Rita Agarwal

All Publications

• The Path to Safety in Dental Anesthesia CURRENT ANESTHESIOLOGY REPORTS Tom, J., Thikkurissy, S., Agarwal, R. 2024

  View details for DOI 10.1007/s40140-024-00619-y

  View details for Web of Science ID 001170315700001

• Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine. Anesthesia and analgesia Kitzman, J. M., Mesheriakova, V. V., Borucki, A. N., Agarwal, R. 2023

  Abstract

  Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.

  View details for DOI 10.1213/ANE.0000000000006623

  View details for PubMedID 37450650

• Error Traps in the Perioperative Care of Children with Chronic Pain. Paediatric anaesthesia D'souza, G., Walia, A., Agarwal, R. 2023

  Abstract

  Pediatric patients with a history of chronic pain frequently have complex health needs that are challenging to meet in the perioperative period. Error traps are consequences or errors that are known to occur due to either gaps in knowledge or cognitive errors. Avoiding common error traps in these children can contribute to improved patient care and patient outcomes and overall better patient and family satisfaction. In patients with chronic pain, common errors during their perioperative care include: failure to adequately prepare the patient and family; failure to incorporate past pain history and therapy into current treatment plans, failure to provide adequate multimodal analgesia; and failure to provide multidisciplinary and multimodal analgesia by incorporating other services such as mental health services and physical therapy. Cognitive errors may play a role in these error traps. Recognizing and avoiding them may improve and optimize pain care and outcome.

  View details for DOI 10.1111/pan.14646

  View details for PubMedID 36785933

• Error Traps in Acute Pain Management in Children. Paediatric anaesthesia Vecchione, T. M., Agarwal, R., Monitto, C. L. 2022

  Abstract

  Providing effective acute pain management to hospitalized children can help improve outcomes, decrease length of stay, and increase patient and parental satisfaction. Error traps (circumstances that lead to erroneous actions or undesirable consequences) can result in inadequately controlled pain, unnecessary side effects, and adverse events. This article highlights five error traps encountered when managing acute pain in children. They include failure to appropriately assess pain, optimally utilize regional anesthesia, select suitable systemic analgesics, identify and treat medication-related side effects, and consider patient characteristics when choosing medication or dosing route. These issues are easily addressed when the clinician is cognizant of ways to anticipate, identify, and mitigate or avoid these errors.

  View details for DOI 10.1111/pan.14514

  View details for PubMedID 35751474

• Anesthesia for the Pediatric Patient With Epilepsy and Minimally Invasive Surgery for Epilepsy CURRENT ANESTHESIOLOGY REPORTS Wong, B. J., Agarwal, R., Chen, M. I. 2021

  View details for DOI 10.1007/s40140-021-00457-2

  View details for Web of Science ID 000686464700001

• Concerns About Pediatric Opioid Prescribing Guidelines. JAMA surgery Agarwal, R., Chidambaran, V., Hays, S. R. 2021

  View details for DOI 10.1001/jamasurg.2021.2084

  View details for PubMedID 34076697

• Anesthesia for a Patient With Aicardi-Goutières Syndrome: A First Case Report. A&A practice Swenson Schalkwyk, A. K., Agarwal, R. n. 2021; 15 (3): e01410

  Abstract

  We present a case of a child with Aicardi-Goutières Syndrome (AGS) undergoing general anesthesia for placement of a laparoscopic gastrostomy tube. AGS is a rare genetic leukodystrophy that can affect most organ systems with extensive neurologic effects. These changes potentially have great anesthetic implications. We describe our anesthetic management and discuss these implications. The patient had a prolonged duration of action of rocuronium and an otherwise uneventful anesthetic course.

  View details for DOI 10.1213/XAA.0000000000001410

  View details for PubMedID 33684075

• The American Academy of Pediatrics; its structure; mission and the importance of getting involved and supporting individual subsections. Paediatric anaesthesia Adler, A. C., Chandrakantan, A. n., Agarwal, R. n. 2020; 30 (10): 1161–62

  View details for DOI 10.1111/pan.14006

  View details for PubMedID 32997859

• East/West Visiting Scholars in Pediatric Anesthesia Program (ViSiPAP): Developing Tomorrow's Pediatric Anesthesia Leaders. Paediatric anaesthesia Ferschl, M. B., Lee, J. K., Lockman, J. L., Black, S. n., Chatterjee, D. n., Agarwal, R. n., Schwartz, L. I., Fiadjoe, J. n., Heitmiller, E. n., Hong Mershon, B. n., Deutsch, N. n., McCloskey, J. n., Infosino, A. n. 2020

  Abstract

  Promoting and retaining junior faculty are major challenges for many medical schools. High clinical workloads often limit time for scholarly projects and academic development, especially in anesthesiology. To address this, we created the East/West Visiting Scholars in Pediatric Anesthesia Program (ViSiPAP). The program's goal is to help "jumpstart" academic careers by providing opportunities for national exposure and recognition through invited lectures and collaborative opportunities. East/West ViSiPAP benefits the participating scholars, the home and hosting anesthesia departments, and pediatric anesthesia fellowship training programs. By fostering a sense of well-being and inclusion in the pediatric anesthesia community, East/West ViSiPAP has the potential to increase job satisfaction, help faculty attain promotion and reduce attrition. Faculty and trainees are exposed to new expertise and role models. Moreover, ViSiPAP provides opportunities for women and underrepresented in medicine faculty. This program can help develop today's junior faculty into tomorrow's leaders in pediatric anesthesia. We advocate for expanding the concept of ViSiPAP to other institutions in academic medicine.

  View details for DOI 10.1111/pan.13867

  View details for PubMedID 32267048

• Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey CUREUS Muffly, M., Scheinker, D., Muffly, T., Singleton, M., Agarwal, R., Honkanen, A. 2019; 11 (9)

  View details for DOI 10.7759/cureus.5745

  View details for Web of Science ID 000487712800010

• Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey. Cureus Muffly, M., Scheinker, D., Muffly, T., Singleton, M., Agarwal, R., Honkanen, A. 2019; 11 (9): e5745

  Abstract

  Introduction We conducted a survey to describe the practice characteristics of anesthesiologists who have passed the American Board of Anesthesiology (ABA) Pediatric Anesthesiology Certification Examination. Methods In July 2017, a list of anesthesiologists who had taken the ABA Pediatric Anesthesiology Certification Examination (hereafter referred to as "pediatric anesthesiologists") was obtained from the American Board of Anesthesiologists (theaba.org). Email contact information for these individuals was collected from departmental rosters, email distribution lists, hospital or anesthesia group profiles, manuscript author contact information, website source code, and other publicly available online sources. The survey was designed using Qualtrics (Qualtrics, Provo, Utah; Seattle, Washington), a web-based tool, to ascertain residency/fellowship training history and current practice characteristics that includes: years in practice, clinical work hours per week, primary hospital setting, practice type, supervision model, estimated percentage of cases by patient age group, and percentage of respondents who cared for any patient undergoing a fellowship-level index cases within the previous year. The invitation to complete the survey included a financial incentive - the chance to win one of twenty $50 Amazon gift cards. Results There were 3,492 anesthesiologists who had taken the Pediatric Anesthesiology Certification Examination since 2013. Surveys were sent to those whom an email address was identified (2,681) and 962 complete survey responses were received (35.9%, 962/2,681). Over 80% (785) of respondents completed a pediatric anesthesiology fellowship. Of these, 485 respondents (50.4%) work in academic practice, 212 (22.0%) in private practice, 233 (24.2%) in private practice and have academic affiliations, and 32 (3.3%) as locum tenens or in other practice settings. The majority of respondents (64.3%) in academic practice work in freestanding children's hospitals. Pediatric anesthesiologists in academic practice and private practice with academic affiliations reported caring for a greater number of younger children and doing a wider variety of index cases than respondents in private practice. Conclusion The extent to which pediatric anesthesiologists care for pediatric patients - particularly young children and those undergoing complex cases - varies. The variability in practice characteristics is likely a result of differences in hospital type, anesthesia practice type, geographic location, and other factors.

  View details for DOI 10.7759/cureus.5745

  View details for PubMedID 31723506

  View details for PubMedCentralID PMC6825435

• The Society for Pediatric Anesthesiology Recommendations for the Use of Opioids in Children During the Perioperative Period. Paediatric anaesthesia Cravero, J. P., Agarwal, R., Berde, C., Birmingham, P., Cote, C. J., Galinkin, J., Isaac, L., Kost-Byerly, S., Krodel, D., Maxwell, L., Voepel-Lewis, T., Sethna, N., Wilder, R. 2019

  Abstract

  Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every two years. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1111/pan.13639

  View details for PubMedID 30929307

• Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know. Anesthesia and analgesia Flannery, K. M., D'Souza, G. n., Agarwal, R. n. 2019

  Abstract

  In 2018, 29 states allow the use of medicinal marijuana. In these states, minors, with parental permission, are granted access. Use has increased in some states, although there remains a paucity of clear evidence regarding usefulness and dosing. There are 2 Food and Drug Administration-approved synthetic derivatives. One purified compound was just approved by the Food and Drug Administration, and another is undergoing Food and Drug Administration review. This article will review the literature regarding the use of each of these compounds in the literature, with particular attention to data in children. The history, known pharmacology, data from nonmedicinal use, current evidence, and anesthetic considerations will be described.

  View details for DOI 10.1213/ANE.0000000000003956

  View details for PubMedID 30985382

• Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network. Anesthesia and analgesia Muhly, W. T., Beltran, R. J., Bielsky, A., Bryskin, R. B., Chinn, C., Choudhry, D. K., Cucchiaro, G., Fernandez, A., Glover, C. D., Haile, D. T., Kost-Byerly, S., Schnepper, G. D., Zurakowski, D., Agarwal, R., Bhalla, T., Eisdorfer, S., Huang, H., Maxwell, L. G., Thomas, J. J., Tjia, I., Wilder, R. T., Cravero, J. P. 2018

  Abstract

  BACKGROUND: There are few comparative data on the analgesic options used to manage patients undergoing minimally invasive repair of pectus excavatum (MIRPE). The Society for Pediatric Anesthesia Improvement Network was established to investigate outcomes for procedures where there is significant management variability. For our first study, we established a multicenter observational database to characterize the analgesic strategies used to manage pediatric patients undergoing MIRPE. Outcome data from the participating centers were used to assess the association between analgesic strategy and pain outcomes.METHODS: Fourteen institutions enrolled patients from June 2014 through August 2015. Network members agreed to an observational methodology where each institution managed patients based on their institutional standards and protocols. There was no requirement to standardize care. Patients were categorized based on analgesic strategy: epidural catheter (EC), paravertebral catheter (PVC), wound catheter (WC), no regional (NR) analgesia, and intrathecal morphine techniques. Primary outcomes, pain score and opioid consumption by postoperative day (POD), for each technique were compared while adjusting for confounders using multivariable modeling that included 5 covariates: age, sex, number of bars, Haller index, and use of preoperative pain medication. Pain scores were analyzed using repeated-measures analysis of variance with Bonferroni correction. Opioid consumption was analyzed using a multivariable quantile regression.RESULTS: Data were collected on 348 patients and categorized based on primary analgesic strategy: EC (122), PVC (57), WC (41), NR (120), and intrathecal morphine (8). Compared to EC, daily median pain scores were higher in patients managed with PVC (POD 0), WC (POD 0, 1, 2, 3), and NR (POD 0, 1, 2), respectively (P < .001-.024 depending on group). Daily opioid requirements were higher in patients managed with PVC (POD 0, 1), WC (POD 0, 1, 2), and NR (POD 0, 1, 2) when compared to patients managed with EC (P < .001).CONCLUSIONS: Our data indicate variation in pain management strategies for patients undergoing MIRPE within our network. The results indicate that most patients have mild-to-moderate pain postoperatively regardless of analgesic management. Patients managed with EC had lower pain scores and opioid consumption in the early recovery period compared to other treatment strategies.

  View details for PubMedID 30346358

• Concerns Regarding the Single Operator Model of Sedation in Young Children PEDIATRICS Agarwal, R., Kaplan, A., Brown, R., Cote, C. J. 2018; 141 (4)

  View details for PubMedID 29500294

• The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035 ANESTHESIA AND ANALGESIA Muffly, M. K., Singleton, M., Agarwal, R., Scheinker, D., Miller, D., Muffly, T. M., Honkanen, A. 2018; 126 (2): 568–78

  Abstract

  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

• Fifty years of the American Academy of Pediatrics Section on Anesthesiology: a history of our specialty. Paediatric anaesthesia Agarwal, R., Riefe, J., Houck, C. S. 2017; 27 (6): 560-570

  Abstract

  The American Academy of Pediatrics Section on Anesthesiology and Pain Medicine celebrated its 50th Anniversary in 2015. The Section was one of the first and only subspecialty organizations in anesthesiology at the time. This special article will focus on the contributions of the Section to the practice of pediatric anesthesiology in the areas of advocacy, education and member contributions. In 1986, the Section created the Robert M. Smith Award to honor those members who had made significant advances in the practice of pediatric anesthesiology. It is named after one of the Section founders, an influential educator, inventor, and researcher in our field. We will focus the latter part of the article on the Robert M. Smith award winners to illustrate the contributions of the Section and its members to the development of the field of pediatric anesthesiology.

  View details for DOI 10.1111/pan.13121

  View details for PubMedID 28332249

• Airway management in laryngotracheal injuries from blunt neck trauma in children PEDIATRIC ANESTHESIA Chatterjee, D., Agarwal, R., Bajaj, L., Teng, S. N., Prager, J. D. 2016; 26 (2): 132-138

  View details for DOI 10.1111/pan.12791

  View details for Web of Science ID 000367788700003

• Airway management in laryngotracheal injuries from blunt neck trauma in children. Paediatric anaesthesia Chatterjee, D., Agarwal, R., Bajaj, L., Teng, S. N., Prager, J. D. 2016; 26 (2): 132-8

  Abstract

  Pediatric laryngotracheal injuries from blunt neck trauma are extremely rare, but can be potentially catastrophic. Early diagnosis and skillful airway management is critical in avoiding significant morbidity and mortality associated with these cases. We present a case of a patient who suffered a complete tracheal transection and cervical spine fracture following a clothesline injury to the anterior neck. A review of the mechanisms of injury, clinical presentation, initial airway management, and anesthetic considerations in laryngotracheal injuries from blunt neck trauma in children are presented.

  View details for DOI 10.1111/pan.12791

  View details for PubMedID 26530711

• Pain and Pain Relief Handbook of Neonatal Intensive Care Gardner, S. L., Hagedorn, M. E., Agarwal, R. 2015
• Educate parents on benefits of smoking cessation before child’s surgery AAP: News Teng, S. N., Agarwal, R. 2015; 36 (13)

  View details for DOI 10.1542/aapnews.2015369-13

• Use of oral opioids during tonsillectomy re-evalauted AAP News Agarwal, R. 2014; 35 (13): 13

  View details for DOI 10.1542/aapnews.2014358-13

• Neonatal Anesthesia Anesthesia Secrets Agarwal, R. Elsevier. 2013
• A practical Approach to the Pediatric Neurosurgical Patient A practical Approach ot Neuroanesthesia Dean, K., Agarwal, R. 2013
• Pediatric Anesthesia Anesthesia Secrets Agarwal, R. Elsevier. 2013
• Acute Pain Services Pediatric Anesthesia: Basic Principles, State of the Art, Future – Update Agarwal, R., Polaner, D. PMPH-USA. 2011
• Improvement of intraoperative samatosensory evoked potentials by ketamine PAEDIATRIC ANAESTHESIA Agarwal, R., Roitman, K. J., Stokes, M. 1998; 8 (3): 263-266

  Abstract

  Many anaesthetics effect the latency and amplitude of somatosensory evoked potentials (SSEP). We present a patient who underwent two anterior/posterior spine fusions (A/PSF) at age 11 and 12 years old after resection of a spinal astrocytoma. She did have residual neurologic deficits of her lower extremities. SSEPs were unobtainable during the first surgery using an opioid-based anaesthetic. A ketamine-based anaesthetic was used for the second surgery and SSEPs were easily monitored. No other factors seem to have changed between the two surgeries. The anaesthetic management during each procedure is reviewed and the contributions of other factors to SSEP monitoring discussed.

  View details for Web of Science ID 000073673600017

  View details for PubMedID 9608975