February 2000
Volume 64 |
Number 2
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| Pediatric Anesthesia
in the Community Hospital |
Raafat S. Hannallah,
M.D., Chair
Committee on Pediatric Anesthesia
Last year the ASA Committee on Pediatric Anesthesia received
several requests from ASA members inquiring about a recent article
in Pediatrics written by members of the Section on Anesthesiology
of the American Academy of Pediatrics (AAP) titled "Guidelines
for Pediatric Perioperative Anesthesia Environment."1
Comments ranged from those who felt that the AAP guidelines may
be useful to anesthesiologists in smaller practice settings who
are pressured by hospital administrators to accept high-risk pediatric
and neonatal cases, to those who feared that this is an attempt
by the pediatric anesthesia community to restrict their practice
in community hospitals, even when they feel qualified and comfortable
doing so.
To address these concerns, the committee presented a panel titled
"Pediatric Anesthesia in the Community Hospital" at the ASA Annual
Meeting last October in Dallas, Texas. The topics included a discussion
of pediatric perioperative anesthesia environment (by Steven C.
Hall, M.D.), management of healthy ambulatory patients (by Raafat
S. Hannallah, M.D.), pediatric and neonatal emergencies (by George
A. Gregory, M.D.) and pediatric pain management (by Julia C. Finkel,
M.D.) A summary of the proceedings is presented here.
Pediatric Perioperative Anesthesia Environment
This term describes elements necessary for providing anesthetic
services in a safe and effective manner to children of different
ages undergoing a variety of procedures. There are several sources
of guidance for evaluating the ability of an institution and its
staff to care for children, including local and state regulations,
Joint Commission on Accreditation of Healthcare Organizations
requirements, Advanced Pediatric Life Support guidelines and ASA's
standards and guidelines for perioperative care. The recent policy
statement by the AAP Section on Anesthesiology1 details
many of the facility-based issues that should be addressed to
promote safe care of children. Important components can be divided
into two broad areas: medical staff and patient-care facility
policies.
Medical Staff Policy Issues -- Written staff policies
should determine a physician's scope of practice. An institution-written
policy should delineate the types and minimal annual volume of
pediatric operative, diagnostic and therapeutic procedures requiring
anesthesia that are suitable and should define the clinical privileges
for those providing anesthesia care. In addition, the facility's
anesthesiology department should designate which categories of
pediatric patients are at increased anesthesia risk. Patient age,
physical status and proposed procedures are all elements that
should be addressed in these policies.
The AAP guidelines state that anesthesiologists should provide
care or directly supervise care. In addition, anesthesiologists
caring for high-risk patients (e.g., the very young) should have
had additional training (fellowship) or have documented demonstrated
historical and continuous competence in the care of such patients.
These elements should be the basis of specific institutional credentialing.
Facility Issues -- A wide variety of facility issues should
be addressed, including having a separate pediatric preoperative
unit or area; adequate laboratory and radiological services; and
a full selection of applicable pediatric airway, resuscitation,
monitoring, vascular access, temperature maintenance and ventilation
equipment for both the operative and postoperative care areas.
There should be facility policies addressing pediatric pain
management, nursing and technical personnel training and experience,
postanesthesia care, postoperative intensive care and transfer
of patients to other facilities. The role of anesthesiologists
in leadership and management of these issues should be clearly
delineated. In addition, an ongoing program of quality-of-care
evaluation should be used as a basis of re-evaluating both policies
and privileges. Published guidelines should be used as the basis
for individual institutions and medical staff policies, procedures
and credentialing activities.
The Ambulatory Patient
Ambulatory surgery represents the majority of pediatric procedures
performed in community hospitals, usually on healthy children
who are scheduled for brief, superficial surgical procedures.
Specific selection criteria detailing such issues as minimum acceptable
age, physical status, type of surgical procedure, etc., must be
established. These criteria should be reviewed and updated regularly
and communicated to the surgeons and other members of the perioperative
team. Most procedures performed in community hospitals are hernia/hydrocele
repairs, eye muscle surgery, circumcision and myringotomies with
or without adenoidectomies. Although many surgeons are comfortable
performing adenotonsillectomies on an ambulatory basis, special
attention must be given to children under age three who are scheduled
for relief of obstructive symptoms. Overnight monitoring and observation
are essential for patient safety.
Preoperative screening is essential to ensure compliance with
instructions and also to ensure the absence of previously unidentified
medical conditions or new symptoms such as upper respiratory tract
infection. While many institutions have established screening
clinics, others have relied on a telephone screening approach
for all children, thus requiring a visit only for those who have
a specific need for further evaluation.
Preoperative fasting guidelines allow normal children to drink
clear liquids up to two hours before the scheduled time of surgery.2
Breast-fed infants can feed until four hours preoperatively. Older
children may consume formula or milk up to six hours before surgery.
These guidelines make children less thirsty and minimize the possibilities
of hypovolemia and/or hypoglycemia that can result from fasting.
Routine preoperative laboratory testing is no longer recommended
in the absence of a definite medical indication.
Oral midazolam syrup is used for preoperative sedation of ambulatory
patients without prolonging emergence or delaying recovery and
discharge times. Sevoflurane has improved the speed and ease of
inhalational induction in children. Desflurane is associated with
the fastest emergence, but should not be used for induction of
anesthesia due to its propensity to cause laryngospasm and coughing.
These two agents, however, frequently need supplementation with
an opioid to reduce the emergence agitation that is frequently
associated with rapid emergence.
Adequate pain relief and prevention of postoperative vomiting
are imperative in pediatric ambulatory surgery. Children should
not be required to drink and retain oral fluids as a condition
for discharge from the facility.
Specific recovery and discharge criteria are essential to ensure
the safety of children when they leave the facility, and they
also provide a legal record that safe discharge criteria were
met.
Pediatric and Neonatal Emergencies
A pediatric or neonatal emergency can arrive at any hospital,
and the staff must accept and deal with the problem. This challenges
remote community hospitals since up to 80 percent of these hospitals
perform less than 50 pediatric cases per year. Consequently, they
must remain proficient in managing such cases. The availability
of telephone consultation from a colleague or an established authority
(similar to the Malignant Hyperthermia hotline) has been suggested
as a way to guide the individual practitioner in the management
of these patients.
Following emergency surgery, it may be necessary to transfer
the child to a facility with a pediatric critical care unit. Arrangement
for transportation of the patient must therefore be made early
during surgery to avoid delays. Postoperative pain relief in children
is also essential.
Pediatric Pain Management
Pediatric perioperative pain management needs to be adapted
to the types of surgical procedures, the individual variations
in pain perception and the analgesic options available. These
options need to be assessed for safety (monitoring, nursing and
physician coverage), side effects and recovery profile. An outline
of some of the most effective interventions and techniques that
may be applied to commonly performed pediatric procedures follows:
Bilateral myringotomies with tubes (BMT): This procedure
is typically performed in infants and small children using a volatile
anesthetic and mask technique without an I.V., thus necessitating
the administration of analgesics by non-I.V. routes. Currently
oral or rectal acetaminophen and nasally administered fentanyl
are the most commonly used methods of reducing pain.
Adenotonsillectomy (T&A): Tonsillectomy with or without
adenoidectomy is often a challenging pain management problem.
Because of the potential of postoperative airway obstruction in
these patients, many opioid-sparing analgesic techniques have
been investigated. The use of acetaminophen (40 mg/kg PR) is preferred.
Dexamethasone (0.5-1mg/kg, IV-up to 25 mg) can be added for children
to minimize tissue injury, edema and pain. Peritonsillar infiltration,
with a combination of bupivacaine and epinephrine, reduces bleeding
but has no impact on opioid requirements. Tramadol hydrochloride,
an agonist at the mu-opioid receptor and a weak inhibitor of norepinephrine
and serotonin uptake, has significantly less potential for inducing
vomiting than opioids. It causes minimal or no respiratory depression.
Herniotomy, Hydrocelectomy and Orchidopexy: Single-shot
caudal epidural anesthesia is ideal for procedures performed below
T10 and is the single most useful regional block in children.
The block is placed after induction of general anesthesia and
generally obviates the need for opioid analgesics. It also allows
the use of lower concentrations of volatile anesthetics, which
permits earlier recovery of airway reflexes and faster emergence
from anesthesia. Alternatively, ilioinguinal and iliohypogastric
nerve blocks can be performed, usually by the surgeon, before
or after skin incision.
References:
1. American Academy of Pediatrics Section on Anesthesiology.
Guidelines for the pediatric perioperative anesthesia environment.
Pediatrics. 1999; 103:512-515.
2. Practice guidelines for preoperative fasting and the use
of pharmacologic agents to reduce the risk of pulmonary aspiration:
Application to healthy patients undergoing elective procedures.
Anesthesiology. 1999; 90:896-905.
Raafat S. Hannallah, M.D., is Professor
of Anesthesiology and Pediatrics, George Washington University
Medical Center, and Chair of Anesthesiology, Children's National
Medical Center, Washington, D.C.
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