Saturday, March 6, 2004
The second day began with Problem-Based Learning Discussions (PBLDs) groups. Thirteen different discussion groups were offered, each moderated by two experts. A broad range of clinical problems were presented, including a Down's syndrome patient with Moya Moya disease scheduled for cerebral revascularization, posterior spinal fusion in a Fontan patient, pinning of a femur fracture in a patient with Duchenne's muscular dystrophy, removal of a safety pin from the trachea, management of CRPS-1, etc. This author attended a discussion of Williams syndrome presented by Anthony Clapcich (Children's Hospital of New York) and Lynne Maxwell (Children's Hospital of Philadelphia). The discussion centered on a child with severe supravalvular aortic and pulmonic stenoses with pulmonary artery hypoplasia who underwent one surgical procedure and several catheterizations. The delicate anesthetic management was discussed in detail and thoroughly integrated with current understanding of the cardiac pathophysiology of Williams syndrome. A handout with a comprehensive summary of published literature on the subject was included.
Oral abstract presentations and the Young Investigator Awards followed as Cynthia Shields (Walter Reed Army Medical Center) presented "The Utility of Bispectral Index Score and the Modified University of Michigan Sedation Scale (MUMSS) in assessing the depth of pediatric sedation." Findings from this study of 38 children undergoing sedation for CT or MRI included: first, patients spent up to 25 percent of the time in a state of deep sedation; second, the correlation between the BIS and MUMSS was poor with all agents used, particularly chloral hydrate; and third, the BIS score frequently underestimated the MUMSS.
Alan Tait presented "Improving the Readability and Processability of an Informed Consent Document for Pediatric Anesthesia Research: Effects on Parents' Understanding and Satisfaction." In this study, a previously used consent form was modified by a reading expert to maximize readability and understanding by modifying the organization and layout, lowering the reading level, providing context clues, and using pictures, etc. Parents demonstrated significantly greater understanding and satisfaction using the modified form compared with the original.
N. Mallavaram (Columbia University), also awarded third place for resident research, presented "EEG and Inhalational Anesthetics in Infants and Children." Children six months - three years had analysis of 128-lead geodesic EEG readings during general anesthesia with isoflurane or sevoflurane. Changes consistent with arousal, including a decrease in 20-30 Hz frontal lobe signals were found with emergence from both agents. Also, an increase in sleep-spindle activity was demonstrated on emergence from isoflurane but not sevoflurane.
The junior faculty Young Investigator Award winner Lisa Wise-Faberowski (Duke University) presented "The Effect of Isoflurane on the Developing Brain: a Function of Age." In a previous in-vivo study, diffuse neurodegeneration was noted in seven-day-old rats exposed to isoflurane. In this provocative study, tissue cultures of rat hippocampal neurons from pups aged four, seven, 14, and 21 days were exposed to 1.5% isoflurane for one, three, or five hours and then assayed for neuronal cell death one or three days later. Significant cell death (>50% compared with air control) was observed only in the slices prepared from seven-day-old pups exposed to five hours of isoflurane. The authors related this age-dependent finding to the ontologic neuronal composition of GABA subunit A and NMDA receptors. Stimulation of these receptors lead to depolarization of neurons from immature rats but inhibition of mature neurons. Isoflurane is a both a NMDA antagonist and GABAA agonist. Dr. Wise-Faberowski was awarded a plaque and $1,000.
Second place for resident research went to M.B. Robinson (Children's Hospital of Philadelphia) for her presentation "Incidence of Neurological Complications Following Placement of Epidural and Caudal Catheters in Anesthetized Children for Postoperative Analgesia." Six hundred, seventy patients had 676 epidural catheters placed. Twenty-one patients required evaluation for neurologic sequelae. These included five cases of motor weakness, four of localized site infection, four cases of muscle spasm or myoclonus, three of mental status changes, three of non-specific headache, one of PDPH, one Horner's syndrome, one hysterical paralysis, and one dysesthesia. All of these complications resolved with appropriate intervention. No epidural abscesses or hematomas were noted.
Mark Crawford (Sick Children's, Toronto) was awarded first place in the resident category for his abstract "Patient Controlled Analgesia (PCA) Opioid Consumption after Laparascopic Cholecystectomy in Sickle-Cell Disease." The duration of PCA use in SSD patients was double that of controls and overall morphine use was three-fold higher in SSD patients.
Anne Lynne, president of SPA, presented Lynne Maxwell with a plaque in appreciation of her excellent job planning the last two Pediatric Anesthesiology meetings. Next, Juan Gutierrez presented the Robert M. Smith Award for Lifetime Achievement in Pediatric Anesthesia to Ted Striker (Cincinnati Children's Hospital). In accepting the award Dr. Stryker commented on the need for continued involvement and advocacy within the AAP Section of Anesthesiology by pediatric anesthesiologists.
Joanne Wolfe (Boston Children's Hospital) presented the AAP Advocacy Lecture "Pediatric Palliative Care, Can We Do Better?" Dr. Wolfe, a pediatric hematologist-oncologist, described the formation and daily functioning of a committee of physicians and ancillary health professionals dealing exclusively with quality of life issues in terminally ill children. Much of this care centers around ambulatory care and control of pain. Often, despite our best efforts, the control of pain and suffering in terminally ill children remains inadequate.
Walk-around poster discussion groups met next. The 10 group leaders were Ira Cohen, Myron Yaster, Joe Tobin, Steve Stayer, Francis McGowan, Doug Ririe, Dean Kurth, James Stevenson, Anne Lynne, and Linda Mason.
During lunch, an "Ask the Experts" panel was convened which answered audience questions in their area of expertise. Participants included Steve Stayer (cardiac), Charles Nargozian (airway), and Santhanam Suresh (pain and regional anesthesia).
Following a brief AAP business meeting moderated by Tom Mancuso, the afternoon workshops commenced. The workshops, by ticket only, lasted two hours and included: Airway, Life Outside the Operating Room, Clinical Trial Designs, What's New in Circulatory Support, Managing Epidurals, Anesthesia for Thoracic Surgery, Regional Anesthesia, and CQI/Outcomes/Database Issues. This author attended the Epidural workshop where K. Goldschneider (Cincinnati Children's Hospital)presented his recent experience using a modified Taylor approach to thread styletted epidural catheters to thoracic dermatomes. Simultaneously, there was a complementary three-hour fellows' workshop by Jerry Lerman and Alan Tait on "Research Skills, How to Write a Grant Proposal, Trial Design, and Academic Career Development."
Refresher courses rounded out the sessions with "Anxiety, Awareness, and Premedication", Carolyn Bannister, "Pitfalls of Pediatric Anesthesia" Linda Mason, "Opioid Tolerance and Abstinence Syndromes" Julia Finkel, and "Complications of Acute Pain Management in Children" John Rose.
The night ended with a barbecue dinner and live music held outside at the hotel's recreation of Tombstone.
Samuel E. Golden, MD, FAAP
Loyola University
Chicago, IL