Features of anesthesia in children at different ages. Why is general anesthesia dangerous for a child? Anesthesia with the use of muscle relaxants and controlled ventilation of the lungs

The choice of method of anesthesia is carried out depending on the clinical picture (tooth condition), the age of the child and the technical capabilities of its implementation.

Anesthesia methods

Non-injectable:

physical methods (cooling, use of electric current);

anesthetic electrophoresis;

application method.

Injection anesthesia:

infiltration;

conductive. 3. Needle-free jet anesthesia. 4. Local anesthesia with sedative preparation. 5. Local anesthesia combined with surface anesthesia. Local anesthesia is performed after:

psychological preparation;

physiological distraction or

medical preparation. The most popular anesthetics based on articaine (Septanest, Ultracaine, Ubistezin) and mepivacaine (Scandonest). Given its vasodilating effect, it is used in combination with vasoconstrictors (eg epinephrine). However, the use of epinephrine is not indicated in children under 5 years of age, as well as those suffering from cardiovascular diseases and endocrine pathology. Pharmacological preparation of children for the purpose of correction emotional state child before tooth extraction is widely used. Preoperative medications currently used are more often herbal sedatives(drops of valerian, motherwort) and tranquilizers. Dosages of individual drugs are presented in Table 4.

Prevention of complications of local anesthesia in children

Peculiarities of a child's psycho-emotional state often present additional difficulties when performing local anesthesia in dentistry. Practical recommendations for the prevention of complications of local anesthesia are presented in the work of Yu. G. Kononenko et al., (2002) and other authors.

Table 4

Doses of drugs used in pediatric practice for preoperative preparation

1. Careful history taking from the child's parents. It is better if at the initial appointment and getting to know the child there was a mother, because. many problems with the general somatic, physical and psycho-emotional development of the child may be due to the peculiarities of the birth act and the nature of the conduct of the birth itself, which led to birth trauma to the bones of the skull, cervical spine and spinal cord. Moreover, these changes can be viewed by a neurologist earlier.

So, in the prevention of complications of local anesthesia is important:

general somatic status and the presence of concomitant diseases, the definition of which allows the child to be assigned to a certain health group (see table in the appendix);

allergic status,

the nature of the child and his current psycho-emotional mood.

H

Do not perform manipulations without the consent of the child!

When injecting anesthesia: a) each child should be tested for tolerability of the anesthetic solution; b) children under 5 years old do not use an anesthetic solution with a vasoconstrictor; We recommend using a 3% solution of mepivacaine without vasoconstrictors. For example: Scandonest 3% SVC, Ultracain D and others; in) children over 5 years old it is desirable to use an anesthetic solution with a low concentration of a vasoconstrictor (1:200,000). For example: Ultracain DS, etc.

3. In children aged 3-10 years, it is better to use infiltration papillary anesthesia, injections into dense dental gums and intraosseous anesthesia. 4. In children over 10-13 years, the use of infiltration anesthesia in the apical region and conduction (mandibular) anesthesia is recommended.

5. The technique of anesthesia must be carefully worked out, the dose of anesthetic is accurately calculated.

A novice doctor can be advised to draw into the syringe only that dose (0.5-1 ml of anesthetic solution) that needs to be injected. If there is a large dose of anesthetic in the syringe, and the child is restless, turns his head, then it is possible to introduce a larger dose of anesthetic than necessary, and this can cause a number of complications (toxic reaction, etc.).

The end result should be 100% pain relief!

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Terminologically, anesthesia during surgical interventions is divided into general, conduction and local.

The main requirement for anesthesia in both adults and children is its adequacy. Under the adequacy of anesthesia understand:

• compliance of its effectiveness with the nature, severity and duration of the surgical injury;
• taking into account the requirements for it in accordance with the patient's age, comorbidities, severity of the initial condition, features of the neurovegetative status, etc.

In this regard, the concept of the so-called ideal anesthetic has been put forward, which determines the main directions and trends in the development of pharmacology.

Anesthesiologists working in pediatrics take into account the characteristics of the child's body that affect the pharmacodynamics and pharmacokinetics of the components of anesthesia. Of these, the most important are:

• decrease in the binding ability of proteins;
• increased volume of distribution;
• reduction in the proportion of fat and muscle mass.

Means of inhalation anesthesia

In most inhalation anesthetics, the role of metabolic transformation is small (20% for halothane), so there is a certain relationship between the value of the inhaled concentration and the concentration in the tissues (directly proportional to anesthesia with nitrous oxide).

The depth of anesthesia mainly depends on the tension of the anesthetic in the brain, which is directly related to its tension in the blood. The latter depends on the volume of alveolar ventilation and the magnitude of cardiac output (for example, a decrease in alveolar ventilation and an increase in cardiac output increase the duration of the induction period). Of particular importance is the solubility of the anesthetic in the blood. Diethyl ether, methoxyflurane, chloroform, and trichlorethylene, which are currently little used, have high solubility; low - modern anesthetics (isoflurane, sevoflurane, etc.).

The anesthetic can be delivered through a mask or endotracheal tube. Inhalation anesthetics can be used in the form of non-reversible (exhalation into the atmosphere) and reversible (exhalation partly into the anesthesia machine, partly into the atmosphere) circuits. The reverse circuit has a system for absorbing exhaled carbon dioxide.

In pediatric anesthesiology, a non-reversible circuit is more often used, which has a number of disadvantages, in particular, heat loss to patients, pollution of the operating room atmosphere, and high consumption of anesthetic gases. AT last years In connection with the advent of a new generation of anesthesia and respiratory equipment and monitoring, the reverse circuit method according to the low flow anesthesia system (low flow anaesthesia) is increasingly being used. The total gas flow in this case is less than 1 l/min.

General anesthesia with inhalation anesthetics in children is used much more often than in adult patients. This is primarily due to the widespread use of mask anesthesia in children. The most popular anesthetic in Russia is halothane (halothane), which is usually used in combination with nitrous oxide.

Children require a higher concentration of inhalation anesthetic (about 30%) than adults, which seems to be due to the rapid increase in alveolar anesthetic concentration due to the high ratio between alveolar ventilation and functional residual capacity. A high cardiac index and its relatively high proportion in cerebral blood flow also matter. This leads to the fact that in children, the introduction into anesthesia and the exit from it, all other things being equal, occur faster than in adults. At the same time, a very rapid development of a cardiodepressive effect is also possible, especially in newborns.

Halothane (halothane, narcotan, fluotan)- the most common inhalation anesthetic in Russia today. In children, it causes a gradual loss of consciousness (within 1-2 minutes); the drug does not irritate the mucous membranes respiratory tract. With its further exposure and an increase in the inhaled concentration to 2.4-4 vol.%, 3-4 minutes after the start of inhalation, complete loss of consciousness occurs. Halothane has relatively low analgesic properties, so it is usually combined with nitrous oxide or narcotic analgesics.

Halothane has a bronchodilator effect, and therefore is indicated for anesthesia in children with bronchial asthma. The negative properties of halothane include increased sensitivity to catecholamines (their administration during anesthesia with halothane is contraindicated). It has a cardiodepressive effect (inhibits the inotropic ability of the myocardium, especially in high concentrations), reduces peripheral vascular resistance and blood pressure. Halothane markedly increases cerebral blood flow, and therefore its use is not recommended for children with increased intracranial pressure. It is also not indicated for liver pathology.

Enflurane (etrane) has a slightly lower blood/gas solubility than halothane, so induction and recovery from anesthesia is somewhat faster. Unlike halothane, enflurane has analgesic properties. The depressive effect on respiration and cardiac muscle is pronounced, but the sensitivity to catecholamines is much lower than that of halothane. Causes tachycardia, increased cerebral blood flow and intracranial pressure, toxic effects on the liver and kidneys. There is evidence of the epileptiform activity of enflurane.

Isoflurane (foran) even less soluble than enflurane. The extremely low metabolism (about 0.2%) makes anesthesia more manageable and induction and recovery faster than halothane. Has an analgesic effect. Unlike halothane and enflurane, isoflurane does not significantly affect the myocardium at moderate concentrations. Isoflurane reduces blood pressure due to vasodilation, due to which it slightly increases the heart rate, does not sensitize the myocardium to catecholamines. Less than halothane and enflurane, affects brain perfusion and intracranial pressure. The disadvantages of isoflurane include an increase in the induction of airway secretion, cough, and fairly frequent (more than 20%) cases of laryngospasm in children.

Sevoflurane and Desflurane- inhalation anesthetics latest generation not yet widely used in Russia.

Nitrous oxide- a colorless gas heavier than air, with a characteristic odor and a sweetish taste, not explosive, although it supports combustion. Supplied in liquid form in cylinders (1 kg of liquid nitrous oxide forms 500 liters of gas). Does not metabolize in the body. It has good analgesic properties, but a very weak anesthetic, therefore it is used as a component of inhalation or intravenous anesthesia. It is used in concentrations of not more than 3:1 with respect to oxygen (higher concentrations are fraught with the development of hypoxemia). Cardiac and respiratory depression, effects on cerebral blood flow are minimal. Prolonged use of nitrous oxide can lead to the development of myelodepression and agranulocytosis.

Components of intravenous anesthesia

These funds are used both in combination with inhalation and without them - the latter method is called total intravenous anesthesia (TVA). It is with this method of anesthesia that it is possible to completely avoid the negative impact on the body of the operating room staff.

Hypnotics provide turning off the patient's consciousness. They tend to be highly lipid soluble, passing rapidly through the blood-brain barrier.

Barbiturates, ketamine, benzodiazepines and propofol are widely used in pediatric anesthesiology. All of these drugs have different effects on respiration, intracranial pressure and hemodynamics.

Barbiturates

Sodium thiopental in children is used mainly for induction intravenously at a dose of 5-6 mg/kg, under the age of 1 year 5-8 mg/kg, in newborns 3-4 mg/kg. Loss of consciousness occurs in 20-30 seconds and lasts 3-5 minutes. Doses of 0.5-2 mg/kg are required to maintain the effect. In children, a 1% solution is used, and in older ones, 2%. Like most other hypnotics, sodium thiopental has no analgesic properties, although it does lower the pain threshold.

In children, thiopental metabolizes 2 times faster than in adults. The half-life of the drug is 10-12 hours, which mainly depends on the function of the liver, since a very small amount is excreted in the urine. It has a moderate ability to bind to proteins, especially albumins (free fraction is 15-25%). The drug is toxic when administered subcutaneously or intra-arterially, has a histamine effect, causes respiratory depression, up to apnea. It has a weak vasodilating effect and causes myocardial depression, activates the parasympathetic (vagal) system. Negative hemodynamic effects are especially pronounced with hypovolemia. Thiopental increases reflexes from the pharynx, can cause coughing, hiccups, laryngo- and bronchospasm. Some patients have tolerance to thiopental, and in children it is less common than in adults. Premedication with promedol in children makes it possible to reduce the induction dose by approximately 1/3.

Hexenal differs little from thiopental in its properties. The drug is easily soluble in water, and such a solution can be stored for no more than an hour. In children, it is administered intravenously as a 1% solution (in adults 2-5%) in doses similar to thiopental. The half-life of hexenal is about 5 hours, the effect on respiration and hemodynamics is similar to thiopental, although the vagal effect is less pronounced. Cases of laryngo- and bronchospasm are less often recorded, so it is more often used for induction.

The dose of thiopental and hexenal for induction in older children (as in adults) is 4-5 mg / kg when administered intravenously. Unlike thiopental, hexenal can be administered intramuscularly (IM) and rectally. With the / m administration, the dose of hexenal is 8-10 mg / kg (in this case, the induction of narcotic sleep occurs after 10-15 minutes). With rectal administration, hexenal is used at a dosage of 20-30 mg / kg. Sleep comes in 15-20 minutes and lasts at least 40-60 minutes (with subsequent prolonged depression of consciousness requiring control). Nowadays, this method is rarely resorted to and only in cases where it is not possible to use more modern methods.

Ketamine is a derivative of phencyclidine. With its introduction, laryngeal, pharyngeal and cough reflexes are preserved. In children, it is widely used for both induction and maintenance of anesthesia. It is very convenient for induction in the form of intramuscular injections: the dose for children under 1 year old is 10-13 mg / kg, up to 6 years old - 8-10 mg / kg, older ones - 6-8 mg / kg. After the / m administration, the effect occurs after 4-5 minutes and lasts 16-20 minutes. Doses for intravenous administration are 2 mg/kg; the effect develops within 30-40 seconds and lasts about 5 minutes. To maintain anesthesia, it is used mainly as a continuous infusion at a rate of 0.5-3 mg / kg per hour.

The introduction of ketamine is accompanied by an increase blood pressure and heart rate by 20-30%, which is determined by its adrenergic activity. The latter provides a bronchodilating effect. Only 2% solution of ketamine is excreted in the urine unchanged, the rest (overwhelming) part is metabolized. Ketamine has a high lipid solubility (5-10 times higher than that of thiopental), which ensures its rapid penetration into the central nervous system. As a result of rapid redistribution from the brain to other tissues, ketamine provides a fairly rapid awakening.

With rapid administration, it can cause respiratory depression, spontaneous movements, increased muscle tone, intracranial and intraocular pressure.

In adults and older children, administration of the drug (usually intravenous) without prior protection benzodiazepine (BD) derivatives (diazepam, midazolam) can cause unpleasant dreams and hallucinations. To stop side effects, not only BD is used, but also piracetam. In 1/3 of children in the postoperative period, vomiting occurs.

Unlike adults, children tolerate ketamine much better, and therefore the indications for its use in pediatric anesthesiology are quite wide.

With self-anaesthesia, ketamine is widely used for painful manipulations, central vein catheterization and dressings, and minor surgical interventions. As a component of anesthesia, it is indicated during induction and for maintenance in the composition combined anesthesia.

Contraindications

Sodium oxybutyrate in children is used to induce and maintain anesthesia. For induction, it is prescribed intravenously at a dose of about 100 mg / kg (the effect develops after 10-15 minutes), orally in a 5% glucose solution at a dose of 150 mg / kg or intramuscularly (120-130 mg / kg) - in In these cases, the effect appears after 30 minutes and lasts about 1.5-2 hours. For induction, oxybutyrate is usually used in combination with other drugs, in particular with benzodiazepines, promedol or barbiturates, and with inhalation anesthetics to maintain anesthesia. There is practically no cardiodepressive effect.

Sodium oxybutyrate is easily included in the metabolism, and after decay is excreted from the body in the form of carbon dioxide. Small amounts (3-5%) are excreted in the urine. After intravenous administration, the maximum concentration in the blood is reached after 15 minutes, when taken through the mouth, this period is extended to almost 1.5 hours.

May cause spontaneous movements, a significant increase in peripheral vascular resistance and some increase in blood pressure. Sometimes there is respiratory depression, vomiting (especially when taken orally), motor and speech excitation at the end of the action, with prolonged administration - hypokalemia.

Benzodiazepines (DB) widely used in anesthesiology. Their action is mediated by an increase in the inhibitory effect of gamma-aminobutyric acid on neuronal transmission. Biotransformation occurs in the liver.

Diazepam is the most widely used in anesthetic practice. It has a calming, sedative, hypnotic, anticonvulsant and muscle-relaxing effect, enhances the effect of narcotic, analgesic, neuroleptic drugs. In children, unlike adults, it does not cause mental depression. Used in pediatric anesthesiology for premedication (usually IM at a dose of 0.2-0.4 mg/kg), as well as intravenously as a component of anesthesia for induction (0.2-0.3 mg/kg) and maintenance of anesthesia in the form boluses or continuous infusion.

When taken orally, it is well absorbed from the intestine (peak plasma concentration is reached after 60 minutes). About 98% binds to plasma proteins. It belongs to the group of slowly excreted drugs from the body (half-life is from 21 to 37 hours), and therefore it is considered a poorly controlled drug.

When administered parenterally in adult patients with hypovolemia, diazepam can cause mild arterial hypotension. In children, a decrease in blood pressure is observed much less frequently - when combined with thiopental, fentanyl or propofol. Respiratory dysfunction may be associated with central muscular hypotension, especially when co-administered with opioids. With intravenous administration, pain along the vein can be observed, which are removed by preliminary administration of lidocaine.

Midazolam is significantly more manageable than diazepam and is therefore increasingly wide application in anesthesiology. In addition to hypnotic, sedative, anticonvulsant and relaxing effects, it causes anterograde amnesia.

It is used for premedication in children: 1) by mouth (in our country, an ampoule form is used, although special sweet syrups are produced) at a dose of 0.75 mg / kg for children from 1 to 6 years old and 0.4 mg / kg from 6 to 12 years old, its effect is manifested after 10-15 minutes; 2) intramuscularly at a dose of 0.2-0.3 mg/kg; 3) per rectum in an ampoule of the rectum at a dose of 0.5-0.7 mg/kg (the effect occurs in 7-8 minutes); 4) intranasally in drops for children under 5 years of age at a dose of 0.2 mg / kg (in this case, the effect occurs within 5 minutes, approaching intravenous). After premedication with midazolam, the child can be easily separated from the parents. Widely used as a component of anesthesia for induction (IV 0.15-0.3 mg/kg) and maintenance of anesthesia as a continuous infusion in a titration regimen at a rate of 0.1 to 0.6 mg/kg per hour and its termination 15 minutes before the end of the operation.

The half-life of midazolam (1.5-4 hours) is 20 times shorter than that of diazepam. When taken orally, about 50% of midazolam undergoes hepatic metabolism. With intranasal administration, due to the lack of primary hepatic metabolism, the effect approaches intravenous, and therefore the dose must be reduced.

Midazolam has little effect on hemodynamics, respiratory depression is possible with the rapid administration of the drug. allergic reactions extremely rare. In recent years, in foreign literature, one can find indications of hiccups after the use of midazolam.

Midazolam works well with various drugs(droperidol, opioids, ketamine). Its specific antagonist flumazenil (anexat) is given to adults at a loading dose of 0.2 mg/kg followed by 0.1 mg every minute until awakening.

Propofol (Diprivan)- 2,6-diisopropylphenol, a short-acting hypnotic with very rapid action. Produced in the form of a 1% solution in a 10% soybean oil emulsion (intralipid). It has been used in children since 1985. Propofol causes a rapid (within 30-40 seconds) loss of consciousness (in adults at a dose of 2 mg / kg, the duration is about 4 minutes), followed by a rapid recovery. When inducing anesthesia in children, its dosage is much higher than in adults: the recommended dose for adults is 2-2.5 mg / kg, for young children - 4-5 mg / kg.

To maintain anesthesia, a continuous infusion is recommended at an initial rate in children of about 15 mg/kg per hour. Further, there are various infusion modes. A distinctive feature of propofol is a very rapid recovery after the end of its administration with a rapid activation of motor functions compared to barbiturates. Combines well with opiates, ketamine, midazolam and other drugs.

Propofol suppresses laryngeal-pharyngeal reflexes, which makes it possible to successfully use the introduction of a laryngeal mask, reduces intracranial pressure and cerebrospinal fluid pressure, has an antiemetic effect, and practically does not have a histamine effect.

Side effects of propofol include pain at the injection site, which can be prevented by the simultaneous administration of lignocaine (1 mg per 1 ml of propofol). Propofol causes respiratory depression in most children. With its introduction, dose-dependent arterial hypotension is observed due to a decrease in vascular resistance, an increase in vagal tone and bradycardia. Excitation, spontaneous motor reactions can be observed.

In schemes of total intravenous and balanced anesthesia, droperidol, a neuroleptic of the butyrophenone series, is widely used. Droperidol has a pronounced sedative effect. It combines well with analgesics, ketamine and benzodiazepine derivatives. It has a pronounced antiemetic effect, has an a-adrenolytic effect (this may be beneficial for preventing spasm in the microcirculation system during surgical interventions), prevents the effect of catecholamines (anti-stress and anti-shock effects), has a local analgesic and antiarrhythmic effect.

Used in children for premedication intramuscularly 30-40 minutes before surgery at a dose of 1-5 mg/kg; for induction, it is used intravenously at a dose of 0.2-0.5 mg / kg, usually together with fentanyl (the so-called neuroleptanalgesia, NLA); The effect appears after 2-3 minutes. If necessary, it is administered repeatedly to maintain anesthesia in doses of 0.05-0.07 mg/kg.

Side effects - extrapyramidal disorders, severe hypotension in patients with hypovolemia.

Narcotic analgesics include opium alkaloids (opiates) and synthetic compounds with opiate-like properties (opioids). In the body, narcotic analgesics bind to opioid receptors, which are structurally and functionally divided into mu, delta, kappa, and sigma. The most active and effective pain relievers are m-receptor agonists. These include morphine, fentanyl, promedol, new synthetic opioids - alfentanil, sufentanil and remifentanil (not yet registered in Russia). In addition to high antinociceptive activity, these drugs cause a number of side effects, including euphoria, depression respiratory center, emesis (nausea, vomiting) and other symptoms of inhibition of the activity of the gastrointestinal tract, mental and physical dependence with their long-term use.

According to the action on opiate receptors, modern narcotic analgesics are divided into 4 groups: full agonists (they cause the greatest possible analgesia), partial agonists (weaker activation of receptors), antagonists (bind to receptors, but do not activate them) and agonists / antagonists (activate one group and block another).

Narcotic analgesics are used for premedication, induction and maintenance of anesthesia, and postoperative analgesia. However, if agonists are used for all these purposes, partial agonists are used mainly for postoperative analgesia, and antagonists - as antidotes for agonist overdose.

Morphine- a classic narcotic analgesic. Its analgesic strength is taken as one. Approved for use in children of all age groups. Doses for induction in children intravenously 0.05-0.2 mg / kg, for maintenance - 0.05-0.2 mg / kg intravenously every 3-4 hours. It is also used epidurally. Destroyed in the liver; morphine metabolites may accumulate in renal pathology. Among the numerous side effects morphine should highlight respiratory depression, increased intracranial pressure, sphincter spasm, nausea and vomiting, the possibility of histamine release when administered intravenously. Newborns have hypersensitivity to morphine.

Trimeperidine (promedol)- a synthetic opioid, which is widely used in pediatric anesthesiology and for premedication (0.1 mg/year of life intramuscularly), and as an analgesic component of general anesthesia during operations (0.2-0.4 mg/kg intravenously in 40-50 minutes) , and for the purpose of postoperative analgesia (in doses of 1 mg / year of life, but not more than 10 mg intramuscularly). After intravenous administration, the half-life of promedol is 3-4 hours. Compared with morphine, promedol has less analgesic power and less pronounced side effects.

Fentanyl- a synthetic narcotic analgesic widely used in pediatrics. The analgesic activity exceeds morphine by 100 times. Slightly changes blood pressure, does not cause the release of histamine. Used in children: for premedication - intramuscularly 30-40 minutes before surgery 0.002 mg / kg, for induction - intravenously 0.002-0.01 mg / kg. After intravenous administration (at a rate of 1 ml / min), the effect reaches a maximum after 2-3 minutes. To maintain analgesia during surgery, 0.001-0.004 mg/kg is administered every 20 minutes as a bolus or infusion. It is used in combination with droperidol (neuroleptanalgesia) and benzodiazepines (ataralgesia), and in these cases, the duration of effective analgesia increases (up to 40 minutes).

Due to the high lipid solubility, fentanyl accumulates in fat depots, and therefore its half-life from the body can reach 3-4 hours. If rational dosages are exceeded, this may affect the timely restoration of spontaneous breathing after surgery (in case of respiratory depression, opioid receptor antagonists nalorfin or naloxone; in recent years, agonist-antagonists such as nalbuphine, butorphanol tartrate, etc. have been used for this purpose).

In addition to central respiratory depression, side effects of fentanyl include marked muscle stiffness and chest(especially after rapid intravenous administration), bradycardia, increased ICP, miosis, sphincter spasm, cough with rapid intravenous administration.

Pyritramide (dipidolor) is close in activity to morphine. The dose for induction in children is 0.2-0.3 mg / kg intravenously, for maintenance - 0.1-0.2 mg / kg every 60 minutes. For postoperative analgesia, it is administered at a dose of 0.05-0.2 mg / kg every 4-6 hours. It has a moderate sedative effect. Virtually no effect on hemodynamics. At intramuscular injection the half-life is 4-10 hours. Metabolizes in the liver. Side effects are manifested in the form of nausea and vomiting, spasm of sphincters, increased intracranial pressure. Respiratory depression is possible when using large doses.

Of the opioid receptor agonist-antagonist drugs in Russia, buprenorphine (morphine, temgezik), nalbuphine (nubain), butorphanol (moradol, stadol, beforal) and pentazocine (fortral, lexir) are used. The analgesic potency of these drugs is insufficient for their use as the main analgesic, so they are mainly used for postoperative pain relief. Due to the antagonistic effect on m-receptors, these drugs are used to reverse the side effects of opiates and, above all, to relieve respiratory depression. They allow you to remove side effects, but maintain pain relief.

At the same time, pentazocine in both adults and children can be used at the end of fentanyl anesthesia, when it allows you to quickly stop the symptoms of respiratory depression and retains the analgesic component. In children, it is administered for this intravenously at a dose of 0.5-1.0 mg / kg.

Muscle relaxants

According to the duration of action, muscle relaxants are divided into ultra preparations. short action- less than 5-7 minutes, short-acting - less than 20 minutes, medium duration- less than 40 minutes and long-acting - more than 40 minutes. Depending on the mechanism of action, MP can be divided into two groups - depolarizing and non-depolarizing.

Depolarizing muscle relaxants have an ultrashort action, mainly suxamethonium preparations (listenone, dithylin and myorelaxin). Neuromuscular blockage caused by these drugs has the following characteristic features.

Intravenous administration causes a complete neuromuscular blockade within 30-40 s, and therefore these drugs remain indispensable for urgent tracheal intubation. The duration of neuromuscular blockade is usually 4-6 minutes, so they are used either only for endotracheal intubation followed by a switch to non-depolarizing drugs, or for short procedures (for example, bronchoscopy under general anesthesia), when their fractional administration can be used to prolong myoplegia.

The side effects of depolarizing MP include the appearance after their introduction of muscle twitching (fibrillation), which usually lasts no more than 30-40 s. The consequences of this are postanesthetic muscle pain. In adults and children with developed muscles, this happens more often. At the time of muscle fibrillation, potassium enters the bloodstream, which may be unsafe for the heart. To prevent this adverse effect, it is recommended to carry out precurarization - the introduction of small doses of non-depolarizing muscle relaxants (MP).

Depolarizing muscle relaxants increase intraocular pressure, so they should be used with caution in patients with glaucoma and should not be used in patients with penetrating ocular injuries. The introduction of depolarizing MP can cause bradycardia and provoke the onset of malignant hyperthermia syndrome.

Suxamethonium by chemical structure can be considered as a double molecule acetylcholine (AH). It is used in the form of a 1-2% solution at the rate of 1-2 mg/kg intravenously. Alternatively, you can enter the drug under the tongue; in this case, the block develops after 60-75 s.

Non-depolarizing muscle relaxants

Non-depolarizing MPs have the following features:

• compared to depolarizing MPs, a slower onset of action (even for short-acting drugs) without muscle fibrillations;
• the effect of depolarizing muscle relaxants stops under the influence of anticholinesterase drugs;
• the duration of elimination in most non-depolarizing MPs depends on the function of the kidneys and liver, although drug accumulation is possible with repeated administration of most MPs even in patients with normal function of these organs;
• most non-depolarizing muscle relaxants have a histamine effect;
• block elongation when using inhalation anesthetics differs depending on the type of drug: the use of halothane causes an elongation of the block by 20%, isoflurane and enfluran - by 30%.

Side effects include a pronounced histamine effect that can lead to the development of laryngo- and bronchospasm, lowering blood pressure, and tachycardia. The drug has a pronounced ability to cumulation.

Pancuronium bromide (Pavulon), like pipecuronium bromide (Arduan), are steroid compounds that do not have hormonal activity. They belong to neuromuscular blockers (NMBs) long action; muscle relaxation lasts 40-50 minutes. With repeated administration, the dose is reduced by 3-4 times: with an increase in the dose and frequency of administration, the cumulation of the drug increases. The advantages of drugs include a low probability of a histamine effect, a decrease in intraocular pressure. Side effects are more characteristic of pancuronium: this is a slight increase in blood pressure and heart rate (sometimes marked tachycardia is noted).

Vecuronium bromide (norcuron)- steroid compound, MP medium duration. At a dose of 0.08-0.1 mg/kg, it allows tracheal intubation for 2 minutes and causes a block lasting 20-35 minutes; with repeated administration - up to 60 minutes. It accumulates quite rarely, more often in patients with impaired liver and / or kidney function. It has a low histamine effect, although in rare cases it causes true anaphylactic reactions.

Atracurium bensilate (Trakrium)- a muscle relaxant of medium duration of action from the group of derivatives of the isoquinoline series. Intravenous administration of trakrium in doses of 0.3-0.6 mg/kg allows tracheal intubation to be performed in 1.5-2 minutes. The duration of action is 20-35 minutes. With fractional administration, subsequent doses are reduced by 3-4 times, while repeated bolus doses prolong muscle relaxation by 15-35 minutes. It is advisable to infusion the introduction of atracurium at a rate of 0.4-0.5 mg/kg per hour. The recovery period takes 35 minutes.

Does not adversely affect hemodynamics, does not accumulate. Due to the unique ability to spontaneous biodegradation (Hoffmann elimination), atracurium has a predictable effect. The disadvantages of the drug include the histamine effect of one of its metabolites (laudonosine). Due to the potential for spontaneous biodegradation, atracurium should only be stored in a refrigerator at 2 to 8°C. Do not mix atracurium in the same syringe with thiopental and alkaline solutions.

Mivacurium chloride (mivacrone)- the only non-depolarizing short-acting MP, a derivative of the isoquinoline series. At doses of 0.2-0.25 mg/kg, tracheal intubation is possible after 1.5-2 minutes. The duration of the block is 2-2.5 times longer than that of suxamethonium. May be given as an infusion. In children, the initial infusion rate is 14 mg/kg per minute. Mivacurium has exceptional block recovery parameters (2.5 times shorter than vecuronium and 2 times shorter than atracurium); almost complete (95%) restoration of neuromuscular conduction occurs in children after 15 minutes.

The drug does not accumulate, minimally affects blood circulation. The histamine effect is weakly expressed and manifests itself as a short-term reddening of the skin of the face and chest. In patients with renal and hepatic insufficiency, the initial infusion rate should be reduced without a significant reduction in the total dose. Mivacurium is the relaxant of choice for short procedures (particularly endoscopic surgery), one-day hospitals, surgeries of unpredictable duration, and where rapid recovery of neuromuscular block is required.

Cisatracurium (Nimbex)- non-depolarizing NMB, is one of the ten stereoisomers of atracurium. The onset, duration and recovery of the block are similar to the atracurium. After administration at doses of 0.10 and 0.15 mg/kg, tracheal intubation can be carried out for about 2 minutes, the duration of the block is about 45 minutes, and the recovery time is about 30 minutes. To maintain the block, the infusion rate is 1-2 mg/kg per minute. In children, with the introduction of cisatracurium, the onset, duration, and recovery of the block are shorter than in adults.

It should be noted that there were no changes in the circulatory system and (which is especially important) the absence of a histamine effect. Like atracurium, it undergoes Hofmann's organ-independent elimination. Possessing all the positive qualities of atracurium (lack of cumulation, organ-independent elimination, absence of active metabolites), taking into account the absence of a histamine effect, cisatracurium is a safer neuromuscular blocker of medium duration of action, which can be widely used in various fields of anesthesiology and resuscitation.

L.A. Durnov, G.V. Goldobenko

Often anesthesia scares people, sometimes even more than surgery. The most fearful thing is the unknown and possible discomfort when falling asleep and waking up. Do not tune in to the positive and numerous conversations that it is dangerous to health. It becomes especially alarming when it comes to the fact that the operation will be performed on a child, and in children it causes negative consequences.

Children's anesthesia - how safe is it for a young organism?

Operations under anesthesia in children are carried out according to the same rules as in adults, taking into account age features. In children, due to anatomical and physiological characteristics, more often than in adults, there are critical conditions, the removal of which requires resuscitation and intensive care. However, in modern medicine exclusively gentle means are used that can introduce an adult and a child into an artificially induced deep sleep.

Anesthesia for children is a loss of consciousness caused by a set of special drugs. It may include many manipulations aimed at facilitating the process of falling asleep, surgery, and awakening. Among the activities carried out are:

• • Setting up drips.
  • Installation of a control system, compensation for blood loss.
  • Prevention of the consequences of the operation.

Parents should understand the essence and risk of anesthesia, the features of the types of anesthesia and contraindications to its use, be sure to tell the doctor:

• • • How was the pregnancy and childbirth?
    • what was the type of feeding: breastfeeding (how long) or artificial;
    • what the child was sick with;
    • reactions to vaccinations;
    • whether he and his next of kin have allergies.

All this is especially important for children. early age, you need to ask the anesthesiologist questions if something is not clear, and the final decision on which anesthesia or anesthesia to carry out is up to the doctor!

Types of pain relief techniques used

AT medical practice There are several types of anesthesia:

• • • Inhalation or hardware-mask - the patient receives a dose of painkillers in the form of an inhalation mixture. It is used when carrying out short simple operations.

See its action and main stages in this video:

• • • Intramuscular anesthesia for children today is practically not used. Because he cannot control the duration of sleep. The drug Ketamine used is harmful to the body. It can turn off long-term memory for almost 6 months, which affects the full development.
    • Intravenous - has a multicomponent pharmacological effect on the body. Ventilation of the lungs is performed by a special apparatus. Anesthesia is used for children extremely rarely, only when absolutely necessary.

Are there contraindications?

Anesthesia for children can always be carried out, with the exception of the refusal of the patient or relatives from the procedure. However, before carrying out a planned operation, it is important to take into account all the nuances, features:

• • • The presence of pathologies of a different nature that can negatively affect the condition during sleep and recovery.
    • If the patient has recently had ARVI or another viral infection, the operation should be postponed for several weeks until the body is fully restored.
    • The presence of allergies to drugs. The doctor examines the records in the card in detail. In case of finding out about the presence of an allergy to medicines, he immediately changes the tactics of action.
    • Health features - heat, runny nose.

Before surgery, the anesthesiologist examines the patient's card in detail, noting all the points that may affect the method of anesthesia. In addition, a conversation is held with parents, in which important points are clarified.

How to prepare a child for anesthesia?

According to modern concepts, any surgical intervention, painful procedures, diagnostic studies in children (especially younger ones) should be carried out under anesthesia or sedation! Young children simply do not know what is ahead of them, and no premedication is needed.

Regardless of the type of anesthesia under which the operation is planned, the patient is preliminarily prepared for surgical intervention.
Age groups of children: newborns, up to 6 months, 6-12 months, 1-3 years, 4-6 years,
7-9 years old, 10-12 years old, over 12 years old.

The anesthesiologist takes an active part in preparing the child for surgery. During planned operations, all preparation can be divided into general medical and pre-anesthesia: psychological and pharmacological premedication. An obstetric history is important: how the pregnancy and childbirth went (on time or not), the anthropometric data of the child - the correspondence of body weight and height to his age, psychomotor development, visible disorders of the musculoskeletal system, behavioral reactions.

Psychological preparation: hospitalization for a child is a difficult moral test, he is frightened by separation from his mother, people in white coats, the environment, and so on. The anesthesiologist, the attending physician and the ward nurse help and explain to the mother how to behave.

Doctors recommend not always telling the baby about what is to come. The exceptions are cases when the disease interferes with him, and he wants to get rid of it. However, if the children are old enough, it is necessary to explain that a special children's will be carried out, as a result of which they will fall asleep and wake up when everything has already been done and there is no trace of the past illness.

It is desirable that the baby is calm and not afraid. It is necessary to provide rest both emotional and physical. The main thing that parents need to remember is that the baby should wake up after anesthesia and see the dearest and closest people to him.
Once again about the most important thing in this video:

General anesthesia: consequences for the child's body

Much depends on the professionalism of the anesthesiologist, since it is he who selects the necessary dosage used for anesthesia. medicines. The result of the work of a good specialist is the child being unconscious for the period necessary for surgical intervention, and a favorable exit from this state after the operation.

Crane rarely happens intolerance to drugs or their components. It is possible to predict such a reaction only if the patient's blood relatives had it. Now we will list the consequences that may arise as a result of drug intolerance, but we note once again that this is an extremely rare case (only 1-2% probability):

• anaphylactic shock;
• malignant hyperemia. A sharp rise in temperature to 42-43 degrees.
• cardiovascular insufficiency;
• respiratory failure;
• aspiration. Ejection of stomach contents into the respiratory tract.

Some studies also suggest that anesthesia can damage the neurons in a child's brain, leading to cognitive impairment. At the same time, memory processes are disturbed: absent-mindedness, inattention, deterioration in learning and mental development for some time after the operation. These processes are opposed by a number of factors:

1. the likelihood of such consequences is highest with intramuscular anesthesia using Ketamine. Now a similar method and drug is practically not used for children.
2. children under two years of age are at greater risk. Therefore, operations under anesthesia, if possible, are postponed for a period after 2 years.
3. the validity of the conclusions made by only a few studies has not been conclusively proven.
4. these symptoms pass quite quickly, and operations are done in connection with real health problems of the child. It turns out that the need for anesthesia exceeds the possible temporary consequences of it.

Parents should understand that the condition of their baby throughout the operation and for 2 hours after it is monitored by modern medical equipment and staff. Even if there are any consequences, he will be provided with the necessary assistance in time.

Anesthesia is an ally that helps the child get rid of health problems in a painless way. Therefore, parents should not worry too much.

In modern medicine, anesthesia is a sparing tactical means, the use of which during an operation is a must.

If you have any questions, we will be happy to answer them. Health to your children!

I created this project to plain language tell you about anesthesia and anaesthesia. If you received an answer to your question and the site was useful to you, I will be glad to support it, it will help to further develop the project and compensate for the costs of its maintenance.

Related questions

Tatyana 10/16/2018 09:43

Good afternoon. On October 1, we had an operation to remove adenoids under general anesthesia. At first, the daughter (4 years old) complained of headaches. After 12-14 days, she periodically began to complain that she could not open her eyes. I thought maybe it was the vinegar fumes, or the smell of onions (complaints in the kitchen). Then it happened more often after waking up. It opens well, then the eyes could not stand being open. And this is not only in the sun but also in the shade. Today, she still couldn't open her eyes completely. Difficulty blinking or eyes closed. Whether there can be it a consequence of an anesthesia? And what can be done?

Valentine 17.09.2018 20:37

Good evening! My son is 4 years and 9 months old, he broke his arm, two bones were broken, one bone was displaced. On the day of the fracture on 11.09, general anesthesia was performed, one bone was straightened, the second remained fractured with displacement. A week later, on September 19, re-administration under general anesthesia. Help with advice, please, is it very dangerous? What consequences?

Olga 27.08.2018 18:33

Good afternoon. The child had the first operation in March, repeated in early August. In both cases, general anesthesia was used. After the first operation, there was an increase in weight, insignificant, but we cannot reduce the weight. Could anesthesia affect metabolism?

Evgenia 08/25/2018 00:09

Hello, Doctor! After the operation to remove the adenoids, my grandson (3 years and 4 months) is not only whiny and nervous, but he has strange psychoses: for example, he demands to go from home to the bus stop again and come back just because his mother did not give him a hand, or got out of the house first, instead of letting him out. Or suddenly he demands to feed his little sister with cucumber in the middle of the night and cries loudly, hysterically, until he achieves his goal .... We are at a loss. We don't know what to do. I think that he just has whims, but it turns out that general anesthesia has a very bad effect on the child's psyche. What do we do now? How to treat it? Help me please!!! Sincerely, Evgenia Grosh

Vladislav 06/07/2018 12:26

Hello. My mom had a very "rapid" delivery with me, my head was half blue. At the age of six, and this is 1994, to the surprise of my mother and doctors, hemorrhoids of the acute stage came out. In the hospital, I had three operations under general anesthesia, a year later two more operations, also under general anesthesia. At the age of 12, a knee injury and again general anesthesia. Now I am 29 years old. From about the age of 7 until the age of 20, I constantly suffered from headaches and low pressure. Now my head hurts very rarely, but I understand that weakness, drowsiness are my enemies for life. I also see the diagnosis "bradycardia" at regular medical examinations from work every year. Is my state of endless weakness a consequence of 6 general anesthesias in childhood?

Alexander 05/28/2018 11:05

Hello, my child is 10 years old. When falling from a height, he hit his head and received a moderate (or severe, I don’t know exactly) concussion. (there was a short-term loss of consciousness about 30-60 seconds), memory loss (does not remember what happened immediately before the fall and the fall itself), also broke his forearm (both radius bones). In traumatology, a plaster cast was immediately applied, but with a second x-ray after 1 day, it was found that the displacement persisted. Doctors say it is necessary to do general anesthesia and combine the bone. Question: Is anesthesia dangerous on the third day after a concussion, and is general anesthesia really necessary for a 10 (almost 11) year old child? Maybe it was possible to get by with a local (after all, he is not quite small and is able to sit quietly)? Thanks in advance for your reply!

Inna 19.04.2018 17:10

Hello. Dear doctor, tell me, please - my son (7 full years old) had an operation to remove appendicitis (with peritonitis) in February. Now we are going to have an operation to remove two hernias (umbilical and white line of the abdomen). How dangerous is it to do general anesthesia after such a short period of time? THANK!

Guzel 04/06/2018 13:41

Good afternoon doctor. The child is 2 months old, we were sent for an MRI (diagnosis of paresis of the III cranial nerves on the left, partial ptosis of the upper eyelid on the left, ophthalmoplegia), but the child fell ill, the child has snot. Can I have an MRI immediately after recovery or do I have to wait a while? And one more question: I'm going to be under general anesthesia. How dangerous is this for a child?

Elena 31.03.2018 20:54

Hello doctor, a child of 12 years old needs to have a papilloma removed on the palatine arch, doctors insist on general anesthesia. What modern drugs are currently used. What to talk about with an anesthesiologist?

Anastasia 03/27/2018 21:28

Hello. Please advise what consequences can be after anesthesia, is it worth doing the operation now, or is it better to wait up to 2 years? Situation: the baby is 4 months old, we have polydactyly, the 6th finger (on the big one 2 pcs). At what age is it better to have an operation, because now the (thumb) finger is growing, and it becomes uneven due to the second ..?

Natalia 03/27/2018 07:38

Hello. Tomorrow, my son, 6 years old, will have treatment and extraction of teeth under mask anesthesia. The anesthesiologist said that for 21 days there should be no snot. what is it connected with? I understand that SARS should not be transferred, but snot if they are dry indoors in the morning?

Lily 03/02/2018 14:50

Hello, Doctor! a child of 5 years old, on Monday, March 5, goes to a planned operation to remove a nevus on the thigh. the child was born prematurely at 33-34 weeks, of course, there was hypoxia and a slight cerebral edema, he was on a ventilator. up to a year, hydrocephalic syndrome was detected, which was treated with diacarb. at 1 year and 4 months they received CTBI, they were in the hospital, after that epilepsy (absences) was questionable, but the doctors themselves do not know if there is or not, who says what is, who is not. Now, according to my observations, everything is calm. at the moment there is a small anomaly in the development of the heart. before the operation, as expected, a general blood test was done, all indicators are normal, but NEU is reduced by 34.2% at a rate of 40.0-75.0, LYM is increased by 41.6% at a rate of 2.01-40.0, MON is increased by 9.6% at a rate of 3.0-7.0, EO is increased by 13.1 %! at a rate of 0.0-5.0. Please tell me: 1 is it possible to carry out general anesthesia in our case? 2 Do ECG and allergy tests for anesthesia before surgery? 3 What kind of anesthesia is used everywhere when removing nevi?

Natalya 16.01.2018 00:25

Hello, Doctor. Please tell me how to prepare a child 1.9 for surgery? The operation is due in two months., still present breast-feeding basically at night the question is: to wean the child now from the breast or after the operation, will the baby help or harm during the operation? Thanks in advance for your reply.

Victoria 12.12.2017 13:50

Hello. My son (3.5 years old) was scheduled for a planned operation to remove umbilical hernia and hernia of the linea alba. 10 days left. The child has not had a rash for about three weeks now (manifestation of an allergy), from time to time complained of pain in the abdomen (now it seems to be gone). The cause of the allergy has not been established. Is it possible to do an operation or is it more reasonable to first undergo an examination by a gastroenterologist, to identify the cause of the operation? If so, how long should it take for the rash to go away? Thank you!

Marina 11/28/2017 22:48

Hello! We are scheduled for a planned operation in the sky (cleft palate, soft palate) in 6 days, on the other side of the country. They waited for their turn for a long time - 6 months, they passed all the examinations - everything is fine. But the child picked up the virus: The snot is liquid and coughs. Tell me, is this a contraindication to surgery? Or is it possible to give antibiotics for a couple of days and go to the operation? Is it possible to do surgery / anesthesia with snot if we do not have time to cure it? And what could be the consequences? Thanks for the answer!

ANNA 11/16/2017 08:25

Hello, a 2-year-old child was scheduled for an operation (general anesthesia), after 10 days the operation, but we caught a cold, we were prescribed the antibiotic cephalexin. Are there any contraindications to general anesthesia after its use?

Julia 13.11.2017 20:01

The dear doctor, I ask you prompt. Treatment of 2 front teeth for a son aged 1, 10 months, after a blow, a flux formed on the gum. Treatment options are available with or without anesthesia. Carry out under intravenous anesthesia so as not to injure the child's psyche, or treat in spite of fear - but refraining from anesthesia? Is it right not to resort to anesthesia in such a critical situation? Thanks in advance!

Olga 09.11.2017 11:20

Hello, the child is 2.2 years old, at 1.3 g, an operation was performed to remove the inguinal-scrotal hernia, at 1.5 g there was a relapse (they operated on at 1.9 g), now there is a relapse again, there will again be an operation under general anesthesia, what could be the consequences of general anesthesia so often?

Fagana 03.11.2017 02:54

Hello, my son is 2 months old, we want to have a circumcision, they will probably do it under anesthesia, please tell me whether it is worth subjecting the body of a small child to anesthesia at this age, or if there is no need to wait for it to grow up?

Antonina 01.11.2017 22:14

Hello. Daughter is exactly 2 years old. Found an inguinal hernia on the right. An operation is coming. We cannot decide between laparoscopy and abdominal method. The surgeon said that in the first case anesthesia will last 30-40 minutes, and in the second 10 minutes. Tell me, is the difference of 20-30 minutes under anesthesia so harmful, as the doctor claims? The first method is more gentle, as well as the postoperative period is easier, we see only pluses. The child is capricious and very mobile, therefore we do not want a cavity. It is only this difference in time under anesthesia that hinders the choice of laparoscopy. Thank you.

Julia Prokhorova 10/19/2017 16:53

Hello, we have an inguinal hernia confirmed at 2 months old, now our daughter is 6 months old. We are advised to wait with the operation for up to a year, but there is no strength to wait and suffer, the child tries to crawl and the hernia protrudes. We, the parents, are afraid that the infringement can be at any moment . The child's tests are good (blood and urine), she is mobile and develops on time, she was born at 39 weeks with hypoxia, according to Apgar scores 7-8, the diagnosis is perinatal damage to the central nervous system of hypoxic-inschemic origin, PVC on the right is 1-2 st, pseudocyst of the left vascular plexus .response to vaccination against pneumococcus-temperature 38°C. Is an operation possible with such diagnoses at 6 months?

Eugene 10/17/2017 18:57

Hello! A boil was cut out for a boy at 2.9, i.e. was general anesthesia. Now I discovered that we have an inguinal hernia, you can’t confuse it with anything. I don't think we can do without surgery. Tell the doctor, how harmful will anesthesia be if the interval between operations is only 2-3 months? And what consequences can be after such operation. Thanks in advance for your reply.

Olga 13.08.2017 15:44

The child is 2.6 years old. Laryngoscopy and cryodestruction of soft tissues were performed. Mask anesthesia, after 20 minutes the child woke up. After 8 days, they want to do laryngoscopy again under anesthesia. Is it often possible?

Olga 08/09/2017 15:46

The child is 1.10 months old and is going to have an operation under general anesthesia. The diagnosis is stenosing ligamentitis of the 1st left hand. Question: what kind of anesthesia is given to children at this age and is there any point in waiting until 2 years old

Yana 08/07/2017 00:07

My daughter (4.5 years old) has grade 3 adenoids and hypertrophied tonsils. Breathing is difficult, ENT recommends removal. BUT, because daughter is registered with a neurologist (absences), then the hospital asked for a conclusion from a neurologist that general anesthesia can be done. A neurologist does not give a conclusion without an examination in a hospital where you need to do an MRI under anesthesia. And it turns out a vicious circle. Is it possible to do an MRI under anesthesia for adenoids?

Marina 05.08.2017 20:03

Hello! My child is 5 years old, she broke 2 bones of her arm with a displacement, they tried to set them intravenously under anesthesia, but it didn’t work out. The needles were inserted under general anesthesia, after 1.5 months the needles were removed under anesthesia. Half a year later, the arm was again fractured with sciatica, it was set under anesthesia, after 2 weeks in the picture - displacement, the orthopedist suggests again under anesthesia to set the bone. Is such frequent administration of anesthesia 5 times in six months dangerous for the body, what are the consequences?

Love 13.07.2017 11:48

Hello, Doctor! My grandson had a papilloma removed from his cheek two days ago. They did it under anesthesia-mask, the whole procedure took about 20 minutes, I quickly and easily came to my senses. The wound is tiny. They were supposed to be discharged tomorrow, but the daughter wrote a refusal and took it today, because. there are many patients, every day they were transferred from ward to ward. He had a fever and vomited twice. Whether it is a consequence of an anesthesia. No one in our family had allergies or drug intolerance.

Natalya 07/05/2017 19:00

Good afternoon! Son 1.2. A month ago, on the back, closer to the right shoulder blade, I found a bump (not hard, painless, does not grow). The doctors said it was either a lipoma or another tumor. They told me to go in for surgery. That only after the operation they will say what it is. scare malignant tumor. Is it possible to somehow determine what kind of cells these are before the operation? The child is only a year old, anesthesia scares me twice. Before the operation, CT under anesthesia and at the operation again anesthesia. Is there a chance that education will dissolve? Appeared sharply at once with a size of 2 * 3 cm.

Ekaterina 06/22/2017 00:51

Hello, Doctor! Son is 10 years old. Next week, a scheduled operation to remove the inguinal-scrotal hernia is due. Which anesthesia is better and safer at this age? Is anesthesia safe if the ECG showed the following: sinus arrhythmia heart rate 68-89 beats / min; vertical direction of the EOS; incomplete blockade right leg bundle of Hiss. Is it possible to use general anesthesia with such an ECG? Unfortunately, we do not have a pediatric cardiologist in our city. Many thanks in advance for your reply!

Eugene 14.06.2017 12:21

Hello. A 6-year-old girl was prescribed cutting of the frenulums: under the tongue and upper lip. They offer general or local anesthesia. They advise a general one so that the child is not afraid. But is general anesthesia justified for such a minor operation, which will take no more than 10 minutes?

Natalia 05/24/2017 13:45

Hello. My baby is 2.5 months old. You will have a cystoscopy under general anesthesia. A week ago, a runny nose appeared, aquamaris dripped, saline solution, snot did not go away in a week. When he sucks through his nose, he breathes normally, otherwise he "grunts". The operation is planned. Should I go to bed for surgery or is it better to wait?

Ekaterina 05/11/2017 09:48

Hello! This coming Monday, a 9-month-old baby will have an operation with anesthesia. The diagnosis is hypospadias. The last few days the child has a runny nose. Washing and instillation of the Nose did not improve the situation significantly. Is it possible to give anesthesia with a cold or is it better to postpone the operation?

Christina 09.05.2017 08:07

Hello dear doctor. I have a question. Child 1.7 will have surgery for craniostenosis. I'm sooooo worried about long-term anesthesia. Since we were born at 30 weeks and at birth, we were diagnosed with PTCNS of hypoxic-ischemic genesis. From birth to this day, the child was treated so that there was no lag in psychomotor development. And now the first long-term anesthesia is coming. Tell me how to act later so that anesthesia does not affect psychomotor and speech development, does not start a delay or stop talking altogether?

Victoria 05/08/2017 00:41

Hello, Doctor! We really need your opinion! My child is 5 years old, they put adenoids of 2-3 degrees. Sleeps with open mouth, does not snore, his mouth is also periodically open during the day, every month he has colds. They suggest an operation, but they did not ask about the characteristics of the child. We have minor anomalies of the heart, a functioning foramen ovale 2mm. , the cardiogram is normal, we are observed by a neurologist (sent to an encephalogram), during childbirth there were complications of asphyxia, a constantly bluish color of the bridge of the nose and nasolabial triangle, also an allergy to washing powder and some types of drugs. About two months ago I had otitis media. Adenoids were checked two weeks after a cold. Ketamine is offered intravenously for five to ten minutes. Is it possible to use anesthesia for my child with such indications, because I do not agree to local anesthesia, or is it better for us to do an encephalogram first? Or do you need to give up and wait?

Anna 20.04.2017 12:39

Hello! My daughter is 4 years old, she needs to do an SCT of the nose and sinuses, but she refuses to lie down! What tests do I need to pass for anesthesia?

Ekaterina 04/20/2017 10:20

Hello, the child is a year and 5 months old. We were diagnosed with ataxia. I want to do an MRI of the brain in order to clearly understand the whole picture of what this ataxia is, so that they can prescribe the right treatment. But the neurologist and osteopath dissuade that anesthesia is very dangerous. risk of MRI under anesthesia for ataxia?

Anastasia 04/05/2017 19:39

Dear doctor, my son is 1.5 years old, a month and a half ago, an inguinal hernia was discovered, the surgeon signed up for a planned operation to remove it, he is afraid of general anesthesia, the doctor says it is more dangerous not to have an operation. How dangerous is anesthesia, which method of anesthesia is safer, do you need any restorative drugs after anesthesia? Thanks in advance!

Elena 03/27/2017 00:31

Hello. My son is 2 years and 4 months old. Behind in the upper part of the thigh, a neoplasm was found. According to the conclusion of the ultrasound myoma, the dimensions are 40 mm by 20 mm. Doesn't bother, doesn't hurt. The ultrasound doctor advises not to operate, as he claims that this is a benign formation, the surgeon advises to operate ... What do you say? I'm very afraid of surgery, especially anesthesia, I'm afraid of any complications ... anything can happen ... What kind of anesthesia is acceptable in our case? Thank you in advance!

Svetlana 25.03.2017 12:40

Hello, Doctor. Daughter 10 months. On Tuesday, March 21, the child underwent an operation to remove a hemangioma (dermal-subcutaneous, diameter 5 cm) on the back. Indurated because the operation was performed in the side position. On Wednesday morning, after the dressing, the attending physician said that he would not be discharged yet, because the babies may have distant reactions to anesthesia, and swelling remained on the wound. On Wednesday, at 6 pm, the child began to vomit, which remained after the injection of cerucal, by night the temperature rose above 39, they knocked down analgin with diphenhydramine, it went down only to 38, by morning it began to rise. There was no vomiting on Thursday. There was no diarrhea, there was liquid stool once or twice a day. Tell me, please, is such a reaction really possible a day after the operation? With the permission of the doctors, I fed the child with the usual diet, that is, cereals, vegetable, meat and fruit purees, although canned, industrial production. At home she supplemented with expressed breast milk, but in the hospital it was not possible to express, she supplemented with a mixture of nan1. Before the operation, we treated dysbacteriosis (Klebsiella, Staphylococcus aureus) for 8 months. The analysis before the operation was normal (Klebsiella was within the normal range, staphylococcus was not detected). Have you encountered such cases in your practice? Or is it intestinal infection, or poor-quality puree, or teeth (only 1 grew, the second one swelled up), or a reaction to medications, or did it all coincide and was aggravated by the operation? Now the child has no vomiting and no temperature, for three days he was put on drips with glucose and Ringer's solution, and yesterday they also did ceftreaxone intravenously once. I give Acipol with water. I started eating myself last night - oatmeal on the water and a small amount of breast milk. Since morning there was a liquid chair once.

Alexandra 21.03.2017 12:51

Hello, in January 2017 there was an operation with general anesthesia for my son (6 years old), in May another operation with general anesthesia was prescribed for a different diagnosis, is the gap between anesthesia small and how to minimize the consequences of complications.

Angela 15.03.2017 16:55

Hello, my 9-year-old daughter has a seal on her foot under her finger, a granuloma is questionable, we are going to cut it out. The doctor wants to do general anesthesia, but I doubt it is necessary, isn’t it already possible to do local anesthesia?

Natalya 09.03.2017 04:47

Hello. My child underwent angiography with embolization. There was a hemangioma on the cheek. After that, she was in intensive care for a day. Then they gave it to me. She ate and slept all day. The condition was lethargic. Now the third day after the procedure. Very capricious. Not so active. What I didn’t like so this crying for no reason is strong, it bends and rolls its eyes up. though this happened twice a day. we are 5 months old, they inject antibiotics. tomorrow bypass. but I would like to read your answer. I think we cannot do without a neuropathologist.

Irina 03.03.2017 12:50

Good afternoon! Three days ago, the child was treated for teeth under general anesthesia (intramuscularly). Thus we treat already the third time. Teeth decayed rapidly. 8 teeth were treated at once, the volume of destruction was large. The child was not given to doctors under any pretext, and therefore anesthesia was used. This time there were two removals and two fillings. The teeth that were removed were practically absent, therefore, again, anesthesia. For two nights the child wakes up and screams, for a short time, but very emotionally. During the day, too, unnecessarily excitable and anxious. Tell me, please, should we go to the doctors with this problem or is it the consequences of stress and over time the situation normalizes. Thank you in advance

Hope 03.03.2017 06:05

Hello! The child is 6 years old, diagnosed with Ecdodermal ahydroctic dysplasia, i.e. dryness of all mucous membranes, impaired thermoregulation of the body. We want to do otoplasty under general anesthesia, please tell me if general anesthesia is possible?

27.02.2017 14:27

Sergei, in the hands of an experienced pediatric anesthesiologist, everything will go well. It is necessary to examine the child, anesthesia will not have a significant side effect.

Cyril 22.02.2017 10:37

Hello! The child is 1 year and 10 months old. She has strabismus, the doctor says it is necessary to have an operation under general anesthesia, either now or at 4 years 6 months old. We don’t know what to do, agree now or wait until 4 years old ??? age to make it safer for the health of the child ???

Tatiana 19.02.2017 00:04

Hello! A 4-year-old child has residual encephalopathy with mental retardation. We want to treat and remove teeth under general ketamine anesthesia. There is also an allergy in the form of rashes to certain drugs. They said that perhaps the teeth will be treated in 2 stages with an interval of a week, i.e. anesthesia will be 2 times. Is it possible to do such anesthesia for an allergic person? Will anesthesia affect the development of a child who is already lagging behind? Thank you.

Zebo 12.02.2017 15:09

Hello. A 5-month-old child is scheduled for an operation under anesthesia. They will operate on his hand for a born constriction of the left forearm. And his leukocytes are 12.9. Why is it dangerous?

Angelina 27.01.2017 09:41

Dear doctor, hello. My daughter is 16 years old, she is going to have an ENT operation. The anesthesiologist offers to choose anesthesia, says that there is a good paid and free one. In addition, they also offer a good paid injection (3000-5000 rubles) after anesthesia, so that the child "easily" comes to his senses. I doubt very much whether there is something similar in medicine. Help, please, to understand.

Ulyana 24.01.2017 23:53

Sergey Evgenievich, what do you think if a child (5 years old) has allergic rhinitis, manifested by nasal congestion at night on the one hand, seasonal rhinitis, can it be dangerous or a ban on performing an operation under anesthesia? Thanks in advance.

abstract

Topic: "Anesthesia in children"

Apparatus and equipment for general anesthesia

Anesthesia machines

The classic requirements for anesthesia machines for general anesthesia in children are to ensure minimal breathing resistance and maximum reduction of dead space. In anesthesia in children aged 2 years and older, practically any anesthesia machine with an open and semi-closed breathing circuit can be used [Trushin A.I., Yurevich V.M., 1989].

When performing anesthesia in newborns, it is safer to use special breathing circuits. The most common is the semi-open breathing circuit without valves according to the Ayre system with various modifications. With this system, the connector of the anesthesia machine is a U-shaped tube, one branch pipe of which is connected to the endotracheal tube, the other to the source of the gas-narcotic mixture, and the third (exhalation) to the atmosphere. With a gas-narcotic mixture flow of 4–6 l/min, it is enough to cover the exhalation hole with your finger to ensure inhalation, and when it is open, exhalation is carried out.

In the Ries modification apparatus, a container (500–600 ml) is put on the exhalation tube in the form of a breathing bag with a hole or an open rubber tube at the opposite end (Fig. 1). At the same time, ventilation can be carried out with one hand, squeezing the bag and closing and opening the free rubber tube or hole on the bag. In addition, the open port can be connected to a long hose that allows the exhaled mixture to be ejected from the operating room. The domestic industry produces a special attachment to anesthesia machines, which provides anesthesia along such a circuit. For anesthesia in newborns, an almost semi-open circuit can be used using special non-reversible valves that separate the inspiratory and expiratory flows, such as the Ruben valve. When a gas flow of 2–2.5 tidal volumes (5 l/min for a newborn) is supplied, this valve has very little resistance - less than 100 Pa (1 cm of water column)

In recent years, special anesthesia machines for newborns and young children have been produced. They not only have a smaller dead space, allow you to stably and accurately maintain the set ventilation parameters (tidal and minute volumes, the ratio of inhalation to exhalation, etc.), free the hands of the anesthesiologist, but also provide monitoring control of the condition respiratory system child.

Anesthesia machines intended for anesthesia in children should be equipped with masks of three sizes (preferably made of transparent plastic material) with inflatable obturators that fit snugly and cover only the mouth and nose.

Laryngoscopes and endotracheal tubes

For laryngoscopy, you can use conventional laryngoscopes with small blades, straight or curved. There are also special children's laryngoscopes with four blades, two of which are designed for newborns.

Most often, smooth plastic or thermoplastic endotracheal tubes are used in young children. Tubes with inflatable cuffs are used only in older children. They also occasionally use reinforced tubes and tubes for separate bronchial intubation. Sometimes Cole tubes are used in newborns, in which the distal end is 1–1.5 cm long (the size of a tube for newborns), and the rest is much wider. This prevents the tube from being displaced deep into the trachea and into the bronchus (Table 1).

Table 1. Sizes of endotracheal tubes depending on the age of the child

To create an optimal microclimate, newborns and, especially, premature babies are placed after surgery in special chambers - incubators that provide the necessary humidity, temperature, and oxygenation. Various manipulations in such children are carried out on special resuscitation tables, which also provide heating.

For continuous monitoring and control of vital important functions children in most cases use the same monitors as for adults. There are special monitors adapted to physiological characteristics of the child's body, the action of which is based on non-invasive methods for monitoring functional indicators. These include, in particular, a device for transcutaneous determination of the partial tension of blood gases TSM-222, monitors that constantly monitor blood oxygen saturation - pulse oximeters, devices that record changes in instantaneous pulse rate and pneumograms - cardiorespirographs, monitors for bloodless automatic recording of blood pressure - sphygmomanometers and other similar equipment

General principles of anesthesia

The general principles of anesthesia are the same for adults and children. In this section, only features related to the children's contingent are considered.

Most children should be operated on under general anesthesia. Only in rare cases, minor surgical interventions in older children can be performed under local anesthesia. The combination is common with various types local anesthesia can be widely used in children.

In the arsenal of the anesthetist there is a fairly large selection of tools and schemes for anesthesia. It is important to correctly determine the components of anesthesia that must be provided in each case. It is important to note that in newborns, a simpler anesthesia regimen with fewer injected ingredients should be chosen. Otherwise, with oppression of breathing and consciousness in the awakening stage, an “equation with many unknowns” is obtained, when it is difficult to clarify the cause of these complications.

In pediatric anesthesiology, as in adults, there is a trend towards more frequent use of non-inhalation methods of anesthesia. However, in pediatric practice non-inhalation anesthesia is rarely used in its pure form. More often we are talking about a combination of inhalation anesthesia with neuroleptanalgesia, ketamine, central analgesics, sodium oxybutyrate and other drugs.

Preparation for anesthesia

Preparation for surgery and anesthesia can be divided into general medical, psychological and premedication.

General medical preparation consists in the possible correction of impaired functions and sanitation of the child. It is better if the anesthesiologist, during planned surgical interventions, gets acquainted with the child not on the eve of the operation, but shortly after admission and, together with the attending physician, outlines a treatment plan.

In young children, it is important to find out the obstetric (birth trauma, encephalopathy) and family (does the relatives have intolerance to any drugs) anamnesis.

It is important to clarify the incidence of acute respiratory viral infections to which young children are very susceptible. Elective surgery should not be performed earlier than 8–4 weeks after these and other respiratory diseases. It is necessary to clarify whether there are any violations of the airway (adenoids, deviated nasal septum, etc.).

When researching of cardio-vascular system it is necessary to find out whether the child suffers from congenital defects.

The risk of vomiting and regurgitation is greater in children than in adults. If the operation is scheduled for the morning, then the child should not have breakfast. In those cases when it is carried out in the second turn, the child can be given half a glass of sweet tea 3 hours before it. It should be remembered that children sometimes hide sweets, cookies and can eat them before the operation.

Psychological preparation of the child is very important. Suffering must be considered little patient caught in an unusual and difficult environment. It is better not to deceive the child, but to win him over and explain the nature of the upcoming manipulations, to convince him that he will not be hurt, to assure that he will sleep and will not feel anything. In some clinics, school-age children are given a colored booklet that introduces them to the upcoming manipulations.

Premedication in children is carried out according to the same principles and for the same purpose as in adults. At present, the expediency of using m-cholinolytic drugs in young children is being questioned. However, most clinics administer atropine to young children. Much more often and with greater effect than in adults, ketamine is used in premedication. According to our data, premedication with ketamine in combination with atropine and droperidol or diazepam in 95% of cases gives a good and only 0.8% unsatisfactory result. It is very important that such a combination provides not only premedication, but also partially induction of anesthesia, i.e. Children enter the operating room almost in a state of narcotic sleep.

In pediatric practice, the following premedication schemes are most common: 1) atropine (0.1 mg/kg) + promedol (0.1 mg/kg), 2) atropine (0.1 mg/kg) + ketamine (2.5 mg/kg). kg) + droperidol (0.1 mg/kg), 3) atropine (0.1 mg/kg) + ketamine (2.5 mg/kg) + diazepam (0.2 mg/kg); 4) thalamonal (0.1 ml per 1 year of life).

The most common route of administration of drugs is intramuscular, although children have a negative attitude towards this. You can use the intravenous route, but the most benign is the reactive route, when drug complexes are used in the form of an enema or in suppositories.

General anesthesia is a procedure by which the patient's autonomic reactions are suppressed, turning off his consciousness. Despite the fact that anesthesia has been used for a very long time, the need for its use, especially in children, causes a lot of fears and concerns among parents. What is the danger of general anesthesia for a child?

General anesthesia: is it necessary?

Many parents are sure that general anesthesia is very dangerous for their child, but they cannot say for sure what exactly. One of the main fears is that the child may not wake up after the operation.. Such cases are indeed recorded, but they occur extremely rarely. Most often, painkillers have nothing to do with them, and death occurs as a result of the surgical intervention itself.

Before performing anesthesia, the specialist receives written permission from the parents. However, before refusing to use it, you should think carefully, as some cases require the mandatory use of complex anesthesia.

Usually general anesthesia is used if it is necessary to turn off the child's consciousness, protect him from fear, pain and prevent the stress that the baby will experience while being present at his own operation, which can negatively affect his still fragile psyche.

Before using general anesthesia, contraindications are identified by a specialist, and a decision is made: is there really a need for it.

Deep sleep provoked medicines, allows doctors to perform long and complex surgical interventions. Usually the procedure is used in pediatric surgery, when pain relief is vital., for example, with severe birth defects heart and other abnormalities. However, anesthesia is not such a harmless procedure.

Preparation for the procedure

It is wiser to prepare the baby for the upcoming anesthesia in just 2-5 days. To do this, he is prescribed hypnotics and sedatives that affect metabolic processes.

About half an hour before anesthesia, the baby can be given atropine, pipolfen or promedol - drugs that enhance the effect of the main anesthetic drugs and help avoid their negative effects.

Before performing the manipulation, the baby is given an enema and removed from Bladder content. 4 hours before the operation, the intake of food and water is completely excluded, since during the intervention vomiting may begin, in which vomit can enter the organs of the respiratory system and cause respiratory arrest. In some cases, gastric lavage is done.

The procedure is performed using a mask or a special tube that is placed in the trachea.. Together with oxygen, anesthetic medicine comes out of the device. In addition, anesthetics are administered intravenously to alleviate the condition of a small patient.

How does anesthesia affect a child?

Currently the probability of severe consequences for the child's body from anesthesia is 1-2%. However, many parents are sure that anesthesia will adversely affect their baby.

Due to the peculiarities of the growing organism, this type of anesthesia in children proceeds somewhat differently. Most often, clinically proven drugs of a new generation are used for anesthesia, which are allowed in pediatric practice. Such drugs have a minimum of side effects and are quickly removed from the body. That is why the effect of anesthesia on the child, as well as any negative consequences, are minimized.

Thus, it is possible to predict the duration of exposure to the used dose of the drug, and, if necessary, repeat anesthesia.

In the overwhelming majority of cases, anesthesia facilitates the patient's condition and can help the surgeon's work.

The introduction of nitric oxide, the so-called "laughing gas", into the body leads to the fact that children who have undergone surgery under general anesthesia most often do not remember anything.

Diagnosis of complications

Even if a small patient is well prepared before the operation, this does not guarantee the absence of complications associated with anesthesia. That is why specialists should be aware of all possible negative effects of drugs, common dangerous consequences, probable causes, as well as ways to prevent and eliminate them.

Adequate and timely detection of complications that have arisen after the use of anesthesia plays a huge role. During the operation, as well as after it, the anesthesiologist must carefully monitor the condition of the baby.

To do this, the specialist takes into account all the manipulations performed, and also enters the results of the analyzes into a special card.

The map should include:

• heart rate indicators;
• breathing rate;
• temperature readings;
• the amount of blood transfused and other indicators.

These data are strictly painted by the hour. Such measures will allow any violations to be detected in time and quickly eliminate them..

Early consequences

The effect of general anesthesia on the child's body depends on the individual characteristics of the patient. Most often, the complications that arise after the baby returns to consciousness are not much different from the reaction to anesthesia in adults.

The most commonly observed negative effects are:

• the appearance of allergies, anaphylaxis, Quincke's edema;
• disorder of the heart, arrhythmia, incomplete blockade of the bundle of His;
• increased weakness, drowsiness. Most often, such conditions disappear on their own, after 1-2 hours;
• increase in body temperature. It is considered normal, however, if the mark reaches 38 ° C, there is a possibility of infectious complications. Having identified the cause of this condition, the doctor prescribes antibiotics;
• nausea and vomiting. These symptoms are treated with antiemetics such as Cerucal;
• headaches, feeling of heaviness and squeezing in the temples. Usually not required special treatment, however, for prolonged pain symptoms the specialist prescribes painkillers;
• pain sensations in postoperative wound. A common consequence after surgery. To eliminate it, antispasmodics or analgesics can be used;
• fluctuations in blood pressure. Usually observed as a result of a large blood loss or after a blood transfusion;
• falling into a coma.

Any drug used for local or general anesthesia can be toxic to the patient's liver tissues and lead to liver dysfunction.

Side effects of drugs used for anesthesia depend on the specific drug. Knowing about all the negative effects of the drug, you can avoid many dangerous consequences, one of which is liver damage:

• Ketamine, often used in anesthesia, can provoke psychomotor overexcitation, seizures, hallucinations.
• Sodium oxybutyrate. May cause convulsions when used in high doses;
• Succinylcholine and drugs based on it often provoke bradycardia, which threatens to stop the activity of the heart - asystole;
• Muscle relaxants used for general pain relief can lower blood pressure.

Fortunately, serious consequences are extremely rare.

Late Complications

Even if the surgical intervention went without complications, there were no reactions to the means used, this does not mean that there was no negative impact on the children's body. Late complications may appear after some time, even after several years..

Dangerous long-term effects include:

• cognitive impairment: memory disorder, difficulty in logical thinking, difficulty concentrating on objects. In these cases, it is difficult for the child to study at school, he is often distracted, cannot read books for a long time;
• attention deficit hyperactivity disorder. These disorders are expressed by excessive impulsivity, a tendency to frequent injuries, restlessness;
• susceptibility to headaches, migraine attacks, which are difficult to drown out with painkillers;
• frequent dizziness;
• the appearance of convulsive contractions in the muscles of the legs;
• slowly progressive pathologies of the liver and kidneys.

The safety and comfort of the surgical intervention, as well as the absence of any dangerous consequences, often depend on the professionalism of the anesthetist and surgeon.

Consequences for babies 1-3 years old

Due to the fact that the central nervous system in young children is not fully formed, the use of general anesthesia can adversely affect their development and general condition. In addition to Attention Deficit Disorder, Pain Relief Can Cause Brain Disorder, and lead to the following complications:

• Slow physical development. Medicines used in anesthesia can disrupt the formation of the parathyroid gland, which is responsible for the growth of the baby. In these cases, he may lag behind in growth, but subsequently is able to catch up with his peers.
• Disturbance of psychomotor development. Such children learn to read late, it is difficult to remember numbers, they pronounce words incorrectly, and build sentences.
• epileptic seizures. These violations are quite rare, however, there have been several cases of epilepsy after surgical interventions using general anesthesia.

Is it possible to prevent complications

It is impossible to say for sure whether there will be any consequences after the operation in babies, as well as at what time and how they can manifest themselves. However, you can reduce the likelihood of negative reactions in the following ways:

• Before the operation, the child's body must be fully examined by passing all the tests prescribed by the doctor.
• After surgery, you should use drugs that improve cerebral circulation, as well as vitamin and mineral complexes prescribed by a neuropathologist. Most often, B vitamins, piracetam, cavinton are used.
• Carefully monitor the condition of the baby. After the operation, parents need to monitor its development even after some time. If any deviations appear, it is worth visiting a specialist once again to eliminate possible risks.

Having decided on the procedure, the specialist compares the need to perform it with the possible harm. Even after learning about the likely complications, you should not refuse surgical procedures: not only health, but also the life of the child may depend on this. The most important thing is to be attentive to his health and not self-medicate.