Pediatric Anesthesiology Fellow

Goals and Objectives

Pain

The objective of education and training in pediatric anesthesiology fellowship are to develop consultant-level knowledge in all areas of the subspecialty and to develop the knowledge and skill, mainly coming from hands-on clinical experience, to provide pediatric anesthesia care in situations likely to be encountered in future pediatric anesthesia practice.

Patient Care

Pre-operative Evaluation and Care:

The fellow will:

  1. Establish rapport with the child and parents/family/caregivers.
  2. Obtain a current and past medical history, with specific emphasis on the current medical condition(s) for which the child is presenting for surgery. Important preoperative information should include:
  3. Allergies
  4. NPO status
  5. Current medications
  6. Past surgeries
  7. Past anesthesia and possible problems/complications for the patient or family
  8. Appropriate laboratory data
  9. Co-morbidities including appropriate information from other specialties (cardiology, neurology, genetics…)
  10. Developmental assessment
  11. Postoperative age related apnea risk assessment
  12. Perform a focused physical examination
  13. Weight
  14. Assessment of physical distress
  15. Respiratory distress, cardiovascular stability, level of hydration, level of consciousness/alertness, need for medical intervention to improve patient stability preoperatively
  16. Airway assessment- size of chin, dysmorphic features
  17. Cardiovascular assessment, with particular attention to:
  18. Precordial exam – rate, presence of murmurs
  19. Peripheral perfusion- capillary refill, temperature of extremities
  20. Developmental assessment, anxiety assessment
  21. Assessment of intravenous access level of difficulty
  22. Assessment of other relevant physical findings-(major abnormalities)
  23. Integrate the history, physical examination and ancillary studies and information, and develop an anesthetic plan including:
  24. Appropriate preoperative fasting orders
  25. Plan for minimizing preoperative/induction anxiety
  26. Induction of anesthesia
  27. Maintenance of anesthesia
  28. Pain management intra- and postoperatively
  29. Fluid management appropriate to patient weight and procedure
  30. Emergence
  31. Postoperative placement (PACU, ICU)
  32. Discuss the anesthetic plan with attending anesthesiologist in a cohesive manner and review plan as needed together.
  33. Anticipate potential problems and prepare contingency plans.

Intraoperative Care

The fellow will:

  1. prepare the OR appropriately including:
  2. Machine and equipment check
  3. Monitors
  4. EKG, size appropriate BP cuffs, O2 saturation proves
  5. Invasive monitoring if appropriate
  6. Airway management equipment
  7. Age/size appropriate masks, oral airways, endotracheal tubes, LMA’s, laryngoscope blades
  8. Intravenous equipment
  9. Iv bag and tubing assembled
  10. Variety of iv catheter sizes
  11. Medications
  12. Resuscitation medications prepared
  13. Appropriate induction, maintenance, muscle relaxant, and pain management medications
  14. Temperature maintenance measures
  15. Warm OR
  16. Appropriate active warming measures (forced air warmers, heat lamps, fluid warmers)
  17. Actively participate in the preoperative management of the patient which includes:
  18. Establishing rapport with the patient/family/caregivers.
  19. Administering appropriate premedication in a safe and effective manner
  20. Actively participate in the induction of anesthesia by demonstrating skill, facility and safety in:
  21. Airway management
  22. Use of monitoring equipment
  23. Selecting and administering induction agents/medication
  24. Establishing intravenous access
  25. Actively participate in the evaluation and treatment of both acute and chronic pain management (thereby actively participating in regional pain management techniques)
  26. Actively participate in establishing invasive monitors if appropriate, including arterial cannulation and central venous access, adhering to guidelines regarding techniques to minimize contamination/infection of lines
  27. Actively participate in putting children on bypass and weaning them from bypass
  28. Actively participate in the care of pediatric patients undergoing cardiac and intrathoracic procedures not involving cardiopulmonary bypass.
  29. Actively participate in transesophageal echocardiogram insertion and reading in infants and children
  30. Remain engaged and maintain vigilance throughout the maintenance of the anesthetic
  31. Keep current of the operative repair
  32. Communicate effectively wit the surgical and nursing team
  33. Manage fluids appropriately for patient weight and intraoperative fluid losses
  34. Manage anesthetic, relaxant, and pain medications appropriately
  35. Actively participate in the smooth termination of the anesthetic
  36. Terminate the anesthetic agents in a timely manner
  37. Reverse muscle relaxants
  38. Plan for and smoothly return the patient’s airway to the patient’s control
  39. extubation
  40. removal of LMA
  41. removal of oral airway
  42. continuous assessment and monitoring of patient ventilation
  43. plan for and manage airway difficulties upon emergence
  44. Actively participate in the safe transition of the patient to the postoperative care unit
  45. Monitor the patient until it is safe to transfer the patient to the postoperative care unity
  46. Communicate effectively with the postoperative care team all of the relevant information for a safe transfer of care
  47. Write appropriate PACU orders for pain, fluid management, PONV, and other specific orders as needed.

Postoperative Care

The fellow will:

  1. Visit the patient within 24 hours post operatively
  2. Elicit information on issues relevant to the patient’s anesthetic course
  3. Write a postoperative note in the patient record
  4. Differentiate between patients requiring treatment in and ICU and other care settings
  5. Identify ICU patients who are ready for ward transfer and the factors important to facilitate safe patient care transfer
  6. Describe the diagnostic criteria and Demonstrate proficiency in the initiation of treatment plans for patients with impending organ failure. (respiratory, cardiac, neurological, hepatic, renal & gastrointestinal)
  7. Identify and initiate timely treatment for the following conditions
  1. Cardiac Insufficiency – arrest
  2. Respiratory Insufficiency – arrest
  3. Acute Lung Injury (ALI)
  4. Acute Respiratory Distress Syndrome (ARDS)
  5. Shock, all types
  6. Sepsis
  7. Electrolyte and acid-base disturbances
  8. Overdose
  9. Increased inter-cranial pressure/Stroke/Closed Head Injury (CHI)
  10. Spinal cord injury
  11. Pneumo-, hemato-, and hydrothorax
  12. Pulmonary Emboli
  13. Cardiac Tamponade
  14. Acute Myocardial Infarction/Ischemia
  15. Intra Abdominal/Pelvic catastrophe
  16. Multi Organ System Failure
  17. Acute/Chronic Liver Failure
  18. Acute/Chronic Renal Failure
  19. Endocrine emergencies
  20. Hematological emergencies
  21. Compartment Syndrome
  22. Rhabdomyolysis
  1. Use data from appropriate invasive and non-invasive monitoring devices to diagnose, treat & titrate patient therapy
  2. Explain the indication, contraindications, complications and pitfalls of emergency airway management and ventilator management. Please discuss the following techniques:
  1. Open airways on non-intubated patients
  2. Ventilation by bag-mask systems
  3. Tracheal intubations
  4. Fiber optic intubations
  5. Bronchoscope use
  6. Contemporary modes of ventilation
  7. Management of complications
  1. Explain the indications, contraindications, & complications of the following ICU associated procedures
  1. Arterial puncture and cannulation
  2. Insertion of central venous catheters
  3. Pulmonary artery catheters
  4. Dynamic/static electrocardiogram interpretation
  5. Cardioversion
  6. Pericardiocentesis
  7. Thoracentesis
  8. Needle and tube thoracostomy
  9. Pacemaker management: transcutaneous and epicardial
  10. Intra-aortic balloon pump
  11. ECHO usage

Medical Knowledge

The fellow will:

  1. Think critically
  2. Demonstrate an investigatory approach to and analysis of clinical situations
  3. Model/foster lifelong learning
  4. Attends and participates in lectures, case conferences, journal club meetings, and other scheduled academic activities
  5. Understanding fasting guidelines
  6. Understand comparative anatomy and physiology for neonates, infants, children and adults
  7. airway
  8. chest wall and lung mechanics
  9. respiratory anatomy and physiology
  10. cardiac anatomy and physiology
  11. renal physiology
  12. Understand age related dosing and pharmacokinetics and dynamics of:
  13. inhalation anesthetics
  14. opioids and benzodiazepines
  15. muscle relaxants
  16. local anesthetics
  17. resuscitation drugs
  18. Understand fluid and electrolyte management for children of all ages
  19. Understand thermoregulation
  20. Understand physiology of neonatal transition
  21. Some understanding of normal child physical development
  22. Some understanding of normal child social development
  23. Understand pediatric equipment (airway equipment, anesthesia circuits, ventilators, monitors)
  24. Understand pediatric history and physical examination skills
  25. Understand neonatal resuscitation
  26. Understand perioperative issues involving the premature and term neonate
  27. apnea-perioperative and monitoring
  28. neonatal emergencies- (diaphragmatic hernia, necrotizing enterocolitis, gastroschesis/omphalocele, tracheo-esophageal fistula, meningomyelocele)
  29. common neonatal procedures- (inguinal hernia repair)
  30. regional anesthesia
  31. Understand perioperative concerns and management of common pediatric procedures
  32. OHNS
  33. General pediatric surgery
  34. Orthopedic surgery
  35. Neurosurgery
  36. Plastic surgery
  37. Urology
  38. ophthalmology
  39. Acquire some knowledge of the preoperative concerns and management of less common pediatric procedures including
  40. thoracic surgery
  41. craniofacial surgery
  42. burns
  43. mediastinal mass
  44. spinal fusion
  45. Understand special problems in pediatric anesthesia
  46. the child with a URTI
  47. the child with a difficult airway
  48. obstructive sleep apnea
  49. sickle cell anemia
  50. malignant hyperthermia
  51. latex allergy
  52. Some understanding of congenital heart diseases in the child presenting for non-cardiac surgery
  53. Acquire understanding of congenital heart disease in infants and children
  54. Understand anesthetic requirements for infants and children with CHD
  55. Understand issues regarding cardiopulmonary bypass; putting infants on and weaning them off bypass; including managing their anesthetic post-bypass
  56. Understand the issues for pediatric anesthesia in off-site locations
  57. Develop some understanding and /or experience with pediatric regional anesthesia, including caudals, epidurals, peripheral and regional blocks
  58. Describe the patho-physiology of common disease processes that might lead to ICU admission and the effects on the Cardiovascular, Pulmonary, Hematological, Neurological, Endocrine as well as Renal and Gastrointestinal systems
  59. Discuss the immediate management of the post-operative, thoracic, standard surgical patients
  60. Compare and contrast the Trauma patient from other surgical and medical patients. Be prepared to discuss the pre-op. inter-op and post-op management concerns
  61. Discuss the common medical problems and concerns associated with the surgical patient; neuron-cognitive, cardiovascular, pulmonary, endocrine, & renal
  62. Discuss the immediate and delayed concerns of the post-surgical
  63. Explain the goals of sedation and analgesia in the ICU. Discuss the various options available to facilitate sedation and analgesia, including sedation scales and various types of sedation medications
  64. Compare and contrast contemporary modes of ventilation and weaning strategies
  65. Explain the goal of basic nutrition support. Discuss the initial nutrition assessment of a ICU patient. Identify risk factors associated with poor nutritional health and prepare a nutritional plan, to include formula selection and caloric needs for ICU patients
  66. Discuss basic infection control goal and the techniques used to help in the prevention of ventilator associated pneumonia (VAP), urinary tract infections (UTI), central venous line (CVL) and post operative wound infections
  67. Discuss the basic patient care protocols and techniques used to help in the prevention of ventilator associated pneumonia (VAP), deep venous thrombosis (DVT), peptic ulcer disease (PUD), central venous line (CVL) and post operative wound infections
  68. Describe treatment strategies for VAP, UTI, CVL, DVT, PUD, soft tissues and intra-abdominal infections
  69. Compare and contrast the most commonly used antibiotics in the ICU. Medications to include Penicillins, Cepthalosporins, Carbopenums, Aminoglycosides, Floroquinalones, Antifungals and new generation medications such as Daptomicin and Linazolid
  70. Present and organized approach to clinical problem solving including a differential diagnosis, well as systematic approach to the use of diagnostic testing and consultant activities
  71. Describe and display a systematic approach to the use of diagnostic testing and consultant activities in the ICU

Scholarship

The fellow will:

  1. Attend Thursday morning Anesthesiology department didactic lectures from 8:00 A.M. to 9:00 A.M.
  2. Attend Grand Rounds every Friday morning from 8:00 to 9:00 A.M.

Teaching

The fellow will:

  1. Prepare and execute didactic lectures to medical students, residents and attending anesthesia staff
  2. Be able to supervise resident and medical student activities and learning within preoperative, intraoperative and postoperative recovery room settings

Research

The fellow will:

  1. Complete a research project approved by the pediatric fellowship director prior to graduation from the pediatric fellowship program.

Practice-based learning and improvement

The fellow will:

  1. Seek and use feedback (physician, patient, ppers0 and their own insight to focus on areas in their performance that need improvement
  2. Read in-depth about issues pertaining to their patient’s anesthesia care. The resident should be able to critically evaluate the literature and try to make patient care decisions based on scientific evidence
  3. Know his/her own limits and to practice within them while striving to safely expand these limits
  4. Pursue excellence
  5. Recognize existing and describe additional patient safety monitoring and error reduction strategies that could be employed in the ICU
  6. Recognize and describe the process of assessing patient and family satisfaction and its importance in ICU care
  7. Recognize and describe basic methods for searching, reviewing and evaluating the medical and scientific literature
  8. Support ongoing basic and clinical science protocols in the ICU by participating in candidate identification or in proposing future projects
  9. Contribute to and support process improvements in the ICU. Meet with the nursing or physician staff to assess current practice and make suggestions

Interpersonal and communication skills

The fellow will:

  1. Listen well and articulate thoughts effectively
  2. Understand the emotional and psychological impact of a child’s illness upon the child and the family, and to use this knowledge to guide his/her interaction with the child and family
  3. Communicate openly, effectively and respectfully with the surgeon, nurses and other members of the operating room team.
  4. Inspire confidence and trust with patients, families and coworkers
  5. Be a role model and mentor for residents within the anesthesia program
  6. Demonstrate effective communication with physicians, nurses, consultants and all other members of the healthcare team on rounds and in daily interactions as observed by attending staff or reported to staff
  7. Communicates clearly, correctly, and concisely in a written report, stressing the important issues and an articulate plan
  8. Communicates clearly, correctly, and concisely in a verbal report, stressing the important issues and an articulate plan
  9. Describe safe order writing and the concept of closed loop communication as it relates to verbal orders
  10. Demonstrates good use of consultants when appropriate in managing complex ICU problems. Seek consultations when appropriate with other specialty physicians in managing complex ICU problems
  11. Displays and can discuss the skills and importance in maintaining a good relationship with other healthcare providers

Professionalism

The fellow will:

  1. Be on time, be prepared, and fulfill responsibilities to patients and other members of the patient care team
  2. Be honest, open and available to the patient and the patient’s parents/family
  3. Interact with all parents, patients, patient care team members, consultants and medical students in a professional and respectful manner
  4. Be a team player
  5. Resolve conflicts in a constructive manner
  6. Be honest, accountable, and responsible
  7. Respectful and recognize and use the particular skill sets of other ICU practitioners, such as ICU nurses, RT, PT, OT, dieticians, pharmacists
  8. Considers ethical issues and patient wishes in treatment decisions

Systems-based practice

The fellow will:

  1. Understand, access, and utilize the resources, providers and systems necessary to provide optimal care for children and their families
  2. Use all available sources of patient information available to construct an appropriate anesthetic plan
  3. Constructively participate in efforts to improve our system of delivery of care
  4. Apply evidence-based, cost-conscious strategies regarding patient perioperative care
  5. Be familiar with the necessary components of a comprehensive pediatric surgical unit.
  6. Support initiatives to improve care of critically ill patients
  7. Discuss the issues of patient safety including the medical systems that put patients at risk, medication, operations, transfusions & nursing ratios
  8. Describe the proper procedure to correctly identify a patient to minimize patient errors
  9. Recognize and describe basic compensation methodologies for critical care services
  10. Recognize, describe and ensure compliance with institutional and unit policies and procedures as well as regulatory policies from accreditation agencies, regulators, and prayers

Assessment and Evaluation

  1. Weekly evaluations by faculty during rounds, presentations, conference participation, procedures performed, patient, family & staff interactions
  2. Monthly evaluations by Program Director based on the six core competencies

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Goals & Objectives

Pain

Pediatric Anesthesiology Fellowship Program