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Background The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force. Methods Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient's arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range). Results In total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30). Conclusions This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

BACKGROUND Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition. METHODS We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey. RESULTS Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again. CONCLUSIONS The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

IntroductionWe sought to evaluate paediatric oncology simulations intended to improve paediatric residents’ skills and comfort in caring for children with cancer.MethodIn a non-randomised trial, controls (the first three rotations) received a standard set of lectures, and the intervention arm received these lectures plus five simulation training scenarios—fever/neutropaenia, a new leukaemia diagnosis, end-of-life care discussion, tumour lysis syndrome and a mediastinal mass. All residents were tested after the rotation on the first three scenarios; management skills were evaluated independently by two raters. Before and after training, all residents completed an emotional-appraisal questionnaire evaluating each scenario as a perceived challenge or threat. Analysis of variance (ANOVA) measured differences by study arm in skills checklist assessments and appraisals; repeated measures ANOVA measured changes in emotional-appraisal scores.ResultsForty-two residents (9 controls, 33 interventions) participated. Inter-rater agreement for skills checklist scores using average-measures intraclass correlation was high (0.847), and overall mean scores were significantly higher for the intervention than control group across both raters (p=0.005). For all residents, perceived challenge increased in the end-of-life simulation, and perceived threat decreased in all three test scenarios. The intervention group, regardless of training year, evaluated the teaching scenarios favourably and felt that challenging oncology situations were addressed, skills were enhanced and the simulations should be offered to other residents.ConclusionsIt was feasible to introduce residents to difficult paediatric oncology scenarios using simulation. The intervention group performed more skills than controls when tested and perceive threat declined in all residents after their paediatric oncology rotation.

Although originally described to assist airway management of fetal congenital malformations with life-threatening airway obstruction, the indications for an ex utero intrapartum treatment (EXIT) have expanded to include surgical resection of lesions that are potentially incompatible with life in the absence of uteroplacental circulatory support. We describe the case of an infantile fibrosarcoma (IFS) that presented with fetal hydrops and was successfully managed with an emergency EXIT that necessitated the initiation of a massive fetal blood transfusion both with and without the support of uteroplacental circulation.

Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong)

INTRODUCTION In the setting of acute injury, a wrong, missed, or delayed diagnosis can impact survival. Clinicians rely on pattern recognition and heuristics to rapidly assess injuries, but an overreliance on these approaches can result in a diagnostic error. Simulation has been advocated as a method for practitioners to learn how to recognize the limitations of heuristics and develop better diagnostic skills. The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries. METHODS Ten scenarios were developed to assess the ability of trauma teams to provide initial care to a severely injured patient. Seven standard scenarios simulated severe injuries that once diagnosed could be effectively treated using standard Advanced Trauma Life Support algorithms. Because diagnostic error occurs more commonly in complex clinical settings, 3 complex scenarios required teams to use more advanced diagnostic skills to uncover a coexisting condition and treat the patient. Teams composed of 3 to 5 practitioners were evaluated in the performance of 7 (of 10) randomly selected scenarios (5 standard, 2 complex). Expert rates scored teams using standardized checklists and global scores. RESULTS Eighty-three surgery, emergency medicine, and anesthesia residents constituted 21 teams. Expert raters were able to reliably score the scenarios. Teams accomplished fewer checklist actions and received lower global scores on the 3 analytic scenarios (73.8% [12.3%] and 5.9 [1.6], respectively) compared with the 7 heuristic scenarios (83.2% [11.7%] and 6.6 [1.3], respectively; P < 0.05 for both). Teams led by more junior residents received higher global scores on the analytic scenarios (6.4 [1.3]) than the more senior team leaders (5.3 [1.7]). CONCLUSIONS This preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach. Simulation can be used to provide teams with decision-making experiences in trauma settings and could be used to improve diagnostic skills as well as study the decision-making process.

Background: Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error. Methods: We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis). Results: Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis. Conclusions: Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.

Sickle cell disease (SCD) is the most common genetic disorderidentifiedbynewbornscreeningintheUnitedStates[1].Fewerthan100,000individualshavebeenidentifiedashavingSCD,resultinginthisdiseasebeingclassifiedasrare[2].Causedbyapointmutationincodon6oftheb-globingene,theresultanthemoglobinSpolymerizeswhendeoxygenatedanddistortsredbloodcellsintothesickleshapedescribed by Herrick in 1910 [3,4]. The combination of decreasedRBC deformability, membrane dysfunction, abnormal nitric oxidemetabolism, and endothelial damage lead to vaso-occlusion andhemolysis [5]. SCD causes tissue ischemia, anemia, and organdamage.Vaso-occlusivepainepisodesarethediseasehallmarkfromwhich life-threatening complications, including acute chest syn-drome and multiple organ failure, can arise [6–8].Vaso-occlusive episodes require health care providers to be asastute in recognizing an impending event as they are in managingclinicalcomplications.AcuteeventsinSCDarerelativelyinfrequentin pediatric medicine [9], and limited patient encounters result infewer educational opportunities for medical students and resi-dents [10]. Acquiring adequate skill for the medical care of indivi-duals with SCD is further hampered by variable clinical exposure,patient geographic distribution, and restrictions on resident workhours[11,12].ThelowrateofacuteeventsinSCD,whileatestamenttomedicaladvances,paradoxicallyplacespediatricresidentsatriskofbeing underprepared when such events do occur [13]. Despite thesechallenges, physicians-trainees require opportunities to learn, teachand provide the definitive medical care for individuals with rarediseases who present with time sensitive medical complications.Medical simulation is a form of deliberate practice, whichpresentsthelearnerwithataskthathaswell-definedgoals, aforumfor feedback, and the opportunity for repetition [14]. Byreproducingevents,simulationensuresatrainee’sinitialexperiencein the management of an acutely ill child does not put an actualpatient at risk. In prior studies from our institution, residentsmanaged simulated acute events from a wide range of clinicalencounters[10,15–17].Thepurposeofthisstudywastocreateasetof SCD-specific acute care scenarios and determine if theassessment could provide reliable and valid measures of pediatrictrainees’ performance. Reliability would be supported throughuniformity in rater scoring and consistency of participantperformance over scenarios. Evidence to support the validity ofthe scores would be obtained by demonstrating more experiencedtrainees outperformed those early in training.

Extracorporeal membrane oxygenation (ECMO) has been reported as an alternative to cardiopulmonary bypass during lung transplantation. The reports in the literature have been limited to adult practice and associated with decreased pulmonary and renal complications, lower mortality, and lower in-hospital mortality. We present four pediatric lung transplantations performed on ECMO and discuss relevant perfusion management.

Objective To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists-in-training would be better prepared to manage the scenarios than teams led by nurse practitioners. Study design A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist-in-training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed. Results The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists-in-training outperformed the teams led by the pediatric nurse practitioners. Conclusions Simulation provides a method for RRTs to develop decision-making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist-in-training-led teams provides some evidence to support the validity of the assessment.

BACKGROUND: Emergency information forms (EIFs) have been proposed to provide critical information for optimal care of children with medical complexity (CMC) during emergencies; however, their impact has not been studied. The objective of this study was to measure the impact and utility of EIFs in simulated scenarios of CMC during medical emergencies. METHODS: Twenty-four providers (12 junior, 12 experienced) performed 4 simulations of CMC, where access to an EIF was block randomized by group. Scenario-specific critical action checklists and consequential pathways were developed by content experts in simulation and pediatric subspecialists. Scenarios ended when all critical actions were completed or after 10 minutes, whichever came first. Two reviewers independently evaluated the video-recorded performances and calculated scenario-specific critical action scores. Performance in scenarios with and without an EIF was compared with Pearson’s χ2 and Mann–Whitney U tests. Interrater reliability was assessed with intraclass correlation. Each provider rated the utility of EIFs via exit questionnaires. RESULTS: The median critical action score in scenarios with EIFs was 84.2% (95% confidence interval [CI], 71.7%–94.1%) versus 12.5% (95% CI, 10.5%–35.3%) in scenarios without an EIF (P < .001); time to completion of scenarios was shorter (6.9 minutes [interquartile range 5.8–10 minutes] vs 10 minutes), and complication rates were lower (30% [95% CI, 17.4%–46.3%] vs 100% [95% CI, 92.2%–100%]) with EIFs, independent of provider experience. Interrater reliability was excellent (intraclass correlation = 0.979). All providers strongly agreed that EIFs can improve clinical outcomes for CMC. CONCLUSIONS: Using simulated scenarios of CMC, providers’ performance was superior with an EIF. Clinicians evaluated the utility of EIFs very highly.

The aims of the study were (1) to create multiple scenarios that simulate a range of urgent and emergent extracorporeal membrane oxygenation (ECMO) events and (2) to determine whether these scenarios can provide reliable and valid measures of a specialist's advanced skill in managing ECMO emergencies.Multiscenario simulation-based performance assessment was performed.The study was conducted in the Saigh Pediatric Simulation Center at St. Louis Children's Hospital.ECMO clinical specialists participated in the study.Twenty-five ECMO specialists completed 8 scenarios presenting acute events in simulated ECMO patients. Participants were evaluated by 2 separate reviewers for completion of key actions and for global performance. The scores were highest for the hemodilution scenario, whereas the air entrainment scenario had the lowest scores. Psychometric analysis demonstrated that ECMO specialists with more than 1 year of experience outperformed the specialists with less than 1 year of experience. Participants endorsed these sessions as important and representative of events that might be encountered in practice.The scenarios could serve as a component of an ECMO education curriculum and be used to assess clinical specialists' readiness to manage ECMO emergencies.

PURPOSE OF REVIEW This article reviews the development of simulation-based training strategies to educate sedation providers. RECENT FINDINGS Medical simulation has been utilized to train and evaluate providers in numerous domains related to sedation. Sedation providers come to the patient with a wide range of clinical training and experience and simulation can serve as a platform for achieving a baseline skill level and for periodic retraining. Although widely accepted by participants in simulation training, data demonstrating simulation's efficacy in improving sedation-related clinical outcomes are lacking. SUMMARY Simulation provides an opportunity for sedation providers to develop deliberative practice, to consider rare or challenging clinical conditions, and to benefit from directed feedback, in a manner that does not put patients in harm's way.

OBJECTIVE: The goal of this study was to develop an inventory of simulated scenarios that mimic pediatric crises and determine if the resident scores could be used to establish the reliability and validity of a multiple-scenario assessment. The long-term objective is to provide pediatric residents with experiences in the recognition, diagnosis, and management of a range of simulated acute conditions. METHODS: Twenty scenarios were constructed. Each resident participated in 10 scenarios that were scored by 2 independent raters using an action-item checklist and a global score. Debriefing occurred after each scenario. Several analyses were performed to investigate the psychometric adequacy of the scores. RESULTS: Twenty-nine residents participated. The residents' scores in both sets of 10 scenarios were reliable when using either the checklist or global scoring method (>0.79). Generalizability analyses indicated that the major source of variance in scores was attributable to the scenario and scenario-resident interaction. The variance attributable to the rater was low, yielding high interrater reliability values. The more-experienced residents who participated in the study outperformed the less-experienced interns. CONCLUSIONS: An inventory of critical events was designed to assess pediatric residents' diagnostic and management skills. A reliable measure of ability could be obtained, provided the residents managed multiple scenarios. The residents outscored the interns, providing evidence to support the construct validity of the scores. Additional validity evidence is needed, including studies to determine if this type of training improves physicians' management of real-life critical events.

Simulation has advanced from the days of Resusci-Annie and basic cardiopulmonary resuscitation training. High-fidelity, computer-controlled mannequins allow early learners and advanced clinicians to explore various domains of sedation practice and prepare for unusual or life-threatening events. This modality has the advantage of permitting deliberative practice toward mastery without putting patients at risk. With increasing demands for patient safety and provider accountability, simulation is likely to play an increasing role in provider training.

Objective: The objective of this study was to determine whether the potent bronchoconstrictor endothelin-1 was coupled to the activation of the inositol phosphate andlor inhibition of the cyclic adenine monophosphate second messenger pathways in porcine airway smooth muscle. Design: Prospective, controlled, in vitro, nonblinded study. Setting: University biochemical and molecular biological research laboratory. Subjects: Pigs of both genders. Interventions: Airway smooth muscle was dissected from the trachea of pigs exsanguinated under anesthesia. Airway smooth muscle from six animals preloaded with 3 H-myoinositol was exposed to endothelin-1, carbachol (positive control) or vehicle for 30 mins. Some tissues were pretreated with antagonists selective for the ET A (BQ-485) and ET B (BQ-788) endothelin receptor subtypes. Newly synthesized 3 H-inositol phosphates were recovered by column chromatography. Airway smooth muscle from an additional 7 pigs was homogenized and incubated in the presence of 32 P-α-adenosine triphosphate, guanosine triphosphate (GTP) and either carbachol or endothelin to measure the inhibitory influence of carbachol (positive control) or endothelin on GTP-stimulated adenylyl cyclase activity. Newly synthesized 32 P-cyclic adenosine monophosphate was isolated by sequential column chromatography over Dowex and alumina. Measurements and Main Results: Total inositol phosphates increased in porcine airway smooth muscle in response to either carbachol or endothelin. The endothelin receptor antagonist BQ-485 (ET A selective) but not BQ-788 (ET B selective) dose-dependently inhibited endothelin-1 induced inositol phosphate accumulation. In adenylyl cyclase assays, carbachol (positive control), but not endothlein-1, significantly inhibited GTP-stimulated adenylyl cyclase activity. Conclusion: Endothelin-1 couples to the activation of the inositol phosphate pathway via the ET A receptor subtype but does not couple to inhibition of the adenylyl cyclase pathway in porcine airway smooth muscle. The potent bronchoconstrictive effects of endothelin likely involve the acute activation of the inositol phosphate pathway in airway smooth muscle.

Simulation-based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer-based simulations to mannequins. Computer-controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in-situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task-training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.

Background Assessment of pediatric anesthesia trainees is complicated by the random nature of adverse patient events and the vagaries of clinical exposure. However, assessment is critical to improve patient safety. In previous studies, a multiple scenario assessment provided reliable and valid measures of the abilities of anesthesia residents. The purpose of this study was to develop a set of relevant simulated pediatric perioperative scenarios and to determine their effectiveness in the assessment of anesthesia residents and pediatric anesthesia fellows. Methods Ten simulation scenarios were designed to reflect situations encountered in perioperative pediatric anesthesia care. Anesthesiology residents and fellows consented to participate and were debriefed after each scenario. Two pediatric anesthesiologists scored each scenario by key action checklist. The psychometric properties (reliability, validity) of the scores were studied. Results Thirty-five anesthesiology residents and pediatric anesthesia fellows participated. The participants with greater experience administering pediatric anesthetics generally outperformed those with less experience. Score variance attributable to raters was low, yielding a high interrater reliability. Conclusions A multiple-scenario, simulation-based assessment of pediatric perioperative care was designed and administered to residents and fellows. The scores obtained from the assessment indicated the content was relevant and that raters could reliably score the scenarios. Participants with more training achieved higher scores, but there was a wide range of ability among subjects. This method has the potential to contribute to pediatric anesthesia performance assessment, but additional measures of validity including correlations with more direct measures of clinical performance are needed to establish the utility of this approach.