SPA Annual Meeting Reviews
Session II: Current Technology and Current Events
Reviewed by Titilopemi A.O. Aina, MD, MPH, FAAP, FASA
Texas Children’s Hospital
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Dr. Aina |
On Saturday, October 10, 2020, the Society for Pediatric Anesthesia commenced its 34th Annual, and first-ever virtual, Meeting. Session II was entitled "Current Technology and Current Events." Katherine G. Keech, MD, and Jamie M. Peyton, MD, moderated this session. The session featured two 15-minute PEDx talks, which debuted at the SPA Annual Meeting in 2018, and are based on the TED Talks format. The session ended with a 30-minute lecture.
The first PEDx talk was given by Sampaguita Tafoya, MD, a pediatric anesthesiologist and Assistant Chair at Shriner's Hospitals for Children – Northern California. Her lecture was entitled "Regional Anesthesia in Patients with Challenging Anatomy." Dr. Tafoya highlighted the importance of having a systematic approach when performing a regional anesthetic for children with challenging anatomies. She noted that the complex anatomy could either be due to musculoskeletal disease or burn injury. Figure 1 shows Shriner’s Hospitals for Children’s approach for these cases.
Figure 1: Shriner’s Approach
Dr. Tafoya used four case scenarios to illustrate this standardized approach. The first case described was a child with arthrogryposis who presented for bilateral infraclavicular blocks. Next was a child with limb deficiency planned for a sciatic nerve block. There was another child with arthrogryposis presenting for bilateral femoral and sciatic nerve blocks. The last case was a child with osteogenesis imperfecta planned for a fascia iliaca block. The images used during this presentation allowed for ease of following the clinical management.
For each of these cases, the first step was to anticipate. She said difficulty should be expected, and the team should be aware that there is little room for error. The next step was to Prepare. This is done by optimizing the position. And whenever possible, other available colleagues should be present in the room to assist with the block. Then, based on the disease type, we can predict what challenges will be encountered during block placement. For example, children with arthrogryposis have shortened inwardly rotated arms that are not easily able to be positioned for upper extremity nerve blocks. Once these three steps have been completed, the block is then attempted. Blocks are placed with ultrasound-guidance, and sometimes with the additional use of a nerve stimulator. In arthrogryposis, the nerves are often deeper and require a steeper needle position. If unable to successfully place the block, then the final step is to adapt. In the cases discussed, adapting was due to a lack of good imaging of the nerve, and absent nerve stimulation. Dr. Tafoya noted that adaptability is only possible when the provider is thoroughly knowledgeable of all alternative blocks. The talk ended with a quote from H.E. Luccok that states “No one can whistle a symphony. It takes a whole orchestra to play it.”
The next PEDx talk was given by Christina D. Diaz, MD, Associate Professor of Pediatric Anesthesiology at Medical College of Wisconsin. The lecture was entitled , “‘Every Breath You Take' – Examining EVALI and our Rebellious Teenagers.” Dr. Diaz began her talk by breaking down the structure of an electronic cigarette (E-cigarette). The mouthpiece, E-liquid reservoir, soaking wick, coil, fitting, on/off button, battery (Figure 2). She described that there are now newer generations of the E-cigarettes that can hide in plain sight. Some are fashioned to resemble a USB drive.
Figure 2: E-cigarette
Dr. Diaz stated that E-cigarettes were first introduced in the USA in 2007 as a smoking alternative, but they have since gained popularity among teenagers. This resulted in the declaration of vaping as an epidemic in 2016 by the US Surgeon General. And in December of 2019, the legal age to buy E-cigarettes was increased to 21 years of age.
A study by Cullen et al. in JAMA in 20191 found that 27.5% of high school students and 10.5% of middle school students had used E-cigarettes within the past 30 days. She described a new disease associated with vaping: E-cigarette, or Vaping Use-Associated Lung Injury (EVALI). The signs and symptoms of EVALI are:
- Lungs – Shortness of breath, hypoxia, cough, chest pain
- GI – Nausea, vomiting, diarrhea, abdominal pain
- Constitutional – Fever, fatigue, headache, weight loss
Imaging findings in EVALI are:
- Chest CT – Bilateral ground-glass opacities, subpleural sparing
- CXR – Bilateral consolidated opacities
Diagnosis can be confirmed by the presence of lipid-laden macrophages on tissue pathology or bronchioalveolar lavage (BAL). Patients with EVALI often present for anesthesia for BAL. Helm et al.2 reported that patients had high oxygen requirements postoperatively. Four of the patients had ARDS and remained intubated, and during the case, they had increased airway reactivity and hypoxia intraoperatively. The reactive airway disease lasted until four to six weeks. Also, pulmonary diffusing capacity also decreased.
Dr. Diaz ended by stating that we all need to take vaping very seriously and educate ourselves, colleagues, and patients/families about the adverse effects of vaping. She can be reached at cdiaz@mcw.edu.
The final talk was given by Adam C. Levine, MD, MPH, an Emergency Medicine physician at Brown University. He also serves as the Director for the Division of Global Emergency Medicine and the Director of the Center for Human Rights and Humanitarian Studies. The lecture was entitled "Epidemics of Fear: Fighting Ebola & Coronavirus."
Dr. Levine was involved with the Ebola response in Liberia, West Africa, in 2014 – 2015, and the COVID-19 response at his Rhode Island institution. He started his talk with "A Tale of Two Hospitals," describing the Ebola experience in two distinct hospitals in West Africa. One hospital was in Liberia, and the other in Nigeria. The Liberian hospital did not promptly recognize the disease in a patient who presented to the emergency room with fever, vomiting, and diarrhea, and had recently been in Guinea where Ebola was ravaging. The patient was admitted without any precautions and soon died. Several healthcare workers were infected and many later died from the disease. The outbreak exploded, and the ministry of health eventually had to divert all its efforts to the Ebola response, and other public health efforts were shut down. The city was devasted. The Nigerian hospital faired better because of prompt recognition and containment once a patient from Liberia presented with fever and vomiting. Although, the patient died, and some of the healthcare workers involved in his care also died, the disease did not spread widely into the community.
Dr. Levine discussed the importance of following the Outbreak Response Structure (ORS) (Figure 3). He gave an example of how the CDC projections of total Ebola cases by January 2015 stated there could be up to 1.4 million cases in Liberia and Sierra Leone if nothing was done. Or, there could be only about 35,000 with adequate isolation and treatment of patients. The latter was the reality due to the robust response in these countries.
Figure 3: Outbreak Response Structure
Dr. Levine compared the four main pillars of the ORS to the four legs of a chair. He said it is useless to argue that one is most important because a chair doesn't work if one of the legs is broken. He noted that unfortunately with the COVID-19 response, disproportionate emphasis has been placed on individual pillars, while ignoring others. Dr. Levine reminded us that it took two years for the Ebola outbreak to be contained, but he concluded the talk by sharing these words of encouragement: “no condition is permanent.”
References
- Cullen KA, et al. JAMA. 2019; 3222(21): 2095-2103
- Helm C, et al. A&A Pract. 2020 Jun;14(8):e01242.
