br. j. anaesth. 1994 stoddart 559 63

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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

http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/http://bja.oxfordjournals.org/


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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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4/5

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.

References

1.

Audit Commission.

Children First: A Study of Hospital

Services.

London: HMSO, 1993.

2 .

Hatch DJ. Anaesthesia for children.

Anaesthesia

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405-406.

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4. Lunn JN. Implications of the National Confidential Enquiry

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Paediatric Anaesthesia 1992; 2 : 69-72.

5. British Paediatric Association. The Transfer of Infants and

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6. Morris P. Training in paediatric anaesthesia.

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Anaesthesia 1993; 3: 269-270.

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Jones PF . The general surgeon who cares for children. British

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Kong AS, Brennan L, Bingham R, Morgan-Hughes J. An

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British

Journal

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14. James I. Emergencies in paediatric anaesthesia. In: Sumner

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15. Salem MR, Wong AY, Fizzott GF. Efficacy of cricoid

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16.

Hughes DG. Anaesthesia for specialist surgery. In: Mather

SJ, Hughes DG, eds.

A

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Hatch DJ . Paediatric anaesthesia. I n: Nimm o W S,

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Ox ford: Blackwell Scientific Publications , 1994; 912 -943 .

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br. j. anaesth. 1994 stoddart 559 63

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