Pediatric Anesthesia

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Welcome to the UCSF Pediatric Anesthesia Department Homepage         

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Our division provides outstanding clinical care during over 7000 anesthetics for infants and children annually. In addition to working in the main operating rooms in the UCSF Moffitt-Long Medical Center, we anesthetize children in the UCSF ambulatory surgery center and in non-operating room (NORA) locations, such as radiology and radiation oncology. On this website, we present information about our pediatric anesthesia faculty, surgeons, nurses, and other staff, the resident rotation, and the ACGME-accredited pediatric fellowship. We include an approach to common surgeries, as well as information for families.

For the Residents

 

Welcome to the Pediatric Anesthesia Rotation. Our division is committed to your education in pediatric anesthesia during your entire residency, but especially during this one-month rotation. We aim to dramatically expand your skills and experience in the care of infants and children. In addition to the core rotation, consider extending your expertise in the perioperative care of pediatric patients by doing a selective with us during your CA-3 year.

To enhance your learning during this rotation, we have scheduled didactic sessions each Monday and Thursday at 6:30am in OR 22. We also schedule an additional didactic session on Tuesday afternoons. The schedule of speakers and topics for both teaching forums will be emailed to you prior to the start of your rotation.

We aim to diversify your experience on the rotation as much as possible by ensuring that you provide care to neonates, infants, and children during a wide variety of procedures, including general, urologic, otolaryngologic, orthopedic, and plastic surgery. Additionally, you may have the opportunity to provide anesthesia in out of operating room locations, such as MRI and interventional radiology. The ACGME requires that you care for 100 patients <12 years, 20 patients <3 years, and 5 patients <3 months during your residency training. Because you will also rotate at Children's Hospital in Oakland, you should aim to complete 50% of these numbers during the UCSF rotation. If you seem to be deficient in any area, please alert us. We find, however, that most residents exceed these numbers easily.

During your rotation, you will not take weekday call in the main operating rooms. However, our days can be long, our schedule is often changing, and we have frequent add-on cases. Please be flexible. We adhere to the ACGME work-hour guidelines strictly and you should expect to be relieved in the evenings to meet these limits.

Your performance on the pediatric anesthesia rotation will be evaluated by your attendings, as well as nurses and a surgeon. This is known as a multisource (360) evaluation.

We look forward to working with you!

Below you will find important resident links:

Resident Rotation Schedule
Mission Bay E1 Residents
Goals & Objectives
Pedi Reference Card
 

For Families

We understand that having a child undergo a medical procedure or surgery is a very stressful situation. Below you will find answers to frequently asked questions regarding the anesthesia for your child's procedure.

What is general anesthesia?
General anesthesia is a state of unconsciousness caused artificially by medications. Patients under a general anesthetic are very deeply asleep and do not feel pain.

What are the risks of anesthesia?
Generally speaking, anesthesia is quite safe. An anesthesia provider will be with you child at all times during the surgery to make sure that his/her heart is beating well, that his/her blood pressure is good, and that he/she is breathing properly. Although complications from anesthesia are quite rare, they can occur. Common side effects include nausea and/or vomiting, a sore throat, or skin irritation. Less common complications, such as serious allergies, broken/chipped teeth, pneumonia, or death can occur, but are very rare. 

Can my child eat before surgery?
No. Having a food or liquid in the stomach can be very dangerous to a person who is undergoing anesthesia. When anesthesia starts, it is possible for this food or liquid in the stomach to go into the lungs and cause pneumonia. Our current rules are that children are to stop eating by midnight the night before the surgery. They can drink clear liquids (water, apple juice, Gatorade) up to 2 hours before arriving at the hospital. Failure to follow these rules will result in your child's surgery getting delayed or cancelled. Special considerations are made for infants less than 6 months of age. 

Will I be able to be with my child when he/she falls asleep?
Maybe. This depends on the type of surgery, as well as your child's age and other medical problems. If you are unable to be with your child when he/she goes to sleep, we may be able to give him a medication in the preoperative area to make him/her quite sleepy and less anxious. In general, children less than one year of age do not require premedication or a parent present for the beginning of anesthesia, as they have not yet developed stranger anxiety. 

Will I be there when my child wakes up?
Because all children respond to anesthesia differently, predicting exactly when a child will wake up is impossible. We make every effort to have parents in the recovery room before their child is completely awake. 

What will my child be like when he/she wakes up from anesthesia?
Children react to and recover from anesthesia differently. Not uncommonly, children can be cranky, and sometimes quite disoriented or confused after anesthesia. Also following surgery, you child may be in pain. Under guidance of the anesthesiologists, recovery room nurses will help manage your child's pain before you leave the recovery room. 

What is a caudal anesthetic?
A caudal anesthetic is a type of epidural anesthesia (see below) that involves putting local anesthesia (numbing medicine) and/or morphine into the space outside the spine in the area of the child's sacrum ("tailbone") to help eliminate pain after your child's surgery. This anesthetic technique is especially useful in urologic and certain general surgeries. A caudal involves a single shot after your child is asleep. If a caudal is appropriate for your child, your anesthesiologist will talk to you more about this option on the day of surgery. 

What is an epidural anesthetic?
An epidural anesthetic is most commonly considered to reduce pain after large, painful surgeries. The procedure involves finding the epidural space with a small needle, and placing a catheter into the epidural space. The needle is removed, but the catheter is left in place to deliver local anesthetic (and possibly other pain medications) during and after the surgery. Pain specialists supervise care of all patients with epidurals post-operatively, to adjust the medications. If your child is a candidate for an epidural, your anesthesiologist will talk with you more about this option on the day of surgery. 

What is a nerve block?
A nerve block is frequently used for orthopedic procedures and involves placing local anesthesia (numbing medicine) on nerves to reduce pain after a surgery. If your child is a candidate for a nerve block, your anesthesiologist will talk with you more about this option on the day of surgery.

Fellowship

Pediatric Fellowship Program

The UCSF Pediatric Anesthesia Fellowship is a 12 month, ACGME-accredited program offering an outstanding clinical fellowship experience. Our boutique program currently accepts two fellows per year. Because of the small program size, fellows are able to tailor their year to maximize learning. Qualified and interested fellows can extend their training to include an additional advanced year fellowship in research or pediatric cardiac anesthesia.

Clinical Rotations
Each fellow will do 13 4-week rotations. Fellows will have clinical exposure at both the UCSF Benioff Children’s Hospital-San Francisco and the UCSF Benioff Children’s Hospital-Oakland. Rotations include:

  • Pediatric Cardiac Anesthesia (2 Blocks)
  • Integrated Pain and Palliative Care (1 Block)
  • ICU--Neonatal, pediatric or pediatric cardiac (1 Block)
  • General Operating Rooms (split between San Francisco and Oakland Campuses)

Each fellow is allocated 20 days of vacation and 5 days of meeting time during their fellowship year.

Didactics
Fellows have the opportunity to participate in a fellow lecture series, weekly case conferences, journal clubs, mock-oral boards, and QI meetings. Additionally, fellows are given the opportunity to lead resident didactic sessions to create their own educational portfolio during the year.

Scholarly Project
All fellows are given non-clinical time to participate in a scholarly project during their fellowship year. Past projects have included case reports, book chapters, retrospective studies, and basic science investigations. 

Application Process
Appointed fellows must have completed an ACGME-accredited anesthesiology residency (or equivalent) and possess a full and unrestricted license to practice medicine in the State of California (an absolute requirement).

Our fellowship program participates in the ERAS application and the NRMP fellowship match.

Completed applications are reviewed in the order that they are received. The fellowship application deadline is June 1.

Fellowship Application
Register online with the Electronic Residency Application Service (ERAS).

Additional documentation necessary to support your application is found here:
https://www.aamc.org/download/471894/data/pediatricanesthesiologyextendedquestions.pdf

Details regarding current match deadlines can be found at:
http://www.nrmp.org/fellowships/anesthesiology-match/

For information on obtaining a California medical license please contact:
California Medical Board -1430 Howe Avenue Sacramento, CA 95825 (916) 263-2499
http://www.mbc.ca.gov/

For further inquiries, please contact:
Fellowship Coordinator
513 Parnassus Avenue, S455E
San Francisco, CA 94143
(415) 476-9734
Marie.Hollero@ucsf.edu

 

Techniques

Below you will find a list of some of the surgeries that you will encounter during your rotation. The anesthetic techniques for several of the commonly encountered surgeries are included but serve only as a reference rather than the "correct" approach. That is, anesthetic plans are individually tailored to the patient, and in addition, details for monitoring, specific drugs, etc, may vary among the attending anesthesiologists. Medicine is an ever-changing science. Please consult other reference materials to confirm dosing and the latest data about appropriate techniques. Of note, in some cases, the FDA may not have yet approved the specific techniques/drug dosing suggested here.

Cleft lip

Cleft palate

Congenital Diaphragmatic Hernia

Craniosynostosis

Lung Isolation in Infants Children

Fetal Surgery Cases

Fetal Surgery-Myelomeningocele Repair

Fetal Surgery-Twin-Twin Transfusion Syndrome

Posterior Spinal Fusion

Pyeloplasty

Pyloric Stenosis

Neuraxial Anesthesia in Infants and Children

Tonsillectomy and/or Adenoidectomy

Tracheoesophageal Fistula

Vertebral Body Stapling

Articles

Airway
Perioperative Cardiac Arrest/CPR in Children
Ex-premature Infant
Foreign Bodies
Pain and Regional
Sedation
Tonsillectomy/OSAS
URI/Laryngospasm
Neurotoxicity
Miscellaneous

Airway

The future of the cuffed endotracheal tube 
Should cuffed endotracheal tubes be used routinely in children?
Anesthesia and the child with asthma
Perioperative implications of common respiratory problems
Effect of Increasing Depth of Propofol Anesthesia on Upper Airway Configuration in Children
Airway Management
The impact of head position on the cuff and tube tip position of preformed oral tracheal tubes in young children 
Maintenance of upper airway patency

Perioperative Cardiac Arrest/CPR in Children

Anesthesia-related Cardiac Arrest in Children (2000) 
Anesthesia-related Cardiac Arrest in Children (Cote editorial)
Did Anesthetics Trigger Cardiac Arrests in Patients with Occult Myopathies? 
Anesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest Registry (2007) 
Anesthesia-Related Cardiac Arrest In Children: An Update 
Pediatric Perioperative Cardiac Arrest: In Search of a Definition 
When Assessing What We Know We Don’t Know Is Not Enough: Another Perspective on Pediatric Outcomes 
The Frequency of Anesthesia-Related Cardiac Arrests in Patients with Congenital Heart Disease Undergoing Cardiac Surgery
Intraoperative reported adverse events in children
Cardiopulmonary resuscitation in children 
Pediatric Cardiopulmonary Resuscitation: Advances in Science, Techniques, and Outcomes 
Background and Epidemiology of Pediatric Cardiac Arrest
Increased Risk of General Anesthesia for High-Risk Patients Undergoing Magnetic Resonance Imaging
Risk Factors for Adverse Events During Cardiovascular Magnetic Resonance in Congenital Heart Disease 

Ex-premature Infant

Postoperative Apnea in Former Preterm Infants after Inguinal Herniorrhaphy: A Combined Analysis
When Is the Ex-Premature Infant No Longer at Risk for Apnea?
Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy (Review
Spinal anesthesia in 62 premature, former-premature or young infants–technical aspects and pitfalls
Newborn Emergencies: The First 30 Days of Life 

Foreign Bodies

How we do it: management of tracheobronchial foreign bodies in children 
Anesthesia for removal of inhaled foreign bodies in children
Pediatric fiberoptic bronchoscopy: Clinical experience with 2,836 bronchoscopies

Pain and Regional

Postoperative Pain Management in Children 
Practical Pediatric Regional Anesthesia
Some current controversies in paediatric regional anaesthesia 
Regional Anesthesia in Children 
Ultrasonographic guidance in pediatric regional anesthesia
Applications of ultrasound in paediatric anaesthesia

Sedation

Conscious sedation: Time for this oxymoron to go away!
Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors 
Pediatric sedation 
Conscious Sedation of Children With Propofol Is Anything but Conscious
Adverse Sedation Events in Pediatrics: Analysis of Medications Used for Sedation
Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room
Round and round we go: sedation – what is it, who does it, and have we made things safer for children?
Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update
Sedation with ketamine and low-dose midazolam for short-term procedures requiring pharyngeal manipulation in young children 
Investigating the pharmacodynamics of ketamine in children 
Ketamine for procedural sedation and analgesia in pediatric emergency medicine: a UK perspective
Effect of propofol on emergence behavior in children after sevoflurane general anesthesia
Training and credentialing in procedural sedation and analgesia in children: lessons from the United States model 
Induction of anesthesia in a combative child; management and issues 

Tonsillectomy/OSAS

Chronic upper airway obstruction and cardiac dysfunction: anatomy, pathophysiology and anesthetic implications 
Obstructive Sleep Apnea Syndrome Clinical Practice Guideline: Diagnosis and Management of Childhood 
Clinical Assessment of Pediatric Obstructive Sleep Apnea 
Children with severe OSAS who have adenotonsillectomy in the morning are less likely to have postoperative desaturation than those operated in the afternoon 
Complications of adenotonsillectomy in children with OSAS younger than 2 years of age 
Can Assessment for Obstructive Sleep Apnea Help Predict Postadenotonsillectomy Respiratory Complications? 
Identification and evaluation of obstructive sleep apnea prior to adenotonsillectomy in children: is there a problem?
A retrospective study of tonsillectomy in the under 2-year-old child: indications, perioperative management, and complications 
Obstructive sleep apnea syndrome due to adenotonsillar hypertrophy in infants
Tonsillectomy
Obstructive sleep apnea and tonsillectomy: do we have a new indication for extended postoperative observation?
Opiate Usage in Children with Obstructive Sleep Apnea Syndrome
Recurrent Hypoxemia in Children Is Associated with Increased Analgesic Sensitivity to Opiates
Recurrent Hypoxia in Rats during Development Increases Subsequent Respiratory Sensitivity to Fentanyl 
Unraveling the Mysteries of Sleep-disordered Breathing in Children
Planning Adenotonsillectomy in Children With Obstructive Sleep Apnea: The Role of Overnight Oximetry 
Urgent Adenotonsillectomy: An Analysis of Risk Factors Associated with Postoperative Respiratory Morbidity 
Sleep and Breathing on the First Night After Adenotonsillectomy for Obstructive Sleep Apnea 
Perioperative Management of Children with Obstructive Sleep Apnea 
Outcome of adenotonsillectomy for obstructive sleep apnea in children under 3 years outcome.
Sleep-Disordered Breathing and Neurobehavioral Outcomes In Search of Clear Markers for Children at Risk

URI/Laryngospasm

Use of the Laryngeal Mask Airway in Children with Upper Respiratory Tract Infections: A Comparison with Endotracheal Intubation
Do Children Who Experience Laryngospasm Have an Increased Risk of Upper Respiratory Tract Infection? 
Clinical predictors of anaesthetic complications in children with respiratory tract infections
Risk Factors for Perioperative Adverse Respiratory Events in Children with Upper Respiratory Tract Infections 
Risk Factors for Adverse Postoperative Outcomes in Children Presenting for Cardiac Surgery with Upper Respiratory Tract Infections
Anesthesia for the Child with an Upper Respiratory Tract Infection: Still a Dilemma?
The Upper Respiratory Tract Infection (URI) Dilemma: Fear of a Complication or Litigation?
The pediatric patient and upper respiratory infections
Pediatric laryngospasm: prevention and treatment
Laryngeal Mask Airway Is Associated with an Increased Incidence of Adverse Respiratory Events in Children with Recent Upper Respiratory Tract Infections
Laryngeal Mask Airway and Children’s Risk of Perioperative Respiratory Complications: Randomized Controlled Studies Are Required to Discriminate Cause and Effect
Risk assessment for respiratory complications in pediatric anesthesia: a prospective cohort study

Neurotoxicity

Use of Anesthetic Agents in Neonates and Young Children 
CON: The Toxic Effects of Anesthetics in the Developing Brain: The Clinical Perspective 
PRO: Anesthesia-Induced Developmental Neuroapoptosis: Status of the Evidence 
An Assessment of the Effects of General Anesthetics on Developing Brain Structure and Neurocognitive Function 
General anesthetics and the developing brain 
Pediatric pharmacology in the first year of life

Miscellaneous

Mediastinal mass syndrome
Anesthesia and Analgesia During and After Surgery in Neonates
Intravascular iodinated contrast media and the anaesthetist