Society for Pediatric Anesthesia/American Academy of Pediatrics/Congenital Cardiac Anesthesia Society: Winter Meeting Review

Society for Pediatric Anesthesia/American Academy of Pediatrics/Congenital Cardiac Anesthesia Society: Winter Meeting Review The 14th annual joint winter meeting of the Society for Pediatric Anesthesia (SPA) and the American Academy of Pediatrics (AAP) was held in Jacksonville, FL, in March 2009. The meeting began on Thursday, March 19, with the gathering of the Congenital Cardiac Anesthesia Society (CCAS) and a meeting of the Special Interest Group (SIG) for Pain Management in Children. The presentations at this meeting can be viewed in greater detail at the SPA website at http://www.pedsanesthesia.org. CONGENITAL CARDIAC ANESTHESIA SOCIETY The CCAS was formed in 2007 to support the advancement of highly specialized knowledge in the field of congenital cardiac anesthesia. Program chair Emad Mossad and the educational committee put together yet another excellent program. The meeting began with welcoming comments from CCAS president Dr. Chandra Ramamoorthy. Dr. Mossad moderated the morning session “Heart Failure/Transplant.” Dr. Jeff Towbin delivered an excellent review, “Cardiomyopathy in Children,” which included the newly identified mitochondrial myopathies. He provided insight on the management of children with dilated, obstructive, and the less common but serious restrictive forms of cardiomyopathy. He emphasized that anesthesia providers should be aware of rhythm disturbances, the unique clinical variables associated with different forms of cardiomyopathy, and implications for anesthetics, cardiac medications, and intravascular volume expansion. Dr. Jack Copeland then spoke on ventricular assist devices (VADs) for children. He noted that 0.6%–6.8% of children undergoing cardiac surgery require postoperative mechanical support, most frequently extracorporeal membrane oxygenation (ECMO). The 1-yr survival in neonates awaiting transplantation on ECMO is 32% compared with 71% in those utilizing VADs as a bridge to transplant. Unfortunately, VADs cost about 3 times as much as ECMO. He concluded his talk with a discussion of the numerous improvements in the new VADs currently in development. These devices are expected to be fully implantable to allow for percutaneous insertion and provide uni- or biventricular assist possibilities with small prime volumes and a possible need for antiplatelet anticoagulation only. Dr. Barry Kussman then gave an overview entitled “Pediatric Heart Transplantation.” He noted that although 350–400 pediatric heart transplants are performed each year, about 17% of recipients die while awaiting transplantation. He identified patient, donor, and institutional characteristics that affect mortality and emphasized the problems with coronary artery vasculopathy in survivors beyond 1 yr. He then reviewed the encouraging experience with ABO incompatible transplant in infants and discussed the growing list of “Failed Fontans” that await transplantation. A lively question and answer period followed. An excellent take-home point was made about the difficulty of providing effective cardiopulmonary resuscitation in patients with Glenn or Fontan physiology and that ECMO should be considered before they arrest. The next session, “Coagulation/Blood Transfusion,” was moderated by Dr. Suanne Daves and began with a discussion by Dr. Nina Guzzetta entitled “Coagulation Monitoring in the OR and ICU.” Dr. Guzzetta described the many causes of coagulopathy after cardiopulmonary bypass (CPB) in children and the need for adequate anticoagulation on CPB. She discussed the possible benefits of tailoring heparin doses using a heparin management system in addition to activated clotting time (ACT) (because it can be affected by factors other than heparin). She emphasized the utility of point-of-care activated whole blood tests of coagulation and suggested that coagulation parameters normalize better when cryoprecipitate rather than plasma is administered when bleeding persists despite platelet administration. Dr. Patricia Massicotte then presented her talk, “Transfusion Dilemmas in Pediatric Cardiac Surgery.” She reviewed the types of blood products, the controversies surrounding leukoreduction, the necessity for irradiation, the age and type specificity of blood products, the use of directed donation, and infectious risks, especially cytomegalovirus (CMV). She identified the need for evidence-based data so that proper pediatric transfusion guidelines may be developed. In an excellent discussion entitled “Life After Aprotinin,” Dr. Michael Eaton reviewed the use of lysine analogs ε-aminocaproic acid and tranexamic acid as antifibrinolytics. He discussed the use of strategies including “platelet anesthesia” or platelet inhibition during CPB with the use of epoprostenol and nitric oxide, combination therapy with heparin and direct thrombin inhibitors, and the concept of “biopassive” CPB circuits. Rescue therapy with recombinant activated factor VII has been found to decrease bleeding, but it has been associated with a significant risk of thrombosis. Dr. Eaton identified a need for randomized, prospective, multicenter trials of the most promising therapies directed at decreasing bleeding and need for transfusion. The final morning session entitled “Hybrid Anesthesia—Myth and Reality” was moderated by Dr. James DiNardo. Dr. Helen Holtby discussed the benefits of the hybrid procedure, the set-up of the hybrid suite, and management of a single ventricle patient undergoing the hybrid procedure. She addressed timing of the atrial septectomy and the use of a “reverse” Blalock-Taussig shunt to prevent coronary ischemia in the event of loss of retrograde flow to the ascending aorta. She reviewed the experience in Toronto from the past 5 yr. Drs. Pablo Motta and Peter Winch also shared their experiences at the Cleveland Clinic and at Nationwide Children's Hospital in Columbus. Although Dr. Motta felt that the hybrid offered no advantage over the Norwood, Dr. Winch was far more enthusiastic. Of 77 consecutive patients at Columbus, 60% were extubated at the end of the procedure, had an average intensive care unit stay of 5 days, and hospital stay of 12 days. He reported an interstage mortality of 14% and suggested that morbidity may be less than in the Norwood because of the ability to avoid CPB in the neonatal period. The afternoon session of the CCAS began with a spirited panel discussion entitled “Who Should Provide Sedation/Anesthesia for Patients Undergoing Cardiac Catheterization?” moderated by Dr. Ramamoorthy. Dr. Laura Diaz presented convincing statistics to support her view that pediatric cardiac anesthesiologists are most suited for this task. Most patients are ASA physical status III and IV, at the extremes of age, and at high risk for cardiac arrest during the procedure. Dr. Ian James suggested that diagnostic catheterizations could be managed by the general anesthesiologist if they understood the hemodynamics, which way the blood flows, and the logistics of the cath suite. He argued that all pediatric anesthesiologists are trained to understand rhythm disturbances, to fear pulmonary hypertension (PHTN), and are able to treat these events. Dr. Jumbo Williams argued in favor of sedation by the cardiologist. He discussed practical issues such as the supply versus demand of pediatric general or cardiac anesthesiologists, as well as reimbursement and institutional support for anesthesiologist-directed sedation. Finally, he made the point that it is the cardiologist who best knows the physiology, the rhythms, the personnel, and procedures. The next session was entitled “Electrophysiology Update.” Cardiologist Dr. Naomi Kertesz offered important pearls and several practical tips in her presentation “Common Postoperative Arrhythmias and Their Management.” The CCAS meeting concluded with a workshop entitled “Transesophageal Echocardiography in Children” moderated by Dr. Wanda Miller-Hance. After an informative overview of the basic transesophageal echocardiographic examination in patients with congenital heart disease by Dr. Miller-Hance, the audience divided into 3 stations for individual workshops on different congenital heart lesions. SIG ON PEDIATRIC PAIN Another exciting new addition to the SPA educational program was the first meeting of the SIG on Pediatric Pain. This afternoon session chaired by Drs. Rita Agarwal and Sabine Kost-Byerly occurred concurrently with the CCAS and attracted more than 50 attendees. Dr. David Polaner presented an update entitled “Pediatric Acute Pain Management.” First, he discussed the ontogeny and development of pain responses in the neonate. He then discussed the use of parent- and nurse-controlled analgesia, which can be used safely within defined boundaries, and emphasized that a dose should never be delivered when the patient is asleep. He touched upon the use of small-dose naloxone infusions for treatment and prevention of opioid side effects and concluded with a discussion of ambulatory regional analgesia using continuous peripheral nerve blocks. Next, Dr. Steven Weisman presented “Perioperative Management of the Child with Chronic Pain.” Patients receiving chronic opioid therapy may have tolerance and hyperalgesia. He emphasized the importance of continuing the patient's preoperative regimen, providing adequate opioid analgesia postoperatively, yet considering potential drug interactions. The nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, and some anticonvulsants may cause increased bleeding. Many drugs used in these patients affect the metabolism of opioids, resulting in their accumulation. For patients receiving selective serotonin reuptake inhibitors that inhibit the 2D6 pathway, it is best to avoid drugs such as tramadol, codeine, and methadone. After surgery, psychotropic drugs should be restarted early. Regional techniques are beneficial, and adjunctive use of gabapentin should be considered. Dr. Adrian Bosenberg presented “Regional Blockade for Postoperative Analgesia.” He focused on ways to reduce the risk of regional blockade including the use of ultrasound to identify anatomic variants and optimal placement of the needle, and reduce the dose of drug necessary to achieve a successful block. He spoke about the fallacy that there is a threshold of current that is indicative of intraneural needle placement or of proper needle position. The best indicator of intraneural placement is resistance to injection greater than 20 psi. Ultrasound can compensate for anatomic variability and erroneous assumptions as to a nerve's location based on inaccurate landmark data. THE REGULAR SESSION OF THE WINTER MEETING OF THE SPA The main session opened on Friday morning, March 20, with welcome messages from the Program Director, Dr. Linda Mason, Dr. Joseph Cravero, and SPA President Dr. Joseph Tobin. The SPA program then began with a session entitled Controversies in Pediatric Anesthesia. Dr. Carolyn Bannister kicked off the morning session with a talk entitled “Brain Function Monitoring in the Pediatric Patient—Where Are We Now?” In 2006, the ASA issued a practice advisory for intraoperative awareness and brain function monitoring in adults; however, there is little evidence on which to base a similar advisory in children. The reported incidence of awareness in children is approximately 1%, but studies are subjective and based on self-reporting. Brain function monitors provide an imprecise measure of the state of hypnosis and Dr. Bannister cautioned against their use in infants because of maturational differences in the electroencephalogram. A strong correlation has been found between anesthetic levels and bispectral index values in children older than 6 mo. Narcotrend and Entropy monitors have been validated in children older than 12 mo. Pediatric studies of the Cerebral State Monitor are lacking, and the auditory-evoked potential monitor poorly predicted end-tidal anesthetic concentrations in infants and children. Pediatric anesthesiologists should take an active role in testing algorithms upon which such monitors can be developed for use in children. Dr. Randall Flick then presented “Clinical Perspectives in Anesthetic Toxicity.” Although it is known that early exposure to some anesthetics and sedatives causes neurohistopathologic and behavioral changes in rodents, extrapolation of these findings to humans is questionable. Dr. Flick presented the findings of a study that evaluated the association between early exposure to anesthesia and learning disability (LD) in 8458 children who required general anesthesia before their fifth birthday.1 Educational records and records of the only private tutoring agency in the community were reviewed. In the final sample of 5357 children, the risk for developing a LD increased with the number of anesthetics before the age of 4 yr (P < 0.001). Although children exposed to a single anesthetic were not at increased risk, those exposed to 2 or more anesthetics or those who received anesthesia for a longer duration were at increased risk of LD. Dr. Flick noted that based on these data, it is not possible to conclude whether exposure to anesthetics was causative for LD or rather a marker for conditions that increase LD risk. The second morning session entitled “Emerging Technologies and Techniques for Pediatric Patients” was moderated by Dr. Lynne Maxwell. Dr. John Arnold reviewed modes of ventilating children with acute lung injury in his lecture entitled “New Modes of Mechanical Ventilation for Children.” He discussed high-frequency oscillation ventilation, which allows for bulk delivery of oxygen and effective recruitment of alveoli, while delivering minimal volumes at high Next, Dr. Arnold described patients with continuous to He on to the concept of that a of to ventilation, within a and between provided from the are used to between the patient and the and to The next Dr. presented of Cardiac the Dr. began with a discussion of and the of ECMO versus ECMO as a or He also spoke about the of ECMO in cardiac but use when is not He discussed for and potential Next, Dr. discussed ECMO in the of extracorporeal cardiopulmonary resuscitation including and delivery is and is of the He with a discussion of VADs including the Heart and the Dr. moderated the session of the morning entitled “New on the for Pediatric Dr. presented which is used in but yet to be in the The benefits of as an and and index with a to the concentrations of in to 2 The of to age 2 yr when it that of in there is no increase of not because neonates have an increased ability to the and the pathway, to the are not Dr. Nina Guzzetta with a talk VII is by the and for the treatment and prevention of bleeding in patients with A and with to factors and or in those with factor VII bleeding associated with such as or postoperative or from studies of a between use of and decrease in blood loss were not by that the use of is more effective when administered before the of bleeding. from to The end of this is required in children because of the and more of the high of an to and a in the effects of the monitoring of levels may the incidence of trials are to and In his talk on the drug Dr. reviewed that side to the side of and resulting in a that is in the drug is in Although not with or it forms with other such as and with much less and not in significant clinical The of required is to the of and side effects are reported of in all pediatric age after administration. Although this is a promising drug with a it has not yet been by the because of of Another be expected high cost compared with Dr. discussed the peripheral opioid and which have received the and function only as peripheral at opioid is administered can also be administered the or is only for the treatment of in patients receiving care or and side effects use in mechanical Pediatric studies are on the use of this The afternoon session a of workshops and These were by a and session of moderated by Dr. This session for audience and a discussion of several practical issues to the care of children. March with a of early morning based learning by the first morning session entitled moderated by Dr. Dr. identified as a chronic disease with but with disease in Patients with may be many and so that drug be for hypertension associated with and bleeding with such as may be by the of may be required in patients with and may be a of should be because and may be may in Dr. then discussed the cause for hospital in children in the Dr. identified therapies with little to no in including and sedation. for mechanical ventilation, when oxygen and use of the of by the benefits of in in are and may be when The of the session, Dr. presented The incidence of is yet is for of mortality in the neonatal intensive care mortality in patients with is with increased ventricular the risk for main for in children lung in developed lung or and in the pulmonary of has been to with increased on these patients is in to and The on and Pain the presented for with which was by Children's Clinic of and Children's Hospital at Dr. the first of a 3 yr with with a and who required of her which was receiving epoprostenol A that is a direct of decrease current cardiac studies the of with oxygen and are of and prevention of and are to in pulmonary treatment of a intravascular volume and cardiac support as the first of and nitric Dr. on the of an yr with chronic with and undergoing He discussed the of a preoperative and the use of and before in such A of anesthesia should be and administered before of the drugs should be is a and could be by the use of a and a dose of at the end of He emphasized the use of and if intraoperative management should time for of volumes and no He cautioned the audience that has minimal compared with the significant morbidity by Dr. described his to the of a with undergoing for studies that management with a is well and has minimal in patients with is common in children after and but is and well He that if there is a potential from the procedure, with surgery is despite with the that postoperative is and in most A of workshops were to on Friday and Winter SPA began with another morning of and a Dr. gave the entitled and the She discussed the role that may in the development of drug therapy and ability to patient The role of be to identify factors that patients that may or problems when they anesthesia or These differences at many changes in differences in differences in and in These can be using techniques that are currently their way from the to the Dr. an meeting at the of to the development of pediatric some of which should the effects of different factors on in children. After the an morning that focused on and Dr. Peter gave the audience important pearls in his presentation entitled a to in a and an to in a Next, the for 3 were presented by Dr. Peter for Anesthesia Dr. for and Dr. for Pediatric Anesthesia. After the by Dr. and a discussion the SPA Winter Meeting was of the of the SPA meeting in was the presentation of the to Dr. and Dr. for their in the field of pediatric anesthesia. OF PEDIATRIC to the SPA of was of Pediatric a to the of general anesthesia who care for children in the community The program by Drs. Randall and included a of to the practice of pediatric anesthesia in this The of the meeting were to provide the with the knowledge required to provide care to children undergoing procedures. it was held concurrently with the winter it of the to the workshops and offered at the SPA The morning session on Friday was moderated by Dr. Rita Dr. opened the morning session with a overview entitled and in Children,” which heart and This was by an entitled and Anesthetic by Dr. Peter Dr. moderated the second session, which began with an excellent discussion on and management by Dr. Next, Dr. discussed the of children for and the many that can during and after this procedure. The program on Friday concluded with an the panel The included Drs. and Randall the program began with a panel on care unit including and and management of discussed by Drs. and These issues several times each in the and as such have to the care of children in that care for and children. In the next session, Dr. Adrian Bosenberg presented “Pediatric Regional Techniques for and offered several practical tips that can be to their The next Dr. about in pediatric anesthesia including in the or bleeding and neonatal such as and Dr. then presented and the by Dr. Lynne who offered several into the management of the pediatric The program concluded with a overview of to the practice of pediatric anesthesia. These included by Dr. of Monitoring in Children” by Dr. by Dr. Joseph Cravero, and by Dr. The attracted approximately 50 attendees. The were well received and the received excellent from the are currently for this program to be held in with the winter meeting in In addition to continuing the for the of and who may also from the of the David the State of of Children's of of of of and of of

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