User:Daaugust/Pediatric Anesthesiology

Pediatric Anesthesiology is a field of medicine devoted to the provision of sedation and/or general anesthesia to children before, during, and after surgery, imaging, or other medical procedures. Along with areas such as cardiac anesthesia, pain medicine, and intensive-care medicine, pediatrics is an officially recognized sub-specialty of anesthesiology. Patients cared for by pediatric anesthesiologists range in age from premature babies through adolescents, and may even include adults with certain illnesses like congenital heart defects.

Colloquially, pediatric anesthesiologist may describe either a physician who has received formal specialty training in this area, or one who has, by virtue of accumulated years of practice, demonstrated expertise in the anesthetic care of children.

The practioner must be differentiated from the drug. Other (non-anesthesiologist) physicians administer sedative or anesthetic medications to children. For example, specialists in pediatric emergency medicine, gastroenterology, otolaryngology (ENT doctors),pediatric dentistry, pediatric radiology, and pediatric intensive care unit (also called 'PICU') doctors sedate children for various examinations, diagnostic, or therapeutic procedures. Although other pediatric specialists may also administer sedation as part of their practice, it is a primary focus of expertise for anesthesiologists. This point is emphasized in recommendations by the Joint Commission and Centers for Medicare and Medicaid Services(CMS) in the United States, which suggest that the anesthesiology department play a 'key advisory role' in all sedation provided within the hospital, and that all sedation protocols ultimately fall under the direction of a single individual (i.e., typically a member of the anesthesiology department).

Scope of Practice
Why is pediatric anesthesiology a unique sub-specialty within the field of anesthesiology? There are a variety of reasons including the age of patients, the spectrum of medical and surgical disease, indications for, and the techniques of, anesthesia.

Age
Pediatric anesthesiologists must be capable of caring for premature (preterm)babies who require anesthesia or sedation for surgery and other procedures. At present (circa 2011), babies at the limit of fetal viability (i.e., those who can just survive outside of the uterus) weigh 500-600 only grams and are born at 24-25(?) weeks of gestational age. For comparison, a normal full-term baby weighs about 3 kg and is born at 37-42 weeks. Premature babies differ markedly from full-term newborns not just in age and weight, but also in their anatomy and in the relative immaturity of their organs. Any of these features may require alterations in the techniques of anesthesia or in the pharmacokinetics and pharmacodynamics of medications that the baby receives. Therefore, specialized training is required for safe administration of anesthetic medications.

In addition to caring for patients at the extremes of prematurity, pediatric anesthesiologists also care for full-term newborns, infants, toddlers, young children, adolescents, and even adults with certain types of disease. For example, adults with congenital heart disease and those with certain syndromes or developmental problems (e.g., severe cerebral palsy, autism, or Down syndrome) are sometimes referred to a pediatric anesthesiologist.

Types of Disease
Pediatric anesthesiologists encounter, and must be familiar with, a different spectrum of disease from those anesthesiologists who primarily care for adults. Heart disease provides one particularly clear example of this difference. Adult heart disease often involves coronary artery disease (occlusion, obstruction, or blockade), and can be fully repaired by coronary artery bypass surgery(also called a 'CABG') or insertion of a stent into the problematic artery. Congenital heart disease, on the other hand, causes to a wide variety anatomical abnormalities within the heart, but does not usually involve blockage of the coronary arteries. For example, in hypoplastic left heart syndrome (HLHS), the heart has only one strong pumping chamber (cardiac ventricle) instead of two. Diseases like HLHS cannot be 'fixed' with a single operation like a CABG, and instead must be palliated with a series of operations. At the end of treatment, the heart remains abnormal, but the patient can survive to adulthood. The physiological goals during anesthesia differ greatly between coronary disease and HLHS with respect to a wide variety of parameters: oxygen levels, hematocrit, pulse rate, and afterload, to name a few. Pediatric anesthesiologists receive specialized training in the management of children with congenital heart disease, but such training may not be required for anesthesiologists in general or for specialty training in adult cardiac anesthesiology.

Indications for Anesthesia
All anesthesiologists care for patients undergoing painful surgical procedures. However, pediatric anesthesiologists frequently anesthetize or sedate children for painless or minimally painful procedures as well. For example, most adults can tolerate a magnetic resonance imaging (MRI) scan without any anesthesia. However, due to developmental immaturity (with accompanying fear, anxiety, impatience, and inability to lie still for prolonged periods of time), many young children cannot complete an MRI scan without either heavy sedation or general anesthesia. Besides MRI scans, pediatric anesthesiologists assist with other painless diagnostic (CAT scan, nuclear medicine scan, eye or ear examinations) or therapeutic (radiation therapy) procedures. Similarly, adults can often undergo simple procedures under local anesthetic (a shot than 'numbs' the skin). Children, on the other hand, may require sedation or anesthesia in addition to (or instead of) numbing. Examples of such procedures include dental restorations, the insertion of long-term central venous catheters, and lumbar puncture ('spinal tap').

Techniques of Anesthesia
Certain anesthesia techniques are used much more commonly in pediatric patients than in adults. Consider one common example: the placement of an intravenous ('IV') line. Adults usually tolerate IV placement while awake, especially if the skin is numbed beforehand. Once in place, this IV may be used to sedate the adult patient (prior to the procedure) or to give them medicine to fall asleep (i.e. to induce general anesthesia). Many children, on the other hand, are fearful of needles, prone to exaggerate painful stimuli (such as the needle 'poke' for the numbing medicine), or may become agitated during IV placement due to a lack of developmental understanding. Thus the pediatric anesthesiologist often provides oral, rather than intravenous, sedation prior to surgery; anesthesia is often induced by having the child breathe a volatile anesthetic agent through a mask ('inhalational induction' or 'mask induction' of anesthesia); and the IV is often started after the child is asleep, rather than beforehand.

Who Needs a Pediatric Anesthesiologist?
There are two separate questions here. First, when is a pediatric anesthesiologist required? Second, when would a pediatric anesthesiologist be beneficial?

The answer depends on the availability of specialized healthcare providers, local practice, type of medical/surgical procedure being performed, and illness severity. In the United States, the Study Group on Pediatric Anesthesia concluded that any anesthesiologist should be able to resuscitate neonates, infants, and children; to care for infants and children getting 'routine' procedures; and to recognize when a pediatric patient needs more speciailzed expertise (either personnel or facilities). Patients who fall outside of these categories (e.g., critically ill children, pediatric emergencies, major pediatric surgery, or procedures on neonates and premature babies) may benefit from a pediatric anesthesiologist.

In addition to policy statements from professional societies and organizations, there is some data to suggest that more favorable outcomes occur when pediatric anesthesiologists are present. For example, in certain settings, cardiac arrest and bradycardia (slowing of the heart-beat) are less likely when a pediatric anesthesiologist is present. A study of about 50,000 pediatric sedations (using a drug called propofol), concluded that the chance of any adverse event was somewhat smaller when an anesthesiologist (as opposed to a non-anesthesiologist) was performing the sedation (odds ratio = 1.38). Another study concluded sedation by non-anesthesiologists emergency medicine doctors was safe, but emphasized that practitioners who perform pediatric sedations must be skilled in airway management, traditionally a major component of anesthesiology training.

However, in practice, there are practical obstacles in this area. In the United States, for example, there are many more pediatric surgeries (up to 25% of all procedures) than available pediatric anesthesiologists. For example, in Northern California, 79% (162 of 205 hospitals) performed anesthesia on children below age six, and approximately 40% of all pediatric anesthetics were done at hospitals performing less than 100 pediatric cases per year.

The answer to the second question may depend more upon details of the patient. Consider a classic example in pediatric anesthesia: an otherwise healthy child presents for surgery with an upper respiratory tract infection (URI) or common cold. The risk of certain types of respiratory complications, especially laryngospasm, is higher among children who undergo anesthesia during or shortly after a URI. It is possible that anesthesiologists who specialize in children are more comfortable judging the risk of continuing with the scheduled procedure, preventing this type of complication, recognizing it as early as possible, and treating it appropriately. Another example is the care of a healthy adolescent. While any anesthesiologist is qualified to care fore these patients, those who specialize in pediatrics may be more attuned to the special concerns and anxieties of teenagers before surgery, and more comfortable responding to these concerns.

Professional Societies and Journals
Anesthesiologists have many professional societies. In the United States, pediatric anesthesiologists are represented by the Society for Pediatric Anesthesia (SPA). The Congenital Cardiac Anesthesia Society (CCAS) is subsection of the SPA focused on children with heart disease. The American Academy of Pediatrics (AAP) also has a section on Anesthesiology and Pain Medicine, open to pediatric subspecialists like pediatric anesthesiologists or fellows.

The primary English-language journal devoted exclusively to this field is called Pediatric Anesthesia, published by Wiley-Blackwell. However, other English-language journals, such as Anesthesiology, Anesthesia and Analgesia , British Journal of Anaesthesia , and XX also publish important articles in this field.

Training
Training in pediatric anesthesiology is country-specific. In the United States, for example, it requires a year of fellowship training after completion of an anesthesiology residency. The fellowship is accredited by the American College of Graduate Medical EducationACGME, involves exposure to various aspects of pediatric anesthesia including general operating room experience, intensive-care medicine, pain medicine, and pediatric cardiac anesthesia. A written examination must be passed as well.

In Great Britain, pediatric anesthesiology expertise may be obtained within the normal seven-year training period. Specifically, the trainee may apply for one year of dedicated pediatric-only experience, possibly in a childrens hospital.