SPA: A Melting Pot of Diverse Interests

SA NEWSLETTER Editor Douglas R. Bacon, M.D., kindly invited me, as the current President of the Society for Pediatric Anesthesia (SPA), to submit an article for the NEWSLETTER. As I pondered which pediatric anesthesiology topics would be of most interest to the ASA membership, I realized that Lynne Maxwell, M.D., 2003 Winter Meeting Program Chair, and the Committee on Education had put together a group of talks on the Sunday morning of our 2003 Winter Meeting last February in Ft. Myers, Florida, which covered areas of great variety and were a good example of the breadth of interests of SPA members. So I will report a short synopsis of my impressions from these talks.

Winter Meeting
Sunday morning began with four speakers discussing different approaches to participating in international pediatric anesthesiology in developing countries. The traditional voluntary medical mission — where anesthesiologists join a complete group to accomplish surgeries — with its immediate personal satisfaction was outlined, including important aspects of planning to maximize good outcomes for those giving and receiving these services. Harvard Medical International (HMI) is a very different model. HMI works with international partners to develop a sustaining medical care delivery and education system, emphasizing global changes in diseases such as the re-emergence of infectious diseases like tuberculosis and HIV. This can be a significantly difficult undertaking if the local infrastructure is not firmly established or funded.

The World Federation of Societies of Anaesthesiologists (WSFA) has established two (soon to be three) pediatric anesthesiology fellowship programs. Anesthesiologists selected by their country’s local society train at these programs for six to 12 months both in general pediatric anesthesiology and in pediatric cardiac anesthesiology. They return to their home country to share their expertise with colleagues.

The fourth presentation was of the long-standing institutional partnership between Indiana University and Moi University in Kenya, an affiliation that has existed since 1989 and which has generated publications and grants that benefit partners and their faculties. The wide spectrum of ways to participate in improving pediatric anesthesiology care in developing countries was impressive.

The next session consisted of two speakers who discussed a recent controversy in the science of pediatric anesthesiology. Studies in newborn rat pups have reported neurodegeneration and long-term maze learning deficits in animals exposed to several hours of isoflurane, nitrous oxide and midazolam. After presenting these studies and reviewing the process of apoptosis in the normal development of the maturing central nervous system, the speakers discussed unresolved issues of species specificity, accompanying hypotension, hypoxia and poor nutrition in the postexposure period in the animal studies, which would not pertain to human neonates and the time equivalence in human neonates of a six-hour exposure in rat pups. The known morbidity of stress from neonatal surgery or pain was reviewed as well.

The second speaker reviewed literature and studies supporting a neuroprotective role for inhalational anesthetics when ischemia occurs (focal or global). Having inhalational anesthetics seems most protective (equivalent to 2 degrees of hypothermia) when they are present for the period immediately preceding the ischemic injury. Both speakers agreed that balancing the stresses of inadequate anesthesia for neonatal surgery with the possibility of anesthetic effects on the neonatal central nervous system during this rapid period of development will require further study, and major changes in neonatal anesthesia would be premature.

The morning finished with presentations by two pediatric anesthesiologists on the development of the subspecialty in California. Over the past 15 years (which parallels the growth of SPA), pediatric anesthesiology has grown as a subspecialty with input in various areas. The formalization of curricula for pediatric anesthesiology fellowship training achieved recognition by the Accreditation Council for Graduate Medical Education (ACGME) in 1997. Currently there are 43 fellowship programs with ACGME certification. The ASA Committee on Pediatric Anesthesia and the American Academy of Pediatrics (AAP) Section on Anesthesiology and Pain Medicine have both published material on the pediatric perioperative environment, outlining space, equipment, ancillary services necessary as well as a process for anesthesiology departments to determine the pediatric procedures that may be undertaken at each institution. The latter outlines the training needed for anesthesiology practitioners to safely accomplish these pediatric procedures, including prior training and ongoing continuous clinical competence. In California this resulted in a model policy for pediatric anesthesia being written by the California Society of Anesthesiologists, which was presented at the 2003 ASA House of Delegates. In the community hospital where one of the pediatric anesthesiologists practices, a subgroup of seven to eight practitioners has evolved with ongoing clinical competence to cover complex pediatric and neonatal cases 24/7.

I am struck again as I write on the diversity of interests (science, clinical care and subspecialty development) that SPA members show. More complete information on these talks is available at the SPA Web site at <www.pedsanesthesia.org> in the form of 2004 Winter Meeting author syllabus submissions and in the Spring SPA Newsletter meeting summary written by SPA members of the newsletter editorial staff.

Anne M. Lynn, M.D., is Professor of Anesthesiology and Pediatrics, University of Washington, Children’s Hospital and Regional Medical Center, Seattle, Washington.