Reader response

Mofya Diallo MD, MPH

I wanted to thank you for the continued discussion on topics that I believe will enhance belonging among Anesthesiologists such as the wellness, career development and diversity, equity and inclusion.

A concept that is not very appreciated is intersectionality, a term coined by Dr. Kimberlé Crenshaw, that describes the concept of how occupying multiple identities has a negative cumulative effect of experienced barriers in society. For instance, a transgender, Black woman in our profession might have a challenge with every point listed in the PAAD in “Becoming a Leader in Anesthesiology: Challenges Women Face”.

As opposed to focusing on the trauma of being isolated and attempting to conform as an underrepresented person in our profession, I would like to point out that identifying as a woman, who is Black and not having left medicine yet does require the development of levels of tolerance, resilience and professionalism that may not be appreciated by others. Until recently, it was not unusual to participate in national meetings and be completely unseen by colleagues. Experiences like these leave scars that are healed as one finds mentors, sponsors and support which can take longer than anticipated. Only to be asked, “how come you don’t have more publications?”.

My truth has been that I have had wonderful support in our profession from those who saw my work, potential and worth. I learned to navigate my career in the best way possible, like many women before me have. My advice is to never stop trying to have it all because by trying, you do get most of what you want and deserve while being true to yourself. It may not look like much but it is how I honor myself as a Black woman anesthesiologist and mother. I remain dedicated to making things better for all of us and our patients.

All professional development programs should consider intersectionality and plan for it otherwise we will continue to perpetuate the lack of diversity at all levels of medicine.

Michael Angel MD:  In response to Dr. Sylvain’s question about iron/epo for craniosynostosis repair: at Gillette Children’s, we give iron/epo to all of the infants. We are certainly an outlier in this regard based on publications from the Pediatric Craniofacial Registry but I’m certain it’s led to significantly fewer transfusions. The infants are coming to the OR with Hgb 12-13 instead of 10. There are costs and risks associated with epo but we feel they are preferrable to risks associated with transfusion.

Sung W. Choi, MD, MALD, Assistant Professor, Division of Pediatric Anesthesia, Anesthesia and Perioperative Medicine, Medical University of South Carolina

Greetings from Charleston, S.C.; I hope you are having a wonderful holiday season! I’m writing to submit a reader response regarding yesterday’s PAAD email (12/19) regarding infantile and childhood hydrocephalus.

As a resident, I had the privilege of rotating at the CURE Children’s Hospital in Mbale, Uganda through the ASA-Global Health Outreach (GHO) Resident International Scholarship Program. As you are probably aware, this hospital specializes in pediatric neurosurgical procedures, in particular endoscopic third ventriculostomies +/- choroid plexus cauterization, aka “ETV-CPC.”

Dr. Benjamin Warf, a neurosurgeon from Boston and author of one of the articles you cited, was instrumental in building their program, aimed at reducing morbidity and mortality in a region where shunt failures are almost uniformly fatal due to the lack of routine access to emergency neurosurgical care. Most cases of hydrocephalus in this region were due to infectious etiologies,

They have certainly become a center of excellence over the last 20 years and regularly train neurosurgeons from the United States in the procedure, several of whom I worked with during my time there. It is common for them to perform up to 5 per day across two operating rooms, staffed by a consultant anesthesiologist and several anesthetic officers.

Age ranges were typically between one week old to 1-2 years of age, though older children also had this procedure performed. Inhalational induction with Halothane was the most common technique, with Sevoflurane available but in limited supply, so reserved for the youngest patients and those with known or suspected cardiac comorbidities. A single intravenous line was obtained, and most patients were intubated after administration of propofol, fentanyl and rocuronium, then remained in the supine position. Anesthesia was typically maintained with Isoflurane and additional intravenous medications as needed. Due to scope placement and proximity to structures such as ventricular walls and the basilar artery, neuromuscular blockade was maintained throughout the case.

Case duration was typically 2-3 hours, and patients were extubated in the operating room and transported to recovery.

The most common complications of endoscopic third ventriculostomy are fever and bleeding. Attempts to perforate the ventricular floor can lead to bleeding, as can damage to ventricular walls or perforation of the basilar artery. Because of their experience with this technique, however, invasive monitors such as arterial lines were not routinely used.

Because the area of the third ventricle where the opening is made is responsible for some hormonal function, there is also a possibility of endocrinologic dysfunction following endoscopic third ventriculostomy. This complication is often short-lived, as is Diabetes insipidus, both of which would not usually present in the immediate perioperative period and present specific challenges to the anesthetic team.

Unfortunately, I cannot comment on the experience of treating these patients in the setting of hemodynamically significant increased intracranial pressure, as the vast majority were actually scheduled procedures.

Ben Walker MD: I fully agree with the need to convert to quantitative monitoring. I'm not yet convinced that routine use of sugammedex over neostigmine in the majority of our pediatric patients is justified, especially given the low baseline risk of postop pulmonary complications and the high cost ($200 vs $3 at my institution). It seems that it is easier to prove residual NM blockade based on monitoring, but far more difficult to prove a clinically significant difference in pulmonary complications (much like it's easier to demonstrate a reduction in opioid needs than a reduction in opioid-related side effects). I'm not an NMB expert, but devoting a PAAD or two to these new guidelines might be worthwhile. From Myron: A PAAD on the recent ASA guidelines will be coming in the next 2 weeks.