Episode 301: Master Clinician Part 6: Scott Licata
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and I'm thrilled to be back with another Master Clinician episode. I have with me someone who was just lauded by his trainees as a true Master Clinician, nominated by several people, and I want to read some of those nominations. I have with me Dr. Scott Licata, who is an attending anesthesiologist at Children's Hospital of Pittsburgh, and let me read some of the things that were sent to him. Here we go.

Here's one quote. Here's another.

Dr. Licata is an attending physician that is truly beloved by all. I'm so fortunate to get to work alongside him and learn from him. He is the type of attending that you feel at ease when they walk in the room and he can always put a smile on your face. And here finally is another...

He's the one I want to in my corner when a case is hitting the fan or an incredibly unstable kid rolls through the trauma bay. He's constantly teaching little tips and tricks in the OR to keep making residents better. But beyond that, I can't even begin to say what a great person he is. He's brilliant, humble, kind, and I can only hope to be half the anesthesiologist he is. Well, that says so much, and I can't wait to talk with him. Scott, welcome to the show.

Wow. Thanks for having me. Those mean a ton. So thank you for reading that and letting me know. And thanks for letting me be here. I'm a longtime listener. Really was honored when you reached out to do this and flattered. Like you said, I'm at the University of Pittsburgh Children's Hospital.

I'm one of the P's anesthesiologists for the majority of my time. A brief period of my time, I do clinical informatics as well. And I think that kind of bleeds into the work as far as how I think about the ORs, how I think about cases from a system standpoint. But yeah, I'm super honored to be here.

Well, my pleasure. And clearly this is all well-deserved. Let me ask you to tell me a little bit more about kind of, you mentioned some clinical informatics that you do. So what exactly does your kind of day-to-day look like and how did you get there where you are now?

So I took a kind of roundabout path to medicine. And for about five years before medicine, I did programming. I was a computer scientist by trade. And then in residency, I did residency at Stony Brook University Hospital in Long Island, where I grew up.

They gave me some time to do like visual analytics and some QA, QI, pulling data from the EMR, using those other skills from my past life. And then when I came to Children's in Pittsburgh, they offered me some time to, if you do 25% of your time for three years, you can be grandfathered into a clinical informatics board specialty program.

So I do that about one day a week working with the chief medical informatics officer, whether that's predictive analytics or QA, QI for the hospital or the department, writing different extracts to pull things from our medical record system. Awesome. So...

When we were talking about this beforehand, you kind of thought, well, it might make sense to go through, you know, a case, a pediatric anesthesia case, and that you could hit kind of a lot of the things you wanted to share by going through the different stages, pre-op, intra-op, post-op. So why don't we do that? Tell me how you want to start. Take us through kind of a case and set it up for us.

Sure. So, yeah, I thought that maybe going through all the steps would make it a little structured for the listeners because PEDS has its own nuances as far as interacting with the child and the family. And so some of the pre-op and induction and airway and then access steps.

might provide a little bit of a structure in learning. So I thought, you know, if we think, okay, so we've got, you know, a four-year-old coming for kind of a standard ENT tonsil and adenoids procedure, let's say something somewhat bread and butter that really anybody, whether you're going into peds or not, might interact with in your practice. And you're going out to the same day to meet an anxious family and an anxious kid. And some of the ways that I approach it is,

are, you know, trying to interact with the child themselves. Um, you have like a lot of anxiety going on in the room and a, and a brief amount of time to get them on board and, and get that trust. Uh, I am a, a big proponent of Versa. I think from a, um, anxiolytic standpoint for the child, but also for the family, uh, it makes a big difference. Um, and I,

I defer a lot to the family's expertise of the kids in the preoperative setting. Engaging them in some of the decisions that occur, I think, helps families get on board with the care. And I'll routinely tell them, you know, I am not an expert in your child. My role is to do what is safe for them, but you are the expert in the child and I won't let you do anything that's not safe.

Um, so many families, you know, I recommend Versed, um, and many times families are like, yep, we're on board with it. And sometimes you get families who are unsure or they, we get a lot of, um, behavioral or combative kids sometimes. And, and then it becomes a discussion of like, Hey,

We're only going to bite once. Most of our kids, as you probably know, many kids are mask induction. So this four-year-old is going to be a mask induction. And then we'll put an IV when we're asleep. So that's already taking some of the stress off the table.

Um, but sometimes they say, Hey, listen, like he's not going to swallow this Versed where it's going to be a fight. And like I said, I usually tell them like, we're going to fight once. So if you think they're going to spit this out, then we're just going to do the mask. Um, but if we can do the Versed, I think it makes a big difference. Um, and finding common ground for the child, uh, becomes important, uh, whether that's video games, whether that's, um,

You know, I carry a lot of superhero things on me, but I've never met a kid who didn't love a device. I keep the streaming services on my phone, but that combined with Versed is a wonderful distraction and anxiolytic in the stress of the perioperative period.

And then it's not uncommon to have a parent who says, like, you know what, I still want to come back. You know, and we deal with parental presence a lot in that setting. And one of the things that I find helpful, because for me, it's about the kid. And if I think the child needs a parent, then that's okay. And if I think they don't, then it becomes...

I think this is something people run into a lot, like the struggle between a parent wanting to come back for themselves versus for the child. And one thing, but parents want to be heard, right? Families want to know that they're

Part of the care. And I think they're also worried that they have to come back or they're not doing the right thing if they don't come back. Lots of the pre-op phone calls that I've seen, like across the institutions, tell them, like, you can be back there with the child. So they feel like, like, I can't leave my child. I'm supposed to be there. So one thing that I find useful is telling them, like, listen, I'm not we're going to make this about your kiddo.

I'm going to try the Versed and let's see how they are. And then we'll get you in that suit, that bunny suit, if you want to come back. But down as we're moving towards, we have a hallway between our preoperative area and the operating rooms. Tell them we're going to start to separate.

And if the child reaches for you, then they've shown that they're not separating well. And if they don't, then you get this free bunny suit. You can take it home to paint in. And you've allowed the child to make the decision without asking or forcing the child to make the decision. And the families feel heard. They feel like they were given the opportunity to

When you, one of my mentors, Dr. Kladis, talks about how when you allow parental presence, your parking scores go up and your food scores go up, which is just a crazy thing. But I think what it points to is that families want to feel heard and involved in their care.

Let me ask a couple, Scott, let me clarify a couple things. For those of us who don't, haven't done this in a long time, when you give Versed, how much do you give and how far, like, do you give it and then come back and talk later? Do you talk, then give the Versed, then come back to get them later? Like, what's the timing look like? Sure. So, so usually I try to give it 20 to 30 minutes. Okay.

I was always taught you need 10 minutes for amnesia and then you start to get the sedative aspect after that. I shoot for 20 minutes. Sometimes that takes a lot of planning. I will often order my Versed kind of the evening before and time it and then call the nurse after I've seen the patient and say like, okay, we're good. You can give it. And

allow myself the time for that to kind of get in. So it takes a little bit of planning. And then from a dose standpoint, most people shoot for oral Versed half a milligram per kilo. I tend to go up to 0.75 per kilo. The dose range is 0.5 to 1, but I find that some kids spit out a little. And if you spit out a little and you got 0.75, you probably get 0.5. And so that's usually kind of where I shoot to be.

If a case is delayed and now you're 40 minutes in, it's okay. Kids tolerate it well. Or say it's your first case and heaven forbid there's a reason that a surgeon can't do the case, it's about an hour of just, hey, we're watching you, and then they can go home. So I don't really stress giving it ahead of time.

Uh, I stress giving it too late. Uh, the only time some kids can have paradoxical reactions, uh, and I warn the families, I tell them, listen, this medicine is like a few too many drinks. And you've all seen someone who've had a few too many drinks. Some people get silly.

Some people get sleepy, but some people get mad and angry, but nobody remembers. And that's all I want from this medicine is that they don't remember. And that way, because it's the truth, if the child has a paradoxical reaction, it's really hard on the family.

But the child doesn't remember. The verset's still doing its amnestic aspect. It is unfortunate if then you have a wait or a delay, but really stressing the amnestic portion of it as my goal for it from both a...

if the child were to need another procedure, stressing or reducing the stress of the separation. But also we know that, you know, giving Versed ahead of time reduces regression behaviors in the week following procedures. So sometimes we have these kiddos who've recently learned, you know, not to wet the bed. And then we see that regression afterwards.

That's usually the timing I shoot for and how I explain to families. Awesome. And you know, one thing, so my wife's a pediatrician. I see this with her. I've seen it with pediatric anesthesiologists that you guys are really good at just, you know, even if it's like at a random party and your friend's kid is there or whatever, like just talking to like initiating conversation with a kid. Like I'm not good at that, but like you guys do it all the time. You're good at it. Are there, you know, little, do you have like go-to phrases? Do you, you know, what do you, what's your initial approach to,

I'm sure it varies by age, but if it's like, you know, in that, I think it can be tough if it's that kind of four to six year old range, like they're old enough to talk, but you know, not, they're not like a teenager who you could probably just talk about sports with. Like what's your approach to initiating a conversation and kind of talking to a kid that age? So every kid likes silly, right?

So, I mean, my first go-to is silly, regardless of what that is. You know, whether it's, and sometimes you let the kid lead it. You know, I'm like, all right, we're going to, you want to watch a movie or a show before we go back? Like, what do you want to watch? Let's get it up on the phone.

you know, hey, if my wife texts me, tell her she's in her own operating room. Like, you just, you know, hand over my phone. And then sometimes that guides it because you know their interests. Like, what are you interested in? And we have wonderful child life people at the hospital too. And sometimes they, you know, key you in like, hey, we're doing this activity or this game. But I find that kind of

explaining things to the kid to start in a calm way. So I usually tell them, hey, we got five things to do today. All right, we're going to do a drink. And I tell them like, you don't get, I don't, they don't let me taste this drink. This is the Versed. So you got to tell me what it tastes like. And, you know, I got to know what to tell the other kids. So, you know, the last kid told me this tastes like strawberry with a yuck.

Um, but some kid told me it tastes like popcorn. Like, so I don't know, like I need your help. And then you're, you know, you're, you're co-opting their, like their investment. And then, so we're going to do this drink and then we're going to go back to this other room and we're going to put a sticker on your finger. I prepared them a little bit for the pulse ox so that they know what's happening. And then we're going to breathe through a mask. Are you breathing? Like you probably breathe every day. And they're like, yeah, I do. And I was like, so you're already doing it. Uh, and then we're going to take a nap.

and then you're gonna have something to eat i was like and then you know those are your five things anything scary you have questions about any of those things and sometimes they do um but it uh de-escalates kind of the stress because they know what's happening um and then i'll turn to mom and dad and be like hey like in addition to that while we're snoozing little ivy goes in to stay safe you know and then we'll talk about breathing tube and that but um

for the kiddo and the conversation towards them, they're like bought in. And then it doesn't so much matter what you say as long as you keep interacting with them, right? It's that like ignoring them that I think builds the stress.

We often get people come in and call it talkesthesia, right? It's like this, like just continual conversation and they lead it and they interact, but silly works. I talked to him. I'm like, Hey, do you have any pets at home? Like, and then sometimes even before they respond, like, do you have a giraffe?

And they're like, no, I'm like, why not? Why wouldn't you have a giraffe? And it's ridiculous. And they love it. Yeah, that's awesome. So it's that kind of stuff that I think comes so naturally to some people. But it's good for folks who maybe like me, who it doesn't come so naturally to to have some of those strategies. So thank you for sharing that. All right. So you had kind of gone through, you know, we have we've given the Versed, we've had this conversation. And now anything else before you kind of taking the kid back to the OR? Yeah.

I mean, we've got a video queued up, the Versed's on, mom and dad are going to walk back with us. And this is really where that conversation with the kids starts, right? Now you're like, we're talking. You are distracting both through pharmacologic means, a device I find extremely useful, and then just a conversation. And this is where some of the conversation relative to induction starts for me.

Whether that's about pets at home or if it's a kid in this age range who's into space and stuff. I've seen really nice inductions where you're like, all right, you know what? We've got this space mask.

And we're going to go and we're going to read that and we're going to go off to space. And sometimes creating a story for them from an induction standpoint that's consistent with this, their experience is is really effective. So we start taking them down down the hall. We're talking about pets or in this age range, like four to five space pets.

Uh, lots of boys are, you know, they're in there, they're like planets and, you know, what's your favorite planet? All right. So we're going to go, we're going to go blast off. Uh, we're going to breathe our space mask and you get them into the room over to the table. Um,

And this is part of why I like the Versa too, because they're oftentimes a little sedated, a little silly, but they're... So your jokes are funnier. And we start to, you know, breathe through the mask and tell them, you know...

If you're going to go with the space kind of storyline, like, all right, so you might start to, you know, feel kind of the rocket ship shake and you shake the bed a little bit. And again, it's about keeping the story kind of consistent with what their experiences are. And then, you know, you might start to smell some of the rocket fuel and we turn on the Civo fluorine and you're

then you might start to feel as you're blasting off and the bed is still rocking, you might start to feel the pressure from the rocket ship because if you've ever, you feel kind of breathing against eight liter flows on your mask or four liter flows if you're being kind,

And, you know, that pressure that you're feeling and you might start to feel dizzy as you're going off to space and then you're coming through the atmosphere and you get some of these precocious four, five, six-year-olds. They know like, oh, this is the stratosphere and you create this conversation and they slowly kind of change.

close their eyes, move, kick a little bit. And it can be a really nice induction when it goes in line with them. And it's not always that way, right? I mean, sometimes they're like, I don't want that mask. And this is sometimes where we have discussions with the trainees, you know, what to do if it doesn't go as such a perfectly smooth mask induction as they sometimes don't. And I think part of it is just

speeding the child through that experience rather than this negotiating that can sometimes happen in this disinhibited state. I remember early in my attending career, I had a nine-year-old who wouldn't, didn't want it. And that, and like, I spent more time than I care to admit trying to negotiate with them. Yeah.

And I quickly learned that the amount of time I will spend negotiating that is really as long as it takes for the time constants of the circuit to prime. And that's it. And that's when you know, like 8% CVO blocked mask and we're going to, okay, okay. And then it's up. And sometimes I think sometimes people feel hesitant about that, but

but they have Versed on board, there's an amnestic aspect, but making the process as swift for them is a reduction in stress for them. And so sometimes you have those kids where you need to just, it's a fully primed 8% SIVA circuit and the mask is on and you roll with them kind of head side to side, but it reduces the time of that induction for them and smooths that experience.

Yeah, that makes sense. Is there an age at which you start doing a pre-op IV or does it just depend on the kid?

It depends on the kid. So we have some really experienced five-year-olds, six-year-olds who are like, I want an IV. I've had a mask before. It smells terrible. I want the IV. Usually when they start to be around nine or 10, I'll talk to them. Hey, you're old enough. Here are your choices. There's two ways we can go off to sleep. One is with this mask and there's no pokes, but it can be stinky.

And one is with an IV and there's a little poke. It's quick. It's small, but there's no mask. And, you know, either is safe. I let them choose. And then once you get old enough to where it's less safe to do a mask induction, then you get less of a choice. Yep. Yep. Fair. Okay. So what about intraop? What are the, what are things that you're teaching, thinking about once you're there and you've, have you induced? Yeah.

So some of the things at the start are really just like have a reason for what you're doing. So if we just like step back to the induction for a second, sometimes people do kind of these graded inductions. They go to 2%, 4%, 6%, 8%. And sometimes that's fine. But sometimes you have a kid who's like really out of it on Versed. And 2%, in my opinion, smells just as bad as 8%. And sometimes, again, this is like you're prolonging it.

But sometimes you have a kid with Down syndrome and you really want to be mindful of the bradycardia that can occur from a mask induction. And then in that setting, kind of grading your induction makes a lot more sense to me. And so oftentimes as like we start these cases with the trainees, I really just want to know like, why are you doing that? There's so many ways to do things, right? And this comes up with oral boards and stuff. Like there's lots of ways to do it, but I need you to be able to verbalize like,

What's your reason for doing that? I see so many people come, they start in their training, they read some of the pizza and they've got nitrous and SIBO.

on. And I was like, okay, but why? Right. 8% works pretty well. Um, what do you need the nitrous for? And, um, and so that becomes like a, you know, have a reason. I hear second gas effect a lot, uh, in that setting, but clinically from, from that standpoint, 8% SIBO inverse, it works, works pretty well. And not so much getting into the environmental aspects of nitrous,

Um, but also just, uh, the like B12 pathway, the demyelination aspects of nitrous. Sometimes I, I mean, I'd like you to have a reason why you're, why you're using it. Um, it's no different for us in peds than like oxygen. As far as you have these neonates who have intracardiac shunts, um, PDAs, and if you're keeping them on a hundred percent oxygen for longer than you need to, you're lowering their PBR and potentially risking over circulation for them. So, um,

first stress you know to the residents like everything is a medication everything should have a reason um and then so we got them asleep and now we're talking about kind of access on these kiddos um and um you know oftentimes uh we teach you know blind saphenous kind of medial malleolus uh dropping your thumb over and kind of angling towards the mid-calf uh as

Kids have, you know, anatomic locations that generally have veins. So your saphenous or the lateral sides of your, the dorsal aspect of your hand are kind of our go-to relatively blind techniques. Yeah.

But ultrasound more and more as kids are heavier and heavier is a wonderful tool, particularly in this setting. Again, let's say we have this four or five-year-old for a TNA and they've got sleep disorder breathing probably because they're a little heavy more than necessarily their consoles or things like that. So ultrasound can be a real saver in these kids reducing the number of attempts for venous access.

Things that I see people kind of mistakes they make in this setting. One of the most common ones is, you know, these vessels are fairly small and

I think people come from a world of like trying to reduce the amount of gel they put on because it's pain and it's messy. But the less gel you have, the more pressure you need to get a good image and the more pressure you use on a kid, the more you compress the veins and you make it harder on yourself. So kind of finding a little, being a little liberal with your ultrasound gel can help you as far as needing less pressure and seeing the vein better, particularly when you are

starting out with ultrasound-guided access, these kids. We use winged IVs. So one of the things in whether it's ultrasound-guided IVs or with intubation that I find is

When you think about the amount of movements that you can make in adults, we get residents come up and they're like, oh, I'm good at, you know, ultrasound guided IVs in adults. And I'm like, okay, but your movements have to, like, you have to grade them down. They have to be smaller. And many of the techniques that we use in adults are,

come with movement from your wrist. So if you imagine how you hold an IV or how you hold a laryngoscope when you're doing procedures on adults, you're using your wrist to do that movement. And so that...

If you can put the point of movement closer to the blade or the IV catheter, it makes for smaller movements. So rather than holding the IV catheter on its sides and move with my wrist, I try to use my thumb on the back of the IV catheter to create the movement.

And this, you know, this is no different like levers and fulcrums. The more you move the fulcrum towards the liver, you get finer movements or less movement on the end.

And so I find this helpful for the IVs. I hold the wing with my pointer finger and my thumb on the back of the catheter, and I move my thumb side to side as opposed to the wrist. And that allows for some finer movements with ultrasound-guided IVs.

Let me just ask you, Scott, or point, I'll agree with you and say that one of my most salient memories from my PEDS rotation as a CA2, which was my first time doing PEDS anesthesia, was that I was very, I was halfway through CA2 year. I was like, I know how to intubate. I was very, you know, confident in my intubating. And then I come to PEDS the first day and we had some baby. And I remember I go into the mouth with the laryngoscope and I, and I like looked, I was like, does this,

Did I – am I holding it with the wrong – like what's happening? I couldn't see anything. I was like this doesn't make any sense. Like I haven't had this happen to me since early, say, one year. And I was like, okay, I don't know. It was a fluke, whatever. And then it kept happening for several patients. And what I realized is exactly what you just said, which is that the – I mean I was going in. I was halfway down the throat before I even stopped to look.

And so the movements are so much smaller and you have to, that's like, it took me a while to learn that. I think it's just a totally different thing. You, you, some of the skills that you can be very good at with adults, you have to kind of relearn completely, at least for little babies. Yeah. And the little babies are right. It's just another end of the spectrum. They have a lot of things that adults don't.

uh, you don't encounter with adults. So like, uh, when we talk about intubation, right. Um, I talked to all the residents, how your adults that you're coming from, because like you said, we have CA2s. That's usually when you do PEDS. And sometimes you're doing it right after, uh, you've right at the start of your CA2 year. So you haven't done any of the subspecialties yet. And now it's like, Hey, do PEDS.

Which also does the subspecialties. And so the stress is there for them. And then you have this little baby. And I think there's a lot of stress and anxiety about that. But they feel confident about their intubation skills. And what you have to recognize is some of the differences in the kids. So your adult larynx is at C4. And your kid's larynx is usually around C2.

And we try to draw a triangle, right? And then your hypotenuse to C4 relative to C2 is much steeper. And these are the things that make kids have those like anterior airways. And if you think, you know,

What tricks can I do so that I don't make that worse? You already have this deep hypotenuse that makes them look anterior. So the things that I think about are you really got to get that tongue out of your way because if the tongue is sitting midline and you're under it, you're just creating a steeper angle for yourself and making your life harder.

If you're holding the laryngoscope like an adult where it's in your palm and your thumb is up against the handle, you are again, you're moving from your wrist. So rather than holding the laryngoscope like that, I hold it between my pointer and middle finger on the blade side and my thumb on the side facing me.

And so it's really just fine movements. And again, if I wiggle my fingers, I can move the tip a lot finer than if I'm holding it like I would an adult and I move my wrist and you have a lot larger motion. Other things that kids, they're small mouths, these little kids, you don't really need to put your hands in their mouth and scissor them, right? It's take your thumb and just chin down.

You have that Phillips 1 blade. In general, I tell people Phillips 1 is my favorite blade for kids. And it's from one kilo until you're about five or six years old.

And then when you're six, seven, you can graduate to a Miller two blade. And then when you're a teenager, you can be a teenager and an adult and you get your mat blade. But you hold that Phillips one really low. You come in at kind of sideways on their mouth, like 45 degrees between their chin and the angle of their lip. And you just rotate your hand like a J to push the tongue all the way off to the left.

And as you go in, kind of rotate and down, and then look. And lots of people come and they're like, hey, this is a straight blade. I need to pin the epiglottis. You don't. It's okay if you don't.

you go in, you're a little deep and you come back and you wiggle your fingers a little bit as you come back because that larynx can sometimes just be caught by the entire blade and pulled up. But if you can wiggle your fingers, sometimes you can sneak it down and it kind of comes down and down. And what I learned

I try to emphasize for the trainees is like, I don't really want you to find cords. These little babies, you can't really see their cords. They don't have your classic adult pearly white vocal cords. What I want you to find is a retinoids. These are like identifiable structures that everybody has. And if you can train your brain to see a retinoids,

you'll know where the trachea is. If you, you know, you put that blade in a little kid, you're a little deep and you lift your hand up, you're going to stretch the esophagus into an ellipse. It's going to look exactly like a trachea, except that it doesn't have arytenoids. And so if you can teach yourself, find the arytenoids, go above the arytenoids,

It's where the trachea is. It has to be. And whether that's in an emergency, where they're doing compressions, then you track. You can see the arytenoids going up and down, and you can, without having to necessarily stop compressions, find it and put it in there. But that's a structure that is consistent regardless of their age, as opposed to those cords that people look for. So reducing your angle, looking for the arytenoids,

Holding the blade lower to reduce the amount of movement at the tip of your laryngoscope are the three things that I like to see the residents starting to do as they're learning to intubate these kids. They often ask, you know, when do you stylet a breathing tube and when do you not? Because oftentimes in PEDS, we don't.

And my general answer is I want you to stylet the tube when the time it will take you to find the stylet and put it in is too much. Because it's a lot easier to take the stylet out than it is to go find it, grab it, open it, put it in, stylet the tube. So really little babies don't give you a lot of time from an apneic standpoint. Okay.

RSIs where, you know, you don't want to then come out and sit there and mask them. These are like reasonable times to stylet the tube, um, as opposed to other times where you can try with a unstyletted tube. Um, and then if you need to, we can grab it, but it's a lot easier to take the stylet out than it is to go and find it. So we've now, you know, we've got the tube, we've got the kid intubated. Um, we talked a little bit about, um,

about access. But some of the other, just from an access standpoint, differences that I find in kids, their tissue is very elastic as opposed to adults. So oftentimes,

Not necessarily in this TNA case, hopefully. But from an arterial access standpoint, people reach for arrow catheter kits. And those tend to... Those are not my favorite in children. They tend to accordion on themselves because of the tissue in kids. And so we'll oftentimes just use angiocaths for arterial access. But...

From an ultrasound standpoint, too, it's a similar technique if you're going to use the ultrasound for arterial access in that you get in, you lower your angle, you are tracking that bevel, that center white dot within kind of the donut of the

vein or artery and you're tracking that up and up until it's in you'll often whether it's arterial or whether it's central access or venous access you'll see kids tent their their tissue and you'll look like you're in but you're really tenting this very elastic tissue and so some of the

movement is, you know, kind of a fine jab and then a little pause and a fine jab or, you know, this staccato movement for access in order to both pierce through, but also give time for the blood to kind of go through the catheter. Because you can imagine you have this little 24 gauge angiocath or 26 gauge in the NICU. It takes a little bit of time for the blood to traverse there and you could move through it if you're moving too quickly. And

And if you're not doing that staccato kind of movement, you do see these kids, you know, you come from an adult world, you're kind of just pushing forward. You just tend to push the vessel out of the way because these kids have youthful tissue. It's not that like nice kind of calcified one that you got to really jam through, but it doesn't kind of push out of your way.

Yeah, that's funny. I do the exact same thing you're describing with adults. I just think there's no downside and the potential upside of not missing something that you would have missed. So yeah, I'm all for that. Great. We talked about tips for IV and A-line placement. What else are you thinking about intra-op? Stay with us. We'll be right back.

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So you're thinking about kind of your ventilation strategies. In this case, if it's a tonsil for sleep disorder breathing, kind of like we're talking about, I generally extubate these kids deep from a control over the airway standpoint. And many, you know, our ENT surgeons are fastidious about their bleeding. So it tends to be a very dry airway.

So we work to get the kiddo now back kind of breathing on their own in a setting where you can use whatever FiO2 you want. An effective way really is you're just trying to build up their entitled CO2 increase to whatever their APNIC threshold is. And

We're a little more liberal about this in kids than we are in adults in general, increased cerebral flow and carotid flow in a kid. They tend not to have carotid plaques or things that you're really worried about, um, from that standpoint. Um, so in a case where you had free reign on your FIO too, um,

I'll often go up on my FiO2 to around 90%, increase my flows, wait till my end tidal FiO2 is around 50, and then just turn the vent off. And now you're, you know, kind of apnically oxygenating them with your flows, but you are not ventilating them. And they come back pretty well and have enough kind of reserve as well as apnic oxygenation not to desaturate. And then, you know,

You can put them on PSV or depending on kind of where you are in the case, build up their FIO2 or build up their end title CBO until they're at a range where you feel like they're safe to to excavate. And that range, you know, people used to some people still sit there and go, you need to be at like 1.3, 1.2 MAC to to excavate them.

But I'm much more of a proponent of just kind of looking at the kid, evaluating whether they're reactive, you know, a jaw thrust, and if they breath hold or things like that. Because oftentimes you've given narcotic, you've probably given Presidex if you're taking care of a kid, because we tend to do that a lot. And there's, you know, lots of other things that go into their anesthetic than just what their entitled SIBO is. So in this case, you know, for this patient,

proposed case as a kid, I would extubate deep. Um, and then why is that Scott? Why would you extubate him deep? Oftentimes for the tonsils, um,

depending on kind of their age range, I find that it gives me a little bit of control over them as far as coughing against the tube. So if I think that they are dry and not, um, not at risk for laryngospasm. So I'll, before anything, I'll look in their mouth. Um, I'll put a little pressure on their jaw because there's a lot of irrigation that they use and that will bring it forward. Um,

The tonsils are obviously lateral, so I'll suction just midline along the tube just to make sure that they're dry. But

Uh, they, you know, you have a kid who's waking up screaming sometimes if, you know, um, their pain is inadequately controlled, just agitated in a general sense. Um, so I find that it is a smoother and safer wake up from kind of an airway standpoint. I do try to stress that a deep excavation is really, you shouldn't be doing it for speed because the second you have a spasm, your speed is, is

He's gone. So it's not like, hey, I'm doing this for turnover time or these things. I think that in the setting that it is appropriate for the case and the child, then it's a smoother emergence for them without the tube when they've already had kind of intraoral work. As opposed to as like a pallet where...

Don't extubate them deep. I don't want them crying, but I don't extubate them deep because of the amount of oozing and things that are after like a palatoplasty is done. And then, you know, we think about how we're going to just kind of stepping back, interrupt, how we're going to ventilate them during the case,

people come and they will look at the minute ventilation for these kids. And you've got this little kid say who breathes, um, 30 times a minute. Right. And, um, so if you're breathing 30 times a minute, then like every other second, right, you're in like this inspiratory phase. And from a preload standpoint, right, your positive pressure, uh, uh, inhalation, and you're, you're kind of affecting your, your preload. So you're,

always or you're frequently in this phase of positive pressure and affecting your preload. So it's not uncommon that we will shoot for a little higher tidal volumes in order to lower our rate so that even though for each of those volumes, maybe you impact it, you're spending less time within that inspiratory phase.

And so I find that many people that I practice with shoot for more of an 8 to 10 range title volumes. And that's different for the trainees as they come from the adult side and implement some of those lung protective ARDSnet strategies in these kids. Interesting. Yeah. Okay. And that's...

There's no, I mean, I assume kids' lungs are very pliant, right? They're not, it's probably, you're not really in danger with those higher tidal volumes of causing damage unless they maybe have some sort of congenital problem with their lungs. Yeah. So certainly, I mean, this is a discussion separate from like CDHs or things like that where you have an issue with your lungs. I think they tolerate the volume. In fact, you know, kids are, the

the spectrum of age, but kids tend to follow the law of LaProsse, right? Small airway is more prone to collapse. So really your lower volumes increase your risk of like a more pronounced atelectasis, um, and difficulty. There's no different really, um,

The second after that kid gets intubated, I find a recruitment strategy for them or recruitment maneuver for them is helpful because even the amount of time that it takes to put the breathing tube in, even if it's swift, they've derecruited and you have atelectasis and you're kind of fighting your way back. And it's, you know, the smaller the kids are, the less their reserve is. And law of Laplace, the smaller airway is, so you end up...

fighting that recruitment, uh, fighting that atelectasis much more commonly. Awesome. All right. So that's how we think about kind of tidal volume, respiratory rate, other things interop. Um, you know, when, so some of the things like if you're, if you're struggling in this setting, just since we're talking about it, um, I find particularly in the smaller kids, um,

sometimes it's really difficult to listen to the chest and decide you know so you're struggling with your tidal volume you're like maybe i main stemmed right but you got this little kid and so you're like all right maybe i mean some so you're going to listen and you listen on both sides you're like i think it's bilateral but the smaller the kid is the more easy it is to hear you know the contralateral side on that side um and so um i find that uh

Palpating the cuff, so putting a little pressure on the pilot balloon with one hand and then gentle pressure on the neck. And I find the cricoid with gentle pressure and I work my way down until I feel kind of the point of maximal intensity on the hand holding the cuff. Gives me a tactile sense of where that pilot balloon is. You don't want to push hard. There is some literature on like injury that can occur

From that, but gentle pressure. And if you can, if you can locate the balloon or the cuff kind of at the sternal notch, then you can feel confident that you are below the cords, but that you're not in the right main area.

So I find that, like, that's a useful tactile confirmation for me that it's in—that it's appropriately located within the trachea. And this is, like, helpful, too, for those situations where maybe listening is hard from the drape standpoint. And then—

We talked about the recruitment maneuver. And then obviously, you know, smaller tubes, more prone to clogging. So when you get down to these 3-0 tubes, I find sometimes people just don't think about, like, the impact that a mucus plug can have on these kids. And sometimes just suctioning the tube gets missed in the stress of, like, this kid is desaturating and I'm not sure what's happening. And is it a shunt? Is it this? And it's just, you just need to suction the tube. It's...

That's it. And how do you – I mean, my memory of a 302 is it's tiny. I mean, do you have a suction catheter that fits down that, or how do you suction out a 302? Just smaller suction catheter. Okay, they exist. Yeah, if you have it. And, yeah, I mean, ideally, if you're taking care of one of those kids, you have –

You have those stocked. Okay, good. All right. I just want to, yeah, I could imagine like, do you have to like hook up your something to the outside or, you know, I don't, okay, so good. So you just do the same thing as you're doing it. I'll just section out the inside of the tube. Okay. Yeah. Um, and then trying to think of, um, other things from an intraop standpoint and ventilation. Um,

No, I mean, I think it's a lot of what we said, you know, protecting against this de-recruitment that kids are more prone to. Kind of just being, this part really not different than adults as far as just being systematic, whether your system in these settings is like from the patient back to the machine, from the machine back to the patient, you know,

But just having like a system of things you check so that like those simple things like suctioning the tube don't get don't get missed. But main stem is, you know, is a pretty common thing just because the amount of movement that you have is is a lot less in these smaller kids as far as the degree of movement.

you know, how far the two can go to, to main stem them. And that can, you might have this child kind of in an extended position, uh, for your intubation and then you flex their head or just put their head in a normal head ring and now your main stem. Um, so just being mindful of two of like the position that both the procedure will be done in, um,

so that you know you're not in some flexed position um as well as uh you know what the the depth of your tube in a neutral position uh are helpful as far as like reducing that because nobody loves having to readjust it once things have started or where the drapes are up absolutely

All right. So intra-op, we've thought about some good stuff. How about, you know, we talked a little bit emergence in terms of extubating deep, uh, other, anything else around the kind of transition out of general anesthesia or should we go just to the post-op? So I think part of the transition out, um, you have to kind of make a little bit of decision about where that's going to occur. So you have a spectrum of kids, right? Uh,

We, you know, preemie kids who are no longer premature and like DPD and these chronic lung diseases that these kids might carry with them. I'm trying to figure out what season kids aren't sick in. I haven't found one yet because they seem to always be sick. And I'm

We have varying degrees of how liberal we are with doing procedures with a URI or how close to a URI you might be. And so a lot of those go into the decision about where that transition out of general anesthesia occurs.

Um, uh, and so, you know, I think that you have to kind of consider all those things, uh, in addition to the surgical factors and the patient factors, when you think about like, okay, am I going to, am I going to put a tube in or I'm going to put an LMA in, uh, you know, am I going to put a tube in, but I'm going to take it out deep, you know, and just treat it like an, an LMA. Um, do I even need to paralyze the kid for this? Um, because there's many, you know, kids that we don't need to, and, and, and, and, and,

And one difference than adults is that paralysis, in addition, plays a big role in the anesthetic as far as reducing the amount of volatile that you need so that you can maintain a blood pressure in a small kiddo and have them tolerate the procedure. Obviously, you want to reduce their stress response and things like that, but the ability to

So maintaining a blood pressure is one of the most critical things in these small kids who often don't tolerate volatile anesthetic. And now, you know, talking more about these, the really, really little kids, you need to rest on paralysis and Burset and fentanyl and a small amount of volatile anesthetic. Yeah.

I find that sometimes trainees are hesitant to turn down the gas as you've come from an adult world. And obviously you don't want to do that in that setting. Um, but I often say, you know, if you don't, you know, the kid's going to have a problem. So, um, yeah,

And then from a post-op standpoint, some of the nuances in kids that we encounter that are different from adults really center around behavior, emergence agitation. So emergence agitation and delirium is something we encounter pretty frequently in children. It's one of the benefits, I think, to adults.

having a recovery room that's specifically pediatrics. Like as we talk about the difference between, you know, you and I were talking about how hospital systems that have like freestanding pediatric hospitals relative to kind of the combined, you know,

Having a recovery room that's accustomed to agitation, having parents who are prepped for the risk of agitation so that they know like, hey, this can happen and it's okay. I try to frame it or refer to it similar to a night terror. It's harder on you than on the kiddo. They don't know what's happening.

Um, but you know, it's normal, they're safe. Um, and having that conversation even before, you know, in the pre-op area is a, is helpful. I think that the stress of it is a big reason why we see in most children's hospitals, Presidex, uh, being, uh, utilized frequently. Uh, and I find that, you know, if you, it's a great rescue, um,

and obviously depending on your setting whether it's like ambulatory or things like that you do have to kind of think about your length of stay for these kids in the recovery room and what that means for the family they'll often you know some families will tell you like oh you know we spent hours here because he wouldn't wake up and you look back and they got precedents and sometimes we tell you oh my gosh he woke up too quick and you know the packing nurse told me he just he woke up too fast

Like, okay, what are we going to shoot for here? You know, if they're experienced, do you want, you know, with the agitation, if they've had it so bad that you want them to sleep longer, because we can do that. Or do you want me to not give it? And then only if we have emergent agitation, then I can come and give it, but then that's going to prolong, kind of likely prolong how long you're sitting in the second phase, right?

Um, but I find for, you know, for example, these tonsils and things like that, uh, if I give it on induction, um, that tends not to, cause now you have the procedure time for it to also sit in the standard recovery time. Uh, it does reduce the incidence of emergence agitation, but that seems to be the best way to also, uh, have the least impact on, you know, their length of stay. And how much do you give Scott?

Um, so the loading dose is kind of what, if you were going to do an infusion, right. And this is kind of what we base that on, uh, is one per kilo. Um, we get them in, uh, 20, uh, you know, it's four mics per ML and you can get five CC syringes. Um, I didn't, I don't think anybody really does one per kilo across the board. Um, most people from just a standard one are probably giving eight to 12 mics just for

even, um, for your five, six year old. This is not like your NICU kid who does not need Presidex. This is a ambulatory healthy kid who's going to the recovery area. Um,

They looked at, actually at UPMC Children's, they randomized tonsils to saline or Presidex, and all the laryngospasms were in the saline group. So in addition to emergence agitation, and it makes sense, right? It's increasing your MAC to some degree, reduces your risk of laryngospasm for deep extubations for these kids. So I find that Presidex on induction is

uh, narcotic, uh, on induction for the tonsils and Tylenol and steroid on induction are kind of my like, uh, tonsil adenoid induction medications. Um,

Because I extubate them deep too, I make an effort to try to not give propofol on induction because sometimes the attending is going to sit down and it's a two-minute tonsil. And so we'll give propofol if we struggle with the intubation. But generally, those meds plus the volatile anesthetic are perfectly fine for intubating.

And then if you do have emergence agitation, I mean, so much of it is, you know, your presence there with the families kind of explaining it and helping them through it. Because sometimes it's just we need to wake up through it. And sometimes you need pharmacologic intervention. And it's also making sure the kid's safe.

you know, not going to hurt themselves as they thrash around, reassuring the families that it's normal, providing kind of like a, you know, if it's like, hey, we really don't want you to give anything and we're safe, we're just screaming and crying, giving them kind of a safe, isolated space, reducing the stimulus, lowering the lights, things like that to help them kind of move through that emergence process.

Nice. So there's a couple of things that you that kind of came up when we were chatting and going over things earlier. I want to just ask if how this applies or what you teach about it. How about growth and grit? What what is that? How does that come up? So I'm you and I when we were talking, you know, I think about why, you know,

how do the residents encounter pediatrics? And like we said, you come as a CAA2 and you're either at the very start of your CAA2 year. Sometimes we even get like late CAA1s and, you know,

approaching these small kids in a setting where you felt confident from your adult skill set. And now you have these set, like, I know I could intubate before. I know I could put in IVs before. And a lot of that, you know, is disheartening. I remember being very disheartened by it in my pediatric training and recognizing that

that in our trainees and emphasizing whether it's

um, the, that you'll get there, right. From a growth mindset, like you can get there. This is not, you know, a thing you can't do. You couldn't, you know, you learned how to do it on adults. Um, and from a grit standpoint, I, you know, being persistent with it, uh, pushing through kind of, you know, you didn't get that one. So we're going to do this one again. It's not like, oh, you didn't get it. So we're not gonna, not gonna do it. Um, so I try to have a

an open discussion with the residents like it stinks. It's really frustrating when you don't get it. You're going to keep trying to get it. And, you know, we're not going to sit here and I'm not going to make you do, you know, 10 IVs and we're going to delay the case until you get it right. There's also a discussion like the case needs to move on. And so we're going to create opportunities for you to get it. So

Some of that for me, like as an attending comes into how I manage the room and how I try to build in time so that we can protect those things, the things that, you know, we want to work on. But I try to be mindful of, you know, how the residents are meeting this training, where they are and, you

emphasize like that you can do it. And, you know, some people come at it with grit and, and a growth mindset. And sometimes that requires some, some work and, um, reinforcement. Um, but I think it's, it's important not to lose sight of kind of where the residents are in their, in their training, as well as, uh, how hard it is to, um,

have what is a perceived setback. Like, you know, I can intubate and now I can't, I can get access and now I can't. Um, sometimes that's difficult to recover from, but more than that, sometimes it's difficult to recognize that in a trainee. Yeah, for sure. How do you help people to find joy in their work? I think, you know, it's,

I have the benefit of working with kids. It was a huge reason that I ended up doing PEDS, but that silly conversation, the ability to laugh and joke and have that have a positive clinical impact, um,

I think is invaluable. Whether it's a complicated case or a simple case, like they all have weight. They're all somebody's kid. They're all a child. And there's a lot of stress, I think, for people around that. But if you can find the joy in the interaction and

find the humor uh in kind of how you approach the family how you approach the kids and how you you know have these kind of uh de-escalating moments where you make it calm uh

I find a lot of joy in the ability to do that, to create that environment and to see the clinical impact that that has for the kids and for the family. But I also think that if you create that, if you look for the fun in it, it opens a kind of a psychologically safe space for

to learn um and to say like hey for the for the trainees to say hey like why didn't this work um i i find that it's a lot easier to have that discussion like hey you know you didn't get that intubation as up when it's uh there's a kind of a jovial kind of aspect to the induction right you're joking with the kid and stuff and hey you didn't get that intubation and here's why um

And, you know, granted, it's you can't always be funny. And there's, you know, certainly serious times. But when it's appropriate, having the ability to have fun.

while doing it certainly, I think, makes the education easier. Yeah. And I think we could probably learn a lot in the adult world from that. You know, it's a little probably easier in peds where you're, as you say, you're joking around in pre-op with your patient all the time to transfer that to like applying joy to the learning process too, whereas it can be a little harder, I think, in the adult world. But we should probably learn more from you all. Yeah.

When you say that sometimes it's important to question authority, what do you mean? I think that, you know, if you don't know why something's happening, you should ask, you know, like, um, in the same way that like we were talking about, like having a reason for why you do things, if you're not sure, you know, why someone, why you're attending is, you know, choosing this blade or choosing to manage it this way. Um,

blindly just following doesn't teach you anything. I remember in training, I had an attending who people were so scared to work with because it was extremely particular and I don't like working with him. But I found that I never really had an issue because anytime he was particular, all I asked was, why do we do it this way? What have you learned? Teach me why this is the way.

to do it. In general, people have an experience or a reason why that's their practice, why that's what they think is the best way to do it. It doesn't necessarily mean you need to agree with that way, but particularly as a trainee where you're trying to find, I mean, part of the goal is finding the way that you're going to do it, particularly with our fellows,

where you're choosing to be here to do this extra year impedes what I want for you is figure out like, how are you going to do this? How will you practice? Asking kind of why and if you can then, as you build your repertoire of these are the different ways I've seen, then also trying your own ways and saying like, hey, I know you like to do it this way, but I'd like to, can I try this?

this way allows you to kind of build your skill set and your practice. And then, I mean, part of like when we talked about that from just the bit of me that does clinical informatics gets from an attending standpoint, gets frustrated when systems are like, oh, you have to do it that way because that's the policy. I'm like, can you show me the policy?

Uh, cause I think we use that a whole lot, that term or the systems use that term a whole lot. Uh, and it's rarely the case. Yeah. And from like a wellness burnout, just moral injury that, uh, we experienced, uh, on the workforce and that front, uh,

Making sure that that's really something that you have to be doing, I think, is important. Yeah. Yeah, I know completely. And I think, you know, the other advantage of if it really is the policy of having it is you can you can decide whether you want to try to change it. Right. But first, you got to know, is it actually a policy? Yeah. Scott, this has been great. Anything we didn't cover that you want to cover before we move on? No, I think it's been great. I really appreciate you being you having me here. Appreciate being here.

Awesome. Well, let's turn to the portion of our show where we make random recommendations. Do you have anything that you would like to suggest the audience check out for fun? I do. Well, I got two. So one for me is that I think I found a resource that allows you kind of look to look at to follow different journals. I always struggled. Like, how do I stay up to date on a

a bunch of different journals at one time, you know, to scroll them kind of like social media. So maybe people have this, but it's called Read. It's an app. It's by a company called QXMD. And if you are like on your hospital's internet and you can then like

The journals, you know, you get the free access to the articles, but you can choose journals to follow. And then it kind of brings up the most recent ones and you can kind of scroll through or search topics. I find it a super useful one just to stay up to date on peds and some of the surgical specialties. I like that one. And then from a lifestyle standpoint, I hate to cook. I'm really bad at it, but I like to have some variety in, you know, food and food.

to make it easy. I have two kids who they have wildly different tastes and will choose at like 7 p.m. to be like, I want salmon. The other one's like, I want tacos. And I'm not good at cooking. So there's this company called CookUnity and you can pick some different meals. They're like prepackaged. You just heat them up and it makes my life like it allows me to spend time with my kids and

allows me to bring one for lunch and just heat it up at work. And it allows like a variety of food in my life that then I don't have to spend time. And it is not overly expensive. So from like a trainee and resident standpoint where like ideally you're eating healthy but not, you know, spending your time grocery shopping or doing those things, this has been a huge changer for me as far as my intake. So...

Awesome. Yeah, we do the same thing. We use factors. I'm sure it sounds like it's a very similar thing, but yeah, it's amazing. It's really liberating to have that as an option. That's the right word for it. Yes. Awesome. Well, I'm going to recommend...

A specific spice, actually. So this goes back to if you actually ever do do some cooking. But this is something that is so easy. And just throwing a little bit, I find like if I'm just going to stir fry some broccoli or something like that, that having... My kids don't normally like it, but I found this spices by Burlap and Barrel, which is a fabulous online spice shop with really fresh harvested spices. And they make a purple shallot powder. And it is...

It's onion-y but different. It's a little sweeter. Shallots are a little sweeter than onions.

And if you make some broccoli, you put some salt. If you like pepper, some pepper and some purple shallot powder on top, man, like my kids who normally don't like broccoli will eat this. It's really delicious. You can put it in soups. You can put it in anything. So on the days when you don't use your prepackaged food coming in and you want to make something or you want to supplement it with some extra vegetable or something, try this purple shallot powder from burlap and barrel. All right, Scott. Awesome. Thank you so much for coming on the show. It's been a pleasure. It's been a pleasure. Thank you so much for having me.

All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say. If you are a fan of the show, you can follow us. We're on Twitter. We are on Facebook. We are on Reddit. And we are on Instagram. I'm at jwolpa on Twitter. And we're at Akrak Podcast. And you can find us on all those other platforms as well.

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