Pediatric Anesthesiologist

[BloodySurgeon]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

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[IMGASMD]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

Had a locum agent told me their malpractice only covers age 2+. That’s one way I’d look at it.

 

[coffeebythelake]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

At my hospital, we can take care of children who fall under ACLS guidelines.
Younger patients who fall under PALS guidelines by default go to the peds anesthesiologists.

 

[WholeLottaGame7]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

Totally depends on your experience, comfort level, location (and support staff), patient factors, hospital requirements, etc.

At our place (non-standalone children's hospital), technically general anesthesiologists are credentialed for everything except neonates. However, as we work towards becoming a "Level One" children's surgery center, their requirements are mandatory peds-boarded for 2 and under and highly recommended for 5 and under (does not technically apply to amb surgery center, however).

In general, the patient you describe does not sound like a great ambulatory candidate and if you have the option to punt to a children's hospital, it might be wise. If not an option, keep in mind that really twitchy asthmatics can sometimes need a little epi and an overnight admission (plus the OSA), so I'd make sure both of those things are available before you get started.

 

[jwk]

We do straight bread-and-butter peds every day- T&A, ear tubes, dental restorations. Hospital policy is no inpatients under 12 years old, so we won't do any peds patients with serious comorbidities. We have two fellowship peds docs, but of course they can't be there every day. Everyone has privileges for peds.

 

[Arch Guillotti]

Hospital policy is no inpatients under 12 years old, so we won't do any peds patients with serious comorbidities.

So what do you do for a little kid with butt pus?

 

[dchz]

So what do you do for a little kid with butt pus?

Sleeping spinal?

 

[jwk]

So what do you do for a little kid with butt pus?

Ship him to one of the two world-class pediatric hospitals in town.

 

[drmwvr]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

Peruse closed claims peds cases...they're all healthy....

 

[Airway]

Scary. Glad I don't do peds

 

[coffeebythelake]

Sleeping spinal?

caudal?

 

[kidthor]

The American College of Surgeons has some good recommendations on who should care for certain ages and complexities. Ironic that ASA does not comment squarely on this, but I sort of get why (they want to allow for variations in practice without forcing things on their membership, basically).

There is a distinction between a board certified / fellowship trained pediatric anesthesiologist vs an anesthesiologist with pediatric expertise. I'm both wary and respectful of this distinction. I'm a board certified pediatric anesthesiologist and feel competent in taking care of all ages of kids. Some I've met are generalists and are competent in taking care of kids of many ages - but I think if I had to choose for my child I'd rather have me. Hubris for me vs hubris for my non-specialists colleagues? Hard to say. But for my CABG please give me a fellowship trained cardiac person.

ACS recs for level II seems on point for many situations. They recommend that anyone 5yo and younger with an ASA 3 or higher "should" be taken care of by a pediatric anesthesiologist. And any kid 2yo or younger MUST be taken care of by a pediatric anesthesiologist. I think that's fair.

And no generalist should ever take care of a neonate unless its an absolute emergency and no specialist is available.

Here's a reference link:

https://www.facs.org/-/media/files/quality-programs/csv/acs-csv_standardsmanual.ashx

Your situation is a 4 yo ASA 3 so I think that should be done by a pediatric anesthesiologist.

 

[drmwvr]

The American College of Surgeons has some good recommendations on who should care for certain ages and complexities. Ironic that ASA does not comment squarely on this, but I sort of get why (they want to allow for variations in practice without forcing things on their membership, basically).

There is a distinction between a board certified / fellowship trained pediatric anesthesiologist vs an anesthesiologist with pediatric expertise. I'm both wary and respectful of this distinction. I'm a board certified pediatric anesthesiologist and feel competent in taking care of all ages of kids. Some I've met are generalists and are competent in taking care of kids of many ages - but I think if I had to choose for my child I'd rather have me. Hubris for me vs hubris for my non-specialists colleagues? Hard to say. But for my CABG please give me a fellowship trained cardiac person.

ACS recs for level II seems on point for many situations. They recommend that anyone 5yo and younger with an ASA 3 or higher "should" be taken care of by a pediatric anesthesiologist. And any kid 2yo or younger MUST be taken care of by a pediatric anesthesiologist. I think that's fair.

And no generalist should ever take care of a neonate unless its an absolute emergency and no specialist is available.

Here's a reference link:

https://www.facs.org/-/media/files/quality-programs/csv/acs-csv_standardsmanual.ashx

Your situation is a 4 yo ASA 3 so I think that should be done by a pediatric anesthesiologist.

Should...MUST....spare us....these patients are expertly cared for in 'fly over country' every day. Moving them to where there might be a subspecialty trained anesthesiologist at the very least presents a logistical problem that in the end contributes to the presenting problem to say nothing of the family's difficulties. Definitely counter narrative...I get that. With a few notable exceptions, well trained, experienced docs can do these cases all day long. What happens in the OR isn't the problem, Sport...it's the rest of the hospital and if the anesthesiologist is unable or unwilling to follow and care for an unusually sick kid, that is the reason (in most places) to call the helicopter.

 

[kidthor]

Should...MUST....spare us....these patients are expertly cared for in 'fly over country' every day. Moving them to where there might be a subspecialty trained anesthesiologist at the very least presents a logistical problem that in the end contributes to the presenting problem to say nothing of the family's difficulties. Definitely counter narrative...I get that. With a few notable exceptions, well trained, experienced docs can do these cases all day long. What happens in the OR isn't the problem, Sport...it's the rest of the hospital and if the anesthesiologist is unable or unwilling to follow and care for an unusually sick kid, that is the reason (in most places) to call the helicopter.

In your non-specialist “flyover” scenario (and I think there probably are decent subspecialists around depending on where you are):

Expertly cared for? No...

But competently cared for? Probably / hopefully yes.

 

[Arch Guillotti]

Ship him to one of the two world-class pediatric hospitals in town.

Sounds like a waste of time and money.

 

[WholeLottaGame7]

Should...MUST....spare us....these patients are expertly cared for in 'fly over country' every day. Moving them to where there might be a subspecialty trained anesthesiologist at the very least presents a logistical problem that in the end contributes to the presenting problem to say nothing of the family's difficulties. Definitely counter narrative...I get that. With a few notable exceptions, well trained, experienced docs can do these cases all day long. What happens in the OR isn't the problem, Sport...it's the rest of the hospital and if the anesthesiologist is unable or unwilling to follow and care for an unusually sick kid, that is the reason (in most places) to call the helicopter.

There's a difference between doing an urgent/emergent case even though the "rest of the hospital" can't care for a sick kid and will require transfer to a tertiary hospital, but the case we're talking about is an elective procedure. If you're doing high-risk (and a poorly controlled asthmatic with OSA for a T&A is fairly high risk) ELECTIVE procedures at a place without the support system in place to take care of forseeable complications, that is a problem.

 

[pjl]

A few years ago (maybe 5?) the pediatric society of anesthesia said no child under a certain age should be taken care of except by a fellowship trained anesthesiologist who does >25% peds.

Or any new grad CRNA.


That was when the pediatricians started sending a lot of our kids under 2 by car about 3 hours away, even for simple cases. We even have a peds trained person, they just aren’t there every day, and don’t do 25% peds.

Somehow, that became unpopular in the community and we are back to doing all those cases except NICU kids.

 

[skankhunt42]

Circa 2012-2013= Pediatric Anesthesiology became an official fellowship. The battle cry was 'do this to take care of sick/ complex kids and work at tertiary centers in 100% pedi jobs.
From 2013-2018= Fellowships added about 70 spots to about 200 per year nationally. Spots barely filled and the pedi market became saturated. About 60-70 pure pedi jobs turnover each year despite upwards of 200 new grads per year. The battle cry was 'do a pedi fellowship if you are going to do any pedi cases anywhere.' So now we do this if you do 25% Peds in PP?
2019= 50% of pedi fellowships don't fill because people smell the BS.
2020= ?

Make a fellowship, saturate the market, move the field goal posts. Its funny how the discussion around who should anesthetized children has mirrored more the supply demand ratio of Pedi trained people and not the actual medicine behind the issues.

 

[OTCAwesome]

My group is actually looking for a peds fellowship person as we just lost one,, DM me if any of you guys are interested

 

[deleted162650]

My group is actually looking for a peds fellowship person as we just lost one,, DM me if any of you guys are interested

Would probably help if you said where you practice.

 

[OTCAwesome]

Would probably help if you said where you practice.

Very true, practice is in northeast Indiana

 

[deleted697535]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

Idk is the morbidity higher intra-op or post op for this little kid?
Id imagine the hospital infrastructure is just as important

 

[BobLoblaw78]

I'm not sure about the seriousness, but I wouldn't do a spinal or caudal with active infection in the area.

 

[btbam]

Did a 4 year old T&A with severe asthma (including hospitalizations) and OSA today. We don't have a pediatric anesthesiologist in our practice which made me wonder:

"At what age or co-morbidity will you refer to a pediatric anesthesiologist?"

I tried looking up if there are any guidelines or cut-off for age or complexity of the case and couldn't find anything substantial. Wondering if a general anesthesiologist has privileges to treat all ages but sub-specialty in pediatric will only strengthen your ability.

What was their AHI? I can't tell from your phrasing if it's severe asthma AND severe OSA. A kid you're describing would be a planned PICU admission at our hospital (high acuity peds) so yea, I wouldn't be doing this at your shop.

 

[BloodySurgeon]

What was their AHI? I can't tell from your phrasing if it's severe asthma AND severe OSA. A kid you're describing would be a planned PICU admission at our hospital (high acuity peds) so yea, I wouldn't be doing this at your shop.

Yea this was the dilemma and discussion i had with the surgeon and mother beforehand. The child had severe asthma (last hospitalization 2.5 months ago), mild OSA based on AHI, and overweight. Our hospital did not have a PICU and although i felt confident i can manage the patient in the OR i was worried about post operative care.

I posted not to discuss threshold for admission but to get a consensus of what the general anesthesiologist feels comfortable doing if the post operative care and resources are available. Although all went well if i did it again i would probably asked for an extra hand to start but probably not cancel the case and transfer patient to another hospital