Depending on whom you ask, pediatric anesthesia is either its own reward or its own punishment. Families of young patients demand a lot of time and attention, and there is a fine line between efficiency and missing the point of this specialty altogether. In addition, relatively few research dollars funnel into pediatric healthcare, leaving the practitioner to base important decisions on scant direct evidence. Yet, for anesthesia practitioners who are dedicated to pediatrics, the reward is great. In this article, I'll review several developments that are helping practitioners meet the unique challenge of pediatric anesthesia.

Refined patient selection
Experience has taught us which pediatric patients are likely to do well in the outpatient setting, and one of the most important developments has been the refinement of patient selection criteria. Here at the University of Virginia -where our surgeons perform general surgery, otolaryngology procedures, ophthalmology procedures, urological procedures, and some orthopedic and plastic surgeries - we routinely accept:

• Otherwise healthy full-term infants born 37 weeks post-conception who are at least 46 weeks post-conceptual age.With safe anesthesia practices, the risk of respiratory complications in these patients is negligible.
• Otherwise healthy premature infants who are at least 50 weeks post-conceptual age, provided they are not reliant upon apnea monitoring or apnea drugs such as caffeine. This is a 'middle-of-the-road' approach; some facilities admit these patients sooner while others wait until they are 60 weeks post-conception.
• Patients with certain congenital diseases who meet these age criteria, provided the condition is stable and the procedure will not pose undue risk. In essence, if we are confident that the patient's function will return to baseline within the first two postoperative hours, we proceed with surgery. We also perform select outpatient procedures on children with other stable systemic conditions, as well as pediatric patients with a history of malignant hyperthermia (MH). Patients with a susceptibility to MH can undergo outpatient surgery safely provided the practitioner follows universal MH precautions and guidelines.

For all patients with pre-existing conditions, the facility must have the capacity to process the necessary preoperative lab work. Laboratory capabilities do affect patient selection in freestanding ambulatory settings. Careful assessment of stability is essential because children with congenital conditions are more susceptible to anesthesia-related cardiac arrest and are more difficult to resuscitate.

The IV option
Although there is a widespread cultural resistance to IV induction of pediatric patients in the United States, the growing experience with pediatric propofol induction in Canada and Europe shows that it can be an appropriate option. European studies suggest that propofol induction hastens emergence in pediatric patients just as it does in adults, thanks to its short duration of action. It also reduces the incidence of emergence delirium - a common inhalational agent-induced state of disorientation and, sometimes, near psychosis that can last from 5 to 30 minutes. Some anesthesiologists estimate that 20 to 30 percent or more of children who receive inhalational anesthesia experience emergence delirium, and it is a real concern in our practice. Most importantly, IV induction may be the "least unkind" approach for children who are very fearful of mask induction.

Although we often induce anesthesia with sevoflurane, we consider IV propofol for fearful patients. When possible, EMLA cream (a euteric mixture of lidocaine 2.5 percent and prilocaine 2.5 percent) applied two hours preoperatively can help anesthetize the injection site.

Stricter monitoring practices
Not so long ago, there was a general consensus that anesthesia practitioners need only oxygenate and ventilate pediatric patients to keep them safe. In reality, even healthy children have a higher risk of anesthesia-related complications than adults. Despite great advances in training and monitoring equipment, the anesthesia-related mortality rate remains higher in children and is highest in children less than a year old.

For this reason, strict monitoring is essential. At our practice, we adhere to the following minimum monitoring standards: We routinely and regularly monitor respiratory function with end-tidal CO2 and pulse oximetry and circulatory function by monitoring the electrocardiogram and automated non-invasive blood pressure of all pediatric patients who receive general anesthesia. Although doing so requires specialized monitoring equipment that accounts for the size and physiology of young patients, this specialized equipment is readily available. It has, however, complicated equipment purchasing and OR setup, as even pediatric hospitals can find it difficult to ensure availability of a full selection of pediatric anesthesia equipment. For this reason, the anesthesiologist must be vigilant in ensuring that the right equipment is accessible before surgery.

The next step
There are many other recent advances that have made pediatric anesthesia substantially easier for the practitioner and more comfortable for the patient, such as the laryngeal mask airway, sevoflurane, propofol and multimodal pain control approaches. While these improvements have not significantly altered the safety or the makeup of procedures that can be done in the outpatient setting, they have improved the quality of care that children receive. The addition of clonidine to the local anesthetic mixture of pediatric caudals, for example, has improved both the quality and duration of the analgesic block postoperatatively, improving patient and parent satisfaction significantly in our practice. The appropriate use of non-steroidal analgesics postoperatively provides a level of pain control not achievable with acetaminophen alone. Prophylactic administration of antiemetics such as decadron, droperidol and ondansetron to high-risk patients - along with elimination of protocols that required children to eat and drink before discharge - have substantially reduced PONV and dehydration, common reasons for readmission in the past. Lastly, upon their request, we have given many parents a greater role in their children's care; parents are often present during some inductions and phase two recovery here and in many other institutes.

In general, pediatric outpatient surgery has advanced more slowly than adult outpatient surgery due to the relative lack of funding for pediatric research, as well as heightened concerns about patient safety and comfort and social moors. For the dedicated pediatric practitioner, however, this is not all bad news. The families of pediatric patients expect and deserve the best guarantee of safety we can give and, as such, a deliberate approach to change is often in everyone's best interest.

Dr. Yemen is the Director of Pediatric Anesthesia at the University of Virginia.