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Pediatric anesthesiology fellowship education has necessarily evolved since Accreditation Council for Graduate Medical Education (ACGME) accreditation in 1997. Advancements in perioperative and surgical practices, emerging roles in leadership, increasing mandates by accreditation and certification bodies, and progression toward competency-based education-among other things-have created pressure to enrich the current pediatric anesthesiology training system. The Society for Pediatric Anesthesia (SPA) formed a Task Force for Pediatric Anesthesiology Graduate Medical Education that included key leaders and subject matter experts from the society. A key element of the Task Force's charge was to identify curricular and evaluative enhancements for the fellowship program of the future.The Task Force executed a nationally representative, stakeholder-based Delphi process centered around a fundamental theme: "What makes a pediatric anesthesiologist?" to build consensus among a demographically varied and broad group of anesthesiologists within the pediatric anesthesiology community. A total of 37 demographically and geographically varied pediatric anesthesiologists participated in iterative rounds of open- and close-ended survey work between August 2020 and July 2021 to build consensus on the current state, known deficiencies, anticipated needs, and strategies for enhancing national educational offerings and program requirements.Participation was robust, and consensus was almost completely achieved by round 2. This work generated a compelling Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis that suggests more strengths and opportunities in the current Pediatric Anesthesiology Graduate Medical Education program than weaknesses or threats. Stakeholders agreed that while fellows matriculate with some clinical knowledge and procedural gaps, a few clinical gaps exist upon graduation. Stakeholders agreed on 8 nonclinical domains and specific fundamental and foundational knowledge or skills that should be taught to all pediatric anesthesiology fellows regardless of career plans. These domains include (1) patient safety, (2) quality improvement, (3) communication skills, (4) supervision skills, (5) leadership, (6) medical education, (7) research basics, and (8) practice management. They also agreed that a new case log system should be created to better reflect modern pediatric anesthesia practice. Stakeholders further identified the need for the development of standardized and validated formative and summative assessment tools as part of a competency-based system. Finally, stakeholders noted that significant departmental, institutional, and national organizational support will be necessary to implement the specific recommendations.A Delphi process achieved robust consensus in assessing current training and recommending future directions for pediatric anesthesiology graduate medical education.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

Introduction Educators require validated tools to assess learner competency in simulation-based mastery learning. We previously created a simulation to incorporate crisis resource management skills after a needs assessment of our pediatric residency program. We present the development of and content evidence for validity of a task list with time-to-task initiation designed to aid in rapid cycle deliberate practice (RCDP) debriefing and assessment of pediatrics resident learners. Methods Five board-certified pediatricians developed the initial task list with 30 tasks. We used the Delphi technique to seek content evidence for validity of the initial task list using 17 board-certified pediatricians at 7 institutions across the United States. After finalizing the task list, we video recorded 3 pediatric experts performing the tasks in a simulation. We then used the Delphi technique to establish and to attain agreement on time-to-task initiation. We calculated Cronbach α coefficient to measure internal consistency of the expert responses. After finalizing the task list, we divided it into 3 stages with 5 separate cycles per stage to direct the educator in performance of RCDP debriefing. Results The group reached 80% agreement after 2 Delphi rounds with a Cronbach α coefficient of 0.95. The resultant list included 25 tasks. The group subsequently achieved 80% agreement on the time-to-task initiation in 2 Delphi rounds. Conclusions We present content evidence for validity of a task list with associated time-to-task initiation for a simulation scenario that incorporates crisis resource management skills and is designed to aid educators in RCDP debriefing. This task list may decrease intereducator inconsistencies in delivery of RCDP for a common pediatric resuscitation scenario.

Introduction Teamwork failures are a major source of preventable error in medicine. Acquisition of skills early in training seems beneficial for impacting system-level change. Simulation-based curricula provide a psychologically safe and formative environment to learn and practice team skills. This project aims to assess teamwork and communication skill acquisition in preclerkship medical students during a longitudinal simulation-based curriculum. Methods This is a prospective, observational study of medical students participating in a high-technology simulation curriculum on team principles. Students, in groups of 5 to 7, participated in 6 mannequin-based simulation sessions over 10 months coordinated with an organ system-based preclerkship course. Each scenario was executed by a simulation technologist and guided by a simulation educator who functioned as a bedside nurse and led a postsimulation debrief. Likert-based, self- and global assessments completed by students and facilitators, respectively, were used to evaluate the teams. Descriptive statistics and Mann-Whitney U test were used to analyze data using a P value of less than 0.05 for statistical significance and a null hypothesis stating that there would be no change in behavior. The primary outcome measure was improvement in the teamwork and communication domains of both assessments. Results Students (N = 231) were divided into the same 32 groups during every session. At the end of every session, each student completed a self-assessment and each educator completed the team's global assessment for teamwork. Median scores for teamwork and communication domains increased between the first and sixth sessions on both assessments. Mann-Whitney U analysis of self-assessment scores showed Z values between -5.30 and -8.83 and P values of less than 0.00001. Mann-Whitney U analysis of global assessment scores showed Z values ranging from -3.43 to -5.24 and P values between 0.0031 and less than 0.00001. Conclusions There was meaningful improvement in scores in the domains of teamwork and communication over the 10-month, simulation-based curriculum designed to teach and hone teamwork skills.

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.

BACKGROUND Transitions of care are a patient-safety priority. Constructs such as SBAR (situation, background, assessment, recommendation) and I-PASS (illness severity, patient summary, action list, situation awareness, synthesis by receiver) have been used to teach the benefit of structured handovers and have demonstrated an impact in simulated and clinical environments. Despite this, there is still a lack of literature describing handover training for medical students that allows early and sustained knowledge and skill acquisition. METHODS We designed a curriculum to teach handovers to medical students that spanned 28 months of a 4-year medical education curriculum at a large medical school. The curriculum included two separate workshops that book-ended medical student core clerkships. The curriculum was evaluated via knowledge-based surveys and open-ended feedback from students. RESULTS Two-hundred and forty students participated in the first 'Transition to clerkship' (T2C) workshop. There was improvement in the mean scores on a knowledge-based survey after the workshop (p < 0.001). The overall improvement in performance remained significant 1 year later (p

BACKGROUND Simulation-based education is a mainstay in education of pediatric anesthesiology trainees. Despite the known benefits, there is variability in its use and availability among various pediatric anesthesiology fellowship programs. AIM The primary aim was to understand the current state of simulation-based education among pediatric anesthesiology fellowship programs and define barriers that impede the development of an effective simulation program. METHODS This survey-based, observational study of simulation activities within United States-based pediatric anesthesiology fellowship programs was approved by the Institutional Review Boards (IRB) of the authors' institutions. A 35-question survey was developed in an iterative manner by simulation educators (AA, WW, DY) and a statistician familiar with survey-based research (AN) using research electronic data capture (REDCap) for tool development and data collation. Descriptive and thematic analyses were performed on the quantitative and qualitative responses in the survey, respectively, and were stratified with small, medium, and large fellowship programs. RESULTS Forty-five of 60 (75%) fellowship programs responded to the survey. The presence of a dedicated simulation program director and number of simulation instructors was positively associated with the size of program and years in operation. Dedicated simulation support was variable across programs and was usually present within the larger programs. A positive association also existed for educational activities among all programs mostly based on size of program and years in operation. Protected time was the most commonly cited barrier to having a comprehensive and sustainable simulation program. There was general agreement for establishing a standardized and shared curriculum among fellowship programs. Approximately 70% of simulation programs had no formal simulation instructor training requirement. CONCLUSIONS Simulation-based curricula are broadly offered by many fellowship programs. Improved collaboration locally, regionally, and nationally may improve educational opportunities for fellowship programs, particularly the small ones. These efforts may begin with the development of a standardized curriculum and formal instructor training programs.

Summary The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

Background Resident education in pediatric anesthesiology is challenging. Traditional curricula for anesthesiology residency programs have included a combination of didactic lectures and mentored clinical service, which can be variable. Limited pediatric medical knowledge, technical inexperience, and heightened resident anxiety further challenge patient care. We developed a pediatric anesthesia simulation-based curriculum to address crises related to hypoxemia and dysrhythmia management in the operating room as an adjunct to traditional didactic and clinical experiences. Aims The primary objective of this trial was to evaluate the impact of a simulation curriculum designed for anesthesiology residents on their performance during the management of crises in the pediatric operating room. A secondary objective was to compare the retention of learned knowledge by assessment at the eight-week time point during the rotation. Methods In this prospective, observational trial 30 residents were randomized to receive simulation-based education on four perioperative crises (Laryngospasm, Bronchospasm, Supraventricular Tachycardia (SVT), and Bradycardia) during the first week (Group A) or fifth week (Group B) of an eight-week rotation. Assessment sessions that included two scenarios (Laryngospasm, SVT) were performed in the first week, fifth week, and the eighth week of their rotation for all residents. The residents were assessed in real time and by video review using a 7-point checklist generated by a modified Delphi technique of senior pediatric anesthesiology faculty. Results Residents in Group A showed improvement between the first week and fifth week assessment as well as between first week and eighth week assessments without decrement between the fifth week and eighth week assessments for both the laryngospasm and SVT scenarios. Residents in Group B showed improvement between the first week and eighth week assessments for both scenarios and between the fifth week and eighth week assessment for the SVT scenario. Conclusion This adjunctive simulation-based curriculum enhanced the learner's management of laryngospasm and SVT management and is a reasonable addition to didactic and clinical curricula for anesthesiology residents.

The American Society of Anesthesiologists (ASA) difficult airway algorithm and the Vortex approach are difficult airway aids. Our objective was to demonstrate that a simpler cognitive model would facilitate improved decision-making during a process such as difficult airway management. We hypothesized the simpler Vortex approach would be associated with less anxiety and task load.Medical students were randomized to the ASA algorithm (n = 33) or Vortex approach (n = 34). All learned basic airway techniques on day 1 of their rotation. Next, they watched a video of their respective aid then managed a simulated airway crisis. We assessed decision-making using a seven-point airway management score and a completeness score. Completeness was at least one attempt at each of four techniques (mask ventilation, supraglottic airway, intubation, and cricothyrotomy). Two validated tools, the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index, were used to assess anxiety and task load.Students in the Vortex group had higher airway management scores [4.0 (interquartile range = 4.0 to 5.0) vs. 4.0 (3.0 to 4.0), P = 0.0003] and completeness (94.1% vs. 63.6%, P = 0.003). In the ASA group, the means (SD) of National Aeronautics and Space Administration Task Load Index scores of 55 or higher were observed in mental [61.4 (14.4)], temporal [62.3 (22.9)], and effort [57.1 (15.6)] domains. In the Vortex group, only the temporal load domain was 55 or higher [mean (SD) = 57.8 (25.4)]. There was no difference in anxiety.Medical students perform better in a simulated airway crisis after training in the simpler Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load.

Neonatal airways present unique management challenges that can be compounded by limitations of an underresourced facility. While little clinical data exist on the safety and efficacy of stylet use, they are commonly utilized to facilitate endotracheal intubation in neonates and anticipated difficult airways. As pediatric airway equipment is often understocked in hospitals, innovative thinking can provide creative solutions to these shortages. We present the use of a 16-gauge intravenous catheter as an intubating stylet for a 2.0-millimeter endotracheal tube in the management of a difficult airway in the neonatal intensive care unit.

Paediatric obesity is a worldwide epidemic with estimations of the prevalence of overweight and obese as high as 23.8% and 22.6% in paediatric and adolescent males and females, respectively. In the United States, significant increases in the prevalence of obesity in children were noted in the 1980s and 1990s but have since levelled off in 2010 at 16.9% overall. Moreover, about 12% of infants 6–23 months of age in the United States are considered overweight. The World Health Organization and the United States Centers for Disease Control have slightly different definitions of paediatric obesity based on body mass index, which leads to somewhat varied estimations of prevalence. Despite this, recent trends suggest the number of overweight and obese children presenting for elective and emergent procedures is increasing. A serious public health concern, paediatric obesity can accompany congenital or genetic comorbidities or be the cause of accelerated comorbidities such as cardiovascular disease, diabetes, and cancers that are typically associated with adult morbidity and mortality. This chapter describes the comorbidities that are typically associated with paediatric obesity as they become relevant in the perioperative period, summarizes surgical procedures in which paediatric obesity is common, and discusses peri-anaesthetic implications of the obese child or adolescent.

Background Modern medical education requires frequent competency assessment. The Accreditation Council for Graduate Medical Education (ACGME) provides a descriptive framework of competencies and milestones but does not provide standardized instruments to assess and track trainee competency over time. Entrustable professional activities (EPAs) represent a workplace-based method to assess the achievement of competency milestones at the point-of-care that can be applied to anesthesiology training in the United States. Methods Experts in education and competency assessment were recruited to participate in a 6-step process using a modified Delphi method with iterative rounds to reach consensus on an entrustment scale, a list of EPAs and procedural skills, detailed definitions for each EPA, a mapping of the EPAs to the ACGME milestones, and a target level of entrustment for graduating US anesthesiology residents for each EPA and procedural skill. The defined EPAs and procedural skills were implemented using a website and mobile app. The assessment system was piloted at 7 anesthesiology residency programs. After 2 months, faculty were surveyed on their attitudes on usability and utility of the assessment system. The number of evaluations submitted per month was collected for 1 year. Results Participants in EPA development included 18 education experts from 11 different programs. The Delphi rounds produced a final list of 20 EPAs, each differentiated as simple or complex, a defined entrustment scale, mapping of the EPAs to milestones, and graduation entrustment targets. A list of 159 procedural skills was similarly developed. Results of the faculty survey demonstrated favorable ratings on all questions regarding app usability as well as the utility of the app and EPA assessments. Over the 2-month pilot period, 1636 EPA and 1427 procedure assessments were submitted. All programs continued to use the app for the remainder of the academic year resulting in 12,641 submitted assessments. Conclusions A list of 20 anesthesiology EPAs and 159 procedural skills assessments were developed using a rigorous methodology to reach consensus among education experts. The assessments were pilot tested at 7 US anesthesiology residency programs demonstrating the feasibility of implementation using a mobile app and the ability to collect assessment data. Adoption at the pilot sites was variable; however, the use of the system was not mandatory for faculty or trainees at any site.

This chapter provides an overview of key healthcare simulation concepts with particular attention to the various spectrum, modalities and key terms used. The key principles and uses of healthcare simulation within the domains of education, research and systems improvement are outlined.

Background Trauma is the leading cause of morbidity and mortality in the pediatric population. However, during the societal disruptions secondary to the coronavirus (COVID-19) stay-at-home regulations, there have been reported changes to the pattern and severity of pediatric trauma. We review our two-institution experience. Methods Pediatric trauma emergency department (ED) encounters from the National Trauma Registry for a large, tertiary, metropolitan level 1 pediatric trauma center and pediatric burn admission at the regional burn center were extracted for children under 19 years from March 15th thru May 15th during the years 2015-2020. The primary outcome was the difference in encounters during the COVID-19 (2020) epoch versus the pre-COVID-19 epoch (2015-2019). Results There were 392 pediatric trauma encounters during the COVID-19 epoch as compared to 451, 475, 520, 460, 432 (mean 467.6) during the pre-COVID-19 epoch. Overall trauma admissions and ED trauma encounters were significantly lower (P

BACKGROUND: Managing pediatric crises necessitates the acquisition of unique skills and confidence in its execution. Our aim was to develop and assess a curriculum based on the constructivist learning environment to enhance learning, orientation, and preparation of graduating pediatric anesthesiology fellows. METHODS: Fifty pediatric anesthesiology fellows from 9 academic institutions in the United States were recruited for an advanced boot camp over a 2-year period. Training stations were developed using high-fidelity simulation, standardized patients, self-reflection modules, and facilitated discussions. The curriculum was evaluated using an anonymous survey that assessed knowledge, self-confidence, appropriateness of case-scenario complexity, and usefulness for transitioning into an independent practitioner on a Likert scale (1 = strongly disagree to 5 = strongly agree). Data points were expressed as the median and interquartile range (IQR). RESULTS: Ninety-eight percent of the fellows completed a survey. Fellow perceptions of the advanced boot camp was positive. The median scores (IQR) for knowledge, self-confidence, appropriateness of case complexity, and usefulness for transition in 2017 were 5 (3,5), 4.5 (3,5), 5 (3,5), and 5 (3,5), respectively, and 5 (3,5), 4.5 (3,5), 5 (4,5), and 5 (3,5), respectively, in 2018. The IQR in the assessment for an appropriate level of complexity for their level of training, narrowed in 2018 (4,5), when compared with 2017 (3,5). CONCLUSIONS: Fellow responses support the idea that the advanced boot camp provided tools and strategies for their transition. A narrowed IQR regarding the appropriate level of complexity of scenarios in 2018, when compared with 2017, might suggest an improvement in the curriculum.

Purpose of review The purpose of this article is to summarize literature in pediatric burn resuscitation and management that is relevant to the pediatric anesthesiologist. The scope of the literature is expanding as long-term survival in even the most critically ill, burn-injured children has increased. Recent findings Longstanding variations in the care of burn-injured children exist despite decades of experience in burn care management. There seems to be a discomfort outside major burn centers in the triage, evaluation, and assessment of burned children. This is evidenced by the prevalence of 'unnecessary intubations', continued overestimation of total body surface area injured, and subsequent fluid administration disproportionate to injury leading to over-resuscitation. Techniques, such as virtual reality and regional anesthesia are increasingly available and serve adjuncts to pharmacologic therapies for anxiolysis and analgesia. Such techniques reduce opioid utilization while maintaining patient comfort and satisfaction particularly during wound dressing changes. Questions about transfusion threshold and ratio of blood products remain topics of ongoing research. Summary Literature review continues to reveal underpowered or retrospective analyses of these very important questions. Public health burden caused by burns warrants rigorous, prospective studies to take the best care of these patients and portend the best long-term outcomes. Collaboration amongst pediatric anesthesiologists who care for these children is necessary to develop and execute powered studies to answer important questions.

BACKGROUND: Academic anesthesiologists have numerous demands on their time, and this can erode teaching quality. Reducing barriers to teaching may ameliorate this. The primary aim of this study is to evaluate the learning environment and identify barriers to clinical teaching using a multicenter survey approach. METHODS: Anesthesiologists at four academic centers were surveyed to understand barriers to clinical teaching. Demographic data and time spent teaching were collected. Faculty attitudes regarding teaching, resident physician perceptions of their teaching, supportiveness of departmental and operating room leadership, whether they enjoyed teaching, and the perceived quality of their own teaching (“self-efficacy”) were assessed using Likert scales. Principal component analysis was performed to identify themes in these data. Pearson correlation, t test, and linear regression analyses were used to evaluate interactions between themes. RESULTS: The response rate was 40.6% (230/566). Responding faculty expressed a high level of engagement with the teaching role. Clinical production pressure was a common theme. Faculty who spent more time teaching reported greater enjoyment of teaching, feeling better about their teaching, and were better prepared to teach. Enjoyment of teaching was not independently associated with more time spent teaching. Regression analysis revealed that perceptions of environmental factors (including production pressure) had no independent effect on time spent teaching or on self-efficacy in teaching quality. Faculty self-efficacy was positively related to enjoyment of teaching as well as making teaching a higher priority. CONCLUSIONS: Improving perceptions of the learning environment might be best achieved by mitigating production pressure and improving faculty self-efficacy in their teaching.

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33–3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined.

Dandy-Walker syndrome is a rare congenital brain malformation that requires unique anesthetic considerations. We present a rare case of an 18-month-old boy with Dandy-Walker syndrome presenting with 17% total body surface area burns undergoing multiple general anesthetics for both operative and bedside procedures. Numerous lessons were learned during multiple anesthetics, which influenced and guided our subsequent anesthetic management. The preoperative assessment, risk for respiratory apnea, opioid management, risk for laryngospasm, and postoperative care of patients with Dandy-Walker syndrome were all lessons learned.

Opioids are the mainstay therapy in burned adults. Little data in the pediatric burn population exists that elucidates opioid prescribing practices. The primary purpose of this report is to quantify opioid and non-opioid analgesic use in pediatric burn patients admitted to a tertiary referral burn center. A retrospective audit of hospital charts and discharge records for patients18 years old from March 2016 to March 2017 was performed. Opioid amounts were converted to either oral morphine miligram equivalents (MME) or oral MME per day and subsequently adjusted for age in kilograms (kg). Of the 226 patients, 223 (98.7%) were administered an opioid during admission. The median total opioid amount administered during admission was 0.4 (IQR: 0.3-0.6) mg oral MME per kilogram per day. Anecdotally, doses above 1 mg/kg/day are considered high risk for opioid tolerance. The median total opioid amount prescribed upon discharge was high at 3.9 (IQR: 2.3, 5.6) mg of oral MME per kilogram. Hydrocodone (96.0%) was the most common opioid administered, followed by morphine (88.1%). The most commonly prescribed discharge opioid was hydrocodone (95.4%). Non-opoioid analgesia during admission was used in 112 patients (49.6%). This study provides novel insight into the opioid practices at a tertiary burn center for pediatric patients, with our analysis showcasing high usage of opioids during admission and discharge for burn analgesia. It emphasizes the need to expand beyond opioids for burn analgesia and the importance of promoting non-opioid, multimodal analgesia in the pediatric burn population.

SummaryBackground Pediatric anesthesiologists must manage crises in neonates and children with timely responses and limited margin for error. Teaching the range of relevant skills during a 12-month fellowship is challenging. An experiential simulation-based curriculum can augment acquisition of knowledge and skills. Objectives To develop a simulation-based boot camp (BC) for novice pediatric anesthesiology fellows and assess learner perceptions of BC activities. We hypothesize that BC is feasible, not too basic, and well received by fellows. Methods Skills stations, team-based in situ simulations, and group discussions of complex cases were designed. Stations were evaluated by anonymous survey; fellows rated usefulness in improving knowledge, self-confidence, technical skill, and clinical performance using a Likert scale (1 strongly disagree to 5 strongly agree). They were also asked if stations were too basic or too short. Median and interquartile range (IQR) data were calculated and noted as median (IQR). Results Fellows reported the difficult airway station and simulated scenarios improved knowledge, self-confidence, technical skill, and clinical performance. They disagreed that stations were too basic or too short with exception of the difficult airway session, which was too short [4 (4-3)]. Fellows believed the central line station improved knowledge [4 (4-3)], technical skills [4 (4-4)], self-confidence [4 (4-3)], and clinical performance [4 (4-3)]; scores trended toward neutral likely because the station was perceived as too basic [3.5 (4-3)]. An interactive session on epinephrine and intraosseous lines was valued. Complicated case discussion was of educational value [4 (5-4)], the varied opinions of faculty were helpful [4 (5-4)], and the session was neither too basic [2 (2-2)] nor too short [2 (2-2)]. Conclusion A simulation-based BC for pediatric anesthesiology fellows was feasible, perceived to improve confidence, knowledge, technical skills, and clinical performance, and was not too basic.

Neurophysiologic monitors in the form of transcranial electric motor evoked potentials (tceMEPs) and somatosensory evoked potentials (SSEPs) have become widely used modalities to monitor spinal cord function during major orthopedic spine procedures. In combination with invasive and non-invasive clinical monitoring and an anesthesia information management system (AIMS), we promptly recognized an acute change in hemodynamic and neurophysiologic parameters, managed intraoperative spinal cord contusion, and successfully minimized iatrogenic injury to the spinal cord during corrective spine surgery.

The value of family-centered care in general and subspecialty pediatrics has been well documented in the literature. Translation of these principles into perioperative medicine has its logistical challenges; however, there are theoretical benefits. Specifically, pediatric patients with psychiatric diagnoses or special needs related to autism benefit from the incorporation of service animals into their daily routines. We describe the presence of one such service dog, at the request of our patient, during induction of general anesthesia. Consideration of the service dog as part of our family-centered care model improved the quality of care we provided this anxious teenager and her mother.