

    As there is always more of a risk to the patient with sedation, I attempt such procedures on those patients whom I feel will cooperate in the outpatient setting with the aid of a fidget spinner. Spinner anesthesia works especially well to distract the patient when injecting local anesthesia when performed without sedation, such as with incision and drainage of chalazions performed in the office setting.

    Fidget spinners are also useful in the operating room setting, where they can help reduce stress and distract attention during insertion of an IV in the preoperative area.

    Spinner anesthesia is not for everyone. The next time you find yourself with a somewhat hesitant patient, especially a young one, have a spinner on hand. I have custom-made spinners for the office, and they are a great giveaway to my patients.

    • Stephen M. Soll, MD, FACS
    • Cooper University Hospital, Camden, New Jersey

    Disclosures: Soll reports no relevant financial disclosures.