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Paediatric anaesthesia

BMJ 1998; 316 doi: (Published 10 January 1998) Cite this as: BMJ 1998;316:S2-7125
  1. Steven Cray, fellow in paediatric anaesthesia,
  1. Hospital for Sick Children, Toronto, Canada

    Changes in the organisation of paediatric intensive care units should increase opportunity for anaesthetists who have experience with children, argues Steven Cray

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    Interest in the organisation of anaesthetic and intensive care services for children has increased in recent years. Well publicised cases of the difficulty in finding intensive care beds for critically ill children have led to increased funding of paediatric intensive care.1

    Debate continues about who should anaesthetise young children and where.2 The first National Confidential Enquiry into Perioperative Deaths concluded that the outcome of anaesthesia and surgery in children was related to the experience of the clinicians involved and that surgeons and anaesthetists should not undertake occasional paediatric practice.3

    Paediatric intensive care in Britain has evolved as a fragmented service provided in a variety of centres. In January 1997, 29 such units were identified in England, but only six had more than seven beds. The government's future policy recommends that paediatric intensive care services should be concentrated in regional lead centres, to which the majority of seriously ill children would be transferred.4

    Previous situation

    Anaesthetic training has involved rotations through a variety of subspecialty areas, such as cardiac, neurosurgical, and paediatric anaesthesia, often in specialist centres, as well as more general experience of anaesthesia and intensive care.5 The fellowship examination of the Royal College of Anaesthetists (FRCA) requires the candidates to show a broad range of knowledge of subspecialty anaesthesia, including paediatric anaesthesia and intensive care. In contrast to the various surgical or medical subspecialties, anaesthesia does not have subspecialty accreditation. However, guidance exists for the amount of training recommended for consultant appointments with a commitment to paediatric anaesthesia: a minimum of six months' training for a district general hospital post with an interest in paediatric anaesthesia and a minimum of 12 months for individuals intending to practise full time in the subspecialty.

    Training requirements for consultant appointments in paediatric intensive care 4

    Paediatric intensive care unit in lead centre:

    • Lead consultant with two years' approved training in paediatric intensive care

    • Consultants providing sessional commitment or on call coverage with approved training in paediatric intensive care

    Major acute general hospitals providing paediatric intensive care:

    • Lead consultant with approved training in paediatric intensive care with major sessional input to unit

    • Cover by consultants with training and continuing experience in paediatric intensive care while children are cared for in the unit

    • All consultants to have advanced paediatric life support (APLS) or paediatric advanced life support (PALS) certification

    Single specialty hospitals:

    • Cover by consultants with training and continuing experience in paediatric intensive care while children are cared for in the unit

    • All consultants to have APLS or PALS certification.

    In the past, many trainees have obtained part of their training in paediatric anaesthesia or paediatric intensive care at major children's hospitals overseas. In addition, post-fellowship registrar posts in anaesthesia were available at Great Ormond Street and Alder Hey Children's Hospitals. Similar posts were also available in paediatric intensive care units at several hospitals in Britain, although the content and level of experience offered was variable and many did not have educational approval from a royal college. There was often a ògapó between passing the FRCA examination and obtaining a senior registrar post which could be profitably spent in such a post.

    Overseas training

    Specialist training in paediatric anaesthesia and intensive care in North America is normally undertaken after completing a residency programme. Paediatric anaesthesia fellowship posts offer a mixture of clinical and research experience or pure clinical experience. Programmes in Australia, Canada, and the United States lasting between one and three years are also available. Obtaining a licence to practise may be a problem for British trainees. It is relatively straightforward at present for those with the FRCA to get an educational licence for Canada, although the bureaucratic process is slow. Anyone wishing to train overseas should plan well ahead and be sure of the quality of the programme and level of supervision before accepting. Posts may not be advertised, so those interested are advised to write to the institution's programme director. Training posts in North America generally have lower pay and longer hours than in Britain.

    Future in Britain

    Paediatric anaesthesia

    The Royal College of Anaesthetists has produced guidance for specialist training in the senior house officer (SHO) and specialist registrar grades (SpR). SHOs should receive closely supervised training in anaesthesia for children over 3 years old. SpRs should gain experience with the management of children of all ages, including neonates, who are undergoing a variety of major surgery. The difficulty in arranging such training is that many anaesthetists need to be taught, but there are few newborns and infants undergoing surgery. The specialised paediatric component of many four year SpR programmes may be only three to four months, and it is unlikely that there will be much exposure to, for example, neonatal anaesthesia during this time. Valuable skills may be gained during a rotation in neonatal intensive care. The SpR grade is designed to offer flexibility so that individuals can obtain subspecialty training, particularly during the final year. However, trainees continue to fulfil a large service commitment, and it may prove difficult to tailor a training scheme to satisfy individual requirements. Some regions are able to offer more paediatric training than others, and this factor may determine which SpR posts are applied for. Overseas posts can in theory count towards the award of the certificate of completion of specialist training (CCST) if approved in advance by the postgraduate dean and royal college, although the reality is that you are unlikely to get approval for the whole period spent abroad, if at all. Regions have different attitudes to SpRs who take a year outside the scheme to go overseas, as the short term vacancies thus created may be difficult to fill. It is important to have confirmation that a national training number (NTN) can be kept while abroad. The alternative is to obtain specialist training after obtaining the CCST, either overseas or in Britain.

    Paediatric intensive care

    Training in paediatric intensive care medicine in Britain has been hampered by the lack of organised training programmes and the plethora of small centres. Because of this, many consultants currently working in paediatric intensive care obtained their skills overseas. Recently an Intercollegiate Committee on Training in Paediatric Intensive Care Medicine (ICTPICM) has been formed with representatives from the Royal Colleges of Paediatrics and Child Health, Anaesthetists, and Surgeons. A similar committee exists for adult intensive care medicine. Application has been made for intensive care medicine to be recognised as a specialty, but currently it is necessary to obtain a CCST in the parent specialty. It is proposed that specialist training in paediatric intensive care medicine could be undertaken by trainees from paediatrics, anaesthesia, or paediatric surgery. Trainees will need to have spent some time in other relevant specialties, depending on their parent specialty. The committee will approve hospitals for training purposesÑcurrently Great Ormond Street, Alder Hey, Glasgow, and Birmingham Children's (subject to confirmation) Hospitals have approved posts.

    Doctors interested in these and similar posts should check with the relevant royal college and postgraduate dean about approval for the CCST and keeping the NTN. For those who have trained or may wish to train overseas, there is an òequivalenceó committee of the ICTPICM which considers the status of such experience. At present consultants in paediatric intensive care generally have as their base specialty paediatrics or anaesthesia, and many maintain sessions in the primary specialty. Neonatal services are almost exclusively the domain of paediatricians, and there is little overlap with intensive care provision for older children.

    Courses such as APLS (advanced paediatric life support) or PALS (paediatric advanced life support) are recommended for anyone who will have to deal with paediatric emergencies. Meetings of relevant societies are always a good place to meet others in the field and perhaps learn something new. The Association of Paediatric Anaesthetists limits membership to consultants who have a major commitment to paediatric anaesthesia, but trainees may attend meetings as guests of a member. The Paediatric Intensive Care Society is a multidisciplinary organisation and holds regular meetings.

    Paediatric anaesthesia and paediatric intensive care represent challenging areas of practice. Training programmes, particularly in intensive care, have still to develop in Britain, and a period overseas is likely to prove valuable. There are many opportunities at consultant level, both in specialist units and general hospitals, for doctors with training in paediatric anaesthesia or intensive care.


    Links to sites of interest on the world wide web

    The Royal College of Anaesthetists maintains a website ( which contains details of basic and higher specialist training in anaesthesia and gives information about college committees, including the ICTPICM. The Intensive Care Society, which is largely concerned with adult intensive care, has a website which has some information about progress being made in the training of intensivists ( The Association of Anaesthetists of Great Britain and Ireland's website ( has details of specialist societies in anaesthesia and a comprehensive list of meetings in Britain and abroad. The Pediatric Critical Care Medicine website ( is a comprehensive resource and includes details of some available fellowship positions, mainly in the United States. An email discussion list for those interested in paediatric intensive care may be joined from this site. The Society for Pediatric Anesthesia, based in the United States, maintains a website (

    Many children's hospitals in North America have a presence on the internet and some include details of their residency and fellowship programmes. For example, Boston Children's Hospital ( and the Hospital for Sick Children, Toronto ( have details of their programmes. The Hospital for Sick Children's site also has an email discussion list for paedaitric anaesthetists. Those interested in training in the United States may wish to check the site of the Educational Commission for Foreign Medical Graduates (, which has details of some of the examination and bureaucratic hurdles they will need to overcome. The Royal Children's Hospital, Melbourne, Australia, has a website with general information about the hospital and an email directory (

    Useful addresses

    Royal College of Paediatrics and Child Health, 5 St Andrew's Place, London NW1 4LB Royal College of Anaesthetists, 48-49 Russell Square, London, WC1B 4JY

    Intercollegiate Committee on Training in Paediatric Intensive Care Medicine, 48-49 Russell Square, London WC1B 4JY. (tel 0171 813 1900 ext 134)

    Association of Paediatric Anaesthetists of Great Britain and Ireland, Honorary Secretary: Dr P M Crean, Department of Anaesthesia, Royal Belfast

    Hospital for Sick Children, Belfast BT12 6BE

    Paediatric Intensive Care Society, Secretary: Dr Jane Ratcliffe, Royal Liverpool Children's Hospital, Alder Hey, Eaton Road, Liverpool L12 2AP


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