Research Focus: Safe Conduct of Anesthesia
Unfortunately, there is no widespread and supported research activity on caseload and experience of anesthesiologists and related complications. Research activity on ‘safe conduct’ of anesthesia is similarly sporadic and not coordinated. A recently reported case series indicates that the conduct of anesthesia directly influences morbidity in vulnerable brains.1
Several reviewers and expert witnesses are in a position to add numerous similar cases but they are difficult or impossible to access. The European Society of Anesthesiology sponsored APRICOT project provides further information regarding the relationship between caseload, organizational setup and outcome in pediatric anesthesia.
What is ‘normal’? What happens when ‘leaving normal’?
Future research on cognitive deficits and learning disabilities following general anesthesia in early childhood must investigate the impact of peri-operative hypotension, hypocarbia, hypoxemia, hyponatremia, hypo- and hyperglycemia on brain injury and neurodevelopment.
The key questions ‘What is normal?’, ‘What is the minimal safe blood pressure?’, ‘What are the effects of anesthetics on the lower limit of cerebral autoregulation ?’ and ‘How is cerebral perfusion during anesthesia safely monitored?’ must be answered. This mandates a considerable investment of precious financial and personal resources.
What is safe?
Future prospective clinical studies investigating potential neurotoxic effects of anesthetic agents on the vulnerable brain have to outline and report peri-operative anesthetic care data. Vital sign data should to be recorded by electronic patient data management systems (PDMS) as written anesthesia charts are not always completed in a timely fashion.
Adverse events are often incorrectly noted or under-reported retrospectively. Similarly, in multi-center studies, no center likes to be identified as an ‘outlier’ with a higher rate of complications and peri-operative adverse events. Therefore, on-going prospective clinical studies without well documented vital sign parameters must be interpreted with care.
Research Focus: Anesthetic Agent induced Neurotoxicity
Current pediatric anesthesia research is concentrating on the effects of neurotoxicity (GABAA, NMDA receptors and apoptosis) instead of the safe conduct of general anesthesia (maintaining physiological norms of blood pressure, PaCO2, electrolytes, temperature and blood glucose) in the vulnerable child. However, is this current research the best we can offer these children or is this merely an academically lucrative one? Unfortunately, evidence-based improvement of pediatric anesthesia is hampered by a lack of financial incentive (grants), recognition (impact factors), and lack of personal gain (professional advancement). Research on ‘anesthetic agent-related neuromorbidity’ rather than evaluation of the impact of good clinical practice as well as dedicated teaching and supervision of residents is currently perceived to be academically more rewarding
Assurance of quality clinical care requires relentless vigilance and a sustained commitment to proper training, education and supervision in pediatric anesthesia. This requires maintenance of knowledge and focused clinical expertise in the care of infants and children. It is our strong conviction that failure to do so will diminish our role in mitigating peri-operative morbidity in this vulnerable age group.
Quality of anesthesiology care and outcome
A huge amount of money is currently invested in animal and clinical research investigating the potential neurotoxic effects of anesthetic agents on the developing brain. However, there is a paucity of research on the effects of the quality of anesthesiology care on outcomes.
The effect of experience and training is ignored
Although it is now common knowledge that children in inexperienced hands have a higher peri-operative anesthetic morbidity, several national anesthesia societies are not willing to accept and pursue a certification of specialized pediatric anesthesia as recently developed by the American Board of Anesthesiology. The concept that a general anesthesiologist is able to provide anesthetic care for all patients from birth to any old age is outdated. In Denmark, anesthesia in children younger than 2 years of age is no longer part of the anesthesiology training curriculum.
- Is it easier, cheaper and more beneficial for governing bodies to fund research on neurotoxicity rather than investing money in standardizing skills, experience and environment/setting for pediatric anesthesia?
- Is it easier to explain that anesthetic agents are responsible for ‘adverse neurological outcomes’ in children following surgery, rather than to admit that there may not be sufficient resources available for, or directed appropriately to adequate peri-operative anesthesia care for each child?
Learn more about …
- causes of neuromorbidity
- how research is currently focused and how it could better help children
- the quality gap between ‘state of the art’ and clinical practice
- the “Big Five W” – What specialist care is about
- 10-N quality – A simple matrix for reviewing your care
- how to meet the concerns of parents
- Safetot’s story and mission
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- the FAQ for practitioners
- the FAQ for parents
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