Reader Response: How low is low in the neonate? Greening the OR (low flow anesthesia), more on assault weapon ban
Myron Yaster MD
Dr. Ruchika Sharma, Clinical Associate Professor, Division of Pediatric Anesthesia, Department of Anesthesiology, University of Virginia, Charlottesville posed many questions to the recent (June 6) PAAD on the management of hypotension and cardiovascular insufficiency in the neonate. I am posting her questions and comments for all of you to think about. I forwarded her questions to the leadership of SPA’s education committee to consider using her questions and this PAAD as a springboard for a future symposium at a SPA annual meeting or for some of you to consider studying. Myron Yaster MD
Original article
Jay P Goldsmith, Erin Keels and Committee On Fetus And Newborn And The National Association Of Neonatal Nurses. Recognition and Management of Cardiovascular Insufficiency in the Very Low Birth Weight Newborn. Pediatrics. 2022 Mar 1;149(3):e2021056051. PMID: 35224636
From Dr. Sharma
So glad you discussed this relevant AAP article with the Peds Anesth community. My questions:
1. There was no mention of etCO2 or transcutaneous pCO2 in the article. Did this strike you, or reflective of the NICU/ELBW trying to move away from intubation to CPAP/HFNC…..
2. You mention normalized centile curves for PMA, would you mind emailing that paper.
3. Do you incorporate the Perfusion Index from the SpO2 probe in your clinical decision making. And how do you use it.( I don’t)
4. Does your NICU use NIRS (ours doesn’t use it for everyone, but is participating in the SafeBOOSc trial), and do you find it useful when you do NICU babies.
5. When you have an arterial line, do you go by MAPs, or base decisions on the SBP, DBP, and pulse pressure.
Neonatologists have developed a ‘pathophysiology based approach to hypotension’ in which they discuss the management based on arterial waveform/SBP/DBP/pulse pressure.
1. Fluid of choice for NICU is either crystalloid or blood….albumin has fallen out of favour(data based). I wasn’t aware of this till very recently! We still use 5% albumin for our surgical neonate, do you? Do most of us?
2. Inotrope of choice for fluid-resistant hypotension is Dopamine, peripherally, 800 mcg/ml, till 7.5 mcg/kg/min. You?
3. For coexisting CHD, I start Epi, peripherally, 8 mcg/ml, with/without Milrinone. You?
4. Do you use Calcium infusions ? I feel like we use it for every cardiac surgical neonate, but not otherwise.
Finally, is there a need for a neonatal anesthesia special interest group (SIG) at SPA?
Greening the OR and low flow anesthesia
From Diane Gordon, chair of SPA’s Sustainability Special Interest Group (SIG)
I'd love to meet at ASA (or by Zoom, depending on when people are available) to talk about low flows and Liz's fantastic implementation work! Count me in!
I (MY) spoke to Liz Hansen and Lynn D Martin about using their study as a springboard for a multi-institutional study to replicate their results and to use their improvement process for others to use in this and other studies. They are all in. Over the next few weeks I will work with Kim Battle of SPA to arrange a meeting room at the annual meeting in New Orleans to pursue this. If you are interested please email me (myasterster@gmail.com) AND Lynn Martin (lynn.martin@seattlechildrens.org) AND Liz Hansen (elizabeth.hansen@seattlechildrens.org)
Finally, for those who want to know more about SPA’s Special Interest Group for Sustainability…(from the SPA website) it “brings together pediatric anesthesiologists with a passion for learning, teaching, and practicing ways to reduce the environmental impact of anesthesia and the wider operating room environment. The SIG will facilitate education on sustainability topics at meetings, foster collaboration across institutions, promote sharing of ideas for projects and publications, and maintain the creative energy of pediatric anesthesiologists working for changes in their hospitals. Diane’s email: dianejwood@gmail.com
From Balazs Horvath MD on call for assault weapon ban
The ongoing discussion about the mass shootings and killing of our children is a vital debate. Not a single person possesses all the wisdom that is needed to tackle this heartbreaking trend. Therefore, it is crucial to listen to the voices with the same ultimate goal of reducing (and even eliminating) gun (and other forms of) violence. As a father of three little children I have "skin in the game", and I hope to make a difference by joining forces and ideas of the well intended people instead of remaining deeply and unnecessarily divided.
I declare my firm conviction that Dr. Yaster and all the physicians who subsequently responded to his original post calling for gun control are driven by the desire and passion to make this country (and the world) better with no violence. To move forward with the discussion on this issue I hope that we agree on this one principle.
When I read Dr. Donahue’s response to Dr. Yaster’s call for banning (certain) guns, I was amazed by his willingness to express his thoughts by exposing the much deeper and multifaceted, intertwined roots of these tragedies that are unique to the United States. Reading his response did not make me think that he cares less for the children and other victims of gun violence than any other decent member of the society at large and our colleagues within our own professional circles.
I am not a gun expert. I grew up in a country where guns belonged to the oppressive regime, yet none of us felt that we needed one at our bedside. I believe the debate about gun control must focus on the historic and cultural facts and their ramifications, since gun violence is largely a cultural problem that is also unique to the United States.
I support Dr. Donahue’s proposition to examine the gun issue as a severe symptom of a historical, cultural, and psychosocial, essentially multiorgan disease. Symptom management is important to ease any pathologic condition. However, without the recognition and acknowledgment of the deeply engraved culture and worship of violence in this society, that is unparalleled in the Western civilization, and without examining it in the context of the steadily evolving mental and social problems in our youth no real improvement can be expected. I strongly urge everyone who cares about the future generations not to sweep aside those who want the same result of eliminating violence but see the problem through somewhat different lenses.
Again, not being a gun expert, I have no idea about the technicalities and definitions of guns. Moreover, I am convinced that such conversation is unnecessary and counterproductive because that is not where the problem lies.
On the other hand, I am rather surprised by the argument that this society is not showing signs of decline, and that our youth is in a good shape. Ignoring the negative trends that are unfolding in front of our eyes does not suggest that we will find the solutions to reverse those trends.
Dr. Flick made an enormous effort to dismantle Dr. Donahue’s points, and he may just be right completely in his lengthy, strictly gun related arguments.
However, Dr. Flick is incorrect about the sad reality that forecasts a gloomy future for our children without profoundly changing our culture in general. That means condemning and stopping worshipping violence in the news, movies, “music”, on social media, etc., and yes, improving education and social skills, stopping exposing them non-stop to threatening and depressing visions and opinions about the future, restoring, and promoting certain traditional values, such as the role of family, respect for others when respect is deserved, respecting quality, hard work etc.
Below is the real-world data on education, mental health, family, and employment trends.
Education – while it is true that there has been steady improvement in the basic educational metrics, none of the student age groups reaches the level of proficiency in those metrics, especially in math. US students perform far below students from other developed countries on standardized tests.
https://www.educationnext.org/international-test-scores-reveal-american-education/
https://www.pewresearch.org/fact-tank/2017/02/15/u-s-students-internationally-math-science/
https://nces.ed.gov/fastfacts/display.asp?id=38
https://www.winginstitute.org/have-naep-math-scores925
Labor – the trend of decreasing unemployment usually follows a major spike of unemployment due to an economic crisis, and such trends do not seem to halt, or even slow down the psychological decline of our youth (see below).
Mental – the rapid rise of mental illness and suicide are the most important signs of a deeply troubled new generation.
https://www.kidsdata.org/blog/?p=9804
https://nihcm.org/publications/youth-mental-health-trends-and-outlook
Family structure – sure there is a modest decline in single parent households, but the association between the highest rate of such households and the highest rate of violence in the African American community cannot be disregarded.
https://www.census.gov/newsroom/stories/single-parent-day.html
https://ucr.fbi.gov/crime-in-the-u.s/2019/crime-in-the-u.s.-2019/tables/table-43
To summarize my opinion; I believe that the two issues, i.e., sensible gun control WHILE addressing the grave cultural and social problems concurrently are mutually inclusive. Condescending tone and disregard of opinions that don’t sound like our own at first will not help anyone. Instead of vindicating the knowledge and expertise based on individual belief, I suggest establishing a task force within SPA or with the involvement of multiple disciplines with members who wants the same outcome but offer different knowledge and ideas for finding solutions for the underlying issues that lead to the outbursts of violence specifically in this country. That is, of course, if this debate is intended to be taken seriously. Sharing individual wisdom is the only way to formulate a united action plan that has the chance to result in a lasting improvement for future generations.