Anesthesia and Analgesia -odober, 1922

Anesthesia in Children: Safest Methods and Agents*

Frances E. Haines, A. M., M. D., Chicago, Ill.

CONSIDERATION of the safest methods of atlministration of general anesthesia in children, intratracheal. spinal, rectal and intravenous can be dismissed at once as being too dangerous, or at least, as not having been proved conclusively to be safe for them. A11 authorities seem quite agreed that the safest method of producing general anesthesia in children is by inhalation. \Vhen local anesthesia is used, the infiltration method is the only one generally recommended. R. E. F a n , of Minneapolis, reports success with local anesthesia in ninety per cent of his operations on children.
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Anesthetic Agents General Consideration S SERIOUS accidents are still occurring with every anesthetic agent and in expert hands, we may consider thc relative safefy only of anesthetics Ether vapor is more irritating tn mucous membranes than any other anesthetic. Chloroform and ethyl chlorid are less irritating, and nitrous oxid-oxygen the least of all. Concerning the changes in character and constituents of the blood under different anesthetics, the researches of T. D. Casto and others seem to indicate that whatever changes occur in coagulability, hemoglobin content, cell relations and morphology, hemolysis. or acidity are more or less transient and do not constitute elements of especial danger. But these investigators are of the opinion that all such effects are far less marked and less endur-

iny under nitrous osid-oxygen than

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Read during the Joint Meeting of t h e American and Mid-Western .-lssocia.tions of Anesthetists. Hotel Jefferson, St. Louis. Mo., May 22-24, 1922.

under other anesthetics. After nitrous osid-oxygen the phagocytic power of the blood and metabolism are disturbed only transiently, if at all. \Vith ether the opsonic index is not hack to its preoperative level until two to five days after anesthesia. Therefore nitrous oxidoxygen is preferable in septic cases. Graham and others have demonstrated that chloroform sometimes Yauses fatty infiltration, necrosis, and a hemorrhagic tendency in the liver and other organs. 411 of us are familiar with the circulatory and respiratory depression that often occurs durinK chloroform anesthesia. Even in Europe, where the use of chloroform has been quite prevalent, ether is rapidly coming into favor. Some noteworthy clinical research work in ethyl chlorid has been done recently by A. E. Guedel, of Indianapolis. H e likes ethyl chlorid for very brief and not too painful operations at all ages, and for induction in the child up to two

Anesthesia and Analgesia -October, 1922

years. Ether is introdwed and the two dove-tailed together before any of the danger signals have appeared. A recognized authority on nitrous oxid-oxygen anesthesia, E. 1. McKeson, of Toledo, asserts that, "In regard to the use of nitrous oxid-oxygen in children, age has no influence a t all in the selection of anesthesia and besides there is not much variation in the technic of administering a babe an anesthetic from the technic for adults. * * * A child is quickly anesthetized as well as quickly deoxygenated. From this fact it is necessary to administer very carefully the proper mixture in order to have a smooth narcosis." McKesson has given many nitrous oxid-oxygen anesthesias f o r abdominal work in children, for congenital pylorispasm et crtcrcr, it1 infants of a few days up. Sometimes he spends as much as ten minutes in securing the proper mixture for infants. Another nitrous oxid-oxygen anesthetist of wide experienece, J. R. McCurdy, of Pittsburg, observes that children are not bad risks for this anesthesia and he uses it in children from six months up. been for the removal of tonsils and adenoids, while in the latter nearly all of the operations have been other than for tonsils and adenoids.
Precautionary Measures

Report of Personal Experiences

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N E S T H E S I A in children, in my own experience, may be divided into two groups. The first group comprises 2,000 cases of anesthesias, which the students of Rush Medical College have given in the Central Free Dispensary under my instruction and personal supervision. The srcond group numbers about 250 cases to whom I have given the anesthetic myself. In the former group practically all of the operations have

scarcely be overestimated. Young children seldom exercise any control over their fears and dislikes. If a child goes to sleep frightened and crying, a mild though definite degree of depression is present during and for some time after the period of anesthesia. If an anesthesia becomes imperative a t any subsequent time, the child will dread the ordeal even to the imperilling of the safety to life itself. Another danger is the consequent irregular breat,hing. When a child cries and struggles, inhalation is prolonged, thus wasting much time. -4 deep, quick inhalation may convey an excessive or paralyzing concentration of the anesthetic agent to the heart. If the anesthetic be ether there is more irritation of the mucous membranes and reflexly an abnormal increase in the flow of saliva and mucous, which often prevents the proper intake of oxygen, obstructs the view of the operator in mouth operations, and lastly, but most seriously of all perhaps, may possibly result in an aspiration pneumonia. Entering into the confidence of, and controlling the thoughts of the child, is even more indispensable with local than with gervral anesthesia. Without the conlidence and co-operation of the child, local anesthesia is a failure except in infants, while general anesthesia becomes a knocking-out process. The methods of obtaining the confidence of a

HE I M P O R T A N C E of the induction period can

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Anesthesia and

Analgesia

-October, 1922

child must be as varied a s are individual dispositions. !t i.r a rare art to gain psychic coiitrol of a child almost iristarltarr~c~itslv.1:irt it cat& be dour in prcj-:tcJi!l l * x ~ r y 2 child of normal ~rierrtali!;*, f o u v years of age or older, who has not bccn frightened by a pr:7:i011c ntirsfhctic, aiid zcho has par:ii:s I-iasoitahljl sensible about the maticr. N o s t youwGer childreii can be martaged so that thcy do not sicfer a*ry s c z w e fright. I t is a mistake to take a child to the operating room long beiorc it is to be anesthetized. An infant should be unconscious before the preparation for operation is begun. -4sepsis is much more satisfactory. The solutions used in cleansing the skin are painfully irritating t o a babys skin, and if awake so as to be sensible to their use, the infant becomes terribly apprehensive and suffers more than could possibly be the case from fii-e minutes more of light anesthesia.

patient i i nitrous axid-oxygen is used for the induction o i ether anesthesia. Great care must be taken to see that the child is well accustomed to a strong ether vapor before changing to straight ether, or, couqhing will often r e sult. Another important practice. which I have tried out thoroughly. is that of making the change from the mask with a gas machine to the one moistened moderately with ether dirririg one cxhalatio?i. so that the child does not get one inhalatioil of air. If these t w o points are observed children practically never cough from the change. IVhen ether alone is administered, the

Methods o Induction f T IS plrasanter for the little

drop-nietkod is employed. A Schimmelbusch mask is covered with two layers of stockinette stretched until it is taut. T h e mask is always lowered slowly, for ether vapor is much less irritating to the respiratory tract if well diluted a t first with air. With very young infants the mask may never be completely lowered. With older children a towel around the edges of the mask excludes air to the required degree. The iritra-pharyngeal tnetkod of giving ether is sometimes used for induction and should always be used in cleft palate, tonsil or other mouth operations lasting longer than about five minutes, in order to insure an even, smooth anesthesia, which is not too deep at any time. 711e pructice of p u f t i n g the child wider drcply enough to hold f o r a rntisidcraDlc lewgth of tinie, in spitc of the fact that the ~ t t o u t h zwidc is i7pt-11.pt.rrrsittirig an uizusually frcc crit.ry of air, is vicious and daiageruus. Thc iriimediate dangcrs are ri~cdl~ss tlcprcssion o f the heart and rt7spiratory centrr, a prolonged total pcriad of arresthesiu, and the greater possibility o f espiratiorr of blood; arid the wore rcniote dangers are dcstruction of the epithelizrnt of tRc rcsp ira t o r y tract and iit j i c ry , tzmp ornry or pcvirianent, to f l i t parettckyrrir~toicsce/Is of the k i d w y s . T h e r e is rrior~ dcrrcasr iir the plzagocytic p o x v r of the blood f r o m such a sat~rration,more ixtcrfcrerice with i,,11 rnrtabolisnz, and more nausea rind coniiting in f l i 2 hours followiiig anrsthesia. \\-it11 riifrous oxid-oxygen in the \-rry young, I start with a mixture containing 5 to 10 per cent oxygen, change to 100 per cent nitrous oxid ior a few inhalations if necessary,
opcn

Anesthesia and Analgesia

and then find the level a t which anesthesia is to be maintained. In older children, five to ten years of age, 100 per cent nitrous oxid is often given first and then oxygen added. The child will be less alarmed if the mask is lowered gradually, the nitrous oxid being forced over t o the patient at first and then the pressure being reduced as soon as the mask is down. In administering nitrous oxid under posifiar pressicrc, I feel safer to use some rebreathing.

-October, 1922

have been four or five in whom the thyroid was enlarged, and m e very recent case, a boy five years eight months old, who had a persistent thymus. This fhymus case, anesthetized over three weeks ago is alive and well now, but he was resuscitated with the greatest of difficulty.

Second Group

Anesthetic Agents

- First Group N THE cases reported ether

and nitrous oxid-oxygen were the only anesthetic agents used. I11 about GOO of the 2,000 tonsil cases a hypodermic of atropin was given one-half hour to one hour or longer before the administration of ether. As these children are carried so lightly that the eyeball has a mild expression and is not fixed staring straight forward, the effect of atropin upon the size of the pupil and its reaction to light is of no consequence. There were no untoward effects from the use of atropin. In the remaining 1,400 tonsil c a w straight ether was given. The anesthesia was not as smooth, there being often a dangerous excess of saliva and mucous which had to he removed by the suction pump during the induction period. Therefore in a teaching clinic, where students are learning to give their first aneithetics and where the patients are children improperly cared for, a child is safer if atropin is adminktered one-half to one hour previoi1.s to etherization. In these 2,000 children the only ones presenting serious difficulties

cases were all ten years of age or younger. Quite a number were under six months, and about one-half of the total number were under six years of age. Most of these children were operated upon for conditions which kept them in the hospital a sufficient length of time for any ill effects of the aner,thetic to be manifested. With tonsil cases in a large city there is little probability of the child returiiing to the original clinic or hospital if untoward effects occur. Then too the anesthetic in these 250 cases was for the most part of longer duration, sometimes of greater depth than is required for tonsil work, and often in children with more pathology than many tonsil cases have. In these cases, the records of which show the urine to be normal before the anesthetic, a trace of albumin occurred in about 5 per cent, and casts and albumin in abou: 3 per cent of those having ether. Unfortunately some prominent surgeons do not make it a routine to have the urine examined the day following the ?mesthetic. In none of the cases were there c!ini.:al symptoms indicative of the kidney irritation. The childreit m-th a tubrmilous hip or spine constitute

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HE CHILDREN in the second group of about 2.50

Anesthesia and Analgesia -October, 1922

a laryc proportion of those s i t o ~ ~ i q

albumin and rnsts i r t f l i t , irri)tc after ether. Nausea and vomiting of any
consequence occur in less thaii 1 pcr cent regardless of whether riitrou i oxid or ether was used. Conjunctivitis has never occurred. 1 have not found record of a single pneiimonia in these children atid lesc than 0.5 per cent have hail I n o w chitis. .4 post-operative temperature. reaching 100" to 101" at somi' time within the first twenty-iuur o r forty-eight hours occurred in ahnit 25 per cent of the children, while a temperature oi lill' to 1'12 occurred in about 1.; per ceiit. Thu3 about -1U per cent of childrcn havr a transient, modcrate rise in ternperature iollnwing anesthesia and operation. l i this risc is markctl or prolonged. the prohahle causes to be looked for are. acute pulmoiiary iniections, constipation. and complications resulting froin the operation includinx iniections of the kidneys. No bad after-etlectj have cvci. been noted izi case?; having had nitrous oxid-oxygen doti,. or cumbined with a Yer) small amount 0 1 ether. There has been only oiir accident with nitrous oxid-oxygrt: and that was in my tirst s i s months as an anesthetist. Thc patient, a hoy about seven years old. ceascd hreathing but respiration was r r sumed spontaneously. The iault lay in my lack o i experierice. I have given nitrous osid-oxygen t t j a number of children under six months and to a considerably larger number two years of age and up. No difficulty has ever been encoiiritered except in the one case cited.
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Summary and Conclusions 1. Accidents and even death may result from the administration of any anesthetic agent even in the most skilful hands. Many slight untoward after-effects, which do not cause much distress clinically. escape the knowledge of all except tlic carcful observer who makes proper use of the laboratory. 2. The safest method of producing general anesthesia in children is hy irihalation. Ether is given by thc opeti drop-method or intrapharyngeally. Nitrous oxid-oxygen is usually given with a higher percentage of oxygen than in adults arid under slight positive pressure. with a proper amount of rebreathiiig. Infiltration is the only method advisahle for local anesthesia. 3. The importaiice of a slow iriduction period with the child's mind calm and respiration regular cannot h e overestimated. a. Children are extremely susceptible to suggestion. Their confidence must be gained and their fears and thoughts COIItrolled. b. The deep inhalations rcsultiiig from fright lead to dangerous irritation of the respiratory tract with ether and cause an excessive concentration of any anesthetic agetit t o reach the heart suddenly. c. If a child is frightened or smothered with his. first anesthetic, his remembrance of the ordeal may imperil his safety if an anesthetic hecomes imperative a t any subsequent time. 4. Chloroform should not be administered to children for the dangers o i immediate depression and of delayed poisoning are too grcat. iCo>ltinued on Pnge 70.)