The highly contagious Delta variant of the SARS-CoV-2 virus is surging among children, filling Children’s Hospitals. Daily, increasing numbers of children have serious and life-threatening infections. Lack of beds, ICU space, and nursing staff are forcing some US pediatric hospitals to postpone elective surgeries. In my town, some pediatric surgeons have begun moving selected pediatric surgery cases away from the Children’s Hospital and into the surgery centers because ORs are closed. This strategy carries potential for significant, but avoidable, risk.
Case
The OR at our local Children’s Hospital was cancelling elective surgery because of pandemic induced staffing problems. To help address community need, one adult surgery center changed its guidelines to allow pediatric surgery center cases for children as young as 12 years (weight cut off of 30 kg).
I did our first twelve-year-old for an ORIF of a bone fracture. I’m a pediatric anesthesiologist with decades of experience with infants and toddlers. A 12 year-old did not seem a problem. Average 12 yo children weigh around 40 kg (90 lbs). However, this 12 yo was a tiny 31 kg (68 lb). I had to place the small adult blood pressure cuff on the thigh as it was too big for his arm. Mid-case, a progressive leak forced me to remove the # 3 LM airway, which was the smallest one I had. I maintained anesthesia for the rest of the case with a mask, using an oral airway which was almost too big. The patient did fine. As experienced as I am, I misjudged our preparedness for this routine case.
The Pandemic Continues To Affect Elective Surgery
Shortages during the early months of the COVID-19 pandemic forced hospital ORs to postpone elective surgeries. Moving most adult elective surgery to the surgery centers literally kept elective surgery going. Now the pandemic threatens to potentially force scheduling elective pediatric surgery center cases as well. This must be done with careful thought and planning in order to be safe. Children are NOT small adults. As I was reminded by my healthy 12 yo patient, don’t take for granted that you have everything ready even with an older child. Plan first.
My anesthesia partners and I had a long discussion of some of the issues we would face if we started doing more children. What are a few of the concerns we discussed?
Children Are Not Small Adults
My review article 10 Common Pediatric Airway Problems — And Their Solutions describes the differences in pediatric anatomy and physiology, explains why those differences increase risks, and details how to modify airway and anesthetic management techniques to avoid common complications.
Infants and small children develop hypoxia easily due to their:
- different respiratory anatomy and physiology,
- immature respiratory system,
- inefficient mechanics of breathing,
- immature brain which is easily over-sedated
- immature sympathetic nervous system with de facto parasympathetic over-drive
- immature cardiovascular system, with a cardiac output that is highly rate dependent
These factors mean an infant or toddler is more likely to develop hypoxia. If hypoxia develops, then parasympathetic predominance triggers bradycardia, not tachycardia. Bradycardia significantly decreases cardiac output, which worsens hypoxia thereby initiating a vicious cycle. Cardiac arrest can occur quickly.
Providers May Lack Recent Experience With Children
Anesthesiologists who perform fewer than 100 pediatric cases on infants and young children per year are five times more likely to experience complications compared with anesthesiologists who do more than 200 cases per year. A 1994 review of anesthetics for over 4,000 infants less than 12 months of age found that the four main risk factors for bradycardia were:
- non-pediatric vs. pediatric anesthesiologist,
- A.S.A. status,
- duration of surgery,
- emergency vs. elective procedure.
To improve safety, pediatric surgical care has increasingly been scheduled in settings with designated pediatric providers. Concentration of pediatric care in children’s hospitals has the unintended consequence of depriving other providers of routinely caring for children. This results in making them less prepared for when they do inevitably have to care for a small child.
The pressure from the surge of pediatric COVID-19 patients is moving some pediatric care back out into a community of providers with less pediatric experience. Extra vigilance is warranted.
Pediatric Surgery Center Case Selection Criteria
Look at age, weight, and comorbidities. Choose older, healthier children for routine, common procedures until staff is trained and systems established.
One of our surgeons asked to schedule a “healthy” 7 yo at a surgicenter that does not normally do children. The weight was 41 kg (90 lb) — about the size of a small adult. A 7 yo should optimally weigh about 23 kg (50 lb). Therefore, this child had pediatric morbid obesity, and was not a good candidate. We did not schedule the case.
Have Age-Appropriate Equipment
Caring for a baby or toddler, or even a 12 yo, without correct-sized equipment jeopardizes patient safety. Ensure the appropriately sized equipment, especially ventilation equipment, is immediately available. If the mask you have is too large for the face, ventilation may be impossible. An incorrectly sized oral airway can make obstruction worse. If the endotracheal tube (ETT) is too large, then you won’t be able to insert it at all.
Optimally have pediatric defibrillator pads available for children less than 8 years old or less than 25 kg (55 lb).
After my 12 yo case, I sat down with the charge nurse and we ordered a few each of the next 2 sizes smaller mask, oral and nasal airways, and LM airways, and a large child blood pressure cuff.
Induction Technique
Anesthetizing babies and toddlers for elective surgery at pediatric hospitals often means considering inhalational mask induction and asleep IV starts. Some locations allow a parent to be in attendance to alleviate anxiety. The alternative is wrestling IVs in preop or the OR in a crying child. Consider induction options in your planning as appropriate.
Use Age Appropriate Airway Management Technique
Pediatric and adult airway management differ slightly because pediatric airway anatomy is different than adult. The infant and toddler have a more “anterior airway,” mandating modification of intubation technique. Hypertrophied tonsils and adenoids predispose to airway obstruction. Successful LM airway use depends on selecting the right size and possibly modifying insertion technique.
For a discussion of modification in intubation technique needed for an infant or toddler see:
Intubating An Infant or Toddler
Laryngospasm Is More Common In Children
The incidence of laryngospasm during anesthesia is higher in children than in adults, and ranges from 1.7 to 25 percent . Twenty-seven percent of cardiac arrests found in the Pediatric Perioperative Cardiac Arrest Registry resulted from respiratory events. Laryngospasm was the most common cause of respiratory related events, followed by airway obstruction, difficult intubation, esophageal intubation and aspiration. Your entire team needs to always be prepared for laryngospasm.
Medication Errors Are Common In Children
The literature states that 5% to 27% of all pediatric medication orders contain errors.
Young children require weight-based dosing. Small doses in small volumes are harder to administer. Immature nervous systems place children at high risk of drug overdose. While anesthesia providers may be well versed with titrating small doses, the same may not be true with preop and recovery room nursing staff. For a discussion of avoiding pediatric drug errors see:
Avoiding Pediatric Drug Errors
Codeine must be used with extreme caution, if at all, in young children or pregnant women because some patients hyper-metabolize the drug to toxic levels of active metabolites. See:
Codeine Risk in Children: Especially Those With Sleep Apnea
Pediatric Airway Management Doesn’t End In The OR
Be aware of any limitations in yourself, your staff and your facility regarding pediatric care. Care of pediatric patients doesn’t end at the OR door. Nursing staff can monitor, recognize, and treat problems early because of familiarity and pattern recognition. However, if the staff is unfamiliar with the anatomy and physiology of younger patients, or even what constitutes normal vital signs, then the risk of missing early warning signs of trouble is greater.
- Know your nursing staff’s experience.
- Understand your staff’s comfort level.
- Verify the availability of emergency pediatric equipment in your center.
- Evaluate whether the appropriate post-op monitoring care for the patient’s co-morbidities and surgery are available.
- Consider whether your staff, and doctors, should be PALS/ACLS certified
- Get your nurses involved with planning implementation
Check Regulatory Requirements
Depending on where you work, health regulations regarding pediatric care will need to be satisfied and changes documented in your Rules and Regulations.
First Do No Harm
COVID-19 continues to stress health care, health care providers, and health care facilities. As providers, we need to solve problems as they arise and be ready to bridge gaps in care. Increasing the number of pediatric surgery center cases may be needed. But we need to do so safely and with thoughtful preparation.
Protect yourself and your patients. Get vaccinated, if you haven’t already. Get family and friends vaccinated. Socially distance. Wear your mask. Wash your hands. Stay safe.
