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SPA Newsletter.
Out and About the ASATuesday Morning General Pediatric Anesthesia Poster Discussions and Poster Sessions of General Pediatric and Pediatric Cardiac Anesthesia Reviewed by: Valerie E. Armstead, MD, FAAPOctober 14, 2003 at the ASA annual meeting was a busy morning for those interested in pediatric anesthesia. The above sessions occurred simultaneously. This proved to be a challenge to those trying to cover all bases of the subspeciality. A variety of issues germane to the care of infants and children requiring anesthesia for surgery or diagnostic procedures were covered this fall. A special emphasis was given to the well-represented cluster of free standing posters related to pediatric cardiac anesthesia. The morning (09:00 to 10:30) pediatric posters were not discussed in the order published in the abstract booklet, this order will be followed for the members not able to attend the meeting. There were eight posters slated for discussion: A-1445 ˙A Multicenter, Randomized Study To Determine the Pharmacokinetics and Pharmacodynamics of Fenoldopam Mesylate in Pediatric Patients . Susan T. Verghese, MD; Gregory B. Hammer, MD; George Lavandosky, MD; Myron Yaster, MD; Joseph R. Tobin, MD; Departments of Anesthesiology and Pediatrics, Children's National Medical Center and George Washington University, Washington DC. In this multicenter study of this unique drug used to lower blood pressure for hypotensive anesthetic techniques the findings were presented by Dr. Verghese. Fenoldopam 1.0-1.2 mcg/kg/min was found to cause clinically significant reductions in MAP in pre-adolescent children; while greater dosages conveyed little additional benefit. This effect is consistent with PK/PD findings in adults. A-1446 Risk Factors for Severe Postoperative Vomiting in Pediatric Patients.˙ Mehernoor F. Watcha, MD; Christopher Lee, MD; Jun Park, MS. Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA. The aim of this study presented by Dr. Meb Watcha, was to identify patient, surgical and anesthetic factors associated with an increased risk for severe postoperative vomiting (POV) as 3 episodes in the first 24 hours after anesthesia. Multiple logistic regression on data extracted from 52,269 computerized anesthetic records identified factors associated with 3 episodes or more of postoperative vomiting in children. ASA 1 or 2 females above the age of 11 years, with a previous history of POV, undergoing long surgical procedures (e.g. middle ear surgery), on an outpatient basis were the pediatric patients with the highest risk for severe POV. These patients may benefit from multimodal POV prophylaxis while sparing the other less affected 2/3rds of the pediatric patient the cost burden A-1447 ˙The Effects of Alterations in Ventilation on Cerebral Oxygen Saturation among Infants after Bidirectional Superior Cavopulmonary Connection Stephen A. Stayer, MD; Ahmed Alomrani, MD; Tia Tortoriello, MD; Zeev Perles, MD; Mott R. Antonio, MD; Divisions of Pediatric Cardiovascular Anesthesiology and Pediatric Cardiology, Baylor College of Medicne, Houston, TX. This study addressed the fact that after bidirectional superior cavopulmonary connection (BSCPC), increasing pH and lowering pCO2 will increase cerebral vascular resistance and lower pulmonary vascular resistance. However, hyperventilation has been shown to decrease PaO2 after BSCPC. The purpose of this study was to determine the effects of alterations in ventilation on cerebral oxygen saturation (rSO2), systemic oxygenation, and hemodynamics among infants after BSCPC. These authors found out that infants may develop significant hypoxemia. Avoiding hyperventilation, and possibly producing mild hypoventilation will optimize both systemic and cerebral oxygen saturation. BSCPC infants benefit from normoventilation and even mild hypercapnia when appropriate. Dr. Jerry Lerman made a comment from the audience that perhaps high-frequency oscillating ventilation (HFO) might have been the better mode of ventilation as the intrathoracic pressures should remain normal in this setting. A-1448 -˙Milrinone and Nitric Oxide: Combined Effect on Pulmonary Artery Pressures Following Cardiopulmonary Bypass in Children. Vadim Khazin, MD; Yefim Kaufman, MD; Lior Sasson, MD; Peter Szmuk, MD; Tiberiu Ezri, MD; Anesthesiology, Edith Wolfson Medical Center, Hulon, Israel. Dr. Khazin presented data addressing the management options of perioperative pulmonary hypertension that include but are not limited to NO and milrinone. An advantage of NO is the lack of systemic hemodynamic effect as it is administered directly to the pulmonary circulation. This group assessed the effect of a combination of milrinone or nitric oxide (NO) versus each drug given alone, in reducing pulmonary artery pressures following CPB in children undergoing surgical repair of congenital heart defects. The authors concluded that a combination of milrinone and NO produced a more pronounced decrease in PAP than each drug separately. A-1449 ˙Cerebrovascular Hemodynamics in Children during Anesthetic Emergence: Propofol vs Desflurane. Ross Barlow, MD; Cengiz Karsli, MD; Igor Luginbuehl, MD; Bruno Bissonnette, MD; Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. Dr. Barlow presented a study investigating the effects of propofol versus desflurane and measured the effects on cerebral blood flow using middle cerebral artery blood flow velocity. Remifentanil was used throughout the study period. There was a 54% increase in middle cerebral artery blood flow velocity when propofol was discontinued and desflurane was added at 1 MAC concentration. Heart rate and mean systemic arterial pressure did not change, which was thought to be due to the concurrent use of remifentanil. The authors concluded that desflurane should be used with caution in children with altered cerebral compliance. A-1450 ˙Peak Inflation Pressure (PIP) Measured at the Tracheal End (PTrach) of the Endotracheal Tube (ETT) Is More Accurate Than PIP Measured by the Ventilator (Pvent) in Children with Respiratory Failure. B. Craig Weldon, MD; Rogelio H. dela Cruz, MD; Michael J. Banner, PhD, Anesthesiology and Pediatrics, University of Florida, Gainesville, FL. Dr. Craig Weldon presented a study comparing the measurement of peak inspiratory pressure (PIP) at the very tip of the endotracheal tube (ETT) tip as opposed to mean PIP as measured by the mechanical ventilator. The distal ETT PIP was measured by means of an internal sideport catheter embedded by the manufacturer. As was suspected by the investigators, the distal ETT PIP was significantly lower (p < 0.05) compared to the PIP reported by the ventilator. It was also noted that the difference between the two PIP measurements was greatest in situations where the peak inspiratory flow rates were high. The authors concluded that caution should be used when considering make a change in mechanical ventilator settings based on ventilator-reported PIPs. Furthermore, the difference between the two PIPs (Pvent) and (PTrach) in children with respiratory failure is exaggerated at high flow ventilator rates. Members of the audience asked if PIP measurement should routinely be measured at the distal ETT tip. Dr. Weldon responded that in an ideal environment, PTrach measurement would be preferred. A-1451 ˙Reduction in Perioperative Blood Loss Following Surgery for Scoliosis: A Prospective, Randomized, Double Blind Examination of Epsilon Aminocaproic Acid Ivan Florentino-Pineda, MD; Dale E. Williams, MD, PhD; George H. Thompson, MD, Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, OH. This study, presented by Dr. Pineda, examined the impact of epsilon aminocaproic acid (EAA) on the perioperative blood loss occurring during surgical correction of idiopathic scoliosis in adolescents. EAA was chosen, as it is an antifibrinolytic shown to reduce perioperative blood loss in other populations. A total of 36 patients were studied, 19 patients received EAA and 17 were in the control group. Analysis of variance detected no statistically significant differences between groups preoperatively. Total perioperative blood loss was less in the EAA group (1,389 ml vs. 1,720 ml; p 0.05). Furthermore, postoperative hemoglobin (8.4 gm/dL vs. 7.2 gm/dL; p < 0.001) and hematocrits (25.2% vs. 21.8%; p < 0.001) were significantly higher in the Amicar group while total autologous blood transfusions were lower (1.0 unit vs. 1.6 units; p 0.05). The authors concluded the use of EAA during anesthesia for scoliosis repair should lead to a practice of reduced autodonation and a significantly reduced need for blood transfusion. Table of Contents
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