Pediatric Anesthesiology Fellow
Goals and Objectives
ICU
PGY-5
The objective of education and training in pediatric anesthesiology fellowship are to develop
consultant-level knowledge in all areas of the subspecialty and to develop the knowledge and
skill, mainly coming from hands-on clinical experience, to provide pediatric anesthesia care in
situations likely to be encountered in future pediatric anesthesia practice.
Patient Care
Pre-operative Evaluation and Care:
The fellow will:
1. Establish rapport with the child and parents/family/caregivers.
2. Obtain a current and past medical history, with specific emphasis on the current medical
condition(s) for which the child is presenting for surgery. Important preoperative
information should include:
a. Allergies
b. NPO status
c. Current medications
d. Past surgeries
e. Past anesthesia and possible problems/complications for the patient or family
f. Appropriate laboratory data
g. Co-morbidities including appropriate information from other specialties
(cardiology, neurology, genetics…)
h. Developmental assessment
i. Postoperative age related apnea risk assessment
3. Perform a focused physical examination
a. Weight
b. Assessment of physical distress
c. Respiratory distress, cardiovascular stability, level of hydration, level of
consciousness/alertness, need for medical intervention to improve patient stability
preoperatively
d. Airway assessment- size of chin, dysmorphic features
e. Cardiovascular assessment, with particular attention to:
i. Precordial exam – rate, presence of murmurs
ii. Peripheral perfusion- capillary refill, temperature of extremities
f. Developmental assessment, anxiety assessment
g. Assessment of intravenous access level of difficulty
h. Assessment of other relevant physical findings-(major abnormalities)
1
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
4. Integrate the history, physical examination and ancillary studies and information, and
develop an anesthetic plan including:
a. Appropriate preoperative fasting orders
b. Plan for minimizing preoperative/induction anxiety
c. Induction of anesthesia
d. Maintenance of anesthesia
e. Pain management intra- and postoperatively
f. Fluid management appropriate to patient weight and procedure
g. Emergence
h. Postoperative placement (PACU, ICU)
5. Discuss the anesthetic plan with attending anesthesiologist in a cohesive manner and
review plan as needed together.
6. Anticipate potential problems and prepare contingency plans.
Intraoperative Care
The fellow will:
1. prepare the OR appropriately including:
a. Machine and equipment check
b. Monitors
i. EKG, size appropriate BP cuffs, O2 saturation proves
ii. Invasive monitoring if appropriate
c. Airway management equipment
i. Age/size appropriate masks, oral airways, endotracheal tubes, LMA’s,
laryngoscope blades
d. Intravenous equipment
i. Iv bag and tubing assembled
ii. Variety of iv catheter sizes
e. Medications
i. Resuscitation medications prepared
ii. Appropriate induction, maintenance, muscle relaxant, and pain
management medications
f. Temperature maintenance measures
i. Warm OR
ii. Appropriate active warming measures (forced air warmers, heat lamps,
fluid warmers)
2. Actively participate in the preoperative management of the patient which includes:
a. Establishing rapport with the patient/family/caregivers.
b. Administering appropriate premedication in a safe and effective manner
3. Actively participate in the induction of anesthesia by demonstrating skill, facility and
safety in:
a. Airway management
b. Use of monitoring equipment
c. Selecting and administering induction agents/medication
d. Establishing intravenous access
2
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
4. Actively participate in the evaluation and treatment of both acute and chronic pain
management (thereby actively participating in regional pain management techniques)
5. Actively participate in establishing invasive monitors if appropriate, including arterial
cannulation and central venous access, adhering to guidelines regarding techniques to
minimize contamination/infection of lines
6. Actively participate in putting children on bypass and weaning them from bypass
7. Actively participate in the care of pediatric patients undergoing cardiac and intrathoracic
procedures not involving cardiopulmonary bypass.
8. Actively participate in transesophageal echocardiogram insertion and reading in infants
and children
9. Remain engaged and maintain vigilance throughout the maintenance of the anesthetic
a. Keep current of the operative repair
b. Communicate effectively wit the surgical and nursing team
c. Manage fluids appropriately for patient weight and intraoperative fluid losses
d. Manage anesthetic, relaxant, and pain medications appropriately
10. Actively participate in the smooth termination of the anesthetic
a. Terminate the anesthetic agents in a timely manner
b. Reverse muscle relaxants
c. Plan for and smoothly return the patient’s airway to the patient’s control
i. extubation
ii. removal of LMA
iii. removal of oral airway
iv. continuous assessment and monitoring of patient ventilation
v. plan for and manage airway difficulties upon emergence
11. Actively participate in the safe transition of the patient to the postoperative care unit
a. Monitor the patient until it is safe to transfer the patient to the postoperative care
unity
b. Communicate effectively with the postoperative care team all of the relevant
information for a safe transfer of care
c. Write appropriate PACU orders for pain, fluid management, PONV, and other
specific orders as needed.
Postoperative Care
The fellow will:
1. Visit the patient within 24 hours post operatively
2. Elicit information on issues relevant to the patient’s anesthetic course
3. Write a postoperative note in the patient record
4. Differentiate between patients requiring treatment in and ICU and other care settings
5. Identify ICU patients who are ready for ward transfer and the factors important to
facilitate safe patient care transfer
6. Describe the diagnostic criteria and Demonstrate proficiency in the initiation of treatment
plans for patients with impending organ failure. (respiratory, cardiac, neurological,
hepatic, renal & gastrointestinal)
7. Identify and initiate timely treatment for the following conditions
3
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
a. Cardiac Insufficiency – arrest
b. Respiratory Insufficiency – arrest
c. Acute Lung Injury (ALI)
d. Acute Respiratory Distress Syndrome (ARDS)
e. Shock, all types
f. Sepsis
g. Electrolyte and acid-base disturbances
h. Overdose
i. Increased inter-cranial pressure/Stroke/Closed Head Injury (CHI)
j. Spinal cord injury
k. Pneumo-, hemato-, and hydrothorax
l. Pulmonary Emboli
m. Cardiac Tamponade
n. Acute Myocardial Infarction/Ischemia
o. Intra Abdominal/Pelvic catastrophe
p. Multi Organ System Failure
q. Acute/Chronic Liver Failure
r. Acute/Chronic Renal Failure
s. Endocrine emergencies
t. Hematological emergencies
u. Compartment Syndrome
v. Rhabdomyolysis
8. Use data from appropriate invasive and non-invasive monitoring devices to diagnose,
treat & titrate patient therapy
9. Explain the indication, contraindications, complications and pitfalls of emergency airway
management and ventilator management. Please discuss the following techniques:
a. Open airways on non-intubated patients
b. Ventilation by bag-mask systems
c. Tracheal intubations
d. Fiber optic intubations
e. Bronchoscope use
f. Contemporary modes of ventilation
g. Management of complications
10. Explain the indications, contraindications, & complications of the following ICU
associated procedures
a. Arterial puncture and cannulation
b. Insertion of central venous catheters
c. Pulmonary artery catheters
d. Dynamic/static electrocardiogram interpretation
e. Cardioversion
f. Pericardiocentesis
g. Thoracentesis
h. Needle and tube thoracostomy
i. Pacemaker management: transcutaneous and epicardial
j. Intra-aortic balloon pump
4
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
k. ECHO usage
Medical Knowledge
The fellow will:
1. Think critically
2. Demonstrate an investigatory approach to and analysis of clinical situations
3. Model/foster lifelong learning
4. Attends and participates in lectures, case conferences, journal club meetings, and other
scheduled academic activities
5. Understanding fasting guidelines
6. Understand comparative anatomy and physiology for neonates, infants, children and
adults
a. airway
b. chest wall and lung mechanics
c. respiratory anatomy and physiology
d. cardiac anatomy and physiology
e. renal physiology
7. Understand age related dosing and pharmacokinetics and dynamics of:
a. inhalation anesthetics
b. opioids and benzodiazepines
c. muscle relaxants
d. local anesthetics
e. resuscitation drugs
8. Understand fluid and electrolyte management for children of all ages
9. Understand thermoregulation
10. Understand physiology of neonatal transition
11. Some understanding of normal child physical development
12. Some understanding of normal child social development
13. Understand pediatric equipment (airway equipment, anesthesia circuits, ventilators,
monitors)
14. Understand pediatric history and physical examination skills
15. Understand neonatal resuscitation
16. Understand perioperative issues involving the premature and term neonate
a. apnea-perioperative and monitoring
b. neonatal emergencies- (diaphragmatic hernia, necrotizing enterocolitis,
gastroschesis/omphalocele, tracheo-esophageal fistula, meningomyelocele)
c. common neonatal procedures- (inguinal hernia repair)
d. regional anesthesia
17. Understand perioperative concerns and management of common pediatric procedures
a. OHNS
b. General pediatric surgery
c. Orthopedic surgery
5
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
d. Neurosurgery
e. Plastic surgery
f. Urology
g. ophthalmology
18. Acquire some knowledge of the preoperative concerns and management of less common
pediatric procedures including
a. thoracic surgery
b. craniofacial surgery
c. burns
d. mediastinal mass
e. spinal fusion
19. Understand special problems in pediatric anesthesia
a. the child with a URTI
b. the child with a difficult airway
c. obstructive sleep apnea
d. sickle cell anemia
e. malignant hyperthermia
f. latex allergy
20. Some understanding of congenital heart diseases in the child presenting for non-cardiac
surgery
21. Acquire understanding of congenital heart disease in infants and children
22. Understand anesthetic requirements for infants and children with CHD
23. Understand issues regarding cardiopulmonary bypass; putting infants on and weaning
them off bypass; including managing their anesthetic post-bypass
24. Understand the issues for pediatric anesthesia in off-site locations
25. Develop some understanding and /or experience with pediatric regional anesthesia,
including caudals, epidurals, peripheral and regional blocks
26. Describe the patho-physiology of common disease processes that might lead to ICU
admission and the effects on the Cardiovascular, Pulmonary, Hematological,
Neurological, Endocrine as well as Renal and Gastrointestinal systems
27. Discuss the immediate management of the post-operative, thoracic, standard surgical
patients
28. Compare and contrast the Trauma patient from other surgical and medical patients. Be
prepared to discuss the pre-op. inter-op and post-op management concerns
29. Discuss the common medical problems and concerns associated with the surgical patient;
neuron-cognitive, cardiovascular, pulmonary, endocrine, & renal
30. Discuss the immediate and delayed concerns of the post-surgical
31. Explain the goals of sedation and analgesia in the ICU. Discuss the various options
available to facilitate sedation and analgesia, including sedation scales and various types
of sedation medications
32. Compare and contrast contemporary modes of ventilation and weaning strategies
33. Explain the goal of basic nutrition support. Discuss the initial nutrition assessment of a
ICU patient. Identify risk factors associated with poor nutritional health and prepare a
nutritional plan, to include formula selection and caloric needs for ICU patients
6
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
34. Discuss basic infection control goal and the techniques used to help in the prevention of
ventilator associated pneumonia (VAP), urinary tract infections (UTI), central venous
line (CVL) and post operative wound infections
35. Discuss the basic patient care protocols and techniques used to help in the prevention of
ventilator associated pneumonia (VAP), deep venous thrombosis (DVT), peptic ulcer
disease (PUD), central venous line (CVL) and post operative wound infections
36. Describe treatment strategies for VAP, UTI, CVL, DVT, PUD, soft tissues and intraabdominal infections
37. Compare and contrast the most commonly used antibiotics in the ICU. Medications to
include Penicillins, Cepthalosporins, Carbopenums, Aminoglycosides, Floroquinalones,
Antifungals and new generation medications such as Daptomicin and Linazolid
38. Present and organized approach to clinical problem solving including a differential
diagnosis, well as systematic approach to the use of diagnostic testing and consultant
activities
39. Describe and display a systematic approach to the use of diagnostic testing and consultant
activities in the ICU
Scholarship
The fellow will:
1. Attend Thursday morning Anesthesiology department didactic lectures from 8:00 A.M. to
9:00 A.M.
2. Attend Grand Rounds every Friday morning from 8:00 to 9:00 A.M.
Teaching
The fellow will:
1. Prepare and execute didactic lectures to medical students, residents and attending
anesthesia staff
2. Be able to supervise resident and medical student activities and learning within
preoperative, intraoperative and postoperative recovery room settings
Research
The fellow will:
1. Complete a research project approved by the pediatric fellowship director prior to
graduation from the pediatric fellowship program.
Practice-based learning and improvement
The fellow will:
1. Seek and use feedback (physician, patient, ppers0 and their own insight to focus on areas
in their performance that need improvement
2. Read in-depth about issues pertaining to their patient’s anesthesia care. The resident
should be able to critically evaluate the literature and try to make patient care decisions
based on scientific evidence
7
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
3. Know his/her own limits and to practice within them while striving to safely expand these
limits
4. Pursue excellence
5. Recognize existing and describe additional patient safety monitoring and error reduction
strategies that could be employed in the ICU
6. Recognize and describe the process of assessing patient and family satisfaction and its
importance in ICU care
7. Recognize and describe basic methods for searching, reviewing and evaluating the
medical and scientific literature
8. Support ongoing basic and clinical science protocols in the ICU by participating in
candidate identification or in proposing future projects
9. Contribute to and support process improvements in the ICU. Meet with the nursing or
physician staff to assess current practice and make suggestions
Interpersonal and communication skills
The fellow will:
1. Listen well and articulate thoughts effectively
2. Understand the emotional and psychological impact of a child’s illness upon the child
and the family, and to use this knowledge to guide his/her interaction with the child and
family
3. Communicate openly, effectively and respectfully with the surgeon, nurses and other
members of the operating room team.
4. Inspire confidence and trust with patients, families and coworkers
5. Be a role model and mentor for residents within the anesthesia program
6. Demonstrate effective communication with physicians, nurses, consultants and all other
members of the healthcare team on rounds and in daily interactions as observed by
attending staff or reported to staff
7. Communicates clearly, correctly, and concisely in a written report, stressing the
important issues and an articulate plan
8. Communicates clearly, correctly, and concisely in a verbal report, stressing the important
issues and an articulate plan
9. Describe safe order writing and the concept of closed loop communication as it relates to
verbal orders
10. Demonstrates good use of consultants when appropriate in managing complex ICU
problems. Seek consultations when appropriate with other specialty physicians in
managing complex ICU problems
11. Displays and can discuss the skills and importance in maintaining a good relationship
with other healthcare providers
8
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program
Professionalism
The fellow will:
1. Be on time, be prepared, and fulfill responsibilities to patients and other members of the
patient care team
2. Be honest, open and available to the patient and the patient’s parents/family
3. Interact with all parents, patients, patient care team members, consultants and medical
students in a professional and respectful manner
4. Be a team player
5. Resolve conflicts in a constructive manner
6. Be honest, accountable, and responsible
7. Respectful and recognize and use the particular skill sets of other ICU practitioners, such
as ICU nurses, RT, PT, OT, dieticians, pharmacists
8. Considers ethical issues and patient wishes in treatment decisions
Systems-based practice
The fellow will:
1. Understand, access, and utilize the resources, providers and systems necessary to provide
optimal care for children and their families
2. Use all available sources of patient information available to construct an appropriate
anesthetic plan
3. Constructively participate in efforts to improve our system of delivery of care
4. Apply evidence-based, cost-conscious strategies regarding patient perioperative care
5. Be familiar with the necessary components of a comprehensive pediatric surgical unit.
6. Support initiatives to improve care of critically ill patients
7. Discuss the issues of patient safety including the medical systems that put patients at risk,
medication, operations, transfusions & nursing ratios
8. Describe the proper procedure to correctly identify a patient to minimize patient errors
9. Recognize and describe basic compensation methodologies for critical care services
10. Recognize, describe and ensure compliance with institutional and unit policies and
procedures as well as regulatory policies from accreditation agencies, regulators, and
prayers
Assessment and Evaluation
1. Weekly evaluations by faculty during rounds, presentations, conference participation,
procedures performed, patient, family & staff interactions
2. Monthly evaluations by Program Director based on the six core competencies
9
Goals & Objectives
ICU
Pediatric Anesthesiology Fellowship Program