1. An Overview of Pediatric Anesthesia
KeywordsSafety of pediatric anesthesiaEmergence deliriumInhalational inductionDay surgery in childrenPost extubation stridorPediatric anesthesia services
‘Pediatric’ or ‘child’ applies to someone aged less than 18 years. The American Academy of Pediatrics defines ‘pediatric’ as less than 21 years, while some centers use 16 years. An infant is a child aged between 1 and 12 months. The term ‘neonate’ applies to the first 4 weeks of life. Children make up a quarter of the population in most Western countries and a higher proportion in developing countries. Pediatric anesthesia is very common—5.5% of children have an anesthetic each year, and about half are preschool age. The commonest indication for anesthesia is ENT surgery, but children often need anesthesia for procedures such as scans and dental treatment that an adult would tolerate without anesthesia.
Pediatric anesthetists have several special attributes described by the late Dr. Kester Brown: they have expertise in caring for neonates and infants during anesthesia and surgery; they understand the anesthetic implications of congenital disease and disability; and they have knowledge of the psychological, physiological, pharmacological and anatomical differences with age.
1.1 Safety of Pediatric Anesthesia
Anesthesia for children has become very safe. Parents can be reassured that the profession has taken many steps over the years to reduce risk. These steps include analysis of past incidents (anesthesia was the first specialty to perform incident monitoring), embracing new monitoring technologies, improved specialist training and taking advantage of safer drugs. The overall mortality from anesthesia alone in a healthy, older child is approximately 1 in 50,000 to 1 in 100,000. Tertiary pediatric centers report overall mortality at 24 h after anesthesia and surgery at about 13 per 10,000 anesthetics. Anesthesia-related mortality in this group is reported as 0.7 per 10,000.
Patient, surgical and anesthetist factors that may increase the risk of anesthesia in children
Factors increasing risk of morbidity and mortality
2 (includes recent URTI)
Cardiothoracic, neurosurgery, scoliosis surgery
Airway and dental surgery
Peripheral, minor surgery
Experience of the anaesthetist
Increased risk with small case load of children of similar age to patient
Most critical incidents are respiratory and airway related. Proficiency in airway management is the cornerstone of safe pediatric anesthesia practice.
The pediatric caseload of the anesthetist affects the rate of complications
Number of anesthetics given per year
More than 200 children
Children aged less than 3 years, and especially aged less than 1 year are at a higher risk from anesthesia than older children.
1.2 Organization of Services
Patient factors to consider in determining level of staff and facilities needed to safely care for children
Age of child, esp. if <12 months
Type of surgery
ASA status/General health of the child
Summary of requirements to safely anesthetize children (based on ANZCA PS29 and RCOA guidelines)
Organization of services
Experience and case load to maintain competency in relevant ages and case mix of:
In addition to equipment and facilities needed to safely anesthetize adult patients:
Size-appropriate breathing circuit, airway equipment and monitoring
Anesthetic machine and ventilator suitable for ages of children being anesthetized
Suitable fluid administration devices (may include burette)
Resuscitation drugs and equipment (including defibrillator and pads suitable for children)
Ability to control temperature of OR
Beds and cots suitable to contain child and prevent falls
Ability for parents to accompany child to theater and be present in recovery
Separated areas from adults-wards, OR, PACU
Accommodation for parents if overnight admission
Links to tertiary pediatric centers for advice and transfer of patients if postoperative problems occur
Pharmacy knowledgeable in pediatric doses
Acute pain service, HDU/ICU if relevant to case-mix
Local hospital group with oversight of scope of practice and suitability of staff involved
Local protocols and regulations for selection of patients and aspects of their care
Gradual implementation of any changes and ongoing quality assurance
The Australian and New Zealand College (ANZCA) guideline PS29 (2019) and the United Kingdom College guidelines (2018) discuss staffing for the care of children in non-pediatric hospitals. These policies particularly apply to infants and neonates because of their greater risk. Anesthetists looking after children should have training in the relevant age group, and should not anesthetize children if they are not comfortable to do so due to either lack of recent experience or inadequate case load. Having a second anesthetist to help should be considered for infants and children ASA3 status or higher. The anesthetic assistant and perioperative staff should have training in the care of children. Not all children can be cared for in tertiary children’s hospitals, so most countries have networks in which information, guidelines and training are exchanged between central specialist and peripheral general hospitals. As part of this, there is generally a lead consultant to oversee provision of pediatric anesthetic services in general hospitals.
1.3 Preoperative Assessment
Facial dysmorphic features that may indicate a congenital syndrome
Widely spaced eyes (hypertelorism)
Beaked or other nose abnormality
Low hairline on forehead
Low slung or malformed ears
Examination needs to take into consideration the modesty of the child, particularly with school-aged children and adolescents. Examination may occasionally reveal a previously unrecognized heart murmur (see Chap. 20, Sect. 20.3.1), signs of asthma or URTI (see Chap. 11, Sects. 11.2 and 11.3), or loose teeth. The most important aspect of airway assessment is mandibular size (see Chap. 4, Sect. 4.2). Investigations such as hemoglobin, CXR and urinalysis are not routinely performed in healthy children undergoing minor surgery. Hemoglobin is not tested because significant anemia is rare in children and mild anemia does not affect the decision to proceed with anesthesia. Some centers use the Sickledex test in patients at risk of sickle cell anemia.
Pre-anesthetic clinics are not always used for healthy children. Clinics are unlikely to reveal significant medical problems, are inconvenient for the family, and do not influence the most likely reason for cancellation of surgery, which is a viral illness just before surgery. Assessment is commonly by a telephone interview before admission and review by the anesthetist on the day of surgery. However, this approach reduces the time available for informed consent for anesthesia.
1.3.1 Loose Teeth
Children lose deciduous teeth from 5 years of age. A very loose tooth may dislodge and be aspirated during anesthesia and is sometimes removed (with parental permission) after induction. The tooth needs to be very loose before trying this, and usually has no visible root (it is resorbed). If the tooth is not very loose it can be surprisingly difficult and unpleasant to remove, and the gum may bleed. A tooth that is not on the verge of falling out can be watched carefully during airway manipulation and checked at the end of the case to make sure it has not been dislodged.
The legal age for consent is usually between 16 and 18 years, depending on the jurisdiction. Consent for a child is therefore obtained from the parent or legal guardian. However, there is growing recognition of the rights of younger people. It is usual to at least obtain the assent (permission) to proceed with anesthesia and surgery in older school aged children, even though they may not be able to give legal consent. Further complicating this area is the increasing recognition by courts of children’s abilities to make their own decisions about treatment. Some health areas have policies in place that allow children as young as 14 years to consent to treatment. However, these policies are not a replacement for laws and it is still usual to obtain parental consent when the child is younger than 16–18 years.
Young people at 16 years of age have the legal ability in most countries to make decisions about their own care, and they must be presumed to be competent to make such decisions unless it can be shown otherwise. A valid refusal of surgery by a child who is competent should usually be respected. Legal advice should be sought if the procedure is felt to be in their best interests despite their refusal, especially if the refusal of treatment could result in death or serious harm.
Children younger than 16 years can consent if they demonstrate Gillick-competency. The Gillick competency test establishes the legal principles to decide a child’s ability to make health care decisions. The Gillick case considered consent for prescription of the oral contraceptive to a 16 year old girl, and whether or not a parent’s permission was required. The findings of this case have been used to determine consent issues in general. For a child to be deemed competent to decide about their healthcare they must have the ability to understand the factual, moral and emotional consequences of their decision. Competence is not reliant on a fixed age, and competence for one situation does not imply competence for all. The child’s age is still considered—the younger the child, the less likely the child can understand the implications of their decision and be considered Gillick-competent.
Although some adolescents are mature enough to consent to anesthesia and surgery, it is wise to obtain the parent’s consent in most perioperative situations.
In certain life-threatening circumstances, society allows the wishes of a child or the parents to be overridden. This is firstly because a child is unlikely to competently rationalize life and death decisions, especially when they are so easily influenced by authority figures. Secondly, society is unwilling to allow any person to make life and death decisions for someone else, including one’s own child. Hence laws make it possible in an emergency to override the wishes of a person aged less than 18 years. The exact legal mechanisms for this vary between jurisdictions, and the involvement of the hospital’s medical administrator is usual. These emergency provisions only apply if the procedure is critical and life-saving—a blood transfusion in severe hypovolemic shock may be permitted, but not force feeding an anorexic child who is not critically ill. As a practical matter, it is best to negotiate a compromise before proceeding to the courts for permission. Consent to treatment is more likely to be given when the child’s and parent’s wishes and concerns are considered.
Fortunately for pediatric anesthetists, consent issues are usually resolved by the time a child presents for surgery. However, consent issues for anesthetists may arise at the time of induction—is it reasonable to proceed when the child withdraws their hand from the IV cannula, or pushes away the facemask? Children older than about 8–10 years who are developmentally normal probably should not be restrained. Fear is often a large part of the child’s refusal, and this can be allayed with discussion, parental involvement, involvement of play therapists in children having many anesthetics, and pharmacological premedication if agreed. Younger children are probably not able to understand the importance of their treatment and it may be reasonable to restrain the child and proceed if other strategies fail. Supervising the parent to help restrain a younger child can help parents to accept this course of action. Although restraining a 2 or 3 year old child is straightforward and not uncommon, restraining a young school-aged child is unpleasant for the child, parent and staff, and should be avoided as much as possible by paying attention to the behavioral management aspects of the child. The age beyond which restraint is not reasonable depends on many surgical, patient, practical, societal and reality factors. A great deal of judgement is involved from case to case. Sometimes during induction, a decision must be made quickly to take one path or another before the child’s cooperation deteriorates further.
1.4.1 Blood Transfusion in a Jehovah’s Witness Child
A blood transfusion critical to survival of the child (usually as determined by more than one doctor) can be given legally without the consent of the parents. In fact, doctors have a legal obligation not to allow a child to die by withholding treatment. In the elective situation, children older than 14–16 years may be able to refuse a transfusion themselves, but the legality of this would need to be determined before proceeding with surgery.
When a child’s parents refuse permission for a blood transfusion, they are usually only trying to do what is best for their child. Indeed, anesthetists should be trying to minimize blood transfusion in every child-there are many risks of transfusion, and children have a long life ahead for these risks to become apparent.
Confrontation over this issue can be minimized by listening to the parents, telling them all the things that you will do to try and avoid blood products, and telling them that you are legally obliged not to let their child die. There is no need to force parents to explicitly agree with this plan and thus refute their own beliefs. There is also little to be gained from a confrontation with parents who are under stress about their child’s anesthesia and surgery when the likelihood of transfusion is extremely low. As medical providers, the legal obligation is straightforward and most parents are aware of this. Ongoing argument serves only to put parents and sometimes the child under further stress.
1.5 Intravenous Access
A short 24G or 22G cannula in the dorsum of the hand is the commonest method of securing IV access in children. The finer 24G cannula may be more difficult to insert, but it is less likely to be felt by the child. The lack of feeling may allow a second attempt to insert the IV if the first attempt failed. The 24G cannula is the usual size for neonates and small infants, but in older children it tends to kink when the child moves post op.