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SPA Newsletter.
Pediatric Anesthesiology 2004 Meeting ReviewPoint Hilton Squaw Peak Resort - March 4-7, 2004 Saturday, March 6, 2004 Quentin A. Fisher (Medstar-Georgetown University Hospital in Washington, DC) moderated the first session "International Medical Services", and provided an overview of the variety of services pediatric anesthesiologists have donated to developing countries. The first speaker, George Politis (University of Virginia) described Voluntary Services Abroad (VSA), a chance for pediatric anesthesiologists to volunteer their skills in developing countries for one to four week periods. By volunteering, anesthesiologists can provide care to children who would not receive it, make contacts and friendships with the host country and enhance the stature of the United States in the world by their presence. Dr. Politis described the pitfalls these missions need to avoid including choosing an inadequate facility for surgery, mistaken expectations of the host country, poor selection of mission team members, and improper selection of patients. He suggested the quality of VSA missions could be improved with better resources and methods of quality assurance to review critical events. Dr. Politis concluded by stating that the ultimate goal of VSA is to empower host countries to improve the medical care of their people. For those interested in participating, he provided a link from the SPA website: www.pedsanesthesia.org/vmsa_search.iphtml The second speaker, Robert K. Crone (Boston Children's Hospital), described Harvard Medical International, a non-profit subsidiary of Harvard University. He noted enhanced communications and travel, and improved economics have led to population shifts from the country into the city. These populations shifts have been accompanied by global changes in disease, including the reemergence of infectious diseases like HIV and TB, increases in chronic diseases like diabetes, and increasing recognition of mental health issues such as depression. Consequently, developing nations are experiencing a great need to create public health and prevention strategies to combat these new trends in disease. The mission of Harvard Medical International is to work in partnership with selected international partners to create medical and health care curriculums in international medical schools, encourage basic and clinical research and help hospitals develop strategic and management programs. Dr. Crone argued that while medical missions may provide immediate help, their impact on a developing country is short term and potentially disruptive. Programs like Harvard Medical International teach countries to develop their own self-sustaining medical system. The challenges that this approach faces are no leadership and support from local and U.S. governments, inadequate feedback and education, and inability to establish financial self-sustainability. The third speaker, Charles J. Coté, (Children's Memorial Hospital, Chicago), described the World Federation of Societies of Anaesthesiologists (WFSA) pediatric anesthesia fellowship programs. The WFSA is a non-governmental organization that in conjunction with the World Health Organization, creates educational programs for anesthesiologists throughout the world. The WFSA has created two pediatric anesthesia fellowships, in Santiago, Chile and Tunisia, with a third planned in Cape Town, South Africa. The oldest program was established in 1996 in Santiago, Chile at the Luis Calvo McKenna Hospital, a 230-bed hospital which performs 8,500-9,000 anesthetics per year. Anesthesiologists from various Latin American countries are selected by their local societies for a six-month to one-year pediatric anesthesia fellowship. Fellows receive training from nine European trained anesthesiologists and do a minimum of four months of general pediatric cases and two months of pediatric cardiac anesthesia. After the fellowship, these anesthesiologists return to their country and become an educational source for pediatric anesthesia for their colleagues. Dr. Coté felt that educational programs like this fellowship are a better use of money and resources compared to short term VSA. The final presenter in this session, Lynda Jo Means (Indiana University) described the collaboration of Indiana University School of Medicine and Moi University and Hospital in Kenya, Africa. This partnership was created in 1990 with the goals of enhancing medical education, creating a collegial relationship and developing health care leaders in both countries. Between these two universities, programs have been created to promote medical education and research in Kenya, HIV prevention and agricultural and nutritional teaching. The second session, moderated by Francis X. McGowan (Boston Children's Hospital) asked, "Will Anesthesia Make My Child Stupid, Doc?" Sulpicio G. Soriano (Boston Children's Hospital) discussed the potential neurotoxicity of anesthetic agents as addressed in a recent study by Jevtovic-Todorovic. This study reported rat pups exposed to midazolam, isoflurane and nitrous oxide developed neurodegeneration and learning disabilities. Other studies found NMDA and GABA antagonists also led to similar neurodegeneration in rat pups, thus leading researchers to question whether these common anesthetic agents could lead to similar neurodegeneration in neonates. However, rat pups exposed to surgical stimuli and stress were shown to experience abnormalities in pain perception and behavior. Dr. Soriano reviewed other possible factors involved in neurodegeneration. For instance, the rat pups that received prolonged, chronic exposure to anesthetic agents had neurodegenerative changes compared to those that received an acute exposure Other insults such as hypoxia, decreased brain perfusion and malnutrition may contribute to neurodegeneration in the immature brain. Finally, the applicability of the results from the rat subjects to human subjects remains unclear. At this time clinicians can address the concerns brought up in these studies by minimizing exposure of the neonate to surgical stress and anesthesia and preventing other insults to the brain. The second speaker, C. Dean Kurth (Children's Hospital Medical Center, Cincinnati) asked whether volatile anesthetics are neuroprotectants or neurotoxins. Volatile anesthetics block NMDA, AMPA and several calcium channel voltage gated receptors and may ameliorate calcium levels and increase tissue oxygenation. Animal studies looking at the effect of volatile anesthetics during ischemia and reperfusion showed these drugs conferred neuroprotection during ischemia and early perfusion. Studies showed during the preconditioning period, a time just before the onset of ischemia, receiving volatile anesthetics might help the brain resist ischemia, although this effect is not clear. He noted neuroprotective effects of volatile anesthetics are not potent, but can be additive with mild hypothermia and the dose needed may be greater than one MAC. Volatile anesthetics may need to present in the brain for some period of time and it is more effective for focal ischemia rather than global ischemia. Regarding the possibility of volatile anesthetics acting as neurotoxins, Dr. Kurth referred to the same study cited in Dr. Soriano's talk. Again, differences between species need to be considered when extrapolating the results of animal studies to humans. Also the amount of exposure to volatile anesthetics leading to neurodegeneration in humans is unclear. At this time he recommended continuing the present course of treatment until new evidence in humans appears. As for surgeries with ischemic risks (e.g. cardiopulmonary bypass) volatile anesthetics can provide protection before and during the period of risk at greater than one MAC. "Pediatric Perioperative Environment: Should Hospitals and Anesthesia Practitioners Have Performance-Based Credentialing: The California Experience" ended the meeting as Alvin Hackel (Stanford University Medical Center), described how SPA, AAP and the Committee of Pediatric Anesthesia of the ASA created guidelines for defining clinical competency, rules for the pediatric perioperative environment and the criteria for pediatric anesthesia fellowships. Since the practice of pediatric anesthesia differs from adult anesthesia due to the unique anatomy and physiology of pediatric patients, standards needed to be set for all involved in the care of children. With input from major medical organizations, hospitals, program directors three major areas were addressed. First was the definition of clinical competency. Guidelines created stated that general anesthesiologist by the end of the CA-3 year would be competent to provide safe anesthesia and post-anesthesia care for infants and children undergoing routine surgical, diagnostic and therapeutic procedures, and recognize when the clinical condition of the patient or the proposed procedure required skills, facilities or support beyond the capability of the anesthesiologist or institution. After at least one year of subspecialty training, the pediatric anesthesiologist would provide anesthesia care for neonates, infants and children undergoing all types of surgical, diagnostic and therapeutic procedures as well as pain management and routine and critical perioperative care. The second is guidelines for the pediatric perioperative environment recommended establishment of a minimum pediatric case number needed for competency as well as type of cases, emergent versus elective cases and ages of patients with neonates being the highest risk population. The final area provided a formal definition of a pediatric anesthesia fellowship adopted by the ACGME in 1997. Future goals of these guidelines include further improvement in pediatric care, expansion of pediatric fellowships and creating similar guidelines for nursing and surgery. The final speaker, Mark A Singleton (Good Samaritan Hospital, San Jose) offered his perspective from the community hospital. He described how his department changed from a group where every anesthesiologist provided care to all pediatric patients to the development of a core group of fellowship trained pediatric anesthesiologists. At this time, the California Children Services was given a mandate to update and revise the criteria for qualifications for anesthesiologists providing care for pediatric patients covered by their funding. The Bay Area Pediatric Anesthesia Consortium and the California Society of Anesthesiologists (CSA) participated in this project. While much progress was made, efforts are now on hold due to the budget issues occupying the state. However in 2003, the LA Times reported cases where infants and children suffered complications and death during anesthesia. The CSA responded to these events by creating a policy on pediatric anesthesia using the published documents from the AAP and ASA as a guide. This policy is available on the CSA website (www.csahq.org). Elizabeth Yun, MD
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