Comment by Tran S, Vogt P, Abdallah C, Yalamanchili V, and Chhaya Patel, MD, SAMBA-F, Emory University School of Medicine, Children's Healthcare of Atlanta
We read with interest the Pediatric Anesthesia Article of the Day (PAAD) on January 6, 2025, focusing on pediatric ambulatory surgery (1).
The volume of pediatric ambulatory surgeries has been increasing rapidly, driven by advancements in anesthesia and surgical techniques. Many procedures can now be performed in ambulatory surgery centers (ASCs) with minimal risk of complications. However, an important and often overlooked issue is the appropriate obesity cutoff for ASC eligibility. Obese children are well-documented to have a higher risk of perioperative respiratory adverse events (PRAE). This could be due to the higher incidence of asthma and obstructive sleep apnea in this patient population while concurrently having reduced lung function from impaired respiratory mechanics.
With the growing shortage of pediatric anesthesiologists, general anesthesiologists are increasingly being called upon to care for children in the ambulatory setting. To ensure safe and effective care, there is a critical need to provide evidence-based guidelines on managing obese children in ASCs, particularly for airway procedures. Currently, there is limited guidance available regarding BMI percentile cutoffs for such cases. The Society for Ambulatory Anesthesia (SAMBA) has proposed using the 95th percentile for age-specific BMI as a cutoff for airway procedures in ASCs (2).
This underscores the need for further research and evidence-based recommendations to optimize preoperative screening and perioperative care for obese pediatric patients in ASCs. As the healthcare landscape evolves, developing such guidelines will be essential to meet the growing demand in this patient population.
References
1. Vogt P, Abdallah C, Tran S, Yalamanchili V, Patel C. Preoperative Challenges for Pediatric Ambulatory Surgery. Int Anesthesiol Clin. 2025 Jan 1;63(1):60-68. doi: 10.1097/AIA.0000000000000468. Epub 2024 Nov 14. PMID: 39651668.
2. Brennan MP, Webber AM, Patel CV, Chin WA, Butz SF, Rajan N. Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement. Anesth Analg. 2024 Sep 1;139(3):509-520. doi: 10.1213/ANE.0000000000006645. Epub 2024 Aug 16. PMID: 38517763.
From Dale F Szpisjak MD
The developmental peds dept often gets genetic tests on children with autism and many have the MTHFR mutation. I stopped using nitrous in autistic kids after reading about that mutation. [Since then I have nearly eliminated nitrous from my practice. Do you or the readers of the PAAD think avoiding it in them is unwarranted for our short term induction/ procedure events?
We received several responses on Rethinking the duration of medical school
From David F. Vener, MD, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX on
There is ample evidence that eliminating medical school tuition debt has little to no impact on specialty choice. Looking at NYU and Johns Hopkins match results have shown no change in the percentage of graduates going into primary care, despite the best of intentions of the donors. Surveys of graduating medical students show that indebtedness was the least impactful of specialty choice. Furthermore, shortening medical school education will just abbreviate the exposure to a wider variety of specialties, including anesthesiology. When you consider that PA programs are 30 months and far more flexible in practice opportunities, there would appear to be little incentive other than financial to attend medical school for 36 months and be locked into another 4-10 years of specialized training. Another alternative is to abbreviate the basic sciences portion of the 4 year curriculum and increase clinical experiences, including more robust primary care exposure.
From Deborah C Richman MBChB FFA(SA), Clinical Associate Professor, Department of Anesthesiology, Stony Brook University Medical Center
As a South African grad – 4 years is too short – especially as most of 4th year is time off to study, interview, research etc. These grads barely recognize a patient when they see one! They are rushed into picking a specialty – often because they liked the personality of a particular attending, not the subject, and these poor souls are at high risk for future unhappiness. They all need much more clinical experience to be good docs; and to know what to choose.
But, agreed the $$ debt is huge. For those who know they want to do medicine I am a fan of a 6 year program like mine and no college degree first. By the end of med school I was really a doctor – could provide a basic anesthetic, could deliver a baby, could place a chest tube etc (and had done many of these things including c/section and appendectomy – admittedly not in the legal climate in the US).Our students and my future doctor/s really lack general clinical acumen.
From J. Grady Crosland M.D., M.A. retired
I completed a 126 hour undergraduate degree in an honors college in 3 years going year round. Medical school should begin July 1 and the basic sciences (which are highly overrated) should be completed in 12 months allowing 22 months for clinical rotations prior to graduation. Further, there should be more in-house call for medical students in preparation for a residency (case responsibility and hours).
From Vikas O'Reilly-Shah, MD, PhD, FASA Professor of Anesthesiology & Pain Medicine University of Washington | Seattle Children's Hospital on The Bleeding Edge: A Deep Dive into Trauma-Induced Coagulopathy in Children
Quick note - all of this data is from Harborview Medical Center, part of the UW Medicine system and not affiliated with Seattle Children's Hospital. Though all the faculty at SCH and HMC are UW faculty, none of the faculty on this study practice clinically at SCH. HMC is the Level 1 trauma center in the region and all pediatric traumas go there, so it is in fact the right place for this study to come from (as opposed to SCH, where we do not really see acute trauma).