Pediatric Anesthesiology at Lurie Children's Hospital with Dr. Olutoyin Olutoye

Lurie Children's Department of Anesthesiology administers tens of thousands of anesthetics every year to treat children with a range of health conditions. Leading these efforts is Anesthesiologist-in-Chief Dr. Olutoyin Olutoye. In this episode, Dr. Olutoye walks through her and her team members’ various roles before, during, and after an operation to ensure successful surgeries for even the tiniest babies. She also shares findings from her research in maternal-fetal anesthesiology as well as in anesthesia drugs and pediatric obesity. 

“We take care of children coming in for the most simple procedures, like ear tubes, to the most complex procedures, like cardiac surgery or craniofacial surgery.” 

Olutoyin Olutoye, MD, MSc
Anesthesiologist-in-Chief; Department Chair, Pediatric Anesthesiology; Attending Physician, Anesthesiology; Arthur C. King Board Designated Professorship in Anesthesiology; Professor of Anesthesiology in the Division of Pediatric Anesthesiology, Northwestern University Feinberg School of Medicine

Show Notes

• Now two decades into her career, Dr. Olutoye was first drawn to pediatric anesthesiology because of the critical and involved nature of the care.
• Compared to general anesthesiologists who can treat young children, pediatric anesthesiologists receive an additional year of training to prepare for treating younger and smaller patients like babies in the neonatal intensive care unit. 
• Dr. Olutoye explains how she prepares and comforts parents or caretakers and children before delivering care. For older children, her team’s pre-op focus is on gaining the child’s confidence. For babies, the focus is on regulating their body temperature, because they lose heat so easily.
• One uncommon possible effect of anesthesia that’s unique to children is emergence delirium, in which a baby or child wakes up from anesthesia confused, inconsolable, and unable to recognize his or her parents. However, there are medications that can resolve this condition.
• In response to the FDA’s “black box” warning against anesthesia for children younger than 3 and women in their third trimester, Dr. Olutoye has studied the effects of maternal-fetal anesthesia and fetal surgery on the neonatal brain in sheep. She found that fetal surgery was protective against any brain damage. She says there is little evidence of lasting neurological side effects in children who received anesthesia
• For procedures that don’t require general anesthesia, such as a lower extremity surgery, Dr. Olutoye recommends exploring spinal anesthesia.
• In Dr. Olutoye’s studies of pediatric obesity and anesthesia drugs, she found that increasing the dose to correlate with a child’s weight did not increase the drug’s efficacy. A lower dose was effective for inducing unconsciousness in children with obesity.
• When a patient is sedated for a minimally invasive procedure, which is common for pregnant patients, Dr. Olutoye says that talking them through the procedure is essential. Lurie Children's also offers translators for patients whose first language is not English.
• Dr. Olutoye is also passionate about faculty development. She highlights simulation training for residents who want to practice skills on mannequins before their rotation at Lurie Children’s.
• At Lurie Children's, all pediatric specialties are located under one roof, conveniently available to the anesthesiologist and the patient at every stage of the procedure.

Transcript

[00:00:00] Erin Spain, MS: This is Precision, perspectives on children's surgery from Ann & Robert H. Lurie Children's Hospital of Chicago. I'm your host, Erin Spain. On this podcast, we introduce you to surgeons at one of the country's most renowned children's hospitals to find out how they're transforming pediatric medicine. Every year, Lurie Children's Department of Anesthesiology administers almost 30,000 anesthetics to treat children with all types of conditions. Lurie Children's pediatric anesthesiologists are crucial for ensuring positive surgical outcomes and promoting optimal recovery in patients. Here to discuss the innovative ways the department provides surgical anesthesia from fetal surgery to routine ear tubes is Dr. Toyin Olutoye, the anesthesiologist-in-chief and chair of the Department of Pediatric Anesthesiology at Lurie Children's. Welcome to the show.

[00:01:02] Dr. Toyin Olutoye: Thank you so much, Erin. I'm glad to be here. Thank you for having me.

[00:01:05] Erin Spain, MS: Let's start things off by talking about your journey into pediatrics. What was it about this field that made you want to pursue it?

[00:01:14] Dr. Toyin Olutoye: I actually was born as a premature infant at 28 weeks, and I consistently heard stories from my parents about how devastated they were because back then these children didn't really have a chance at survival. And I stayed in the hospital for about two months before I eventually came home. And I grew up being indebted to the physicians that took care of me, and I vowed to be able to help children in the future. And that drew me to pediatrics, particularly the pediatric subspecialty of anesthesia.

[00:01:45] Erin Spain, MS: Anesthesiologists are pretty special. You see so many patients undergoing a variety of procedures. What was it about anesthesiology that drew you into the sub-specialty?

[00:01:55] Dr. Toyin Olutoye: I would say the critical nature of anesthesia care and the fact that it's a very short interaction but very involved interaction. And just being able to get a patient asleep, monitor the patient while they're awake, do whatever you need to do within that surgical time to ensure the best outcome for the patient, which ranges from not just monitoring their vital signs but also giving blood if necessary, making sure the patient is warm, making sure the patient is deep enough and under anesthesia or even providing nerve blocks to help ensure the patient wakes up pain free. All of these things that we're doing within a short period of time really drew me to anesthesia. And I would say for pediatric anesthesia, the opportunity to engage in this care in even the smallest of babies, which is more critical and which is not widely embraced by many people, drew me to pediatric anesthesiology.

[00:02:54] Erin Spain, MS: It does take a specially trained pediatric anesthesiologist to be able to take care of the smallest of babies. Tell me about these smallest patients that you care for.

[00:03:04] Dr. Toyin Olutoye: Sure. Every pediatric anesthesiologist has first been trained as an anesthesiologist and then embarks upon a one-year fellowship training to specialize in the care of children. We do have general anesthesiologists first who can take care of some pediatrics. And depending on the institution, you might have different guidelines. In some hospitals, you would have a general anesthesiologist taking care of children above five. In some places it's above three. But regardless, I think it takes a specially trained pediatric anesthesiologist to be able to take care of the smallest of babies. We are comfortable taking care of the babies that are in the neonatal intensive care unit, those that can fit in the palm of your hand or that are just barely bigger than the palm of your hand. Because we've had this year of extra training, we are comfortable taking care of these babies for a myriad of congenital anomalies that they may be presenting to the operating room. So, I think this specialty training of pediatric anesthesia is very important because you do need people that are comfortable taking care of these children in the middle of the night, or whatever odd time they present to the hospital. While you have a general anesthesiologist who may take care of older children, you still do need a pediatric anesthesiologist to take care of the critically ill, particularly the smallest of patients.

[00:04:21] Erin Spain, MS: Administering anesthesia to children also requires someone who can put a child and their caregivers at ease. I mean, some of these children, they can't talk yet. It's hard for them to communicate. Tell me about your approach to these patients and their families.

[00:04:35] Dr. Toyin Olutoye: Most of the parents, as you can imagine, come to the hospital very apprehensive and anxious about what this entails, what this care means for their child. So when I walk into a room, the first thing I do is introduce myself to the family and tell them what I do, namely I'm the anesthesiologist who will be caring for your child, and I ask up, front, do they have any questions I can answer before I go into the process and what to expect? And from there a lot of them will tell you what's been bothering them on their drive into the hospital or stories that they've heard, they're concerned about. So once I address those, I then move on to the process, telling them what to expect from the time I'm speaking to them until the time I leave and then when I come back to pick up their child ready for surgery. And in that process of going step by step, of course they may have questions and then I stop and answer the questions as well. Not only do I talk to the parents, depending on the age of the child, I also try to quickly establish rapport with the child, see if I can catch the child's attention,if the child would give me high five. And depending on how they interact with me, I would then be informed as to whether or not this child needs some some pre-medication to kind of make them a little drowsy so they're not as anxious when we separate, or if the child would benefit from interacting with our child life specialists who engage the children in toys or games and even show the children a little bit of what they'll be doing once they get into the operating room. And sometimes we may not need anything at all if the child is very playful and engaged and I feel the child would separate easily, then I would realize and conclude that we don't need any additional aid in getting us back to the operating room.

[00:06:15] Erin Spain, MS: You mentioned a couple of key players on your team. Child Life specialists are one of them. Explain everyone that is involved in your team and how each player helps make things go very smoothly.

[00:06:27] Dr. Toyin Olutoye: The members of our team, in addition to the child life specialists, include the preoperative nurses who admit the children to the pre-op holding area before surgery. They usually go through the patient's charts. We may have children who have recommendations from the hematologist to receive a certain medication. These nurses would identify this order and work with the anesthesiologist to make sure that this medicine is received before the patient goes back into the operating room.

[00:06:51] Erin Spain, MS: Tell me about your leadership of this team. How do you talk to your folks to get everyone on the same page and create a culture that's very welcoming and warming for the parents and patients?

[00:07:02] Dr. Toyin Olutoye: Most of the anesthesiologists on my team are here because they love taking care of the children. They love working with each other. They love working with the surgeons. They love working with the nurses. One of the things that is attractive in a children's hospital is that everybody that's here is interested in moving the day along, is interested in working well together, and I think that's one unique feature of a children's hospital compared to an adult hospital. And due to the camaraderie that exists and the playful attitude and playful nature of everyone, everyone enjoys the day and the day seems to go by very fast. Amongst the members of my team, I do have some anesthesiologists that have specific interests in particular areas. I have an interest in maternal fetal anesthesia, for example, and neonatal anesthesia and craniofacial. But I would say in our team, we have people that have interests in general pediatric surgery, bariatric surgery, cardiac surgery, maternal fetal surgery, as has been mentioned, transplant surgery and we also have some that are interested placing or performing regional nerve blocks, and those help alleviate pain during the surgery and after the surgery. We do have little teams in our big department of faculty that readily provide care for children in these areas. They write papers on pertinent findings in these areas, collaborate with other colleagues outside the institution on work under that umbrella. I think it's a good mix of people doing different things and those pursuing things that are of specific interest to them.

[00:08:32] Erin Spain, MS: You've already alluded to some of this, but there are many nuances of taking care of children before, during and after surgery. Can you walk me through some of those nuances that parents might not think of.

[00:08:43] Dr. Toyin Olutoye: For the older child, I would say the biggest thing is gaining the child's confidence really quick before you get into the operating room. And once we get into the operating room, you want to continue to engage the child as they breathe in anesthesia gas. We playfully place a fragrance on the mask, asking them what flavor they want. Bubblegum, strawberry, watermelon, cherry, orange, and the child gets to pick. And once they get into the room, in the process of breathing in the anesthesia gas, they're blowing up a balloon, so they watch the balloon blow up, and then next thing you know, they fall asleep. And for the younger kids, the babies, the main issue for them, or main concern, I would say, is temperature regulation because they're so little and they lose heat very quickly. So we warm up the room before we have little babies come into the room. We have overhead warmers that radiate heat onto the bed. We also have bear huggers, which are blankets that insufflate warm air around the patient. So even when they lay down on the bed, they're not laying down on something cold. We also have caps that we put over the heads for babies and younger children that also helps to conserve heat. So these are the things that we do as we're bringing the child into the operating room, even while we're getting them asleep. Some surgeries are more prone to more heat loss than other surgeries . Big procedures where you have big abdominal procedures done, they tend to lose heat much more than other children that are having extremity procedures done.

[00:10:08] Erin Spain, MS: And what about the waking up part? What can that be like for children, and what do you do to really help smooth that transition as much as possible?

[00:10:16] Dr. Toyin Olutoye: In general, children have decreased oxygen reserve and they tend to drop their oxygen levels very quickly compared to adults. So this is something that we keep an eye on as the children are falling asleep during surgery and even when they're waking up. When we use a breathing tube or any breathing device in a child and we're taking the breathing device out, it's not uncommon for the oxygen level to be a little low initially and we make sure, obviously, that the oxygen levels come back up to where we're comfortable before we take the children to the operating room. So I would say every part of the anesthetic is important, from falling asleep to keeping them asleep and monitoring the vital signs to waking them up. One feature that is common in children that you don't see in adults sometimes is emergence delirium where the child may wake up extremely agitated, is not recognizing the parents at all and is inconsolable. This is obviously very frightening for the parents, and we do have medicines that we give the children that makes them fall back asleep in the recovery room, and when they wake up, they're back to their normal selves.

[00:11:19] Erin Spain, MS: How often are you seeing that?

[00:11:21] Dr. Toyin Olutoye: I wouldn't say it's common. If I were to give it a percentage, I would say maybe 10-15 percent of children. It's more common with very short procedures, and sometimes you can have them even on medium -duration procedures. On occasion, it may be associated with pre-medications that the children receive to make them calm during surgery. And on very rare occasions, we might have to reverse that medicine if we notice that the kids are waking up with emergence delirium. But for the most part,the incidence is very low, fortunately. 

[00:11:50] Erin Spain, MS: You mentioned maternal fetal anesthesiology, and this is an area that's really fascinating where you're actually working with pregnant women and babies before they are born. Tell me about this work and what draws you to this and what this is like.

[00:12:04] Dr. Toyin Olutoye: I think that's an interesting field because you get to interact with two patients, the mom and her unborn child. And again, very much like pediatric anesthesiology, you're trying to allay the fears and concerns of these mothers that come for a variety of procedures on their unborn children. And these procedures range from shunt placement or maybe drainage of extra fluid in either a lung or a heart or fixing a valve anomaly within the heart to the more involved procedures in which the baby may have spina bifida. And this is repaired in utero fetoscopically with minimally invasive equipment, or it could be open where the baby's back is positioned such that the surgeons can easily repair it and then they close the mother back up. And we also have instances where the babies may have difficulty breathing when they're born, either due to a large mass around the neck or a mass in the mouth, and these babies are monitored until they're close to term. And then they're delivered in a controlled situation in which they're partially delivered, and an airway is established such that when the baby is completely separated from mom, the baby is breathing with the help of a breathing tube, which is almost always necessary if there's an anomaly obstructing the airway. So the child is delivered with an artificial airway, a breathing tube, instead of having to struggle to breathe when they're born because of a mass.

[00:13:28] Erin Spain, MS: I mean, this is really incredible. The stakes are always high when it's someone's child and parents are always concerned. But when it's a pregnant woman, maybe even a more experimental procedure, I'm sure this is something where you're having to have a dialogue with this patient. Just kind of walk me through that exchange and what it's like.

[00:13:45] Dr. Toyin Olutoye: The minimally invasive procedures are interesting because the mothers are sedated for the most part, so many times you have to talk them through what's going on. This is what's going on now. You might feel pressure here and, you know, it's a constant conversation because it really is a minimally invasive procedure and it doesn't need general anesthesia. So many times these procedures are done either with IV sedation or with an epidural catheter, which most women receive when they are in labor. But an epidural catheter can also be used during these procedures because it basically serves the same function: it numbs up the abdominal area through which the surgeon will be working. And the mothers are in and out of sleep during this time, but we are constantly talking with them and explaining what's going on. And particularly here at Lurie Children's, they've incorporated the use of translators, so even for mothers who do not have English as their first language, they're able to have somebody with them in the room throughout the whole procedure , explaining what's going to happen. Those kinds of things help allay the mom's anxiety and also help the procedures occur smoothly.

[00:14:50] Erin Spain, MS: So, you're also interested in the effect of pediatric obesity on the efficacy of anesthesia drugs. Tell me about this topic and how you're studying it.

[00:15:01] Dr. Toyin Olutoye: We have an increased number of children that are obese presenting to the operating room, and this is a reflection of what's happening in our society in general. And the question comes up: How exactly do you dose medications in this group of patients? Do you dose it on the actual body weight or do you consider the ideal body weight? A lot of times when the children show up, we have just their actual body weights to deal with and that's what's put in the chart. So I decided to look at propofol, which is a drug that we commonly use in the operating room, and to try to figure out what the dosing of propofol should be in obese children. And we actually found that using the actual weight of a child, we needed a lower dose of propofol to induce unconsciousness, which is not intuitive. You would think you would need a higher dose. So this information has been helpful, and I use that in my practice when caring for children that are obese. It's very important for people to realize that the actual weight should not necessarily be utilized when we're administering drugs to patients. And each class of drugs has a different desired dose to use in an obese patient. So you've published about this. Is this something that's been embraced by fellow colleagues around the country?

[00:16:10] Dr. Toyin Olutoye: It is one, yes. So there are many different publications on pediatric obesity and the drugs that we use. In Europe, they use a lot of target-controlled infusions where they infuse the medication to the desired effect in different patients. We don't have that exact methodology here in the United States, but the consideration for the dosing of the drug is utilized by many people in their different practices.

[00:16:34] Erin Spain, MS: Are there any other concerns when it comes to caring for a child with obesity who is about to undergo surgery?

[00:16:41] Dr. Toyin Olutoye: There are quite a few actually. When children are obese, sometimes their airways can be affected. It could be difficult to secure an airway in these children, in which case we might need video laryngoscopy to secure the airway. And video laryngoscopy just means equipment that can actually show you a video as you're trying to put in a breathing tube into the child. And that is just at the beginning, getting the child to sleep. Sometimes these children come with comorbidities, so they have other conditions that are related to obesity. Some of them have obstructive sleep apnea , which is disturbed sleep pattern. They hold their breath when they're sleeping and they have pauses in their sleep. And this makes the children very sensitive to pain medication. So if they're coming for big surgeries, one consideration would be to try to use regional nerve blocks to control their pain as opposed to using opioids because they could be sensitive to opioids and have problems with breathing after surgery because they've received opioids. Sometimes these children have diabetes, and we have to monitor their blood sugar during surgeries depending on how long the surgery is. Positioning is also a factor when we have obese patients, trying to get them well positioned on the bed and make sure that they don't have any nerve injury, particularly for longer procedures.

[00:17:53] Erin Spain, MS: Are you ever able to uncover undiagnosed conditions through the process of administering anesthesia and monitoring the patient?

[00:18:01] Dr. Toyin Olutoye: It's not uncommon because we do have a preoperative clinic where patients are screened, particularly patients with complex medical histories, prior to coming to surgery. And we take a thorough medical history before inducing anesthesia. However, on occasion, we do find patients who under anesthesia now decompensate or are not doing so well. And then we might have to get a consultation from either cardiology or from some other service. So it does happen occasionally, but I wouldn't say it happens very commonly.

[00:18:31] Erin Spain, MS: That's one of the benefits of working in a specialized children's hospital like Lurie Children's because you have all pediatric specialists under one roof and you can easily pick up the phone and call and they would come and see the patient, be it in the operating room or in the holding area before surgery or even in the recovery room. Are there any other innovations or research that your department is focused on that you'd like to share?

[00:18:53] Dr. Toyin Olutoye: One area of research that is being embarked upon now is the use of simulation in training of residents. Many times we have residents come over to Lurie Children's for their pediatric anesthesia rotation, and they are engaged in procedures that they may not have ever experienced before. One of them is placing a caudal block, which is medicine in the epidural space, kind of like an adult, but in the children we put them in a lower area called the sacral hiatus and many of them are just seeing this for the first time. So simulation will be a process by which they get to practice this on mannequins before they actually start their rotation with the hope of getting them familiar with it, getting them more comfortable with the process so they know what they're doing when they're actually trying it on human beings, and I think that's an excellent idea.

[00:19:39] Erin Spain, MS: So as we are wrapping up today for all the parents listening, what would you like to say to them and what would you like them to know about pediatric anesthesiology at Lurie Children's?

[00:19:49] Dr. Toyin Olutoye: I would like the parents to know that pediatric anesthesiology at Lurie Children's is as great as you're going to get it anywhere. It is a place where you have the best pediatric anesthesiologists, and we do have pediatric CRNAs as well, certified registered nurse anesthetists, that work hand in hand with us here at Lurie Children's. We have a plethora of consultants that are specialized in different areas related to child care. We take care of children coming in for the most simple procedures, like ear tubes, to the most complex procedures, like cardiac surgery or craniofacial surgery, and everybody is trained to take care of these patients, everybody has had the special training, be it in pediatric anesthesiology or pediatric cardiac anesthesiology. It definitely is a one-stop shop, and I would highly recommend any parent whose child needs surgery in the Chicagoland area to definitely give Lurie Children's Pediatric Anesthesiology a try.

[00:20:45] Erin Spain, MS: Well, thank you so much. This was such a comprehensive view of everything offered, and I'm sure it puts a lot of parents' minds at ease.

[00:20:52] Dr. Toyin Olutoye: Thank you so much, Erin. I appreciate your time.

[00:20:55] Erin Spain, MS: For more information, including how to make a referral or an appointment, visit LurieChildrens.org.

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