More than 3 million children receive anesthesia in operating rooms in the United States each year. Countless others will receive anesthesia for diagnostic or painful procedures outside the operating room. Studies of anesthesia related morbidity and mortality during the past fifty years have consistently reported that infants and young children are at significantly greater risk of a serious complication or death associated with anesthesia than the older child or adult. Why?
Infants and small children have striking physiological differences that place them at much higher risk of anesthesia than the older child or adult. Infants and small children have substantially higher metabolic rates and oxygen demand. The infant has much smaller lung volumes, a smaller airway that is more prone to obstruction, and far less respiratory reserve. The infant airway is not only smaller but also anatomically different. The epiglottis is relatively large and floppy; minor airway irritation or infection (croup, epiglottitis) may result in swelling that can cause dangerous narrowing or even closure of the airway. Infants are prone to cold stress, which may lead to cardiovascular instability, decreased oxygen levels in the blood, and bleeding disorders. The physiological conditions present in the infant and small child make them far more prone to life-threatening complications, including hypoxemia (low oxygen level in the bloodstream) and cardiac arrest.1
Anesthesia for infants and small children requires specialized equipment and a special skill set. General anesthesiologists are appropriately concerned when asked to anesthetize infants and small children. General anesthesiologists typically receive little specialized training in anesthesia for infants and children; and even if they have received some training during residency, many haven't administered anesthesia to an infant in months or years. The general anesthesiologist is aware that infants and small children are prone to sudden and dramatic airway and cardiovascular deterioration that may be life-threatening. The margin for error in pediatric anesthesia is far less than the older child and adult. If problems are not handled quickly and adroitly, the patient may suffer cardiac arrest and death.
Pediatric Surgery and the Importance of Location, Location, Location
In most industries, there is a demonstrable improvement in efficiency with experience (the so-called learning curve). As a team gains experience, the number of errors decreases, efficiency increases, and the cost of producing an item decreases. This is a quality observed in virtually all human endeavors, not just in industry. Thus operating room conditions are safest and smoothest when everyone on the team is regularly participating in the care of infants and young children.
To properly care for the infant and young child requires appropriately trained and qualified surgical staff, nursing staff, and anes thesia staff in a facility where this type of patient is routinely cared for. Studies show that the "occasional" pediatric surgeon has substantially higher complication rates, including death, than the surgeon who regularly performs surgery on children.2 It has been shown that surgeons who perform procedures on children as simple as a hernia repair have higher complication rates than surgeons who are specialists in pediatric surgery.3 There are also differences in mortality between institutions that specialize in pediatric care and hospitals that do not specialize in pediatric patients even for procedures as common as a tonsillectomy.4
What the anesthesiologist, surgeon, and hospital do on a regular basis is probably what they do best. I personally would choose an anesthesiologist who is regularly anesthetizing infants and children for my child for any surgical procedure being done. I would insist on a surgeon who is a pediatric specialist to perform the surgery. I would allow the procedure to be done only at a facility that regularly cares for infants and children. The added risk may be sufficiently great for your infant or child that you may be willing to travel a greater distance to receive specialized care at a hospital or ambulatory facility that has anesthesiologists and surgeons who are also pediatric specialists.
If your managed-care health plan sends your child for surgery to a facility that is ill-equipped to care for infants and children, that is staffed by individuals who are not adequately trained in the care of pediatric patients, and employs surgeons and anesthesiologists who are only occasionally taking care of pediatric patients—all for financial reasons—please inform the health plan that the scientific literature suggests that this may not be the best medical care for your child and they may be placing your child at added risk.
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