Encouraging research, education, and scientific progress in the field of pediatric anesthesia
A DRAFT of an update to the evidence based American Society of Anesthesiologists’ Guideline for the Management of the Difficult Airway is available for review and comment. The Task Force that developed this update was comprised of anesthesiologists representing thirteen international organizations. Interested members are encouraged to access the DRAFT and provide input. The DRAFT of the update may be accessed at the following site:
https://www.asahq.org/standards-and-guidelines
SPA has issued a joint statement with the American Society of Anesthesiologists, Society for Obstetric Anesthesia and Perinatology, American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in response to the article, “Association Between Epidural Analgesia During Labor and Risk of Autism Spectrum Disorders in Offspring,” a new retrospective database study published in JAMA Pediatrics on October 12, 2020. This article does not provide credible scientific evidence that labor epidurals for pain relief cause autism, and it fails to address the numerous other causes of autism that do exist. SPA is dedicated to the safety and health of pediatric patients of all ages and will continue to work with these and other organizations to foster research and education in all aspects of pediatric care. The full joint statement in response to this article can be read here:
The Board of Directors of the Society for Pediatric Anesthesia (SPA) wishes to express shock, outrage, and sadness at the recent depraved killings of African-Americans, and to acknowledge the senseless acts of violence happening across the nation. Consistent with our commitment to inclusion, mutual respect, and peaceful dialogue, we express our solidarity with the families and communities affected by these horrible acts of brutality. In this moment, we cannot remain silent, or fail to acknowledge the burden of racism that still exists in our country.
Rooted in our core mission to improve the lives of children and their families, we condemn all acts of racism, discrimination, and violence. Through future educational programming and initiatives led by SPA’s Committee on Diversity, Equity and Inclusion and Committee on Public and Professional Affairs, we pledge to actively address the issue of social injustice. We recognize the disproportionate burden that communities of color have suffered from the COVID-19 pandemic, and we reiterate our commitment to equity in health and healthcare delivery. We stand united with our patients and their families, with our friends, colleagues, and fellow citizens of color as we grieve for the senseless loss of lives, and empathize with the palpable anger being expressed via peaceful protests in our communities and cities around the country.
Dear SPA members, patients, and families,
As the COVID-19 crisis escalates in the US and around the world, the SPA urges members to follow common sense precautions that are highlighted on the Centers for Disease Control and Prevention (CDC) website. The CDC website offers advice to communities and individuals to prevent illness as well as to deal with the onset of any symptoms suggestive of a respiratory illness that may be COVID 19.
We have elected to provide you with web and social media links that are continuously updated with the latest information from professional organizations, and a few useful sites are listed below.
Please do not hesitate to contact us if you have any questions.
Sincerely,
Kirk Lalwani, MBBS, FRCA, MCR
President, SPA
Disclaimer: Content provided on this site is not intended to constitute the practice of medicine or the furnishing of medical, nursing, or professional health care advice, diagnosis, consultation, treatment, or services in any jurisdiction. The opinions expressed are not necessarily those of the Society for Pediatric Anesthesia or its Sections.
NEW!
Joint Statement on COVID-19 Vaccination of Health Care Personnel
GENERAL RESOURCES
U.S. Centers for Disease Control and Prevention (CDC) Resources
https://www.cdc.gov/
https://www.cdc.gov/coronavirus/2019-ncov/index.html
World Health Organization (WHO) Resources
https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/news-room/q-a-detail/q-a-coronaviruses
PROFESSIONAL ORGANIZATIONS
American Society of Anesthesiologists (ASA) Website
https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information
Society for Critical Care Medicine
https://www.sccm.org/disaster
Pediatric Intensive Care Society
https://picsociety.uk/covid19/
Anesthesia Patient Safety Foundation (APSF)
www.apsf.org
https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-novel-coronavirus-covid-19/
American Academy of Pediatrics (AAP)
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/
https://redbook.solutions.aap.org/selfserve/ssPage.aspx?SelfServeContentId=rbo_outbreaks_page_3
Association of Anaesthetists Webinars
https://anaesthetists.org/
American College of Emergency Physicians
https://www.acep.org/corona/COVID-19/
Children’s Hospital Association (CHA)
https://www.childrenshospitals.org/covid19
https://www.childrenshospitals.org/-/media/Files/CHA/Main/Quality_and_Performance/covid19/covid_cha_pediatric_consolidation_guidance.pdf
Pediatric Anesthesia Journal – International Links and Resources
https://onlinelibrary.wiley.com/page/journal/14609592/homepage/covid-19
John’s Hopkins Coronavirus Resource Center
https://coronavirus.jhu.edu/
WFSA
https://www.wfsahq.org/resources/coronavirus
University of Melbourne Updates
COVID-19 kids research evidence update
ADARPEF (French Resources)
http://e-adarpef.fr/covid-19/
SEDAR (Spanish Resources)
https://pedsanesthesia.org/wp-content/uploads/2020/04/2020_Ped_Covid19_recomendaciones_final.pdf
STATEMENTS
ASA- multiple patients on one ventilator
https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/joint-statement-on-multiple-patients-per-ventilator
ASA/ACS/AORN- Surgical triage
https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/joint-statement-recommending-a-surgical-review-committee-for-covid-19-related-surgical-triage-decision-making
ASA/APSF- Anesthesia machines as ventilators
https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information/purposing-anesthesia-machines-for-ventilators
ASA/ACS/AHA/AORN – Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic
https://www.asahq.org/about-asa/newsroom/news-releases/2020/04/joint-statement-on-elective-surgery-after-covid-19-pandemic
RESOURCES FOR PHYSICIANS
Latest Medical Literature
https://www.ncbi.nlm.nih.gov/research/coronavirus/
Pediatric Literature Summary
https://onlinelibrary.wiley.com/doi/full/10.1111/pan.13889
https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
JAMA Network
https://jamanetwork.com/journals/jama/pages/coronavirus-alert
Ventilator Simulator/Training
https://www.openpediatrics.org/assets/simulator/ventilator-simulator
Pediatric COVID Airway Management Guidelines: Pediatric Difficult Intubation Registry (PeDI) Collaborative and the Canadian Pediatric Anesthesia Society
https://journals.lww.com/anesthesia-analgesia/Abstract/publishahead/Pediatric_Airway_Management_in_COVID_19_patients__.95683.aspx
Airway Safety Movement
https://www.airwaysafetymovement.org/
Airway Management: Consensus Guidelines
https://onlinelibrary.wiley.com/doi/10.1111/anae.15054
Epidemiology
https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56
https://link.springer.com/article/10.1007/s12630-020-01620-9
https://www.nejm.org/doi/full/10.1056/NEJMc2004973?query=featured_home
https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf
ENT
Practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchosopy during the COVID-19 pandemic
https://www.sciencedirect.com/science/article/pii/S0165587620301737?via%3Dihub
Pediatric Microlaryngoscopy and Bronchoscopy in the COVID-19 Era
https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2765507
Ethics
https://jamanetwork.com/journals/jama/fullarticle/2764239
Using Chloroquine to treat COVID-19
https://advances.massgeneral.org/research-and-innovation/article.aspx?id=1145
COVID Refresher for Anesthesiologists and Intensivists, by Dr. Jen Lau, MD
https://pedsanesthesia.org/wp-content/uploads/2020/03/J.-Lau-COVID-19-for-SPA-3.19.20.pdf
Intraoperative and ICU Management
Donning and Doffing PPE Videos from UCSF
https://infectioncontrol.ucsfmedicalcenter.org/covid/donning-and-doffing-novel-coronavirus-covid-19-videos
Intensive Care/Ventilation
https://link.springer.com/article/10.1007/s00134-020-06033-2?tk=eo_8ec810cc-57e5-4bc1-bb85-e22b9e068904_JOUOgWdVMbWC4XIzzfHwSizVS09ocy3MoJOK
Ventilator Management Tips
https://pedsanesthesia.org/wp-content/uploads/2020/03/Ventilator-Management_Covid-19-ICU-EXPERT-OPINION-Gattinoni.pdf
Practical Recommendations for ICU and Anesthesia Teams
https://pedsanesthesia.org/wp-content/uploads/2020/03/Wax-Christian2020_Article_PracticalRecommendationsForCri.pdf
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_home
https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=featured_home
Immunology
https://www.nature.com/articles/s41423-020-0400-4
Multisystem Inflammatory Syndrome in Children (MIS-C)
https://www.aappublications.org/news/2020/05/14/covid19inflammatory051420
https://emergency.cdc.gov/han/2020/han00432.asp
https://hosppeds.aappublications.org/content/early/2020/04/06/hpeds.2020-0123
COVID and the CVS
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047549?tk=eo_8ec810cc-57e5-4bc1-bb85-e22b9e068904_JOUOgWdVMbWC4XIzzfHwSizVS09ocy3MoJOK
COVID-19 FAQ’s in Pediatric Cardiac Surgery
https://chss.org/FAQ.cgi
COVID and Renin Angiotensin Blockers
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047022?tk=eo_8ec810cc-57e5-4bc1-bb85-e22b9e068904_JOUOgWdVMbWC4XIzzfHwSizVS09ocy3MoJOK
Aerosol and Surface Stability of the Coronavirus
https://www.nejm.org/doi/10.1056/NEJMc2004973?tk=eo_8ec810cc-57e5-4bc1-bb85-e22b9e068904_JOUOgWdVMbWC4XIzzfHwSizVS09ocy3MoJOK
CPAS Webinars
https://www.pediatricanesthesia.ca/education/70-2nd-covid-19-and-the-pediatric-anesthesiologist-webinar
Other Physician Resources
https://www.anesthesia.utoronto.ca/news/coronavirus-and-safety-precautions
https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf
http://csahq.org/issues-advocacy/covid-19-resources
JAMA Interview with Dr. Cecconi from Italy
https://www.youtube.com/watch?v=TKS1pahoPRU
Canadian Journal of Anesthesia
https://link.springer.com/article/10.1007/s12630-020-01620-9
The New Yorker: How Does the Coronavirus Behave Inside a Patient?
https://www.newyorker.com/magazine/2020/04/06/how-does-the-coronavirus-behave-inside-a-patient
The New Yorker: From Bats to Human Lungs, the Evolution of a Coronavirus
https://www.newyorker.com/science/elements/from-bats-to-human-lungs-the-evolution-of-a-coronavirus
Science: How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes
https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes
Resource Document from China, in English
https://pedsanesthesia.org/wp-content/uploads/2020/03/China-Resources.pdf
ACGME FOR TRAINEES AND PROGRAM DIRECTORS
https://acgme.org/Newsroom/Newsroom-Details/ArticleID/10111/ACGME-Response-to-the-Coronavirus-COVID-19
Wellness and Healthcare Workers
“Human Factors Messages While Working Under Pressure”
https://chfg.org/key-human-factors-messages-to-support-the-nhs/
Keeping Healthcare Workers Safe
https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers
Caring for Yourself and Others During Disasters
https://vimeo.com/398097042
Yale’s massively popular ‘happiness’ course is available free online
https://www.cnn.com/2020/03/23/health/yale-happiness-course-wellness/index.html
Vital Signs in Anaesthesia: A guide for anaesthetists seeking help and advice during the COVID crisis
https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Vital_Signs_in_Anaesthesia2020.pdf?ver=2020-03-31-134435-910
Discounts
https://blog.healthjobsnationwide.com/freebies-discounts-frontline-medical-workers/
Marriott International – Community Caregiver Discount
https://pedsanesthesia.org/wp-content/uploads/2020/03/Marriott-International-Community-Caregiver-Rate.pdf
SOCIAL MEDIA COVERAGE
Twitter
@CDCGov #COVID #Covid_19 #COVID19 #COVID-19 #coronavirus
Facebook COVID Group for Physicians ONLY
https://www.facebook.com/groups/novelcoronavirusdoctorsonly/
RESOURCES FOR STRESS, ANXIETY, WELLNESS
US Centers for Disease Control & Prevention (CDC):
Coping with Stress
https://www.cdc.gov/violenceprevention/suicide/copingwith-stresstips.html
Mental Health and Coping During COVID-19
https://www.cdc.gov/coronavirus/2019-ncov/about/coping.html
Taking Care of your Emotional Health
https://emergency.cdc.gov/coping/selfcare.asp
American Psychiatric Association (APA):
Coronavirus & Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks
https://www.psychiatry.org/news-room/apa-blogs/apa-blog/2020/02/coronavirus-and-mental-health-taking-care-of-ourselves-during-infectious-disease-outbreaks
Center for the Study of Traumatic Stress (CSTS):
Coronavirus & Emerging Infectious Disease Outbreaks Response
https://www.cstsonline.org/resources/resource-master-list/coronavirus-and-emerging-infectious-disease-outbreaks-response
Taking Care of your Family during Coronavirus Fact Sheet
https://www.cstsonline.org/assets/media/documents/CSTS_FS_Corona_Taking_Care_of_Your_Family.pdf.pdf
American Psychological Association:
Research Information: Pandemics
https://www.apa.org/practice/programs/dmhi/research-information/pandemics
Five ways to view coverage of the Coronavirus
https://www.apa.org/helpcenter/pandemics
Speaking of Psychology: Coronavirus Anxiety
https://www.apa.org/research/action/speaking-of-psychology/coronavirus-anxiety
RESOURCES FOR HOME
https://www.cdc.gov/coronavirus/2019-ncov/community/home/index.html
RESOURCES FOR PARENTS
US Centers for Disease Control & Prevention (CDC):
Helping Children Cope with Emergencies
https://www.cdc.gov/childrenindisasters/helping-children-cope.html
The National Child Traumatic Stress Network:
Parent/Caregiver Guide to Helping Families Cope with COVID-19
https://www.nctsn.org/sites/default/files/resources/fact-sheet/outbreak_factsheet_1.pdf
IASC – Inter-Agency Standing Committee
My Hero is You, Storybook for Children on COVID-19
https://interagencystandingcommittee.org/iasc-reference-group-mental-health-and-psychosocial-support-emergency-settings/my-hero-you
National Public Radio:
Just for Kids: A Comic Exploring the New Coronavirus
https://www.npr.org/sections/goatsandsoda/2020/02/28/809580453/just-for-kids-a-comic-exploring-the-new-coronavirus
New York Times:
Talking to Teens & Tweens about Coronavirus
https://www.nytimes.com/2020/03/02/well/family/coronavirus-teenagers-anxiety.html
Multisystem Inflammatory Syndrome in Children (MIS-C)
https://www.aappublications.org/news/2020/05/14/covid19inflammatory051420
https://www.doh.wa.gov/Emergencies/NovelCoronavirusOutbreak2020/ParentsCaregivers
https://childmind.org/about-us/
https://archive.org/details/nationalemergencylibrary
Online Learning Resources for Parents
https://sea.mashable.com/tech/9719/online-learning-websites-thatll-level-you-up-during-the-coronavirus-lockdown
https://www.cde.ca.gov/ci/cr/cf/distancelearnresources.asp
https://www2.ed.gov/parents/landing.jhtml
https://www.childwelfare.gov/topics/preventing/prevention-programs/parented/education-resource/
Joint Statement from the American Society of Anesthesiologists, the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation Regarding the Use of Deep Sedation/General Anesthesia for Pediatric Dental Procedures Using the Single-Provider/Operator Model
The late 20th and early 21st centuries have seen a continuous reduction in mortality and morbidity from intraoperative and periprocedural accidents involving sedation and general anesthesia for children. In the last 31 years, the American Society of Anesthesiologists (ASA) and the American Academy of Pediatrics (AAP) have separately created guidelines for the management of children and adults based on a rigorous examination of the scientific literature.1-4 There are minor differences in the statements from these two groups, but the provision of a second well-trained professional capable of monitoring the patient, managing the airway, establishing venous access for the administration of rescue medications, and resuscitation is an essential feature common to both. This approach is termed the multi-provider team-based safe practice model, as the surgeon or proceduralist and the professional responsible for the monitoring and sedation of the patient are two distinct individuals with separate patient-specific tasks.5
The oral surgery community has practiced a different approach to providing sedation/anesthesia for children. The single-provider/operator practice model, whereby the operating dentist is simultaneously performing the procedure and directing the anesthesia or deep sedation, that they have embraced, uses a dental assistant as the monitoring entity.6 This person has virtually no hands-on or formal medical training, cannot administer drugs, cannot establish venous access and cannot reliably provide definitive airway assistance. These activities, critical to the safe administration of sedation, are outside the scope of practice of a dental assistant.
The goal of procedural sedation is to provide anxiolysis, analgesia and amnesia. Safety requires proper pre-sedation evaluation, fasting, informed consent and a systematic approach that includes physiologic monitoring, age and size-appropriate equipment, knowledge of the pharmacology of all medications administered for sedation, antagonism and resuscitation, appropriate recovery observation, and strict discharge criteria. Sedation is a continuum, and each patient is unique. The response to a particular dose of medication or combination of medications may result in minimal sedation in one child but deep sedation/general anesthesia in another. A life-threatening emergency may occur at any time, regardless of health status. One must always be prepared for unexpected adverse events. For children, this most commonly means compromised breathing (apnea, airway obstruction, laryngospasm). The concept of swift recognition of crisis and rescue is essential, i.e., if one intends to provide moderate sedation, the provider must have the skills to rescue from deep sedation, and if the intent is to provide deep sedation, then one must have the skills to rescue from a state of general anesthesia. The needed flexibility in the management of the child is why, over the past 31 years, sedation guidelines have evolved to include specific skill sets for practitioners administering sedation. At a minimum, the sedation provider must be “able to provide advanced pediatric life support (PALS) and capable of rescuing a child with apnea, laryngospasm, and airway obstruction. Required skills include the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, laryngeal mask airway) and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation.”1 A second observer, who is also skilled, and PALS certified, must also be present to assist with the anesthetic emergency while additional support is summoned; this is particularly critical in a dental office-based setting as the only backup is to call 911.7
The AAP recently updated their Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures.1 The original 1985 guideline was developed following concerns regarding children in California who died undergoing dental or oral surgery procedures.8 The guideline has now matured to include the latest in anesthesia monitors including capnography. Input from pediatric physician anesthesiologists, pediatric emergency medicine specialists, pediatric intensivists, the American Academy of Pediatric Dentistry (AAPD), dentist anesthesiologists and others, provided sound recommendations regarding the skills needed to provide a multi-provider team-based safe practice model for deep sedation and general anesthesia for children undergoing dental procedures. Most importantly, the guideline now specifies that a separate skilled anesthesia trained provider must administer sedation/anesthesia and be the independent observer; the operating oral surgeon or dentist must be PALS certified to provide skilled help should an emergency arise.
Unfortunately, the AAP guideline update was prompted by continued tragic outcomes in children undergoing dental or oral surgery procedures, ironically some in California.5,9-13 These deaths or injuries were directly related to a different treatment paradigm from that recommended by the AAP, the American Society of Dentist Anesthesiologists (ASDA), the AAPD, and ASA.9-12,14 The single-provider/operator practice model advocated by the American Association of Oral and Maxillofacial Surgeons (AAOMS) allows the oral surgeon to direct sedation/anesthesia while simultaneously performing the procedure. With the single-provider/operator practice model, crucial monitoring of the child’s vital signs may be left primarily to a dental assistant who is not medically trained and is incapable of assisting with a life-threatening medical emergency (e.g., laryngospasm, apnea, seizure, anaphylactic reaction). All other sedation guidelines specifically require a skilled observer who is PALS certified, whose only responsibility is to observe the patient and is capable of assisting with emergencies. The oral surgery community has developed a nationwide program called DAANCE (Dental Anesthesia Assistant National Certification Examination) specifically designed to circumvent the recommendations of the AAP patient care multi-provider team-based safe practice model. This program of self-directed study has no accredited educational requirements and consists of 36 hours of online education and an online examination. The prerequisite of this AAOMS certification program only consists of a current cardiopulmonary resuscitation (CPR) or basic life support (BLS) card.6
With this minimal online review, the AAOMS claims that Dental Anesthesia Assistants (DAA) are said to “possess the expertise to provide supportive anesthesia care safely and effectively.6 The DAA is knowledgeable in the perioperative and emergent care management of patients undergoing office-based outpatient anesthesia.” We are at a complete loss as to how such an individual with no real-life medical experience and no significant hands-on training could provide skilled help with a life-threatening event since DAANCE does not even qualify participants to draw up or independently administer medications. Even if trained to do so, drawing up and administering anesthetic or resuscitative medications runs counter to most state dental regulations where dental assistants cannot even administer intra-oral local anesthesia.6 With the single-provider/operator practice model, the only medically skilled individual may be a single oral surgeon. Imagine the child who develops laryngospasm during a procedure. The oral surgeon or dentist must simultaneously attempt to clear the airway, perform bag/mask ventilation, start an I.V., and draw up and administer lifesaving medications since the DAA is incapable of providing skilled help to rescue the child. The oral surgeon must stop providing oxygenation with bag-mask ventilation with the hope of rapidly establishing venous access and administration of rescue medications before a hypoxic injury.11,12,15-17
The model that the AAOMS continues to embrace does not ensure an appropriately qualified, dedicated monitor who is prepared to meaningfully help in the event of a patient emergency. ASA, the Society for Pediatric Anesthesia (SPA), the ASDA, and the Society for Pediatric Sedation (SPS) in the interest of safe oral surgery/dental care for all children, endorse the highest standards for procedural monitoring, administration of sedating drugs, and resuscitation by trained professionals independent of the operating surgeon/dentist, as clearly stated in the revised AAP guidelines. The use of a second oral surgeon to manage sedation, monitoring and rescue would be entirely consistent with this standard.18,19 The standards that continue to be espoused by the AAOMS are wholly inconsistent with the standards of practice for any clinician under any circumstance involving elective pediatric care, including those of the World Health Organization.19 We call on oral surgeons and other dental practitioners who provide deep sedation or general anesthesia using the single-provider/operator model to abandon this practice for the care of pediatric patients sedated in dental offices.
Raeford Brown, M.D., FAAP
Professor of Anesthesiology and Pediatrics
The University of Kentucky
Charles J. Coté, M.D., FAAP
Professor of Anesthesia (Emeritus)
Harvard Medical School
Linda J. Mason, M.D., FASA
ASA President
Kirk Lalwani, M.D.
SPA President
Cynthia Fukami, D.M.D., M.S.
ASDA President
Susanne Kost, M.D., FAAP, FACEP
SPS President
SPA-AAP Pediatric Anesthesiology 2025
March 28-30, 2025
Orlando World Center Marriott
Orlando, FL
Mobile Meeting Guide
Registration
Hotel Reservations