Twelfth Annual Meeting of the Society for Pediatric Anesthesia, Orlando, Florida, October 16, 1998

Abstract

The Society for Pediatric Anesthesia (SPA) held its 12th annual meeting on October 16, 1998, at the Omni Rosen Hotel in Orlando, FL. The meeting was co-sponsored by the American Society of Anesthesiologists and was attended by more than 350 physicians from 16 countries. Invited speakers included internationally recognized lecturers from across the United States and the United Kingdom. Opening remarks were made by SPA President Dr. Mark A. Rockoff (Associate Professor of Anesthesiology, Harvard Medical School, Children's Hospital, Boston, MA) and SPA Program Chair Dr. Lynn D. Martin (Associate Professor, Departments of Anesthesiology and Pediatrics, University of Washington School of Medicine, Children's Hospital and Regional Medical Center, Seattle, WA). Remarks included comments regarding the continued growth and maturation of the Society and an invitation to all SPA members and meeting participants to take full advantage of the day-long program. The morning program focused on recent advances in pediatric resuscitation. The first session, moderated by Dr. Alvin Hackel (Professor of Anesthesiology and Pediatrics, Stanford University, Stanford, CA) included discussions of recent changes in recommendations for pediatric resuscitation, areas of active investigation in the resuscitation of infants and children, and an extensive discussion of the history of cerebral resuscitation in head injury, as well as areas of active clinical investigation for the head-injured patient. Speakers for this session included Dr. Donald H. "Hal" Shaffner, Jr. (Associate Professor, Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Johns Hopkins University, Baltimore, MD) and Dr. Patrick M. Kochanek (Associate Professor, Departments of Anesthesiology/Critical Care Medicine and Pediatrics, University of Pittsburgh, Director, Safar Center for Resuscitation Research, Pittsburgh, PA). Dr. Donald H. Shaffner, Jr. Advances in Pediatric Cardiopulmonary Resuscitation. Dr. Shaffner reviewed recent changes in recommendations in pediatric resuscitation as published by the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) in the Pediatric Advanced Life Support (PALS) guidelines. Changes of particular importance include the recommendation for using saline flush when giving resuscitation medications either via a peripheral IV line or intraosseous line to assure delivery into the central circulation. The recommendation stems from animal studies suggesting that drugs given peripherally and followed by a 0.25-0.50 mL/kg saline flush have an onset similar to drugs given through a central venous line. The use of the intraosseous route of venous access was emphasized for children <6 yr old when peripheral access cannot be obtained quickly. Using the intratracheal route of medication administration was also discussed with emphasis on the unreliability of this route and the need for doses 2.5-10 times larger than the IV dose. The controversy surrounding serum glucose levels and outcome in cardiopulmonary resuscitation (CPR) was briefly mentioned with a reminder to avoid both hypo- and hyperglycemia. The epinephrine dosing scheme has changed in that subsequent doses are larger (0.1-0.2 mg/kg) and can be given more frequently (every 3 min instead of every 5 min). The initial dose remains 0.01 mg/kg to limit the occurrence of a dramatic overshoot in heart rate and blood pressure resulting in myocardial injury. Attendees were reminded of the few indications for calcium use during resuscitation, including hyperkalemia, ionized hypocalcemia, calcium channel blocker intoxication, and hypotension induced by hypermagnesemia. The use of adenosine was emphasized not only in stable supraventricular tachycardia (SVT), but also in situations of unstable SVT before the use of cardioversion. Dr. Shaffner provided an excellent overview of methods of monitoring the CPR effectiveness and likely outcome, including intensity of ventricular fibrillation (VF; course VF is better than fine VF), a diastolic blood pressure of >20 mm Hg, end-tidal CO2 >15 mm Hg, and mixed venous oxygen saturation >70 mm Hg, which all predict survival. New methods of CPR were also reviewed and compared with standard CPR. Methods such as vest CPR, simultaneous compression ventilation CPR, interposed abdominal compression ventilation CPR, active compression-decompression CPR, and phased chest and abdominal compression-decompression CPR are under continued investigation in a limited number of patients and in animal models. None has, as of yet, been shown to be superior to standard CPR in humans. The use of open-chest CPR and cardiopulmonary bypass are effective but confined to relatively few situations. Dr. Patrick M. Kochanek Frontiers in Cerebral Resuscitation: Lessons Learned from Human Head Injury. Dr. Kochanek provided the attendees with a fascinating overview of the physiology and molecular aspects of cerebral resuscitation and their clinical implications. Recent findings of initial hypoperfusion after traumatic brain injury (TBI) were contrasted to classically described cerebral hyperemia and have been associated with poor outcome. Computed tomography and magnetic resonance imaging studies have recently demonstrated that secondary brain swelling is the result of edema rather than vascular engorgement. Future therapies directed at minimizing edema rather than hyperemia may be more effective in improving outcomes. Conventional views on luxury perfusion after TBI were contrasted with more recent evidence suggesting that a state of increased glucose utilization (hyperglycolysis) exists in the injured brain, possibly in an attempt to facilitate glutamate uptake by astrocytes. The finding of increased glutamate in samples of cerebrospinal fluid removed from the ventricular drains of patients with TBI suggests that increased levels of glutanmate correlate with poor outcomes, especially in victims of child abuse. Efforts at reducing secondary brain injury by inhibiting the inflammatory response associated with TBI have not shown benefit in laboratory models. Increasing evidence suggests that some aspects of this response are beneficial in reducing the deleterious effects of TBI, possibly through its effects on stimulating regeneration. The role of apoptosis was discussed, including studies of tissue obtained from cerebral contusions, which suggests that both apoptosis and necrosis play a role in neuronal cellular injury. Additional investigation is needed to further define the role of apoptosis in TBI. The second half of the morning session was moderated by Dr. Randall C. Wetzell (Professor of Anesthesiology and Pediatrics, University of Southern California; Director, Critical Care Services, Children's Hospital of Los Angeles, Los Angeles, CA) and featured an entertaining presentation titled, "Pediatric Resuscitation, The European Perspective," by Dr. David A. Zideman (Consultant Anaesthetist, Hammersmith Hospitals Trust, Secretary of the European Resuscitation Council, London, UK). Dr. Zideman's talk was followed by a stimulating examination of the outcomes of pediatric perioperative resuscitation by Dr. Jeremy M. Geiduschek (Associate Professor, Department of Anesthesiology, University of Washington School of Medicine, Children's Hospital and Regional Medical Center, Seattle, WA). Dr. David A. Zideman Pediatric Resuscitation, The European Perspective. Changes in the recommendations of the Paediatric Working Party of the European Resuscitation Council were compared with those of the AHA in a very entertaining and enlightening discussion. The Working Party agreed to define a young child as one <8 yr of age based on anatomical and epidemiological considerations. In response to recognized difficulties in accurately determining the presence or absence of a pulse in young children and infants, the Group has recommended that, in situations in which the pulse cannot be felt after 10 s, CPR should be initiated if the child is unresponsive and not breathing spontaneously. The European Resuscitation Council recommendation for depth of chest compressions has been changed to a proportion of the resting chest diameter (one-fourth to one-half the diameter of the chest) rather than an absolute depth. It is also recommended that the emergency medical system (EMS) be activated after 1 min of basic life support. Changes in Advanced Life Support (ALS) include a consolidation of the resuscitation algorithm into only two pathways for both children and adults. Pathways are determined by the presence or absence of VF or ventricular tachycardia. The Paediatric European Working Party recommendations for epinephrine dosing remain identical to those of the AHA/AAP guidelines (0.01 mg/kg initially and 0.1 mg/kg for all subsequent doses). The Paediatric European Working Party also addressed changes in recommendations for resuscitation of the newborn. The currently recommended sequence is based on ongoing assessment of breathing, heart rate, and color. Heart rate <100 bpm triggers the initiation of active resuscitation in the European recommendations, in contrast to the current AHA level of 60 bpm. Finally, emphasis was placed on minimizing the unnecessary resuscitation of newborns who require only minimal stimulation or no resuscitation at all. Dr. Jeremy M. Geiduschek Lessons Learned from the Pediatric Cardiac Arrest Registry. Results of the first 3 yr data from the Pediatric Perioperative Cardiac Arrest (POCA) Registry were presented by Dr. Geiduschek. Demographics of the 262 cases submitted to the Registry were described and confirmed previously published data suggesting that infants are disproportionately represented in events involving cardiac arrest and death in the perioperative period. A strongly positive correlation was described between ASA physical status and entry into the Registry, although ASA physical status I and II patients still represent a substantial proportion of cases. Contrary to the previous belief that most adverse outcomes in children were airway-related, the Registry results suggest that most are cardiovascular events and occur not during induction but during the maintenance phase of anesthesia. Dr. Geiduschek suggested possible explanations for the disparity between the finding of the Registry and past analyses. They included the overrepresentation of academic and pediatric centers in the Registry and of cardiac patients among the registrants. Of those patients entered into the Registry, 20 experienced cardiac arrest related to the use of halothane; the number of these events has declined over the past 2 yr. This observation stimulated a great deal of spirited discussion among the audience as to the potential role of sevoflurane in this observation. Importantly, no cases of malignant hyperthermia, succinylcholine-related hyperkalemia, latex allergy-related arrest, or aspiration-induced arrests have been reported to the Registry, nor has a case of arrest related to the unanticipated difficult airway been reported to the Registry. Survival among patients reported to the Registry is significantly higher than that in a series of both out-of-hospital and in-hospital arrests reported in the literature. Overall survival was reported to be 53%, with 43% of patients having no discernable injuries as a result of the event. The most powerful predictors of mortality were described to be ASA physical status, age, and emergency status. The ASA physical status was the single most powerful predictor of poor outcome. A new feature of this year's meeting was the conduction of the biannual business meeting of the Society during the sit-down luncheon by Dr. Rockoff. Dr. David G. Nichols (Professor, Departments of Anesthesiology/Critical Care Medicine and Pediatrics, Chief, Division of Pediatric Anesthesia and Critical Care, Johns Hopkins University, Baltimore, MD), Chair of the SPA committee on research, provided a brief update on the activities of the committee, including ongoing efforts to obtain funding from the National Institutes of Health (NIH) for a multicenter, randomized, controlled clinical trial evaluating the efficacy of ipatropium pretreatment of children with recent or active viral respiratory infections undergoing elective outpatient surgery. Dr. Rockoff acknowledged the hard work of the SPA Board of Directors with specific praise for Dr. Nichols, Dr. Raeford E. Brown, Jr. (Professor, Department of Anesthesiology, University of Kentucky Medical School, Lexington, KY), and Dr. James Viney (Chief, Department of Anesthesiology, Primary Children's Medical Center, Salt Lake City, UT), whose 4-yr terms were expiring. Immediate Past President of the SPA and Chair of the SPA nominating committee, Dr. William J. Greeley (Professor of Anesthesiology/Critical Care Medicine, University of Pennsylvania; Chair, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA) presented to the audience the names of nominees for the vacant board positions, as well as the nominations for SPA Treasurer. Balloting occurred during the luncheon, with the election of Dr. Francis X. McGowan (Associate Professor of Anesthesiology, Harvard Medical School, Children's Hospital, Boston, MA) as SPA Treasurer and Drs. Patricia J. Davidson (Assistant Clinical Professor, Department of Anesthesiology, Ohio State University, Columbus Children's Hospital, Columbus, OH), Jerrold R. Lerman (Professor, Department of Anesthesia, University of Toronto, Hospital for Sick Children, Toronto, Canada), and Lynne G. Maxwell (Associate Professor, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Baltimore, MD) as new directors. Finally, SPA President-Elect Dr. Steven C. Hall (Professor, Department of Anesthesiology, Northwestern University Medical School, Chief, Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, IL) presented Dr. Rockoff with a small token of appreciation for his many years of service to SPA. The afternoon session was devoted to different perspectives on office-based anesthesia provided by Dr. Stephen Wilson (Professor, Department of Dentistry, Chief, Section of Pediatrics, Columbus Children's Hospital, Columbus, OH), a pediatric dentist; Dr. Richard A. Berkowitz (Assistant Professor, Departments of Anesthesiology, Pediatrics and Surgery, Director, Pediatric Anesthesia, University of Illinois School of Medicine, Chicago, IL), an anesthesiologist with extensive experience in office-based anesthesia; and Dr. Charles J. Cote (Professor of Anesthesiology and Pediatrics, Northwestern University Medical School, Vice-Chairman and Director of Research, Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, IL), who provided data on adverse outcomes associated with office-based practice. The session was moderated by Dr. Mark A. Helfaer (Chief, Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA). Dr. Stephen Wilson Office-Based Anesthesia: A Dentist's Perspective. Dr. Wilson outlined the frequent need for either sedation or general anesthesia when providing dental care to children, especially those of lower socioeconomic status, in whom dental disease occurs at a disproportionately high rate. He provided an overview of the current methods used to provide sedation or anesthesia, including the use of both inhaled and IV anesthetics. The most popular drugs used have traditionally been and remain chloral hydrate or meperidine alone or in combination with an antiemetic such as hydroxizine. Pharmacologic management of children undergoing dental procedures is performed under guidelines first published by the American Academy of Pediatric Dentistry in 1985. These guidelines have been updated and are consistent with those of the AAP. Sedation or anesthesia is provided to children by a variety of practitioners, including both certified registered nurse anesthetists and anesthesiologists. More often, however, it is provided by the practitioner alone-a dental anesthesiologist or oral surgeon. A dental anesthesiologist is a dentist who has received 2 yr of additional training in the provision of anesthesia services to patients undergoing dental procedures. Oral and maxillofacial surgeons receive 6 mo of specific training in the provision of anesthesia during dental procedures. Dr. Wilson provided insights into the financial aspects of the provision of dental anesthesia to children. Few carriers provide coverage for dental anesthesia, and only one state (Minnesota) requires reimbursement for anesthesia services provided to children undergoing dental procedures. The cost of anesthesia for a child undergoing an office dental procedure in Ohio is $350 for the first hour and $200 an hour thereafter. This was contrasted to a range of $500-$1500 for the same procedure if it is performed in a hospital operating room. Dr. Richard A. Berkowitz Office-Based Anesthesia: An Anesthesiologist's View. Dr. Berkowitz provided the audience with an insightful overview of the practice of office-based anesthesia. Various aspects of this emerging area of anesthesia practice were discussed, including its history, reasons for its recent rapid expansion, types of procedures currently provided, and the challenges associated with establishing an office-based practice. The expansion of office-based anesthesia was attributed to a variety of factors, most notably the rise of managed care. Along with cost pressures induced by the changes in patterns of reimbursement, the convenience of office surgery to the surgeon cannot be overlooked. Improvements in equipment, such as portable anesthesia machines and monitoring equipment, were also cited as facilitating the expansion of this new area of anesthesia practice. Initial data from a survey study were discussed and confirmed the predominance of dental procedures in pediatric office-based anesthesia. Other less common indications for office procedures in children were eye examinations and procedures, as well as minor orthopedic and plastic procedures. Suitable patients are ASA physical status I or II who have been judged to be appropriate after an adequate preanesthetic evaluation. Suitable locations are those with the space and facilities and support staff sufficient to accommodate the anesthesiologist and his or her equipment. The importance of ensuring the credentials of the surgeon was also emphasized. The increasing regulatory oversight relative to office-based practice was described, with brief mention of state licensing, Medicaid and OSHA requirements, as well various accrediting agencies. Finally, the need for organizations such as the SPA to participate in the establishment of state and federal regulations applicable to office-based anesthesia were discussed. Dr. Charles J. Cote Outcomes of Office Based Anesthesia. The discussions of office-based anesthesia concluded with a fascinating description of the history of the development of sedation guidelines by the AAP in response to the deaths of children undergoing dental procedures with the use of sedation. A description of the process by which the guidelines were formulated and subsequently revised was provided. The use of the terms "conscious" and/or "deep sedation" has been de-emphasized as a result of confusion regarding the meaning of these terms. Conscious sedation has been erroneously interpreted to include situations in which the child's only response to painful stimulation is reflex withdrawal. This problem and others have led to a number of sedation disasters, reports of which are being collected and published by Dr. Cote. Dr. Cote provided some initial insights into the results of his inquiry into adverse outcomes related to the use of sedation in children, suggesting that outcomes in the nonhospital-based cases were substantially worse than those that occurred within the hospital setting. It seems that problems inevitably occur in both settings; however, his data suggest that the inability to provide appropriate and expeditious management of these problems leads to worse outcomes when they occur outside the hospital environment. The lack of appropriate equipment, facilities, and support was cited as the reason for the disparity. The final session on contemporary management issues featured a discussion of perioperative anxiety by Dr. Zeev N. Kain (Associate Professor, Department of Anesthesiology; Chief, Pediatric Anesthesiology, Yale University School of Medicine, New Haven, CT) and of medicine on the final frontier, a discussion of medicine in the microgravity environment of space by Dr. M. Rhea Seddon (Assistant Chief Medical Officer, Vanderbilt Medical Group, Vanderbilt University, Nashville, TN), a former NASA astronaut. Dr. Karen S. Bender (Chief, Department of Anesthesiology, Arnold Palmer Hospital Children & Women, Orlando, FL), moderated the session. Dr. Zeev N. Kain Perioperative Anxiety: The Patient, Parent, and Anesthesiologist. Dr. Kain gave an informative talk that provided a review of not only the factors contributing to the development of perioperative anxiety in children, but also the methods available to limit its occurrence. Risk factors for perioperative anxiety are not well described; however studies have suggested that the mother's prediction, young age, previous surgery, shy or inhibited children, and children of anxious parents may be at higher risk. Interventions available to manage perioperative anxiety, consisting of behavioral methods, parental presence during induction of anesthesia (PPIA), and the use of pharmacological interventions, were described. Behavioral methods, usually videotapes, puppet shows, tours, play therapy, coping, modeling, or printed materials, are usually effective to a variable extent in reducing anxiety in children. The most effective methods are coping, modeling, and play therapy. Unfortunately, recent data suggest that the methods most often used (tours and printed material) are the least effective. It was emphasized that additional factors, such as timing of preparation and age of the child, are as important as the content of the preparation. PPIA, an area of continued controversy, was reviewed, with emphasis on the behavior of the parents, rather than simply their presence or absence. No clear consensus exists as to the benefit of PPIA, and an individualized approach was suggested. Pharmacologic preparation is used to a variable extent in children. Studies suggesting that the very young and very old are significantly less often given preoperative sedatives were described. Geographic differences were noted in a survey of anesthesiologists, with those practicing in the Southwest being the least likely to use preoperative sedatives and those in the Northeast being the most likely. Dr. Kain suggested that regional differences in practice patterns may have been influenced by the degree of managed competition penetration with its emphasis on rapid discharge and day surgery. Studies of outcomes of preoperative anxiety that suggest that several maladaptive behaviors occurring in the postoperative period can be linked to preoperative anxiety were described. Pharmacologic intervention was effective in reducing those maladaptive behaviors, but only transiently. Pharmacologic preparation seems to lose its advantage 2 wk after the procedure. Dr. M. Rhea Seddon Medicine on The Final Frontier: A Microgravity Environment. The session concluded with a fascinating discussion by Dr. Seddon of the challenges of medical care in the microgravity environment encountered in Earth orbit. Dr. Seddon's experiences on three shuttle missions were described and illustrated using videotapes made during the missions. Experiments performed on these missions have demonstrated consistent physiologic changes that occur in the microgravity environment. A brisk diuresis occurs in association with a redistribution of total body water and a reduction in central venous pressure. Both stroke volume and heart rate decrease and may contribute to the orthostatic hypotension frequently observed after returning to Earth. Motion sickness, muscle atrophy, osteopenia, and a decline in red cell mass are also common after prolonged exposure to the microgravity environment. Dr. Seddon described experiments to test the crew's ability to perform medical tasks, such as CPR, minor suturing, and routine physical examination skills in microgravity. Indwelling central venous catheters and echocardiography have been used on these missions in an attempt to answer some of the questions posed by the physiologic changes induced by the absence of gravity. The meeting closed with a buffet reception at EP-COT's American Adventure Pavillion, punctuated by a spectacular laser and fireworks display. As in the past, the meeting provided an opportunity for those interested in the perioperative care of children to gather, exchange ideas, renew old acquaintances, and make new ones. The winter meeting of the SPA, jointly sponsored with the AAP Section of Anesthesiology, is scheduled for February 18-21, 1999, at The Desert Inn Resort & Casino in Las Vegas, NV (Dr. Lynda J. Means, Program Chair). The 13th annual meeting of the SPA will be in Dallas, TX, October 8, 1999 (Dr. Lynn D. Martin, Program Chair). As in previous years, the SPA annual meeting will precede the ASA annual meeting. A limited supply of program syllabi and reference lists from the 1998 meeting are available at nominal cost from the Society's headquarters. Further information is available by mail from the SPA, PO Box 11086, 1910 Byrd Ave., Suite 100, Richmond, VA 23230-1086; by phone (804)282-9780; or by e-mail at [email protected] The finalized 1999 program will be posted to the SPA web site (http://www.uams.edu/spa/spa.htm).