From David F. Vener, M.D., Professor of Pediatrics and Anesthesiology, Baylor College of Medicine / Texas Children's Hospital, Houston, TX 77030 on neurodevelopmental outcomes in CHD
I think the relationship between improved survival and a lack of corresponding improvement in neurodevelopmental outcomes is intrinsically linked; we are saving more children with marginal repairs and cardiac pathology that in previous years either would not have been operated on or would not have survived. Many of these children have the burden of prolonged cyanosis and erythrocytosis, poor cardiac function and multiple trips to the OR and Cath Lab - not too mention all of the in-utero factors impacting brain development. Looking at a subset of patients with typically good survival and limited surgeries such as repairs of dTGA is not as discouraging.(1) They are operated on in the neonatal period and typically do not need multiple repairs or trips to the lab or other issues.
The authors of the PAAD review mention the impact of complexity but I think as a society and as physicians we should be taking a more ethical approach to offering complex repairs to marginal patients at all facilities. From a hospital's financial point of view, a marginal outcome in some ways is more financially advantageous to the hospital than a great outcome - it results in longer stays in the ICU and hospital, more lab and diagnostic tests, more procedures, etc. As long as there is a financial incentive to offer these highly complex operations at every children's hospital in the country, regardless of their expertise and support systems, and not centralize complex CHD care at specific referral centers we will continue to have an overall disconnect between mortality and morbidity.
Soares C, Vieira RJ, Costa S, Moita R, Andrade M, Guimarães H. Neurodevelopment outcomes in the first 5 years of the life of children with transposition of the great arteries surgically corrected in the neonatal period: systematic review and meta-analysis. Cardiol Young. 2023 Dec;33(12):2471-2480. doi: 10.1017/S104795112300375X. Epub 2023 Nov 15. PMID: 37965690.
From Brian Schloss, MD, Pediatric Anesthesiologist, Chief Medical Officer, OFFOR Health on plastics and waste
I work with an office based pediatric anesthesia group and after reading the recent PAAD by Dr. Mark Schreiner I am interested to know if anyone in our modern/wasteful/conservative anesthesia world is reusing circuits?. Our wastefulness feels somewhat amplified in an office setting, as piles and piles of disposable items feel even more substantial when working in a small office. But selfishly, I would love for our teams to not have to carry so much stuff!
There is definitely some literature out there, and a few new products to boot. This almost seems like a no brainer from a waste standpoint, so what am I missing? I have yet to see or hear of anyone doing this in the real world. We all know that hospital systems care about the bottom line. Surely there is a forward-thinking hospital system that wants to save money and be able to boast about less waste. Right?
From Myron: I know that several institutions use disposable filters to minimize the need to waste the entire circuit. I sent Brian’s question to Drs. Liz Hansen and Diane Gorgdon who told me there are several abstracts and papers in the pipeline that address this question. We will feature them in the PAAD once they are published.
From Walter I. Weiss MD D.ABA FASA, Chief, Pediatric Anesthesiology, NYU Langone Hospital-Long Island on timing of neonatal hernia repair
We do (almost) all of these cases with spinal anesthesia and to the best of my (unofficial) knowledge have had no significant incidents in years for those cases.
Unfortunately our newest surgical colleague was trained and prefers to do these laparoscopically and will require GA. We’ll see how these babies compare.