Selected
Highlights of the American Society of Anesthesiologists (ASA) and
American Society of Critical Care Anesthesiologists (ASCCA) Annual
Meetings October 2000, San Francisco By Douglas
Coursin, M.D.
This
review provides one man’s perspective on some interesting Anesthesia
and Critical Care topics presented at ASCCA and ASA
scientific sessions and ASA committee meetings. The Transfusion
Practice Committee meeting touched on various topics and revisited ASA
transfusion guidelines. Concerns over the current practice of allowing a
patient to have an increasingly low hemoglobin prior to transfusion and
the potential for deleterious ischemic events, be they cardiac or retinal
(such as patients undergoing prolonged prone positioning during spinal surgery),
were discussed. Evolution in practices such as nucleic acid testing to identify
viral-mediated disease; use of pooled SD (solvent-detergent treated) plasma;
strategies to limit the amount of blood phlebotomized and application point-of-care
testing to modify iatrogenic blood loss; and administrative methods to track
blood use and limit clerical errors were discussed. Members of the committee
who represented practices throughout the US described a wide range of applications
of transfusion guidelines and newer blood products.
The Critical Care and Trauma Committee meeting of the ASA had
a lively discussion on several topics. Most important was commentary on
the newest Advanced Cardiac Life Support (ACLS) guidelines
(Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care. The American Heart Association in collaboration with the International
Liaison Committee on Resuscitation). These superb updated guidelines
were published recently as a supplement to the August 2000 issue of Circulation
(see citation and commentary below). To the dismay of various committee
members, myself included, this expanded and timely state-of-the-art international
commentary was published only in Circulation. Over the past
25+ years, updated ACLS guidelines and recommendations were
published in JAMA as they were revised. This facilitated widespread
distribution to practitioners. It is my understanding that the American
Heart Association (AHA) decided to implement a stronger proprietary
approach to the use of this information. I find this discouraging in light
of the need for broad dissemination of advances in ACLS and
the very nature of AHA and contributing societies’ missions
as educational, investigative and not-for-profit medical organizations.
Of note, the circulation for the AHA’s journal Circulation
is only 23,300 compared to a worldwide readership of 700,000 for JAMA.
Furthermore, I and other textbook authors or editors are discouraged by
the publication fees that AHA charges to reproduce their algorithms.
In revising the 2nd edition of Murray’s Critical Care
Medicine — Perioperative Management, the editors must spend
an inordinate amount of their limited publication budget to pay AHA
for permission to reproduce ACLS algorithms. I suppose Dr.
Charles Otto, a contributor to the AHA ACLS program and a highly
respected international CPR expert, may have to delete these useful guidelines
from the chapter on CPR he is revising for Murray’s text. Dr. Paul
Barash, senior editor of the well regarded textbook, Clinical Anesthesia,
informs me that he and his co-editors, Drs. Stoelting and Cullen, encountered
the same problem in preparing their recently revised and released 4th
edition.
Nonetheless, the newest ACLS and Emergency Cardiovascular Care
(ECC) guidelines provide a tremendous resource and underscore
the international scope of CPR, ACLS, and ECC.
The presentation is divided into 12 parts. Parts 1—5 focus on BLS,
ethics, and first aid. Part 6 covers ACLS and provides guidance
on ventilation, defibrillation, updated pharmacologic care and algorithms
as well as post-CPR care. Part 7, "The Era of Reperfusion," emphasizes
the acute coronary syndrome (now used as a replacement term for acute MI)
and acute stroke. Part 8, "Advanced challenges in resuscitation"
provides an expanded series of select topics including management of hypothermia,
certain intoxications, and respiratory insufficiency. Parts 9 - 11 update
Pediatric BLS, Advanced Life Support (PALS), and
neonatal resuscitation, respectively. Part 12 provides a philosophical overview
on "strengthening the chain of survival" followed by several thoughtful
accompanying editorials that discuss controversies and future developments.
In the introduction to Guidelines
2000, the authors emphasize how different societies and countries
may approach CPR, ACLS and ECC. They
go on to state that "the guidelines are no longer descriptive —
This is how we do it here, but now prescriptive — This is how we should
be doing it in the future." They also emphasize that 50% of patients
with acute coronary syndromes present for the first time with a life-threatening
event. There is a concise overview of the major changes in the recommendations.
These include elimination of bretylium from the protocols. They no longer
advocate routine administration of high dose epinephrine to enhance flow
during protracted CPR. Although somewhat controversial, they suggest consideration
of vasopressin as a replacement for epinephrine. They caution about excessive
use of adenosine, particularly in wide complex SVT, but propose
wider use of amiodarone as an antiarrhythmic of choice in many patients
with SVT or VT. Finally they emphasize the crucial
requirement for documentation of proper intubation and adequate ventilation
through routine measurement or identification of ETC02.
The guidelines use an evidence-based
medicine approach to grade recommendations. I plan to discuss some of the
newer recommendations and interesting points to ponder from the document
in next month’s commentary.
The 13th annual ASCCA meeting was held the day prior
to the ASA meeting. According to a poll of various attendees,
this was the best annual meeting that ASCCA has had to date.
The morning session focused on scientific abstracts of human and animal
studies presented by leaders in our subspecialty. In two separate presentations,
Pam Roberts, Mike Wall, and colleagues from Wake Forest University examined
gut feeding effects on animals treated with vasopressin (AVP)
and the effect of endotoxin on vascular reactivity from infused dopamine
or fenoldopam, the selective DA-1 agonist. Vasopressin, a potent
vasoconstrictor of the mesenteric circulation, is used by some in hypotensive
patients after CP bypass, during septic shock, and in CPR (see
ACLS guidelines). There is concern that AVP-induced
gut ischemia may worsen the progression to multiple organ failure. This
group reported that enteral feedings improved visceral blood flow in AVP
treated rats. This may prove to be another benefit of enteral vs. parenteral
alimentation if this finding translates into clinical use. Dr. Winters and
a group of investigators from Johns Hopkins presented interesting data on
the blunted vascular responsiveness of animals with the ob/ob obesity gene.
Several papers discussed ICU patient outcome for patients who did or did
not receive prophylactic admission to the ICU and the survival and quality
of life in cardiac surgical patients who had protracted ICU stays.
Dr. David Cullen, Professor
of Anesthesiology at Tufts University School of Medicine and Chair of Anesthesiology
at St. Elizabeth’s Hospital in Boston, was the distinguished lecturer.
Dr. Cullen, formerly a Professor at Harvard and the director of the ICU
at Massachusetts General Hospital presented The Adverse Drug Event
Study: A Decade of Progress in Patient Safety. He reviewed the sentinel
work of his group of clinicians, nurses and ICU pharmacists in identifying
prescriptive practices and errors, and discussed his group’s efforts
to limit untoward drug interactions, misapplication of medications, and
predictable but unrecognized toxicity. His lecture was all the more timely
with the recent press reports about the Institute of Medicine’s study
proclaiming the widespread iatrogenic problems in modern medicine.
Dr. Neal Swissman, President of ASA, presented a forceful commentary
on the state of the practice of Anesthesiology in the US, governmental affairs
and ASA, and the need for involvement in maintaining the highest standards
and levels of care. He spoke passionately about educating the public about
our roles as practitioners and responding strongly to misrepresentation
of anesthetic practices and outcomes.
Dr. Louis J. Ignarro, Nobel Laureate and co-discoverer of nitric oxide (NO),
the mediator formerly known as endothelium relaxing factor (EDRF),
provided an amazing luncheon lecture to a combined audience from the annual
meetings of ASCCA, SNACC, and SPA.
He provided a humble and humorous review of the evolution of the discovery
of this ubiquitous molecule, its actions, and the Nobel Prize award ceremony
in Stockholm.
He reported that every time someone asked him if he had identified exactly
what EDRF was, he would reply, "NO," little knowing
that his negative would turn out to be correct, NO for nitric oxide. His
outstanding talk was complimented by afternoon lectures by Drs. Laureen
Hill of Stanford and Robert Sladen of Columbia University that focused on
the clinical monitoring and application of NO.
All in all, both the ASCCA and ASA meetings were
successes. I attended several excellent refresher courses that can be reviewed
in the annual refresher course lecture book or CD. I also chaired a scientific
session and attended several other sessions where there were interesting
presentations on topics varying from use of inhaled Xenon as an ICU sedative
to mini-thoracotomy in the field to place an internal heart massager in
an attempt to improve outcome from out-of-hospital cardiac arrest. Scientific
material from either meeting can be accessed in the September supplement
of Anesthesiology, on CD, or via the journal’s web page if you are
a subscriber.
