By Drs. Paul Reynolds, Jay Shayevitz, and Shobaha Malviya, Sandra Merkel, R.N., et.al.
The pediatric staff has increased to 11 permanent faculty, plus two visiting faculty from the United Kingdom, six certified registered nurse anesthetists, two nurse specialists, four secretaries, a research assistant, and six anesthesia technologists. The senior faculty, Drs. Uma Pandit and Abraham Van DerSpek, have been on staff since 1978 and 1982, respectively, and have contributed significantly to the growth and development of the department. Recent additions to the faculty within the current academic year are Drs. Celia D'Errico, Sean O'Kelly, Hamish Munro and John Huntington. In January 1994, staff and office personnel moved into a new wing at Mott which is conveniently located adjacent to the operating suite.
Approximately 6500 procedures are performed under anesthesia each year at C. S. Mott Hospital, 46% of these are performed on an outpatient basis. The typical patient presenting for surgery at Mott is a child with complex medical problems, who may require anesthesia for a wide spectrum of surgical procedures.
Jay Shayevitz, M.D., assistant professor of anesthesiology, says in the pediatric section, "Ten percent of our patients have congenital heart disease and require a high acuity of care. In addition, 25-30% of our cardiac cases are sick neonates or premature infants with underlying medical and surgical problems."
The pediatric cardiac program ranks as one of the top three centers in the country that perform pediatric open heart surgery. The pediatric cardio-thoracic surgeons perform 700 operations each year in the Mott operating room, making it one of the busiest pediatric centers in the nation. The cardiac anesthesia team includes Drs. Paul Reynolds, Jay Shayevitz, Shobha Malviya, Lori Riegger, Sean O'Kelly and Hamish Munro.
In July 1993, Dr. Shayevitz developed a cardiac anesthesia database which now logs almost 750 patients. The database is used primarily for research purposes and for evaluation of practices related to cardiac anesthesia. It is also serving as a prototype for a pediatric cardiology/cardiac surgery database, which is in the planning stage. The goal is to compile a common database for access by cardiology, cardiac surgery, and pediatric anesthesiology services.
Based on research completed within the section, cardiac anesthesiologists have incorporated state of the art techniques such as the use of aprotinin for hemostasis into their daily practice. Another focus of the cardiac team is pain management and sedation of children undergoing bypass surgery.
The pediatric anesthesia team is called upon with increasing frequency to provide services for children undergoing diagnostic and therapeutic procedures outside of the operating room. Since the off-site caseload increased by almost 40% in 1994, one faculty anesthesiologist is responsible for these procedures every day with at least one resident, and one nurse anesthetist. Almost 600 children were anesthetized last year for procedures such as angiography, magnetic resonance imaging, nuclear medicine scans, and cardiac catheterization. These procedures often require resourcefulness and skill from the anesthesia team because of special considerations unique to the procedures, limited space and access to the patients. The nurse anesthetists and the anesthesia technologists have provided invaluable assistance in developing standards and practices for the safe management of these patients. "Although our service adds to the expense of the procedures as well as the duration, it provides more efficient utilization of resources by eliminating incomplete or technically inadequate studies, or the need to reschedule the procedure," said Dr. Shayevitz.
Formalized in 1990, the focus of this service is to provide effective and humane approaches to treating pain and providing sedation. In 1994, 850 children were cared for by the service, including more than 100 children who received epidural analgesia.
Pain management is provided to children by direct services or through consultation to the primary service. Services consist of PCA (Patient Controlled Analgesia) and epidural analgesia as appropriate. PCA is generally used in children that are at least nine-years-old. Young children, or cognitively impaired children who can benefit from pain management via a PCA machine but cannot operate the pump, are treated with NCA (Nurse Controlled Analgesia). This method works especially well for children who may need continuous opioid infusions and small bolus doses for procedures such as suctioning, turning, and dressing changes. In addition to postoperative pain, PCA is used for the treatment of chronic and acute pain related to sickle cell disease and cancer.
Epidural analgesia is available for select patients undergoing urologic procedures, cardiac surgery and general pediatric surgery. These patients are monitored daily by the pain service staff and by the nursing staff in accordance with protocols developed by the pain service. In addition, protocols for the management of cancer, sickle cell, and post-cardiac surgery pain have been developed. The pain service is directed by Howard Gutstein, M.D. Sandra Merkel, R.N., is the clinical nurse specialist responsible for the day-to-day operation of both the pain and sedation services.
Sedation consultation services are provided to hospitalized patients, particularly in the ICU. Individualized treatment plans are suggested for the control of anxiety, agitation and physical activity that interfere with medical treatments. Drug treatment regimens and dosing schedules are recommended for patients with problems related to withdrawal, prolonged intubation requirements, and ICU psychosis. Faculty also act as resources for the conscious sedation of children undergoing diagnostic and therapeutic procedures outside of the operating room. Guidelines for transporting sedated patients and for monitoring their recovery have been developed. Anesthesiology staff also train personnel involved in the sedation of children in didactic and hands-on teaching sessions regarding airway management. Dr. Shobha Malviya directs the sedation service and coordinates teaching related to conscious sedation.
Despite strides made in technology and changes in practice, there is still much to be learned about pain management and sedation of children. Our faculty and staff are involved in evaluating the efficacy of prescribed treatment modalities and studying the effects of pain management on outcomes. The continued efforts of physicians and other specialists will provide even more humane and effective approaches to pediatric pain and sedation.
A formal education program provided by the section includes both didactic as well as hands-on teaching. Faculty and fellows deliver a series of lectures covering all aspects of pediatric anesthesiology three mornings a week prior to the start of the operating room schedule. In addition, a weekly case conference allows discussion of unique clinical problems and complications. The faculty host quarterly journal clubs attended by fellows, residents, and nurses. Specialized techniques such as fiberoptic intubation, hemodilution, and combined regional and general anesthesia are taught in the operating room. The faculty are frequently invited to lecture at outside institutions in their areas of expertise. Education related to airway management, analgesia and sedation techniques is provided to hospital nurses, physicians, and medical students.
The number of fellowships offered each year in the section has expanded from one to five in the current academic year. Fellows are instructed in the management of children with complex underlying disease for cardiac and non-cardiac surgery. Because of their advanced level of training, fellows are helpful in providing the expertise and skill required to care for these children. In addition to clinical responsibilities in the operating room, the fellows participate in resident education and research.