Anesthesiology is the practice of medicine focused on the evaluation of complex medical problems, planning and care for patients ranging from sedation to general anesthesia for surgery or other diagnostic medical procedures and treatment of pain.

Physicians who specialize in anesthesiology are called anesthesiologists.

A pediatric anesthesiologist is a highly skilled and fully trained anesthesiologist who completed at least 1 year of specialized training in anesthesia care of infants and children in addition to 4 years of medical school and 4 years of anesthesia residency.

On the day of surgery or your child’s procedure, you will meet your anesthesiologist to discuss the anesthesia plan. You and your child can ask questions and express concerns at this time.

Pediatric anesthesiologists are responsible for the care of infants and children requiring general anesthesia, sedation or pain management. These services may be needed if your child is having surgery or they require diagnostic imaging procedures.

General anesthesia will make your child unconscious during surgery or other required procedures. This is performed using medications that are inhaled or administered into the vein (IV). If children are going to sleep using a mask (typically young children), we offer “flavors” your child can pick and a mask they can decorate with stickers. For older children who are going to sleep using an IV, we offer distraction and pain control techniques to assist with IV placement. Either way, your child will sleep through their procedure and wake with no memory of what happened.

The anesthesia team, which includes a pediatric anesthesiologist as well as either an anesthesia resident or Certified Registered Nurse Anesthetist, are prepared to prevent as many side effects of general anesthesia as possible by continuously monitoring your child during their surgery. If your child is under general anesthesia, they may need a breathing tube inserted into their windpipe while they are asleep so they can breathe properly for their surgery. The anesthesia team manages side effects including nausea and vomiting and helps alleviate pain by administered medications.

Regional anesthesia provides pain relief to specific parts of the body which are being operated on. Often, general anesthesia is used with regional anesthesia to assist with pain control during and after surgery. There are several types of regional anesthesia which may be utilized.

• Spinal anesthetics may be used for lower abdominal, pelvic, lower extremity or back surgeries. The anesthesiologist injects a single dose of anesthetic into the spinal fluid which numbs the lower half of the body.
• Caudal/Epidural anesthetics are similar to spinal anesthetics but can also allow medications to be continuously infused through a thin catheter left in place to numb the lower body for surgical procedures for a length of time.
• Peripheral Nerve Blocks may be used to numb specific nerves affected by surgery. This can be done for surgeries involving the extremities or other areas where specific nerves can be identified. This can be done as a single dose of medicine or continuously infused through a thin catheter left in place for a length of time.
• Local anesthesia may be used if these other techniques cannot be used. The medication injected will numb a specific area to help with pain control after surgery.

Anesthesia can be administered different ways. Medications can be inhaled through a mask that allows your child to fall asleep. Needle sticks are then done after your child is asleep. Medications can also be administered through intravenous (IV) injection, a method that is used mainly for older children and adults. When IV medications are used, we utilize the “Lion’s Pledge” to ensure your child has a pleasant experience. This technique utilizes numbing and distraction to help with any anxiety your child has. Your anesthesiologist will talk to you and your child about the best and safest method for falling asleep for your child’s procedure.

While there is mounting evidence based on animal studies there is need for more human research into this. The FDA released a black box warning regarding this issue.

You may also find the following link useful:

• Smart Tots - FAQs for parents and caregivers

If you have any concerns, it is best to discuss this with your child’s pediatric anesthesiologist.

Yes, your child will have to fast. You will be given instructions on when your child must not eat and drink the day before their procedure.

All children must fast before surgery. That’s because of the anesthesia, not because of the surgery. Here’s why:

• When patients receive anesthesia for surgery, they become very relaxed and sleepy which relaxes the muscles of the stomach and throat that would normally stop food from coming up and going into the lungs.
• When patients get food or liquid into their lungs from the stomach, this can cause pneumonia or even death.
• If the stomach is empty, the risk of anything coming up from the stomach and getting into the lungs is very low which makes anesthesia safer.

Some surgeries that involve the gastrointestinal tract (stomach and intestines) may have special fasting rules that relate to the procedure.

Food and milk take longer to empty from the stomach than clear liquids. To make sure the stomach is empty before your child gets anesthesia, we will tell you what types of food are

You should always check to see what your doctor recommends. Here are some fasting times for different types of food and liquids that are often recommended:

• Type of food or liquid and the fasting time before surgery
  • Fatty or fried food: 8 hours
  • Milk, tube feeds, or formula (infants): 6 hours
  • Breast milk (infants): 4 hours
  • Clear liquids: 2 hours
  • These are general guidelines. The final decision will be at the discretion of the attending anesthesiologist.

Clear liquids are any liquids that you can see through. Some examples are:

• Water
• Electrolyte solutions (such as Pedialyte or Gatorade)
• Apple juice.

Any liquid that you can’t see through, such as orange juice or milk, empties from the stomach more slowly and require more time (6 hours).

You will be given instructions by phone before surgery on what medications to take:

• Some medicines should be taken until just before surgery.
• Other medicines may need to be stopped before the day of surgery.
• Usually medicines that are taken with a sip of water before surgery don’t make the stomach "full,” and won’t raise the risk of problems from the anesthesia
• Please tell us if your child can only take their medicines with food

Emergency surgery can’t be planned ahead of time. If your child has to have that kind of surgery here’s what may happen:

• The child won’t be allowed to eat or drink before surgery.
• If the child’s stomach is not empty, but surgery cannot wait, the anesthesiologist will use special safety measures to reduce the risk of any stomach contents getting into the child’s lungs.
• These measures require your child to have an IV started beforehand to give medication and fluids

Research shows that children with colds may have more problems during anesthesia than children who are healthy.

Because children with colds have more mucus and may have more airway inflammation, they might react to the anesthetic gas. This can cause:

• Coughing
• Narrowing or spasms of the airway (e.g. wheezing)
• A decrease in the oxygen level in the blood

Studies of children who have colds and need surgery have found a number of causes that can increase the chance of problems. These causes include:

• A history of asthma
• Children who need assistance with breathing for their surgery (e.g. a breathing tube)
• Children who have a lot of mucus or nasal congestion
• Particular surgical procedures
• Being around tobacco smoke
• A history of snoring
• Being born prematurely

If your child has a cold, their anesthesiologist may feel it is best to postpone your child’s surgery until their illness is gone due to the increased risks associated with illness. This is done after your anesthesiologist and surgeon have a discussion about the urgency of your child’s operation.

If the decision is that you child’s surgery cannot be postponed, he or she will have the best possible monitoring and care. Children with colds often have more mucus and may have more sensitive air passages. We will take extra precautions in managing the effects of a cold.

Research shows that children with colds may have sensitive air passages, or airways, for a number of weeks after the symptoms are gone. Sensitive air passages are more likely to cause problems during surgery, so it’s usually best to wait a few weeks until the airways have fully healed.

How long to wait before rescheduling surgery varies and you should decide after speaking with your anesthesiologist and surgeon. If your child's surgery was canceled, it’s most likely because the symptoms were severe enough to cause worry.

In these cases:

• The recommended wait time usually 4-6 weeks.
• The wait allows the air passages enough time to get better.

If your child had a bacterial infection of the lungs or airways, give him or her antibiotics and postpone surgery for at least four weeks.

It’s normal for children to be anxious about surgery and being away from their parents. Children who may be more likely to be anxious may have:

• Shy personalities
• A history of surgeries and hospitalization
• Very anxious parents

Children may show signs of anxiety while in pre-surgery by:

• Not talking
• Fearing hospital staff
• Crying

Start in the surgeon's office

• That’s where you and your child are hopefully starting to trust and bond with the doctor who will do the procedure. Many surgeons have brochures in their offices that you can read. They may even have videos to watch which will tell you and your child about the procedure
• Don’t be afraid to ask questions or talk about your concerns
• Try to be ready yourself and let us know if you’re anxious
• Talk about your anxiety with your child's doctors and try to talk without your child there. When you’re comfortable and confident, your child will likely be also.
• Try not to apologize to your child about the surgery. Instead, be matter-of-fact about the surgery; this will help ease worry and fear.

Children of all ages need to know that someone will be with them at all times. Tell your child to feel free to ask any questions at any time before the procedure. If needed, write down the questions so they can be answered later. It’s also important to choose your words carefully. For example:

• You might want to use words like "sore" after surgery, instead of saying "pain."
• When explaining the surgery, you could use the words like "make an opening" instead of "cut."

Explaining surgery to teenagers

Teenagers are more like adults in the way they’re able to understand things like surgery. What will happen to them should be explained in open, honest detail. Teens most often worry about concepts such as:

• Body disfigurement, like scars
• Pain
• Needles
• Diagnosis or Prognosis (the likely outcome of a disease or sickness)
• Death

Explaining surgery to school-age children

School-age children also need an upfront and honest explanation at a level that’s right for their age. In a direct but simple way, they need to be told:

• The surgery needs to be done to fix a problem that will not go away by itself.
• Although you’ll be apart from them for a while, they’ll see you again when they wake up.

Let your child guide your talk by asking what worries he or she may have. Try to respond to them clearly and honestly.

Young children ages 3 to 7 have limits to their understanding about certain things. Make sure to tell them:

• They will be apart from you for only a short time and will be okay.

• Use age-appropriate words like "boo-boos" and "Band-Aids®.”
• It’s helpful at this age to show them the facemask and calm children with an anxiety-relieving medicine.
• Some parents try to keep young children from knowing they’re going to have surgery. This isn’t a good idea because it:
  • Builds distrust and fear later on
  • Makes a child worry about medical procedures over time

Help from home:

• Bring a familiar item from home such as a stuffed toy, blanket, game, tablet (like an iPad®)
• These items may comfort and distract the child, and help make the process smoother.\
• Children are usually allowed to bring those items into the operating room with them.
• If your child has special needs such as autism or any other type of developmental delay, please let the staff know ahead of time about the child’s likes, dislikes or sensitivities.

There are two main ways to lower anxiety on surgery day:

• Explain the process in a comforting way
• Give medicines

Child Life Specialists explain the process

At Penn State Health Children’s Hospital, our specially trained staff of Child Life specialists meet with each child as they’re getting ready for surgery. These experts:

• Help children cope with the stress of surgery
• Guide children through the process by teaching age-appropriate coping skills and using distraction
• Assist children who have special needs such as autism

For example, a Child Life Specialist may:

• Let your child play with a scented face mask and give instructions on how to breathe with it.
• Show your child other medical tools so they can examine, touch and play with them.

This can make the whole process seem less scary. This and other forms of age-appropriate play therapy greatly help the child cope with having surgery.

Pediatric Anesthesia staff helps by giving medicine

• Your child's anesthesiologist will try to calm fears by soothing the child and/or giving the child a sedative medication either by mouth or through an IV.  This is called a “pre-medication.”
• The oral form is given 15 to 30 minutes before surgery. The IV form (given in a vein) is given just before leaving the pre-surgery area.
• The medicine works by:
  • Calming the child
  • Relieving anxiety
  • Clouding the memories of going to the operating room

Most medicines and fluids are given based on the child's weight. That’s why we weigh your child before surgery. Along with weight-based dosing, we monitor:

• Responses to surgical stimulation
• Levels of anesthetic gases in the exhaled air
• Vital signs such as blood pressure, heart rate, oxygenation and carbon dioxide levels

These things let us know when we have reached the right level of anesthesia. 

Anesthesia for children is very safe, thanks in large part to better monitoring devices such as the pulse oximeter and better anesthesia drugs. We closely monitor and manage each child throughout the surgery, making sure they stay safe.

It’s natural for a parent or guardian whose child is having surgery to wonder whether the anesthesia is safe for their child. Even though anesthesia today is much safer than it’s ever been, all anesthesia has some risk. In fact, sometimes it’s hard to separate the anesthesia risks from the risks of the surgery. Anesthesia aims to:

• Take away the pain and discomfort of surgery or other procedures
• Make it easier for the procedure to be a success

These benefits must be weighed against the risks of the anesthesia itself.

The risks of anesthesia will vary based on:

• The type of surgery
• Whether it’s an emergency
• The child’s age
• Any other medical problems or illnesses

Also, each type of anesthetic has a certain set of risks and side effects that come with it. The anesthesiologist will talk to you about the types of anesthesia that may be used for your child, and the risks and benefits of each. 

Usually, a family member can be with the child shortly after he or she is taken to the pediatric recovery room. We ask that:

• Only one or two family members at a time be present
• You wait until the nurse or doctor calls for you before you come to the pediatric recovery room

Keep in mind, your child may be upset or confused when first waking up, or may be slow to wake up. This will go away over time.

It depends on the sedative medicine used and how the child responds. Children show different responses to sedatives. It’s often hard to tell how sedated or sleepy the child will be after the procedure.

• Most children will be monitored and observed in the recovery room until they’re awake.
• Some children may be awake at the end of the procedure and ready to go home soon after.
  • Many children will have a type of confusion when they wake up from anesthesia, called “emergence delirium”. This is a normal response to anesthesia and is very common in preschool-aged children. 
  • For a short time - usually 30 minutes or less - they may be irritable or can’t be comforted.

The best way we can describe “emergence delirium” is to ask you to imagine waking up in a hotel room in the middle of the night. For a brief moment you’re confused and not sure where you are. It can even give you a moment of panic. The same thing sometimes happens to children who are in pediatric recovery.

• They wake up in a strange room, with strangers all around them, and Mom and Dad are not close by.
• Even though we know from what teenagers and adults have told us - which is that most patients don’t remember what happens in the recovery area - a younger child may still be very upset at the time.

The parents’ role in recovery

Here at Penn State Health Children’s Hospital, we make sure to bring a parent to the bedside as soon as the child starts to wake up. The best medicine is often a familiar face, a soothing voice and being held in a parent’s arms. This approach:

• Helps give the parents a major role in their child's recovery
• Helps make sure a child isn’t taking too much medicine when what’s really needed is some TLC

Still, if a child continues to be very upset, we may talk with you about giving additional pain medicine or sedation.

The decision about whether the child needs to stay in the hospital is based on the type of surgery they had. It’s usually the surgeon who decides how long the child will stay after waking up from anesthesia.

Most children are able to start a few normal activities just hours after surgery, including eating, drinking and walking

The surgeon will also decide when it’s best for your child to become normally active again.

Based on the medicine used, children may stay sleepy and unsteady on their feet for a few hours after surgery. That’s why we recommend that children be watched closely on the ride home. Other safety measures include:

• A responsible adult should stay with the child for 12 to 24 hours after sedation.
• Because the following activities need the child to use coordination, he or she shouldn’t try these or similar activities for 24 hours, or until you’re sure the child is stable:
  • Swimming
  • Using playground equipment
  • Climbing
  • Bike riding
  • Roller blading or skating

Sometimes we may decide it’s best for your child to stay in the hospital overnight for observation, for example if your child is a premature infant.

Children lose very little blood in most of the surgeries they have. They will have an intravenous (IV) line in place during most surgeries to give them hydration since they have fasted and replace fluid and blood losses that occur during an operation. A blood transfusion is a safe, common procedure in which blood is given to a patient through an intravenous (IV) line in a blood vessel.

The chances your child will need a blood transfusion are very small if your child is:

• Healthy
• The procedure is simple

The chances go up if your child is:

• Very anemic
• Having complex surgery, such as heart surgery

Without enough red blood cells, the body may starve for oxygen. Not having enough oxygen can lead to life-threatening problems such as brain or heart damage. A blood transfusion helps the body have enough red blood cells to carry oxygen to your child’s organs.

Other parts of the blood include:

• Coagulation factors (a group of proteins) and platelets (cell pieces), which are needed to form clots that help stop bleeding.
  • The surgery team may need to transfuse these parts of the blood during and/or after the procedure to help cut down on the loss of red blood cells.
• Colloids, such as albumin, which are the protein part of blood, may also be used to help treat blood loss.

Magnetic resonance imaging, known as MRI, uses a powerful magnetic field to scan and capture images of parts of the child’s body. It does not use harmful radiation. 

The MRI scanning takes place in a special room on a special table, inside a long tube or tunnel. Most young children, and even some adults, may not do well with the scanning because:

• The magnet makes a thumping, droning sound during the scan. These loud noises sound like a motorcycle engine and can scare a child.
• If they’re awake, some children may also feel claustrophobic (afraid of being in a closed space) during the scan.
• The MRI scan may take between 30 minutes to 4 hours based on the body parts to be studied. Some children may not be able to stay still during that time.

Since any movement from your child may affect the image quality, children may be referred for sedation or general anesthesia.

No, MRI scanning is not painful.

Doctors and nurses who care for the child during the MRI procedure will decide on the need for anesthesia based on the child’s:

• Age
• Health history
• Past medical procedures

You’ll get a phone call from a nurse who works in the MRI area. The nurse will tell you what to expect and give you instructions about how your child should fast and what medications they can take.

On the day of the procedure:

• Your child will be seen first by a nurse who will complete a checklist.
• Next, you and your child will be seen by the anesthesiology team, which includes:
  • An attending pediatric anesthesiologist.
  • A resident anesthesiologist or a CRNA (certified registered nurse anesthetist).
• The anesthesia team will get a detailed history of your child and then examine the child.
• After that, you’ll sign a consent form that gives us permission to given anesthesia to your child.

The “induction room” is where your child will go to have the anesthesia or sedation administered. The process follows these steps:

• In younger children, anesthesia is most often given using anesthetic gases through a face mask. This is called a “gas induction.”
• Once your child is asleep, an intravenous (IV) drip begins and anesthesia is constantly given either through a gas mask or an IV.
• In some cases, the anesthesiologist may insert a "breathing tube" that goes down the throat to help your child breathe better. The tube is removed as your child wakes up.
• After your child is asleep under anesthesia, they will be moved into the MRI scanner where the anesthetic administration will continue.

Our expert pediatric anesthetic team will monitor your child throughout the MRI scanning.

IV anesthetic medicine in older children

Older children are better able to handle an IV line placement. IV anesthetic medicine may be given to induce sleep instead of a “gas induction.” The attending anesthesiologist will choose which method to use.

The “excitement phase” of anesthesia

If you decide to be there when your child is being anesthetized, you may see your child:

• Resist the mask
• Splutter
• Cough
• Make gurgling sounds
• Roll his or her eyeballs

This is called the “excitement phase” of anesthesia. It happens in most children before they drift off to sleep. Please don’t worry when you see it. Also, keep in mind that the anesthesiologist may ask you to step out of the room at any time while your child is given the anesthesia.

All children must fast before the MRI. That’s because of the anesthesia, not because of the scan. Here’s why:

• When patients receive anesthesia for MRIs, they become very relaxed and sleepy which relaxes the muscles of the stomach and throat that would normally stop food from coming up and going into the lungs.
• When patients get food or liquid into their lungs from the stomach, this can cause pneumonia or even death.
• If the stomach is empty, the risk of anything coming up from the stomach and getting into the lungs is very low which makes anesthesia safer.

• The MRI may take between 45 minutes and up to 4 hours. It depends on:
  • The body parts to be studied
  • How complex the anesthesia care is
• Although we make every effort to stay on schedule, there will be times when we run behind schedule.
  • This may be based on how complex the children’s care or it may be for technical reasons.
  • If there’s a delay in the schedule, we’ll let you know how long it may be.
  • You can choose to wait or you can schedule a new appointment.
• Parents and family members can wait in the MRI waiting room. You can also leave the waiting area if you wish, but please give your cell phone number to the MRI nurses so that we can call you when your child arrives in the recovery area.

After the MRI scan is done, your child will be moved to the recovery area. A specialized pediatric nurse will monitor your child there.

When your child is awake and cleared for discharge by the anesthesia team, your child will be able to go home. This is usually about 45-60 minutes after the MRI exam is done. If your child is small or was born premature, they may need to be admitted to the hospital after their MRI for additional monitoring.

If you have questions about your child’s care at any time, please ask a member of our staff.

The decision on whether you can be present until you child is asleep will be at the discretion of the anesthesiologist, but usually depends on your child’s age or their medical history. During the process of starting anesthesia, your child may seem excited right before appearing floppy. This is a normal response to anesthesia. As soon as your child is asleep, we’ll escort you to the MRI waiting room. We’ll call you back as soon as your child is in the recovery area.

Yes, feel free to bring your child’s toy with you.