COVID-2019 Alert

The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 6 months and older.

La información más reciente sobre el nuevo Coronavirus de 2019, incluidas las clínicas de vacunación para niños de 6 meses en adelante.


James Fehr, MD

  • James Joseph Fehr

Especialidades médicas y/o especialidades quirúrgicas


Trabajo y educación


University of Michigan Medical School, Ann Arbor, MI, 06/01/1988

Últimos años de residencia

Baylor College of Medicine Internal Medicine Residency, Houston, TX, 6/30/1992

Johns Hopkins Anesthesiology Residency, Baltimore, MD, 06/30/1995


Johns Hopkins Pediatric Anesthesiology and Critical Care Fellowship, Baltimore, MD, 6/30/1997

Certificado(s) de especialidad

Anesthesia, American Board of Anesthesiology

Pediatric Anesthesia, American Board of Anesthesiology

Pediatric Critical Care Medicine, American Board of Pediatrics

Todo Publicaciones

Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard. Applied clinical informatics Safranek, C. W., Feitzinger, L., Joyner, A. K., Woo, N., Smith, V., Souza, E. D., Vasilakis, C., Anderson, T. A., Fehr, J., Shin, A. Y., Scheinker, D., Wang, E., Xie, J. 2022; 13 (2): 370-379


BACKGROUND: Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers.OBJECTIVES: This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data.METHODS: We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation.RESULTS: The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data.CONCLUSION: A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.

View details for DOI 10.1055/s-0042-1744387

View details for PubMedID 35322398

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Smith, H. A., Besunder, J. B., Betters, K. A., Johnson, P. N., Srinivasan, V., Stormorken, A., Farrington, E., Golianu, B., Godshall, A. J., Acinelli, L., Almgren, C., Bailey, C. H., Boyd, J. M., Cisco, M. J., Damian, M., deAlmeida, M. L., Fehr, J., Fenton, K. E., Gilliland, F., Grant, M. J., Howell, J., Ruggles, C. A., Simone, S., Su, F., Sullivan, J. E., Tegtmeyer, K., Traube, C., Williams, S., Berkenbosch, J. W. 1800; 23 (2): e74-e110


RATIONALE: A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available.OBJECTIVE: To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility.DESIGN: The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to.METHODS: Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence.RESULTS: The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.CONCLUSIONS: The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

View details for DOI 10.1097/PCC.0000000000002873

View details for PubMedID 35119438

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved? Anesthesia and pain medicine Schmidt, A. R., Fehr, J., Man, J., D'Souza, G., Wang, E., Claure, R., Mendoza, J. 2021


Background: The goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force.Methods: Data from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient's arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range).Results: In total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30).Conclusions: This study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

View details for DOI 10.17085/apm.21025

View details for PubMedID 34289299

The Immunologic Effect of Early Intravenous Two and Four Gram Bolus Dosing of Tranexamic Acid Compared to Placebo in Patients With Severe Traumatic Bleeding (TAMPITI): A Randomized, Double-Blind, Placebo-Controlled, Single-Center Trial FRONTIERS IN IMMUNOLOGY Spinella, P. C., Thomas, K. A., Turnbull, I. R., Fuchs, A., Bochicchio, K., Schuerer, D., Reese, S., Coleoglou Centeno, A. A., Horn, C. B., Baty, J., Shea, S. M., Meledeo, M., Pusateri, A. E., Levy, J. H., Cap, A. P., Bochicchio, G. V., TAMPITI Investigators 2020; 11: 2085


The hemostatic properties of tranexamic acid (TXA) are well described, but the immunological effects of TXA administration after traumatic injury have not been thoroughly examined. We hypothesized TXA would reduce monocyte activation in bleeding trauma patients with severe injury.This was a single center, double-blinded, randomized controlled trial (RCT) comparing placebo to a 2 g or 4 g intravenous TXA bolus dose in trauma patients with severe injury. Fifty patients were randomized into each study group. The primary outcome was a reduction in monocyte activation as measured by human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes 72 h after TXA administration. Secondary outcomes included kinetic assessment of immune and hemostatic phenotypes within the 72 h window post-TXA administration.The trial occurred between March 2016 and September 2017, when data collection ended. 149 patients were analyzed (placebo, n = 50; 2 g TXA, n = 49; 4 g TXA, n = 50). The fold change in HLA-DR expression on monocytes [reported as median (Q1-Q3)] from pre-TXA to 72 h post-TXA was similar between placebo [0.61 (0.51-0.82)], 2 g TXA [0.57 (0.47-0.75)], and 4 g TXA [0.57 (0.44-0.89)] study groups (p = 0.82). Neutrophil CD62L expression was reduced in the 4 g TXA group [fold change: 0.73 (0.63-0.97)] compared to the placebo group [0.97 (0.78-1.10)] at 24 h post-TXA (p = 0.034). The fold decrease in plasma IL-6 was significantly less in the 4 g TXA group [1.36 (0.87-2.42)] compared to the placebo group [0.46 (0.19-1.69)] at 72 h post-TXA (p = 0.028). There were no differences in frequencies of myeloid or lymphoid populations or in classical complement activation at any of the study time points.In trauma patients with severe injury, 4 g intravenous bolus dosing of TXA has minimal immunomodulatory effects with respect to leukocyte phenotypes and circulating cytokine, identifier NCT02535949.

View details for DOI 10.3389/fimmu.2020.02085

View details for Web of Science ID 000574254900001

View details for PubMedID 33013880

View details for PubMedCentralID PMC7506112

The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States. Anesthesia and analgesia Welch, T. P., Kilbaugh, T. J., McCloskey, J. J., Juriga, L. L., Abdallah, A. B., Fehr, J. J. 2020


BACKGROUND: Combined practice in pediatric anesthesiology (PA) and pediatric critical care medicine (PCCM) was historically common but has declined markedly with time. The reasons for this temporal shift are unclear, but existing evidence suggests that length of training is a barrier to contemporary trainees. Among current practitioners, restriction in dual-specialty practice also occurs, for reasons that are unknown at present. We sought to describe the demographics of this population, investigate their perceptions about the field, and consider factors that lead to attrition.METHODS: We conducted a cross-sectional, observational study of physicians in the United States with a combined practice in PA and PCCM. The survey was distributed electronically and anonymously to the distribution list of the Pediatric Anesthesia Leadership Council (PALC) of the Society for Pediatric Anesthesia (SPA), directing the recipients to forward the link to their faculty meeting our inclusion criteria. Attending-level respondents (n = 62) completed an anonymous, 40-question multidomain survey.RESULTS: Forty-seven men and 15 women, with a median age of 51, completed the survey. Major leadership positions are held by 44%, and 55% are externally funded investigators. A minority (26%) have given up one or both specialties, citing time constraints and politics as the dominant reasons. Duration of training was cited as the major barrier to entry by 77%. Increasing age and faculty rank and lack of a comparably trained institutional colleague were associated with attrition from dual-specialty practice. The majority (88%) reported that they would do it all again.CONCLUSIONS: The current cohort of pediatric anesthesiologist-intensivists in the United States is a small but accomplished group of physicians. Efforts to train, recruit, and retain such providers must address systematic barriers to completion of the requisite training and continued practice.

View details for DOI 10.1213/ANE.0000000000005024

View details for PubMedID 32665467

Perioperative Management of Pediatric Patients With Type 1 Diabetes Mellitus, Updated Recommendations for Anesthesiologists ANESTHESIA AND ANALGESIA Martin, L. D., Hoagland, M. A., Rhodes, E. T., Wolfsdorf, J. I., Hamrick, J. L., Soc Pediat Anesthesia Quality Saf 2020; 130 (4): 82127


Approximately 1 of every 300 children in the United States has type 1 diabetes mellitus (T1D), and these patients may require anesthetics for a variety of procedures. Perioperative coordination is complex, and attention to perioperative fasting, appropriate insulin administration, and management of hypo- and hyperglycemia, as well as other metabolic abnormalities, is required. Management decisions may be impacted by the patient's baseline glycemic control and home insulin regimen, the type of procedure being performed, and expected postoperative recovery. If possible, preoperative planning with input from the patient's endocrinologist is considered best practice. A multi-institutional working group was formed by the Society for Pediatric Anesthesia Quality and Safety Committee to review current guidelines in the endocrinology and anesthesia literature and provide recommendations to anesthesiologists caring for pediatric patients with T1D in the perioperative setting. Recommendations for preoperative evaluation, glucose monitoring, insulin administration, fluid management, and postoperative management are discussed, with particular attention to increasingly prevalent insulin pumps and continuous glucose monitoring (CGM).

View details for DOI 10.1213/ANE.0000000000004491

View details for Web of Science ID 000529444900027

View details for PubMedID 31688079

Distraction-Free Zones Need to be Respected ANESTHESIA AND ANALGESIA Brustowicz, R. M., Fehr, J., Clebone, A., Malviya, S. 2020; 130 (4): E112-E113

View details for DOI 10.1213/ANE.0000000000004623

View details for Web of Science ID 000529444900013

View details for PubMedID 31904638

Individualized simulations in a time of social distancing: Learning on donning and doffing of an COVID-19 airway response team. Journal of clinical anesthesia Rama, A. n., Murray, A. n., Fehr, J. n., Tsui, B. n. 2020; 67: 110019

View details for DOI 10.1016/j.jclinane.2020.110019

View details for PubMedID 32862074

Pediatric-Oncology Simulation Training for Resident Education. BMJ simulation & technology enhanced learning Smink, G. M., Jeffe, D. B., Hayashi, R. J., Al-Hammadi, N., Fehr, J. J. 2019; 5 (3): 15560


Introduction: We sought to evaluate pediatric oncology simulations intended to improve pediatric residents' skills and comfort in caring for children with cancer.Method: In a non-randomized trial, controls (the first three rotations) received a standard set of lectures, and the intervention arm received these lectures plus five simulation-training scenarios-fever/neutropenia, a new leukemia diagnosis, end-of-life care discussion, tumor lysis syndrome, and a mediastinal mass. All residents were tested after the rotation on the first three scenarios; management skills were evaluated independently by two raters. Before and after training, all residents completed an emotional-appraisal questionnaire evaluating each scenario as a perceived challenge or threat. Analysis of variance (ANOVA) measured differences by study arm in skills-checklist assessments and appraisals; repeated-measures ANOVA measured changes in emotional-appraisal scores.Results: Forty-two residents (9 control, 33 intervention) participated. Inter-rater agreement for skills-checklist scores using average-measures intraclass correlation was high (0.847), and overall mean scores were significantly higher for the intervention than control group across both raters (P = 0.005). For all residents, perceived challenge increased in the end-of-life simulation, and perceived threat decreased in all three test scenarios. The intervention group, regardless of training year, evaluated the teaching scenarios favorably and felt that challenging oncology situations were addressed, skills were enhanced, and the simulations should be offered to other residents.Conclusions: It was feasible to introduce residents to difficult pediatric oncology scenarios using simulation. The intervention group performed more skills than controls when tested, and perceive threat declined in all residents after their pediatric oncology rotation.

View details for DOI 10.1136/bmjstel-2018-000347

View details for PubMedID 31485338

Massive Fetal Transfusion During an Emergency Ex Utero Intrapartum Treatment for a Congenital Infantile Fibrosarcoma: A Case Report. A&A practice Oster, A. S., Reina, E., Fehr, J. J., Moore, R. P., Cox, T. E., George, P. 2019


Although originally described to assist airway management of fetal congenital malformations with life-threatening airway obstruction, the indications for an ex utero intrapartum treatment (EXIT) have expanded to include surgical resection of lesions that are potentially incompatible with life in the absence of uteroplacental circulatory support. We describe the case of an infantile fibrosarcoma (IFS) that presented with fetal hydrops and was successfully managed with an emergency EXIT that necessitated the initiation of a massive fetal blood transfusion both with and without the support of uteroplacental circulation.

View details for DOI 10.1213/XAA.0000000000001050

View details for PubMedID 31206387

In Response. Anesthesia and analgesia Clebone, A., Strupp, K. M., Fehr, J., Burian, B. K. 2019

View details for DOI 10.1213/ANE.0000000000004138

View details for PubMedID 30925558

Developing a risk-based composite neurologic outcome for a trial of hydroxyurea in young children with sickle cell disease CLINICAL TRIALS Casella, J. F., Adams, R. J., Brambilla, D. J., Strouse, J. J., Maier, P., Dlugash, R., Avadhani, R., Vermillion, K., Tonascia, J., Voeks, J. H., Hanley, D. F., Thompson, R. E., Lehmann, H. P., Goldenberg, N. A., Hale, G. A., Case, C., Manwani, D. G., Callaghan, M. U., Sarnaik, S. A., Kwiatkowski, J. L., Boswinkel, J. P., Ichord, R. N., Kalpatthi, R. V., Nickel, R. S., Heitmiller, E. S., Guerrera, M. F., Aygun, B., Park, H., Green, N. S., Fuh, B. R., Brown, R. C., Inusa, B. D., Rees, D. C., Thompson, A. A., Jackson, S. M., Kanter, J., Villella, A. D., Bansal, M. M., Telfer, P. T., Fixler, J. M., Kirby-Allen, M., Vichinsky, E. P., Neumayr, L. D., Lebensburger, J. D., Black, L. V., Hsu, L. L., Alvarez, O. A., Redding-Lallinger, R. C., King, A. A., McKinstry, R. C., White, D. A., Fehr, J. J., Noetzel, M. J., Jordan, L. C., Panepinto, J. A., Shaw, D. W., Whittle, J. P., Majumdar, S., Pecker, L. H., Whyte-Stewart, D. A., Smith, C. A., Shay, J. E., Kraut, M. A., Barron-Casella, E. A., Jones, K., Hackman, A. W., Weiss, D. C., Mould, W., Mayo, S. W., Ostapkovich, N., HU Prevent Investigators 2019; 16 (1): 2031


Studies of interventions to prevent the many neurological complications of sickle cell disease must take into account multiple outcomes of variable severity, with limited sample size. The goals of the studies presented were to use investigator preferences across outcomes to determine an attitude-based weighting of relevant clinical outcomes and to establish a valid composite outcome for a clinical trial.In Study 1, investigators were surveyed about their practice regarding hydroxyurea therapy and opinions about outcomes for the "Hydroxyurea to Prevent the Central Nervous System Complications of Sickle Cell Disease Trial" (HU Prevent), and their minimally acceptable relative risk reduction for the two outcome components, motor and neurocognitive deficits. In Study 2, HU Prevent investigators provided overall weights for these two components. In Study 3, they provided more granular rankings, ratings, and maximum number acceptable to harm. A weighted composite outcome, the Stroke Consequences Risk Score, was constructed that incorporates the major neurologic complications of sickle cell disease. The Stroke Consequences Risk Score represents the 3-year risk of suffering the adverse consequences of stroke. In Study 4, the results of the Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP2) and Silent Infarct Transfusion Trials were reanalyzed in light of the composite outcome.In total, 22 to 27 investigators participated per study. In Study 1, across three samplings between 2009 and 2015, the average minimally acceptable relative risk reduction ranged from 0.36 to 0.50, at or below the target effect size of 0.50. In 2015, 21 (91%) reported that a placebo-controlled trial is reasonable; 23 (100%), that it is ethical; and 22 (96%), that they would change their practice, if the results of the trial were positive. In Studies 2 and 3, the weight elicited for a cognitive decline (of 10 IQ points) from the overall assessment was 0.67 (and for motor deficit, the complementary 0.33); from ranking, 0.6; from rating, 0.58; and from maximal number acceptable to harm, 0.5. Using data from two major clinical trials, Study 4 demonstrated the same conclusions as the original trials using the Stroke Consequences Risk Score, with smaller p-values for both reanalyses. An assessment of acceptability was performed as well.This set of studies provides the rationale, justification, and validation for the use of a weighted composite outcome and confirms the need for the phase III HU Prevent study. Surveys of investigators in multi-center studies can provide the basis of clinically meaningful outcomes that foster the translation of study results into practice while increasing the efficiency of a study.

View details for DOI 10.1177/1740774518807160

View details for Web of Science ID 000456739900005

View details for PubMedID 30426764

In Response. Anesthesia and analgesia Clebone, A. n., Strupp, K. M., Fehr, J. n., Burian, B. K. 2019; 129 (6): e198e199

View details for DOI 10.1213/ANE.0000000000004138

View details for PubMedID 31743204

Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application. Anesthesia and analgesia Clebone, A. n., Strupp, K. M., Whitney, G. n., Anderson, M. R., Hottle, J. n., Fehr, J. n., Yaster, M. n., Schleelein, L. E., Burian, B. K., Galvez, J. A., Lockman, J. L., Polaner, D. n., Barnett, N. R., Keane, M. J., Manikappa, S. n., Gleich, S. n., Greenberg, R. S., Vincent, A. n., Oswald, S. L., Starks, R. n., Licata, S. n. 2019; 129 (6): 163544


When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists-the Pedi Crisis 2.0 application-as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.

View details for DOI 10.1213/ANE.0000000000003935

View details for PubMedID 31743185

Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application. Anesthesia and analgesia Clebone, A., Strupp, K. M., Whitney, G., Anderson, M. R., Hottle, J., Fehr, J., Yaster, M., Schleelein, L. E., Burian, B. K., Galvez, J. A., Lockman, J. L., Polaner, D., Barnett, N. R., Keane, M. J., Manikappa, S., Gleich, S., Greenberg, R. S., Vincent, A., Oswald, S. L., Starks, R., Licata, S., Pedi Crisis Application Working Group 2018


When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists-the Pedi Crisis 2.0 application-as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology.

View details for DOI 10.1213/ANE.0000000000003935

View details for PubMedID 30540613

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children PEDIATRICS Feld, L. G., Neuspiel, D. R., Foster, B. A., Leu, M. G., Garber, M. D., Austin, K., Basu, R. K., Conway, E. E., Fehr, J. J., Hawkins, C., Kaplan, R. L., Rowe, E. V., Waseem, M., Moritz, M. L., Subcomm Fluid Electrolyte Therapy 2018; 142 (6)
Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics Feld, L. G., Neuspiel, D. R., Foster, B. A., Leu, M. G., Garber, M. D., Austin, K., Basu, R. K., Conway, E. E., Fehr, J. J., Hawkins, C., Kaplan, R. L., Rowe, E. V., Waseem, M., Moritz, M. L., SUBCOMMITTEE ON FLUID AND ELECTROLYTE THERAPY 2018


Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).

View details for PubMedID 30478247

Simulation and the diagnostic process: a pilot study of trauma and rapid response teams DIAGNOSIS Juriga, L. L., Murray, D. J., Boulet, J. R., Fehr, J. J. 2017; 4 (4): 24149


Simulation is frequently used to recreate many of the crises encountered in patient care settings. Teams learn to manage these crises in an environment that maximizes their learning experiences and eliminates the potential for patient harm. By designing simulation scenarios that include conditions associated with diagnostic errors, teams can experience how their decisions can lead to errors. The purpose of this study was to assess how trauma teams (TrT) and pediatric rapid response teams (RRT) managed scenarios that included a diagnostic error.We developed four scenarios that would require TrT and pediatric RRT to manage an error in diagnosis. The two trauma scenarios (spinal cord injury and tracheobronchial tear) were designed to not respond to the heuristic management approach frequently used in trauma settings. The two pediatric scenarios (foreign body aspiration and coarctation of the aorta) had an incorrect diagnosis on admission. Two raters independently scored the scenarios using a rating system based on how teams managed the diagnostic process (search, establish and confirm a new diagnosis and initiate therapy based on the new diagnosis).Twenty-one TrT and 17 pediatric rapid response managed 51 scenarios. All of the teams questioned the initial diagnosis. The teams were able to establish and confirm a new diagnosis in 49% of the scenarios (25 of 51). Only 23 (45%) teams changed their management of the patient based on the new diagnosis.Simulation can be used to recreate conditions that engage teams in the diagnostic process. In contrast to most instruction about diagnostic error, teams learn through realistic experiences and receive timely feedback about their decision-making skills. Based on the findings in this pilot study, the majority of teams would benefit from an education intervention designed to improve their diagnostic skills.

View details for DOI 10.1515/dx-2017-0010

View details for Web of Science ID 000416316800008

View details for PubMedID 29536940

ECMO for Pediatric Lung Transplantation ASAIO JOURNAL Olsen, M. C., Anderson, M. J., Fehr, J. J., Christensen, J. L., Shepard, M. P., Poe, J. B., Eghtesady, P. 2017; 63 (6): E77E80


Extracorporeal membrane oxygenation (ECMO) has been reported as an alternative to cardiopulmonary bypass during lung transplantation. The reports in the literature have been limited to adult practice and associated with decreased pulmonary and renal complications, lower mortality, and lower in-hospital mortality. We present four pediatric lung transplantations performed on ECMO and discuss relevant perfusion management.

View details for DOI 10.1097/MAT.0000000000000534

View details for Web of Science ID 000415716800002

View details for PubMedID 28125461

The Simulation-Based Assessment of Pediatric Rapid Response Teams JOURNAL OF PEDIATRICS Fehr, J. J., McBride, M. E., Boulet, J. R., Murray, D. J. 2017; 188: 258-+


To create scenarios of simulated decompensating pediatric patients to train pediatric rapid response teams (RRTs) and to determine whether the scenario scores provide a valid assessment of RRT performance with the hypothesis that RRTs led by intensivists-in-training would be better prepared to manage the scenarios than teams led by nurse practitioners.A set of 10 simulated scenarios was designed for the training and assessment of pediatric RRTs. Pediatric RRTs, comprising a pediatric intensive care unit (PICU) registered nurse and respiratory therapist, led by a PICU intensivist-in-training or a pediatric nurse practitioner, managed 7 simulated acutely decompensating patients. Two raters evaluated the scenario performances and psychometric analyses of the scenarios were performed.The teams readily managed scenarios such as supraventricular tachycardia and opioid overdose but had difficulty with more complicated scenarios such as aortic coarctation or head injury. The management of any particular scenario was reasonably predictive of overall team performance. The teams led by the PICU intensivists-in-training outperformed the teams led by the pediatric nurse practitioners.Simulation provides a method for RRTs to develop decision-making skills in managing decompensating pediatric patients. The multiple scenario assessment provided a moderately reliable team score. The greater scores achieved by PICU intensivist-in-training-led teams provides some evidence to support the validity of the assessment.

View details for DOI 10.1016/j.jpeds.2017.03.030

View details for Web of Science ID 000410641100049

View details for PubMedID 28434554

View details for PubMedCentralID PMC5572541

Emergency Information Forms for Children With Medical Complexity: A Simulation Study PEDIATRICS Abraham, G., Fehr, J., Ahmad, F., Jeffe, D. B., Copper, T., Yu, F., White, A. J., Auerbach, M., Schnadower, D. 2016; 138 (2)


Emergency information forms (EIFs) have been proposed to provide critical information for optimal care of children with medical complexity (CMC) during emergencies; however, their impact has not been studied. The objective of this study was to measure the impact and utility of EIFs in simulated scenarios of CMC during medical emergencies.Twenty-four providers (12 junior, 12 experienced) performed 4 simulations of CMC, where access to an EIF was block randomized by group. Scenario-specific critical action checklists and consequential pathways were developed by content experts in simulation and pediatric subspecialists. Scenarios ended when all critical actions were completed or after 10 minutes, whichever came first. Two reviewers independently evaluated the video-recorded performances and calculated scenario-specific critical action scores. Performance in scenarios with and without an EIF was compared with Pearson's (2) and Mann-Whitney U tests. Interrater reliability was assessed with intraclass correlation. Each provider rated the utility of EIFs via exit questionnaires.The median critical action score in scenarios with EIFs was 84.2% (95% confidence interval [CI], 71.7%-94.1%) versus 12.5% (95% CI, 10.5%-35.3%) in scenarios without an EIF (P < .001); time to completion of scenarios was shorter (6.9 minutes [interquartile range 5.8-10 minutes] vs 10 minutes), and complication rates were lower (30% [95% CI, 17.4%-46.3%] vs 100% [95% CI, 92.2%-100%]) with EIFs, independent of provider experience. Interrater reliability was excellent (intraclass correlation = 0.979). All providers strongly agreed that EIFs can improve clinical outcomes for CMC.Using simulated scenarios of CMC, providers' performance was superior with an EIF. Clinicians evaluated the utility of EIFs very highly.

View details for DOI 10.1542/peds.2016-0847

View details for Web of Science ID 000381002500043

View details for PubMedID 27436504

View details for PubMedCentralID PMC5603153

Simulation-Based Assessment of ECMO Clinical Specialists SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Fehr, J. J., Shepard, M., McBride, M. E., Mehegan, M., Reddy, K., Murray, D. J., Boulet, J. R. 2016; 11 (3): 19499


The aims of the study were (1) to create multiple scenarios that simulate a range of urgent and emergent extracorporeal membrane oxygenation (ECMO) events and (2) to determine whether these scenarios can provide reliable and valid measures of a specialist's advanced skill in managing ECMO emergencies.Multiscenario simulation-based performance assessment was performed.The study was conducted in the Saigh Pediatric Simulation Center at St. Louis Children's Hospital.ECMO clinical specialists participated in the study.Twenty-five ECMO specialists completed 8 scenarios presenting acute events in simulated ECMO patients. Participants were evaluated by 2 separate reviewers for completion of key actions and for global performance. The scores were highest for the hemodilution scenario, whereas the air entrainment scenario had the lowest scores. Psychometric analysis demonstrated that ECMO specialists with more than 1 year of experience outperformed the specialists with less than 1 year of experience. Participants endorsed these sessions as important and representative of events that might be encountered in practice.The scenarios could serve as a component of an ECMO education curriculum and be used to assess clinical specialists' readiness to manage ECMO emergencies.

View details for DOI 10.1097/SIH.0000000000000153

View details for Web of Science ID 000378021100007

View details for PubMedID 27093507

Summer camp, boot camp, and the formation of a new fellow PEDIATRIC ANESTHESIA Fehr, J. J., Kuan, C. 2016; 26 (5): 46667

View details for PubMedID 27059415

The important role of simulation in sedation CURRENT OPINION IN ANESTHESIOLOGY Fehr, J. J., Chao, J., Kuan, C., Zhong, J. 2016; 29: S14-S20


This article reviews the development of simulation-based training strategies to educate sedation providers.Medical simulation has been utilized to train and evaluate providers in numerous domains related to sedation. Sedation providers come to the patient with a wide range of clinical training and experience and simulation can serve as a platform for achieving a baseline skill level and for periodic retraining. Although widely accepted by participants in simulation training, data demonstrating simulation's efficacy in improving sedation-related clinical outcomes are lacking.Simulation provides an opportunity for sedation providers to develop deliberative practice, to consider rare or challenging clinical conditions, and to benefit from directed feedback, in a manner that does not put patients in harm's way.

View details for DOI 10.1097/ACO.0000000000000313

View details for Web of Science ID 000373238000002

Decision Making in Trauma Settings Simulation to Improve Diagnostic Skills SIMULATION IN HEALTHCARE-JOURNAL OF THE SOCIETY FOR SIMULATION IN HEALTHCARE Murray, D. J., Freeman, B. D., Boulet, J. R., Woodhouse, J., Fehr, J. J., Klingensmith, M. E. 2015; 10 (3): 13945


In the setting of acute injury, a wrong, missed, or delayed diagnosis can impact survival. Clinicians rely on pattern recognition and heuristics to rapidly assess injuries, but an overreliance on these approaches can result in a diagnostic error. Simulation has been advocated as a method for practitioners to learn how to recognize the limitations of heuristics and develop better diagnostic skills. The objective of this study was to determine whether simulation could be used to provide teams the experiences in managing scenarios that require the use of heuristic as well as analytic diagnostic skills to effectively recognize and treat potentially life-threatening injuries.Ten scenarios were developed to assess the ability of trauma teams to provide initial care to a severely injured patient. Seven standard scenarios simulated severe injuries that once diagnosed could be effectively treated using standard Advanced Trauma Life Support algorithms. Because diagnostic error occurs more commonly in complex clinical settings, 3 complex scenarios required teams to use more advanced diagnostic skills to uncover a coexisting condition and treat the patient. Teams composed of 3 to 5 practitioners were evaluated in the performance of 7 (of 10) randomly selected scenarios (5 standard, 2 complex). Expert rates scored teams using standardized checklists and global scores.Eighty-three surgery, emergency medicine, and anesthesia residents constituted 21 teams. Expert raters were able to reliably score the scenarios. Teams accomplished fewer checklist actions and received lower global scores on the 3 analytic scenarios (73.8% [12.3%] and 5.9 [1.6], respectively) compared with the 7 heuristic scenarios (83.2% [11.7%] and 6.6 [1.3], respectively; P < 0.05 for both). Teams led by more junior residents received higher global scores on the analytic scenarios (6.4 [1.3]) than the more senior team leaders (5.3 [1.7]).This preliminary study indicates that teams led by more senior residents received higher scores when managing heuristic scenarios but were less effective when managing the scenarios that require a more analytic approach. Simulation can be used to provide teams with decision-making experiences in trauma settings and could be used to improve diagnostic skills as well as study the decision-making process.

View details for DOI 10.1097/SIH.0000000000000073

View details for Web of Science ID 000356237100002

View details for PubMedID 25710315

Paracorporeal lung assist device: An innovative surgical strategy for bridging to lung transplant in an infant with severe pulmonary hypertension caused by alveolar capillary dysplasia JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Boston, U. S., Fehr, J., Gazit, A. Z., Eghtesady, P. 2013; 146 (4): E42E43

View details for DOI 10.1016/j.jtcvs.2013.06.014

View details for Web of Science ID 000324481400011

View details for PubMedID 23871141

Acute care of pediatric patients with sickle cell disease: A simulation performance assessment PEDIATRIC BLOOD & CANCER Burns, T. L., DeBaun, M. R., Boulet, J. R., Murray, G. M., Murray, D. J., Fehr, J. J. 2013; 60 (9): 149298


Sickle cell disease (SCD) is a rare disorder with cardinal features including hospitalization for vaso-occlusive pain episodes, acute pulmonary injury, and increased infection rates. For physician-trainees, learning optimal SCD management is challenging because of limited exposure to life threatening complications requiring timely interventions.To create, demonstrate reliability, and validate simulation-based, acute care SCD scenarios for physician-trainees, seven scenarios were derived from SCD patient cases. For each scenario, participants had 5 minutes to complete diagnostic and treatment interventions. Participants were divided into two groups based on clinical experience: interns or residents/fellows. Two raters scored performances using diagnostic and therapeutic checklists--indicating whether specific actions were performed and a global, 1 (poor) to 9 (excellent), rating. Scenario scores were calculated by averaging rater scores on each metric. Reliability was defined through uniformity in rater scoring and consistency of participant performance over scenarios. Validity was demonstrated by the performance gradient where the more experienced trainees outperform those early in training.Twenty-eight pediatric residents and hematology fellows took part in the study. Reliability for assessment scores overall was moderate. Performance on all but one scenario was moderately predictive of overall performance. Senior resident/fellows performed significantly better than interns. Positive associations existed between overall performance scores (P < 0.01) and months of postgraduate training (P < 0.01).Mannequin-based simulation is a novel method for teaching pediatric residents SCD-specific acute care skills. The assessment provided reliable and valid measures of trainees' performance. Further studies are needed to determine simulation's utility in education and evaluation.

View details for DOI 10.1002/pbc.24558

View details for Web of Science ID 000321703900084

View details for PubMedID 23633232

Simulation-Based Education Is an Effective Teaching Tool for Pediatric Trainees, in the Diagnosis and Management of Pediatric Anaphylaxis Miller, N., Fehr, J., White, A., Bacharier, L. B., Ellis, A. G. MOSBY-ELSEVIER. 2013: AB221
Simulation in pediatric anesthesiology PEDIATRIC ANESTHESIA Fehr, J. J., Honkanen, A., Murray, D. J. 2012; 22 (10): 988-994


Simulation-based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer-based simulations to mannequins. Computer-controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in-situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task-training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.

View details for DOI 10.1111/pan.12001

View details for Web of Science ID 000308638300009

View details for PubMedID 22967157

Is Simulation the Best Way to Assess Pediatric Anesthesia Skills? Reply ANESTHESIOLOGY Fehr, J. J., Murray, D. J. 2012; 117 (1): 220
Simulation-based Assessment of Pediatric Anesthesia Skills ANESTHESIOLOGY Fehr, J. J., Boulet, J. R., Waldrop, W. B., Snider, R., Brockel, M., Murray, D. J. 2011; 115 (6): 130815


Assessment of pediatric anesthesia trainees is complicated by the random nature of adverse patient events and the vagaries of clinical exposure. However, assessment is critical to improve patient safety. In previous studies, a multiple scenario assessment provided reliable and valid measures of the abilities of anesthesia residents. The purpose of this study was to develop a set of relevant simulated pediatric perioperative scenarios and to determine their effectiveness in the assessment of anesthesia residents and pediatric anesthesia fellows.Ten simulation scenarios were designed to reflect situations encountered in perioperative pediatric anesthesia care. Anesthesiology residents and fellows consented to participate and were debriefed after each scenario. Two pediatric anesthesiologists scored each scenario by key action checklist. The psychometric properties (reliability, validity) of the scores were studied.Thirty-five anesthesiology residents and pediatric anesthesia fellows participated. The participants with greater experience administering pediatric anesthetics generally outperformed those with less experience. Score variance attributable to raters was low, yielding a high interrater reliability.A multiple-scenario, simulation-based assessment of pediatric perioperative care was designed and administered to residents and fellows. The scores obtained from the assessment indicated the content was relevant and that raters could reliably score the scenarios. Participants with more training achieved higher scores, but there was a wide range of ability among subjects. This method has the potential to contribute to pediatric anesthesia performance assessment, but additional measures of validity including correlations with more direct measures of clinical performance are needed to establish the utility of this approach.

View details for DOI 10.1097/ALN.0b013e318238bcf6

View details for Web of Science ID 000297581800024

View details for PubMedID 22037637

Perioperative management of the pediatric cardiac transplantation patient. Current treatment options in cardiovascular medicine Gazit, A. Z., Fehr, J. 2011; 13 (5): 42543


OPINION STATEMENT: The major diagnoses carried by children undergoing cardiac transplantation worldwide are congenital heart defects, cardiomyopathies, and retransplantation. The leading diagnosis in infancy is congenital heart disease, whereas cardiomyopathy predominates in older children. In view of this wide spectrum of diagnoses, the perioperative management of these children requires medical, interventional, and surgical expertise in treatment of complex congenital heart defects, end-stage heart failure, and cardiac transplantation. According to the Pediatric Heart Transplantation Survey database, the majority of children listed for cardiac transplantation eventually require higher levels of cardiac support before transplantation. The team caring for these children should be prepared to escalate support in a timely fashion in order to avoid end-organ dysfunction or a catastrophic event that will remove the patient from the cardiac transplantation list. The first step is advanced hemodynamic monitoring in a specialized pediatric cardiac intensive care unit and initiation of inotropic support. Further escalation of care should be based on careful analysis of the hemodynamic profile, end-organ function, and biochemical markers of perfusion and myocardial stress. A patient who continues to deteriorate in spite of inotropic support requires positive pressure ventilation, and if deterioration continues, mechanical circulatory support is initiated. Cardiac transplantation is a challenging operation, and even more so in children with complex congenital heart defects. The abnormal cardiovascular anatomy requires planning and anticipation of possible pitfalls as hypoplasia of the aortic arch, abnormal pulmonary arteries, and abnormal systemic and pulmonary venous connections. The time required to remove adhesions in children with prior cardiac operations increases the ischemic time of the graft and the risk of primary graft dysfunction. Assessment of pulmonary vascular resistance in children with congenital heart defects is problematic, and even children with a normal transpulmonary gradient and pulmonary vascular resistance are at increased risk of postoperative pulmonary hypertension and right ventricular graft failure. The postoperative course is directly linked to the patient's preoperative physical condition and perioperative course. The induction of immunosuppression and the use of plasmapheresis in children with a positive cross-match may lead to further hemodynamic compromise. If severe primary graft dysfunction evolves, early initiation of extracorporeal membranous oxygenator is indicated to avoid irreversible end-organ dysfunction.

View details for DOI 10.1007/s11936-011-0143-8

View details for PubMedID 21773731

Simulation in Pediatrics: The Reliability and Validity of a Multiscenario Assessment PEDIATRICS McBride, M. E., Waldrop, W. B., Fehr, J. J., Boulet, J. R., Murray, D. J. 2011; 128 (2): 33543


The goal of this study was to develop an inventory of simulated scenarios that mimic pediatric crises and determine if the resident scores could be used to establish the reliability and validity of a multiple-scenario assessment. The long-term objective is to provide pediatric residents with experiences in the recognition, diagnosis, and management of a range of simulated acute conditions.Twenty scenarios were constructed. Each resident participated in 10 scenarios that were scored by 2 independent raters using an action-item checklist and a global score. Debriefing occurred after each scenario. Several analyses were performed to investigate the psychometric adequacy of the scores.Twenty-nine residents participated. The residents' scores in both sets of 10 scenarios were reliable when using either the checklist or global scoring method (>0.79). Generalizability analyses indicated that the major source of variance in scores was attributable to the scenario and scenario-resident interaction. The variance attributable to the rater was low, yielding high interrater reliability values. The more-experienced residents who participated in the study outperformed the less-experienced interns.An inventory of critical events was designed to assess pediatric residents' diagnostic and management skills. A reliable measure of ability could be obtained, provided the residents managed multiple scenarios. The residents outscored the interns, providing evidence to support the construct validity of the scores. Additional validity evidence is needed, including studies to determine if this type of training improves physicians' management of real-life critical events.

View details for DOI 10.1542/peds.2010-3278

View details for Web of Science ID 000293336200049

View details for PubMedID 21746717

Care of the Pediatric Cardiac Surgery Patient-Part 2 CURRENT PROBLEMS IN SURGERY Gazit, A. Z., Huddleston, C. B., Checchia, P. A., Fehr, J., Pezzella, A. 2010; 47 (4): 261376

View details for DOI 10.1067/j.cpsurg.2009.12.003

View details for Web of Science ID 000275798500002

View details for PubMedID 20207257