From Rebecca Gray (South Africa), Mary Nabukenya (Uganda), Raymond Ndikontar (Cameroon), Pokua Sarpong (Ghana), Faye Evans (USA), Mark Newton (US), and Zippy Gathuya (Kenya) on behalf of the Paediatric Anaesthesia Training in Africa (PATA) leadership team in response to the March 28, 2023 PAAD entitled: “Anesthesia for repair of anorectal malformations in infants in low resource environments: is ketamine-dexmedetomidine combination plus epidural analgesia the solution?”
We are always excited to see a research publication on the anesthetic care of neonates and infants for fairly complex procedures that have applicability beyond the well-resourced high income country (HIC) setting. The paper reviewed in the March 28th PAAD is, despite appearances, not this. The technique by Villa Moutinho et al.1 is unlikely to be replicated in the setting described or in most other low-income country (LIC) settings. In addition, your commentary on it fails to address multiple ethical issues.
Fortunately, the editors of Pediatric Anesthesia published an editorial by Dare and Anderson2 that addresses general ethical issues surrounding short-term surgical mission work and some of the specific issues with this paper. We would like to share a previous publication by members of this team on this same topic and in the same journal.3 I would suggest that all readers of PAAD take the time to read this editorial (see Myron’s response below). In addition to the issues raised in the Dare editorial, we would also like to point out that there was no description by the authors that informed consent was obtained from the parents of the children who were included in this case series. The fact that the authors of PAAD ask for any reports on experience from the readers on this sedation technique in this age group underscores the point that this is not, as yet, a well accepted practice.The same criteria that apply to research and the publication of case series in an HIC should apply in all settings. In this particular setting, with the power dynamic invariably present in an HIC-LIC surgical outreach setting, it is particularly important to pay close attention to these details.
Regarding the applicability of the technique for other LIC settings, while ketamine is widely available none of the following are likely to be available: dexmedetomidine, an epidural set (even less likely in pediatric sizes), an ultrasound, a syringe driver for infusions of sedation or an elastomeric pump for post-operative continuation of the epidural. This renders the described technique essentially unreplicatable in the very setting in which it is espoused for use unless all these items are brought in by a charitable mission. There is also no mention made of the post-operative care of the patients receiving ongoing local anesthesia via epidural infusion. Safe and responsive post-operative monitoring of patients is a yet another particular challenge in LICs.
Instead of providing us with a reasonable model to work towards, this paper has made clear the lack of understanding of the greater context in which these four infants live and the context in which the anesthesia providers in LICs struggle to provide safe and effective perioperative care to children. Useful and sustainable new approaches are more likely when local expertise is utilised both in the planning and execution phases, followed by (ethically conducted) research to assess their effectiveness.
In response from Myron Yaster MD. First thank you and both Lynne (Maxwell) and I are profoundly sorry about this PAAD. We were simply reviewing the article published in the Journal Pediatric Anesthesia. The editors of the journal really blew it (as did we). We assumed it was vetted by the journal’s editorial staff. I/We should have done a better job in our review. I am forwarding your letter to the editors of the journal as well.
Further, at the SPA annual meeting held last week in Austin Texas, I asked Dr Faye Evans and Dr. Zippy Gathuya to permanently join the executive council of the PAAD. In the future, I will ask them to be the primary reviewers on articles published on global pediatric anesthesia.
References
1. Vila Moutinho Tavares S, Tavares JC, Borges Marques J, Teixeira de Figueiredo J, Passos de Souza RL. Ketamine-dexmedetomidine combination for sedation in pediatric major surgery in a low-income country. Paediatric anaesthesia. Apr 2023;33(4):278-281. doi:10.1111/pan.14465
2. Dare T, Anderson S. Editorial: Ethics and short-term surgical visits to low-income countries. Paediatric anaesthesia. Apr 2023;33(4):272-273. doi:10.1111/pan.14614
3. Nthumba PM, Newton MW, Gathuya Z. Global surgery in the 21st century: The voice from Africa - We need a new model. Paediatric anaesthesia. May 2021;31(5):510-512. doi:10.1111/pan.14162
From Jennifer Chiem, MD, Assistant Professor, University of Washington, Department of Anesthesiology and Pain Medicine, Pediatric Anesthesiologist, Seattle Children's Hospital
We read with interest the recent PAAD on the use of ‘ketodex’ in limited resource environments.1 These medications (ketamine and dexmedetomidine) have ideal characteristics in the United States as well because they provide sedation plus analgesia without respiratory depression. And as Lynne and Myron mentioned, this medication combination nicely offset their respective hemodynamic effects. Olutoye and others2 showed in 2010 that dexmedetomidine 1 mcg/kg has equivalent analgesic effect to morphine 100 mcg/kg for pediatric adenotonsillectomies. At Seattle Children’s Bellevue Clinic and Surgical Center we’ve focused on opioid free anesthesia for our ambulatory patients since 2019. 3,4 To achieve this, we have routinely incorporated ketorolac (0.5 mg/kg), dexmedetomidine (1 mcg/kg), and more recently (3/2021) ketamine (0.4 mg/kg) as part of our multi-modal approach for pain management.
The primary procedure for this medication combination has been adenotonsillectomy. In 1,033 adenotonsillectomies performed, our PACU maximum pain scores have remained stable at 3.4, the PACU morphine rescue rate is 6.7%, the PONV rate is 0.6%, and the average PACU length of stay is 68.5
minutes. With our opioid free approach, we have relaxed the OSA criteria for hospital admission from Apnea Hypopnea Index of 10 to 15, resulting in 52 hospital bed days saved over the last 2 years. Our 30-day return to OR rate is unchanged at 1%, and the home opioid prescription dose has been reduced by 46% (13 to 7 doses) without a change in ED visits or hospital admissions and a reduction in inbound postoperative phone calls (4% to 1%).
In January 2022, we also expanded ketamine use to additional procedures (mostly orthopedic) in 807 patients. PACU maximum pain scores are 2.9, PACU morphine rescue rate is 7.5%, and PONV rate is 2%. We have had minimal side-effects from this medication combination and have seen improving clinical outcomes. Perhaps it is time to reconsider ‘ketodex’ as a routine part of multi-modal analgesia even in the ‘developed’ world.
References
1. Vila Moutinho Tavares S, Tavares JC, Borges Marques J, Teixeira de Figueiredo J, Passos de Souza RL. Ketamine-dexmedetomidine combination for sedation in pediatric major surgery in a low-income country. Paediatr Anaesth. 2023 Apr;33(4):278-281. PMID: 35445494
2. Olutoye OA, Glover CD, Diefenderfer JW, et al. The effect of intraoperative dexmedetomidine on postoperative analgesia and sedation in pediatric patients undergoing tonsillectomy and adenoidectomy. Anesth Analg 2010;111:490-5. PMID: 20610555
3. Franz AM, Dahl JP, Huang H, Verma ST, Martin LD, Martin LD, Low DKW: The Development of an Opioid Sparing Anesthesia Protocol for Pediatric Ambulatory Tonsillectomy and Adenotonsillectomy Surgery - A Quality Improvement Project. Pediatric Anesthesia 2019; 29:682-9. PMID: 31077491
4. Franz A, Martin LD, Liston D, Latham G, Richards M, Low DKW: In pursuit of an Opioid-Free Pediatric Ambulatory Surgery Center – A Quality Improvement Initiative. Anesth Analg 2021; 132:788-97. PMID: 32282383