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Pediatric Anesthesiology 2002 |
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Miami Beach, Florida |
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The 8th Joint Conference on Pediatric Anesthesiology of the Society for Pediatric Anesthesia and the American Academy of Pediatrics Section on Anesthesiology and Pain Management convened March 7, 2002, in Miami Beach, Florida. The scientific sessions began on Friday morning with an address by James Cottrell, MD (Downstate Medical Center, NY), President-elect of the ASA, who briefed the attendees on current issues affecting all anesthesiologists and on the agenda of the ASA in the coming year. Dr. Cottrell discussed manpower, noting that the number of American medical graduates applying for residencies in anesthesiology continues to climb. He provided an update on the states which are currently at risk of "opting-out" of the supervision rules for nurse anesthetists, and urged our continuing support of efforts to prevent the erosion of medical direction and patient safety. He discussed the successful ASA campaign to rescind inequitable Medicare and Medicaid reimbursement cutbacks for the coming year, and the efforts of the ASA to address drug shortages with manufacturers. On the academic and research fronts, Dr. Cottrell described several initiatives to increase research, both through increased grant award amounts from the FAER, and described concern over the decline in papers submitted to Anesthesiology by US authors. The ASA plans to investigate the promulgation of new clinical care standards in pain medicine, office based anesthesia, and obstetrical anesthesia, and will work in liaison with the American College of Surgeons to further common goals in perioperative care. He lauded the pediatric anesthesia community for their successful efforts in raising the image and profile of anesthesiologists, and stated that the ASA plans to emulate our efforts. The morning session, moderated by Peter Davis, MD (Children's Hospital of Pittsburgh and SPA President) was devoted to discussions of "Pharmaco-politics". Mark Schreiner, MD (Children's Hospital of Philadelphia and Children's Clinical Research Institute) discussed the evolution of regulation of pharmaceuticals and the rise of clinical trials to evaluate and demonstrate efficacy and safety. He described how much of the regulations were "disaster driven", and how the new FDA requirements and inducements for studying drugs in infants and children have evolved. He discussed the limitations and problems that remain in designing clinical trials for children and the unmet needs that persist. Christopher-Paul Milne DVM, MPH, JD (Tufts University School of Medicine and Center for the Study of Drug Development, Boston) spoke on how pediatric clinical trials have and will continue to influence practice. He noted that although there has been a four-fold increase in the number of pediatric patients studied and the number of pediatric research centers over the past four years, the needed research still lags way behind work done in drug development for the elderly. The majority of drug research in pediatric drug research still is performed on antimicrobial agents. The new Office of Pediatric Drug Development at the FDA, and mandatory rules for pediatric drug testing may provide further impetus for continued increases. Jerrold Lerman, MD (The Hospital for Sick Children, Toronto) gave a well- illustrated presentation on post-marketing drug safety and the problems of untoward reactions that come to light only after a drug achieves widespread use. Sometimes these problems are due to possibly deceptive practices by the drug developer, illustrated by Rezulon, an oral hypoglycemic; more commonly, as was the case with rapacuronium, the limited exposure to pediatric patients during phase II studies did not demonstrate the true risk and incidence of adverse reactions. Dr. Lerman pointed out that FDA mechanisms in the past have not always dealt effectively with problems, producing long delays in addressing these issues. In the case of rapacuronium, the rapid exchange of information through the Pediatric Anesthesia Conference discussion listserver lead to unprecedented efficiency in disseminating the severity and magnitude of bronchospastic reactions to this drug, and its subsequent withdrawal from the market. Dr. Lerman cautioned us to remember that FDA approval of any new drug is not a guarantee of safety. Clair M. Callan, MD, MBA (American Medical Association) discussed generic drugs and the problem of drug shortages. She provided surprising information on the standards which generics must meet to be certified as equivalent to their branded counterparts (only ±20% bioavailability, which may be further altered by differences in non-active ingredients in the generic product). She delineated the various causes of shortages, and noted that drug shortage information from the FDA website (www.fda.gov/cder/drug/shortages) only lists drugs deemed "critical", and that more complete information can be obtained from www.ashp.org/shortages. A fascinating afternoon session, moderated by Francis McGowan, MD (Children's Hospital, Boston) informed the audience about the cutting-edge work being done in fetal surgery to correct congenital defects. N. Scott Azdick, MD (Department of Surgery, Children's Hospital of Philadelphia), a pioneer in the field, reviewed the work to date, and showed remarkable images of several of the procedures. These ranged from EXIT procedures (securing the neonatal airway during delivery while the newborn remains on fetal-placental circulation) to open repair of sacrococcygeal teratomas and congenital cystic adenomatoid malformations, to in-utero fetoscopic repair of posterior urethral valves and in-utero palliation of diaphragmatic hernias. Jeffery Galinkin, MD (Children's Hospital of Philadelphia) described the anesthetic techniques that have been used to care for the women and fetuses undergoing these procedures. Tocolysis and uterine relaxation is of paramount importance for the mother, and anesthesia and muscle relaxation is administered by IM injection to the fetus. Leslie N. Sutton, MD (Department of Neurosurgery, CHOP) bridged the topic of this session with the previous session, speaking on the in-utero repair of neural tube defects and the ethical and scientific issues implicit in the ongoing clinical trial of this operation. Not only can such repairs be accomplished successfully, but in cases of lumbar or low thoracic defects, and with intervention prior to 26 weeks of gestation, in-utero repair may prevent the development of Arnold-Chiari malformation and the need for ventricular shunting post-partum. The day's plenary sessions finished with a "pro and con" debate on the use of standards to effect the quality of clinical care. Burton S. Epstein, MD (George Washington University School of Medicine, Washington, DC) promoted the use of practice guidelines as a means to improve quality of care. He used the ASA Standards on Monitoring as a paradigm to demonstrate the efficacy and importance of standards, practice parameters, and guidelines in anesthesia. Frederic A. Berry, MD (University of Virginia School of Medicine) countered this argument by noting the problem of electronic monitoring failures, and emphasized the necessity for teaching appropriate clinical responses when devices inevitably fail, rather than emphasizing monitoring standards per se. He encouraged the use of non-technological monitoring solutions, especially the precordial stethoscope and close observation of the patient. This discussion was taken up with enthusiasm by many of the audience members. The day concluded with elective workshops and refresher courses on topics including airway management, pain, regional anesthesia, clinical trial design, PACU problems, ventilators, myopathies, and apnea in former premies. Many started the second day of the conference by attending one of the Problem-Based Learning Discussions. The choice of which to attend can be difficult to make, as each offers opportunities for in depth analysis of both clinical experiences as well as expert-based theoretical options for select cases relevant to the pediatric anesthesiologist. The awards and oral presen-tations session was moderated by Joseph R. Tobin, MD (Wake Forest University School of Medicine) and Lynne R. Ferrari, MD (Children's Hospital Boston).
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How inspiring to watch Dolly D. Hansen, MD receive this year's Robert M. Smith Award for outstanding lifetime contribution in pediatric anesthesiology. Dr. Hansen completed her medical training, including only one year of pediatric anesthesia, in Copenhagen, Denmark before moving to the United States in 1971 to start as a consultant in the department of anesthesiology at Boston Children's Hospital. It was there that she devoted her career to advancing and teaching pediatric cardiac anesthesia. She collaborated with cardiothoracic surgeon Aldo Castaneda, MD to pioneer the anesthetic management of infants undergoing DHCA during first stage repair of HLHS. She has authored some 30 publications during her illustrious career at Boston Children's Hospital. In her honor the Dolly Hansen Chair of Pediatric Anesthesia has been established at the Children's Hospital in Boston. By unanimous decision of the AAP governing board, despite having trained outside of the United States, she was recently bestowed honorary fellowship in the AAP based upon her enormous contributions in establishing the subspecialty of pediatric cardiac anesthesia. The First Place SPA Young Investigator Award went to Andreas W. Loepke, MD from Children's Hospital of Philadelphia for "Desflurane Confers Neuroprotection for Hypothermic Low-Flow Cardio-Pulmonary Bypass in Neonatal Pigs". His co-authors are Drs. C. D. Kurth, M. A. Priestly, J. McCann, S. E. Schultz, and J. Golden. There was a tie for this year's Second Place SPA Young Investigator Award. First, Michael J. Eisses, MD described the work he completed with co-author Dr. W. L. Chandler (Children's Hospital and Regional Medical Center, Seattle) entitled, "Low Volume Sampling Protocol for Use in Hemostatic Evaluation of Infants during Cardiopulmonary Bypass". Second, Chantal Frigon, MD, FRCPC, presented her study "Fraction of Inspired Oxygen in Relation to Subarachnoid CSF Hyperintensity during Brain MRI Images in Children under General Anesthesia". Dr. Frigon and her co-authors Drs. D. S. Jardine, S. R. Heckbert, E. Weinberger, and D. Shaw were also from Children's Hospital and Regional Medical Center, Seattle. Next, the John J. Downes Resident Research Awards were presented. First Place went to Kelley Groeper, MD for "Synthetic Factor VIIa to Treat Coagulopathy Unresponsive to Conventional Therapy in the Pediatric ICU Population". She and her co-authors Drs. J. W. Berkenbosch and J. D. Tobias are from University of Missouri, Columbia. Second Place was awarded to R. Chaudhari, MD for "Complications Associated with Routine Aprotinin Administration in Children". She, along with her co-authors Drs. N. Setzer, J. Ojito, E. Saade, R. Burke, and R. Hannon are from Miami Children's Hospital. The Third Place recipient was David K. Barclay who presented his study entitled "Does Preoperative Sciatic Nerve Block or Local Infiltration More Effectively Inhibit Mechanical Hyperalgesia in Young Rats?". He and co-author Dr. D. Ririe are from Wake Forest University School of Medicine. The American Association of Pediatrics Advocacy Lecture, moderated by Lynne R. Ferrari, MD (Children's Hospital Boston), followed the awards presentations and had two parts this year. First, E. Greg Koski, MD, PhD spoke on "Ethical Implications of Pediatric Research". He is the Director of Human Resource Protection in the Department of Health and Human Services in Rockville, MD. Second, Robert M. Nelson, MD, PhD described "Pediatric Research from the Child's Perspective". He is the Chair of the IRB at Children's Hospital of Philadelphia. Inspiring Walk-Around poster discussions were next on Saturday's agenda. There were 65 posters which were grouped into either Potpourri, Equipment and Monitoring, Techniques, Pain/Regional, Pharmacology I, Pharmacology II, and Physiology and Co-Existing Disease which were moderated by, respectively, Steven A. Stayer, MD (Texas Children's Hospital, Houston), Frank H. Kern, MD (Duke University School of Medicine), Zeev Kain, MD (Yale University School of Medicine), Santhanam Suresh, MD (Children's Memorial Hospital, Chicago), Myron Yaster, MD (Johns Hopkins Hospital), C. Dean Kurth, MD (Children's Hospital of Philadelphia), and Francis X. McGowan, Jr., MD (Children's Hospital Boston). The highly recommended Workshops were repeated Saturday afternoon, with the premier addition of "Magical Distractions for Children" presented by J. C. Abajian, MD (University of Vermont). Saturday's program ended with four extremely well presented Refresher Courses: "Anesthesia for Children in Remote Locations" by Andrew Infosino, MD (University of California, San Francisco), "Induction Techniques in Children" by Aubrey Maze, MD (Phoenix, Arizona), "Sedation Systems" by Thomas J. Mancuso, MD (Children's Hospital Boston), and "Neonatal Pain Management" by Joseph D. Tobias, MD (University of Missouri). Those who went on the dinner cruise on Saturday night were in for a real treat! The weather was nearly perfect, the Miami Skyline was captivating, the food was wonderful, and the boat was elegant! This was a relaxing opportunity to visit with current as well as previous colleagues and some of their family members. Sunday's portion of the meeting began with the Baxter sponsored breakfast lecture moderated by Myron Yaster, MD (Johns Hopkins Hospital). This year, Julia C. Finkel, MD (Children's Hospital National Medical Center, Washington, DC) presented "Oral Analgesics in Children". She described pharmacology and clinical use of prostaglandin synthesis inhibitors, synthetic and semisynthetic opioids, the NMDA receptor antagonist dextromethorphan, and the antiepileptic gabapentin. Following this was a session entitled "Update in Pediatric Cardiac Anesthesia" moderated by Anne M. Lynn, MD (Children's Hospital and Regional Medical Center, Seattle). First, Dean B. Andropoulos, MD (Texas Children's Hospital, Houston) spoke on "Anesthesia Agents and Myocardial Function in Congenital Heart Disease". Dr. Andropoulos presented and summarized key conclusions from research studies attempting to elucidate the effects of volatiles, N2O, opioids, midazolam, propofol, ketamine, etomidate, and barbiturates on cardiovascular function in children with CHD. Second, Peter C. Laussen, MBBS (Children's Hospital, Boston) presented "Anesthetic and Stress Ablation". Dr. Laussen stated that either high-dose fentanyl or general anesthesia with caudal opioids attenuate both endocrine stress and hemodynamic responses to surgical stimulation, but anesthetics do not obtund the endocrine inflammatory responses to the effects initiated by cardiopulmonary bypass. Advances in both surgical expertise and perioperative diagnosis and management; improving pump prime composition; and the use of ultrafiltration and antioxidants (mannitol and steroids) all limit physiological consequences of the inflammatory response. Finally, C. Dean Kurth, MD (Children's Hospital of Philadelphia) described studies addressing "Neuroprotection". Pediatric Anesthesia Jeopardy endures as the entertaining educational ending event! Frederic A. Berry, MD (University of Virginia) and Myron Yaster, MD (Johns Hopkins Hospital) fielded comments from the audience while Lynne G. Maxwell, MD (Johns Hopkins Hospital) moderated the expert panel consisting of Rita Agarwal, MD (Children's Hospital, Denver), Joseph P. Cravero, MD (Dartmouth Hithcock Medical Center), Scott D. Cook-Sather, MD (Children's Hospital of Philadelphia), and Santhanam Suresh, MD (Children's Memorial Hospital, Chicago).
David M. Polaner, MD, FAAP The Children's Hospital |