Important Skills for a Pediatric Anesthesiologist

There are skills intrinsic to the management of children that must be acquired by residents prior to independent practice. These skills, once they have been learned, will make the difference between the enjoyment and dread of the care of children. I have listed many, but not all of these skills below. Use this list as a take off point for discussion with the attending in the operating room.

1. The ability to do a mask induction on an infant or child – A part of learning this skill set is losing the anxiety, which often attends anesthetizing someone without an IV. Some of learning this skill is dealing with something small. This is not difficult. Place the mask on the face. Use a non-pungent potent agent in oxygen. Keep your fingers on the mandible and out of the airway. When the infant is still, put an oral airway in to prevent obstruction by the tongue. Allow the infant to breathe spontaneously if an IV is being placed. Control ventilation if you are trying to attain sufficient depth of anesthesia to place an endotracheal tube without muscle relaxants. A shoulder role sufficient to place the infant’s airway in the sniffing position can be very helpful. Be gentle. It’s a baby.

2. The ability to establish rapid intravascular access – Look in places where there are veins – the saphenous, the cubital fossa, the dorsum of the hand. Look for the best vein before you poke the kid. Retract the skin before the cannula goes through. Use a small catheter for a small vein.  Go slowly.

3. The ability to assess volume loss in infants – Think about how long it has been since the infant had anything to drink. We say NPO after five am, but in reality it may have been twelve hours or more since the baby had any fluids. When was the last wet diaper? Is the baby perky or somnolent? Are the mucous membranes wet? Remember that potent inhalational agents severely depress the myocardium and this especially reduces cardiac output in dehydrated infants. Be very careful.

4. The ability to talk to parents – Try to think about what you would feel like if your baby had to go to the operating room and you were putting the baby’s safety in the hands of a complete stranger. Then sit down and calmly talk to the parents about their child and their worries. Play with the baby. Establish rapport. Talk to the parents about your or your attending’s wealth of experience. Be calm.

5. The ability to assess the airway of an infant – All infants have tough airways because of the small mouth, large tongue and large occiput problem. But some have a small chin, a small mouth or a very large tongue. These children can be a real problem if you don’t recognize this until the muscle relaxants are given.  A good rule of thumb is to look up any syndrome that you are unfamiliar with before it becomes a Wednesday Morning Conference.

6. The ability to recognize a sick child – Sick kids look sick. They are listless, somnolent and glassy eyed. They may be mottled or have cold extremities. Their skin will often have a doughy consistency.
   These infants and children respond poorly to the administration of potent anesthetic agents. Extreme caution should be exercised in the conduct of this child’s care. In other words low doses administered slowly. Often these children are dehydrated. It makes sense to assess the need for rehydration in a sick child prior to administering an anesthetic.

7. The ability to manage the pain of surgery in an infant – Infants and children suffer after painful procedures to the same extent as adults. There are many ways to safely control the pain of surgery without added risk. Become familiar with simple blocks that effectively ablate pain after common procedures in children. Discuss the pharmacokinetics and pharmacodynamics of analgesics in infants and older children.

8. The ability to recognize common postoperative problems of infants and children – Laryngospasm, croup and apnea are the three most common life threatening postoperative problems in infants. These can all be predicted with a remarkable degree of certainty by the clinical situation. Laryngospsm rarely occurs in patients with dry airways in which a non-pungent agent has been used. Sevoflurane is very forgiving. In a patient that is somnolent, has a wet airway or has been exposed to Desfluane, the risk of airway obstruction is great after removal of an endotracheal tube.
   Croup is an inflammatory response secondary to a superimposed infectious process or the placement of a large endotracheal tube in a small airway. Croup is tolerated well by children older than three and not at all by infants. This scenario of airway obstruction and respiratory failure can be eliminated by using a small endotracheal tube and leak testing after every intubation in children less than three. Get your attending to demonstrate a leak test if you are uncertain.
   Apnea and/or periodic breathing are uncommon in infants greater than three kgs and fairly common in infants less than 1500 Gms. Be on the look out!

9. The ability to resuscitate a newborn infant in the delivery room – The ability to oxygenate and ventilate the depressed newborn is key to improving survival. In this regard the effective use of the bag-valve-mask can be life saving. It is uncommon for newborn infants to fail to respond to adequate delivery of 100% Oxygen. If this fails consider long-standing acidosis, volume depletion secondary to blood loss, or a central nervous system catastrophe. 

10. The ability to recognize and treat common life threatening problems in newborns – The common life threatening problems in the delivery room include diaphragmatic hernias, severe meconium aspiration, gastroschisis and omphalocoele. Fortunately, with the use of preterm Echo, it is rare for these diagnoses to be made in the delivery room. Because the diagnosis is not in doubt, plans can be made for airway management and other emergent care before the delivery.
    Meconium aspiration represents the end result of stress and hypoxia in a just delivered infant. Aspirated meconium may produce severe airway obstruction and air trapping sometimes leading to respiratory compromise and death. Meconium can be suctioned out of the airway prior to the first breath. This procedure is probably warranted if an infant has had a long hypoxic period or has a large amount of thick meconium in the amniotic fluid. Infants that are vigorous at birth or have thin, non-particulate “pea-soup” meconium do not require direct laryngoscopy before the first breath.