Anesthesia services during operation unified assistance, aboard the USNS Mercy, after the tsunami in Southeast Asia.

The tsunami that struck Southeast Asia on December 26, 2004, resulted in the deaths of >300,000 individuals. The U.S. response included the formation of the first combined civilian/ military peacetime humanitarian effort, directed by the National Command Authority as Operation Unified Assistance. This effort included military personnel from the U.S. Navy and civilians assembled by Project HOPE. Anesthesiologists and certified nurse anesthetists provided care in >150 cases. We discuss the initial response, medical and cultural planning, logistical support, procedures, and lessons learned in this unique opportunity.

Individualized remediation during fellowship training.

The Accreditation Council for Graduate Medical Education requires medical training programs to monitor, track, and formally document a fellow's performance. If deficiencies are found, programs are expected to prepare and implement an effective plan of action for improvement and to ensure that graduates acquire the personal and professional attributes of an independent physician. We revised our evaluation policy and instituted a remediation protocol in 2008. Since that time, 130 pediatric anesthesia fellows have graduated. Seven fellows (5%) underwent departmental formal consultation for deficient behavior or poor performance. Of these 7 fellows, 4 underwent an individualized remediation program (IRP). A formal performance review and written contract, with specifically identified problems and general themes, recommendations for time-based successful behaviors, and clearly identified consequences for unsuccessful behaviors, was initiated for each fellow undergoing an IRP. All fellows who participated in this program completed their subspecialty training in pediatric anesthesia, and all eligible fellows have successfully achieved their subspecialty board certification. Our approach has the advantage of multimodality, time-based daily evaluations, and group discussions in the context of a Clinical Competency Committee. Utilization of an IRP as a metric for progress has features similar to effective cognitive behavioral therapy contracts and has ensured that our graduates are held to clearly delineated and specified skills and behaviors that allow them to work independently in the field of pediatric anesthesiology.

Perioperative management of a child with severe hypertension from a catecholamine secreting neuroblastoma.

Increased catecholamine secretion from neuroblastomas can occasionally be demonstrated, but severe hypertension is uncommon. We report the perioperative management of a 5 year old child with stage III adrenal neuroblastoma who presented with malignant hypertension and high norepinephrine and dopamine levels. Hypertensive crises occurred during anesthesia for surgical biopsy and during chemotherapy. After blood pressure control using phenoxybenzamine and enalapril, doxazosin was used successfully as the preoperative alpha-adrenergic receptor antagonist for surgical tumor resection.

The perioperative management of a patient with complex single ventricle physiology and pheochromocytoma.

Pheochromocytoma is associated with intense physiologic effects of alpha- and beta-adrenergic stimulation from catecholamine secretion. Perioperative management for these patients includes alpha-adrenergic receptor blockade, intravascular volume replacement, and, if necessary, beta-adrenergic receptor blockade. Significant perioperative changes in preload and afterload, fluid status, heart rate and rhythm, and inotropy can occur and may be contrary to anesthetic management goals for patients with certain conditions of congenital heart disease. We report the perioperative management with doxazosin of a patient with single ventricle physiology and cavo-pulmonary and aorto-pulmonary lung perfusion who presented for resection of a pheochromocytoma.