Society For Pediatric Anesthesia Research Articles

Pediatric Research and Scholarship: Another Gordian Knot?

Peter J. Davis, MD Appearing in this issue of the journal are four clinical papers on the use of dexmedetomidine in children (1–4). Previous studies of the use of this drug in children have dealt with sedation in the intensive care unit (5), prevention of postoperative agitation associated with sevoflurane anesthesia (6,7), and sedation for noninvasive procedures (8–12). These articles also illustrate a number of subtle concerns that are relevant to drug development in children and the ethical principles that guide research in human subjects as proposed by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, and summarized in the Belmont Report. In a randomized study of 30 pediatric cardiac surgical patients anesthetized with isoflurane and undergoing cardiopulmonary bypass (CPB), Mukhtar et al. (1) evaluated the effects of a continuous dexmedetomidine infusion on patients’ underlying hemodynamics and neuroendocrine system compared with patients receiving a saline control infusion. The authors infused dexmedetomidine after anesthetic induction until the termination of CPB. Dexmedetomidine attenuated the increase in the neuroendocrine markers of stress caused by sternotomy and CPB. In addition, dexmedetomidine provided better intraoperative hemodynamic stability in children with congenital heart disease. The report focused on hemodynamic outcome and did not address how this drug affected tracheal extubation time, recovery, length of hospital stay, or long-term outcome. Thus, the reader is left to ponder whether the reduction in the cortisol and norepinephrine, markers of neuroendocrine response, affect outcome. Moreover, we do not know how to titrate dexmedetomidine or if the optimum dose was administered. Are there dexmedetomidine doserelated adverse effects in this population? Should the dose be altered at the start of CPB? What is the effect of the fluctuation in the patient’s temperature (37° to 25° and return) on plasma levels achieved using a standard infusion rate? Why was dexmedetomidine not continued until the end of surgery? Why did the dexmedetomidine infusion not allow for less anesthetic administration, as had been shown in an adult study (13)? Did dexmedetomidine improve hemodynamic stability after bypass? Although this study measured biochemical endpoints to assess stress response, can we infer that the effect of this drug will be as salutary as the effect of opioids in the mortality of children having surgery for congenital heart disease? These questions were not answered because the study was not funded, limiting the number of subjects and the resources available to the investigators. Had this study been funded by the pharmaceutical manufacturer, the authors could have enrolled more patients, perhaps included other study centers, assayed blood for dexmedetomidine concentrations, developed pharmacokinetic models of dexmedetomidine in this population, and performed a pharmacodynamic concentration-versus-response analysis. In a study of 60 children undergoing magnetic resonance imaging, From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Department of Anesthesia, Stanford University, Stanford, California; Department of Anesthesiology, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania. Accepted for publication March 22, 2006. Address correspondence and reprint requests to Peter J. Davis, MD, Professor of Anesthesia and Pediatrics Anesthesiologistin-Chief, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA 15213. Address e-mail to davispj@anes.upmc.edu. Copyright © 2006 International Anesthesia Research Society DOI: 10.1213/01.ANE.0000220033.34889.CE

Post-operative confusion and the practice of pediatric anesthesia

METHODS: A standardized questionnaire was sent to 120 members of the Canadian Pediatric Anesthesia Society. Members were given 13 case scenarios involving 5 year old children with different medical condition. Each underwent a different surgery/procedure but emerged with the same post-op behavior. Members were asked to choose from the following treatment options: midazolam, fentanyl, propofol, or one other drug, if any, of their choice to treat post-op confusion.

Awareness During Anesthesia in Children

Source: Davidson AJ, Huang GH, Czarnecki C, et al. Awareness during anesthesia in children: a prospective cohort study. Anesth Analg. 2005;100:653–661.Investigators from The Royal Children’s Hospital in Melbourne, Australia carried out a prospective cohort study to assess the incidence and nature of awareness during anesthesia in children. This study was “nested” in a larger study of behavioral changes in children after hospitalization and anesthesia. Patients ages 5 to 12 years having general anesthesia for any procedure were eligible for the study. Study children were randomly enrolled from each day’s operating room schedule. The type of general anesthesia provided was not controlled. Following anesthesia, enrolled subjects were asked a set of screening questions at 3 different times; the first or second day, the third day, and finally the 30th day post-anesthesia. Behavior changes were assessed at 30 days post-anesthesia. One of the principal investigators interviewed all cases of possible awareness and generated a case report. The reports were reviewed by 4 pediatric anesthesiologists from outside locations and classified as “awareness,” “possible awareness,” or “not awareness.”Eight-hundred-sixty-four children were interviewed using questions such as “Did you have any dreams or feel or hear anything while you were having the operation?” There were 28 cases of suspected awareness based on the screening questionnaire. At least 1 of the 4 outside reviewers felt that 12 of these 28 reports represented “awareness.” Seven of the 12 cases had a unanimous consensus of “awareness” by all 4 reviewers, giving an incidence of awareness of at least 0.8% (95% CI, 0.3 to 1.7%). Five of these children reported pain, classified as “mild” in 4, and “moderate” in 1. No child reported being upset at the time of the interview. One of 5 of the “aware” children had a significant deterioration in behavior. This was not significantly different from the 15.8% incidence of behavior deterioration in the “non-aware” group. The authors were unable to demonstrate a statistically significant difference between the “aware” and “non-aware” groups in the use of sedative premedication, type or length of anesthesia, use of muscle relaxants, age, or incidence of critical events.Dr. Valley has disclosed no financial relationships relevant to this commentary.The authors demonstrated an incidence of awareness (0.8%) in a cohort of pediatric patients who were relatively healthy and undergoing elective surgery; that percent-age is considerably higher than that quoted for adults (0.1 to 0.2%).1 Only 1 of the “aware” subjects received muscle relaxants. As the authors discussed, higher anesthetic requirements (minimum alveolar anesthetic concentration [MAC]) and differences in the pharmacology of intravenous anesthetics may partially account for a higher incidence of awareness in children.2,3 An interesting clinical practice by the anesthesiologists at the study site may also explain some of the cases of awareness. After induction of anesthesia in an “Induction Room,” the patient was disconnected from the anesthesia circuit and transported a short distance to the operating room where the patient was then reconnected to an anesthesia circuit and inhalation anesthesia resumed or started. Six of the 7 “aware” subjects had an inhalation (versus intravenous) induction. Hence, it is possible that some “lightening” of anesthetic depth occurred during this time. The authors acknowledge that this could have been a factor in 5 of the 7 reported cases of awareness.This article comes on the heels of a “Sentinel Event Alert” sent out by JCAHO in October 2004,4 which alerted anesthesia providers to the problem of awareness during anesthesia and suggested how it could be prevented and managed. The Society for Pediatric Anesthesia, the AAP section on Anesthesiology and Pain Medicine, and the ASA Pediatric Anesthesia Committee took issue with some of the recommendations and sent a joint letter to JCAHO asking that the alert be withdrawn. The letter noted the paucity of data on the use of “awareness monitors” for pediatric patients, cited evidence that in some situations these devices can be misleading, and expressed concern about the recommendations on the use or avoidance of certain anesthetic agents and muscle relaxants.Awareness during anesthesia can and does occur in children. Clinicians and researchers are now charged with developing sound clinical guidelines to prevent, detect, and deal with cases of awareness in children.Knowledge of this problem may result in better awareness on the part of anesthesiologists both in transferring children receiving inhaled anesthesia from an “induction room” to an operating room, and in the OR.

The Society for Pediatric Anesthesia: the first joint meeting of the Society for Pediatric Anesthesia and the Japanese Society of Pediatric Anesthesiology.

The Society for Pediatric Anesthesia: the first joint meeting of the Society for Pediatric Anesthesia and the Japanese Society of Pediatric Anesthesiology.

Cardiac calendar—2003 to 2005

Joint Meeting of the Society for Pediatric Anesthesia and the Japanese Society of Pediatric Anesthesia, San Francisco, CA, October 10, 2003. Contact: Society for Pediatric Anesthesia, 2209 Dickens Road, Richmond, VA 23230–1086.

A survey of obstetric complications and pregnancy outcomes in paediatric and nonpaediatric anaesthesiologists.

Obstetric complications such as spontaneous abortion, preterm labour, preterm delivery, low birth weight and congenital anomalies may be associated with exposure to anaesthetic gases. We hypothesized that female anaesthesiologists practicing primarily paediatric anaesthesia, with increased exposure to trace anaesthetic agents, experience a greater prevalence of obstetric complications than female anaesthesiologists performing primarily adult anaesthesia. Questionnaires were sent to all female Society for Pediatric Anesthesia (SPA) members and to an equal number of randomly selected female American Society of Anesthesiologists (ASA) members. Subjects were asked to answer questions regarding their pregnancy outcomes, work history and personal habits. Parametric data were analysed by unpaired t-tests. Nonparametric data were analysed by chi-square, Fisher's exact test and Mann-Whitney U-test as appropriate. Paediatric anaesthesiologists were defined as those having >75% paediatric practice. Paediatric anaesthesiologists were older and had greater operating room exposure during their pregnancies than nonpaediatric anaesthesiologists. There was a significantly higher prevalence of spontaneous abortion among paediatric anaesthesiologists than nonpaediatric anaesthesiologists. In an exploratory analysis, the following factors were found to be significantly associated with the development of spontaneous abortion: age >35 years, gravida >1, exercise during pregnancy, percentage of inhalational anaesthetics >75% and paediatric anaesthesia practice >75%. Independent risk factors for spontaneous abortion among anaesthesiologists included exercise (>1 time/week) and age. Our results suggest a higher prevalence of spontaneous abortion in anaesthesiologists whose practice is >75% paediatrics.

Fourteenth annual meeting of the Society for Pediatric Anesthesia, San Francisco, California, October 13, 2000.

Fourteenth annual meeting of the Society for Pediatric Anesthesia, San Francisco, California, October 13, 2000.

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Thirteenth Annual Meeting of the Society for Pediatric Anesthesia, Dallas, Texas, October 8, 1999

Report of the Society for Pediatric Anesthesia 13th annual meeting.

Report of the Society for Pediatric Anesthesia 13th annual meeting.

The Perioperative Management of Patients with Sickle Cell Disease: a Survey of Members of the Society for Pediatric Anesthesia

BURT, NAPOLEON; BAILEY, MELINDA K.; PINOSKY, MARK L.; WILLIAMS, ANDREA R. Author Information

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

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

Twelfth annual meeting of the Society for Pediatric Anesthesia, Orlando, Florida, October 16, 1998.

Twelfth annual meeting of the Society for Pediatric Anesthesia, Orlando, Florida, October 16, 1998.

Allocating Subspecialist Pediatric Anesthesiologists

In Response: In our editorial, we primarily addressed the issue of subspecialty training for pediatric anesthesiologists. Accreditation of programs (not of individuals) by the Accreditation Council for Graduate Medical Education provides standardization of this process. Graduates are trained to care for high-risk patients. Atkins is disturbed, however, by what he believes is a trend by some families and pediatricians to desire that a pediatric anesthesiologist be involved in the care of their children. This is an issue that is influenced not only by the personnel available in an institution, but also by the standards and expectations of the community. For instance, do individuals understand and appreciate the differences between the qualifications of an anesthesiologist versus an anesthetist, or between a board-certified versus a non-board-certified anesthesiologist? Similarly, do they even know that some anesthesiologists have special experience and/or training in pediatric, pain, obstetric, or cardiac care, among others? These are intriguing matters that our editorial did not address, primarily because the local environment frames these questions differently. Moreover, this is not simply a concern for anesthesiologists. For example, some parents bring their children to a family practitioner; others bring them to a pediatrician. Some feel comfortable with an adult specialist (such as a surgeon, cardiologist, etc.) providing care for their children, whereas others prefer a pediatric specialist (such as a pediatric surgeon, pediatric cardiologist, etc.). Likewise, some parents and pediatricians (as well as pediatric surgeons) prefer that their children receive care from a pediatric anesthesiologist rather than from a generalist. Individuals who request this are likely seeking an anesthesiologist with special training and/or experience in the care of children. In most situations, a careful explanation of one's background, along with appropriate reassurance, is all that is necessary. Nevertheless, the ability to choose one's own caregivers is an important aspect of American medicine. Hopefully, this will not be lost in the current restructuring of reimbursement for medical services. Patients and families who wish to know the education, training, and experience of their physicians certainly have that right, and many medical societies are already making this information available to the public via the Internet. Attempts by regulatory agencies or practitioners to discourage patients from seeking specialty or subspecialty care are unwarranted and inappropriate. However, as Atkins notes, it is important for the leadership in pediatric anesthesia to help all anesthesiologists who care for children. This means providing not only consistent, high-quality subspecialty training, but also education for the generalist anesthesiologist. The pediatric anesthesia community has been particularly responsive in this regard. We invite Atkins and all others interested in the care of children to take advantage of the many educational opportunities in pediatric anesthesia, such as those offered through state and national anesthesia societies, including the two annual educational programs of the Society for Pediatric Anesthesia. It is also worth noting that the Society for Pediatric Anesthesia welcomes as members all anesthesiologists with an interest in pediatric care. This is because it is clearly in the best interest of children to have anesthesiologists who provide pediatric care continually updated in their knowledge, as well as experience. Mark A. Rockoff, MD* Steven C. Hall, MD[dagger] Departments of Anesthesia; * Harvard Medical School; Children's Hospital; Boston, MA 02115-5735 [dagger] Northwestern University Medical School; Children's Memorial Hospital; Chicago, IL

Allocating Subspecialist Pediatric Anesthesiologists

In Response: In our editorial, we primarily addressed the issue of subspecialty training for pediatric anesthesiologists. Accreditation of programs (not of individuals) by the Accreditation Council for Graduate Medical Education provides standardization of this process. Graduates are trained to care for high-risk patients. Atkins is disturbed, however, by what he believes is a trend by some families and pediatricians to desire that a pediatric anesthesiologist be involved in the care of their children. This is an issue that is influenced not only by the personnel available in an institution, but also by the standards and expectations of the community. For instance, do individuals understand and appreciate the differences between the qualifications of an anesthesiologist versus an anesthetist, or between a board-certified versus a non-board-certified anesthesiologist? Similarly, do they even know that some anesthesiologists have special experience and/or training in pediatric, pain, obstetric, or cardiac care, among others? These are intriguing matters that our editorial did not address, primarily because the local environment frames these questions differently. Moreover, this is not simply a concern for anesthesiologists. For example, some parents bring their children to a family practitioner; others bring them to a pediatrician. Some feel comfortable with an adult specialist (such as a surgeon, cardiologist, etc.) providing care for their children, whereas others prefer a pediatric specialist (such as a pediatric surgeon, pediatric cardiologist, etc.). Likewise, some parents and pediatricians (as well as pediatric surgeons) prefer that their children receive care from a pediatric anesthesiologist rather than from a generalist. Individuals who request this are likely seeking an anesthesiologist with special training and/or experience in the care of children. In most situations, a careful explanation of one's background, along with appropriate reassurance, is all that is necessary. Nevertheless, the ability to choose one's own caregivers is an important aspect of American medicine. Hopefully, this will not be lost in the current restructuring of reimbursement for medical services. Patients and families who wish to know the education, training, and experience of their physicians certainly have that right, and many medical societies are already making this information available to the public via the Internet. Attempts by regulatory agencies or practitioners to discourage patients from seeking specialty or subspecialty care are unwarranted and inappropriate. However, as Atkins notes, it is important for the leadership in pediatric anesthesia to help all anesthesiologists who care for children. This means providing not only consistent, high-quality subspecialty training, but also education for the generalist anesthesiologist. The pediatric anesthesia community has been particularly responsive in this regard. We invite Atkins and all others interested in the care of children to take advantage of the many educational opportunities in pediatric anesthesia, such as those offered through state and national anesthesia societies, including the two annual educational programs of the Society for Pediatric Anesthesia. It is also worth noting that the Society for Pediatric Anesthesia welcomes as members all anesthesiologists with an interest in pediatric care. This is because it is clearly in the best interest of children to have anesthesiologists who provide pediatric care continually updated in their knowledge, as well as experience. Mark A. Rockoff, MD* Steven C. Hall, MD[dagger] Departments of Anesthesia; * Harvard Medical School; Children's Hospital; Boston, MA 02115-5735 [dagger] Northwestern University Medical School; Children's Memorial Hospital; Chicago, IL

Eleventh Annual Meeting of the Society for Pediatric Anesthesia, San Diego, California, October 17, 1997

Eleventh Annual Meeting of the Society for Pediatric Anesthesia, San Diego, California, October 17, 1997

Eleventh annual meeting of the Society for Pediatric Anesthesia, San Diego, California, October 17, 1997.

Eleventh annual meeting of the Society for Pediatric Anesthesia, San Diego, California, October 17, 1997.

Subspecialty Training in Pediatric Anesthesiology

Subspecialty Training in Pediatric Anesthesiology

Preoperative laboratory testing in children undergoing elective surgery: Analysis of current practice

Study Objective: To evaluate current practice in preoperative testing of healthy children undergoing elective surgery that is not expected to result in significant blood loss. Design: Survey of members of the Society for Pediatric Anesthesia. Setting: Anesthesiologists practicing in North America. Population: A total of 1,200 questionnaires were mailed. Interventions: Questionnaires were mailed to all members of the Society for Pediatric Anesthesia. All members were asked to specify which tests were routinely performed and to state why. Specific questions were asked about performing complete blood count (CBC), hemoglobin (Hb), hematocrit (Hct), and urine analysis (UA) in all patients, pregnancy test in adolescents, prothrombin time (PT) and activated partial thrombin time (PTT) prior to tonsillectomy, and sickle cell testing in black and/or Mediterranean children. Measurements and Main Results: 685 of 1,200 (57%) questionnaires were returned. No attempt was made to identify and follow-up with nonresponders. Hb testing is routinely performed in 27% to 48% of the children depending on the age of the patient. UA is ordered preoperatively in less than 15% of the children. Pregnancy test was ordered by 43% of the respondents. Hemostatic tests prior to tonsillectomy were conducted by 45% of the anesthesiologists. Conclusion: The results indicate the present practice of routine preoperative laboratory testing for children undergoing elective outpatient surgery. In spite of the many studies that indicate no specific benefits of performing routine preoperative testing in healthy children undergoing scheduled surgery, many physicians continue to order these tests in all such children.

Tenth Annual Meeting of the Society for Pediatric Anesthesia, New Orleans, Louisiana, October 18, 1996

Tenth Annual Meeting of the Society for Pediatric Anesthesia, New Orleans, Louisiana, October 18, 1996