Anaesthesia for heart surgery- information for parents and carers

You and your child will be seen in the anaesthetic preoperative assessment clinic in the weeks before your procedure by a specially trained nurse or doctor. This is usually done as an online video consultation.

The purpose of this appointment is to help prepare your child for their procedure, to make sure we have all the important information about them and their medical care, book any additional tests or treatment that they may need, and to share information with you and your child about the side effects and risks of general anaesthesia.

We will ask about any previous anaesthetics they have had, and if there were any problems, for example feeling sick or vomiting afterwards. It is also important that your child has regular dental check-ups and should be seen by a dentist every 6 months. All of this is to make sure that things run as smoothly and as safely as possible on the day.

Please have ready a list of all the medications your child is taking. This should include all the medications they are taking- not just the ones for the heart- and include medicines like the contraceptive pill. Most medications should be taken as usual before and after a procedure. Sometimes it is necessary to stop taking certain medications before a procedure. You will be given clear instructions by your anaesthetist or cardiologist if this is the case.

This is a good time to ask us any questions you may have. If you are worried about anything, please do let us know and we will do our best to address your concerns. If you do not wish your child to be present when we discuss the side effects and risks of general anaesthesia, please let us know.

If your child becomes unwell in the days or weeks before your procedure, please call us to let us know. Please let us know if they have any of the following:

• Cough or flu-like symptoms
• High temperature or chills
• Vomiting or diarrhoea
• New skins rash (for example, chicken pox or shingles)

Having an infection can increase the risks of anaesthetic. Therefore, it is very important that you tell us if your child has been unwell. If the procedure can wait, it will be safer to postpone it until they are feeling better. If the procedure is urgent, we will weigh up the risks and benefits of postponing the procedure versus going ahead.

It is very important to follow the instructions given to you regarding fasting before your child’s procedure. The purpose of fasting is to ensure your child’s stomach is empty and to reduce the risk of vomiting during the procedure. You will be provided with specific times at which you should stop feeding your child. This depends on the time of the procedure, but in general solid food should be stopped 6 hours before, breast milk 4 hours before and clear fluids 1 hour before an anaesthetic. In certain heart conditions it is very important that your child stays well hydrated and if that is the case, we will tell you to make sure your child keeps drinking plenty of water.

Medications can be given with a sip of water during this time, unless instructed otherwise by your anaesthetist or cardiologist.

Having an anaesthetic can be stressful and scary for some children. It is a good idea to prepare your child by talking them through what is going to happen in way they will understand. You should tell your child in a simple and truthful way that they are coming to hospital for a reason. Depending on the age of your child, it may help to describe in simple terms that they will go to sleep for their procedure. Showing age-appropriate pictures or demonstrating with toys or teddies can help. You know your child best, and how best to reassure them.

GOSH also has a team of play specialists who can help your child prepare for the procedure using techniques such as role play, drawing and practicing what will happen. Please let us know if your child would like the support of our play team.

It is normal for a child to be afraid or anxious when in hospital. Usually with preparation and reassurance children cope very well with the process of coming to hospital and having an anaesthetic.

In certain cases, if your child is feeling especially anxious, we may consider giving them premedication to help them feel calmer and more at ease before the anaesthetic. These are medications used to provide sedation on the ward before coming to theatre. If this is felt to be something your child would benefit from your anaesthetist will discuss premedication options with you.

You and your child will be seen by an anaesthetist shortly before the procedure. They will review your child’s medical history and go over what was discussed with you in the cardiac anaesthetic preoperative assessment clinic.

Important information to tell us includes:

• When your child last had food or drink.
• If your child is unwell, or has been unwell in the last few weeks.
• What medications your child is taking, and when these were last given.
• Any allergies.
• If your child has had any issues after previous anaesthetics (e.g. feeling sick or vomiting).

If your child has loose teeth or dental work (e.g. braces, caps, crowns).

We routinely screen for pregnancy in all girls aged 12 and older. For this your child will be asked for wee into a sample pot so we can test their urine. Please don’t let your child go to the toilet just before you arrive on the ward or there won’t be any urine left for us to collect!

You are welcome to accompany your child to the anaesthetic room and stay with your child until they are asleep, if you would like. Alternatively, a member of our team can accompany your child to the anaesthetic room instead. This will depend on how you and your child are feeling on the day. This can be a stressful time for parents and carers. Children can be very observant and can sense when the people they love are worried. Providing your child with comfort and reassurance during this time will help them. Our team are always available to support you during this time.

There are two ways to start an anaesthetic:

• Facemask or a cupped hand.

We will hold a facemask or our hand over or very close to, your child’s mouth and nose. They will then breathe in and out an anaesthetic gas that will drift them off to sleep over a minute or so. This time can be longer depending on how big and how cooperative your child is.

• Using a cannula.

We will put local anaesthetic cream on your child’s hands, arms or feet to numb the skin before we insert a cannula. The cannula is usually inserted into the back of the hand in the anaesthetic room but is sometimes inserted on the ward before coming to theatre. We will hold your child’s arm firmly and safely while the cannula is being placed. Anaesthetic medicine is then injected through the cannula to drift your child off to sleep.

Different children may tolerate one method better than the other. For example, some children may not accept a facemask held near their face and so will more readily tolerate a cannula. In some cases, there are medical reasons, for example certain cardiac conditions, why putting a cannula in before going off to sleep is the safer option. Your anaesthetist will discuss this with you.

When your child is asleep, we will ask you to leave the anaesthetic room so that we can perform our necessary interventions and keep your child as safe as possible. You will be accompanied by a member of our team.

When your child is asleep, we will place some additional monitoring to help us to keep you safe during the surgery:

Arterial line

We will insert a cannula into an artery to allow continuous and accurate blood pressure monitoring during the procedure. They usually do not cause any problems. In rare cases the artery may become damaged or blocked, which can affect the blood flow to your child’s arm or leg. In the unlikely event that this were to occur, it usually resolves with removal of the arterial line. Sometimes it may require treatment. It is extremely rare for any permanent harm, such as limb damage, to occur because of an arterial line.

Central line

This is a catheter that we insert it into a large vein in the neck or groin while your child is asleep. It allows us to monitor the pressure in the heart and give medications to support your child’s heart and blood pressure that can’t be given elsewhere. We use sterile precautions and ultrasound to see during the procedure, to reduce the risk of complications.

Complications can include:

• Infection which will require antibiotics and possibly line removal
• Blood clot in the vein which may require blood-thinning medications or line removal
• Bleeding
• Injury to the lung
• Abnormal heart rhythm

Transoesophageal echocardiography (TOE)

An ‘echo’ is a type of scan used to look at the heart and nearby blood vessels. We may insert a probe through the mouth into the oesophagus to perform an echo during the procedure. This carries a very small risk of damage to the oesophagus, tongue, teeth and lips.

An anaesthetist will stay with your child for the entire duration of their surgery and for some time afterwards. They will ensure they are asleep throughout the surgery, to monitor them to make sure they are safe, and to respond quickly to any issues that may arise.

Most children will receive a blood transfusion and/or other blood components during cardiac surgery. This is to stop them becoming anaemic and to help the blood clot after surgery.

In most cases, once surgery is complete, we will transfer your child to the cardiac intensive care unit (CICU), sedated and usually with a breathing tube still in their nose or mouth, to provide them with ongoing support. They will be woken up and the breathing tube removed when the CICU team deem it is safe to do so. Sometimes, we may decide to remove the breathing tube once the surgery is complete and transfer your child to CICU breathing on their own, if we feel this best for your child.

You should prepare yourself to see your child on CICU with several tubes, lines and monitors attached to them. These are all for your child’s safety and comfort.

Anaesthesia is very safe in most cases. Life-threatening complications of anaesthesia are rare but possible. Children with significant heart disease are at higher risk of serious anaesthesia-related complications. Your anaesthetist will discuss the risks specific to your child with you. The following is a general description of the risks of general anaesthesia.

Common side effects include:

• Feeling sick, maybe vomiting
• Sore throat
• Sometimes children can wake up very agitated, for example crying and screaming inconsolably. This can be very distressing for parents and care givers to see. This is usually short-lived.

Uncommon side effects include:

• Breathing problems, sometimes needing treatment, or extra time in hospital for observation
• Damage to skin or lips

Even rarer complications include:

• Eye injury
• Damage to teeth

Very serious complications of anaesthesia are extremely rare.

• Having a bad allergic reaction
• Awareness during a surgery
• Death or disability

It is important to remember that there will be a highly trained anaesthetist with your child the entire time to monitor them, to make sure they are asleep throughout the procedure, and to make sure they are as safe as possible.

For perspective, the risk of death as a direct result of an anaesthetic in a healthy person is between 1 in 100,000 and 1 in 1,000,000 (1 million). This is similar to the risk of being killed by lightning.