Airway management in pediatric patients with Pierre Robin Sequence (PRS) requires a detailed understanding of pediatric airway anatomy, which differs significantly from adults—neonates have a larger tongue, smaller jaw (micrognathia), anterior larynx, and floppy epiglottis, all of which are exaggerated in PRS. These features increase the risk of airway obstruction and difficult intubation.

Learning Objectives:

1. Understand airway anatomical differences in neonates, infants, and children compared to adults.
2. Describe developmental changes in respiratory physiology.
3. Identify predictors of a difficult pediatric or neonatal airway, including syndromic features (e.g., Pierre Robin, Down syndrome, Goldenhar, CHARGE).
4. Understand selection and sizing of airway equipment.
5. Understand the ASA Difficult Airway Algorithm and adaptations for neonates and pediatric patients.

Video-Assisted Thoracoscopic Surgery (VATS) is a minimally invasive alternative to open thoracotomy, using small incisions and a thoracoscope to perform intrathoracic procedures such as wedge resections, lobectomies, and pleural biopsies. This is a case of a 48 year old female who presented initially with dysphagia due obstructive sensation at her throat. After a series of workup including a PET SCAN, she is about to undergo resection of Pulmonary Nodule in the Right Middle Lobe (To Consider Metastasis). Compared to thoracotomy, VATS offers reduced postoperative pain, shorter recovery time, and fewer pulmonary complications.

Learning Objectives:

1. Define Video-Assisted Thoracoscopic Surgery (VATS) and differentiate it from open thoracotomy.
2. Explain the anesthetic goals specific to VATS, including:
   • Lung isolation and deflation
   • Optimal gas exchange during one-lung ventilation (OLV)
   • Hemodynamic stability
   • Postoperative analgesia
3. Identify the types of procedures commonly performed with VATS (e.g., wedge resection, lobectomy, pleural biopsy).
4. List common anesthetic challenges in VATS:
   • Hypoxemia during OLV
   • Hypercapnia
   • Surgical interference with ventilation
5. Describe the advantages and limitations of VATS compared to thoracotomy from an anesthetic perspective.

Total Intravenous Anesthesia (TIVA) in neonates, particularly for MRI, requires careful consideration of neonatal physiology—including immature hepatic and renal function, sensitive airway anatomy, and poor thermoregulatory control. These factors affect drug metabolism and increase the risk of adverse events such as apnea, bradycardia, and hypothermia.

Learning Objectives:

Pre-Sedation

1. Identify the unique physiological and pharmacological considerations in neonates (e.g., immature hepatic/renal function, airway anatomy, thermoregulation).
2. List indications and contraindications for sedation or anesthesia in neonatal MRI.
3. Describe commonly used anesthetic and sedative agents in neonates (e.g., propofol, dexmedetomidine, chloral hydrate) and their safety profiles.
4. Explain fasting guidelines appropriate for neonates prior to sedation.
5. Discuss the importance of screening for underlying medical conditions (e.g., apnea of prematurity, congenital heart disease).

Intra-Procedural

1. Describe challenges of delivering anesthesia in the MRI environment (e.g., limited access, MRI-compatible equipment).
2. Explain MRI safety principles for anesthetic equipment (e.g., non-ferromagnetic monitors, gas delivery systems).
3. Discuss the goals of anesthesia during MRI: immobility, airway protection, hemodynamic stability, and maintenance of normothermia.

Post-Sedation

1. Recognize potential complications of neonatal sedation (e.g., hypoxia, apnea, bradycardia).
2. Describe appropriate monitoring and discharge criteria for neonates post-MRI sedation.

This module covers the principles and practices of anesthesia for hip surgery, including preoperative assessment, anesthetic techniques (general vs regional), intraoperative management, and postoperative care. Emphasis is placed on optimizing patient safety, managing comorbidities, and facilitating early recovery.

Learning Objectives:
By the end of this module, learners will be able to:

1. Describe the common types of hip surgeries and their anesthetic implications.
2. Compare and contrast regional and general anesthesia techniques for hip procedures.
3. Identify key patient factors (e.g., age, comorbidities, anticoagulation) that influence anesthetic planning.
4. Formulate an anesthetic plan tailored to individual patient and surgical needs.
5. Demonstrate knowledge of intraoperative monitoring, fluid management, and pain control strategies.
6. Recognize and manage potential complications, including hypotension, blood loss, and postoperative delirium.
7. Outline strategies for enhanced recovery and postoperative analgesia following hip surgery.

This session provides an overview of neonatal surgical emergencies, focusing on early recognition, differential diagnosis, initial stabilization, and the principles guiding surgical intervention. Emphasis is placed on the clinical approach to common presentations like bilious vomiting and abdominal distension, with a review of key diagnostic tools and urgent management steps. Learners will explore the most frequent surgical emergencies encountered in neonates and understand factors influencing the urgency and timing of surgical treatment.

Learning Objectives:

1. List the differential diagnoses for bilious vomiting and abdominal distension in neonates.
2. Describe the immediate stabilization and investigation steps for a neonate presenting with suspected surgical emergency.
3. Interpret key radiographic findings suggestive of common neonatal surgical conditions.
4. Differentiate between surgical and non-surgical causes of neonatal abdominal symptoms.
5. Identify the most common neonatal surgical emergencies and discuss their pathophysiology, presentation, and management.
6. Evaluate the factors that influence the timing of surgery in critically ill neonates.

This discussion focuses on hypertension in pregnancy, with an emphasis on severe preeclampsia and its anesthetic implications. Participants will explore the underlying pathophysiology, including endothelial dysfunction, intravascular volume changes, and coagulopathy. The session also covers maternal and fetal complications, anesthetic goals, choice of anesthesia technique, and the pharmacologic management of hypertensive disorders in pregnancy.

Learning Objectives:

1. Explain the pathophysiology of hypertension and preeclampsia and its implications for anesthetic care, including:
   • Endothelial dysfunction
   • Intravascular volume depletion
   • Coagulopathy (e.g., HELLP syndrome)
2. List maternal and fetal complications associated with severe preeclampsia (e.g., eclampsia, placental abruption, fetal growth restriction).
3. Describe the goals of anesthesia management in severe preeclampsia:
   • Blood pressure control
   • Maintenance of uteroplacental perfusion
   • Avoidance of complications such as stroke or pulmonary edema
4. Compare the indications, risks, and benefits of regional vs general anesthesia in severe preeclampsia.
5. Discuss the role of medications such as magnesium sulfate, antihypertensives (e.g., labetalol, hydralazine), and their anesthetic implications.

This session explores the complex interplay between coagulopathy, trauma, and liver disease, with a focus on trauma patients with cirrhosis. Learners will examine the pathophysiological changes in coagulation balance in cirrhotic patients, how these are affected by trauma and hemorrhage, and the challenges in interpreting standard coagulation tests. The discussion also addresses anesthetic considerations, transfusion strategies, and the role of viscoelastic testing in guiding targeted management during resuscitation and surgery.

Learning Objectives:

1. Explain the impact of trauma and hemorrhage on coagulation balance in cirrhotic patients.
2. Identify clinical and laboratory signs of coagulopathy in a trauma patient with cirrhosis (e.g., elevated INR, low platelets, prolonged PT/aPTT).
3. Evaluate the risks of bleeding versus thrombosis in cirrhotic patients with trauma.
4. Interpret coagulation studies in the context of cirrhosis, understanding limitations (e.g., INR may not reflect bleeding risk accurately).
5. Assess the need for viscoelastic testing (e.g., TEG/ROTEM) in guiding blood product administration.
6. Recognize anesthetic considerations in cirrhotic patients, including drug metabolism, fluid shifts, and hemodynamic instability.
7. Plan perioperative strategies to manage coagulopathy, including use of FFP, cryoprecipitate, platelets, and possibly antifibrinolytics (e.g., TXA).
8. Demonstrate appropriate airway and hemodynamic management in trauma patients with liver dysfunction.
9. Discuss the role of damage control resuscitation and massive transfusion protocols in cirrhotic trauma patients.

This discussion focuses on the anesthetic considerations for spine surgery, highlighting the complexity of managing patients in the prone position and the need for careful coordination with surgical and neuromonitoring teams. Key topics include preoperative evaluation, positioning risks, intraoperative management strategies, blood conservation, and planning for postoperative analgesia and complication prevention.

Learning Objectives:

1. Conduct a comprehensive preoperative evaluation including airway, neurologic status, and comorbidities (e.g., obesity, obstructive sleep apnea, cardiac disease).
2. Recognize and mitigate complications related to prone positioning (e.g., pressure injury, vision loss, venous air embolism).
3. Manage anesthetic depth, neuromonitoring compatibility (e.g., SSEPs, MEPs), and blood pressure targets.
4. Implement blood conservation strategies (e.g., antifibrinolytics, cell salvage, permissive hypotension). Monitor for and treat massive blood loss and transfusion needs.
5. Develop multimodal analgesia plans including opioids, NSAIDs, acetaminophen, and regional techniques.
6. Identify risks of postoperative complications such as respiratory depression, delayed emergence, and neurologic deficits.

This discussion addresses the recognition and anesthetic management of obstetric hemorrhage, a leading cause of maternal morbidity and mortality. The session covers the classification of hemorrhage, underlying causes using the "4 Ts" framework, pathophysiological changes during massive bleeding, and critical anesthetic considerations including fluid resuscitation, transfusion strategies, and medication use. Special attention is given to decision-making around anesthetic techniques in hemodynamically unstable obstetric patients.

Learning Objectives:

1. Define obstetric hemorrhage, including major categories:
   • Antepartum hemorrhage (e.g., placenta previa, abruption)
   • Postpartum hemorrhage (PPH: >500 mL vaginal, >1000 mL cesarean)
2. List common causes of obstetric hemorrhage using the “4Ts mnemonic”:
   • Tone (uterine atony)
   • Trauma (lacerations, uterine rupture)
   • Tissue (retained placenta)
   • Thrombin (coagulopathy)
3. Explain the pathophysiology and hemodynamic changes during massive obstetric hemorrhage.
4. Describe the anesthetic implications of hemorrhage, including:
   • Fluid resuscitation and transfusion management
   • Hemodynamic monitoring
   • Effects on anesthetic drug pharmacokinetics
5. Discuss anesthetic options in unstable obstetric patients:
   • When general anesthesia is preferred over neuraxial
   • Risks of neuraxial anesthesia in hypovolemia or coagulopathy
6. Summarize the use and implications of:
   • Uterotonics (e.g., oxytocin)
   • Tranexamic acid (TXA)
   • Massive transfusion protocols (MTPs)

This discussion explores the recognition, causes, and management of perioperative hypotension, a common and potentially harmful complication in surgical patients. The session reviews the physiological basis of blood pressure regulation during anesthesia, effects of common anesthetic agents, and phase-specific causes of hypotension. Learners will also assess patient risk factors and understand the shortand long-term consequences of inadequate perfusion during the perioperative period.

Learning Objectives:

1. Define perioperative hypotension and its common thresholds (e.g., MAP <65 mmHg).
2. Describe the physiological mechanisms underlying blood pressure regulation during anesthesia.
3. List common causes of hypotension in each perioperative phase:
   • Preoperative (e.g., dehydration, medications)
   • Intraoperative (e.g., anesthetic agents, blood loss, positioning)
   • Postoperative (e.g., residual anesthetics, bleeding, sepsis)
4. Explain the effects of various anesthetic agents (e.g., propofol, volatile anesthetics, opioids) on hemodynamics.
5. Identify high-risk patient populations for perioperative hypotension (e.g., elderly, cardiac disease, autonomic dysfunction).
6. Discuss the short- and long-term consequences of intraoperative hypotension (e.g., myocardial injury, AKI, stroke).
7. Explain the role of POCUS aided anesthesia management by differentiating causes of hypotension (e.g., hypovolemia, cardiac dysfunction, vasodilation, tamponade, pneumothorax).