Unique challenges in pediatric anesthesia created by COVID-19

This review article focusing on the lessons learned from 20 paediatric patients worldwide was produced following a MEDLINE literature search for paediatric patients with COVID-19 who underwent anaesthesia. A total of 8 publications met inclusion criteria and were described.

Delays in surgery can and do lead to increased morbidity and mortality from complications associating with delayed repairs or delays affecting the efficacy of that repair.

Challenges similar to adults included the use of appropriate PPE to minimise aerosol transmission.

Unique to anaesthetising children is the high level of asymptomatic carriers with a high viral load and the relative insensitivity of the PCR testing methods.

In addition, the multisystem inflammatory syndrome specifically associated with children with COVID-19 infection is rare but well documented and has a high incidence of myocardial dysfunction (up to 50%).

The usual practice of parental presence in theatre and an inhalation induction in many centres poses real risks of increased healthcare provider virus exposure and increased use of PPE. This must be weighed against the risk of generating aerosols and droplets associated with crying and an IV induction. Premedication may be employed but again consideration should be given to type and route and typical child behaviours such as spitting it out, coughing and crying potentially increasing droplet and aerosols.

Paediatric literature around the world have focused on intravenous induction of anaesthesia, a rapid sequence induction using indirect laryngoscopy with a video laryngoscope and avoidance of bag mask ventilation where possible to try and mitigate these risks. Intubation boxes have been used in some centres, but this carries with it unfamiliarity and the inherent risk of this leading to longer intubation times or failed first intubations.

Equal consideration is given to extubating, consideration of deep extubation or adjuncts to avoid coughing. Patients should be recovered in the operating theatre if a negative pressure recovery room is unavailable with an enhanced terminal cleaning afterwards.

Increased numbers will lead to further adaptations in our practice as our knowledge base expands.

Reviewed by Katherine Lanigan