In Response : Anesthesia & Analgesia

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Letters to the Editor: Letter to the Editor

In Response

Odegard, Kirsten C. MD; Walker, Scott G. MD

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Anesthesia & Analgesia 125(3):p 1078-1079, September 2017. | DOI: 10.1213/ANE.0000000000002284
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We thank Drs Jerome and Sun1 for their letter elaborating on our recent “Expert Consensus Statement for Anesthesia and Sedation Practice: Recommendation for Patients undergoing Diagnostic and Therapeutic Procedures in the Pediatric and Congenital Cardiac Catheterization Laboratory.” This consensus statement was a collaboration between interventional pediatric cardiologists and pediatric anesthesiologists with the goal to provide practitioners and institutions performing these procedures with guidance that is consistent with national standards, and to provide clinicians and institutions with consensus-based recommendations and supporting references to encourage their application in quality improvement programs. We wrote in our statement that recommendations could neither encompass all clinical circumstances nor replace the judgment of individual clinicians in the management of each patient.

The literature confirms that children with congenital heart disease (CHD) are at significant risk for morbidity and mortality in the catheterization laboratory.2,3 This is particularly true for infants, for patients with specific cardiac pathology, for patients with American Society of Anesthesiologists patient status III or above, and for patients undergoing certain transcatheter interventions. Specific knowledge of congenital cardiac anomalies and physiology with an applicable skill set is necessary for prevention and management of hemodynamic compromise and cardiac arrest in the catheterization laboratory. Nowhere in our statement did we write or imply that a pediatric cardiac anesthesiologist was necessary to take care of these children. What we did emphasize was that anesthesiologists involved in pediatric cardiac catheterization procedures should, as is true for cardiologists, have sufficient subspecialty training or experience to provide expert care. Our recommendation is that the expertise of those providing anesthetic care for these patients be appropriate to the level of risk associated with the procedure. For higher-risk patients, care should be provided, at a minimum, by anesthesiologists with advanced skills and knowledge relevant to the pathophysiology of CHD. This knowledge must include a comprehensive understanding of the effects of anesthetic drugs, inotropes, and respiratory interventions on the physiology specific to each congenital heart lesion and surgical palliation. This understanding is critical to providing a stable hemodynamic state that allows the accurate measurement and interpretation of the hemodynamic parameters obtained in the catheterization laboratory.

There are no up-to-date or perfect risk categorizations or groupings identifying high-risk patients, and as mentioned in your letter, prospective studies and outcome data are necessary to risk stratify patients with CHD undergoing cardiac and noncardiac procedures. The CRISP score is the closest we have right now and could be used as a guideline.4 In Table 2, describing the CRISP score, a “pediatric cardiac anesthesiologist” is defined as a “pediatric anesthesiologist with either advanced training or extensive experience in congenital cardiac anesthesia.”

As we emphasized in the text, there is currently no standard definition of a pediatric cardiac anesthesiologist, as there is no board certification or accredited subspecialty training in this field. We believe it is clear in the text that long-standing expertise and knowledge of CHD is comparable to pediatric cardiac anesthesia fellowship training. Many leaders in this field have not had fellowship training. Our goal in the consensus statement was to emphasize the importance of expertise and knowledge of the pathophysiology of CHD to avoid morbidity and to maintain stability and hemodynamics as close to baseline as possible, all of which are key for cardiologists and surgeons in making treatment decisions for children with CHD.

Kirsten C. Odegard, MD
Department of Anesthesiology, Perioperative and Pain Medicine
Harvard Medical School
Boston, Massachusetts

Scott G. Walker, MD
Department of Anesthesia
Indiana University School of Medicine
Riley Hospital for Children
Indianapolis, Indiana


1. Jerome EH, Sun LS. Letter concerning SCAI/CCAS/SPA expert consensus statement for anesthesia and sedation practice in the cardiac catheterization laboratory. Anesth Analg. 2017;125:1078.
2. Vitiello R, McCrindle BW, Nykanen D, Freedom RM, Benson LN. Complications associated with pediatric cardiac catheterization. J Am Coll Cardiol. 1998;32:1433–1440.
3. Odegard KC, Bergersen L, Thiagarajan R, et al. The frequency of cardiac arrests in patients with congenital heart disease undergoing cardiac catheterization. Anesth Analg. 2014;118:175–182.
4. Nykanen DG, Forbes TJ, Wei D, et al. CRISP: catheterization rIsk score for pediatrics: a report from the congenital cardiac interventional study consortium (CCISC).Catheter Cardio Inte. 2016;87:302–309.
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