CHaD Pain Free Sedation Service
Goals and Objectives
PL-1 pediatric residents rotating through CHaD Pain Free
General Issues
1. The resident should understand the anesthesiologist's role as part of a team of
pediatric surgeons, pediatricians, pediatric subspecialists, nurse practitioners and
nursing staff dedicated to providing optimal medical and anesthesia care to
neonates, infants, and children.
2. The resident should become familiar with ASA guidelines concerning
perioperative care and sedation of neonates, infants and children:
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Requirements for preoperative physical evaluation
Pediatric Airway Evaluation
NPO status requirements for different ages
Impact of coexisting disease on anesthesia management (i.e. asthma)
Perioperative Fluid management
Neonatal, Infant, and Child Physiology
1. The resident should understand the unique physiology of neonates, infants and
children:
 Cardiac physiology of newborns and infants
 Respiratory physiology of newborns and infants
 Liver and renal function in newborns
 Hematological considerations of the newborn
 Fluid and electrolyte management of newborns and infants
2. The resident should appreciate the anesthetic implications for neonates and infants
 Changes in Minimal Alveolar Concentration (MAC)
 Volume of distribution of anesthetic agents
 Maximal doses of local anesthetics
3. The resident should understand approaches to neonatal resuscitation and pediatric
advanced life support with special attention to implications for the management of
pediatric sedation.
Management of Pediatric Sedation and Anesthesia
1. Preoperative Evaluation and Preparation for Sedation – the resident should be
familiar with:
 Psychological aspects of hospitalization and attendant procedures
 Preoperative medical evaluation, with emphasis on identifying factors that
increase the risk of sedation/anesthesia in pediatric patients
 Indications for preoperative laboratory testing
 Preoperative fasting guidelines
 Indications for preoperative sedation medication and different classes of
medications:
o Anticholinergic Drugs
o Sedatives, in particular the benzodiazepines
o Opiates
o Ketamine
2. Anesthesia Equipment for Pediatrics- the resident should be familiar with:
 The anesthesia machine – safety features
 Masks used for positive pressure ventilation, and be able to chose an
appropriately sized mask
 Anesthesia breathing circuits, and be able to assemble a standard anesthesia
circuit
 Suction apparatus
 Resistance of anesthesia airway equipment
 Ventilatory requirements and work of breathing for patients of different ages
 Endotracheal tubes, and be able to chose an appropriately sized ETT
 Laryngeal mask airways (LMAs), and be able to chose an appropriately sized
LMA
3. Induction of Anesthesia- the resident should be familiar with:
 The many modes of anesthesia induction:
o Inhalational
o Intravenous
o Intramuscular
o Rectal
 Perform successful inhalation induction of anesthesia with anesthesia staff
assistance
 Display an ability to bag-mask ventilate a variety of pediatric patients
 Successfully secure peripheral IV access
4. Monitoring During Anesthesia- the resident should be familiar with:
 Cardiovascular monitoring
o Monitoring by auscultation
o ECG monitoring
o Blood pressure monitoring
 Respiratory monitoring
o End-tidal gas monitoring
o Airway pressure monitoring
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Temperature monitoring
5. Maintenance of Anesthesia–the resident should understand the indication for
different medication and their use in anesthesia for children
 Inhaled Anesthetic Agents
o Nitrous Oxide
o Sevoflurane and Halothane characteristics
 Intravenous agents
o Propofol
o Thiopental
o Ketamine
o Etomidate
o Opiates – fentanyl, morphine, demerol, remifentanil
 Muscle relaxants
o Succinylcholine
o Rocuronium
o Vecuronium
o Atracurium
 Temperature support methods
 Fluid requirements
6. Emergence from anesthesia- the resident should be familiar with:
 Emergence delirium characteristics
 Management of extrathoracic obstruction
 Management of bronchospasm
 Management of postoperative nausea and vomiting
 Pain management in the post anesthesia care unit
Recommended Reading:
1. Cote CJ, Wilson S and the Work Group on Sedation. Guidelines for monitoring
and management of pediatric patients during and after sedation for diagnostic and
therapeutic procedures: an update. Pediatrics. 118(6):2587-2602, 2006.
2. American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring
and management of pediatric patients during and after sedation for diagnostic and
therapeutic procedures: addendum. Pediatrics. 110(4):836-8, 2002.
3. American Academy of Pediatrics Committee on Drugs. Guidelines for monitoring
and management of pediatric patients during and after sedation for diagnostic and
therapeutic procedures. Pediatrics. 89(6):1110-5, 1992.
4. Krauss, Baruch and Robert M. Brustowicz, eds. Pediatric Procedural Sedation and
Analgesia. Lippincott, Williams & Wilkins, 1999.
5. Stoelting, Robert K. and Ronald D. Miller, eds. Basics of Anesthesia, Third
Edition. Churchill Livingstone, 1994. (A precise and readable textbook of
anesthesiology- Chapters 2,3,4,5,6,7, and 26)
6. Morgan, G. Edward and Maged S. Mikhail. Clinical Anesthesiology, Fourth
Edition. Appleton & Lange, 2005. (A Lange Medical Book used by many of our
residents- Chapters 2, 3, 4, 5, 6, 7, 8, 9, 44)