Pediatrics

1. Definition – Pediatric Anesthesiology is a one-month rotation for the CA-2 resident which will provide training and learning in the perioperative care of the pediatric patient undergoing surgical and non-surgical procedures.
2. Curriculum – This rotation takes place at the parent institution, including University Hospital and the Doctor’s Office Center Same Day Surgery Unit. The primary goal of this rotation is to provide a learning experience which will enable the resident to develop knowledge and skill necessary to administer anesthesia to infants and children in a general anesthesia practice.  A secondary goal is to foster residents’ interest in Pediatric Anesthesiology such that selected residents pursue fellowship training.  The resident will be exposed to all surgical cases commonly seen in a tertiary care setting, as well as a broad age range of patients.  Anesthetizing locations include the main operating rooms, MRI, CT Scan, Medical Special Procedures Unit, and Interventional Radiology.  University Hospital is a high risk obstetric center with a Level III Nursery, therefore residents will participate in the care of premature infants.  Teaching and supervision is provided by core faculty for routine, emergent, and complex cases.  Emphasis will be placed on the special concerns of the pediatric patient, including airway, pharmacologic and physiologic differences in various age groups, and psychological needs of the patients and their parents.  A one-month block in the yearly didactic schedule is dedicated to Pediatric Anesthesiology.
3. Clinical Duties with Learning Pathway

   1. Complete thorough preoperative assessments for pediatric patients, including the history and physical, gestational age at birth and complications during pregnancy, delivery and the perinatal period. Common pediatric congenital abnormalities and their anesthetic implications are noted, with particular emphasis on congenital heart disease in the patient for non-cardiac surgery.  Attention is directed to coexisting medical diseases.  Apply the appropriate NPO guidelines for various age groups.  Preoperative evaluations are presented to the pediatric anesthesia attending prior to each case.  The Pediatric Anesthesiology faculty is always available for consultation regarding questions of patient care that arise preoperatively.  All electively scheduled patients who are ASA III or higher must be discussed with the attending the night before surgery.
   2. Formulate an anesthetic plan including an assessment of appropriate level of monitoring and selection of anesthetic agents and technique for the planned surgery.  The plan will include consideration of preoperative disease states, airway management and possible complications related to the surgical procedure.  The anesthetic plan is discussed with the pediatric anesthesia attending, with attention given to any alternative techniques.
   3. Appreciate the differences between the pediatric and the adult airway.  Perform a thorough airway exam and identify patients with potentially difficult airway.  Formulate a safe anesthetic plan for securing the airway and demonstrate proficiency in various intubation techniques, including fiberoptic laryngoscopy, intubating LMA, lighted stylet, etc.  The plan for airway management will be discussed with the pediatric anesthesia attending.
   4. The resident will participate in the care of various neonatal and pediatric surgical emergencies as they present, such as congenital diaphragmatic hernia, omphalocele, gastroschisis, necrotizing enterocolitis and epiglottitis.  The anesthetic plan is formulated by the resident and discussed with the attending.
   5. Perform various anesthetic techniques, including general anesthesia, regional anesthesia and conscious sedation in pediatric patients.  Manage patients of various age groups, from premature infants to adolescents.  Anesthesia for 100 children under the age of twelve, including anesthesia for fifteen infants less than one year of age, are required for graduation from the program and are recorded in the resident’s electronic log.
   6. The resident will apply the pharmacokinetic principles of anesthetic drugs in infants and patients, e.g. renal excretion, hepatic metabolism, protein binding and volume of distribution; and will appropriately and judiciously utilize premedicants, agents for induction and maintenance of anesthesia, and resuscitation medications. 
   7. An understanding of the mechanisms by which heat loss occurs in the operating room and the physiology of thermal regulation in infants necessitates that the resident institute measures to decrease heat loss intraoperatively and during patient transport. 
   8. Formulate a plan for postoperative pain management for various age groups, including the use of narcotics, analgesics and local anesthetics as appropriate.  Discuss the risks and benefits of the various modalities with the parents preoperatively.  The plan will be discussed with the pediatric anesthesia attending.
   9. The resident will apply appropriate postoperative discharge criteria to infants and neonates, with an emphasis on postoperative implications for infants less than 60 weeks post-conception.
   10. The resident is expected to participate in all didactic sessions during the Pediatric Anesthesia rotation.  He/ she will read all assigned materials and prepare discussions of interesting cases and journal articles. 
4. References – Residents are expected to complete required readings from major textbooks (e.g. Miller, Barash) during the three year program.  In addition, selected journal articles will be provided, and the following references are suggested to help you meet your learning objectives: (see hand-out for additional references)
5. Objectives - attached
6. Evaluation – All learning objectives will be evaluated as stated in section V.  Each resident will receive at the beginning of the rotation a topic card for discussion by the Director of Ambulatory Anesthesia or his designee.  When the resident has prepared and presented this information to the satisfaction of the DOAA or the supervising attending, the card must be signed by the attending.  It is the resident’s responsibility to fulfill these responsibilities as well as to turn in the card to the Resident Education Committee (in the person of Ms.Venino.

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