Correspondence (reply): In Reply

We thank our colleagues for their valuable contributions and the lively discussion. The correspondence from our anesthesiology colleagues expresses concerns about the required competences of non-anesthesiologists in terms of administering analgesia-sedation in children and adolescents. In contrast to anesthesiologists, a satisfactory qualification in non-anesthesiologists cannot be taken for granted. Even for anesthesiologists, distinction has to be made between those with experience in treating children and those without such experience.

We thank Ms Soppart for giving us the opportunity to focus on this particular issue. The term “non-anesthesiologists” was introduced by the American Society of Anesthesiology (1) and applies to all doctors without a specialist qualification in anesthesiology; it is thus an imprecise term. For example, this category includes pediatricians with experience in intensive care medicine and neonatology—that is, physicians with competences in life saving and life sustaining measures in children. In our article, we said that if a doctor has insufficient competence and experience in administering analgesia-sedation or emergency management in children, regardless of whether anesthesiologist or non-anesthesiologist, then he or she is not qualified to provide analgesia-sedation in this age group. The safety aspects that we and others mentioned (1– 4) apply without exception to all those administering sedation. To gain the required qualification, provide it, and prove it may pose a problem for many, which has to be resolved within hospitals (for example, by collaboration of anesthesiologists with pediatric hospitals). The regulation for specialist training in pediatrics and adolescent medicine already includes the treatment of acute emergencies, which entails life saving measures and basic intensive medical care for children. The catalogue of obligatory requirements for additional qualifications in neonatology and pediatric intensive care medicine includes knowledge of extended resuscitation, airway management, and sedation techniques. If international and national guidelines and the described safety standards are adhered to, and after the patient (or the person in loco parentis) has been fully informed and given written consent, then we think that the necessary requirements have been met. We are not in a position to answer legal questions.

We thank Spiess, Schmidt, Nachtigall, Bührer, Krude, Henning, and Ringe for their question about the necessity of a “sedation team.” Staff shortages are a real problem, but should not be a reason for cutting quality. Optimal care should be provided either by using existing resources (as mentioned in your correspondence) or by creating the necessary structures. The sedation team may consist of anesthesiologists and/or pediatricians with experience in intensive care medicine, who take on the supervision and training of less experienced colleagues or those still in training. The presence of a qualified nurse is also essential. The advantages of a sedation team are also mentioned in the decision of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin, DGAI) and the Professional Association of German Anaesthesiologists (Berufsverband Deutscher Anästhesisten, BDA) (4). We don’t think that a new qualification is needed, but practical training on patients as proof of an existing qualification. Our article should therefore be understood as an invitation to shape and improve the existing quality of structures and processes in such a way that maximum safety for patients is guaranteed (2).

We thank Strauß, Becke, van Aken, and Philippi-Höhne for mentioning the recently published recommendations from the DGAI/BDA. We are pleased that our article is consistent with the decision of the DGAI/BDA, which, with regard to those administering sedation, says: “Deep sedation in children should be administered only by anesthesiologists or pediatricians with experience in intensive care medicine” (4). As we said in our article, incidents may occur at any stage during analgesia-sedation, independently of which ASA class applies to the patient.

Finally, we thank the Shahs for their constructive contribution and agree with their suggestions. We did not claim to provide complete lists in Table 2 and the eTable in our article. For further explanations of the topic we’d like to refer readers to the publications cited in our bibliography and the current guideline from the DGAI/BDA (1– 4).