SPA Meeting Reviews
Sunday Advanced Practice Provider Symposium
Anesthesia for Pediatric Patients Undergoing TPIAT: Titrating Pumps of Insulin All the Time | Current Topics in Anesthesia for Pediatric Spine Surgery | SEEing the Future: Intra-Arterial Chemotherapy for the Child with Retinoblastoma | Bioethics Consults: Principles and Practice | Pediatric Anesthesia in the Military: The Good, the Bad, and the Impossible Made Possible by Incredibly Dedicated People
Anesthesia for Pediatric Patients Undergoing TPIAT: Titrating Pumps of Insulin All the Time
Reviewed by: Elyse Parchmont, DNP, CRNA
Texas Children’s Hospital/Baylor College of Medicine
Carrilee Powell, MSN, CRNA (Cincinnati Children’s Hospital Medical Center, Cincinnati, OH) opened the Advanced Practice Provider Symposium with her lecture explaining various aspects of Total Pancreatectomy and Islet Autotransplantation (TPIAT). Ms. Powell discussed current management and pertinent pathophysiology of patients with chronic pancreatitis, indications and contraindications for TPIAT, and finally appropriate anesthetic plan formulation for pediatric patients undergoing TPIAT.
Delving into the background of this unique procedure and patient population, Ms. Powell informed the audience that TPIAT is performed on patients with recurrent, severe and chronic pancreatitis, providing pain relief when all other conservative medical and surgical options have failed. The procedure, which was first performed in adult patients in 1977 and then in pediatric patients in 1989, preserves beta cell mass and insulin secretory capacity to prevent or minimize diabetes.
Chronic pancreatitis is a progressive inflammatory process of the pancreas that results in irreversible structural changes, loss of parenchyma, fibrosis, and exocrine and endocrine insufficiency. It is most often due to hereditary causes with specific identifiable genetic mutations and can cause chronic abdominal pain, exocrine pancreatic insufficiency, diabetes, and increased medical interventions and hospitalizations which can impair the child’s quality of life and affect school attendance. Treatment for chronic pancreatitis can include pain management (non-narcotic and narcotic analgesics), nerve blocks, pancreatic enzymes for pancreatic suppression, treatment of pancreatic exocrine insufficiency, dietary changes, endoscopic retrograde cholangiopancreatography, partial or total pancreatectomy, or TPIAT.
Ms. Powell described the criteria for TPIAT, including indications for the procedure which are: intractable abdominal pain due to chronic pancreatitis; impaired quality of life; hereditary pancreatitis; abnormal findings on CT, ERCP, or pancreatic function tests; failure to respond to medical treatment or endoscopic procedures; or history recurrent acute pancreatitis (>3 episodes). Relative contraindications are: diabetes; pre-existing liver disease; portal hypertension; portal vein thrombosis; or psychosocial issues. She then described the complex procedure itself which consists of an open laparotomy including: a total pancreatectomy; splenectomy; cholecystectomy; appendectomy; Roux-en-Y duodenojejunostomy and choledochojejunostomy; and the placement gastrojejunostomy tube. The procedure can be 10-14 hours or longer, with the islet cell isolation portion being approximately 3.5-4 hours alone.
Anesthesia for this procedure consists of starting with ample large bore IV access, a fluid warmer, arterial and central venous lines, and multiple infusion pumps (12-16 pumps). Monitoring arterial, central and portal venous pressures are key during the TPIAT. iSTAT and glucometer will also be necessary throughout the case. The patient will need a Foley catheter, nasogastric tube, and warming ability. The blood loss is generally around 350 ml, and though transfusing blood products is generally avoided due to inflammation and immune system effects, two units of PRBCs are crossmatched and ready in the case that they are needed.
The primary anesthetic concerns are: intraoperative glucose control; fluid management; management of hemostasis; pain management; and patient care management during islet cell infusion. Ms. Powell listed medications that must be available for the case including maintenance fluids, vasoactive medications, glucose management, hemostasis, pain management, and antibiotic therapy - stressing the point that medications should not be mixed in glucose containing solutions.
Pain management can be challenging in chronic pancreatitis patients. Therefore, a multimodal approach is often employed utilizing IV adjuncts such as: fentanyl; hydromorphone; methadone; and ketamine, as well as continuous infusions such as ketamine and lidocaine. It was stressed that NO IV acetaminophen should be used for these cases due to interference with glucose monitoring. Regional anesthetics are possible choices as adjuncts, such as: paravertebral nerve blocks; subcostal TAP catheters; and mid-thoracic epidurals. However, avoidance of hypotension and use of heparin perioperatively must be considered when choosing these modalities.
Glucose control is crucial to maximize survival and engraftment of islet cells, and is strictly monitored throughout the case, with the target goal being 80-120 mg/dL. The goals and consideration of fluid management and insulin titration were reviewed and listed in detail. Islet cell infusion is a stressful and busy time during the case. Goals and procedures were explained and discussed, including the risk of portal vein hypertension or thrombosis during this period. Heparin and dextran are administered prior to infusion of the cells for this reason.
Post-operative considerations for ICU are: glucose control; heparin and dextran infusion; and pain control. Ms. Powell stressed that steroids therapy should be avoided for these patients. Improvement in pain, islet function and glucose control, and quality of life are the main goals for this invasive procedure. Ms. Powell ended her presentation by listing impressive statistics from her literature review on positive outcomes of the TPIAT procedure for patients with chronic severe pancreatitis.
Current Topics in Anesthesia for Pediatric Spine Surgery
Malgorzata S. Lutwin-Kawalec, MD (Nemours/AI DuPont Hospital for Children, Wilmington, DE) presented the second lecture of the Symposium. Dr. Lutwin-Kawalec discussed the anesthetic management for a novel scoliosis correction technique called anterior vertebral body tethering (VBT). She then reviewed protocols for multimodal analgesia when treating children undergoing scoliosis correction surgery. And finally, Dr. Lutwin-Kawalec reviewed risk factors associated with changes in evoked potentials and strategies useful in restoring potentials to baseline.
Dr. Lutwin-Kawalec reviewed scoliosis explanation and epidemiology. It was explained that idiopathic scoliosis is the most common presentation (75-90%) and can be further broken down into infantile, juvenile, and adolescent categories. While non-idiopathic scoliosis (10-25%) consists of congenital, neuromuscular, and mesenchymal etiologies. Treatment options are: observation; bracing; and surgery - dependent upon the degree of the curve and the impact of the condition on the patient. Approximately 38,000 surgical corrections are completed every year, per Dr. Lutwin-Kawalec.
Risk factors for posterior spinal fusion are: extensive surgical incision; potential for significant blood loss; neurological injury; sequelae of prolonged prone positioning; and significant post-operative pain. Per Dr. Lutwin-Kawalec, disadvantages of posterior spinal fusion are permanent fusion; cessation of growth; decreased spine mobility; risk of adjacent segment disc degeneration; and persistent post-surgical pain.
VBT consists of “fusionless” scoliosis correction technique and allows the spine to grow, move, and bend. It allows growth modulation, slowing growth on the elongated side & maintaining growth on the concave side and the correction occurs over time. VBT is FDA approved in adults, but is still “off label” in pediatrics. VBT is done laparoscopically in the lateral decubitus position, convex side up. Ports and trocars are placed in anterior axillary line and the screws are placed in the antero-lateral vertebral bodies. Cords are then passed through screws from top down and tether locked with set screws. The deformity is corrected by tension on the cord over time.
Anesthetic management for VBT was discussed in detail. Per one study quoted by Gal, et al. (2017), a premedication regimen may consist of oral celecoxib, gabapentin, acetaminophen, and/or IV midazolam. Induction can be accomplished using lidocaine, propofol, fentanyl and succinylcholine. One lung ventilation is necessary with a bronchial blocker or double lumen ETT. Dexamethasone, ketamine, methadone, tranexamic acid 10-15 mg/kg q 3 hrs may be administered for the case. Maintenance of anesthesia can be propofol 100-150 mcg/kg/min, ketamine 0.5 mg/kg/hr, fentanyl 1-3 mcg/kg/hr, and dexmedetomidine 0.2-0.3 mcg/kg/hr. Standard neuromonitoring is utilized and an autologous blood recovery system is employed.
Intraoperative anesthetic management and considerations during correction were discussed. During spinal cord exposure, compressive and derotational forces can decrease venous return and cardiac output. Preemptive intravenous fluid loading 250-750 ml can be beneficial for this reason. Phenylephrine can be utilized to maintain MAP >85 mmHg. Frequent MEP monitoring is key.
Anesthetic management for these procedures at Nemours is completed with one lung ventilation (OLV), tranexamic acid: bolus 30 mg/kg → 10 mg/kg/hr, methylprednisolone 2 mg/kg for OLV, and TIVA with propofol and sulfentanil. These patients generally recover in the inpatient unit post-operatively with a continuous 0.2% ropivacaine infusion via chest wall catheter that was placed by the surgeon at the end of the case. Post-operative pain management guidelines for Nemours were displayed and discussed. They generally discharge these patients on POD 2-3 with an AMBU Pain Pump and Clonidine patch.
Multimodal post-operative pain modalities were reviewed and discussed. Other topics in the presentation that were reviewed were intraoperative neuromonitoring (SSEPs and MEPs), spinal cord blood supply, and intraoperative neuromonitoring changes and treatment algorithms.
In summary Dr. Lutwin-Kawalec reiterated the importance of a stable anesthetic environment, constant depth of anesthesia, utilization of anesthetics with rapid onset and minimal effects on intraoperative neuromonitoring (IONM), avoidance of medication boluses, maintenance of spinal cord perfusion, and close communication with the perioperative team as key points.
SEEing the Future: Intra-Arterial Chemotherapy for the Child with Retinoblastoma
Andria Janos, MSN, CRNA (Children’s Hospital of Philadelphia, Philadelphia, PA) presented the third lecture in the Symposium, speaking about intra-arterial chemotherapy for treatment of retinoblastoma in pediatric patients. She explained the treatment goals of intra-arterial chemotherapy, discussed the management of anesthesia for intra-arterial chemotherapy, and review potential neuroradiology, respiratory, and cardiovascular complications of this procedure, as well as their management.
Retinoblastoma was reviewed and it was stated that 50% of these cases present as “congenital or heritable” and the other 50% present “non-heritable or sporadic.” The main goals of treatment are not only to preserve life, but also to preserve vision, if possible. Enucleation, radiation, cryotherapy, and systemic chemotherapy are some of the treatment modalities for retinoblastoma. Ms. Janos then went through the history and progression of the treatment of retinoblastoma. Intra-arterial chemotherapy, or “ophthalmic artery chemosurgery,” is directly injected into the ophthalmic artery. Intra-arterial chemotherapy optimizes the effectiveness of the agent and reduces systemic side effects.
Ms. Janos states that considerations for these cases are that they may be longer than three hours, the patients may present neutropenic and may need to be optimized prior to surgery, and that they may have had multiple procedures and subsequent difficult IV access. The suggestion for the anesthetic plan is to utilize endotracheal intubation with paralysis and controlled positive pressure ventilation. Treating the tumor side nare with vasoconstricting drops such as oxymetazoline is useful to vasoconstrict the nasal vessels locally without vasoconstriction of the vessels around the eye.
Having epinephrine diluted and ready prior to the case start is key as there have been multiple incidences of cardiorespiratory sequalae such as bradycardia and bronchoconstriction during catheter placement into the artery in close proximity to the ocular area. This pathophysiologic response is not currently scientifically explained; however, some thoughts are the oculocardiac reflex or the dive reflex response. Ms. Janos concluded the presentation by discussing the future for anesthetic options for this procedure and further investigation into the reason for the cardiorespiratory sequalae.
Bioethics Consults: Principles and Practice
David G. Mann, MD, D. Be. (Texas Children’s Hospital/Baylor College of Medicine) presented the fourth lecture in the Symposium. Dr. Mann’s recent education in ethics enabled his expertise in the subject of the principles and practice of bioethics, and he presented a wonderful synopsis to the audience.
Dr. Mann started by going over the main principles and their loose definitions. The main principles discussed were: autonomy; beneficence; non-maleficence; and justice. Dr. Mann went on to present case scenarios of consults and explained refusal of consent and how autonomy, honoring concern for “individual” rights of liberty, self-determination, and privacy pertain to this subject matter. He then went on to discuss informed consent, and how the decision is made with three main situational concepts: competently; knowingly; and voluntarily.
Dr. Mann further explained “competently,” which is the first of three general conditions of informed consent – stating that the decision must be made by a person having emotional, psychological, and intellectual capacity to weigh data in relation to their personal values, principles, and life goals and must be made by a person having attained the legal age of majority. In other words, they must be “of adult years and sound mind.”
He explained how the terms "capacity" and "competence" are used interchangeably in the literature and in the law. Capacity was described as having emotional, psychological, and intellectual capacity to weigh data in relation to their personal values, principles, and life goals. Dr. Mann the delved into and assessed the terms "cognition", "communication", and "stable value set".
The term “non-adult” or “legal age of minority,” was explained in the settings of emancipation and (enabled) non-emancipation. It was stressed that emancipation must be done in a court of law (court ruling) and that emancipation laws differ from state to state. The term "surrogate decision-maker" was then explained as it relates to informed consent and four decision-making standards were listed. Decision making in the “child’s best interest” was discussed, pointing out that the medical provider and the parent may have different views on the child’s best interest, and that providers must be aware of this divergence in thought.
The “Harm Principle” was elaborated upon, stating, “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others” whereby Dr. Mann quoted literature from Dr. Diekema (2004). The second of the three general conditions is “knowingly” (informed), and this decision is based on sufficiently complete data regarding benefits, burdens, consequences, and alternatives. The third of the three general conditions is “voluntarily.” This decision is made without implicit or explicit coercion.
"Informed assent" was explained, listing the “Rule of 7’s,” which delineates age in years and decision-making capacity. Dr. Mann concluded his presentation by giving the audience members examples as to assent, and why this concept matters, by displaying and discussing several scenarios related to common anesthesia events and how the concept is pertinent.
Pediatric Anesthesia in the Military: The Good, the Bad, and the Impossible Made Possible by Incredibly Dedicated People
LTCOL Barclay (United States Air Force; Cincinnati Children’s Hospital, Cincinnati, OH) began the last presentation of the Symposium by taking the audience through his impressive history. He originally enlisted in the US NAVY in 1988, and eventually became a USMC hospital corpsman in Desert Storm. LTCOL Barclay then utilized his GI Bill to obtain his Bachelors of Science and Nursing. He then went back into the NAVY and served as an ICU RN at Balboa Naval Hospital as an ICU RN during 9/11. LTCOL Barclay later joined the Air Force reserves and for the last 12 years has served at Wright Patterson Air Force Base. LTCOL Barclay is currently also a CRNA at Cincinnati Children’s Hospital.
LTCOL Barclay’s presentation identified challenges associated with providing pediatric anesthesia care when deployed, listed common obstructers to providing safe pediatric anesthesia in a war zone, described personal and patient safety priorities unique to providing anesthesia while deployed, and explained the difference between military and civilian triage.
Some of the challenges that were delineated were: the physical environmental challenges such as working in makeshift tent hospitals or cramped helicopters; the geographical challenges that are present in the different areas of the world, such as extremes in climate, temperature, and terrain; evacuation capabilities; supply and demand; decreased number of providers that are experience in pediatric anesthesia; political environment and safety issues; and the possibility and issues of treating foreign nationals.
Per LTCOL Barclay, common obstructions to caring for patients are: weather that can affect patient or supply transport; legal, ethical, or moral obligations regarding the medical treatment of foreign nationals; patient and staff safety (as the makeshift treatment hospitals may be close to the front lines, risk of friendly fire, or hidden weapons and other than honorable motives from the patient population); and language, cultural or religious barriers. Further safety concerns were discussed such as: armed patients with intent to sabotage the unit; errors in coordinates and large caliber weapons; the need to wear protective gear while in the OR such as gas masks and Kevlar vests; and constant necessary awareness of ones’ surroundings while working in the OR which makes this a high stress environment. Major military hospitals may not be prepared for pediatric cases, especially trauma cases. Therefore, military providers learn to adapt and may be forced to improvise with the materials that they have.
LTCOL Barclay explained that there are few pediatric fellowship trained providers in the military. Only CRNAs and MD/DOs are present, with no AA providers being present in the military; and at times, the CRNA may outrank their MD/DO colleagues. The ratio of MD/DOs and CRNAs in the ARMY and Air Force was discussed. Astonishingly with these low numbers of pediatric trained providers, still over 15,000 pediatric cases under eight years of age were completed in over 24 major military centers in the US (ARMY, NAVY, AIR FORCE, and MARINE CORPS). However, some hospitals have a policy that they will not provide anesthesia to any child under two years of age that may require endotracheal intubation.
LTCOL Barclay explained to the audience that there is a “Law of Armed Conflict” that states that there is a duty to provide care to the sick and injured civilians, including children, in so far as it is practical to do so. He taught the group that in certain situations, such as severe pediatric burns: temperature regulation; warming or cooling of fluids; and absence of needed supplies or staff can be an issue, and that some patients do not survive due to the combat field scenario.
Comparing the civilian to the combat military situation, LTCOL Barclay separated the distinct realms. In the civilian hospital situation: hours are generally set; technology is at our beck and call; sterility is fairly guaranteed; weather is not generally an issue (with the exception of power outages, however, most hospitals have backup generators); supply and demand is usually taken care of; and civilian triage is utilized.
In the military combat hospital situation: the hours could be 24/7, and the CRNA provider may be the sole provider; technology is sometimes adequate, however, if something breaks it can be detrimental; sterility is attempted, but it is difficult in the makeshift hospital tent OR; the weather can be extreme and the walls may be tent material; supplies may not be available, and are likely limited to begin with; and military triage can take a toll on the provider mentally. The ultimate goal in military triage is to sort and prioritize casualties based on the tactile situation, mission, and resources that are available with the goal of returning the most warfighters to combat and preserving life, limb, and sight. Most military CRNAs have less than five years’ experience and only 22% have been previously deployed. Military CRNAs reported that they felt more training in trauma anesthesia would be beneficial prior to being deployed.
The two US NAVY floating hospitals were discussed. One is the USNS Mercy, located in San Diego, California. This hospital was originally built as an oil tanker and then converted to a hospital ship. The other is the USNS Comfort, located in Norfolk, Virginia. These boats are meant to provide rapid, flexible, mobile acute medical and surgical care. They may be utilized in such scenarios where military personnel are transported and trauma management and medical care is necessary, such as in a natural or man-made disaster - nationally or internationally.
LTCOL Barclay then educated the room on some of the equipment and anesthetic combinations that may be utilized in the military combat hospital situation. Several attendees expressed their eye-opening experiences after the lecture was completed. LTCOL Barclay, as well as all of our military CRNAs and MD/DOs, deserve our sincere thanks for serving our country and our wounded in such harsh and unpredictable situations. The heroes of our military spend countless days away from their families and friends so that we may enjoy our freedom, and they deserve our respect and admiration. LTCOL Barclay…Thank you for your service!
