Part of your anesthesiology training is devoted to the care of pediatric patients. Some of you will go on to either complete a fellowship in pediatric anesthesiology or decide to work full time in pediatric anesthesia. Or you may decide to complete your training and take care of pediatric patients on a part time basis.
But, I know that not everyone wants to take this path. You might plan on never taking care of another pediatric patient in career when you are done with your training.
Even if you have no desire to go into pedi anesthesia, your pediatric anesthesia rotations will still be able to teach you five important lessons. This lessons will improve your skills, regardless of your desire to practice pediatric anesthesia in the future.
5 Things to Learn on Your Pediatric Anesthesia Rotation
1. Learn Your Drug Dosages Better
Let me guess what you used on your last adult anesthesia induction:
- 2mg of Versed
- 150mcg of Fentanyl
- 200mg of Propofol
- 50mg Rocuronium … then you put in the endotracheal tube.
Unfortunately, when you work exclusively with adults, you can start getting into the habit of “shooting from the hip” when it comes to drug dosages. At some point in your training, you had the drug doses memorized. Once you progressed far enough in your training, you just started to “eyeball” the amount you need to give.
When you do you pediatric anesthesia rotation, you will have to be constantly calculating dosages. In one day you may care for a 2kg patient, then a 20kg patient, then a 70kg patient, then back to a 10kg patient … all in the same room. You will get to know the dosages of medications, because of the large variability in your patients.
Learning the dosages of drugs will help you on your boards and also when you are out practicing. This is helpful for you to move from a technician to a practitioner.
2. Learn Airway Finesse
Anesthetists are well known for our airway skills. We tend to be the “go to” professionals for airway management, because we manage airways on a daily basis. We also become airway experts by managing different sizes and shapes of patients.
As I said in my book Anesthesia Made Easy, I like to think of airway management with the US Navy SEAL phrase of “Slow is smooth, smooth is fast.” SEALs describe this with weapons training and you can use this with your airway management skills. When you get the mechanics down, you will get faster. Trying to go fast or use bruit force to visualize the airway is a rookie mistake.
Your pediatric anesthesia rotation can help you work on your airway technique, because you have to. You have to learn how to use technique and not brute force to manage smaller airways in the pediatric population. When you can mask, place LMAs, and intubate the pediatric airways with various sizes, you will become better at airway management. It will expand your skill set even to help with adult sized airways.
3. Learn how to Anticipate Problems, Not React to Them.
Part of your training in anesthesiology is to learn how to anticipate problems before they happen. With pediatric patients, you have to get really good at anticipating issues and fixing them, before bad stuff happens. Pediatric patients do not have the physiologic reserves that adult patients have. When you start to have a problem you need to move quickly to remove the issue.
Bag masking pediatric patients is a great example: If you are not getting good ventilation, or you are not getting good gas exchange, you need to fix the issue quickly before the problem escalates. With low oxygen reserves, and high oxygen consumption, pediatric patients will develop relative bradycardia faster than adults. If on the other hand, you adjust your ventilation and can reestablish good air exchange, your desaturation will recover. Disaster avoided.
Improving your “anticipation skills” will also translate into adult anesthesia when you have brittle patients who will require faster intervention than healthier ones.
4. Learn How to take care of Healthy Pediatric Patients
There are a number of our residents who did not plan on going into pediatric anesthesia after they graduated. However, the private practice group that they are joining take care of healthy children for routine surgical cases. If you are in anesthesia school, you might find a great job as an AA or CRNA where you will be taking care of pediatric patients.
Take time to learn how to deal with routine challenges such as pre-medication/parental presence, laryngospasm, bronchospasm, and other things you will see on your rotation. You might need these skills when you graduate if you join a group that takes care of pediatric patients.
You will also want to learn when not to do proceed with anesthesia: how long to wait after an upper airway infection before elective surgery, when patients should not be done in an outpatient setting, and when the patient should be taken care of by someone who takes care of pediatric patients on a routine basis. These skills will be valuable to you in the future.
5. Learn the Most Common Procedures, Complications, and Pediatric Topics that will be on your Boards.
Finally, learn all you can about pediatric anesthesia while you are on your rotation for your boards. You will have some pediatric anesthesia questions on your boards, so now is the time to review the information.
Take some time and read up on pediatric topics because it will help you reenforce your clinical work and the clinical work will reinforce the didactic work. I went into detail on this on my post about Studying on the Move. Below you will also find some pediatric specific resources to help you make the most of your pediatric anesthesia rotation.
Pediatric Anesthesia Resource
There have been several people asking me when I am going to publish a Pediatric Anesthesia Made Easy. (I do have some pediatric doses and a chapter devoted to pediatric airway management in my book Anesthesia Made Easy.) While the idea is intriguing , there is already another good resources available for you.
- Start with your Basic Anesthesia books. Whether you use M&M, Baby Miller, or Baby Barash, each one has pediatric chapters to get you started learning about pediatric anesthesia.
- Once you have read through your basic book chapters, then consider doing the questions in your Hall Question Book or Matthes Question Book that are on the topic of pediatric anesthesia. This will help you prep for the written boards.
- When you are read to get a pediatric specific book, start with Basics of Pediatric Anesthesia by Dr. Ron Littman. (He wrote a book The Requisites, Pediatric Anesthesia, which has since gone out of print). He then went on to write Pediatric Anesthesia, which is a fantastic book much like The Requiests. It is
available in print and on kindle for a fantastic price.
Advanced Pediatric Anesthesia Resources
If you are planning on going on to work in pediatric anesthesia or you are considering a fellowship in pediatric anesthesiology, then you should get one of two available pediatric anesthesiology reference textbooks. Much like deciding between Miller and Barash, either one of these books will provide great information. It really comes down to either personal preference, or which book your training program requires.
A Practice of Anesthesia for Infants and Children … also known as simply as “Cote”. This is the Miller Anesthesia equivalent for Pediatric Anesthesiology. It has been used by generations of anesthesia trainees, pediatric anesthesiology fellows, and pediatric staff. Cote is one of the two major reference guides for pediatric anesthesia. It is available as a hardcover book or in a kindle version.
Smith’s Anesthesia for Infants and Children … also known as “Smith’s”. This is the Barrish equivalent for Pediatric Anesthesiology. This is the book that I used during fellowship. I personally liked Smith’s a little better than Cote, but I have referenced Cote in some of my lectures. It is a dense book, but it reads well and will provide some great advanced information. It is available as a hardcover or in a kindle version.
Two Simple Pediatric Anesthesia Tools
Two Really Simple Tools to get to help you with Pediatric Cases:
Do yourself a favor and get a pediatric stethoscope. I use a 3M Littmann Classic II Pediatric Stethoscope. I have a black one and a blue one and I love them both. There are a number of different colors you can choose from here. It is easy to carry around and it works well with small patients. It is really worth the investment if you enjoy working with pediatric patients and you are planning on doing so in the future.
Respironics Wee Sight Transilluminator Vein Finder. (I know, I know. Every time I read “transilluminator” I imagine the accent of Dr. Heinz Doofenshmirtz. I guess I work in children’s hospital for a reason.) Sometimes the hardest part of pediatric anesthesia is obtaining IV access. The Wee Sight is used to transilluminate veins. If you are going on a mission trip, or plan on working in pediatric anesthesia, this tool is a life saver.
Hopefully this short list of recommendations and resources will give you some things to consider when you do your pediatric rotations. If you are considering doing a fellowship in pediatric anesthesia, stop by the Society for Pediatric Anesthesia website and see what they have to offer.