Smith's Anesthesia for Infants and Children, 8th Edition

1436 Pages·2011·162.21 MB·English

by  Peter J. Davis MD

S m i t h ’S
Anesthesia

Infants
for
Children
and
E i g h t h E d i t i o n
Peter J. davis, Md, FAAP
Professor
Department of Anesthesiology
Department of Pediatrics
University of Pittsburgh School of Medicine;
Anesthesiologist-in-Chief
Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania
Franklyn P. Cladis, Md
Assistant Professor
Department of Anesthesiology
University of Pittsburgh School of Medicine
Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania
Etsuro K. Motoyama, Md, FAAP
Professor Emeritus
Department of Anesthesiology
Department of Pediatrics (Pulmonology)
University of Pittsburgh School of Medicine;
Former Director, Pediatric Pulmonology Laboratory
Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
SMITH’S ANESTHESIA FOR INFANTS AND CHILDREN ISBN: 978-0-323-06612-9
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Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dr. Robert Moors Smith
The eighth edition of Smith’s Anesthesia for Infants and physiological monitoring. By using a stethoscope taped on the
Children is dedicated to Dr. Robert Moors Smith, who died on chest wall over the trachea and heart, Dr. Smith could assess
November 25, 2009, 2 weeks before he would have been 97. ongoing changes in heart and breath sounds. Furthermore,
The eulogy published by the Harvard Medical School’s Office Dr. Smith, together with Ms. Betty Lank, his chief nurse anes-
of Communications began with this statement: “The Harvard thetist, developed a homemade latex infant blood pressure cuff
Medical School flag is at half-mast today in memory of Robert (referred to as the Smith cuff) and advocated its routine use
M. Smith, MD, Clinical Professor of Anesthesia, former Chief for patient safety when inhaled anesthetics consisted of diethyl-
of Anesthesiology at Children’s Hospital Boston and pioneer in ether and cyclopropane. These advancements were early steps
clinical anesthesiology in children.” This was an extraordinary in the development of elaborate physiological monitoring sys-
tribute from an institution that has produced literally hundreds tems that are essential for safe anesthesia care today.
of world leaders in medicine. In 1959, Dr. Smith published the first comprehensive text-
Dr. Smith was one of the most distinguished pioneers of mod- book for pediatric anesthesia, entitled Anesthesia for Infants and
ern anesthesia for children in the world. In the United States Children. It was well received among practitioners and trainees
he was considered the “Father of Pediatric Anesthesiology.” in pediatric anesthesia and soon became a classic, often referred
During his tenure at Children’s Hospital Boston, Dr. Smith was to as the “Bible of Pediatric Anesthesia.” For the ensuing 20 years
a superb and compassionate clinician and educator who con- until his retirement from Harvard in 1980, Dr. Smith revised and
tinually advanced practices in pediatric anesthesia and kept expanded the book through the fourth edition, as he kept abreast
abreast with the fast progress of increasingly complex surgery with the rapid progress in the practice and science of pediat-
on smaller and younger patients. He was an early advocate of ric anesthesia and other pediatric surgical specialties. Shortly
compassionate patient safety—more than 30 years before the thereafter, Dr. Smith asked the current editors to assume the
term even existed. editorship. To continue his vision, the book was modified and
Along with Dr. Margo Deming of Philadelphia, Dr. Smith expanded to a multi-authored volume and was renamed Smith’s
was an early supporter of endotracheal intubation with ster- Anesthesia for Infants and Children in Dr. Smith’s honor. The
ile and child-appropriate–sized tubes to prevent aspiration fifth through the seventh editions were published between
and postintubation croup. He also encouraged the wrapping of 1990 and 2006. With this eighth edition, Smith’s Anesthesia for
small children to prevent heat loss. In the early 1950s when the Infants and Children has been in publication for more than half
monitoring of infants and children consisted of visual observa- a century, making it the longest ongoing textbook of pediatric
tion of the patient and intermittent palpation of the patient’s anesthesiology in the world. It has been a great honor and privi-
radial pulse, Dr. Smith pioneered a new approach of continuous lege for us to carry on Dr. Smith’s legacy.
iii
C
ontributors
Ann G. Bailey, MD Adrian Bosenberg, MB ChB, FFA(SA)
Professor, Anesthesiology and Pediatrics Professor, University of Washington School
University of North Carolina of Medicine;
Chapel Hill, North Carolina Director, Regional Anesthesia Services
Seattle Children’s Hospital
David Barinholtz, MD Seattle, Washington
President and CEO, Mobile Anesthesiologists, LLC
Chicago, Illinois Barbara W. Brandom, MD
Professor, Department of Anesthesiology
Victor C. Baum, MD University of Pittsburgh School of Medicine;
Professor, Anesthesiology and Pediatrics Attending Physician, Department of Anesthesiology
Executive Vice-Chair, Department of Anesthesiology Children’s Hospital of Pittsburgh of UPMC;
Director, Cardiac Anesthesia Director, North American Malignant Hyperthermia Registry
University of Virginia of MHAUS
Charlottesville, Virginia Pittsburgh, Pennsylvania
David S. Beebe, MD Claire Brett, MD
Professor, Department of Anesthesiology Professor, Clinical Anesthesia and Pediatrics
University of Minnesota Department of Anesthesiology and Perioperative Care
Minneapolis, Minnesota University of California, San Francisco
San Francisco, California
Kumar G. Belani, MBBS, MS
Professor, Departments of Anesthesiology, Medicine, Robert B. Bryskin, MD
and Pediatrics Regional Anesthesia Coordinator
University of Minnesota Nemours Children’s Hospitals;
Minneapolis, Minnesota Assistant Professor, Anesthesiology
College of Medicine, Mayo Clinic
Richard Berkowitz, MD Jacksonville, Florida
Chairman and Medical Director, Department of Anesthesiology
and Pain Medicine Patrick Callahan, MD
Community Hospital Assistant Professor of Anesthesiology
Munster, Indiana; University of Pittsburgh School of Medicine
Visiting Associate Professor, Department of Anesthesiology Children’s Hospital of Pittsburgh of UPMC
and Pediatrics Pittsburgh, Pennsylvania
University of Illinois College of Medicine
Chicago, Illinois Franklyn P. Cladis, MD
Assistant Professor
Bruno Bissonnette, MD, FRCPC Department of Anesthesiology
Professor Emeritus of Anesthesia University of Pittsburgh School of Medicine
University of Toronto Children’s Hospital of Pittsburgh of UPMC
Toronto, Ontario; Pittsburgh, Pennsylvania
Founder and President, Children of the World Anesthesia
Foundation
Rimouski, Quebec
iv
Contributors v
David E. Cohen, MD Demetrius Ellis, MD
Associate Professor, Anesthesiology and Critical Care Professor, Nephrology and Pediatrics
and Pediatrics University of Pittsburgh School of Medicine;
University of Pennsylvania; Director, Pediatric Nephrology
Perioperative Medical Director, The Children’s Hospital Children’s Hospital of Pittsburgh of UPMC
of Philadelphia Pittsburgh, Pennsylvania
Philadelphia, Pennsylvania
Jeffrey M. Feldman, MD, MSE
Ira Todd Cohen, MD, MEd Division Chief, General Anesthesia
Professor, Anesthesiology and Pediatrics Children’s Hospital of Philadelphia;
Director of Education, Department of Anesthesiology Associate Professor, Clinical Anesthesia
and Pain Medicine University of Pennsylvania School of Medicine
Children’s National Medical Center Philadelphia, Pennsylvania
Washington, DC
Kathryn Felmet, MD
Andrew Davidson, MBBS, MD Assistant Professor, Critical Care Medicine and Pediatrics
Associate Professor, University of Melbourne; University of Pittsburgh School of Medicine
Staff Anaesthetist, Royal Children’s Hospital; Children’s Hospital of Pittsburgh of UPMC
Head, Clinical Research Development Pittsburgh, Pennsylvania
Murdoch Children’s Research Institute
Melbourne, Victoria, Australia John E. Fiadjoe, MD
Assistant Professor, Anesthesia
Jessica Davis, BA, JD, LLM Children’s Hospital of Philadelphia
Adjunct Professor, Widener University School of Law Philadelphia, Pennsylvania
Wilmington, Delaware
Jonathan D. Finder, MD
Peter J. Davis, MD, FAAP Professor of Pediatrics
Professor University of Pittsburgh School of Medicine
Department of Anesthesiology Clinical Director, Pulmonary Medicine
Department of Pediatrics Children’s Hospital of Pittsburgh of UPMC
University of Pittsburgh School of Medicine; Pittsburgh, Pennsylvania
Anesthesiologist-in-Chief
Children’s Hospital of Pittsburgh of UPMC Randall P. Flick, MD, MPH, FAAP
Pittsburgh, Pennsylvania Associate Professor of Anesthesiology
Chair, Division of Pediatric Anesthesiology
Duncan de Souza, MD, FRCP(C) Medical Director, Eugenio Litta Children’s Hospital
Assistant Professor, Anesthesiology and Pediatrics Mayo Clinic
Department of Anesthesiology Rochester, Minnesota
University of Virginia
Charlottesville, Virginia Michelle Fortier, PhD
Licensed Psychologist
Nina Deutsch, MD Center for the Advancement of Pediatric Health
Assistant Professor, Anesthesiology and Pediatrics University of California Irvine School of Medicine;
Children’s National Medical Center Department of Anesthesiology and Perioperative Care
Washington, DC Center for Pain Management
Orange, California
James A. DiNardo, MD, FAAP
Associate Professor of Anesthesia Salvatore R. Goodwin, MD
Harvard Medical School; Associate Professor, Anesthesiology
Senior Associate in Cardiac Anesthesia Mayo Medical School
Program Director, Pediatric Cardiac Anesthesia Fellowship Rochester, Minnesota;
Children’s Hospital Boston Chairman, Department of Anesthesia
Boston, Massachusetts Nemours Children’s Clinic
Jacksonville, Florida
Peter Ehrlich, MD, Msc, RCPS(C), FACS
Associate Professor of Surgery, Section of Pediatric Surgery George A. Gregory, MD
University of Michigan Medical School; Professor Emeritus of Anesthesia and Pediatrics
Medical Director, Pediatric Trauma University of California, San Francisco
University of Michigan CS Mott Children’s Hospital San Francisco, California
Ann Arbor, Michigan
vi Contributors
Lorelei Grunwaldt, MD Nathalia Jimenez, MD, MPH
Assistant Professor of Surgery Assistant Professor, Department of Anesthesiology
University of Pittsburgh School of Medicine and Pain Medicine
Division of Pediatric Plastic Surgery University of Washington School of Medicine
Children’s Hospital of Pittsburgh of UPMC Seattle Children’s Hospital
Pittsburgh, Pennsylvania Seattle, Washington
Dawit T. Haile, MD Lori T. Justice, MD, FAAP
Instructor of Anesthesiology Clinical Staff Pediatric Anesthesiologist
Mayo Clinic Children’s Anesthesiologists, PC
Rochester, Minnesota East Tennessee Children’s Hospital
Knoxville, Tennessee
Steven Hall, MD
Arthur C. King Professor of Pediatric Anesthesia Zeev N. Kain, MD, MBA
Feinberg School of Medicine Professor, Anesthesiology and Pediatrics and Psychiatry
Northwestern University; and Human Behavior
Anesthesiologist-in-Chief Chair, Department of Anesthesiology and
Children’s Memorial Hospital Perioperative Care
Chicago, Illinois Associate Dean of Clinical Operations, School of Medicine
University of California, Irvine
Gregory Hammer, MD Orange, California
Professor, Anesthesia and Pediatrics
Stanford University School of Medicine; Evan Kharasch, MD, PhD
Associate Director, Pediatric ICU Vice Chancellor for Research
Director, Pediatric Anesthesia Research Russell D. and Mary B. Shelden Professor
Lucile Packard Children’s Hospital at Stanford of Anesthesiology
Stanford, California Director, Division of Clinical and Translational Research
Department of Anesthesiology;
Michael W. Hauser, MD Professor of Biochemistry and Molecular Biophysics
Staff Anesthesiologist Washington University in St. Louis
Cleveland Clinic St. Louis, Missouri
Cleveland, Ohio
Sabine Kost-Byerly, MD, FAAP
Eugenie S. Heitmiller, MD Director, Pediatric Pain Management
Associate Professor, Anesthesiology and Pediatrics Department of Anesthesiology and Critical Care
Department of Anesthesiology and Critical Care Medicine Medicine
The Johns Hopkins University School of Medicine; The Johns Hopkins Hospital;
Vice Chairman for Clinical Affairs Associate Professor of Anesthesiology
Department of Anesthesiology and Critical Care Medicine The Johns Hopkins University School of Medicine
The Johns Hopkins Hospital Baltimore, Maryland
Baltimore, Maryland
Elliot J. Krane, MD
Andrew Herlich, DMD, MD Professor, Department of Anesthesia and Pediatrics
Professor of Anesthesia, Department of Anesthesiology Stanford University School of Medicine
University of Pittsburgh School of Medicine; Stanford, California;
Chief of Anesthesia, UPMC Mercy Hospital Director of Pain Management
Pittsburgh, Pennsylvania Lucile Packard Children’s Hospital at Stanford
Palo Alto, California
Robert S. Holzman, MD, FAAP
Associate Professor of Anesthesia Barry D. Kussman, MBBCh, FFA (SA)
Harvard Medical School; Assistant Professor of Anesthesia
Senior Associate, Perioperative Anesthesia Harvard Medical School;
Children’s Hospital Boston Senior Associate in Cardiac Anesthesia
Boston, Massachusetts Children’s Hospital Boston
Boston, Massachusetts
Elizabeth A. Hunt, MD, MPH, PhD
Assistant Professor, Department of Anesthesiology and Critical Ira S. Landsman, MD
Care Medicine Associate Professor, Department of Anesthesiology
The Johns Hopkins University School of Medicine; and Pediatrics;
Drs. David S. and Marilyn M. Zamierowski Director Chief, Division of Pediatric Anesthesiology
The Johns Hopkins Medicine Simulation Center Vanderbilt University Medical Center
Baltimore, Maryland Nashville, Tennessee
Contributors vii
Ronald S. Litman, DO George M. McDaniel, MD, MS
Attending Anesthesiologist Assistant Professor of Pediatrics and Internal
The Children’s Hospital of Philadelphia; Medicine
Professor, Anesthesiology and Pediatrics Director, Pediatric Electrophysiology
University of Pennsylvania School of Medicine University of Virginia
Philadelphia, Pennsylvania Charlottesville, Virginia
Joseph Losee, MD, FACS, FAAP
Francis X. McGowan, Jr., MD
Professor of Surgery and Pediatrics
Professor of Anesthesia
University of Pittsburgh School of Medicine
Harvard Medical School;
Chief, Division Pediatric Plastic Surgery
Chief, Division of Cardiac Anesthesia
Children’s Hospital of Pittsburgh of UPMC
Director, Anesthesia and Critical Care
Pittsburgh, Pennsylvania
Medicine
Research Laboratory
Igor Luginbuehl, MD
Children’s Hospital Boston
Associate Professor of Anesthesia
Boston, Massachusetts
Department of Anesthesia and Pain Medicine
The Hospital for Sick Children
Toronto, Ontario Constance L. Monitto, MD
Assistant Professor, Anesthesiology and Critical
Anne M. Lynn, MD Care Medicine
Professor, Department of Anesthesiology The Johns Hopkins University School
and Pain Medicine of Medicine
Adjunct Professor, Pediatrics Baltimore, Maryland
University of Washington School of Medicine
Seattle Children’s Hospital Philip G. Morgan, MD
Seattle, Washington Professor, Department of Anesthesiology
University of Washington;
Seattle Children’s Research Institute
Thomas J. Mancuso, MD
Seattle, Washington
Associate Professor of Anesthesia
Harvard Medical School;
Senior Associate in Anesthesia Etsuro K. Motoyama, MD, FAAP
Children’s Hospital Boston Professor Emeritus
Boston, Massachusetts Department of Anesthesiology
Department of Pediatrics (Pulmonology)
University of Pittsburgh School of Medicine;
Brian P. Martin, DMD
Former Director, Pediatric Pulmonology Laboratory
Clinical Assistant Professor
Children’s Hospital of Pittsburgh of UPMC
University of Pittsburgh School of Dental
Pittsburgh, Pennsylvania
Medicine;
Chief, Division of Pediatric Dentistry
Children’s Hospital of Pittsburgh of UPMC Julie Niezgoda, MD
Pittsburgh, Pennsylvania Pediatric Anesthesiology
Children’s Hospital Cleveland Clinic
Keira Mason, MD Cleveland Clinic
Associate Professor of Anesthesia Cleveland, Ohio
Harvard Medical School;
Director, Department of Radiology, Anesthesia, David M. Polaner, MD, FAAP
and Sedation Professor of Anesthesiology and Pediatrics
Children’s Hospital Boston University of Colorado School of Medicine;
Boston, Massachusetts Attending Pediatric Anesthesiologist
Chief, Acute Pain Service
William J. Mauermann, MD Anesthesia Informatics
Assistant Professor of Anesthesia The Children’s Hospital, Denver
Mayo Clinic Aurora, Colorado
Rochester, Minnesota
Paul Reynolds, MD
Lynne G. Maxwell, MD Uma and Sujit Pandit Professor and Chief of Pediatric
Associate Professor of Anesthesiology and Critical Care Anesthesiology
University of Pennsylvania Department of Anesthesiology
Senior Anesthesiologist University of Michigan
Children’s Hospital of Philadelphia Ann Arbor, Michigan
Philadelphia, Pennsylvania
viii Contributors
Mark A. Rockoff, MD Kyle Soltys, MD
Professor of Anesthesia Assistant Professor of Surgery
Harvard Medical School; University of Pittsburgh School of Medicine
Vice-Chairman, Department of Anesthesiology, Perioperative Thomas E. Starzl Transplant Institute
and Pain Medicine Hillman Center For Pediatric Transplantation
Children’s Hospital Boston Children’s Hospital of Pittsburgh of UPMC
Boston, Massachusetts Pittsburgh, Pennsylvania
Thomas Romanelli, MD, FAAP Sulpicio G. Soriano, MD
Clinical Instructor, Harvard Medical School; Children’s Hospital Boston Endowed Chair in Pediatric
Consultant Anesthesiologist Neuroanesthesia
Shriners Burns Hospital Boston; Associate Professor of Anesthesia
Assistant in Anesthesia Harvard Medical School;
Massachusetts General Hospital Senior Associate, Department of Anesthesiology, Perioperative
Boston, Massachusetts and Pain Medicine
Children’s Hospital Boston
Allison Kinder Ross, MD Boston, Massachusetts
Associate Professor and Chief, Division of Pediatric Anesthesia
Duke University Medical Center Brian P. Struyk, MD
Durham, North Carolina Assistant Professor, Clinical Anesthesiology
and Critical Care
Joseph A. Scattoloni, MD University of Pennsylvania School of Medicine;
Clinical Lecturer, Department of Anesthesia Director, Radiology Anesthesia
Section of Pediatric Anesthesia Children’s Hospital of Philadelphia
University of Michigan Health System Philadelphia, Pennsylvania
Ann Arbor, Michigan
Kevin J. Sullivan, MD
Jamie McElrath Schwartz, MD Assistant Professor of Anesthesiology
Assistant Professor, Departments of Anesthesiology and Rochester, Minnesota;
Critical Care Medicine and Pediatrics Clinical Associate Professor of Pediatrics
The Johns Hopkins University School of Medicine University of Florida Health Science Center
Baltimore, Maryland Jacksonville, Florida;
Staff Pediatric Anesthesiologist, Critical Care Physician,
Robert J. Sclabassi, MD, PhD, DABNM, FASNM and Medical Director
Attending Neurophysiologist Pediatric Intensive Care Unit
Chief, Intraoperative Monitoring Service Wolfson Children’s Hospital
West Penn Alleghany Health System Jacksonville, Florida
Pittsburgh, Pennsylvania
Jennifer Thomas, MBChB, FFA (SA), BSc (Ed)
Victor L. Scott, II, BSc, MD Associate Professor, Department of Pediatric Anaesthesia
Professor of Anesthesiology, Department of Anesthesiology Red Cross War Memorial Children’s Hospital
University of Pittsburgh School of Medicine University of Cape Town
Children’s Hospital of Pittsburgh of UPMC Cape Town, Western Cape, South Africa
Pittsburgh, Pennsylvania
Stevan P. Tofovic, MD, PhD, FAHA, FASN
Donald H. Shaffner, MD Assistant Professor of Medicine
Associate Professor, Department of Anesthesiology University of Pittsburgh School of Medicine
Critical Care Medicine and Pediatrics Pittsburgh, Pennsylvania
The Johns Hopkins University School of Medicine
Baltimore, Maryland Kha Tran, MD
Assistant Professor of Anesthesia and Critical Care Medicine
Avinash C. Shukla, MBBS, FRCA University of Pennsylvania School of Medicine;
Associate in Cardiac Anesthesia Attending Anesthesiologist and Clinical Director, Fetal
Children’s Hospital Boston Anesthesia Team
Boston, Massachusetts Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
†Robert M. Smith, MD
Clinical Professor Emeritus of Anesthesia Donald C. Tyler, MD, MBA
Harvard Medical School and Children’s Hospital Boston Associate Professor of Anesthesiology and Critical Care
Boston, Massachusetts University of Pennsylvania
Department of Anesthesiology and Critical Care Medicine
The Hospital of the University of Pennsylvania
and Children’s Hospital of Philadelphia
†Deceased. Philadelphia, Pennsylvania
Contributors ix
Robert D. Valley, MD Jay A. Werkhaven, MD
Professor of Anesthesiology and Pediatrics Associate Professor and Director, Pediatric Otolaryngology
University of North Carolina School of Medicine Vanderbilt Bill Wilkerson Center for Otolaryngology
Chapel Hill, North Carolina and Communication Sciences
Vanderbilt University
Monica S. Vavilala, MD Nashville, Tennessee
Associate Professor, Department of Anesthesiology and Pain
Medicine and Pediatrics Susan Woelfel, MD
Adjunct Associate Professor, Neurological Surgery Associate Professor of Anesthesiology
and Radiology University of Pittsburgh School of Medicine
University of Washington; Children’s Hospital of Pittsburgh of UPMC
Associate Director, Harborview Injury Prevention Pittsburgh, Pennsylvania
and Research Center
Seattle, Washington Myron Yaster, MD
Richard J. Traystman Professor
Lisa Vecchione, DMD, MDS Departments of Anesthesiology, Critical Care Medicine,
Director, Orthodontic Services and Pediatrics
Cleft-Craniofacial Center The Johns Hopkins University School of Medicine
Children’s Hospital of Pittsburgh of UPMC; Baltimore, Maryland
Assistant Clinical Professor of Surgery
University of Pittsburgh School of Medicine Aaron L. Zuckerberg, MD
Pittsburgh, Pennsylvania Director, Pediatric Anesthesia and Critical Care Medicine
Director, Children’s Diagnostic Center Department
Kerri M. Wahl, MD, FRCP(C) of Pediatrics and Anesthesia
Associate Professor, Department Sinai Hospital;
of Anesthesiology Assistant Professor, Department of Pediatrics
Duke University Medical Center University of Maryland Medical School;
Durham, North Carolina Director of Pediatric Anesthesia, Department of Anesthesia,
NAPA/MD
Baltimore, Maryland
C s m
ontributors to the upplemental aterial
Cuneyt M. Alper, MD James G. Cain, MD
Professor of Otolaryngology Visiting Associate Professor
University of Pittsburgh School of Medicine Department of Anesthesiology
Division of Pediatric Otolaryngology University of Pittsburgh School of Medicine
Children’s Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania
Pittsburgh, Pennsylvania
Franklyn P. Cladis, MD
Lawrence M. Borland, MD Assistant Professor
Associate Professor Department of Anesthesiology
Departments of Anesthesiology and Pediatrics University of Pittsburgh School of Medicine
University of Pittsburgh School of Medicine Children’s Hospital of Pittsburgh of UPMC
Children’s Hospital of Pittsburgh of UPMC Pittsburgh, Pennsylvania
Pittsburgh, Pennsylvania
Peter J. Davis, MD, FAAP
Robert B. Bryskin, MD Professor
Regional Anesthesia Coordinator Department of Anesthesiology
Nemours Children’s Hospitals; Department of Pediatrics
Assistant Professor, Anesthesiology University of Pittsburgh School of Medicine;
College of Medicine, Mayo Clinic Anesthesiologist-in-Chief
Jacksonville, Florida Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, Pennsylvania