Meeting Reviews

Problem-Based Learning and Roundtable Discussions Overview

By Bevan Londergan, MD

Introduction
Groups of intrepid CCAS attendees braved the early hour to kick off the CCAS conference with problem-based learning discussions (PBLDs) and roundtable discussions. After tucking into the breakfast spread and reviving with some coffee, the early risers dove in for some collegial discourse.

PBLD 1: Does the ECMO Circuit Fit in the Dental Anesthesia Suite? The Ongoing Challenge of Anesthetizing the Patient with Williams Syndrome
Nina Deutsch, MD; Andrew Matisoff, MD

Dr. Nina Deutsch and Dr. Andrew Matisoff led a lively discourse at PBLD table 1 on the care of Williams Syndrome patients for dental and other noncardiac procedures. The conversation involved review of the physiology and common issues of instability and/or arrest seen with Williams Syndrome children under anesthesia care. The approach to induction and maintenance of an individual anesthetic was discussed as well as the institutional variability of approach to coordinating the care of this group of patients through their procedural experiences, including potential arrangements for extracorporeal membrane oxygenation (ECMO) standby.

PBLD 2: Adult Patient for Percutaneous Pulmonary Valve Replacement: Anesthetic Considerations and Potential Pitfalls
Jane Heggie, MD; Annette Vegas, MD

Dr. Jane Heggie and Dr. Annette Vegas addressed the anesthetic management of an adult patient undergoing percutaneous pulmonary valve replacement at PBLD table 2. There was active participation from a diverse group of physicians including attendees from Canada and Central America. The discussion centered on two cases that highlight rare but serious complications of percutaneous pulmonic valve replacement and strategies to manage and mitigate those complications.

PBLD 3: Bivalirudin for Procedural Anticoagulation: The What, Why, When, and How?
Viviane G. Nasr, MD; Katherine L. Zaleski, MD

At PBLD table 3, Dr. Katherine Zaleski and Dr. Viviane Nasr led a discussion about the use of bivalirudin for procedural anticoagulation. They reported an engaging discussion about the indications, dosing, pediatric pharmacokinetic/pharmacodynamic profile, and pitfalls of bivalirudin use as a procedural anticoagulant.

As expected, most providers have had minimal if any experience with bivalirudin in the operating room or catheterization laboratory setting even though most noted that bivalirudin is increasingly being used within their institutions for patients requiring ECMO or ventricular assist device (VAD) support (the latter point received additional attention during the morning VAD session).

The PBLD provided a great platform to share knowledge and pediatric-specific resources and to build a collective experience with a drug that is rarely used and tends to make providers very nervous.    

PBLD 4: 16-year-old Patient with Friedriech's Ataxia and Severe Hypertrophic Cardiomyopathy for Posterior Spinal Fusion
Kelly Chilson, MD; Teresa Murray-Torres, MD

PBLD table 4 hosted a lively discussion regarding the care of a child with Friedrich’s Ataxia and severe hypertrophic cardiomyopathy for posterior spinal fusion. The moderators, Dr. Kelly Chilson and Dr. Teresa Murray-Torres reported an excellent discussion, general agreement of management principles, and some variation in practice across institutions.

RDT 1: Excessive Bleeding After Neonatal Cardiac Repair: How do I Decide What Blood Products, Complex Concentrates or Factors to Use?
Laura Downey, MD; Kelly A. Machovec, MD

Dr. Laura Downey and Dr. Kelly Machovec led a great discussion at round table 1 among a group of anesthesiologists from a range of practice types and sizes. Challenges specific to neonatal bleeding risk - including long complex procedures, hypothermia, and immature coagulation systems - were discussed along with the importance of understanding developmental hemostasis to better inform management of neonatal coagulopathy.

There is wide practice variation in administration of factor concentrates – which products are used, how they are used, and when they are administered. The use of prothrombin complex concentrates (PCC) depended on institutional availability and comfort as there is a paucity of evidence and the use is off label in pediatrics. They also discussed concerns with issues of thrombosis, particularly in neonates. 

The differences between factor concentrate dynamics were noted specifically with reference to the increased lag time and decreased peak thrombin generation caused by bypass. Activated Factor VII increases thrombin generation peak but not lag time, 3 and 4 factor PCC decrease lag time, and 4 factor PCC increases peak thrombin generation. The loose consensus was a preference for FEIBA if available, which is a 4 factor PCC that contains factors II, VII, IX, and X as well as activated factor 7.

Many also noted that surgeon preference is a significant driving factor in patterns of practice. It was agreed that few institutions have official transfusion algorithms but that many physicians have a rough idea of their institution/surgeon/surgery-specific transfusion requirements. 

RDT 2: Strategies for Managing Confrontation with a Challenging Colleague
Jeremy M. Geiduschek, MD; Steven R. Tosone, MD

At round table 2, strategies for managing confrontation with a challenging colleague, attendance was affected by travel delays the night before. Moderators Dr. Jeremy Geiduschek and Dr. Steven Tosone discussed with Dr. James Spaeth their collective experiences with conduct issues among colleagues. All remarked on how the issue of challenging behavior touches every anesthesia practice in some way.

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