Pediatric Anesthesiology 2002
March 7-10, 2002
Fontainebleau Hilton Resort
Miami Beach, Florida

Primary Objectives

• Review and expand current knowledge of pediatric perioperative practices.
• Introduce and incorporate new information and techniques from anesthesiology, surgery, and pediatric medicine.
  
• Facilitate the exchange of didactic and practical information between practitioners who care for pediatric patients in the perioperative period.

Secondary Objectives

Pharmaco-politics

Clinical trials: Are clinicians getting the information they want?

• Describe the study designs employed in typical pharmaceutical trials
• Contrast the information required for FDA approval from that which a clinician would ideally need to make treatment choices.

How have pediatric clinical trials influenced practice: Past and future.

• Review the historical evolution of drug trials in children from a practical and ethical standpoint.
• Project the manner in which clinical, regulatory, commercial and ethical forces might influence the conduct of future clinical trials.
• Relate this evolution in clinical trials to changes in patient care.

Post-marketing drug safety: Does FDA approval provide guarantees?

• Describe the limitations with respect to drug safety of research oriented to obtaining FDA approval.
• Cite specific examples in which drugs that achieved approval were subsequently found to pose significant safety concerns.

Generic drugs: Availability and viability

• Describe the various considerations that may have an impact on availability as a drug moves off patent.
• Evaluate whether generic drug shortages are increasing in frequency and any factors that might contribute.
• Propose a model that would enhance the commercial viability and availability of generic drugs.

Fetal Surgery

Evolution and spectrum of fetal interventions

• Describe the evolution and current status of fetal interventions in humans.
• Project the future directions for fetal therapy and its enabling technologies.

Anesthesia for fetal surgery

• Discuss the physiologic, pharmacologic, and logistical implications that govern anesthetic management of the mother and fetus.
• Contrast the anesthetic approaches for various broad categories of fetal/intrapartum interventions.
• Weigh the merits of one anesthetizing team versus two (i.e. one each for fetus and mother).

Designing a clinical trial of fetal surgery: The myelomeningocele saga

• Describe the criteria, technique and results of fetal surgery for myelomeningocele.
• Discuss the barriers to design and conduct of a high-profile randomized clinical trial posed by philosophical differences between centers, media hype, and an enlightened consumer population.

Pro/Con: Standards improve quality of clinical care

• Discuss the evolution and formulation of standards in clinical medicine.
• Debate the evidence that standards have had a measurable impact on the quality of clinical patient care.

AAP Advocacy Lectures

Ethical implications of pediatric research.

• Review the ethical considerations that pertain to clinical research in human subjects.
• Contrast these considerations as they pertain to research on adults and children.
• Describe the impact these considerations have on regulatory initiatives.

Pediatric research from the child's perspective.

• Discuss the issue of "consent" from the pediatric subject's perspective.
• Relate the motivational factors that might influence a child to consider participation in research.
• Consider the impact of age on these issues.

Oral analgesics in children

• Outline pharmacological advances in oral analgesic options for children.
• Compare safety, efficacy, and side-effect profiles for oral analgesics in pediatric patients.
• Describe rational regimens for oral analgesia in specific painful conditions (e.g. acute postoperative, chronic inflammatory, or neuropathic pain).

Update in Cardiac Anesthesia

Anesthesia and myocardial function

• Review the current data on the impact of specific anesthetic agents on myocardial function.
• Link desired hemodynamic objectives to qualitatively predictable impact of anesthetics on cardiovascular variables.

Anesthetics and stress ablation

• Review the evolution of hypotheses linking stress response to outcome
• Critically appraise whether the stress response offers any adaptive benefits in the context of cardiac surgery.
• Consider current evidence that complete ablation of the stress response is necessary to achieve optimal patient outcome.

Neuroprotection

• Review the myriad strategies proposed to promote neuroprotection in the context of open heart surgery in infants and children.
• Consider the role that anesthetic agents might play in neuroprotection.

Jeopardy

• Solicit common problems and controversies encountered by pediatric anesthesiologists from registrants prior to the meeting
  • Submit Questions
• Refer these topics to a panel of experts in advance.
• Survey meeting participants for additional pediatric anesthesia problems and controversies.
• Conduct a discussion of the best evidence available to arrive at potential solutions

Refresher Courses

PACU problems and solutions

• Describe the array of problems commonly encountered in the PACU (e.g. emergence agitation, pain, vomiting, airway edema).
• Develop strategies for management of these issues.

Anesthesia for children in remote locations

• Identify the potential hazards and pitfalls when providing anesthesia outside the OR suite.
• Describe unique equipment and technique adaptations necessary for anesthesia in the non-OR environment.

Neonatal pain management

• Describe recent advances and specific concerns in pain management in neonates.
• Summarize protocols employing regional techniques, potent intravenous analgesics and adjuvant therapies in neonates.

Ventilators in the OR

• Describe the physiologic considerations for intraoperative mechanical ventilation in infants and children.
• Discuss the technological alternatives available to meet these specific goals.

Myopathies in pediatric anesthesia

• Summarize the more common myopathies of childhood and their physiologic ramifications.
• Describe the clinical manifestations that might suggest undiagnosed myopathy.
• Discuss ramifications of myopathies for anesthetic management.

Perioperative apnea in neonates

• Review the development of respiratory control and the epidemiology of perioperative apnea in neonates.
• Discuss management considerations including monitoring, pharmacologic intervention and discharge following elective surgery.

Sedation systems

• Discuss the evolution of sedation guidelines in improving the safety of infants and children.
• Consider the implications of credentialing and other policies designed to regulate practitioners and restrict use of certain drugs when sedation is conducted by health professionals of varying qualifications.

Induction techniques in children

• Summarize the options for induction of anesthesia in children.
• Discuss the merits of various facilitating "P" strategies: psychological preparation, parental presence and premedication.

Workshops

Airway

• Demonstrate advanced airway management techniques, including Bullard laryngoscope, lighted stylette, fiberoptic bronchoscope, airway camera, and emergency tracheostomy.
• Registrants will have the opportunity to perfect their skills with these devices.

Regional anesthesia for the lower extremity

• Demonstrate femoral, sciatic, knee and ankle blocks; techniques and drug selection.

Managing epidurals

• Review caudal to cervical approach, single-shot techniques, catheter placement and confirmation, monitoring, problem-solving and patient selection.

Sub-arachnoid blocks

• Develop familiarity with various anatomical approaches, equipment, drug selection, indications and complications of spinal anesthesia in infants and children.

Regional anesthesia for the upper extremity

• Consider the indications, anatomy, techniques and potential complications of a variety of approaches to the brachial plexus as well as other nerve blocks of the hand and forearm.

What's new for acute pain

• Demonstrate the spectrum of therapies available in the treatment of acute pain.

Designing clinical trials

• Review the essential components in design and execution of clinical trials.
• Describe the resources available to support clinical research endeavors.

Magical distractions for children

• Demonstrate magic illusions that can be employed to distract children (or surgeons) during induction of anesthesia.
• Compare the benefits of magic and other distractions to alternatives such as premedication.

PBLD's

After the completion of the PBLD, the participant should be able to:

1. Penetrating eye injury in a child with full stomach.
Case: 2 ½ year old presents to an ER with penetrating injury to the left eye. Parents report he just ingested a full breakfast.

• Prioritize the anesthetic considerations involved with management of the full stomach and the impact of anesthetic management on intra-ocular pressure.

2. Appendectomy in a child with motor weakness.
Case: 5 year-old presents with acute abdomen believed due to acute appendicitis. On careful questioning, parents describe progressive inability to keep up with peers and delayed onset of walking in infancy. They have some vague recollection that an uncle died during anesthesia.

• Ooutline the potential anesthetic hazards posed by myopathies and arrive at an anesthetic plan that encompasses drug selection, monitoring, airway management, as well as a follow-up instruction plan.

3. Spinal surgery in a patient with residual congenital heart disease.
Case: 20 year-old with scoliosis and tetralogy of Fallot. He had a repair early in childhood, but has cardiac sequelae including moderate branch pulmonary artery stenosis, severe pulmonary insufficiency, right ventricular dysfunction and ventricular arrhythmias.

• Design a perioperative plan including: necessary pre-operative evaluations, hemodynamic monitoring, anesthetic induction and maintenance, intraoperative hemodynamic manipulation strategies and postoperative analgesia.

4. Head trauma with difficult airway.
Case: 9 year-old with Hurler's syndrome presents with a depressed skull fracture sustained in a fall. Parents report doctors saying it was nearly impossible to "get the breathing tube in" for previous surgeries. One elective procedure had to be cancelled after 4 hours of unsuccessful attempts. The child is unconscious, but breathing spontaneously.

• Construct an anesthetic plan taking into account airway management and intracranial pressure as well as monitoring and other considerations raised by clinical conditions.

5. Pyloric stenosis without IV access.
Case: 4 week old infant presents for pyloromyotomy. He arrives in the OR holding area with an infiltrated IV. Intern in her first week of training reports that she has been trying to get a new one for the past 5 hours. Extremities are notable for numerous ecchymoses.

• Identify the important elements in pre-operative evaluation, management and timing of surgery, relative merits of various airway interventions, and postoperative analgesia options.

6. Multiple trauma with pulmonary infiltrates
Case: 7 year old unrestrained passenger in a MVA presents with multiple traumatic injuries including closed head injury, bilateral femoral fractures, an open elbow fracture. Preoperative chest film shows bilateral pulmonary infiltrates.

• Describe the differential diagnosis of pulmonary infiltrates with multiple trauma patients and prioritize the evaluation and management plans necessary to conduct resuscitation, monitoring and anesthetic care.

7. Critical care medicine fellow and propofol sedation
Case: Quality assurance nurse monitor reports to you that a critical care medicine fellow has taken a 4 year-old trauma patient to the MRI scanner and has asked the nursing staff to prepare propofol for infusion to facilitate the scan. The child is breathing through a natural airway. The fellow states that his attending is at home, but he is fully qualified to manage any airway issue that might arise.

• Outline the considerations that enter into the development of sedation protocols; the basis of constraints upon practitioners from a regulatory or credentialing perspective as well as practical guidelines that govern the use of "anesthetic" drugs at various sites throughout the institution.

8. Tracheoesophageal fistula and murmur
Case: Newborn 35-week gestation infant with tracheoesophageal fistula scheduled for repair. Found to have a murmur on pre-operative evaluation.

• Discuss the key features of preoperative assessment; intraoperative management of induction and maintenance; implications for co-existing cardiac and pulmonary disease; and postoperative analgesic options.

9. Mediastinal mass for bone marrow aspirate in oncology clinic
Case: 6 year old with newly diagnosed anterior mediastinal mass and leukocytosis for bone marrow aspirate in oncology clinic. Family reports a new "bluish" tinge to his face and mild periorbital edema. Oncologist advocating this "less invasive" diagnostic approach to avoid going to the OR for mediastinal biopsy.

• Identify the important implications of mediastinal masses; the vital components of pre-anesthetic evaluation; strategic options for management (both timing and techniques).

10. Thoracic epidural for coarctation repair
Case: 4 year old with discrete coarctation of the aorta presents for surgical repair. Parents have heard that epidural analgesia is superior to conventional (intravenous) methods.

• Describe the considerations relevant to regional analgesia for coarctation repair; appropriate patient selection; timing of placement (sedated vs. anesthetized; pre-clamp vs. post-clamp); impact systemic heparinization might have on decision; considerations related to neurologic surveillance; drug selection.

11. Failing spinal in a former premie
Case: 10 week old former 29-week gestation infant for bilateral herniorrhaphy. Infant had been home for one month prior to surgery on home apnea monitoring. Parents report several alarms, but they are questionable because the baby is fine when they check him. Spinal anesthesia selected, but the infant becomes quite restless and agitated, crying intermittently, before the surgeons have finished the first side.

• Develop a management plan for this patient; list the various options; what are the consequences of these options; whether these options influence timing of discharge; the use and implications of respiratory stimulants; list the potential flaws in the original plan that might have influenced outcome.

12. Infant for total cranial vault reshaping.
Case: 9 month-old infant with severe Apert's syndrome for major craniofacial surgery.

• Identify the critical features in perioperative plan for major craniofacial surgery; pre-operative assessment; intraoperative monitoring; airway management options; preparation for massive blood loss and replacement; postoperative expectations.