Association of Paediatric Anaesthetists of Great Britain & Ireland and the Society for Pediatric Anesthesia

42nd APA ANNUAL SCIENTIFIC MEETING Joint meeting with Society for Pediatric Anesthesia, providing an opportunity to compare and contrast practice on both sides of the Atlantic

14th - 15th May 2015

Aberdeen Exhibition & Conference Centre

Plus

13 May 2015 th

Half day meeting on Congenital Cardiac Anaesthesia Jointly presented by the Congenital Cardiac Anaesthesia Network and Congenital Cardiac Anesthesia Society

www.apagbi2015.co.uk

Programme

Welcome The Association of Paediatric Anaesthetists and the Society for Pediatric Anesthesia would like to welcome you to our joint meeting in Aberdeen, the Oil Capital of Europe, and home of the University of Aberdeen, founded in 1495. With a programme preceded by a joint meeting of the Congenital Cardiac Anaesthesia Network and the Congenital Cardiac Anesthesia Society, a wide range of topics are covered. Subjects covered include thoracic anaesthesia, quality improvement, management of metabolic disease, plus innovative interactive sessions on management of abnormal blood pressure and dealing with the difficult child. There is also a programme of lectures and workshops aimed at fulfilling aspects of the continuing professional development (CPD) matrix of the Royal College of Anaesthetists. The workshops provide an opportunity to try your hand at technical (surgical skills, neonatal resuscitation and bagpiping), and non-technical (human factors in paediatric anaesthesia) skills.

Photograph ©Archie Foundation

Association of Paediatric Anaesthetists of Great Britain & Ireland 21 Portland Place, London, W1B 1PY

An excellent social programme comprises a Civic Reception in the award winning Aberdeen Maritime Museum, and the Annual Dinner at the fabulous Art Deco Beach Ballroom. Come prepared to have a ceilidh! Aberdeen is synonymous with golf, but is also an ideal base for enjoying a wide range of sporting activities in the area. This meeting is hosted by the Department of Paediatric Anaesthesia of the Royal Aberdeen Children’s Hospital.

Dr Bob Bingham, President, APAGBI Telephone: +44 (0)20 7631 8887 Dr Shobha Malviya, President, SPA Fax: +44 (0)20 7631 4352 Dr Graham Wilson, Chair, APA 2015 Local Organising Committee Email: [email protected] 2

Contents Programme and workshops

4

Workshop descriptions

10

Exhibition floor plan & exhibitor list

11

Lecture summaries

12

Social programme

25

Oral presentations

27

Poster prizes

28

Posters

29



This meeting has been approved by the Royal College of Anaesthetists for the purposes of continuing professional development. Claim up to 2.5 points for the Congenital Cardiac Anaesthesia symposium (Wednesday) and 5 CPD points for each of the scientific programme days (Thursday and Friday). 1 CPD point is equivalent to 1 hour of learning.

3

Half day symposium on Congenital Cardiac Anaesthesia

Wednesday 13th May

Jointly presented by the Congenital Cardiac Anaesthesia Network and Congenital Cardiac Anesthesia Society. 13:00-13:30

Registration (Concourse) / Tea & coffee (Gordon Suite A) Location: Gordon Suite B

13:30-15:00

Session A Chair: Dr Helen Holtby, Toronto, Canada

13:30-13:55

‘Anarchy in the UK’/Shunts (2F01, 3F00) Dr Philip Arnold, Liverpool

13:55-14:20

‘Born in the USA’/RVOTO (3G00) Dr Mark Twite, Denver, USA

14:20-14:45

‘Handsworth Revolution’/Cath lab (2A04, 3G00) Dr Monica Stokes, Birmingham

14:45-15:00

Discussion

15:00-15:30

Tea & coffee (Gordon Suite A)

15:30-17:00

Session B Chair: Dr Tony Moriarty, Honorary Secretary, APA

15:30-15:55

‘Check Yoself’/Data and performance (1G01, 1I01, 1I05) Dr David Vener, Houston, USA

15:55-16:20

‘Blood and Chocolate’/CPB and Coag Management (2A05, 2A07, 3G00) Dr Helen Holtby, Toronto, Canada

16:20-16:45

‘Atlantic Crossing’/Training in UK and the USA (2H01, 2H02, 3J02) Dr Stuart Hall, Houston, USA & Dr Jon Smith, Newcastle

16:45-17:00

Discussion

4

Scientific Programme & Workshops 08:00-08:45

Registration (Concourse) & Industry exhibition (Boyd Orr)

08:45-09:00

Welcome by Dr Bob Bingham, President, APA (Fleming Auditorium) Location: Fleming Auditorium

Thursday 14th May

Location: Gordon Suite B

Location: Room 15/16 Workshops Please note: This workshop runs parallel to session 1

09:00-10:30

Session 1a: Common problems Chair: Dr Bob Bingham, President, APA

09:00-10:30

Session 1b: Thoracic anaesthesia Chair: Dr Kay Davies, Aberdeen

09:00-09:20

PONV (1D02, 2D02, 3A06, 3A12, 3I00) Prof Alison Carr, Plymouth

09:00-09:25

Thoracic surgery/endobronchial strategies (2A03, 2A07) Dr Stuart Hall, Houston, USA

09:20-09:40

Diabetes (2D01, 3I01) Dr Martin Jöhr, Lucerne, Switzerland

09:25-09:50

Empyema (2D01, 2D02) Dr David Spencer, Newcastle

09:30-10:30 Highland bagpipe workshop @ £65

09:40-10:00

Anaphylaxis (1B03, 2A06, 2C03, 2D01, 3D00) Dr Francis Veyckemans, Leuven, Belgium 09:50-10:20

10:00-10:20

Cerebral palsy (2D02, 3A08, 3I00) Dr Kathy Wilkinson, Norwich

Anaesthetic/analgesia (Nuss Bar) (2D02, 2E01, 2G03) Dr Ellen Rawlinson, London

Dr Thomas Engelhardt, Dr Kenneth McHardy & Prof George Youngson, Aberdeen

10:20-10:30

Discussion

10:20-10:30

Discussion

10:30-11:00

Tea & coffee/Industry exhibition/Posters (Boyd Orr) Location: Fleming Auditorium

Location: Gordon Suite B

11:00-12:30

Session 2a: The Parents say ‘Yes’ but the child says ‘No’ (1F01, 1F02, 1F05, 2D02, 3J00) Chair: Dr Jillian McFadzean, Edinburgh

11:00-12:30

Session 2b: Papers/things that changed my practice Chair: Dr Shobha Malviya, President, SPA

11:00-11:20

Lecture on session topic Dr Paul McConnell, Kilmarnock

11:00-11:20

Dr David Vener, Houston, USA

11:20-11:25

Case presentation on session topic Dr Graham Wilson, Aberdeen Management comment 1 Dr Hugo Wellesley, London

11:20-11:40

Prof Robert Friesen, Aurora, USA

11:25-11:40

5

Scientific Programme & Workshops

Thursday 14th May

Location: Fleming Auditorium

Location: Gordon Suite B

Session 2a: The Parents say ‘Yes’ but the child says ‘No’ (1F01, 1F02, 1F05, 2D02, 3J00) Chair: Dr Jillian McFadzean, Edinburgh

Session 2b: Papers/things that changed my practice Chair: Dr Shobha Malviya, President, SPA

11:40-11:55

Management comment 2 Dr Dean Kurth, Cincinnati, USA

11:55-12:10

Management comment 3 Ms Sara Payne, London

12:10-12:25

11:40-12:00

Dr Martin Jöhr, Lucerne, Switzerland

Management comment 4 Dr Lynne Maxwell, Philadelphia, USA

12:00-12:20

Prof Andrew Davidson, Melbourne, Australia

12:25-12:30

Discussion

12:20-12:30

Discussion

12:30-13:30

Lunch/Industry exhibition/Posters (Boyd Orr) Location: Fleming Auditorium

Location: Gordon Suite B

Location: Room 15/16

Session 3b: APA AGM

Workshops Please note: This workshop runs parallel to session 3

13:30-14:30

Session 3a: Training for rare events (2A06, 2D02, 3J02) Chair: Dr Elin Jones, Trainee Member, APA

13:30-13:50

High Tech Dr David Rowney, Edinburgh

13:30-14:30 Highland bagpipe workshop @ £65

13:50-14:10

High Tech – SPA Dr James Fehr, St. Louis, USA

14:10-14:30

Discussion

Dr Thomas Engelhardt, Dr Kenneth McHardy & Prof George Youngson, Aberdeen

13:30-14:30

6

Scientific Programme & Workshops

Thursday 14th May

Location: Fleming Auditorium 14:30-16:00

Session 4a: Management of abnormal BP (2D01, 2D02, 2D04) Chair: Dr Tom Hansen, Odense, Denmark

14:30-14:50

Lecture on session topic Prof Laszlo Vutskits, Geneva, Switzerland

14:50-15:05

Case presentation on session topic Dr Thomas Engelhardt, Aberdeen

15:05-15:15

Management comment 1 Dr Karen Bartholomew, Halifax

15:15-15:25

Management comment 2 Dr Randy Flick, Minnesota, USA

15:25-15:35

Management comment 3 Dr Anil Visram, London

15:35-15:45

Management comment 4 Dr Jurgen de Graaff, Utrecht, The Netherlands

15:45-16:00

Discussion

16:00-16:30

Tea & coffee/Industry exhibition/Posters (Boyd Orr)

Location: Gordon Suite B 14:30-16:00

14:30-14:55

Session 4b: QI-initiatives (1I01, 1I05, 3I00) Chair: Dr Suellen Walker, Chair of Scientific Commitee, APA

QI Projects Dr Dean Kurth, Cincinnati, USA

14:55-15:20

QI Projects APA Dr Sally Wilmshurst, London

15:20-15:50

NAP5 Dr Mike Sury, London

15:50-16:00

Discussion

Location: Fleming Auditorium 16:30-17:00

Session 5: APA Awards & Citations Chair: Dr Bob Bingham, Immediate Past President, APA

17:00-17:45

Session 6: Jackson Rees Lecture Chair: Dr Bob Bingham, Immediate Past President, APA Managing risk in the oil industry post Piper Alpha – Are there any lessons for patient safety? (1I03, 1I05, 2A12, 3J00) Mr Chris Allen, Group Director HSSEIA, Petrofac



7

Scientific Programme & Workshops

Friday 15th May

08:00-09:00

Registration (Concourse) & Industry exhibition (Boyd Orr) Location: Fleming Auditorium

Location: Room 15

09:00-10:30

Session 7: Scientific abstracts Chair: Dr Suellen Walker, Chair of Scientific Commitee, APA and Dr Tom Engelhardt, Aberdeen

Workshops Please note: These workshops run parallel to session 7

10:30-11:00

Location: Room 16

09:00-10:30 Surgical skills @ £65 Mr Chris Driver, Aberdeen

09:00-10:30 Neonatal resuscitation (1B03, 1B04, 2B07, 2D01, 3A01, 3D00) @ £65 Dr Michael Munro, Aberdeen

Location: Room 10

Location: Room 15/16

Tea & Coffee/Industry exhibition/Posters (Boyd Orr) Location: Fleming Auditorium

Location: Gordon Suite B

11:00-12:30

Session 8a: Metabolic disease (2A01, 2D01, 2D02) Chair: Dr Shobha Malviya, President, SPA

11:00-12:30

Session 8b: Charities – Contrasting styles Workshops Chair: Dr Graham Wilson, Chair, Please note: These workshops run parallel to session 8 APA 2015 Local Organising Committee

11:00-11:25

Mitochondrial disease Dr Grainne Gorman, Newcastle

11:00-11:20

Vietnam Dr William Casey, Dublin

11:25-11:50

Mucopolysaccharidosis Dr Lynne Maxwell, Philadelphia, USA

11:20-11:40

Ethiopia Dr Grant Rodney, Dundee

11:40-12:00

Nicaragua Dr Mark Twite, Denver, USA

11:50-12:20

Current management, future developments in metabolic disease Dr Saikat Santra, Birmingham

12:00-12:20

Charity viewpoint Mr Steve Sosebee, CEO, The Palestine Children’s Relief Fund

Discussion

12:20-12:30

Discussion

12:20-12:30

11:00-12:30 How to get published (1F05, 1G02, 1H02, 3J00) @ £35 Prof Andrew Davidson, Editor-in-Chief, Pediatric Anesthesia

Lunch/Industry exhibition (Boyd Orr) 812:30-13:30

11:00-12:30 Paediatric anaesthesia and human factors – tips and tools (1I02, 2D07, 3J02) @ £65 Drs John Rutherford & David Macnair, Dumfries

Scientific Programme & Workshops Location: Fleming Auditorium

Friday 15th May

Location: Gordon Suite B

Location: Room 15/16 Workshops Please note: This workshop runs parallel to session 9

13:30-15:00

Session 9a: First response and major trauma (1B04, 2D01, 3A10) Chair: Dr Carolyn Smith, Edinburgh

13:30-15:00

Session 9b: Emerging issues, new approaches Chair: Dr Alistair Cranston, Honorary Treasurer, APA

13:30-13:55

Paediatric trauma in the US Dr James Fehr, St. Louis, USA

13:30-13:55

Coagulation strategies (1A02, 2D04, 3I00) Dr Thorsten Haas, Zurich, Switzerland

13:55-14:20

Trauma system development in Scotland Mr Jan Jansen, Aberdeen

13:55-14:20

Apps and social media (1H02, 3J01, 3J02) Dr Sumit Das, Oxford

14:20-14:45

Paediatric first response: Issues around the prehospital management of children Dr Roland Armes, Aberdeen

14:20-14:45

14:45-15:00

Discussion

14:45-15:00

15:00-15:30

Tea & coffee/Industry exhibition (Boyd Orr)

13:30-15:00 Paediatric anaesthesia and human factors – tips and tools (1I02, 2D07, 3J02) What do you have to achieve to stay current/ @ £65 revalidated in the US/UK (1H02, 2H01) Drs John Rutherford & Dr Randy Flick, Minnesota, USA & Dr Teresa David Macnair, Dumfries Dorman, Sheffield Discussion

Location: Fleming Auditorium 15:30-16:30

Session 10: The President’s Session Chair: Dr Bob Bingham, Immediate Past President, APA

15:30-16:30

How would you do it in the real world? (2D02, 3D00) Prof Andy Wolf, President, APA; Dr Shobha Malviya, President, SPA; Dr Bob Bingham, Immediate Past President, APA & Dr Helen Holtby, Congenital Cardiac Anesthesia Society

16:30

Close of APA 2015 Meeting

9

Workshop Descriptions

If you have registered to attend, your name will be displayed in the APA registration area. If you would like to register, please come to the APA enquiries desk to check availability. A fee of £65 (unless stated otherwise) is payable for each workshop in addition to the registration fees.

Highland bagpipe This hands-on (!) workshop will introduce the basics of Highland bagpipes. Attendees will have the opportunity to study the setup and workings of the iconic Scottish musical instrument with enthusiastic and charismatic tutors in small group settings. Chanters (practice pipes) will be provided and are yours to take away to practice.

Paediatric anaesthesia and human factors – tips and tools This workshop will provide a brief introduction to human factors and non-technical skills. This will be followed by the opportunity to discuss the behaviours of anaesthetists on videos of simulated theatre work. We will consider some of the tips and techniques that can be used to reduce the risk of human errors. The workshop does not require any previous training in human factors or non-technical skills.

Neonatal resuscitation This workshop will give you the opportunity to update your knowledge and skills of the current Resuscitation Council (UK) guidelines for Newborn Life Support. An area that paediatric anaesthetists may find themselves involved in infrequently, there are substantial differences from paediatric resuscitation that merit an opportunity for a refresher session.

How to get published (£35) This workshop is run by section editors from the journal Pediatric Anesthesia and is designed to provide practical advice on how to prepare a paper for publication, and how to review a paper for a journal. There will be a brief interactive talk on what elements are essential to make a paper publishable, tips on how to format a paper, and basic do’s and don’ts in writing style. Attendees will then be divided up into groups to work with the editors to critically evaluate mock papers sent to them previously. Target audience ranges from senior trainees keen to get their projects published, to old hand reviewers keen to brush up their reviewing skills.

Surgical skills Are you happy that your suturing skills and both competent and safe? Are you fed up of being mocked by your surgical colleagues when suturing in a central line? Do you want your lines to be more secure? This surgical workshop will focus on the skills anaesthetists need to suture safely and competently. It will focus on instrument handling, instrument ties and safe needle practice. After some simple skills training using jigs there will be the opportunity to learn how to suture central lines in place more securely than you have ever done before.

10

Exhibition Floor Plan & Exhibitor List Location: Boyd Orr Stand No.

Company Name

12

APA Education and Training Committee

16

ARCHIE Foundation

26

Covidien - Now part of Medtronic

30

Dräger Medical UK Limited

11

Fannin (UK) Ltd

13

Fast Aid Medical & Mobility

20

Ferndale Pharmaceuticals Ltd

25

FUJIFILM SonoSite Ltd

1

Intersurgical

5

Karl Storz Endoscopy (UK) Ltd

19

MAQUET Ltd

21

Mercy Ships

8

MRI Devices Ltd

28

Sarstedt

3&4

Smiths Medical

10

Society for Pediatric Anesthesia

27

Verathon Medical UK Ltd

11

Lecture Summaries

Wednesday 13th May

Session A

Session B

‘Anarchy in the UK’/Shunts (2F01, 3F00) Dr Philip Arnold, Liverpool

‘Born in the USA’/RVOTO (3G00) Dr Mark Twite, Denver, USA

Over the last 10 years the outcome for cardiac surgery performed in children has continued to improve and all case mortality has almost halved. The marked exception to this is mortality for BT shunts performed in neonates, in the UK, which has increased substantially in the same time period. The available data makes it difficult to be conclusive about the cause for this; however the impression of many clinicians is that there has been an increase in the complexity of patients due to smaller size, less favourable cardiac anatomy and more complex co-morbidities. Whilst a number of alternative procedures, both in the operating room and the catheter lab, are becoming more popular BT shunts remain the only viable palliation for a subset of patients (and often the rescue therapy when other approaches fail).

Right ventricular outflow tract obstruction (RVOTO) may be the result of abnormalities at the mid-RV, the infundibulum, the pulmonary valve, the supravalvular region, or the pulmonary arteries. Previous surgery may be responsible for some obstructive lesions as well, for example stenosis of a right ventricle to pulmonary artery conduit. Depending on patient age, anatomy, and other factors, a variety of techniques, prosthetic materials, and valves are used to reconstruct the RVOT, but essentially all become dysfunctional over time, with obstruction, pulmonary regurgitation or both. The pathophysiology and treatment options of different forms of RVOTO will be discussed. In particular, management strategies for tetralogy of Fallot will be reviewed from initial treatment options to the life long sequelae. Clinical and diagnostic advances will be discussed and how they may help with decisionmaking, particularly the timing and type of future reinterventions.

During this talk I will review the data on outcome, review the physiology of shunts and aim to challenge some of our beliefs about the management of these patients. This is a very heterogeneous group and there is a lack of outcome based research, making it difficult to support any particular clinical approach. I won’t give clear answers to these problems but will hopefully lead us to ask the right questions.

‘Check Yoself’/Data and performance (1G01, 1I01, 1I05) Dr David Vener, Houston, USA Since 2010, the Congenital Cardiac Anesthesia Society has paired with the Society of Thoracic Surgeons to include anaesthesia-related data on patients with congenital cardiac diseases undergoing cardiac surgery and catheterisations. The purpose of the database is to provide a research forum for investigators as well as monitor anaesthesia-related management and outcomes data. There are approximately 120 surgical programs in the US, of which 112 participate in the surgical database and 47 in the anaesthesia portion. The database has already served as the foundation for multiple presentations and several publications. Outcomes and data from the anaesthesia module are presented here as an example of multi-disciplinary collaboration.

Learning objectives 1. Know that the speaker was really born in the USA! 2. Describe the anatomy and pathophysiology of different lesions which result in right ventricular outflow tract obstruction (RVOTO) 3. Understand the many therapeutic options to treat RVOTO 4. Appreciate the life long sequelae of tetralogy of Fallot and the diagnostic and decision making challenges they present 5. Understand the different treatment strategies for tetralogy of Fallot throughout a patient’s lifetime

12

Lecture Summaries

Wednesday 13th May

Session B ‘Blood and Chocolate’/CPB and Coag Management (2A05, 2AO7, 3G00) Dr Helen Holtby, Toronto, Canada Red ink and ketchup is more like it! Our understanding of coagulation has evolved from the concept of an exponential biochemical reaction to a cell based implosion of proteins, which occurs on a regular basis in vivo and is tempered by the instantaneous action of anticoagulant proteins and inhibitors. It is a system in constant flux. Cardiopulmonary bypass presents a profoundly procoagulant challenge which requires the use of heparin or other anticoagulants to prevent devastating thrombosis. Measuring the effectiveness of any given dose of anticoagulant in a timely fashion requires the use of point-of-care testing. At the end of the procedure, we would all be much more cheerful if the patient stopped bleeding instantaneously but this is seldom the case. The monitoring of both coagulation and anti-coagulation is fraught with variation and error. The ramifications of persistent bleeding are serious: thrombosis, tamponade, cardiac arrest and death. Learning objectives 1. Discuss the variations and shortcomings of bedside tests of anticoagulation; ACT measurement, HMS and I–stat as examples 2. Present the available information on tests of coagulation; TEG, Rotem, PLateletworks and laboratory testing 3. Review available data on prothrombotic compounds; Factor isolates and combination therapy 4. New technology, clear prime for infants and outcome data



Thursday 14th May Session 1a: Common problems

‘Atlantic Crossing’/Training in UK and the USA (2H01, 2H02, 3J02) Dr Stuart Hall, Houston, USA & Dr Jon Smith, Newcastle I’ll present the American Board of Anesthesiology basic curriculum for residents, including core measures of competence and a discussion of how anaesthesiologists are boarded (qualified) in the United States. Having spent time in both the US and Canadian systems, I’ll talk about their differences and similarities. I will also talk about the controversies surrounding the Maintenance of Certification in Anaesthesiology (MOCA) programme specifically and the maintenance of board certification in general in the US. Learning objectives 1. Participants will learn and analyse the basic format of medical training in general, and anaesthesiology training specifically, in the United States 2. Participants will also be able to appraise the “core competencies” in anaesthesiology as canonised by the American Board of Anaesthesiology

PONV (1D02, 2D02, 3A06, 3A12, 3I00) Prof Alison Carr, Plymouth During this lecture, I will review the POV guidelines developed in 2009 for the APAGBI and identify any new evidence for further recommendations. This will be an interactive session where I present the most up-to-date guidelines on POV and ask the audience for feedback on how best the guidelines can be disseminated. Learning objectives 1. Important factors in preventing and treating post-operative vomiting in children 2. The APAGBI recommendations on the prevention and treatment of post-operative vomiting in children 3. Other important factors that need to be considered when using antiemetics to prevent and treat POV in children 4. What antiemetics do you not have any proven efficacy in children

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Lecture Summaries

Thursday 14th May

Session 1a: Common problems Diabetes (2D01, 3I01) Dr Martin Jöhr, Lucerne, Switzerland

Anaphylaxis (1B03, 2A06, 2C03, 2D01, 3D00) Dr Francis Veyckemans, Leuven, Belgium

Cerebral palsy (2D02, 3A08, 3I00) Dr Kathy Wilkinson, Norwich, UK

In the UK, type 1 diabetes is a common long term condition in children (incidence 1:450).

Anaphylaxis, and especially anaphylactic shock, is a rare event during anaesthesia in children: its incidence is about 1-2/10,000 anaesthetics. Anaphylaxis is a lifethreatening systemic hypersensitivity reaction. Its cause is either allergic, which means related to pre-existent IgE antibodies reacting with their antigen, or not related to any immunologic mechanisms: the latter was previously called anaphylactoid reaction. Both mechanisms lead to release of histamine and other kallicreine-related molecules. According to the most recent French database, about 50% of the cases of anaphylaxis under anaesthesia are IgE-related and their main causes are allergy to latex, muscle relaxants and antibiotics. Nonallergic (ie non IgE-related) reactions are usually less severe but can be severe. The only way to make the precise diagnosis of the cause and mechanism of the reaction is to measure plasma tryptase shortly after the start of the reaction and to make skinprik tests and/ or RAST 4-6 weeks after the acute event. It is often difficult to establish an early diagnosis of anaphylactic reaction under anaesthesia because its signs are unspecific and the child is hidden under the surgical drapes. Some considerations will be developed about atopy and its different presentations in childhood, as well as allergy to antibiotics and mastocytosis. The treatment of anaphylaxis is based on volume loading and epinephrine, with bronchodilators in case of bronchospasm. Norepinephrine or vasopressin needs sometimes to be added, and glucagon is necessary in β-blocked patients.

Cerebral palsy is the most common motor disability in childhood and affects about 1 in 350-400 children in both the UK and US. It results from central nervous system damage which can occur antenatally or in the immediate perinatal period. There are important associations with extreme prematurity, perinatal hypoxia, multiple birth and maternal infection. However the term cerebral palsy encompasses a broad and variable diagnostic group which includes a spectrum of problems ranging from relatively mild disability as in lower limb diplegia to severe quadriplegia with associated co-morbidities and disability. The motor manifestations (which can be classed as spastic, dyskinetic, ataxic or mixed) generally occur alongside variable degrees of associated problems including visual and hearing loss, and difficulties with communication, learning and intellectual processing. Epilepsy is a common associated co-morbidity as is spinal/chest deformity and/or pulmonary aspiration. Many children and young people are underweight, with gastro-oesophageal reflux and swallowing and feeding difficulties being particularly common in the more severe forms of cerebral palsy.

Insulin: Regular insulin is widely used for intravenous administration in perioperative medicine. Technology allows to produce insulin analogues with altered pharmacokinetic properties: Lispro insulin (Humalog®) and aspart insulin (Novolog®) with earlier onset, sharper peak and shorter duration of action. Glargine insulin (Lantus®) is soluble in the packed acid solution but relatively insoluble at physiologic pH, this leads to delayed absorption. Insulin degludec is promising. Today the majority of children with newly diagnosed diabetes will be treated with these new compounds, and/or with an insulin pump. Three different scenarios have to be considered: 1. Minor superficial surgery allowing a rapid return to normal nutrition. 2. Minor superficial surgery in patients on an insulin pump. 3. Major surgery with an undetermined duration of postoperative fasting. The aim is to maintain the glucose concentration at the upper normal level; targeting between 7 and 10 mmol/l will allow to avoid hypoglycaemia in most cases. The cornerstone of a safe practice is measuring blood glucose repeatedly. It is important not only to focus on glucose concentration but also to avoid catabolism; insulin and glucose have to be administered perioperatively.

Learning objectives 1. The different properties of the new “insulin analogues” 2. Dosing of glucose and insulin 3. Prescription for a diabetic child 4. The most common mistakes

Learning objectives 1. Two types of anaphylactic reactions; causes of anaphylaxis in children; signs of anaphylaxis under anaesthesia; treatment of anaphylaxis

Anaesthesia for patients with cerebral palsy (CP) occurs in the context of all types of surgery and invasive procedures, and includes the emergency medical or surgical setting. The need for orthopaedic surgery (for correction of hip dislocation, contractures and spinal deformity) and general surgery (for the management of GO reflux and insertion of feeding gastrostomy) are both common. CP children also frequently present for Squint, Dental and ENT

14

Lecture Summaries Session 1a: Common problems surgery and for MRI scan. The anticipated perioperative problems include difficult venous access, temperature maintenance, and communication which will make e.g. pain assessment less straightforward. Chest complications are a real risk after prolonged surgery, and are aggravated by pre-existing chest deformity, immobility and/or poor cough. Cerebral palsy is one of the important causes of death in children and young people in the UK. In patients with a severe degree of cerebral palsy, anaesthesia and surgery pose additional risks, and there is no doubt that very careful pre-operative assessment is required, with appropriate provision of information about the risks to carers. Preparation includes the anticipated need for high dependency/ and or intensive care in some instances. Learning objectives 1. Incidence and prevalence of cerebral palsy 2. Common associated co-morbidities 3. Red flags in anaesthetic pre-assessment of CP cases 4. Tips for post operative care of CP cases 5. Risk factors and causes of death In CP

Thursday 14th May Session 1b: Thoracic anaesthesia Thoracic surgery/endobronchial strategies (2A03, 2A07) Dr Stuart Hall, Houston, USA I will discuss the most common (and perhaps uncommon) thoracic procedures in paediatric populations with emphasis on the anaesthetic management of patients undergoing these procedures. We will also survey the various strategies used to achieve lung isolation in paediatric patients, who range in size from premature infants to full-grown young adults. Learning objectives 1. Participants will be able to recall and explain the most common thoracic procedures in paediatric patients 2. Participants will criticise and appraise the various available techniques for endobronchial isolation in paediatric patients and assess their efficacy and safety

Empyema (2D01, 2D02) Dr David Spencer, Newcastle Empyema is an ancient and serious condition in children, but it became somewhat uncommon at the start of the antibiotic era leading some to consider that it was going to disappear. However, during the early 1990s the incidence and severity of this condition again increased, and the reason, or reasons for this phenomenon were initially unclear. The lack of familiarity of many paediatricians and surgeons with this condition certainly contributed to uncertainty and debate as to the best way to manage this condition. One of the initial difficulties in understanding the nature of the problem was that the great majority of cases were culture negative, probably as a consequence of antibiotic use prior to sampling of pleural fluid. It has only been with the advent of pneumococcal PCR and serotype specific detection techniques that we now know that the great majority of UK cases were related to re-emergence of S. pneumoniae serotype 1 as a major pathogen. The development of new conjugate pneumococcal vaccines and their inclusion into routine paediatric vaccination programmes has had a complex impact on this problem across the globe, partly because only a small number of the more than ninety pneumococcal serotypes can be contained in a single vaccine, and partly because use of these vaccines may lead to the development of disease from non-vaccine serotypes, so called “serotype replacement disease”. Approaches to the management of empyema remain divided across the UK and elsewhere. The reasons



15

Lecture Summaries

Thursday 14th May

Session 1b: Thoracic anaesthesia for this are also complex, but include the facts that paediatricians cannot even agree on the most important outcome measures, and the fact that skills and specialist resources vary considerably across the country. I will present the latest UK-ESPE data on the incidence and management of empyema across the UK, which should fuel some interesting debate!

Session 2a: The parents say ‘Yes’ but the child says ‘No’ Anaesthetic/analgesia (Nuss Bar) (2D02, 2E01, 2G03) Dr Ellen Rawlinson, London Surgical correction of pectus excavatum may involve the insertion of a shaped, titanium ‘Nuss’ bar into the chest cavity. The primary indication for this surgery is aesthetic; many children complain of symptoms such as breathlessness and chest pain but there is little objective evidence to support physiological compromise. Although termed minimally invasive due to the size of surgical scars, this is a significant surgical intervention. Postoperative analgesia can be very challenging, even with the use of multi-modal analgesia and regional techniques. Satisfaction levels following surgery are high and there is a clear improvement in psychological wellbeing. However, perioperative risks are not trivial and bar displacement/removal has been associated with catastrophic damage to intra-thoracic organs. Chronic pain develops in some children but the precise incidence is poorly defined. Learning objectives 1. Surgical intervention for chest wall abnormalities is primarily for aesthetic reasons 2. Establishing adequate postoperative analgesia is difficult even with multi-modal strategies and regional techniques 3. Perioperative complications are potentially highly significant

Lecture on session topic (1F01, 1F02, 1F05, 2D02, 3J00) Dr Paul McConnell, Kilmarnock The issues of consent and capacity are sometimes complex, and when applied to children even more so. Are children merely extensions of their parent’s will or do they have their own rights to self determine? Does acting to the letter of the law equate to acting in an ethically correct manner? Can it ever be right to act against a child’s wishes? The purpose of this session is to address these questions in a practical way marrying classical ethical thought with district general pragmatism. Learning objectives 1. To define and examine the concepts of consent and capacity 2. To review the current state of the law as it applies to consent in children 3. To review classical ethical concepts and their place in law and clinical practice 4. To create a toolkit and approach for managing consent dilemmas in children 5. To utilise this approach and apply it to clinical scenarios

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Lecture Summaries

Thursday 14th May

Session 2b: Papers/things that changed my practice

Session 3a: Training for rare events

Papers that changed my practice of paediatric Cardiac Anaesthesia Prof Robert Friesen, Aurora, USA

Papers that changed my practice Prof Andrew Davidson, Melbourne, Australia

High Tech (2A06, 2D02, 3J02) Dr David Rowney, Edinburgh

Paule et al. Ketamine anesthesia during the first week of life can cause long-lasting cognitive deficits in rhesus monkeys. Neurotoxicol Teratol 2011; 33:220-30

In this session, I will describe the simulation modalities that I employ on courses aimed at enhancing the performance of doctors in training and senior doctors. I will focus mainly on how I aim to deliver ‘immersive’ simulation creating a high degree of ‘fidelity’ for the learners. I will conclude by giving my views on the use of simulation for licensing and revalidation.

During the past seven decades, paediatric cardiac anaesthetists have been faced with clinical challenges that have affected morbidity and mortality outcomes. This lecture will review the papers that influenced clinical practice to meet the following clinical challenges. Learning objectives 1. Perioperative mortality rate has been reduced through advances in monitoring technology, anaesthetic equipment, knowledge of the hemodynamic effects of anaesthetic drugs, and development of dedicated cardiac anaesthesia teams 2. Postoperative coagulopathy and bleeding has been improved through the development of small extracorporeal circuits and rapid coagulation tests 3. Pulmonary and systemic circulatory balance in single ventricle patients can be achieved without impairment of systemic oxygenation 4. Adverse neurodevelopmental outcomes have decreased through and understanding of the many contributing factors

Of all the papers investigating the impact of anaesthesia on the developing brain, this is by far the most important. This paper is the strongest evidence that, give enough anaesthetic and you’ll almost certainly get an effect in primates. The relevance to routine practice is still unclear, but this paper makes me stop and think before I give any anaesthetic agent to an infant. Hill AB. The environment and disease: association or causation? Proceedings of the Royal Society of Medicine 1965; 58:295-300

Learning objectives 1. Understand the components of ‘immersive’ simulation 2. Understand what ‘High-Fidelity’ means 3. Understand the issues surrounding the use of simulation for licensing and revalidation

This paper elegantly explains how to coalesce all forms of evidence – not just the “levels of evidence”. As a way of understanding what shapes our clinical decisions, it is essential reading for any academic of thinking clinician. Davidson AJ, Eyres RL, Cole WG. A comparison of prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children. Pediatric Anesthesia 2002; 12:146-50 In preparing this paper Rob Eyres taught me the most important part of doing research; it’s the question that counts and not the P value.



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Lecture Summaries Session 3a: Training for rare events High Tech – SPA (2A06, 2D02, 3J02) Dr James Fehr, St. Louis, USA The simulation centre at St. Louis Children’s hospital was created in 2009 to provide a space for simulationbased education and research. The centre serves all providers at the 275-bed children’s hospital from patient care assistants to nurses, from providers to parents and from residents to faculty. The centre is extensively utilised with over 4000 individuals participating in simulation-based activities annually. The mantra for programme development is to create high quality programmes that are sustainable. Developing and sustaining the mission of the center is challenged by limitations of time, resources and physician engagement. This talk with discuss some of the lessons learned and development plans for the future. Learning objectives 1. Describe the simulation set up at St. Louis Children’s Hospital 2. Describe how the simulation centre is used to enhance the skills of physicians in training and experienced attendings 3. Difficulties in developing and maintaining a quality simulation programme 4. Simulation for licensing and maintenance of certification

Thursday 14th May Session 4a: Management of abnormal BP Lecture on session topic (2D01, 2D02, 2D04) Prof Laszlo Vutskits, Geneva, Switzerland Appropriate blood pressure management in neonates and young children is a difficult and highly controversial issue. Indeed, neither consensus on the definition of blood pressure nor agreement on the best approach to treat the perceived abnormalities are available. This is most probably explained by the fact that despite the existence of detailed normative values for blood pressure based on age or weight, the physiological blood pressure range that allows adequate organ transfusion is essentially unknown. This presentation will particularly focus on currently available human data linking systemic blood pressure values with cerebral blood flow and autoregulation in infants. Learning objectives 1. The limitations of systemic blood pressure values as surrogates for monitoring adequate cerebral oxygen delivery 2. The high interindividual variability in cerebral blood flow values, vasoreactivity and autoregulatory thresholds making the applications of normative values highly questionable 3. The technical and ethical difficulties to conduct clinical trials on these issues 4. The potential role of NIRS monitoring in the assessment of adequate tissue oxygenation

Session 4b: QI-initiatives QI Projects Dr Dean Kurth, Cincinnati, USA All over the world, healthcare faces a critical economic crossroad: How do we deliver better and more care at lower cost? Quality improvement science (QI) has been proven time and again in every industry to increase quality and decrease cost. Paediatric anaesthesiologists must learn and apply QI to our operating rooms, critical care units, and in-patient wards to help address the healthcare economic crossroad. QI contains subject matter knowledge and profound knowledge. Subject matter knowledge is specific to the field, such as paediatric anaesthesiology. Profound knowledge is general to all fields and contains 4 components: appreciation of a system, understanding variation, action learning, and change management. For paediatric anaesthesiologists to conduct QI, it is necessary to learn profound knowledge. Appreciation of a system. A system is an interdependent group working together toward a common purpose. It contains people, equipment, supplies, and processes. Understanding the system and getting everyone in the system to work together toward a common purpose is key to high quality. Poor service can arise from one or more failures in these systems. Improving quality requires the QI team to identify the role of each system and parts within a system in the poor service and to get the parties to accept responsibility and work together. Understanding variation. High quality is all about reducing variation. Common cause variation is the variation that is inherent to the process (the “noise”). Special cause variation is not part of the process but arises from a special situation. Run and control chart plot the product specification over time. A control chart also incorporates upper and lower control limits (3 standard deviations). High quality has very low common cause variation and special cause variation

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Lecture Summaries

Thursday 14th May

Session 4b: QI-initiatives rarely occurs. Action learning. QI follows the scientific method which contains hypothesis, purpose, inductive and deductive reasoning, study design, and experiment. The scientific method appears in the Roadmap and PDSA cycle. The Roadmap begins with a smart aim (purpose) followed by key drivers (hypotheses) about the system and designing interventions (experiments) to test the key drivers. QI makes several hypotheses and conducts a series of experiments to test the system, known as PDSA cycles: plan the test of the new process, do the test, study the results, and act on the results. Change management. People inherently resist change. Excellent communication skills by the QI project leader, proper incentives from management, and overt support by the leadership remain absolutely essential to overcome this resistance. QI vs. QA. QA involves systematic measurement and comparison with a standard. QA is goal directed to meet the standard and is widely used in benchmarking. QI involves a formal approach to the analysis of performance and the systematic efforts to increase it. The approach applies the elements of Profound Knowledge as well as systematic measurement. QI encompasses QA along with the methodology to improve the product or service if it is substandard. QI vs Research. Research aims to generate new, generalisable scientific knowledge, whereas QI focuses on making care better at local sites. However, healthcare systems share commonalities and thus QI results at one site are usually applicable other sites. Learning objectives 1. Define quality 2. List the 4 key elements of QI 3. Distinguish QA vs QI, and Research vs QI 4. Describe benchmarks, roadmap, FEMA, run charts, control charts, and PDSA ramps



QI Projects APA Dr Sally Wilmshurst, London A brief overview of quality improvement in healthcare will be covered along with the future aspirations of the APAGBI in this area.

Patient experiences varied considerably (“from the trivial to something akin to feelings of torture”). Psychological consequences varied too (none to lifechanging). Distress was particularly likely when patients experienced paralysis (93% of reports involved NMBs).

Learning objectives 1. What is quality improvement 2. Why should we do it? Where can we learn more 3. What the APA hopes to achieve in this field

NAP5 recommends adoption of an ‘anaesthetic checklist’ to be used after movement or transfer of the patient, to prevent incidents of AAGA arising from human error, monitoring problems, circuit disconnections and other ‘gaps’ in delivery of anaesthetic agent. The overall findings support DOA monitoring in selected circumstances: during TIVA with NMB.

NAP5 Dr Mike Sury, London

Learning objectives 1. Spontaneous reporting of AAGA is very rare and may be delayed until adulthood 2. Children’s reports can be as reliable as those from adults 3. Children should be believed and treated sympathetically 4. Serious long term psychological harm and anxiety states are rare, but do occur

The NAP5 is the largest ever study of the topic in the world. Within the UK National Health Service hospitals (and separately in Ireland) there were > 300 spontaneous reports of AAGA: 50% were reported within a day of the event and a considerable number were delayed (some > 60 y after the event). Reports were categorised: 141 certain/probable/possible cases; 17 awake paralysis due to drug error; 7 ICU and 32 after sedation. The estimated incidence of reports was ~1:19,000 Gas but this varied according to setting: ~1:8,000 when neuromuscular blockade was used, 1:8,600 for cardiothoracic anaesthesia ~1:670 for Caesarean section.

The full NAP5 report can be found online (http://nap5.org.uk/NAP5report).

The incidence of reports of AAGA in children in NAP5 is significantly lower than the previously reported incidence in prospective studies which used a Brice-type questionnaire (~1:60,000 versus ~1:135 respectively).

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Lecture Summaries

Friday 15th May

Session 8a: Metabolic disease Mucopolysaccharidosis (2A01, 2D01, 2D02) Dr Lynne Maxwell, Philadelphia, USA Anesthetic Concerns and Management in Children with Mucopolysaccharidoses (MPS): Difficult Airway and Beyond. Genetic, biochemical and phenotypic characteristics of different types of mucopolysaccharidoses. Issues of concern to the anesthesiologist • Airway o Obstruction due to infiltration of tissues in upper airway, epiglottis and arytenoids o Anatomic concerns for ventilation and intubation • Large tongue • Short and immobile neck • Pulmonary o OSA o Chronic parenchymal pulmonary disease • Cardiovascular o Valvular heart disease o Cardiomyopathy • Cervical spine instability o Odontoid hypoplasia or dysplasia • Other skeletal anomalies o Kyphoscoliosis • Difficult IV access • Cognitive impairment/developmental delay Types of surgery common in patients with MPS

Preparation for difficult ventilation and intubation • Premedication • IV access • Drugs • Equipment and techniques • Surgical backup Impact of enzyme replacement therapy and bone marrow/stem cell transplant on natural history of MPS and anesthesia concerns. Organisation for delivery of anaesthetic care to children with MPS in the USA. Learning objectives 1. Distinguish the phenotypic differences among the various mucopolysaccharidoses and their implications for anaesthetic management 2. Identify the important elements of preoperative assessment of children with mucopolysaccharidoses 3. Design a plan for safe induction of anaesthesia and airway management with appropriate backup plans 4. Understand the most common causes of adverse events during and after surgery and anaesthesia in children with MPS 5. List newer therapies that are being used to mitigate the progression of MPS, and what impact these therapies have on anaesthetic management

Current management, future developments in metabolic disease (2A01, 2D01, 2D02) Dr Saikat Santra, Birmingham Children with inherited metabolic disorders often require a number of surgical procedures and present a wide range of unique challenges for anaesthetists. During this talk we will look in broad terms at the different approaches to managing different metabolic disorders, focussing on specific precautions needed during anaesthesia. We will also consider how the management of many metabolic disorders is changing as newer treatments are being developed, and treatments such as liver or stem cell transplantation are increasingly being used and thereby exposing a number of children to potentially challenging anaesthesia when previously they might not have been. Learning objectives 1. To understand why some children with metabolic disorders cannot fast safely for surgery and need modified fasting advice 2. To appreciate some of the intraoperative challenges children with metabolic disorders can pose 3. To understand the role of organ and stem cell transplantation in the management of some metabolic disorders 4. To appreciate the range of newer therapies being developed for some metabolic disorders and the need for procedures under anaesthesia to evaluate/deliver trials of these

Preoperative evaluation and preparation

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Lecture Summaries

Friday 15th May

Session 8b: Charities - Contrasting styles Vietnam Dr William Casey, Dublin

Ethiopia Dr Grant Rodney, Dundee

Nicaragua Dr Mark Twite, Denver, USA

In 2007, Ho Chi Minh City (HCMC) Children’s Hospital No 2 requested assistance from Our Lady’s Children’s Hospital, Crumlin (OLCHC) to help them establish a CHD surgical and interventional catherisation programme. A cardiac team from OLCHC visited Children’s Hospital No. 2 and an understanding was signed. The Vietnamese Government committed funds to the hospital to establish this programme. This included establishing a cardiac theatre, a cardiac ICU and also up-skilling the cardiac team with education and teaching. The cardiac team spent approximately one year in the adult cardiac programme in HCMC and then subsequently visited and worked in OLCHC for 2 six month periods. In 2010, the Irish cardiac team which included a cardiac surgeon, cardiologist, a cardiac anaesthetist/intensivist, perfusionist, biomedical engineer, nurse visited HCMC. Working with the local team, they carried out two or three operations on patients with ASDs for approximately two weeks. Ho Chi Minh (HCM) cardiac team continued on operating for a further six months on children with ASD repair. They did approximately 140 cases in that six month period. This was repeated yearly with increasing complexity of surgery. They are now achieving over 300 cases per year and the planned programme is for a second theatre and expansion of the ICU to commence in 2015. CH No 2 will now have the capacity to operate on over 500 children with CHD per year.

The focus of the presentation is the perioperative care of NOMA (cancrum oris) patients receiving reconstructive facial surgery in Ethiopia www.facingafrica.org.

Providing specialised care in developing countries is often criticised for using limited resources to benefit a small number of people. However, in the current era of world politics and with a greater awareness of how one country’s misfortune can impact another country’s fortune, it is essential to develop a comprehensive approach to health care in these less fortunate countries.

Learning objectives 1. Establishing a successful and sustainable surgical and interventional congenital heart programme in a region that previously had little access to CHD interventional procedures



The technical (airway management and major surgery delivery) skills required for such work will be highlighted. As will the non technical skills, including the necessary teamwork, preparation, planning and organisation to safely deliver such complex care in a resource poor setting. The value of teaching and training, of local anaesthetists and of the recent innovation of an RCOA funded airway fellow, will be described. This is an example of a ‘vertical care’ (disease specific) program. An honest appraisal of such programs will be debated. Means to ensure an effective program will be presented. Learning objectives 1. Short term working trips (weeks) abroad are feasible and usually focus on surgical or on educational programs 2. Such programs can be rewarding and beneficial for both patients, hosts and visiting health care professionals 3. If engaged in such vertical programs its important to ensure that these are done to the highest standards, including excellent clinical care, proper audit and meticulous follow up of patients 4. The skills transferable back to UK practice are significant, and can enrich both individuals and the health care systems we work in

Primary care, such as providing clean water, sanitation, education, preventive health care and immunisations is the foundation. Secondary care helps identify and treat many common medical problems, but many less common complex medical problems will also be identified. It is no longer acceptable to inform patients requiring specialised care in developing countries that nothing can be done to help them because they already know that their condition is often treatable if they lived in a more developed country. In an effort to help patients with complex medical problems, ‘medical tourism’ (where health care teams visit from developed countries, bring all of their supplies, treat patients and leave) should be avoided. Instead, it is important to build collaborations with local providers, develop partnerships with governments, and develop sustainable infrastructure and training which will result in long term benefit to many patients needing specialised care. Learning objectives 1. Understand why it is important to build tertiary level care services in developing countries

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Lecture Summaries Session 8b: Charities - Contrasting styles 2. 3. 4. 5.

Appreciate the challenges of building a cardiac care programme in a developing country Describe some of the steps necessary to develop a successful programme Find out how a successful programme has been implemented in Nicaragua Understand that as physicians it is not what we bring but what we leave behind that is important

Charity viewpoint Mr Steve Sosebee, CEO, The Palestine Children’s Relief Fund The purpose of humanitarian medial relief missions are to provide short-term immediate urgent care and aid for patients in need who are not able to be treated within the local healthcare sector, and also to build up long-term sustainable programs that will give the system more self-sufficiency. The Palestine Children’s relief Fund (PCRF) is an American NGO who have been sending hundreds of volunteer surgery teams all over the Middle East for twenty years, and have been able to address adequately the weaknesses in the health care sector there, both within the short-term and long-term needs. How individual volunteer physicians can play a positive role in this will be the main focus of my talk.

Friday 15th May Session 9a: First response and major trauma Paediatric trauma in the US (1B04, 2D01, 3A10) Dr James Fehr, St. Louis, USA

Trauma system development in Scotland (1B04, 2D01, 3A10) Mr Jan Jansen, Aberdeen

Trauma is the major cause of death for children in the US outside of the neonatal period. The response to paediatric trauma requires an integrated approach of the various components of the health care system including first responders, ambulance crews, emergency room physicians, hospitals, and surgeons. Many children who suffer trauma in the US live are injured in close proximity to a Level 1 paediatric trauma centre and benefit from the resources available. Paediatric trauma care from a US has both unique challenges and similarities with other nations which will be explored in this lecture. Outcomes vary as a result of numerous factors and protocols that have been found useful will be reviewed. Team preparation through education endeavors, team training and simulation will be discussed.

The configuration of services is of key importance when expeditious access to complex care is required. Treatment within a trauma system – a network of designated trauma centres, with stratified capability, supported by emergency medical services – has been shown to be associated with improved mortality and functional outcomes. However, the design of trauma systems is often contentious. Scotland is currently in the process of establishing a national trauma system. This lecture will explore some of the considerations, developments and compromises, supported.

Learning objectives 1. Review how trauma care for children is organised and paid for in the United States 2. Examine the role of anaesthesiology in the initial response to trauma in the field and in the emergency room 3. Consider how paediatric trauma outcomes are defined and measured in the United States 4. Review protocols that are deemed beneficial in paediatric trauma care 5. Explore the role of simulation for trauma team training

Learning objectives 1. To understand the concept of an inclusive trauma system 2. To appreciate the importance of a region’s geospatial injury profile 3. To appreciate the additional complexities of providing specialist paediatric trauma care

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Lecture Summaries

Friday 15th May

Session 9b: Emerging issues, new approaches Coagulation strategies (1A02, 2D04, 3I00) Dr Thorsten Haas, Zurich, Switzerland The etiology of haemostatic changes during major paediatric surgery is multifactorial and may be related to dilutional coagulopathy, hyperfibrinolysis, and surgical complexity, as well as the impact of preexisting coagulation disorders or drug-related side effects. Fibrinogen is the first coagulation factor that achieves a critical low value during massive blood loss, while all other factors seem to be less affected by blood loss and haemodilution. A fast and reliable monitoring of the entire coagulation process (e.g. thromboelastometry) might be of extreme value for detection and guidance of effective coagulation management. Although the transfusion of fresh frozen plasma was recommended in several guidelines, the use of coagulation factors might offer an alternative and potentially superior approach in managing perioperative coagulation disorders. Based on the recommendation of the European guidelines for perioperative bleeding management and on observational data from a university children’s hospital in Zurich, the consequent use of prophylactic administration of tranexamic acid for high risk procedures, substitution of critical low fibrinogen levels, and maintenance of adequate FXIII levels, has shown to reduce the amount of transfused FFP and platelets significantly. Thereby, the mean total costs per patient consisting for transfused allogeneic blood products and coagulation factor concentrates were reduced likewise.



Learning objectives 1. Fibrinogen is the first coagulation factor that achieves a critical low value during intraoperative bleeding 2. Viscoelastic testing (ROTEM®/TEG®) offers a fast and reliable monitoring for major paediatric surgery 3. A ROTEM®/TEG®-based coagulation management using purified coagulation factors may reduce bleeding and transfusion requirements during major paediatric surgery

Apps and social media (1H02, 3J01, 3J02) Dr Sumit Das, Oxford Over two billion individuals have a social media account. Amongst the medical profession, there are eight new users of mobile social media every second. Social media describes web-based applications that allow people to create and exchange content. It’s like being delivered a journal whose headlines you’ll always find interesting – discover news as it’s happening and learn more about topics that are important to you. Following social media discussions can widen professional networks and ‘e-introduce’ delegates at meetings such as this. Social media has revolutionised the way people stay up-to-date with both medical and current affairs. While the benefits of social media in healthcare are broad ranging, there are also pitfalls for the unwary. The excessive use of social media can be a behavioural addiction influenced by psychological, social and biological factors and there are clear confidentiality issues. The level of smartphone and tablet usage by medical professionals is increasing exponentially. Applications (apps) now exist for all manner of medical situations, from resuscitation to ECG monitoring. Paediatric anaesthesia, with its inherent variability in patient size and resulting drug dose and equipment, lends itself perfectly to the use of specialist apps. Learning objectives 1. Understand the role of social media in helping an individual, department or education group to improve communication 2. How can apps enhance the training and education of doctors young and old? 3. Learn which apps and websites can help improve your work and access to information on a day-to-day basis

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Lecture Summaries

Friday 15th May

Session 9b: Emerging issues, new approaches

Session 10: The President’s Session

What do you have to achieve to stay current/ revalidated in the US/UK (1H02, 2H01) Dr Randy Flick, Minnesota, USA & Dr Teresa Dorman, Sheffield

process within the designated body and is responsible for making a recommendation about the doctor to the GMC. The RO can make one of 3 recommendations and recommendations are made on the information available from the appraisal process.

Relicensing in the UK is controlled by the General Medical Council and is based on a 5 yearly cycle of revalidation that started on the 3rd December 2012. Revalidation is the process by which doctors of all grades show they are up to date and fit to practice. The basis of this process is an annual appraisal done by a trained appraiser and based on the four domains of Good Medical Practice. The doctor has to supply supporting information to evidence that they meet the requirements of Good Medical Practice.

Learning objectives 1. Basis of relicensing in the UK 2. Differences to USA 3. Pro and cons of the 2 systems 4. Understanding of the approaches to maintenance of certification in the UK versus the USA

How would you do it in the real world? (2D02, 3D00) Panel members: Prof Andy Wolf, President, APA; Dr Shobha Malviya, President, SPA; Dr Bob Bingham, Immediate Past President, APA & Dr Helen Holtby, Congenital Cardiac Anesthesia Society

Supporting information covers the following 6 areas: •

Continuing professional development

•

Quality improvement activity

•

Significant events

•

Feedback from colleagues

•

Feedback from patients

•

Complaints and compliments

The key to the supporting information is the reflection by the doctor on all six are as and the implications and effects on their practice. Each doctor is assigned a designated body by the GMC, usually the trust where their employment contract is held. The responsible officer for that designated body is responsible for the revalidation

Within the speciality of paediatric anaesthesia, there are large variations in how to approach not only the complex case but also the so called straightforward case (for example an infant pyloromyotomy). Evidence based approaches to medicine have been promoted to optimise and standardise care, and yet there is often insufficient evidence within our field to advocate a definitive care pathway. Paediatric anaesthesia has become remarkably safe within the developed world and has often relied on the experience over many years of what works and what does not. Interestingly, this has led to differences in practice between individual institutions and geographical cultures. Our colleagues from North America offer an opportunity to discuss these differences. In this panel based session, we hope to provoke lively audience participation and challenge. We will ask the panel members to describe both a simple case that lies in mainstream practice, as well as a more complex scenario. It is expected that both audience and panel members will have different views on management of these cases, and it is hoped that the discussion of these varied approaches will be enlightening and entertaining.

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Social Programme

If you would like to register for any of the social events, please visit the APA enquiries desk

5K Run Evening Social Reception

Annual Dinner

Wednesday 13th May, 19:00 – 21:00

Thursday 14th May, 19:30 – 00:00

The evening social reception will be held at the Aberdeen Maritime Museum, with stunning views over the busy harbour. There will be drinks and canapés served during the evening, with light entertainment.

This year’s APA Annual Dinner will be taking place at the Beach Ballroom, Aberdeen; a fabulous Art Deco venue. There will be a drinks reception, 3 course dinner, wine, entertainment and the famous highland hospitality.

Location: Aberdeen Maritime Museum, Shiprow, Aberdeen, AB11 5BY

Location: Beach Ballroom, Beach Promenade, Aberdeen, AB24 5NR

Price: £10.00 per ticket

Price: £65.00 per ticket Dress code: Dress smart (black tie optional)



Friday 15th May 2015, Start time: 06:45 The 5K run will be taking place along the Beach Esplanade and it will be starting at 06:45 on Friday 15th May 2015. On your arrival at the meeting point, you will be given a bib and number for the run. There are also a couple of prizes for the runners with the quickest times. Meeting point: Main entrance of Beach Leisure Centre, Sea Beach, Aberdeen AB24 5NR Price: Free To register for the run, please go to the APA enquires desk where you will be given a map of the run and a disclaimer form. Before you are allowed to run, you will need to sign a copy of the disclaimer form and hand it to a member of APA staff before or on the morning of the run.

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H G R U B N I ED SCOTLAND

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Oral Presentations No.

Author

Co-Authors

Title

1

O Nafiu

H Tuckwell

Diagnostic performance of indices of adiposity to identify children with perioperative respiratory complications

2

H Tuckwell

O Nafiu, S Kanmanthreddy

Association of high body mass index (BMI) and incident bronchial asthma (BA) with paediatric perioperative laryngospasm

3

S Redfern

J Lutz

Impact of Oramorph TTO protocol used for day case tonsillectomy

4

L Tan

E Taylor, B Anderson, J Hannam

Pharmacokinetics of parecoxib and its metabolite in children

5

S Ritchie-McLean

D Frear

Specialist paediatric anaesthetists: an unnecessary luxury?  A service evaluation assessing the need for paediatric anaesthetists in a regional paediatric centre

6

J Dawes

E Cooke, R JimenezMendez, K Brand, P Winton, G Lauder, B Carleton, G Koren, K Aleska, M Rieder, C Montgomery

Pharmacokinetics of single dose oral morphine in healthy children following surgery

7

A Kirkwood

M Lilaonitkul, JK Kiwanuka, MT Nabukenya, F Evans, M White, IA Walker

Safer Anaesthesia from Education (SAFE) paediatric anaesthesia in Uganda

8

G Lauder

M Görges, E Karlsdóttir, N West

Neonatal vital sign deviations during general anaesthesia for pyloromyotomy

9

A Mathieson

G Wilson

Hyponatraemia in paediatric surgical patients receiving intravenous fluids: A comparison of two departments



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Poster Prizes No.

Author

Co-Authors

Title

13

V Duffin-Jones

I Aguilera

Efficacy of post-operative analgesia for repair of Hirschsprung’s Disease and imperforate anus – An audit

17

H Tuckwell

O Nafui, J Neil, T Phan

Endotracheal tube size estimation in children undergoing anaesthesia: effect of high body mass index

21

C Wallace

A King, K Davies

Emergence delirium after paediatric dental extractions

28

A King

C Wallace, K Davies

Pain @ home in ambulatory children after dental surgery - A re-audit following protocol changes

38

L Elgie

A Visram

Laryngeal mask airways in children: cuff pressure and sore throat

73

C Raistrick

H Bhangoo, T Nazir

The incidence and factors affecting paediatric distress in the anaesthetic room

84

S Mir

B Graino, S Ray

Paediatric status epilepticus and barriers towards local extubation

101

A Keaney

R Copeland, A Varughese, M Kanjia, D Buck

Understanding and reducing peri-operative errors in acetaminophen (paracetamol) administration: An improvement collaborative between Royal Belfast Hospital for Sick Children (RBHSC), N.  Ireland and Cincinnati Children's Hospital Medical Center (CCHMC), USA

122

J Leedham

V Hancox, Z Kulcsar

Capnography and rebreathing in the Paediatric Post Anaesthetic Care Unit (PACU) at Royal Manchester Children's Hospital (RMCH)

127

H Gan

W Karlen, D Dunsmuir, G Zhou, G Dumont, JM Anserminio

Comparison of the performance of a mobile phone respiratory rate counter with the WHO ARI timer

28

Posters No.

Author

Co-Authors

Title

2

O Nafiu

G Tazhibi, H Tuckwell

Elevated preoperative blood pressure is a risk factor for pre-incision hypotension in paediatric surgical patients

4

M Ross

A Baxter

Experience of using a new Aircraft Medical McGrath® MAC 1 videolaryngoscope blade to facilitate intubation in neonates and infants 

5

M Ross

A Dalton, I Amir, R Forrest, P Neal, A Sharma, U Theilen

Acute tongue entrapment and injury by a sports bottle lid 

6

P Stewart

A Keaney

Audit of epidural, patient-controlled (PCA) and nurse-controlled analgesia (NCA) prescriptions in the regional children's hospital in Northern Ireland

7

P Stewart

A Keaney

“What matters to me today?” In the regional paediatric intensive care unit (PICU)

8

Y Nyman

A Fredriksson, P-A Lönnqvist, H Viberg

Exposure to etomidate in neonatal mice: effects on adult spontaneous behaviour and apoptosis assessed by activated caspase-3

9

L Tan

A Rainey, S Pickup, S Thornton

An evaluation of the pain management of patients undergoing repair of pectus excavatum

10

L Shepherd

J Gordon

Improving fasting times for urgent and emergency surgery at Sheffield Children's Hospital

11

ZA Smith

S Lobo

Paediatric uvular necrosis following general anaesthesia in the prone position

12

L Jack

E Wallace

A review of chronic pain services at the Royal Hospital for Sick Children, Glasgow, 2013

14

AM McClean

A Keaney

Making paediatric intensive care safer: Implementation of a PICU safety brief

19

H Lewis

D Barman, J Owen

A survey of anaesthetic management for congenital tracheo-oesophageal fistula repair in a UK tertiary paediatric centre

20

C Wallace

K Davies, Z Kusnirikova

Persistent excessive preoperative fasting – Time to address the problem

23

J Montague

M Julian

Patient safety audit: Why are we still getting residual drugs in paediatric cannulae?

24

A Simpson

G Bell

Yorkhill Royal Hospital for Sick Children, Glasgow. Simple analgesia audit Aug-Dec 2014

26

R Stoddart

J Hammerschlag

Peri-operative paracetamol prescribing practice in paediatric patients



29

Posters No.

Author

Co-Authors

Title

29

A Ray

D Burton

Paediatric anaesthesia: A survey of pre-operative information delivery, parental anxiety and overall parental satisfaction

30

EM Hoogenboom

E Fernandez-Garcia

Respiratory adverse events in post-anaesthesia care unit (PACU) as a quality outcome measure

31

EM Hoogenboom

M George

Anaesthesia for removal of foreign body from the respiratory tract: A review of practice in a tertiary referral centre

32

B Tingle

R Evans

A novel web based device for patient feedback in paediatrics

33

R Copeland

A Keaney

Paracetamol in paediatrics: What's happening, why and what to do about it?

34

A King

K Reilly, M Canning, A Moores, G Bell

A retrospective audit of analgesia for NUSS procedures in RHSC, Glasgow

35

L Young

A Sehgal, R Gande, J Harding

Audit of paediatric day surgery pain assessment

36

M Johnson

D McNeill, J McGinley

Pectoralis block in paediatric practice. A case series

37

J Montague

J Lee

Audit of post-operative analgesia following cleft lip and palate surgery after the withdrawal of codeine phosphate

39

L Schwartz

M Twite, S Stenquist, S Miyamoto

Cardiac arrest in a heart transplant patient receiving dexmedetomidine during cardiac catheterisation

40

M Ross

S Boyle, M Crawford, E Dickson

Blood loss in spinal scoliosis correction in children and adolescents: A retrospective analysis

41

M Ross

A Baxter, K McCarthy

The incidence of neurodevelopmental issues following neuraxial ketamine in children: A 9-year retrospective analysis of 690 administrations of ketamine

42

K Francis

R Evans

An audit of post-operative analgesia prescribing and pain assessment in major paediatric craniofacial surgery

43

G Christodoulides

R Dulai

A case of difficult intubation in a paediatric patient with I-Cell disease, mucolipidosis type II

44

NS Wilder

S Yu, JE Donohue, CS Goldberg, RM Lombel, NB Blatt

Fluid overload is associated with late poor outcomes in neonates following cardiac surgery

45

C Kelly

D Fradkin, R Davison, M Abdelrahman

Inflation pressures during hand ventilation – where do we really peak?

30

Posters No.

Author

Co-Authors

Title

46

M Naatjes

L Segura

Anaesthetic management of a large anterior mediastinal mass in a child with Tumor Lysis Syndrome

47

P Winton

L Armstrong

Mapping the 'MEPAT' paediatric anaesthesia simulation course to the Royal College of Anaesthetists UK (RCoA) training curriculum

48

A Schure

L Brown, C Allan, P Weinstock

In-situ simulation in the paediatric cardiac catheterisation laboratory: A useful tool to prepare for potential disasters

49

J Dick

DT de Wet, S Krosnar, D Rowney, P Winton

High fidelity simulation for revalidation in paediatric anaesthesia - linking the tertiary unit with a local district general hospital (DGH)

50

N Sharma

H Wrigley, S Syed

Magnesium use in paediatric cardiac surgery, an evaluation of our practice

54

A Kirkwood

E Rawlinson

Anaesthesia for non-bypass surgery in children with Berlin Heart Excor VAD - a 10 year case series

55

V Patle

K Daborn, R Manek, S Misquita

Audit of post-operative pain relief following tonsillectomy

59

L Forbes

G Rodney, S Byer, D Cameron

Development of a paediatric theatre ticket

60

A Agrawal

L Tooke, RP Kaur

The model of effective theatre utilisation

62

J Sumal

P Angadi, N Ware

Waiting times for paediatric emergency surgery

64

A Dalton

H Dunne, S Byer, D Cameron, G Rodney

Pregnancy testing in paediatric surgery

65

A Dalton

S Byer, C McGee, D Cameron, G Rodney

Post-list debriefing in paediatric surgery

68

C Kelly

D Fradkin, J Owen

Near-infrared spectroscopy - the next step in neonatal perioperative monitoring?

69

K Pearson

S Crawley, G Rodney

Post-operative opioid analgesia for children in Scotland

70

K Pearson

S Crawley, G Rodney

Nursing perspectives on changes to oramorph use in children

71

S Poulose

H King

Anaesthetic management of a child with Allgrove's syndrome



31

Posters No.

Author

Co-Authors

Title

72

C Woo

M Avanis, R Martin

Supraventricular tachycardia on induction of anaesthesia in paediatric electrophysiology studies

74

C Targett

C Cumming

What's that smell in children's theatre? The use of essential oils to promote inhalational induction of anaesthesia

75

M Same

S Mallory

Paediatric neuroanaesthesia and the difficult airway

76

H Davies

S Barnes, R Craig

Using what you've got - difficult paediatric intubation in a child with Dandy Walker Syndrome in status epilepticus

77

M C Avanis

L O'Donohoe, N Dobby

Audit of paediatric airway assessments

78

M C Avanis

L O'Donohoe, N Dobby, K Ong

Predicting a paediatric difficult airway – a pilot study

79

S Bapat

N Panesar, B Patel, K Wouters

Service evaluation of adenoidtonsillectomies to improve quality of care delivered at a tertiary referral centre

80

V Duraiswamy

R Grimaldi, A Mishra

A study of intra-operative regional analgesia for paediatric hypospadias repair over a 5-year period

81

C Kelly

E Whetton, A Dobson, G Briggs

One year of anaesthesia for MR scans - a service evaluation

83

R Pegg

G Welch

A review of equipment and strategies available for intraoperative ventilation in neonates

85

D Wright

N Soundararajan

Challenges for the provision of paediatric anaesthetic services in a large, non-specialist centre

87

D Marriott

M Walters

Won't someone think of the children? A survey of consultant exposure to anaesthetising infants in a large district general hospital

88

P Stevens

S Berridge, M Scott, I Smith

Closing the loop and maintaining the standard - a re-audit of the rate of PONV after paediatric strabismus surgery following the introduction of an anaesthetic protocol

89

S Honnesh

M Thadsad, C Davies, S Elnour, L Tooke, N Seth

National survey of perioperative pain management for Adolescent Idiopathic Scoliosis (AIS)

90

H Vail

S Ranson

Paediatric emergence delirium: An evaluation of cases at Southampton University Hospital

91

R McCrossan

M Clement

The paediatric acute pain service at the Great North Children's Hospital: A survey of patient/parent satisfaction

32

Posters No.

Author

Co-Authors

Title

92

M Bowler

J Diacono

A survey of analgesic practice amongst anaesthetists for adenotonsillectomy/tonsillectomy surgery in the North West Deanery

93

J Abbott

E Johnson, E Tokidis, K Thomas, K Tzifa

Audit of the anaesthetic management and patient outcomes of endoscopic tympanoplasty compared with open tympanoplasty surgery

94

L Talbot

P Shorrock, L Hartley

Adenotonsillectomy for sleep disordered breathing - an audit of peri-operative practice

95

E Jones

T Moriarty

A good match? A comparison of paediatric anaesthesia consultant jobs at specialist centres with the number of specialty training posts available

96

E Jones

V Yates

Post-operative analgesia following adenotonsillectomy - a telephone survey

97

S Matthews

N Edmonds

Development of a paediatric scoliosis surgery service: The first 18 months at the Royal London Children’s Hospital

98

T Bevir

P James, B Thiessen

Management of paediatric difficult airways at the Evelina London Children's Hospital

99

E Perritt

T Soskova, R Evans, K Lai, J Li Wan Po, S Chitgopkar, B Batuwitage

Use of a modified WHO checklist for corrective cleft surgery during an overseas outreach project: a safety improvement initiative

100

N Kirodian

T Engelhardt

Parental satisfaction survey - a quality assurance process

102

R McKendry

R Colhoun, A Phiri, S Musamara, P Dart, D Snell

Improving standards in paediatric recovery and documentation in the University Teaching Hospital (UTH), Lusaka, Zambia: First audit cycle of practice following recovery nurse education

103

S Naithilath

A Walker

Airway topicalisation for neonatal and infant microlarygoscopy and bronchoscopy

104

S Martin

T Naylor

The impact of emergence delirium on subsequent behaviour 2 weeks postoperatively

105

B Vlassakova

D Perry

Improving the experience of children with autism and their families in the perioperative period - work in progress

106

B Vlassakova

C Munoz, R Blum

Ensuring essential clinical experience in a paediatric anaesthesia fellowship

108

G Lauder

M Görges, N West, E Karlsdóttir

Neonatal vital sign deviations during general anaesthesia: Developing consensus on what represents significant change



33

Posters No.

Author

Co-Authors

Title

111

D Gaona-Atienza

LE Fernandez, MD Carceles, P Motta, E Dagohum, R Lopez

Congenital complete atrioventricular block (CCAVB) in newborn. Permanent pacemaker implantation. Multidisciplinar management

112

M Redmond

M Khater

Facilitating timely non-elective surgical intervention in children – clinical audit and recommendations

113

S Slinn

M Roberts, L Webster

A quality improvement project for discharge analgesia in children undergoing adenotonsillectomy

114

J Scheffczik

E Allison

How useful is audit?  Our experience of completing an audit cycle....

115

RP Kaur

DJ Taylor, A Agrawal, A Janowicz

Parental satisfaction with perioperative arrangements

116

C Liossi

117

K Peiris

Z Forster, J Sumal, B Cagney

Continuous local anaesthetic (LA) infusion in the transversus abdominis plane (TAP) using an elastomeric pump: post-operative analgesia regimen for abdominal surgery in children

118

T Makinde

J Norman, L Walker, E Monahan

Parental survey evaluating opinions of providing a drug chart for analgesia administration at home

119

J Abbott

O Bagshaw, A Tatman

Peri-operative airway complications in children - a comparison of volatile anaesthesia and TIVA techniques

120

J Owen

W Costigan

Audit of anaesthetic approaches to tracheo-oesophageal fistula repair at a paediatric tertiary referral centre in the UK

121

J Scheffczik

R Rogers

Blood loss and insertion of central lines for early-onset scoliosis surgery

124

V Ramanathan

J Whitton, A Maguire

Evaluation of quality of pain relief following discharge of paediatric surgical patients

125

D Rangappa

R Danha, S Sykes, A Mayell

Pre-operative paediatric anxiety - novel ways to tackle it

126

S King

C Vimalanathan

The investigation of a “near-miss incident” to improve patient safety in the theatre environment

128

R Barbour

R Subramanian, C Wetherill, V Guruswamy

Robotic paediatric urology: anaesthetic implications.  A case series

Development and evaluation of a theory driven, evidence based, online intervention to prepare young children for general dental anaesthesia

34

Posters No.

Author

Co-Authors

Title

129

A Mesbah

K Thies

Anaesthetic management of laparoscopic nissen fundoplication in a child with bilateral cavopulmonary shunts for Hypoplastic Left Heart Syndrome

130

J McFadzean

C McDougall, G Manning

Which children need critical care admission after adenotonsillectomy for obstructive sleep apnoea?

131

A Mesbah

R Danha, S Chari, A Johnson, T Thwaites

Audit of analgesia for paediatric adenotonsillectomy

132

C Wilson

SB Suderson

Harlequin ichthyosis child - anaesthetic management: A case presentation

133

N Forshaw

L Lofton, M Burmester, A Desai, M Lane

Perceived impact of interprofessional paediatric simulation on anaesthetsist compared with paediatricians

134

D Greaney

P Harper, C Guerin, S MacColgain, A Aglan, S Harte, B O'Hare

Quality of analgesia following elective day surgery at an Irish Children's Hospital

135

S Cavanagh

K Megaw

Review of tranexamic acid use and analgesia for paediatric scoliosis surgery

136

D Celnik

P Farquharson, G Rodney

Paediatric tonsillectomy

A PDF download of the abstract book and speaker lecture summaries are available at www.apagbi.org.uk

35

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