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Pediatric Anesthesia

Pediatric
Anesthesia
Practice Recommendations
Task Force on
Pediatric Anesthesia of
the ASA Committee on
Pediatric Anesthesia
INTRODUCTION
Optimal perioperative care of infants and children
requires proximate availability of qualified medical
personnel and contemporary equipment designed
specifically for this purpose. Local and regional circum-
stances may differ with respect to the immediate availability
of specialized personnel and access to facilities. With due
consideration of the practical necessities of safe, convenient
and facilitative medical care, the Task Force on Pediatric
Anesthesia offers the following recommendations by which
the medical staff of each patient-care facility may determine
explicit credentialing criteria within the bounds of applica-
ble state regulations. They are intended to address the pro-
vision of elective anesthesia services for infants and children
in all patient-care facilities. Anesthesia care required under
emergency circumstances may preclude their explicit appli-
cation and use.
These recommendations are proposed in response to
requests by anesthesiologists for assistance in establishing
institutional standards and criteria that will enhance their
ability to provide anesthesia care to infants and children.
They are suggested based on the experience of the members
of the task force and an earlier document addressing this
subject (Hackel A, Badgwell JM, Binding RR, et al.
Guidelines for the pediatric perioperative anesthesia environ-
ment. American Academy of Pediatrics. Section on
Anesthesiology. Pediatrics. 1999; 103(2):512-515.)
PATIENT CARE FACILITY AND
MEDICAL STAFF POLICIES
Categorization of Operative Procedures and
Pediatric Surgical Patients
In consideration of the special clinical needs of pediatric
surgical patients, patient-care facilities are advised to
authorize written policies for the purpose of designating
and categorizing the types of pediatric operative, diagnostic
and therapeutic procedures requiring anesthesia on elective
and emergent bases. These categories are intended to iden-
tify pediatric patients at increased anesthesia risk. In consul-
tation with its clinical administration, the medical staff of
each patient-care facility is advised to stipulate the minimum
level of ongoing clinical experience required in each catego-
ry in order for the facility to maintain clinical competence in
its performance. Categories may be evaluated to determine
whether anesthesiologists providing or directly supervising
anesthetic care for patients in a specific category may
require special clinical privileges. Examples of relevant cri-
teria include patient age, patients with special anesthesia
risks based on coexisting medical conditions and high-risk
surgical procedures.
Annual Minimum Case Volume for Anesthesiologists to Maintain
Clinical Competence
The medical staff of individual patient-care facilities
should determine criteria for anesthetic care for pediatric
patients. Anesthesia for pediatric patients may be provided
and/or directly and immediately supervised by an anesthesi-
ologist with clinical privileges as noted below. Unless super-
seded by state regulation, the annual minimum case volume
required to maintain clinical competence in each patient
care category should be determined by the facility’s depart-
ment of anesthesiology, subject to approval by the facility’s
medical staff and governing board.
CLINICAL PRIVILEGES FOR
ANESTHESIOLOGISTS
Regular Clinical Privileges
Anesthesiologists providing and/or directly supervising
clinical care for pediatric patients should be gradu-
ates of anesthesiology residency training programs
accredited by the Accreditation Council for Graduate
Medical Education (ACGME) or its equivalent, should be
board-certified or board-eligible and should have docu-
mented continuous competence in the care of patients in
specified categories in order to maintain those clinical priv-
ileges.
Special Clinical Privileges
In addition to the requirements noted above, it is sug-
gested that anesthesiologists providing and/or directly
supervising the anesthetic care of patients in the categories
designated by the facility’s department of anesthesiology as
being at increased risk for anesthetic complications (thus
requiring special clinical privileges) should be graduates of
pediatric anesthesiology fellowship training programs
accredited by ACGME or its equivalent or should be fully
credentialed members of the department of anesthesiology
who have demonstrated continuous competence in the
care of such patients as determined by the department of
anesthesiology.
New or Renewed Privileges
Clinical privileges may be applied for or renewed in the
manner determined by the facility’s bylaws in compliance
with applicable state regulations. In this framework, granting
special clinical privileges should be in a manner determined
by the facility’s department of anesthesiology and approved
by the facility’s applicable credentialing committee and
should include a period of preceptorship for new applicants
or clinical review for renewal applicants.
Pain Management
Each facility should establish policies for effective pedi-
atric pain treatment in the perioperative environment,
which should be based on the prevailing standard of care
and reviewed on a regular basis by the department of anes-
thesiology or other multidisciplinary body designated by the
medical staff.
PATIENT CARE UNITS
Preoperative Evaluation and Preparation Units
In order to offer privacy and a comforting environment, a
preoperative unit or a specialized area within a general
preoperative unit should be provided in order to accom-
modate pediatric patients and their families. This special-
ized area should have age- and size-appropriate equipment
required for the preoperative evaluation and preparation of
infants and children.
Operating Room
•
Anesthesiologists
In order to apply specific expertise in the provision of
pediatric anesthesia services, an anesthesiologist with
pediatric anesthesia experience and regular or special
clinical privileges (i.e., as noted above) may be assigned
formal responsibility for the organization of the pediatric
anesthesia services.
•
Pediatric Anesthesia Equipment and Drugs
In order to provide proximate availability of specialized
pediatric equipment, a complete selection of such equip-
ment may be made available for clinical application to the
pediatric patient. This equipment should be easily acces-
sible and regularly maintained under the direct supervi-
sion of the department of anesthesiology. In order to
prepare for unforeseen emergencies, a resuscitation cart
with equipment appropriate for pediatric patients of all
ages, including pediatric defibrillator paddles, should be
immediately available in all facilities providing pediatric
care. Vasoactive resuscitative drugs and dantrolene sodi-
um should be immediately available in appropriate pedi-
atric concentrations. A written pediatric dose schedule for
these drugs also should be immediately available.
Other requisite items for routine pediatric anesthetics
include:
• Airway equipment for all ages of pediatric patients,
including ventilation masks, laryngeal mask airways,
endotracheal tubes, oral and nasopharyngeal airways,
and laryngoscopes with pediatric blades
• Positive-pressure ventilation systems appropriate for
infants and children
• Devices for the maintenance of normothermia (e.g.,
warming lamps, circulating warm-air devices, room ther-
mal regulation capability, airway humidifiers and fluid-
warming devices)
• Intravenous fluid administration equipment, including
pediatric volumetric fluid administration devices,
intravascular catheters in all pediatric sizes and devices
for intraosseous fluid administration
• Noninvasive monitoring equipment for the measure-
ment of blood pressure, pulse oximetry, capnography,
anesthetic gas concentrations, inhaled oxygen concentra-
tion, electrocardiography and temperature as per ASA
standards
• Specialized equipment for management of the difficult
pediatric airway by a variety of techniques for airway con-
trol, intubation and ventilation, including but not limit-
ed to fiberoptic bronchoscopy and emergency
cricothyrotomy
Additional items necessary for the care of high-risk pedi-
atric patients include:
• Equipment for invasive measurement of arterial and cen-
tral venous pressures
• Portable equipment for oxygenation, ventilation, moni-
toring and transport to the postanesthesia care unit
(PACU) or intensive care unit (ICU)
Postanesthesia Care Unit
•
Anesthesiologist/Physician Staff
In order to apply specific expertise in the provision of
pediatric anesthesia services, an anesthesiologist or other
physician trained and experienced in pediatric periopera-
tive care, including the management of postoperative
complications and the provision of pediatric cardiopul-
monary resuscitation, may be made immediately available
to evaluate and treat any child in distress. Pediatric
advanced life support or advanced pediatric life support
certification is recommended.
•
Pediatric Anesthesia Equipment and Drugs
In order to provide proximate availability of specialized
pediatric equipment, the pediatric anesthesia equipment
and drugs specified under the subtitle “Operating Room”
(above) should be available for patients in the PACU.
Every child admitted to the PACU should have his or her
vital signs monitored. Suction equipment and oxygen
should be available at each bedside. A respiratory oxygen
delivery system should be available for use in the trans-
port of infants and children from the operating room to
the PACU and/or ICU, when medically indicated.
Intensive Care Unit
In order to apply specialized expertise in the postopera-
tive recovery of nonroutine pediatric patients, facilities in
which operative procedures are performed that require
postoperative intensive care should have an ICU (neona-
tal/pediatric) appropriate for the age of the patient. The
ICU should be designed, equipped and staffed to meet state
and federal standards for the care of critically ill neonates,
infants and children. An exception to this recommendation
may be applied in the case of an operative procedure
required under acute circumstances involving a life-threat-
ening emergency.
Patient-care facilities (including ambulatory surgical cen-
ters) that perform operative procedures for which postopera-
tive intensive care is not anticipated may develop a proactive,
clearly delineated plan (i.e., a “transfer agreement”) to trans-
fer children to an appropriate hospital facility when compli-
cations requiring inpatient monitoring/care occur. In some
states, specific requirements regarding applicability and con-
tent of transfer agreements may be stipulated by regulation
and/or law.
Clinical Laboratory and Radiology Services/Availability and
Capabilities
Clinical laboratory and radiology services should be con-
temporaneously available when pediatric patients are receiv-
ing care at the facility. The clinical laboratory should have
the capability to provide hematologic and chemical analyses
on small samples.
Task Force on Pediatric Anesthesia of the ASA
Committee on Pediatric Anesthesia
Alvin Hackel, M.D.
Stanford, California
Co-chair
Joseph F. Cassady, Jr., M.D.
Ponte Vedra Beach, Florida
Co-chair
Randall M. Clark, M.D.
Denver, Colorado
George A. Gregory, M.D.
San Francisco, California
Zeev N. Kain, M.D.
New Haven, Connecticut
Ronald S. Litman, D.O.
Philadelphia, Pennsylvania
Joel A. Saltzman, M.D.
Las Vegas, Nevada
Mark A. Singleton, M.D.
San Jose, California
Carolyn F. Bannister, M.D.
Atlanta, Georgia
ad hoc
This document has been developed by the ASA Task Force on
Pediatric Anesthesia, but has not been reviewed or approved as a
practice parameter or policy statement by the ASA House of
Delegates. Variances from the recommendations contained in this
document may be acceptable based on the judgment of the
responsible anesthesiologist. The recommendations are designed
to encourage quality patient care and safety in the workplace but
cannot guarantee a specific outcome. They are subject to revision
from time to time as warranted by the evolution of technology and
practice.
Copyright © 2002 by the American Society of Anesthesiologists.
All rights reserved.
2001-02 American Society of Anesthesiologists
Committee on Pediatric Anesthesia
Carolyn F. Bannister, M.D.
Atlanta, Georgia
Chair
Joseph F. Cassady, Jr., M.D.
Ponte Vedra Beach, Florida
Co-chair
Lawrence S. Berman, M.D.
Gainesville, Florida
Wendy B. Binstock, M.D.
Chicago, Illinois
Keith K. Brosius, M.D.
Atlanta, Georgia
Edgar D. Canada, M.D.
San Diego, California
Randall M. Clark, M.D.
Denver, Colorado
William J. Greeley, M.D.
Philadelphia, Pennsylvania
George A. Gregory, M.D.
San Francisco, California
Steven C. Hall, M.D.
Evanston, Illinois
Raafat S. Hannallah, M.D.
Washington, D.C.
Zeev N. Kain, M.D.
New Haven, Connecticut
Ronald S. Litman, D.O.
Philadelphia, Pennsylvania
Lynda J. Means, M.D.
Indianapolis, Indiana
Joel A. Saltzman, M.D.
Las Vegas, Nevada
Anne M. Savarese, M.D.
Ashton, Maryland
Joseph D. Tobias, M.D.
Columbia, Missouri
50M207LC