REVIEW ARTICLE

The future of pediatric anesthesiaAndrew Davidson

Department of Anaesthesia and Pain Management, Royal Children’s Hospital, Parkville, Vic., Australia

Recently we moved into a completely new hospital.

Moving to a new theatre suite required some thought

about how to accommodate future changes in pediatric

anesthesia, so perhaps it is fitting that Isabelle Murat

and Martin Johr asked me to prepare a paper on the

future of pediatric anesthesia. However there is more

to the future of pediatric anesthesia than just what to

fit into a new operating room.

The future of pediatric anesthesia can be thought of

as the future of the practice of anesthesia in terms of

drugs and techniques, and also as the future of the

profession of pediatric anesthesia. Moving hospital also

entailed evicting dusty old books from the department

library. These old texts quickly provide insight into the

substantial advances over the last 50 years in drugs

and techniques. In the 1960s halothane was the most

modern volatile anesthetic and pulse oximetry unheard

of. Will there be similar leaps forward in future dec-

ades? In contrast the texts indicate that there have

been only subtle changes in our profession. In 1967

one pediatric anesthesia text noted that ‘Real team-

work can be developed … with much advantage to our

patients. The day is past when the surgeon knew all

the answers or at least thought he did’ (1). The same

book discusses at length the issues of who should give

pediatric anesthesia and how they should be trained.

The future of the profession

The future of the profession will be determined by a

mix of external forces and by where the members of

the profession want it to go. It would be very pre-

sumptuous of me to say how the profession will

develop, or to provide any indication of how it should

develop. I can only identify likely directions and sug-

gest crucial questions that may arise. The most obvi-

ous external force is cost. The cost of health care is

rising and funders are increasingly wishing to see

greater return for their dollars. There will be an

increase in the emphasis on service delivery. While

efficiency in service will be a priority, it is unlikely

that any organization will tolerate an increase in risk

or reduced quality. We may be increasingly judged on

our throughput, but quality and safety are likely to

remain equally important. The profession will be

expected to find ways to be more efficient and fiscally

responsible, but also to maintain high standards of

care. Efficient and effective quality improvement and

quality assurance requires skill and training (2). Good

quality programs involve a more rigorous process

than just performing occasional audits for random

interests. The profession will have to become expert in

quality.

Keywords

general anesthesia; history; quality

improvement; outcomes; research

Correspondence

Andrew Davidson, Department of

Anaesthesia and Pain Management, Royal

Children’s Hospital, Flemington road,

Parkville, Vic. 3052, Australia

Email: andrew.davidson@rch.org.au

Section Editor: Neil Morton

Accepted 16 April 2012

doi:10.1111/j.1460-9592.2012.03887.x

Summary

The future of pediatric anesthesia can be thought of in terms of what will

happen to the practice of anesthesia, or what will happen to the profession

of pediatric anesthesia. The profession will change both under external

forces, and by how pediatric anesthetists themselves decide to shape of the

profession. The largest external force is likely to be cost. The profession

will increasingly be expected to maintain efficiency without compromising

quality. Other future issues include credentialing, training and the role of

the anesthetists beyond the operating room. It’s harder to predict how the

practice of pediatric anesthesia might change. New drugs may change prac-

tice, though perhaps it’s more likely that practice will change with better

use of existing drugs. New technologies will have an impact in monitoring

and in the gathering and dissemination of information. Practice will also

change with changes in surgery. Perhaps the biggest changes will come in

areas with the greatest unknowns; neonatal anesthesia is an area with many

unknowns and thus great potential for change and improvement.

Pediatric Anesthesia ISSN 1155-5645

570 ª 2012 Blackwell Publishing Ltd

Pediatric Anesthesia 22 (2012) 570–572

Some aspects of medical practice and surgery are

likely to become increasingly complex and specialized.

Will pediatric anesthesia increasingly become the

domain of specialists? Already there are few, if any,

anesthetists that would claim they could safely anesthe-

tize all patients from neonatal cardiac surgery to the

morbidly obese adult laparoscopy to the elderly having

carotid endarterectomies. Specialization within anes-

thesia is likely to increase and the profession will

adjust. The profession will have to work out what

qualifications are required to anesthetize children.

Should only qualified pediatric anesthetists look after

very young or complex cases? Similarly what level and

type of training is required? How much extra training

might be required to be a ‘pediatric’ anesthetist?

Should nonmedical anesthesia providers have a greater

role in pediatric anesthesia? If so who should do what?

The profession will serve children best if the solutions

are based on the maintenance of standards and on fis-

cal responsibility. This may require some flexibility,

leadership, and change. Engaging in turf wars and

blindly sticking to principles based on income protec-

tion does not optimally serve the children’s needs.

The core role of the anesthetist is to care for the child

during surgery and anesthesia—this will not change.

However, anesthetists are also involved in acute and

chronic pain management, intensive care, resuscitation,

and emergency care, and the general perioperative care

of the child. In many countries intensive care is increas-

ingly run by physicians who do not see themselves as

anesthetists. This trend may continue. Perhaps intensive

care will become increasingly multidisciplinary, with

anesthetists more involved as part of the team rather

than leader of the team. In contrast to intensive care,

the general perioperative care is increasingly becoming

the responsibility of the anesthetist rather than the sur-

geon. Once again this trend may continue, or perhaps

‘hospitalists’ that are specifically focussed and trained

for perioperative care will lead the perioperative care.

To a large extent the choice is ours. The perioperative

care is also likely to increasingly extend beyond the hos-

pital, with better preoperative assessment using infor-

mation technology and better management after

discharge, especially in analgesia (3). Giving sedation

and the management of procedural distress is another

area where the particular skills of anesthetists may

ensure they have a key role. We are heading toward the

concept of a children’s hospital being ‘pain and distress

free’. This will require a change of culture and a multi-

disciplinary approach. There is no doubt that pediatric

anesthetists will be involved.

Will pediatric anesthesia continue to be an aca-

demic profession? Anesthesia is often noted to have

relatively few practitioners with higher degrees and a

relatively small proportion of national research

grants. Will this worrying trend continue? There is

perhaps a danger if we continue to emphasize anes-

thesia as completely safe and effective. This ‘mission

accomplished’ approach could lead to a further

decline in academia. Of course ‘mission accom-

plished’ has become a famously foolhardy claim. In

fact there are many unanswered questions in pediat-

ric anesthesia; many highlighted in a recent editorial

in this journal. For example the optimal anesthetic

management for a neonate is still largely unknown

(4). Given the uncertainties of our profession,

research for pediatric anesthesia should increase

rather than decline. It is also likely that there will

be a greater emphasis on translation. Translation

involves taking basic science discovery into clinical

research. It also involves ensuring existing knowledge

is effectively disseminated and incorporated into evi-

dence-based practice (5). In turn the effectiveness of

our practice will be gauged by measuring meaningful

outcomes relevant to the children, families, and

funders. Pressure for efficiency will lead to more

health care delivery research to determine how we

can provide efficient and safe care at an organiza-

tional level.

The practice of pediatric anesthesia

It is difficult to predict which drugs and technologies

will appear and transform our practice. Is it possible

to produce inhalational agents that are affordable,

potent, odorless, and free of unwanted side effects?

Similarly will there be effective analgesics that are also

free of any unwanted effects? Will there be local anes-

thetics that have no systemic toxicity? Even more fan-

tastically, will the whole concept of ‘anesthesia’

become arcane? Instead of inducing a senseless coma

will we induce a pleasant fugue like state; not unlike in

the film ‘Total Recall’ where Arnold Schwarzenegger

buys a custom made dream? Our knowledge of basic

molecular mechanisms suggests subtle improvements

are likely, but the drugs are unlikely to come soon, or

be a complete utopia.

It is likely that we will make better use of existing

drugs. The algorithms for total intravenous anesthesia

such as with propofol and remifentanil will improve.

This may lead to a substantial shift in practice. Phar-

macogenomics will also change our practice (6). It will

provide more detail on likely pharmacokinetics, effec-

tiveness and side effects of drugs in individual patients.

This will lead to fewer complications, and more effec-

tive medication, particularly for analgesia.

A. Davidson The future of pediatric anesthesia

ª 2012 Blackwell Publishing Ltd 571Pediatric Anesthesia 22 (2012) 570–572

New technologies will also influence our monitoring.

Exhaled propofol concentrations may give us a real

time measure of plasma propofol concentrations. Mea-

sures of cardiac output and organ perfusion will likely

improve. Increasingly better measures of brain oxygen-

ation will emerge. As we understand more about the

mechanisms of consciousness and how anesthetics

work, then depth monitors – or more accurately ‘mea-

sures of desired anesthesia effect’ – are also likely to

steadily improve, and to be developed specifically for

children.

There are still huge gaps in our understanding of

neonatal physiology and pharmacology. Filling these

will give a better understanding of what blood pres-

sure, ventilation, and fluid management are ideal. We

should know the effect of anesthetics on the develop-

ing brain, and we should have a better understanding

of what anesthetic technique provides the best outcome

for neonates, and indeed how much anesthesia to give.

The most obvious change will be in information

technology. It is inevitable that access to detailed med-

ical records and laboratory results will be easier and

faster. Similarly information about diseases, proce-

dures, and drugs will become immediately available.

Hopefully there will be more accurate collection, pool-

ing, and analysis of large sets of patient data. This will

allow us to better identify rates and causes of compli-

cations.

Changing attitudes and expectations of the public

will also change our practice. Families are likely to be

well informed and expect to be kept involved in their

child’s care. Parental presence at induction and emer-

gence of anesthesia may continue to become the norm;

perhaps parents will expect to be present during sur-

gery too.

Changing pathology will change our practice.

Increasing rates obesity and trauma will change the

type of surgery performed. Similarly changes in surgi-

cal and diagnostic procedures will change our practice.

MRI scanning may be as quiet and rapid as a CT

scan. Genetic testing will remove the need for muscle

biopsies. More effective screening and antenatal diag-

nosis with effective therapy may reduce the incidence

of congenital malformations. In our new hospital we

have an intra-operative MRI scanner; thus as a neuro-

anesthetist, my own future is to spend the rest of my

working career locked in a Faraday cage in awkwardly

close proximity to the surgeon. In contrast robotic sur-

gery may place the surgeon in a far corner or country.

Minimally invasive surgery is also likely to increase.

As neonatal anesthesia improves, surgeons may be

tempted to operate even earlier for major and minor

malformations. Ultimately fetal surgery may well

increase.

The global perspective

Finally how will pediatric anesthesia look globally?

Will there continue to be massive differences in care

between the developed and developing nations? Pediat-

ric anesthesia is increasingly becoming a global profes-

sion. The World Federation of Societies of

Anesthesiologists and the International Assembly for

pediatric anesthesia are two examples of increasing col-

laboration between societies. Such collaboration, along

with increasingly global information technology, will

aid the free dissemination of knowledge and coordina-

tion of training. This will hopefully help reduce the

divide between rich and poor.

In summary, while drugs and techniques will change,

the goals of providing safe and effective anesthesia to

children will not change. There are substantial external

forces that will subtly shape our profession, but much

of how the profession will look will be up to us. In my

dusty book from the 60s it is noted that ‘…paediatric

anaesthesia requires the services of persons with unlim-

ited optimism and energy’ (1). I don’t expect this to

change.

Conflict of interest

No conflicts of interest declared.

References

1 Davenport HT. Paediatric Anaesthesia. Phil-

adelphia: Lea and Febiger, 1967.

2 Varughese AM, Hagerman NS, Kurth CD.

Quality in pediatric anesthesia. Pediatr

Anesth 2010; 20: 684–696.

3 Wolf AR. Tears at bedtime: a pitfall of

extending paediatric day-case surgery without

extending analgesia. Br J Anaesth 1999; 82:

319–320.

4 Davidson AJ. Neurotoxicity and the need for

anesthesia in the newborn: does the emperor

have no clothes? Anesthesiology 2012; 116:

507–509.

5 Davidson A. Translational research: what

does it mean? Anesthesiology 2011; 115: 909–

911.

6 Eisenach JH, Schroeder DR. Genomic discov-

eries in perioperative medicine: educating the

audience. Anesthesiology 2009; 110: 693–695.

The future of pediatric anesthesia A. Davidson

572 ª 2012 Blackwell Publishing Ltd

Pediatric Anesthesia 22 (2012) 570–572