Overview of Pediatric Anesthesia

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© Springer Nature Switzerland AG 2020
Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric Anesthesiadoi.org/10.1007/978-3-030-19246-4_1



1. An Overview of Pediatric Anesthesia



Craig Sims1   and Tanya Farrell1  


(1)
Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia

 



 

Craig Sims (Corresponding author)



 

Tanya Farrell



Keywords

Safety 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.


Morbidity is common with anesthesia in children. More than half of critical incidents are respiratory incidents and are mostly airway related such as laryngospasm, bronchospasm, hypoxia, and hypoventilation. The risk increases with decreasing age, because of smaller airway diameter and a predisposition to develop apnea and airway obstruction from airway irritation (Fig. 1.1). Infants and young children also desaturate rapidly. Children 3 years and younger have a higher risk than older children. Infants are particularly at risk, with critical incidents four times more likely compared to older children. Surveys show critical incidents (again most commonly respiratory) occurring in 3–5% of infants. Risk is also increased by underlying pathology including congenital disease, the urgency of the procedure, and the hospital setting (Table 1.1).

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Fig. 1.1

The incidence of critical respiratory events (those requiring immediate intervention and that led (or could have led) to major disability or death) during anesthesia in children of different age groups. Based on data from APRICOT study, Lancet Respir Med 2017; 5:412–25




Table 1.1

Patient, surgical and anesthetist factors that may increase the risk of anesthesia in children






































Factors increasing risk of morbidity and mortality

 

High risk


Medium risk


Low risk


Age


Neonates, infants


1–3 years


>3 years


ASA status


3–5


2 (includes recent URTI)


1


Surgery


Cardiothoracic, neurosurgery, scoliosis surgery


Airway and dental surgery


Peripheral, minor surgery


Emergency surgery


Increases risk


Experience of the anaesthetist


Increased risk with small case load of children of similar age to patient



Keypoint


Most critical incidents are respiratory and airway related. Proficiency in airway management is the cornerstone of safe pediatric anesthesia practice.


The risk of morbidity is lower if the anesthetist is experienced and has a large pediatric case load (Table 1.2). Although there are no formal requirements for anesthetists caring for children, it is generally agreed that practitioners anesthetizing children aged 3 years and less should regularly anesthetize this age group, and anesthetists caring for children aged less than 1 year should regularly anesthetize infants. Neonatal anesthesia should be performed by those who have a fellowship in pediatric anesthesia.


Table 1.2

The pediatric caseload of the anesthetist affects the rate of complications




















Number of anesthetics given per year


Complications


1–100 children


7/1000


100–200 children


2.8/1000


More than 200 children


1.3/1000



Based on Auroy and Ecoffey, Anesth Analg 1997



Keypoint


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


If you are anesthetizing a child in a non-pediatric hospital it is important to make sure it is safe to do so. Several factors determine if a child can be safely cared for at a particular facility. Broadly, there are factors relating to the patient and the type of surgery planned (Table 1.3), and factors relating to the hospital such as the level of staffing, equipment and facilities (Table 1.4). An older child undergoing day stay surgery has different health facility requirements compared with an infant with coexisting medical problems requiring overnight admission after surgery.


Table 1.3

Patient factors to consider in determining level of staff and facilities needed to safely care for children



















Patient factor


Age of child, esp. if <12 months


Type of surgery


ASA status/General health of the child


Overnight admission


Emergency procedure




Table 1.4

Summary of requirements to safely anesthetize children (based on ANZCA PS29 and RCOA guidelines)






















Organization of services


Staff


Experience and case load to maintain competency in relevant ages and case mix of:


 anesthetist


 assistant


 recovery


 ward nurses


Equipment


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


Facilities


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


Governance


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


As in adults, assessment of children before anesthesia includes a history and examination, aiming to assess previous anesthetic problems and the severity of co-existing diseases. It is also an opportunity to establish rapport with the child and parents, assess the child’s behavior and reassure the parents with your manner and professionalism. Most children are healthy and active, although there is always the possibility of an unrecognized abnormality or syndrome. Some children have dysmorphic features suggesting an underlying syndrome (Table 1.5). If a child has one congenital malformation it is more likely that there will be another. Common conditions to specifically ask about include preterm delivery, recent upper respiratory tract infection, obstructive sleep disorder, developmental concerns and bleeding disorders.


Table 1.5

Facial dysmorphic features that may indicate a congenital syndrome





















Dysmorphic feature


Widely spaced eyes (hypertelorism)


Beaked or other nose abnormality


Low hairline on forehead


Low slung or malformed ears


Craniosynostosis


Microcephaly


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.


1.4 Consent


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.



Keypoint


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.


1.5.1 Positioning of the Awake Child for IV Access


Tapes and equipment should be prepared before inserting the cannula to facilitate quick fixation, as the child may move and dislodge the cannula. If the child lies on the bed, blankets can be placed to hide their hand and restrict movement. Younger children can also sit across the parent’s lap, with the child’s arm brought under the parent’s arm (Fig. 1.2). This position hides the hand from the view of the child and parent and helps to keep the hand still by placing the child at a mechanical disadvantage.

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Fig. 1.2

Positioning the clingy or uncooperative toddler for insertion of an IV. All equipment, including tape, is prepared beforehand. The child sits sideways across the seated parent’s lap and is distracted with stickers or a toy. The parent’s arm hugs the child’s back and the child’s arm is brought under the parent’s arm. An assistant stabilizes the child’s arm and squeezes it as a tourniquet. The anesthetist holds the child’s hand and stabilizes it for insertion of the cannula


1.5.2 Assistance


A good assistant is vital to maximize the chances of successful venipuncture. Just using a tourniquet for a young child is unlikely to work. It is important that the assistant holds the child’s hand and arm correctly, aiming to distend the veins and prevent withdrawal of the child’s hand. The assistant needs to hold the forearm tight enough to act as a tourniquet, but not so tight that the hand turns white from arterial compression. The assistant also gently retracts the child’s skin up the limb, which helps to fix the vein. The assistant’s other hand can be placed across the child’s elbow joint, which helps prevent sudden limb movement if the child feels the needle (Fig. 1.3). The anesthetist can stabilize their own arm by resting their elbow on something to compensate for sudden movements by the child.

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