The Million Dollar Question

One of the biggest questions I get asked when I'm on obstetric and pediatric anesthesia is how an anesthetic may affect a child. This is a complicated question, both sufficiently and excessively vague. If a child absolutely needs surgery or a mother needs a stat C-section, then any theoretical risks from anesthesia would be dwarfed by the actual risks of not getting surgery. Since pediatrics and obstetrics are rarely amenable to randomized controlled trials, what we know is often incomplete and extrapolated from animal trials or retrospective studies. My conclusions on reading the literature is not easy to summarize. If I give opiate through an epidural, its potency is greatly enhanced, but some of that opiate can cross the placenta. Yet this is much more preferred than IV opiate which crosses at much higher concentrations. But if I withhold opiate from the epidural, then a woman may need much higher doses of local anesthetic to get adequate relief. And perhaps that will increase the risk of local anesthetic toxicity, failure of the epidural block, and even C-section rate. With all these conditional statements and wishy-washy clauses, it's hard for patients to objectively assess the risks and benefits. Similarly, we don't think there are any long-term effects from a healthy child receiving one anesthetic. Yet some studies show that repeat anesthetics, especially in a vulnerable population like premature infants, can have long-term consequences. Are those consequences due to anesthesia or having multiple surgeries or having multiple medical problems and risk factors? How do we present that to a patient or parent?

This touches on the nuances of informed consent. I used to think that informed consent was easy. You'd tell the patient the recommended procedure, what the common and most serious complications could be, what alternatives the patent could choose (including doing nothing), and why it was recommended. Then the patient should have enough information to decide. But in cases like this, where evidence is confusing, much of it poor in quality, much of it contradictory, how do we give a balanced viewpoint to a patient or parent? When practitioners spend hours reading and making our own judgments, how can we expect a patient or parent to decide immediately?