Meeting of the Congenital Cardiac Anaesthetic Network (UK), Bristol, April 2010
By Philip Arnold, MBBS, FRCA
Liverpool Childrens' Hospital, UK
Heart surgery in children is currently performed in twelve hospitals throughout the UK, performing around 4000 operations (http://www.ccad.org.uk/congenital). We would estimate that 70-80 doctors practice paediatric cardiac anaesthesia in the UK. The Congenital Cardiac Anaesthetists Network (CCAN) is a network of these doctors.
The CCAN has a much less formal structure than the CCAS. It has no board of directors, no formal affiliations, and no written objectives. Rather it is an informal group of anaesthetists. Given the relatively small numbers involved this approach has worked well. We have organised three successful annual meetings, the most recent held in April this year in Bristol. Each meeting has been organised by the hosting hospital. Email discussion has also been informative and a web page is maintained with the help of the Association of Paediatric Anaesthetists (http://www.apagbi.org.uk). The group has been a catalyst for proposals for multi-centre research.
Health care in the UK is organised differently than in the United States or Canada. In principle the National Health Service provides centralised care available without cost to patients. Whilst this principle has been eroded over the last 20 years, central planning retains some control of how services are delivered. Recently an initiative backed by the (‘Self and Sustainable Children’s Cardiac Surgery’) has proposed a move to fewer children cardiac surgical centres. Whilst there are different opinions as to the wisdom of this move, it is clearly important that congenital cardiac anaesthesia has a voice in such a process.
The Bristol meeting of the CCAN was attended by over 40 people. As well as around half the paediatric cardiac anaesthetists in the UK this also included a number of people travelling from Scandinavia and mainland Europe for the meeting. The first session was chaired by Andy Wolfe (who also organised the meeting). Neil Morton gave a talk on use of TIVA for paediatric cardiac anaesthesia. He described his technique using target controlled infusion of 2% propofol (Paedifuser) and alfentanil. Neil has had a major role in the development of TCI in children. He discussed the specific application of these techniques during heart surgery.
Saadeh Suleiman is the professor of cardiac physiology in Bristol with a background in research into myocardial protection in adults and children. He gave an excellent synopses of the molecular biology and current thinking on myocardial protection, with reference to children and the role of anaesthetic agents. Including the role of mitochondrial pores and reperfusion injury. Whilst relatively few conclusions could be reached it was an excellent introduction to the research on going on this subject, and the potential for future developments.
After a break Tony Moriarty chaired the session. Yves Durandy from Institut Hospitalier Jacques Cartier in Paris discussed their use of normothermic bypass and miniaturised bypass circuits. Neonatal cases are routinely conducted at normothermia in his institution. The degree to which they have miniaturised the circuit is impressive and has been achieved principally by placing the pump nearer to the patient with little need for bespoke equipment. The system for cardioplegia (warm blood) takes blood directly from the circuits arterial side and adds a cardioplegic solution from a syringe driver.
Following this was a discussion of coagulopathy and bleeding after bypass. The discussion focussed on the treatment of bleeding, rational for use of blood products and monitoring of coagulation. Agents, which are new to the UK, including rFVIIa, prothrombin complexes and fibrinogen concentrate, were discussed. There was useful input from delegates from Germany and Scandinavia where fibrinogen concentrates have been in use for some time and are proving a useful adjunct in the management of bleeding.
To close the meeting Tim Murphy reviewed recent publications relevant to our practice. He also proposed an initiative to collectively highlight relevant publications.
Much of the discussion continued after the meeting in the pub and over dinner. The group plans to meet again next year in Newcastle.
