Author Archives: litmanr
Great news! The Philadelphia Pediatric Anesthesia Consortium (PPAC) has been officially formed and consists of pediatric anesthesia representatives from Children’s Hospital of Philadelphia, Dupont Hospital for Children, St. Christopher’s Hospital for Children, and Jefferson Medical Center. PPAC is kicking off our beginnings with an inaugural conference on Saturday December 2, 2017 here at CHOP, with a theme of Cutting Edge and Controversial Topics in Pediatric Anesthesia. It will be an innovative Ted-style 1-day conference that targets new and controversial practices in pediatric anesthesia. Tentatively scheduled topics include anesthetic neurotoxicity in the developing infant, pain relief for Nuss procedures, management of anesthetic crises, malignant hyperthermia related diseases, best practices for hand-offs, and Dr. Alan Flake will tell us about his ground-breaking research in fetal physiology and viability, as featured this year in Nature. Stay tuned, more info to appear here as the lecture schedule is finalized.
I was catching up on some reading recently and came across this nice review of neonatal resuscitation in the April 22 issue of Lancet (Manley BJ, Owen LS, Hooper SB, et al. Towards evidence-based resuscitation of the newborn infant. The Lancet; 389(10079): 1639-48). It’s an excellent overview of the physiological process of birth and the principles of neonatal resuscitation. In the article, the authors reproduced the Newborn Life Support Algorithm of the UK Resuscitation Council. The choices within this algorithm rely on the appearance of “chest movement” during inflation. This term presumably means the rise of the thoracic cavity that is an indication of lung inflation. But in clinical practice, this is difficult to discern, especially in the newborn population, and is often confused with the movement associated with gastric inflation. Over the years, I have been asked to consult on several medical malpractice cases wherein a newborn suffered hypoxia despite the treating clinicians’ insistence that they were achieving adequate “chest movement”. These clinicians were so convinced of the adequacy of their bag-mask ventilation that they discounted the severely low oxyhemoglobin saturation and heart rate values, and did not consider the placement of an endotracheal tube or laryngeal mask airway. The adequacy of bag-mask ventilation should not be judged on “chest movement” but rather on achievement of normal oxyhemoglobin saturation and heart rate values. If these are subnormal, clinicians should presume that bag-mask ventilation is not sufficient, and the child should immediately receive tracheal intubation or placement of a laryngeal mask airway.
The most recent version (2015) of the AHA Neonatal Resuscitation has incorporated this decision into their treatment algorithm (https://doi.org/10.1161/CIR.0000000000000267. Circulation. 2015;132:S543-S560) and I’ve reproduced it here:
Hope everyone is having a restful Christmas Eve. It’s nearly 11 pm and the ORs here at CHOP are rockin’ with a swallowed penny, aspirated hot dog, and a first for me, bilateral emergency SCFE! Good thing we have great nursing and surgical colleagues, and way too much sugar everywhere.
I’ll be lecturing on MH at the PGA in NYC this Tuesday morning at 9 AM in a panel called “Recent Advances Affecting Your Practice”. The title of my talk is “Malignant Hyperthermia: Hot Off the Press!” Get it? It is scheduled to take place in the North Broadway Ballroom on the 6th Floor of the Marriott Marquis. I’ll be highlighting some recent changes in the way we diagnose and manage MH, including use of charcoal filters, and use of the new dantrolene preparation, Ryanodex. I will go over the types of patients that really need a non-triggering technique, and I’ll also discuss some recent changes to the MHAUS website, where we will be omitting recommendations for treatment of myoglobinuria, and the story behind our removal of the recommendation to avoid calcium channel blockers when also administering dantrolene. If you are there, make sure to stop and say hi.
There’s not much better (well, almost) than relaxing with coffee on an early Saturday morning with absolutely nothing planned for the weekend ahead. After reading the excellent profile of Dave Eggers in the WSJ weekend magazine, I perused this month’s A&A, which contains a great article on the relationship between temperature monitoring and mortality in patients that develop MH. I wrote a commentary on it in the Journal Club section of the blog. Check it out here.
Although the summer is winding down, there’s much to be happy for: the U.S. Open is in full swing, school starts soon (the real Mother’s Day!), and football season starts this week. I took a break from my obsessive tennis watching to record this interview with @OpenAnesthesia’s Ed Nemergut. We discussed the current state of fetal surgery, anesthetic-related neurotoxicity in children, susceptibility to malignant hyperthermia, and discharge criteria after tonsillectomy. Listen to it here: http://www.openanesthesia.org/OpenAnesthesia.org:MultimediaPlayer#tab=Ask_the_Expert
Here at CHOP, we’ve run out of chloral hydrate (for the foreseeable future), which has been the mainstay for the pulmonologists’ sedation for PFTs. We haven’t found a good alternative. Has anyone had success with anything else? Ideally it should be oral only, so no IV is necessary, but we’ll consider anything.
Check out this nice review of Basics in the December issue of A&A: http://journals.lww.com/anesthesia-analgesia/Fulltext/2013/12000/Basics_of_Pediatric_Anesthesia___Tablet_Edition.42.aspx even though the author thought my sense of humor was “distracting” (can you imagine?). But I wish she would have mentioned the two most important parts of the book: the search function (no more looking in indexes) and the fact that the reader can just touch a referenced hyperlink and the article miraculously appears! I think another review will be in the Sunday NY Times sometime soon, I hope.
So…for a few days this week the CHOP OR hallways were filled with the recountings (and often trashings) of the new Pediatric Anesthesia Board Exam experience. Various faculty members were heard asking…”What did you put for that question on pyloric stenosis?” Answer: “Which one of the twelve questions on pyloric stenosis do you mean??!!” Invariably, answers were different. I wasn’t one of the lucky ones to take the exam (I, um, forgot to sign up), but I heard that it would be beneficial if you were a pediatric endocrinologist, or a specialist in anesthesia for fetal surgery. So help me – what should I study for next year? Which books, review courses, etc. were actually helpful? Was my book useful? What should I add in the 2014 update (besides adrenogenital syndrome) that would be helpful?