Sheraton San Diego Hotel & Marina • San Diego, CA • February 22-25
The American Academy of Pediatrics Section on Anesthesiology and Pain Management and the Society for Pediatric Anesthesia held their 7th joint winter meeting in San Diego, CA in February. Once again, a sunny warm locale was graced with the traditional AAP/SPA weather- cold and rainy. Although this has become so frequent that it led many participants to conclude that there is a curse on this gathering, the inclement weather was certainly not reflected in the atmosphere of the conference. The meeting began on Thursday evening with a forum discussing evidence-based data on various topics of controversy in pediatric anesthesia practice, conducted by Steven Hall, MD (Children's Memorial Hospital, Chicago), Lynne Maxwell, MD (Johns Hopkins, Baltimore), Jerrold Lerman, MD (The Hospital for Sick Children, Toronto) and Peter Davis (Children's Hospital of Pittsburgh).
Friday's assembly was centered on several plenary sessions. The first was devoted to three lectures on the management of trauma and resuscitation, and was moderated by Anne Lynn, MD (University of Washington/ Children's Hospital and Regional Medical Center, Seattle). Flaura Winston, MD, PhD (TraumaLink, the Interdisciplinary Pediatric Injury Research Center at Children's Hospital of Philadelphia), spoke on the mechanisms of injury in pediatric trauma. She emphasized the need to understand the biomechanics of an injury in order to both provide optimal care for the patient and to gain further understanding to redesign cars, bicycles, toys, etc. to reduce the risk of future similar injuries. An engineering approach to the investigation of injuries divides an automobile crash, for example, into three components: the initial impact of the vehicle with the patients (crash dynamics), the collision of the passenger with interior of the vehicle and its restraint devices (occupant kinematics), and the impact of the internal organs on each other and on bony structures within the occupant's body. The latter can result in rapid deceleration injuries as well as shear injuries. Dr. Winston showed digital simulations of how these factors inter-relate in a vehicle crash, which graphically illustrated these principles.
Dr. John Rose (Children's Hospital of Philadelphia [CHOP]), discussed the anesthetic management of the pediatric trauma patient. Ninety-four percent of trauma cases at CHOP involve blunt trauma, particularly falls and vehicular injuries. Head injuries are the most common cause of death in pediatric trauma. He emphasized the relationship between head trauma and cervical spine injury. Spinal cord injury without obvious radiological abnormality (SCIWORA) is a particular problem in small children due to ligamentous laxity and the ability of the spinal column to allow much greater deflection than the cord itself. Since respiratory compromise is the most common preventable cause of death in the pediatric trauma victim, he discussed the priorities of airway assessment and management. Dr. Rose reviewed current thinking about volume resuscitation, and discussed several other issues impacting on cerebral resuscitation.
In the final lecture in this session, Charles Schlein, MD (Babies Hospital/ Columbia University College of Physicians and Surgeons, New York), updated us on the most recent guidelines for pediatric resuscitation from the American Heart Association. The use of intra-abdominal compression CPR, which may increase aortic diastolic pressure and increases venous return, priming the thoracic pump, is now recommended for adolescents. End-tidal CO2 monitoring is recommended for both confirming endotracheal intubation as well as for assessing adequacy of cardiac output during CPR (values should be >10 torr).
The next series of talks focused on optimizing clinical care, and was moderated by James Steven, MD (Children's Hospital of Philadelphia). David Cullen, MD (St. Elizabeth's Hospital/ Tufts University School of Medicine, Boston) discussed errors in clinical medicine and described the processes by which adverse drug events and potential adverse drug events occur. He emphasized that the most common etiology of these events is not individual errors, but systems problems that make such errors inevitable. He also discussed the need to alter the usual ABC's of medical quality assurance (assess, blame, and criticize) to a paradigm where systems errors are identified and processes are modified to reduce the likelihood of recurrence.
John Nance, JD, a former military and commercial pilot who serves on both the National Transportation Safety Board and National Patient Safety Board, delivered the Nellcor Lecture on "The Aviation Paradigm" in anesthesia. He spoke of the revolution in cockpit culture, which has resulted in dramatic improvements in aviation safety. The captain-oriented focus has been replaced with Crew Resource Management. In this system, the captain utilizes all of the resources available to deal with problems, and systems are designed to minimize and absorb errors, the occurrence of which are recognized to be inevitable. Communication between all members of the crew is the key to the success of this system, and these principles are directly transferable to the operating room environment.
David Gaba, MD (Stanford University School of Medicine), a leader in the development of simulator technology, described the uses and benefits of simulation in anesthesia training and education. The simulator can be used to practice responses to rare but critical events, and debriefing sessions can help anesthesiologists learn from errors. Anesthesia Crisis Resource Management, the direct corollary to Cockpit Resource Management described by Mr. Nance, can be ideally taught in the simulator, and systems problems can be identified and rectified. Presently, there are only limited pediatric simulations available.
The last lecture of this session, given by David Nichols, MD (Johns Hopkins University School of Medicine), discussed how evidence-based medicine can aid in decision making. A clinical question is formulated, the evidence (data from clinical trials) is critically analyzed, and outcome oriented therapeutic strategies are identified and rated, based on the strength of the evidence supporting those conclusions. The selection of valid questions and the use of clinically important (as opposed to surrogate) outcomes are vital to the effective application of evidence-based medicine. Dr. Nichols discussed in detail how to critically evaluate the validity of clinical investigations, and gave many Internet-based resources for evidence-based medicine.
The final session of the day, moderated by Frank McGowan, MD (Children's Hospital and Harvard Medical School, Boston), was devoted to survivors of childhood diseases, and how their prior medical treatment and experiences influence subsequent anesthetic management. Victor Baum, MD (University of Virginia, Charlottesville) discussed the child with "repaired" congenital heart disease. He emphasized that even after complete correction, these children do not have normal hearts, and that hemodynamic, electrophysiologic, and functional disturbance will always remain. It is crucial to have an understanding of the anatomy and physiology of the underlying lesion and its surgical correction in order to safely care for these children.
Claire Brett, MD (University of California, San Francisco) gave a comprehensive lecture on the former premature infant, discussing the many effects of premature birth has on all organ systems. She placed particular emphasis on respiratory function and chronic lung disease of infancy (BPD), and on neurological complications and outcome, discussing both the pathophysiology of those problems as well as an approach to their management in the ex-premie.
The final lecture was delivered by Steven Weissman, MD (Children's Hospital of Wisconsin, Milwaukee) on late effects in survivors of childhood cancer. The dramatic improvements in cancer therapy in the last few decades have produced nearly a quarter of a million children who have survived childhood malignancies. The effects of cancer chemo- and radiotherapy on the endocrine, cardiac, pulmonary, and musculoskeletal systems were described in detail. He also discussed the effects these therapies have on neuropsychiatric function and quality of life, and noted that the risk of secondary malignancy in these patients is high- as much as 20%.
Saturday morning's Problem-Based Learning Discussions offered a chance to discuss a wide range of prepared poignant cases, to analyze personal clinical experiences and idiosyncrasies, and to assimilate expert-based theoretical options. There were 12 cases discussed including such diverse topics as Craniotomy in a Child on DDAVP, to Emergence Delirium.
Next, six sets of concurrent walk-around poster discussions promoted
invigorating scientific exchange. The grouping of these discussions into
Physiology, Equipment and Monitoring, Techniques, Pain, Potpourri, and
Pharmacology facilitated the option of focusing on specific areas. There
were 56 excellent posters moderated by President
Peter J. Davis, MD (Children's Hospital, Pittsburgh), Immediate Past President Steven J. Hall, MD (Children's
Memorial Hospital, Chicago), Zeev N. Kain, MD (Yale University School of Medicine),
Frank H. Kern, MD (Duke University School of Medicine),
President-Elect Anne M. Lynn, MD (Children's
Hospital and Regional Medical Center, Seattle), Mark A. Rockoff,
MD (Children's Hospital, Boston), and James M. Steven, MD (Children's Hospital, Philadelphia).
The Poster Session was followed by the Awards and Oral Abstract Presentations (page 7).
The AAP advocacy lecture, "Post-Traumatic Stress Disorder in Children and Parents" was a thought provoking presentation by Nancy Kassam-Adams, PhD (Children's Hospital, Pittsburgh). Most surprising was the finding that the likelihood of developing the disorder is related not to injury severity, but to gender (F>M), having experienced prior trauma events, pre-existing depression or anxiety, perception of a threat to life during the event, and parental stress response. She encouraged us to facilitate resiliency in our pediatric patients as well as in their parents, and to encourage parents to seek and accept support to effectively manage their own stress reactions.
The popular Friday workshops were repeated Saturday afternoon with the addition of an 8th in which Zeev N. Kain, MD (Yale University School of Medicine), who has recurrently set creative precedence in this area, revealed key guidance for Designing Clinical Trials.
Saturday's scientific program ended with a new set of refresher courses: Pediatric Critical Care for the Anesthesiologist by Maurice S. Zwass, MD (University of California, San Francisco); Sedation Solutions: Potions, Practitioners, Policies by Charles J. Coté, MD (Children's Memorial Hospital, Chicago); Vascular Access in Infants and Children by Peter C. Laussen, MD (Children's Hospital, Boston); and Neonatal Pain Management Protocols by Constance S. Houck, MD (Children's Hospital, Boston).
Saturday's meeting concluded with a high energy, well-attended cocktail and tempting hors d'oeuvres reception at the Westin.
There were two main events on Sunday morning. Navil Sethna, MB, ChB (Children's Hospital, Boston) started the final day with his breakfast talk, sponsored by Baxter, "Advances in Acute Pain Management in Children". He highlighted the roles of epidural clonidine, epidural ropivacaine, epidural ketamine, propacetamol, and tramadol in treating pediatric acute pain. He also revisited the established effectiveness of preemptive analgesia in the pediatric surgical population.
The second event on Sunday, which some would describe as the main event of this meeting, the fun we may just wait all year for--was the Pediatric Anesthesia Jeopardy!! The all-creative, entertaining, and expert panel members were Rita Agarwal, MD (Children's Hospital, Denver), Francis X. McGowan, MD (Children's Hospital, Boston), James P. Steven, MD (Children's Hospital, Philadelphia), and Myron Yaster, MD (Johns Hopkins University).
David M. Polaner, MD, FAAP
Jennifer Krupp, MD, FAAP
The Children's Hospital
University of Colorado School of Medicine
Denver, CO