Regulations for Pediatric Anesthesia

This information is taken from the SFAR Pediatrics 2023 Guidelines and the SROS Circular for Children and Adolescents (October 28, 2004):

A Care Pathway Specifically Dedicated to Children

Surgical and Psychological Safety in Children

·      Dual Approach to Safety: It is essential to establish a care pathway that ensures not only technical safety during the procedure, but also the psychological well-being of the child, taking into account the specificities of their health condition. This involves appropriate preoperative preparation, clear protocols, and comprehensive care from admission to postoperative follow-up.

·      Regional Agreements and Protocols: The implementation of agreements and operating charters, validated by the Regional Health Agency (ARS) and integrated into a regional network (SROS for children and adolescents), allows for the precise definition of activities that can be carried out in the local center and those requiring transfer to a specialized center.

Organization and Training of the Anesthesia Team

Skills and Regularity of Practice in Children

·     Required Activity Volume: To be considered "regular" in pediatrics, an anesthesiologist must practice at least half a day per week in pediatric anesthesia, with an annual volume of approximately 200 anesthetics for practitioners with less than 10 years of experience.

· ♥ ♥ ♥ Continuing Education and Simulation: Individual continuing professional development (CPD) and simulation sessions are strongly recommended to master specific procedures, such as induction in a child over 3 years old and stabilization in case of resuscitation. This training allows for updating knowledge and preparing the team for critical situations.

Role Distribution and Support During Critical Phases

· ♥ ♥ Critical phases identified in pediatric anesthesia and intensive care: The induction, intubation, IV placement, and awakening phases are particularly sensitive. It is therefore recommended that these phases be carried out by two professionals, with a dedicated anesthesiologist-intensivist (AIN) and an identified backup to provide immediate support if needed.

· Team structure in pediatric intensive care: The presence of an AIN dedicated to the operating room and a second responder during critical phases enhances safety. This organization relies on a precise distribution of roles and the team's ability to mobilize quickly in case of unforeseen events.

Post-operative organization in the post-anesthesia care unit (PACU) For pediatric anesthesia

Adapting space and teams

·      Recovery room dedicated to children: The PACU must be designed to meet the specific needs of children, with an appropriate number of beds (1.5 to 2 beds per operating room).

·      Workload and staff training: PACU nurses are subject to an increased workload in pediatrics. It is therefore essential that staff be specifically trained to recognize and intervene quickly in cases of life-threatening distress. Early warning protocols must be established, or even the creation of a dedicated position (PACU Nurse Anesthetist) in centers with significant pediatric activity.

Regional Coordination and the Role of the Regional Healthcare Organization Scheme

Integration into a Structured Network

·      Definition of Local vs. Referred Skills: The circular of October 28, 2004, emphasizes the importance of collective reflection to define what can be done in a local center and what requires transfer to a specialized center. This distribution ensures that each establishment knows its limitations and collaborates within a pre-established framework with the regional healthcare organization scheme for anesthesia consultations.

·     ♦ Validation by the Regional Health Agency (ARS): The agreement between the local center and the regional SROS center (level 2) is validated by the ARS, thus ensuring consistency of practices and a high level of safety for pediatric patients.

Management of specific cases: the example of a tonsillectomy revision

Specifics of tonsillectomy management

· ♦ ♦ High-risk situation: A tonsillectomy revision clearly illustrates the need to adapt the organization to specific clinical characteristics. A child presenting with "blood in the mouth" requires increased vigilance.

· ♦ On-call schedule and organization:

o Working hours: For daytime procedures (until 5:00 PM), the simultaneous presence of two anesthesiologists is mandatory (either two anesthesiologists or a combination of nurse anesthetist and anesthesiologist) and the mandatory presence of an ENT specialist in the operating room.

o Critical periods (weekends, holidays, nights): In these situations, the organization must be adapted with an on-call system (one anesthesiologist on call) supplemented by an emergency physician, while noting that the paramedical presence may be reduced outside of working hours.

·     Risk Prevention: The recommendation emphasizes the importance of clarifying the situation before the end of the day to avoid any ambiguity regarding the management of a patient presenting with warning signs (e.g., blood in the mouth) after 5 p.m., when the operating room can be closed.

Conclusion

In summary, pediatric anesthesia requires a comprehensive and multidisciplinary approach:

• • ... Rigorous organization of the anesthesia team, with precise requirements in terms of workload, continuing education, and role allocation during critical phases.

· ♥ ♥ ♥ Adaptation of postoperative monitoring structures to meet pediatric specific needs.

· ♥ ♥ ♥ Regional coordination via the SROS for optimized care, validated by the ARS, and appropriate management of complex cases, particularly in specific situations such as repeat tonsillectomy.

These recommendations aim to strengthen the safety of care and ensure that every child benefits from an optimal care environment, both technically and humanly.

In practice, what is the care pathway for a child hospitalized for surgery, taking into account the specificities related to pediatric anesthesia and intensive care?

1. ♥ ♥ ♥ ♥ Consultation and preoperative preparation
Before the procedure, it is recommended to schedule a consultation several days in advance (minimum 48 hours) with the child present. This allows for an explanation of the fasting protocol (6 hours for solids, 4 hours for breast milk, 1 hour for water) as well as the anesthesia procedures and safety measures. Distraction techniques (for example, the use of iPads or games) and premedication with paracetamol and ibuprofen are offered to reduce preoperative anxiety, incorporating pediatric anesthesia practices.

2. ♥ ... A starting dose of 6% allows for rapid induction, followed by adjustment to a maintenance dose of around 1.5 MAC (approximately 3.25% sevoflurane) to avoid prolonged elevated Fe levels that could lead to hypocapnia and promote complications such as laryngospasm.

3. Pain Management and Regional Techniques
For procedures such as circumcision, regional anesthesia can be used, although general anesthesia is sometimes necessary. For example, infiltration of a local anesthetic (such as ropivacaine at 2 or 2.5 mg/ml, with a maximum dose of 0.4 ml/kg) is performed after an aspiration test to avoid the risks of intravascular injection.

4. ♂ ♂ ♂ ♂ Management of ENT Patients at Risk of Respiratory Complications
In the context of ENT surgery (such as adenoidectomy), the preoperative assessment emphasizes examination of respiratory status (auscultation, asthma screening, signs of upper respiratory tract infection). In the presence of risk factors (recent upper respiratory tract infection, fever above 38°C, wheezing on auscultation), rescheduling the procedure is considered to reduce the risk of complications such as laryngospasm and bronchospasm.

5. ♂ ♂ ♂ ♥ Optimizing Respiratory Status
For children with bronchial hyperreactivity, maintenance therapy (long-acting beta2 agonists, possibly combined with inhaled corticosteroids a few days before surgery) may be implemented. Additionally, in cases of acute symptoms, the administration of salbutamol (dosage adjusted according to weight: 2.5 mg for children under 20 kg and 5 mg for those over 20 kg) via aerosol helps stabilize respiratory status.

These examples illustrate some of the approaches to anesthetic management in pediatrics, both for surgical procedures such as circumcision and for ENT interventions, with an emphasis on preoperative preparation, induction, pain management, and optimization of respiratory conditions.

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