Before diving into this week’s reader responses, to our Muslim friends, colleagues, brothers and sisters on Eid al-Adha: Eid Mubarak! May your sacrifices be accepted and your days be filled with blessings that last a lifetime. As the crescent moon shines, may it bring peace and harmony to your life. On this sacred day, may your prayers be answered and your sacrifices be rewarded.
From Dr. Joe Cravero, Boston Children’s Hospital
I read with interest the PAAD “Through the glass, darkly: variability in GA use for MRI by race” (June 21, 2023) While there are a lot of potential confounders in the paper that was discussed, I applaud the attempt to continue to evaluate potential issues with related to in anesthesia/sedation care. At Boston Children’s we have attempted to evaluate both subjective outcomes and objective measures of care in several projects. There remains much to be done in this area.
I was particularly interested in the discussion of how we define “sedation” vs. general anesthesia vs. monitored anesthesia care. As pointed out in this entry, we have problems with how we describe and discuss this care. I am regularly asked to review papers describing emergency medicine physician protocols that include significant doses of ketamine and propofol (ketofol) described as “procedural sedation” (the preferred lexicon of ACEP). Likewise, I sign anesthesia records for Monitored Anesthesia Care when patients have received propofol, dexmedetomidine, AND fentanyl – clearly unresponsive to noxious stimuli of (almost) any kind. As most of us would agree, even though there is no ET tube involved, these regimens represent “anesthesia” and should be treated as such with all the implications for credentialing, oversight, and quality assurance/improvement..
I have also spent much of the last 20 years working with various institutions across the country collecting data on “sedation” practice from a variety of sedation services, staffed by all types of providers, through the Pediatric Sedation Research Consortium (PSRC). Rather than engage in an exchange over “who can do what” we have used this data to understand the nature of the care provided, training regimens, adverse event rates, and effectiveness of the protocols. Our reports of this practice indicate that, when provided by high performance sedation services, adverse events are rare and the quality of care is impressive. (1,2,3) Along with Ron Litman and others in our specialty, I (long ago) came to the conclusion that, as anesthesiologists, our focus should be less on restricting the use of medications such as propofol (and entering that regulatory morass), but rather to insist on the highest standards of training, comorbidity triage, monitoring, back-up systems, and the need to collaborate with anesthesiologists, so that patients receive safe and effective care. Regardless of what label we place on propofol sedation/anesthesia, we need to continue to engage and insist on the kinds of practice improvements that have allowed anesthesiologists to lead all of medicine in the improvement of the safety and reliability of our care systems.
Regarding the article from the Stanford group evaluating “general anesthesia” vs “sedation” care, I would submit that (unless specific measures of responsiveness are included in the data) the study is more indicative of the differences in care processes that existed between cohorts than it is comparing sedation to general anesthesia.
Mallory MD, Baxter AL, Yanosky DJ, Cravero JP. Pediatric Sedation Research Consortium. Emergency Physician-Administered Propofol Sedation: Report on 25,433 Sedations from the Pediatric Sedation Research Consortium. Ann Emerg Med. 2011 May;57[5]:462-8
Kamat P, Hebbar K, Stockwell J, Gillespie S, Fortenberry J, Cravero JP. Pediatric Critical Care Physician-Administered Procedural Sedation Using Propofol: A Report from The Pediatric Sedation Research Consortium Database Pediatr Crit Care Med. 2015 Jan;16(1):11-20.
Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: Report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009;108(3):795-804.
From Myron: Last week’s PAAD “Through the glass, darkly: variability in GA use for MRI by race” was based on data from a national insurance data base. Dr. Glaucomflecken has a lot to say about health insurance physicians.
More from Dr. Bob Spear, San Diego, CA commenting on racial inequality and bias in MRI (PAAD June 21, 2023)
Perhaps I’m overly optimistic, but I believe the concerns regarding racial inequality in two of the PAAD discussions last week likely had more benign explanations. I think the reviewer of the “GA for MRI” did a fantastic job…we simply cannot draw conclusions from this billing study. I might add that I’d find it difficult to decide if either of the following are remotely racist, 1) more Black children received GA for MRI or 2) less Black children received GA for MRI.
The PONV study showed Black people received less anti-emetics than White people; importantly, rescue doses as well as prophylactic doses were counted. A study from South Africa showed that Africans had a significantly lower incidence of PONV than non-African Caucasians. (Ref 1) Based on these data, we’d expect White patients with a higher incidence of PONV to receive more rescue doses..exactly the finding in the PONV study in the PAAD. Another study showed the same findings following spinal anaesthesia for Caesarian section. (Ref 2) Several biochemical reasons were briefly discussed. One article was summarized by stating, “Variations of 5-HT3A receptor genes have been shown to be associated with the individual risk of developing post-operative vomiting”. (Ref 3) (I must admit, I have absolutely no idea what that means, nor did I read the article).
The recent discussions have mentioned “implicit bias” or “unconscious bias” enough that I finally spent some time re-exploring it. Yes, I think we all have instinctual reactions or biases about nearly everything, but I’m guessing that most people who care for other people’s children have an armamentarium of adaptations to compensate for such biases. Kindness, empathy, and a nurturing spirit come to mind as qualities that allow some semblance of equity to be achieved. I’m not saying these adaptations are uniform or perfect. Maybe a life-long work in progress.
Brief sport’s analogy: Forty-eight years ago, I first saw a classic case of bias and compensatory behavior. My roommate, Bill Molinari was a junior varsity basketball coach at our college. One of the referees was Jim Filson, our fraternity brother. Most of us assumed Fils would give borderline calls to Mol, (the hometown advantage results in the referee being called a “homer”). Bottom line, Mol lost and he blamed Fils for horrible calls saying, “Fils was so worried about being a homer, he favored the other team, you know, like a counter-homer theory”. Jim later was a top Big Ten Football referee, despite losing his right eye in a freak accident. He was fired when Lloyd Carr of Michigan blamed a bad call on Jim, despite Jim receiving medical clearance and fighting his way back to the Big Ten. He was well-compensated in a discrimination lawsuit.
References
1. The effect of ethnicity on the incidence of PONV in moderate to high risk patients undergoing general anesthesia in South Africa: a controlled observational study. Alli, et al. Middle East J Anaesthesiol. 2017;June 24(2): 119-129
2. Incidence of intraoperative nausea and vomiting during spinal anaesthesia for caesarean section. Magni et al. Southern African Journal of Aneasthesia and Analgesia. 2016
3.Do variations in the 5HT3A and 5HT3B serotonin receptor genes influence the occurrence of postoperative vomiting? Rueffert et al. Anesth Analg 2009;109:1442-1447
From Mark Schreiner MD on language
I’ve been permanently warped by Russ (Raphaely) and Jack (Downes) and the editor from Anesthesiology long ago (the journal). “Pretreatment” means the treatment before the treatment. It is either treatment or pre-operative treatment.
I used the term premedication in my first submission to Anesthesiology and was promptly smacked down. A premedication would mean the medication before the medication. In the journal’s style, the term is preoperative medication or preanesthetic medication, usually the latter.
So now I spend my life wondering why we preheat the oven (heating it before heating it) instead of just heating it. And on and on. Once these things get inside one’s head, it’s hard to let it go.
From Nick Ettinger, MD, PhD, FAAP, FCCM Texas Children's Hospital commenting on the leak test and corticosteroids to reduce extubation failure
An important article relevant to your discussion is the recent PALISI extubation liberation guidelines published early this year.
Am J Respir Crit Care Med 2023 Jan 1;207(1):17-28.
“Recommendation 9. We suggest using dexamethasone at least 6 hours before extubation in children at high risk of developing postextubation UAO”
Thank you. I enjoy reading the PAAD!
From Myron: Thanks Nick…will pass this article to our airway and ICU team to review for a future PAAD.
From James Xie MD Stanford University on the leak test and microcuff tubes
Really interesting discussion on the leak test and its utility! At our institution, I would say Microcuff endotracheal tubes are certainly not "standard" in the ICU, and at least in the ORs they are merely "available" - should you choose to use it. My colleague Dr. Jonathan Barnett and I presented on the theoretical and evidence-based clinical advantages of the microcuff ETT at last year's SPA meeting (see poster: https://tinyurl.com/microcuffposter). Notably, for us the microcuff ETT is 4.5x more expensive than a Hi-Lo ETT so for most patients who will be extubated at the end of the case... is it even worth the expense?