Pediatric Anesthesia – PediaCast 552

Show Notes


  • Dr Vanessa Ng and Amber Craver visit the studio as we consider pediatric anesthesia. We explore the latest advances in the field and discuss preparing your child for a procedure, anesthesia safety, and the short and long-term consequences in kids. We hope you can join us!


  • Pediatric Anesthesia




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads.
This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It's episode 552. We're calling this one "Pediatric Anesthesia". I want to welcome all of you to the program.
So, before we get into our topic today, I just have to say, it is so cold outside here in Ohio right now. Well, actually, as I look at the temperature, I guess I would call 19 degrees Fahrenheit "balmy", only because it's been in the single digits for several days leading up to this one. 
And so, hopefully, all of you are bundling up and staying warm, those of you who live in the northern latitudes of the United States. And I've actually done several television interviews on keeping kids safe during the cold weather, including one for the Weather Channel. So maybe you'll see me on the Weather Channel.
And I have to say that, and people who know me well will understand that if I weren't a doctor, I would have wanted to be a TV weatherman. And I'm always following the weather, tracking storms. If I could do the whole Jim Cantore bit and report from the hurricane in a safe and practical kind of way, I would have loved that. 
But as it is, being a pediatrician is fantastic. And bringing up-to-date child health and wellness and parenting information to all of you is also really really terrific. So, I don't have any regrets, I love what I do. But those weather people, I think, probably are having a great time with their job. 
So, you do want to bundle up. Layers are great because then when you go inside, you can remove some layers. You're not stuck in a really hot, heavy sweatshirt. So, I'm a big fan of layers. 
And of course, this time of the year, we do see lots of flu and COVID and RSV and strep throat. And a lot of that has to do with people being inside and school in and the kids all sharing their microbiota with one another in the classroom and then bringing it home to moms and dads, and then they take it to work and share. So, school does drive a lot of this. Not actually the cold weather, it's really more being inside and close to each other. 
So those vaccines at the beginning of the season are always important so that to prevent severe COVID, flu and RSV for select patients. It's not too late to get a flu shot if you haven't gotten one this year. I mean, the flu season sometimes does go into March and April. So, if you haven't had a flu shot this year, it's still a good idea to get one.
And of course, when you're sick, be sure you stay home so you're not spreading your germs. We say you can be back around, folks when you've gone 24 hours without a fever and without the need for acetaminophen, ibuprofen, that sort of thing. 
And then one more thing I want to say about these viral illnesses that we see, strep throat, of course, is the exception to that. We are seeing quite a bit of strep throat right now. But in terms of flu and COVID and RSV, complications of those, ear infections and pneumonia, I guess, kind of make sense because mouth bacteria can go up the eustachian tube into the ear or down into the lungs when your body's fighting off a virus and you've got all this mucus. So, it's easy to understand how those can happen. 
But something else that we see as a complication of viral respiratory illnesses is actually urinary tract infections, and especially in little girls. And the reason for that is because when you're sick, you're not drinking as much and you're not peeing as much. And it's actually, especially in girls, where the urethra, which connects the bladder to the outside world, is pretty short. It's easy for skin bacteria to sort of crawl up into the bladder. But frequent urination helps rinse them out and prevents you from getting an infection. 
But if you are sick with a virus and you're on the couch all day, you're not drinking like you normally do, and you're not active, so your kidneys aren't perfusing and making a lot of urine. So, you may not be going to the bathroom as often, which then in turn, can lead to urinary tract infections, especially in little girls, because they aren't really emptying their bladder and getting those bacteria out of there. 
So, I hope that makes sense. And that's a reason why we always say if you have a fever and a cold and then you don't have a fever for one to however many days, and then a few days later, you get another fever, it could be a second virus that you've just caught. Or it could be one of those complicating things, like a urinary tract infection or an ear infection or a pneumonia. 
So, just some little tidbits there to keep in mind during the cold weather and viral season. So, let's move on to our topic today. We're going to talk about pediatric anesthesia. When is it needed? What does it entail? Who performs it and what sort of training do they need? 
What are some safety considerations with anesthesia in children? How do we reduce fear and anxiety and help really prepare kids for the experience? What to watch for at home afterward and long-term effects and the latest advancements in the field of pediatric anesthesia, it's all coming your way. 
We have a couple of great guests this week. Dr. Vanessa Ng is a pediatric anesthesiologist here at Nationwide Children's Hospital. And Amber Craver is a certified registered nurse anesthetist also at Nationwide Children's. They will be here in a moment.
But first, I want to remind you, you can find us wherever podcasts are found. We're in the Apple and Google podcast apps and really all the podcast places out there you should be able to find us. If you can't find us in your favorite podcast app, let us know and we'll see what we need to do to be included. Please also subscribe to our show.
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So, let's take a quick break. We'll get Dr. Vanessa Ng and Amber Craver settled into the studio and then we will be back to talk about pediatric anesthesia. It's coming up right after this. 
Dr. Mike Patrick: Dr. Vanessa Ng is a pediatric anesthesiologist at Nationwide Children's Hospital and an assistant professor of Anesthesia at the Ohio State University College of Medicine. 
Amber Craver is a certified registered nurse anesthetist at Nationwide Children's. They both have a passion for helping children and families journeying through pediatric surgical and imaging procedures in a controlled, safe, and comfortable way.
That's what they're here to help us explore, pediatric anesthesia. But first, let's give a warm PediaCast welcome to our guests, Dr. Vanessa Ng and Amber Craver, thank you both so much for being here today. 
Amber Craver: Thank you so much for having us. 
Dr. Vanessa Ng: Thanks for having us.
Dr. Mike Patrick: Yeah, I really appreciate you guys taking time. And it's early in the morning, and I know surgical cases start really early, so you're used to being up and at them. And I just really appreciate you taking time to visit with us this morning. 
Dr. Vanessa Ng: Glad to be here.
Dr. Mike Patrick: So, Dr. Ng, let's start with you. What is pediatric anesthesia and how does it differ from anesthesia in adult medicine? 
Dr. Vanessa Ng: So, anesthesia is medications that we give to patients to help them go to sleep for surgical or interventions or imaging procedures that need to be done. And so, it allows us to help them not have any pain, not have any memory, not feel anything, and just be able to have these surgeries done.
In terms of pediatric anesthesia, it means that we are anesthetizing or putting to sleep patients usually from the age of newborn to adolescent. In terms of how it differs from adult anesthesia, pediatric anesthesia, it's a much more specialized approach that just really takes into consideration the age, size, and physiologic differences in children. 
And so, children's physiology differs from adults in terms of their metabolism, respiratory rate, their cardiac output, like how big they are. And so that just requires oftentimes for us to dose differently in terms of the medications that we're giving. Just putting together the anesthetic plan just may differ because they're babies versus adults. 
Dr. Mike Patrick: One thing that always surprises me, and I work in our emergency department and do procedural sedation stuff. So, when you say, like, the metabolism is different, of course, littler kids, of course, the doses are going to be smaller. But in medicine, we measure things in milligrams per kilogram. So you have to take into account a child's body weight. 
And I'm always surprised, those little kids, boy, they just go right through it. The milligrams per kilogram is oftentimes for the total dose is so much higher than in older kids because their body just metabolizes it and eats right through it, so to speak. And so, you just have to give more medicine. It's still not as big of a dose as adults, of course, but when you think about how big the dose is compared to their body size, it is different, right?
Dr. Vanessa Ng: It is always really surprising. Yeah, relatively speaking, we do give them a larger dose. But everything, like I said, is very specifically dosed on their weight.
Dr. Mike Patrick: And then when you were talking, typically, I think as people think about anesthesia, they think about sort of a mask going over a patient's face as though they're breathing in the medicine. But there's other ways to give medicines that you would use in the course of your work, right?  Through the IV, for example. Of course, the gas. 
Is there a preference? Do you decide which is going to be better in a specific case, or how does that all get done? 
Dr. Vanessa Ng: So, it really depends on how the child or children come to us. If the patient has been an inpatient and they already have an intravenous line or some kind of central access, then we can give medicines through the IVs to help them go off to sleep. If they come to us and they're young and healthy and probably not going to sit real still to have an IV placed, then we'll use the anesthesia gas to help them breathe down before we put an IV in. And that's how they drift off to sleep. 
Dr. Mike Patrick: What are some of the common procedures in pediatrics that require anesthesia? 
Amber Craver: So, we do a lot of different procedures here and a lot of things that people probably wouldn't think of. So obviously, if your child is coming in to have their tonsils removed or a bone fixed, we're obviously putting those patients to sleep. Anything an adult would need to go to sleep for, children do. 
But in addition, children oftentimes can't sit still for a dental procedure or too nervous for a dental procedure. So, we do a lot of dental anesthesia. 
Also, pictures and imaging, so a child needs an MRI, those typically are longer than 30, 45 minutes, so they can't move at all while they're in the scanner. And that's difficult enough for an adult to do. So, those patients often get anesthesia for that. 
Sometimes we're doing cases in CT scan where they are identifying lesions that they need to inject. And so, those patients get anesthetized so that they can be still and the interventionalist can find that exact location that they need to inject. So anywhere that a patient needs to be still or the anxiety levels are too high to perform, whatever intervention they're doing, you'll find us.
Dr. Mike Patrick: Yeah. And I do think people would be surprised, like, "You need anesthesia to get an MRI?", but you're in a machine that's making noise and it's enclosed and you can't see your mom or dad. And so, you can imagine that kids are going to be moving around and then you're not going to get a great picture. 
And so probably more so than an adult medicine, in pediatrics, you're going to have to use something to help them relax and stay still. So, it's definitely an important thing. Dr. Ng, what sort of training then is required to become a pediatric anesthesiologist? 
Dr. Vanessa Ng: So, it usually starts with undergrad education. So that's four years. And then at that time, you're usually studying the classic classes that you need in order to take your entrance exams into medical school. So medical school in and of itself is four years. 
And then, residency in anesthesiology is another four years. And that training provides that foundation of anesthesia, covering sort of everything from pediatrics to cardiac to pain.
And then after that, we do a pediatric anesthesia fellowship, which is one year, which may soon go to two. And then, after that you can become a pediatric anesthesiologist, after you take all your exams. 
Dr. Mike Patrick: And speaking of all the exams, I mean, there's three exams just during medical school. And then you have your, I would imagine, the general anesthesiology board exam. And then is there a pediatric anesthesiology board exam on top of that? 
Dr. Vanessa Ng: Yes, there is. And then, we actually do oral boards, as well as written boards for anesthesia, in addition to the pediatric.
Dr. Mike Patrick: Yeah. So, lot of training. And I think the reason that I'm kind of stressing that is it can be scary when your kid is having anesthesia and you think, oh, they're so small, and as a family, we're entrusting our child with this team. But there is a lot of training and experience that ends up going into this, not just on the physician side, but on the nursing side as well. 
So, Amber, I mentioned you were a certified registered nurse anesthetist, or CRNA. What is a CRNA and what kind of training is required to do that job? 
Amber Craver: Right. So as the name says, I was first a registered nurse. So, I went to a four-year nursing college where I got my bachelors of science in nursing. 
And then usually, and it just depends on which program you're going to, you have to do one to two years of an ICU experience, whether that be in medical ICU, CT ICU, some kind of intensive care experience. And then a master's program, which are now master's to Doctor of Nurse programs that are about 36 months of training, which are both clinical and book training. So, the moment that you get into your anesthesia program, you're generally put into the ORs right away and starting hands-on training with patients. 
Dr. Mike Patrick: It's a very competitive field to get in. And again, very rigorous training. And that ICU experience is really, really important for this position, correct? 
Amber Craver: Absolutely, yeah. To understand how to manage tasks, how to take care of patients, how to talk to patients, how to prioritize putting lines in all the things that you do as an RN, you take with you to the operating room where you do your anesthesia.
Dr. Mike Patrick: Yeah, absolutely. And then, of course, this is a team effort, a team approach, for sure. So, we have nurse anesthetists, we have anesthesiologists. How do you guys ensure that what you're doing is safe for children? 
And I think this is a question that is on a lot of parents' minds. What goes into making this a safe thing for kids? 
Dr. Vanessa Ng: It's a great question. I think you mentioned right from the start, it's a team approach. I always have a teammate with me. It's usually a member of two, taking care of one patient all the time, and it's like a collaborative sort of event. 
And I rely on my nurse anesthetists and other anesthesiologists to take the best care of the patients. The patients' safeties are the number one thing.
And so, we do that in a multitude of ways. And usually, we take this holistic approach in terms of, A, we have all this training in our back pocket. And then, the other things that we do is, I usually dig into each patient's chart, really sort of like figuring out who they are, what kind of medical history they have, what kind of surgery they're going to be having. And then, creating a plan with a nurse anesthetist to make sure that we're doing the best thing we can do for the patient, making sure that they're going to be the safest they can possibly be. 
We always, like I said before, we're always dosing specifically on that patient. And if they have any kidney issues, if they have any liver issues, we're taking that into consideration in terms of choosing our medications.
We're always using the size-appropriate, age-appropriate equipment, in terms of managing their airway or putting IVs and lines in. And then, like I mentioned before, we really tailor that anesthetic to that specific patient, and then we're monitoring them the entire time that they're under anesthesia. And we're with them the whole time.
Dr. Mike Patrick: It's not only the family that has concerns, of course, about safety, but kids. This is definitely a foreign environment. The hospital, in the operating room, people are serious, you know that you're going to go someplace where mom and dad is not able to go.
So, there's a lot of fear and anxiety on the part of kids. So especially when you do pediatric anesthesiology, it's going to be so important to help kids overcome the fear and the anxiety that they have. What are some of the ways, Amber, that you are able to achieve that? 
Amber Craver: Well, a lot of it is taking consideration into the patient's age, developmental age as well, and being able to recognize that you have to treat a two-year-old differently than you're going to treat a ten-year-old. Their concerns are going to be different. 
The two-year-old is going to be scared to leave mom and dad, but they're easily distractable. So we can use different songs, games, stuffed animals to sort of play with them while they're on their way back to the OR, when they get to the OR and things seem really scary. They're a lot more easily distracted.
A ten-year-old is going to be different. But you try to find something to connect to them with so that they're more at ease. They feel like you're a person and not this scary being that's going to do something to them that they're unaware of. I think talking to them and asking questions about what makes them scared.
For instance, yesterday I had a patient who did not want to go to sleep. She was seven years old, and she did not want to go to sleep. And she had been under anesthesia multiple times prior to that. 
And so, we asked her, well, what are you scared of? What is the problem? She's like, "I don't like the mask." And so, we were able to tailor her anesthetics so that she didn't need to use the mask to go off to sleep at that point. And that really helped her ease her anxieties. 
Also, if we know somebody who is particularly nervous, we can use our child life specialists to come in. And they have toys and games and build a rapport with them. And they can come back to the operating room, sometimes, with us or to our different procedure areas and help the child's mind be put at ease a little bit or at least distract them enough.
And we also have pharmacological ways to do that. If there's a very anxious child, we have medicine that they can take prior to, to help them just kind of calm down and not care quite as much. 
And I think a big thing though, too, is for parents, is prior to getting into the hospital, is actually having the discussion about where they're going, what's going to happen, what it might look like, and really for parents to be honest with patients. We find that when patients don't have any idea of what they're coming into or walking into or being told that maybe they're not coming to the hospital or going somewhere else, that we have a much harder time with anxiety than if we were honest with the children ahead of time.
Dr. Mike Patrick: And a lot of times I feel like the parent is also probably anxious and fearful, especially the more removed you are from the medical field. And this is not an everyday thing by any means, but we're also modeling behavior. And so, our kids really pick up on if a parent is nervous about something, it's going to be important, even if you're nervous inside, to at least be strong for your kids. Is that right? 
Amber Craver: Yes, absolutely. Kids definitely feed off of their parents' emotions. And obviously, as a parent whose child is going into a very stressful situation, you're going to have some anxiety and you're going to have emotion. But talking to your child and hugging them and loving them and trying to not panic yourself is a really difficult thing, but really important thing to do for them. 
And hopefully this podcast helps, too, to parents that are really nervous about their children having surgery, knowing that we are well prepared and we're well educated and we want what's best for those children, too.
Dr. Mike Patrick: Yeah, definitely. So important. I want to pause for just a moment. And a question that I think comes up a lot is, can parents be there when anesthesia starts? So, in other words, the parent's presence during this whole thing, is it something where the kid is rolled away? Or does the process start with mom or dad there with them? 
Amber Craver: It really is dependent on where and what procedure they're having, where it's being done, and the child and the parent relationship. I would say for the majority of the time, the parents do not come back to the OR with us, for multiple reasons. 
One, it's sterility. We're all in scrubs and caps and what-not. It's a sterile environment. So that's one of the reasons. 
Secondly, sometimes what it looks like in the OR and what it looks like to have your child go under anesthesia can be frightening. Even though we're used to it as anesthesia providers and we care for it and we expect it, it's really hard for parents to watch their child actually fall asleep sometimes. Even when we talk to the parents about what it'll look like. 
So that's another reason. And sometimes it's just not in the best, it doesn't benefit the parent to be there to see it all the time. 
There are some situations where a parent's quite used to it. The patient has had multiple anesthetics, and the parents do really have a really good rapport with the OR staff and the patient, and that it does help. 
But I would say most of the time, the child does a really good job separating, whether that's because they've had the child life specialist or some pharmacological agent to help them relax. And then, we do a quick hug and a kiss and usually get to wherever we're going pretty quickly and off to sleep pretty quickly as well.
Dr. Mike Patrick: And I would imagine that that really involves forming a connection with the child while mom and dad's still there and before you go off to the operating room with them because your kiddo feels like that they're going with a trusted person. And that really involves, especially for kids in the beginning, not only talking about the procedure and the anesthesia, but also talking about, "Hey, do you have any dogs or cats at home?" And "Have you gone on any trips lately?" And "What did you do for the holidays?" 
And just forming that human bond can be so reassuring. Again, as you said previously, that you're not just someone in a mask and a cap and scrubs, but that you really are a person that cares about this kid. And that could sometimes be helpful too, I would imagine. 
Amber Craver: Yep.
Dr. Mike Patrick: All right, let's move on to Dr. Ng, again. And I want to know what the day of the procedure looks like from the lens of the child. So, you get up in the morning, you probably weren't allowed to eat anything or drink anything before you went to bed. And so, right from the beginning, it's definitely a different day. 
Dr. Vanessa Ng: So, actually, my two boys had their tonsils out over the summer. So, I can tell you from a parent's perspective how that sort of like pre-hospital day kind of went. And it was really a normal morning. The boys got dressed. We had been, kind of leading up to the surgery, we talked about what they were going to expect, what we were going to be doing, how they were going to go to sleep, what was going to happen.
And so, it was a very kind of easy morning, just reminding them, we cannot have anything to eat, we can't have anything to drink. And I think we're going to touch upon this in a little bit, but we just had some rules that we needed to follow. And so we were very mindful of that. 
We brought some books, games. We packed books and games, some toys, some stuffies, some Bobblies. And then we went to the hospital. We checked in, and we met the receptionists.
They checked us in. We definitely saw some other kids and other families. They're waiting as well. And then started seeing some of the nurse and the staff in scrubs. And then, we were brought to the pre-op room, where we met some more nurses. And then, we started speaking with more of the staff. 
And so, from the hospital perspective, once our patients and families arrive, they are brought into the pre-op waiting room, where they get changed into hospital gowns with buttons and that type of thing and socks.
And then they get weighed. They get their vitals taken by some of our nurses. And then, they start meeting some of the physicians.
And so, the anesthesiologist comes in and starts talking to us about the procedure, going over what anesthesia is, how we would go to sleep, that type of thing, all the expectations, and then really talking to the kids about what they're going to expect. So almost like two conversations there. 
Then you see the surgeon or the interventionalist, and they kind of talk about what they're going to be doing that day. 
And then, there's usually some time that you just get to hang out with your family, maybe watch a show on the tv in the room or play some games, read some books, hang out with your family. 
And then, the time is right and you meet some of the OR staff, more people in scrubs, and then you go off and you have your surgery or your procedure. And at that point, the patients don't remember anything else because they're under anesthesia. 
And so, when the surgery is done, we wake them up. They hang out in the wake-up room or the recovery room for a little bit, where more of our nurses watch them as they wake up. We want to make sure that everything is good. They're breathing well, they're comfortable, everything is good. 
And then, they're usually reunited with their families in either a floor room, or if they're going to go home that same day, in another room, where they're sort of prepped to leave. 
Dr. Mike Patrick: I would imagine that, not that we wish surgery or anesthesia on any kids, but I would imagine it is helpful to go through this yourself as a parent, in terms of having empathy for the mom and dad and the family. So even though something that you do every day when it's your child, was there a little speck of anxiety or fear for you? 
Dr. Vanessa Ng: 100%. I knew everyone. I knew all the nurses. I knew the surgeons. I knew the people that would be taking care of my kids. But I think as a parent, this is some of the most important people, this is your child, it is the most important person in your life. And you will do anything to protect them and so, you worry.
It is a very natural and normal thing to experience it. But we hope that as the anesthesia providers and people in the hospital, we can impart that sense that we will treat your children like ours. And we would do anything to protect them and make sure that they stay safe. 
Dr. Mike Patrick: And that's such an important point. And the reason that that fear and anxiety is there is because there are potential risks and side effects and maybe even long-term effects of anesthesia in children. And, of course, when we're trying to decide whether we're going to use an anesthetic agent, you're always thinking about risks versus benefits. You certainly don't want to do unnecessary procedures or expose kids to chemicals that they don't need to be exposed to. 
So, what are some of those potential risks and possible side effects of anesthesia in children? 
Dr. Vanessa Ng: So, I think some of the most common things that people think about are an allergic reaction. So, some kids might be allergic to a lot of things. And so, families wonder and worry, are they going to be allergic to anesthesia? And a lot of times we do try to elicit, like, is there a family history? Have they had anesthesia before?
And then just something to bear in mind that there is no better place to have an allergic reaction happen than with us in the operating room, where we are continuously monitoring their kids and we can intervene immediately. There's no better place to have that happen than with us. And if that was the case, we would take care of it.
Some of the other things that are very common or that can be common with anesthesia is post-op nausea and vomiting. So, a lot of times we prophylactically will give anti-nausea medications while the kids are still asleep through their IVs. 
And then, if children have had prior anesthetics where they had very bad nausea, we can sort of pre-medicate them with some of our medications that are really sort of spectacular and work really well, or even change our anesthetic technique so that we can sort of optimize them.
Sometimes, people have sore throats after their procedures. It just sort of depends on what procedure they're having or if we need to use a breathing device, a breathing tube, after the procedures themselves. 
Sometimes, our kids that are school age can experience something called emergence delirium. I usually tell my parents it's when the kids wake up, very cheerful, combative, really crabby. Sometimes they can be inconsolable for a short period of time. 
It's usually a self-limiting thing. But we just did a lot to them. They had surgery, they had anesthesia. This is not their normal day. They feel different afterwards. 
And so, sometimes our kids wake up a little bit cuckoo for cocoa puffs. And that is one of the common things that can happen after a procedure. But it can be very traumatic for the families when they see that their kids are sort of inconsolable.
And then, we have these rules in terms of no eating, no drinking. And that is because we want to prevent something, a risk of aspiration, where anything that might be in the stomach comes up and goes into the lungs. And so, we make these rules of when you have to stop eating and stop drinking to decrease that risk.
And then, most importantly, in flu and RSV season, when our kids are sick with upper respiratory tract infection and we put them under anesthesia, there is a risk of respiratory issues where they kind of act like they have asthma or they have breathing problems afterwards. They need oxygen, or even in the worst-case scenarios, they need to go to the ICU afterwards. And so, we really try to elicit if the kids are sick at the time of having their surgeries. 
Dr. Mike Patrick: We have a lot of pediatric providers in the audience, in addition to moms and dads. And for those of us who have gone through medical training, one of the things you hear about associated with anesthesia is a malignant hyperthermia. Is that something that you actually see? Or is it just one of those things that's in the textbooks and it doesn't really happen very often at all? 
Amber Craver: It can be a very real thing. I think the rule is that you see it once in your anesthesia career. I was lucky enough to see it once, like five years into my career. So, I've been here for eleven. 
And it is very real and it is quite scary. But again, we are monitoring continuously and constantly and are able to pick up on it very quickly. And we have all the medications and the resources that we need to take care of that patient, even on our off-sites. Even our Westerville Surgery Center has all the things that we need to combat that situation. 
Dr. Mike Patrick: Yeah. And that's just the core body temperature goes up really high. Is that what that is? 
Amber Craver: Right. It goes up really high. You're at risk for rhabdomyolysis. You are having metabolic derangements. It is an emergency. It is serious and usually requires an ICU stay for at least 24 to 48 hours afterwards to get the anecdote. 
Dr. Mike Patrick: But again, I just want to point out when it's something that anesthesiologist who is doing cases, multiple cases, every single day, and to see it happen one time in your career, it's really, really rare. And the chance of being in a car accident on your way to the hospital is probably much higher than this happening. 
Amber Craver: Right. And there's only two triggering agents for that. So, when we know that there's a family history of malignant hyperthermia or when we do our pre-op assessments on patients, we usually will ask, "Do you know anybody who's had complications with anesthesia?" "Were they on the ventilator for a long time?" "Did they have a really high fever with anesthesia?" 
Usually, that triggers family or parents or family members to say, "Oh, yeah, my grandmother," or "My mom." And that usually is a light bulb that tells us we're going to do our anesthetic in a different way.
Dr. Mike Patrick: Very good. So definitely from a parent point of view, because we have lots of moms and dads listening, it is important to think about your family history. And if anyone has had any difficulties with anesthesia, talk to your doctors about that. Doesn't mean that your kid's going to have problems, but you definitely want everybody to know past history. It's going to be important. 
So, a child has the procedure, they are in recovery. Hopefully, they get to go home the same day. Sometimes, they need to be watched overnight.
What then should parents watch for when they get home with their child after having anesthesia? 
Amber Craver: So, when you think about when you get home, your child is probably going to still be pretty groggy, sleepy, want to nap for most of the day. You'll want to watch for their breathing and make sure that they're not breathing too fast or too slow. And again, when they're discharged from the hospital, most of the time they are going to be sleepy, but they'll be breathing normally. Their color should be pretty normal, their skin color. 
You want to watch for their pain levels. And when you get your discharge instructions, there'll be medications on there such as like Motrin or Tylenol. And it tells you when you can take those again, what medications you should take. You may get another pain medication that is prescribed to you. 
All of that will be on your discharge instruction. It's really important to keep that paperwork and look at it. And if you have any questions, always call.
In addition, nausea and vomiting, because it's still, even if you're not nauseous or sick at the hospital, sometimes you can go home and have post-op nausea and vomiting. We really want to try to get your child to drink fluids, water, stuff with electrolytes in it, because they didn't have any fluids or food for the first part of the day, probably depending on what time your surgery was. So, they're going to might be a little bit behind on their fluids. Plus, fluids will help nausea and vomiting. 
They may not want to eat very much for the first few hours or day. And that's okay, as long as you can make sure that they're taking in some fluids and that they're still using the bathroom. If you have any concerns that maybe their fluid intake is down too much or they're not urinating as much, just call. Always call if you have any concerns.
And they may have some changes in their behavior for a few days afterwards. So, Vanessa touched upon having emergence delirium that can kind of extend into the next few days. They might have trouble with their sleep-wake cycles. That's all normal. But again, if you are finding that this is extended and you're very concerned, you can always call. 
And then, in addition, obviously, if your child had a procedure that there's a wound or a dressing, your surgeon or your proceduralist should give you instructions about what that should or could look like. But again, anytime you have any concerns about your post-operative course, we will gladly take your call and your concerns.
Dr. Mike Patrick: And I would imagine the behavioral changes can last for a few days, would be pretty concerning to parents, but so it's good to know that that's sort of a normal thing. What kind of behavioral changes are we talking about? Is it just like they might be more active, they might be less active, maybe not quite their normal funny self sort of thing?
Amber Craver: Yeah, for sure. Like I said, they might be a little bit more drowsy than you're used to. They may be waking up at night where they hadn't before. Maybe they'll have a bedwetting where they didn't before. They've had a stressor; they've had a life changing event. So, some of that.
And they also might be a little inconsolable at times, just like they were after their initial surgery. Normally, this doesn't happen to most children, but you will probably notice a little bit of a difference in yours.
Dr. Mike Patrick: Now, so we're talking days now after the surgery. What about longer term than that? And there's been a lot of stuff in the news, and as parents are Googling things, they're going to come across information about the possibility of long-term developmental behavioral effects of anesthesia on children. Is that something to worry about? Or is that misinformation and myths? And there's really no evidence that that happens. Where are we with that? Dr. Ng? 
Dr. Vanessa Ng: Actually, I think you've hit it right on the head. A lot of times, one of the big questions I get from parents is like, what about neurodevelopmental issues post these procedures? 
And there are some studies that have showed there might be some potential impact of anesthesia on neurodevelopment in very young children. These are usually animal studies that show cognitive and behavioral changes, especially in the developing brain. So, like very young, like neonates, infants, and that type of thing.
Human studies have also reported some associations between multiple exposures to anesthesia at a very young age, with a slightly increased risk of learning behavioral issues. Now, what that means is really unclear, and that is part of what they're studying now.
It's really hard to say because they had the anesthesia, this is what's happening now with this child. And to make that causation an absolute is really not fair.
Sometimes we do have to take into account, like, well, is it because they had this medical condition that required multiple anesthetics? Did that have something to play? Did they have a part in that sort of issue? There's just so many factors that could contribute to that. 
I will say that our surgeons in general and our guidelines usually state we really try to not do elective procedures on children under the age of three. So, if you're having surgery younger than the age of three, then it's a necessary procedure. It's a necessary imaging type of thing. It needs to happen.
And usually, a one-time brief exposure to anesthesia is not going to harm your child in any sort of way, but it's definitely concerning multiple exposures, multiple long exposures. But at the same time, we don't take that decision to operate and put these kids under anesthesia lightly. So, it's usually a necessary thing.
But we will do everything we can to make sure that we're giving them the right amount, not like excessive, too much, overdosing them in any sort of way. We really want to give them the minimum amount to make sure that they're safe, they're comfortable, and that it's appropriate for the surgery or procedure.
Amber Craver: And avoiding it as much as possible, if we can. If there's other techniques, we can try to safely get the child through the procedure, then we will do that, too.
Dr. Mike Patrick: And I think that from a parent's point of view, when we have kids who do then end up having autism, for example, when it's something that a lot of people experience, that's very common, like immunizations, for example. It's sort of the same thing. Of course, kids who are neurodivergent, that's going to sort of show up during the young toddler ages. And that's also when they're getting all their immunizations.
And so, to say that something is associated in time doesn't necessarily make it cause and effect. And I think, sometimes, that's something that's difficult, especially for folks who aren't used to thinking from a science background. You understand why you would make those connections, because our brain is built to make connections between things.
But again, it's not always cause and effect, and that's an important point. But I would imagine there's still studies going on. And we're always trying to keep things safe for kids and study this and get the evidence and make sure that we're making good decisions that are in the best interest of children.
And I would imagine then that there are advancements that have been made over the years in pediatric anesthesia and will continue to have advances that make this safe for kids.
Dr. Ng, what are some of the recent, sort of hot topics in terms of research in pediatric anesthesia? 
Dr. Vanessa Ng: You know, I think to just continue on that prior topic, they're always following patients years out in terms of neurotoxicity research. We're always trying to develop new medications, so pharmacological advances, figuring out what the next best drug might be in terms of risk-benefit profile, the maximum effect with the minimum amount of side effects. 
We're always trying to improve regional techniques, so sort of the ability to do peripheral nerve blocks, continuing to push the boundaries in terms of what we can do. Because if you do a peripheral nerve block and just sort of numb the area that's being operated on, we can usually give less overall systemic medications. And that's always a good thing.
We're usually trying to improve with protocols. We have something called ERAS. It's enhanced recovery after surgery protocols, which sort of maximizes outcomes in terms of getting the patients out of the hospital as soon as possible, getting them up and walking, eating, back to their baseline as soon as possible, with sort of maximizing regional techniques, decreasing the amount of narcotics that we're using and that type of thing. And then things like simulation training, really always continuing to make sure that we are providing the safest anesthetics possible.
Dr. Mike Patrick: And then tell us a little about Pediatric Anesthesia at Nationwide Children's Hospital. I think I saw that you guys see over 30,000 patients every year. That's a lot of kids that you guys are providing anesthesia services for.
Amber Craver: I actually think it might have been 40,000 this year. Yes, so, we are doing a lot of anesthetics here at Nationwide Children's, which means we get pretty good at it, too, though.
And chances are we've seen what your child has or what your child needs before. So, we were all pretty well rounded when it comes to taking care of different unusual cases and things. So, we have that going for us. 
We have a large team of anesthesiologists and CRNAs. I think there's almost 100 of us combined in our department, and it just keeps growing.
And I've been here for 11 years, I think I said that earlier. And I've seen such an incredible growth here and so many new things that we do. For example, the enhanced recovery after surgery and different procedures that we're trying and working with our surgeons to really maximize safety profiles and have best outcomes and patient satisfaction over the past 11 years. 
It's really incredible place, incredible place to work. There are great surgeons, great staff, just really good people that when you come here, you know that somebody who really wants to be here and really wants to take care of these children. 
Dr. Mike Patrick: And not only for the kids of Central Ohio, but we see folks who come from all over the country who travel to get care here. And so, part of those 40,000 patients are not just here in Ohio, correct? 
Amber Craver: Or in the states. We see people coming from overseas too, for some of our procedures.
Dr. Mike Patrick: All right, well, Dr. Vanessa Ng and Amber Craver, we really appreciate you guys stopping by so much. We are going to have quite a few links in the show notes for you. So, if you head over to, you'll find those. 
Of course, we'll have a link to Anesthesiology and Pain Medicine at Nationwide Children's Hospital. There are also some links there from the American Academy of Pediatrics. For example, what is a pediatric anesthesiologist? Information for parents, more info on the day of the procedure, frequently asked questions that you may have about anesthesia safety in infants and toddlers. All from the American Academy of Pediatrics.
So, if you want to read more about the things that we've been talking about, just head over to the show notes at Also, a link to the Society for Pediatric Anesthesia, which has some interesting information, both for professionals but also for parents, too.
So once again, Dr. Vanessa Ng, pediatric anesthesiologist at Nationwide Children's Hospital, and Amber Craver certified registered nurse anesthetist here at our hospital, thank you both again so much for stopping by and visiting with us today. 
Amber Craver: Thanks so much for having us.
Dr. Vanessa Ng: Thanks for having us, Dr. Mike.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guests this week, Dr. Vanessa Ng, pediatric anesthesiologist at Nationwide Children's Hospital and Amber Craver, certified registered nurse anesthetist, also at Nationwide Children's. 
You know, after we get done recording, I try to make sure that the guests said everything that they wanted to say. And if there's something that was important that we didn't get to in the course of the conversation, we'll record it real quick and stick it in where it best fits. 
But today there was a couple of links that the guests, after we were all done, were like, "Oh man, we should have mentioned these." So, I'm going to mention them now and you will find them in the show notes, over at 
One is a surgery guide from Nationwide Children's. And this is an excellent PDF handout that you can either look at online or download and print. And it really just talks about how to prepare your kids for surgery, all of the pre-surgery instructions. There's a lot of answers to frequently asked questions, really a section all about anesthesia, a lot of the things that we talked about during this podcast and some helpful hints on preparing your child for the experience. 
So, if you do want a pediatric surgery guide, just check out the show notes. You'll find it there over at and this is Episode 552. 
Another is an Instagram video from one of our other pediatric anesthesiologists. And she describes why it is so important to follow NPO guidelines before anesthesia. NPO is just, in medical jargon, it means nothing by mouth. And it just goes back to the Latin, and that's why we get the initials NPO. 
But why is it important? They say, don't have anything to eat or drink after midnight or for 8 to 12 hours before the procedure. So why is that important? And this is a great video on Instagram explaining it. And again, we'll put a link in the show notes so you can find it easily. 
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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody. 
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.


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