AAP Guidelines Address Perioperative Anesthesia Environment

New American Academy of Pediatrics (AAP) guidelines, published November 30 in Pediatrics, identify key components for the pediatric perioperative anesthesia environment to optimize anesthetic care and reduce adverse events.

“[T]he pediatric perioperative anesthesia environment is defined as areas of a patient care facility in which the patient preparation for, performance of, and recovery from surgical procedures occur or where anesthesia is administered for nonoperative procedures,” write David M. Polaner, MD; Constance S. Houck, MD; and Policy Statement authors from the Section on Anesthesiology and Pain Medicine.

Infants aged between 1 month and 1 year have an approximately four times greater risk for anesthesia-related cardiac arrest compared with children aged 1 to 18 years, and those younger than 1 month have an approximately six times greater risk for cardiac arrest compared with infants aged between 1 month and 1 year, the authors explain.

“Important facility-based component issues for the perioperative anesthesia environment include the training and experience of the health care team, the resources (both human and structural) committed to both the medical and psychosocial care of infants and children in the perioperative period, and pediatric-specific techniques for airway management, fluid administration, temperature regulation, vascular catheter insertion, cardiorespiratory monitoring, and pain management,” the authors write.

Specific recommendations include the following:

• Pediatric facilities should have written policies designating and categorizing the types of pediatric operative, diagnostic, and therapeutic procedures requiring elective or emergency anesthesia, indicating the minimum number of cases in each category to maintain clinical competence.
• Risk categories should include age, need for postoperative intensive care, and special anesthesia risks caused by comorbid conditions.
• Anesthesia care for pediatric patients should be provided or supervised by anesthesiologists with graduation from an accredited anesthesiology residency training program, clinical privileges, and an annual minimum case volume.
• Anesthesiologists caring for high-risk patients should also be graduates of an Accreditation Council for Graduate Medical Education pediatric anesthesiology fellowship training program or its equivalent.
• Facilities should have policies for effective pediatric pain management during perioperative anesthesia, and regional blockade is encouraged when indicated and when expertise is available.
• A separate preoperative unit or area should be designated for pediatric patients and their families.
• Age- and size-appropriate equipment should include a resuscitation cart; cognitive aids; 20% lipid emulsion for emergency treatment of local anesthetic systemic toxicity from regional blocks; airway equipment; a separate, completely stocked “difficult airway cart”; thermal regulation devices; pediatric volumetric fluid administration devices; noninvasive monitoring equipment; and so on.
• Nursing and technical personnel should be trained and experienced in both routine and emergency pediatric perioperative care.
• Child life specialists may help prepare children for their emotional and behavioral responses to the perioperative experience.
• Clinical laboratory and radiologic services should be available at all times.
• Patient care facilities in which operative procedures are performed that involve postoperative intensive care should have age-appropriate intensive care facilities designed, equipped, and staffed to meet state and federal standards for the care of critically ill neonates, infants, and children.
• Patient care facilities should have a transfer agreement in place with an appropriate facility to facilitate prompt transfer, should unexpected complications occur.