Letter Concerning SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice in the Cardiac Catheterization Laboratory

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We read with interest “SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice: Recommendations for Patients Undergoing Diagnostic and Therapeutic Procedures in the Pediatric and Congenital Cardiac Catheterization Laboratory” by Odegard et al.1 We agree with the authors that there are many issues that place patients with congenital cardiac disease at risk under anesthesia and sedation in the cardiac catheterization suite. We are, however, concerned by the strong recommendations made by the authors that “pediatric cardiac anesthesiologists” should be the physicians who take care of these high-risk patients in the catheterization suite. These recommendations were made essentially without any evidence to support that this level of care will lead to an improved outcome for these patients.
In this era of data-driven clinical care, it seems premature to call for “pediatric cardiac anesthesiologists” to care for these patients in the catheterization suite without such supporting evidence. Before the recommendations of this consensus statement become a standard of care, carefully conducted studies at institutions with a variety of models of providing anesthesia care in the catheterization suite should be undertaken. At Children’s Hospital of New York/Columbia University Medical Center, we reported that the incidence of adverse events in the cardiac catheterization suite were comparable between those anesthesiologists on the cardiac anesthesia team (physicians who provide anesthesia for open heart surgery: “cardiac anesthesiologists”) and those who are not on the cardiac anesthesia team.2 We are completing this study of the comparative incidence of adverse events in the catheterization suite at our institution, stratifying patients by severity of disease and type of procedure. We would welcome collaboration with institutions that have a different model of care for patients with congenital heart disease in the catheterization suites and in other sites for noncardiac surgery.
As the authors noted, there are currently an insufficient number of pediatric anesthesiologists with further subspecialty training in cardiac anesthesia for congenital cardiac diseases to provide care for all cardiac catheterization suite procedures. They propose assigning risk categories for patients and procedures planned in the catheterization suite, based on the Catheterization Risk Score for Pediatrics (CRISP). Patients with a CRISP score of 5 or greater are to be cared for by a provider who is a “pediatric cardiac anesthesiologist” (Table 2). In the footnote to Table 2 (and the text of the article), the authors further defined this provider as a “pediatric anesthesiologist with either advanced training or extensive experience in congenital cardiac anesthesia.” The authors acknowledged that “the clinical impact of such tools [CRISP score] remains to be seen because resource utilization requires careful consideration of what is needed, but also of what might be excessive.” It must be recognized that a possible consequence of this consensus statement will be that cardiologists and other pediatric physicians will request that “pediatric cardiac anesthesiologists,” that is, those who regularly work in the cardiac operating room, provide care for those patients undergoing cardiac catheterization. This would certainly place an undue burden on pediatric anesthesia services, in the absence of convincing evidence to support such practice.
It would be more appropriate for the consensus statement to indicate that the practice at many institutions is to have “pediatric cardiac anesthesiologists” to care for patients in the cardiac catheterization suite, but outcome data are much needed. Thus, the consensus statement should also include a call for research to determine the safety of different care models for patients with congenital cardiac disease in the catheterization laboratory.

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