 |
|
|
|
 |
 |
 |
|
 |
|
||
|
|||||||||||
Home About SPA Join SPA Education Newsletter Jobs & Fellowships Volunteer Service Abroad Links of Interest
|
SPA Newsletter.
Joint meeting of SPA and JSPA
The first joint meeting of the Society for Pediatric Anesthesia (SPA) was held with its counterpart from Japan, the Japanese Society of Pediatric Anesthesiology (JSPA) on October 12 at the St. Francis Hotel in San Francisco, CA. The meeting was well attended and simultaneous translation was provided both English and Japanese attendees. Program Chairs, Mark A. Rockoff, MD (Children's Hospital, Boston) and Yasuhiro Shimada, MD, PhD, FCCP (Nagoya University School of Medicine, Nagoya, Japan) provided welcoming remarks. The morning session "Innovative Approaches to the Surgical Neonate" moderated by Anne M. Lynn, MD (Children's Hospital and Regional Medical Center, Seattle), Michael Harrison, MD (University of California, San Francisco) lectured on the surgical perspective of fetal surgery. Fetendo techniques (minimally invasive techniques for fetal intervention) have revolutionalized fetal surgery in the last 10-12 years. He discussed a myriad of conditions including hydrocephalus, congenital cystic adenoid malformation (CCAM) of the lung, sacrococcygeal teratoma (SCT), congenital heart block, twin-twin transfusion syndrome (TTTS), where treatment has been attempted, and incorporated a "Fetal Surgery Report Card" to depict grades for understanding of disease, patient selection and treatment options (either open or fetoscopic). He mentioned that while fetal surgery did not change neonatal outcome for some conditions like congenial diaphragmatic hernia (CDH), endoscopic laser ablation of vessels and amnioreduction has been very effective in TTTS. Of special note, he discussed the ex-utero intrapartum treatment procedure (EXIT), in which children with anticipated airway problems are dealt with by the fetus being half delivered, leaving a connection to the placenta to allow up to several hours of time without an airway emergency to intubate and perform corrective surgery, rather than traditional postnatal correction. Dr. Harrison concluded that fetal surgery was the best way to go for radiofrequency ablation for TTTS (90% success), CCAM resection, SCT, but offered no advantage with some conditions like myelomeningocele. Laura Myers, MD (Children's Hospital, Boston) discussed the anesthesia perspective of fetal surgery. She opened her talk with evidence to support the presence of fetal pain and need for anesthesia. This was measured by a stress response during fetal development, resulting in increased cytokines that speed uterine maturation and increase risk for preterm labor. Noxious stimuli can trigger release of norepinephrine at 18 weeks, and at 20 weeks slower cortisol and beta-endorphin responses. Touch and pain sensation develop first in the fetus, with nocioception around the mouth as early as seven weeks, and the development and synapsing of peripheral afferent nerves in the spinal cord between 10-30 weeks. Importantly, she stated that the receptive field is larger in utero, and that various stimuli might induce an exaggerated response in the fetus. Of the four routes of fetal anesthesia, intravenous/intramuscular/transplacental/intraamniotic, the intra-amniotic route offers rapid uptake by the fetus, with minimal entry into the maternal circulation. Real time video footage illustrating fetal resuscitation via drug and blood administration was shown. A final video of the management of a 30-week fetus with polyhydraminios, an oropharygeal teratoma extending to the mediastinum with airway compromise, and scalp and trunk edema was shown. The EXIT procedure was shown allowing delivery of the head and neck, an ultrasound probe to monitor fetal function and identify tracheal rings and surgical tracheotomy in an unpressured and safe time frame. Shoichi Uezono, MD (Tokyo Women's Medical University, Japan) discussed the Japanese approach to CDH. Low perinatal and infant mortality is attributed to the Japanese social background including good prenatal education, low teenage pregnancy and strong familial support. In addition he also attributed this low rate to strengths of their medical system including perinatal/neonatal care centers and regionalization and advances of medical management such as high-frequency oscillatory ventilation (HFOV). His group has attempted transplacental anesthesia to deliver an antenatally diagnosed CDH baby depressed enough to allow intubation without breathing or swallowing effort. Then HFOV is exclusively utilized on admission to the NICU, and the neonate is stabilized prior to delayed surgery. In their small study of 12 patients from 1996-2001 undergoing CDH repair, their management achieved a 90% survival rate, without the use of ECMO therapy. All of the CDH survivors were free from pulmonary complications. Limitations included small study size, higher maternal and neonatal risks such as inability to intubate, and lack of ECMO as rescue therapy. Etsuro Motoyama, MD (Children's Hospital of Pittsburgh) moderated the second session "The Upper Airway in Pediatric Anesthesia", and opened with a discussion of maintenance of upper airway patency in children. The effects of anesthesia on airway patency were contrasted with the pathogenesis of upper airway obstruction (UAO) during sleep in obstructive sleep apnea (OSA). He concluded his talk with the measures that the anesthesiologist can utilize to prevent UAO under general anesthesia. Of note, chin lift with jaw thrust with CPAP offer the best upper airway patency. Shiroh Isono, MD (Chiba University, Japan) discussed the physiology of the upper airway. He opened his talk with an overview of the multiple functions of the pharynx including swallowing, vocalization, and the facilitation of breathing by anatomical and neural mechanisms, which interact to adjust lumen size and stiffness. Methods of airway maintenance during breathing were described with a "meat and container model" -the "meat" being the soft tissue, muscle, and fat, and the "container" being the bony support. Some examples were used to illustrate-with obesity, macroglossia, Prader-Wili syndrome, airway patency decreases due to increases in size of pharynx (meat); with small maxilla, mandible, Pierre-Robin syndrome, airway patency decreases due to decreases in the size of the container (meat unchanged). Measures to counter same include advancement of the mandible and extension of the neck to improve airway patency. He stressed the sequential interaction between anatomical and neural factors that occurs upon loss of consciousness, to facilitate airway patency and contrasted these mechanisms in neonates, children and adults. Neonates rely on reflexes and chemical responses to maintain airway patency during sleep. This has important implications because anesthesia probably depresses neural mechanisms which may affect infant postoperatively. Children have greater anatomical stability (smaller head, larger jaw, increased container) with a higher closing pressure between age 1-13 years, with diminished risk of airway obstruction. Adults have a higher body mass index compared to children which decreases airway patency, and rely more on arousal for maintenance of upper airway. The final lecture of the morning by Thomas G. Keens, MD (Children's Hospital, Los Angeles) explored sleep apnea in infants and children. The cortex influences behavioral control of breathing and the brainstem affects chest wall movement via chemoreceptors. In REM sleep, the cortex controls breathing; during quiet sleep, breathing is controlled by brainstem, and regularly timed. The causes of obstructive sleep apnea were elaborated- (the most important being a small upper airway), as well as symptoms, diagnosis (gold standard-polysomnography) and treatment. OSA is common in infants, and is largely obstructive not central. Older children usually have obstructive apnea secondary to tonsils/adenoids. Treatment is required when problems with gas exchange are manifest such as hypoxia or hypercarbia. Robert Crone, MD (Harvard Medical School, Boston) moderated the afternoon session "Medical and Anesthesia Care in Japan and the U.S.A". John Takayama, MD, MPH (National Center for Child Health and Development, Tokyo, Japan) contrasted the problems and differences between the respective health care systems, health insurance, organization of health care, education of physicians, physicians and facilities, health status, causes of death and health care options. While 99% of the Japanese population has mandatory national health insurance, health outcomes are negatively impacted by unfavorable changes in policy issues such as immunization, where the childhood immunization rate against measles is 10% lower than the U.S.A., and last year there were 100,000 cases with 100 deaths. Health care is more intervention- based than prevention-based. Unintentional injury has a high incidence in Japan with drowning occurring secondary to deeper tubs (versus pools in U.S.A.), and motor vehicle accidents -most children do not wear bicycle helmets, and many automobile passengers do not use seat belts. Yasuhiro Shimada, MD, PhD (Nagoya University, Japan) focused on the Japanese point of view on controversial issue in pediatric anesthesia training and practice. He first opened with the history of the JSPA started by Seizo Iwai in 1971 to provide a forum exchanging information on pediatric anesthesia. He then described data collected from questionnaires to 106 university hospitals (UH) and 17 children's hospitals (CH). While both hospital types perform equal numbers of pediatric cases, training opportunities vary-two-thirds of UH don't have specialty training, whereas at CH the average training period is nine months. Currently there are not enough pediatric anesthesiologist positions. In Japan, of the 17 CH only 78 staff positions and 34 resident positions exist. The future goal is that CH become pediatric anesthesia training centers and academic leaders as their U.S. counterparts. The questions of subspecialty certification of pediatric anesthesia is open-in another questionnaire provided to the council members of the Japanese Society of Anesthesiologists (JSA) 60% responded pediatric anesthesia a not a subspecialty of anesthesia. However, 69% responded experience in pediatric anesthesia should be mandatory. Steven C. Hall, MD (Children's Memorial Hospital, Chicago) concluded the afternoon session with the U.S.A. point of view on controversies in pediatric anesthesia training and practice. He discussed six contentious areas. In particular, these included (1) which hospitals should handle high risk pediatric cases, (2) what minimum equipment and systems are in place for institutions that care for children, (3) if pediatric anesthesiology is affected by changes in nature of pediatric surgery, (4) how to guarantee that children get the care they need, (5) who should provide anesthesia to pediatric patients, (6) what is next priority for the specialty in the country and who will do it. He concluded that the question of subspecialty certification is pending. The final lecture of the day was provided by our guest lecturer, Sten Lindahl, MD, PhD, FRCA (Karolinska Hospital and Institute, Stockholm, Sweden) the first anesthesiologist to head the Nobel Committee for the Prize in Physiology or Medicine. Dr. Lindahl described the history of the Nobel Prize, starting with a brief biography of Alfred Nobel. Alfred Nobel himself discovered dynamite and held 300 patents in several countries Ironically Mr. Nobel died because he could not conceive how the substance that he used in the creation of dynamite-nitroglycerin could be taken internally to help with his chest pain. He died on December 10th , which is the day that the Nobel Prize is awarded every year. Alfred Nobel specified in his last will and testament that there should be five prizes awarded to "those who have conferred the greatest benefit on mankind" in five areas. These areas are physics, chemistry, physiology or medicine, literature and peace. Dr. Lindahl is currently on the Nobel Committee for the Prize in Physiology and Medicine. The Committee is made up of 15 members chosen from Medical Nobel Assembly; five are regular members and ten are adjunct members. They are responsible for presenting 2-3 final candidates to the Medical Nobel Assembly. The Medical Nobel Assembly is made up of 50 Professors from the Karolinska Hospital and Institute. Dr. Lindahl concluded the lecture by comparing the first ten prizes awarded in this area with the last ten. He also noted that in the last 50 years the United States has dominated the Awards, but that there are an increasing number of winners from Japan. The conference was well received by the audience, who look forward to the Joint Winter Meeting of the SPA and AAP Anesthesia Section in Phoenix, AZ. Table of Contents
|
|
| © 2008 Society for Pediatric Anesthesia 2209 Dickens Road, Richmond, VA 23230-2005 • Phone: 804-282-9780 • Fax: 804-282-0090 |
