From Bob Spear MD (retired), Anesthesia/PICU, Rady Children’s Hospital San Diego on apneic oxygenation
I love your strategy of pre-oxygenation via nasal cannula. Late in my career, I stumbled upon a couple of techniques with nasal cannulae that are similar. Some children come to the OR on nasal cannulae oxygen and therefore likely will need it in the PACU. I noticed that removing the cannulae prior to anesthetic induction in these oxygen-dependent (I know, I know, we all are oxygen dependent) children involved significant displeasure if it involved tape removal etc. I’m hoping I was smart enough to have left the oxygen flowing, but I knew that the induction was smoother (decibel level was lower for sure) if I proceeded with the induction without removing the nasal cannulae. Second point: At the conclusion of the case, this child likely will require the nasal cannulae; why would you remove it at the start of the case if you will need it at the end of the case?
When extubating fretful children (redundant) in the PICU or even the PACU, how many times have we removed the ET tube and then engaged in hand-to-hand combat as we attempt to place plastic objects (aka nasal cannulae) into the nares of a suddenly awakened child who not uncommonly is breath-holding, flailing and engaging in a 1970s game of “Twister”? Too often! Noticing the degree of difficulty in this seemingly simple task of proper placement of nasal cannulae in an unwilling recipient, I talked our respiratory therapists into putting the nasal cannulae in place minutes BEFORE extubation (not with oxygen flow, however). We were all pleasantly surprised how calm the transition was after removing the ET tube when the nasal cannulae was already in place. The child would literally take one spontaneous breath via the ET tube, the next quietly without the ET tube. What happened to the post-extubation chaos? I think we all have had the unpleasant experience of seeing unique shades of blue during this transition, fortunately accompanied by enough agitation/activity that the oxygen saturation monitor couldn’t monitor what we were seeing. I guess if I had to win an argument on why this makes sense, I’d ask anyone in opposition to this: “If a child needed a urinary catheter at the end of surgery, would you let the child awaken, then place the catheter? Of course not. So why would you do anything unpleasant to a child if you could do it a few minutes earlier under anesthesia?”
From anonymous on Board certification and training in Europe
I am a European pediatric anesthesiologist and regular reader of the PAAD. The recent PAAD detailing differences in resident and fellow education and Board certification across Europe is an important quality and safety issue facing all of us in Europe. There is much work to do! Unfortunately, I don't think that it will be an easy job, mostly because of political reasons. Let me explain this politically incorrect/unqualified response: General anesthesiologists (who are the majority of the membership in the national European societies) are not in favor of "pediatric anesthesia" subspecialization and board certification because they are afraid of losing pediatric patients in their practices. In Europe, most children who are operated on receive general anesthesia by generalists. Providing anesthesia to children is easy money (short procedures with full financial compensation). Furthermore, there is not a clear patient-parent representative organization for "anesthesia". So there is no "public force" to change the present situation in favor of better patient care.
From Myron: we had identical issues and concerns in the United States until 3 courageous and relentless individuals, Drs. Steve Hall, Mark Rockoff, and Frank McGowan fought for and ultimately got the ACGME and the ABA to break this deadlock and get subspecialty board approval. I’ve asked Dr. Mark Rockoff to provide some insight on how he and “rebel alliance” were able to accomplish this change.
From Mark Rockoff MD on European sub board certification and fellow training
Concerns recently expressed about the difficulties in getting pediatric anesthesia subspecialty training “formalized” in Europe are certainly understandable, especially since many different nations are involved. However, objections from general anesthesiologists who fear losing pediatric patients should not be a deterrent.
Similar issues arose when such training standards were initially proposed in the USA in the 1990s. Nevertheless, this effort was ultimately successful because it was advanced jointly by the leadership of all the major national organizations focused on anesthesia care for children, including the Society for Pediatric Anesthesia, the Section on Anesthesiology of the American Academy of Pediatrics, and the Committee on Pediatric Anesthesia of the American Society of Anesthesiologists. Furthermore, support was received from the leadership of the American Academy of Pediatrics and several societies representing other pediatric subspecialties, including pediatric surgery and pediatric radiology.
Acceptance ultimately occurred when it became clear that this was not an attempt to “monopolize” the care of children, which, in any case, would not be realistic. Instead, the intent was to set standards that could improve the training of those who would be responsible for caring for the youngest and sickest patients, help educate all anesthesiologists who would be treating the majority of pediatric patients, and develop investigators who could focus on advancing pediatric care.
This was indeed a very difficult and time-consuming process. However, the Accreditation Council for Graduate Medical Education authorized fellowship programs in pediatric anesthesia in the USA in 1997. (For more about this, see the editorial in Anesthesia and Analgesia 1997; 85: 1185-90). Certification of pediatric anesthesiologists by the American Board of Anesthesiology followed later in 2013.
Clearly, the European Union has its own unique challenges. Nevertheless, similar efforts might also be successful, at least in some European nations.
PS from Myron: As I’ve often said, as a profession and as a subspecialty, we all owe an immense sense of gratitude to Drs. Mark Rockoff, Steve Hall, and Frank McGowan who fought the good fight and made the sub-board in pediatric anesthesiology possible.
From Maria Matuszczak M.D., Professor of Anesthesiology, Division of Pediatric Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine
McGovern Medical School at UT Health, Texas Medical Center Houston
I am in Vietnam at the Children’s Hospital of Hanoi with a group of pediatric cranioplasty plastic surgeons. Your PAAD on the role of anesthesiologists in infection control (March 12, 2024) is just in time for my observation here. After induction and intubation all children get their mouth and nose flashed with a diluted betadine solution ( 5%). This seems to be standard of care in many Asian countries, I am wondering why we don’t do this in the USA, at least I haven’t seen this being done. It would be interesting to know what the best concentration would be. How beneficial it is. Are there any particular indications or just every intubated kid. I will look into it when back in Houston, but maybe others are already knowledgeable about it. Many questions………
From Justin B. Long, MD, MHI, FAAP, Associate Professor of Anesthesiology, Emory University School of Medicine, Director of Pediatric Cardiac Anesthesiology, Medical Director, Periprocedural Informatics and Medical Technology, Children's Healthcare of Atlanta at Egleston
I appreciate the need for standardized handoff tools. I also appreciate the amount of time that this study would have taken to complete both in terms of data extraction and data analysis. However, the OR of 1.08 is statistically significant thanks to the high number of cases, is that clinically significant? This paper is an entire textbook in statistics which is extremely commendable; however, weighting reduced the differences between the handover and non-handover cases, it didn’t eliminate small still observable differences between the populations in handover versus non-handover cases. “Handover cases tended to be longer, be delayed and start later in the day, involve a resident physician, utilize general anesthesia, be nonelective, involve more surgeons, have higher blood loss, utilize vasoactive drugs, and have a higher procedure severity score than nonhandover cases.” Again, while weighting balanced out most of these to a statistical certainty, it didn’t eliminate the differences and all of these differences sound like reasons to have a worse outcome. Further, the anesthesia start hour (i.e. late in the day) and duration of the anesthetic could not be completely balanced.
So, cases that were longer and started later had a small increased risk of worse outcomes? That’s true in almost any study. Again, small differences still exist in the populations even after weighting and the OR is also small. While it is intuitively true that standardized handoffs improve outcomes, I don’t know that this study is definitive proof. But, it is an amazing statistical feat that they undertook in this analysis and the authors did an amazing job wrangling this data.
From Kathleen C. Fabian DNP, CPNP-AC/PC, NEA-BC Pediatric Hospitalist NP University of New Mexico Children’s Hospital, Department of Pediatrics on the late and greatly missed Dr. Jack Downes
I was sharing a tale about my nurse beginnings with Jack with my wards team this afternoon and came across your PAAD article published in December 2021 (https://ronlitman.substack.com/publish/posts/detail/45721642?referrer=%2Fpublish%2Fposts%2Fpublished%3Fsearch%3Ddownes.) I had no idea that Jack had passed.
I was a green 21-year-old nurse in the PICU from 1991-1996. I remember one of the first days when Jack was rounding and he asked me about my patient's gas and what I thought we should do about it! I barely knew what I didn't know. I was terrified! I wasn't completely correct but Jack did not make me feel stupid but he taught us and I listened!
I went home and called my dad and told him all about it. He said, Jack Downes? You gotta be kidding me? He must be ancient! He was old when he taught me! It turns out he taught my father respiratory therapy.
One funny story.....back when there was an intermediate PICU, the 10-bed unit with the chronic trach/vent mostly BPD kids, Fridays were the dreaded dayshift for most nurses. In that unit on Fridays, therapists came in and every kid who was stable enough to get out of their bed/crib was down on mats on the floor for therapy. Fun for them, logistical nightmare for us. Anyway, one particular Friday the therapists had a bunch of toddlers fingerpainting, which is fine, but someone has the great idea that red paint would be included in the activity. Well of course one of the 2-year olds, who was having a blast, managed to get paint on their vent tubing. Jack walked in and saw that kid with red paint on their tubing and had a moment of panic thinking there was pulmonary hemorrhage going on that we were missing! It took a minute, but we managed to convince him that it was only paint and not blood. He agreed that fingerpainting was developmentally appropriate, but could we please skip the red next time?
Dr. Downes was not on as often as the other attendings but the 4 of them, Jack, Drew Costarino, Russ Raphaely, and Mark Magnusson taught me so much and really helped shape my early career.
I did appreciate your article! Thanks for stirring up some great memories!