Pediatric anesthesiology 2016 reviews

CRNA Symposium

Reviewed by Sarah Laqua, CRNA
Texas Children's Hospital, Houston

The final day of the SPA meeting was highlighted with the Special Interest Group (SIG) Symposium moderated by Eileen Griffin, CRNA (Monroe Carell Jr. Children's, Nashville). This breakout session prominently focused on evidenced-based medicine and its impact on outcomes.

Jennifer Aunspaugh, MD (Arkansas Children's, Little Rock) kicked off the symposium by presenting the anesthetic challenges for craniosynostosis repair in infancy. Craniosynosis may be categorized as simple, involving one suture, or complex, the latter commonly associated with Apert’s, Crouzon’s, or Pfeiffer Syndromes. Patients with associated syndromes have high potential for difficult airway management and intravascular access. Indications for craniosynostosis repair are ultimately due to increased ICP, OSA, severe exophthalmos or craniofacial deformity, or psychosocial reasons.

Surgical approach to craniosynostosis repair may be endoscopic, by spring-assisted cranioplasty, or by open vault reconstruction, with the incidence of venous air embolism as high as 83% in open repairs. Endoscopic and spring-assisted cranioplasty are most often the chosen approach in infants and confer advantages such as shorter hospital stay and minimal blood loss. Conversely patients can lose up to one blood volume with open vault reconstruction. Blood conservation techniques, massive blood loss and transfusion, hypovolemic cardiac arrest, transfusion reactions and hyperkalemia are poignant concerns for anesthesia providers caring for patient undergoing craniosynostosis repair.

Terri Voepel-Lewis, RN (C.S. Mott Children's, Ann Arbor) followed by discussing translation of evidence-informed practice (EIP) in anesthesia. Providers are responsible for the integration of EIM with pay for performance-led organizational models, though we may lack time, resources, evidence and confidence in new practices. Providers must continually consider whether EIP is relevant, useful and feasible, with benefit exceeding risk and cost.

Evidence-informed practice is formed from the culmination of data from clinical samples, the creation of a population evidence statement, and clinical decisions. Providers must infer evidence from a sample to a population or from single-subject studies, whereby a population evidence statement is made. Clinical decisions are made when inferences are deduced from a population to be applied to an individual. Many barriers to EIP include imperfect randomization, conflicts of interest, lack of impact and harm in translation, which altogether raise skepticism for integration into daily practice.

Nihar Patel, MD (Texas Children's Hospital, Houston) followed by presenting the evolution of the perioperative surgical home at Texas Children's Hospital. It evolved from considering the large population of patients undergoing scoliosis repair with no cohesive measure of quality assurance, quality improvement or outcomes. The development of a perioperative surgical home aims to minimize morbidity and mortality and improve quality outcomes by optimal collaboration of a multidisciplinary team and care pathway. The perioperative surgical home must essentially be a patient-based comprehensive team care model committed to quality and safety, optimizing a patient’s accessibility to care. Benefits include improved safety, efficiency, cost-savings, collegiality, quality outcomes and patient satisfaction.

Beginning with initial identification of key players in patient health and recovery, a multidisciplinary team evaluates candidacy for scoliosis repair. The scoliosis perioperative surgical home specifically includes orthopedics, pulmonary, nutrition, anesthesia, and other designated specialties. The patient is seen in the preanesthesia screening clinic, and recommendations for health optimization are made. By multidisciplinary review and collaboration, inpatient preparations are coordinated so the child may be cleared for surgery. Quality tools used to support the care pathway include an anesthetic protocol, spine scorecard, and patient guides for preoperative preparation and recovery course.

Lastly, Saeed Yacouby, CRNA (Texas Children's Hospital, Houston) presented transfusion principles and strategies. His presentation encompassed a thorough overview of hematological considerations, guidelines, concerns, and considerations for transfusion in the pediatric population. Risks for transfusion include infectious, non-infectious, immune and non-immune risks. Reduction of these risks are facilitated by explicit blood center testing, leukocyte reduction, irradiation, and washing, with specifications for the latter two guided by institution protocol. New considerations include concern for the spread of the Zika Virus from donors who’ve travelled to affected areas. Regarding this, the Center for Disease Control states the Zika Virus can be spread from blood transfusion, though no confirmed cases from blood transfusion transmission exist.

Overall, transfusion in pediatric patients is well-studied, showing benefits of conservative over liberal transfusion techniques among extremely low birth weight and stable critically ill children. Transfusion algorithms can guide product utilization for improved outcomes. Research is evolving regarding blood conservation techniques and off-label utilization of factor and platelet concentrates.