Anesthesia and Infants

Dr. Nelson and Dr. Geronemus Respond to Article on Anesthesia and Infants

An article recently appeared on the Internet which has caused a tremendous amount of anxiety for the parents of children receiving anesthesia in conjunction with laser surgery of vascular malformations. We would like the opportunity to comment on the article. (

Since the study was conducted during the period of 1976-1982, all children likely would have received halothane as the anesthetic agent. At our institutions, for all infants and young children we now exclusively use sevoflurane (introduced in the mid-1990's), which has a much faster on-set and off-set of anesthesia, as compared to halothane. Moreover, sevoflurane doesn't induce the overall global body beta blockade (such as slow heart rate), which was a major problem with halothane.

As pointed out by the authors, subjects included in the study had a variety of major medical illnesses requiring multiple complicated surgical procedures, which makes anesthesia much more problematic. The vast majority of our patients are essentially healthy. Patients with vascular malformations are only medically cleared for same day surgery procedures if they are medically stable, thus they are usually not categorized in the major medical illness category.

The degree of learning disability was most pronounced in those children undergoing procedures that lasted several hours. Our procedures are significantly shorter and only performed with an experienced anesthesia team.

Finally, and most importantly, the study predates the development and institution in 1984 of pulse oximetry and capnography which have made all anesthesia procedures much safer due to the ability to make real-time measurements of blood and lung concentrations of gases. Undetected brain hypoxia (lack of oxygen) was the most worrisome complication of anesthesia before pulse oximetry became standard practice. When children are put under anesthesia at our institutions we constantly monitor pulse oximetry. Any time the pulse oximeter goes below 90%, the laser procedure is stopped and our anesthesiologist replaces the mask and brings the pulse oximeter reading back up to 100%. Capnography, which measures the amount of carbon dioxide, is an important indicator of early broncho- or laryngo-spasm or other causes of inadequate ventilation or gas exchange by the lungs.

In conclusion, safer and shorter acting anesthetics, shorter time of procedures, treatment of a category of healthier patients and, most importantly, improved real-time monitoring, has significantly lowered the risk of complications from anesthesia. Without question, some of the most dramatic improvements in medicine have been in anesthesia in general, and pediatric anesthesia in particular. It was regrettable that it was not pointed out in the article that the anesthetic medications and technology used for most of the reported cases was more than 30 years old and now obsolete.

We would be happy to speak with you directly regarding children's individual case at your convenience.


J. Stuart Nelson, M.D., Ph.D., Beckman Laser Institute, University of California, Irvine
Roy G. Geronemus, M.D., Laser & Skin Surgery Center of New York