From Bishr Haydar MD in response to a reader’s response using ChatGPT
I'd like to propose a moratorium on ChatGPT in PAAD. I think people consider PAAD a trusted source, as it often includes nationally-recognized experts. A previous (excellent) posting clearly showed how ChatGPT confabulates by making up references that sounded plausible. I'm very suspicious of its current ability to parse the delicate language of journal abstracts and articles and contextualize them, akin to how google search fails miserably sometimes for specific medical content.
Posting ChatGPT-generated content on trusted venues like PAAD lends it undue credibility. There's a risk that people will make clinical decisions informed by incorrect fever-dream text generated by a chatbot. The benefit is only novelty/curiosity; the risks - especially trusting an innately untrustworthy platform - are much greater. Things may be very different in a few years, but we'll cross that bridge when we get there.
From Dr. Randy Flick, Mayo Clinic on DEI and the SPA - Better late than never.
The article by Reece-Nguyen et. al. highlighted in todays PAAD raises important issues and highlights critical challenges for the Society, the specialty, for medicine and ultimately for society. Although the article highlights the need to do more it also highlights the advances, we, as a society have made over the past decade and especially in the past 5 years. Not so many years ago the SPA leadership and board was rightly called an; “old boys club.” This is confirmed by the roster of SPA presidents since its creation nearly 40 years ago. In the first decade only, white males were elected to the presidency, it was not until Anne Lynn was elected in 2002 that a women led the organization. However, since 2012 when the second women, Nancy Glass, was elected as president; the Society has achieved gender parity at the senior leadership level. Something we can be proud of as it is not necessarily true of other anesthesia organizations.
Unfortunately, the same cannot be said for ethnic and racial equity. Hope springs eternal. Take a look at the current SPA Board roster ( https://pedsanesthesia.org/about/board-of-directors/) and you will see the results of the organizations efforts to advance an inclusive slate of leaders. The work of the past 5 years since the Board took a more proactive stance on issues of diversity equity and inclusion are just now bearing fruit. The current board is populated by a highly diverse group of individuals who are not only racially, ethnically and gender diverse but also are broadly representative of programs across the country both large and small. They are also incredibly, bright, talented emerging leaders who earned a position on the board by making significant ongoing contributions to the work of the society and specialty. There is nothing political about ensuring that we have a broad diversity of thought and opinion at the leadership table. And yes, all those on the board engaged in networking. Networking is what makes the world go round and is what helps one become a member of the “in crowd” at the SPA and everywhere else.
But we have work to do. Despite past efforts private practice members are not represented nor are international members. It may be time to address those issues in a more proactive manner. And although we may have made great strides within the Society those strides are not necessarily reflected within the many departments and divisions from which our members are drawn. Programs like WELI are intended to address gender disparity but more focused efforts need to be made for other underrepresented groups either through an expanded WELI program or an alternative program. Engaging trainees earlier in their career paths is critical to ensuring a diverse pool of applicants ot our fellowship programs and as importantly it is important to the growth and vitality of the specialty.
Yes, we have much to do but we also have much to be proud of and should not hesitate to take a moment to reflect on our success…and then get back to work. Better late than never…
A glance at the authorship of this paper speaks volumes. We owe you the authors our thanks for highlighting our successes and more importantly the enormous amount of work we have left to do.
As always we owe Myron and the PAAD team our thanks for bringing this to the peds anesthesia community.
From Dr. Mark Schreiner on Non-Operating Room Anesthesia
The recent PAAD about NORA brought back memories of a more primitive era. When Hospital of the University of Pennsylvania installed a new MRI in the 1980’s, we had to transport patients from CHOP through basement tunnels only to arrive in a room not designed for anesthetics. There was a 3-inch hole in a wall about 30 feet from the bottom of the MRI table. Through that hole a Mapleson D circuit could be threaded and connected to the anesthesia machine outside the scanner room. The anesthesiologist in the scanner room received feedback the bag of the Mapleson D circuit and could signal to the other anesthesiologist to increase or decrease the gas concentration. The one outside the room watched through a window into the scanner room across across from the base of the table and would have to run from that room to the one down the hall to adjust the anesthetic. The only monitor was the anesthesiologist’s hand on the bag to assess anesthetic depth. Subsequently, we found anesthesia machines with brass parts that could stay in the scanner room but still no monitors except for a hand on the bag.
I did a drawing in 1991 based on a day in the MRI suite in which I envisioned the Mapleson D circuit as a long umbilical cord to our distant patient.
I wonder how many anesthesiologists would feel comfortable today in such an austere environment.
PS from Myron: I had many similar experiences and our monitoring was even more primitive…a paper cup on taped to the chest to observe the rising and falling of the chest during respiration…and Mark, I’m not sure how many of our readers even know what a Mapleson D circuit is?
From Michael Wadle, Jennifer Chiem, Amber Franz, Valerie Mok, Rachel Feldman, Daniel Low Seattle Children’s Hospital commenting on “Does the condition of middle ear fluid at the time of PE tubes make a difference in pain management: a response.”
We read with great interest the recent PAAD regarding the management of pain in patients undergoing bilateral myringotomy with pressure equalization tube placement1 . As the article correctly states, the group at Seattle Children’s Bellevue Clinic and Surgical Center (BCSC) has made considerable effort and multiple protocol iterations to foster opioid-free anesthesia for multiple procedures2 . Since January 1, 2019, anesthesia has been provided in 19,003 cases (as of May 10, 2023) without intraoperative narcotic analgesia. Bilateral myringotomies represent a considerable fraction of this cohort. Since April 1, 2014, 5,336 patients have undergone this procedure at our ambulatory surgery center. Over that time, four PlanDo-Study-Act (PDSA) cycles occurred in this population to improve patient outcomes and arrive at our current practice. Our standard anesthesia technique for these patients is pre-operative oral ibuprofen and mask induction with sevoflurane and oxygen. Anesthesia is maintained with mask technique, and intravenous access is not obtained for the majority of these patients, given the brevity of the surgery. The figures below show how our anesthetic management has changed over time corresponding to the different cycles. The first cycle saw the administration of no pre-operative or intraoperative analgesia (n=1,416, blue) from April 1, 2014 to October 31, 2016. The second cycle included pre-operative acetaminophen 15 mg/kg PO (n=477, green) from November 1, 206 to July 31, 2017. The third cycle exchanged acetaminophen for intraoperative fentanyl 1 mcg/kg intranasal (n=304, yellow) from August 1, 2017 to January 31, 2018. The fourth and current cycle uses pre-operative ibuprofen 10 mg/kg PO for analgesia (n=3,139, purple) ever since February 1, 2018. Figure 1 shows the average PACU maximum pain scores. During the third cycle, in which intranasal fentanyl was the preferred analgesic, the average maximum pain score was 2.19. The fourth cycle, in which ibuprofen was the analgesic of choice, demonstrates an average pain score of 1.9. These data suggest pain is better controlled on average with ibuprofen versus fentanyl, though there is no sustained improvement with the ibuprofen from a statistical process control chart (QI) perspective. Thus, in our experience, ibuprofen appears noninferior/equivalent to fentanyl with regards to pain control in patients undergoing bilateral myringotomy. Figure 2 shows the average PACU time in minutes across the four PDSA cycles. While we do not have a Post Anesthesia Care Unit delirium score, the time spent in recovery offers an approximate surrogate of delirium management. PACU time was on average 34.6 minutes during the cycle that prioritized fentanyl versus 36.3 minutes in the current cycle prioritizing ibuprofen administration. This may suggest ibuprofen as inferior to fentanyl with regards to preventing delirium in this patient population. However, the significant variability and increase in PACU times starting in summer 2019 corresponds with main hospital OR renovations/shutdowns followed by the COVID pandemic. During this time, lack of main hospital ORs resulted in sicker patients undergoing surgeries at BCSC with some requiring transport back to main campus postoperatively. During the COVID pandemic, case numbers decreased, with some longer cases performed at BCSC. These confounders may explain at least part of the increased PACU times during the fourth cycle. Since resuming normal operations, variability and PACU times have returned to the 2018 baseline for the ibuprofen group, with times comparable to the fentanyl group. The work by Cohen et al should be commended for expanding on the causes and management of pain in bilateral myringotomy surgery. Though their work suggests less fentanyl predisposes patients to more pain and emergence delirium, our real-world data from 5,336 patients undergoing bilateral myringotomy suggests pain can be well controlled with ibuprofen or fentanyl. This corroborates prior studies done by Dewhirst et al and our own colleagues here at Seattle Children’s who studied the benefits of intranasal fentanyl in this patient group3,4 . If any institution has a technique with superior results than we have shared, please share so we might adjust our protocols to better serve our patients.
References
1. Cohen, William G. BA*,†; Zhang, Bingqing MPH‡; Lee, David R. MD*, Ampah, Steve B. PhD‡, ; Sobol, Steven E. MD*,†; Cook-Sather, Scott D. MD†,§ . Middle Ear Condition at the Time of Pediatric Myringotomy Tube Placement: Pain Associations Following Intraoperative Fentanyl/Ketorolac and Seasonal Variation. Anesthesia & Analgesia 136(5):p 975-985, May 2023. | DOI:10.1213/ANE.0000000000006230
2. Franz AM, Martin LD, Liston DE, Latham GJ, Richards MJ, Low DK. In Pursuit of an Opioid -Free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2021 Mar1;132(3):788-797. doi: 10.1213/ANE.0000000000004774. PMID: 32282383.
3. Dewhirst E, Fedel G, Raman V, Rice J, Barry N, Jatana KR, Elmaraghy C, Merz M, Tobias JD. Pain management following myringotomy and tube placement: intranasal dexmedetomidine versus intranasal fentanyl. Int J Pediatr Otorhinolaryngol. 2014 Jul;78(7):1090-4. doi: 10.1016/j.ijporl.2014.04.014. Epub 2014 Apr 16. PMID: 24814231; PMCID: PMC4160729.
4. Rampersad S, Jimenez N, Bradford H, Seidel K, Lynn A. Two-agent analgesia versus acetaminophen in children having bilateral myringotomies and tubes surgery. Paediatr Anaesth. 2010 Nov;20(11):1028-35. doi: 10.1111/j.1460-9592.2010.03427.x. PMID: 20964769; PMCID: PMC4005868.