The 14th Annual SPA Meeting was held in beautiful San Francisco, at the San Francisco Hilton on Oct 13th (Friday the 13th!). After Registration and a continental breakfast with the exhibitors, Dr. Steve Hall (Children’s Memorial Hospital, Chicago), President of the SPA, welcomed the participants and introduced the new SPA President Dr. Peter Davis (Children’s Hospital, Pittsburgh). A brief business meeting was conducted prior to the start of the lectures.
Jeffrey Fineman, MD (University of California - San Francisco) began the morning by discussing the Transitional Circulation. He reviewed the fetal circulation, with emphasis on pulmonary anatomy and physiology. Dr. Fineman discussed both normal and abnormal adaptations made at birth and the neonate’s responses to these. Clinical conditions that can lead to a failure in the decrease in pulmonary vascular resistance at birth can lead to hypoxemia, myocardial dysfunction, reduced systemic oxygen delivery. Treatment options for such conditions, both general and more specific were presented. These included: prevention of aspiration, maintenance of a neutral thermal environment, oxygen, alkalosis, pulmonary vasodilating agents, nitric oxide and ECMO. Dr. Jon Meliones (Duke University Medical Center) continued the morning session with a presentation on Left and Right Heart Management. Evolving surgical techniques and peri-operative care have improved the outcome for infants with congenital heart disease (CHD). A multi-disciplinary approach optimizes the patient’s recovery. The neonatal myocardium has reduced myocardial reserve, limited recruitable stroke volume and a blunted response to circulating catecholamines. Management of left ventricular dysfunction begins by optimizing the patients’ heart rate, preload, contractility and afterload. Right heart dysfunction can cause decreased cardiac output and increased right sided filling pressures. Patients develop hypotension, tachycardia and poor tissue perfusion. Vasoactive agents in patients with right heart failure are aimed at increasing right ventricular contractility and increase coronary blood flow. Decreasing right ventricular afterload is also important. After a thought-provoking question and answer period, there was a coffee break and time for the participants to mingle with the exhibitors.
Dr. Wanda Miller-Hance (University of California, San Francisco) presented a fascinating review of the Natural History of the Repaired Heart. As an increasing number of children with CHD survive into adolescence and young adulthood, more patients will require additional surgery either related to or unrelated to their heart disease. In almost all patients with repaired or palliated CHD some residual abnormality exists. Either right sided, left sided, regional or global ventricular dysfunction may exist. Patients are at risk for bacterial endocarditis. They may be at risk for systemic air embolus, may continue to be cyanotic or to have conduction abnormalities and dysrythmias. Ventricular pressure or volume overload may exist and will need careful management in the perioperative period. Patients may have excessive pulmonary blood flow, pulmonary hypertension and/or myocardial ischemia. Corrective surgery for CHD may have resulted in phrenic nerve or recurrent laryngeal nerve palsies. Finally, children (or adults with repaired CHD may still have diminished cardiac reserve and therefore be more sensitive to the peri-operative stress response.
The highlight of the day was the luncheon speaker Dr. Louis Ignarro, 1998 Nobel Laureate in Medicine, and winner of numerous teaching and research awards. The SPA, Society of Neurosurgical Anesthesia and Critical Care (SNACC) and American Society of Critical Care Anesthesia (ASCCA) co-sponsored the lunch. The topic of the lecture was Nitric Oxide as a Unique Signaling Molecule in the Cardiovascular System. His lecture was a delightful blend of science and humor as Dr. Ignarro described the process of discovering Nitric Oxide and its subsequent isolation. He then described how he discovered that he had won the Nobel Prize in Medicine (he was in a French airport terminal on his way to Italy), and the celebrations afterwards.
The afternoon session focused on Resource Utilization: A Quandary. Dr. Robert Nelson (Children’s Hospital of Philadelphia) approached the topic from an ethical perspective. He reviewed the four choices for distributing medical resources fairly: 1) restricting access, 2) limiting certain forms of medical care, 3) cutting reimbursement, 4) increasing spending. The ethical dilemmas posed by each of these situations were presented as well as examples of how they have or could be implemented. Carol B. Michael, a parent and a former special education teacher, then talked about the medical health care system from a parent’s perspective in a lecture titled "What’s Left That Which Cannot Be Measured". She described the challenges of living with and getting medical treatment for a child with Tuberous Sclerosis and multiple developmental disabilities. She spoke about the art and humanity of medicine and the importance of simple gestures to families and patients in a high tech field.
Dr. William Greeley (Children’s Hospital of Philadelphia) wrapped up the session with a discussion on Bottom Lines: Mission and Money, The Hospital Perspective. He reviewed the organizational structure of most hospitals and business principles governing optimization of the shareholders value. Since most hospitals are not-for-profit, the application of business principles is not completely valid. He presented the unique challenges faced by pediatric institutions in providing quality healthcare, while remaining fiscally responsible.
The final lecture of the day was one on Alcohol and Health, given by Dr. Alfred A. de Lormier (University of California, San Francisco and owner of the de Lormier Winery). The French have a much lower incidence of cardiac disease than Americans despite their high fat diets, increased incidence of smoking and decreased exercising. This difference is attributed to moderate alcohol consumption. Dr. de Lormier presented research supporting the role of moderate alcohol consumption in decreasing mortality, the incidence of some cancers, peptic ulcer disease, URI, gall stones, kidney stones and type 2 diabetes. He emphasized that these benefits are derived from moderate alcohol consumption only, and excessive drinking increases mortality from a variety of causes.
The Conference concluded with a delicious wine and cheese reception featuring some of the great wineries in California.
Rita Agarwal, MD
Editor
The Children’s Hospital, Denver, CO
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