Wednesday, February 25, 2015

It's Pediatric Anesthesia's Turn Under The Gun

Uh oh. Is anything in medicine really safe for patients? Michael Jackson exposed the dangers of propofol to a public who were previously complacent, if not ignorant, of anesthetics. Then last week we were all exposed to the panic from drug resistant bacteria that may find safe harbor inside sophisticated GI endoscopic equipment. Now the New York Times has printed an article pointing to the dangers of anesthesia to childhood brain development.

The paper talks about two types of research that points to potential pediatric brain injury under anesthesia. Animal studies have shown that anesthesia can kill brain cells and impair learning in young monkeys and other mammals. Human studies of children who have undergone surgical procedures have shown that multiple exposure to anesthesia can cause learning difficulties in the future. However single exposure to anesthesia hasn't been found to be a detriment to brain development.

These ambiguous results have resulted in pediatric anesthesiologists trying to awkwardly explain the risks of anesthesia to concerned parents. Says Dr. Randall Flick, director of the Mayo Clinic Children's Center and a pediatric anesthesiologist, "On the one hand, we don't want to overstate the risk, because we don't know what the risk is, if there is a risk. On the other hand, we want to make people aware of the risk because we feel we have a duty to do so."

Boy that's an awkward conversation to have with a concerned parent. We want to warn parents about potential brain damaging risks of anesthesia on children, but we don't really know if that risk really exists. Do you think most parents, when they hear an explanation like that, will believe there is no risk? Or will they most likely assume that the doctor is not telling the whole truth about the dangers of anesthesia? My feeling is that many parents will automatically assume the worst and start stressing about the surgery even more than they already do.

What gets lost in the conversation is that almost all children have surgery because they have a medical necessity. They're not like adults who can decide to have an unnecessary surgical procedure like plastic surgery just because they want it. No surgeon will operate on small children unless there is a sound medical reason to do so. Also most children will not have multiple operations at that age. Common operations like hernias and appendectomies are one and done. The children who have multiple operations like spine and cardiac cases probably already have a predilection towards other abnormalities that can lead to a higher incidence of learning difficulties in the future.

The Society for Pediatric Anesthesia recognized the confusion about the safety of anesthetics given to children over two years ago and released a statement that was endorsed by both the American Academy of Pediatrics and the Food and Drug Administration. It encourages anesthesiologists to, "Discuss with parents and other caretakers the risks and benefits of procedures requiring anesthetics or sedatives, as well as the known health risks of not treating certain conditions." Also, "it must be recognized that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures."

That in essence is the bottom line. Children almost always receive anesthesia only when they need it. We don't administer anesthesia just because we enjoy watching children fall asleep and getting paid for it. Anesthesia is risky in even the healthiest adults, more so with children. Anesthesia is a necessity for surgery and is one of the miracles that makes modern medicine possible. Parents can talk to the anesthesiologist about the risks of anesthesia to children but the only alternative is no anesthesia or sedation for a frightened child in an extremely stressful and potentially painful event.

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