Pediatric Cardiothoracic Anesthesia

[Iso4ane]

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Per prior posts, it seems that if one wants to pursue this route, that going through peds fellowship first may the more straightforward route. But, how difficult would it be go from adult cardiothoracic to peds. Obviously the patient population and types of issues seen in these population differ greatly, but does it really matter which on is (ped vs cv) is done first?

 

[Libertas]

Adult CT would not be helpful. Maybe there are a fair amount of people that became experienced and grandfathered through that route, but programs now want pediatric fellowship trained people, then either OTJ training or a 2nd fellowship in peds cardiac specifically.

I suppose I'm not an expert on that, but since peds cardiac is something I have/am considering, I know a little.

 

[AdmiralChz]

Per prior posts, it seems that if one wants to pursue this route, that going through peds fellowship first may the more straightforward route. But, how difficult would it be go from adult cardiothoracic to peds. Obviously the patient population and types of issues seen in these population differ greatly, but does it really matter which on is (ped vs cv) is done first?

Academic center here, 4 of our 5 Peds cardiac attendings went through adult CV. Probably more common in academic hospitals (vs standalone Peds hospitals?), but absolutely possible (2 are grads within the last 3-5 years). Ask yourself what you'd like to do outside of the Peds heart room - general Peds vs adult hearts?

 

[2Fast2Des]

I'm not sure why there's a necessity to do peds or peds cta. I've rotated at a children's hospital where the crna's do everything including peds hearts and some who seem to have no problem talking back to the attendings without recourse

 

[teacher2md]

I'm not sure why there's a necessity to do peds or peds cta. I've rotated at a children's hospital where the crna's do everything including peds hearts and some who seem to have no problem talking back to the attendings without recourse

Wow...who's letting these people do peds hearts? That's insane.

 

[pgg]

About the only thing peds cardiac and adult cardiac cases have in common is the fact that there's (usually) a bypass machine involved.

 

[Man o War]

Wow...who's letting these people do peds hearts? That's insane.

Agreed. CRNAs aren't even allowed in *adult* cardiac rooms where I've worked and they had a very limited role where I trained- think charting vitals and pushing drugs only when told to by the attending or fellow. I never heard them offer an opinion much less talk back. And it would be a cold day in hell before they did anything in the peds cardiac rooms at all.

 

[mikey014]

Wow...who's letting these people do peds hearts? That's insane.

That's highly unlikely. There must be an incomplete story here. No peds cardiac surgeon would let an unsupervised nurse do anesthesia on a peds cardiac case.
To do peds cardiac means you can do any peds cardiac case (mechanical assist device, fontan, heart transplant, etc)

These surgeons are the most high strung surgeons on the sickest patients.

Especially if said medical center has residents rotating there ... => academic hospital. If residents are rotating there ... That means there are board certified anesthesiologist there. No peds cardiac surgeon is choosing an unsupervised nurse over an anesthesiologist (fellowship trained or not).

 

[2Fast2Des]

That's highly unlikely. There must be an incomplete story here. No peds cardiac surgeon would let an unsupervised nurse do anesthesia on a peds cardiac case.
To do peds cardiac means you can do any peds cardiac case (mechanical assist device, fontan, heart transplant, etc)

These surgeons are the most high strung surgeons on the sickest patients.

Especially if said medical center has residents rotating there ... => academic hospital. If residents are rotating there ... That means there are board certified anesthesiologist there. No peds cardiac surgeon is choosing an unsupervised nurse over an anesthesiologist (fellowship trained or not).

They are "supervised" but they are also requested to do the big pedi cases (crani, synostosis, scoliosis, etc) as well, and let's just say I've heard bad things happening intraop in the non cardiac cases because of mismanagement... even after I rotated there I was thinking to myself no way would I bring my kid here for anything.

Side note.. not sure why using phenylephrine is such heresy in the peds world for hypotension, I used a few boluses in cases of those 16-18 year old "kids" who are muscular athletes and could kick the stuff out of everyone in the room but crna let's the map ride in in the 40s and saying we don't use neo on peds and just slam fluids if anything. Aren't these "kids" hearts no longer only stroke volume dependent?

 

[HalO'Thane]

I think one merely has to look at where the majority of pediatric cardiac surgeries are performed: they are usually children's hospitals. Just think of the big-name programs: Boston Children's, CHOP, CHLA, Mott (U of M), Texas Children's. Unless you exclusively do peds cardiac, you will probably be expected to do peds general cases as well. Most of these institutions will now require you to be peds anesthesia certified, which now even requires a peds anesthesia fellowship (unless you are grandfathered in). You may be limited in your options if you try to do peds cardiac anesthesia after going the adult cardiac anesthesia route.

 

[urge]

Side note.. not sure why using phenylephrine is such heresy in the peds world for hypotension, I used a few boluses in cases of those 16-18 year old "kids" who are muscular athletes and could kick the stuff out of everyone in the room but crna let's the map ride in in the 40s and saying we don't use neo on peds and just slam fluids if anything. Aren't these "kids" hearts no longer only stroke volume dependent?

Is it heresy? What did the attendings have to say? Why were you in the room with a nurse?

Is a 16 y/o a ped patient?

 

[2Fast2Des]

Is it heresy? What did the attendings have to say? Why were you in the room with a nurse?

Is a 16 y/o a ped patient?

Attendings aren't really there a whole lot but when they check in randomly and see that I gave it they ask what the clinical indication was and say that they've never given phenylephrine in their careers in peds (this is in 2 hospitals, mind you). Also the attendings say that its better for new residents and claim that for safety and all they have the nurses supervise while attendings are busy with other rooms/preop/pacu scut monkey. I guess only in 18 and above the heart magically changes from baby to adult status in their minds. I did relieve a crna one time who was doing a crani in a 19 y/o and the kid was slammed with fluids throughout the case to manage hypotension (zilch pressors) even though the clear cause was from the anesthetic and not any bleeding, I was astounded to find out that somehow he was managed to be extubated the next day in the ICU since we were concerned about volume overload and extubating in the OR at the time.

 

[Libertas]

.....so your peds rotation was a crna supervising you?

 

[kidthor]

Attendings aren't really there a whole lot but when they check in randomly and see that I gave it they ask what the clinical indication was and say that they've never given phenylephrine in their careers in peds (this is in 2 hospitals, mind you). Also the attendings say that its better for new residents and claim that for safety and all they have the nurses supervise while attendings are busy with other rooms/preop/pacu scut monkey. I guess only in 18 and above the heart magically changes from baby to adult status in their minds. I did relieve a crna one time who was doing a crani in a 19 y/o and the kid was slammed with fluids throughout the case to manage hypotension (zilch pressors) even though the clear cause was from the anesthetic and not any bleeding, I was astounded to find out that somehow he was managed to be extubated the next day in the ICU since we were concerned about volume overload and extubating in the OR at the time.

I'm a little confused by your scenario - but I'll tell you that while phenylephrine is often not appropriate for children, it sometimes is - for example kids with TOF in Tet crisis absolutely need phenylephrine... and in peds cardiac cases coming off pump it is often appropriate. It's also appropriate if you have a huge blood pressure drop and you need to temporize the kid during resus (in major ortho cases on older kids, for example).

That said, you'll often see that inexperienced folks will give phenylephrine to push a kid's MAP up to unnecessary levels. And - as you noted, sometimes people end up volume overloading as a means to chase a MAP appropriate for adults but not kids (or because they're overanesthetizing a patient).

I'd suggest discussing appropriate MAP goals with your attending, and also strategies for increasing the BP when everything is fine (e.g. you're not bleeding out, hypovolemic, hypocalcemic, etc). Often it's indicated to give a kid a low dose pressor (e.g. dopamine or whatever else may be clinically indicated) rather than blasting the kid with volume.

 

[2Fast2Des]

Yes to being supervised, but it's the only major children's hospital in the area so not much choice...

Regarding phenylephrine, I feel like an older healthy teen is appropriate to use phenylephrine for hemodynamic support since I think their heart is more similar to adult status and especially with ERAS stuff that talks about careful use of fluids, I'd like to treat the cause, which in the case I felt is the anesthesia. But so far it seems the only answer in peds to hypotension is only fluids and more fluids from what I have observed.

 

[btbam]

Yes to being supervised, but it's the only major children's hospital in the area so not much choice...

Regarding phenylephrine, I feel like an older healthy teen is appropriate to use phenylephrine for hemodynamic support since I think their heart is more similar to adult status and especially with ERAS stuff that talks about careful use of fluids, I'd like to treat the cause, which in the case I felt is the anesthesia. But so far it seems the only answer in peds to hypotension is only fluids and more fluids from what I have observed.

Volume and turning down the gas fixes hypotension in the vast majority of peds patients, teenage football players are not peds imho.