Specialist pediatric anesthesia care should be provided for children aged less than 3 years. Children undergoing anesthesia have an increased peri-operative risk for morbidity and mortality when compared to adults. 1 A minimum annual caseload of 200 – 300 children up to 10 years of age including 1 infant / per month / per anesthesiologist is recommended to minimize complications.2,3
Residents and fellows in pediatric anesthesia departments must be supervised in a 1:1 manner by an experienced consultant during induction and emergence as well as at any time during surgery if required.
General anesthesiologists should be able to provide emergency anesthesia for “life and limb saving” interventions as well as transportation to a specialized pediatric center. Education, regular training and updates in pediatric centers are essential to ensure maintenance of pediatric competencies.
Regionalization of pediatric anesthesia
The pediatric population undergoing anesthesia is too small to allow maintenance of sufficient skills for every anesthesiologist. Therefore, care of children undergoing anesthesia should ideally be regionalized4 with children cared for in specialized pediatric operating theatres staffed by pediatric anesthesiologists and pediatric nurses.
Neonates and infants must be anesthetized in specialized pediatric centers. These vulnerable patients require referral to appropriately resourced multidisciplinary pediatric environments.
Hospitals with day cases and in-patients require a minimum volume of 1000–1500 children aged < 10 years per annum. This minimum volume allows the provision of a pediatric anesthesia emergency service with at least 5 pediatric anesthetic consultants.
Advantages of Regionalization
- 24/7 pediatric anesthesia emergency service without compromise in care quality
- Specialized pediatric nursing staff
- Appropriate equipment range for daily routine and crisis situations for all targeted age groups
- Development and implementation of standard operating protocols (SOP) for routine processes and crisis situations
- Dedicated pediatric pain service
Remote Areas, Smaller Hospitals, Dental Suites and Medical Practices
Children treated or investigated in remote areas (Radiology, Cardiac Cath-Lab, Proton Therapy, MRI and other special facilities) and who require deep sedation or general anesthesia mandate a specialized pediatric anesthesia team.
Hospitals responsible for elective loco-regional pediatric surgical services without resident pediatric anesthesia expertise should rely on an external sufficiently trained pediatric anesthesia team. This also applies to private dental suites and other specialized pediatric areas. Children requiring deep sedation or general anesthesia in remote work areas (diagnostic imaging, cardiac catheter lab, radio-oncology, and other special facilities) require a specialized pediatric anesthesia team.
Hospitals providing elective pediatric surgery without resident pediatric anesthesia expertise should rely on support from an external sufficiently trained pediatric anesthesia team. This also applies to private dental suites and other specialized medical practices.
Pediatric patients requiring highly specialized or major surgery (cardiac, thoracic, major visceral, orthopedic, neurosurgical, burns and craniofacial procedures) must be anesthetized in dedicated pediatric centers.
Patients who have significant co-morbidity, syndromes or are unstable must be anesthetized in dedicated pediatric centers.
Anesthesia for routine operations (common ENT/ORL procedures, simple fractures, wound repairs, laparoscopic appendectomy) in otherwise stable and healthy children can be performed in smaller district hospitals by specialist pediatric anesthesiologists or anesthesiologists with an expertise in pediatric anesthesia.
Optimal timing of elective operative procedures is crucial.
Careful considerations should be given to balance the high risk of anesthesia in newborns and infants regarding peri-operative complications and death 5,6 versus the impact of delaying elective procedures/diagnostics on the future well-being of the child.
A delay in elective or scheduled surgery may result in emergency procedures which do carry a higher peri-operative risk.
Safe anesthesia is provided by avoiding the known peri-operative factors that compromise patient’s well-being and outcome.7,8
- Ensure the 10 N for quality of pediatric anesthesia
- Avoid survival medicine for economic reasons
- Establish continuous education, training and supervision
- Supplement general anesthesia with regional anesthesia whenever possible. Regional anesthesia avoids morbidity associated with high doses of anesthetic agents and intra-/postoperative opioids
- Prevent the (mis)use of regional anesthesia as a substitute for skilled general anesthesia and expert airway management
- The concept that neonates have no explicit memory is erroneous.9
Expertise in all pediatric anesthetic techniques is required to provide optimal care for all children in all situations.10
Learn more about …
- causes of neuromorbidity
- how research is currently focused and how it could better help children
- the quality gap between ‘state of the art’ and clinical practice
- the “Big Five W” – What specialist care is about
- 10-N quality – A simple matrix for reviewing your care
- how to meet the concerns of parents
- Safetot’s story and mission
- our network and members
- the FAQ for practitioners
- the FAQ for parents
- our Publications
- Safetot’s sponsors
- Safetot’s supporting organisations
1. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology. 1993; 78: 461-7.
2. Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics. Anesth Analg. 1997; 84: 234-5.
3. Lunn JN. Implications of the National Confidential Enquiry into Perioperative Deaths for pediatric anesthesia. Paediatr Anaesth. 1992; 2: 69–72.
4. Harrison TE, Engelhardt T, MacFarlane F, Flick RP. Regionalization of pediatric anesthesia care: has the time come? Paediatr Anaesth. 2014; 24: 897-8.
5. Whitlock EL, Feiner JR, Chen LL. Anesthesiology. 2015; 123: 1312-21.
6. Nunnally ME, O’Connor MF, Kordylewski H, Westlake B, Dutton RP. Anesth Analg. 2015; 120: 364-70.
7. Anesthetist rather than anesthetics are the threat to baby brains. Weiss M, Bissonette B, Engelhardt T, Soriano S. Paediatr Anaesth 2013;23:881-2.
8. Weiss M, Hansen TG, Engelhardt T. Ensuring safe anaesthesia for neonates, infants and young children: what really matters. Arch Dis Child.2016; 101: 650-2.
9. Ho AM. Comment on ‘Anesthetists rather than anesthetics are the threat to baby brains’ Weiss M, Bissonnette B, Engelhardt T, Soriano S. Paediatr Anaesth. 2014; 24: 224.
10. Weiss M, Engelhardt T, Bissonnette B, Soriano S. Response of Dr. Ho’s comments. Paediatr Anaesth. 2014; 24: 224-5