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The 8th Joint Conference on Pediatric Anesthesiology
of the Society for Pediatric Anesthesia and the American Academy of Pediatrics
Section on Anesthesiology and Pain Management convened March 7, 2002,
in Miami Beach, Florida.
The scientific sessions began on Friday morning with an
address by James Cottrell, MD (Downstate Medical Center, NY), President-elect
of the ASA, who briefed the attendees on current issues affecting all
anesthesiologists and on the agenda of the ASA in the coming year. Dr.
Cottrell discussed manpower, noting that the number of American medical
graduates applying for residencies in anesthesiology continues to climb.
He provided an update on the states which are currently at risk of "opting-out"
of the supervision rules for nurse anesthetists, and urged our continuing
support of efforts to prevent the erosion of medical direction and patient
safety. He discussed the successful ASA campaign to rescind inequitable
Medicare and Medicaid reimbursement cutbacks for the coming year, and
the efforts of the ASA to address drug shortages with manufacturers. On
the academic and research fronts, Dr. Cottrell described several initiatives
to increase research, both through increased grant award amounts from
the FAER, and described concern over the decline in papers submitted to
Anesthesiology by US authors. The ASA plans to investigate the
promulgation of new clinical care standards in pain medicine, office based
anesthesia, and obstetrical anesthesia, and will work in liaison with
the American College of Surgeons to further common goals in perioperative
care. He lauded the pediatric anesthesia community for their successful
efforts in raising the image and profile of anesthesiologists, and stated
that the ASA plans to emulate our efforts.
The morning session, moderated by Peter Davis, MD (Children's
Hospital of Pittsburgh and SPA President) was devoted to discussions of
"Pharmaco-politics". Mark Schreiner, MD (Children's
Hospital of Philadelphia and Children's Clinical Research Institute) discussed
the evolution of regulation of pharmaceuticals and the rise of clinical
trials to evaluate and demonstrate efficacy and safety. He described how
much of the regulations were "disaster driven", and how the
new FDA requirements and inducements for studying drugs in infants and
children have evolved. He discussed the limitations and problems that
remain in designing clinical trials for children and the unmet needs that
persist. Christopher-Paul Milne DVM, MPH, JD (Tufts University School
of Medicine and Center for the Study of Drug Development, Boston) spoke
on how pediatric clinical trials have and will continue to influence practice.
He noted that although there has been a four-fold increase in the number
of pediatric patients studied and the number of pediatric research centers
over the past four years, the needed research still lags way behind work
done in drug development for the elderly. The majority of drug research
in pediatric drug research still is performed on antimicrobial agents.
The new Office of Pediatric Drug Development at the FDA, and mandatory
rules for pediatric drug testing may provide further impetus for continued
increases.
Jerrold Lerman, MD (The Hospital for Sick Children, Toronto)
gave a well- illustrated presentation on post-marketing drug safety and
the problems of untoward reactions that come to light only after a drug
achieves widespread use. Sometimes these problems are due to possibly
deceptive practices by the drug developer, illustrated by Rezulon, an
oral hypoglycemic; more commonly, as was the case with rapacuronium, the
limited exposure to pediatric patients during phase II studies did not
demonstrate the true risk and incidence of adverse reactions. Dr. Lerman
pointed out that FDA mechanisms in the past have not always dealt effectively
with problems, producing long delays in addressing these issues. In the
case of rapacuronium, the rapid exchange of information through the Pediatric
Anesthesia Conference discussion listserver lead to unprecedented efficiency
in disseminating the severity and magnitude of bronchospastic reactions
to this drug, and its subsequent withdrawal from the market. Dr. Lerman
cautioned us to remember that FDA approval of any new drug is not a guarantee
of safety.
Clair M. Callan, MD, MBA (American Medical Association)
discussed generic drugs and the problem of drug shortages. She provided
surprising information on the standards which generics must meet to be
certified as equivalent to their branded counterparts (only ±20%
bioavailability, which may be further altered by differences in non-active
ingredients in the generic product). She delineated the various causes
of shortages, and noted that drug shortage information from the FDA website
(www.fda.gov/cder/drug/shortages) only lists drugs deemed "critical",
and that more complete information can be obtained from www.ashp.org/shortages.
A fascinating afternoon session, moderated by Francis
McGowan, MD (Children's Hospital, Boston) informed the audience about
the cutting-edge work being done in fetal surgery to correct congenital
defects. N. Scott Azdick, MD (Department of Surgery, Children's Hospital
of Philadelphia), a pioneer in the field, reviewed the work to date, and
showed remarkable images of several of the procedures. These ranged from
EXIT procedures (securing the neonatal airway during delivery while the
newborn remains on fetal-placental circulation) to open repair of sacrococcygeal
teratomas and congenital cystic adenomatoid malformations, to in-utero
fetoscopic repair of posterior urethral valves and in-utero palliation
of diaphragmatic hernias. Jeffery Galinkin, MD (Children's Hospital of
Philadelphia) described the anesthetic techniques that have been used
to care for the women and fetuses undergoing these procedures. Tocolysis
and uterine relaxation is of paramount importance for the mother, and
anesthesia and muscle relaxation is administered by IM injection to the
fetus. Leslie N. Sutton, MD (Department of Neurosurgery, CHOP) bridged
the topic of this session with the previous session, speaking on the in-utero
repair of neural tube defects and the ethical and scientific issues implicit
in the ongoing clinical trial of this operation. Not only can such repairs
be accomplished successfully, but in cases of lumbar or low thoracic defects,
and with intervention prior to 26 weeks of gestation, in-utero repair
may prevent the development of Arnold-Chiari malformation and the need
for ventricular shunting post-partum.
The day's plenary sessions finished with a "pro and
con" debate on the use of standards to effect the quality of clinical
care. Burton S. Epstein, MD (George Washington University School of Medicine,
Washington, DC) promoted the use of practice guidelines as a means to
improve quality of care. He used the ASA Standards on Monitoring as a
paradigm to demonstrate the efficacy and importance of standards, practice
parameters, and guidelines in anesthesia. Frederic A. Berry, MD (University
of Virginia School of Medicine) countered this argument by noting the
problem of electronic monitoring failures, and emphasized the necessity
for teaching appropriate clinical responses when devices inevitably fail,
rather than emphasizing monitoring standards per se. He encouraged the
use of non-technological monitoring solutions, especially the precordial
stethoscope and close observation of the patient. This discussion was
taken up with enthusiasm by many of the audience members.
The day concluded with elective workshops and refresher
courses on topics including airway management, pain, regional anesthesia,
clinical trial design, PACU problems, ventilators, myopathies, and apnea
in former premies.
Many started the second day of the conference by attending
one of the Problem-Based Learning Discussions. The choice of which to
attend can be difficult to make, as each offers opportunities for in depth
analysis of both clinical experiences as well as expert-based theoretical
options for select cases relevant to the pediatric anesthesiologist.
The awards and oral presen-tations session was moderated
by Joseph R. Tobin, MD (Wake Forest University School of Medicine) and
Lynne R. Ferrari, MD (Children's Hospital Boston).
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How inspiring to watch Dolly D. Hansen, MD receive this
year's Robert M. Smith Award for outstanding lifetime contribution in
pediatric anesthesiology. Dr. Hansen completed her medical training, including
only one year of pediatric anesthesia, in Copenhagen, Denmark before moving
to the United States in 1971 to start as a consultant in the department
of anesthesiology at Boston Children's Hospital. It was there that she
devoted her career to advancing and teaching pediatric cardiac anesthesia.
She collaborated with cardiothoracic surgeon Aldo Castaneda, MD to pioneer
the anesthetic management of infants undergoing DHCA during first stage
repair of HLHS. She has authored some 30 publications during her illustrious
career at Boston Children's Hospital. In her honor the Dolly Hansen Chair
of Pediatric Anesthesia has been established at the Children's Hospital
in Boston. By unanimous decision of the AAP governing board, despite having
trained outside of the United States, she was recently bestowed honorary
fellowship in the AAP based upon her enormous contributions in establishing
the subspecialty of pediatric cardiac anesthesia.
The First Place SPA Young Investigator Award went to Andreas
W. Loepke, MD from Children's Hospital of Philadelphia for "Desflurane
Confers Neuroprotection for Hypothermic Low-Flow Cardio-Pulmonary Bypass
in Neonatal Pigs". His co-authors are Drs. C. D. Kurth, M. A.
Priestly, J. McCann, S. E. Schultz, and J. Golden.
There was a tie for this year's Second Place SPA Young
Investigator Award. First, Michael J. Eisses, MD described the work he
completed with co-author Dr. W. L. Chandler (Children's Hospital and Regional
Medical Center, Seattle) entitled, "Low Volume Sampling Protocol
for Use in Hemostatic Evaluation of Infants during Cardiopulmonary Bypass".
Second, Chantal Frigon, MD, FRCPC, presented her study "Fraction
of Inspired Oxygen in Relation to Subarachnoid CSF Hyperintensity during
Brain MRI Images in Children under General Anesthesia". Dr. Frigon
and her co-authors Drs. D. S. Jardine, S. R. Heckbert, E. Weinberger,
and D. Shaw were also from Children's Hospital and Regional Medical Center,
Seattle.
Next, the John J. Downes Resident Research Awards were
presented. First Place went to Kelley Groeper, MD for "Synthetic
Factor VIIa to Treat Coagulopathy Unresponsive to Conventional Therapy
in the Pediatric ICU Population". She and her co-authors Drs.
J. W. Berkenbosch and J. D. Tobias are from University of Missouri, Columbia.
Second Place was awarded to R. Chaudhari, MD for "Complications
Associated with Routine Aprotinin Administration in Children".
She, along with her co-authors Drs. N. Setzer, J. Ojito, E. Saade, R.
Burke, and R. Hannon are from Miami Children's Hospital. The Third Place
recipient was David K. Barclay who presented his study entitled "Does
Preoperative Sciatic Nerve Block or Local Infiltration More Effectively
Inhibit Mechanical Hyperalgesia in Young Rats?". He and co-author
Dr. D. Ririe are from Wake Forest University School of Medicine.
The American Association of Pediatrics Advocacy Lecture,
moderated by Lynne R. Ferrari, MD (Children's Hospital Boston), followed
the awards presentations and had two parts this year. First, E. Greg Koski,
MD, PhD spoke on "Ethical Implications of Pediatric Research". He is
the Director of Human Resource Protection in the Department of Health
and Human Services in Rockville, MD. Second, Robert M. Nelson, MD, PhD
described "Pediatric Research from the Child's Perspective".
He is the Chair of the IRB at Children's Hospital of Philadelphia.
Inspiring Walk-Around poster discussions were next on
Saturday's agenda. There were 65 posters which were grouped into either
Potpourri, Equipment and Monitoring, Techniques, Pain/Regional, Pharmacology
I, Pharmacology II, and Physiology and Co-Existing Disease which were
moderated by, respectively, Steven A. Stayer, MD (Texas Children's Hospital,
Houston), Frank H. Kern, MD (Duke University School of Medicine), Zeev
Kain, MD (Yale University School of Medicine), Santhanam Suresh, MD (Children's
Memorial Hospital, Chicago), Myron Yaster, MD (Johns Hopkins Hospital),
C. Dean Kurth, MD (Children's Hospital of Philadelphia), and Francis X.
McGowan, Jr., MD (Children's Hospital Boston).
The highly recommended Workshops were repeated Saturday
afternoon, with the premier addition of "Magical
Distractions for Children" presented by J. C. Abajian, MD
(University of Vermont).
Saturday's program ended with four extremely well presented
Refresher Courses: "Anesthesia for Children in Remote Locations" by Andrew
Infosino, MD (University of California, San Francisco), "Induction
Techniques in Children" by Aubrey Maze, MD (Phoenix, Arizona),
"Sedation Systems" by Thomas J. Mancuso, MD (Children's
Hospital Boston), and "Neonatal Pain Management" by Joseph D. Tobias, MD
(University of Missouri).
Those who went on the dinner cruise on Saturday night
were in for a real treat! The weather was nearly perfect, the Miami Skyline
was captivating, the food was wonderful, and the boat was elegant! This
was a relaxing opportunity to visit with current as well as previous colleagues
and some of their family members.
Sunday's portion of the meeting began with the Baxter
sponsored breakfast lecture moderated by Myron Yaster, MD (Johns Hopkins
Hospital). This year, Julia C. Finkel, MD (Children's Hospital National
Medical Center, Washington, DC) presented "Oral Analgesics in Children". She described pharmacology
and clinical use of prostaglandin synthesis inhibitors, synthetic and
semisynthetic opioids, the NMDA receptor antagonist dextromethorphan,
and the antiepileptic gabapentin.
Following this was a session entitled "Update in Pediatric Cardiac Anesthesia" moderated
by Anne M. Lynn, MD (Children's Hospital and Regional Medical Center,
Seattle). First, Dean B. Andropoulos, MD (Texas Children's Hospital, Houston)
spoke on "Anesthesia Agents and Myocardial Function in Congenital Heart
Disease". Dr. Andropoulos presented and summarized key conclusions
from research studies attempting to elucidate the effects of volatiles,
N2O, opioids, midazolam, propofol, ketamine, etomidate, and
barbiturates on cardiovascular function in children with CHD. Second,
Peter C. Laussen, MBBS (Children's Hospital, Boston) presented "Anesthetic
and Stress Ablation". Dr. Laussen stated that either high-dose fentanyl
or general anesthesia with caudal opioids attenuate both endocrine stress
and hemodynamic responses to surgical stimulation, but anesthetics do
not obtund the endocrine inflammatory responses to the effects initiated
by cardiopulmonary bypass. Advances in both surgical expertise and perioperative
diagnosis and management; improving pump prime composition; and the use
of ultrafiltration and antioxidants (mannitol and steroids) all limit
physiological consequences of the inflammatory response. Finally, C. Dean
Kurth, MD (Children's Hospital of Philadelphia) described studies addressing
"Neuroprotection".
Pediatric Anesthesia Jeopardy endures as the entertaining
educational ending event! Frederic A. Berry, MD (University of Virginia)
and Myron Yaster, MD (Johns Hopkins Hospital) fielded comments from the
audience while Lynne G. Maxwell, MD (Johns Hopkins Hospital) moderated
the expert panel consisting of Rita Agarwal, MD (Children's Hospital,
Denver), Joseph P. Cravero, MD (Dartmouth Hithcock Medical Center), Scott
D. Cook-Sather, MD (Children's Hospital of Philadelphia), and Santhanam
Suresh, MD (Children's Memorial Hospital, Chicago).
David M. Polaner, MD, FAAP
Jennifer Krupp, MD, FAAP
The Children's Hospital
University of Colorado School of Medicine
Denve, CO
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