The 5Ws listed below are closely related to the Rights of the Child (10Rs). In particular children have
- the “Right to enjoy the highest attainable standard of health”
- the “Right to avoid pain, fear and stress”
- the “Right to have their parents with them”
These basic rights are respected if the 5Ws are applied.
Anesthesia for children should always be delivered by competent and appropriately experienced anesthesiologists and care teams.
Children aged less than 3 years, ASA physical status ≥ III (all ages), with underlying congenital and metabolic diseases and/or those undergoing major or complex surgery are those at highest risk for perioperative complications and poor outcome. It is recommended that these children should receive care by an anesthesiologist with specific education, training and ongoing experience in pediatric anesthesia.
Anesthesiologists with mixed practice can deliver pediatric anesthesia for healthy children aged >3 years simple and routine procedures provided they have the adequate expertise and regular practice in pediatric anesthesia. They should maintain their competence with regular exposure to pediatric lists and keep their knowledge up-to-date. This will minimize the occurrence of life-threatening complications.
Continuing education and regular updates in pediatric centers are recommended to maintain competency. Specialist centers should support those in non-specialist practice.
Residents and fellows in pediatric anesthesia departments must be supervised in a 1:1 manner by experienced staff during induction and emergence as well as at any time during the anesthesia if required.
Children should receive pediatric anesthesia care in children’s hospitals or in general/district hospitals with dedicated pediatric areas.
Regionalization of pediatric anesthesia
The pediatric population is too small to allow maintenance of sufficient skills for every anesthesiologist. Care of children undergoing anesthesia should ideally be regionalized in specialized pediatric settings staffed by pediatric anesthesiologists and pediatric nurses.
In particular, the most vulnerable pediatric population, such as neonates and infants, those with co-morbidities and with underlying congenital and metabolic diseases as well as children undergoing major or complex surgery require referral to appropriately resourced multidisciplinary pediatric environments.
Advantages of specialized children’s hospitals
- 24/7 pediatric anesthesia emergency service
- Specialized pediatric nursing staff
- Appropriate equipment for daily routine and critical situations for all targeted age groups
- Development and implementation of standard operating protocols (SOP) for routine processes and crisis situations
- Pediatric pain service
- Pediatric Intensive Care provision
District hospitals providing pediatric anesthesia care
Anesthesia for elective routine operations in otherwise stable and healthy children can be performed in district hospitals by teams with sufficient expertise in pediatric anesthesia. This requires appropriate staffing, equipment, facilities and support services.
Out of hours and emergency care must be provided by a team with sufficient expertise in pediatric anesthesia in a suitable environment with clear operational policies.
Remote Areas and the Critically Ill Child
Children who undergo anesthesia in remote areas (imaging, interventional procedures, dental suites and other special facilities) and who require deep sedation or general anesthesia must receive the same standard of care.
An effective referral and retrieval system must be in place for critical ill children.
Pediatric patients requiring highly specialized or major surgery (cardiac, thoracic, major visceral, major orthopedic, neurosurgical, burns and craniofacial procedures), those with significant and uncontrolled co-morbidities as well as critically ill children will benefit from specialized anesthetic care 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 district hospitals by specialist pediatric anesthesiologists or anesthesiologists with an expertise in pediatric anesthesia provided appropriate staffing, equipment, facilities and support services are in place.
Careful considerations must be given to balance the increased perioperative risks for newborns and infants and the impact of delaying elective procedures/diagnostics for the well-being of the child.
A delay in elective or scheduled procedures may result in avoidable emergency procedures, which do carry a higher peri-operative risk.
High Quality and Safe Anesthesia Care promotes the well-being of the child (see Rights of the Child). It maintains physiological homeostasis (see 10Ns) and addresses the known peri-operative risk factors (See 10Cs) in an appropriately resourced multidisciplinary pediatric environment.
Expertise in all pediatric anesthetic techniques is required to provide optimal care for all children in all situations. Several European countries have well established ‘pediatric anesthesia fellowships’ with the duration of one or two years.
This is a mandatory prerequisite for those anesthesiologists that are willing to provide specialized pediatric care. In countries where a pediatric fellowship program is not established, the European Training Requirements (ETR) should be considered.
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