Reader response
Myron Yaster MD
From Myron Yaster MD
I received an interesting letter from Dr. Andrew Davidson, the editor in chief of the journal Pediatric Anesthesia suggesting that we occasionally provide links to Grand Rounds presentations as part of the PAAD’s ongoing teaching/education mission. Our executive council is considering this and I will report back to you if and how we would do this. As an example of how this might work, we posted a PAAD on December 03, 2024 entitled: Perioperative pain management for cleft palate repair: can we determine what is optimal? Andrew sent me the following grand rounds from the Royal Children's Hospital, University of Melbourne on this topic (link below). Let me know what you think about this idea. As a start we might offer these Grand Round links as references within PAADs.
https://blogs.rch.org.au/
grandrounds/2024/07/17/the-cleft-palate-initiative/
From David A. Rosen, MD, FAAP Professor, Departments of Anesthesia and Pediatrics, Pediatric Cardiac Anesthesia, Vice Chair for Anesthesia Research WVU Medicine Children’s West Virginia University Morgantown, WV 26506 on Mitigating the systemic loss of nitrous oxide
Boy does that take me back. At one of the Baylor’s hospitals (Ben Taub) where I did my anesthesia training, we had to place our Nitrous Oxide tanks on the machine as part of your daily set-up. There was no nitrous coming from the wall. The process of getting the E cylinder on the back of the machine was more difficult for some than others (particularly if you wear braces on your legs). It did encourage you to run low flows, so you didn’t have to change your nitrous out during the case. You always turned your tank off at the end of the case. I am aware that some of the newer anesthesia machines claim that the tanks can be left open because they don’t leak but I have not found to be true. One thing I will always remember was the sound of a nitrous tank falling over and then the roar of what sounded like a jet aircraft taking off. The nitrous tank spinning around was dangerous but not as bad of the oxygen tank piercing the wall. Going back to nitrous in E cylinders would decrease the GHG impact of leaked nitrous. Hopefully, the nitrous tanks have been made safer, so the roar of the jet engines won’t have to be heard in the halls of the operating rooms.
From Scott Hines Children's Hospital of the King's Daughters (CHKD)
For those of us who've developed proficiency at ultrasound PIVs, this is akin to asking "do my reading glasses help me to see the page?" Reading glasses just work, and so do ultrasounds.
That said, there is a place for standard palpation/visualization vs ultrasound guidance. In a busy OR, using U/S for every PIV could slow down the workflow of the day and is unnecessary in the majority of kids. Conversely, in those patients for whom we know PIV access will be a major challenge, going straight to the ultrasound is sound practice.
The benefits - massive time saved in bigger line-ups, no cancellations for inability to get PIV, skipping the central line (if appropriate) in many cases where adequate PIV access is obtained, e.g., neuromuscular spines, and much improved patient experience when placed on awake patients in the pre-op area. One unexpected outcome - I have a much better sense of where the cephalic vein is in the forearm and this has greatly helped me to hit this vein even without the U/S. There are many others.
A couple of caveats - proficiency at U/S takes a couple years of deliberate practice, placing at least one PIV with U/S per day. U/S PIVs infiltrate at a higher rate, use of longer catheters and added vigilance during the case and on the floors is necessary. Some locations are more challenging for U/S - the saphenous for example, as it travels in an arc and then dives deep - possible for sure, but trickier.
All pediatric anesthesiologists should be mastering use of U/S as a standard practice. There is a long learning phase, but once you get it, the ultrasound becomes your eyes, and the "Bart Simpson Speaks French" effect occurs. And that's pretty gratifying.