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British Journal o f Anaesthesia 1994; 73: 559-563
Postal survey of paediatric practice and training among consultant
anaesthetists in the UK
P. A. ST O D D A RT , L. B R E N N A N , D. J. H A T C H AN D R. B I N G H A M
Summary
A postal survey of previous paed iatric anaesthetic
training, current paediatric experience
and man-
agement of an infant p yloromyotom y was under-
taken among consultant anaesthetists
in the
UK.
A
total of 851 questionnaires were returned, giving a
response rate of
31
; 3 52 (41 ) consultants had
at
least
one
paediatric list each we ek,
180 (21 )
anaesthetized more than one infant less than 6
months
old
each month
and 373 (44 ) had
obtained more than 6 months ' specialist training.
Consultants trained most recently
had
received
significantly longer P <
0.001)
specialist training
thanthe irseniorcolleag ues: 558 (66 ) consultants
dealt with infants requiring
a
pyloromyotomy,
348
with one or two cases annually. T wo -third s pre-
ferred
to use an i.v.
induction technique
and
less
than half used cricoid pressure. Choice of technique
was related to the duration of specialist paediatric
training
and
when
it was
received,
but not to
current paediatric anaesthetic experience. The
results are discussed in relation to recently pub lished
recommendations on paediatric anaesthetic
services.
B. J.
Anaesth. 1994;
73:
559- 563 )
K e y w o r d s
Anaesthesia, paediatric. Anaesthesia, audit.
The provision of anaesthetic services for young
children is challenging for both individual anaes-
thetists and the health service as a whole. Metho ds of
improving the latter have recently been considered
by the Audit Commission [1]; it recommended that
purchasing health authorities should develop
strategies to ensure that children are concentrated in
separate operating lists. This would minimize the
number of different surgeons and anaesthetists
involved, so tha t only staff w ith sufficient skill and
experience would care for children. Additionally, an
excellent training opportunity would be provided
[2].
These policies follow the 1989 NCEPOD report
[3] which found that th e outcome
of
surgery
and
anaesthesia in children is related to the experience of
the clinicians involv ed and stated that surgeons and
anaesthetists should not unde rtake occasional
paediatric practice.
No
recommendation was made
on the level of paediatric experience a consultant
anaesthetist should have and maintain to be deemed
compe ten t in the care of sick children. Lu nn [4]
has subsequently suggested that designated
child ren's ana esthetists should have received a
' ' reasonable amoun t of training as a senior r eg istra r''
and moreover, currently anaesthetize 300 children
less than
10
yr old, 50 children less than 3 yr old and
12 infants less than 6 mon ths old annually.
The British Paediatric Association [5] endorsed
Lunn's suggestions, although they recommend that
consultant anaesthetists designated
for
care
for
children should have a regular weekly paediatric
commitment, equivalent
to at
least
one
full list,
without stipulating the number of any particular age
group. Furthermore, if any hospital is unable to
provide such competent
staff,
arrangements should
be made for the children especially those less th an
3
yr
requiring em ergency surgery,
to
be transferred
to another hospital with the necessary expertise.
The duration of paediatric anaesthetic training
required by anaesthetists caring for children has
recently been addressed by the Joint Committee for
Higher Training of Anaesthetists (JCHTA) [6]; they
recommend that
all
consultan ts sh ould receive
3
months' specialist training, consultants with
an
interest in paediatric anaesthesia working in a district
hospital should have at least 6 mon ths, w hile those
with a full-time paediatric commitment should have
a minimum of 12 m onth s' specialist training.
If fully implemented, these recommendations will
have major implications on the organization of
anaesthetic services for young children in the UK.
We have therefore undertaken a postal survey to see
to what extent the level of previous specialist train ing
and continuing anaesthetic practice in children less
than 3 yr of age are being met by consultant
anaesthetists who are currently pro viding a service to
young children.
The consultants were also asked about their
anaesthetic management of a 4-week-old infant
requiring a pyloromyotomy for congenital pyloric
stenosis. This was chosen as an index case as it
represents the comm onest surgical condition
affecting small infants [7].
Methods
The survey consisted of a questionnaire which was
conducted initially among colleagues at both the
P. A.
STODDART,
BSC
MRCP(UK), FRCA,
D. J.
HATCH, FRCA,
R.
BI N G HAM, FRCA,
Hospital for Sick C hildren, G reat Ormond
Street , London WC1 N 3JH. L.
BREN NAN , B SC, FRCA,
St T h om as
Hospital , London SE 1 7E H. Accepted for publicat ion: Apri l 26
1994.
Correspondence to R . B .
b y g u e s t onM a y1 8 ,2 0 1 6
h t t p : / / b j a . oxf or d j o ur n a l s . or g /
D o wnl o a d e d f r om
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560 British Journal of Anaesthesia
Table 1
Num ber of consultant anaesthetists according to their
main place of work and current paediatric experience. *Other
specialist units were: not specified =18, cardiac = 6,
neurosurgery = 3, orthopaedic = 2, ophthalmic = 2,
burns/plastics = 2. fOther were: community dental =11,
private = 7, military = 5, postgraduate medical school = 1
Main place of paediatric practice
District hospital
Teaching hospital
Specialized paediatric unit
Other specialist unit*
Otherf
Not stated
Total
Current paediatric practice
Less than one list each week
More than one list each week
Not stated
Number of children aged 6-36 months
anaesthetized annually
< 12
13-24
25-18
> 4 8
Not stated
Number of children < 6 months
anaesthetized annually
< 6
6-12
13-24
> 2 4
Not stated
n
57 3
163
4 8
33
2 4
10
85 1
49 2
35 2
7
184
2 2 0
196
2 46
5
47 5
19 6
79
101
0
0/
/o
67
19
6
4
3
1
58
41
1
2 2
2 6
2 3
2 9
1
56
2 3
9
12
0
Hospital for Sick Children, Great Ormond Street
and St Thomas' Hospital. After modification it was
enclosed with a covering letter and pre-paid envelope
in the May 1993 edition of the fellow's co py of
British Journal of Anaesthesia
that was sent to all
fellows of the Royal College of Anaesthetists in the
UK. The covering letter asked for consultant
anaesthetists who anaesthetize c hildren less than 3 yr
old to complete a questionnaire.
The relationship between duration of training and
time elapsed since training was examined using
Spearman's correlation coefficient; the Mann-
Whitney test was used to relate these times to cu rrent
paediatric workload and the preferred management
of a case of infant pyloromyotomy. The chi-square
test (with Yates' correction) was used to relate
treatment preference to paediatric workload.
Results
There were 851 completed questionnaires returned
from a total of 4500 that were circulated. The actual
response rate is difficult to estimate as the most
recent data from the Department of Health on the
number of consultant anaesthetists in the UK are
based on figures from September 30, 1991 [personal
communication, Department of Health]. At that
time there were 2708 consultants. Moreover, con-
sultants who are not fellows of the Royal College of
Anaesthetists would not have received a question-
naire and only consultants who anaesthetize children
less than 3 yr of age were asked to reply.
The majority of responding consultants' main
place of paediatric practice was in district h ospitals,
with most spending less than a list a week anaes-
thetizing children (table 1). Only
29
of consultants
anaesthetized more than 48 children between 6
months and 3 yr old annually, with 2 1 % anaes-
thetizing more than 12 infants less than 6 mo nths old
annually.
Just over 50 of consultants anaesthetizing more
than one small infant each m onth worked in either a
teaching hospital or specialist paediatric unit (table
2 ).
Eighty percent of these consultants also anaes-
thetized mo re than one child less than 3 yr each
week. They had significantly longer training in
paediatric anaesthesia P
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Postal survey of paediatric practice in UK
561
Table
3
Num ber of consultants anaesthetizing infants for
pyloromyotomy
1001
Number of infants anaesthetized
None
1-2
3-7
8-12
> 12
Not stated
Total number of consultants
n
2 88
34 8
175
2 3
12
5
55 8
o/
/o
34
42
2 0
3
1
0
66
Table 4 Num ber of consultants and their preferred anaesthetic
technique
n
%
Induction
Local anaesthesia
Awake intubation
Inhalation
I.v.
Not stated
Airway maintenance
None
Mask and airway
Laryngeal mask
Intubation
Not stated
Cricoid pressure used
Y es
N o
Not stated
3
2 0
168
36 5
2
3
2
2
54 9
2
2 47
30 1
8
0
3
30
66
0
0
0
0
99
0
45
54
1
DG H
Figure 1 Duration of paediatric training according to place of
work. (• ) = > 12 months, (0 ) = 7-12 m onths, (Ej) = 3-6
months, (D) = < 3 months. DH = District hospital, TH =
teaching hospital, SPU = specialist paediatric hospital, OSU =
other specialist hospital, O = other.
10 0
i
75 •
50 •
o
o
25 -
>20
10-20
Time since trainin g (years)
Figure 2 Changes in the duration of paediatric anaesthetic
training. (• ) > 12 months, (0 ) = 7-12 months, (H) = 3-6
months, (D) = < 3 months.
Table 5 Num ber of consultant anaesthetists managing infants for pyloromyotomy according to their place of
work, previous paediatric anaesthetic training, current experience and preferred anaesthetic technique (% =
percentage of total number, n). SPU = Specialist paediatric unit, OSU = other specialist unit. APA = Association
of Paediatric Anaesthetists
Place of work
District hospital
Teaching hospital
SP U
OSU
Other
Not stated
APA members
Training
< 3 months
3-6 months
> 6 months
Not stated
When
<
10
yr ago
10-20 yr ago
> 20 yr ago
Not stated
Work load
> 1 per pa ediatric list
per week
> 12 under 6
months old per year
Consultants
anaesthetizing for
pyloromyotomy
r = 558)
(*( ))
447 (80)
52(9)
40(7)
3(1)
13(2)
3(1)
47(8)
109
(20)
192 (34)
252(45)
5(1)
245
(43)
184
(33)
93(17)
36(6)
260(46)
141 (25)
Inhalational
induction
(n = 168)
(»(%))
145
(86)
8(5)
10(6)
0(0)
5(3)
0(0)
7(4)
47(28)
63(38)
55
(33)
3 ( 2 )
41 (24)
68(40)
43 (26)
3C2)
77(46)
3 6 ( 2 2 )
I.v.
induction
(n = 365)
(«(%))
283
(78)
43(12)
30(8)
2(5)
6 ( 2 )
1(0)
40(11)
56(15)
122 (33)
185(51)
2 (1 )
199
(55)
105
(29)
44(12)
17(5)
169(46)
101 (27)
Cricoid
pressure
(n = 247)
(n (%))
192
(78)
26(10)
2 2 ( 9 )
2(1)
5(2)
0(0)
25 (10)
36(15)
79 (32)
130
(52)
2 (1 )
131
(53)
71 (29)
32(13)
14(6)
125(51)
83 (29)
No cricoid
pressure
(n = 301)
(«(%))
250 (83)
25(8)
18(6)
1(0)
6 ( 2 )
1(0)
21(7)
71
(24)
109(36)
118(39)
3(1)
109
(36)
111
(37)
60(20)
21(7)
126
(42)
67 (22 )
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562
British Journal of Anaesthesia
paediatric anaesthesia, except for those working in
specialist paediatric units. In these units, 72 % had
received more than 12 months' training (fig. 1).
The duration of paediatric training appeared to
have chan ged, with a significant P
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Postal survey of paediatric p ractice in UK
563
intubation has previously been associated with an
increased incidence of hypoxaemia [10]. In this
survey only three of 20 advocates of awake intu bation
meet Lunn's current experience criteria for a
children's anaesthetist (all three were trained more
than 10 yr ago). Altho ugh awake intuba tion for
newborns was widely taug ht u ntil the m id-1980s, it
has been emphasized that infants for pyloromyotomy
are usually too lusty for awake intubation [14].
The role of cricoid pressure in congenital pyloric
stenosis was not clearly defined, with only
45
% of
responding consultants using this manoeuvre. Its
use also appeared to be related to the time elapsed
since, and extent of, previous specialist training.
Cricoid pres sure is effective in infancy [15] and many
standard anaesthetic texts recommend its use
[16,
17]. The reluctance of a large num ber of
consultant anaesthetists to use cricoid pressure in
this group of infants was unexpected. Presumably
they are satisfied with the efficacy of gastric washouts
or feel that the rapid sequence induction used in
adults may impede intubation and oxygenation in
infants.
Th e relationship between preferred technique and
previous paediatric anaesthetic training is interesting .
Th is suggests that there m ay be a need for develop-
ments and changes in anaesthetic techniques to be
disseminated to all consultants who provide an-
aesthetic services to children. The development of a
specific continuing medical education programme
may help. Th e recent report from the Royal College
of Anae sthetists has started to address this issue [18].
We have attempted to determine if the recently
suggested standards for paediatric anaesthetic
services are currently being met. Despite the limita-
tions of this postal survey, the results indicated that
a large number of consultant anaesthetists who
manage small children do not have the specialist
training or current experience suggested in these
recommendations. This is highlighted in the specific
example of infant pyloromyotomy. Clearly further
efforts need to be made to reorganize paediatric
anaesthetic services if these new standards are to be
fulfilled. Furthermore, regular audit of the service
and continuing medical education programmes
should be developed to promote changes and
improvements in anaesthetic practice.
Acknowledgement
This study was funded by a grant from the Quality of Practice
Committee of the Royal College of Anaesthetists.
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