Handle with Care

Anesthesia

By: Stephanie Wasek

Published: 10/10/2007

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Your smallest patients may carry the biggest anesthesia risk. Here's how to make your pediatric cases safer.


In the early morning of March 13, 2003, 3-year-old Hannah Yutzy, all 36 inches and 36 pounds of her, had an uncomplicated tonsillectomy, adenoidectomy and bilateral myringotomy under general anesthesia at the Clinton County Outpatient Surgery in Wilmington, Ohio. Moments later in the recovery room, the blue-eyed girl with blonde, braided pigtails went into respiratory arrest following extubation and gasped her final breaths. The Montgomery County (Ohio) Coroner's Office summarized Hanna's death in four typewritten lines:

Cause of death: respiratory arrest
Due to: acute morphine intoxication
Contributing factor: unsecured airway following general anesthesia
Manner of death: accident

Before completion of the surgery, Hannah was given 1 mg of morphine. "The decedent showed spontaneous respirations following extubation," according to the coroner's report, "but shortly thereafter in the recovery room the decedent entered respiratory arrest."

Efforts to resuscitate Hannah failed, one after the other. Ventilating by bag valve mask didn't work. Reintubation was met with apparent airway obstruction. Staff reported briefly hearing bilateral breath sounds during one of many attempts to insert an endotracheal tube, but those sounds disappeared. Hannah was airlifted from the outpatient surgery center to a children's hospital and pronounced dead at 10:02 a.m.

"They told us that she breathed a few breaths after they took the tubes out," Hannah's father, Leon Yutzy, told Outpatient Surgery in a March interview. "[But] they couldn't get the tube back in, because the vocal cords were closed."

What went wrong?
Hannah's death is a stark reminder that seemingly routine pediatric cases can turn bad in a blink. Any number of things could have gone wrong, but could Hannah's death have been avoided? Anesthesiologist Adam Dorin, MD, MBA, who analyzed Hannah's 13-page autopsy report, called the management of the airway "problematic." Jay Horowitz, CRNA, says: "Unsecured airway after general anesthesia could mean poor PACU observation, laryngo or broncho spasm or some other mechanical obstruction after extubation."

Clinton County Outpatient Surgery's medical director would not explain what, if anything, went wrong after Hannah's surgery. "I have absolutely no comment to you," says Samuel DelMauro, MD.

A lawsuit has not been filed, and "there's no intention of one, either," says Mr. Yutzy.

"The manner of death is an accident; we don't know if somebody made a mistake or not for sure," says Mr. Yutzy. "As far as we know, nobody did. Even if they did, we want to forgive them. We're Amish ' from a Christian standpoint, this is easiest. [The doctors] can look back, as with anything, and look for where they could have done something, but hindsight is always 20/20. We choose to forgive them."

Can your facility do a better job assessing the risks of operating on children and implementing safeguards against the potential dangers? This article will explore those and other issues.

Steps for Safer Pediatric Anesthesia

In addition to having an anesthesia provider who has experience and interest working on pediatric cases, you can implement other safeguards before, during and after surgery to ensure safer pediatric anesthesia in your facility.

  • Develop an age protocol. You have to decide how young is too young for a patient to be operated on in your outpatient facility or department. Adam Dorin, MD, MBA, recommends setting a standard of 50-to-52 weeks post-conception age, or 2-and-a-half to 3 months after a full-term delivery for otherwise healthy children undergoing simple procedures, and deferring any procedures on ex-preemies until much older because "they have a greater risk of post-anesthesia apnea."
  • Build relationships with referring physicians. Educate the pediatric practitioners in your area regarding what they need to know about referring cases to your outpatient facility. "Make sure they know what the limits are," says Andy Herlich, MD, DMD. "Invite the pediatricians in the community to a lecture on what's appropriate for the outpatient setting. They need to tell you about the child and not just write 'clear for surgery' on a prescription sheet. It happens far too frequently."
  • Schedule a day of kids. "It gets you thinking in peds mode for several cases in a row," says Alan Marco, MD. "On the first case, you may not do something quite right, but the next case you do it the right way - and in cases three, four and five."

Dr. Marco likens such a system to residency training or honing an athletic skill: "On training programs, for example, you do a month of cardiac, do the drill every day - and it reinforces your behavior."

  • Pre-screen thoroughly. "You need a mechanism and process for evaluating kids pre-op before the day of surgery," says Dr. Marco. "Depending on the practice and the culture, that may be a close working relationship with the surgeons who are big utilizers or a big screening process where the nurses are trained in doing phone interviews, for example."

Here are the red flags your pre-op evaluation program should be able to catch:
' cough, cold and fever;
' congenital problems;
' metabolic disorders;
' obstructive sleep apnea;
' whether the child has taken herbal supplements within the previous two weeks;
' problems with pre-op blood tests, X-rays or other tests;
' whether the child is an ex-preemie; and
' frequent respiratory issues, such as asthma.

Sometimes red flags such as a cold may not be enough to delay surgery, but examining each pediatric case a day in advance gives you the opportunity to ensure your facility is prepared to handle the case - and the time to move the case to a hospital, if necessary.

"You can figure out if a child is too sick on a screening telephone interview if the people doing the interview have a good knowledge base," says Dr. Marco. "Does the child have a fever? Is he playing the same as always? Is he eating well? Kids get a cold every three to four weeks. But if the kid is acutely ill, you have to ask yourself, 'Why are we doing this today?' There may be a reason. Sometimes the risks of delaying a procedure outweigh the risks of doing it today. But you have to make a conscious decision."

  • Stress NPO rules to parents. Whether your facility follows American Society of Anesthesiologists fasting guidelines (www.asahq.org/ publicationsAndServices/NPO.pdf) or another set or rules, explain the guidelines to parents and give them written instructions to take home. "Often parents feel treatment in the office-based setting is different than the [inpatient hospital] OR setting, so the rules are different," says Anthony Charles Caputo, DDS. "Often they will restrict fluids for the same time they restrict solids; you have to ensure a young child is maintaining fluid intake up to two hours prior to the procedure."
  • Know when to say when to parents. Allowing parents in the OR for induction can soothe the child's nerves, but it shouldn't be done at the expense of the anesthesia provider's concentration.

"Sometimes, you end up with the parent as a second patient," says Jay Horowitz, CRNA. "They get all sweaty and sometimes almost pass out. If it's my child, I don't want that anesthesia provider worried about me or doing something different because I'm in the room."

Letting the parent know what to expect can help prevent such an occurrence.

"If you're doing inhalational induction, there's an excitement phase kids go through," says Dr. Marco. "I tell parents to expect that the kid will start thrashing around a little bit. I give them this analogy: It's much like just before kids go to bed at night, suddenly they get all fidgety."

Still, it's a good idea to set rules, such as one parent only, or allowing a parent if it aids communication (for example, with a deaf child). And your anesthesia provider needs personnel willing to back him up.

  • Pick up the phone. "When in doubt, have a practitioner-to-practitioner phone call," says Dr. Herlich. "Don't go through intermediaries; it just prevents telephone whisper-down-the-lane. You'll have far fewer screw-ups and far better outcomes."
  • Listen to the anesthesia provider. "No other physicians can clear a patient for surgery," says Dr. Dorin. "Only anesthesiologists can clear a patient for surgery and only we can manage anesthesia in its totality in the OR."
  • Warm the room. Most surgeons are comfortable in a cold OR. However, children have higher surface-area-to-volume ratios, they cool more rapidly than adults - and they need a warm OR to help ensure they maintain a stable body temperature.

"Mixing in kids to a regular room is a real problem; you can't just turn the thermostat up before the case," says Dr. Marco. "It takes a while for the OR to warm up, and when you have the odd case here and there, it's not going to do much good. If you turn it up too early, you're going to get complaints. Maintaining a warm OR is another advantage of doing a day full of kids."

  • Check staff experience. "You want the staff to be aware of how quickly complications can pop up in kids," says Dr. Marco. "They have less reserves than adults, and the staff needs to be responsive to requests for help."

The best way to ensure this, says Dr. Herlich, is to surround an anesthesia provider with a staff that also has experience working with children.

"Most anesthesiologists are comfortable taking routine pediatric cases, provided they have the support staff and equipment to deal with it," says Dr. Herlich. "You can't have everyone starting from Day 1 at the same time - it's a prescription for disaster." Dr. Herlich says one-third to one-half of the OR staff should have experience with peds.

  • Have the right equipment. An outpatient facility must be equipped with a whole range of pediatric equipment, not just retrofitted, small adult pieces of equipment, says Dr. Herlich. He recommends having on hand a full range of blood pressure cuffs, endotracheal tubes, oral and nasal airways, laryngeal mask airways and resuscitation equipment that can be used on infants and older children, including defibrillators. "All that must be in place," he says, "or one is going to have a lot of problems."
  • Double-check everything. "With children, you use similar drugs to those used in adults, but you have to be familiar with dosing," says Kristin Meyer, MD, a fellow at the Children's Hospital of Philadelphia. "In children, you do everything very strictly per weight, so you have to be very careful about dosing meds for children and giving IV fluids to kids. Before you give anything, check it twice."
  • Manage the airway. "With kids, it all comes down to airway," says Dr. Dorin. "You have less of a margin of error. Everyone should be ACLS trained at the minimum. You should also have one anesthesiologist on site who's also Pediatric Advanced Life Support (PALS) trained." n

- Stephanie Wasek

'They turn blue far too easily'
For parents, having their child's surgery done on an outpatient basis is a very attractive option - in addition to the same-day conveniences, the child doesn't have to experience the trauma of staying overnight in a hospital, away from his bed, his toys and all that he is familiar with.

Plus, children have the ability to recover faster, says Andy Herlich, MD, DMD, which, generally speaking, makes children good candidates for routine outpatient procedures such as tonsil and/or adenoid removal, hernia repair, circumcision and the insertion of tympanostomy/"pressure equalization" (PE) tubes. However, cautions Dr. Herlich, a professor of anesthesiology at the Temple University School of Medicine in Philadelphia, while children may "bounce back faster" after surgery, "when they get into trouble, they get there a lot faster."

"They turn blue far too easily," agreed one anesthesiologist. "That's why I avoid pediatric cases like the plague."

Even in routine surgeries, there are inherently more risks when operating on children, usually those 10 to 12 and younger, than when dealing with adults.

"The anatomic and physiologic differences between the pediatric and adult populations are key to the different practices of anesthesia in these two patient populations," says Dr. Dorin, the medical director for Grossmont Plaza Surgery Center in San Diego. "With regard to anesthesia, children are not simply small adults."

There are several differences regarding children's and adult's heads, for example, says Mr. Horowitz, the president of Quality Anesthesia Care Corp. in Sarasota, Fla.:

  • Children's tongues are bigger proportionally to their mouths than adults'.
  • Children's heads are on a proportionally shorter neck.
  • Children's heads are, compared to the rest of the body, proportionally larger than adults' heads.
  • In order to intubate a child, the angle toward which the epiglottis is approached is different than in an adult.

All this results in more difficulty controlling the airway.

In addition, says Mr. Horowitz, children's smaller lung capacities mean they desaturate faster, so the importance of controlling the airway is imperative.

Dr. Herlich, who is a staff anesthesiologist at both Temple University's Children's Medical Center and the Shriner's Hospital of Philadelphia, notes that children's airways are, of course, much smaller, and "the tolerance for airway trauma is much less. The consequences of traumatic intubation are more serious in infants and small children than they may be in older children and adults."

Thus, children are "more likely to have problems with laryngospasm, whether it's just a drop of mucous from the mouth on the vocal cords or a reaction to medicine," says Dr. Dorin. On top of that, "laryngospasm in a child has deleterious effects more quickly than in an adult," says Mr. Horowitz.

Children's metabolic and heart rates are also a factor.

"Kids have a higher metabolic rate," says Dr. Dorin. "You have to do things a lot faster."

Dr. Herlich points out that the cardiac reserve in infants "is dramatically lessened because they depend on heart rate only."

In addition, children tend to have more colds and upper respiratory infections than adults, are more sensitive to temperature and are more difficult to start an IV on.

Challenges of pediatric cases
These differences present more challenges when it comes to anesthetizing children. The anesthesiologists we talked to listed numerous different challenges regarding children, but airway management was No. 1 - or Nos. 1 through 3: "Airway, airway, airway," says Anthony Charles Caputo, DDS, of Southwest Dental Anesthesia. Dr. Caputo names IV access among his top challenges. J.P. Abenstein, MD, a consultant in anesthesiology for the Mayo Clinic in Rochester, Minn., adds fluid and temperature management to the list.

Not all the challenges come from the children themselves or arise out of their physiology, however. Finding support staff properly trained in handling pediatric cases is one of the most important difficulties anesthesiologists say they face when taking on children.

"No. 1 for me is reminding the other OR team members, including nurses and surgeons, that these are not just little adults," says Alan Marco, MD, an associate professor of anesthesiology at the Medical College of Ohio in Toledo. "This is particularly tough when the volume of kids is low."

"This is probably more important than anything else," says Dr. Herlich. "Tackling cases with improper equipment and support staff is a big problem, as are administrative egos wanting to take on all comers when they clearly shouldn't."

Other difficulties include dealing with parental expectations and "old-fashioned attitudes toward fasting and parental presence at induction and in the PACU," says Dr. Marco, who doesn't believe in long fasting periods or keeping parents out of the loop.

Pediatrics vs. general providers
With all the challenges of administering anesthesia to pediatric patients, do you need a pediatric-fellowship-trained anesthesiologist? Not necessarily.

"I don't think that, for most routine cases, there's a significant advantage to having a pediatrics-trained person," says Dr. Marco. And as Dr. Caputo, a dentist anesthesiologist, points out, "There are other anesthesia providers who have very good and strong training in the treatment of children."

Experience and interest are important if a general anesthesiologist (GA) will be working on pediatric cases, says Dr. Abenstein, and reality dictates that GAs must sometimes do just that.

In the first place, there aren't enough anesthesia providers to go around, let alone pediatric-fellowship-trained anesthesiologists.

"The reality is there's not enough providers. Some are grateful to grab anybody, regardless of subspecialty care," says Dr. Herlich.

Second, it would be too expensive for outpatient facilities to hire only such specialized practitioners.

"There's no way you could ever have only pediatric anesthesiologists on kids' surgeries - pediatric surgery would grind to a halt," says Dr. Marco.

Besides, most pediatric surgeries performed in the outpatient setting are in that venue because the procedure is simple and the patient healthy.

"If you feel comfortable doing anesthesia for bread-and-butter operations, there's nothing wrong with that," says Dr. Dorin. "The operations are done [outpatient] because it's a minor case. The caveat here is that any complex or high-risk cases should be referred to pediatric anesthesiologists."

The important factor to consider when dealing with healthy patients, then, should be the regularity with which an anesthesia provider works on pediatrics cases.

"Tonsils, tubes, operations like that, are so routine that, as long as you have anesthesia providers who do it on a regular basis, that's fine," says Mr. Horowitz. "However, I would be reluctant to have a child of mine go to a place that does not frequently do children. I'm not trying to say every outpatient facility should have an anesthesiologist or CRNA who has done a pediatric fellowship. They just need to do it on a regular basis."

The magic number
OK, maybe you don't need a pediatrics anesthesiologist to do cases in the outpatient setting. So how many pediatric cases should your anesthesia provider be doing to maintain his skill level?

"This is a nebulous question vexing experts at all levels," says Dr. Herlich. "You need to do two to three children a month to at least be competent. Some think you need to do two to three a week to be competent. Is there a magic number? No. Is there a percent? That's probably more likely."

Dr. Caputo, who sees 20 to 25 pediatric patients per week, suggests one per day or five per week. Dr. Marco says an average of one case per week may be sufficient. He feels the best approach is to schedule "a day of kids one day a month instead of spreading them out evenly."

While the numbers vary, Dr. Abenstein says one thing's for sure: "More is better than less."

Saying no
Even before you implement safeguards in your pediatric anesthesia routine, you still need to be able to flat-out turn a case away.

"Everyone has to have the skills and judgment to say, 'It's inappropriate to do this here,'" says Dr. Herlich. "You can't pretend to be able to handle kids when you don't do them."

Increasing your facility's case load may seem attractive, but with all the risks pediatric cases involve, the bottom line should not be the bottom line.

"The goals of money and cranking out cases can be so inappropriate sometimes," says Dr. Dorin. "Some people are not comfortable with kids. Then you're putting patients at risk."

Dr. Herlich recommends the family-member test: "If you can look yourself in the mirror and say 'I wouldn't do this surgery to my child,' then you shouldn't do it." Besides, he says, "you'll gain market share in the long run by doing the right thing."

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