Dr. Sam Rodriguez is a native of New Jersey and practicing Pediatric Anesthesiologist at Stanford Children's Hospital. He is best known for being the husband of the Stanford Cardiologist Dr. Fatima Rodriguez. Sam was a member of the self proclaimed greatest Anesthesia Residency Class in history (MGH 2012). He is a founder and co-director of the Stanford CHARIOT Program which creates and studies innovative approaches to treating pediatric pain and stress through technology. The CHARIOT Program has positively impacted thousands of children around the world and has grown to include emerging technologies like virtual reality, augmented reality, and interactive video games. Dr. Rodriguez is also highly involved in medical humanities education at Stanford Medical School and teaches courses at the undergraduate and graduate levels on how studying art can make better physicians.
- Pediatric Anesthesia
Clinical Associate Professor, Anesthesiology, Perioperative and Pain Medicine
Fellowship: Boston Children's Hospital (2013) MA
Residency: Massachusetts General Hospital (2012) MA
Medical Education: Perelman School of Medicine University of Pennsylvania (2008) PA
Board Certification: American Board of Anesthesiology, Anesthesiology (2013)
Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2013)
VR Usage in Non-Invasive Surgical Sub-Specialty Procedures
Preprocedural, preoperative, and prevascular access anxiety in pediatric patients has been previously shown to increase the likelihood of family stressors, agitation, sleep disturbances, and negative behavioral changes. The purpose of this study is to determine if a non-invasive distracting device (Virtual Reality (VR) headset, Augmented Reality (AR) headset, or bed mounted Video Projection unit (i.e. BERT, Bedside EnterRtainment Theater)) is more effective than the standard of care (i.e., no technology based distraction) for preventing anxiety before non-invasive surgical sub-specialty procedures among children during out-patient clinic visits. Examples of the most common procedures include, but are not limited to gastrostomy tube exchanges, suture removals, dressing changes, foley insertions, EEG set up, chest tube removals, cast removals, pin removals and other similar procedures. (The investigators refer to these procedures under an umbrella term of non-invasive surgical subspecialty procedures). The anticipated primary outcome will be reduction of child's anxiety during and after procedures.
Evaluation of Technology-Based Stress Reduction Techniques Prior to Vascular Access
Preprocedural, preoperative, and prevascular access anxiety in pediatric patients has been previously shown to increase the likelihood of family stressors, postoperative pain, agitation, sleep disturbances, and negative behavioral changes. The purpose of this study is to determine if a non-invasive distracting devices (Virtual Reality headset) is more effective than the standard of care (i.e., no technology based distraction) for preventing anxiety before vascular access among hospitalized children undergoing vascular access prior to anesthesia, procedures, surgery, blood draws, port access, or peripheral IV placement. The anticipated primary outcome will be reduction of child's anxiety during and after vascular access.
Stanford is currently not accepting patients for this trial. For more information, please contact Sam Rodriguez, MD, 650-723-5728.
Screen-Based Distraction Tool for Preoperative Preparation
Preoperative anxiety in pediatric patients undergoing surgical procedures has been previously shown to increase the likelihood of family stressors, post- operative pain, agitation, sleep disturbances, and negative behavioral changes. The purpose of this study is to determine whether the use of a bed mounted Video Projection unit (i.e. BERT, Bedside EnterRtainment Theater) is more effective than the use of a standard of care tablet (i.e., iPad) for preventing anxiety before surgery among children undergoing anesthesia and surgery. The anticipated primary outcome will be reduction of child's anxiety in the preoperative and operating room setting and compliance with mask induction.
Stanford is currently not accepting patients for this trial. For more information, please contact Spectrum Child Health, 650-724-1175.
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) Use in Pediatric Procedures
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.
- Mending a broken heart: The Anatomy, Physiology and Psychology of congenital heart disease
ANES 74Q (Spr)
- The Art of Medical Diagnosis
ANES 72Q (Spr)
- The Art of Observation: Enhancing Clinical Skills Through Visual Analysis
SOMGEN 213 (Win)
- Independent Studies (3)
Prior Year Courses
- Mending a broken heart: The Anatomy, Physiology and Psychology of congenital heart disease
ANES 74Q (Win)
- The Art of Observation: Enhancing Clinical Skills Through Visual Analysis
SOMGEN 213 (Win)
- The Art of Medical Diagnosis
ANES 72Q (Spr)
- Mending a broken heart: The Anatomy, Physiology and Psychology of congenital heart disease
Small surgeries, big smiles: using virtual reality to reduce the need for sedation or general anesthesia during minor surgical procedures.
Pediatric surgery international
PURPOSE: Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures.METHOD: In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children's hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times.RESULTS: Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65min, p<0.001). Participant satisfaction scores were high, with 95% recommending VR to others.CONCLUSIONS: VR is a feasible alternative to sedation or GA for select pediatric patients undergoing minor surgical procedures.
View details for DOI 10.1007/s00383-021-04955-6
View details for PubMedID 34269867
- Commentary on A Body of Work: Painting a Decade of Gross Dissection. Academic medicine : journal of the Association of American Medical Colleges 2018; 93 (3): 429
- Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety. Paediatric anaesthesia 2017; 27 (6): 668–69
Interactive video game built for mask induction in pediatric patients.
Canadian journal of anaesthesia = Journal canadien d'anesthesie
View details for PubMedID 28646461
- The transfer of care. Anesthesia and analgesia 2015; 120 (3): 687-?
- Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2021; 7 (5): 431-434
Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study
2021; 8 (5)
The aim of this pilot study was to assess: (1) the feasibility and acceptability of a Mindfulness-Based Virtual Reality (MBVR) intervention among children and young adults with Inflammatory Bowel Disease (IBD), and (2) the preliminary efficacy of MBVR on key psychological (anxiety) and physical (pain) outcomes. Participants were 62 children to young adults with IBD (M = 15.6 years; 69.4% Crohn's disease; 58% male) recruited from an outpatient pediatric IBD clinic. Participants completed a baseline assessment, underwent the 6-min MBVR intervention, completed a post-intervention assessment and study satisfaction survey, and provided qualitative feedback. Results suggest strong feasibility and acceptability. Participants reported high levels of satisfaction with MBVR including high levels of enjoyment (M = 4.38; range 1-5) and relaxation (M = 4.35; range 1-5). Qualitative data revealed several key themes including participants interest in using MBVR in IBD medical settings (e.g., hospitalizations, IBD procedures, IBD treatments), as well as in their daily lives to support stress and symptom management. Preliminary analyses demonstrated improvements in anxiety (t = 4.79, p = 0.001) and pain (t = 3.72, p < 0.001) following MBVR. These findings provide initial support for the feasibility and acceptability of MBVR among children and young adults with IBD. Results also suggest MBVR may improve key IBD outcomes (e.g., anxiety, pain) and highlight the importance of conducting a randomized controlled trial and more rigorous research to determine intervention efficacy.
View details for DOI 10.3390/children8050368
View details for Web of Science ID 000653585100001
View details for PubMedID 34063034
- Unique considerations of virtual reality utilization for perioperative pediatric patients. Paediatric anaesthesia 2021; 31 (3): 377–78
Leveraging VR/AR to combat chronic pain in youth: Position paper from the Interdisciplinary Network on Virtual and Augmented (AR/VR) Technologies for Pain (INOVATE-Pain) Management.
Journal of medical Internet research
Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions, but in this young field there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.The INOVATE-Pain consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.An interdisciplinary meeting of 16 academics, clinicians, industry and philanthropy partners was held in January 2020.Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR/AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR/AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.To realize the promise of this realm of innovation, key ingredients for the success include productive partnerships among industry, academic, and clinical stakeholders, a uniform set of outcome domains and measures for standardized evaluation, and widespread access to the latest opportunities, tools and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.
View details for DOI 10.2196/25916
View details for PubMedID 33667177
Virtual reality for pediatric periprocedural care.
Current opinion in anaesthesiology
2021; 34 (3): 284–91
Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.
View details for DOI 10.1097/ACO.0000000000000983
View details for PubMedID 33935176
Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial.
American journal of physical medicine & rehabilitation
Virtual reality (VR) facilitates physical therapy (PT) via improved engagement. While shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient PT. The primary objective was to compare total PT-guided Movement supplemented with VR (PTMVR) to PT guided Movement alone, without VR (PTM).This pragmatic, randomized, crossover study compared PTMVR to PTM in outpatients (ages 6-80). This community sample had variable PT indications (injury, postoperative, chronic pain) and in preexisting conditions, therefore participants served as their own controls. Participants received 10 minutes of both PTMVR and PTM, separated by five minutes. The primary outcome was differences in aggregate movement of PT guided exercises. Secondary outcomes explored OMNI rating of perceived exertion (RPE) and participant and physical therapist satisfaction. Paired t-tests, chi-squared tests, and regression models were used to analyze differences.The 41 participants (17 pediatric and 24 adult) moved significantly more during PTMVR compared to PTM (1120.88 meters vs 672.65 meters p < 0.001), regardless of which intervention was completed first. PTMVR treatment was associated with more movement of the target limbs, lower-body (p < 0.001), upper-body (p <0.05). OMNI RPE scores did not differ between those who started with PTMVR or PTM, and physical therapist and patient surveys endorsed PTMVR.Patients completed more PT guided movement during PTMVR than PTM and therapists and patients supported its use. Future studies will examine finer tracking of movements.
View details for DOI 10.1097/PHM.0000000000001779
View details for PubMedID 33935153
Virtual Reality Facilitates Engagement in Physical Therapy in the Pediatric CVICU.
Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association
2021; 33 (1): E7–E9
The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays.While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge.While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.
View details for DOI 10.1097/PEP.0000000000000769
View details for PubMedID 33337780
Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study.
JMIR rehabilitation and assistive technologies
2020; 7 (2): e22620
BACKGROUND: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.OBJECTIVE: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.METHODS: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.RESULTS: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.CONCLUSIONS: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.
View details for DOI 10.2196/22620
View details for PubMedID 33226346
A Retrospective Cohort Study of Predictors and Interventionsthat Influence Cooperation with Mask Induction in Children.
BACKGROUND: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation.AIM: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation.METHODS: This retrospective cohort study included patients 2 -11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed effects logistic regression was used to examine the association between preoperative interventions and cooperation.RESULTS: 9,692 patients underwent 23,474 procedures during the study period. 3,372 patients undergoing 5,980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002).CONCLUSION: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.
View details for DOI 10.1111/pan.13930
View details for PubMedID 32452092
Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital.
Pediatric quality & safety
2020; 5 (2): e293
Introduction: Virtual reality (VR) is an emerging tool for anxiety and fear reduction in pediatric patients. VR use is facilitated by Certified Child Life Specialists (CCLS) at pediatric hospitals. The primary aim of this study was to retrospectively review the safety of VR by analyzing adverse events after the utilization of VR under CCLS supervision. Secondary objectives were to characterize the efficacy of VR in enhancing patient cooperation, describe the integration of VR into Child Life services, and identify interventions that accompanied VR.Methods: The Stanford Chariot Program developed VR applications, customized VR interfaces, and patient head straps, and distributed these to CCLS. Chart review analyzed VR utilization through CCLS patient notes. Inclusion criteria were all patients ages 6 to 18-years-old who received a Child Life intervention.Results: From June 2017 to July 2018, 31 CCLS saw 8,098 patients, 3,696 of which met age criteria with pre- and post-intervention cooperation data. Two hundred thirteen patients received VR with an accompanying intervention, while 34 patients received only VR. Adverse events were rare, and included increased anxiety (3.8%, n=8), dizziness (0.5%, n=1), and nausea (0.5%, n=1). Patients were more likely to be cooperative after receiving VR (99.5%, n=212) compared to pre-intervention (96.7%, n=206, p=0.041). VR use was most common in the perioperative setting (60%, n=128), followed by outpatient clinics (15%, n=32).Conclusion: VR is safe in pediatric patients with appropriate hardware, software, and patient selection. Side effects were rare and self-limited. VR appears to be associated with improvements in cooperation.
View details for DOI 10.1097/pq9.0000000000000293
View details for PubMedID 32426648
Impact of Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) on Anesthesia Use, Payer Charges, and Treatment Time in Pediatric Patients.
Practical radiation oncology
PURPOSE: Pediatric radiotherapy requires optimal immobilization that often necessitates daily anesthesia. To decrease anesthesia use, we implemented a novel XXX system which projects video onto a radiolucent screen within the child's line of vision to provide attentional diversion. We investigated its reduction on anesthesia use, payer charges, and treatment time, as well as its impact on radiation delivery.METHODS AND MATERIALS: A 6-year retrospective analysis was performed among children undergoing radiotherapy (n=224), 3 years before and 3 after introduction of XXX. The frequency of anesthesia use before and after XXX implementation, as well as radiotherapy treatment times were compared. The number of spared anesthesia treatments allowed for a charge to payer analysis. To document lack of surface dose perturbation by XXX, a phantom craniospinal treatment course was delivered both with and without XXX. Additionally, an ion chamber course was delivered to document changes to dose at depth.RESULTS: More children were able to avoid anesthesia use entirely in the post-XXX cohort, compared to the pre-XXX cohort (73.2% vs 63.4%, p=0.03) and fewer required anesthesia for each treatment (18.8% vs 33%; p = 0.03). XXX introduction reduced anesthesia use for all ages studied. Treatment time per session was reduced by 38% using XXX compared to anesthesia. There were 326 fewer anesthesia sessions delivered over three years after XXX was introduced, with an estimated savings of > $500,000. OSLDs revealed a small increase in dose of 0.8%-9.5% with XXX, while the use of a thermomolded face mask increased skin dose as much as 58%.CONCLUSIONS: XXX introduction decreased anesthesia use in children undergoing radiotherapy; more avoided anesthesia entirely, and fewer needed it for every treatment. This resulted in a reduction in treatment time, and savings of nearly $550,000 in approximately 3 years, with minimal perturbation of radiotherapy dose delivery.
View details for DOI 10.1016/j.prro.2019.12.009
View details for PubMedID 31935524
Mobilization and calibration of the HTC VIVE for virtual reality physical therapy.
2020; 6: 2055207620950929
Aims: The HTC VIVE virtual reality (VR) system is a potential tool for collecting kinematic data during inpatient and outpatient physical therapy (PT). When validated against research-grade systems, the VIVE has a reported translational error between 1.7mm-2.0cm. Our purpose was to portabilize the VIVE for room to room PT and validate the motion tracking software.Methods: The VIVE was configured on a mobile cart. To validate the motion tracking software, the VIVE sensors (motion tracker, controller, headset) were mounted on a rigid linear track and driven through 10, one-meter translations in the X, Y, and Z axes.Results: The mean translational error for all three sensors was below 4.9cm. While error is greater than that reported for research-grade systems, motion tracking software on the portable VIVE unit appears to be a valid means of tracking aggregate movement.Conclusion: Some therapy may require more precise measurements, however, the advantages of portability and accessibility to patients may outweigh the limitation of reduced precision.
View details for DOI 10.1177/2055207620950929
View details for PubMedID 32963801
Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures.
This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 2020.
View details for DOI 10.1002/lary.29098
View details for PubMedID 32886794
- Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) augments oxygenation in children with cyanotic heart disease during microdirect laryngoscopy and bronchoscopy JOURNAL OF CLINICAL ANESTHESIA 2019; 56: 53–54
Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial.
BACKGROUND: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behaviour. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.AIM: The primary aim was to determine if a large projection based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.METHODS: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included 1) induction compliance, 2) child fear, 3) frequency of emergence delirium, and 4) satisfaction.RESULTS: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51)=13.18, p<0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) x group (BERT vs. Tablet) was not significant, f(2, 51)=1.96, p=0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.CONCLUSION: In a low risk population, preoperative anxiety was low and induction compliance was high when pairing screen based distraction interventions, regardless of size, with parental presence at induction of anesthesia. This article is protected by copyright. All rights reserved.
View details for PubMedID 30916447
Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study.
Anesthesia and analgesia
BACKGROUND: Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation.METHODS: We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight.RESULTS: In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046).CONCLUSIONS: These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.
View details for PubMedID 30633054
Virtual Reality during Pediatric Vascular Access: A Pragmatic, Prospective Randomized, Controlled Trial.
Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics.The primary aim was to determine if pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events.A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified induction compliance checklist, and satisfaction surveys, respectively. Chi-squared, t-tests, and regression models were used to analyze the results.The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in post-procedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, p=0.59), post-procedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater) or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96 to 5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events.This study demonstrates no reduction in pain while using VR across a heterogeneous pediatric inpatient population undergoing vascular access.
View details for DOI 10.1111/pan.13778
View details for PubMedID 31785015
Virtual reality use in adult ICU to mitigate anxiety for a patient on V-V ECMO.
Journal of clinical anesthesia
2018; 55: 26–27
View details for PubMedID 30590187
- Saphenous nerve block for medial foot surgery: Saphenous nerve beyond cutaneous sensory distribution. Journal of clinical anesthesia 2018; 54: 160–61
The Precision Portrait.
AMA journal of ethics
2018; 20 (9): E891–893
The Precision Portrait is a mixed-media portrait illustrating the future of precision medicine and its ethical challenges.
View details for PubMedID 30242821
Active Virtual Reality Improves Vascular Access Compliance in Anxious Children
LIPPINCOTT WILLIAMS & WILKINS. 2018: 114–15
View details for Web of Science ID 000453838000050
A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety.
Pediatric quality & safety
2018; 3 (4): e087
Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."
View details for PubMedID 30229198
- Continuous erector spinae plane block for an open pyeloplasty in an infant. Journal of clinical anesthesia 2018; 47: 47–49
- Augmented reality for intravenous access in an autistic child with difficult access. Paediatric anaesthesia 2018; 28 (6): 569–70
- A Body of Work: Painting a Decade of Gross Dissection. Academic medicine : journal of the Association of American Medical Colleges 2018; 93 (3): 428
Contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection: a technique for oncological resection of posterolateral spinal tumors
JOURNAL OF NEUROSURGERY-SPINE
2017; 26 (3): 275-281
En bloc resection of tumors involving the spinal column is technically challenging and is associated with high morbidity to the patient due to the proximity of critical neurological and vascular structures and the destabilizing nature of this surgery. Nevertheless, evidence has shown improved progression-free survival with en bloc resection for certain low-grade malignant and aggressive benign musculoskeletal tumors. To avoid the morbidity of en bloc spondylectomy in patients with tumors localized to the lateral and posterolateral spinal column, the authors have found that the goals of surgery can be accomplished through a contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection (COPPER). They reviewed their series of 5 patients who underwent successful tumor removal through a COPPER approach. These patients were all found to harbor spinal column tumors involving the posterolateral elements that, based on pathology, would benefit from en bloc resection. Tumor pathology included chondrosarcoma, leiomyosarcoma, osteoblastoma, and liposarcoma. Resections were performed by completing ipsilateral facetectomies above and below the lesion and ipsilateral pedicle osteotomies from a contralateral approach following hemilaminectomy. By disarticulating the posterolateral elements while carefully protecting the thecal sac, the tumors were removed en bloc along with the affected lamina, pedicles, pars interarticularis, and spinous processes, allowing tumor-free margins. This technical report suggests that the COPPER approach is safe and effective for en bloc resection of tumors involving the posterolateral aspect of the spinal column with tumor-free margins and that it eliminates the need for anterior column reconstruction.
View details for DOI 10.3171/2016.8.SPINE16398
View details for Web of Science ID 000394925900001
Initial clinical outcomes of audiovisual-assisted therapeutic ambience in radiation therapy (AVATAR).
Practical radiation oncology
Radiation therapy is an important component of treatment for many childhood cancers. Depending upon the age and maturity of the child, pediatric radiation therapy often requires general anesthesia for immobilization, position reproducibility, and daily treatment delivery. We designed and clinically implemented a radiation therapy-compatible audiovisual system that allows children to watch streaming video during treatment, with the goal of reducing the need for daily anesthesia through immersion in video.We designed an audiovisual-assisted therapeutic ambience in radiation therapy (AVATAR) system using a digital media player with wireless streaming and pico projector, and a radiolucent display screen positioned within the child's field of view to him or her with sufficient entertainment and distraction for the duration of serial treatments without the need for daily anesthesia. We piloted this system in 25 pediatric patients between the ages of 3 and 12 years. We calculated the number of fractions of radiation for which this system was used successfully and anesthesia avoided and compared it with the anesthesia rates reported in the literature for children of this age.Twenty-three of 25 patients (92%) were able to complete the prescribed course of radiation therapy without anesthesia using the AVATAR system, with a total of 441 fractions of treatment administered when using AVATAR. The median age of patients successfully treated with this approach was 6 years. Seven of the 23 patients were initially treated with daily anesthesia and were successfully transitioned to use of the AVATAR system. Patients and families reported an improved treatment experience with the use of the AVATAR system compared with anesthesia.The AVATAR system enables a high proportion of children to undergo radiation therapy without anesthesia compared with reported anesthesia rates, justifying continued development and clinical investigation of this technique.
View details for DOI 10.1016/j.prro.2017.01.007
View details for PubMedID 28242188
- Induction. Anesthesia and analgesia 2017
Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients.
Canadian journal of anaesthesia = Journal canadien d'anesthesie
View details for PubMedID 28861855
Epidural Steroid Injections for Radiculopathy and/or Back Pain in Children and Adolescents: A Retrospective Cohort Study With a Prospective Follow-Up.
Regional anesthesia and pain medicine
2016; 41 (1): 86-92
Epidural steroid injections (ESIs) are commonly performed for adults with spinal pain and/or radiculopathy. Previous pediatric ESI case series were not identified by literature review. The primary aim of this study was to examine the safety and provisional outcomes of pediatric ESIs.With institutional review board approval, medical records were reviewed for patients aged 9 to 20 years receiving a first ESI at Boston Children's Hospital from 2003 through 2013. A subset of patients completed a Web-based follow-up questionnaire. Descriptive statistics included frequencies, medians, interquartile ranges, and Kaplan-Meier methods. Statistical comparisons were made using Wilcoxon rank sum, χ2, Fisher exact, and Cox proportional hazards regression analyses.A total of 224 patients aged 9 to 20 years underwent 428 ESIs. One hundred seventy-four (76.0%) patients had a lumbar disc herniation with radiculopathy; the others had a spectrum of other spinal disorders. There were no serious adverse events, hospitalizations, dural punctures, or nerve injuries. During follow-up, 69 (41.6%) of 166 previously nonoperated lumbar disc plus radiculopathy patients underwent discectomy at a median time of 128 days (interquartile range, 76-235 days) after first injection. Degrees of straight-leg raising at presentation was significantly associated with subsequent discectomy. On follow-up, patients who did and did not undergo discectomy had low pain scores and high function scores.Children and adolescents can receive ESIs under conscious sedation with good safety. Further prospective studies may better define the role for these injections in the comprehensive management of pediatric spinal pain disorders.
View details for DOI 10.1097/AAP.0000000000000338
View details for PubMedID 26655219
- Artist's statement: the mighty fellow. Academic medicine 2015; 90 (11): 1527-?
The development of pediatric anesthesiology and critical care medicine at the Cincinnati Children's Hospital: an interview with Dr. Theodore Striker
2015; 25 (8): 764-769
Dr. Theodore W. 'Ted' Striker (1936-), Professor of Anesthesiology and Pediatrics at the University of Cincinnati, has played a pioneering role in the development of pediatric anesthesiology in the United States. As a model educator, clinician, and administrator, he shaped the careers of hundreds of physicians-in-training and imbued them with his core values of honesty, integrity, and responsibility.
View details for DOI 10.1111/pan.12677
View details for Web of Science ID 000357730600002
View details for PubMedID 25989362
Extensive spinal epidural abscess treated with "apical laminectomies" and irrigation of the epidural space: report of 2 cases
JOURNAL OF NEUROSURGERY-SPINE
2015; 22 (3): 318-323
Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.
View details for DOI 10.3171/2014.11.SPINE131166
View details for Web of Science ID 000350266300015
View details for PubMedID 25555055
A patient with surgically unrepaired single ventricle and uncontrolled amiodarone-induced thyrotoxicosis for emergent thyroidectomy.
A & A case reports
2014; 3 (5): 61-64
We present the case of a 20-year-old woman with a history of hypoplastic left heart syndrome, D-transposition of the great arteries, and mitral/pulmonary valve atresia without surgical palliation, who was admitted with persistent atrial flutter/fibrillation and worsening cardiac function from amiodarone-induced thyrotoxicosis. Despite maximal medical therapy, she continued to have uncontrolled thyrotoxicosis and underwent successful emergent thyroidectomy under general anesthesia. With advances in the treatment of congenital heart disease, more patients are surviving to adulthood and require emergent noncardiac surgery. Therefore, anesthesiologists must understand the principles for managing patients with congenital heart disease and how the patient's physiology may affect the anesthetic plan.
View details for DOI 10.1213/XAA.0000000000000080
View details for PubMedID 25611355
Minimally invasive spine surgery for adult degenerative lumbar scoliosis
2014; 36 (5)
Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.
View details for DOI 10.3171/2014.3.FOCUS144
View details for Web of Science ID 000335969300008
View details for PubMedID 24785489
Breaking the glass ceiling: an interview with Dr. Shirley Graves, a pioneering woman in medicine
2014; 24 (4): 440-445
Shirley Graves M.D., D.Sc. (honorary) (1936), Professor Emeritus of Anesthesiology and Pediatrics at the University of Florida, was one of the most influential women in medicine in the 1960 and 1970s, a time when the medical profession was overwhelmingly male-dominated. In today's society, it is hard to believe that only 50 years ago, women were scarce in the field of medicine. Yet Dr. Graves was a pioneer in the fields of pediatric anesthesia and pediatric critical care medicine. She identifies her development of the pediatric intensive care unit and her leadership in the Division of Pediatric Anesthesia at the University of Florida as her defining contributions. Through her journal articles, book chapters, national and international lectures, and leadership in the American Society of Anesthesiology and the Florida Society of Anesthesiology, she inspired a generation of men and women physicians to conquer the unthinkable and break through the glass ceiling.
View details for DOI 10.1111/pan.12363
View details for Web of Science ID 000332773500012
View details for PubMedID 24571660
The development of a specialty: an interview with Dr. Mark C. Rogers, a pioneering pediatric intensivist.
Dr. Mark C. Rogers (1942-), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long-term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.
View details for DOI 10.1111/pan.12497
View details for PubMedID 25065470
Assessment of the length of myotomy in peroral endoscopic pyloromyotomy (G-POEM) using a submucosal tunnel technique (video).
Peroral endoscopic pyloromyotomy is a novel technique that has recently been described in the literature. There is little data to guide the length of myotomy created. The aim of study was to evaluate the proper incision length of the muscular layer during peroral endoscopic pyloromyotomy using a submucosal tunnel technique.The study was designed as a prospective ex vivo study. Fresh ex vivo porcine stomachs from animals weighing 80-100 kg and porcine stomachs from animals weighing 15-25 kg were used for pyloromyotomy. Four different myotomy lengths (1, 2, 3, and 4) were compared in the large animal series and three different myotomy lengths (1, 2, and 3) were compared in the small series. A total of 23 cases of the submucosal tunnel technique were performed by two endoscopists using 12 large stomachs and 11 small stomachs.The mean overall procedure time (±SD) of pyloromyotomy was 65.7 (±14.3) min. In the large stomach series, the mean pyloric diameter (±SD) and change from baseline (as percentage) following a 1, 2, 3, and 4 pyloromyotomy were 13.3 ± 9.5 mm (7.1 %), 20.7 ± 11.7 mm (10.6 %), 31.1 ± 15.0 mm (15.2 %), and 33.0 ± 15.0 mm (16.0 %), respectively. In the small stomach series, the changes of mean pyloric diameter following a 1, 2, and 3 cm pyloromyotomy were 12.2 ± 5.6 mm (7.5 %), 23.1 ± 7.6 mm (13.1 %), and 28.0 ± 10.4 mm (15.5 %), respectively.A 3 cm pyloromyotomy for a large animal series and 2 cm for the small animal series appeared to be most appropriate for enlargement of the pylorus.
View details for DOI 10.1007/s00464-014-3948-1
View details for PubMedID 25424365