This guideline covers all children and young people requiring surgery and anaesthesia at Frimley Park, Wexham Park and Heatherwood Hospitals, Frimley Health NHS Foundation Trust (FHFT). This guideline is required to ensure that all paediatric surgery and anaesthesia is carried out in the most appropriate environment, at the most appropriate time and by the most competently qualified surgical and anaesthetic practitioners. Emergency procedures should be carried out as soon as is safely possible with consideration of transfer to a paediatric tertiary centre.

The guideline takes into account national guidance in relation to paediatric surgery and anaesthesia and details the expectations of practice within FHFT. Anaesthetic and surgical staff will always have the relevant competencies and current level of expertise to perform the procedure and to meet the physiological needs and age requirements of the child. When appropriately competent surgical or anaesthetic staff are unavailable the specialty consultant should refer to the paediatric tertiary centre, primarily Oxford or Southampton. Discussion with and or transfer to a paediatric tertiary centre should always be considered for children with complex physiological needs.

This guideline applies to all staff involved in paediatric surgery and anaesthesia carried out at Frimley Park, Wexham Park and Heatherwood Hospitals. This includes all theatre and recovery staff and ward-based paediatric medical, nursing and play staff.

Frimley Health NHS Foundation Trust is committed to ensuring patients’ safety and being clinically effective at all times. Following the processes set out within this document, paediatric surgery and anaesthesia will be carried out safely and effectively.

• The minimum age for paediatric elective surgery/anaesthesia varies by speciality at Frimley Park with a minimum of 6 months old for surgery and anaesthesia for MRI (magnetic resonance imaging). The speciality-specific minimum ages are as follows:

  • General Surgery – 6 months

  • Urology – 6 months

  • ENT – 1 year

  • Gynaecology – 15 years

  • Orthopaedics – 1 year

  • Oral Surgery and Dentistry and Maxillofacial Surgery – 1 year

  • Plastic Surgery – N/A

  • Ophthalmic Surgery -1 year

  • MRI – 6 months

• The minimum age for paediatric elective surgery/anaesthesia varies by speciality at Wexham Park with a minimum of 1 year for surgery and 6 months old for anaesthesia for MRI (magnetic resonance imaging). The speciality-specific minimum ages are as follows:

  • General Surgery – 1 year

  • Urology - 1 year

  • ENT – age not utilised, >12kg

  • Gynaecology – 15 years

  • Orthopaedics – 1 year

  • Oral Surgery and Dentistry and Maxillofacial Surgery – 1 year

  • Plastic Surgery – 1 year

  • MRI – 6 months

• The minimum age for elective surgery/anaesthesia at Heatherwood Hospital is 16 years.

• Specialty and trainee doctors should inform/discuss with a consultant any child they have on a list that is under 12 years.

• The minimum age for emergency surgery or anaesthesia is not defined in this guidance. Lifesaving procedures (e.g. endotracheal intubations) may be required in a child of any age. Each case will be discussed on a case-by-case basis between the surgical and anaesthetic consultants on call and, if necessary, the intensive care consultant. The decision to operate should be made with the best care for that child in mind.

• In general terms, emergency surgery in a child under one year old would be best managed in a tertiary centre. Intra-abdominal emergencies would routinely be transferred to a tertiary centre if the child is less than 5 years old; and under 2 years for urological emergencies.

Peri-Operative Guidance

• A specialty consultant will book a child onto a waiting list and the child will be health screened, and pre-operative assessment appointment (telephone or face-to-face) will be organised with a pre-operative nurse or anaesthetist.

• Children with anticipated complex pre-, intra- or post-operative needs should be referred a tertiary paediatric centre. This includes the expectation for the requirement for critical care support as FHFT critical care cannot support paediatric patients.

• Pregnancy testing should be conducted as described in Appendix A.

Elective Surgery – List Management

• Wherever possible, elective paediatric lists may be used as a teaching opportunity to allow exposure of non-specialist anaesthetists to paediatric work.

• Ideally, elective paediatric surgical cases should be grouped together on dedicated children’s lists to allow the best use of resources and manage perioperative anxiety. When this is not possible, children should be placed at the beginning of operating lists, generally ordered from youngest to oldest child.

• There may be exceptions when older children with specific needs are placed earlier on the list than younger children, which will be in discussion with the anaesthetist, surgeon, theatre team and ward team.

• Paediatric elective surgery should take place between 0800 – 1900.

Emergency surgery

• Children 12 years or younger should not have emergency surgery out of hours until the duty surgical consultant and anaesthetist have been informed, unless considered immediately life threatening. When the on-call consultant is notified, they will make a clinical decision whether to attend or not.

• Paediatric emergency surgery should take place as soon as is safely possible.

• The duty consultant surgeon and anaesthetist will usually be expected to attend to all children under 5 years of age unless a prior agreement has been made between the specialty doctor or trainee and the on-call consultants.

• In extreme cases, clinicians may be required to work outside their standard clinical roles to attempt a life or limb-saving procedure for an acutely and seriously ill child where transfer would further endanger life. In such rare cases, it may not be possible to follow the procedures detailed in this guideline and clinicians should exercise their professional judgement, linking with the multidisciplinary team and fully document their rationale, decision-making process and procedure as soon as possible. FHFT recognises the difficulty caused by such unusual situations and will support clinicians requiring to work outside their usual area of expertise and experience due to the nature of the situation.

• In cases where a child presents with complex or co-morbidities, the decision to anaesthetise must be made in discussion with a consultant anaesthetist and the consultant surgeon who has reviewed the child and any previous clinical notes. The decision is to be clearly documented in the patient records, including a summary of the discussions with the child and parent/carer(s). If the decision is not to anaesthetise, the child should be referred to a paediatric tertiary centre for surgery and transfer arranged.

Joint team responsibility for care of emergency paediatric surgical patients

Children are admitted to children’s ward under a surgical team with a named responsible consultant surgeon. The paediatric medical team may be sought to provide further management advice when clinically indicated. Children admitted with head injuries are assessed and managed by the paediatric medical team.

Transfer of a child to and from theatre

• Children undergoing general anaesthesia must have two identification bands in situ and allergy band, when indicated.

• A checklist must be completed and signed by a registered nurse immediately before transfer to theatre.

• Every effort should be made for the parent/carer to accompany the child to and from theatre, if that is the child’s preference and in the best interests of the child.

• The child and parent/carer will be escorted to theatre by a competently trained member of the ward team which could be a Band 2 – 8.

• The anaesthetist in theatre will perform the WHO checklist sign in

• The ward staff will remain with the child and parent/carer, until the anaesthetist asks the parent/carer to leave and escort the parent/carer out of theatre

• The waiting time in theatre before induction of anaesthesia should be kept to a minimum.

• The child will be recovered in a designated children’s area of the recovery room by two registered nurses with paediatric recovery experience

• The child will be collected from the theatre after regaining consciousness by a competently trained member of the ward team; on some occasions, the recovery staff will bring the child back to the ward.

• The child will receive supervision within the ward until adequately recovered from the anaesthetic and surgery.

Chief Responsibilities

• The responsibility of having this guideline in place rests with the Chief Executive Officer.

• The overall responsibility for the governance of paediatric surgery across Frimley Health will be with Named Surgical Chief of Service, who attends the Trust Board and the Children & Young People’s Board.

Surgeon Responsibilities

• Surgeons are responsible for ensuring that surgical procedures on paediatric patients are carried out by staff with the relevant competencies and current level of expertise, in the most appropriate environment at the best time for the benefit of the patient.

• The surgical team will discuss paediatric inpatients at each surgical team’s handover, will inform the duty surgical consultant about children admitted between these handovers and inform the duty surgical consultant about children who require emergency surgery out of hours.

• Surgeons will complete the consent process robustly and be adequately informed themselves. They will gain informed consent from a person with an appropriate level of capacity to understand the risks and consequences which can be the young person or, for younger children, the person who has parental responsibility.

• Surgeons will mark the site for surgery pre- operatively, when required and sign relevant paperwork.

• Surgeons will document both the pre- and post-operative treatment plan, including discharge advice and follow up plans.

Anaesthetist Responsibilities

• Anaesthetists are responsible for ensuring that anaesthetic procedures on paediatric patients are carried out by staff with the relevant competencies and current level of expertise, in the most appropriate environment at the best time for the benefit of the patient.

• Anaesthetists are responsible for explaining the anaesthetic process and risks to the person with an appropriate level of capacity to understand which can be the young person or, for younger children, the person who has parental responsibility

• The anaesthetist designated for the patient should perform the immediate pre-anaesthetic assessment.

• Anaesthetists will prescribe relevant pre, intra and post- operative pain relief, anti-emetics and intra-operative fluids as required.

Theatre and Recovery Staff Responsibilities

• Are responsible for ensuring the provision of appropriate care for the child with correctly sized paediatric equipment, anaesthetic drugs and appropriately competent staff available.

Ward-Based Paediatric Medical Staff Responsibilities

• Are responsible for ensuring they have an awareness of paediatric surgical inpatients on the children’s wards; to provide paediatric advice and expertise when requested by surgical or anaesthetic teams or in emergency situations.

Ward-based Paediatric Nursing Staff Responsibilities

• Providing care for the child and their family whilst they are inpatients on the children’s wards

• Ensuring the child is fully prepared for their surgery by taking and recording observations;

• Completing paperwork which includes the pre-operative checklist

• Administering medications

• Escorting to theatre and staying with child until the anaesthetist releases them (Note: this may be a nurse or member of the ward team with appropriate competencies);

• Collecting from recovery

• Meeting their nursing needs until discharge.

• On discharge, they will check the child and parent’s understanding of what has happened, explain what they can expect may happen and ensure they know what to do if they have a concern.

Ward-based Play Staff

• Helping prepare children for their procedure pre-operatively

• Explaining the process of going to and coming back from theatre at a level that they understand or to their parents to help the child to understand, using books and where possible showing them around the ward.

• At times, they may escort the child to the anaesthetic room.

This guideline has been circulated to all clinical specialty leads with a paediatric interest and comments have been incorporated where appropriate.

General Requirements

• Those performing surgery and anaesthesia on children must:

  • Complete annual paediatric basic life support level 2 updates.

  • Complete and update safeguarding children training relevant to their role and in line with intercollegiate standards

  • Ensure that they maintain evidence of achievement of appropriate paediatric continuing professional development.

  • Those performing surgery and anaesthesia on children must identify and discuss appropriate training needs during appraisals and on an ongoing basis when identified.

Anaesthetic requirements

• In addition, all anaesthetists caring for children must:

  • Be trained in paediatric resuscitation level 3 annually and be competent in advanced airway skills.

  • Anaesthetist anaesthetising children should satisfy the requirements in line with RCoA’s GPAS document. This should be facilitated through a process of peer support, mandatory training, CPD and the appraisal process

Theatre staff requirements

• All registered recovery staff receive in-house training on safe management of paediatric patients in the Post Anaesthetic Care Unit (PACU Level 2 - Intermediate Post Anaesthetic care skills – Adult/paediatric patients)

• All theatre anaesthetic practitioners (ODPs and anaesthetic nurses) will receive UK-accredited training that incorporates paediatric theoretical and clinical skills competencies

• All Band 6/7 anaesthetic and recovery senior staff will receive the UK Resuscitation Paediatric Immediate Life Support (PILS) Level 3 training delivered by Trust Resuscitation Team

• All the theatre anaesthetic practitioners (ODPs and anaesthetic nurses) will receive Level 3 training in the relevant elements of Paediatric Life Support and paediatric anaesthesia-specific education required for their role.

All paediatric patients will have surgery and anaesthesia carried out as per guideline. Six monthly audits will be undertaken to ensure compliance with the guideline. These will be conducted by a surgical middle grade as part of the annual audit programme, with local action plans developed in response to improve compliance with responsibility held at local level.

Royal College of Surgeons (2015) Standards for non-specialist emergency surgical care of children. Available at: https://www.baps.org.uk/content/uploads/2017/03/Service-standards-for-non-specialist-emergency-childrens-surgery-2015.pdf.

Kenny, S.E. (2021) Paediatric General Surgery and Urology: GIRFT Programme National Specialty Report. Available at: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/PaediatricSurgeryReport-Sept21w.pdf

Department of Health (2006) The acutely or critically sick or injured child in the district general hospital: a team response. Available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20130123191141/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_062668.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2011) Surgery in children: are we there yet? Available at: https://www.ncepod.org.uk/2011sic.html.

Royal College of Nursing (2011) Transferring children to and from theatre. London: RCN.

Royal College of Anaesthetists (2023) Chapter 10: Guidelines for the provision of paediatric anaesthesia services 2024. Available at: https://www.rcoa.ac.uk/gpas/chapter-10

Children’s Surgical Forum of The Royal College of Surgeons of England (2013) Standards for children’s surgery. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/rcs_standards_for_childrens_surgery_2013.pdf.

Children’s Surgical Forum of The Royal College of Surgeons of England (2010) Ensuring the provision of general paediatric surgery in the district general hospital: guidance to commissioners and service planners. Available at: https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/guidance_gps_2010.pdf.

Royal College of Surgeons of England (2022) Emergency general surgery. Available at: https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/service-standards/emergency-surgery/.

Royal College of Surgeons of England (2022) Good surgical practice. Available at: https://www.rcseng.ac.uk/standards-and-research/gsp/.

It is normal practice in our trust to carry out pregnancy testing on all female patients between 12 and 55 years of age, prior to general anaesthesia, surgical procedure or exposure to ionising radiation.

Patients and their families will be informed of this prior to the day of surgery/investigation by using the patent information leaflet.

Patients and/or her parents/carers, depending on their level of capacity and understanding will be asked to give verbal consent for this test to take place on the day of the procedure. Testing will be undertaken by the admitting ward nurse and consent documented in the medical notes.

Unexpected positive results will be immediately discussed with the operating surgeon. Any young patient with a positive pregnancy test should be well supported during her visit, with consideration of ongoing pregnancy care also. This will usually involve the patient’s GP. It may be appropriate to discuss the case with the safeguarding team if there are concerns.

It may not be possible to obtain a urine sample in young women who are incontinent of urine with physical or learning disabilities These patients will be discussed with the operating surgeon and anaesthetist on an individual basis.

In the event that consent to a pregnancy test is denied, the clinical team must determine whether the procedure should go ahead with an unconfirmed pregnancy status. The risks of proceeding should be explained to the patient/carers. Where possible, this should include a quantifiable risk to the foetus, although this may be difficult. The patient needs to be able to consent to the procedure acknowledging any risk to the potentially undetected foetus.

The surgeon is justified to decline undertaking the procedure if they feel the risk is unacceptable.

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

Related Documents