From Vikas O'Reilly-Shah, MD, PhD, FASA (he/him), Associate Professor of Anesthesiology & Pain Medicine, Associate Chief for Perioperative Informatics and Outcomes, Seattle Children’s Hospital, Director, Center for Pain and Perioperative initiatives in Quality Safety and Outcomes (PPiQSO), University of Washington | Seattle Children’s Hospital commenting of racial disparity and PONV
I was the session moderator when this was presented at the ASA and remember how shocking it was. I even took a grainy photo of the key figure, which I show to people often. I had always wondered what happened to this important work of Dr. White and colleagues, and why it had not been published yet. (On the other hand, based on the comments of colleagues whose primary work is in this space, it is perhaps not surprising that it was difficult to publish this work. For whatever reason, it appears that skepticism of disparities work runs high.)
As far as your question about whether or not this occurs in pediatric anesthesiology, the answer is a resounding yes. We did some work here at Seattle Children's looking at this question and definitely found evidence of disparities.
I know that one contributor to these disparities is outdated beliefs about PONV medication requirement. A celebrated member of the pediatric anesthesia community, whom no one would call racist, once told me that he does not give Black or African American patients PONV medications because they don't need them - based on anecdotal personal experience and observation.
As is rightly pointed out, there is no biological basis on which this is to be believed. Show me the SNP that is associated with reduced PONV risk, and I might change my practice once we have genome-driven personalized medicine for all. Until then, all patients should be given equivalent, adequate PONV prophylaxis as indicated and commensurate to their risk.
From Drs. Mihir Parikh and Ethan Sanford, UT Southwestern commenting on the PAAD titled ‘Congenital diaphragmatic hernia, ECMO and continuous EEG monitoring’
We introduced EEG to guide anesthetic delivery about six months ago to our institution. Following is a brief overview of the process of implementation of EEG monitoring in the ORs, and a few challenges that we faced (or are facing).
Dr. Dean Kurth from Children’s Hospital of Philadelphia (CHOP) was invited to speak and engage in structured, real-time education regarding EEG interpretation. We hosted Dr. Kurth in the OR to gain experience with EEG monitoring. We are now engaged in teaching our peers. These activities have been extremely helpful to understand the current and potential usefulness of EEG monitoring and its implementation in a structured way.
Ultimately, widespread use of EEG requires 1) educational activities to inform use, 2) practical implementation strategies and 3) buy in from the community that it is useful. Here are some thoughts on these components.
1) Dr. Yuan and colleagues describe their experience as an institution in the paper titled, ‘Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice.’1 Additionally, there are online interactive models that may help gain some basic understanding: https://purdonlab.mgh.harvard.edu/tutorials/eeg_part1/. Lastly, on-site training from an experienced practitioner is very helpful. A network of practitioners who can help with some onsite training may go a long way in aiding implantation broadly.
2) Implementation requires resource allocation, so the first step must be leadership commitment for initial purchase and ongoing maintenance. We are far from completely implementing EEG as a standard monitor in most of our cases. However, we are more accepting of this technology that what we were six months ago. Here are the few challenges that we have faced (are facing) along the way.
- It is our opinion that using EEG to guide an anesthetic is best learned with a propofol based anesthetic (narrow alpha band, ‘crisp’ DSA). We faced a challenge to convince our staff to use propofol when they had planned on using sevoflurane as a primary anesthetic. To clarify, EEG can be used to monitor sevoflurane (or any inhaled gas) anesthetic. However, the data generated with propofol is easier to understand as a first-time learner.
- We ran out of EEG sensors after the initial site visit and lost some momentum with a pause of using this technology.
- Identification of cases with long enough time to gather relevant, actionable data can be challenging. This may improve with practitioner comfort and ease of application.
- Documenting the use of EEG in Epic has been a challenge. Despite working with our Epic team lead and having dedicated areas to document SEFs, having QR codes and a ‘cheat sheet’ attached to every monitor, we struggled with documenting the use of EEG and the SEF values intraoperatively. This is making it harder to track and follow the progress that we have made so far.
3) Despite these challenges we have identified ‘early adopters’ of this technology and have witnessed those staff (attendings, fellows and APPs) use this as a routine monitor in their cases with positive influences on patient outcomes. Buy-in is mostly derived from the ability to dynamically monitor and adjust anesthetic depth based on EEG rather than standard practice of adjusting based on vital sign changes or common dosage regiments. Anecdotally, we have found we most commonly are able to use less anesthetic dosing to achieve goals, a finding correlating to a recent publication regarding EEG implementation. Ultimately, as knowledge and experience accumulates, it is very likely that EEG will allow further titration of anesthetic dosing and possibly more personalized anesthetic regimens. It is our opinion that this opportunity should be pursued by our community.
1. Yuan I, Missett RM, Jones-Oguh S, et al. Implementation of an electroencephalogram-guided propofol anesthesia education program in an academic pediatric anesthesia practice. Paediatric anaesthesia. Jul 6 2022;doi:10.1111/pan.14520
From Katherine R. Gentry MD, MA Seattle Children’s Hospital. I appreciated today’s PAAD on alpha-1 acid glycoprotein and local anesthetic dosing in neonates.
I practice at Seattle Children’s, where we do a fair amount of regional anesthesia in infants. For baby epidurals (under 10 kg), we typically do the initial bolus with 0.2% ropivacaine and then run an infusion of 1.5% chloroprocaine.
Our usual 0.2% ropi epidural bolus dose is 0.4 mL/kg if it’s thoracic, 0.5 mL/kg if it’s around T12-L1, and 0.6 mL/kg if lumbar.
For the infusion, our range for chloroprocaine is 0.2-0.7mL/kg/hr, and we find that 0.4 mL/kg/hr usually strikes a good balance between adequate spread without excessive leaking.