ASA Clinical Forum Review
By Chris D. Glover, MD
Texas Children's Hospital
The ASA Pediatric Clinical Forum, moderated by Dr. Thomas Cox (St. Louis Children’s Hospital), delved into the dynamics of organizing and implementing a pediatric perioperative surgical home. The perioperative care model for a child with Duchenne ’s muscular dystrophy (DMD) undergoing neuromuscular scoliosis repair was used as a case stem.
Dr. Marjorie Brennan (Children’s National Medical Center) discussed the preoperative phase of care for this patient. The discussion included a thorough overview of DMD and anesthetic implications during care. DMD is caused by an abnormality in the dystrophin glycoprotein complex. This defect results in skeletal muscle membranes having increased permeability to calcium manifesting as progressive muscle degeneration and weakness. A muscle biopsy is needed for definitive diagnosis with pathologic features of fatty infiltration along with skeletal muscle degeneration.
Clinical manifestations reviewed by Dr. Brennan included:
Progressive weakness starting around age 3 with the pelvic girdle initially affected.
Respiratory issues from inspiratory muscle weakness and decreased cough.
Cardiomyopathy by adolescence.
Death from progressive respiratory failure and congestive heart failure.
The association between succinylcholine exposure and the development of rhabdomyolysis and hyperkalemic cardiac arrest were also reviewed. Dr. Brennan further reported literature linking DMD patient exposure to anesthetics and the increased likelihood of hypercalcemic arrest. While this has traditionally been viewed as malignant hyperthermia, the literature points to a hyper-metabolic syndrome that occurs via a different biochemical process [1-3].
Some of the successful traits cited at Johns Hopkins for a thriving preoperative care clinic include dedicated clinic space and ready access and ability to coordinate care with both nursing and administrative support.
Preoperative screening in a perioperative home model included pulmonary function testing with specific concerns for those with FVC <50%. Cardiac assessment should include both a functional (echocardiography) and arrhythmia assessment (EKG / Holter). Coagulation status and transfusion triggers were also covered as Dr. Brennan noted 64% of DMD patients in a spinal fusion study had a consumptive coagulopathy .
The second part of this panel session covered the organization and implementation of an acute pain service by Dr. Chris Glover (Texas Children’s Hospital). The initial points of the talk dealt with the utility and feasibility of having an acute pain service. While the concept of a formal acute pain service was first proposed in 1988, further justification occurred after consensus statements by the American Board of Anesthesiology in 1995. Even with that, pain remains a difficult entity to treat. A 1995 survey followed by a subsequent survey in 2003 by Apfelbaum reported no change in the frequency of moderate to severe pain in the postoperative period. Over 75% of patients postoperatively experienced moderate to severe pain following their surgery . From an outcomes perspective, Dr. Glover reported on two studies – one by Tsui (1997) and another by Werner (2002) that pointed to shorter length of stay, lower incidence of pulmonary and cardiac complications as well as a decrease in overall pain intensity. Significant weaknesses with these studies include assessment of patient satisfaction and postoperative morbidity [6, 7]. From a practice perspective, JCAHO mandates on pain management standards and efforts by CMS to tie reimbursements to patient satisfaction scores further justify the need for hospitals to have successful pain teams.
Dr. Glover pointed to three main goals for an acute pain service. They included:
The need for 24/7 availability.
Provision of optimal pain management for every surgical patient in the facility.
Serving as a resource institution wide on policies, procedures, and education on the topic of pain control.
Organizationally, the acute pain service should have an anesthesiologist lead, an acute pain nurse or physician extender, pain representatives from nursing and surgery as well as a hospital executive. These representatives would connect and facilitate better care through enhanced communication and advocacy.
One challenge commonly encountered by acute pain services is structural issues in a hospital system given the silo care model. Physical challenges include the enormous clinical demand of most anesthesia departments in the operating rooms sometimes relegating acute pain staff as an afterthought. Executive buy-in also mitigates some of the concerns surrounding the financial viability of an acute pain practice.
Technology limitations relate to the myriad of devices incorporated in healthcare with specific emphasis by Dr. Glover on data informatics in driving changes to pain protocols. Political challenges were also discussed. Educational and systems change was also covered in some detail. Pain management education should be extended beyond anesthesia personnel and participation in multi-disciplinary conferences is a necessity to continue guiding hospital staff on the importance of pain control.
Of particular interest, care for neuromuscular scoliosis patients starts well before day of surgery. Dr. Glover reviewed some of the data behind pain control options for scoliosis patients. This was particularly poignant as one study revealed the majority of deaths following scoliosis repair occur after day 3 with the highest incidence occurring on days 3-7 . Pain management for scoliosis is primarily opioid based and usually institution specific. Retrospective evidence cited by Dr. Glover on the merits of intrathecal morphine at a dose of 11 mcg/kg resulted in decreased use of crystalloids, colloids, blood loss, and volume transfused. However, it was also noted that the use of intrathecal morphine resulted in a statistically higher incidence of respiratory depression [9, 10]. Ketorolac as an adjunct was also reviewed by Dr. Glover. Use of ketorolac was not associated with increased incidences of pseudoarthrosis or retransfusion [11, 12].
Dr. Glover rounded out his presentation on lessons learned by the acute pain service in the care of these children. They include:
Avoidance of long acting opioids (primarily methadone)
Analgesic adjuncts scheduled for all patients unless contraindicated.
Importance of nutrition in the neuromuscular population can not be overstated.
From a staffing perspective, implementation of the surgical home process at Texas Children’s resulted in neuromuscular cases being shifted earlier in the week to allow a full complement of staff during the majority of a patient’s recovery.
Summary points for successful acute pain service implementation include: a collaborative approach with a primary mission of educational outreach combined with 24/7 availability. The use of data to further improve outcomes cannot be overstated and technology infrastructure should be leveraged whenever feasible.
Dr. Sydney M Nykiel-Bailey (St. Louis Children’s Hospital) concluded the panel discussion by discussing a novel service line at her institution covering difficult airways. Dr. Nykiel-Bailey gave a brief overview of the Pediatric Perioperative Cardiac Arrest (POCA) registry and noted that respiratory events account for 27% of the cardiac arrests seen in pediatric children. Of further importance is that ¾ of the respiratory events occurred secondary to an inability to intubate or adequately ventilate . The Difficult Airway Service (DAS) consists of a collaborative service line made up of anesthesiologists and otolaryngologists. Their mission is to coordinate care among multiple specialties for patients with difficult airways. Systems implemented by St. Louis Children’s include technology changes allowing for a difficult airway alert on the “banner” of the electronic medical record, unique identifier bracelets for those with difficult airways similar in some respects to med alerts bracelets, and the use of colored tape to secure ETT’s to reinforce the difficult airway patient. Having a dedicated service between the primary airway providers allowed for a standardized difficult airway cart to meet the needs of the hospital system. For this patient with a difficult airway s/p scoliosis repair, the DAS would have coordinated care to ensure either a tracheostomy prior to surgery or extubation occurring in the operating room. Further points of consideration per Dr. Nykiel-Bailey included post-extubation assessments, reintubation triggers, and communication with the providers caring for this child.
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- Kannan, S., et al., Bleeding and coagulation changes during spinal fusion surgery: a comparison of neuromuscular and idiopathic scoliosis patients. Pediatr Crit Care Med, 2002. 3(4): p. 364-9.
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- Shaffrey, E., et al., Defining rates and causes of mortality associated with spine surgery: comparison of 2 data collection approaches through the Scoliosis Research Society. Spine (Phila Pa 1976), 2014. 39(7): p. 579-86.
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- Sucato, D.J., et al., Postoperative ketorolac does not predispose to pseudoarthrosis following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Spine (Phila Pa 1976), 2008. 33(10): p. 1119-24.
- Vitale, M.G., et al., Use of ketorolac tromethamine in children undergoing scoliosis surgery. an analysis of complications. Spine J, 2003. 3(1): p. 55-62.
- Bhananker, S.M., et al., Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg, 2007. 105(2): p. 344-50.