Kaiser Infant Anesthesia Problems Spark Debate by Charles Ornstein  
 

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Infant Anesthesia Problems Spark Debate
By Charles Ornstein, Times Staff Writer
February 24, 2003 
Originally Posted from but since removed at http://www.latimes.com/news/local/la-me-kaiser24feb24004423,1,7598591.story?coll=la%2Dheadlines%2Dcalifornia%2Dmanual 

Infant Anesthesia Problems Spark Debate
At Kaiser in Woodland Hills, doctors say pediatric specialists are needed. Hospital says a death and a near-death were aberrations.
By Charles Ornstein
Times Staff Writer
February 24, 2003

The soul-searching among anesthesiologists at Kaiser Permanente's Woodland Hills hospital began in 1999, after 2-month-old Grant Wray nearly died as he was being sedated for hernia surgery.

Doubts grew the following year when 19-month-old Jose Fajardo III suffered throat spasms during anesthesia, then died.

General anesthesiologists at Woodland Hills questioned whether they could safely care for children so young; they implored hospital leaders to send these patients elsewhere or hire pediatric specialists.

Hospital administrators said the two cases were aberrations and strongly defended using general anesthesiologists for pediatric surgeries. They did, however, make some changes, such as enlisting neonatologists, who specialize in caring for newborns, to help sedate the youngest infants.

Today, hospital officials and many of the anesthesiologists remain at odds. But the dispute has wider significance: It dramatizes a national debate about how much training and experience anesthesiologists need to safely care for young children.

Most experts agree that pediatric anesthesia is a specialty markedly different from its adult counterpart, involving different equipment, doses and techniques.

Children are not miniature adults. Their bodies and reactions to anesthesia are different, sometimes making surgery more difficult and risky, especially for infants.

Experts say that children fare better when their doctors handle a steady pediatric caseload.

But many hospitals don't have such a stream of patients, and pediatric expertise is in short supply. As a result, some community hospitals rely on general anesthesiologists for pediatric cases -- sometimes with the help of neonatologists.

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Task Force Formed

Several states, including California, have formed task forces to study the issue. California Children's Services, a state program that pays for specialized pediatric care, is considering a proposal to require participating anesthesiologists to treat at least 25 infants and children annually.

"There's a general consensus among people ... that anesthesiologists who take care of kids all the time are more comfortable with what they're doing and do a better job," said Dr. Mark Singleton, a San Jose anesthesiologist who is on the state's task force.

At Woodland Hills, doctors trace the turmoil to what should have been a routine hernia operation on a 2-month-old boy in November 1999.

At the start of the operation, anesthesiologists were unable to get enough air into Grant Wray's lungs, so they inserted a tube into his trachea, according to medical records obtained by The Times with the permission of Grant's parents.

The boy's heart rate slowed, and he had a cardiac arrest.

Grant's parents remember hearing the hospital's loudspeakers broadcast a "code pink" in Operating Room No. 7, where Grant was. Moments later, three doctors walked toward them in the waiting area.

" 'There's been complications,' " Kelly Wray remembers the physicians telling her. "My heart dropped. I thought he was gone at that point. I thought he had died."

He nearly did. The OR staff called the neonatology unit for help, performed CPR and other procedures -- and the boy was revived.

In the child's medical record, pediatric neurologist Dr. William Goldie -- who examined Grant after he was stabilized -- wrote: "It is difficult to determine exactly what went wrong."

But an independent expert who reviewed Grant's medical records for The Times said he has a good idea: The anesthesiologist initially used a breathing tube that was too narrow to provide sufficient oxygen to a child of Grant's age and weight.

"The tube size they put in clearly shows that they didn't know what they were doing," said Dr. William J. Greeley, chair of anesthesiology and critical care medicine at Children's Hospital of Philadelphia, a respected pediatric center.

"You wonder about their capability if they can't judge something as simple as the right size tube," added Greeley, past president of the Society for Pediatric Anesthesia.

Dr. Denise Emmons, the Kaiser anesthesiologist who handled Grant's case, declined to comment. Dr. Thomas Schares, the current chairman of the anesthesiology department, was not at the hospital at the time of Grant's case, but acknowledged in a recent interview that the tube may have been too small.

Eight months after Grant's case, the Fajardo boy was brought to the outpatient surgery center at the Woodland Hills hospital for an operation to correct a muscular condition that caused his eyes to wander.

Moments after anesthesia was delivered, the boy experienced throat spasms, according to medical records obtained by The Times, with his parents' permission. Doctors also had difficulty inserting an IV into his arm and getting oxygen into his lungs.

This time, the patient died.

After reviewing Jose's records at The Times' request, Greeley blamed -- at least in part -- anesthesiologists' use of isoflurane, a pungent anesthetic gas that irritates the airway and causes some children to have vocal-cord spasms. Several other gases are considered better and safer to start anesthesia, he said.

"If you showed this to 100 anesthesiologists in the country, I bet a large majority would say that this is inappropriate," Greeley said. "The anesthetic care is so egregious ... it's clearly injurious to the health of children."

Dr. Rodolfo Amaya, a former Kaiser anesthesiologist who supervised Jose's procedure, told The Times that a certified registered nurse anesthetist gave the child isoflurane without his approval. He said the anesthetic was quickly switched to sevoflurane, which is easier to tolerate.

The drug switch is not noted in the medical records.

In addition, Amaya said that he was unaware of a potential complication noted in the medical records of Jose's Kaiser pediatrician: a congenital heart condition. Had he known, Amaya said, he would probably have given the case to an anesthesiologist more experienced with children.

After an autopsy, a Los Angeles County coroner listed a malformation of Jose's pulmonary artery as the cause of death, and said the boy's reaction to anesthesia was a significant contributing factor.

In the months afterward, tensions at Woodland Hills escalated. Early last year, 11 of the hospital's 12 anesthesiologists wrote in an e-mail to hospital administrators that they didn't feel comfortable handling surgeries for babies and sick children.

"We have neither the resources nor relevant experience to safely manage these high-risk patients," they wrote on Feb. 7. "Either these patients can be referred out to another Kaiser facility for their care, or this medical center can contract with an outside pediatric anesthesia group to provide anesthesia support services...."

The e-mail was written on the account of anesthesiologist Dr. Robert Watson, who declined to comment on its contents.

Three Woodland Hills anesthesiologists, who spoke on condition that they not be identified, told The Times that the problems cited in the e-mail were never corrected to their satisfaction.

Woodland Hills administrators, however, say they were careful to respond to the issues raised by the death and near-death, and vigorously defend the hospital's current practices.

After Grant Wray's case, the hospital began requiring that neonatologists be on hand for all surgeries involving babies younger than 4 weeks (older if the baby is premature).

And after reviewing Jose Fajardo's case, the hospital required that anesthesiologists evaluate children days or weeks before surgery to ensure that doctors know about medical conditions that may pose complications.

Also, the hospital last year hired Schares, an anesthesiologist specializing in pediatrics, as chairman of the department. He has handled some children's cases there, but said he could not recall how many.

Kaiser officials said that Jose's death in 2000 is the only pediatric anesthesia-related fatality in the hospital's 16 years of operation. They also said that individual anesthesiologists can request an exemption from handling pediatric cases, but that none have.

"No patients have been put at risk in this medical center. I wouldn't allow it," said Dr. Jeffrey Weisz, the hospital's medical director.

Weisz said he believes the anesthesiologists' objections stem from personal resentments against management, not medical concerns.

"All of our anesthesiologists are qualified to give superior care. That doesn't mean they don't have trouble with their personalities," said Weisz, who was recently selected as medical director for all Kaiser's Southern California physicians.

Though the dispute at Woodland Hills has at times become personal, experts say the broader issue is relevant to any hospital that anesthetizes children for surgery.

Research has shown that infants and young children have a higher incidence of complications from anesthesia, including cardiac arrest and death, compared with adult patients. And two studies have suggested that infants cared for by general anesthesiologists have a higher incidence of cardiac arrest and oxygen loss during surgery than those cared for by pediatric anesthesiologists.

But research hasn't determined exactly how much experience is required to produce better outcomes.

Kaiser officials say that all anesthesiologists receive some training during their residencies in caring for children.

Data compiled by the state, however, show that anesthesiologists at Kaiser Woodland Hills have relatively little experience with young children. The hospital performed 26 inpatient surgeries on children under age 1 in 2000, compared with 993 such surgeries at Children's Hospital Los Angeles and 389 at UCLA Medical Center.

(Including outpatient surgeries, Kaiser Woodland Hills says it handled 88 surgeries on children under age 1 in 2000, 48 in 2001, and 41 in 2002.)

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Fewer Young Patients

Many hospitals -- especially in rural areas -- don't get a high volume of young surgery patients. And, as it is, the state doesn't have enough pediatric anesthesiologists to go around, given that children account for about a quarter of all inpatient anesthesia cases.

Anesthesiologists themselves have different notions of what should be done.

Singleton, who is advising the state, said general anesthesiologists can handle children's surgeries as long as they are comfortable doing so.

He doesn't object to neonatologists helping out, but he said the anesthesiologists should remain in charge.

But Dr. Randall Wetzel, chief of anesthesia and critical care medicine at Children's Hospital Los Angeles, said he's troubled by the use of neonatologists as a backup, except in rare cases, because they do not have broad training in anesthesia.

"If the anesthesiologist is uncomfortable with the baby in the room and the neonatologist thinks he has to be there, then the baby shouldn't be," he said.
 
 

Copyright 2003 Los Angeles Times  

 

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