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• W4387655573 abstract "Delivery of modern medical care for complex problems is characterized by collaboration among subspecialists across multiple disciplines. Procedural experts as well as experts in diagnostic imaging and biomarker interpretation are necessary participants in successful operative procedures, such as the abdominal aortic aneurysm repair in a 19-month child described in the Case Presentation published in this issue of JCVA.1 As regards provision of the anesthetic care of the child, the authors of the Case Presentation contend that this child and children with similar complex cardiovascular pathophysiology would be best managed by an anesthesiologist “adept in both adult and pediatric cardiothoracic anesthesiology”.1 While at first glance this does not appear to be an unreasonable suggestion, it takes but a moment of reflection to realize that the practicality of this approach is contingent on the ready availability of the appropriate personnel to deliver care and is entirely dependent on the definition of “adept at”. Let us take “adept at” to mean an individual with fellowship training in both pediatric and adult cardiac anesthesia or with the equivalent expertise obtained with on-the-job training. A recent survey sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States found there to be 307 self-identified pediatric cardiac anesthesiologists.2 Only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) had gained experience during their clinical practice. The remaining 18% (55 of 307) of providers had adult cardiac anesthesiology or pediatric critical care backgrounds.2 Clearly then, having care provided by “adept” practitioners as described is far from realistic or practical, given that a pool of approximately 50-100 itinerant anesthesiologists would have to circulate around the nation providing care. For the sake of this discussion, it will be useful to delineate more carefully the skill sets unique to practitioners of pediatric cardiac anesthesiology and to adult cardiac anesthesiology. This is a relatively easy task because both fellowships have ACGME accreditation and well-established training requirements and milestones.3,4 As would be expected, there is significant overlap of educational goals across these two fellowships. It should also be kept in mind that there is considerable overlap of the educational goals of these two fellowships with those of a pediatric anesthesia fellowship. In addition, completion of either a pediatric anesthesia fellowship or an adult cardiac anesthesia fellowship is necessary before acceptance into an ACGME accredited pediatric cardiac anesthesia fellowship.5,6 It would be the expectation that an individual with both pediatric anesthesia and pediatric cardiac training could appropriately manage the patient described in this Case Discussion. It could be argued that a fellowship trained pediatric anesthesiologist with some addition experience in pediatric cardiovascular procedures could also manage this case. Fellowship trained pediatric anesthesiologists with or without additional cardiac anesthesia fellowship training routinely manage critically ill children of all ages, many with multiple comorbidities, for procedures such as liver and kidney transplantation. These procedures involve cross-clamping of major vascular structures as well as potential for significant blood loss and large fluid shifts and are managed using TEE/TTE in conjunction with innovative monitoring modalities such as plethysmography variability index and pressure field analysis.7,8 In addition, they manage critically ill neonates for major intra-abdominal and intra-thoracic procedures for which adult cardiac anesthesia skills are of limited value. With all this being said, let us address the elephant in the room as regards the unique skill set possessed by fellowship trained adult cardiac anesthesiologists as compared to other anesthesia practitioners: advanced perioperative transesophageal echocardiography (TEE) training and certification.9 It can be argued that one of the “deficiencies” of pediatric cardiac anesthesia fellowship training is lack of well-defined, rigorous intraoperative TEE training and certification. The only formal pathway to certification in pediatric echocardiography is via a formal pediatric cardiology fellowship with most non-invasive imaging subspecialists pursuing an additional 1- or 2-year imaging fellowship. For this reason, and because pediatric cardiologists never relinquished primary responsibility for the performance of intraoperative TEE, pediatric cardiac anesthesiologists have not assumed, and will likely never assume on a universal basis, the same level of responsibility for the continuous performance and interpretation of intraoperative TEE images as their adult cardiac anesthesiology colleagues. To be in compliance with ACGME requirements, fellowship training in pediatric cardiac anesthesiology requires at least one core faculty member to have certification in echocardiography; this could be a cardiac anesthesiology faculty member, but is more likely to be a pediatric cardiologist. As regards knowledge acquisition, fellowship training requires only that “fellows must demonstrate knowledge of how cardiac and congenital diseases affect the administration of anesthesia and life support to patients, including: non-invasive cardiovascular evaluation, to include electrocardiography, transthoracic echocardiography, transesophageal echocardiography, stress testing, and cardiovascular imaging.”4,5 The author of this commentary formerly served as Chair of the Advanced PTEeXAM® Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography and can attest to the fact that, with appropriate diligence on the part of the program directors, pediatric cardiac anesthesia fellows can gain sufficient expertise in both TTE and TEE to be effective practitioners without formal certification. Obviously, close collaboration with pediatric cardiology imaging specialists is necessary to achieve this. 1Gorbea MS, Duarte IM. Anesthetic Management of an Infant with Dilated Cardiomyopathy and Congestive Heart Failure Undergoing Open Aortic Abdominal Aneurysm Repair: The Critical Role of Dual-Trained Pediatric and Adult Cardiothoracic Anesthesiologist Ref.: Ms. No. JCVA-D-23-006882Nasr VG, Staffa SJ, Vener DF, et. al. The Practice of Pediatric Cardiac Anesthesiology in the United States. Anesth Anal2022;134:532–9.3https://www.acgme.org/globalassets/pfassets/programrequirements/041_adultcardiothoracicanesthesiology_2023.pdf accessed September 26, 20234https://www.acgme.org/globalassets/pfassets/programrequirements/047_pediatriccardiacanesthesiology_2023.pdf accessed September 26, 20235Nasr VG, Ambardekar A, Grant S, et. al. Evolution of Accredited Pediatric Cardiac Anesthesiology Fellowship Training in the United States: A Step in the Right Direction. Anesth Analg 2023;137:313–21.6https://www.acgme.org/globalassets/pfassets/programrequirements/042_pediatricanesthesiology_2022.pdf accessed September 26, 20237Garg K, Kayina CA, Kajal K, Gourav KP,et. al. Pediatric Renal Transplant With Dilated Cardiomyopathy: A Stepwise Hemodynamic Management—A Case Report. A A Pract 2023;17:e01709.8Woodford SF, Miles LF, Lee D-K, et. al. A Software-Guided Approach to Hemodynamic Management in a Renal Transplant Recipient: A Case Report. A A Pract 2022;16:e01622.9https://www.echoboards.org/wp-content/uploads/2022/11/Final-AdvPTE-2023.pdf accessed September 26, 2023 None" @default.
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• W4387655573 title "Commentary on Anesthetic Management of an Infant with Dilated Cardiomyopathy and Congestive Heart Failure Undergoing Open Aortic Abdominal Aneurysm Repair: The Critical Role of Dual-Trained Pediatric and Adult Cardiothoracic Anesthesiologist" @default.
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