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When a child goes to the doctor, sometimes sedative and/or anesthetic medications are used during examinations, treatments, and surgeries. Many parents are concerned about the effects of drugs on their child’s nervous system and growth and development during examinations or procedures.
In clinical situations where sedation and/or anesthesia is required, pediatric anesthesiologists have the following goals in mind when selecting sedation and/or anesthesia.
1. To protect the safety and interests of the child.
2, to reduce the child’s physical discomfort and pain.
3. To control anxiety, minimize psychological trauma, and try to make the child forget.
4.Control behavior and/or activities to complete the diagnostic (treatment) operation.
5.Safely remove the child from medical supervision.
In view of this, many pediatric clinical trauma or non-trauma operations and examinations are actually performed under sedation and/or anesthesia, including ultrasonography, CT (computed tomography) and MRI (magnetic resonance imaging), tracheoscopy, gastroscopy, bone marrow aspiration, deep venipuncture, electroencephalography, electrocardiography, etc. Adults do not require anesthesia and/or sedation for any of these common clinical tests.
About sedation and/or anesthesia
I use the term “sedation and/or anesthesia” rather than anesthesia because sedation and anesthesia use almost identical drugs. Although there is a clear conceptual distinction between sedation and anesthesia, there is a practical continuity. The change between sedation, especially deep sedation, and general anesthesia lacks clear clinical indications, so that sometimes, although sedated, one is actually in anesthesia. It is impossible for a highly skilled anesthesiologist to achieve precise control over the perfect separation of sedation and anesthesia in clinical work.
Many parents have questions about whether children (especially newborns) can perceive pain. Often the doctor is asked, “Can we do it without anesthesia and/or sedation?” It is important to be clear: children, even small infants, can perceive pain and have a series of physiological responses to pain; adverse memories from childhood can affect the child’s future life, and without anesthesia and/or sedation, painful experiences and memories of clinical operations can last a lifetime, causing social and psychological problems in the child, such as violent tendencies.
Safety and metabolism of sedative and/or anesthetic drugs
The origin of anesthesia can actually be traced back to the invention of “Tsusansen” by Hua Tuo in ancient China, but there is no evidence of the existence of this drug. The second anesthesia he administered was to a pediatric patient. Because children have long been the future of society and have been the target of social protection, almost all sedative and/or anesthetic drugs in clinical use have not been clinically tested in children prior to their introduction to the market, thus the history of pediatric anesthesia is not short, but its development lags far behind that of adult anesthesia.
Despite the lack of pre-market pediatric clinical trials, the vast majority of sedative and/or anesthetic drugs used in adult clinics have been used in pediatric sedation and/or anesthesia, and today millions of children undergo anesthesia and surgery each year. Decades of use have shown that the safety profile is similar to that of adults.
Compared to adults, pediatric sedation and/or anesthesia is administered by a variety of routes, including intravenous, inhalation, rectal, nasal, subcutaneous or intramuscular, and (depending on the method of anesthesia) intrathecal (including sacral), subarachnoid, and nerve block (drug injection around the nerve plexus), with intravenous and inhalation administration being more commonly used in pediatric anesthesia.
Regarding the metabolism of sedative and/or anesthetic drugs. The biggest difference between adults and pediatric patients is the “growth and development” process, in which we can see a huge change in the height and weight of the pediatric patient, as well as in the growth and development of the enzymes that metabolize certain sedative and/or anesthetic drugs. However, the metabolism of sedative and/or narcotic drugs in children cannot be generalized, children are not shrinking adults, the factors that determine the effects of drugs in children are not only multiple but also complex, the absorption, distribution, metabolism and clearance of drugs may be different from adults; even if the drug concentration is the same, the strength and nature of the pharmacological response may be different; the types of diseases are also different, some diseases occur only in children, some diseases have a different course than adults. disease processes are different from those of adults, and the etiology is not the same. However, for different sedative and/or anesthetic drugs, due to different metabolic pathways and the development of enzymes that metabolize drugs, the metabolism of some drugs may be slowed down in children, but the metabolism of some drugs may be enhanced, and if the dosage is calculated according to kilograms of body weight, the dosage of some drugs is greater than that of adults, for example, we commonly use an analgesic drug “remifentanil” and an intravenous anesthetic drug “remifentanil”. “and the intravenous anesthetic “isoproterenol”.
Will sedative and/or narcotic drugs affect my child’s intelligence?
The concern of many parents, “Can narcotic drugs affect a child’s intelligence?” The story began with a paper published in 1999, which concluded that the use of NMDA receptor blockers (ketamine is one of the drugs commonly used in clinical practice) increased apoptosis in newborn animals and consequently affected neurogenesis; then in 2003, another author found that after 6 hours of anesthesia with imipramine, laughing gas and isoflurane (commonly known as cocktail anesthesia) in newborn rats, the A physiological function of the hippocampus (a functional area of the brain associated with learning memory) was impaired in rats and led to spatial cognitive impairment in rats at 4 weeks to 4 months. These and subsequent studies quickly generated intense interest in the anesthesiology community and society, but is this really the case?
There are several points worth noting about animal experiments.
① The doses used are often much greater than clinical (human), for example, ketamine dosage is up to 20-100mg/kg, clinical 2mg/kg; isoproterenol dosage is up to 10-60mg/kg, clinical 1mg/kg; imipramine dosage is up to 9mg/kg or more, clinical 0.1mg/kg is commonly used.
②Anesthesia in animal experiments is a “bad” anesthesia, nearly half of the animals will die after anesthesia, and the animals that survive may experience a series of complications such as hypoxia and disturbance of the internal environment due to very deep anesthesia.
(3) In humans (mammals), neurogenesis is completed before birth, and only some brain regions are retained for neuroregenerative functions, one of which is the hippocampus, which is concerned with learning and memory capacity. However, the apoptosis in it is a normal physiological metabolism. To date, no causal relationship between sedation and/or anesthesia-induced apoptosis of brain cells and learning and memory has been found to exist.
Human learning and intelligence are influenced by a variety of factors, and the ability to learn is more than just learning math, language, physics, etc. Moreover, in general, twins live in almost identical environments and it may be more convincing if one undergoes anesthetic surgery and the other does not (of course it is undeniable that even twins have their own learning abilities). Happily, retrospective analyses have been performed to confirm that there is no effect of sedation and/or anesthesia. The anesthesia medicine community has long believed that anesthesia causes post-surgical psychiatric disorders in adults, but recent studies have shown that the incidence of psychiatric disorders in hospitalized patients is the same in medical and surgical patients, noting that medical patients generally do not undergo surgery and anesthesia.
In 2007, a U.S. Food and Drug Administration (FDA) advisory committee concluded that “based on the available evidence, there is no need to change the current state of clinical anesthesia”; in 2013, experts concluded that “even if (if) anesthesia had a small neurological effect, it would be a good idea to change the patient’s The 2013 expert opinion was that “even if (if) anesthesia had a small neurological impact, changing the existing anesthetic technique or not having anesthesia at all could lead to greater neurological harm”.
Adverse reactions after sedation and/or anesthesia
There is an old Chinese saying that “medicine can be poisoned in three parts”, which also applies to sedative and/or anesthetic drugs, and in fact some sedative and/or anesthetic drugs, especially analgesic drugs, are usually derived from “drugs”, so most anesthetic drugs are Most narcotic drugs are “controlled substances”.
Possible adverse reactions after sedation and/or anesthesia include allergy, respiratory depression, nausea, vomiting, itching, irritability, and chills. When a child develops allergy and respiratory depression he or she needs to inform the healthcare provider quickly; nausea and vomiting are also common after surgery, but most of them will subside over time. In severe cases (frequent vomiting or vomiting of the heart), the child needs to be brought to the attention of the healthcare provider for timely treatment. When the child vomits, care should be taken to assist him or her in tilting the head to the side to expel the vomitus from the body, and extreme care should be taken not to have aspiration (into the lungs); pruritus may also accompany allergy, and the degree Postoperative irritability is common, and the child is often extremely uncooperative, but it will gradually recover over time. The transition from one state of consciousness to another is usually accompanied by a change in mood, for example, a child may have a tantrum when waking up in the morning, and the transition from sedation and/or anesthesia to awakening may be similar. Parents of children with postoperative irritability should be aware of the need to prevent the child from falling out of bed to avoid further injury; warmth should be observed during chills, but warmth will not necessarily eliminate chills. It is important to note that some children may undergo two surgeries, for example, the left eye and right eye are operated on separately, and the adverse reactions after the two surgeries may be different, which may be related to the anesthetic drugs, the surgical environment, the ward environment, the drugs used, and the food ingested. After sedation and/or anesthesia, the focus should be on whether the child regains consciousness, whether breathing is stable (compared to pre-surgery), and whether the skin color is as normal. In conclusion, postoperative care requires the joint efforts of parents and health care professionals. Children are our future and we should take good care of them together.