Pediatric cancer patients are individuals diagnosed with cancer before reaching adulthood. Although a rare condition, it significantly impacts young patients and their families. The most common types of pediatric cancers include leukemia, brain and central nervous system tumors, and lymphoma. Fortunately, pediatric cancer survival rates have improved significantly over the past few decades, with more than 80% of children diagnosed with cancer expected to survive for five years or more. However, pediatric cancer treatment can be complex, often requiring multiple treatment rounds over several years, which can greatly affect the child’s and their family’s quality of life.
Anesthesia is a crucial component of pediatric cancer care, ensuring patient comfort and safety during surgical procedures and imaging tests. Moreover, anesthesia plays a vital role in pain management, especially for patients experiencing pain related to cancer or its treatment. Anesthesia providers collaborate closely with the treatment team to guarantee safe and effective care during chemotherapy and radiation therapy, particularly important for younger patients who may struggle to remain still during these procedures. During radiation therapy, patients may need repeated anesthesia and sedation within short periods, making iterative anesthesia a challenging aspect of pediatric anesthesia that is not widely known, with protocols varying among centers worldwide.
The webinar aims to discuss the role of anesthesia in pediatric cancer care, focusing on its use during surgical procedures, imaging tests, and pain management. Furthermore, the webinar will address the challenging activity of iterative anesthesia in pediatric anesthesia and explore methods for ensuring its safe and effective implementation. The goal is to enhance the understanding of anesthesia’s importance in pediatric cancer care and to improve the skills and knowledge of anesthesia providers in this field.
Webinar program
1. Opening Remarks
Wayne Morriss
President, WFSA
Christchurch, New Zealand
2. Anesthesia Consideration for Pediatric Oncology Patients: Case Presentation
Saeedah Asaf
Associate Professor, Department of Anesthesia, Arkansas Children’s Hospital & University of Arkansas Medical Sciences, Little Rock, AR, USA
Professor & Lead, Department of Anesthesia, The Children’s Hospital & University of Child Health Sciences, Lahore, Pakistan.
3. Pain Management for Pediatric Oncology Patients in Low Resource Settings
Maria Alejandra Echeto
Paediatric Anaesthesia Staff Specialist in San Pedro Sula, Honduras at Hospital del Valle, Hospital Bendaña and Quirúrgica Integral, Pediatric Anesthesia Consultant at Hospital Mario Catarino Rivas and Social Security Institute in San Pedro Sula. Honduras
4. Procedural Sedation for Imaging and Radiation Therapy
Z Serpil Ustalar Ozgen
Dept of Anesth and Reanim, Uni of MAA Acıbadem, Istanbul Turkey
President-Elect of ASPA
5. Iterative Anesthesia
Lucas Opitz
Head of Pediatric Anesthesia, Centre Antoine Lacassagne
Neonatologist, University Hospital Nice, Nice, France
6. Round Table Discussion
Moderators: Z Serpil Ustalar Ozgen (Turkey), Norifumi Kuratani (Japan)
Commentator: Zolzaya Chinzorig (Mongolia)
submit your question or comment to Nori Kuratani, MD, PhD, MPH norifumi.kuratani.a1@tohoku.ac.jp
Live start okay good morning good afternoon good evening to everyone around the world thank you very much for joining us today my name is Nori katani a pediatric an geologist from Japan I’m also acting as a pediatric Ania committee chair of wfsa a World Federation of society of
Anesthesiologist it is my great pleasure and honor to be one of the moderators in this webinar I would like to thank Professor shami the professor shami is Congress chairman of jspa 2023 for giving us such a wonderful opportunities to have a webinar co-hosted by wfsa and jspa 20
2023 our topic today is focused on the role of anesthesia in pediatric Cancer Care Pediatric cancer is rare however the impact of pediatric cancer is significant to both the young patients and their families an ins plays very important role in managing pediatric cancer ranging from Sur IAL interventions procedural sedations and the pain
Management in this webinar speakers around the world will discuss the diverse roles of anesthesiologist in pediatric Cancer Care our goal is to enhance deeper understanding of the importance of anesthesia in pediatric Cancer Care and also uh and facilitate our deeper discussions in this important field we are excited to have
Participants around the world via YouTube and we warmly welcome all of you we also encourage the participants to ask questions make comments and to share your insights and experiences with us if you have comments or questions you can submit your questions to YouTube chat or you can email me directly can
You can find my email address on the YouTube uh website we may address some of the questions in the round table discussion in this webinar we hope this webinar will be both informative and engaging to to for everyone okay let’s get started the first of all Professor why
Moris the wfsa president will give us opening remarks dear friends and colleagues my name is Dr Wayne Morris and I am the current president of the World Federation of societies of anesthesiologists w FSA greetings from wfsa and greetings from my country New Zealand I am delighted to welcome you to
This wfsa jspa webinar entitled anesthesia and Cancer Care in Pediatrics this event will highlight The crucial roles that anesthesiologists play at multiple points in the care pathway for children with cancer pediatric cancer Cancer Care is a rapidly evolving field and it is essential that we stay up toate with the latest
Developments thank you very much to the organizers and also an amazing group of international experts from Turkey Japan United States and Pakistan Honduras France and Mongolia wsa’s theme for 2023 is anesthesia and cancer care and we will be holding a another webinar focusing on global issues relating to Cancer Care on
World anesthesia day Monday the 16th of October please go to the wfsa website for more details thank you for joining us today enjoy this webinar and I look forward to seeing you at our world anesthesia day event okay our first Speaker Professor SAA Asa from Pakistan she has also appointed
With the aranso children hospital United States our topic today is anesthesia consideration for pediatric oncology patient good afternoon this is Dr SAA Asif I’m a pediatric anesthesiologist and I divide my time between the Children’s Hospital in lahor Pakistan and Aransas Children’s Hospital in the United States I’m greatly indebted to
The Japanese Society of pediatric anesthesiologist in the wfsa Pediatric committee for inviting me to talk about the anesthesia considerations in children with cancer today my hope is that at the end of this presentation you will be able to describe the incidents of cancer and the types of cancer in
Children the key pre-operative concerns uh in children presenting for surgery and the anesthesia implications of cancer therapy for children with cancer I also want to go over tumor liis syndrome in interior media stanel mass and briefly describe the global initiative to improve cancer outcomes in children and I’d be happy to answer any
Questions at the end 400,000 children and Adolescence velop cancer each year worldwide cancer is the leading cause of death past infancy among children in the United States 15, uh 590 children were expected to be diagnosed with cancer in 2021 and unfortunately nearly 1,800 children were expected to die of cancer in
2021 leukemias are the most common childhood tumor followed by brain tumors and neuroblastomas uh Wilms tumor uh Hotchkins and non- hodkin lymphomas romios sarcomas retinoblastomas and sarcomas are some other common childhood tumors in younger infants and uh younger um age group we’re more likely to see neuroblastomas and retinoblastomas and
Among teenagers sarcomas and lymphomas become more common when we look at um cancer estimates from the cancer registry data in Japan from 2009 to 2011 so about under 3,000 CH children developed were diagnosed with cancer and the leading causes of cancer were leukemia brain tumors lymphomas and gonadal germ cell
Tumors children with cancer can uh can present with multiple uh challenges for the anesthesiologist the anesthesiologist will see patients with children with tumor for for their initial diagnosis and May and see them subsequently for follow for follow-up treatment and even for non-cancer related therapies you they can present for both diagnos
Diagnostic and therapeutic therapies such as bone marob biopsy intal chemotherapy lymph node biopsy line placements tumor reections and radiation we can encounter them in the operating room or outside of the operating room which can ALS which can be a challenge in itself so when we’re looking at a tumor preoperatively I’d
Like to remind my resident that remember the four M’s the tumor’s local effect or Mass Effect any uh um any complications as a result of the metastatic disease or metabolic or systemic uh effects of the tumor or the chemotherapy itself these children require a careful review of the labs uh Imaging studies
Such as CT scan or M and and a uh thorough discussion with the surgical team as to what the surgical plan is and what are the implications for potential blood loss any in any posttop requirements for that chemotherapy is a double-edged sword for patients with cancer on the
One hand it provides them with the hope of cure and on the other hand it leads to side effects in from the acute period to long-term uh effects many many decades later if we look at I just want to go over briefly uh what different agents are associated and what are their main
Um complications are the enyan such as doxorubicin adamy Don Rubin are associated with cardiomyopathy and these children should have a pre-operative echo and ECG available besides CBC Methotrexate like other uh chemotherapeutic agent is associated with nausea vomiting Milo supression mucositis so you require pre-operative CVC uh for any invasive
Procedure and lfds if uh including your Billy Rubin and albumin bluy is associated with pulmonary fibrosis so you need to document your pre-operative saturation and possibly look at your chest x-ray and pulm function test cyclophosphomide again is associated with nausea maiting Milo supression as well as cardio myopathy and Pulmonary Fibrosis it’s
Also associated with syndrome of inappropriate ad8 so these patients will require um should have an echo and ECG and a serum sodium um along with an uh if siadh is suspected carop platin and cisplatin are associated with neurotoxicity autotoxicity and hemolytic ureic syndrome when Christine is associated with peripheral neuropathy
And these patient should have a documented preop neurological exam steroids are used frequently in chemotherapy uh to cause tumor liis these patients can present commonly with hypertension or Cushing syndrome uh they may also require stress do steroids from from adrenal suppression as you saw on the previous side many chemotherapeutic agents are
Associated with Milo supression and present with pen cytopenia including thrombocytopenia and may require peroperative PL transfusion it dep depends on the type of procedure the potential for bleeding and the function of the existing platelet so for example if you the the patient is coming in with a platelet count of
45,000 uh for a central line placement you may consider transfusing platelets as the procedure is going on or having a plater transfusion IM me before the beginning of the procedure more invasive procedures such as uh abdominal surgery may require High higher platelet counts of 880,000 to 100,000 neuro exal is
Contraindicated if thrombocytopenia is present um as a part of the pancytopenia these patients do have chronic anemia but hematocrits in the low to mid-20s are generally well tolerated if these patients require treatment consider irradiated rbcs to prevent graph versus host disease and lucco depletion to prevent transmission of cytomegalo
Virus so Milo supression can lead to profound pancytopenia and neutropenic patients who have less than 500 cell count are at a increased rate for bacterial and viral infections um as a part of our anesthesia care we must be aware of this risk these uh we need to observe protective and reverse isolation
Observe strict hand washing and asep technique during any procedures and medication administration and the and we cannot Place rectal probes or any rectal administration of medication enth cycling and antibiotics such as doxorubicin Donar Rubin epirubicin idarubicin and cyclophosphamide can cause cardiotoxicity this can range anywhere from minor changes on the ECG such as
Non-specific stdt wave changes prolongation of qt2 to arhythmia ventricular dysfunction myocarditis pericarditis syndrome to congestive heart failure and even cardiogenic shock cardiac toxicity can be both early on or later in fact the risk of death from cardiac related events is eight times higher in uh children who survive pediatric
Cancers so like I said they can present early in weeks or months after therapy or weeks in or years later in the late form we believe that this results from the oxidative Dam damage from the chemotherapy to the heart tissue itself the myocardial depression with congestive heart failure unfortunately
Is often not very responsive to medication cardiotoxicity risk is dependent on the cumulative dose uh that the patient received however in children the heart is unable to grow and you can see cardiotoxicity even at lower doses so these children require follow up with base L and serial echo cardiogram even
For many years after the treatment intraoperative fatalities have occurred in children from chemotherapy IND Ed cardiomyopathy so as enologist we must be aware of this risk even many years after completion of the therapy and A cardiology consultation and echocardiographic assessment is not unwarranted in these patients um they
May also have a prolongation of QT interval so consider uh cardiotoxic toity especially when you are um choosing your induction A induction and maintenance agents and be vigilant about possible cardiovascular collapse and postop hypertension in the pacu lung damage can occur from infection from disregulated immune function and inflammation and from the
Chemotherapeutic agents itself such as bomy Bulan cyclophosphamide it can present some immediately in weeks following therapy or many years after the therapy itself bluy can lead to intertial pneumonitis and pulm fibrosis we must use F2 30% or less because higher f2s can precipitate acute lung injury and ards in these patients mortality from
This injury can be as high as 8s 3% thoracic radiation can cause clinically significant lung injury in 5 to 15% of the patients it’s really dependent on the total dose of radiation that’s given however in children under 3 years of age because of interference with lung
And chest wall growth we can see uh lung injury from radiation even at a lower dose uh lung injury can present either immediately in the first few months after exposure or it may uh evolve as pneumonitis and then subsequently fibrosis over the next year or
So 50 to 90% of children uh May develop nerve injury within a few days of starting therapy with agents such as wind blastin wind Christine Cy platin and monoclonal antibodies they can be both sensory and motor changes and can also lead to balance or or fall risk
Neuropathic pain has to be treated with tricyclic anti-depressants and gabapentinoids these patients must be positioned uh very carefully with padding of all the pressure points these patients often have high opioid requirements to addition of ketamine is very helpful any neurological deficit should be documented before placing a peripheral nerve block and consider
Using a lower dose of local anesthetic in peripheral nerve blocks in these patients recent advances in immunotherapy have led to uh these genetically modified te- cells that Express Chic antigen receptors that are capable of recognizing and destroying tumors this immunotherapy has given New Hope especially to children with relapsed or reflectory be cell
Malignancies uh with complete remission rates of 50 to 90% And even a possible Curative response car cell immunotherapy was initially restricted to few large centers as an experimental therapy but with with this encouraging results uh we expect that this is going to be included in various other solid and liquid tumor
Protocols and uh may be adopted at a uh why at at more other hospitals as well car T Cell therapies is associated with prolong cytopenias enaxis tumor liis syndrome and the risk of potentially uh fatal infectious complications so we must be care uh we must be aware of uh
Anything that we do intraoperatively that will increase this risk further cyto cyto release syndrome occurs in 70 to 94% of the patients uh undergoing car cell therapy usually U you see it two days after the car cell infusion it may be delayed even up to two weeks there is
An activation of the vascular endothelial system leading to loss of vascular Integrity capillary leak um eventually dealing to consumptive ciliopathy and Vascular smooth muscle dysfunction CRS can represent as fever techic cardia teyia and in more serious cases can progress to hypoxia hypotension coagulopathy respiratory failure shock and multiorgan failure
Some of these patients may end up going to the ICU for supportive care second distinct adverse effect of party cell therapy is neurotoxicity there is blood brain barrier with local local cyto kind production uh it can lead to incopy with Aphasia it usually starts 5 days po infusion and can last
Up to 10 days we see diffused Bogen edema on U Imaging it can also lead to raise inflammatory cyto mines on CSF fluid analysis these patients can progress to upt ation seizures raised ICP and even brain herniation our main anesthesia concerns for patient who have undergone CTI cell
Therapy is that we need to know what the timing and the indication and the type of carti cell that was administered if there’s any quag opathy or refractory cytopenia avoid elective or invasive procedures because of the risk of bleeding and infection steroids should never be administered without talking to
The oncology team because they may affect T cell uh function we must be aware of cyrine uh release syndrome and neurotoxicity these patients may be on anti interlan six therapy or steroids or anti-convulsants um for these uh complications uh we need to be prepared to treat any potential uh progression to
These complications with vasopressors inotropic agents and mechanical ventilation any patient who has neurotoxicity we must be prepared for increased intracranial pressure another dreaded complication of induction of chemotherapy is toris syndrome with the beginning of chemotherapy there is tumor liis which can result in massive sudden release of intracellular contents such as nucleic
Acid uric acid phosphorus potassium into the circulation as you can see on this slide that there is an acute rise in potassium with Hyper calmia hyperphosphatemia um hyper hyperuricemia and hypog Galia this is a potentially life-threatening complication that needs to be re that needs to be anticipated and recognized and treated early usually
We see toris syndrome in large tumors with rapid rate of proliferation that are sensitive to cancer therapy and particularly in burket lymphomas tumor liis Syndrome has also been reported in children who were not diagnosed uh with leukemia and were undergoing routine tonson and ectomy when dexamethasone was administered
Leading to tumor liis and Hyper calmia toris has been associated in leukemia again with dexamethasone Administration in a patient with leuk emia so be very careful when if you decide if uh in a patient with cancer when you are going to administer dexamethasone spontaneous tumor liis has
Also been reported in patients with secr coxial teratoma before the beginning of any chemotherapeutic agent hyperemia in tumor liis syndrome can lead to malignant arrhythmias and hyperosmia can result in obstructive uropathy and acute renal failure so in in patients with large tumors or High cell Lis potential usually anti-tumor
Liis therapy is started before chemotherapy is begun with aggressive hydration and diuresis along with agents that aim to reduce hyposmia such as alopurinol and rasb case patients who have developed tumor liis may be monitored more closely and some of them may require admission to an ICU interior medial mass is associated with high
Peroperative morbidity and mortality especially in the high risk patients usually we see anti metal masses in patients with lymphomas Al germ cell tumors and teratomas interior medal cell masses can put pressure on the airway on the heart and this can lead to complete obstruction of the airway it can also
Lead to SVC syndrome or IVC compression a um along with fever night sweats and weight loss so the most important thing to establish on with these patients are is whether they have oropa or or any dnia and if they do have any oropa what is the most comfortable position for
Them and what is the least comfortable position for them uh it is imperative that we discuss these patients in a multi-disciplinary team and look at the chest x-ray CT scan the echocardiograph um and the peak exper flow rates to see to evaluate if if there is any obstruction which
Structures are being obstructed and the degree of obstruction now there’s an urgency in in their treatment because the doubling time for some of these tumors is 12 hours or so so in children who have no symptoms and no radiographic Airway compression are generally cons or or cardiac or vascular compression are considered low
Risk but if there’s any Airway compression with uh symptoms of dnia or oropa but no Bron compression these are considered intermediate risk patients patients with oropa Strider uh tracheal compression of uh More than 70% or with bronchial compression uh tonar physiology on Echo are high-risk patients in lowrisk proced patients you
Can proceed with general anesthesia while preserving spontaneous ventilation and intrathoracic pressure but in highrisk patient you want to discuss potentially preoperative steroids or radiotherapy to shrink the side size of the tumor and its compression on the surrounding structures Hematology Oncology team generally does not like this plan because it can alter the
Biopsy results for them and we may have to proceed with a highrisk uh patient now in high risk patients you have to have rigid bronchoscope available in case you’re not able to ventilate the patient after induction um you uh I cardiopul bypass is uh advocated as a potential uh backup
Strategy but it’s really difficult to set up and go on bypass in an acutely deteriorating patient in these patients consider increasing your F2 adding some peep or CPAP to these patients and rigid bronchoscopy as the last resort if you’re not able to establish an airway at all another thing to consider that
Helps is turn these patients sideways or in lateral or in prone position so that you can get the uh the compression off of the tra AA and the vascular structures we had a patient who became very difficult to ventilate during a lymph node biopsy uh for interior media
Stal Mass uh we had to uh he also developed SBC syndrome with facial swelling we ended up turning him lateral and in semi-prone position we uh turned the gas off and uh the procedure was finished quickly and he was woken up sitting up without any problems most Childhood Cancer can be cured with
Generic medication and other forms of treatment including surgery and radiotherapy however only 29% of the population in low-income countries has access to cancer medication versus 96% in high income countries in this patient the time from from presentation to the healthcare facility to a tissue diagnosis was over
Two weeks and you can see how much is uh interor medal Mass has grown and his risk has increased for anesthesia as well so so diagnosis delayed diagnosis and obstacles to access to care are all part of avoidable Debs in Low Middle income chronic infections such as HIV
Evb virus and malaria are also risk factors for childhood cancers in high income countries 80% of the children with cancer have a 5year survival rate in Low Middle inome countries less than 30% have a 5-year survival rate so Childhood Cancer data systems are needed to continuously improve the quality of care that is
Being provided and also to influence po the global Initiative for Childhood Cancer aims to raise the survival rate for all children to 60% by the year 2030 they hope to provide technical assistance to develop more effective uh programs for cancer treatment in low middle- inome countries the Japanese
Cancer group is is so is uh involved in three global initiatives hepatoblastoma and hepatocellular carcinoma relapse preb cell Al and Al in children with triom 21 so in conclusion I would say that as time goes on we expect to see more and more patients who are cancer uh
Survivors and also more cancer patients in itself U and as an anolog it is imperative that we understand the unique challenges each one of these patients present to us I’d be happy to answer any questions in the group discussion after this okay thank you very much for like comprehensive lectures regarding the
Anesthesia considerations for pediatric oncology patients we’ll take questions or comments in the round table discussions okay let’s move on to the second speaker second speaker is Dr Mar Alejandra ESO from San Pedro Sula hondras topic today is pain management for Pediatric onology patients in a low resource
Setting hello everyone I hope you’re all enjoying and learning a lot from this wonderful webinar the topic I will be sharing with you today is Fain management for PD atric oncology espcially focused on the many challenges low resource settings have to endure let me begin with some very worrisome
Statistics one big issue for cancer treatment and pain management is that more than two-thirds of the world’s population in 90% of diagnosed cancers each year leing limited resource settings and to make it even worse lowincome countries and low middle-income countries only account for 6.2% of the financial expenditures on
Cancer It is believed that by the end of this decade cases of pediatric cancer will increase by 30% another big issue is the fact that one of the greatest indicators of cure for cancer is where they live this is sad but true of the more than 300,000 cases that actually in
The most recent data it’s up to 400,000 of cancer cases diagnosed each year 80% Liv in low-income and low middle-income countries and on that 80% only 20% get cured on the other hand only 20% live in high income countries and of those approximately 60,000 cases 80% get cured
That disparity is very obvious and also very sad but what about pain is it the same for pain sadly it is in high-income countries reported prevalence of moderate to severe pain is about 40% and in most cases is tumor or treatment related in low-income and low middle- inome countries the prevalence of
Moderate to severe pain is 70% and due to limited Registries and published data its related cost is not known but it is assumed to be tumor related since most cases present with Advanced disease on diagnosis it has been reported that prevalence of pain has been reduced by approximately 10% over the past decade
But this reduction is not significant if we compare it to the 40% of patients that still receive an inadequate treatment so how do we manage pain it is important that we first outline some important aspects on pain management in pediatric oncology patients before we list all the challenges faced in
Low-income countries and middle-income countries and to address management we always need to begin with the basics these are the steps that we have to consider before establishing our treatment or management strategy first we need to assess the child and conduct thorough physical examination we have to determine the primary and the secondary
Causes of pain number two we need to develop an individualized treatment plan there is no recipe for all child we need to individualize every treatment plan and always consult a pain management expert early if possible with within the first Contact number three include pharmacological and integrative treatments prevent and treat all Adverse
Events number four implement the plan and remember we have to always uh have into consideration the five World Health Organization recommendations whenever when every every time we have prescribed a drug an analgesic that we have to remember that we always have to take in consideration the most appropriate route
Analgesics should be given at a regular interval and also we have to establish rescue doses they should be prescribed according to pain intensity and dosing should be Accord according and adapted to every child’s need and always with constant concern to detail and number five we need to conduct routine evaluations to assess
Pain and the effects of the treatment given change of plan if needed but how do we decide what pharmacological or non-pharmacological approach is best for the patient we need to First identify the many causes of pain in an oncology patient pain may be associated with diagnostic procedures with on with oncological
Surgeries with the treatment itself and from advancing tumors or metatastic disease and of course we need to have very present that pain can be somatic can be viseral viseral can be neuropathic or a mixture of all the types of pain also we need to identify if it’s acute chronic or if it’s
Breakthrough pain after establishing pain characteristics we also also need to remember to access pain no pain treatment can be given if we do not access pain before and continuously throughout the management remember there are age appropriate pain assessment scales and we have different types of pain assessment scales we have
Self-reporting scales we have observational scales and we have physiological sign based scales here we have a nice table that summarizes according to H the scales that can be used we can also use This Acronym quest with a Double T at the end to remember the steps to assess pain in a child
First we have to question the child if the child is old enough to self-report or to describe what he is feeling use always age appropriate pain rating scales evaluate the child’s Behavior because sometimes children don’t tell us what they feel but they do express it with their behavior secure
Parents involvement or the caregiver’s involvement take the cause of pain always into account and take the earliest action possible another important issue we must not forget is a documenting of our assessment results our observations and the chosen regimen to favor a correct and easy follow-up of the patient so
Once we have identified the cause and the type of pain and we have also accessed our patient we proceed to follow a suggested approach to guide our management this approach was suggested by the World Health Organization since 1986 they suggested the use of a three-step latter approach to guide the
Best choice of therapy for patients in pain the latter has gone through many modifications and adaptations one of the latest versions includes a fourth step that provides the option of Interventional treatment it added the need of aduen and Integrative Medicine in all of the steps of the ladder in an
Attempt of reducing oped misuse and abuse arrows were also added to emphasize on the different approaches for acute with a rapid Descent of the ladder and chronic with slowly moving up the steps the World Health Organization L educational value and capability of worldwide dissemination are definitely unquestionable but some believe that the
First step is insufficient for intense pain management or that the latter is not really good for certain types of pain or for certain types of management therefore a fast track diagram starting directly at step three or a modified two-step lad approach have been proposed the two-step approach is a
Valuable alternative for cancer pain treatment this adaptation of the latter suggests the use of strong opioids in low doses instead of weak opioids we must remember that the term weak refers to analgesic potency and customary manner in which the drugs are used but not on the pharmacologic of pure opio agonism or
Opioid equivalence it doesn’t mean that this type of opioids are harmless or are safe coding in terminal are both Pro drugs and their metabolism is subject to genetic polymorphisms their clinical response is very unpredictable it has been observed that using this approach we can achieve the same analgesic effect
Less side effects and much lower costs so some countries have adapted this two-step approach to simplify management and to save costs now there are some important facts we need to remember when establishing a pain management strategy number one is prescribe a treatment plan with the simplest type and regimen of administration and the
Least invasive method possible management of pain on any step includes acetaminophen and or nsh except if contraindicated like for example with primary liver or metastasic disease to the liver thrombocytopenia caution with Kor and metamol in younger than two years of age curac may cause gastropathy and bleeding diastasis
Metamol or dieron has been banned from many countries due to the risk of agrostis and reports of severe allergic reactions few analgesics are FDA approved in children off label use is very common and precaution must be taken when using certain drugs in patients younger than 18 years of age tramol and
Codine have an unreliable effect dependent on genetic polymorphisms and severe cases of respiratory depression at normal doses have been reported methodone although it has a good oral bioa bioavailability long half life and no and doesn’t have an active metabolite also it has an oral liquid formulation that it’s super fit for children and
It’s also cheap some concerns have arise from its use due to the prolongation of the QTC interval so Baseline and control ECGs after those modifications have to be taken and his dosaging in children should be only be done by pain experts meperidine has an active metaboli Not to cause neurotoxic effects even in
Patients with correct dosing and no renal impairment plus its analgesic effect can be achieved by using other opioids as for the actil salicylic acid or ASA in children younger than 12 years it has been related to rise syndrome we have to remember that non-pharmacological treatment strategies must always be used if available without
Replacing analgesics but they are always necessary since they provide comfort and wellbe for the patient we need to remember also that morphing is a treatment of choice in cases of moderate to severe pain rescue doses for breakthrough pain must be treated with immediate release formulation opioids and 10 10 to 20% of
The total 24-hour dose that is given when withdrawing opioids you never suspend abruptly it must be done progressively more or less 20 to 50% of the original dose withdrawn per week to reduce opioid side effects because almost 77% of patients have at least one side effect you need to do a
Dose reduction change opioids change the root and also add symptoma IC therapy anti-convulsants and anti-depressant drugs are usually added when there is neuropathic component of pain steroids have beneficial effects on appetite nausea mood and Malice the mechanism of analgesia produced by these drugs especially the steroids speaking may involve anti-i effects
Anti-inflammatory effects and direct influence on the electrical activity of damaged nures so now that we have in our mind some important aspects of pain management in pediatric on techology we will now least some of the challenges encountered by low resource settings let’s start with some Financial challenges patients are usually too poor
To pay for transportation food or shelter too expensive or highly restriced assets for pain medication and or treatment because there is very few specialized Cancer Treatment Centers and the very few existing are too expensive because they are usually private and the public ones are only located in main
Cities also Mal nutrition is over 50% in children in low-income countries and this makes them very propense to um toxicity and Adverse Events infrastructure and government policies have inconsistent availability and an unreliable stock of pain medications there are very various restrictions for medical use of controlled drugs there’s lack of
Radiation Imaging facilities few pain pal pain or paliative care services available there is low priority ass assigned to pain relief all of this gives us late assessment and early abandonment or neglection of the therapy and high toxicity rates or Adverse Events with high percentage of Childrens with pain in Low Middle income
Countries what about Workforce lack of oncology or paliative care specialist and they all and the few that exist have very increased workload there is a lack of first Contact Health Providers and nurses that have high level of awareness no but for salaries training or even home
Visits there is a lack of health care workers that are able to prescribe there is difficulty for pain assessment in young ages because there is really no knowledge on the different pain scales on the most appro or the most appropriate ones for children and usually dosages are extrapolated from
Adult the lack and deficiencies of available Workforce cause late diagnosis and assessment increased risk of complications longer hospital stays and increased morbidity other important obstacles are education and cultural benefits of the population religious beliefs that cancer will heal from Faith or the lack of complete understanding of cancer and its
Consequences the under report of Pain by patients due to the belief that pain is an unavoidable part of the treatment fear of adverse effects addictions or other medical consequences if you report pain the distrustfulness towards medical system and the experience of guilt and depression all of these uh cause patients to under report
Pain the research and Registries are really bad there is a lack of accurate registration system missing reachers skate holders and advocacy there is no budget for research and there’s a lack of evidence and funding for research on most treatments these all cost under diagnosis of cancer and of pain under
Recognition of Pain by staff and the lack of accurate data and un recognized need of implementing changes besides all of the previously mentioned challenges there are some realities faced at public hospitals in limited resource settings usually public hospitals at loow income and Low Middle inome countries do not have pain
Medicines there is no availability or an unregular availability of different Med medications Imaging and treatment services available are very few you usually publicly only x-rays are available and the rest of the treatments if they are available they are usually only in private sectors and um or Outreach aided hospital bed availability is very
Low and they have a high rotation that means that they have to dispatch patients very early and they only have very few bets if they have beds for pallative care or for severely ill there is no Workforce very few anesthesiologists if there is an anesthesiologist there’s only one and
Maybe only one paliative Care Specialists there are no CRNA nurses so Workforce is a very important issue anesthetic and Equipment available the existing equipment is usually outdated with no reliable maintenance and anesthetics usually the most constant availability is the fenel and usually the others are once in a while
You have them then maybe some other times you don’t and under all of this not so favorable conditions how do lowincome and low middle- income countries manage pain we usually adapt the World Health Organization an aestic ladder to whatever we have available Sometimes using off label medications for children
And not following some recommendations for pain management we use Tramadol with a reduction of the dose usually we use it at point5 milligrams per kilo we use metamol because sometimes IV paracetamol is not available or if it’s available it’s very expensive some countries have banned as we mentioned earlier metamol
But we still use it Interventional therapies are only available privately and they are very expensive various medications are not available on a regular basis so we use whatever we have in on our hands and we do the best we can with what we have but all great changes are preceded
By chaos so this is something a little bit encouraging some countries are already working on government policies that follow the hoop paliative care policy and cure oil guidelines some are working to address drug availability problems although this requires a lot of work because in the effort to control
Misuse and abuse of controll drugs they become scarse and become unavailable for clinical use in education much is being done a lot of short courses mentoring virtual certifications are being sponsored and carry out and of course local Champions are always the key the Dynamics of changing and always making better adaptations of management
Protocols for even the most resource limited environments but what else can we do what else can each of us contribute with we need to get everyone involved more non-governmental organization Charities civil societies volunteers schools to create and support hospices shelter and maybe food for Children and Families education is always the key for
Everything we need radio and television ads for public awareness curriculum incorporation of a paliative care in nursing medical uh general physicians um in med school in everything we need to innovate and think of incredible ways to make our cancer patients life easier more likable more bearable to the point that maybe they
Want to come to the appointments and of course never cease to call for Action within our countries and worldwide spread the word of what real numbers are and the impact of little help may have on a child’s quality of life and at last but not least I want to
Outline the key elements for implementing initiatives for better Cancer Care and Pain Management in any low resource setting first we need to identify the problems so we know exactly what needs to be done usually local problems have local Solutions then prioritize and choose one of two problems to establish a realistic action
Plan International partners chips and Twining very important to nurture support and maximize excuses multidisciplinary teams are very important and probably the key to avoid resistance to change and always record and register Baseline data and the results to be able to evidence all the positive changes and always always remember that
Change will not come if we wait for another person or maybe some other time we are the ones we’ve been waiting for and we are the change that we seek I do not want to finish without giving acknowledgements to Dr roosan Martinez Gloria Manas and Lenny Alvarado they are the Pediatric and Ma
Oncologists at my city and one of them is the only pediatric pist in the whole country so thanks for them because they helped me with the sum of data of the presentation thank you very much for your attention okay thank you very much Maria for interesting lecture I am very impressed
The there is a big huge disparities in pediatric oncology care among lower middle income countries maybe we may address this issue later in the round table discussions okay let’s move on to this third speaker Dr Professor sa hotkim from Turkey her topic today is procedural sedation for Imaging and radiation uh
Therapy hi kicha I’m really honored to be invited to speak at this valuable meeting thank you Dr kuratani I hope this collaboration will nourish in the future uh at Vari degrees in numerous fields of pediatric anesthesia this is the hospital where I work aadam atum Hospital one of the
Leading Private health groups in Istanbul Turkey ER we are lucky that uh we have a very safe environment in means of nonoperating room anesthesia uh as you know the need for for anesthesia service outside the operating theaters has expanded exponentially in the past decade few hospitals are constructed with Nora as a
Priority nobody wants to go there it’s usually taken as a burden so we’ll go over uh procedural sedation for IM Imaging and radiation therapy for our oncological children now uh in this panel we try to Enlighten some aspects of pro procedure sedation we overview the indications different levels of
Sedation medication used uh how do we prepare the patient uh monitoring and documentation requirement and some potential complications of pro procedure sedation and their prevention and management strategies uh I think there’s no need to over emphasize uh that procedural sedation is a continuing process uh you begin with minimal sedation uh
However you can end up at general anesthesia depending on the patient the comorbidities the procedure and the environment and the personal and your team so when the word sedation is in the sentence we should be ready and prepared for general anesthesia as well and Nora locations are known to FL with patient
Safy concerns and high stress more than the opting theaters when we talk about procedur sedation for children having oncological care this is a bit more different this is called something new iterative anesthesia we will discuss why do we have to give repetitive sedation what are the problems confronted during this
Sedation and anesthesia procedures patient related factors anesthesia type equipment and environment problems and some safety guidelines radiotherapy has been used as the primary treatment in childhood childhood mananes with surgery and or chemotherapy tumors of the Pediatric age group like nephroblastoma neuroblastoma osteosarcoma epanda Masta Cora Goma and primitive neur neuro eoic
Tumors are preferred to be treated by chem and radiotherapy sequences and during these treatments frequent MRI controls are also needed by maintaining healthy tissue during radiotherapy it’s imperative to provide immobilization to achieve a more accurate radiation those distribution at the Target volume so the children on oncological care need sedation and or anesthesia
During their Diagnostic Imaging a some uh Imaging for planning some painful procedures like bone marrow aspiration Lumber punction or inal injections and their surgeries and also for the radiotherapy sequences we have a patient and his family they are all uh very fragile very tiny patients we have who had undergone
Uh who had recently undergone a major surgery and just recovered ing from the pain of it infection may be a problem W healing and some he may have some neurological deficits like postera syndrome or insufficient Airway protection and maybe cerebral paly or convulsions and also there are all psychologically fragile anxiety both
Parental and the patient is a pro problem of as also possible simultaneous chemotherapy it may have some side effects he ological deficiencies like anemia trombos spania and infectious May upute the way Nosa vomiting insufficient food bake nutritional instability frequent almost everyday fasting are the problems we face as you know radiotherapy is applied
By a source of external beam by protons or photons uh and by therapy which is applied from a short distance for retinoblast or SAR uh planning is necessary with simulation for MRI CT and head scan so these children has to be sedated during these procedures as well there are lots of
Side effects of radiotherapy in the short term we may have emotional tiredness uh Nos and vomiting taste sand changes diarrhea loss of hair headache blur Vision skin changes and radiation bones and coitis in the LT the child may have claustrophobia regression in behaviors tissue warms hormonal changes fertility changes abnormal growing
Neurocognitive deficits urinary and bladder changes secondary meanes or complications like vascular and cardiac diseases by maintaining a health tissue during radiotherapy it’s imper to provide immobilization to achieve the accurate radiation dose distribution at the Target volume these children are especially aged between 0 to five gen anesthesia and sedation is necessary to
Achieve this immobilization these children has to have repeated anesthesia up to six weeks every day coming fasting for with alien devices around they have to stay in a closed area for 10 to 14 minutes and because of the high energy radiation applied the patient must be alone during
The treatment parents they are all anxious about the procedure and the disease itself and the future and we are also far from the anesthesia team who are at the operating theaters the goal of the sedation U is to decrease the potential systemic and neurological toxicity however the risks
Of anesthesia and station are increased in these remote places technique has to be applied to prevent the harmful consequences timing is a problem there are ti schedules in the radiotherapy units and they have to consider the sedation and general and St durations during appointment Arrangements the infrastructure in the radiotherapy units
Is a problem they should be in concordance with rt unit and safe anesthes requirements uh the anesthesia team should be ready to a at all means capable of managing every clinical and non-clinical crisis uh the there are position constraints required by the practitioner in children with planned R procedures and restrictions on airation
Duty patient like patient specific FAL masks are used uh for the treatment of head and neck tumors and these uh May olude our access to the airway uh and the measurement of these face masks should be uh made taking in consideration the airway or the L place
So you should have the measurement when with your Airway devices monitors should be charged enough to be able to work in these distance places and the we don’t forget that we have a difficulty in accessing the patient the problems AR arising from the patient primary diagnosis and chemotherapy require careful preparation
And attention uh there are St stabilization tools used throughout the body to prevent movement and falling of the children during treatment uh there may be some side effects of the cor concurrent chemotherapy comorbidity caused by the tumor or surgery as well as the side effects or radiotherapy the location of
The RT units is usually far from the operating TRS some distant parts of the host hospitals or the radiotherapy is a separate place on his own so we may have shortage of equipment personal and monitors uh we have it is necessary to monitor the patients with Clos monitoring systems and usually the
Anesthesist and the anesthesia team is the only physician the parents are fa seeing and regarding all these Publications are very limited to ensure the safy and efficacy of sedation the patient is monitored by camera system in a closed area this can cause difficulties in in the dose satation of the anesthetic agents since
We are far away the P away from the patient uh as I said the radiotherapy units are far from the rest of the hospital or the P so we have to transfer the patient after the uh procedure to those units also we are fing sedation or anesthesia we
Have or our drugs have their own complications apnea desaturation a obstruction cough aspirational secretions are the most common complications we encounter ricardia Tash cardia hypotension hypertension txis tolerance uh intolerance agitation Are all uh confronted the uh the complications are the nightmares Port malfunctions IV access difficulties are very difficult
For us for the family and for the child himself uh we have toate our patients before the procedure uh proper fasting guidelines should be applied informed con consent with a detailed description to the parents how the sedation and procedure will be carried on should be given to
The patients and the patients in their um understanding uh level and to the parents every child has a rual ritual so we have to obey these rituals of these children monitorization PR pred PR procedure as appropriate should be applied at all times every Clinic has their own recipes
Or formulas for Sedation uh but these differentation General techniques are depending on the patient infrastructure and Equipment you have like some techniques transm sedation can be applied inal lingu re rectile depending on the child however these have unpredictable Effectiveness oral sedation for with chloral Hy hydrate is out ofd of label and
Dangerous and should not be used perent exess is inevitable in these children uh we have to have ports or long run long-term lines however um if you don’t have these the IV access will be a problem uh midam uh is a choice de medoin is inspiring and hopeful with
Minimum cereal effects ketamine has uncontrollable um has is causing some uncontrollable movements and ex excess secretions at the airway and some psychiatric complications and txis unpleasant psychological experiences double vision longer recovery uh High incidence of nosi and vomiting is the problems K of using ketamine the usually preferred technique is lowo
Propil tiated to effect and very slow infusion if there’s pain we can use pil also so uh but the low do prop is the most used TAA technique in most of the RT units uh we have to have qualified efficient Venus lines C Central equ
World as I said Pat RC or P lines are the standards however the complications of these lines is the infection so we have to be very careful about the disinfecting uh techniques during giving are the administration of the drugs alternatively periperal lines can be used but these should be changed at
Every two days and this is very difficult in small children this causes pain anxiety and fear uh even we use local atic creams we sometimes we have to seate the child with Nitros oxide putting IV with u inhalation anesthesia Airway safet should be maintained at all times inational anesthesia is a
Choice but we need anesthesia machine vors and breathing systems filters gas Scavenging systems Airway safety devices and like laring mask Airways are very useful in this uh scenario uh some children may wake up with uncontrollable hyperactive movements and additional anesia may be necessary for them in the postoperative uh Recovery Place uh when
You use inhalation anesthesia sometimes IV is not necessary If the child is a very experienced and had gone under had undergone many many therapies we can combine gen anesthesia and sedation I with begin with IV induction uh in children with anxiety and fear from the fast mask or has insufficient protective Airway reflexes
And maintenance with L mask Airway after interational anesthesia quick recovery may be obtained so you can choose your uh formula or recip or technique of uh sedation uh according to the needs of the patient equipment and infrastructure of the environment you have and this defines the antic protocol uh internal
Dein versus oral medam has been studied and it found to be very effective but we studies are still needed about that uh our friends had uh made a study with CR 4 based balanced anesthesia and they had concluded that the balance anesthesia with prop fall was safe uh sedation rapid Awakening and
Rapid discharge without side effects uh in radiotherapy units kop pantin has been tried in oncological patients and ketamine as as it’s known as battal felds anesthetic and this is a b fed as well but the advantage of ketamine is that you can keep the a reflexes intact and the H dynamically
Stable uh provides a safety zone for sedated but spontaneously ventilated patients especially at REM places like it Ms however there is a disagreement about whether it gives continuous and steady level of sedation during repeated RT sedations sessions or um it may have a tendency to tolerance occurrence to
Ketamine uh this has been claimed however when used repetitive and in the receptor antimonies are stated to be tolerance preventive so most of these are uh to be done so rather than the recipes of the generales sedation we need a properly educated team there should be consensus statements and Appliance
International standards and guidelines every day the invasiveness of the Care should be discussed with the multidisciplinary team uh shall we intubate the child every day or IV excess every day so we have to discuss these defining the incidence of complication rates in the RT units is necessary the effects of anesthetics
Other than in the maure growing brain should be studied the neurod degenerative and emotional effect of iterative anesthesia should be kept in mind so sedation needs sufficient equipment IV is necessary and monitorization is a must the care of children treated in RT and chemotherapy centers have specific and very special and have very
Special difficulties very and very few studies and SCI the consensus has in this field uh in the RT units we have to keep the minimum safety requirements anes should ask for the minimum necessary equipment and infrastructure when gener anesia and sedation of these children is provided the centers should meet the standards
Equal to the operating rooms and suggestions for international standard requirements at least there should be one spare room for anesthesia or people with sufficient equipment capable of providing anesthesia B and equip enough uh we need air or oxygen aspiration systems monitorization equipment chargeable and mobile monitors all all necessary drugs with sterile
Port needles proper disinfection material and special ven Access Equipment should be ready we have to have CPR equipments protocols for transport of critical children to the related P or oncological clinics uh has to be made and the necessary agreements should be there RT personel should be trained to help the anesthesia team
Approach to the experienced very experienced patient uh and the IV access and safy of Airway and breathing are utmost important video monitoring of the patients is mandatory as well we can elaborate the r is like this but um there is nothing important as this gentleman who carries the child and the
Child sees this uh their brother every day uh he’s very valuable so in the uh r care for the complex psychological status of the oncological child and the family is very important we do not have to for we do not forget that the anesthesia team is the only team that
The family and child is meeting every day for six weeks care for the riches of the child uh is very important we have to try to obey them uh so that we can keep the child’s anxiety at minimum minimally we can use we we should use minimal invasive
Manipulations uh keep in mind that L mask Airways are safe and life saving in times of Crisis so as a conclusion iterative anesthesia is less known underestimated neglected taken as easy yet time consuming difficult and needs well experienced team approach pediatric subgroups techniques and protocols change at every Center regulations does
Not exist to decrease ad effects the quality of infrastructure and Equipment education and experience of the team should be increased animation plays rituals for every patient is necessary to apply the daily daily appropriate uh Appliance to decrease the psychological and physical effects side effects Domo arato for listening me uh
And keeping your time uh and I want to invite you to the 20th meeting of Asian Society of pediatric which will be held in July in Kink Malaysia thank you hi uh now I would like to introduce uh Dr Mr Lucas Opitz who is a distinguished Medical Professional with
A dual role as the head of the Pediatric anesthesia at s antoan laan and the neologist uh at University Hospital n uh in France with an impressive background in anesthesia pediatric anesthesia and neology Dr Opitz has made significant contributions to the in the field of anesthesiology he is recognized for
Pioneering the concept of iterative anesthesia a Noel approach that has the potential to change the way we give anesthesia to our pediatric patients his inovative idea ideas and dedication to improving the care of children undergoing anesthesia procedures has gained him International recognition his lecture will be a valuable contribution
And the floor is yours Dr Lucas dear colleagues from all over the world thank you so much for inviting me to this webinar thank you for to Dr kuratani uh for organizing this uh web conf on uh anesthesia and Cancer Care for the behalf on behalf of wfsa
Um I don’t have any conflict of interest and my name is Lucas and I’m a neonatologist and pediatric anesthesiologist and I’ve been asked to work uh eight years ago while to start to implement a center of uh anesthesia for children in a proton therapy center in nce which was a very interesting
Experience and I want to share this experience with you as an anesthesiologist for children and neonatologist I’m very sensitive to the fragility of children we care for be it in niku and or in um oncological Center and I’m asking you what do these children have in common what does this
27 weaker of uh of 700 grams in our niku in common with this 7.2 kilo uh not even one yearold baby with a nephroblastoma yes they are very fragile and they’re fragile for a very long time they are high-risk patients and we as anesthesiologists have always this need this understandable need to be
Mastering the risks and um therefore we need monitoring and of course with monitoring we get more and more invasive and therefore also we expose these children to some geogenic risk so my question is what is the right dosage of invasiveness in these fragile oncological children these children are fragile because they are
Young they are below five years very often below three years sometimes below one year of age and we have to give them anesthesia every day in a repeated way during three four five six weeks or even more 33 sessions they have undergone surgery so sometimes we need to take care of this
Surgical or postsurgical aspects they are not always but sometimes under chemotherapy with all the side effects they have uh nutritional issues because onc I olical patients are nutritionally uh fragile but they are especially in this context with chemotherapy and with our fasting that we impose to these
Children four to six hours before on our anesthesia very often we have uh children that are noser that sometimes do vomit we have children that have an impact on um their hematological system with imunity suppression with anemia trombocitopenia we have to deal with this and very often these children are extremely fragile just
Globally and they athenic they have very often especially of course our um patients uh we treat for cable tumors neurological signs we have to deal with and they have especially for those who we treat for ear nose throat tumors mucositis swelling of the carom which has an
Impact on on the Airways and on secretions we have to take care for so the question again is how do we deal with this may we delay a start of radiation the therapy or is it a lack of chance if we did so or may we interrupt
A treatment if a child is especially weak for a certain period uh or what is the impact on the outcome of radiation therapy so we have been trying to discuss this um together with our colleagues and uh I’ve been trying to promote some meetings and to speak at certain conferences also in association
With the international uh Society of pediatric oncologists and uh the aim was to create a network on this and it seems that this network might um be built up thanks to scop Europe um anyway we uh started doing some activities and and we started our activities with a first
Survey which I want to uh share with you the results that the results that on certain questions one of the questions was where our radiation therapy departments were located and we could see that they are very far from pediatric hospitals in the majority of the cases which means that there is no Safety
Net in infrastructures were not sufficient in many cases up to 25% had no remote control more than the half of the people interviewed did not have an induction room and about 30% did not have a recovery room it also became clear that um many colleagues up to
30% uh do not have a specific pediatric um activity in their daily life and that they um treat children in less than 10% of the cases this little experience uh in Pediatrics is true as well globally in radiation centers um up to 15% of the radiation centers we interviewed had
Less than 10 patients a year under general anesthesia we asked also some descriptive questions and had uh these answers on the biggest concerns in pediatric anesthesia in radiation centers and as you probably all can understand respiratory issues were number one but in general very often uh the we
The expression of lacking uh of uh safety issues lacking of experienced staff and uh the lack of equipment as well was very often expressed um respiratory problems is always number one I think we all agree on that we always have this uh little thing in our mind even if we are
Experienced pediatric anesthesiologist bronol lingos spasm is something we really uh want to avoid um in specifically in ration centers um very often our colleagues answered about uh a concern which was the one of having non-sufficient sedation with movement uh and even a child that fell off the
Table so I want to ask you um well how risky is our uh work in radiation centers in general in Pediatrics we say that it is a more risky matter than uh if when we treat healthy young adults of course uh and this you know probably
About this um survey uh which is called abricot that has been done in 33 countries in Europe uh concerning the severe critical events and uh per operatively they have been up to 5.2 to uh problematic issues that have been observed uh interestingly um in certain countries there were some
Statistically different uh results um especially regarding lingo spasm and it seems that Scandinavian countries had much better scores in uh this um critical events um my question is also how do we Define these critical events is it uh something that is really objective or is it also more an
Emotional thing because uh uh what is a normal uh event for the one might be a very critical one for the other and this is where expertise maybe has to uh play its role the same study um pointed out that experience is an important factor for safety and the more you are experienced
The less you have critical respiratory events and they actually put it in a mathematical way that that every year of experience you get 1% less critical respiratory events it’s an interesting um information we also should adapt in our adopt in our radiation centers Food and Drug Administration of America stated that repeated anesthesia
Is a probably um negative has a negative impact on child children’s development and therefore they recommend not to use anesthesia in children unless it was really necessary I think we in our centers with children having tumors surgery chemotherapy plus anesthesia this kind of problem about this concern about the
Impact of anesthesia on long term is uh should not be um should not take too much place in our thoughts especially if you consider that there is no real statistical evidence on this so allow me to give you some hints hints about this problematic uh issues we were
Discussing at the beginning about the young age I think experience expertise is important to face uh in a uh Serene way all the risk factors of young children the fact that we do anesthesia every day for such a long time means that we have to use minimal handling and
I’m willing to discuss this with you later what is minimal handling but this concept which has been implemented now more than 20 years ago in neonatology has an huge uh impact on the outcome of the newborns in terms of morbidity in terms of uh the surgical
Context we can use and we can take advantage out of anesthesia with wound treatment during anesthesia we have we are the one to deal with pain in these contexts we have to prescribe the painkillers we have to also to organize sometimes the chemotherapy and to organize it uh in order to make it
Compatible with our activities in radiation centers and therefore I my hint would be that uh it is important to have um chemotherapy during weekends if that is feasible regarding uh vomiting well the stomachs have to be empty and this um recommendations of using six hours of fasting plus two hours for um clear
Liquid should still be U uh uh used on in our basis even though some scientifical uh public ation showed that 4 hours for food would be enough but in the oncological context for me this is well still uh relatively uh tricky but I’m willing to to learn more about
It uh nutrition very important as we said before it is important that we can have we can use anesthetics that are on off that means that the children wake up fast and that right after The Awakening they are allowed to eat very typically our children once they wake up the first
Thing they do is being fed be breastfed or uh having their uh bottle of milk or other any other food they want um if that is not enough and if we see that there is a a loss of weight we can Implement nocturnal feeding through gastro gastric uh sound with the gastric
S gastrostomy is very rarely needed um we need monitoring for the immunos supression we need to have a very very careful approach and sterile approach to the central catheters we have to deal with uh um transfusion of blood red blood cells or platelets in these contexts and regarding athenia which is
Very frequent in these cases we should be always be objective and not let ourselves be impressed by these children that seem to be so tired uh we need objective vital signs to be in order to say this child is not fit for anesthesia because uh the benefit of going through this radiation
Therapy is so much higher than the risks uh which are spontaneous momentaneous anesthesiologic and uh therefore we should always have a positive approach and even go beyond recommendation saying that uh Ania should not be performed in in this and that case especially also for children who have some let’s say minor respiratory
Problems regarding ear noose throat patients who have mucositis also in the context with chemotherapy uh the swelling of and CA I really would would like to recommend you the use of lingel masks which really allows us to uh perform uh ventilation and maintenance of anesthesia in uh safe monitoring conditions with understanding exactly
What is happening in terms of um tidal volume and and uh monitoring of anesthesiological gases if they are being used so the question we will maybe discuss later is should we always use intravenous lines my answer would be not always and should we have some lines as
A rescue system I would say most of the time yes but not always but we can uh also discuss what kind of line would be uh uh useful yes I know I’m a little bit obsessive about lenel mask but it’s really very helpful in your radiation
Centers look at the left you see this chart that has an irradiation of uh ear nose throat uh it had a tumor of the carom there were Hemorrhage in the in the Airways with uh with Hyper with CA and L angel mask just bypass that very
Easily on the right you can just see that there are the landmarks of the between the nostrils and the lingal mass so you can really position the baby in a comfortable way and lose it and not losing too much time for the positioning regarding Airways this is
All what we can say in Pediatrics is don’t do things halfway throw yourself into the water don’t handle Airways if the baby is not uh perfectly deeply asleep so erogenic include many aspects and we should not forget the thermal homeostasis uh the psychological discomfort and the akathesia which means
That the child would at is its Awakening be extremely agitated irritated and in a in between state that is very very badly accepted by the child itself of course but by the parents as well and by ourselves because it is not satisfying so in order to wrap up our
Presentation yes we can say that the conditions of safety are not always met in our radiation centers and we have to do something about this and the question is do we have need a special license for treating these very young patients and I want to come back to neonatology since regionalization has
Been introduced in many many countries we can see that um the morbidity and mortality in neurology has dropped dramatically and I think the same could be true not in terms of mortality because I don’t speak about death in radiation centers but about risk factors in radiation centers but we can in a
Certain way implement this regionalization or we can think about it and try to have some referral centers to which children will be sent uh especially those children who need general anesthesia in this uh context so as I said before in order to discuss all this we have this multidisciplinary
Network that is being um constructed let’s say there will be workers working groups there will be four subgroups and we try to use the dely process in order to give give recommendations that can be useful for our colleagues uh so we need moderators and we need experts and I
Want you to ask if you are interested please contact me because we we we need a keen enthusiastic people to work on this so I think we we about to say that the times for improvising are over we should really try to get clearer ideas on what is acceptable what is should be
Done in radiation centers and therefore uh these working groups these subgroups could help and I want to well again to invite all people who want to join to do so you can get me very easily through this email address and I want to thank you uh for your attention and um uh well
I’m very keen on uh the discussions which will follow to my presentation thank you so much and here you can see an induction of a child with in the arms of the mother in our proton Center thank you so much esteem participants audience and distinguished speakers we now welcome
You to the discussion part of our webinar Today We Gather to Del into the topic of uh importance anesthesia and Cancer Care in Pediatrics the knowledge and insights share here today and they hold the potential to transform the way we care for our youngest F patients facing the challenges of cancer
Treatment the intersection of anesthesia and pediatric oncology is a critical area where Innovation and collaboration can make a profound impact in the lives of our young patients we are fortunate to have a panel of experts who have contributed their expertise to this discussion uh before we Dive Into the
Heart of our agenda I kindly request each of our distinguished speakers to provide a brief self introduction uh this will help us to get to know each other better and get the set the stage for the productive and insightful uh discussion let’s begin by hearing from our esteemed speakers
Starting with Dr sad ASA thank you for contributions thank you uh CLE so I’m a p pediatric anesthesiologist and uh I’ve been working in pediatric anesthesia since 2004 I been working in I work in the United States and came back to Pakistan in 2009 I’m originally from Pakistan uh
And I’ve have this divided practice where I spent half the year working at an academic center in the United States and I spent half the year uh at a tare public Hospital in Pakistan so I do have uh some of the challenges that Maria was talking about and um I think no matter
Where live all children with cancer and their families are very traumatized by their diagnosis and the treatment itself is and its side effects um are something that traumatizes them every day so I’m um really grateful for this group because these patients are increasing in number and we need to address how we can
Support them better than what we’re how we’re doing it at the moment we can continue with Dr Maria hello everyone my name is Maria Alejandra eeto and I’m a pediatric anesthesiologist I am from Honduras I live in Sedro Sula Honduras it is not the capital city but it is the second
Most important city in the country uh I’ve been doing pediatric anesthesiology since 2014 more or less as a pediatric anesthesiologist and um I know part of Both Worlds uh in Honduras we have the public sector which is like you saw um uh very scars in in every way drugs
Equipment Etc so I know that horrible part of the job but I also know the other part which is the private sector um in the private sector we have a whole different world we we have everything available and it’s very the disparity is very obvious and we need to do something
About that and I wish um all of us uh the ones that we can have ideas and do something about it we can chare and uh start implementing new strategies to fight this thank you thank you Maria uh and we have Dr uh Lucas also in our discussion yes hello uh so
As I said in my introduction my name is Lucas and well I feel a bit old because uh I’ve been doing pediatric anesthesia since 1990 so anyway uh yes I’m anesthesiologist for children and also I work a lot in intensive care units be PE but mainly
Also niku and um I’m very sensitive to both worlds because you both both expressed uh the knowledge about high uh let’s say high specialized with well equipped um environments and those of lowincome countries and me myself have been working a lot also in uh let’s say more difficult countries be in Africa or
In um Eastern Europe and so I’m very sensitive and open also in to to let’s say to discuss our matters in an adapted way because of course those standards we want to give that are high level standards cannot be uh applied everywhere and we always have to make
Compromises with the reality and so so this discussion can be really very very interesting and we have Dr Dr zya chining hi Dr zya hi everyone yeah my name is Sal I’m pediatric anist from mongola now I’m living in Sydney I’m doing my research at University of Sydney so before I’ll thank
You so much for Dr kuratani Who organizing this interesting webinar and I’m so enjoyed all the speaker speech it was really interesting and I believe that it’s um uh really helpful for all anthologist all around the world because this uh Ana anesthesia and pediatric anesthesia field is always the struggling and
Challenging field for every pediatric an olist so I believe that this webinar is very useful for uh us yeah thanks Doo and do and I long friends and he used to do be a staff anesthesiologist at the uh maternal and the children hospital at UL Mongolia and he has been involved to
Pediatric Cancer Care in his home country so thank you very much for joining us and could you tell us or like a have any questions or comments to the speakers so the firstly I really want to ask the do Dr seril so um what do you recommend the the
Sedation level and outside the operating room because it’s always the struggling uh especially without any specific anesthesia machine you are muted sorry okay sorry didn’t realize that outside the operating room it depends on what uh what kind Services you’re providing I think if you’re in the
MRI service in the CT scan it’s a different kind of service radiation uh Suite is a very different place uh I think the radiation suite are is uh a proall infusion but if you are in a low resource resource place with limited monitoring uh may be considered pre to
Look at your patient carefully um unfortunately sometimes dexman atomine can be more expensive uh to in low middle- income countries you can multi-dose from a single while which helps or mix it up with a very lowd dose ketamine like2 milligrams per kilo of ketamine and some medam and that also
Helps I be curious to know what Maria thinks of that yes usually that’s what we do we combine ketamine at very low dose with propol so it’s like a kapol thing uh the best thing is to have them both separate but sometimes even that is difficult and
You have to mix them in one siren because of the trying to use the less insum as possible but the best thing is to separate both uh because if you want to add more propo then you do not add more ketamine to the you know to the
Mixture but yes we usually do that privately we do use deck uh because um now there’s some generic um presentations and it’s a lot cheaper now but still it’s only used in the private sector but not publicly it’s not available yeah in Japan uh the Pediatric NOA non operating room anesthesia is one
Of the H topics in pediatric anesthesia um the My Children Hospital is the one of the leading top children hospital for the Cancer Care we take care of the lot of the uh cancer patients in a hospital actually we do a k one of the only a few institutions
Which can do K therapy in our country but the most the non-operating RO sedations are done by pediatrician and the probably the uh Coral hydrates are the most commonly prescribed stives when they need MRI still and so I think the an should be involved more for the nonoperating room anesthesia but we
Need more anesthetist that’s the problem so what I’m sorry yes Mr yeah uh can I ask a question about the catapult the Maria so what what about the mixture of the kapo I mean the proportion in the mixure in one’s high range could you please tell more about
That yes you usually calculate the those uh per milligram per kilo of the child for about an hour and uh you you know if you have I don’t know a 30 uh kilo um child and you go point two for ketamine and you go like two for um propol and
You place what it’s supposed to um go for one hour in the same sing like I said I do not like that um method I usually like to separate because if I want to add more propol then I do not add at the same time more dose of
Ketamine so I do like to separate them but that’s what we usually do we prepare it uh according to the milligrams per kilo and we usually calculate for the time that’s going to take the the procedure approximately usually 45 in our MRI for example 45 or 1 hour 45 minutes or 1
Hour I also don’t like them up I like to give my ketamine separately and actually as a part of my premedication I don’t know why but the children in Pakistan when we give them IV medas Lam have a uh have an adverse reaction and actually get more anxious with it so what we
Discovered is that if we add a very low dose ketamine like 0.1 to2 grams per kilo along with the low dose of medam to separate from the parents that helps give it a few minute it kicks in then you can separate from the parents go in
And you can add propal very slowly keep them breathing so maybe 0 five really depends on the kid children like Lucas talked about are very very fragile one milligram per kilo is going to really knock them out uh some kids are going to come back over and over again well one
Milligram per kilo they just laugh at you you won’t even see any effect um so I kind of try to look at their previous record see how much they’ve used how they reacted to that dose and then adjust your dose maybe start a little bit slow because you can always
Have the option of adding more more yes I think there is the one key word which would be adaptability we have to adapt and I think uh we have to adapt to our environment and we have to adapt to with whom we work and we have to
Adapt to the child and to the parents so all this makes a mixture which makes it so difficult to give you recipes actually and therefore you can you can actually almost invent anything what is important is that in the end is the comfort for the child and the safety for
The child and your own Comfort because if you do something and you feel stressed with this then well in a certain way you will have to maybe to change it or to feel more comfortable so uh any technique which you don’t really you’re not really used to makes you feel
Uncomfortable and I think the risk factors will increase a lot when you yourself do not feel uh comfortable so um I yeah I I that’s why I always spoke about this lingel mask I know it’s a kind of obsession as I told you but I think it really gives you a lot of
Safety because you will really understand what happens to the child because uh in sedation or the child is not well enough sedated and it it’s moving exactly in the in the wrong moment when the MRI is has a sequence and has to be repeated and so you will
Repeat the exam once more and will take another 20 minutes or you give him too much sedative and the child will just stop breathing in in in urine UPA and you don’t know you have to rush you have to give him oxygen you have so there are
Different ways to handle this of apart from lingel mask which will help you a lot which of course needs a very deep anesthesia but if you use propal or halogenic uh The Awakening will be relatively fast as well and I don’t think it has has an an impact on the
After the after mes uh but we did not speak about one another device which is very useful and it’s not very costly which is the high flow um um oxygen so uh if we have if you have these devices and also in in lowi income countries I
Think they’re not very costly and we can uh give uh very satisfying oxygenation to Children even if they are in almost hypo ventilating or even in UPA so this High Earth uh or very high flow devices are very very useful they I don’t know about if you know how uh important they have
Become in our intensive care settings and uh we very often ventilate well uh newborns with very high flow with like two lit or even three liters kilo per minute of uh of very often normal air normal uh um 21% of oxygen but it really improves a lot the respiratory
Conditions and I think in this settings it could be helpful okay thanks and actually unfortunately time is running short but before we finish I would like to ask one question to all the speakers this webinar is hosted by DSA and our one of the mission is like a delivering high
Quality anesthesia care for everyone everywhere in the world and in this webinar we engaged the speakers all around the world and we learned there is Big unacceptable disparities in Pediatric ccer Care among the countries and my question is how can we address how can we fix the disparities inequalities
That maybe Lucas you are working in like a most advanced research Rich environment and do you have any suggestions or how can we help the Maria or that’s very difficult I think because we need people we need money and we need adapted politics look at the world how
The world is actually look at the the world wars we have all over the which are we we spend money billions of dollars for killing each other and but we don’t have the money for just taking care of our children I think it would not be so very
Very expensive but we need a political will so there are so many things I could tell you but I mean we need four hours speaking now I don’t think this is the propos but I I think this is a very important uh discussion very very important yes and we really should think
About this thanks SAA you are working like both ends so no zaa you have any questions no any comments you’re working the two ends America and Pakistan so St Judes and wh have started this uh this collaboration and the hospital where I work at in Pakistan is
A part of this collaboration and as as a part of it they’re taking the Pediatric oncologists offering them um training periods in the United States and uh for example the neurosurgeon from Pakistan right now is visiting St Judes to see how they for uh children there and so so
There is this collaboration and transfer of knowledge and transfer of skills that is taken I think that’s very important as people come back they get exposed to different environments so so you asked do I think the most important thing is is offer Physicians and health care providers in low and middle income countries
Exposure and train them better so go back and work in their own environment and and then they are able to identify the gaps themselves and they can come up with their own local Solutions on how to approach their problem I agree with Sadia I think education is the first step to take
Number one maybe wfsa has a EPM program but um it’s directed to uh any kind of pain maybe if we could do an EPM for cancer pain specifically for Pediatrics like for example directed to nurses general physicians pediatricians uh not only anesthesiologists that would be one thing another one would be uh
Scholarships for um our resident we have a resident program here in Honduras and maybe one of them is interested in pain and paliative Care uh and to rotate where um uh Dr Lucas has his uh you know very high-end and technology and they could see all that or they can be trained in
Fain specialty and then they come back here and they want to do a department we do not have a pain service in the public hospitals that there’s no pain service so uh it would be interesting to have them go study uh that and or even have
Uh virtual uh classes with you guys with specialty uh in Specialties in pallative service and pain service um the that would be very nourishing so Education First and then when we have a group of a very good uh um Workforce that knows a lot and knows the importance of this
They can address it together we can do many things so I would start from education okay if I may add I think we have to also address faila of care more than 70 to 80% of these children in in resource score settings are not going to be cured they
Un are going to not have a good outcome but they are forced their final days without appropriate pain medicine and any really Pia of support to for the family and the child uh and a very painful thing for mean to experience in Pakistan um somebody that recently was
They had so one one of our main problems is because of the volume um that we see nobody really owns the cancer patients for for their biopsies and their biopsy in my Hospital gets delayed by as much as two months so somebody who came in walking and could
Possibly have been cured if they had been if treatment had started the day they started they came in the Hospital ative patient two months later when they’re biopsying that patient and at that point I was like listen why do we need biopsy this this Legion what we
Need to talk about is how are we going to leave this family and this child with their final uh moments okay s you are the president of aspa agent Society of pediatric and indologist and do you have any uh ideas how the international societies can help to achieve Universal coverage
Of high quality CH of care in Pediatrics uh first of all thank you Nori for uh presenting this uh webinar and organizing all these and thank you for Dr Lucas for igniting the flame I think it was before the uh before the pandemic that you had written something iterative Anastasia and has organized
The first meeting in France uh I think now the group is enlarging uh Asian Society of pediatric anist has every month webinars uh and they have some subgroups like uh pediatric pain and the sedation or other subgroups so we are uh giving some webinars but I think uh webinars are not
Enough people are um tired of listening to webinars or attending so we have to reach them uh but uh world is in somehow big somehow small uh through webinars and workshops uh online uh meetings we can reach each other but we have to have handson uh educations um we need guidelines
Policies uh and people to work uh not only the anesthesiologists the nurses the anesthesia technicians we have in hand so we have to um educate them as well I think every people has something to do in this field so we have to have some uh teams like uh dealing with these
Oncological patients it’s um we can work with cop like Dr Lucas has um just begun the team and the collaboration is is increasing uh so we we should put the guidelines and then reach these people and the uh coner patients um it’s a very difficult very touchy part of this uh even
Premedication of these children or anesthesia of these children are neglected uh they come and go and they’re in their real world and they see this as their normal uh this is this is a Pity so the international organizations like wfsa has some safe P courses or uh small Asia or small train
We have some charity organizations like that we may have some cancer anesthesiology Charities or uh like SM Smile Train we we can make some organizations like that which can travel and uh see the what are the problems onside and then help people uh whatever their conditions are this is
Just the beginning thank you for putting this forward yeah if you allow me just one word I would um the wh and um the international agency of atom of atomic energy the uh iaea uh actually is are working on some protocols or some standards in for radiation centers because they want to
To amplify the spectrum of of these cares because they are of course aware that in many countries there are no radiation centers and they want to help to to in implementing these centers in certain countries and so they are building up some standards and uh I was
Collaborating with them but now for a certain time I haven’t got any uh news but uh perhaps some very well I I might meet some of them quite soon and I will ask about it if if there is anything uh new and I mean this is also one of the
Steps that can be done for uh and of course you remember a radiation Center is in itself a very very expensive Center which we were talking about money and about means and I mean anesthesia is is just nothing compared to the to the amount of money which which is needed
For building up an a radiation Center but still anesthesiologists and radiation oncologists should go hand inand because it is very surprising that oncologists or administratives uh build up centers and just don’t think about anesthesia and so you find yourself in a center with no recovery room with no
Oxygen with no aspiration syndrome etc etc in this in Europe not only somewhere in far in a country with low income so it’s really interesting and I think we have to push forward for for making people more sensitive about this thank you and we are sorry that we are uh we come
To the end of this enlightening webinar I would like to express my sincere gratitude to all our esteemed speakers uh attendees our audience and the organizations that make this event possible The Joint Society The Joint Society of pediatric anesthesia and the World Federation of societies of anesthesiologists throughout our
Discussions today we have witnessed the power of collaboration Innovation and dedication to improving care of our pediatric oncology patients the insights shared by our distinguished panelists have eliminated the path forward highlighting the pivotal role of anesthesia pediatric CER area each speaker has brought unique perspectives experiences and knowledge to the table enriching our
Understanding section the ideas exchanged to get today have the potential to make a profound impact on our lives of the children uh our fragile children let us leave this virtual Gathering inspired and motivated to continue our work striving for better outcomes and embracing The Spill of continual impairment the Journey of
Improving anesthesia care for pediatric oncology patients is go ongoing our Collective efforts are the driving force behind the positive change I encourage everyone to keep the knowledge and insights gained here today into their respective fields in their countries in their hospitals they work let us continue to provide the best possible
Care to the youngest members of our society who look up to us for strength and hope and health thank you once again for your participation and I look forward to seeing the transformative impact of discussions held here today in the future of pediatric Cancer Care until we meet again stay inspired and
Committed to making difference goodbye and take
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