Dr Agarwal is a Pediatric Anesthesiologist who went to medical school and completed her anesthesia residency at Baylor College of Medicine, with a fellowship in pediatric anesthesiology at Denver Children's Hospital. Her interests include pediatric acute pain management, regional anesthesia, ambulatory anesthesia and neuro-anesthesia and medical student, reisident fellow education. She was the Pediatric Anesthesia Program Director at the University of Colorado for 18 years and the Course Director for the Colorado Review of Anesthesiology for Surgicenters and Hospitals for 17. She has served as the Editor for the Society for Pediatric Anesthesia Newsletter, Communication Chair and member of the Board Of Directors. She is immediate past Chair for the American Academy of Pediatrics:Section on Anesthesiology and Pain Management, and the Vice President for the Society of Pediatric Pain Management. She is delighted to be at Stanford and Lucille Packard Children's Hospital
- pediatric pain management
- Acute Pain Service
Clinical Professor, Anesthesiology, Perioperative and Pain Medicine
Chair, American Academy of Pediatrics Section on Anesthsiology (2015 - 2017)
President, Society for Pediatric Pain Medicine (2019 - 2021)
Pediatric Anesthesia Trauma Liaison, Stanford (2015 - Present)
Director Pediatric Anesthesia Education, Stanford/ LPCH (2014 - Present)
Boards, Advisory Committees, Professional Organizations
Chair-Elect, American Academy of Pediatrics:Section on Anesthesiology and Pain Management (2013 - 2014)
Junior Editor, American Board of Anesthesiology: Pediatric Anesthesiology Examination (2009 - Present)
Senior Editor, American Board of Anesthesiology (2011 - Present)
Director -At -Large, Pediatric Anesthesia Program Directors (2010 - 2014)
Course and Program Director, Colorado Review of Anesthesiology for Surgicenters and Hospitals (CRASH) (1997 - 2015)
Treasurer, Society for Pediatric Pain Medicine (2014 - Present)
At-large Director, Society for Pediatric Anesthesia (2006 - 2014)
Residency: Baylor College of Medicine Anesthesiology Residency (1990) TX
Internship: Baylor College of Medicine Surgery Residency (1987) TX
Fellowship: Childrens Hospital of Colorado Pediatric Anesthesiology Fellowship (1991) CO
Medical Education: Baylor College of Medicine Registrar (1986) TX
Board Certification: Pediatric Anesthesia, American Board of Anesthesiology (2013)
Pediatric Anesthesiology, Denver Children's Hospital, Pediatric Anesthesiology (1991)
Anesthesiology, Baylor College of Medicine, Anesthesiology (1990)
Board Certification: Anesthesia, American Board of Anesthesiology (1992)
MD, Baylor College of Medicine, Medicine (1986)
BA, Texas A&M, Biology (1982)
Current Research and Scholarly Interests
Part of a multi=institutional national group comparing various techniques of analgesia used in the management of surgical repairs. The first surgical procedure we are studying is Pecturs Excavatum repair. Each institution follows its usual protocols and data is collected on a variety of outcomes, including length of stay, pain scores, opioid consumption, time to start walking and any long term issues.
Once data collection and analysis of that procedure is complete we will start looking at Spinal Fusion
- Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey CUREUS 2019; 11 (9)
The Society for Pediatric Anesthesiology Recommendations for the Use of Opioids in Children During the Perioperative Period.
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
Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey.
2019; 11 (9): e5745
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
Perioperative Management of the Pediatric Patient on Medicinal Marijuana: What Anesthesiologists Should Know.
Anesthesia and analgesia
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
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
2018; 141 (4)
View details for PubMedID 29500294
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
Fifty years of the American Academy of Pediatrics Section on Anesthesiology: a history of our specialty.
2017; 27 (6): 560-570
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 2016; 26 (2): 132-138
Airway management in laryngotracheal injuries from blunt neck trauma in children.
2016; 26 (2): 132–38
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 PubMedID 26530711
- Pain and Pain Relief Handbook of Neonatal Intensive Care 2015
Educate parents on benefits of smoking cessation before child’s surgery
2015; 36 (13)
View details for DOI 10.1542/aapnews.2015369-13
Use of oral opioids during tonsillectomy re-evalauted
2014; 35 (13): 13
View details for DOI 10.1542/aapnews.2014358-13
- Neonatal Anesthesia Anesthesia Secrets Elsevier. 2013
- A practical Approach to the Pediatric Neurosurgical Patient A practical Approach ot Neuroanesthesia 2013
- Pediatric Anesthesia Anesthesia Secrets Elsevier. 2013
- Acute Pain Services Pediatric Anesthesia: Basic Principles, State of the Art, Future – Update PMPH-USA. 2011
Improvement of intraoperative samatosensory evoked potentials by ketamine
1998; 8 (3): 263-266
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