Pediatric Sedation Training

[Perrotfish]

Is anyone here aware of any formal training programs for pediatric sedation that last for a month or two? There is an increasing push for pediatric hospitalists to take over sedation services for minor procedures and scans, and so far the training programs they are using seems to be following the dental model (i.e. two days of training and then best of luck). I was wondering if anyone knew of an alternative that was more substantial.

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[daneeka]

What type of sedation are we talking? A bit of oral midazolam or clonidine? Nitrous oxide?

Pushing an IV anesthetic drug passes a point of no return; that child depends on you to rescue them from whatever comes next. I wouldn't want to find that I've reached the limitations of a weekend (or even month-long) sedation course alone in radiology with a blue child.

 

[Perrotfish]

What type of sedation are we talking? A bit of oral midazolam or clonidine? Nitrous oxide?

Pushing an IV anesthetic drug passes a point of no return; that child depends on you to rescue them from whatever comes next. I wouldn't want to find that I've reached the limitations of a weekend (or even month-long) sedation course alone in radiology with a blue child.

We are talking about inducing moderate and deep sedation by giving medications including ketamine, nitrous oxide, opiates, midazolam, and propofol. It seems like most of these hospitalist sedation programs rely on anesthesiology being in house, but definitely not in the room. PICU and ER have both been doing this for awhile, but now there is a push for pediatric hospitalists to take over responsibility for sedation, presumably to free up the more expensive physicians to do other things.

This is on my mind because I about to take the one day sedation course through the society for pediatric sedation (it was available as part of the pediatric hospitalist medicine conference and seemed like a good review of airway management) This course seems to be emerging as the standard for pediatric sedation certification for hospitalists. Its good training but doesn't feel like nearly enough. I'm not actually on the line to provide sedation right now but it seems like this is becoming a thing and I'm not sure I'll be able to avoid it indefinitely.

 

[nimbus]

Is anyone here aware of any formal training programs for pediatric sedation that last for a month or two? There is an increasing push for pediatric hospitalists to take over sedation services for minor procedures and scans, and so far the training programs they are using seems to be following the dental model (i.e. two days of training and then best of luck). I was wondering if anyone knew of an alternative that was more substantial.

You won’t find much support for the “dental model” here. It’s not something that should be emulated. Agree you need to seek out something better.

Pediatric dental anesthesia: The Dental Board gets it wrong

An Anesthesiologist's Thoughts on Dental Sedation Laws

In 2015, healthy, happy 6-year-old Caleb Sears suffered a cardiac arrest in his oral surgeon’s office after receiving midazolam, ketamine, propofol...

opmed.doximity.com

 

[Perrotfish]

You won’t find much support for the “dental model” here. It’s not something that should be emulated.

Pediatric dental anesthesia: The Dental Board gets it wrong

Yeah, I think this is a 'perfect is the enemy of the good' situation. Peds sedation is become a thing for hospitalists and already is for PICU. I suspect we can either try to set a higher but still achievable standard for training and safety (i.e. 1 month training, minimum number of airways, anesthesia in house) or there just won't be standards and we will be working on something similar to the dental model (2 days of training providing deep sedation alone in a clinic with no back up). It still won't be quite as bad as the dental model, because we get some airway training in residency and also because we wouldn't simultaneously provide sedation and perform the procedure, but still not good

So does anyone know of a good rotation or training program for peds sedation that lasts for more than 2 days?

 

[Pinkegg]

So does anyone know of a good rotation or training program for peds sedation that lasts for more than 2 days?

There are dozens of them. They’re called anesthesia residencies.

You are correct in your apprehension about being asked to perform services you are not trained in. Your hospital is asking too much of you and your colleagues. You can be sure that when a baby dies the administrators will point at you.

 

[nimbus]

You may be asking in the wrong forum.

Most people here would probably say “anesthesia residency”. Obviously that is not practical for a pediatrician already in practice. Even most anesthesia residencies don’t let you do a pediatric anesthesia rotation until CA-2 year after you’ve had a good amount of experience on adults.

 

[B-Bone]

This sounds unlike anything i've ever heard of. The difference between the people who are generally allowed to do deep sedation (anesthesia, EM, PICU, ICU) with things like propofol and ketamine and those who aren't, is (among a bunch of other important stuff) significant airway training and experience. We don't let GI docs push propofol for healthy adults, let alone on sick kids? I can't imagine the trouble peds hospitalists could get into in this model. Glad it's not happening in my neck of the woods. Best of luck, I guess.

 

[Perrotfish]

There are dozens of them. They’re called anesthesia residencies.

You are correct in your apprehension about being asked to perform services you are not trained in. Your hospital is asking too much of you and your colleagues. You can be sure that when a baby dies the administrators will point at you.

Its not my hospital, at least so far. I am looking ahead.

Part of the issue is that pediatrics is trying to push for hospitalists to become fellowship trained in hospitalist medicine. In order to justify the existence of the fellowship they are pushing for hospitalists to do things that, generally, have previously been the territory of intensivists. So sicker patients on the floor and sedation services offered by the hospitalist group. I am worried the effects will eventually reach my hospital.

This isn't unprecedented. Dentists are certainly doing much more with much less training an much less back up. I do think there needs to be some kind of middle ground.

 

[deleted126335]

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tenor.com

 

[shepardsun]

Only after I finished my pediatrics residency and started my anesthesia residency did I realize how insanely dangerous many of the "simple sedation" situations were during the former. Most of the hospitalists doing them hadn't intubated a kid in years. Where I trained at an academic tertiary center, there were so many ED and PICU fellows that pediatric residents NEVER managed any airways short of suctioning NICU kids. I've since had six months of pediatric anesthesia and am still uncomfortable with certain situations.

 

[shepardsun]

Tangentially, pediatric hospitalist fellowships are a despicable and evil invention designed to maximize the indentured servitude of graduate medical education and only pediatricians (I'm one so I can say this) are soft enough to have completely rolled over and taken it so hard. Can you imagine what internists would say if they were told they needed an extra 2-3 year fellowship to do the core thing their residency should have prepared them to do? Can't wait for the two year outpatient peds fellowships to spring up.

/end rant

 

[nimbus]

Tangentially, pediatric hospitalist fellowships are a despicable and evil invention designed to maximize the indentured servitude of graduate medical education and only pediatricians (I'm one so I can say this) are soft enough to have completely rolled over and taken it so hard. Can you imagine what internists would say if they were told they needed an extra 2-3 year fellowship to do the core thing their residency should have prepared them to do? Can't wait for the two year outpatient peds fellowships to spring up.

/end rant

Seriously. Shouldn’t ward months be considered the hospitalist fellowship?

 

[Perrotfish]

Tangentially, pediatric hospitalist fellowships are a despicable and evil invention designed to maximize the indentured servitude of graduate medical education and only pediatricians (I'm one so I can say this) are soft enough to have completely rolled over and taken it so hard. Can you imagine what internists would say if they were told they needed an extra 2-3 year fellowship to do the core thing their residency should have prepared them to do? Can't wait for the two year outpatient peds fellowships to spring up.

Seriously. Shouldn’t ward months be considered the hospitalist fellowship?

Its a supply and demand thing. If too many people want to take care of a certain type of patient they add training until the number of providers approximates the number of patients. Pediatricians do multi year sports medicine fellowships, even though you could learn most of what you need to know about that field in a few months at most, because there are way more people who want to take care of athletes than there are injured athletes. Pediatricians also take jobs covering perinatal call after 2 months of NICU opposed by fellows, or to cover sedation after 2 days of formal training, because there is an infinite demand for people to do those thigs and no one wants to do them.

Internal medicine would never create a hospitalist fellowship because there are an infinite number of elderly people in hospitals who need care and they know they'd be hired without one. Similarly there will never be a fellowship for outpatient pediatrics because there are an infinite number of outpatient pediatric jobs. Hospitalist fellowships are spring up because a mid sized city can usually get by with a single 30 bed pediatric floor and an 8 bed PICU

 

[propadope]

Yeah, I think this is a 'perfect is the enemy of the good' situation. Peds sedation is become a thing for hospitalists and already is for PICU. I suspect we can either try to set a higher but still achievable standard for training and safety (i.e. 1 month training, minimum number of airways, anesthesia in house) or there just won't be standards and we will be working on something similar to the dental model (2 days of training providing deep sedation alone in a clinic with no back up). It still won't be quite as bad as the dental model, because we get some airway training in residency and also because we wouldn't simultaneously provide sedation and perform the procedure, but still not good

So does anyone know of a good rotation or training program for peds sedation that lasts for more than 2 days?

Just to clarify the ‘dental model’ does not allow deep sedation in children with 2 days of training. You need to have completed a residency in oral surgery or dental anesthesia in the US/Canada. Oral surgery is a 4 yr residency with minimum of a 5 month rotation in anesthesia which must include 1 month in peds.

A dental anesthesia residency requires
Eight hundred (800) total cases of deep sedation/general anesthesia to include the following:
(1) Three hundred (300) intubated general anesthetics of which at least fifty (50) are nasal intubations and twenty-five (25) incorporate advanced airway management techniques. No more than ten (10) of the twenty five (25) advanced airway technique requirements can be blind nasal intubations.
(2) One hundred and twenty five (125) children age seven (7) and under, and
(3) Seventy five (75) patients with special needs,

 

[shepardsun]

Similarly there will never be a fellowship for outpatient pediatrics because there are an infinite number of outpatient pediatric jobs.

It's already starting

General Pediatrics Fellowship

Program goals, learning activities and requirements for applicants of the General Pediatrics Fellowship at the Johns Hopkins Children’s Center in Baltimore, MD.

www.hopkinsmedicine.org

 

[shepardsun]

OH GOD IT'S ALREADY STARTING

Academic General Pediatrics Fellowship

The 2-year Academic General Pediatrics Fellowship Program (AGP) provides comprehensive training in academic general pediatrics and pediatric research.

www.nemours.org

 

[deleted875186]

Any amount of propofol is inappropriate for a hospitalist to administer. Frankly, I feel the same way about EM doctors. There is a lack of appreciation here for how quickly things can go wrong, and the time frame we are discussing could not possibly make someone comfortable with using these IV anesthetics.

I think if this sedation is done by a hospitalist, there needs to be strict guidelines flexible what types of medications are appropriate and safe.

As a side note, even places like the NICU get away with bad airway management because they avoid inducing babies and making them apnic, and will attempt intubations with just opioids and mantain spontaneous ventilation.

 

[Robotic Wis-Hipple]

We are talking about inducing moderate and deep sedation by giving medications including ketamine, nitrous oxide, opiates, midazolam, and propofol. It seems like most of these hospitalist sedation programs rely on anesthesiology being in house, but definitely not in the room. PICU and ER have both been doing this for awhile, but now there is a push for pediatric hospitalists to take over responsibility for sedation, presumably to free up the more expensive physicians to do other things.

This is on my mind because I about to take the one day sedation course through the society for pediatric sedation (it was available as part of the pediatric hospitalist medicine conference and seemed like a good review of airway management) This course seems to be emerging as the standard for pediatric sedation certification for hospitalists. Its good training but doesn't feel like nearly enough. I'm not actually on the line to provide sedation right now but it seems like this is becoming a thing and I'm not sure I'll be able to avoid it indefinitely.

This is literally insane. Anyone that is going to give moderate->deep sedation needs to be able to perform general anesthesia and rescue any airways that are required. You do not get that in a weekend or a month to be honest. This is entirely outside your scope and there will be no shortage of people lining up to testify to that fact.

Just because pushing propofol looks easy, does not mean the apnea is easy to deal with. Especially in kids. Double that for sick kids. Unbelievable. We have to get the business people/administrators away from the practice of medicine which is basically what this type of decree/push is.

 

[Perrotfish]

This is literally insane. Anyone that is going to give moderate->deep sedation needs to be able to perform general anesthesia and rescue any airways that are required. You do not get that in a weekend or a month to be honest. This is entirely outside your scope and there will be no shortage of people lining up to testify to that fact.

I don't currently practice sedation and I'm not trying to advocate for it to be practiced by hospitalists.

However this has, in fact, already creeped into other specialties. PICU already administers routinely administers deep sedation for non-emergent proceedures. Anyone who thinks that they have extensive airway experience hasn't been in a PICU lately. Even unopposed by fellows (which none of them are) how often to they really need to do airways outside of those sedation days? Its not going to get better as the procedures move to hospitalists, and there are definitely hospitalists who are providing sedation now.

So it seems like the answer to my question is that currently there is no middle ground for training physicians in moderate or deep sedation between a full fellowship (which may or may not actually provide appropriate training) and a 2 day course. I have found a few courses aimed specifically at dentists providing parenteral sedation that are 2 or 3 weeks long (spread over 3 months), that seems to be about as good as it gets and you can't even take those courses if you can't actually do the dental work in addition to the sedation.

There is probably a lot of lives that could be saved, and also a lot of money to be made, if someone could set up an 8 or 10 week course for practicing hospitalists to learn sedation and airway management and actually set some kind of standard in terms of patients seen prior to certification. Again, not perfect, but definitely better than the way this seems to be heading now.

 

[WholeLottaGame7]

Any amount of propofol is inappropriate for a hospitalist to administer. Frankly, I feel the same way about EM doctors. There is a lack of appreciation here for how quickly things can go wrong, and the time frame we are discussing could not possibly make someone comfortable with using these IV anesthetics.

Username checks out...

 

[WholeLottaGame7]

I don't currently practice sedation and I'm not trying to advocate for it to be practiced by hospitalists.

However this has, in fact, already creeped into other specialties. PICU already administers routinely administers deep sedation for non-emergent proceedures. Anyone who thinks that they have extensive airway experience hasn't been in a PICU lately. Even unopposed by fellows (which none of them are) how often to they really need to do airways outside of those sedation days? Its not going to get better as the procedures move to hospitalists, and there are definitely hospitalists who are providing sedation now.

So it seems like the answer to my question is that currently there is no middle ground for training physicians in moderate or deep sedation between a full fellowship (which may or may not actually provide appropriate training) and a 2 day course. I have found a few courses aimed specifically at dentists providing parenteral sedation that are 2 or 3 weeks long (spread over 3 months), that seems to be about as good as it gets and you can't even take those courses if you can't actually do the dental work in addition to the sedation.

There is probably a lot of lives that could be saved, and also a lot of money to be made, if someone could set up an 8 or 10 week course for practicing hospitalists to learn sedation and airway management and actually set some kind of standard in terms of patients seen prior to certification. Again, not perfect, but definitely better than the way this seems to be heading now.

Our PICU intubates kids fairly routinely. Are they amazing at it? No. Are they better than the ED? Yes. I'd put them 3rd behind anesthesiology/ENT as far as who I'd want intubating kids. They also have a fair amount of experience sedating kids on ventilators, etc. I think they part they struggle with is the sick, non-intubated kids.

I don't really know what to tell you. Our peds sedation service is run by the peds anesthesiologists. We have NPs that direct moderate and light sedations, so a pediatrician should be able to handle that. We're involved for deep sedation/general anesthesia and obviously for failed lower levels of sedation. It seems to work pretty well, but I believe the department gets a stipend from the hospital because it's not a money maker.

I think the trick is to be very clear with expectations. You have to know the sedation continuum front to back. Limit yourself to light and moderate sedations. As someone else mentioned, you have to be prepared for one level of anesthesia deeper than what you're planning for. So if you're planning a deep sedation, you have to be prepared to manage a general anesthetic, and that's obviously out.

Try to figure out which kids are safe to sedate and which ones aren't. This can be tricky, even for experienced anesthesiologists. If in doubt, ask someone smarter than you.

Have very clear guidelines for what drugs you can use and acceptable dosage ranges. If you stick to nitrous, dexmedetomidine, and benzos/ketamine in reasonable doses, there's only so much damage you can do.

Know what the backup plan is if the sedation fails, and know when and who to call for help if you run into trouble.

Try to practice effective bag valve mask ventilation. That will save more lives than anything else. Practice some LMA placements. Trying to get good with intubations with limited opportunities is useless, and will probably only give you false confidence that you can bail yourself out of a sticky situation.

Best of luck to you.

 

[WholeLottaGame7]

You are probably already aware of this, but there is a pediatric sedation society that offers coursework, conferences, etc.

Home - Society for Pediatric Sedation

Striving to be the international multidisciplinary leader in the advancement of pediatric sedation by promoting safe, high quality care, innovative research and quality professional education. Our Mission Education Quality & Safety Get Involved Research SPS Sedation Provider Course® Options...

www.pedsedation.org

 

[Perrotfish]

You are probably already aware of this, but there is a pediatric sedation society that offers coursework, conferences, etc.

Home - Society for Pediatric Sedation

Striving to be the international multidisciplinary leader in the advancement of pediatric sedation by promoting safe, high quality care, innovative research and quality professional education. Our Mission Education Quality & Safety Get Involved Research SPS Sedation Provider Course® Options...

www.pedsedation.org

That's the course I am taking that got me thinking about all of this, yes.

 

[Robotic Wis-Hipple]

I don't currently practice sedation and I'm not trying to advocate for it to be practiced by hospitalists.

However this has, in fact, already creeped into other specialties. PICU already administers routinely administers deep sedation for non-emergent proceedures. Anyone who thinks that they have extensive airway experience hasn't been in a PICU lately. Even unopposed by fellows (which none of them are) how often to they really need to do airways outside of those sedation days? Its not going to get better as the procedures move to hospitalists, and there are definitely hospitalists who are providing sedation now.

So it seems like the answer to my question is that currently there is no middle ground for training physicians in moderate or deep sedation between a full fellowship (which may or may not actually provide appropriate training) and a 2 day course. I have found a few courses aimed specifically at dentists providing parenteral sedation that are 2 or 3 weeks long (spread over 3 months), that seems to be about as good as it gets and you can't even take those courses if you can't actually do the dental work in addition to the sedation.

There is probably a lot of lives that could be saved, and also a lot of money to be made, if someone could set up an 8 or 10 week course for practicing hospitalists to learn sedation and airway management and actually set some kind of standard in terms of patients seen prior to certification. Again, not perfect, but definitely better than the way this seems to be heading now.

I applaud you for understanding that there’s more than meets the eye here and that you want to be as prepared as possible. My main point is that it’s still insane.

This is 100% money savings focused, trying to utilize the bodies they have, and possibly the “cheaper” source as you yourself stated. I mean there’s a reason Academic/high risk children’s centers utilize pediatric fellowship trained anesthesiologists. I myself am not peds anesthesia trained and wouldn’t want to take this on. There is a reason anesthesia core training is 3 years after internship.

This is not designed in the interests of these patients (children) and any anesthesia department or PICU/Critical care department that lets this happen in their hospital is weak and should be ashamed.

 

[Robotic Wis-Hipple]

Another thought; how is propofol not a medication limited by pharmacy from administration by anyone other than a “trained airway provider”?

How is it that someone like me, a boarded Anesthesiologist can’t get credentials to provide anesthesia to children <8years old at my hospital without a peds fellowship graduate certificate, peds anesthesia board certification, or documentation of at least 50 anesthetics of children in the last year yet hospitals are giving the keys to hospitalists?

 

[dhb]

Can you give a little detail on what kind of procedures the hospital would like to have hospitalist providing sedation for?
The problem is everybody needs to be sedated and have the best time of their lives, big smiles wink wink to the camera... Since anesthesia is so safe even nurses can do it let's give a buzz to anybody that rolls in to the hospital.
A scan takes a couple of seconds i fail to see where a sedation that will last minutes to hours is indicated.

 

[propadope]

Just wanted to mention that aside from the physiological and anatomical differences that make pediatric sedation/anesthesia challenging; there is the psychological component. Children can be pre-cooperative meaning too young to understand what is going on and incapable of following instructions. They can also be uncooperative. They have anxiety and fear of strangers, the unknown, being separated from their parents... Give them sedative medications and take away their inhibitions and then you will see a paradoxical reaction. What you are left with is a ‘hot mess’. A crazed, psychotic ‘bad drunk’. This is why minimal and moderate sedation has a fairly high failure rate in children. And if you are inexperienced you might think that you need to give more medication which will push the kid into deep sedation/GA...

 

[deleted875186]

Just wanted to mention that aside from the physiological and anatomical differences that make pediatric sedation/anesthesia challenging; there is the psychological component. Children can be pre-cooperative meaning too young to understand what is going on and incapable of following instructions. They can also be uncooperative. They have anxiety and fear of strangers, the unknown, being separated from their parents... Give them sedative medications and take away their inhibitions and then you will see a paradoxical reaction. What you are left with is a ‘hot mess’. A crazed, psychotic ‘bad drunk’. This is why minimal and moderate sedation has a fairly high failure rate in children. And if you are inexperienced you might think that you need to give more medication which will push the kid into deep sedation/GA...

100% agree. This is why deep and general anesthesia are the only realistic options for young kids, and having someone not properly trained give deep sedation is dangerous.

OP, what type of procedures are these folks sedating for?

 

[PTPoeny]

Can you give a little detail on what kind of procedures the hospital would like to have hospitalist providing sedation for?
The problem is everybody needs to be sedated and have the best time of their lives, big smiles wink wink to the camera... Since anesthesia is so safe even nurses can do it let's give a buzz to anybody that rolls in to the hospital.
A scan takes a couple of seconds i fail to see where a sedation that will last minutes to hours is indicated.

Based on my residency and fellowship program: Lp, bone marrow biopsy, PICC placement, port removal, ABR, echo, g-j tube exchange in some kids, and burn care are the common procedures. Peds anesthesia does all the MRIs in the hospitals I have been in.

I interviewed at a (peds) residency program where third year residents could get credentialed for sedation and earn extra money...

 

[IMGASMD]

Based on my residency and fellowship program: Lp, bone marrow biopsy, PICC placement, port removal, ABR, echo, g-j tube exchange in some kids, and burn care are the common procedures. Peds anesthesia does all the MRIs in the hospitals I have been in.

I interviewed at a (peds) residency program where third year residents could get credentialed for sedation and earn extra money...

What’s your take regarding OP?

 

[Perrotfish]

OP, what type of procedures are these folks sedating for?

Again, not my hospital. This seems to be uncharted territory and there is a wide range of opinions about what is appropriate.

 

[shepardsun]

You absolutely can, particularly with the former. The issue isn't so much the individual mechanism of each agent in how it provides sedation, but the acute change in sensorium coupled with removal of regulatory cortical function which leads to the disinhibition. Only when you remove those responses entirely- i.e. general anesthesia- can you be sure of attaining the desired effect, and even that has its caveats.

 

[PTPoeny]

What’s your take regarding OP?

I think we are sedating too many kids. I know the anesthesia literature supports the safety of single anesthetic experiences for development and the PICU literature shows developmental effects for kids we sedate for long periods of time. Many of these kids get sedated over and over again so I worry the developmental effects will be closer to the PICU literature than anesthesia. I personally wouldn't sedate my kids for some of the things I see on the sedation schedule. I think hiring extra child life people, going slowly with good timing would get most kids through a lot of these procedures (with a few exceptions)

I do sometimes wonder if part of the disconnect is a generational gap. When the current pediatric leadership was in residency they intubated every baby born through meconium and there was no high flow or NIPPV so many more bronchiolitic babies got intubated and apparently ett weren't actually secured as they tell me they were reintubating babies that self extubated on a daily basis. General peds residents used to graduate with more tubes than PICU fellows graduate with now. I think everyone in pediatrics knows that less kids are getting intubated but I wonder if they really understand that means people are graduating residency and getting hospitalist jobs without ever managing an airway.

Where I did residency sedations were done by both PICU and hospitalist. If PICU had done all the sedations they wouldn't have enough people free to cover the unit. That hospital also had no fellows so residents were involved in managing the airway more often than many other places and most of their hospitalists were home grown. There were strict criteria for who could get anything done with sedation services, they had to be over a certain age and not very sick. It has been a few years so I don't remember the exact details, just the frustrations when a kid couldn't go with sedation.

For OPs actual question, no I don't know of a better course

Edited for typo...

 

[Perrotfish]

hurting extra cold life people,

 

[Perrotfish]

I personally wouldn't sedate my kids for some of the things I see on the sedation schedule.

I'm curious what you're seeing. I feel like I see the opposite: they won't sedate the kids in my community for anything unless it absolutely requires complete immobility (i.e. an MRI). 3 year old with a laceration? Hold him down. 8 year old needs a VCUG? Look forward to a memorable experience. Unsedated VCUGs are a personal pet peeve.

 

[shepardsun]

I'm curious what you're seeing. I feel like I see the opposite: they won't sedate the kids in my community for anything unless it absolutely requires complete immobility (i.e. an MRI). 3 year old with a laceration? Hold him down. 8 year old needs a VCUG? Look forward to a memorable experience. Unsedated VCUGs are a personal pet peeve.

One of the disheartening things about the culture at the center I did my peds training is that the idea that (built probably from a mix of good intentions and a customer service mentality wanting to make parents happy) kids should have no discomfort with any procedure at all meant that the increasing amount of sedations impacted our ability to get experience with other procedures. We NEVER did LPs on the floor- they always got sent to interventional radiology to have it done under sedation/anesthesia, which meant that I never did any LPs outside of the ED on neonates, where I was competing with fellows. @PTPoeny is bang on the money with respect to what the combination of new technologies and increased number of providers means for the overall procedural competency of your average bear. Which is one of the primary reasons I did anesthesia training after.

 

[deleted875186]

My personal experience having given general anesthesia for LPs done by the peds residents at my residency is that I would never want them giving sedation to a kid .... seriously all thumbs.

 

[Perrotfish]

. @PTPoeny is bang on the money with respect to what the combination of new technologies and increased number of providers means for the overall procedural competency of your average bear. Which is one of the primary reasons I did anesthesia training after.

Whether or not we do sedation, I do wish that more pediatricians had multiple dedicated rotations with peds anesthesia to learn airways. Long before the sedation thing started happening Peds hospitalists were frequently graduating and going on call for emergent intubations on the labor deck with no NICU in house. Even with 6 months of NICU unopposed by fellows I didn't get all that many intubations. There are lots of residencies where the Pediatricians graduate having done 2 opposed NICU months and no airways, and they still get hired to cover perinatal call.

 

[shepardsun]

There are lots of residencies where the Pediatricians graduate having done 2 opposed NICU months and no airways, and they still get hired to cover perinatal call.

There are few tougher (normal) airways than that floppy, fiddly, tiny neonatal glottis. Not the best place to start learning about airway anatomy and techniques.

 

[dhb]

I think we are sedating too many kids.

 

[PTPoeny]

My local H/O group seems to promise parents that their children with cancer will never feel a single needle stick. Ever. Even if said child is a normally developed 18 year old...

Recently a school aged kid got put on the schedule for the removal of a single stitch. Not buried... not inflamed and awful looking. Just removal of a single suture. The PICU attending that was supposed to be sedating the kid may have simply removed the stitch during the pre-sedation exam and canceled the case...

 

[dannyboy1]

Are you fu(king kidding me!!!!!
never having managed an airway in your life and you are going to be pushing propofol after a weekend course!!!!
On someone’s kid? Contact your malpractice carrier and see what they think of the idea .....

 

[BigRedBeta]

I don't know of any course, but that doesn't mean you can't make one specific to your institution

I would work with your service chief and the credentialing office for your hospital to work out guidelines to make this a safe proposition. I think OR time with the anesthesiologists at your locale would be great idea. There should be a focus on bag-valve mask technique (with BVM having a clear priority over intubation skills) and a clearly defined algorithm of who to call when things go sideways. Being able to buy yourself time for help to get there is more important than having just enough knowledge to be dangerous.

Additionally, it should be made readily apparent to all involved that Hospitalist sedation service is to take only the lowest hanging of fruit, the kids who clearly have zero risk factors. In my system, our sedation service is all PEM/PICU people and even with that, even being on 1LPM of LFNC is enough to guarantee that the case will be deferred to Anesthesia.

 

[dchz]

Are you fu(king kidding me!!!!!
never having managed an airway in your life and you are going to be pushing propofol after a weekend course!!!!
On someone’s kid? Contact your malpractice carrier and see what they think of the idea .....

I had a friend who was a new hospitalist in peds that asked me the same thing. I understood where she was coming from, it took her a while to get this job and she likes it. I didn't scream this at her, because u know, people are way more civil in person than the internet. But I did walk her through a scenario where she would have to intubate the patient. She told me she had no clue how to do that. I asked her what she would do if the patient aspirated. She had no clue.

The conversation ended there.

But i think she still sedated kids for procedures. Lucky for her patients that I didn't hear of anything bad happening.

 

[dchz]

Even with 6 months of NICU unopposed by fellows I didn't get all that many intubations.

Why not take a week and follow a pedi anes around? on ENT rooms? best bang for the buck and they're usually bored enough to let you do everything you'd want to do.

 

[IMGASMD]

Lucky for her patients that I didn't hear of anything bad happening.

LMFTFY.
Lucky for her patients that I didn't hear of anything bad happening, yet.

 

[dannyboy1]

Why not take a week and follow a pedi anes around? on ENT rooms? best bang for the buck and they're usually bored enough to let you do everything you'd want to do.

I had a friend who was a new hospitalist in peds that asked me the same thing. I understood where she was coming from, it took her a while to get this job and she likes it. I didn't scream this at her, because u know, people are way more civil in person than the internet. But I did walk her through a scenario where she would have to intubate the patient. She told me she had no clue how to do that. I asked her what she would do if the patient aspirated. She had no clue.

The conversation ended there.

But i think she still sedated kids for procedures. Lucky for her patients that I didn't hear of anything bad happening.

Who the hell is Credentialing these people to do sedation with propofol. It is a monumental risk to the facility if they credential providers who are demonstrably inadequately trained to give sedation. There will be no shortage of expert witnesses lining up....

 

[dchz]

Who the hell is Credentialing these people to do sedation with propofol. It is a monumental risk to the facility if they credential providers who are demonstrably inadequately trained to give sedation. There will be no shortage of expert witnesses lining up....

Couldn't agree more... But anesthesiologists are so damn expensive...

 

[IMGASMD]

Couldn't agree more... But anesthesiologists are so damn expensive...

And you have people who line up to do it, because it looks so easy. You just push some of that white stuff..... anyone can do it.

Tell that to Michael Jackson I suppose.