Beyond Standard Perioperative Care: The Hidden Risks Facing Children With Medical Complexity

Children with medical complexities, characterized by rare multisystem disease, are often candidates for frequent, life-sustaining surgeries. Surgical advancements have significantly improved survival outcomes over the past few decades. However, the risk for increased morbidity and mortality in these patients remains high, while their multidisciplinary teams navigate challenges in the perioperative landscape.

Many of these children are faced with chronic respiratory failure, airway issues, feeding challenges, neurologic impairment, congenital heart disease or medical device dependence. Cleveland Clinic pediatric hospitalist Moises Auron, MD, explains that even a relatively minor procedure can become high-risk if communication breaks down or planning begins too late.

Complicated conditions, fragmented care

“We kept seeing the same problem across institutions. Children with medical complexity were coming to surgery with enormous physiologic risk, yet perioperative care often remained fragmented,” says Dr. Auron. “One team focused on the airway; another focused on nutrition; another worried about medications or postoperative disposition. Everyone worked hard, but the process itself could still feel disconnected.”

The stakes are high, he emphasizes. These inconsistencies can contribute to poorer outcomes and frequent, recurrent hospitalizations. Additionally, children with medical complexity account for a significant proportion of the pediatric healthcare expenditure.

While care teams can adopt new approaches and strategies to ensure more seamless perioperative management, Dr. Auron also acknowledges that workflow flaws can be a symptom of a larger system-level issue, even when the system works reasonably well for otherwise healthy patients.

A clinically grounded resource

Dr. Auron’s clinical observations and involvement with the Society for Perioperative Assessment & Quality Improvement sparked a desire to create a practical resource clinicians could actually use. He coedited an issue titled Perioperative Management and Optimization of the Pediatric Patient with Complex Medical Needs, published in Pediatric Clinics, alongside Mirna Giordano, MD, of Columbia University.

“It’s not a textbook filled with theory,” he clarifies. “It’s a clinically grounded issue that brings pediatric hospitalists, anesthesiologists, surgeons, intensivists, subspecialists and perioperative teams into the same conversation.”

His goal was to invite readers to see these patients differently, not as isolated diagnoses, but as children whose perioperative risk is a confluence of multiple chronic conditions, healthcare dependence, family dynamics and other system-level factors.

Drs. Auron and Giordano avoided organizing the text as a catalog of surgical specialties. Instead, they focused on perioperative principles and high-risk clinical domains that disproportionately affect children with medical complexity across different surgical settings.

“The early sections focus on foundational topics, like preoperative assessment, shared decision-making, perioperative systems, pharmacology, care coordination and enhanced recovery concepts,” he says. From there, the issue moves into specific physiologic and clinical challenges, including the following:

· Pulmonary disease

· Cardiac conditions

· Neurologic disorders

· Nutrition

· Pain management

· Intraoperative considerations

· Technology-dependent populations

Addressing misconceptions

Dr. Auron is hopeful that readers will walk away with a more nuanced understanding of these patients' unique needs and perioperative strategies to optimize their care. He also addresses common misconceptions that may hinder clinical decision-making by offering the following arguments:

Medically complex children are not “too complicated” for standardized perioperative processes. “This thinking is backward. Complexity is exactly why structured systems matter. Standardization creates a safer starting point while still leaving room for individualized decisions.”

Perioperative optimization should occur well in advance of surgery. “Real optimization may involve pulmonary treatment plans, nutritional interventions, medication adjustments, specialty input, blood management planning, rehabilitation discussions and family preparation weeks in advance.”

The procedure itself may not be the highest risk part of hospitalization. “It’s incredibly important, of course, but transitions of care, postoperative respiratory decline, medication interactions, communication failures, discharge planning and pain management are often bigger threats that may be discounted.”

One specialty alone does not “own” the perioperative management. “That model doesn't work well for these patients. Safe care depends on co-management and shared accountability.”

The takeaway message: Proactive planning, early communication and family involvement

Dr. Auron stresses that proactive perioperative planning is essential, adding “reactive management is rarely enough.” He also says communication and early coordination can unequivocally change outcomes and potentially reduce complications, unnecessary testing, delays and prevent escalation of care.

Finally, he advocates integrating family members into the core clinical team as true partners.

“Perioperative optimization isn't just about getting a child through surgery safely. It's about improving the entire episode of care with fewer complications, better recovery, smarter resource use and a more positive patient and family experience,” he says. “That's the standard we should aim for.”