natomic and physiologic differences between children and adults make the administration of anesthesia different for these populations. Younger patients have increased perioperative anesthesia-related morbidity and mortality. Neonates are at higher risk than older infants, and older infants are at a greater risk than children older than two years of age. It appears that fewer complications occur when anesthesia is provided by anesthesiologists who have special knowledge and training and who have ongoing experience anesthetizing infants and children.

There are forces at work that are affecting how and where anesthesia will be delivered for pediatric patients. Organizations such as the American Academy of Pediatrics, ASA and the Society for Pediatric Anesthesia have emphasized the added responsibility of anesthesia care for infants and children. These organizations have recently published policy statements for the pediatric perioperative anesthesia environment, including the qualifications and competency required for anesthesiologists who administer anesthesia for routine and special cases.^1-3 The American Association for Accreditation of Ambulatory Surgical Facilities and the Accreditation Association for Ambulatory Health Care have included requirements for pediatric anesthesia care in their certification manuals.

These policy statements indicate that the medical board and department of anesthesiology of each hospital must determine whether or not they have the resources to provide the appropriate pediatric perioperative environment, and they must decide who will provide pediatric anesthesia and how to maintain the competency of the anesthesiologists who do so. Many community hospitals and anesthesiologists are concerned that they cannot meet these guidelines because they have insufficient pediatric patients for even one anesthesiologist to remain competent. The hospital and surgeons, however, often require them to do some pediatric cases if, for instance, there is no pediatric center within a reasonable distance.

In 2003, several adverse events in a hospital in Southern California were reported in the Los Angeles Times. Response to this report caused radical changes in the practice of the anesthesiology groups involved and prompted the California Society of Anesthesiologists House of Delegates to adopt a resolution based on the above-mentioned guidelines that put into place a standard of care for the anesthesiology community for pediatric anesthesia in California.⁴

Pediatricians, pediatric surgeons and parents are demanding that anesthesia for infants and children be done in facilities that provide care for large numbers of pediatric patients. Data from other areas of medicine support this demand and show that fewer complications arise the more often practitioners perform a procedure. The problem is that the number of trained pediatric anesthesiologists and pediatric facilities required to meet these demands are insufficient. Even pediatric hospitals and universities often struggle to find sufficient numbers of trained anesthesiologists to meet their needs. Without a concerted effort to increase the number of pediatric anesthesiologists and pediatric facilities, anesthesia for all pediatric patients cannot be performed in pediatric facilities. Consequently we need to provide other solutions to this problem.

By the end of the CA-3 year of residency, anesthesiologists are expected to be competent to provide safe perioperative anesthesia care for children undergoing routine surgical, diagnostic and therapeutic procedures. They also are expected to recognize when the clinical condition of the patient, or the proposed procedure, requires skills, facilities and/or support beyond the capability of the anesthesiologist and/or the institution. In these circumstances, the guidelines suggest that surgery and anesthesia be done in a pediatric facility. Anesthesiologists leaving residency also are expected to effectively resuscitate neonates, infants and children. Thus many pediatric cases can and should be done in community hospitals. The problem is to ensure that once an anesthesiologist graduates from an anesthesiology training program, he/she maintains her/his ability to safely provide anesthesia for routine surgical, diagnostic and therapeutic pediatric procedures. This may not be easy because in 70 percent of hospitals in Northern California, for instance, there are too few pediatric patients for even one anesthesiologist to maintain his/her skills. This being the case, how can we anesthesiologists solve this problem?

One solution might be to regionalize all pediatric anesthesiology care, as was done for pediatric and neonatal intensive care. There are, however, insufficient numbers of trained pediatric anesthesiologists and not enough pediatric facilities to do this. Some movement toward regionalization of anesthesiology care and surgery has already begun, though. Procedures that require anesthesia for neonates, young infants and for children who require complicated or life-threatening surgery are increasingly being sent to these centers, especially if the child requires preoperative or postoperative intensive care. Transferring these patients, however, can at times overwhelm pediatric centers. Even with these transfers, a large population of pediatric patients remains that must be cared for in community hospitals which have a small number of pediatric patients. How can the anesthesiology community make it possible for the anesthesiologists in these hospitals to maintain their skills so they can safely provide anesthesia care for infants and children undergoing routine surgery?

One way is to create a small group of anesthesiologists within a larger group of community anesthesiologists and have the smaller group provide all anesthesia care for children at increased risk in their hospital. The larger group must agree to limit the number of people providing pediatric anesthesia and stick to the agreement. Since someone must be available to anesthetize these patients 24 hours a day, seven days a week, one person cannot do all pediatric anesthesia alone. Consequently several anesthesiologists who are competent to provide anesthesia care for infants and children will be required. As stated above, this may be a problem because there often are too few pediatric patients in a given hospital to ensure that even one anesthesiologist remains competent.

Several community hospitals in an area could band together and have all of the pediatric surgery and anesthesia done in one hospital or, if that is not possible, at least have a small group of anesthesiologists from the several hospitals provide anesthesia care for these infants and children. This scenario would increase the number of patients available to help maintain the competency of the anesthesiologists and would assure adequate coverage of patients at all times of the day and night. For this to happen, a few barriers would need to be broken down. Hospitals and groups of anesthesiologists would need to work together, and CEOs would have to look beyond their own parochialism. Hospital boards and committees making staff appointments would have to readjust their thinking. Competition, at least for this population of patients, might have to be suspended.

Another solution would be to establish regional systems that allow anesthesiologists who work in community hospitals to work each year for a period of time in academic centers that have large pediatric populations. This would help community anesthesiologists with limited numbers of pediatric patients maintain their ability to safely anesthetize children by doing a specific number of anesthetics for pediatric patients under the supervision of a pediatric anesthesiologist. Having successfully done this, the anesthesiologist would be “certified” to provide anesthesia for routine surgical cases for children for another year. Who would pay for this? Who would pay the salary of the anesthesiologist while he/she is being certified? If the community hospital wishes to have pediatric surgery and meet the evolving guidelines, the hospital probably should pay. Would there be liability to the regional center doing the training? Training using simulators is part of many anesthesiology residencies, and simulators could be used to effectively maintain the competency of community anesthesiologists and could be a part of the time spent in a pediatric center. This, too, costs money and time. Again, who will pay for this?

Part of the solution must come from state anesthesiology societies. These societies can be of immense help in providing policy statements and continuing education, and they can apply appropriate pressure on hospitals through the guidelines generated. The California Society of Anesthesiologists has been a leader in this area. It has produced a policy statement that provides guidelines to practitioners, and these guidelines indicate what is required for a hospital to provide anesthesia for pediatric patients.⁴ All state societies should look at this document and make similar commitments to help their members.

The intent of the movement to organize pediatric care in the United States is not to ensure that all infants and children are anesthetized in pediatric centers, nor is it to say who can or cannot provide pediatric anesthesia. It is to improve the quality of anesthesia care for infants and children in all patient care facilities and to ensure that anesthesiologists who provide anesthesia for these patients remain competent to do so. The ideas outlined above also give the anesthesiologist backup when he/she does not feel it to be appropriate for a child to be anesthetized in a given hospital or outpatient facility.

References:

1. Section on Anesthesiology, American Academy of Pediatrics. Guidelines for the pediatric perioperative anesthesia environment. Pediatrics. 1999; 103 (2):512-515. <www.aap.org/policy/re9820.html>. Accessed on February 1, 2005.

2. American Society of Anesthesiologists Task Force of the Committee on Pediatric Anesthesia. Pediatric Anesthesia: Practice Recommendations, 2002. <www.ASAhq.org/clinical/PediatricAnesthesia.pdf>. Accessed on February 1, 2005.

3. Society for Pediatric Anesthesia. Policy Statement on Provision of Pediatric Anesthesia Care, 2004 <www.pedsanesthesia.org/policyprovision.html>. Accessed on February 1, 2005.

4. California Society of Anesthesiologists, 2003. CSA Policy on Pediatric Anesthesia. <csahq.org/pdf/prof/csapedpolicy.pdf>. Accessed on February 1, 2005.

Alvin Hackel, M.D., is Professor of Anesthesia and Pediatrics, Emeritus (Active), Stanford School of Medicine, and Attending Physician, Stanford University Hospital and Lucile Packard Children’s Hospital, Stanford, California.

George A. Gregory, M.D., is Professor Emeritus of Anesthesiology and Pediatrics, University of California School of Medicine, San Francisco, California.