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SPA Newsletter
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14th Annual Meeting Review
San Francisco, CA, October 13, 2000
The 14th Annual SPA Meeting was held in beautiful San Francisco,
at the San Francisco Hilton on Oct 13th (Friday the 13th!). After Registration
and a continental breakfast with the exhibitors, Dr. Steve Hall (Children’s
Memorial Hospital, Chicago), President of the SPA, welcomed the participants
and introduced the new SPA President Dr. Peter Davis (Children’s Hospital,
Pittsburgh). A brief business meeting was conducted prior to the start of the
lectures.
Jeffrey Fineman, MD (University of California - San
Francisco) began the morning by discussing the Transitional Circulation.
He reviewed the fetal circulation, with emphasis on pulmonary anatomy and physiology.
Dr. Fineman discussed both normal and abnormal adaptations made at birth and
the neonate’s responses to these. Clinical conditions that can lead to a failure
in the decrease in pulmonary vascular resistance at birth can lead to hypoxemia,
myocardial dysfunction, reduced systemic oxygen delivery. Treatment options
for such conditions, both general and more specific were presented. These included:
prevention of aspiration, maintenance of a neutral thermal environment, oxygen,
alkalosis, pulmonary vasodilating agents, nitric oxide and ECMO. Dr. Jon
Meliones (Duke University Medical Center) continued the morning session
with a presentation on Left and Right Heart Management. Evolving surgical
techniques and peri-operative care have improved the outcome for infants with
congenital heart disease (CHD). A multi-disciplinary approach optimizes the
patient’s recovery. The neonatal myocardium has reduced myocardial reserve,
limited recruitable stroke volume and a blunted response to circulating catecholamines.
Management of left ventricular dysfunction begins by optimizing the patients’
heart rate, preload, contractility and afterload. Right heart dysfunction can
cause decreased cardiac output and increased right sided filling pressures.
Patients develop hypotension, tachycardia and poor tissue perfusion. Vasoactive
agents in patients with right heart failure are aimed at increasing right ventricular
contractility and increase coronary blood flow. Decreasing right ventricular
afterload is also important. After a thought-provoking question and answer period,
there was a coffee break and time for the participants to mingle with the exhibitors.
Dr. Wanda Miller-Hance
(University of California, San Francisco) presented a fascinating review of
the Natural History of the Repaired Heart. As an increasing number of
children with CHD survive into adolescence and young adulthood, more patients
will require additional surgery either related to or unrelated to their heart
disease. In almost all patients with repaired or palliated CHD some residual
abnormality exists. Either right sided, left sided, regional or global ventricular
dysfunction may exist. Patients are at risk for bacterial endocarditis. They
may be at risk for systemic air embolus, may continue to be cyanotic or to have
conduction abnormalities and dysrythmias. Ventricular pressure or volume overload
may exist and will need careful management in the perioperative period. Patients
may have excessive pulmonary blood flow, pulmonary hypertension and/or myocardial
ischemia. Corrective surgery for CHD may have resulted in phrenic nerve or
recurrent laryngeal nerve palsies. Finally, children (or adults with repaired
CHD may still have diminished cardiac reserve and therefore be more sensitive
to the peri-operative stress response.
The highlight of the day was
the luncheon speaker Dr. Louis Ignarro, 1998 Nobel Laureate in Medicine,
and winner of numerous teaching and research awards. The SPA, Society of Neurosurgical
Anesthesia and Critical Care (SNACC) and American Society of Critical Care Anesthesia
(ASCCA) co-sponsored the lunch. The topic of the lecture was Nitric Oxide
as a Unique Signaling Molecule in the Cardiovascular System. His lecture
was a delightful blend of science and humor as Dr. Ignarro described the process
of discovering Nitric Oxide and its subsequent isolation. He then described
how he discovered that he had won the Nobel Prize in Medicine (he was in a
French airport terminal on his way to Italy), and the celebrations afterwards.
The afternoon session focused on Resource Utilization: A
Quandary. Dr. Robert Nelson (Children’s Hospital of Philadelphia)
approached the topic from an ethical perspective. He reviewed the four choices
for distributing medical resources fairly: 1) restricting access, 2) limiting
certain forms of medical care, 3) cutting reimbursement, 4) increasing spending.
The ethical dilemmas posed by each of these situations were presented as well
as examples of how they have or could be implemented. Carol B. Michael,
a parent and a former special education teacher, then talked about the medical
health care system from a parent’s perspective in a lecture titled "What’s
Left That Which Cannot Be Measured". She described the challenges
of living with and getting medical treatment for a child with Tuberous Sclerosis
and multiple developmental disabilities. She spoke about the art and humanity
of medicine and the importance of simple gestures to families and patients in
a high tech field.
Dr. William Greeley
(Children’s Hospital of Philadelphia) wrapped up the session with a discussion
on Bottom Lines: Mission and Money, The Hospital Perspective. He reviewed
the organizational structure of most hospitals and business principles governing
optimization of the shareholders value. Since most hospitals are not-for-profit,
the application of business principles is not completely valid. He presented
the unique challenges faced by pediatric institutions in providing quality healthcare,
while remaining fiscally responsible.
The final lecture of the day was one on Alcohol and Health,
given by Dr. Alfred A. de Lormier (University of California, San Francisco
and owner of the de Lormier Winery). The French have a much lower incidence
of cardiac disease than Americans despite their high fat diets, increased incidence
of smoking and decreased exercising. This difference is attributed to moderate
alcohol consumption. Dr. de Lormier presented research supporting the role
of moderate alcohol consumption in decreasing mortality, the incidence of some
cancers, peptic ulcer disease, URI, gall stones, kidney stones and type 2 diabetes.
He emphasized that these benefits are derived from moderate alcohol consumption
only, and excessive drinking increases mortality from a variety of causes.
The Conference concluded with
a delicious wine and cheese reception featuring some of the great wineries in
California.
Rita Agarwal, MD
Editor
The Children’s Hospital, Denver, CO
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