Shout out to the good ones...

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My wife recently had a procedure and leading into it was quite literally terrified of the anesthesia portion despite my best efforts to calm her.

That fear was handled beautifully by the anesthesiologist....she was calming and informative like she was putting on a seminar on how to do the pre-op meeting. Did a great job explaining everything and all the feelings/effects my wife would have in a way that made her feel educated about the process.

So here's a general thank you to those that nail the patient interactions as well as they do the drug interactions... :bow:

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My wife recently had a procedure and leading into it was quite literally terrified of the anesthesia portion despite my best efforts to calm her.

That fear was handled beautifully by the anesthesiologist....she was calming and informative like she was putting on a seminar on how to do the pre-op meeting. Did a great job explaining everything and all the feelings/effects my wife would have in a way that made her feel educated about the process.

So here's a general thank you to those that nail the patient interactions as well as they do the drug interactions... :bow:

#MDAanesthesia4life
 
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My toddler is having surgery soon and my wife is freaking out. Hoping to get one of the good ones. Our children's hospital does use CRNAs with docs supervising 2:1, so lots of questions for the attending.
 
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My toddler is having surgery soon and my wife is freaking out. Hoping to get one of the good ones. Our children's hospital does use CRNAs with docs supervising 2:1, so lots of questions for the attending.
There are lots of crnas that mostly do peds. They are also very good as long as the right supervision is present. A good one needs very little supervision but knows when they need it. Talk to your surgeon and ask that the best available person, whether MD or RN be there.
 
My toddler is having surgery soon and my wife is freaking out. Hoping to get one of the good ones. Our children's hospital does use CRNAs with docs supervising 2:1, so lots of questions for the attending.
We do solo or 2:1 as well with CRNAs/fellows/residents.
If you want to discuss something, discuss with the surgeon the proper timing of the surgery and if it could be delayed without consequence.
There is growing evidence that our anesthetics may be causing damage to the developing brain.
As the existing evidence is still inconclusive and hard human evidence with modern drugs and techniques is still years away, the only advice I would give you is to put off elective and semi elective surgery as long as is reasonable to allow for more brain development and reduce potential risk of injury.
The only cases that we still do that are usually completely elective are circs. Maybe they should be delayed until after 3 or 5? Our urologists are aware of the issue and concern, but they do them anyway.
That's probably not an option for you though.
 
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We do solo or 2:1 as well with CRNAs/fellows/residents.
If you want to discuss something, discuss with the surgeon the proper timing of the surgery and if it could be delayed without consequence.
There is growing evidence that our anesthetics may be causing damage to the developing brain.
As the existing evidence is still inconclusive and hard human evidence with modern drugs and techniques is still years away, the only advice I would give you is to put off elective and semi elective surgery as long as is reasonable to allow for more brain development and reduce potential risk of injury.
The only cases that we still do that are usually completely elective are circs. Maybe they should be delayed until after 3 or 5? Our urologists are aware of the issue and concern, but they do them anyway.
That's probably not an option for you though.
Good use for Precedex? There has got to be...:)
 
We do solo or 2:1 as well with CRNAs/fellows/residents.
If you want to discuss something, discuss with the surgeon the proper timing of the surgery and if it could be delayed without consequence.
There is growing evidence that our anesthetics may be causing damage to the developing brain.
As the existing evidence is still inconclusive and hard human evidence with modern drugs and techniques is still years away, the only advice I would give you is to put off elective and semi elective surgery as long as is reasonable to allow for more brain development and reduce potential risk of injury.
The only cases that we still do that are usually completely elective are circs. Maybe they should be delayed until after 3 or 5? Our urologists are aware of the issue and concern, but they do them anyway.
That's probably not an option for you though.
I totally agree with this. I didn't want to go into it but I'm glad IlDestriero did. It is something to consider.
I tried to get our dental pimp to delay all dental restorations till age 3 or greater. We settled on age 2. He was bringing in kids as young as 14 months. I was appaulled since they barely have teeth at that age.

IlDestriero, do,you have any new literature on this?
Are you doing dental restorations? What ages?
T&A's?
 
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There's really no new data. The Wake Up Safe and/or SmartTots groups are working on some new statement, but it's not out yet and I've not seen a draft.
I'm sure it will be more of the same.
The reality is that most procedures that we do are necessary. What is not clear is what can wait, and how long. Maybe until 3 or 6 months or 3 years or 5 years? Or when to set those intervals. I'm sure some surgeries can be delayed without significant risk, perhaps for years. (I'm talking to you circ!)
As for the T&As, the ones we do on the young kids are generally for significant sleep apnea and the literature supports its clear benefit. Most little kids aren't going to tolerate cpap/bipap for years waiting for some arbitrary time. And dental restorations are usually done for pain, though some may be cosmetic. I've done a bunch of the rich and famous's kids who just throw a bottle in and call it a night leading to dramatic destruction of their teeth. I give the poor moms the benefit of the doubt that they didn't know, etc.
 
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There's really no new data. The Wake Up Safe and/or SmartTots groups are working on some new statement, but it's not out yet and I've not seen a draft.
I'm sure it will be more of the same.
The reality is that most procedures that we do are necessary. What is not clear is what can wait, and how long. Maybe until 3 or 6 months or 3 years or 5 years? Or when to set those intervals. I'm sure some surgeries can be delayed without significant risk, perhaps for years. (I'm talking to you circ!)
As for the T&As, the ones we do on the young kids are generally for significant sleep apnea and the literature supports its clear benefit. Most little kids aren't going to tolerate cpap/bipap for years waiting for some arbitrary time. And dental restorations are usually done for pain, though some may be cosmetic. I've done a bunch of the rich and famous's kids who just throw a bottle in and call it a night leading to dramatic destruction of their teeth. I give the poor moms the benefit of the doubt that they didn't know, etc.
Baby teeth are important for chewing, speaking and holding space for the permanent teeth to erupt properly. Leaving cavities results in pain, infection and the teeth need to be extracted. This causes problems with all of the above including cosmetics. Infection can also damage the developing permanent tooth/teeth.
 
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I just spoke with the head of urology about this a week or so ago and he said the national organization doesn't have a position on it as there is no clear evidence of significant human injury, and there may never be for a 20 minute procedure, but I bet if I told the parents that there were primate studies showing significant and likely permanent brain injury after anesthesia during periods of high brain development and are they really sure they want to have their circ at 6 months and not 3 years when the risk should be lower, most would wait.
These are the same parents that obsess over everything and micromanage to the extreme. If they laid it out for them pre op at the clinic, we'd be doing a lot more at 3-5 years and not 3-6 months.
I do get asked about this occasionally, and I just tell them the party line, and I can't discuss delaying the case, as that's not something we know anything about. That conversation should have happened with the surgeon before the case was scheduled.
 
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Noyac and IlDestriero....thank you for the information. The surgery is considered elective, but necessary, so from what I'm gathering from your comments, age 3 if it was your kid? Not sure it can wait until 5, but might be able to swing 3. It's an inguinal hernia repair, surgeon called it "small", possibly bilateral. I need to do some lit search on this, I'm so far removed from peds, and I'm glad you guys said something about this. Thank you.
 
We do these cases and I don't feel like we are jeopardizing these kids greatly. But I don't know. I don't have the information. Nobody does.

So, what you want to know probably is, what if it was my child?
If it was my child, I'd try to wait as long as possible which may be 1yr or more. If I made it to 3yrs then I'd feel better but that isn't supported tremendously either. Waiting til 3yo isn't exactly ideal either since there can be complications from the hernia. So I would just have it done at a reasonable age but before there are complications from the hernia. The reason the surgeon said it might be bilateral is strictly because there is an increased incidence of bilaterality in infants.

If it were my child I would not stress this too much. We have done these cases on kids for many many years and they still turn out to be normal annoying kids and know-it-all adults. My sister had this very surgery at age 1. Actually, that's probably why she is such as bleeding heart liberal.
 
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The question for the surgeon is how big is the hernia and what is the risk of waiting. How long to wait is anyone's guess. Hopefully the surgeon has some data on realistic risk and you can use that to decide.
You can do a hernia repair with a spinal and a pacifier, though probably not if they want to do a quick laparoscopic look on the other side, which our general surgeons do all the time. Maybe that's what we will be doing for these cases in babies in a few years.
Don't worry too much, if he/she needs it they need it.
 
We do solo or 2:1 as well with CRNAs/fellows/residents.
If you want to discuss something, discuss with the surgeon the proper timing of the surgery and if it could be delayed without consequence.
There is growing evidence that our anesthetics may be causing damage to the developing brain.
As the existing evidence is still inconclusive and hard human evidence with modern drugs and techniques is still years away, the only advice I would give you is to put off elective and semi elective surgery as long as is reasonable to allow for more brain development and reduce potential risk of injury.
The only cases that we still do that are usually completely elective are circs. Maybe they should be delayed until after 3 or 5? Our urologists are aware of the issue and concern, but they do them anyway.
That's probably not an option for you though.
I predict that in the near future we will see a dramatic decrease in the number of elective surgical procedures performed on infants and children in general.
 
I appreciate the insights. Will look into this further.
 
I wonder if anyone has started altering their anesthetic techniques for children based on all these preliminary studies. I went to a lecture and the speaker stopped using ketamine, vapour, nitrous. Used a heavy narcotic technique, low dose propofol, local anesthesia when possible etc...
 
The last i heard they had done a big retrospective study in a Scandinavian country comparing children that had had surgery as children to controls and found no difference...
The French society recommends having a dedicated pedi anesthesiologist (although there is no fellowship for that in Europe) for kids under 1 y/o so most elective procedures are delayed til then.
 
The last i heard they had done a big retrospective study in a Scandinavian country comparing children that had had surgery as children to controls and found no difference...
The French society recommends having a dedicated pedi anesthesiologist (although there is no fellowship for that in Europe) for kids under 1 y/o so most elective procedures are delayed til then.

Yes, a pedi-anesthesiologist has a lock and key. Such a joke.
 
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I wonder if anyone has started altering their anesthetic techniques for children based on all these preliminary studies. I went to a lecture and the speaker stopped using ketamine, vapour, nitrous. Used a heavy narcotic technique, low dose propofol, local anesthesia when possible etc...
I'm not sure propofol is the answer.
 
I'm not sure propofol is the answer.
Im not sure either. He said it was not as 'bad' as vapour. He said ketamine was the worst offending agent. Ill have to try dig up the research. This was just what I remember off the top of my head.
 
I wonder if anyone has started altering their anesthetic techniques for children based on all these preliminary studies. I went to a lecture and the speaker stopped using ketamine, vapour, nitrous. Used a heavy narcotic technique, low dose propofol, local anesthesia when possible etc...
I think it's ridiculous , i don't use ketamine for children because of it's side effects but i don't believe any of the drugs we commonly use can be extremely neurotoxic.
 
I think it's ridiculous , i don't use ketamine for children because of it's side effects but i don't believe any of the drugs we commonly use can be extremely neurotoxic.
I'm hoping not. Only time will tell as more studies are done... What do you consider extremely? What would you do if it was your child needing surgery? Postpone until a certain age if possible? Avoid/use certain drugs? Just ignore it all and take a chance?
 
I'm hoping not. Only time will tell as more studies are done... What do you consider extremely? What would you do if it was your child needing surgery? Postpone until a certain age if possible? Avoid/use certain drugs? Just ignore it all and take a chance?
If the surgery is truly needed then i'd go ahead and wouldn't care about meds administered.
I don't consider it taking a chance in respect of the literature available, i think the current trend of fear mongering is more about people in need of scientific publications than actual sound data.
 
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