Welcome

By Julie J. Niezgoda, MD
Winter Meeting Program Chair

FROM PRINTED PROGRAM
This year’s Pediatric Anesthesiology meeting will be held in conjunction with the American Academy of Pediatrics Section on Anesthesiology and Pain Medicine at the Marriott Tampa Waterside Hotel and Marina in sunny southwest Florida, February 23-26, 2012. This wonderful location provides the setting for the advancement of education in trauma and hematologic issues, while interacting with colleagues.

As program chair, I can attest that countless hours involving conference calls and e-mails have been logged by myself, Assistant Program Chair- Kirk Lalwani (Workshop Coordinator), Genie Heitmiller (PBLD Coordinator), Constance Houck (AAP Section Chair), Nancy Glass (Chair, SPA Education Committee) and Kim Battle (SPA Association Manager) in order to create a meeting that offers many great educational opportunities. Our efforts have resulted in 35 CME credits for the SPA/AAP meeting plus additional 9.5 credits for the Congenital Cardiac Anesthesia Society (CCAS) and 8 credits for the Special Interest Group for Pediatric Pain Management (SIGPPM) meetings on Thursday. Hal Shaffner will be leading a PALS course offsite at the All Children’s Hospital in St. Petersburg for SPA attendees. The PALS course is limited to 30 people so register early! Registration for the PALS, CCAS and SIGPPM are separate, but available in this brochure.

Based on feedback from our registrants we have made changes in many of the workshops. We have added a basic ultrasound guided regional anesthesia and basic TEE workshop for the more novice practitioner in addition to the advanced workshops. The difficult pediatric airway will demonstrate new techniques and have more stations and instructors. The simulation workshop will discuss resources needed, as well as how to design, test, and refine scenarios based on previous registrant feedback desiring information on how to set up courses. We have added “The Art of Scientific Writing” in addition to previously offered epidemiology and research courses in hopes of addressing recent issues of plagiarism and data fabrication in peer reviewed journals. A new workshop on designing and moderating a PBLD was implemented to familiarize participants with this style of lecturing. Lastly, we have added a military workshop and TIVA -theory and practice workshop, as well as have “resurrected” the ventilator workshop because of new advances in technology.

In response to the large number of PBLD submissions, we have increased the PBLDs to 48 tables in order to provide as many authors as possible, the opportunity to present. In addition, we are piloting a Saturday evening PBLD session based on results from the attendee evaluations from last year’s meeting.
Thursday will feature innovative meetings of the CCAS and SIGPPM, and the ability to obtain PALS certification. The six-hour leadership workshop designed to prepare young faculty to increase their departmental administrative roles will be repeated this year. The advanced ultrasound guided regional workshop is offered on Thursday, with an additional session available on Saturday.

Friday’s theme is disaster preparedness and trauma, including traumatic brain injury, acute spinal cord injury and hemorrhagic shock in the pediatric patient. The next session is entitled “News You Can Use,” and will feature updates on the current status of Wake Up Safe, Pediatric Regional Anesthesia Network and Pediatric Sedation Research Consortium databases. We will end this session with disasters outside the hospital, to raise awareness and discuss ways in which we can impact this area. Dr. Dana Braner, a pediatric critical physician with vast experience in disaster issues, including almost two months of service in post-tsunami rescue efforts, will deliver the AAP Advocacy Lecture entitled “Disaster and Humanitarian Response, Kids are Still Different.” The coveted AAP- Robert M. Smith Award will be given to Dr. Nishan Goudsouzian, followed by lunch. Keeping with the trauma theme, the Friday refresher courses will cover single lung ventilation in infants/children and common rhythm disturbances with review of cardiac rhythm management devices.

Saturday’s session will review issues regarding hemoglobinopathies, thromboembolism and coagulopathies in the session “To Bleed or not to Bleed.” After the morning scientific session, including the poster session and presentation of the AAP and SPA abstract awards, the AAP “Ask the Experts” panel will discuss cases addressing the anesthetic management of patients relating to the morning discussions. Sim Wars, a pediatric anesthesia simulation scenario with audience participation, will also be offered again this year. Refresher courses will cover an update on neonatal resuscitation and newer options for older drugs in pediatric pain.

Sunday opens with “Editor’s Best Picks” where the editors from Anesthesiology, Anesthesia and Analgesia and Pediatric Anesthesia will review the past year’s most significant articles. The final session of the meeting is entitled “The Young and the Restless vs. The (B)old and the Beautiful” where junior staff will challenge senior staff on approaches to challenging and controversial pediatric cases in a lively game show format.

As I complete my three-year term of being involved in the planning of this meeting, I would like to extend a heartfelt thank you to Kirk Lalwani, who I am passing the baton to, as well as Genie Heitmiller, Nancy Glass, Constance Houck, the Education Committee, the SPA board members and the wonderful staff at the SPA office. Their collective expertise and great ideas have helped to assemble an outstanding meeting!

Enjoy!

Education Mission Statement

The annual Winter/Spring Meeting will focus on topics of interest to those who provide anesthesia, sedation, pain management, and critical care services to infants and children. The overall goals for attendees of the program are to reinforce and enhance their existing fund of knowledge, and to introduce them to new and state-of-the-art techniques and information that affect their practice and improve the perioperative/critical care of pediatric patients.

Scope & Types of Activities

The program brings together experts from clinical and basic science disciplines related to pediatric medicine, anesthesia, and surgery.

General topic areas include anatomy, pathophysiology, anesthetic pharmacology, sedation, pain management, patient safety, and child advocacy. We will also discuss practice and career management issues. The presentation format is varied, and includes lectures and refresher courses, panel discussions, hands-on workshops and problem-based learning discussions. Additionally, an important part of the program is the presentation of new clinical and basic science research in oral and moderated poster-discussion forums. Significant attendee involvement and feedback are encouraged in all aspects of the program, and will be facilitated by the use of real time computerized audience polling as well as sessions where the audience directly participates in case discussions. Program content is, in fact, the direct result of membership input and extensive audience polling at prior meetings.

Target Audience

This program is intended for anesthesiologists and other practitioners who care for children in their practice of anesthesiology and/or critical care. It is also intended for clinical and basic science researchers whose areas of investigation relate to pediatric anesthesia.

Accreditation & Designation

SPA/AAP Program: The Society for Pediatric Anesthesia is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Society for Pediatric Anesthesia designates this Live activity for a maximum of 35 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

CCAS Program: The Society for Pediatric Anesthesia is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Society for Pediatric Anesthesia designates this Live activity for a maximum of 9.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Special Interest Group – Pediatric Pain Medicine: The Society for Pediatric Anesthesia is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Society for Pediatric Anesthesia designates this Live activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Americans With Disabilities Act (ADA)

The Society for Pediatric Anesthesia has fully complied with the legal requirements of the ADA and the rules and regulations thereof. If any participant in this educational activity is in need of accommodations, please contact SPA at (804) 282-9780 by February 1, 2012 in order to receive service.

Hotel & City Information

A striking silhouette along the Channel Riverwalk, the Tampa Marriott Waterside Hotel and Marina in Ybor City overlooks Tampa Bay in the heart of Downtown. This world-class Downtown Tampa hotel’s 50,000 square feet of newly renovated meeting space, full-service spa, and several delicious restaurants such as Café Waterside and Champions, make it the perfect destination for work and play.

Part of the Channelside District, the Tampa Marriott is among the most luxurious of hotels in the city, with newly renovated rooms and suites offering private bay or city view balconies. After a busy day, unwind in one of the hotel’s lounges or enjoy culinary excellence at Il Terrazzo. For ultimate relaxation, try the spa, jacuzzi, or rooftop pool!

Tampa’s restaurants and shopping venues are sure to delight and surprise. Golf courses, parks, and nature trails beckon you outside. Museums, history, and the arts add to the rich diversity of cultures. Entertainment complexes and nightlife options are exciting and appealing.

Need to get around? No Problem! The area’s transportation system creates tremendous connectivity between hotels, the convention center, and entertainment venues. The historic electric streetcar and the in-town trolleys are fun, hassle-free ways to get around downtown.

Pediatric Pain Medicine Special Interest Group Objectives

Pain, Analgesics, and the Developing Brain: How much and for how long?

Upon completion of this lecture, the attendee will be able to:

• Understand the long-term effects of repetitive or prolonged pain on the developing brain
• Understand the neurotoxic vs. neuroprotective effects of analgesics given in the presence or absence of pain
• Appreciate the effects of concentration and duration of drug exposure on immature neurons and neural stem progenitor cells
• Recognize some practical applications of these data in our clinical care

Weaning from High-Dose Opioids and Sedatives in ICU

Upon completion of this lecture, the attendee will be able to:

• Appreciate the mechanisms of opioid and sedative tolerance and
  withdrawal
• Identify groups at increased risk for tolerance and withdrawal
• Choose strategies for prevention and management
• Discuss potential novel therapies and future research opportunities

Pharmacogenetics of Analgesics

Upon completion of this lecture, the attendee will be able to understand:

• The basis for inter-individual variations in responses to opioids
• Genotype associations with important clinical outcomes such as postoperative pain and opioid related respiratory depression and other adverse effects
• Racial differences in postoperative pain perception and opioid responses
• Medico-legal implications of serious adverse events associated with perioperative opioids

Update on Pediatric Acute Pain Management: An evidence-based review

Upon completion of this lecture, the attendee will be able to:

• Examine the evidence of efficacy and safety of different current pain management modalities and learn to implement the necessary changes.
• Understand how to minimize analgesic risks and side effects based on evidence guided therapy
• Learn to improve acute pain management to minimize the potential for development of chronic pain

Standardized Protocols are the Back-Bone of Acute Pain Management

Upon completion of this lecture, the attendee will:

• Understand some of the advantages offered by standardized protocols for acute pain management in pediatric patients.
• Recognize some of the limitations inherent to standardized protocols for acute pain management in pediatric patients.
• Reach informed conclusions regarding the role of standardized protocols for acute pain management in pediatric patients in their practice.
  

When Navigating the Headache Treatment Options Becomes a Headache

Upon completion of this session the attendee will be able to:

• Understand the different therapeutic options available for management of pediatric headache
• Understand the role of integrative approach to management of headache
• Recognize the optimal time to initiate a particular treatment modality for headache

Case Based Discussions on Managing Complex Pain Consults

Upon completion of this case-based discussion, the attendee will have a better understanding of:

• The logistical challenges of undertaking a comprehensive biopsychosocial assessment and providing multidisciplinary treatment of pediatric pain in the inpatient setting
• The interface and transition between an inpatient and outpatient pediatric pain service
• The management of their own and others’ examples of complex and challenging acute, chronic, and acute-on-chronic pediatric pain patients in the inpatient setting

Can We Prevent Chronic Pain?

Upon completion of this lecture, the attendee will:

• Understand the common conditions associated with the development of chronic pain
• Understand the common modalities used to prevent the development of chronic pain
• Design a perioperative plan to reduce the development of chronic pain in patients at risk for developing chronic pain

Brain Imaging and Neuroplasticity in Three “Strange” Pain Disorders: CRPS, Phantom Limb Pain, and Fibromyalgia

Upon completion of this lecture, the attendee will be able to:

• Understand some of the advantages, limitations, and promise of currently available imaging and electrophysiologic techniques to evaluate plastic changes in brain structure and function among adults and children with chronic pain
• Appreciate an emerging view of these “strange” pain disorders as involving “distortion” or “misprogramming” of the brain’s “maps” of the body,
• Consider implications of this research for chronic pain treatment

Peri-operative Considerations for a Patient with Chronic Pain

Upon completion of this lecture, the attendee will

• Be able to identify patients with chronic pain that may require special per-operative planning
• Develop strategies for preop, intraop, and/or post op management for patients with chronic pain
• Understand the importance of communication with all care providers for optimum outcomes in these patients

WORKSHOP: The Hardware of a Functional Acute Pain Service

Upon completion of this lecture, the attendee will be able to:

• Identify if there is a need for a pediatric acute pain service at their institution.
• Ensure they have appropriate hospital and departmental support for their proposed medical consult service.
• Ensure they have appropriate pain nurse practitioners to provide the daily evaluation and treatment of patients. And also provide the nursing education to the floor/PACU nurses.
• Ensure that all pain medicine order sets have built in/idiot proof safety mechanisms that are individualized to each institution.
• Ensure that pain staff MDs have appropriate pediatric pain/regional anesthesia experience.

SPA/AAP Objectives

Session I Disaster and Trauma

Management of Traumatic Brain Injury (TBI) in the Pediatric Patient
At the end of this presentation, the participant will be able to:

• Understand the public health significnace of TBI in children
• Understand the risk factors pathophysiology of TBI in children
• Discuss the best evidence for anesthetic care of the child with TBI

Perioperative management of Acute Spinal Cord Injury in Children
At the end of this presentation, the participant will be able to:

• Identify unique features of spinal cord injury in the pediatric population
• Determine the most appropriate management of the pediatric patient with a spinal cord injury
• Discuss the role of different treatment modalities in the early peri-operative period for pediatric patients with a spinal cord injury.

Hemorrhagic Shock in the Pediatric Patient: New Therapies and Practices
At the end of this presentation, the participant will be able to:

• Understand the pathophysiology of hemorrhagic shock
• Learn new therapies for hemorrhaging patients: deliberate hypotension, hemostatic resuscitation, deep anesthesia
• Understand the role of factor concentrates and pro-hemostatic agents
• Learn which emerging adult therapies will be most applicable to pediatric patients

Session II News You Can Use

Update on Wake Up Safe (WUS)
Update on Pediatric Regional Anesthesia Network (PRAN)
Update on Pediatric Sedation Research Consortium (PSRC)
Upon completion of this session the participant will be familiar with the current knowledge obtained from data collections and publications generated thus far from Wake Up Safe (WUS), Pediatric Regional Anesthesia Network (PRAN) and Pediatric Sedation Research Consortium (PSRC).

Sedation Disasters Outside the Hospital: How Can We Impact?
At the end of this presentation, the participant will be able to:

• Recognize common etiologies and themes for sedation disasters outside the hospital setting
• Identify appropriate and inappropriate patients for sedation outside the hospital setting
• Recommend system “fixes” for our colleagues performing diagnostic and therapeutic procedures outside the hospital setting.

Session III

AAP Advocacy Lecture: Disaster and Humanitarian Response, Kids are still Different
At the end of this presentation, the participant will be able to:

• Understand the principles of continuous disaster response
• Understand how current disaster relief plans are built to cover the (increasingly mythical) 70 kg adult and severely underestimate the needs of children.
• Understand the specific needs of children during disaster relief operations

Sim Wars - A Pediatric Anesthesia Simulation Scenario with Audience Participation
Upon completion of this presentation, the participant will experience an innovative approach to active learning and evaluation, learn about crisis-resource management during an acute pediatric perioperative event, discuss the importance of communication during and after a patient complication, ascertain and gather different approaches, guidelines and evidence for the management of unanticipated events in infants and children during the perioperative period.

Core Lectures: To Bleed or Not to Bleed? That is the question.

Fragile Hemoglobinopathies
At the end of this presentation, the participant will be able to:

• Develop an understanding of the various types of hemoglobinopathies and their implications for anesthetic management
• Consider the perioperative management of patients with sickle cell disease and the indication for simple and exchange transfusion.
• Contemplate the various ways one can make their team ready to manage patients with sickle cell disease.

Thromboembolism prevention and management in the pediatric Patient
At the end of this presentation, the participant will be able to:

• Identify differences in the incidence of venous thromboemoblism (VTE) in children vs. adults
• Understand current recommendations for Anticoagulation Prophylaxis and Treatment in children
• Recognizing and managing perioperative anticoagulation issues and guidelines in current clinical practice.

Perioperative management of coagulopathies/ bleeding dyscrasias in the pediatric patient.
At the end of this presentation, the participant will be able to:

• Identify the congenital and acquired bleeding disorders that are likely to be encountered by the anesthesiologist who cares for children undergoing non-cardiac surgery
• Review the preoperative assessment of a pediatric patient’s coagulation status
• Discuss the perioperative management of selected coagulation disorders.

Editors Best Picks
Upon completion of this session, the participant will have the opportunity to
critically review a few outstanding pediatric anesthesia papers published in
the last year, Anesthesiology, Anesthesia and Analgesia, and Pediatric
Anesthesia.

Pro/Con: Current Anesthesia Practices
The Young and The Restless vs The (B)old and the Beautiful
Upon completion of this session, the participant will have the opportunity to review current pediatric anesthesia practice in a game-show format.

Workshop Objectives

SPA Leadership Skills Workshop
Upon completion of the workshop the participant will be able to:

• Differentiate between leadership and management
• Define the components of emotional intelligence and how it relates to leadership
• Define organizational culture
• Delineate the relationship between organizational culture and leadership
• Identify the characteristics of an effective leader and team member
• Discuss characteristics of effective health care teams
• Demonstrate use of key communication skills and modalities of conflict management to work effectively in a team
• Describe different leadership models and identify when each style is most appropriately used
• Evaluate leadership style usage through different instruments and be able
  to discuss one’s relative strengths and weaknesses

Advanced Ultrasound Guided Regional Anesthesia
Upon completion of this workshop, the participant will have an understanding of:

• Basic functions of the US machine with particular attention to the US probes
• Machine settings for various age groups
• Anatomy using US guidance of all peripheral nerve blocks including upper and lower extremity, truncal and central neuraxial blocks
• Provide an instructional hands-on course with low faculty to attendee ratio to provide an understanding of how to scan and block most common peripheral/central neuraxial nerve blocks in children

Junior Faculty Research: Trials and Tribulations
This workshop is designed for junior and mid-level faculty who are beginning an academic career or who simply wish to advance their knowledge of research methodology. Topics include, but are not limited to: research design, statistical methods, and grant writing.

Basic Ultrasound Guided Regional Anesthesia
After completing the basic ultrasound guided regional anesthesia workshop, the participant should be able to:

• Understand basic ultrasound physics, knobology and optimization of
  images in commonly used ultrasound machines
• Identify common nerves including femoral, brachial plexus, truncal and sciatic nerves, as well as surrounding structures
• Demonstrate competence in needle advancement under real time ultrasound
  guidance on phantom models

Professionalism
Upon completion of this workshop, the participant will be able to:

• Define professionalism and discuss its importance in the modern practice of medicine
• Discuss professionalism as it relates to patient safety
• Define the role of professionalism in effective communication and crew resource management
• Define disruptive behavior and explore how to confront it
• Discuss methods for encouraging professionalism in colleagues

Overview of Personal Financial Planning
Upon completion of the workshop, the participant will be able to:

• Define basic financial planning topics and terminology.
• Discuss common financial planning goals of many families and individuals.
• Present an overview of reasonable, commonly accepted planning techniques used to approach these goals, even in difficult times.

Advanced Techniques for Peripheral Vascular Access
Upon completion of this workshop, the participant will be able to:

• Demonstrate and practice use of ultrasound to obtain peripheral venous access
• Demonstrate and practice the use of two types of intraosseous catheters to obtain emergent vascular access
• Identify the potential advantages of near infra-red technology to optimize peripheral venous access

Epidemiology: Study Design and Data Analysis Workshop
Upon completion of this workshop, the participant will understand:

• The practical basics of biostatistics, including sample size, power analysis, effect size, and confidence intervals,
• The practical basics of clinical epidemiology,
• The sources of bias in study design,
• The concept of confounding in study design,
• The various methods used to identify and control bias and confounding, including regression modeling and propensity scores
• The readily available, user-friendly biostatistics and epidemiology software options for the clinical researcher

How to Design and Moderate an Effective PBLD
At the end of this two-hour workshop, participants will be able to:

• State the rationale for case-based group learning
• Recognize the characteristics of a case suitable for discussion
• Be able to differentiate between a case appropriate for a Medically Challenging Case and a PBLD
• Take a brief stem and develop a PBLD suitable for the designated audience
• Compile a set of Best Practices for leading an inclusive, robust discussion

Success in Academics
Upon completion of this workshop, the participant will be able to discuss:

• The elements of career management
• Enhancement their professional network
• Completion of their career development plan
• Taking a proactive role in managing their career.

Difficult Pediatric Airway
Upon completion of this workshop, the participant will gain:

• An understanding of situations in which alternative methods of securing the airway may be necessary
• An understanding of the development of a systematic anatomic and physiologic approach to the assessment of the difficult airway and to planning airway management
• An understanding of the availability of new devices and technologies for securing the airway and what their indications and limitations are, and
• Hands on experience with these devices.

Theory & Practice of Using Total Intravenous Anesthesia (TIVA), Target Controlled Infusion (TCI) and Closed Loop Systems in Children - Why, When & How?
Upon completion of this workshop, the participant will:

• Appreciate pharmacokinetic & pharmacodynamic principles critical to the safe use of TIVA, TCI and closed loop systems in children - the ‘why?’
• Identify clinical scenarios for which evidence and faculty clinical experience supports the selection of TIVA as a good anaesthetic technique - the ‘when?’
• Decide upon a TIVA regimen for use in various clinical settings - the ‘how?’

From Iraq & Afghanistan to Haiti: Pediatric anesthesia in the military from deployments to humanitarian missions
Upon completion of this workshop, the participant will have an understanding of:

• Pediatric anesthesia in a wartime setting: types of cases, equipment challenges
• Responding to a natural disaster and providing anesthetic care in austere environments
• Intensive care unit experiences on the ground & in the air during war
• Military anesthesia care during humanitarian missions, both on the ground & water

Designing and Testing Simulation Scenarios
Upon completion of this workshop, the participant will be able to:

• Review key elements in scenario design
• Understand the resources required to run a scenario
• Understand how to test and refine scenarios

The Art of Scientific Writing
Upon completion of this workshop, the participant will:

• Understand the building blocks that make clear and concise writing.
• Understand the elements that create readable, understandable and unambiguous manuscripts.
• Appreciate what editors look for in a manuscript to view the submission favorably; to recognize the utility of plagiarism software

Anesthesia Ventilators
Upon completion of this workshop, the participant will:

• Understand the mechanical design of different anesthesia machines and the impact of design on clinical management including the implications of compliance and fresh gas compensation.
• Understand the different modes of ventilation and rationale for selecting a particular mode.
• Understand the methods of ventilation monitoring, their pitfalls and the utility of bedside monitors to guide the ventilation strategy.
• Understand the role of dead space and proper circuit design when ventilating pediatric patients.
• Discuss modes of ventilation strategies for pediatric patients with poor lung compliance.

Basic TEE/Advanced TEE
Upon completion of these workshops, the participant will understand the mechanics of conducting a basic TEE exam, and will have learned the principles necessary to conduct a comprehensive exam in patients with complex congenital heart disease.

Anesthesia and the Law
Participants in this workshop will be provided information relating to the intricacies of the medical-legal process. Case studies and examples will be presented to include common malpractice claims and legal issues when treating minor patients. In addition an overview of the litigation process will be presented.

Refresher Course Objectives

Single Lung Ventilation in Infants and Children
At the end of this presentation, the participant will be able to: understand the avantages of single lung ventilation with a single-lumen ETT vs. bronchial blocker vs. double-lumen ETT; know the advantages and disadvantages of placing a bronchial blocker inside or outside of the ETT; and recognize the pitfalls of single lung ventilation in children.

When Kids Have Short Circuits
At the end of this presentation, the participant will have: recognition and anesthetic management of selected rhythm disturbances: WPW, JET, SVT, V-tach, long QT; review of cardiac rhythm management devices (CRMD): pacemakers, defibrillators, and preventing sudden death; and m agnets: their uses and limitations.

Update on Neonatal Resuscitation
At the end of this presentation, the participant will be able to: review the changes in teaching resuscitation including the AAP’s NRP (Neonatal Resuscitation Program) and the new emphasis on teamwork skills development; understand the scientific basis for changes in the NRP algorithm; and apply these evolving recommendations to the practice of anesthesia for newborns.

Pain, Pain, Go Away! Older Drugs, Newer Options for Pediatric Perioperative Pain Management
At the end of this presentation, the participant will be able to: review newer formulations of several conventional analgesic agents now available for use in children; explore recent applications of various adjunctive analgesic agents to the perioperative setting in children; and discuss the potential role these formulations and applications may play in current pediatric perioperative pain management.

PBLD Objectives

Problem-based learning discussions will offer the opportunity for group discussion with faculty and other attendees of common clinical problems. The format will highlight aspects of clinical decision-making including preoperative evaluation and preparation, anesthetic induction and intra-operative management and possible intra- and postoperative pain and other management dilemmas.