ROTATION: Pediatric Anesthesia (P)
TYPE: Required or elective
DURATION: 4 weeks
FACULTY: Sno White, MD (Chief), Lawrence Berman, MD, Nicole Dobija, MD, Alex Matveevskii, MD
PREREQUISITES: Completion of clinical base year and 6 months of clinical anesthesia
CA-3 Rotation Information, click here (includes information on Nemours Children's Hospital and All
CORE ROTATION INFORMATION
General Goals
- Administer anesthesia safely to children for routine surgical, diagnostic, and therapeutic procedures
- Recognize and treat intraoperative and postanesthesia problems in children
- Recognize when you or your institution cannot provide adequate care for a particular surgical problem or to a child with certain medical problems.
SPECIFIC COMPETENCIES: (General Competencies also apply)
PATIENT CARE SKILLS:
- Review the chart, take an adequate history, assess the major systemic problems, identify special problems such as latex allergy or apnea related to prematurity, and develop a plan of care
- Recognize and cope with the emotional problems of parents and child, and attempt to alleviate them
- Induce anesthesia in a distraught or uncooperative child
- Transport safely a sick pediatric patient to the operating room and be able to state and perform the solutions to any problems which may arise in the following areas:
- Heat maintenance
- Cardiovascular stability
- Ventilation
- Oxygenation
- Record and estimate preoperatively blood volume, hourly fluid requirements, estimated fluid deficit, third space loss, red cell mass at the patient's hematocrit, acceptable red cell mass loss, and acceptable blood loss
- Induce and maintain anesthesia by inhalation, intravenous, intramuscular, and rectal routes
- Administer mask or laryngeal mask airway anesthesia when appropriate
- Maintain the airway of an anesthetized pediatric patient and intubate the trachea without trauma in 98% of cases within 1 minute; provide appropriate size and length ET tubes for children of different ages and sizes
- Manage a pediatric patient with a full stomach
- Perform awake intubation (relatively rare in 2003)
- Recognize abnormal airways and maintain them during anesthesia
- Recognize and manage laryngospasm
- Recognize the following signs of hypoxia: bradycardia, poor color, poor venous filling, distant heart tones, and abnormal electrocardiogram
- Apply consistently and interpret data from a blood pressure cuff,
electrocardiogram, oximeter, capnograph, and a thermistor- Apply a heat lamp and heated humidifier when appropriate
- Master the techniques of sevoflurane and isoflurane/nitrous oxide/oxygen/muscle relaxant anesthesia
- Manage the following in pediatric patients undergoing anesthesia and surgery:
- Blood replacement
- Drug administration and anesthetic requirement (minimum anesthetic concentration)
- Fluid and electrolyte balance, glucose requirement, and renal maturation
- Hypocalcemia
- Hypoglycemia
- Metabolism
- Temperature control
- Vitamin K administration
- Perform deep and awake extubation as appropriate
- Appropriately administer neuromuscular blockade in children
- Appropriately assess when anesthesia is adequately reversed and the child is ready for extubation
- Transport safely and manage immediate postoperative care in the following areas: ventilation, oxygen administration, temperature control, cardiovascular monitoring, fluid balance, and pain relief
- Recognize postoperative airway stridor and treat it
- Be able to care for children requiring anesthesia with the following unusual problems (may be theoretical knowledge only):
- Congenital heart disease
- Epiglottitis
- Malignant hyperpyrexia
- The child with the anatomically difficult airway (e.g. Pierre Robin syndrome)
- Be able to care for children requiring anesthesia for:
- Bronchoscopy (in particular for foreign body aspiration)
- Tonsillectomy (in particular for the rebleeding tonsil)
- Computerized axial tomographic scan and magnetic resonance imaging
MEDICAL KNOWLEDGE: (See also General Competencies)
- Know the principles of and medications used for preoperative sedation
- Know the anatomic, physiologic, and pharmacologic differences and similarities in the major organ systems between children and adults
- Know how to estimate blood volume, hourly fluid requirements, estimated fluid deficit, third space loss, red cell mass at the patient's hematocrit, and know how to calculate acceptable red cell mass loss, and acceptable blood loss
- Know appropriate endotracheal tube sizes--cuffed and uncuffed for different age / size children
- Be familiar with the following neonatal emergency surgical procedures and with the anesthetic considerations for these operations (you may or may not personally experience any of these procedures)
- Diaphragmatic hernia
- Omphalocele and gastroschisis
- Pyloric stenosis
- Tracheoesophageal fistula
- Be familiar with and able to recognize Pierre Robin syndrome; be aware of the airway difficulties associated with this syndrome
- Be able to describe the management of laryngospasm; be able to describe factors contributing to the development of laryngospasm and strategies to prevent laryngospasm
- Understand the various forms of breathing circuits used in pediatric anesthesia : specifically adult and pediatric circle systems (know differences), Mapleson D systems and modifications such as the Ayers T-piece and Bain circuits.
- Know concepts about thermoneutrality in pediatric patients and know proper use of :
- Heat lamp
- Heat blanket
- Heat humidifier
- Room temperature
- Know when deep or awake extubation is appropriate
- Understand the basic concepts of neuromuscular blockade in children and know the differences between dose/effect in infants and children as compared to adult patients
- Know basic pediatric resuscitation concepts, drugs used and doses, and proper use of defibrillation
- Understand the benefits and risks of regional anesthesia, including spinal anesthesia and regional analgesia for postoperative pain
- Understand postanesthesia apnea, factors associated with it, the appropriate duration of monitoring for it, and treatment of it.
INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM
- See general competencies section
- Be able to communicate with and relate to small children and their families who are very anxious about surgery
- Be able to relate directly to the child and separately with the parents
- Be able to communicate with and deal with uncooperative, frightened children
- Be able to relate appropriately according to the developmental age of the child
- While maintaining a compassionate relationship with the patient and his / her family, the practitioner must be able to keep his or her own feelings under strict control in these sometimes very emotionally taxing situations.
PRACTICE-BASED LEARNING AND IMPROVEMENT
- See general competencies section
- Learn to smoothly induce anesthesia using inhalation techniques
- Learn to be able to manage both the airway and placing an intravenous catheter in a routine pediatric case.
SYSTEMS-BASED PRACTICE
- See general competencies section
- Be aware of the unique recovery requirements for infants and children
- Know when it is appropriate for the pediatric patient to go home following surgery and when hospitalization is necessary solely from an anesthetic standpoint.
Evaluation to Determine Goal Achievement
- Daily feedback from attendings
- You are evaluated every week by all attendings who worked with you using our contact-based online evaluation system. These forms are reviewed quarterly by the Clinical Competence Committee and continuously by the program director. Your advisor informs you of any problems identified, and serious problems will be discussed with you immediately after they occur.
- You will complete a Departmental Rotation Evaluation Form
- The Program Director will evaluate the results of the In-Training Examination for the American Board of Anesthesiologists (ABA) in general and for areas of departmental weakness. Consistent weaknesses may result in adjustment of the above goals
Teaching Resources to Accomplish the Objectives
- Patients admitted to Shands Teaching Hospital and the Florida Surgical Center, respectively, who require general, cardiovascular, neurological, and other pediatric surgical subspecialty care as follows
- Newborns: 190
- 30 days to 1 year of age: 568
- 1 to 2 years of age: 307
- 2 to 12 years of age:
- Patients admitted to Nemours Childrens Hospital for surgical procedures including:
- Appendectomy
- Bone marrow harvest
- Cardiac procedures
- Dentistry
- General Surgery
- Hernia repair
- Immune deficiency medical management (infusion)
- Miminally Invasive procedures including Laproscopy
- MRI with pediatric anesthesia
- Neurosurgery - craniotomy, VP shunt
- Nerve stimulation (for epilepsy)
- Ophthalmology - Electroretinogram (ERG)with sedation
- Orthopaedics including Sports Medicine, limb deformity corrections and hand program)
- Otolaryngology (Ear, Nose & Throat) - Facial reconstruction, Cleft palate, Cochlear Implants
- Tonsillectomy
- Urological procedures - Lithotripsy
- Core curriculum and introductory lectures by all pediatric faculty
- Text books:
- Gregory GA: Pediatric Anesthesia, 2nd ed
- Steward D: Handbook of Pediatric Anesthesia
- Additional miscellaneous texts available in Anesthesiology Residents' Library and on Reserve at the Health Science Center Library
- Reading/topics
- General pediatric anesthesia reading file developed by attending faculty
- Preoperative evaluation reading file written by general pediatric anesthesia attending faculty
- A list of twenty plus topics developed by consensus by general pediatric anesthesia attendings
- Reprints provided by attendings on an individual basis to augment bedside teaching
- Faculty: The following general pediatric anesthesiologists do the majority of the anesthesia for general pediatric surgery and such surgical subspecialty cases as ophthalmology, urology, orthopedics, dental and plastic surgery. Some of these attendings also provide care for neurological and cardiovascular surgical cases. Attendings in cardiovascular, neurological and transplant anesthesia care for children in these subspecialties and provide the associated education.
1. Lawrence S. Berman, MD
2. Alexander Matveevskii, MD
3. Sno E. White, MD (chief)4. Salvatore Goodwin, MD (Nemours Children's Hospital)
5. Stephanie Schrumm, MD (Nemours Children's Hospital)
Dr. White is the faculty member responsible for these rotations,
Given the move of Shands Children's Hospital to the Shands at Alachua General Hospital location, at least part of your rotation will be conducted at that site. Keep tuned to this page for updates and changes that occur as this move develops over the next year. I will announce any changes by generalized housestaff e-mailings.
Basic Information
Shands at AGH is located approximately 1 mile from Shands at UF. To reach the hospital, drive East on Archer Road (about 1/8 mile) to its intersection with 13th St. (US 441). Turn left onto 13th street and drive north to 2nd avenue or 4th avenue depending on which parking lot you intend to use. The map below shows the hospital location as well as all parking lots open for resident use.
Parking for residents is available in any lot marked with a green dot. DO NOT PARK IN ANY OTHER LOCATIONS. If you are required to come in at night, you may park at the lot directly in front of the East Tower (lot#3 with RED dot). This location will have the best security.
Parking permits must be displayed in your car. These permits may be obtained from the residency office on the 2nd Floor of Shands at UF (Joanie Nyland's office). ID Badges from Shands at AGH must also be worn at all times. These badges may also be obtained from Joanie Nyland's office. Both the parking permit AND the badges must be returned on the last day of your pediatric anesthesia rotation.
This is the main entrance of Shands at AGH facing SW 2nd Avenue. Enter the hospital at the entrance marked "Main Entrance." Just beyond the welcome center on your left is the entrance to the OR suite. A locker will be provided for you to change clothes and to store items. Keep valuables with you at all times.
In the very near future, we will have videoconferencing ability at this location so you will not have to miss conference. This should be in place in the next 2 weeks. You will be able to watch conference and sign in online.
AFTER-HOURS COVERAGE
Please note, AGH cases may finish quite early on some days. Residents assigned to AGH must carry their pager and return to the hospital as needed prior to 6pm to cover urgent / emergent add-on cases occuring prior to 6pm. After 6pm, residents from the mole team will cover urgent / emergent cases as described below, if available.
Pediatric emergency surgical cases at Shands at AGH will be covered by University of Florida Anesthesiology Faculty and Resident Physicians. Faculty coverage will be provided by the physicians designated on Neonatal Call. Resident coverage will be by physicians from the mole team (weeknights) or the Saturday call team. This system may not work perfectly, and problems need to be promptly reported to the residency program director (Dr. Mahla - 494-6782), preferably in real time, but certainly no later than the next working day. At this time, we will not increase the size of the mole team or Saturday call team to accomodate this need.
Basic Ground Rules for Operation:
1. There must be a mole team / Saturday team resident free at all times for trauma at Shands at UF.
2. If #1 condition is met, then a resident from the mole team or Saturday call team will go to Shands at AGH for Pediatric Emergent / Urgent cases after hours. This resident should preferably be a resident with significant pediatric exposure.
3. If #1 condition cannot be met while sending a resident to Shands at AGH, then the faculty member on call for Shands at AGH will provide anesthesia care for the emergency case personally.
STAY TUNED FOR CHANGES AND UPDATES.
CA-3 LEVEL GOALS AND COMPETENCIES
Advanced level rotations in Pediatric Anesthesiology are available at Shands at UF and at Nemours Children's Hospital in Jacksonville. In addition to those outlined for the basic rotation in Pediatric Anesthesia, the resident will develop the following competencies:
PATIENT CARE SKILLS:
- Independently perform a preoperative evaluation, anesthetize, and care for postoperatively ASA I pediatric patients for surgical procedures such a herniorrhaphy or tonsillectomy.
- Develop technical skills and judgment which lead to independent conduct of complex pediatric cases.
- Consistently successfully insert invasive monitors such as central venous cannulas (internal jugular approach) and arterial lines.
- Administer neuroaxial blocks for regional anesthesia and/or postoperative pain.
- Demonstrate competence in use of the fiberoptic bronchoscope in the pediatric difficult airway.
- Be able to instruct (under the direct supervision of a pediatric anesthesia attending) a junior resident in the basics of an ASA I pediatric case. This is particularly relevant to those aiming toward an academic career or a job that entails teaching other care givers. The resident will never substitute for the attending.
MEDICAL KNOWLEDGE: (See also General Competencies)
- In the areas outlined above, develop a body of knowledge built on but beyond that learned in the CA1 and CA2 rotations.
- Gain a greater understanding on the pathophysiology of the surgical and medical diseases of children, particularly neonates, and how they impact on anesthetic management (e.g. complex neonatal surgical diseases, including congenital heart disease, other congenital abnormalities, especially those involving the airway).
Dr. White is the responsible faculty member for Shands at UF Rotations, Dr. Schrumm is the responsible faculty member for the Nemours Children's Hospital Rotation and Dr. Linda Jo Rice is the responsible faculty member for the All Children's Hospital Rotation.
RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 5/4/2007
