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 Designed for 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 child’s psychological well-being, taking into account the specific characteristics of their health condition. This involves appropriate preoperative preparation, clear protocols, and comprehensive care from admission through postoperative follow-up.

· Regional Agreements and Protocols: The implementation of agreements and operating charters, approved by the Regional Health Agency (ARS) and integrated into a regional network (SROS for children and adolescents), enables the precise definition of which services can be provided at the local center and which require referral to a specialized center.

Organization and Training of the Anesthesia Team

Skills and Consistency of Practice in Children

· Required Activity Volume: To be considered "regular" in pediatrics, an anesthesiologist must perform pediatric anesthesia for at least half a day per week, with an annual volume of approximately 200 anesthetic procedures 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 intubation in children over 3 years of age and stabilization during resuscitation. This training helps keep knowledge up to date and prepares the team for critical situations.

Role, Deployment, 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 performed by two professionals, including a dedicated anesthesiologist-intensivist (AIN) and a designated backup to provide immediate support if needed.

· Team structure in pediatric intensive care: Having an AIN assigned to the operating room and a second responder during critical phases improves safety. This structure relies on a clear division of roles and the team’s ability to respond quickly in the event of unforeseen events.

Postoperative care in the post-anesthesia care unit (PACU) for pediatric anesthesia

Adapting spaces and teams

· Recovery room for 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 face an increased workload in pediatric care. It is therefore essential that staff receive specialized training to recognize and respond quickly to life-threatening emergencies. Early warning protocols must be established, and centers with significant pediatric activity may even need to create a dedicated position (PACU Nurse Anesthetist).

Regional Coordination and the Role of the Regional Healthcare Organization Scheme

Integration into a Structured Network

· Definition of Local vs. Referred Skills: The circular dated October 28, 2004, emphasizes the importance of collective deliberation to determine which procedures can be performed at a local facility and which require referral to a specialized center. This division of responsibilities ensures that each facility understands its limitations and collaborates within a pre-established framework with the regional healthcare organization’s system for anesthesia consultations.

· ♦ Approval by the Regional Health Agency (ARS): The agreement between the local center and the regional SROS center (Level 2) is approved by the ARS, thereby ensuring consistency in 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 revision tonsillectomy clearly illustrates the need to tailor the approach 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 required (either two anesthesiologists or a combination of a nurse anesthetist and an anesthesiologist), and an ENT specialist must be present in the operating room.

o Critical periods (weekends, holidays, nights): In these situations, the organization must be adjusted to include an on-call system (one anesthesiologist on call) supplemented by an emergency physician, while noting that the number of paramedical staff may be reduced outside of regular 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 may be closed.

Conclusion

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

• • ... A well-structured anesthesia team, with clear guidelines regarding workload, continuing education, and role assignments during critical phases.

· ♥ ♥ ♥ Adaptation of postoperative monitoring systems to meet the specific needs of pediatric patients.

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

These recommendations aim to improve the safety of care and ensure that every child benefits from an optimal care environment, both in terms of technical resources and human support.

In practice, what is the care pathway for a child hospitalized for surgery, taking into account the specific considerations 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 (at least 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 (such as the use of iPads or games) and premedication with acetaminophen and ibuprofen are offered to reduce preoperative anxiety, in accordance with pediatric anesthesia practices.

2. ♥ ... A starting dose of 6% allows for rapid induction, followed by adjustment to a maintenance dose of approximately 1.5 MAC (approximately 3.25% sevoflurane) to avoid prolonged elevated Fe levels that could lead to hypocapnia and increase the risk of 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 anesthesia management in pediatrics, both for surgical procedures such as circumcision and for ENT procedures, with an emphasis on preoperative preparation, induction, pain management, and optimization of respiratory conditions.

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