Clinical Program

The Division of Pediatric Anesthesia is charged with providing comprehensive care for the pediatric patient. We provide a wide range of pediatric anesthesia services both in the operating room and at multiple remote anesthetizing sites, including a regular bone marrow clinic, an endoscopy/bronchoscopy suite, interventional radiology, radiation oncology, eye center, and a cardiac catheterization suite. Increasingly, more anesthesia services are being incorporated into the Duke Children’s Hospital to improve the comfort for our patients. The pediatric division has continued to grow to support children’s services at Duke and is an integral part of the peri-operative experience including the intake area, children-specific ORs, and a separate pediatric postoperative recovery unit (PACU), and the pediatric intensive care unit (PICU).

Training Program

Resident education continues to be an important aspect of teaching in the department. In addition to hands-on training and didactic lectures, pediatric anesthesia has a 6-month subspecialty course for CA-3 residents and a 1-year postgraduate fellowship in pediatric anesthesia, which includes experience in pediatric general, cardiac, and critical care medicine. We have also established an interdepartmental conference program dedicated to pediatric anesthesia and perioperative care of children. Fellow education, research, and participation in national organizations remain important goals for the pediatric anesthesia group. We have established a Pediatric Anesthesia Fellowship training program, which consists of pediatric anesthesia, pediatric cardiac anesthesia and pediatric intensive care unit experience. Opportunities for clinical research are abundant.

Research Program

Our research efforts have been devoted to physiology, pharmacology, neurosciences, cardiac development and regional anesthesia.

Pharmacology Research. Our group has had a long-standing interest in pediatric drug development in sedative, analgesic and cardiovascular agents. Under the leadership of Dr. Scott Schulman, we have developed a comprehensive program in pharmacologic investigation. Dr. Schulman has been a site principal investigator for several industry-sponsored trials in the perioperative setting. He has published articles on the ethical challenges of recruiting pediatric patients into clinical trials (Erb and Schulman 2002) and has a record of successful patient accrual into several trials.

Dr. Schulman is actively enrolling patients in an NIH Pediatric Off-Patent Drug study (PODS) for sodium nitroprusside. This project will perform studies of the use of sodium nitroprusside in pediatric patients in order to develop FDA-approved labeling in compliance with the Better Pharmaceuticals for Children Act (BPCA).

Other projects include a study for the Duke Pediatric Cardiology Clinical Center’s Pediatric Heart Disease Clinical Research Network, an NIH study on lorazepam and midazolam in pediatric patients, and an NIH trial for the North Carolina Collaborative Pediatric Pharmacology Research Unit Network.

Physiologic Research. The physiologic effects of CPB on cerebral blood flow, cerebral metabolism, systemic inflammation, calcium regulation and cardio-respiratory interactions have been major focus areas for our group. In the recent past, our section has described the effects of deep hypothermic circulatory arrest on cerebral blood flow and metabolism. Publications have demonstrated marked differences in brain blood flow and metabolism between children undergoing continuous flow deep hypothermic cardiopulmonary bypass and children undergoing deep hypothermic circulatory arrest and the importance of dissolved oxygen on cerebral oxygen utilization during profound hypothermia. We have also observed that cerebral blood flow falls linearly with temperature reduction, whereas metabolism falls exponentially using alpha stat blood gas regulation. We have defined a metabolic index for predicting safe circulatory arrest times based on metabolic reduction due to hypothermia.

Our group has also described the effects of CO 2 on cerebral blood flow during deep hypothermia in children, and we have pioneered the use of jugular venous saturation and near infrared spectroscopy as monitors for effective cooling of the brain prior to the institution of circulatory arrest.

Recently, we defined the detrimental effects of CPB and circulatory arrest on respiratory and myocardial function. We are currently evaluating the effects of CPB on the neonatal myocardial alpha and beta-receptors. While inflammatory modification of CPB remains the “Holy Grail” in congenital heart surgery, our efforts at modifying the inflammatory response through circuit miniaturization, high-dose steroids, and inhibition of inflammatory mediator release are recent projects.

In addition, the inflammatory effects of CPB are clinically being evaluated through the sampling of pro-inflammatory and anti-inflammatory cytokine ratio in plasma and tracheal aspirate in infants undergoing corrective heart surgery. This will serve as a preliminary model for anti-inflammatory interventions to decrease the effects of CPB on neonatal cardio-respiratory function.

Regional Anesthesia. Regional anesthesia has proven to lessen pain, facilitate early discharge from the PACU, and minimize the deleterious effects of general anesthesia in high-risk patients. Examples of the latter include newborns, ex-premature infants with respiratory insufficiency, and children with abnormal respiratory function due to CNS injury, myopathies, neuropathics, and lung disease. Regional anesthesia continues to be a fertile area of research for our group and an important area for the control of pain in children undergoing surgery and children with complex medical problems.

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Allison K. Ross, MD

Chief, Division of Pediatric Anesthesia
Associate Clinical Professor of Anesthesiology

Faculty

Warwick Ames, MBBS, FRCAGuy deLisle Dear, MB, FRCA
John B. Eck, MD
Heather J. Frederick, MD
H. Mayumi Homi, MD
Richard Ing, MBBCh, FCA(SA)
Scott Schulman, MD
B. Craig Weldon, MD

CRNA Staff

Carleen Bagnall, CRNA
Donalie Guin, CRNA
Daniel Geniton, CRNA
Janet Goral, CRNA
Janet Hall, CRNA
Shelley Hilliard, CRNA

Support Staff

Myra Stein
Shelia Johnson