Patient Care
This two-week rotation is designed to provide critical care, emergency medicine, gastroenterology, cancer center, and hospitalist Fellows broad exposure to the practice of pediatric sedation.
This will be accomplished by assignment of the Fellows to locations such as: Pediatric Radiology in West Tower (MRI, CT, Nuclear Medicine, and Interventional Radiology) or CCC (MRI and CT). The Fellow will acquire an appreciation for the unique challenges of providing deep sedation for a varied patient population in remote locations.
Medical Knowledge
General Knowledge
• Achieve an understanding of imaging studies appropriate for moderate or deep sedation.
• Achieve an understanding of interventional procedures appropriate for moderate or deep sedation.
• Achieve an understanding of airway management in multiple remote locations.
• Achieve an understanding of sedation medications and routs of administration (IV, IM, IN) appropriate for moderate and deep sedation.
o Propofol
o Dexmedetomidine
o Ketamine
o Benzodiazepines
o Barbiturates
o Narcotics
o Nitrous oxide
• Achieve an understanding of temperature homeostasis in a cold environment (MRI).
• Achieve an understanding of distinguishing levels of sedation using sedation scales
• Achieve an understanding of discharge readiness following sedation.
• Achieve an understanding of safety hazards in remote locations (i.e. radiation safety, MRI safety).
• Achieve an understanding of unique specifications of monitors, infusion pumps, and equipment used in the sedation environment.
• Achieve an understanding of non-pharmacologic adjuncts to avoid or reduce need for medications.
• Achieve an understanding of the role of anesthesiology consultation in a sedation service.
Case Management
• Perform a comprehensive pre-study or pre-procedure evaluation and examination.
• Determine the need for consultation of subspecialists involved in the patient’s care.
• Determine the need for consultation with the radiologist assigned to evaluating the imaging study.
• Determine the need for sedation / anesthesia in patients undergoing imaging or other procedure.
• Determine the need for anesthesia consultation.
• Determine the safety of transporting the patient to remote locations.
• Determine the sedation plan for each patient, to include medications needed and the potential for required airway intervention.
• Manage the patient undergoing sedation with nasal cannula, nasal trumpet, or oral airway.
• Manage airway emergencies (i.e. obstructive apnea and larygnospasm).
• Manage and direct the safe positioning of patients undergoing procedures on the scanner tables.
• Monitor the patient for movement (motion artifact) and determine a plan to correct.
Practice-Based Learning and Improvement
• The Fellow is expected to read the Sedation Provider Course Syllabus provided by the Society for Pediatric Sedation.
• The Fellow is expected to read and discuss assigned literature on sedation:
o The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: A report from the Pediatric Research Sedation Consortium.
o Propofol Sedation: Intensivists’ experience with 7304 cases in a Children’s Hospital.
o Propofol-fentanyl versus propofol alone for lumbar puncture sedation in children with acute hematologic malignancies: Propofol dosing and adverse events.
o Dosing ketamine for pediatric procedural sedation in the Emergency Department.
o High dose dexmedetomidine as sole agent for MRI.
o Level of Sedation with Nitrous Oxide for Pediatric Medical Procedures.
o Anesthesia for the child with an upper respiratory tract infection: Still a dilemma?
o A study of intravenous lidocaine as a suppressant of cough reflex.
o Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model.
o Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging.
• The Fellow is expected to participate in consultations.
• The Fellow is expected to communicate adverse events by completing Quality Improvement forms.
Professionalism
• The Fellow should conduct himself/herself with a high degree of professionalism.
• The Fellow is expected to demonstrate respect to families and patients in all areas.
• The Fellow is expected to maintain patient confidentiality.
• The Fellow will be expected to demonstrate respect and clearly communicate with the nurses and technologists.
• The Fellow should wear Identifications badges at all times.
• The Fellow will dress in accord with hospital guidelines and are expected to remove metal objects that may pose a safety hazard to patients or healthcare team members in the MRI scanner.
• The Fellow will understand the role of the technologists in refusing entry into the MRI scanner when a metal object poses a safety risk.
Interpersonal and Communication Skills
• The Fellow is expected to communicate a sedation plan with the assigned faculty.
• The Fellow is expected to communicate effectively with Pediatric Radiology Nurse Coordinator in charge of patient flow.
• The Fellow is expected to communicate clearly and be available for consultation with the Pediatric Nurse Practitioners assigned to sedation locations.
• The Fellow is expected to be available for consultation with nurses providing moderate sedation in the Pediatric Radiology suites.
• The Fellow is expected to communicate concerns to the radiologist when the sedation is prolonged.
Systems-Based Practice
One of the challenges of managing patients in remote locations outside the operating room is that the sedation provider may be the only physician on the healthcare team. The fact that the sedation sites for the Pediatric Radiology sedation service span not only different floors, but different buildings, presents a unique opportunity to teach multi-tasking. The Fellow will:
• Achieve an understanding of the complexity of scheduling appropriate patients for moderate sedation by nursing teams, deep sedation by sedation practitioners, or deep sedation/anesthesia by anesthesiologists.
• Achieve an understanding of how the scheduling of such patients affects the throughput and efficiency of diagnostic suites (MRI).
• Achieve an understanding of how throughput and efficiency in the presence of limited number of MRI scanners affects backlog and leads to delayed imaging for patients awaiting a diagnosis.
• Achieve an understanding of the complexity of coordinating imaging studies of different modalities (i.e. CT followed by MRI).
• Develop a plan to coordinate a diagnostic imaging study with planned surgical procedure.
• Communicate a plan (including safe transport) with the O.R. GOAT, the anesthesiologist assigned to the surgery, the surgical team, and the diagnostic imaging healthcare team.
• Develop a plan to continue sedation after imaging to allow therapeutic or diagnostic procedures by subspecialists (i.e. LP, BMA, PICC lines, EUA, etc.)
• Achieve an understanding of developing policies and guidelines for the safe administration of sedation medications by non-anesthesiologists, mid-level practitioners, and nurses.
• Develop the requirements of establishing a sedation service: manpower, practitioners, medication regimens, recovery room, and discharge criteria.
• Determine how Quality Improvement data can impact the structure of the sedation service.
This two-week rotation is designed to provide critical care, emergency medicine, gastroenterology, cancer center, and hospitalist Fellows broad exposure to the practice of pediatric sedation.
This will be accomplished by assignment of the Fellows to locations such as: Pediatric Radiology in West Tower (MRI, CT, Nuclear Medicine, and Interventional Radiology) or CCC (MRI and CT). The Fellow will acquire an appreciation for the unique challenges of providing deep sedation for a varied patient population in remote locations.
Medical Knowledge
General Knowledge
• Achieve an understanding of imaging studies appropriate for moderate or deep sedation.
• Achieve an understanding of interventional procedures appropriate for moderate or deep sedation.
• Achieve an understanding of airway management in multiple remote locations.
• Achieve an understanding of sedation medications and routs of administration (IV, IM, IN) appropriate for moderate and deep sedation.
o Propofol
o Dexmedetomidine
o Ketamine
o Benzodiazepines
o Barbiturates
o Narcotics
o Nitrous oxide
• Achieve an understanding of temperature homeostasis in a cold environment (MRI).
• Achieve an understanding of distinguishing levels of sedation using sedation scales
• Achieve an understanding of discharge readiness following sedation.
• Achieve an understanding of safety hazards in remote locations (i.e. radiation safety, MRI safety).
• Achieve an understanding of unique specifications of monitors, infusion pumps, and equipment used in the sedation environment.
• Achieve an understanding of non-pharmacologic adjuncts to avoid or reduce need for medications.
• Achieve an understanding of the role of anesthesiology consultation in a sedation service.
Case Management
• Perform a comprehensive pre-study or pre-procedure evaluation and examination.
• Determine the need for consultation of subspecialists involved in the patient’s care.
• Determine the need for consultation with the radiologist assigned to evaluating the imaging study.
• Determine the need for sedation / anesthesia in patients undergoing imaging or other procedure.
• Determine the need for anesthesia consultation.
• Determine the safety of transporting the patient to remote locations.
• Determine the sedation plan for each patient, to include medications needed and the potential for required airway intervention.
• Manage the patient undergoing sedation with nasal cannula, nasal trumpet, or oral airway.
• Manage airway emergencies (i.e. obstructive apnea and larygnospasm).
• Manage and direct the safe positioning of patients undergoing procedures on the scanner tables.
• Monitor the patient for movement (motion artifact) and determine a plan to correct.
Practice-Based Learning and Improvement
• The Fellow is expected to read the Sedation Provider Course Syllabus provided by the Society for Pediatric Sedation.
• The Fellow is expected to read and discuss assigned literature on sedation:
o The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: A report from the Pediatric Research Sedation Consortium.
o Propofol Sedation: Intensivists’ experience with 7304 cases in a Children’s Hospital.
o Propofol-fentanyl versus propofol alone for lumbar puncture sedation in children with acute hematologic malignancies: Propofol dosing and adverse events.
o Dosing ketamine for pediatric procedural sedation in the Emergency Department.
o High dose dexmedetomidine as sole agent for MRI.
o Level of Sedation with Nitrous Oxide for Pediatric Medical Procedures.
o Anesthesia for the child with an upper respiratory tract infection: Still a dilemma?
o A study of intravenous lidocaine as a suppressant of cough reflex.
o Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model.
o Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging.
• The Fellow is expected to participate in consultations.
• The Fellow is expected to communicate adverse events by completing Quality Improvement forms.
Professionalism
• The Fellow should conduct himself/herself with a high degree of professionalism.
• The Fellow is expected to demonstrate respect to families and patients in all areas.
• The Fellow is expected to maintain patient confidentiality.
• The Fellow will be expected to demonstrate respect and clearly communicate with the nurses and technologists.
• The Fellow should wear Identifications badges at all times.
• The Fellow will dress in accord with hospital guidelines and are expected to remove metal objects that may pose a safety hazard to patients or healthcare team members in the MRI scanner.
• The Fellow will understand the role of the technologists in refusing entry into the MRI scanner when a metal object poses a safety risk.
Interpersonal and Communication Skills
• The Fellow is expected to communicate a sedation plan with the assigned faculty.
• The Fellow is expected to communicate effectively with Pediatric Radiology Nurse Coordinator in charge of patient flow.
• The Fellow is expected to communicate clearly and be available for consultation with the Pediatric Nurse Practitioners assigned to sedation locations.
• The Fellow is expected to be available for consultation with nurses providing moderate sedation in the Pediatric Radiology suites.
• The Fellow is expected to communicate concerns to the radiologist when the sedation is prolonged.
Systems-Based Practice
One of the challenges of managing patients in remote locations outside the operating room is that the sedation provider may be the only physician on the healthcare team. The fact that the sedation sites for the Pediatric Radiology sedation service span not only different floors, but different buildings, presents a unique opportunity to teach multi-tasking. The Fellow will:
• Achieve an understanding of the complexity of scheduling appropriate patients for moderate sedation by nursing teams, deep sedation by sedation practitioners, or deep sedation/anesthesia by anesthesiologists.
• Achieve an understanding of how the scheduling of such patients affects the throughput and efficiency of diagnostic suites (MRI).
• Achieve an understanding of how throughput and efficiency in the presence of limited number of MRI scanners affects backlog and leads to delayed imaging for patients awaiting a diagnosis.
• Achieve an understanding of the complexity of coordinating imaging studies of different modalities (i.e. CT followed by MRI).
• Develop a plan to coordinate a diagnostic imaging study with planned surgical procedure.
• Communicate a plan (including safe transport) with the O.R. GOAT, the anesthesiologist assigned to the surgery, the surgical team, and the diagnostic imaging healthcare team.
• Develop a plan to continue sedation after imaging to allow therapeutic or diagnostic procedures by subspecialists (i.e. LP, BMA, PICC lines, EUA, etc.)
• Achieve an understanding of developing policies and guidelines for the safe administration of sedation medications by non-anesthesiologists, mid-level practitioners, and nurses.
• Develop the requirements of establishing a sedation service: manpower, practitioners, medication regimens, recovery room, and discharge criteria.
• Determine how Quality Improvement data can impact the structure of the sedation service.