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PEDIATRIC ANESTHESIA

Goldilocks: The Pediatric Anesthesiologist’s Dilemma

Section Editor, Pediatric Anesthesia, Anesthesia & Analgesia, and Professor of Anesthesiology, Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

In this issue of the Journal, Davidson et al. (1) report on a frequent incidence of intraoperative awareness in children—an incidence fourfold to eightfold more frequent than reported in adults, according to criteria that the authors consider valid. In adults, intraoperative awareness is a rare but well described complication of anesthesia. It has an incidence of 0.1% to 0.2%, but in certain populations (i.e., cardiac patients, trauma patients, obstetrical patients, and patients undergoing light anesthesia supplemented with muscle relaxants), the risk is greater (2–9). As with any single-center study using unique criteria, the reader should evaluate the data closely before drawing conclusions. However, this study adds one more dilemma for the pediatric anesthesiologist—the Goldilocks conundrum. How much is "too much," how much is "too little," and when is it "just right"?

The Goldilocks conundrum started with the realization that children are at higher risk for anesthesia-related cardiac arrest and other anesthesia-associated adverse events (10–14). This is not surprising in view of the larger anesthetic requirements and the associated increased incidence of cardiovascular instability observed in infants and small children. These adverse events frequently led clinicians to withhold or minimize the administration of anesthetics to infants and neonates—i.e., the "too little" component of Goldilocks. However, over the years, as studies focused on patient outcomes, objective measures of biochemical markers of stress hormones (15), and public awareness focused on the practice of surgery without anesthesia, "too little" anesthesia became an unacceptable practice both medically and socially.

With clinical outcome data and a better understanding of the developmental maturational changes that occur in pain pathways and pain responsiveness, clinicians shifted their attitudes toward administering rather than withholding anesthesia. However, more recently, the paradigm of anesthetizing infants has been challenged by work in neonatal animals which suggests that infant rats and mice exposed to anesthetics have an increase in apoptotic neurodegeneration in the brain (16–19). Although the applicability of this to humans and our practice is not clear, it has raised concerns for the pediatric anesthesiologist and brings an added dimension to the Goldilocks conundrum: how much of our drugs and techniques is "too much," how much is "too little," and how much is "just right"?

In this issue of the Journal, Davidson et al. reveal a potentially darker side to the problem of "too little." In the first large-scale pediatric study of awareness during anesthesia, this prospective cohort study by Davidson et al. asks a fundamentally important but difficult question: how many of our pediatric patients are not asleep?

The perioperative experience can have a profound effect on the emotional well-being of children. Studies performed in children suggest that up to 54% of children undergoing outpatient surgery experience behavioral changes such as anxiety, nighttime crying, enuresis, separation anxiety, and tantrums during the first two postoperative weeks (20–22). In the present study, the incidence of postoperative behavioral problems in the children not thought to have awareness was 16% (1). Because of these known behavioral changes, numerous interventions are used to help children cope with the anxiety surrounding the perioperative experience. In addition to preanesthetic medications, preoperative preparation programs and programs involving music therapy, parental presence, and acupuncture have all become ways to help children and families cope with the stress of surgery and anesthesia. Parental presence and induction rooms have become a popular method of inducing anesthesia in children. However, there is large variability among institutions in attitudes and policies toward parental presence during induction. Over the years, parental involvement and the frequency of parental presence at the induction of anesthesia have increased (23). One of the salient features in the design of this study is that the standard practice of the institution was maintained. Thus, induction rooms and parental presence were used to produce less emotionally traumatic experiences for the children. However, by the authors’ own account, anesthesia was not continued in the transport from the induction area to the operating room, and no effort was made to prevent partial awakening during patient transfer. Is the fourfold to eightfold increase in awareness of children a function of something unique to children, or is it a function of how the authors anesthetized and transported the children? Some institutions use induction rooms and transport beds equipped with a vaporizer and breathing circuit: would the incidence have been as frequent in this setting? Is the way the institution has set up its parental presence with the anesthetic induction and efforts to allay the fears of their children a factor in having "too much" or "just right" become "too little?"

Another concern of the study is how the information was extracted and analyzed. How does one extract this kind of information from a child without altering the results? In their classic book (required reading for parents and chairpersons) How to Talk so Kids Will Listen and Listen so Kids Will Talk, Faber and Mazlish (24) espouse the concept that dealing with children takes patience, time, and energy. How reluctant were the children in this study to talk about the experience? What about the 16% of children with behavioral problems? Could that have been a sign of awareness? Thus, Davidson et al. may have considerably underreported the incidence of awareness. Conversely, the ability for young children to separate reality from fantasy is not often clear. How likely is the incidence to be overreported? Parents conducted the second and third set of interviews. Could parental bias have been introduced? In a study that requires people to have a special skill set to avoid introducing bias, should professionals have conducted the second and third set of pediatric interviews? The determination of what was and what was not awareness was made by outside "skilled pediatric anesthesiologists." If other "skilled pediatric anesthesiologists" were sent the same information, would the conclusions have been the same?

Finally, what is the pediatric anesthesiologist to do with the information of the study? If the incidence of awareness is frequent, maybe monitoring can reduce this. Although there is currently significant controversy in the adult literature on this topic, some authors, such as Myles et al. (25), note that bispectral index-monitored anesthesia decreases the risk of awareness by 82%. Cerebral monitoring has been used in children, but no one has demonstrated its ability to decrease awareness in this population. In addition, in our youngest and most vulnerable patients, children <6 months of age, a time period associated with tremendous neurological maturational change and an inability to communicate, bispectral index monitoring is unreliable. How much should a concern about potential awareness drive our anesthetic monitoring and management? This study by Davidson et al. begs for the design and support of a multi-institutional study on pediatric awareness.

For the pediatric anesthesiologist, there is no fairy tale ending. Like Goldilocks, we know that "too much" is not good and we know that "too little" is not good, but just when we thought we knew "just right," Davidson et al. may be telling us something different.

	Footnotes

 
Accepted for publication October 29, 2004.

Peter J. Davis, MD, Children's Hospital of Pittsburgh, 3705 Fifth Ave., Pittsburgh, PA 15213-2583. Address e-mail to davispj{at}anes.upmc.edu.

	References

Top References

 

1. Davidson AJ, Huang GH, Czarnecki C, et al. Awareness during anesthesia in children: a prospective cohort study. Anesth Analg 2005;100:653–61.[Abstract/Free Full Text]
2. Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: a prospective case study. Lancet 2000;355:707–11.[Web of Science][Medline]
3. Myles PS, Williams DL, Hendrata M, et al. Patient satisfaction after anaesthesia and surgery: results of a prospective survey of 10,811 patients. Br J Anaesth 2000;84:6–10.[Abstract/Free Full Text]
4. Liu WH, Thorp TA, Graham SG, Aitkenhead AR. Incidence of awareness with recall during general anaesthesia. Anaesthesia 1991;46:435–7.[Web of Science][Medline]
5. Wennervirta J, Ranta SO, Hynynen M. Awareness and recall in outpatient anesthesia. Anesth Analg 2002;95:72–7.[Abstract/Free Full Text]
6. Sebel PS, Bowdle TA, Ghoneim MM, et al. The incidence of awareness during anesthesia: a multicenter United States study. Anesth Analg 2004;99:833–9.[Abstract/Free Full Text]
7. Ranta SOV, Laurila R, Saario J, et al. Awareness with recall during general anesthesia: incidence and risk factors. Anesth Analg 1998;86:1084–9.[Abstract]
8. Lyons G, Macdonald R. Awareness during caesarean section. Anaesthesia 1991;46:62–4.[Web of Science][Medline]
9. Bogetz MS, Katz JA. Recall of surgery for major trauma. Anesthesiology 1984;61:6–9.[Web of Science][Medline]
10. Keenan RL, Boyan CP. Cardiac arrest due to anesthesia: a study of incidence and causes. JAMA 1985;253:2373–7.[Abstract/Free Full Text]
11. Cohen MM, Cameron CB, Duncan PG. Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 1990;70:160–7.[Abstract/Free Full Text]
12. Morray JP, Geiduschek JM, Caplan RA, et al. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology 1993;78:461–7.[Web of Science][Medline]
13. Murat I, Constant I, Maud’Huy H. Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period. Paediatr Anaesth 2004;14:158–66.[Web of Science][Medline]
14. Rackow H, Salanitre E, Green LT. Frequency of cardiac arrest associated with anesthesia in infants and children. Pediatrics 1961;28:697–704.[Abstract/Free Full Text]
15. Anand KJS, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:1–9.[Abstract]
16. Ikonomidou C, Bosch F, Miksa M, et al. Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain. Science 1999;283:770–4.[Free Full Text]
17. Olney JW, Wozniak DF, Jevtovic-Todorovic V, et al. Drug induced neurodegeneration in the developing brain. Brain Pathol 2002;12:1–11.[Web of Science][Medline]
18. Jevtovic-Todorovic V, Hartman RE, Izumi Y, et al. Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 2003;23:876–82.[Abstract/Free Full Text]
19. Anand KJS, Soriano SG. Anesthetic agents and the immature brain: are these toxic or therapeutic? Anesthesiology 2004;101:527–30.[Web of Science][Medline]
20. Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioral changes following routine ENT operations in 2-to-10-year-old children. Paediatr Anaesth 1996;6:45–9.[Web of Science][Medline]
21. Kotiniemi LH, Ryhanen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997;52:970–6.[Web of Science][Medline]
22. Kain Z. Postoperative maladaptive behavioral changes in children: incidence, risk factors and interventions. Acta Anaesthesiol Scand 2000;51:217–26.
23. Kain ZN, Caldwell-Andrews AA, Krivutza D, et al. Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995–2002: results of a follow-up national survey. Anesth Analg 2004;98:1252–9.[Abstract/Free Full Text]
24. Faber A, Mazlish E. How to talk so kids will listen and listen so kids will talk. New York: HarperCollins, 2002.
25. Myles PS, Leslie K, McNeil J, et al. Bispectral index monitoring to prevent awareness during anaesthesia: the B-Aware randomized controlled trial. Lancet 2004;363:1747–8.[Web of Science][Medline]

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