The effect of the COVID-19 pandemic on normal perioperative functioning has been profound, with disrupted elective surgical schedules, stress surrounding supplies of PPE, and concerns about how to maintain social distancing in post-anesthesia care units and waiting rooms. With the onset of the COVID-19 pandemic came a distinct wave of uncertainty about how to best protect our OR team, our patients, and their families. While pediatric patients have thankfully been mostly spared the brunt of COVID-19 morbidity, there have been significant alterations to the practice of pediatric anesthesiology and the experience of the children under our care. In this article, we highlight the experiences of anesthesiologists at our institution, where we benefited from widespread and consistent preoperative PCR COVID-19 testing for all electively scheduled patients. Most of what we describe can be extrapolated to other pediatric settings, though we acknowledge that some aspects of decision-making were impacted by local availability of both testing and adequate PPE. Regardless of such resource availability, practice has still changed.
One aspect of the perioperative experience unique to pediatrics is the commonplace presence of parents in the OR. While this practice is controversial with regard to whether it reduces perioperative anxiety in children and parents, in many pediatric centers it is customary to allow one parent to accompany the child to the operating theater or procedure room and to remain through inhalational induction of general anesthesia (Anesthesiology 1996;84:1060-7; Anesthesiology 2000;92:939-46; Paediatr Anaesth 2002;12:261-6). For many of our pediatric patients who come in for repeated procedures, such as oncology patients or children with complex chronic medical needs, there is a routine and rhythm to their inductions that has been adjusted and honed over time to work best for that particular child. Often, this involves parental presence.
In spring 2020, prior to the availability of widespread pre-procedural COVID-19 testing, some providers deferred inhalational inductions, choosing instead to obtain I.V. access preoperatively to facilitate inductions without generation of significant aerosols by a struggling child under a mask (Anesth Analg 2020;131:61-73). While this facilitated the administration of preoperative I.V. anxiolytics to ease the separation from parents, it was certainly a change in the usual practice for many pediatric anesthesiologists. Once widespread testing began, offering the reassurance of a negative pre-procedure COVID-19 test, inhalational inductions returned to favor at our institution. However, the practice of allowing a parent to accompany the child to the OR was strongly discouraged since we could not reasonably know the parental COVID-19 status. The anesthesia induction space at the head of the bed typically does not allow for social distancing, and the introduction of “unnecessary” people into that space was, justifiably, concerning to many. Thus, parent-present inductions became an extremely rare phenomenon throughout the rest of 2020 and continuing through today. Increased utilization of electronic devices such as iPads for distraction, combined with increased preoperative oral anxiolytics in selected patients, has proven helpful during this time. It will be enlightening to query pediatric anesthesiologists who have made this transition to see if perceived patient anxiety was better or worse without parental presence and what other methods of preoperative anxiolysis have proven useful.
The change in these perioperative practices and routines can cause a significant increase in medical anxiety, especially for children who are in frequent need of anesthetics. In addition to changes in induction practices and parental presence, ubiquitous mask-wearing among perioperative personnel, even in areas where faces were typically uncovered, such as in the pre-operative bays, may be frightening to some children. Children who do not understand language either because of age, developmental challenges, or because they speak a different language than their providers may rely on nonverbal cues such as warm smiles to calm their nerves. With faces covered, those cues are lost, with the impact on emotional inferences being a current area of study (PLoS One 2020;15:e0243708). We know that it is critical for medically complex children that their hospital and anesthetic experiences are as smooth and as atraumatic as possible so as not to add to the already-staggering emotional burden of chronic disease. In addition to patients, the changes in practice can impact the parents who have become accustomed to parental presence during induction. In situations of chronic medical complexity, areas of control and predictability are precious, so the loss can be experienced acutely. An honest and open discussion of these changes, the very real impact they have on the family, and strategies to mitigate the associated stress has been a strategy employed during perioperative discussions.
The change in anesthetic inductions is not the only different aspect of perioperative pediatric care in the COVID-19 era. We are also seeing children present later in the course of acute surgical illnesses due to parental anxiety about presenting to a health care facility for evaluation, particularly during local surges. As a result, we have noticed children with appendicitis presenting later in their course, sometimes with perforations and far sicker than they might have been otherwise; when questioned, the parents admit that they really didn't want to go to the hospital unless absolutely necessary. This has been noted by other centers and published about as well (Am J Surg September 2020). We are seeing busier call nights, as community hospitals and general hospitals that usually have some pediatric surgical capacity are diverting all pediatric patients to our tertiary care children's hospital in order to create bed space for adult COVID-19 patients. Anecdotally, my colleagues have noted that we seem to have more cases of healthy children and teenagers with high-acuity, time-sensitive surgical issues such as testicular or ovarian torsion or appendicitis. All of this is occurring while still managing our usual high-volume, high-acuity pediatric patients with the same ongoing pediatric-specific needs.
There have been some reprieves: the decrease of children in daily, in-person daycares and schools, combined with consistent mask-wearing, handwashing, smaller class sizes and social distancing has had a profound impact on the incidence of influenza, RSV, and other typical cold-weather contagions. This has significantly altered the makeup of inpatient admissions. Because of the decrease in typical childhood upper-respiratory infections (URIs), children are getting fewer ear infections, and thus there is less need for tympanostomy tubes. Finally, one of the most predictable aspects of pediatric anesthesia in the winter is the need to cancel and reschedule cases due to URIs. Given the decreased incidence of URIs and increased preprocedural screening, we rarely have to cancel cases due to illness (asamonitor.pub/3aCln5z).
Still, the stressors of busier call nights with a larger volume of healthy community children needing our services, and the disruptions to our usual practices, have made this an interesting and challenging time to be a pediatric anesthesiologist. As more and more people in our department, hospital, and community obtain vaccination, we are hopeful that we can move toward a return to usual operations in the next couple of years, particularly if the vaccines become approved for pediatric usage. When that happens, open-mindedness will be a virtue. There will be some aspects of change that are ultimately deemed an improvement and other aspects where a return to prior practice will be welcome. Until then, we continue to rely on our resourceful and compassionate colleagues to deliver the best care under trying circumstances and to support each other as we move through this pandemic together.