Dr. Thomas Caruso specializes in the treatment of pediatric anesthesiology. Dr. Caruso has a special interest in regional anesthesia, quality and safety, medical education, and immersive technologies used for childhood pain and anxiety reduction.

Clinical Focus

  • Pediatric Anesthesia
  • Pediatric Regional Anesthesia

Administrative Appointments

  • Director Midcareer Advancement Program, Stanford School of Medicine (2023 - Present)
  • Director Pediatric Anesthesiology Fellowship, Stanford School of Medicine (2021 - Present)
  • Director of the Stanford Chariot Program, Stanford School of Medicine, Lucile Packard Children's Hospital Stanford (2015 - Present)
  • Graduate Medical Education Faculty Adviser, Stanford University Department of Graduate Medical Education (2014 - Present)
  • Co-chair Type IV MOC Portfolio, Lucile Packard Children's Hospital (2017 - 2023)
  • Co-chair Value Based Selection Committee, Lucile Packard Children's Hospital (2017 - 2021)
  • Physician Lead for Perioperative Improvement, Lucile Packard Center for Quality and Clinical Effectiveness (2013 - 2021)

Boards, Advisory Committees, Professional Organizations

  • Vice-Chair Regional Anesthesia for Cardiac Enhanced Recovery Special Interest Group, American Society of Regional Anesthesia (2018 - 2020)
  • Member, International Anesthesia Research Society (2019 - Present)
  • Member, International Pediatric Simulation Society (2019 - Present)
  • Member, Society of Technology in Anesthesiology (2017 - Present)
  • Member, Anesthesia Patient Safety Foundation (2017 - Present)
  • Education Committee, California Society of Anesthesiologists (2012 - Present)
  • Member, Society of Pediatric Anesthesia (2011 - Present)
  • Member, American Society of Anesthesiologists (2009 - Present)

Professional Education

  • Doctor of Philosophy, Stanford University Graduate School of Education, Education (2023)
  • Master's Degree, Johns Hopkins School of Education, Education for the Health Professional (2015)
  • Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2013)
  • Board Certification: American Board of Anesthesiology, Anesthesia (2013)
  • Fellowship: Stanford University Pediatric Anesthesia Fellowship (2013) CA
  • Residency: Massachusetts General Hospital (2012) MA
  • Internship: Kaiser Permanente Santa Clara Internal Medicine Residency (2009) CA
  • Medical Education: Stanford University School of Medicine (2008) CA
  • Bachelor of Science, University of Virginia, Chemistry with a subspecialty in Biochemistry, High Distinction (2004)

Community and International Work

  • Invincikids



    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

My research pursuits are focused on system based improvement projects. At Lucile Packard Children's Hospital Stanford, I use system based approaches to improve the quality of care patients receive in the perioperative area and in the ICUs, with a focus on safe transitions of care. Through the Department of Graduate Medical Education at Stanford School of Medicine, I advise residency and fellowship programs on evidence based methods to improve their programs, with a focus on mentorship.

Clinical Trials

  • Evaluation of Technology-Based Stress Reduction Techniques Prior to Vascular Access Not Recruiting

    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.

    View full details

  • HRAD-Vascular Access Not Recruiting

    The perioperative setting is a common site of pediatric anxiety and distress. Perioperative anxiety in pediatric patients can result in uncooperative behavior, poor postoperative outcomes, and trauma. Given the fast-paced nature of the perioperative environment, many anxiety measures are too time consuming for clinical implementation prior to surgery. Pediatric anesthesiologists need reliable and efficient assessment tools to quickly measure childhood distress to target prophylactic and therapeutic interventions.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Regional Anesthesia for Cardiothoracic Enhanced Recovery (RACER) Study Not Recruiting

    The erector spinae plane block is a novel regional anesthetic technique that allows for analgesia of the thorax and abdomen with a peripheral nerve block. The goals of this study are to determine if bilateral erector spinae plane blocks (ESPB) after sternotomy for congenital heart repair in high risk children and adults can decrease outcomes such as duration of postoperative mechanical ventilation (MV), perioperative opioid consumption, days in the intensive care unit (ICU) and length of stay (LOS).

    Stanford is currently not accepting patients for this trial. For more information, please contact Ahtziri Fonseca, (650) 497 - 0927.

    View full details

  • Screen-Based Distraction Tool for Preoperative Preparation Not Recruiting

    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.

    View full details

  • Technology-Based Distractions During Minor Procedures Not Recruiting

    The purpose of this study is to determine if non-invasive distracting devices (Virtual Reality headset, Augmented Reality Headset) are more effective than the standard of care (i.e., no technology-based distraction) for decreasing anxiety and pain scores in pediatric patients undergoing various minor procedures (i.e lumbar punctures and cardiac catheterization). The anticipated primary outcome will be a reduction of overall cumulative medication and secondary outcomes include but are not limited to: physician satisfaction, discharge time, pain scores, anxiety scores, and procedure time.

    Stanford is currently not accepting patients for this trial. For more information, please contact Ahtziri Fonseca, (650) 497 - 0927.

    View full details

  • 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

  • VR Usage in Non-Invasive Surgical Sub-Specialty Procedures Not Recruiting

    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.

    Stanford is currently not accepting patients for this trial. For more information, please contact Sam Rodriguez, MD, 650-723-5728.

    View full details

2023-24 Courses

Graduate and Fellowship Programs

All Publications

  • Virtual Reality Facilitated Exercise Increases Sympathetic Activity and Reduces Pain Perception: A Randomized Crossover Study. American journal of physical medicine & rehabilitation Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2024


    Both virtual reality (VR) and exercise reduce pain while avoiding the risks of traditional pharmacotherapy. The aim of this study was to assess how VR-facilitated exercise modulates sympathetic activity and pain perception.Healthy adult volunteers were randomized by hand dominance and then subjected to a standardized cold pressor test while experiencing a VR application. After a 5-minute washout, participants were crossed-over and repeated the test on their other hand while undergoing a VR-facilitated exercise application. Sympathetic activation, pain sensation, and pain tolerance data were collected identically during both conditions.110 participants were analyzed. Sympathetic activity increased in both conditions but was higher in the VR-facilitated exercise condition (p < 0.0001). Pain sensation scores were initially higher with VR-facilitated exercise but dropped below the VR-only condition by the end of the intervention (p = 0.0175). There were no differences in pain tolerance between conditions (p = 0.18).The decrease in pain perception with VR-facilitated exercise condition compared to VR alone indicates VR-facilitated exercise can be a useful tool for managing pain. Though this effect did not translate into higher pain tolerance, VR-facilitated exercise may be a useful intervention in the setting of physical therapy or for patients with chronic pain.

    View details for DOI 10.1097/PHM.0000000000002550

    View details for PubMedID 38842101

  • 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

  • Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population. Journal of pediatric surgery Salimi-Jazi, F., Sabapaty, A., Santos Dalusag, K., Abrajano, C., Nguyen, J., Robinson, B., Caruso, T. J., Rodriguez, S., Hartman, G., Chao, S. D. 2024


    In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children.A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia.A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded.VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting.

    View details for DOI 10.1016/j.jpedsurg.2024.01.002

    View details for PubMedID 38307749

  • Reducing Preoperative Caregiver Anxiety With Virtual Reality: A Pragmatic, Randomized Controlled Study. Journal of patient experience Fonseca, A., Qian, D., Forbes, T., Li, B. S., Lee, C., Burdsall, K., Rodriguez, S., Jackson, C., Wang, E. Y., Caruso, T. J. 2024; 11: 23743735231220190


    Pediatric patients and their caregivers often experience perioperative anxiety. Interventions reduce caregiver anxiety improve cooperation and contribute to an improved patient experience. This study seeks to evaluate the efficacy of virtual reality (VR)-assisted mindfulness on perioperative caregiver anxiety. Participants were randomized into a standard of care (SOC) group, which included snacks but no technology-based distractions, or a VR group, which included snacks and a VR-guided meditation. Caregiver anxiety was measured before and after the intervention using the Visual Analogue Scale for Anxiety (VAS-A). Secondary aims explored participants' baseline anxiety with the State-Trait Anxiety Inventory (STAI). VR group participants completed a satisfaction survey. Linear regression models of VAS-A and STAI were used to compare group differences. Satisfaction survey results were reported with descriptive statistics. 26 participants were included, with 12 randomized to the SOC group and 14 to the VR group. VAS-A scores in the VR group were lower than those in the SOC group (p = .002). The STAI found no change in participants' state of anxiety in the SOC group (p = .7108), compared to a significant reduction (p = .014) in the VR group when controlling for anxiety traits. 12 of 14 caregivers in the VR group expressed satisfaction or strong satisfaction. This study supports the implementation of VR mindfulness as a method to reduce caregiver anxiety. VR use in the pediatric healthcare setting is safe and inexpensive, and the intervention had a high degree of participant satisfaction.

    View details for DOI 10.1177/23743735231220190

    View details for PubMedID 38188533

    View details for PubMedCentralID PMC10771051

  • A Quality Improvement Project to Improve the Utilization of an Intraoperative Rapid Response System. Pediatric quality & safety Rama, A., Qian, D., Forbes, T., Wang, E., Knight, L., Berg, M., Caruso, T. J. 2023; 8 (6): e686


    Rapid response teams (RRTs) improve morbidity by reducing the incidence of cardiac arrests. Although providers commonly activate RRTs on acute care wards, they are infrequently used perioperatively. At our institution, two intraoperative calls for help exist: staff assists (SAs) and code blues (CBs). The SA functions analogously to an RRT, and the CB indicates cardiopulmonary arrest. Given the success of RRTs, this project aimed to increase the use of the SA system. Our primary goal was to increase the ratio of SA to CB alerts by 50% within 6 months.A quality improvement team led this project at an academic pediatric hospital in Northern California. The team analyzed the current state and identified an achievable goal. After developing key drivers, they implemented monthly simulations to teach providers the signs of clinical deterioration and to practice activating the SA system. In addition to measuring the ratio of SA to CB alerts, the team surveyed the etiologies of SA and measured process satisfaction.Before the introduction of this initiative, the ratio of SA to CB alerts were 1:13.3. These improvements efforts led to an increase of SA to CB alerts to 1.5:1 (P = 0.0003). Twenty-three anesthesiologists provided etiologies for SA, reporting laryngospasm as the most common reason (30.4%). Nineteen nurses completed the SA survey and reported high satisfaction.This project successfully increased the utilization of a rapid response protocol in a pediatric perioperative setting using improvement methodologies and a simulation-based educational program.

    View details for DOI 10.1097/pq9.0000000000000686

    View details for PubMedID 38089833

    View details for PubMedCentralID PMC10715782

  • Innovating pediatric care with social robots to alleviate anxiety. Paediatric anaesthesia Nguyen, T., Yamaguchi, C., Tilton, L., Caruso, T. 2023

    View details for DOI 10.1111/pan.14798

    View details for PubMedID 37936541

  • Predicting pediatric healthcare provider use of virtual reality using a technology acceptance model. JAMIA open Wang, E. Y., Kennedy, K. M., Zhang, L., Qian, D., Forbes, T., Zuniga-Hernandez, M., Li, B. S., Domingue, B., Caruso, T. J. 2023; 6 (3): ooad076


    The primary aim of this study was to apply a novel technology acceptance model (TAM) for virtual reality (VR) in healthcare. The secondary aim was to assess reliability of this model to evaluate factors that predict the intentions of pediatric health providers' use of VR as an anxiolytic for hospitalized pediatric patients.Healthcare providers that interacted with pediatric patients participated in a VR experience available as anxiolysis for minor procedures and then completed a survey evaluating attitudes, behaviors, and technology factors that influence adoption of new technologies.Reliability for all domain measurements were good, and all confirmatory factor analysis models demonstrated good fit. Usefulness, ease of use, curiosity, and enjoyment of the VR experience all strongly predict intention to use and purchase VR technologies. Age of providers, past use, and cost of technology did not influence future purchase or use, suggesting that VR technologies may be broadly adopted in the pediatric healthcare setting.Previous VR-TAM models in non-healthcare consumers formulated that age, past use, price willing to pay, and curiosity impacted perceived ease of use. This study established that age, past use, and cost may not influence use in healthcare. Future studies should be directed at evaluating the social influences and facilitating conditions within healthcare that play a larger influence on technology adoption.The VR-TAM model demonstrated validity and reliability for predicting intent to use VR in a pediatric hospital.

    View details for DOI 10.1093/jamiaopen/ooad076

    View details for PubMedID 37693368

    View details for PubMedCentralID PMC10483581

  • Virtual reality facilitated exercise improves pain perception: A crossover study. Journal of clinical anesthesia Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2023; 91: 111257


    STUDY OBJECTIVE: Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.DESIGN: Within-subject cross-over clinical trial.SETTING: The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).PATIENTS: Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.INTERVENTIONS: Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.MEASUREMENTS: Pain sensitivity was scored 0-10 and collected every 30s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30s epochs by a biosensor. In all analyses, data were nested by participant.MAIN RESULTS: Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p<0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.CONCLUSIONS: The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

    View details for DOI 10.1016/j.jclinane.2023.111257

    View details for PubMedID 37708601

  • Enhancing Telemedicine Perioperative Simulations Using Augmented Reality. The journal of education in perioperative medicine : JEPM Rama, A., Tsai, A. H., Caruso, T. J. 2023; 25 (3): E711

    View details for DOI 10.46374/volxxv_issue3_Rama

    View details for PubMedID 37720372

  • Participant Perceptions of Augmented Reality Simulation for Cardiac Anesthesiology Training: A Prospective, Mixed-Methods Study. The journal of education in perioperative medicine : JEPM Tsai, A., Bodmer, N., Hong, T., Frackman, A., Hess, O., Khoury, M., Jackson, C., Caruso, T. J. 2023; 25 (3): E712


    Background: Simulations are a critical component of anesthesia education, and ways to broaden their delivery and accessibility should be studied. The primary aim was to characterize anesthesiology resident, fellow, and faculty experience with augmented reality (AR) simulations. The secondary aim was to explore the feasibility of quantifying performance using integrated eye-tracking technology.Methods: This was a prospective, mixed-methods study using qualitative thematic analysis of user feedback and quantitative analysis of gaze patterns. The study was conducted at a large academic medical center in Northern California. Participants included 7 anesthesiology residents, 6 cardiac anesthesiology fellows, and 5 cardiac anesthesiology attendings. Each subject participated in an AR simulation involving resuscitation of a patient with pericardial tamponade. Postsimulation interviews elicited user feedback, and eye-tracking data were analyzed for gaze duration and latency.Results: Thematic analysis revealed 5 domains of user experience: global assessment, spectrum of immersion, comparative assessment, operational potential, and human-technology interface. Participants reported a positive learning experience and cited AR technology's portability, flexibility, and cost-efficiency as qualities that may expand access to simulation training. Exploratory analyses of gaze patterns suggested that trainees had increased gaze duration of vital signs and gaze latency of malignant arrythmias compared with attendings. Limitations of the study include lack of a control group and underpowered statistical analyses of gaze data.Conclusions: This study suggests positive user perception of AR as a novel modality for medical simulation training. AR technology may increase exposure to simulation education and offer eye-tracking analyses of learner performance.

    View details for DOI 10.46374/volxxv_issue3_Tsai

    View details for PubMedID 37720369

  • Prehospital Pediatric Emergency Training Using Augmented Reality Simulation: A Prospective, Mixed Methods Study. Prehospital emergency care Friedman, N., Zuniga-Hernandez, M., Titzler, J., Suen, M. Y., Wang, E., Rosales, O., Graham, J., D'Souza, P., Menendez, M., Caruso, T. J. 2023: 1-18


    ObjectivePediatric emergencies are high-stakes yet low-volume clinical encounters for emergency medical services (EMS) clinicians, necessitating innovative approaches to training. We sought to explore the acceptability, usability, and ergonomics of a novel augmented reality (AR) software for EMS crisis management training.MethodsThis was a prospective, mixed-methods study employing qualitative and quantitative analyses. We enrolled emergency medical technicians (EMTs) and paramedics at a municipal fire service in Northern California. We ran the Chariot Augmented Reality Medical simulation software (#details_redacted_for_peer_review) on the ML1 headset (Magic Leap, Inc., Plantation, FL), which enabled participants to view an AR image of a patient overlaid with real-world training objects. Participants completed a simulation of a pediatric hypoglycemia-induced seizure and cardiac arrest. Participants subsequently engaged in structured focus group interviews assessing acceptability, which we coded and thematically analyzed. We evaluated the usability of the AR system and ergonomics of the ML1 headset using previously validated scales, and we analyzed findings with descriptive statistics.ResultsTwenty-two EMS clinicians participated. We categorized focus group interview statements into seven domains after an iterative thematic analysis: general appraisal, realism, learning efficacy, mixed reality feasibility, technology acceptance, software optimization, and alternate use cases. Participants valued the realism and the mixed reality functionality of the training simulation. They reported that AR could be effective for practicing pediatric clinical algorithms and task prioritization, building verbal communication skills, and promoting stress indoctrination. However, participants also noted challenges with integrating AR images with real-world objects, the learning curve required to adapt to the technology, and areas for software improvement. Participants favorably evaluated the ease of use of the technology and comfortability of wearing the hardware; however, most participants reported that they would need technical support.ConclusionParticipants positively evaluated the acceptability, usability, and ergonomics of an AR simulator for pediatric emergency management training, and participants identified current technological limitations and areas for improvement. AR simulation may serve as an effective training adjunct for prehospital clinicians.

    View details for DOI 10.1080/10903127.2023.2224876

    View details for PubMedID 37318845

  • Preoperative Anxiety in Children Open Anesthesia Yun, R., Caruso, T. J. 2023;
  • Integrating leadership into interprofessional non-acute care pediatric provider resuscitation training. Journal of clinical and translational research Gupta, R., Toppozini, C., Caruso, T. J., Lobos, A. T. 2022; 8 (6): 499-505


    Due to limited clinical exposure, non-acute care pediatric providers often rely on simulated experiences to maintain resuscitation skills. Few training options designed for the non-acute care setting exist, are often difficult to access, and lack incorporation of non-technical skills. The first five minutes (FFM) is a previously published curriculum designed to train non-acute care providers. The goal of this study was to determine the curriculum's effectiveness during a pilot intervention.A single cohort of multi-professional, non-acute care pediatric providers participated. The primary outcome skill was "establishing leadership," and secondary outcomes included other technical and non-technical skills. Learning of outcome skills was assessed using changes in retrospective pre-post self-assessment Likert scale scores. Differences were compared using paired t-tests and ANOVA.Thirty-seven participants submitted self-assessments. There was improvement in establishing leadership (pre-mean 1.14, post-mean 2.30, P < 0.01), and all other objectives studied. Compared to each other, subgroups of nurses, physicians, and respiratory therapists demonstrated significant differences in learning of technical skills, but similar improvements with non-technical skills.These findings suggest that the FFM curriculum is an effective tool for training non-acute care pediatric providers interprofessional resuscitation skills. Future research should assess provider behavioral changes, retention of training requirements, and patient outcomes.Traditional resuscitation education programs focus largely, or entirely, on performance of technical skills and algorithmic actions. However, non-technical skills, such as leadership, are crucial to the overall success of resuscitation efforts. The FFM program was developed to incorporate leadership principles into the resuscitation education of non-acute care pediatric inpatient providers, and this curricular evaluation suggests that improvements in participant leadership skills occurred due to the program.

    View details for PubMedID 36452004

    View details for PubMedCentralID PMC9706314

  • Virtual Reality-Augmented Physiotherapy for Chronic Pain in Youth: Protocol for a Randomized Controlled Trial Enhanced With a Single-Case Experimental Design. JMIR research protocols Simons, L. E., Hess, C. W., Choate, E. S., Van Orden, A. R., Tremblay-McGaw, A. G., Menendez, M., Boothroyd, D. B., Parvathinathan, G., Griffin, A., Caruso, T. J., Stinson, J., Weisman, A., Liu, T., Koeppen, K. 2022; 11 (12): e40705


    BACKGROUND: Chronic musculoskeletal (MSK) pain is a prominent health concern, resulting in pain-related disability, loss of functioning, and high health care costs. Physiotherapy rehabilitation is a gold-standard treatment for improving functioning in youth with chronic MSK pain. However, increasing physical activity can feel unattainable for many adolescents because of pain-related fear and movement avoidance. Virtual reality (VR) offers an immersive experience that can interrupt the fear-avoidance cycle and improve engagement in physiotherapy. Despite promising initial findings, data are limited and often lack the rigor required to establish VR as an evidence-based treatment for MSK pain.OBJECTIVE: This trial evaluates physiorehabilitation with VR in adolescents with MSK pain. This protocol outlines the rationale, design, and implementation of a randomized controlled trial enhanced with a single-case experimental design.METHODS: This study is a 2-group randomized controlled trial assessing the use of physiorehabilitation with VR in adolescents with MSK pain. The authors will collaborate with physical therapists to integrate VR into their standard clinical care. For participants enrolled in standard physiotherapy, there will be no VR integrated into their physical therapy program. Primary outcomes include physical function and engagement in VR. Secondary outcomes include pain-related fear and treatment adherence. Moreover, we will obtain clinician perspectives regarding the feasibility of integrating the intervention into the flow of clinical practice.RESULTS: The pilot study implementing physiorehabilitation with VR demonstrated that high engagement and use of physiorehabilitation with VR were associated with improvements in pain, fear, avoidance, and function. Coupled with qualitative feedback from patients, families, and clinicians, the pilot study results provide support for this trial to evaluate physiorehabilitation with VR for youth with chronic MSK pain. Analysis of results from the main clinical trial will begin as recruitment progresses, and results are expected in early 2024.CONCLUSIONS: Significant breakthroughs for treating MSK pain require mechanistically informed innovative approaches. Physiorehabilitation with VR provides exposure to progressive challenges, real-time feedback, and reinforcement for movement and can include activities that are difficult to achieve in the real world. It has the added benefit of sustaining patient motivation and adherence while enabling clinicians to use objective benchmarks to influence progression. These findings will inform the decision of whether to proceed with a hybrid effectiveness-dissemination trial of physiorehabilitation with VR, serving as the basis for potential large-scale implementation of physiorehabilitation with VR.TRIAL REGISTRATION: NCT04636177; REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40705.

    View details for DOI 10.2196/40705

    View details for PubMedID 36508251

  • What every anesthesiologist should know about virtual reality. Paediatric anaesthesia Rodriguez, S., Caruso, T. J. 2022; 32 (12): 1276-1277

    View details for DOI 10.1111/pan.14464

    View details for PubMedID 36352521

  • 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

  • Use of virtual reality for targeted physical rehabilitation: Case report on managing functional motor disorder. Journal of pediatric rehabilitation medicine Nguyen, A. T., Hemphill, S., Donahue, B., Menendez, M., Rodriguez, S., Caruso, T. J. 2022


    Virtual reality (VR) technology has seen increasing use in physical rehabilitation and in the management of acute and chronic pain. Functional movement disorders (FMDs) are a source of disability with no known association to neurologic pathology, and patients are generally offered multidisciplinary treatment approaches to improve functional movement. However, patients who are not compliant with rehabilitation may have persistent FMD and long-term disability. Given VR's use in physical rehabilitation, it may serve as a useful adjunct for the management of FMD. Utilizing an application called MovementTM to create a playlist of targeted applications for the restoration of motor function and balance, this case study presents the application of VR as a tool to engage patients in physical therapy for the management of FMD. The VR games were selected to encourage movement while customization of levels within the games facilitated achievement of physical therapy goals. Physical rehabilitation aided by VR, when used in collaboration with a multidisciplinary care team, may be used to facilitate recovery from FMD.

    View details for DOI 10.3233/PRM-210009

    View details for PubMedID 36120795

  • Virtual Immersion into a Poorly-Managed Medical Crisis Worsens Subsequent Performance: A Randomized, Controlled Trial CLINICAL SIMULATION IN NURSING Rama, A., Neiman, N., Burdsall, K., Fonseca, A., Lee, C., Domingue, B., Jackson, C., Caruso, T. J. 2022; 70: 47-55
  • Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial. Journal of pediatric orthopedics Richey, A. E., Hastings, K. G., Karius, A., Segovia, N. A., Caruso, T. J., Frick, S., Rodriguez, S. 2022


    BACKGROUND: Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.METHODS: A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.RESULTS: One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores (P<0.001) and anxiety scores (P=0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.CONCLUSION: VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.LEVEL OF EVIDENCE: Level I.

    View details for DOI 10.1097/BPO.0000000000002250

    View details for PubMedID 36040069

  • Enhanced Recovery After Cleft Palate Repair: A Quality Improvement Project. Paediatric anaesthesia Esfahanian, M., Marcott, S. C., Hopkins, E., Burkart, B., Khosla, R., Lorenz, H. P., Wang, E., De Souza, E., Algaze-Yojay, C., Caruso, T. J. 2022


    BACKGROUND: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery.AIMS: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay (LOS), timeliness of oral intake, and respiratory recovery.METHODS: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts.RESULTS: Pathway compliance was 77.0%. Patients during the intervention period (n=39) experienced a 49% reduction in postoperative opioid consumption (p<0.0001) relative to our historical cohort (n=63), with a mean difference of -0.33 ±0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p=0.002), with a mean difference of -0.27 ±0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p=0.02) relative to our historical cohort, with a mean difference of -3.81 ±1.56 hours (95% CI -6.9 to -0.70). There was no difference in PACU or hospital LOS, but there was a significant reduction in variance of all secondary outcomes.CONCLUSION: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital LOS.

    View details for DOI 10.1111/pan.14541

    View details for PubMedID 35929340

  • Communication Skills Training Using Remote Augmented Reality Medical Simulation: a Feasibility and Acceptability Qualitative Study. Medical science educator Hess, O., Qian, J., Bruce, J., Wang, E., Rodriguez, S., Haber, N., Caruso, T. J. 2022: 1-10


    Introduction: Augmented reality (AR) has promise as a clinical teaching tool, particularly for remote learning. The Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator with a holographic patient and monitor. The primary aim was to analyze feedback from medical and physician assistant students regarding acceptability and feasibility of the simulator.Methods: Using the CHARM simulator, we created an advanced cardiovascular life support (ACLS) simulation scenario. After IRB approval, preclinical medical and physician assistant students volunteered to participate from August to September 2020. We delivered augmented reality headsets (Magic Leap One) to students before the study. Prior to the simulation, via video conference, we introduced students to effective communication skills during a cardiac arrest. Participants then, individually and remotely from their homes, synchronously completed an instructor-led ACLS AR simulation in groups of three. After the simulation, students participated in a structured focus group using a qualitative interview guide. Our study team coded their responses and interpreted them using team-based thematic analysis.Results: Eighteen medical and physician assistant students participated. We identified four domains that reflected trainee experiences: experiential satisfaction, learning engagement, technology learning curve, and opportunities for improvement. Students reported that the simulator was acceptable and enjoyable for teaching trainees communication skills; however, there were some technical difficulties associated with initial use.Conclusion: This study suggests that multiplayer AR is a promising and feasible approach for remote medical education of communication skills during medical crises.Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01598-7.

    View details for DOI 10.1007/s40670-022-01598-7

    View details for PubMedID 35966166

  • Assessing Pediatric Life Support Skills Using Augmented Reality Medical Simulation With Eye Tracking: A Pilot Study. The journal of education in perioperative medicine : JEPM Qian, J., Rama, A., Wang, E., Wang, T., Hess, O., Khoury, M., Jackson, C., Caruso, T. J. 2022; 24 (3): E691


    Background: Augmented reality (AR) and eye tracking are promising adjuncts for medical simulation, but they have remained distinct tools. The recently developed Chariot Augmented Reality Medical (CHARM) Simulator combines AR medical simulation with eye tracking. We present a novel approach to applying eye tracking within an AR simulation to assess anesthesiologists during an AR pediatric life support simulation. The primary aim was to explore clinician performance in the simulation. Secondary outcomes explored eye tracking as a measure of shockable rhythm recognition and participant satisfaction.Methods: Anesthesiology residents, pediatric anesthesiology fellows, and attending pediatric anesthesiologists were recruited. Using CHARM, they participated in a pediatric crisis simulation. Performance was scored using the Anesthesia-centric Pediatric Advanced Life Support (A-PALS) scoring instrument, and eye tracking data were analyzed. The Simulation Design Scale measured participant satisfaction.Results: Nine each of residents, fellows, and attendings participated for a total of 27. We were able to successfully progress participants through the AR simulation as demonstrated by typical A-PALS performance scores. We observed no differences in performance across training levels. Eye tracking data successfully allowed comparisons of time to rhythm recognition across training levels, revealing no differences. Finally, simulation satisfaction was high across all participants.Conclusions: While the agreement between A-PALS score and gaze patterns is promising, further research is needed to fully demonstrate the use of AR eye tracking for medical training and assessment. Physicians of multiple training levels were satisfied with the technology.

    View details for DOI 10.46374/volxxiv_issue3_qian

    View details for PubMedID 36274998

  • Anesthesiologists With Advanced Degrees in Education: Qualitative Study of a Changing Paradigm. JMIR medical education Aggarwal, A., Hess, O., Lockman, J. L., Smith, L., Stevens, M., Bruce, J., Caruso, T. 2022; 8 (2): e38050


    Anesthesiology education has undergone profound changes over the past century, from a pure clinical apprenticeship to novel comprehensive curricula based on andragogic learning theories. Combined with institutional and regulatory requirements, these new curricula have propagated professionalization of the clinician-educator role. A significant number of clinician-educator anesthesiologists, often with support from department chairs, pursue formal health professions education (HPE) training, yet there are no published data demonstrating the benefits or costs of these degrees to educational leaders.This study aims to collect the experiences of anesthesiologists who have pursued HPE degrees to understand the advantages and costs of HPE degrees to anesthesiologists.Investigators performed a qualitative study of anesthesiologists with HPE degrees working at academic medical centers. Interviews were thematically analyzed via an iterative process. They were coded using a team-based approach, and representative themes and exemplary quotations were identified.Seven anesthesiologists were interviewed, representing diverse geographic regions, subspecialties, and medical institutions. Analyses of interview transcripts resulted in the following 6 core themes: outcomes, extrinsic motivators, intrinsic motivators, investment, experience, and recommendations. The interviewees noted the advantages of HPE training for those wishing to pursue leadership or scholarship in medical education; however, they also noted the costs and investment of time in addition to preexisting commitments. The interviewees also highlighted the issues faculty and chairs might consider for the optimal timing of HPE training.There are numerous professional and personal benefits to pursuing HPE degrees for faculty interested in education leadership or scholarship. Making an informed decision to pursue HPE training can be challenging when considering the competing pressures of clinical work and personal obligations. The experiences of the interviewed anesthesiologists offer direction to future anesthesiologists and chairs in their decision-making process of whether and when to pursue HPE training.

    View details for DOI 10.2196/38050

    View details for PubMedID 35771619

  • It Takes a Village: A Narrative Review of Anesthesiology Mentorship. Anesthesiology clinics Tsai, A. H., Bodmer, N. J., Gupta, K., Caruso, T. J. 2022; 40 (2): 301-313


    Mentorships play a critical role in the development of physician careers and should be tailored within a structured, evidence-based mentoring program to ensure mutual benefit and avoidance of pitfalls. We offer a narrative review of the current literature and commentary on mentoring at the medical student, GME trainee, and early career faculty levels within anesthesiology, and propose a framework on which an effective mentoring program can be implemented.

    View details for DOI 10.1016/j.anclin.2022.01.005

    View details for PubMedID 35659402

  • Quantifying virtual reality pain modulation in healthy volunteers: A randomized, crossover study. Journal of clinical anesthesia Neiman, N. R., Falkson, S. R., Rodriguez, S. T., Wang, E. Y., Hemphill, S. F., Khoury, M. E., Kist, M. N., Jackson, C. D., Caruso, T. J. 2022; 80: 110876


    STUDY OBJECTIVE: Virtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain.DESIGN: Randomized, controlled crossover within-subject clinical trial.SETTING: This study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine.PATIENTS: 156 healthy volunteers were included.INTERVENTIONS: Participants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed.MEASUREMENTS: Outcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR.MAIN RESULTS: 153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P<0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P<0.001). SCRD increased as time progressed for both VR and control groups (P=0.047 combined), with no significant mean group differences.CONCLUSIONS: Participants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR.

    View details for DOI 10.1016/j.jclinane.2022.110876

    View details for PubMedID 35525050

  • 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

  • A Pilot Quality Improvement Project to Reduce Intraoperative MRI Hypothermia in Neurosurgical Patients. Pediatric quality & safety Wong, B. J., Rama, A., Caruso, T. J., Lee, C. K., Wang, E., Chen, M. 2022; 7 (2): e531


    Intraoperative hypothermia increases patient morbidity, including bleeding and infection risk. Neurosurgical intraoperative magnetic resonance imaging (iMRI) can lead to hypothermia from patient exposure and low ambient temperature in the MRI suite. This quality improvement project aimed to reduce the risk of hypothermia during pediatric neurosurgery laser ablation procedures with iMRI. The primary aim was to increase the mean lowest core temperature in pediatric patients with epilepsy during iMRI procedures by 1 °C from a baseline mean lowest core temperature of 34.2 ± 1.2 °C within 10 months and sustain for 10 months.Methods: This report is a single-institution quality improvement project from March 2019 to June 2021, with 21 patients treated at a pediatric hospital. After identifying key drivers, temperature-warming interventions were instituted to decrease hypothermia among patients undergoing iMRI during neurosurgery procedures. A multidisciplinary team of physicians, nurses, and MRI technologists convened for huddles before each case. Interventions included prewarmed operating rooms (ORs), blanket coverings, MRI table and room; forced-air blanket warming, temperature monitoring in the OR and iMRI environments; and the MRI fan turned off.Results: Data were analyzed for five patients before and nine patients after the institution of the temperature-warming elements. The sustainment period included 15 patients. The mean lowest intraoperative temperature rose from 34.2 ± 1.3 °C in the preintervention period to 35.5 ± 0.6 °C in sustainment (P = 0.004).Conclusion: Hybrid OR and MRI procedures increase hypothermia risk, which increases patient morbidity. Implementation of a multidisciplinary, multi-item strategy for patient warming mitigates the risk.

    View details for DOI 10.1097/pq9.0000000000000531

    View details for PubMedID 35369418

  • Systemic lidocaine absorption from continuous erector spinae plane catheters after paediatric posterior spine fusion surgery. Regional anesthesia and pain medicine Pan, S., Lee, C. K., Caruso, T. J., Vorhies, J. S., Tsui, B. C. 2022

    View details for DOI 10.1136/rapm-2021-103234

    View details for PubMedID 35012993

  • Integrated diversity, equity, and inclusion curriculum into pediatric anesthesia fellowship training: Another step forward. Paediatric anaesthesia Murray, A., Reece-Nguyen, T., Caruso, T. J. 1800

    View details for DOI 10.1111/pan.14385

    View details for PubMedID 34971019

  • Real-time reorientation and cognitive load adjustment allow for broad application of virtual reality in a pediatric hospital. Journal of clinical and translational research Caruso, T. J., Fonseca, A., Barreau, A., Khoury, M., Menendez, M., Wang, E., Lawrence, K., Jackson, C., Rodriguez, S. 1800; 7 (6): 750-753


    Background: With a new generation of affordable portable virtual reality (VR), clinicians are discovering more utility for VR, while also identifying opportunities for improvement, such as the inability to reorient the horizon line during repositioning or transport, or modulate cognitive load in real time.Aim: At our institution, this lack of functionality prohibited or decreased VR usage in some clinical scenarios such as dressing changes with dynamic positioning. The purpose of this brief report is to describe the development and use of a VR application that is optimized for the healthcare setting and report historical effects of patients who utilized VR as supplement to Child Life procedures. Eligible affects per chart review included Happy, Relaxed, Anxious, Distressed, Unable to Assess.Materials and Methods: Given the need for real-time reorientation and cognitive load modulation, we created the Space Pups VR application. The experience was launched as part of the Stanford Chariot Program in the summer of 2017, and its usage was tracked through the electronic medical record and a VR application dashboard. Chart review was queried from 3 January 2018 to 9 August 2021 for pediatric patients who used VR with real-time reorientation and cognitive load modulation as a supplement to their Child Life interventions.Results: The Space Pups experience has been successfully used in a variety of settings, including perioperative care, vascular access, wound care, and ENT clinic, a total of 1696 times. Patients ranged from 6 years to 18-year old, with no reports of side effects. Significant results (P<0.001) were observed pre- and post-VR use for affect improvements in Happy, Relaxed, and Anxious, but not for Distressed.Conclusions: The ability to reorient VR experiences in real time has increased functionality where other applications have failed.Relevance for Patients: While more studies are needed to quantify the anxiolytic and pain-reducing effect of Space Pups, our report demonstrates the feasibility of this VR experience as a non-pharmacological modality to safely increase patient cooperation in a wide variety of clinical settings.

    View details for PubMedID 34988325

  • Use of Bedside Entertainment and Relaxation Theater (BERT) to Reduce Fear and Anxiety Associated With Outpatient Procedures in Pediatric Orthopaedics. Journal of pediatric orthopedics Richey, A. E., Khoury, M., Segovia, N. A., Hastings, K. G., Caruso, T. J., Frick, S., Rodriguez, S. 2021


    BACKGROUND: The aim of the present study was to evaluate the effectiveness of the Bedside Entertainment and Relaxation Theater (BERT) on fear, anxiety, and pain outcomes in pediatric orthopaedic patients associated with cast removal and/or pin removal in the outpatient clinic setting.METHODS: A total of 66 pediatric patients between the ages of 2 and 6 undergoing clinic procedures were recruited for this study and randomized into the control group or the intervention (BERT) group. Patients in the control group received standard of care during the cast room procedure; patients in the BERT group were given headphones and watched a movie on a projector during the procedure. Fear, anxiety, and pain were measured before and after the procedure. Procedures included cast removal, pin removal, or a combination of the 2.RESULTS: Patients in the BERT group reported less fear and anxiety overall after the procedure than patients in the control group (P=0.009, 0.015). Adjusting for procedure type (ie, pin removal), patients in the BERT group reported a 0.67 point decrease (95% confidence interval: 0.04, 1.30) on the fear scale after the procedure (P=0.039) and a 1.81 point decrease (95% confidence interval: 0.04, 3.59) on the anxiety scale associated with the procedure (P=0.045), compared with the control group. Patients and caregivers reported high satisfaction with BERT.CONCLUSION: This randomized, controlled trial demonstrates an evidence-based distraction tool that can be implemented across medical centers for pediatric patients undergoing office based orthopaedic procedures. BERT can be used to reduce fear and anxiety associated with these procedures, and increased patient and parent satisfaction.LEVEL OF EVIDENCE: Level I.

    View details for DOI 10.1097/BPO.0000000000002005

    View details for PubMedID 34739431

  • 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

  • Small surgeries, big smiles: using virtual reality to reduce the need for sedation or general anesthesia during minor surgical procedures. Pediatric surgery international Taylor, J. S., Chandler, J. M., Menendez, M., Diyaolu, M., Austin, J. R., Gibson, M. L., Portelli, K. I., Caruso, T. J., Rodriguez, S., Chao, S. D. 2021


    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

  • The Physiologic and Emotional Effects of 360-Degree Video Simulation on Head-Mounted Display Versus In-Person Simulation: A Noninferiority, Randomized Controlled Trial. Simulation in healthcare : journal of the Society for Simulation in Healthcare Caruso, T. J., Armstrong-Carter, E., Rama, A., Neiman, N., Taylor, K., Madill, M., Lawrence, K., Hemphill, S. F., Guo, N., Domingue, B. W. 2021


    INTRODUCTION: A key simulation component is its capability to elicit physiological changes, improving recall. The primary aim was to determine whether parasympathetic responses to head-mounted display simulations (HMDs) were noninferior to in-person simulations. The secondary aims explored sympathetic and affective responses and learning effectiveness.METHODS: The authors conducted a noninferiority trial. Hospital providers who did not use chronotropic medications, have motion sickness, or have seizures were included. The authors randomized participants to in-person or HMD simulation. Biometric sensors collected respiratory sinus arrhythmia and skin conductance levels to measure parasympathetic and sympathetic states at baseline, during, and after the simulation. Affect was measured using a schedule. The authors measured 3-month recall of learning points and used split-plot analysis of variance and Mann-Whitney U tests to analyze.RESULTS: One hundred fifteen participants qualified, and the authors analyzed 56 in each group. Both groups experienced a significant change in mean respiratory sinus arrhythmia from baseline to during and from during to afterward. The difference of change between the groups from baseline to during was 0.134 (95% confidence interval = 0.142 to 0.410, P = 0.339). The difference of change from during the simulation to after was -0.060 (95% confidence interval = -0.337 to 0.217, P = 0.670). Noninferiority was not established for either period. Sympathetic arousal did not occur in either group. Noninferiority was not established for the changes in affect that were demonstrated. The mean scores of teaching effectiveness and achievement scores were not different.CONCLUSIONS: Although a parasympathetic and affective response to the video simulation on an HMD did occur, it was not discernibly noninferior to in-person in this study.

    View details for DOI 10.1097/SIH.0000000000000587

    View details for PubMedID 34120135

  • Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study CHILDREN-BASEL Wren, A. A., Neiman, N., Caruso, T. J., Rodriguez, S., Taylor, K., Madill, M., Rives, H., Nguyen, L. 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 Yuan, J. C., Rodriguez, S., Caruso, T. J. 2021; 31 (3): 377–78

    View details for DOI 10.1111/pan.14108

    View details for PubMedID 33631038

  • A pilot, randomized controlled trial of telementorship: A useful tool during social distancing. Journal of clinical and translational research Prionas, N. D., Kung, T. H., Dohn, A., Piro, N., von Eyben, R., Katznelson, L., Caruso, T. J. 2021; 7 (1): 66-71


    Background: During social distancing, resident mentorship may be an unmet need. Telementorship, mentorship through video conferencing software, presents a unique approach to overcome these challenges.Aims: This study evaluated whether telementorship through video conference increased access to mentorship encounters and decreased perceived barriers to access, factors that determine likelihood to maintain mentor relationships, and quality of mentorship.Methods: A year-long randomized, prospective cohort study was conducted in 2016-2017 with pairs of resident mentors from seven different training programs and medical student mentees, randomized to telementorship or in-person mentorship. The number of quarterly encounters was monitored and demographic predictors of meeting were determined. Likert scale survey responses were analyzed with linear regression.Results: Forty-three of 46 (93.5%) volunteer mentor-mentee pairs participated. Telementorship did not alter likelihood of meeting or attitudes toward mentorship barriers (time and distance). Mentee satisfaction increased from 42.5% to 65.4% (P<0.05) throughout the year. Operating room-based practice (P<0.05) and higher postgraduate level (P=0.02) decreased the likelihood of meeting.Conclusion: Telementorship provided an equal number of encounters compared to the pairs who were asked to meet in-person. Telementorship may serve as an adjunct modality for flexible communication.Relevance for Patients: Medical mentorship is a key component to medical education. Effective mentorship increases academic research productivity, job satisfaction, and advancement of clinical skills, which translate to improved patient care.

    View details for PubMedID 34104809

  • Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report. BMJ simulation & technology enhanced learning Caruso, T. J., Hess, O., Roy, K., Wang, E., Rodriguez, S., Palivathukal, C., Haber, N. 2021; 7 (5): 431-434


    Augmented reality (AR) has been studied as a clinical teaching tool, however eye-tracking capabilities integrated within an AR medical simulator have limited research. The recently developed Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator. The purpose of this project was to refine the gaze-tracking capabilities of the CHARM simulator on the Magic Leap One (ML1). Adults aged 18 years and older were recruited using convenience sampling. Participants were provided with an ML1 headset that projected a hologram of a patient, bed and monitor. They were instructed via audio recording to gaze at variables in this scenario. The participant gaze targets from the ML1 output were compared with the specified gaze points from the audio recording. A priori investigators planned to iterative modifications of the eye-tracking software until a capture rate of 80% was achieved. Two consecutive participants with a capture rate less than 80% triggered software modifications and the project concluded after three consecutive participants' capture rates were greater than 80%. Thirteen participants were included in the study. Eye-tracking concordance was less than 80% reliable in the first 10 participants. The investigators hypothesised that the eye movement detection threshold was too sensitive, thus the algorithm was adjusted to reduce noise. The project concluded after the final three participants' gaze capture rates were 80%, 80% and 80.1%, respectively. This report suggests that eye-tracking technology can be reliably used with the ML1 enabled with CHARM simulator software.

    View details for DOI 10.1136/bmjstel-2020-000782

    View details for PubMedID 35515734

    View details for PubMedCentralID PMC8936533

  • Alternating Side Programmed Intermittent Repeated (ASPIRe) Bolus Regimen for Delivering Local Anesthetic via Bilateral Interfascial Plane Catheters. Journal of cardiothoracic and vascular anesthesia Tsui, B. C., Brodt, J., Pan, S., Caruso, T. J., Kim, R., Horn, J. L., Boublik, J., Tsui, J. H. 2021

    View details for DOI 10.1053/j.jvca.2021.02.036

    View details for PubMedID 33731299

  • Virtual Reality Reduces Pediatric Anxiety During Food Allergy Clinical Trials: A Pilot Randomized, Pragmatic Study. Frontiers in allergy Alonzi, S., Caruso, T. J., Sindher, S. B., Cao, S., Varadharajulu, S., Collins, W. J., Chinthrajah, R. S. 2021; 2: 779804


    Phlebotomy procedures required in food allergy (FA) diagnosis and clinical trials often induce fear and anxiety for pediatric patients. The primary aim of this study was to determine whether virtual reality (VR) applications were effective in reducing anxiety for pediatric FA patients undergoing phlebotomy during FA clinical trials. Secondary aims assessed fear, pain, procedural compliance, and adverse events. Participants undergoing phlebotomy were enrolled and randomized to a VR group or standard of care (SOC) group for this prospective pilot randomized, pragmatic study. Participants in the VR group played interactive applications on a customized Samsung Gear VR headset and those in the SOC group received the standard of care. Participants' anxiety, fear, and pain were assessed with the Children's Anxiety Meter, Children's Fear Scale, and FACES pain scale pre, during, and post phlebotomy procedure. Compliance was assessed using the modified Induction Compliance Checklist during the procedure and compared between two groups. Forty-nine participants were randomized to VR (n = 26) and SOC (n = 23) groups. Although both the VR and SOC groups experienced a decrease in anxiety and fear from pre- to post-procedure, those in the VR group experienced less anxiety and fear during the procedure than SOC participants. Similarly, both groups experienced an increase in pain from pre- to post-procedure; however, the VR group reported less pain during the procedure than SOC. Fewer symptoms of procedural non-compliance were reported in the VR group. Interactive VR applications may be an effective tool for reducing fear, anxiety, and pain during phlebotomy for FA clinical trials.

    View details for DOI 10.3389/falgy.2021.779804

    View details for PubMedID 35387040

    View details for PubMedCentralID PMC8974765

  • 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 Logan, D. E., Simons, L. E., Caruso, T. n., Gold, J. I., Greenleaf, W. n., Griffin, A. n., King, C. n., Menendez, M. n., Olbrecht, V. n., Rodriguez, S. n., Silvia, M. n., Stinson, J. n., Wang, E. n., Williams, S. n., Wilson, L. n. 2021


    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

  • Publication misrepresentation amongst pediatric anesthesiology fellowship applicants: A retrospective single center cohort study. Paediatric anaesthesia Mehta, A., Patel, P., Caruso, T. J., Anderson, T. A. 2021


    Many medical specialties have found publication misrepresentation in residency and fellowship applications, but pediatric anesthesia fellowship application data is lacking.We sought to determine the prevalence of publication misrepresentation among pediatric anesthesia fellowship applications.In this retrospective cohort study, fellowship applications to Stanford University's pediatric anesthesiology fellowship program from 2009 to 2019 were reviewed. Only peer-reviewed journal articles listed as accepted or published were included. Nine additional variables were collected: applicant age, gender, citizenship status, American vs. international medical school, public vs. private medical school, allopathic doctor versus osteopathic doctor, number of years between college and medical school, additional degrees, and application year. The primary outcome was the rate of publication misrepresentation, defined as peer-reviewed journal citations listed on the application that could not be verified or on which the applicant was not listed as an author. Secondary outcomes were the associations between publication misrepresentation and the additional collected variables.1280 peer-reviewed journal publications from 877 applicants were reviewed. 3.4% of all citations listed as peer-reviewed journal articles were misrepresented and 9.0% of all applicants with at least 1 publication had ≥ 1 misrepresented publications. 30.2% of publications labelled "misrepresented" were located in our search of databases but did not have the applicant as an author, and 69.8% could not be located using the search databases. Only one of the 9 collected variables (public vs private medical school) was significantly associated with publication misrepresentation.In this single center retrospective study, publication misrepresentation was found to occur in one out of 11 pediatric anesthesia fellowship applications with at least one publication. Since residency and fellowship applicant publications may be heavily weighted during the application process, programs may want to include additional inquiries into the accuracy of applicant publications.

    View details for DOI 10.1111/pan.14251

    View details for PubMedID 34214229

  • Virtual reality for pediatric periprocedural care. Current opinion in anaesthesiology Wang, E. n., Thomas, J. J., Rodriguez, S. T., Kennedy, K. M., Caruso, T. J. 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 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 Hemphill, S. n., Nguyen, A. n., Kwong, J. n., Rodriguez, S. T., Wang, E. n., Caruso, T. J. 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 Augments Movement during Physical Therapy: A Pragmatic Randomized Trial. American journal of physical medicine & rehabilitation Hemphill, S. n., Rodriguez, S. n., Wang, E. n., Koeppen, K. n., Aitken-Young, B. n., Jackson, C. n., Simons, L. n., Caruso, T. J. 2021


    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 in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR rehabilitation and assistive technologies Griffin, A., Wilson, L., Feinstein, A. B., Bortz, A., Heirich, M. S., Gilkerson, R., Wagner, J. F., Menendez, M., Caruso, T. J., Rodriguez, S., Naidu, S., Golianu, B., Simons, L. E. 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

  • Transnasal Humidified Rapid-Insufflation Ventilatory Exchange in pediatric bronchoscopy: A prospective pilot study. Journal of clinical anesthesia Caruso, T. J., O'Connell, C., Qian, J., Menendez, M., Fonseca, A., Lawrence, K., Sidell, D. R., Darling, C., Tsui, B. 2020; 68: 110086

    View details for DOI 10.1016/j.jclinane.2020.110086

    View details for PubMedID 33075630

  • The virtual visit: Using immersive technology to visit hospitals during social distancing and beyond. Paediatric anaesthesia Dinh, A., Furukawa, L., Caruso, T. J. 2020; 30 (8): 954–56


    Medical trainees face substantial financial and scheduling burdens during the interview process at various levels of training. With current social distancing and travel restrictions in place, in-person interviews now carry an additional health risk that make it difficult for training programs and applicants to conduct a thorough interview process. Virtual interviews and presentations are some of the technology-driven solutions that have been accelerated in the current social context to mitigate financial burdens and health risks. By utilizing immersive technology to provide virtual tours of training sites, applicants have the opportunity to gain a comprehensive perspective before making the critical decision of where to continue their training. We provide our experiences with creating a 360-degree virtual tour of our children's hospital and the methods for distribution to pediatric anesthesia fellowship applicants. Moving forward, training programs may consider immersive virtual tours as an alternative to face-to-face site visits to not only help alleviate the financial and scheduling burden for applicants but also to protect the well-being of healthcare personnel and patients in the context of a global pandemic.

    View details for DOI 10.1111/pan.13922

    View details for PubMedID 32959974

  • A Retrospective Cohort Study of Predictors and Interventionsthat Influence Cooperation with Mask Induction in Children. Paediatric anaesthesia Marquez, J. L., Wang, E., Rodriguez, S. T., O'Connell, C., Munshey, F., Darling, C., Tsui, B., Caruso, J., Caruso, T. J. 2020


    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

  • A Quality Improvement Project to Reduce Combination Acetaminophen-opioid Prescriptions to Pediatric Orthopedic Patients. Pediatric quality & safety Caruso, T. J., Trivedi, S., Chadwick, W., Gaskari, S., Wang, E., Marquez, J., Lagasse, S., Bailey, M., Shea, K. 2020; 5 (3): e291


    Background: Acetaminophen-opioid analgesics are among the most commonly prescribed pain medications in pediatric orthopedic patients. However, these combined opioid analgesics do not allow for individual medication titration, which can increase the risk of opioid misuse and hepatoxicity from acetaminophen. The primary aim of this quality improvement project was to alter the prescribing habits of pediatric orthopedic providers at our institution from postoperative acetaminophen-opioid analgesics to independent acetaminophen and opioids.Methods: The study took place in a level 1 trauma center at a children's hospital. A multidisciplinary team of health professionals utilized lean methodology to develop a project plan. Guided by a key driver diagram, we removed acetaminophen-oxycodone products from hospital formulary, implemented a revised inpatient and outpatient electronic order set, and conducted multiple education efforts. Outcomes included inpatient and outpatient percent combined acetaminophen-opioid orders by surgical providers over 27 months.Results: Before the intervention, inpatient acetaminophen-opioid products accounted for an average of 46% of all opioid prescriptions for orthopedic patients. After the intervention and multiple educational efforts, we reported a reduction in the acetaminophen-opioid products to 2.9%. For outpatient prescriptions, combined analgesics accounted for 88% before the intervention, and we reported a reduction to 15% after the intervention.Conclusions: By removing acetaminophen-oxycodone products from hospital formulary, educating the medical staff, and employing revised electronic order sets, the prescribing practice of pediatric orthopedic surgeons changed from the routine use of acetaminophen-opioid analgesics to independent medications.

    View details for DOI 10.1097/pq9.0000000000000291

    View details for PubMedID 32607456

  • From Socrates to Virtual Reality: A Historical Review of Learning Theories and Their Influence on the Training of Anesthesiologists. The journal of education in perioperative medicine : JEPM Caruso, T. J., Qian, J., Lawrence, K., Armstrong-Carter, E., Domingue, B. W. 2020; 22 (2): E638


    Over the past couple of centuries, the training of American physicians, and anesthesiologists in particular, has undergone a radical transformation. The revolution of medical training has been and continues to be fueled by insights from learning theorists. In this historical review, we discuss the origins of American medical education in the 1700s and continue through the centuries illustrating the impact of learning theories on the education and training of anesthesiologists. In particular, we explore the impact of learning theories of the 1800s and the adult-centered teaching strategies of the 1900s. We also discuss the role of learning theories in molding medical education in the modern technological age.

    View details for DOI 10.46374/volxxii-issue2-Caruso

    View details for PubMedID 32939366

    View details for PubMedCentralID PMC7485431

  • Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatric quality & safety Caruso, T. J., O'Connell, C., Qian, J. J., Kung, T., Wang, E., Kinnebrew, S., Pearson, M., Kist, M., Menendez, M., Rodriguez, S. T. 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

  • Mobilization and calibration of the HTC VIVE for virtual reality physical therapy. Digital health Hemphill, S., Nguyen, A., Rodriguez, S. T., Menendez, M., Wang, E., Lawrence, K., Caruso, T. J. 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

  • Prospective Evaluation of the Safety and Efficacy of THRIVE for Children Undergoing Airway Evaluation. Pediatric quality & safety Okland, T. S., Liu, G. S., Caruso, T. J., Sidell, D. R. 2020; 5 (5): e348


    Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a humidified high-flow nasal cannula capable of extending apneic time. Although THRIVE is assumed to stent upper airway soft tissues, this has not been objectively evaluated. Also, there are no prior studies providing safety and efficacy data for those patients undergoing upper airway evaluation using THRIVE.This report is a prospective study of the safety and efficacy of THRIVE in pediatric patients younger than 18 years old undergoing drug-induced sleep endoscopy. We positioned a flexible laryngoscope to view the larynx, and photographs were taken with no THRIVE flow (control) and with THRIVE flow at 10 and 20 liters per minute (LPM). Upper airway patency was measured using epiglottis to posterior pharynx distance, laryngeal inlet area, and modified Cormack-Lehane score at the trialed parameters. Vomiting and aspiration were our primary safety endpoints.Eleven patients (6 women) with a mean age of 5.3 ± 2.1 years (2-8 years; SD, 2.05) were enrolled. Measurements of upper airway patency showed a significant THRIVE flow-associated increase in epiglottis to posterior pharynx distance (105 ± 54 at 10 L/min and 199 ± 67 at 20 L/min; P = 0.007) and nonsignificant increase of laryngeal inlet area (206 ± 148 at 10 L/min and 361 ± 190 at 20 L/min; P = 0.07). Cormack-Lehane score improved significantly at higher THRIVE volumes (P = 0.006).THRIVE appears to safely improve upper airway patency during sleep endoscopy in the pediatric patient. In this study, we objectively document the flow-dependent increase in laryngeal patency associated with THRIVE.

    View details for DOI 10.1097/pq9.0000000000000348

    View details for PubMedID 34616964

    View details for PubMedCentralID PMC8483875

  • Introduction of the EMR-integrated I-PASS ICU Handoff Tool. Pediatric quality & safety Caruso, T. J., Su, F. n., Wang, E. n. 2020; 5 (4): e334

    View details for DOI 10.1097/pq9.0000000000000334

    View details for PubMedID 32766505

    View details for PubMedCentralID PMC7382550

  • Systemic Absorption of Lidocaine from Continuous Erector Spinae Plane Catheters After Congenital Cardiac Surgery: A Retrospective Study. Journal of cardiothoracic and vascular anesthesia Caruso, T. J., Lin, C. n., O'Connell, C. n., Weiss, D. n., Md, G. B., Wu, M. n., Kwiatkowski, D. n., Maeda, K. n., Tsui, B. C. 2020


    To examine postoperative serum lidocaine levels in patients with intermittent lidocaine bolus erector spinae plane block (ESPB) catheters after cardiac surgery with or without cardiopulmonary bypass (CPB).A retrospective study.Single-center pediatric quaternary teaching hospital.Patients who received ESPB catheters after congenital cardiac surgery from April 2018 to March 2019.Postoperative serum lidocaine levels were extracted from the record.Twenty-seven of 40 patients were included in the final analyses (19 with CPB and 8 with no CPB, age 1-47 years, undergoing congenital heart repair). Patients who received ropivacaine or were missing data were excluded. The initial intraoperative bolus of lidocaine ranged from 0- to- 3.72 mg/kg, and the range of postoperative intermittent lidocaine boluses ranged from 0.35- to- 0.83 mg/kg, which were administered every hour. Serum lidocaine levels were measured by the hospital laboratory and ranged from <0.05- to- 3.0 μg/mL in the CPB group and from <0.05- to- 3.2 μg/mL in the no- CPB group. CPB was not associated with differences in lidocaine levels when controlling for time (P = 0.529). Lidocaine concentrations ranged from 0.50- to- 1.68 μg/mL in the CPB group and 0.86- to- 2.07 μg/mL in the no- CPB group. There was a normally distributed overall mean peak level of 1.818 ± standard deviation of 0.624 μg/mL, with 95% confidence interval of 0.57- to- 3.06 μg/mL. No patients had clinical signs of toxicity.Postoperative serum lidocaine concentrations did not appreciably differ due to CPB. Serum lidocaine concentrations did not reach near- toxic doses despite the presence of additional lidocaine in the cardioplegia. The results suggested that lidocaine for ESPBs after cardiac surgery is below systemic toxic range at the doses described.

    View details for DOI 10.1053/j.jvca.2020.05.040

    View details for PubMedID 32622712

  • Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures. The Laryngoscope Caruso, T. J., Madill, M. n., Sidell, D. n., Meister, K. n., Wang, E. n., Menendez, M. n., Kist, M. N., Rodriguez, S. n. 2020


    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

  • Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation. Pediatric quality & safety Rama, A., Knight, L. J., Berg, M., Chen, M., Gonzales, R., Delhagen, T., Copperman, L., Caruso, T. J. 2019; 4 (6): e222


    Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

    View details for DOI 10.1097/pq9.0000000000000222

    View details for PubMedID 32010849

  • A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatric quality & safety Nye, A., Conner, E., Wang, E., Chadwick, W., Marquez, J., Caruso, T. J. 2019; 4 (6): e246


    Despite guidelines allowing clear liquids up to 2 hours before anesthesia, preoperative fasting for pediatric inpatients is often unnecessarily prolonged. This delay can lead to prolonged recovery time and increased postoperative pain. Efforts to reduce fasting duration in pediatric surgical patients is an evolving standard in pediatric anesthesiology. The primary aim of this quality improvement project was to reduce the average inpatient fasting duration undergoing anesthesia by 25% within a year of our pilot intervention. Secondary aims included measuring the adoption rate of the intervention and comparing aspiration rates as a balancing measure.Methods: At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates.Results: Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates.Conclusion: This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.

    View details for DOI 10.1097/pq9.0000000000000246

    View details for PubMedID 32010870

  • Virtual reality successfully provides anxiolysis to laboring women undergoing epidural placement. Journal of clinical anesthesia Kist, M., Bekemeyer, Z., Ralls, L., Carvalho, B., Rodriguez, S. T., Caruso, T. J. 2019: 109635

    View details for DOI 10.1016/j.jclinane.2019.109635

    View details for PubMedID 31662229

  • Regional anesthesia for cardiac surgery. Current opinion in anaesthesiology Caruso, T. J., Lawrence, K., Tsui, B. C. 2019


    PURPOSE OF REVIEW: Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.RECENT FINDINGS: Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.SUMMARY: New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.

    View details for DOI 10.1097/ACO.0000000000000769

    View details for PubMedID 31356362

  • A Sustainable and Effective Mentorship Model for Graduate Medical Education Programs. Journal of graduate medical education Caruso, T. J., Kung, T., Piro, N., Li, J., Katznelson, L., Dohn, A. 2019; 11 (2): 221-225


    Mentorship models rarely seek generalizability across training programs at the graduate medical education (GME) level.We examined the sustainability and effectiveness of an intervention to increase the number and usefulness of trainee mentorship.A 0.20 full-time equivalent GME faculty adviser position (MD, MEd) implemented mentorship programs in residencies and fellowships. In group 1, 6 GME programs implemented the mentorship strategies prior to 2014, which were used to measure whether the number of mentor relationships were longitudinally sustained. In group 2, 10 different GME programs implemented the mentorship strategies in 2016, which were used to measure whether the intervention immediately increased the number of mentor relationships. To measure mentorship usefulness, trainees rated mentors' ability to promote clinical skills and personal and professional development. The remaining programs were the comparison. Responses from the 2014 and 2016 annual institutional trainee survey were analyzed.The incidence of group 1 reporting mentor relationships in 2014 compared to the incidence of group 1 in 2016 were 89% (41 of 46) and 95% (42 of 44), respectively, suggesting that the intervention was sustained for 2 years (P = .26). Group 2 showed a higher proportion of trainees reporting mentors in 2016 (88%, 149 of 170) compared to preintervention (66%, 71 of 108; P = .00001). Groups 1 and 2 reported significant increases in mentorship usefulness.A GME initiative to enhance mentoring across specialties in 16 GME training programs was self-sustaining and effective.

    View details for DOI 10.4300/JGME-D-18-00650.2

    View details for PubMedID 31024657

    View details for PubMedCentralID PMC6476078

  • Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial. Paediatric anaesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A. J., Caruso, T. J., Simons, L. 2019


    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

  • Accreditation Improves Quality of Oncology Education in Low- and Middle-Income Countries: Perspectives of African Oncologists. Journal of cancer education : the official journal of the American Association for Cancer Education Hammad, N., Stockley, D., Hastings-Truelove, A., Vanderpuye, V., Rubagumya, F., Caruso, T. 2019


    The purpose of this study is to understand the perspectives of African Oncologists on the role of accreditation and on global standards. We developed a survey that addressed African oncologists' opinions on the role of accreditation. The survey also included 187 standards from World Federation of Medical Education Postgraduate medical education (PGME) standards, American Council of Graduate Medical Education (ACGME)-I standards for hematology/oncology, and the Royal College of Physician and Surgeons of Canada Medical Oncology standards. A 3-point scale was employed for each standard: 1 = not important, 2 = important but not essential, 3 = essential. The survey was sent to 79 physicians, 38 responded. Eighty-seven percent agreed that accreditation ensures quality. Forty-five percent agreed it will not increase migration of qualified doctors. Twenty-two individuals who completed the entire survey were analyzed for the standards. Five standards received the highest ratings of 3 (essential) from all respondents. One standard received a rating of < 2.0. The majority of standards had ratings between 2.6 and 2.94 indicating African oncologists found most standards to be useful. Ratings < 2.6 were mostly related to resource constraints. Most African Oncologists believed that accreditation ensures quality of education, and most standards were considered important. This data is useful for developing and adapting accreditation standards in resource-constrained settings.

    View details for DOI 10.1007/s13187-019-01497-3

    View details for PubMedID 30806905

  • Toward Opioid-Free Fast Track for Pediatric Congenital Cardiac Surgery. Journal of cardiothoracic and vascular anesthesia Esfahanian, M., Caruso, T. J., Lin, C., Kuan, C., Purkey, N. J., Maeda, K., Tsui, B. C. 2019

    View details for DOI 10.1053/j.jvca.2019.02.003

    View details for PubMedID 30852093

  • Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) augments oxygenation in children with cyanotic heart disease during microdirect laryngoscopy and bronchoscopy. Journal of clinical anesthesia Caruso, T. J., Sidell, D. R., Lennig, M., Menendez, M., Fonseca, A., Rodriguez, S. T., Tsui, B. 2019; 56: 53–54

    View details for PubMedID 30690312

  • Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study. Anesthesia and analgesia Muffly, M. K., Ku, A., Drover, D. R., Rodriguez, S., Caruso, T. J., Ku, A., Tsui, B. C. 2019


    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 ( 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. Paediatric anaesthesia Caruso, T. J., George, A. n., Menendez, M. n., De Souza, E. n., Khoury, M. n., Kist, M. N., Rodriguez, S. T. 2019


    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

  • Intraoperative Methadone Is Associated with Decreased Perioperative Opioid Use Without Adverse Events: A Case-Matched Cohort Study. Journal of cardiothoracic and vascular anesthesia Robinson, J. D., Caruso, T. J., Wu, M. n., Kleiman, Z. I., Kwiatkowski, D. M. 2019


    To determine if there is an association of intraoperative methadone use and total perioperative opioid exposure in patients undergoing congenital heart surgeries.Retrospective, case-match cohort study.Single center quaternary care teaching hospital.Seventy-four patients with congenital heart disease (CHD) undergoing surgical repair or palliative surgery.Thirty-seven patients undergoing CHD surgeries receiving intraoperative methadone were matched to 37 patients based upon age and procedure who did not receive intraoperative methadone. The primary study outcome was to evaluate total opioid use in intravenous milligrams of morphine equivalents per kilogram (mg ME/kg) within the first 36-hours postoperatively. Mann-Whitney U test was used to compare total opioid exposure.The total opioid use was compared between groups. The methadone cohort required less opioids intraoperatively, in the first 12 hours postoperatively, and during the first 36 hours postoperatively (2.51 v 4.39 mg ME/kg, p < 0.001; 0.43 v 1.28 mg ME/kg, p = 0.001; and 0.83 v 1.91 mg ME/kg, p < 0.001) compared with the matched control cohort. There were no differences in clinical outcomes or adverse events. A dose-dependent reduction in opioid consumption in high- versus low-dose groups also was not observed.Intraoperative methadone use was associated with a decrease in perioperative opioid exposure in patients undergoing congenital heart surgery and was not associated with adverse events or prolonged durations of mechanical ventilation or ICU stay.

    View details for DOI 10.1053/j.jvca.2019.09.033

    View details for PubMedID 31699597

  • A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery. Paediatric anaesthesia Colletti, A. A., Wang, E. n., Marquez, J. L., Schwenk, H. T., Yeverino, C. n., Sharek, P. J., Caruso, T. J. 2019


    Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists.Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic).At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014 and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert five minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences.3,015 antibiotic redoses were administered during 2,341 operative cases between May 1, 2014 and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (p < 0.001). Dose-only compliance increased from 76% to 89% (p < 0.001) and time-only compliance increased from 4.9 to 82% (p < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs. 86% (p = 0.015).This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. This article is protected by copyright. All rights reserved.

    View details for PubMedID 31034725

  • Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team. Pediatric quality & safety Caruso, T. J., Rama, A. n., Knight, L. J., Gonzales, R. n., Munshey, F. n., Darling, C. n., Chen, M. n., Sharek, P. J. 2019; 4 (3): e172


    Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

    View details for DOI 10.1097/pq9.0000000000000172

    View details for PubMedID 31579871

    View details for PubMedCentralID PMC6594783

  • Crowd Sourced Assessment of Ureteroscopy with Laser Lithotripsy video feed does not correlate with Trainee Experience. Journal of endourology Conti, S. L., Brubaker, W., Chung, B. I., Sofer, M., Hsi, R. S., Shinghal, R., Elliott, C. S., Caruso, T., Leppert, J. T. 2018


    OBJECTIVES: We sought to validate the use of crowd sourced surgical video evaluation in the evaluation of flexible ureteroscopic laser lithotripsy videos using a modified global assessment scale previously validated for ureteroscopic skills.METHODS: We collected video feeds from 30 intra-renal ureteroscopic laser lithotripsy cases where residents post graduate year(PGY) 2 through 6 handled the ureteroscope. The video feeds were annotated to represent the overall performance and to contain the parts of the procedure being scored. The videos were submitted to a commercially available surgical video evaluation platform. We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to account for the fact that this scoring system looked at the video feed only. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk as well as 5 Endourology trained experts. Mean scores were calculated and intraclass correlation coefficients(ICCs) were computed for the expert domain and total scores. The ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and the expert average scores.RESULTS: 30 videos were reviewed 2,488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation(0.30) with the overall score having an ICC of .000. Overall the crowd scores did not correlate with expert scores except for the stone retrieval domain (0.60 p = 0.015). Crowd sourced scores had a negative correlation with PGY level(-0.44 p=0.019).CONCLUSIONS: Given the poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy, assessment of skills using intraoperative video feeds may not be reliable. This is further supported by the inverse correlation between crowd scores and PGY level.

    View details for PubMedID 30450963

  • The erector spinae plane (ESP) block: A pooled review of 242 cases. Journal of clinical anesthesia Tsui, B. C., Fonseca, A., Munshey, F., McFadyen, G., Caruso, T. J. 2018; 53: 29–34


    STUDY OBJECTIVE: The erector spinae plane block (ESPB) was first described in 2016 as a regional block for thoracic neuropathic pain. Given its short history, there are a paucity of controlled clinical trials, yet an abundance of case reports. The primary aim of this review is to examine pooled clinical data from published literature to gain an understanding of ESPB characteristics.DESIGN: A PubMed search was conducted to identify all ESPB related publications. Inclusion criteria included reports of ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. Only publications obtained in English were included. Measures included type of publication, year and country of publication, journal of publication, block technique, anatomic location, age, opioid and adjunct pain medication use, sensory and motor changes, side effects and adverse events. Qualitative statistics were used.MAIN RESULTS: The initial search yielded 201 publications. After application of inclusion and exclusion criteria, 85 publications from 21 journals were included in the pooled review which yielded 242 reported cases between 2016 and 2018. The majority of publications reported single shot techniques (80.2%), followed by intermittent boluses (12.0%) and continuous infusions (7.9%). 90.9% reported use of multimodal analgesia in addition to the ESPB and 34.7% reported sensory changes from ESPB. A reduction in opioid use was reported in 34.7% of cases. One adverse event involving a pneumothorax was reported.CONCLUSIONS: To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.

    View details for PubMedID 30292068

  • Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience. Anesthesia and analgesia Munshey, F., Caruso, T. J., Wang, E. Y., Tsui, B. C. 2018


    With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery.

    View details for DOI 10.1213/ANE.0000000000003817

    View details for PubMedID 30252704

  • Safety Stop: A Valuable Addition to the Pediatric Universal Protocol JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Caruso, T. J., Munshey, F., Aldorfer, B., Sharek, P. J. 2018; 44 (9): 552–56


    The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk.The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption.In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice.Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

    View details for PubMedID 30166039

  • The successful application of high flow nasal oxygen during microdirect laryngoscopy and bronchoscopy in patients under 7 kg. Journal of clinical anesthesia Caruso, T. J., Gupta, A., Sidell, D. R., Darling, C., Rodriguez, S., Fonseca, A., Tsui, B. 2018; 52: 27–28

    View details for PubMedID 30153541

  • A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety. Pediatric quality & safety Caruso, T. J., Tsui, J. H., Wang, E., Scheinker, D., Sharek, P. J., Cunningham, C., Rodriguez, S. T. 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

  • Augmented reality for intravenous access in an autistic child with difficult access. Paediatric anaesthesia Rodriguez, S. n., Munshey, F. n., Caruso, T. J. 2018; 28 (6): 569–70

    View details for DOI 10.1111/pan.13395

    View details for PubMedID 29878540

  • A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Joint Commission journal on quality and patient safety Caruso, T. J., Wang, E. Y., Schwenk, H. n., Marquez, J. L., Cahn, J. n., Loh, L. n., Schaffer, J. n., Chen, K. n., Wood, M. n., Sharek, P. J. 2018


    Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p = 0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

    View details for DOI 10.1016/j.jcjq.2018.05.009

    View details for PubMedID 30170753

  • Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: often overlooked areas that may reduce surgical site infections. Paediatric anaesthesia Caruso, T. J., Wang, E. n., Colletti, A. A., Sharek, P. J. 2018


    It was with great interest that we read Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures by Morse, et al.1 The authors should be applauded for presenting a well-balanced review of the rationale behind the use of prophylactic antibiotics, data supporting dosing intervals, and potential outcome measures. This article is protected by copyright. All rights reserved.

    View details for PubMedID 30592343

  • Lumbar erector spinae plane catheter via a thoracic approach for iliac crest autograft in a pediatric patient. Journal of clinical anesthesia Darling, C. E., Lin, C. n., Caruso, T. J., Tsui, B. C. 2018; 54: 164–65

    View details for DOI 10.1016/j.jclinane.2018.12.008

    View details for PubMedID 30554043

  • Cervical erector spinae plane block catheter using a thoracic approach: an alternative to brachial plexus blockade for forequarter amputation. Canadian journal of anaesthesia = Journal canadien d'anesthesie Tsui, B. C., Mohler, D. n., Caruso, T. J., Horn, J. L. 2018

    View details for PubMedID 29868941

  • Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of Cardiac Regional Anesthesia. Journal of clinical anesthesia Tsui, B. C., Navaratnam, M. n., Boltz, G. n., Maeda, K. n., Caruso, T. J. 2018; 48: 9–10

    View details for DOI 10.1016/j.jclinane.2018.04.005

    View details for PubMedID 29684728

  • Successful directional thoracic erector spinae plane block after failed lumbar plexus block in hip joint and proximal femur surgery. Journal of clinical anesthesia Darling, C. E., Pun, S. Y., Caruso, T. J., Tsui, B. C. 2018; 49: 1–2

    View details for PubMedID 29775780

  • Improving Satisfaction with Pediatric Pain Management by Inviting the Conversation. Joint Commission journal on quality and patient safety Caruso, T. J., Kung, T. H., Good, J. n., Taylor, K. n., Ashland, M. n., Cunningham, C. n., Gonzalez, E. n., Wood, M. n., Sharek, P. n. 2018; 44 (4): 227–32


    Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management.In an academic pediatric hospital, nurse manager rounds were used to invite a conversation about pain management. The question, "Pain management is very important to us. Has your child's pain been well controlled?" was added to the established standard questions asked during nurse manager rounds. Effectiveness was measured using the preexisting Press Ganey survey question, "How well was your child's pain controlled?" Responses were compared between those patients who were and were not exposed to the rounding question.Data for 1,032 patients were used to establish baseline satisfaction with pain management scores. In the intervention period, 328 patients received nurse manager rounds and 121 did not. The median of the weighted mean patient survey satisfaction scores were baseline, 91.5%; receiving intervention, 94.2%; and not receiving intervention, 90.0%. Patients who received the intervention reported higher satisfaction with pain management than those who did not (p <0.0001).Hospitals seeking to improve satisfaction with pain management should encourage health care providers to reliably discuss pain control with pediatric patients.

    View details for DOI 10.1016/j.jcjq.2017.10.003

    View details for PubMedID 29579448

  • Caution with the Posey(®) Cufflator™ cuff pressure manometers. Paediatric anaesthesia Kiberd, M. B., Swenson-Schalkwyk, A. K., Caruso, T. J. 2017; 27 (12): 1279-1280

    View details for DOI 10.1111/pan.13262

    View details for PubMedID 29110434

  • A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710


    The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

    View details for DOI 10.1111/pan.13137

    View details for PubMedID 28321988

  • Standardized ICU to OR handoff increases communication without delaying surgery. International journal of health care quality assurance Caruso, T. J., Marquez, J. L., Gipp, M. S., Kelleher, S. P., Sharek, P. J. 2017; 30 (4): 304-311


    Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format. Anticipatory calls from the OR nurse to the ICU nurse were made to prepare the patient for transport. Data collected included frequency of handoff, patient transport readiness, turnover time between OR cases, and anesthesia provider satisfaction. Findings In total, 57 audits were completed. The frequency of handoffs increased from 25 to 86 percent ( p<0.0001) and the frequency of patient readiness increased from 61 to 97 percent ( p=0.001). There were no changes in timeliness of first start cases and no significant change in turnover times between cases. Anesthesia provider satisfaction scores increased significantly. Practical implications A standardized, team based ICU to OR handoff increased the frequency of face-to-face handoffs, patient readiness and anesthesia provider satisfaction within increasing turnover between cases. Originality/value Although studies have identified the transition of patients from the ICU to the OR as a period of increased harm, the development of a preoperative ICU to OR handoff had not been described. This intervention may be used in other institutions to design ICU to OR transitions of care.

    View details for DOI 10.1108/IJHCQA-02-2016-0015

    View details for PubMedID 28470134

  • Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety. Paediatric anaesthesia Rodriguez, S. n., Caruso, T. n., Tsui, B. n. 2017; 27 (6): 668–69

    View details for DOI 10.1111/pan.13133

    View details for PubMedID 28474813

  • Pediatric Postoperative Pulse Oximetry Monitoring During Transport to the Postanesthesia Care Unit Reduces Frequency of Hypoxemia. Joint Commission journal on quality and patient safety Caruso, T. J., Mokhtari, T. E., Coughlan, M. J., Wu, D. S., Marquez, J. L., Duan, M. n., Freeman, H. n., Giustini, A. n., Tweedy, M. n., Sharek, P. J. 2017; 43 (3): 146–50


    The standard use of pulse oximetry during the transport of postoperative patients from the operating room (OR) to the postanesthesia care unit (PACU) is not routinely practiced. A study was conducted to determine if the frequency of hypoxemia on admission to the PACU decreased after implementation of routine use of transport pulse oximeters for postoperative patients being transferred to the PACU.In this prospective cohort study, which was conducted at an academic pediatric hospital, the primary outcome measure was the frequency of hypoxemic events on arrival to the PACU.A total of 506 patients in the preintervention phase and 597 in the postintervention phase met the inclusion criteria. Six hypoxemic events on arrival to the PACU were identified in preintervention phase versus zero in the postintervention period, p = 0.009. Use of oxygen monitors during transport from the OR to the PACU increased from 0% to 100%, p < 0.0001, in the postintervention phase. The median duration of unmonitored time during transport decreased from 272 seconds to 13 seconds, p < 0.0001. Of the 605 patients who met the inclusion criteria for sustainment audits-conducted 18 months after the postimplementation evaluation-99.8% were transported to the PACU with a pulse oximeter, and there were zero reported hypoxemic patients on PACU admission.The routine use of portable oxygen monitoring when transferring patients from the OR to the PACU is a low-cost, noninvasive safety measure that should be considered at any institution performing pediatric general anesthesia.

    View details for DOI 10.1016/j.jcjq.2016.12.001

    View details for PubMedID 28334593

  • Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Yuan, J. C., Rodriguez, S. n., Caruso, T. J., Tsui, J. H. 2017

    View details for PubMedID 28861855

  • Interactive video game built for mask induction in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Rodriguez, S. n., Tsui, J. H., Jiang, S. Y., Caruso, T. J. 2017

    View details for PubMedID 28646461

  • A Strategic Approach to Implementation of Medical Mentorship Programs. Journal of graduate medical education Caruso, T. J., Steinberg, D. H., Piro, N., Walker, K., Blankenburg, R., Rassbach, C., Marquez, J. L., Katznelson, L., Dohn, A. 2016; 8 (1): 68-73


    Mentors influence medical trainees' experiences through career enhancement and psychosocial support, yet some trainees never receive benefits from involved mentors.Our goals were to examine the effectiveness of 2 interventions aimed at increasing the number of mentors in training programs, and to assess group differences in mentor effectiveness, the relationship between trainees' satisfaction with their programs given the presence of mentors, and the relationship between the number of trainees with mentors and postgraduate year (PGY).In group 1, a physician adviser funded by the graduate medical education department implemented mentorships in 6 residency programs, while group 2 involved a training program with funded physician mentoring time. The remaining 89 training programs served as controls. Chi-square tests were used to determine differences.Survey responses from group 1, group 2, and controls were 47 of 84 (56%), 34 of 78 (44%), and 471 of 981 (48%, P = .38), respectively. The percentages of trainees reporting a mentor in group 1, group 2, and the control group were 89%, 97%, and 79%, respectively (P = .01). There were no differences in mentor effectiveness between groups. Mentored trainees were more likely to be satisfied with their programs (P = .01) and to report that faculty supported their professional aspirations (P = .001). Across all programs, fewer first-year trainees (59%) identified a mentor compared to PGY-2 through PGY-8 trainees (84%, P < .001).A supported mentorship program is an effective way to create an educational environment that maximizes trainees' perceptions of mentorship and satisfaction with their training programs.

    View details for DOI 10.4300/JGME-D-15-00335.1

    View details for PubMedID 26913106

    View details for PubMedCentralID PMC4763391

  • Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Joint Commission journal on quality and patient safety / Joint Commission Resources Caruso, T. J., Marquez, J. L., Wu, D. S., Shaffer, J. A., Balise, R. R., Groom, M., Leong, K., Mariano, K., Honkanen, A., Sharek, P. J. 2015; 41 (1): 35-42


    In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

    View details for PubMedID 25976722

  • Images in clinical medicine. Severe vitamin D deficiency--rickets. New England journal of medicine Caruso, T. J., Fuzaylov, G. 2013; 369 (9)

    View details for DOI 10.1056/NEJMicm1205540

    View details for PubMedID 23984751

  • Airway management of recovered pediatric patients with severe head and neck burns: a review PEDIATRIC ANESTHESIA Caruso, T. J., Janik, L. S., Fuzaylov, G. 2012; 22 (5): 462-468


    There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

    View details for DOI 10.1111/j.1460-9592.2012.03795.x

    View details for Web of Science ID 000302540900009

    View details for PubMedID 22260458

  • Complementary and Alternative Medicine for Pain: An Evidence-based Review CURRENT PAIN AND HEADACHE REPORTS Dhanani, N. M., Caruso, T. J., Carinci, A. J. 2011; 15 (1): 39-46


    Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

    View details for DOI 10.1007/s11916-010-0158-y

    View details for Web of Science ID 000286230400007

    View details for PubMedID 21063917

  • Magnetic resonance Imaging detected renal volume reduction in refluxing and nonrefluxing kidneys JOURNAL OF UROLOGY Chang, S. L., Caruso, T. J., Shortliffe, L. D. 2007; 178 (6): 2550-2554


    Renal parenchymal damage is a well recognized sequela of urinary tract infection in the setting of vesicoureteral reflux. We investigated renal magnetic resonance imaging as a quantitative modality to detect renal parenchymal damage in children with primary vesicoureteral reflux and urinary tract infection.We retrospectively reviewed the medical records of children with primary vesicoureteral reflux and urinary tract infection who underwent renal magnetic resonance imaging evaluation. Those with other genitourinary pathology were excluded. Controls underwent magnetic resonance imaging for nongenitourinary pathologies. Kidneys were segregated among control, nonrefluxing, and low grade (I to III) and high grade (IV to V) reflux. Size plots (magnetic resonance imaging volume vs age) were drawn for comparison. Gross imaging abnormalities observed were renal scarring and small size.Magnetic resonance imaging was performed in 114 patients with vesicoureteral reflux (228 kidneys, patient age 0.5 to 17.8 years) and 21 controls (42, 0.5 to 12). Higher grades of reflux were associated with smaller volume, and smaller volume was noted in the refluxing and nonrefluxing kidneys of children with vesicoureteral reflux. Kidneys from patients with unilateral or bilateral reflux had significantly decreased renal volume compared to controls (p <0.0001). Kidneys in which vesicoureteral reflux spontaneously resolved had renal volumes similar to control kidneys (p = 0.23).Use of magnetic resonance imaging derived renal volume allows renal comparison and is helpful in evaluating patients with vesicoureteral reflux. In patients with a history of a febrile urinary tract infection and reflux the finding of measurably smaller kidneys appears to be more common than scarring. Whether these findings represent renal atrophy or hypoplasia needs further investigation.

    View details for Web of Science ID 000250847900082

    View details for PubMedID 17937957

  • Treatment of naturally acquired common colds with zinc: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Prober, C. G., Gwaltney, J. M. 2007; 45 (5): 569-574


    Over the past 20 years, the use of zinc as an over-the-counter alternative therapy for the common cold has vastly grown in popularity. Recent reports of potentially permanent anosmia caused by intranasal zinc therapy warrant careful analysis of the therapeutic effects of zinc.A search of the Medline database (including articles published during 1966-2006) for studies of zinc and the common cold produced 105 published reports. Fourteen were randomized, placebo-controlled studies that examined the effect of zinc lozenges, nasal sprays, or nasal gels on naturally acquired common colds. Eleven features of experimental design affecting signal quality, chance, bias, and blinding were used to evaluate the 14 placebo-controlled studies. These criteria were validated case definition, quantifiable hypothesis, sample size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of dropout rate, analysis by intent to treat, description of methods of analysis, and measurements of probability. Equal weight was given to each criterion, because failure to meet any one could potentially invalidate the findings of a clinical trial.Four studies met all 11 criteria. Three of these studies reported no therapeutic effect from zinc lozenge or nasal spray. One study reported positive results from zinc nasal gel. Of the remaining 10 studies, 6 reported a positive effect and 4 reported no effect. Intent-to-treat analysis was the most common criterion not met.This structured review suggests that the therapeutic effectiveness of zinc lozenges has yet to be established. One well-designed study did report a positive effect of zinc nasal gel.

    View details for DOI 10.1086/520031

    View details for Web of Science ID 000248557000016

    View details for PubMedID 17682990

  • Efficacy of echinilin for the common cold - Echinacea, vitamin C, the common cold, and blinding - Reply CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 41 (5): 763–64

    View details for DOI 10.1086/432628

    View details for Web of Science ID 000230995600032

  • Treatment of the common cold with echinacea: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 40 (6): 807-810


    Echinacea is a herbal preparation that is frequently used to treat the common cold. Spending on echinacea in the United States has risen to >300 million dollars annually.A total of 322 articles related to echinacea and colds, including 9 placebo-controlled clinical trials, were identified using the Medline and PubMed databases. Eleven features of experimental design that affect the accuracy of the measurement of features of interest, the probability of a chance relationship, bias, and blinding were used to evaluate the 9 placebo-controlled studies. The criteria were validated case definition, quantifiable hypothesis, sample-size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of drop-out rate, analysis by intention to treat, description of the methods of analysis, and measurement of probability. Equal weight was given to each criterion, since failure to meet any one of them could potentially invalidate the findings of a clinical trial.Of the 9 studies, 2 met all 11 criteria. The results of both studies were judged to be negative by the people who performed the studies. Of the remaining 7 studies, 6 were judged to have positive results, and 1 was judged to have negative results. The criterion most commonly not met was proof of blinding.This structured review suggests that the possible therapeutic effectiveness of echinacea in the treatment of colds has not been established.

    View details for Web of Science ID 000227492800005

    View details for PubMedID 15736012

  • Evaluating Studies of Echinacea of Treating the Common Cold Contagion Caruso, T. J. 2005; 9: 378-381