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Pediatric Anesthesiology 2004 Meeting Review
Point Hilton Squaw Peak Resort - March 4-7, 2004
Friday, March 5, 2004
Friday began with welcome remarks from Anne Lynn, President of the SPA, Patty Davidson, Chair AAP Section on Anesthesiology and Pain Medicine, and Lynne Maxwell, Program Chair.
James Steven (Children's Hospital of Philadelphia) moderated the morning session "Patient Safety: Process Improvement / What to do When Bad Things Happen". The first speaker Lucian Leape (Harvard University School of Medicine) presented "Patient Safety - A Systems Approach to Minimize Errors". His thesis was to understand the complexity of medical errors, we must consider the systems under which those in the health care professions operate. The systems are replete with latent errors and defects, triggering factors, unsafe acts, defenses against errors, and errors. When circumstances are such "the holes line up" - i.e. when systems in place allow errors to get through undetected, medical errors can occur. Errors are commonly contributed to by bad systems, not bad doctors. The culture of blame in medicine today does not address the complex cause of most medical errors. He also discussed barriers to a more universal acceptance of a systems approach to medical error. He attributed cost, public perception, lack of administrative leadership, and doctors themselves as obstacles.
Robert Brown (Bloomberg School of Public Health, Baltimore) opened the next session "Unanticipated Events in the OR" where his lecture "Anaphylaxis" revealed while rare in the OR (incidence of 1/10,000-20,000), mortality remains high. He stressed that anaphylactic reactions are mediated by IgE, and anaphylactoid reactions are not, the end results are the same. He reviewed the allergy cascade. Signs and symptoms of anaphylaxis can be widespread, affecting skin, eyes, the upper and lower respiratory tract, the cardiovascular system, and the GI tract. Treatment requires eliminating exposure, and the ABC's of resuscitation. Epinephrine remains the mainstay of pharmacologic treatment, and large resuscitation doses are often not necessary. Causes of anaphylaxis in the OR are changing with Neuromuscular blockers decreasing and Latex increasing in frequency as a cause. A study from his institution found that 12 percent of anesthesia personnel tested positive to Latex. He felt that OR's should be Latex free to decrease exposure of patients and personnel, and that heightened awareness of potential Latex allergy is important in terms of prevention of anaphylaxis.
Jeff Morray (Phoenix Children's Hospital) spoke next "Unexpected Cardiac Arrest in the Anesthetized Child". He discussed the PeriOperative Cardiac Arrest (POCA) project results, which looked at 150 cases of perioperative cardiac arrest in children where 55 percent of the cases were less than one year of age, and most less than one month. Survival was no different across age groups and far more likely in ASA class 1-2 patients than in ASA class 3-4. The causes of cardiac arrest have been changing; inadequate ventilation has been replaced with underlying medical conditions, and primary cardiac events are increasing in frequency. Hyperkalemia, secondary to massive transfusion (not succinylcholine) is rising in frequency as a cardiac cause, and it is recommended that blood be washed if it is old or irradiated to reduce the K+ concentration. He recommended that a comprehensive analysis of events be undertaken following such events.
Susan Retzack (Medical College of Wisconsin) started the second session of the morning "Managing Bad Outcomes", with her talk "Personal / Professional". This was an honest and frequently heart-felt account of her personal experience with an unexpected death in the OR. She described the events and her reactions to them. She elucidated that our reactions as physicians to such events are ones of sadness, shame, guilt, isolation, and fear. Most physicians react to such an event or subsequent lawsuit with depressive symptoms, which if poorly managed, may increase stress and possibly increase the likelihood of a second event occurring. She suggested coping strategies should include seeking support, reasserting control over ones personal life, and changing the meaning of the event (a claim does not always equal negligence). Lawsuits are less likely to occur following a bad outcome if good communication exists with the patient and family.
Steve Kern, a defense lawyer with Kern, Augustine, Conroy and Schoppmann (Bridgewater, NJ) spoke about the legal perspective in his talk "Legal / Media". He asserted bad things happen to good doctors, and his over-riding theme was protect yourself, because no one else will. He discussed perspectives of various parties involved in a lawsuit over a bad outcome, and how interests for all parties are different from your own. In his words, "Your enemies are everywhere. Your friends are few and far between."
The final presentation for the morning "Sentinel Event Process" by Eugenie Heitmiller (Johns Hopkins University Hospital) involved the process of root cause analysis, and how important it is to look at the whole system, not just at the primary individuals involved.
Catherine R. Bachman, MD
Friday noon was an industry-supported lecture on recombinant rVIIa with Guy Young (Children's Hopital,Orange, CA), expert hematologist and Joseph Tobias (University of Missouri). They opened the session with clear disclosure that this drug is currently recommended for Hemophilia A and B only and any other use is clearly off label. Dr. Young gave an update on new changes in coagulation pathways. He gave a nice animated presentation and elaborated the central role of factor VIIa. Afterwards Dr. Tobias reiterated the dangers of transfusion of PRBC and FFP. He then went on to multiple case reports where he has used rVIIa with the hospital committee approval and the success in decreasing the blood and factor transfusions including spine fusions, Jehovah's witnesses and trauma among others. Of particular mention was a comment by a surgeon on prompt hemostasis as "what did you do?" He mentioned the cost of the factor to be about $4,000 with concerns from pharmacy regarding the source of reimbursement. His talk ended with questions like the level of platelets or fibrinogen needed for the drug to be effective, the prophylactic use, use in Post CABG or repair of congenital heart diseases among others but most importantly the end point of the treatment remaining unanswered.
Linda Jo Mason (Loma Linda University Medical Center) and Francis X. McGowan (Children's Hospital Boston) heralded the afternoon session. Dr. McGowan gave a superb song and dance performance frequently interrupted with thorough and diligent discussion of adult patients with congenital heart diseases undergoing mostly non cardiac surgery. He first presented an overview of basic pathophysiologic problems including shunts, volume vs. pressure overload, pulmonary hypertension and contractile problems of myocardium. He stated the importance in consulting the cardiologist after reading the cardiology report. Use of positive pressure ventilation vs. spontaneous ventilation use in the face of altered pulmonary blood flow was another important point discussed. Dr. Mason presented a detailed and informative approach to managing patients for non-transplant surgery who have had transplants. She emphasized the need to look for clues regarding stability or complications of drug therapy with references towards Calcineurin inhibitors, Antimetabolites, IL-1 inhibitors and TOR inhibitors. She emphasized that often the signs of rejection may be very subtle and nonspecific. She presented pre-operative, peri-operative and post-operative management of these patients in a very comprehensive way.
Bells and whistles kept everyone attentive during Jeopardy, as important questions were discussed in a game-show format.
In the afternoon refresher courses, the audience attended individual sessions. Refresher courses included "Size Does Matter" with Robert Holzman (Children's Hospital Boston) discussing the importance of not extrapolating the adult anesthesia teachings to pediatric practices. Melissa Wheeler's (Children's Memorial Hospital, Chicago) session on "Neonatal Surgical Emergencies", Alan Tait's (University of Michigan) session "Perioperative Control of Infection" and Zeev Kain's (Yale University School of Medicine) "Myths of Pediatric Anesthesia" discussing NPO guidelines, URI, and parental presence.
Zulfiqar Ahmed, MD
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