In order to thrive in the current managed care environment Anesthesiology Departments need to expand their practice outside of the operating room. For pediatric anesthesiologists the opportunity exists to provide services which are designed specifically for children.
We have expanded our care outside of the operating room to include acute pain, chronic pain, palliative care, and office based anesthesia. These services provide a unique community resource for the children of Jacksonville.
Thomas Jefferson in 1786 wrote, "The art of life is the avoiding of pain." Perhaps no group is more ill equipped to avoid pain than infants and children. In 1988 the Department of Anesthesiology at Nemours Children's Clinic stepped out of the operating room and developed a Pediatric Pain Service at Wolfson Children's Hospital.
Prior to the 1960's, the medical literature offered little on the subject of pediatric pain management. In 1968, Swafford and Allen1 stated "Pediatric patients seldom need medication for relief of pain. They tolerate discomfort well. The child will say he does not feel well or that he is uncomfortable or that he wants his parent, but often he will not relate this unhappiness to pain."
Clinically this attitude manifested itself in significant under treatment of pain, particularly in the postoperative setting. In 1970, Eland2 reviewed the treatment of 25 children, age's four to eight years. The patients had surgical procedures such as amputations, nephrectomies, and atrial septal defects. Astonishingly she found that only 12 patients received an analgesic during their hospital stay. Of that 12 only 24 doses of analgesics were administered. A comparison of 18 adult surgical patients revealed that they received 372 narcotic and 299 nonnarcotic doses of analgesics. Schechter3 and others have confirmed that children received significantly less analgesia after surgery. This pattern of under treatment of pain in children continued in the intensive care setting. Commonly pain and sedation were a low priority. Children were pharmacologically paralyzed because of the fear that pediatric patients could not tolerate potent sedatives or analgesics. Reasons for under treatment of pediatric pain include limited clinical information, persistence of misinformation, and attitudes that denigrate adequate pain management.
In 1988, Wolfson Children's Hospital's Department of Pediatric Anesthesiology accepted responsibility for postoperative pain management of surgical pain. At that time most pediatric patients who received narcotics had them administered via the intramuscular route. This discourages most children from requesting analgesics, as they fear the needle as much as, if not more than, the pain.4 Compounding this, some clinicians ordered inadequate doses of analgesics at time intervals longer than could be expected to provide adequate analgesia. Mather and Mackie5 also demonstrated that nursing chose not to administer analgesics that had been ordered for children 40% of the time. The children weren't asking, the doctors weren't ordering, and the nurses weren't giving analgesics.
Initially the service offered most was patient controlled analgesia (PCA) utilizing Morphine Sulfate or Meperidine. A PCA is a device that allows a patient to self-administer a dose of analgesic within prescribed parameters. Adjustable parameters include the type of analgesic, bolus dose, incremental dose, lockout time, four-hour lockout, and background infusion. Pediatric patients age seven years and older, with support and education from the nursing staff, could safely self-administer appropriate analgesics. PCA advantages compared with traditional methods of pain management include superior analgesia, less side effects (due to superior drug titration), and increased patient and parent satisfaction. The nursing staff time requirement for analgesia administration decreased and referring physicians no longer received phone calls regarding pain for the patients on the service. These patients also have improved pulmonary function tests, decreased pulmonary complications, and enhanced activity level following surgery.6 The service transitions patients from PCA to oral narcotics prior to discharge from the hospital. Tools to assess pain utilizing physiological, behavioral, and cognitive assessment were taught to the nursing staff and recorded routinely on the medical record along with the patient's vitals.
Since 1994 the pain service has increasingly utilized postoperative epidural analgesia. For major surgery, including abdominal, orthopedic (on lower extremities), and urological procedures, epidural catheters provide excellent analgesia. For certain patients epidural analgesia has been demonstrated to reduce postoperative morbidity. Medications such as local anesthetics (i.e., Bupivicaine®) and narcotics (i.e., Fentanyl®, Hydromorphone®) can be infused through small catheters. These catheters are placed in the lumbar or caudal areas of the spinal column. Because a child's fear of the needle is so great, most pediatric anesthesiologists place the epidural catheter after the child is anesthetized. Safe analgesia is possible for these patients with minimal side effects. The service provides rounds twice daily for surgical patients. Acceptance is very high among surgeons, nurses and patients.
The service currently participates on a multispecialty team treating patients with chronic pain. The team has representation from Occupational and Physical Therapy, Behavioral Pediatrics, Gastroenterology, Orthopedics, Neurology, Pharmacology, and Rheumatology. Behavioral Pediatrics is able to provide cognitive behavioral therapy for patients and families as part of the "organic" workup of these patients. Patients with recurrent abdominal pain, reflex sympathetic dystrophy, and phantom experiences represent only a small percentage of painful conditions in children. This multispecialty team meets to discuss pediatric chronic pain management that was not offered in the past.
Patients with sickle cell disease have vaso-occlusive crises. Ischemia and infarction of the involved organ system is responsible for the severe pain. Frequently involved systems include abdominal, cardiopulmonary and musculoskeletal. About one percent of the patients have more than six episodes per year. The department is involved in pain management of children and adolescents with sickle cell disease, with the goal to develop a consistent approach to vaso-occlusive crisis. Improvement in pain management and decreased emergency room visits and hospitalization are achievable goals for these patients.
When a child has a life threatening disease and suffers a major setback, the focus may change. Before the setback, the therapy was directed at the primary disease. Now the focus is on palliative care for relief of physical, emotional, social, and spiritual distress. A Palliative Care Team was developed to facilitate the care of children with life limiting and/or terminal illnesses. The goal is to provide a consultative service for these children and their primary physicians and nurses. Pain and symptom management (i.e., dyspnea, agitation, and anxiety) is the main objective.
In the office setting, demand for anesthesia during painful procedures started in the Hematology/Oncology Clinic in the early 1990's. The desire of anesthesiologists was to care for these children in the operating room. The cost was prohibitive and it was inefficient for the hematologists/oncologists. The Oncology Clinic also provided other therapies for these patients and there was a desire to limit exposure to other children. Some Anesthesiology Departments used inhalational anesthetic agents for this type of service, but this was not practical in our setting. As most of this population has some type of central venous access, the decision was made to provide intravenous anesthesia. These patients receive intravenous anesthetic agents Propofol and Alfentanyl and breathe oxygen via a Mapleson circuit. The children are anesthetized for bone marrow aspiration, lumbar puncture, and intrathecal medication. If the child needs an intramuscular medication, he receives it while asleep. These patients are monitored with the same standard of care as in the operating suite. The children are accompanied by their parents and many times by a child life specialist. Many children lose their fear of these procedures, as they no longer associate them with pain. The child generally wakes up about two to five minutes after the procedure and many children walk out of the procedure room to a play area. We can generally do about four to six procedures per hour. The service has grown immensely with half a morning each week devoted to anesthetizing children with cancer for painful procedures. After five years experience, there have been minimal complications with only two patients transferred for inpatient services. This service is extremely popular with the families and patients needing these procedures.
Office based anesthesia specific to pediatric patients continues as an area of growth. One pediatric anesthesiologist believed that a pediatric anesthesiologist could facilitate successful outcomes for dental procedures. In the past some patients have required multiple visits to complete a dental restoration and each visit required sedation. An alternative is to bring the child to the operating room and complete the entire procedure under general anesthesia. Disadvantages of this approach include the high cost associated with ambulatory surgery centers, and many surgery centers are not fully equipped for dental cases. A pediatric anesthesiologist working in a dentist's office can provide anesthesia services that allow the dentist to complete the entire restoration at one sitting.
Newer pharmacological agents such as Propofol®, Remifentanyl®, and Midazolam® can be used intravenously to produce sedation, analgesia or anesthesia. These agents have rapid clearance profiles so that depth of sedation/anesthesia can be easily controlled. There is minimal nausea, patients awaken rapidly, and are ambulatory within 15-30 minutes. Because the drugs are given by infusion, a costly and bulky anesthesia machine is not necessary.
The growth in office space procedures has also raised concerns about safety. Some older offices are not physically suitable for procedures. Credentialing of providers is also an issue. However if basic principles of the safe practice of anesthesia and surgical care are followed, select patients undergoing select procedures can be safely cared for in the office setting.
For Anesthesiology Departments to thrive, new and unique services must be designed to meet the needs of our patients. Some of these services may change how we see our specialty; however, the future is bright for those able to accept the challenge.
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