PEDIATRIC ANESTHESIA OUTSIDE THE OPERATING ROOM: The Anesthesiologist as Pioneer

Abstract

Anesthesiologists have a history of being pioneers in health care. They have been in the forefront of exploring the properties of new medications and their uses. It has been anesthesiologists who have defined the parameters of use of not only anesthetics, such as the volatile agents, but also drugs, such as the synthetic narcotics, that have use outside the realm of operating room anesthesia. Anesthesiologists have also pioneered the use of drugs in new ways, such as nasal midazolam and transmucosal fentanyl. They have been eager and quick to explore the extended range of use of tools available to them. Anesthesiologists have in the last 30 years identified several opportunities to use their expertise to provide service outside the traditional operating room environment. In each instance, the service had two things in common. First, the knowledge and skills of the anesthesia community provided a new level of expertise. Second, at the time anesthesiologists became involved, there was a dearth of other practitioners serving the needs of patients. Anesthesiologists were among the first involved in critical care units , bringing their expertise in hemodynamic and respiratory management to an area that lacked a unified focus in the approach to acutely ill patients. As anesthesiologists increasingly provided support and care in this dynamic area, the potential for careers in critical care became obvious. In later years, anesthesiologists pioneered the principles and practice of acute and chronic pain management . Again, the potential for careers in this dynamic and overlooked area became noticeable. In both these forays outside the operating room, anesthesiologists brought a new level of patient care and service to the medical community. As these practitioners had success, however, other nonanesthesiologists became interested in these areas. Anesthesiologists began to find surgeons, internists, and pediatricians competing with them to provide service for these populations. Anesthesiologists increasingly found stiff competition to maintain their roles in areas where they had pioneered the principles of care. In many cases, anesthesiologists have been content to abandon their new areas and return to the operating room environment. Now, anesthesiologists have been asked to fill a new niche—advisor and provider of services outside the traditional operating room environment. The interest in our involvement has come for several reasons. There is an increase in diagnostic and invasive procedures performed by nonsurgeons outside the operating room. Radiologists, cardiologists, and gastroenterologists, among others, have expanded their practices by noninvasively performing evaluations and treating conditions that they previously had not done. Also, there is an increase in the number of pediatric patients undergoing procedures that require sedation or anesthesia, such as MR imaging. 15 Often the reason for sedation or general anesthesia being needed is that the child is frightened by factors such as a claustrophobic setting, the need for immobility, and the loud noise or discomfort that accompanies these studies. Another important factor is the increased appreciation by radiologists and others that there are benefits to providing sedation and proper analgesia for procedures that are either frightening or painful. Traditionally, the pediatric patient has been undertreated compared with adults in terms of both analgesia and sedation because of the fear of overdose or adverse reactions when administering medication to children. Practitioners of all types have now appreciated that the proper care of children involves provision of adequate sedation and analgesia as well as age and condition-appropriate monitoring and evaluation. Because of uncertainty about how to provide this care, many practitioners have increasingly looked to anesthesiologists to either provide this care or guide the practitioners' efforts to provide it themselves. Anesthesiologists are asked to assist with care outside the operating room in a variety of ways. In the most straightforward situation, the anesthesiologist is asked to provide general anesthesia in a manner similar to that provided in the operating room setting. In other cases, the anesthesiologist is asked to provide monitored anesthesia care (MAC) services for diagnostic and therapeutic procedures. In adults, this often has been associated with administering sedation in addition to monitoring the patient. In children, the usefulness of sedation is tempered by the need to sedate a child that is terrified versus the ease of providing general anesthesia. The anesthesia department of an institution may also be requested to assist with advice about care and development of institution-wide sedation practices that will be provided by nonanesthesiologists. This involvement has the disadvantage of removing the anesthesia service from providing clinical care under their own control (with a consequent loss of revenue). It does provide an opportunity to influence and improve pediatric care within the institution. This change in the type and level of care provided children can precipitate a major growth in sophisticated and humane management of children.