Anaesthetists and care of the critically ill child

In August 2002, the Royal College of Anaesthetists (RCOA) send out a ‘Flyer’ reminding Departments of Anaesthesia in all hospitals receiving unrestricted emergency paediatric admissions that on-call anaesthesia/critical care teams may be asked to help in the resuscitation and stabilisation of the critically ill child. It went on to indicate that such help should always be available. Twenty years ago it would have been unthinkable that such a ‘Flyer’ would be necessary. What has lead to such a situation arising and how can we as a profession address the problem? The 1989 Report of the National Confidential Enquiry into Perioperative Deaths (NCEPOD) [1], published in 1990, addressed the issue of deaths in children less than 10 years of age in the first 30 days following surgery. It made the following two recommendations: (i) Surgeons and anaesthetists should not undertake occasional paediatric practice; (ii) Consultants who take responsibility for the care of children (particularly in district general hospitals and single specialty hospitals) must keep up to date with the management of children. This report was followed by a series of reports [2-4] reiterating the theme that children undergoing surgery would benefit from care by practitioners who undertook paediatric care on a regular basis. Importantly, these reports also stressed the need for appropriate paediatric support services in all hospitals providing paediatric surgical services. The debate intensified within anaesthesia following the publication of editorials by McNicol [5] and Rollin [6], in which they outlined their views on how the care of children requiring surgery could be optimised. The constant theme throughout was that fewer anaesthetists (and surgeons) should be involved, but these reports were related to surgical care and did not consider the care of the critically ill child (often non-surgical). Concern about the potential dangers of deskilling district general hospital consultant anaesthetists who may be required to care for the critically ill child brought to their hospital (major trauma in particular) was clearly stated by Rollin [6] and it was reiterated in subsequent correspondence [7]. Some hospitals responded to these reports by developing designated consultant paediatric anaesthetic on-call rotas; however, many departments of anaesthesia had insufficient consultant numbers to produce sustainable specialist on-call rotas. Some developed ad hoc arrangements for out-of-hours paediatric cover many of which continue to this day, to the credit of those involved. Many others agreed that cover would be provided by the on-call consultant; however, some devolved the decision to the individual consultant anaesthetist on call. This latter arrangement often led to confusion, with some children receiving suboptimal care because of reluctance on the part of some anaesthetists to attend when requested. Finally, some decided to withdraw surgical services for the young child (under 2 years of age being a frequent lower age limit). The RCOA ‘Flyer’ reiterates the guidance found in its document The Royal College of Anaesthetists Guidelines for the Provision of Anaesthetic Services[8] where the provision of resuscitation services is identified as a key element in service provision. The response to the ‘Flyer’[9] suggests that there is need for an urgent reassessment of current arrangements. The changes originally proposed [1-4], and often implemented, relate to surgical care. Many anaesthetists felt disenfranchised by these changes and one reaction was to withdraw all emergency services for the care of children, often stating that it was unreasonable to be expected to provide emergency care when denied the opportunity to maintain the necessary skills in day-to-day practice. Further, Lunn suggested a minimum paediatric anaesthetic case load necessary for maintaining appropriate skills [10] which was beyond the reach of the majority of consultant anaesthetists working in district general hospitals, thus adding to the sense of frustration. There was also the perceived threat of medicolegal action against the occasional practitioner should anything untoward occur. It is probable that this pressure is felt even more acutely today. Why should anaesthetists become involved in the care of the critically ill child? When such a child is admitted to the local hospital, initial resuscitation and management requires assessment of airway, breathing and circulation, with the instigation of early appropriate care – the very areas in which we as a speciality have the greatest skill. The majority of paediatricians who receive the initial referral will not possess airway management skills approaching those of anaesthetists who undertake these duties during the course of a normal days work, albeit infrequently in children. Is it right that we deny the sickest children the benefit of our skills at the very time when they may be of greatest benefit? Some may suggest that their skills have been lost as a result of the centralisation of paediatric services, yet it is basic resuscitation skills that are required. Maintenance of an airway with the aid of an oral airway whilst applying intermittent positive pressure ventilation should be possible for most anaesthetists, as should intubation. The majority of paediatric anaesthetists visualise the larynx of an older infant/young child in the same way as for adults, using an adult laryngoscope blade placed in the vallecula, thus obtaining the same view of the laryngeal opening – the safe passage of a tracheal tube should therefore be possible. Although challenging even for the most experienced anaesthetist, our knowledge of basic pharmacology should ensure that, if indicated, a rapid sequence induction in a critically ill child is safer in our hands than in those of a paediatric operator with little formal training or practical experience. Both anaesthetists and paediatricians will find intravenous access challenging in critically ill children, although the popularisation of intraosseous access has dramatically changed the initial management of fluid administration. Telephone advice from the local paediatric intensivist leading the retrieval team about the most suitable resuscitation drugs and fluids can be invaluable. It is clear that several factors combine to make it increasingly difficult for all consultant anaesthetists to maintain what are perceived to be adequate skills to assist in the resuscitation of the critically ill child. These include: the centralisation of surgical services; the effect of the European Working Time Directive; increasing consultant numbers; increasing trainee numbers; proposals for reducing time in training. Yet we have a duty of care ‘in an emergency, wherever it may arise, to offer anyone at risk the assistance you could reasonably be expected to provide’[11]. Within these constraints, what are the options open to individual Trusts and Departments of Anaesthesia and how can sufficient numbers of consultants retain the necessary skills and confidence? ▪ Firstly, all Trusts receiving unrestricted paediatric emergency admissions must recognise that they have a responsibility to ensure these patients receive the best possible care. A regional working party in the West Midlands has published a set of Standards for the Care of the Critically Ill Children in the West Midlands[12], which provides an excellent framework against which to benchmark services in any hospital. Involvement of local paediatricians, emergency physicians, anaesthetists, surgeons and clinical governance leads will encourage corporate responsibility for the care of these children. ▪ As consultant numbers increase, Departments should resist the understandable desire to reduce the frequency of on-call and develop two (or more) tiers of consultant on call. Once this has been achieved, one of the consultants on call each night should be recognised as the one with specific paediatric skills. For this to occur, they should have regular exposure to routine paediatric anaesthetic practice (one to two lists per month if possible). Such a development acknowledges that severely restricting the numbers of consultants undertaking routine paediatric anaesthetic practice is not, after all, in the best interests of all children. A nominated ‘lead’ paediatric anaesthetist remains essential to be actively involved in identifying and equipping the resuscitation areas and developing local guidelines. This will help foster good working relationships with local paediatric colleagues, an important part of the team approach to the management of the critically ill child. ▪ The development of dedicated paediatric lists will help ensure that all those providing paediatric cover obtain reasonably regular experience. It is probable that there will be insufficient clinical material in most district general hospitals for all those providing paediatric cover to have a weekly commitment, thus there is a need for some flexibility from both anaesthetist and surgeon. Many consultants indicate that it is a lack of confidence that is the major problem when dealing with the unforeseen paediatric resuscitation – access to a regular theatre commitment (even if only once a month) will ensure continued confidence in drug doses and the use of paediatric equipment. Such flexibility should be common place in all departments as there is a need for all consultants to maintain core clinical skills in all areas for which they have out-of-hours responsibilities. ▪ Continuing experience can be augmented, if necessary, by visits to the local specialist centre to gain further ‘hands on’ experience, particularly in the intensive care environment – this will also help foster good relations between colleagues, which may be invaluable in an emergency. All this should be part of formal continuing professional development agreed through the appraisal process. The time away may have an effect on an individual Trust's ability to meet targets and therefore Trust management need to be aware of the cost of such a service and include it in contract negotiations. ▪ All staff who may be involved in the care of critically ill children will benefit from attending a paediatric life support course. The common structured approach has greatly improved the care of these children, as well as communication between specialties. It is notable, however, that the end point of most of the scenarios in these courses is ‘call the anaesthetist’, with no further advice forthcoming! The specialty needs to develop specific courses to address this deficiency, in conjunction with paediatricians and paediatric intensivists. Whilst paediatric resuscitation forms part of the core knowledge and skills for Competency Based Specialist Registrar Training [13], more emphasis should be placed on such training by local schools of anaesthesia. The difficulties associated with the maintenance of appropriate skills for paediatric anaesthetic practice, apply equally to other areas of anaesthetic practice. The development of single subspecialty consultant rotas in large tertiary hospitals is not difficult, indeed the training required to undertake such an on-call commitment is arguably less than is required for consultants who intend to work in district general hospitals, where a greater breadth of skills needs to be retained. The development of more than one tier of on call will help limit the breadth of practice covered, but many core skills must still be retained. We must ensure that those of us responsible for providing cover for all emergency admissions, including paediatric, are given the necessary support to ensure that appropriate skills are retained and that we respond to calls for help. Surely we should not deny the future generation the best chance of survival by withholding our skills when they are most needed?