Clinical Focus

  • Pediatric Anesthesia

Academic Appointments

Professional Education

  • Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2013)
  • Board Certification: American Board of Anesthesiology, Anesthesia (2012)
  • Fellowship: Stanford University (2012) CA
  • Residency: Stanford University (2011) CA
  • Internship: MetroHealth Medical Center (2008) OH
  • Medical Education: Case Western Reserve School of Medicine (2007) OH

Clinical Trials

  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) Use in Pediatric Procedures Not Recruiting

    THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) refers to the use of high-flow nasal cannula to augment the ability to oxygenate and ventilate a patient under general anesthesia. The use of high-flow nasal cannula oxygen supplementation during anesthesia for surgical procedures has been a recent development in the adult population, with limited data analyzing the pediatric population. This study will determine whether high flow nasal cannula oxygen supplementation during surgical or endoscopic procedures can safely prevent desaturation events in children under anesthesia.

    Stanford is currently not accepting patients for this trial. For more information, please contact Thomas J Caruso, M.D., M.Ed., 650-723-5728.

    View full details

All Publications

  • Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study. Journal of patient experience Yun, R., He, E. M., Zuniga, M., Guo, N., Wang, E. Y., Ho, F., Pearson, M., Rodriguez, S. T., Caruso, T. J. 2024; 11: 23743735241241146


    Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

    View details for DOI 10.1177/23743735241241146

    View details for PubMedID 38549806

    View details for PubMedCentralID PMC10976515

  • A prospective, observational validation of HRAD±, a novel pediatric affect and cooperation scale. Journal of clinical anesthesia Yun, R., Qian, D., Wang, E., Zuniga, M., Forbes, T., Li, B., Rodriguez, S. T., Jackson, C., Caruso, T. J. 2024; 94: 111410


    STUDY OBJECTIVE: HRAD± was developed to quickly assess pediatric perioperative affect and cooperation. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD± as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD± and predictive validity of induction HRAD± with emergence delirium.DESIGN: This was a prospective observational investigation.SETTING: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California.PATIENTS: A total of 197 patients were included in this investigation. Children 1-14years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible.INTERVENTIONS: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence.MEASUREMENTS: RAs scored each mask induction using the following scales: HRAD±, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD±. IRR of HRAD± between the RAs as well as predictive validity of HRAD± to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.840, p<0.0001) with moderate correlation to OSBD (r=0.685, p<0.0001) and ICC (-0.663, p<0.0001). IRR was moderate for the affect and cooperation portion of the HRAD± scale, respectively (kappa=0.595 [p<0.0001], kappa=0.478 [p<0.0001]). A weak correlation was observed with PAED (r=0.134 [p=0.0597]) vs HRAD±. No correlations were observed between Watcha (r=0.013 [p=0.8559]) and Cravero and HRAD± scales (r=0.002 [p=0.9767]).CONCLUSIONS: HRAD± is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales.

    View details for DOI 10.1016/j.jclinane.2024.111410

    View details for PubMedID 38340678

  • A systematic review of patient-reported outcome measures used in maternal postpartum anxiety. American journal of obstetrics & gynecology MFM O'Carroll, J., Ando, K., Yun, R., Panelli, D., Nicklin, A., Kennedy, N., Carvalho, B., Blake, L., Coker, J., Kaysen, D., Sultan, P. 2023: 101076


    To perform a systematic review and evaluate the psychometric measurement properties of instruments in postpartum anxiety using Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines and identify the best available patient-reported outcome measure.We searched 4 databases (CINAHL, Embase, PubMed, and Web of Science in July 2022) including studies which evaluated at least one psychometric measurement property of a patient reported outcome measurement instrument. The protocol was registered with PROSPERO CRD42021260004 and followed the COSMIN guidelines for systematic reviews.Studies eligible for inclusion included those that assessed a patient-reported outcome measure examining postpartum anxiety. We included studies where the instruments had undergone some form of psychometric property assessment in the postpartum maternal population, consisted of at least 2 questions, and were not subscales.This systematic review used COSMIN and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify the best patient reported outcome measurement instrument for postpartum anxiety. A risk of bias assessment was performed, and a modified GRADE approach used to assess the level of evidence with recommendations being made for the overall quality of each instrument.A total of 28 studies evaluating 13 instruments in 10,570 patients were included. Content validity was sufficient in 9, with 5 instruments receiving a class A recommendation (recommended for use). Postpartum Specific Anxiety Scale, Postpartum Specific Anxiety Scale Research Short Form, Postpartum Specific Anxiety Scale Research Short Form Covid, Postpartum Specific Anxiety Scale- Persian and State-Trait Anxiety Inventory demonstrated adequate content validity and sufficient internal consistency. Nine instruments received a recommendation of class B (further research required). No instrument received a class C recommendation (not recommended for use).Five instruments received a class A recommendation, all with limitations such as not being specific to the postpartum population, not assessing all domains, lacking generalizability or evaluation of cross-cultural validity. There is currently no freely available instrument assessing all domains of postpartum anxiety. Future studies are needed to determine the optimum current instrument or development and validation of a more specific measure for maternal postpartum anxiety.

    View details for DOI 10.1016/j.ajogmf.2023.101076

    View details for PubMedID 37402438

  • Assessing Pediatric Perioperative Affect: A Concise Review of Research and Clinically Relevant Scales. Paediatric anaesthesia Yun, R., Hess, O., Kennedy, K., Stricker, P. A., Blake, L., Caruso, T. J. 2022

    View details for DOI 10.1111/pan.14568

    View details for PubMedID 36178764

  • Expert Consensus Regarding Core Outcomes for Enhanced Recovery after Cesarean Delivery Studies: A Delphi study. Anesthesiology Sultan, P., George, R., Weiniger, C. F., El-Boghdadly, K., Pandal, P., Carvalho, B., CRADLE Study Investigators, Ansari, J. R., Benhamou, D., Baluku, M., Bernstein, P. S., Bollag, L. A., Bowden, S. J., Fay, E., Habib, A. S., Halder, S., Landau, R., Lim, G., Liu, V., Moreno, C., Nelson, G. S., Powell, M. F., Pujic, B., Sharawi, N., Singh, N., Smith, R., Stockert, E., Sultan, E., Tiouririne, M., Wilson, R. D., Wrench, I. J., Yun, R., Zakowski, M. 2022


    BACKGROUND: Heterogeneity among reported outcomes from enhanced recovery after cesarean delivery impact studies is high. This study aimed to develop a standardized enhanced recovery core outcome set for use in future enhanced recovery after cesarean delivery studies.METHODS: An international consensus study involving physicians, patients and a director of Midwifery and Nursing Services, was conducted using a three-round modified Delphi approach (2 rounds of electronic questionnaires and a 3rd round e-discussion), to produce the core outcome set. An initial list of outcomes was based on a previously published systematic review. Consensus was obtained for the final core outcome set, including definitions for key terms, and preferred units of measurement. Strong consensus was defined as ≥70% agreement and weak consensus as 50-69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate. All 32, 31 and 26 stakeholders completed Rounds 1, 2 and 3, respectively.RESULTS: The number of outcomes in the final core outcome set was reduced from 98 to 15. Strong consensus (≥70% stakeholder agreement) was achieved for 15 outcomes. The core outcome set included: length of hospital stay; compliance with enhanced recovery protocol; maternal morbidity (hospital re-admissions or unplanned consultations); provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption / requirement and incidence of nausea or vomiting); fasting times; breastfeeding success; and times to mobilization and urinary catheter removal. The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Areas identified as requiring further research included readiness for discharge and analysis of cost savings.CONCLUSIONS: Results from an international consensus to develop a core outcome set for enhanced recovery after cesarean delivery are presented. These are outcomes that could be considered when designing future enhanced recovery studies.

    View details for DOI 10.1097/ALN.0000000000004263

    View details for PubMedID 35511169

  • Augmented Reality as Sole Anxiolytic for Pediatric Inhalational Induction of General Anesthesia Sanofsky, B., Caruso, T. J., Zuniga, M., Rodriguez, S., Yun, R. LIPPINCOTT WILLIAMS & WILKINS. 2022: 81-84
  • Perioperative Pediatric Anxiety: A Cry for Universal Scale Adoption. Pediatric quality & safety Yun, R., Kennedy, K. M., Caruso, T. J. 2022; 7 (2): e542

    View details for DOI 10.1097/pq9.0000000000000542

    View details for PubMedID 35369415

  • Development and assessment of an efficient pediatric affect and cooperation scale. Journal of clinical anesthesia Kennedy, K., Wang, E., Rodriguez, S. T., Qian, J., Khoury, M., Kist, M. N., Jackson, C., Yun, R., Caruso, T. J. 2021; 76: 110569


    STUDY OBJECTIVE: HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales.DESIGN: We conducted an observational study.SETTING: Videos of pediatric patients were collected in the perioperative environment.PATIENTS: Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included.INTERVENTIONS: To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±.MEASUREMENTS: Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.846, p<0.0001) and OSBD scores (r=0.723, p<0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r=-0.715, p<0.0001) and in the PIV group (r=-0.869, p<0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p<0.0001) and for PIV assessment was 0.378 (p<0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p<0.0001) and PIV assessment was 0.683 (p<0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765.CONCLUSIONS: HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales.

    View details for DOI 10.1016/j.jclinane.2021.110569

    View details for PubMedID 34739949

  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) Use During Microdirect Laryngoscopy and Bronchoscopy: Initial Data from a Randomized, Prospective, Multi-Collaborative Trial Swanger, A., Yun, R., Olbrecht, V., Winograd, V., Evans, M. A., Stein, M., Ravula, N., Menendez, M., Wang, E., Sidell, D., Caruso, T. LIPPINCOTT WILLIAMS & WILKINS. 2021: 784-785
  • Application of Echogenic Technology for Catheters Used in Ultrasound-Guided Continuous Peripheral Nerve Blocks JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Yun, R. D., Kim, T. E., Carvalho, B. 2014; 33 (5): 905-911


    Limited data exist regarding the echogenicity of perineural catheters, but visualization is crucial to ensure accurate placement and efficacy of the subsequent local anesthetic infusion. The objective of this study was to determine the comparative echogenicity of various regional anesthesia catheters. In an in vitro porcine-bovine model, we compared the echogenic qualities of 3 commercially available regional anesthesia catheters and 1 catheter under development to optimize echogenicity. Outcomes included visual echogenicity ranking, image quality, and scanning time, as assessed by 2 blinded investigators. The experimental catheter was found to be more echogenic than 2 of the 3 comparators.

    View details for DOI 10.7863/ultra.33.5.905

    View details for Web of Science ID 000335620700018

    View details for PubMedID 24764346

  • Temperature-controlled radiofrequency treatment of tonsillar hypertrophy for reduction of upper airway obstruction in pediatric patients. Archives of otolaryngology--head & neck surgery Coticchia, J. M., Yun, R. D., Nelson, L., Koempel, J. 2006; 132 (4): 425-30


    To determine if temperature-controlled radiofrequency (TCRF) tonsil reduction and adenoidectomy (TCRF&A) and conventional tonsillectomy and adenoidectomy (T&A) are statistically similar in outcome and to compare morbidity between TCRF&A and conventional T&A.Randomized control trial.Tertiary care children's hospital.The study population comprised 23 patients aged 2.6 to 12.5 years with symptoms of obstructive sleep apnea, hypertrophic tonsils with no other areas of upper airway obstruction with the exception of hypertrophic adenoids, and a body mass index (calculated as weight in kilograms divided by the square of height in meters) of less than 30.Temperature-controlled radiofrequency tonsil reduction (mean +/- SD, 12.6 +/- 1.5 ablations per patient and 994.68 +/- 91.88 J per insertion) and adenoidectomy or traditional bovie T&A.Primary outcomes were respiratory distress index and total volume reduction. Secondary outcomes include postoperative pain, daytime sleepiness, speech and swallowing problems, weight and diet, narcotic use, and analogue snoring scale.The respiratory distress index difference for TCRF&A was 5.63 vs 6.56 for standard T&A. On postoperative day 1 for the 13 patients who underwent TCRF&A, 0 reported severe pain, 11 (85%) had mild to moderate pain, and 2 (15%) had no pain. In the 10 patients who underwent standard T&A, 1 (10%) had severe pain and 9 (90%) had mild to moderate pain. By postoperative week 1, all TCRF&A patients experienced mild or no pain, whereas 1 (10%) of the standard T&A patients still had moderate pain. Mean visual analogue snore scores (0-10) 4 weeks after surgery were less than 1 for both groups. The mean +/- SD weight loss at postoperative week 1 for TCRF tonsil reduction patients was 1.0 +/- 3.5 lb (0.45 +/- 1.58 kg) vs 4.6 +/- 3.9 lb (2.07 +/- 1.76 kg) for standard T&A patients. Return to normal diet at postoperative week 1 occurred in 11 TCRF&A patients (85%) and 0 standard T&A patients.The respiratory distress indexes were similar for TCRF&A patients and standard T&A patients. In addition, there were similar analog snoring scales, decreased pain, and weight loss.

    View details for DOI 10.1001/archotol.132.4.425

    View details for PubMedID 16618912

  • Age-, site-, and time-specific differences in pediatric deep neck abscesses. Archives of otolaryngology--head & neck surgery Coticchia, J. M., Getnick, G. S., Yun, R. D., Arnold, J. E. 2004; 130 (2): 201-7


    To clarify presentations, organisms, and locations of deep neck abscesses in children.Retrospective review.Tertiary children's hospital. The study population comprised 169 patients younger than 19 years who were surgically treated for deep neck abscesses between 1989 and 1999.Resolution of abscess.Neck mass (91%), fever (86%), cervical adenopathy (83%), poor oral intake (66%), and neck stiffness (59%) were common in all ages. Patients younger than 4 years, compared with patients 4 years or older, presented with agitation (50% vs 14%), cough (35% vs 14%), drooling (27% vs 12%), lethargy (46% vs 33%), oropharyngeal abnormalities (45% vs 60%), respiratory distress (5% vs 2%), retractions (5% vs 2%), rhinorrhea (53% vs 15%), stridor (4% vs 2%), and trismus (14% vs 53%). Children younger than 1 year were infected with Staphylococcus aureus (79%) vs group A streptococcus (6%). Children 1 year or older were infected with group A streptococcus (29%) vs S aureus (16%). Retropharyngeal or parapharyngeal regions were involved in children 1 year or older (49%) vs younger than 1 year (21%). Anterior or posterior triangles and submandibular or submental regions were involved in 39% and 36%, respectively, of children younger than 1 year vs 30% and 23%, respectively, of children 1 year or older. Retropharyngeal and parapharyngeal abscesses yielded group A streptococcus (34%) vs S aureus (11%). Anterior and posterior triangle abscesses yielded S aureus (35%) vs group A streptococcus (19%), as did submandibular and submental abscesses (42% vs 19%).Abscesses in children younger than 1 year affected anterior or posterior triangles and submandibular or submental regions, yielding S aureus. Abscesses in children 1 year or older affected retropharyngeal or parapharyngeal regions, yielding group A streptococcus.

    View details for DOI 10.1001/archotol.130.2.201

    View details for PubMedID 14967751

  • mSin3A/histone deacetylase 2- and PRMT5-containing Brg1 complex is involved in transcriptional repression of the Myc target gene cad. Molecular and cellular biology Pal, S., Yun, R., Datta, A., Lacomis, L., Erdjument-Bromage, H., Kumar, J., Tempst, P., Sif, S. 2003; 23 (21): 7475-87


    The role of hSWI/SNF complexes in transcriptional activation is well characterized; however, little is known about their function in transcriptional repression. We have previously shown that subunits of the mSin3A/histone deacetylase 2 (HDAC2) corepressor complex copurify with hSWI/SNF complexes. Here we show that the type II arginine-specific methyltransferase PRMT5, which is involved in cyclin E repression, can be found in association with Brg1 and hBrm-based hSWI/SNF complexes. We also show that hSWI/SNF-associated PRMT5 can methylate hypoacetylated histones H3 and H4 more efficiently than hyperacetylated histones H3 and H4. Protein-protein interaction studies indicate that PRMT5 and mSin3A interact with the same hSWI/SNF subunits as those targeted by c-Myc. These observations prompted us to examine the expression profile of the c-Myc target genes, carbamoyl-phosphate synthase-aspartate carbamoyltransferase-dihydroorotase (cad) and nucleolin (nuc). We found that cad repression is altered in cells that express inactive Brg1 and in cells treated with the HDAC inhibitor depsipeptide. Using chromatin immunoprecipitation assays, we found that Brg1, mSin3A, HDAC2, and PRMT5 are directly recruited to the cad promoter. These results suggest that hSWI/SNF complexes, through their ability to interact with activator and repressor proteins, control expression of genes involved in cell growth and proliferation.

    View details for DOI 10.1128/mcb.23.21.7475-7487.2003

    View details for PubMedID 14559996

    View details for PubMedCentralID PMC207647