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PEDIATRIC ANESTHESIA ROTATION

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					Pediatric Anesthesia Rotation                                University of Calgary Anesthesia Training Program


         OBJECTIVES OF TRAINING AND SPECIALTY TRAINING REQUIREMENTS IN
                                   ANESTHESIA

                                              Revised May 2008




PEDIATRIC ANESTHESIA ROTATION
The pediatric anesthesia experience at the Alberta Children’s Hospital includes a mixture of general and
tertiary care cases. All surgical subspecialties are represented except Open hearts and Liver transplants,
which are based in Edmonton.

The resident on the pediatrics rotation will be assigned to either an operating room or clinic by the resident
coordinator. Along with the pediatric anesthetic fellow, the resident has the first priority for any emergency
neonatal/pediatric cases. It is recognized that further pediatric experience may be gained throughout the
general rotations at other hospitals.

The pediatrics resident will be involved with anesthetics in remote locations (dental, MRI, CT, radiotherapy).
Acute and chronic pain are also included in the rotation, the resident will spend at least 2 weeks attached to
the acute pain team during a 3 month block.

Allocation will be individualized to the resident but in general:
         The resident will concentrate on basic pediatric anesthetic skills in the first month at ACH before
moving on to more complex and challenging cases.
         The aim is that by the end of 3 months the resident is capable of providing anesthesia for ASA 1 and
2 patients for simple surgery with minimal direct supervision. The resident will able to plan and discuss the
management of neonates and more complex cases, and provide anesthesia with appropriate supervision.

MEDICAL EXPERT


ANATOMY AND PHYSIOLOGY:


The resident will understand the anatomic and physiologic characteristics of the newborn and older child
particularly as they differ from the adult:

    a)    respiratory maturation
    b)    cardiovascular maturation
    c)    thermoregulation
    d)    neuromuscular function
    e)    renal function and acid base regulation
    f)    response to surgical stress


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Pediatric Anesthesia Rotation                                 University of Calgary Anesthesia Training Program




PHARMACOLOGY:


The resident will know how the pediatric patient's pharmacodynamic and pharmacokinetic response may
differ from the adult's:
     a) inhaled anesthetics
     b) induction agents
     c) sedatives
     d) opiates
     e) muscle relaxants
     f) local anesthetics


PREOPERATIVE EVALUATION AND PREPARATION:


The resident will understand:

    a) psychologic considerations and developmental stages in children
    b) preoperative assessment including:
       i) common concurrent illnesses such as infectious diseases
       ii) rational fasting guidelines
    c) premedication choices and their advantages/disadvantages
    d) outpatient considerations

FLUID MANAGEMENT:


The resident will understand the appropriate pediatric fluid management for maintenance requirements as
well as how to correctly replace deficits. The resident will also understand the rational use of blood products
in the pediatric patient and how their use can be minimized.

SPECIAL EQUIPMENT:


The resident will become familiar with specific equipment needs in the anesthetic care of children:

    a)   anesthetic circuits and ventilators
    b)   airway equipment
    c)   monitors
    d)   thermal control devices
    e)   vascular access and intravenous equipment




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Pediatric Anesthesia Rotation                               University of Calgary Anesthesia Training Program


MANAGEMENT OF ANESTHESIA:


The resident will understand:

    a) anesthetic options including induction techniques for pediatric patients including their advantages
       and disadvantages
    b) principles of airway management including use of the laryngeal mask airway and fiberoptic
       intubation.
    c) rational use of regional anesthesia in children including spinals, epidurals, caudals and peripheral
       nerve blocks for intraoperative and postoperative use
    d) maintenance of general anesthesia
    e) use of muscle relaxants

The resident will describe and/or demonstrate understanding of the following pediatric concerns:
   a) the full stomach
   b) awake intubation
   c) rapid sequence induction
   d) the pre-term infant
   e) the open eye
   f) the compromised airway
   g) non cardiac surgery in cardiac patients

POSTOPERATIVE CARE:


The resident will understand:
   a) general principles
   b) management of pain
   c) management of postintubation croup
   d) transportation of the critically ill child




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Pediatric Anesthesia Rotation                                University of Calgary Anesthesia Training Program


SPECIFIC PEDIATRIC PROBLEMS:


During the pediatric rotation as well as the general rotations the resident will be exposed to and understand
considerations for the following pediatric problems:

    a) difficult airway problems
       • foreign body aspiration
       • Congential syndromes associated with a difficult airway

    b) common syndromes/conditions
       • trisomy 21
       • cerebral palsy
       • diabetes
       • epilepsy
       • asthma
       • GERD

    c) full stomach / RSI approaches

    d) neonatal emergencies
       • tracheo-esophageal fistula
       • diaphragmatic hernia
       • gastroschisis/omphalocele
       • necrotizing enterocolltis/bowel obstruction

    e) infant procedures
       • pyloromyotomy
       • cleft lip and palate repair
       • hernia repair
       • craniosynostosis
       • intussusception

    f) other procedures/problems
       • tonsillectomy including hemorrhage
       • corrective spinal surgery.
       • common malignancies
       • hydrocephalus/VP shunt
       • dental procedures
       • cardiac surgery
       • noncardiac surgery for the cardiac patient




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Pediatric Anesthesia Rotation                                 University of Calgary Anesthesia Training Program


Specific Pediatric Procedural skills:

    a)   PIV placement
    b)   Airway management including bag mask ventilation. LMA use and intubation
    c)   Principles and execution of deep vs awake intubation.
    d)   Use of fiberoptic laryngoscope
    e)   caudal epidural
    f)   lumbar epidural
    g)   spinal anesthetic
    h)   arterial cannulation
    i)   central venous cannulation
    j)   Use of ultrasound for vascular access and regional block


Specific neonatal learning objectives:

1. The resident will know the transitional physiology of major organ systems for fetal to extra uterine life.

2. The resident will know the anatomical and physiological differences associated with:
   a) the premature
   b) the newborn
   c) the neonate

3. The resident will know the pharmacokinetic and pharmacodynamic changes presented by the neonate.

4. The resident will know the management concerns for common neonatal congenital surgical problems
   including:
   a) diaphragmatic hernia
   b) TE fistulae
   c) Meningo myelocele
   d) Omphalocoele/gastroschisis
   e) Hernia repair
   f) PDA repair

5. The resident will be able to describe the anesthetic management principles for palliative surgery (closed
   heart) for congenital heart disease.




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Pediatric Anesthesia Rotation                                University of Calgary Anesthesia Training Program


COMMUNICATOR:

The resident will:

     •    be able to use a variety of approaches in dealing with children of all ages in their preparation for
          anesthesia and surgery.
     •    recognize the psychological impact of hospitalization, anesthesia, and surgery on both the patients
          and their families.
     •    provide accurate, appropriate information in a timely fashion to the family.
     •    ensure that informed consent is obtained prior to undertaking invasive procedures.
     •    effectively communicate with all members of the treatment team using effective verbal and written
          communication.
     •    ensure that written communication, including charting of the perioperative events, will consist of
          concise and clear documentation.

COLLABORATOR:

The resident will:

    •    demonstrate the capacity to consult effectively with the other anesthesia staff, neo and
         perinatologists, pediatricians, intensivists and surgeons to assure optimal management of patients.
    •    work effectively as an integral member of the perioperative team. This will include the ability to
         resolve conflicts, provide feedback and assume a leadership role where appropriate.

MANAGER:

General Aims:
   • Utilize resources effectively to balance patient care, learning needs, and outside activities
   • Allocate finite health care resources wisely
   • Work effectively and efficiently in a health care organization
   • Utilize information technology to optimize patient care, life-long learning and other activities

Specific Aims:
   • utilize resources effectively to provide anesthesia services to the pediatric patient
   • By the end of the rotation manage an operating list of simple cases in a safe, effective and time
        efficient manner.
   • Practice according to regional, national standards and provincial guidelines for the management of
        pediatric patients.

HEALTH ADVOCATE:

The resident will:

General aims:
   • Identify the important determinants of health affecting patients



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Pediatric Anesthesia Rotation                                University of Calgary Anesthesia Training Program


    •      Contribute effectively to improved health of patients and communities
    •      Recognize and respond to those issues where advocacy is appropriate

Specific

     •     demonstrate increasing expertise and leadership in maintaining and improving the standards of
           pediatric anesthesia practice and patient care.

SCHOLAR:
The resident should:
General:
   • Develop, implement and monitor a personal continuing education strategy
   • Critically appraise sources of medical information
   • Facilitate learning of patients, house staff/students and other health care professionals
   • Contribute to development of new knowledge

Specific:
   • Identify personal knowledge deficits, and create a plan of action to fill the resident’s need
   • Perform a literature search, critically appraise the literature, and use principles of evidence based
        medicine in the practice of anesthesia and ICU
   • have the ability to critically review the literature and understand and evaluate new information and
        research.
   • contribute to the learning of others.
   • contribute to the development of new knowledge when possible.
   • contribute to teaching and educational activities of the department in a professional and informed
         manner

PROFESSIONAL:

The resident should:
General:
   • Deliver highest quality care with integrity, honesty and compassion
   • Exhibit appropriate personal and interpersonal professional behaviors
   • Practice medicine ethically consistent with obligations of a physician

Specific:
   • Demonstrate a continuous assessment of one’s ability and competence in the practice of
        anesthesiology and critical care medicine
   • Develop personal techniques to balance personal and professional obligations and boundaries
   • Demonstrate an increasing sense of responsibility and “case ownership”.
    • Deliver the highest quality of care with integrity, honesty and compassion.
    • Demonstrate appropriate respect of the opinion of patients and team members in the provision of
         quality pediatric care.




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