Anesth Analg 2006;103:859-862
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000237318.64843.a2
PEDIATRIC ANESTHESIA
Section Editor:
Peter J. Davis
Don’t Confuse the Anesthetic with the Anesthesiologist!
Randall C. Wetzel, MB, BS, MBA, FCCM, FAAP
From the Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, The Keck School of Medicine of the University of Southern California, California.
Address correspondence and reprint requests to Randall C. Wetzel, Professor of Pediatrics and Anesthesiology, Department of Anesthesiology Critical Care Medicine, Childrens Hospital Los Angeles, The Keck School of Medicine of the University of Southern California, CA. Address e-mail to rwetzel{at}chla.usc.edu.
How many more reports from diverse practitioners, using various anesthetics, given by various routes, either alone or in combination, will we have to read before we realize that the situation is out of hand—perhaps irretrievably so—and that it is our fault?
But wait! The report by Dalal et al. (1) in this issue of the journal is from a department of anesthesiology. Anesthesiologists have collaborated, some might say colluded, with nonanesthesiologist pediatricians and nurses to provide a tiered approach to sedation and general anesthesia for infants requiring radiological procedures. This department of anesthesiology trained, facilitated, and oversaw the giving of IV propofol by nonanesthesiologists and IV pentobarbital by nurses. This collaboration to induce general anesthesia necessitates comment.
How did we get here? The shortage of providers, particularly anesthesiologists, has been cited as the most common barrier to the development of pediatric sedation services (2). Occasionally, anesthesiologists have resisted the administration of the most effective, and perhaps safest, drugs by nonanesthesiologists providing sedation for a wide spectrum of procedures in children who deserve the safest, most effective regimens. To top that off, some have then shouted "inadequate manpower" and scurried back to the operating room, forbidding others from providing what they cannot or will not provide. Unconscionable really. Dalal et al. (1) have sallied forth to work with their colleagues to provide a comprehensive sedation service. They took local responsibility and now have gone public with their little secret.
Who should provide sedation/anesthesia for children in the magnetic resonance imaging scanner? This is necessary, without doubt. Small children who need these studies will not hold still, and hospitals must provide these services for children. They have to be sedated, but how should it be done and by whom? In a perfect world, pediatric anesthesiologists would directly provide the service. Unfortunately, there simply are not enough pediatric anesthesiologists to directly meet this need. So, how to respond? Do we tell the hospital to forget it—we do not have the resources, the job does not pay or whatever. If we do take that course, do we have the right to comment about who provides this necessary service? Is it justifiable to refuse to provide this care and then forbid others from providing it? Is this the fulfillment of our responsibility to provide safe anesthesia, sedation, and pain management services for the children we serve and for the hospitals in which we work?
The consequences of our failure to provide this service are all around. Everyone from pediatricians to intensivists to subspecialists to nurses has provided various drugs orally, IV, rectally and transdermally, and compared them in a plethora of ways. There are several hundred articles touting techniques for this purpose. The message appears to be, "come one, come all, anyone can do this with a number of drugs" and "it’s better than nothing" although few studies have been adequately powered to attest to safety (3–5). Diverse nonanesthesiologists already use various anesthetic drugs, alone and in combination, in various settings (emergency department to magnetic resonance imaging), to provide sedation that is often tantamount to general anesthesia and certainly has the risk of inducing general anesthesia. Already the medical literature is plagued by under-powered studies rehashing what is already commonplace knowledge in anesthesiology. No doubt they will soon rediscover bispectral index, the effect of propofol on arterial blood pressure and perhaps even generate a pediatric physical status score from I–IV ± E. These practitioners have filled the void left by our absence.
Yet some departments of anesthesiology and pediatric anesthesiologists eschew involvement with such practice. Why? Is it fear of litigation, disdain for unsafe practices, restraint of trade, or not wanting to be involved with less than the level of care a pediatric anesthesiologist can provide for children? Risk aversion is an admirable virtue, especially among anesthesiologists, but like any virtue it can be taken to excess. It is not laudable when it leaves children vulnerable to other, perhaps worse, risks. What are the consequences of leaving these nonanesthesiologists to their own designs? They include less than optimal care for children, a denial of our responsibility to shepherd children through scary and painful procedures commonplace in hospitals, a level of practice that may be less than we expect and children deserve, and performed by practitioners perhaps ignorant of the potency of the drugs they use and the effects these drugs may induce. All of this is done without the risk aversion and safety ethos inherent to anesthesiology. This is even more unfortunate when it occurs in institutions where expert pediatric anesthesiologists practice daily. Are we going to continue to shirk our responsibility and turn a blind eye as others take on sedation and anesthesia for children? Is it really safer to acquiesce to practitioners giving IV midazolam and fentanyl (a dangerous synergistic combination of uncertain duration) rather than a single, short-acting drug such as propofol?
Cote (6) and numerous others among us have taken responsibility and assiduously promulgated guidelines for sedation in children by nonanesthesiologists (7,8). The ASA and American Academy of Pediatrics guidelines for sedation discuss the continuum from light sedation to general anesthesia and liken deep sedation to general anesthesia. As these guidelines emphasize, care is a continuum. To assume that there is only one level of care for the entire anesthetic continuum is fallacious. As the level of care can vary over the continuum, surely the qualifications and training of the caregiver may also vary. Furthermore, the existence of these guidelines is, at least in part, tacit approval for nonanesthesiologists to provide deep sedation and be required to rescue from general anesthesia. Who can best train these nonanesthesiologists, oversee their practice, and provide their quality assurance? Surely the answer is, "departments of anesthesiology." After all, these are anesthesia services. Do we really want nonanesthesiologists providing oversight for sedation services? Instead of the occasional pediatric sedation provider supervised by nonanesthesiologists, would not a trained, skilled, practiced, and appropriately supervised provider, working in a system designed to monitor quality and assure support be better? When departments of anesthesiology take global responsibility for sedation services, our full expertise can assure more appropriate care for the entire continuum of anxiolysis, sedation, and general anesthesia.
Is there an alternative to either noninvolvement or providing pediatric anesthesiologists for all sedations? These procedures are commonplace. It is our job to make the commonplace safe. Can we train nonanesthesiologists to provide sedation/anesthesia and create a safe system in which they may practice? Can we direct the service, determine which patients get what care where, and provide the oversight and quality assurance, in fact, manage the service and take responsibility for these children, without directly providing the hands-on service? What do we say in response to those who exclaim the obvious, "but they are not anesthesiologists!" Does credentialing a pediatrician to give IV propofol imply they are now able to administer inhaled anesthesia? Of course not. Do pediatric anesthesiologists add value other than to push propofol? Of course we do. Let us not confuse the anesthetic with the anesthesiologist.
Can we help our colleagues and, more importantly, children, by sharing our hard won knowledge with others who may provide the hands-on care, but with our guidance and oversight? In addition to personally administering anesthesia, anesthesiologists also build systems, manage the complex perioperative environment, provide hospital-wide pain services, and organize training programs from residencies to cardiopulmonary resuscitation, advanced pediatric life support, and airway skills. These are aspects of our responsibility to safely alleviate the pain and anxiety that accompanies hospital care. It is also part of our responsibility to oversee the care environment, to insist that the standard of care is appropriate and reproducible, to insist that suction, airway and resuscitation equipment, defibrillators, oxygen, and monitoring are provided to the same standard as we would provide for the same care in the operating room. We know and understand this practice better than any, and our constant vigilance of the sedation environment is our responsibility. Who better? This surely would be more helpful than simply proclaiming "you can’t give propofol."
When departments of anesthesiology step forward to accept their responsibility for this care by supervising nonanesthesiologist providers, training, oversight, correction, quality, and safety become our roles (as responsibly provided by Dalai et al.). Further, we provide the much needed solution for hospitals and for children. In addition, if we credential and oversee the practitioners, in most states these procedures can be remunerated in the same fashion as when performed by a pediatric anesthesiologist, as they should be when under the auspices of departments of anesthesiology. The argument focuses on training, credentialing, and quality assurance, not on what drug was given by whom. It focuses on a safe, efficient, and humane system for providing this care. Lone practitioners working autonomously do not provide safe and efficient anesthesia services. This requires well-designed, constantly controlled systems involving many people for the care of each child, and we are the system experts. This is the approach that we have taken at Children’s Hospital Los Angeles and Dalai et al. have reported from St. Louis (1).
There are other reasons to be involved with these services. The line between deep sedation and general anesthesia is subtle, blurred, and unenforceable. Children drift back and forth and titration to effect often goes over the line. Will nonanesthesiologists determine whether they are providing deep sedation or general anesthesia? The ASA sedation guidelines recommend that patients receiving the general anesthetics propofol, methohexital, or thiopental receive care consistent with deep sedation. This reflects the intrinsic confusion and the artificiality of defining sedation by the ambiguous concept of the difference between deep sedation and general anesthesia. Anesthesia is not defined by the anesthetic or sedative drugs used, nor by the route administered, but rather by the effects achieved, which require the appropriate care, oversight, and systems. Do we think that deep sedation is safer than general anesthesia? Giving IV propofol is intent to induce general anesthesia. Obfuscating this by calling it sedation or deep sedation is either naive or disingenuous. Looking the other way while pediatricians, intensivists, and others operate under the guise of "deep sedation" is simply irresponsible. Wouldn’t it be better, when motionless unarousability and perhaps analgesia is required, that we simply call it general anesthesia and prepare the environment for general anesthesia? To say that nonanesthesiologist can provide deep sedation but not general anesthesia induced by short-acting rapid onset drugs IV, and send them on their way, trusting that general anesthesia will not be induced (either inadvertently or advertently) is fatuous. As anesthesiologists we prefer to use propofol; yet some think that less-experienced doctors should use less-advantageous drugs, an argument posited somewhat speciously around "safety."
Other drugs—take your pick—midazolam and fentanyl or choral hydrate and pentobarbital—often called merely sedation (even more disgracefully "conscious sedation")—also share the "risk" of inducing general anesthesia. Some combinations can be lethal. In addition, they often provide less than adequate conditions. If we dichotomize these services to anesthesiologists—general anesthesia—propofol versus nonanesthesiologists, any regime they like (yikes!-demerol-phenergan-thorazine?), we are forced to make impossible or bad choices. Just because we do not have enough anesthesiologists should we abdicate our responsibility to nonanesthesiologists using suboptimal and potentially dangerous regimens and leave them on their own? Wouldn’t it be better to step up by extending the benefits of our meticulous, informed, systematic care for children, requiring anesthesia services even when directly provided by other less well, but adequately trained personnel?
Recently published in the journal Pediatrics by emergency medicine physicians is a report of a radiology sedation service staffed exclusively by nonanesthesiologists (9). They state: "We recognize that several of our patients who were administered propofol—or pentobarbital-based regimens or ketamine may have been assessed under the category of general anesthesia at some time during the procedural sedation." They recognize they are inducing general anesthesia yet continue to call it sedation within the same sentence. They assessed just over 1000 "sedations" and deem their practice safe and effective! I am sure I am not alone in finding this chilling. Soon there will be no apologies. We will be reading articles by nonanesthesiologists, largely ignorant of the history and practice of pediatric anesthesiology, discussing how to provide general anesthesia for children. Our absence from this arena—except perhaps to occasionally shout into it "stop that"—and our failure to take responsibility for these children, will only hasten this retrograde step in pediatric health care.
We cannot continue to avoid, for one reason or another, caring for these children. Myriad others have filled the void we have left. Having attempted to eschew responsibility, the solution remains ours. Can we fulfill this responsibility to children requiring safe, efficient, and timely sedation and anesthesia services by collaborating with other practitioners whose patients need our services? Yaster and Cravero (10) likened the conundrum of pediatric sedation to the La Brea Tar Pits. If we fail to take responsibility for these procedures and do not collaborate with our colleagues and our hospitals, we may become the dinosaurs trapped in this tar pit.
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Footnotes
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Accepted for publication June 5, 2006.
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REFERENCES
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- Dalal PG, Murray D, Cox T, et al. Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants: provider and pharmacologic considerations. Anesth Analg 2006;103:863–8.[Abstract/Free Full Text]
- Lalwani K, Michel M. Pediatric sedation in North American children’s hospitals: a survey of anesthesia providers. Paediatr Anaesth 2005;15:209–13.[Medline]
- Pitetti R, Davis P, Redlinger R, et al. Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines. Arch Pediatr Adolesc Med 2006;160:211–16.[Abstract/Free Full Text]
- Sanborn PA, Michna E, Zurakowski D, et al. Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 2005;237:288–94.[Abstract/Free Full Text]
- Blike G, Cravero J. Review of pediatric sedation. Anesth Analg 2004;99:1355–64.[Abstract/Free Full Text]
- Cote CJ. Strategies for preventing sedation accidents. Pediatr Ann 2005;34:625–33.[Web of Science][Medline]
- Committee on Drugs, AAP. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: Addendum. Pediatrics 2002;110:836–8.[Abstract/Free Full Text]
- ASA Task force on Sedation and Analgesia by non-anesthesiologists. Practice Guidelines for sedation and analgesia for non-anesthesiologists. Web site: http://www.asahq.org/publicationsAndServices/sedation1017.pdf.
- Pershad J, Gilmore B. Successful implementation of a radiology sedation service staffed exclusively by pediatric emergency physicians. Pediatrics 2006;117:e413–22.[Abstract/Free Full Text]
- Yaster M, Cravero JP. The continuing conundrum of sedation for painful and nonpainful procedures. J Pediatr 2004;145:10–12.[Web of Science][Medline]
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