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THE 5 Ws – THE WHO, WHERE, WHAT, WHEN AND HOW

ANESTHESIA SHOULD BE PROVIDED IN CHILDREN

THE WHO

Children undergoing anesthesia have an increased perioperative 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 / fellows in pediatric anesthesia departments must be supervised in an 1:1 manner by an experienced consultant at minimum during induction and emergence as well as at any time during surgery if required.   General anesthesiologists should be able to provide emergency anesthesia for limb and live saving interventions as well as transportation to a specialized pediatric center. Education und regular training and update in pediatric centers are essential to ensure maintenance of their competencies.

THE WHERE

The pediatric population undergoing anesthesia is too small in order to maintain sufficient skills for every anesthesiologist. Therefore, care of children undergoing anesthesia should be regionalized. (4)  Such centers pool these patients in specialized pediatric theatres staffed by pediatric anesthesiologist and pediatric nurses. 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.  Neonates and infants must be anesthetized in specialized pediatric centers. 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 setup of a 24/7 pediatric anesthesia emergency service with at least 5 consultants. A structured pediatric anesthesia service with departmental regulations, standard operating protocols (SOPs) for acute crisis situations, pain service, specialized nursing staff and appropriate equipment must be established.  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. 

THE WHAT

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 comorbidities, syndromes or are unstable must be anesthetized in dedicated pediatric centers. Routine operations (common ENT procedures, simple bone fractures, wound repair, laparoscopic appendectomy) in otherwise stable and healthy older children can be performed in district hospitals provided that an anesthesiologist with expertise in pediatric anesthesia is available.

THE WHEN

The 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 perioperative complications and death (5, 6) versus the impact of delaying elective procedures/diagnostics on the future wellbeing of the child. A delay in elective or scheduled surgery may result in emergency procedures which do carry a higher perioperative risk.  The HOW Safe anesthesia is provided by avoiding the known factors that compromise patient’s wellbeing and outcome. (7, 8)  Secure 10-N-quality points of pediatric anesthesia Survival medicine for economic reasons must be avoided; instead education, training and supervision must be guaranteed. General anesthesia should be supplemented with regional anesthesia techniques whenever possible in order to reduce the need for excessive anesthetic agents (low blood pressure) and the need for opioids (nausea and vomiting, respiratory depression, hyperalgesia). Prevent the misuse of regional anesthesia in order to avoid all general anesthesia/ airway management in children or the believe that neonates have no explicit memory. (9) Expertise of all pediatric anesthetic  techniques is required to provide optimal care for all children. (10)   References 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. Perioperative Mortality, 2010 to 2014: A Retrospective Cohort Study Using the National Anesthesia Clinical Outcomes Registry. Anesthesiology. 2015; 123: 1312-21. 6. Nunnally ME, O'Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. 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.  
The initiative will define the ‘who‘, ‘where‘, ‘what‘, ‘when‘ and ‘how’ in this context which provides the framework for the safe conduct of anesthesia.
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