The overall general objectives of resident education and training in Pediatric Anesthesiology are to develop consultant-level knowledge in all areas of the subspecialty and to develop the knowledge and skill, based especially on hands-on clinical experience, to provide state-of-the-art pediatric anesthesia care in most situations likely to be encountered in future practice. Residents may also be encouraged, though not required, to participate in clinical research projects under the direction of the attending staff. Our two to three month Pediatric Anesthesia Rotation is focused on facilitating the achievement of these and the following more specific goals and objectives.

Pediatric Anesthesia Rotation CA1/2/3. Duration: 2-3 months

Description
The rotation is designed as two separate months during the CA1 and/or CA2 years, plus an elective third month during the CA3 year. Pediatric anesthsia information for preview and concurrent study is available online. Suggested reading list follows. During the three months residents are directly supervised by faculty members of the MHMC Department of Anesthesia in the provision of anesthesia and post-anesthetic care for newborns, infants, children and adolescents to age 18 undergoing therapeutic, diagnostic and surgical procedures. This care is inclusive of general anesthesia, regional anesthesia, intravenous sedation as well as appropriate regimes for analgesia in this population.

A core curriculum of topics in Pediatric Anesthesia is presented throughout the year as part of the regular Tuesday morning, Wednesday afternoon and Thursday afternoon lecture series. This didactic material emphasizes the anatomy, physiology and pharmacology as it pertains to the practice of pediatric anesthesiology. A syllabus of regularly updated study material is available online. Each resident is expected to begin study of the relevant material prior to the first month of the rotation.

Goals
Specifically, residents will be able to demonstrate:

• Essential Character Attributes
  • Be punctual
  • Be honest and ethical
  • Learn from experience
  • React appropriately in stressful situations
• Good judgment (including recognition of personal limitations)
• Understanding and application of:
  1. Special pediatric considerations in temperature regulation
  2. Malignant hyperthermia
  3. Resuscitation of the newborn
  4. Pediatric apparatus, including breathing circuits, humidifying methods, thermal control
  5. Appropriate thorough preoperative evaluation and development of positive rapport with the pediatric patient and family.
  6. Appropriate preparation of the operating room and equipment for the pediatric patient.
  7. Premedication: drugs, dosage, routes, vehicles
  8. Agents and technics
     • Anesthetic: actions different from adults
     • Neuromuscular blockers (sensitivity, congenital diseases)
     • Selection of and demonstrate skillful application of technics of pediatric anesthetic induction:
       intravenous (IV)
       inhalational
       rectal
       intramuscular (IM)
       
     • Skillful management of the pediatric airway by hand and mask
     • Achievement of IV access in the pediatric patient
     • Performance of efficient atraumatic endotracheal intubation of the pediatric patient
     • Appropriate selection and performance of basic pediatric regional anesthetic technics including
       • Caudal epidural block
       • Spinal
       • Ilioinguinal-hypogastric nerve block
       • Penile block
       • Peripheral nerve blocks
  9. Fluid therapy and blood replacement, physiologic anemia
  10. Problems in intubation (full stomach, diaphragmatic hernia, T-E fistula, Pierre-Robin, awake intubation)
  11. Proficiency in the anesthetic management of routine pediatric cases (tympanotomy tubes, adenoidectomy and tonsillectomy, herniorrhaphy,...) explaining the selection of airway, fluid type and rate, agents and adjuvants
  12. Anesthetic implications of common and critical pediatric conditions
      • Asthma
      • Upper respiratory infection (URI)
      • Tonsillar and adenoidal hypertrophy/tonsillitis
      • Serous otitis media (SOM)
      • Croup
      • Epiglottitis
      • Obstructive sleep apnea (OSA)
  13. Neonatal physiology
      • Respiratory
        • Development, anatomy, surfactant
        • Pulmonary oxygen toxicity
        • Pulmonary function
        • Lung volumes vs. adult
        • Airway differences, infant vs. adult
      • Cardiovascular
        • Transition, fetal to adult
        • Persistent fetal circulation
      • Metabolism, fluid distribution and renal function
      • Thermal regulation (neutral temperature, brown fat)
      • Fetal hemoglobin
      • Clinical problems of prematurity
        • Respiratory distress syndrome (RDS)
        • Bronchopulmonary dysplasia (BPD)
        • Apnea of prematurity
        • Retinopathy of prematurity (ROP): anesthetic implications
        • Necrotizing enterocolitis (NEC)
  14. Congenital heart disease
      • Cyanotic defects, primary pulmonary hypertension
      • Acyanotic defects
      • Altered uptake/distribution of IV and inhalation anesthetics
      • Other anesthetic considerations
      • Anesthetic considerations of specific lesions
        • Patient ductus arteriosus (PDA)
        • Atrial septal defect (ASD)
        • Ventricular septal defect (VSD)
        • Tetralogy of Fallot (TOF)
        • Transposition of the great arteries (TGA)
        • Persistent pulmonary hypertension of the newborn ("PFC")
  15. Emergencies in the newborn
      • Diaphragmatic hernia
      • T-E fistula
      • Neonatal lobar emphysema
      • Pyloric stenosis
      • Necrotizing enterocolitis
      • Omphalocele/gastroschisis
      • RDS: etiology, management, ventilation technics
      • Myelomeningocele
  16. Management of the anesthetic recovery of pediatric patients
  17. Postoperative analgesia

CA3 Residents completing the third month of Pediatric Anesthesia will additionally be able to

1. Supervise junior residents and medical students in performing pediatric anesthesia care
2. Appropriately manage anesthesia for complex and/or difficult cases (diaphragmatic hernia, T-E fistula, omphalocele/gastroschisis, Pierre-Robin syndrome, epiglottitis, ...)
3. Lead discussions with junior residents on principles of pediatric anesthesia
4. Assume role of consultant anesthesiologist

Pediatric Anesthesia Educational Objectives
The following serves as a guide to the education and evaluation of residents rotating in Pediatric Anesthesia.

1. MEDICAL KNOWLEDGE:
   • Cognitive ability: residents will learn the principles of anesthesia for pediatric patients including the anatomy and physiology of neonates and children; the pathophysiological process involved in pediatric surgical conditions; the pharmacology of anesthetic agents as it effects neonates, infants and children; the principles of temperature regulation for neonates, infants and children; the principles of equipment and monitoring devises used in pediatric anesthesia;
   • Psychomotor ability: residents will develop a working knowledge and understanding of the indications and contraindications, risks and benefits of the various procedures they learn; residents will develop technical skill with procedures such as intravenous, intraarterial and central venous catheter insertion in infants and children, neuroaxial and other regional procedures in infants and children.
   • Affective ability: residents will begin to develop behavior patterns related to working with pediatric patients and their parents in the preparation and administration of anesthesia, including the need for careful assessment, the ability to respond to rapidly changing patient conditions and the team approach to pediatric anesthesia..
2. PATIENT CARE:
   • Cognitive ability: residents will learn the basic principles of caring for pediatric patients undergoing surgery for general, urological, orthopedic, ENT, cardiac, neurosurgical, ambulatory and other surgical procedures; residents will also understand the principles of sedation and monitoring for pediatric patients having procedures outside the operating room such as radiological procedures; the recognition, treatment and prevention of postoperative pain in children and infants.
   • Psychomotor ability: residents will have the opportunity to anesthetize at least 100 patients aged between 2 to 12 years and at least 15 under 2 years, including neonates and premature babies; residents will learn how to perform invasive procedures with appropriate concern for patient safety such as epidural, caudal and spinal anesthesia; sedation and monitoring techniques;
   • Affective ability: residents will develop a behavioral approach that pays attention to all aspects of caring for pediatric patients and their parents in the perioperative period; residents will pay particular attention to patient safety; residents will be expected to work at the appropriate level of supervision for their training and for the condition of their patients; residents should demonstrate independent thinking but also show appropriate judgment and decision making including knowing when to ask for help from their supervising attendings.
3. INTERPERSONAL & COMMUNICATION SKILLS:
   • Cognitive ability: residents will learn techniques for effective communication with pediatric patients and their parents concerning pre-operative assessment, explaining the process of anesthesia and discussing risks of general and regional anesthesia.
   • Psychomotor ability: residents will be able to demonstrate skills for making a thorough preoperative assessment of each patient, they will also develop effective communication skills for explaining the process of anesthesia and discussing risks of general anesthesia to patients and their parents; residents will develop effective listening skills and show effective communication with patients, their parents and families and other members of the pediatric care team.
   • Affective ability: residents will demonstrate behaviors that show commitment to effective communication with patients, their families and other members of the pediatric surgical team; residents should be able to communicate pertinent data about the patient to their attending in a precise and efficient manner.
4. PROFESSIONALISM:
   • Cognitive ability: residents will learn the basic definitions of professional conduct as it applies to the practice of anesthesia for pediatric surgery and basic ethical principles.
   • Psychomotor ability: residents will act in a way that shows commitment to professional practice in their interactions with patients, their parents and families, colleagues and other members of the pediatric health care team; residents will be expected to contribute to the smooth running of the pediatric operating rooms; residents will be expected to complete all pre, intraoperative and post operative documentation in accordance with departmental requirements.
   • Affective ability: residents will demonstrate commitment to professional practice in their interactions with patients, their families, colleagues and other members of the pediatric health care team.
5. PRACTICE-BASED LEARNING:
   • Cognitive ability: residents will learn the practice of reflection on their performance and how to learn from expereince; they will understand the principles of life-longer learning and evidence � based medicine as it relates to pediatric anesthesia.
   • Psychomotor ability: residents will demonstrate reflective practice and develop skills to enhance learning from various sources including the use of web-based learning; residents will participate in feedback with their tutors to help improve their practice of pediatric anesthesia.
   • Affective ability: residents will demonstrate commitment to continually trying to improve their performance and take an active role in furthering their knowledge by attending organized educational activities especially the pediatric didactic lecture schedule and by preparing a 20 minute presentation for the end of the rotation.
6. SYSTEMS BASED PRACTICE:
   • Cognitive ability: residents will understand the team approach to how pediatric patients present, are investigated and assessed and optimized for their surgical procedures and how their management impacts on this team approach; residents will understand how the pediatricians, surgeons, nurses and intensive care departments interact with the pediatric surgical patients.
   • Psychomotor ability: residents will take part in practices and initiatives such as quality improvement programs that interact with other areas of the health care system; residents will be expected to function as a team member and work with nurses, surgeons and operating room staff to improve the care they offer their patients and their own understanding of the broader aspects of the health care system.
   • Affective ability: residents will develop behaviors that show an appreciation for the impact of their practices on the whole system caring for pediatric patients undergoing surgery.