Home About SPA Join SPA Education Newsletter Jobs & Fellowships Volunteer Service Abroad Links of Interest

SPA Newsletter

.

Dr Rita Agarwal MD, Associate Editor
The Children's Hospital, Denver, CO

Over 350 attended the 6th Annual Pediatric Anesthesiology Meeting which was held at the Sanibel Harbour Resort and Spa in Fort Myers, Florida on February 24-27. The Meeting was sponsored jointly by the American Academy of Pediatrics, Section on Anesthesiology and the Society for Pediatric Anesthesia. Dr. Lyn Means (Riley Children's Hospital, Indianapolis) as Program Chair, and the entire Education Committee, should be heartily congratulated for doing a superb job. This year's meeting added a new element, the Problem-Based Learning Discussions, to an excellent program of Didactic Sessions, Refresher Courses, abstract/poster presentations and the ever-popular Workshops.

Ronald MacKenzie, DO

The meeting opened with a welcome reception on Thursday. Once old acquaintances had been renewed, and new ones made, the meeting got into full swing. Friday morning started with a welcome from Dr. Steve Hall, Children's Memorial Hospital, Chicago and Dr. Lynne Ferrari, Children's Hospital, Boston. Dr. Ronald MacKenzie, President of the American Society of Anesthesiologists, gave an update on issues currently facing the ASA, including the initiatives by CRNAs to get independent practice privileges. The Health Care Finance Administration (HCFA) is scheduled to implement the final rule in June. He compared the CRNA political action committee (PAC) to the ASA's and noted a large discrepancy in contributions in favor of the CRNAs. He discussed political reality in Washington and the fact that money and lobby groups determine policy.

This thought-provoking presentation was followed by a session on Critical Care Issues for the Pediatric Anesthesiologist, moderated by Dr. Anne Lynn, Children's Hospital, Seattle. Dr. Frank Kern, Duke University Medical Center, discussed Ventilator Modes, Methods and Minutia. Dr. Kern presented the characteristics, advantages and disadvantages of newer ventilators, including different flow patterns (decelerating, square, sine and accelerating) and improved triggers. Termination sensitivity and limit variables are a few of the other advancements in ventilator technology. Dr. James Steven, Children's Hospital of Philadelphia, presented Inotropes and Neonates: A Developmental Approach. Normal neonatal myocardial development was reviewed, including the increased sensitivity to extracellular ionized calcium and calcium channel blocking drugs. b- Adrenergic receptors reach maximal density at term and while they do stimulate cAMP this response is immature. A rational approach to the use of inotropes including dopamine, dobutamine, isoproterenol, epinephrine, dopexamine and the phosphodiesterase III inhibitors and mentioned the new exciting class of calcium sensitizing agents. The final speaker of the morning was the venerable Dr. George Gregory, University of California-SF, who enlightened the audience on DNR in the Operating Room. The advances in technology have made it possible for patients to survive for long periods of time in a persistent vegetative state. Physicians have the difficult task of being the patients' advocate and allowing that patient a "peaceful death". Anesthesiologists should be familiar with their hospital's policies with regard to DNR and resuscitation in the OR. Discussion with the family, guardian and other physicians is important. A lively question and answer period followed.

The Oral Abstract Presentation started after the break and was moderated by Dr. Mark Rockoff, Children's Hospital, Boston and Dr. Rita Agarwal, Children's Hospital, Denver. A wide variety of topics were discussed including: the effects of ketamine on neuronal apoptosis in the developing rat brain, hypoxia and antioxidant defenses in cultured astrocytes, BIS monitoring in out-patient anesthesia, ropivacaine use for caudal analgesia in children, in-house mortality for volunteer pediatric cardiac surgery missions in Guatemala, spinal anesthesia in infants, the effects of 17% O2 or 3% CO2 on cerebral O2 desaturation in neonates with hypoplastic left heart syndrome and emergence agitation in pediatric patients after sevoflurane. Dr. Thomas Mancuso, Children's Hospital, Boston, moderated the afternoon session entitled Syndromes and their Anesthetic Implications. Dr. Kenneth Jacobson, New York University Medical Center, presented an overview of Trisomy 21, with a special emphasis on areas of particular concern to the anesthesiologist. Macroglossia, hypotonia small tracheas and micrognathia complicate airway management in these patients. Obstructive sleep apnea, pulmonary hypertension, mental retardation, hypothyroidism and congenital heart disease and atlanto-occipital instability can all complicate the care of these patients. Dr. Charles Nargozian, Children's Hospital, Boston, discussed the Hypoplastic Mandible, its presence in a variety of craniofacial anomalies and options for airway management in these patients. Among the syndromes discussed were Apert's, Crouzons, Klipple Feil, Hemifacial Microsomias, and arteriovenous and venous lymphatic malformations. Strategies to maintain the airway in these patients included topicalization and awake intubation, LMA, and fiberoptic intubation. Dr. Phil Morgan, University Hospital, Cleveland, Ohio discussed Genetic Muscle Disorders. While the molecular causes of genetic diseases are better understood, anesthetic concerns have remained the same. Dr. Morgan succinctly reviewed the four broad categories of genetic muscle disease-muscular dystrophies, myotonic syndromes, mitochondrial myopathies, and myasthenic syndromes-as well as malignant hyperthermia. The characteristics of each syndrome and their anesthetic concerns were presented.

Following these very informative presentations were the concurrent Refresher Courses and Workshops. This year the Refresher courses included: Pediatric Sedation Service Update by Dr. Thomas Mancuso, Children's Hospital, Boston, Fluid and Blood Infusion in Kids by Dr. Charles Côte, Children's Memorial Hospital, Chicago, and Evaluation and Preparation of the Child for Anesthesia by Dr. Lynne Ferrari, Children's Hospital, Boston. Workshops included: Airway by Dr. Ira Landsman, Children's Hospital, Pittsburgh; Dr. Ken Jacobson, New York University Medical Center, New York; Dr. Guy Dear, Duke University Medical Center, Durham; Dr. Scott Cook-Sather, Children's Hospital, Philadelphia; Dr. Jacquelyn Morillo-Delerme, Children's Hospital, Boston; Dr. Morton Green, Riley Children's Hospital, Indianapolis; and Dr. Robert Greenberg, Johns Hopkins Hospital, Baltimore; New Trends in Topical Anesthesia/Analgesia by Dr. Constance Houck, Children's Hospital, Boston; Upper Extremity and Lower Extremity by Dr. Allison Ross, Duke University; Managing the Epidural Space by Dr. Nancy Glass, Texas Children's Hospital, Houston and Spinal Anesthesia by Dr. J. Christian Abajian, Fletcher, Allen Health Care, Willston, VT.

On Saturday, February 26th, another beautiful, blustery, Florida day, the Program Committee introduced Problem-Based Learning Discussions. These were informal round table discussions with 2 experts and up to 10 attendees. Each discussion focused on an interesting management dilemma. The subjects of these discussions included newborn resuscitation, increased intracranial pressure and a newly diagnosed murmur, difficult airway management in a child and laser use, sickle cell disease, PACU problems and obstructive sleep apnea, difficult neonatal airway, intraoperative wheezing in the prone child, regional anesthesia and postoperative pain control, intraoperative hypotension, one-lung anesthesia, management of the trauma victim, and foreign body retrieval.

Poster Discussions

A walk-around poster discussion followed the PBLD. During the session each moderator discussed on average 9 posters after the authors had presented them. The panel of moderators/discussion coordinators was composed of Dr. Frank Kern, Duke University Medical Center; Dr. Peter Davis, Children's Hospital, Pittsburgh; Dr. Steven Hall, Children's Memorial Hospital, Chicago; Dr. James Steven, Children's Hospital, Philadelphia; Dr. Mark Rockoff, Children's Hospital, Boston; Dr. Anne Lynn, Children's Hospital, Seattle and Dr. Myron Yaster, Johns Hopkins Hospital. There were over 60 posters on a variety of topics including pharmacology, physiology, equipment, techniques, pain, and sedation.

The annual Awards Presentation was moderated by Dr. Patricia Davidson, Children's Hospital, Columbus.

Dr. Lynne Ferrari, Children's Hospital, Boston, was the moderator for the AAP Advocacy Issue. Dr. Kathi Kemper, Children's Hospital, Boston discussed Integrating Alternative Therapies: Do You Know What Your Patients Are Taking? This lively and informative lecture focused on the variety of "natural remedies" available and the percentage of the US population (including children) taking these substances. Several surveys have revealed that the use of complementary/alternative therapies (CAM) are widespread, with an incidence ranging from 11% - 70% in children. Patients and parents often don't inform their physician for a variety of reasons including fear of censure, perceived lack of physician interest, embarrassment and not worth mentioning (since products are "natural"). Many of these natural herbs have minimal side effects though most are inadequately studied. After lunch there were additional workshops and refresher courses. These included Anesthesia in Non-OR Settings by Dr. Morton Green, Riley Children's Hospital, Indianapolis; Pain Management Protocols for Neonates and Infants by Dr. Constance Houck, Children's Hospital, Boston; Surgical Emergencies in Infants & Children by Dr. Scott Walker Riley Children's Hospital, Indianapolis; Anesthesia for the Cardiac Patient for Non-cardiac Procedures by Dr. David Rosen, West Virginia University, Morgantown; Alternative and Complementary Techniques in Pediatric Pain Management by Dr. Thomas Vetter, Children's Hospital and Medical Center, Akron; Acupuncture by Dr. Yuan-Chi Lin, Stanford University; and Upper Extremity and Lower Extremity by Dr. Joseph Tobias, Health Science Center, Columbia, Missouri.

Gilligan's Castaway Barbecue was held that evening. Entertainment was provided by the Crab races and the small children (mine being the primary culprit) determined to hurl themselves into the swimming pool.

On Sunday, February 27th, (another gorgeous day) Dr. Peter Davis, Children's Hospital, Pittsburgh, moderated the morning sessions. The Plenary Session Speaker was Dr. KS Anand, Arkansas Children's Hospital, Little Rock, who started the morning with a discussion on Opioid Tolerance and Withdrawal: the clinical implications of cellular mechanisms. He presented a very timely review of the cellular mechanisms involved in acute and chronic opioid exposure as well as exploring the intricate interactions between opioid receptor mediated phenomena and other receptor populations. While the correlation between molecular mechanisms and behavioral correlation is still unclear, investigations into these mechanisms may lead to exciting new therapeutic modalities for diverse patient populations.

Pamela Zeitlin, MD

The session on Co-Existing Diseases included three discussions. Dr. Pamela Zeitlin, Johns Hopkins Hospital, Baltimore, MD, spoke on Asthma. She gave an update on the status of new treatments that gained popularity in the 1990's including inhaled corticosteroids and antileukotrienes, before launching into a discussion of the drugs of the future. Future therapy may consist of anti-IgE agents, cytokine modulators, new anti-inflammatories and gene therapy. Dr. Salvatore Goodwin, University of Florida, Gainesville, reviewed the pathology and presentation of Sickle Cell Disease. The majority of the session was spent discussing peri-operative care. The morbidity and mortality rate for SSD patients is much higher than the general population. The results of studies for preoperative transfusion (simple vs aggressive), intraoperative and postoperative care were also presented. Dr. David Adelson, Children's Hospital, Pittsburgh, was the final speaker of the sessions and presented Surgery for Seizures. He outlined the history of epilepsy, the differences between adult and pediatric seizures and evaluation of potential candidates for surgery. The types of surgical techniques possible and anesthetic consideration were delineated.

After the break, Dr. Francis McGowan, Children's Hospital, Boston, moderated a Pro/Con session on Anesthesia and CNS Monitoring-Should They Go Hand-in-Hand? The Pro side was presented by Dr. Peter Laussen, Children's Hospital, Boston and Dr. Jerrold Lerman, Hospital for Sick Children, Toronto, took the opposing view. This was a fast-paced, fun and extremely informative discussion. Dr. Laussen argued that the BIS monitor could help us better monitor our patients' depth of anesthesia, decrease awareness, save money (by allowing a decrease in the use of volatile agents) and speed emergence times and turnover times, while decreasing PACU times. Dr. Lerman with great panache countered that most of Dr. Laussen's presentation (as well as currently available literature) was propaganda. Studies have not actually shown a decrease in the incidence of awareness and the studies that show decrease in the use of volatile agent with the BIS monitor also show an increase in the incidence of intra-operative movement and the use of muscle relaxants!

The last session of the conference has now become a tradition: Pediatric Anesthesia Jeopardy hosted by Dr. Patricia Davidson, Children's Hospital, Columbus; Dr. James Steven, Children's Hospital, Philadelphia; Dr. Myron Yaster, Johns Hopkins Hospital, Baltimore; Thomas Mancuso, Children's Hospital, Boston and Dr. Rita Agarwal, Children's Hospital, Denver. Written questions from the audience were entertained, some answered using the audience response system. The questions were diverse and included: age at which to allow outpatient surgery on former premature infants, management of a terminal child requiring radiation therapy, and appropriateness of elective surgery at night.

The SPA/AAP Awards Presentation was moderated by Patricia Davidson, MD, Columbus Children's Hospital.

Dr. Lynn Ferrari presented the The John B. Downes Award to the top three resident presentations at the meeting.

First Place (Tie): Hideaki Hayashi, MD, Department of Anesthesia, Children's Hospital, Boston, Massachusetts for the presentation entitled Effect of a Single Dose of Ketamine on Neuronal Apoptosis in the Developing Rat Brain.
First Place (Tie): A.J. Davidson, MBBS, Department of Anesthesia Children's Hospital, Boston, Massachusetts for Hypoxia and Antioxidant Defenses in Cultured Astrocytes.
Second Place: Lisa W. Faberowski, MD, Department of Anesthesia Children's Hospital, Boston, Massachusetts for Angiotension IV Attenuates Hypoxia and Ishemia-Induced Neuronal Apoptosis.
SPA Young Investigator Award
Patricia Davidson presents the Young Investigator Award to Jeffery Galinkin, MD, Department of Anesthesia, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania for his research topic Does Nasal Fentanyl Reduce the Incidence of Emergence Agitation in Children after Bilateral Myringotomy and Tube Placement?