Pain, Pain Go Away
Pediatric anesthesia is an ever-evolving science at Riley Hospital for Children.

It's a few minutes before seven o'clock in the morning and the surgery department at Riley Hospital for Children is wide awake. Parents cluster in the waiting room, sipping coffee from Styrofoam cups, reading newspapers and filling out paperwork. In one corner, a clergyman prays with a young couple while the toddler at their feet sucks on the ear of a grinning purple dinosaur.

It's more hectic beyond the double doors leading into the OR suites. Pagers beep and chirp constantly as ringing telephones mix with the occasional voice over the intercom. Doctors and nurses cluster in hallway huddles and make last-minute preparations; some are in scrub rooms, washing their hands and arms furiously, reviewing out loud with their teams the work ahead.

The little girl arrives aboard one of Riley's red-wagon fleet. She seems relaxed and calm as she's helped to the table. "Feeling okay, sweetheart?" one of the nurses asks. "Um-huh," she responds.

Blood pressure, heart rate and body temperature blink on the overhead monitor while the nurse carefully arranges orthopaedic surgical tools on the cloth-covered tray. Gopal Krishna, MD, the anesthesiologist, stands behind the patient's head, checking equipment and dials and monitoring vital signs. In reassurance, he lightly rubs his hand over the girl's head and reminds the resident anesthesiologist to tape her studded earrings. A mask is gently fitted over her nose and mouth, and she slowly inhales.

"Do you know what you want to dream about?" a nurse asks the youngster, hol ding both of her hands. "How about a pretty blue sky and sunshine and clouds floating by?" A faint smile comes to the girl's face and she sighs. Her eyes flutter, then close.

"You're doing well, very nice," Dr. Krishna says just above a whisper, checking the gauges on the anesthesia machine. He looks at the resident, then nods. "Okay, she's ready for you."

The resident starts an IV in the child's hand, beginning several hours of work for the surgical team, during which the anesthesiologist will be monitoring the young patient's condition every step of the way.

Anesthesiology by definition is the study and science of using drugs or gases to relieve or temporarily remove pain. Its best known applications are to sedate patients before a surgical procedure as well as to ease non-surgical chronic or acute pain through the use of drugs and other therapies.

In bygone days, pre-surgical anesthesia, if used at all, might be several slugs from a whiskey bottle (to the patient, one hoped) or a chloroform-soaked rag pressed over the patient's nose. As recently as the 1960s, the most common approach was to deliver a rush of noxious smelling ether gas through a mask, sending the patient on an often-hallucinogenic journey from which he or she awoke nauseated and reeling.

Today anesthesiologists take great care to individually assess patients prior to surgery or other treatment, and pediatric patients pose unique challenges both in and out of the operating room. Indiana University School of Medicine pediatric anesthesiologists at Riley Hospital for Children long have pioneered the best ways to ease and prevent youngsters' surgery-related pain and the long-term pain associated with cancer and other debilitating diseases and conditions.

While anesthesia is best known for its value in the operating room, IU School of Medicine pediatric anesthesiologists also strive to relieve and manage non-surgical chronic pain caused by malignant bone and spinal cancers, chemotherapy, sickle cell disease, arthritis, gastrointestinal disorders and migraine headaches. That task largely is the responsibility of Pediatric Chronic Pain Clinic, whose patients come to Riley on referral from specialists.

"You cannot practice anesthesiology in a vacuum and that's why we work closely with pediatric physicians, hematologists and oncologists and other specialists," says Clinical Associate Professor Thomas A. Majcher, DO, clinic director. "It's a total team effort and that's what makes our work at Riley so successful."

Now celebrating its 75th anniversary as Indiana's only comprehensive children's hospital, Riley Hospital continues to draw the most complicated pediatric cases, including those in cancer, cardiology, cardiac surgery and neonatology, as well as general surgery. Each year, pediatric anesthesiologists at IUSM handle more than 10,000 cases in the hospital's fourteen ORs and nearly a thousand non-surgical procedures such as cardiac catheterization and MRI.

Dr. Krishna, who is vice chairman of the IUSM Department of Anesthesia and director of the Section of Pediatric Anesthesia, heads a team of nineteen full-time pediatric anesthesiologists and oversees training of scores of anesthesia residents, rotating residents from other medical specialties and medical students.

He notes that IUSM's anesthesia residency program is unique in that anesthesia residents rotate at Riley for a much longer period than in most other programs, giving them extensive experience in pediatric anesthesia. Anesthetic management of newborns, infants and children not only requires specialized knowledge of the disorder being treated, but also of the unique physiology of these young patients, who are not simply small versions of an adult.

"For me, neonates embody the essence of pediatric anesthesiology and offer the greatest challenge, requiring the fullest understanding possible of pharmacology and physiology," Dr. Krishna says. With their high metabolic rates, decreased kidney function and immature cardiac, pulmonary and thermoregulatory systems, newborns are at far greater risk from minor changes in physiological parameters.

For example, poor temperature regulation can lead to hypothermia which, if not recognized and dealt with immediately during surgery, can cause an anesthetic overdose or slow emergence from anes- thesia. To prevent such complications, Riley physicians use forced-air warming devices, radiant heat lamps, warm infusion solutions and inhaled gases. They also keep the operating room temperature warmer than is done for adults. Generally, the OR temperature at Riley ranges from 70-75 degrees Fahrenheit for children, to 80 degrees for term newborns and 85 for premature babies, five-to-fifteen degrees higher than the level used for adult patients.

These and other approaches are part of rigid preoperative protocols followed by IUSM pediatric anesthesiologists for both infants and older children. The pre-op pathway can begin weeks before surgery and incorporates a healthy amount of education and reassurance. Physicians and nurses meet with the child and parents, providing easy-to-understand literature and videos and, in some cases, a tour of the OR.

A complete family his-tory and up-to-date medical history alerts the physician to potential problems such as upper respiratory ailments and allergies to anesthetic agents and antibiotics. The patient's history takes into account the mother's health during gestation and delivery, and the pediatric anesthesiologist also notes real and potential inherited disorders.

For instance, malignant hyperthermia (MH), a rare muscle condition triggered by volatile anesthetics and certain muscle relaxants, can set up a potentially lethal chain of events for the patient: accelerated muscle metabolism, increased oxygen consumption and skyrocketing body temperature. Three decades ago, the mortality rate of MH-related complications was ninety percent; today the rate is seven percent thanks to more thorough screening, vigilant monitoring during surgery, and use of drug treatments in rapid response to MH symptoms.

"For young children and even their parents, it's not the surgery or use of anesthesia that scares them as much as the anxiety of being separated from one another," says Stephen Dierdorf, MD, IUSM professor of anesthesia. "We're careful during the preoperative interview to use everyday language that describes the process and reassures children and parents."

Part of the protocol followed by IUSM pedi- atric anesthesiologists is that virtually all young children are sedated by oral medication before they are wheeled into the operating room for the induction process. "The age of a child is an important consideration," adds Dr. Dierdorf. "Ultimately, the goal is to have a child who is cooperative and calm while remaining conscious."

Though sedated, children still come to Riley's surgical rooms with anxieties. The sight of an inhalant mask often fuels their fear. To divert their concerns, masks often are laced with candy or fruit-flavored scents, which have no medicinal value but make the experience more tolerable for children.

Anesthetizing youngsters for surgery can be approached through a variety of means. An IV is commonly used with infants and toddlers who have acceptable vein access because it is fast, reliable and provides a ready route to administer other drugs if needed during surgery. "IV induction, combined with local anesthetics, is used at Riley for patients whose conditions suggest they might be at increased risk of physiological instability during surgery or develop complications related to other forms of induction," says Dr. Dierdorf.

Anesthesia for older infants and toddlers also is induced through inhaled gases such as sevoflurane and halothane because of their pleasant smell and reliability. However, how they are administered is critical. In a 1992 article, Assistant Professor Ruth E. Bennie, MD, and Associate Professor William L. McNiece, MD, noted that the two inhalants cause hypotension in infants. To avoid this, these and other inhaled gases are delivered through sophisticated anesthesia machines.

Pediatric anesthesiologists, in collaboration with the Sections of Pediatric Cardiology and Cardiovascular Surgery, are investigating the addition of tiny amounts of nitric oxide to the ventilator-delivered gases for some newborns, infants and children undergoing surgery to repair congenital heart disease and defects. This approach may benefit patients who develop high pressures in the lung blood vessels after cardiac surgery, critically reducing the blood and oxygen supply to the rest of the body.

"The potential advantage of nitric oxide is that by giving this compound through the ventilator, the arteries to the lungs relax, increasing the flow of blood that is able to pick up oxygen in the lungs," says Associate Professor Simon C. Hillier, MD, a specialist in pediatric anesthesia with a particular interest in pediatric cardiac anesthesia and the pulmonary circulation. "The amount of oxygen-rich blood that can be pumped by the heart to the vital organs is increased, recovery is enhanced, and the patient can avoid more extreme measures such as the heart-lung machine or prolonged mechanical ventilation after heart surgery."

Preempting post-op pain is equally important. Dr. Majcher explains that peripheral nerve and caudal blocks, administered by injection before a surgical incision is made and again following closure, are effective pain-relief measures.

Older children, like adults, can have a direct hand in managing their pain by using IV-delivered, patient-controlled analgesia. "If a child can operate a Nintendo, in most cases he can operate a PCA," says Dr. Majcher. "The patient pushes a button on a computer-controlled infusion device to self-administer pain medication. Intervals and maximum dosage are set by the physician."

Still, beyond the ongoing research, technology and teaching resources available to the pediatric anesthesiologist, the most effective pain-relief tools are the ones that garner the trust and confidence of a youngster facing surgery - a calming touch of the hand and a reassuring word.