The regulation of pediatric anesthesia

This information comes from the SFAR pediatrics RPP 2023 and the SROS circular for children and adolescents (October 28, 2004):

A care pathway specifically dedicated to children

Surgical and psychological safety in children

- A dual approach to safety: It is essential to establish a care pathway that ensures not only technical safety during the operation, but also the child's psychological well-being, taking into account the specificities of his or her state of health. This requires appropriate pre-operative preparation, clear protocols and comprehensive care from the moment the child is admitted to the hospital, right through to post-operative follow-up.

- Regional agreements and protocols: The implementation of operating agreements and charters, validated by the ARS and integrated into a regional network (SROS de l'enfant et de l'adolescent), makes it possible to define precisely which activities can be carried out in the local center and which require transfer to a specialized center.

The organization and training of the anesthesia team

Skills and consistency of practice in children

- Required volume of activity: To be considered "regular" in pediatrics, the anesthetist must practice at least half a day a week in pediatric anesthesia, with an annual volume of around 200 anesthesias for practitioners with less than 10 years' experience.

- Continuing education and simulation: Individual training (CPD) and simulation sessions are highly recommended to master specific procedures, such as induction in children over 3 years of age and stabilization in the event of a dechoquage. These courses help to update knowledge and prepare the team for critical situations.

Distribution of roles and reinforcements during critical phases

- Critical phases identified in pediatric anesthesia-intensive care: Induction, intubation, insertion of venous lines (VVP) and recovery are particularly sensitive. It is therefore recommended that these phases be carried out by two professionals, with a dedicated anesthesiologist (MAR) and an identified back-up to provide immediate support if necessary.

- Team architecture in pediatric intensive care: Safety is enhanced by the presence of a dedicated MAR in the room and a second MAR during critical phases. This organization is based on a precise division of roles and on the team's ability to mobilize rapidly in the event of unforeseen circumstances.

Post-operative organization in the recovery room (PACU) for pediatric anesthesia

Adaptation of space and teams

- Recovery room for children: The SSPI must be designed to meet the specific needs of children, with an adapted number of places (1.5 to 2 stations per operating room).

- Workload and staff training: ICU nurses are subject to an increased workload in pediatrics. It is therefore essential that staff are specifically trained to recognize and intervene rapidly in the event of vital distress. Early warning protocols need to be introduced, or a dedicated position (IADE SSPI) created in centers with significant pediatric activity.

Regional coordination and role of the SROS

Integration into a structured network

- Defining local vs. referred skills: The circular of October 28, 2004 stresses the importance of collective reflection to define what can be performed in a local center and what needs to be transferred to a specialized center. This distribution ensures that each facility knows its limits, and works within a pre-established framework with the regional SROS network for anesthesia consultation.

- ARS validation: The agreement between the local center and the regional SROS center (level 2) is validated by the ARS, ensuring consistent practices and a high level of safety for pediatric patients.

Management of specific cases: the example of revision tonsillectomy

Specificities of tonsillectomy management

- High-risk situation: Tonsillectomy revision is a good illustration of the need to adapt the organization to specific clinical circumstances. A child with "blood in the mouth" requires extra vigilance.

- On-call schedules and organization :

o   Working hours: For scheduled interventions during the day (until 5:00 p.m.), the simultaneous presence of two anesthesiologists (either 2 MDAs, or a combination of Nurse Anesthetist + MDA) and the mandatory presence of the ENT specialist in the operating room is imperative.

o   Critical periods (weekends, public holidays, night): In these contexts, the organization must be adapted with an on-call system (1 MDA on call) supplemented by an emergency physician, while noting that the paramedical presence may be reduced outside of working hours.

- Risk prevention: The recommendation stresses the importance of clarifying the situation before the end of the day, to avoid any ambiguity about the management of a patient presenting warning signs (e.g. blood in the mouth) after 5pm, when the OR can be closed.

Conclusion

To summarize, pediatric anesthesia requires a comprehensive and multidisciplinary approach:

- Dedicated care pathway integrating both surgical safety and psychological support.

- Rigorous organization of the anesthesia team, with precise requirements in terms of volume of activity, ongoing training and distribution of roles during critical phases.

- Adaptation of post-operative monitoring structures to meet specific pediatric needs.

- Regional coordination via the SROS for optimized care, validated by the ARS, and adapted management of complex cases, particularly in special situations such as tonsillectomy revision.

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

In practice, what does the care pathway of a child hospitalized for surgery look like, taking into account the specificities related to pediatric anesthesia and resuscitation?

1.        Preoperative consultation and preparation
Before the procedure, it is recommended to organize a consultation several days in advance (minimum 48 hours) in the presence of the child. This allows to explain the fasting protocol (6 hours for solids, 4 hours for breast milk, 1 hour for water) as well as the methods of anesthesia 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, integrating the practice of pediatric anesthesia.

2.        Adapted anesthetic induction
Induction is often performed by inhalation with sevoflurane. Starting at 6% allows for rapid induction, followed by an adjustment to maintenance around 1.5 MAC (approximately 3.25% sevoflurane) to avoid prolonged high 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 may 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 risk of intravascular injection.

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

5. Optimization of respiratory status
For children with bronchial hyperreactivity, maintenance therapy (long-acting B2 mimetics, possibly combined with inhaled corticosteroids a few days before surgery) may be implemented. In addition, in case of acute symptoms, 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, emphasizing preoperative preparation, induction, pain management, and optimization of respiratory conditions.

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