Reader response
Myron Yaster MD and Lynne G. Maxwell MD
From Samuel Vanderhoek, Anna Varughese, Sapna Kudchadkar, Johns Hopkins commenting on PAAD 1/23/2025 Pediatric Ambulatory Anesthesia: It Is About Time!
Thank you for reviewing our article on pediatric ambulatory anesthesia. We believe this is an extraordinary time for this subspecialty, ripe with opportunities in clinical care, research and advocacy.
The outcome of our perspective piece has been the creation of the Children’s Ambulatory Anesthesia Multisite Partnership (CHAAMP), a consortium of large pediatric centers that are leading the charge to establish the first national registry dedicated to pediatric ambulatory anesthesia. Existing pediatric registries have notable gaps in their ability to zero in on issues unique to ambulatory anesthesia and the challenges and risks associated with this perioperative space. Commercially available software is cost-prohibitive for many institutions; at this time, CHAAMP is a grant-funded initiative with no subscription fees. We invite interested individuals and institutions who wish to get involved and join the effort to contact us (svande20@jhmi.edu). Additionally, we would welcome the opportunity to partner with AdaptX and bring this technology to CHAAMP while maintaining the zero-fee structure of our research collaborative.
From Chhaya Patel, MD, SAMBA-F, Emory University School of Medicine, Children's Healthcare of Atlanta, Marjorie Brennan, MD, Children's National Medical Center, and Audra M Webber, MD, Children's Hospital of Philadelphia
We read with great interest the PAAD on January 23, 2025, and are pleased with this recent focus on pediatric ambulatory anesthesia (1,2)! Both Dr. Martin and the Vanderhoek et al. paper highlight the increase in pediatric ambulatory surgical volumes and current shortage of pediatric-trained anesthesiologists we are facing nationally,
We wholeheartedly agree that a collaboration among pediatric ambulatory centers would be a welcome step forward in analyzing outcomes and establishing practice recommendations. If it could be done efficiently and affordably, we imagine many academic institutions would be eager to participate. Data-driven recommendations are undeniably valuable for guiding clinical practice, but in the absence of good data consensus statements can serve as a critical interim resource (3).
Additionally, such a collaboration would contribute significantly to our understanding of a portion of the current ambulatory landscape. It would, however, fail to capture data from non-academic affiliated mostly “combined” ASCs that care for both children and adults and are staffed by general anesthesiologists and frequently general surgeons. It is important to recognize that guidelines derived from and designed for academic ambulatory centers may not be universally applicable, as community-based settings face unique challenges and constraints.
It is undeniable that many general anesthesiologists provide care for children in ambulatory surgery centers nationwide (4), and this is not a bad thing. What matters is that it is done safely. While the goal of ensuring that every child is cared for or consulted on by a pediatric anesthesiologist is noble, it is neither practical nor feasible. We make this statement as dedicated academic pediatric anesthesiologists with a primary focus on ambulatory surgery.
One of the cornerstones of anesthesia residency training is to equip graduates with the education and experience necessary to provide care for healthy children undergoing common procedures such as tonsillectomies and hernia repairs. Our oral boards contain entire pediatric stems. While we wholeheartedly agree with many of the points raised, there remains a critical gap in addressing the education of residents in pediatric ambulatory anesthetic skills. In addition to creating ambulatory databases and establishing virtual pediatric consultative care, why are we not prioritizing the teaching of pediatric ambulatory skills such as patient selection criteria within residency programs?
It has been repeatedly highlighted that most pediatric surgical cases occur in ambulatory settings, yet much of our education in pediatric anesthesia does not focus on the cases residents are most likely to encounter out in practice. Incorporating this education, in addition to the recommendations of Drs. Martin, Vanderhoek, et al., would significantly advance pediatric anesthetic care in the ambulatory setting.
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. Vanderhoek SM, Varughese AM, Kudchadkar SR. Pediatric Ambulatory Anesthesia: Confronting Challenges, Embracing Opportunities. Anesth Analg. 2024 Oct 18. doi: 10.1213/ANE.0000000000007169. Epub ahead of print. PMID: 39466626.
3. 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.
4. Webber AM, Brennan M. The high-risk pediatric patient for ambulatory surgery. Curr Opin Anaesthesiol. 2023 Dec 1;36(6):630-635. doi: 10.1097/ACO.0000000000001321. Epub 2023 Oct 10. PMID: 37865843.
From Elizabeth E Hansen MD PhD, Associate Professor of Anesthesiology and Pain Medicine, University of Washington | Seattle Children’s Hospital and Diane Gordon MD, Associate Professor of Anesthesiology, University of Colorado | Children’s Hospital Colorado
We read with interest (and some flashbacks to college chemistry classes) Dr. Schwartz’s PAAD on the history of inhaled anesthetics and their relationship with refrigerants. As mentioned in the original article, refrigerants and inhaled anesthetics have undesirable properties: some are flammable, some have ozone depleting potential (ODP, indicating their impact on stratospheric ozone reduction, leading to increased UV radiation to the surface of the planet) and some have significant global warming potential (GWP100, an indicator of how effectively a gas traps heat in the atmosphere compared to carbon dioxide over 100 years). Ozone depletion and greenhouse gas emissions have health implications for patients and communities, even if they are not receiving these medications themselves.
1st and 2nd generation refrigerants are often referred to as chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs). Third generation refrigerants (hydrofluorocarbons) have low ODP but high GWP100. As this readership is well aware, desflurane has the highest GWP100 at 2540, then isoflurane (539), nitrous oxide (273), and sevoflurane (144). Both isoflurane and nitrous oxide have ODP as well.
Adding to our chemistry refresher, we offer this history lesson. In the mid-1980s, a large hole in the ozone layer was identified over Antarctica and parts of Australia. Due to widespread concerns about UV radiation and increased cancer risk, the Montreal Protocol (signed 1987, enacted 1989) and subsequent amendments aimed to phase out CFC and HCFC to stop the growth of the hole in the ozone layer and protect public health. This effort has been successful- the ozone layer is projected to recover to 1980s levels by 2066! Notably, medical gases (even those that are ozone depletors- Isoflurane, Nitrous oxide) were exempted from the protocol.
As the global community grapples with the realities of climate change and works to reduce the greenhouse gas emissions and release of ozone-depleting agents that are contributing to harm, we remind the PAAD readership that children are among the most vulnerable to the effects of climate change and our care of them ironically contributes to the climate impacts that harm them. It is our duty to provide anesthesia care that considers the environmental impact of the agents we choose to use. The legacy of volatile anesthetics echoes their roots in the chemical experimentation that created compounds with important uses but also with considerable environmental detriments.
At minimum we should be avoiding desflurane (the most potent greenhouse gas inhaled anesthetic), avoiding nitrous oxide (the most dominant ozone-depleting substance emitted in the 21st century) and using low fresh gas flow if we choose to use inhaled anesthetics.
References
Roy RC. Agents that came in from the cold: Enflurane, isoflurane, desflurane, and sevoflurane. Anesth Analg. 2025;140(1):205-209. doi:10.1213/ANE.0000000000007017
Sulbaek Andersen, Mads P., Ole J. Nielsen, Timothy J. Wallington, Boris Karpichev, and Stanley P. Sander. 2012. “Medical Intelligence Article: Assessing the Impact on Global Climate from General Anesthetic Gases.” Anesthesia and Analgesia 114 (5): 1081–85.
Ravishankara AR, Daniel JS, Portmann RW. Nitrous oxide (N2O): the dominant ozone-depleting substance emitted in the 21st century. Science. 2009;326(5949):123-125. doi:10.1126/science.1176985
The Environmental Impact of Inhaled Anesthetics. Accessed January 21, 2025. https://www.asahq.org/about-asa/governance-and-committees/asa-committees/environmental-sustainability/greening-the-operating-room/inhaled-anesthetics
Ozone Hole Continues Healing in 2024 (NASA) https://earthobservatory.nasa.gov/images/153523/ozone-hole-continues-healing-in-2024 Accessed 1/28/2025
Montreal Protocol, (Wikipedia) https://en.wikipedia.org/wiki/Montreal_Protocol#cite_note-6. Accessed 1/28/2025