Anesthesia and Perioperative Considerations in Pediatric Ophthalmology and Adult Strabismus
Tamiesha Frempong, MD, MPH
INTRODUCTION
Anesthesia care plays a significant role in pediatric ophthalmic and adult strabismus cases. Perioperative planning has a major impact on the workflow efficiency, patient comfort and safety, and postoperative care and recovery.
Order of Surgical Cases
Typically, patients are scheduled from youngest to oldest. Ordering by age minimizes the amount of time young children must fast prior to their procedure.
In addition, cases are often grouped by type of procedure (ie, intraocular cases are scheduled first followed by strabismus cases, etc.). Grouping cases facilitates room set up and equipment planning.
A variety of reasons may require a patient to jump the queue. For example, an older, nervous adult patient with anxiety or one with a need to resume anticoagulation in a time-controlled fashion if a blood thinner was stopped for the purpose of surgery may need to be one of the first cases, despite an older age.
Impact of General Anesthesia on Pediatric Patients
Distress/anxiety behaviors often exhibited at the time of anesthesia induction1:
Verbal protestations.
Crying, screaming, or verbally communicating fear or sadness.
Attempts to delay surgery or run away.
Nonverbal resistance such as pushing away the face mask.
Potential sequelae of surgery and general anesthesia:
Postoperative pain.
Emergence delirium.
Behavioral changes:
General anxiety.
Appetite changes.
Sleep disturbances and nightmares.
Enuresis.
Temper tantrums.
Cognitive risks (see below).
Management of Pediatric Patient Stress and Anxiety Associated With General Anesthesia
Nonpharmacologic interventions: The behavior of health care providers and parents/caregivers impact children’s coping strategies and distress behaviors at anesthesia induction.2
Parents’ emotion-focused behavior such as empathy, empathetic touch, and reassurance may inadvertently increase distress and negative coping behavior.
Anesthesiologist/ophthalmologist/operating room staff—humor and distracting talk such as asking about school or hobbies, in addition to medical reinterpretation (ie, anesthesia mask as part of “the astronaut game”), lessens a child’s distress and improves coping behavior.
Pharmacologic interventions (premedications).
Midazolam—oral or rectal; used in combination with atropine for premedication, followed by ketamine and midazolam for induction of anesthesia.
Reliable.
Well tolerated.
Provides good postoperative analgesia.
Dexmedetomidine—intranasal.
Lowers overall anesthetic requirements by reducing sympathetic outflow in response to painful surgical stimuli.3
Has sedative, analgesic, and anxiolytic properties.3
Clonidine—oral, rectal, or caudal.
In the United States, 50% of young children undergoing surgery receive premedication, most commonly with midazolam.3
Induction Methods
The factors to be considered in choosing the mask or needle for induction include preexisting respiratory disease, level of anxiety, previous experience of the patient and parents, and vein quality.6
Intravenous:
Advantages—reduced respiratory events and postoperative behavioral issues.
Disadvantages—more anxiety at the time of induction.
Mask:
Advantages—a better option in patients with poor vein quality.
Disadvantages—higher risk of respiratory events and postoperative behavioral issues.
Risk of General Anesthesia in Early Childhood
Evidence in the literature supports that multiple exposures (not one single exposure) to general anesthetics in children under the age of 3 years results in decreased fine motor coordination and processing speed, as well as reported behavior and reading difficulties. However, no difference in general intelligence has been found.7 These data may serve to guide the timing of surgery and second surgeries in young children. Whenever possible, consider combining procedures with other specialties in order to minimize the risk of anesthetic exposure (ie, examination under anesthesia with a tympanostomy). However, it is important to avoid combining procedures that might increase risk of postoperative infection.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
