Friends before reading today’s reader response please be aware that over the next month there may be some interruption of the daily PAADs. I will be in Israel volunteering at one of Israel’s larger teaching hospitals to help relieve the faculty who have been called up for active military duty. I’ve tried to keep my thoughts about the horrific murders, rape, brutality and really pogrom that occurred on Oct 7 from the PAAD community…this was my personal opportunity to help. As most of you who are regular readers of the PAAD know, my parents were holocaust survivors and the rise of antisemitism around the world has had a profound effect on me.
I’ve preloaded a bunch of PAADs to minimize this disruption and have asked my friends and colleagues on the PAAD’s executive council to help pick up the slack but it’s more likely than not that there will be a some interruption of daily postings next month. Am Yisrael Chai! Myron Yaster MD
From Proshad Efune, MD, Assistant Professor, Department of Anesthesiology and Pain Management, Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas
I absolutely agree that non-emergent procedures should be deferred until children with brain injury (of any etiology, including cardiac arrest) are no longer at risk of secondary injury. Of course, this timeline is not entirely clear. My typical rule of thumb is if the ICU is still implementing neuroprotective measures, we should not be transporting a patient off the unit and exposing them to homeostatic disruptions. One of the most detrimental disruptions is often overlooked - the need for change in position from head of bed elevated to flat for operative intervention or diagnostic imaging.
Our institutional guidelines recommend neuroprotective measures for 5 days following cardiac arrest. We often get a request from ICU (or more often, neurology consultants) for a "prognostic" brain MRI following cardiac arrest. I nearly routinely turn these requests down (whether I'm wearing my anesthesia hat or my intensivist hat) unless it's been more than 5 days.
If an emergent procedure is needed during the time of risk for secondary brain injury, I don my ICU hat more than my anesthesia hat. If possible, keep the head of the bed elevated, maintain normoventilation, maintain normoxemia, do NOT allow fever, watch for clinical seizure activity and treat immediately, prevent hypoglycemia, and prevent or treat hyponatremia (with 3% hypertonic saline). If an intracranial pressure monitor is in place, continue monitoring throughout the entire perianesthesia period. And lastly, to maintain normoventilation, transport with the end-tidal CO2 monitor and watch it closely during manual ventilation. If the child also has lung injury, it may be more prudent to transport with the ICU ventilator instead of manual ventilation to avoid changes in PaCO2.
PS from Myron: As discussed in the PAAD, I am particularly interested in the management of children, really adolescents, who have concussions, usually after sports injuries. They are usually triaged and rarely get to the ICU but they often do undergo diagnostic imaging studies like MRIs. Some (many?) undergo general anesthesia to produce immobility and are often anesthetized with a natural airway or allowed to breathe spontaneously. Is this safe? Based on the article I don’t think so. I hope this will be a topic at a future SPA meeting and the development of a multi-institutional prospective study.
From Ellen Basile, DO on the Smith award
As you know there has been extensive literature, editorials, and feature articles on women in anesthesiology in the last few years. An emphasis on decreased promotion, pay, and recognition have been the topics of these articles. The lack of recognition for women and their achievements is still in need of improvement. Per Dr. Monica Harbell’s et al. recent article Women Representation in Anesthesiology Society Leadership Positions, the Society for Pediatric Anesthesia (SPA) has the highest rate of women leaders at 47.8%, we also lead with women members 52.7%. These two numbers are significantly higher than our representation in residency (33-36%), and the number of women actively working in the field (26%). The strongest pipeline in anesthesia in the US.
I am disappointed to see that since 1986, the very first time the Robert M. Smith award was given, there have only been 5 (16%) women recipients. Likewise, the SPA Myron Yaster Lifetime achievement award, presented since 2014, has had only 2 (22%) women recipients. Of note, the women who have held the leadership role of president of SPA stands at 4 (22%). The latter is exceptional in that it far exceeds the number of female presidents of any other anesthesiology society. Still it falls noticeably short of our representation in SPA.
The Society for Pediatric Anesthesia leads the way on so many fronts. I believe we can do better in highlighting our colleagues who represent 52.7% of our society. I am certain there are many, many deserving women in my sub-specialty field that deserve the recognition. Let’s look harder, and work harder on this.
In response from Myron. The Smith and Yaster awards are lifetime achievement awards and usually recognize outstanding contributions over 25+years of practice. When I was a medical student in the 1970s less than 10% of my classmates were women; today the numbers are above 50%. As more and more women enter our profession and rise to leadership positions in their home institutions and nationally their numbers in these lifetime achievement awards will rise as well…indeed, they already have. Of equal importance is the lack of unrepresented minorities amongst the award winners. I think we’ve made great progress but the work is hardly done.
From Katherine R. Gentry MD, MA, Remigio A Roque MD, Joseph T Sofia MD, Jennifer L Chiem MD, Elizabeth E Hansen MD PhD University of Washington, Seattle Children’s Hospital
We read with interest the PAAD by Drs. Brule and Reece-Nguyen reviewing the Gender Affirming Surgical Perioperative Program at Boston Children’s Hospital.
At Seattle Children’s Hospital, gender-affirming top surgeries have been performed since 2021. To date, we have performed a total of 231 gender affirming top surgeries: 57 at our ambulatory surgical center (Bellevue Clinic and Surgical Center BCSC) and 174 at our main campus location. (8.6% of cases at the main campus are admitted postoperatively).
BCSC employs enhanced recovery after surgery (ERAS) pathways for all of its patients including those presenting for gender-affirming chest surgery. Common components of this care include preoperative administration of acetaminophen and carbohydrate loading, enhanced preoperative screening and family education, a focus on euvolemia, normothermia, and multimodal analgesia including use of regional anesthesia and opioid-sparing analgesia both intra- and post-operatively.1 At both sites, multimodal analgesia is prioritized, however, administration of intraoperative opioids at the main hospital is at the discretion of the anesthesiologist.
Regional anesthesia is a standard component of our anesthetic care for gender affirming chest surgery. We perform bilateral ultrasound-guided serratus anterior plane blocks after the patient is under general anesthesia with a secure airway. This regional approach blocks the lateral cutaneous branches of the intercostal nerves T2-T9. It can be thought of as similar to a TAP block of the chest. For our serratus plane blocks, we use 0.2% ropivacaine and give between 20-40 mLs per side, depending on the patient’s weight and maximum allowable local anesthetic dose.
Of note, our surgeons do administer an additional 10-20 mLs of a 0.5% lidocaine/0.25% bupivacaine mixture to the mid-chest incision lines intraoperatively, because serratus plane blocks spare this region.
We track our postoperative outcomes using the QI software solution AdaptX™. Our average maximum pain scores are 5.05 at main hospital and 4.16 at BCSC, average PACU rescue opioids are (56.9% IV and 13.8% PO) at main campus and (14% IV and 10.5% PO) at BCSC and need for additional PACU antiemetics is 12% at main and 8.8% at BSC.
In comparison to the protocol at Boston, intravenous tranexamic acid (TXA) has not been requested by our surgeons. However, one of our surgeons infiltrates TXA through the drains at the end of surgery.
Our efforts to spare opioids via the use of regional anesthesia plus multimodal analgesics has been met with enthusiasm amongst our patients and surgical colleagues. We are writing up our experience for publication and have plans to further study the impact of our regional anesthetics on post-op pain scores beyond the PACU.
We applaud the work that BCH and other groups are doing to improve the quality of anesthetic care for transgender and gender diverse patients. We believe it is increasingly important for institutions with gender programs to continue providing high quality gender affirming care given the current political climate in which access to this care is being restricted across the country.
Lynn D Martin, Jennifer L Chiem, Elizabeth E Hansen, Daniel K Low, Kayla Reece, Corrie Casey, Christina S Wingate, Leah K Bezzo, Paul A Merguerian, Sanjay R Parikh, Srinivas M Susarla, Vikas N O'Reilly-Shah. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2022 Dec 1;135(6):1271-1281. PMID: 36384014