The dilemma of paediatric anaesthesia

Children are not miniature adults. Their bodies and reactions to anaesthesia are different, sometimes making surgery more difficult and risky, especially for infants


The soul-searching among anaesthesiologists at Kaiser Permanente's hospital in the San Fernando Valley, California, USA, began in 1999, after two-month-old Grant Wray nearly died as he was being sedated for hernia surgery.

Doubts grew the following year when 19-month-old Jose Fajardo III suffered throat spasms during anaesthesia, then died in the hospital's outpatient surgery centre.

General anaesthesiologists at the hospital questioned whether they could safely care for children so young; they implored hospital leaders to send these patients elsewhere or hire paediatric specialists.

Hospital administrators said the two cases were aberrations and strongly defended using general anaesthesiologists for paediatric surgeries. They did, however, make some changes, such as enlisting neonatologists, who specialise in caring for newborns, to help sedate the youngest infants.

Now, more than three years after Grant's cardiac arrest, administrators at this Kaiser and many of the hospital's anaesthesiologists remain at odds. But the dispute has significance beyond the walls of the Southern California hospital: It dramatises a national debate about how much training and experience anaesthesiologists need to safely care for young children.

Most experts agree that paediatric anaesthesia is a speciality markedly different from its adult counterpart, involving different equipment, doses and techniques. Children are not miniature adults. Their bodies and reactions to anaesthesia are different, sometimes making surgery more difficult and risky, especially for infants.

Experts say that children fare better when their doctors handle a steady paediatric caseload.

But many hospitals don't have such a stream of patients, and paediatric expertise is in short supply. As a result, some community hospitals rely on general anaesthesiologists for paediatric cases -sometimes with the help of neonatologists.

Several states in the U.S. have formed task forces to study the issue. California Children's Services, a state programme that pays for specialised paediatric care, is considering a proposal to require participating anaesthesiologists to treat at least 25 infants and children annually.

"There's a general consensus among people that anaesthesiologists who take care of kids all the time are more comfortable with what they're doing and do a better job," said Dr. Mark Singleton, a San Jose, California, anaesthesiologist who is on the state's task force.

At the Kaiser, doctors trace the turmoil to what should have been a routine hernia operation on a two-month-old boy in November 1999. At the start of the operation, anaesthesiologists were unable to get enough air into Grant Wray's lungs, so they inserted a tube into his trachea, according to medical records obtained by the Los Angeles Times with the permission of Grant's parents. The boy's heart rate slowed, and he had a cardiac arrest.

Grant's parents remember hearing the hospital's loudspeakers broadcast a "code pink" in Operating Room No. 7, where Grant was. Moments later, three doctors walked toward them in the waiting area.

"'There's been complications'," Kelly Wray remembers the physicians telling her. "My heart dropped. I thought he was gone at that point. I thought he had died."

He nearly did. The OR staff called the neonatology unit for help, performed CPR and other procedures -and the boy was revived.

In the child's medical record, paediatric neurologist Dr William Goldie - called in after Grant experienced breathing problems - wrote: "It is difficult to determine exactly what went wrong."

But an independent expert who reviewed Grant's medical records for The Times said he has a good idea: The anaesthesiologist initially used a breathing tube that was too narrow to provide sufficient oxygen to a child of Grant's age and weight.

"The tube size they put in clearly shows that they didn't know what they were doing," said Dr William J. Greeley, chair of anaesthesiology and critical care medicine at Children's Hospital of Philadelphia, a respected paediatric centre."You wonder about their capability if they can't judge something as simple as the right size tube," added Greeley, past president of the Society for Paediatric Anaesthesia.

Dr Denise Emmons, the Kaiser anaesthesiologist who handled Grant's case, declined to comment. Dr Thomas Schares, the current chairman of the anaesthesiology department, was not at the hospital at the time of Grant's case, but acknowledged in a recent interview that the tube may have been too small.

Eight months after Grant's case, the Fajardo boy was brought to the outpatient surgery centre at the hospital for an operation to correct a muscular condition that caused his eyes to wander. Moments after anaesthesia was delivered, the boy experienced throat spasms, according to medical records obtained by The Times, with his parents' permission. Doctors also had difficulty inserting an IV into his arm and getting oxygen into his lungs.

This time, the patient died.

After reviewing Jose's records at The Times' request, Greeley blamed - at least in part - anaesthesiologists' use of isoflurane, a pungent anaesthetic gas that irritates the airway and causes some children to have vocal-cord spasms. Several other gases are considered better and safer to start anaesthesia, he said.

"If you showed this to 100 anaesthesiologists in the country, I bet a large majority would say that this is inappropriate," Greeley said. "The anaesthetic care is so egregious. It's clearly injurious to the health of children."

In the months afterward, tensions at the hospital escalated. Early last year, 11 of the hospital's 12 anaesthesiologists wrote in an e-mail to hospital administrators that they didn't feel comfortable handling surgeries for babies and sick children.

"We have neither the resources nor relevant experience to safely manage these high-risk patients," they wrote on February 7. "Either these patients can be referred out to another Kaiser facility for their care, or this medical centre can contract with an outside paediatric anaesthesia group to provide anaesthesia support services."

Kaiser officials said that Jose's death in 2000 is the only paediatric anaesthesia-related fatality in the hospital's 16 years of operation. They also said that individual anaesthesiologists can request an exemption from handling paediatric cases, but that none have.

"No patients have been put at risk in this medical centre. I wouldn't allow it," said Dr Jeffrey Weisz, the hospital's medical director.

Although the dispute at Kaiser has at times become personal, experts say the broader issue is relevant to any hospital that anaesthetises children for surgery.

Research has shown that infants and young children have a higher incidence of complications from anaesthesia, including cardiac arrest and death, compared with adult patients. And two studies have suggested that infants cared for by general anaesthesiologists have a higher incidence of cardiac arrest and oxygen loss during surg