Central Line
Episode Number: 123
Episode Title: Subspecialty: Pediatrics
Recorded: February 2024
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA’s Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ADAM STRIKER:
Welcome to ASA Central
Line. I'm your host and editor, Dr. Adam Striker, and this is our second
subspecialty focused episode. We're trying this year to focus some of our
episodes on various subspecialties of anesthesiology. We'll be continuing that
throughout the year. Today, we're turning our attention to pediatrics. We
actually recently did do an episode highlighting SEE and one of the articles
involved, Pediatric Airways. So this will actually be a nice follow up to that.
I can't think of two other guests that I'd rather have discussing this topic
with me. One is Dr. Annery Garcia Marcinkiewicz and the other is Dr. John Fiadjoe,
both from the Society of Pediatric Anesthesia, to talk specifically about
pediatric airways and also the pediatric difficult intubation registry. So Drs.
Fiadjoe and Garcia-Marcinkiewicz, thank you so much for joining us.
DR. JOHN FIADJOE:
Thank you for having us.
DR. ANNERY GARCIA-MARCINKIEWICZ:
Thank you.
DR. STRIKER:
Before we jump in, if
you don't mind, each of you just telling our listeners a little bit about
yourselves, where you practice your roles and how you got interested in the
specific topic of pediatric airways. Let's start with Dr. Garcia-Marcinkiewicz.
DR. GARCIA-MARCINKIEWICZ:
Okay. Thank you very
much. My name is Annery Garcia Marcinkiewicz, and I'm a pediatric
anesthesiologist at the Children's Hospital of Philadelphia. I have a special
interest in taking care of patients with difficult airways. And a lot of that
interest came about when I met Dr, Fiadjoe when I was a fellow at Chop. And,
um, really watching him and his expertise and learning from him was so
inspirational to me to really want to learn more about how to keep patients
with difficult airways safe. And I was introduced to the pediatric difficult
intubation registry and just enjoyed doing research and, you know, finding out
more and learning more from this fantastic registry. And currently at Chop, I,
uh, co-direct our Difficult Airway program. I love finding new ways to improve
our practices in keeping patients with difficult airways safe, and also
teaching these practices and methods to our trainees and doing refresher
courses for our colleagues when we can.
DR. STRIKER:
Great. Dr. Fiadjoe?
DR. FIADJOE:
Yeah, that was kind of
you, Dr, Marcinkiewicz. My name is John Fiadjoe. I practice for about 15 years
at Children's Hospital of Philadelphia and currently practice at Boston
Children's Hospital. I became interested in difficult airway management,
especially in children, when I was a resident. As a resident, I recognized that
although anesthesia was touted to be the safe specialty, these children who had
difficult airways often had complications, and we often struggled to intubate
them. And so early on as a resident, I made it kind of one of my missions and
purposes, uh, clinically and academically, to take care of these patients and
also to learn as much as I could about outcomes in these patients. So that's
that sparked my interest in pediatric airway management.
DR. STRIKER:
Well, love to talk about
how the science or art of pediatric airway management has evolved. And I think
probably the best way to do that is to start off by talking about the, um,
Pediatric Anesthesia Airway Database that the SPA or Society of Pediatric
Anesthesia is sponsored. So I think hopefully, as both of you talk about this,
the evolution and how it's continued on and evolved over time, we'll get a
better sense of just where we've come from with managing pediatric airways and
where we're headed. So why don't we start off, um, talking a little bit about
the database and where it came from and how it has evolved. Dr. Fiadjoe, do you
mind tackling that one?
DR. FIADJOE:
Yeah, I can dive into
that. So that started early on uh, when I became faculty at Children's Hospital
of Philadelphia. One of my uh, colleagues, Mohammed Rehman, was working with
electronic medical record systems and asked me to lead a special interest group
within the Society of Pediatric Anesthesia to try to define on what exactly is
a difficult airway. How do we track that in the EMR? And that group started
meeting regularly at the Society of Pediatric Anesthesia meetings, and also at
the American Society of Anesthesia meetings. And, uh, one of the members of the
group, Peter Schmuck, suggested the idea that we create a registry to look at
outcomes because we all knew that the outcomes were worse than most people
thought. And, uh, that sparked the idea to create this registry and to create
the pedi collaborative network. We started off with three sites Boston
Children's Hospital, Children's Hospital Philadelphia and Dallas Children's.
And with the intent of conducting research, benchmarking, and quality
improvement. We have now evolved over the years to more than 40 international
sites that are active. I think we actually have probably close to 60 sites, but
40 are are active and have accumulated, uh, I believe the last time I checked,
more than 7000 instances of difficult airway management cases in the registry
and have published several, I think, important papers using that data.
DR. STRIKER:
Great. And Dr. Garcia
Marcinkiewicz, do you mind telling us how the registry works?
DR. GARCIA-MARCINKIEWICZ:
So there's a lot of
enthusiasm and many more sites that have expressed interest in joining the
registry and that have joined the registry ever since the time that Dr. Fiadjoe
described. And basically interested sites contact the main site in
Philadelphia, which is the Children's Hospital of Philadelphia. And there's a
robust process for capturing the data and the quality of that data and cleaning
those data. So information is collected on patient demographics such as their
gender, weight, their airway exam, whether they have a genetic syndrome, the
preoperative plan, the ventilation technique that's planned, the anesthetic
technique and case data are collected. So was mask ventilation possible? What
airway devices were used? What medications and complications that occurred
during that airway encounter? Complications are generally cataloged as
non-severe versus severe complications. Non-severe complications being
hypoxemia, laryngospasm, bronchospasm, immediate recognition of esophageal
intubations. And severe complications being things like a pneumothorax, you
know, pulmonary aspiration, delayed recognition of esophageal intubations, and
cardiac arrest. And so we then look at the processes and outcomes. See what we
learn. We send reports to all institutions about their performance
benchmarking. And hopefully that is a direct benefit to each site. And that's
where the idea for the studies come out and, you know, help inform the next
studies and improve the safety of patients.
DR. STRIKER:
Great. Well, Dr. Fiadjoe,
can you give us a little more detail on what kind of data is being mined from
this registry?
DR. FIADJOE:
Yeah. So, you know, when
we started early on, it took us about two years to decide on the data elements
that we wanted to collect. And we really had to think really carefully about
the research questions we wanted to answer. Because when whenever you create a
registry, it has to be a balance between collecting too much information and
collecting the relevant information to the question. So we spent two years
having discussions about what was important and what things we wanted to
explore. And so we we collect traditional data like demographic information
about the patients, but we also collect very granular data about airway
management. Some of the data is not often collected in your standard airway note.
We collect details about the drugs that were used, the techniques and devices
that were attempted, how many attempts occurred, who performed those attempts,
whether the patient had a neuromuscular blocking drug administered during that
attempt. And then we looked at the types of complications that occur with each
attempt and document those as well. And we categorize those complications into
severe and non severe complications, as I referred to earlier. And the
interesting thing that we learned, and I was surprised by this, was that we had
cases where there were 20 or more attempts at tracheal intubation. Um, I wasn't
expecting to see that. But that is not common. But it happens more often than I
would have expected. Those cases are often associated with significant
complications. So one of the benefits of the registries, we highlighted some of
the risk factors associated with with complications.
DR. STRIKER:
That example of 20 plus
attempts. Were you surprised that even if that did occur, that it was reported
that way?
DR. FIADJOE:
Yeah. One of the things
that we we realized, because when I was at Children's Hospital Philadelphia,
we'd have a research assistant actually documenting the attempts, and we
defined an attempt by the entry of the laryngoscope into the pharynx till it
was removed. And so you'd see what the research assistant documents, and you'd
ask the team, you know, the research assistant will document 10 to 15 attempts
or whatever it is. And you ask the team and they say, oh, we only made five
good attempts, right? So there's this bias when we're, uh, documenting our own
data to underestimate the data. So I think a lot of the data in the registry
has this underestimation bias, especially when it's documented by the
clinicians involved. So yeah, I think that's a interesting point.
DR. STRIKER:
Yeah. Very interesting.
Well, let's all talk a little bit about how the registry has changed our
understanding of pediatric airways. First let's start there. How has the
understanding changed. Then let's delve into a little bit of the findings that
we think our listeners should know about that has come from the registry and
maybe how it informs best practices. Um, so let's start with, Dr. Garcia-Marcinkiewicz,
do you mind leading us off?
DR. GARCIA-MARCINKIEWICZ:
So it all started with
that first study that was done in 2016. At the time, there were 13 sites
involved and a little over a thousand patients in the registry. And that study
really showed the scope of complications and kind of taught us a little bit about
what was going on as far as the use of airway devices and some of the
complications related to that in particular. So one thing that was, you know,
really an important finding was that the most frequently used device for first
attempt tracheal intubation, the direct laryngoscope, was the least successful
device. So direct laryngoscope used 46% of the time. And its first attempt
success 3%. Compared to other devices such as the glidescope or the fiberoptic
scope. So that was an important finding. Another important thing from that
study was that the number of attempts matters, with each attempt at intubation
increasing the odds of complication by 1.5 fold per attempt, particularly more
than two intubation attempts really putting that patient at risk. One of the
most common non-severe complications found in the study was hypoxemia. And
sometimes people say, well, a little bit of hypoxemia. What's the problem? You,
you know, ventilate the patient, bag them up and they'll be fine. But a little
hypoxemia is in the pathway to cardiac arrest, which was the most common severe
complication found in that first study.
DR. STRIKER:
You know, it's, uh, it's
interesting because I imagine a lot of us that practice pediatric anesthesia
might have guessed some of those things, but did you find that the numbers were
just more staggering, or was it the concept itself surprising the number of
attempts and how the odds of, uh, complications went up so drastically?
DR. GARCIA-MARCINKIEWICZ:
You know, it's one of
those things that, you know, write more attempts just can't be good. More bad
things happen when more attempts occur. You know, your your initial very
orchestrated, um, and very well thought out first attempt progressively
declines as more and more attempts continue. Things get sloppier, things get
messy. You know, human factors come into play. All kinds of things happen,
right? But just to see those numbers and to, you know, really catalog each
complication and how much risk, you know, is posed with each one of those
attempts was really eye opening.
DR. FIADJOE:
Yeah, I'll agree with
that. I'll say that I think we all know clinically that, you know, making more
attempts is going to be associated with more hypoxemia and more issues. What we
didn't know, we didn't have actual data to support it until that study. And at
the time, the reported incidence of cardiac arrest in normal, healthy children
coming to the operating room was about 1 in 10,000. And what we found in this
population, I call them the vulnerable population, was a cardiac arrest
incidence of 1 in 80 or so. So significantly different, which makes these
patients, I think, require some more vigilance, attention as we take care of
them.
I will also say that
after that first paper, I kind of categorize their subsequent work in a few
categories. The first is, we did some studies to assess how we ventilate and
anesthetize patients using neuromuscular blocking drugs, etc., giving oxygen
during the intubation. And then we had a category of studies that were
comparative studies looking at a variety of techniques. We showed video
laryngoscopy is more efficacious. And that actually when you think about video
laryngoscopy, you can think about standard blades which have the standard Mac
or Miller blade configuration, and non-standard blades, which are the more
angulated ones, and we showed that most clinicians find it easier to use
standard blades. We compared combined combination techniques, the flexible
intubation scope through a laryngeal mask and other combinations. And then we
showed that laryngeal masks are actually quite good at rescuing the impossible
face mask ventilation situation. And so we've had a number of retrospective
studies in those in the categories that I've mentioned. And then we've had some
prospective randomized trials looking at video laryngoscopy and comparing it to
direct laryngoscopy in normal children, which was a deviation from our focus on
difficult airways. I think we've expanded our scope to look at normal children,
and I think we're going to continue doing that to improve airway management in
our patients, no matter if they have difficult airway anatomy or not.
DR. STRIKER:
Well, this is great. And
I want to talk a little bit about what is coming next as this registry grows
and is as your knowledge of pediatric airways continues to grow as well. But
let's go ahead and take a short patient safety break, and then we'll come back
and talk about that. So please stay with me.
(SOUNDBITE OF MUSIC)
DR. KIMBERLY CANTEES:
Hi, this is Dr. Kimberly
Cantees. I'm the vice chair of equity, diversity, inclusion at the University
of Pittsburgh Department of Anesthesiology and Perioperative Medicine. We all
want to live and work in a culture where we are appreciated for our
contributions and feel supported. Applying the principles of diversity, equity
and inclusion, or DEI, to perioperative care can not only improve work
productivity and satisfaction, but also patient safety and outcomes. You can
start applying a DEI lens to enhance patient safety today. First, take a team
approach to patient safety, including people with diverse perspectives and
lived experiences to spot biases and address barriers in creative ways. Second,
implement translator services as standard of care. This can help patients feel
valued and facilitate trust, communication, and satisfaction, all of which are
important for patient safety. Third access and analyze demographic data when
assessing safety metrics to identify disparities that need to be addressed.
Incorporating DEI principles into your everyday practice can help address
patient safety challenges.
VOICE OVER:
For more patient safety
content, visit asahq.org/patientsafety.
DR. STRIKER:
Well, we're back. And Dr.
Garcia Marcinkiewicz, I'd like to hear a little bit about what you think is
coming next from this registry and what we know about pediatric difficult
airways. What is the potential? Where do you see this going next?
DR. GARCIA-MARCINKIEWICZ:
So I think we've learned
a lot from the studies from the registry thus far. But there are a lot of
questions that remain and areas for improvement that we have. For example, one
of the studies that looked at video laryngoscopy versus direct laryngoscopy in
particular, hyper angulated blade video Laryngoscopy, the glidescope video
Laryngoscopy compared to direct laryngoscopy, in children who are difficult to
intubate, found that the initial and eventual tracheal intubation success rate
of the glidescope is greater than direct laryngoscopy. So that was not too
surprising. Now, when you look closer at that study and you look at, well, the
glidescope performed better compared to direct Laryngoscopy, and that was true
across all age groups in children. However, the magnitude of that effect was a
little less so for those children less than ten kilos, those typically under
one years old. So you might ask, well, why might that be? And there could be a few
reasons for that. Maybe those patients in the younger age group need
oxygenation during their tracheal intubation attempts. Additionally, maybe
there's some room for improvement in how we use hyper angulated blade video
laryngoscopy. And subsequent to that, there have been a few other studies that
have suggested that, including a study that came after that in the PD registry,
one that Dr. Fiadjoe alluded to, the one looking at hyper angulated blade video
laryngoscopy compared to standard blade video Laryngoscopy. And that study
found that in patients less than five kilos, standard blade video Laryngoscopy
had greater tracheal intubation success rate. A few other studies, even outside
of the registry, have found similar things. And so a lot of this is suggesting
that our hyper angulated blade video laryngoscopy skills could use a little bit
more improvement in the younger, more vulnerable population. So that's another
study that is in development.
Finally oxygenation. Oxygenation
in our most youngest vulnerable patients, you know, should peri intubation
oxygenation be the standard? That's another question there too. And then from
the ventilation technique studies, looking at when neuromuscular blockade is
used for initial tracheal intubation versus when it's not. And spontaneous
ventilation. What are our rates of complications? Well, that study found that
spontaneous ventilation has greater complications compared to controlled
ventilation with muscle relaxant and controlled ventilation without muscle
relaxant. Initially making one think, well, maybe it's the muscle relaxant
that's protective. And when you look closer, you find that the differential in
complications between those with spontaneous ventilation technique and those
with controlled ventilation technique is actually related to airway reactivity.
Another PD study after that found that when you compare sedation to general
anesthesia for initial tracheal intubation, that about 27% of cases that are
managed with sedation have to be converted to general anesthesia in order to
complete the intubation. All of this is suggesting that anesthetic depth is an
area for quality improvement in pediatric patients. And it's understandable we
might hesitate to give too much medication. We don't want to lose the airway.
It's a big risk, but we can possibly improve how we assess anesthetic depth.
And that's another study coming up.
DR. FIADJOE:
One of the interesting
things that has evolved over the years is, the gold standard for the management
of the difficult airway seems to be evolving. Many of my colleagues reach for a
video laryngoscope for their first attempt, rather than the fiberoptic
bronchoscopes. I was trained in the era of the fiberoptic bronchoscope, and
I've always thought of it as the gold standard. But the question is, is video
Laryngoscopy performing just as well? And given that we have this multicenter
registry, I think it gives us the opportunity to do a randomized trial where we
randomized patients to fiberoptic bronchoscopy versus video laryngoscopy for
their first attempt, um, to get some information about the various success
rates. I mean, I think many clinicians find it much easier to use the video
laryngoscope. It's more readily available. But I do wonder if losing the
fiberoptic bronchoscopy skills will be a detriment to our patients. So it's
another question that we're going to explore.
DR. STRIKER:
Well, this is a great
segue, because I did want to delve a little bit more into the debate between
direct Laryngoscopy and video Laryngoscopy. How do we reconcile what we see in
databases or retrospective trials, or even prospective trials, with how each
individual practitioner might be more comfortable with a certain technique? And
this is something I've heard time and time again, and I'm not dismissing it. I
think there's a lot of practitioners that that feel this way. In my hands--we've
all heard that--or I'm so much better with a fiber optic bronchoscope or I
trained with a retromolar approach and I'm better with the direct laryngoscope.
So for me, it's more successful. How do we reconcile those two thought
processes?
DR. FIADJOE:
Yeah, that's a great
one. I think we are always going to feel more comfortable with a certain
approach, and I don't discount that. I'm very supportive of people using the
technique they think they're most facile with. I will say that whenever new
technology comes in, there's always going to be some resistance to that new
technology, even if it's safer because we're more comfortable with the old
technology. And so that's always going to be an element of this. I do think we
have to look at the aggregate data and use that to guide our quality
improvement, even in experienced hands. With direct laryngoscopy, you often
need help from others. And we are fallible human beings. Sometimes we see
things that are actually not there. That is in many domains. There's a great
video that that shows a couple of people bouncing a basketball, and they asked
them to count the number of bounces, and a gorilla walks by and most people
listen. There's that change blindness. So you may think you're looking at the
glottis, but you could be looking at something else. You may need someone to
assist you by giving you external laryngeal manipulation to get a better view.
They can help you better if you're using a video laryngoscope. So on all
fronts. I think having that tool from a patient perspective is better. Do video
laryngoscope blades stop functioning? Does the light not function at a critical
moment? Yes, those things do happen and I do think we need to teach direct
laryngoscopy. I just think you can teach direct Laryngoscopy better with a
video laryngoscope than with a direct laryngoscope.
DR. GARCIA-MARCINKIEWICZ:
I would also add to that
I think we need to rehearse more, right? I think that airway management is not
a static thing. It's a dynamic thing. And I think we're responsible for knowing
how to use each device and perform each technique. And so, you know, someone
once told me that the best players are not the ones who play the game more.
They're the ones who practice more. Right? And so we need to benefit from
practicing some of these airway skills. And, you know, with simulation and in
airway labs and looking at airway management as something that we can go ahead
and do during ten minute, you know, OR turnovers and just do some drills.
Right. Get our hands warm with some of these airway devices that we
infrequently use so that we're prepared when the moment comes. And that is the
best tool to use for the patient at two in the morning.
DR. STRIKER:
Yeah. And I don't know
if it's the best analogy, but do you feel like the ultrasound used for vascular
access is a good analogy? At first people might have been resistant because
they don't need it. They're used to doing it without it. But now I would think
that most people would agree that there's a much higher success rate by using
ultrasound for vascular access across the board.
DR. FIADJOE:
That's a great example,
Dr. Striker, I think, um, I remember early on in my career many cases that were
canceled because the team was unable to obtain vascular access. I've not seen
that happen in years since we started using ultrasound. And it's just been a
game changer. And so I think that is a that is a great analogy.
DR. STRIKER:
Well, let's talk a
little bit about limitations of the registry, Dr. Fiadjoe. What are they?
FIADJOE:
Yeah I like to tell the
story about World War Two, when the French planes were coming back with bullet
holes and the French were losing a lot of planes during the war, and they
started looking at the planes that returned. And they had the idea to look at
the areas where the, you know, the wings of the planes had a lot of holes in
them, and they wanted to protect the wings and add armor to the wings. And an
astute statistician, mathematician, Dr. Wald pointed out that the planes that
didn't come back were probably hit in the midsection, and actually, they
shouldn't protect the wings, they should protect the opposite areas. And so it
made the point that they had a selection bias. They were looking at the planes
that made it back. And so I think whenever you have these kinds of registries
and data collection, you run the risk of having a selection bias. People may
document cases they remember more vividly. And so that's a limitation. I also
think that whenever you have a registry, the collection of data can be a
problem entry of data in a timely fashion, incorrect data. And we do a really
good job of going through every entry and cleaning that data. But sometimes you
can still miss some things. And then the longevity of the registry, you know,
right now we have a close to 8000 cases of difficult intubations. And so
collecting additional data is unlikely to change much. But right now, I think
the registry is fueling our quality improvement efforts. But we're using the
initial data in the registry to guide future studies, which is the important
thing. So, you know, those are some of the limitations of the registry. And
then obviously there's the cost issue, which, you know, has always comes up
with these kind of efforts.
DR. STRIKER:
And Dr. Garcia
Marcinkiewicz. If individuals want to sign up or inquire about the difficulty
with participating. Difficulty meaning the effort, I should say, in submitting
data to the registry if they're interested in participating. Is it
straightforward? Is it time consuming?
DR. GARCIA-MARCINKIEWICZ:
If they're interested in
participating, they can contact us. We have a fantastic research coordinator.
Her name is Paula Hughes. She is wonderful. She will guide them through the
process and make it as easy as possible to, you know, have them enter their
data and get it to us at the central site at Chop.
DR. STRIKER:
Great. And along those
lines, for our listeners whose interest has been piqued by this conversation,
and they're saying to themselves, boy, I'd love to delve more into this
information that this registry has produced or some of the recommendations.
What would be the best mechanism for them to obtain that? Is there a site or a
collection of information that they could go find, or a primer and pediatric
airways that has been the result of of the information obtained from the
registry?
DR. GARCIA-MARCINKIEWICZ:
Yeah, the PD registry
has a website hosted on the SPA, and you can get a lot of information about the
registry. Some of the members, some of the studies that have been done through
that mechanism. And of course, feel free to reach out to any of us. We're happy
to help and, you know, help get people engaged into this work.
DR. STRIKER:
And you can access that
from the SPA website. So that's pedesanesthesia.org.
And one last question
before I let both of you go. I know you're both heavily involved with the SPA.
Can you talk a little bit about how you see the role of this important
subspecialty society and how it plays with the ASA, and why it's important to
be a member of both? Dr. Fiadjoe, let's start with you.
DR. FIADJOE:
Yeah, I, I'm a big fan
of our organizations. I think they really fostered development. Whether you're
an academic clinician or someone in private practice, you will gain benefit
from being a member of the SPA and the ASA. It is really where this registry
idea was born. You know, as a member of the Society of Pediatric Anesthesia, I
can tell you that a lot of people's careers have blossomed in the society. Not
only have careers blossomed in the society, we've had lots of friendships and
lifelong connections that that have helped us and supported growth of many
individuals in the society. And I'll just mention a few of the special interest
groups in the Society of Pediatric Anesthesia that I think are wonderful.
There's a women's empowerment and leadership initiative that was spearheaded by
Dr. Jenny Lee, who's at Hopkins, that has a goal of mentoring the next
generation of and current generation of women leaders. Um, there's an
educational special interest group. And Dr. Joseph Sisk has worked on these
individual case guides that tell you details of various types of pediatric
anesthesia cases accessible on the pediatric anesthesia website. Matthew Kind
leads the Global Health SIG is a disaster preparedness SIG that Meera
Gangadharan spearheads. There's a craniofacial registry that's taking a very
similar path to what we have done with the airway doctor Paul Stricker. Doctor
Alison Fernandez has spearheaded the society for Pediatric Anesthesia
Improvement Network, Spain, looking at outcomes in children undergoing painful
surgeries and point of care ultrasound sustainability the PD collaborative
Agnes Hunyadi is the current, uh, chair of that of the PD collaborative. So
lots of opportunities to really grow and then attending the meetings. Both this
SP and the ASA have workshops and lectures. And I'll tell you, my practice has
evolved over the years from things I've heard in lectures, invaluable
experience and finally, the social connections. The largest study on longevity,
the Harvard study, I think, is called looks at the things that are associated
with longevity. And it's not your cholesterol, it's not your blood pressure.
It's not any of these things that we traditionally think. It's your social
connections. And these societies are really opportunities for us to make those
social connections and that support that we really need in anesthesia today,
given the high amounts of burnout that we see across the country. So that's my
case for why it should be a member of of our societies. And I hope to see all
of you who are listening. Please come up to me and let's have a conversation at
any of the meetings, because I'm always there.
DR. STRIKER:
Excellent. Dr. Garcia
Marcinkiewicz. What do you think?
DR. GARCIA-MARCINKIEWICZ:
Yes, I'll tell you this.
The SPA and ASA has been where I've met some of the best friends that I
currently have. You know, people who practice in different institutions that I
might have otherwise not met. And. These friendships have just strengthened
throughout the years. You know, collegial relationships, exchange of ideas. You
know, I we all look forward to these meetings happening to, you know, talk
about what we're doing, learn from each other, catch up, see what people are up
to. And it's really just wonderful and a ton of fun.
DR. STRIKER:
Well, I certainly echo
those sentiments greatly, and I just want to thank you both for joining us
today on this episode of Central Line to talk about this topic. It's an
important topic. It's a fascinating one. And the work you both do, along with
everyone else putting together and collating the data and coming up with the
studies and just producing the information from this registry is so valuable.
And so, so thank you both for not only all the work you do, but for joining us
today to talk about it.
DR. FIADJOE:
Thank you so much for
having us on the podcast. It's been a pleasure.
DR. GARCIA-MARCINKIEWICZ:
Thank you so much.
DR. STRIKER:
And for our listeners,
as we mentioned before, if you're interested in any of the information
discussed, you can check out the society for Pediatric Anesthesia website at www.pedsanesthesia.org
and please tune in again next time to Central Line. Take care.
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