Dr. Honkanen joined the Stanford Faculty in 2003 in the Division of Pediatric Anesthesiology. She has been the Chief of the Division since 2006, and splits her time between clinical care, administrative duties, teaching, and research. She helped develop the in-situ pediatric simulation models used at LPCH and now at other institutions, and assists with MOCA simulation courses for ABA recertification. Her current research interests relate to perioperative systems of care and outcomes for pediatric surgery and anesthesia.
- Pediatric Anesthesia
Clinical Professor, Anesthesiology, Perioperative and Pain Medicine
Instructor in Anesthesia, Harvard Medical School (1995 - 1999)
Clinical Assistant Professor in Anesthesia, Stanford Medical School (2003 - 2006)
Clinical Associate Professor in Anesthesia, Stanford Medical School (2006 - 2011)
Chief of Pediatric Anesthesia, Stanford University (2006 - Present)
Co-Director Operating Rooms, Lucile Packard Children's Hospital (2007 - 2016)
Clinical Professor of Anesthesia, Stanford University (2011 - Present)
Boards, Advisory Committees, Professional Organizations
Section on Anesthesiology and Pain Medicine, Executive Committee, American Academy of Pediatrics (2013 - Present)
Residency: Massachusetts General Hospital Anesthesiology Residency (1995) MA
Fellowship: Boston Children's Hospital Dept of Anesthesiology (1994) MA
Medical Education: Tufts University School of Medicine Office of the Registrar (1987) MA
Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2013)
Board Re-Certification, American Board of Anesthesiology, Anesthesia (2009)
MS, Stanford University, Health Services Research (2012)
Board Certification: American Board of Anesthesiology, Anesthesia (1996)
Internship: Walter Reed Army Medical Center (1988) DC
Anesthesia, Massachusetts General Hospital, Anesthesiology (1994)
Pediatric Anesthesia, Children's Hospital Boston, Pediatric Anesthesia (1994)
Aviation Medicine, US Army Medical Corp, Aviation Medicine (1988)
MD, Tufts University, Medicine (1987)
BS, M.I.T., Biology (1983)
Current Research and Scholarly Interests
Developing educational and system testing models for team OR environment using high fidelity simulation
Studying Pediatric Perioperative Outcomes and Cost-effectiveness for Pediatric Surgical and Anesthetic Care
Graduate and Fellowship Programs
Ultrafast pediatric chest computed tomography: comparison of free-breathing vs. breath-hold imaging with and without anesthesia in young children.
BACKGROUND: General anesthesia (GA) or sedation has been used to obtain good-quality motion-free breath-hold chest CT scans in young children; however pulmonary atelectasis is a common and problematic accompaniment that can confound diagnostic utility. Dual-source multidetector CT permits ultrafast high-pitch sub-second examinations, minimizing motion artifact and potentially eliminating the need for a breath-hold.OBJECTIVE: The purpose of this study was to evaluate the feasibility of free-breathing ultrafast pediatric chest CT without GA and to compare it with breath-hold and non-breath-hold CT with GA.MATERIALS AND METHODS: Young (≤3years old) pediatric outpatients scheduled for chest CT under GA were recruited into the study and scanned using one of three protocols: GA with intubation, lung recruitment and breath-hold; GA without breath-hold; and free-breathing CT without anesthesia. In all three protocols an ultrafast high-pitch CT technique was used. We evaluated CT images for overall image quality, presence of atelectasis and motion artifacts.RESULTS: We included 101 scans in the study. However the GA non-breath-hold technique was discontinued after 15 scans, when it became clear that atelectasis was a major issue despite diligent attempts to mitigate it. This technique was therefore not included in statistical evaluation (86 remaining patients). Overall image quality was higher (P=0.001) and motion artifacts were fewer (P<.001) for scans using the GA with intubation and recruitment technique compared to scans in the non-GA free-breathing group. However no significant differences were observed regarding the presence of atelectasis between these groups.CONCLUSION: We demonstrated that although overall image quality was best and motion artifact least with a GA-breath-hold intubation and recruitment technique, free-breathing ultrafast pediatric chest CT without anesthesia provides sufficient image quality for diagnostic purposes and can be successfully performed both without and with contrast agent in young infants.
View details for PubMedID 30413857
The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035
ANESTHESIA AND ANALGESIA
2018; 126 (2): 568–78
A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035.The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures).In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035.If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.
View details for PubMedID 29116973
- In Response. Anesthesia and analgesia 2017
The Geographic Distribution of Pediatric Anesthesiologists Relative to the U.S. Pediatric Population.
Anesthesia and analgesia
The geographic relationship between pediatric anesthesiologists and the pediatric population has potentially important clinical and policy implications. In the current study, we describe the geographic distribution of pediatric anesthesiologists relative to the U.S. pediatric population (0-17 years) and a subset of the pediatric population (0-4 years).The percentage of the U.S. pediatric population that lives within different driving distances to the nearest pediatric anesthesiologist (0 to 25 miles, >25 to 50 miles, >50 to 100 miles, >100 to 250 miles, and >250 miles) was determined by creating concentric driving distance service areas surrounding pediatric anesthesiologist practice locations. U.S. Census block groups were used to determine the sum pediatric population in each anesthesiologist driving distance service area. The pediatric anesthesiologist-to-pediatric population ratio was then determined for each of the 306 hospital referral regions (HRRs) in the United States and compared with ratios of other physician groups to the pediatric population. All geographic mapping and analysis was performed using ArcGIS Desktop 10.2.2 mapping software (Redlands, CA).A majority of the pediatric population (71.4%) lives within a 25-mile drive of a pediatric anesthesiologist; however, 10.2 million U.S. children (0-17 years) live greater than 50 miles from the nearest pediatric anesthesiologist. More than 2.7 million children ages 0 to 4 years live greater than 50 miles from the nearest identified pediatric anesthesiologist. The median ratio of pediatric anesthesiologists to 100,000 pediatric population at the HRR level was 2.25 (interquartile range, 0-5.46). Pediatric anesthesiologist geographic distribution relative to the pediatric population by HRR is lower and less uniform than for all anesthesiologists, neonatologists, and pediatricians.A substantial proportion of the U.S. pediatric population lives greater than 50 miles from the nearest pediatric anesthesiologist, and pediatric anesthesiologist-to-pediatric population ratios by HRR vary widely across the United States. These findings are important given that the new guidelines from the American College of Surgeons Children's Surgery Verification™ Quality Improvement Program state that pediatric anesthesiologists must care for a subset of pediatric patients. Because of the geographic distribution of pediatric anesthesiologists relative to the pediatric population, access to care by a pediatric anesthesiologist may not be feasible for all children, particularly for those with limited resources or in emergent situations.
View details for PubMedID 27984248
The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution
ANESTHESIA AND ANALGESIA
2016; 123 (1): 179-185
There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States.We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA).We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering.This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.
View details for DOI 10.1213/ANE.0000000000001266
View details for Web of Science ID 000378083300024
View details for PubMedID 27049856
Postoperative Complications in Pediatric Tonsillectomy and Adenoidectomy in Ambulatory vs Inpatient Settings
JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY
2016; 142 (4): 344-350
A large-scale review is needed to characterize the rates of airway, respiratory, and cardiovascular complications after pediatric tonsillectomy and adenoidectomy (T&A) for inpatient and ambulatory cohorts.To identify risk factors for postoperative complications stratified by age and operative facility type among children undergoing T&A.This retrospective review included 115 214 children undergoing T&A in hospitals, hospital-based facilities (HBF), and free-standing facilities (FSF) in California from January 1, 2005, to December 31, 2010. The analysis used the State of California Office of Statewide Health Planning and Development private inpatient data and Emergency Department and Ambulatory Surgery public data. Inpatient (n = 18 622) and ambulatory (n = 96 592) cohorts were identified by codes from the International Classification of Diseases, Ninth Revision, and Current Procedural Terminology. Data were collected from September 2011 to March 2012 and analyzed from March through May 2012.Rates of airway, respiratory, and cardiovascular complications.A total of 18 622 inpatients (51% male; 49% female; mean age, 5.4 [range, 0-17] years) and 96 592 ambulatory patients (37% male; 35% female; 28%, masked; mean age, 7.6 [range, 0-17] years) underwent analysis. The ratio of ambulatory to inpatient procedures was 5:1. Inpatients demonstrated more comorbidities (≤8,compared with ≤4 for HBF and ≤3 for FSF patients) and, in general, their complication rates were 2 to 5 times higher (seen in 1% to 12% of patients) than those in HBFs (0.2% to 5%), and more than 10 times higher than those in the FSFs (0% to 0.38%), with rates varying markedly by age range and facility type. Tonsillectomy and adenoidectomy was associated with increased risk for all complication types in both settings, reaching an odds ratio of 8.5 (95% CI, 6.6-11.1) for respiratory complications in the ambulatory setting. Inpatients aged 0 to 9 years experienced higher rates of airway and respiratory complications, peaking at an odds ratio of 7.5 (95% CI, 3.1-18.2) for airway complications in the group aged 0 to 11 months.Large numbers of pediatric patients undergo T&A in ambulatory settings despite higher rates of complications in younger patients and patients with more comorbidities. Fortunately, a high percentage of these patients has been appropriately triaged to the inpatient setting. Further research is needed to elucidate the subgroups that warrant postoperative hospitalization.
View details for DOI 10.1001/jamaoto.2015.3634
View details for PubMedID 26915058
Critical Elements for the Pediatric Perioperative Anesthesia Environment
2015; 136 (6): 1200-1205
The American Academy of Pediatrics proposes guidance for the pediatric perioperative anesthesia environment. Essential components are identified to optimize the perioperative environment for the anesthetic care of infants and children. Such an environment promotes the safety and well-being of infants and children by reducing the risk of adverse events.
View details for DOI 10.1542/peds.2015-3595
View details for Web of Science ID 000370254400055
View details for PubMedID 26620064
Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration.
Joint Commission journal on quality and patient safety / Joint Commission Resources
2015; 41 (1): 35-42
In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.
View details for PubMedID 25976722
Variations in inpatient pediatric anesthesia in California from 2000 to 2009: a caseload and geographic analysis
2014; 24 (12): 1295-1301
Regional referral systems are considered important for children hospitalized for surgery, but there is little information on existing systems.To examine geographic variations in anesthetic caseloads in California for surgical inpatients ≤6 years and to evaluate the feasibility of regionalizing anesthetic care.We reviewed California's unmasked patient discharge database between 2000 and 2009 to determine surgical procedures, dates, and inpatient anesthetic caseloads. Hospitals were classified as urban or rural and were further stratified as low, intermediate, high, and very high volume.We reviewed 257,541 anesthetic cases from 402 hospitals. Seventeen California Children's Services (CCS) hospitals conducted about two-thirds of all inpatient anesthetics; 385 non-CCS hospitals accounted for the rest. Urban hospitals comprised 82% of low- and intermediate-volume centers (n = 297) and 100% of the high- and very high-volume centers (n = 41). Ninety percent (n = 361) of hospitals performed <100 cases annually. Although potentially lower risk procedures such as appendectomies were the most frequent in urban low- and intermediate-volume hospitals, fairly complex neurosurgical and general surgeries were also performed. The median distance from urban lower-volume hospitals to the nearest high- or very high-volume center was 12 miles. Up to 98% (n = 40,316) of inpatient anesthetics at low- or intermediate-volume centers could have been transferred to higher-volume centers within 25 miles of smaller centers.Many urban California hospitals maintained low annual inpatient anesthetic caseloads for children ≤6 years while conducting potentially more complex procedures. Further efforts are necessary to define the scope of pediatric anesthetic care at urban low- and intermediate-volume hospitals in California.
View details for DOI 10.1111/pan.12500
View details for Web of Science ID 000345151700015
The Pediatrician's Role in the Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia
2014; 134 (3): 634-641
Pediatricians play a key role in helping prepare patients and families for anesthesia and surgery. The questions to be answered by the pediatrician fall into 2 categories. The first involves preparation: is the patient in optimal medical condition for surgery, and are the patient and family emotionally and cognitively ready for surgery? The second category concerns logistics: what communication and organizational needs are necessary to enable safe passage through the perioperative process? This revised statement updates the recommendations for the pediatrician's role in the preoperative preparation of patients.
View details for DOI 10.1542/peds.2014-1840
View details for Web of Science ID 000341362600067
View details for PubMedID 25157004
Simulation in pediatric anesthesiology
2012; 22 (10): 988-994
Simulation-based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer-based simulations to mannequins. Computer-controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in-situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task-training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.
View details for DOI 10.1111/pan.12001
View details for Web of Science ID 000308638300009
View details for PubMedID 22967157
Cost-effectiveness Analysis of Adjunct VSL#3 Therapy Versus Standard Medical Therapy in Pediatric Ulcerative Colitis
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
2011; 53 (5): 489-496
Inflammatory bowel diseases (IBDs) are costly chronic gastrointestinal diseases, with pediatric IBD representing increased costs per patient compared to adult disease. Health care expenditures for ulcerative colitis (UC) are >$2 billion annually. It is not clear whether the addition of VSL#3 to standard medical therapy in UC induction and maintenance of remission is a cost-effective strategy.We performed a systematic review of the literature and created a Markov model simulating a cohort of 10-year-old patients with severe UC, studying them until 100 years of age or death. We compared 2 strategies: standard medical therapy versus medical therapy + VSL#3. For both strategies, we assumed that patients progressed through escalating therapies--mesalamine, azathioprine, and infliximab--before receiving a colectomy + ileal pouch anal anastamosis (IPAA) if the 3 medical therapy options were exhausted. The primary outcome measure was the incremental cost-effectiveness ratio (ICER), defined as the difference of costs between strategies for each quality-adjusted life-year (QALY) gained. One-way sensitivity analyses were performed on variables to determine the key variables affecting cost-effectiveness.Standard medical care accrued a lifetime cost of $203,317 per patient, compared to $212,582 per patient for medical therapy + VSL#3. Lifetime QALYs gained was comparable for standard medical therapy and medical therapy + VSL#3 at 24.93 versus 25.05, respectively. Using the definition of ICER <50,000/QALY as a cost-effective intervention, medical therapy + VSL#3 produced an ICER of $79,910 per QALY gained, making this strategy cost-ineffective. Sensitivity analyses showed that 4 key parameters could affect the cost-effectiveness of the 2 strategies: cost of colectomy + IPAA, maintenance cost after surgery, probability of developing pouchitis after surgery, and the quality of life after a colectomy + IPAA. High surgical and postsurgical costs, a high probability of developing pouchitis, and a low quality of life after a colectomy + IPAA could make adjunct VSL#3 use a cost-effective strategy.Given present data, adjunct VSL#3 use for pediatric UC induction and maintenance of remission is not cost-effective, although several key parameters could make this strategy cost-effective. The quality of life after an IPAA is the single most important variable predicting whether this procedure benefits patients over escalating standard medical therapy.
View details for DOI 10.1097/MPG.0b013e3182293a5e
View details for Web of Science ID 000296383000007
View details for PubMedID 21694634
Affordable Simulation for Small-Scale Training and Assessment
SIMULATION IN HEALTHCARE
2010; 5 (2): 112-115
High-fidelity patient simulation is increasingly recognized as an effective means of team training, acquisition and maintenance of technical and professional skills, and reliable performance assessment; however, finding a cost effective solution to providing such instruction can be difficult. This report describes the rationale, design, and appropriateness of a portable simulation model and example of its successful use at national meetings.The Stanford Simulation Group, in association with several other centers, developed a portable Pediatric Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) and presented it at two national meetings. The technical challenges and costs of development are outlined, and a satisfaction survey was conducted at the completion of the program.All respondents (100%) either agreed or strongly agreed that the course was useful, met expectations, was enjoyable, and that the scenarios were realistic.The Portable Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) presents innovative educational and financial opportunities to assist in both training and assessment of critical emergency response skills at smaller institutions and allows specialized instruction in an in situ setting.
View details for DOI 10.1097/SIH.0b013e3181c76332
View details for PubMedID 20661010