Episode 116: Overview of Pediatric Anesthesia with Bommy Mershon

Hey there, Ac Rackers. You know what can make a real difference in your quality of life at work, comfortable scrubs. And not just any scrubs, but FIGs scrubs. They're made for awesome humans, and I think can truly make a difference for healthcare workers by keeping our needs in mind. Plus, it's a new year, a new you, or at least a new uniform. If you're in healthcare, it's the perfect time to upgrade your scrubs to FIGs. They're lightweight, durable, super functional, and ridiculously soft. I love my FIGs, and let me tell you, my wife, a pediatrician loves her so much. It's all she wears to work. Ever since COVID, she's all FIGs all the time. It doesn't matter if you're a dentist, a nurse, a nurse practitioner, a medical student, CRNAs, S-R-N-A, or an anesthesiologist like me. Investing in a couple of pairs of FIGs is totally worth it. With new limited edition colors and styles, FIGs is putting the fresh and uniform refresh. Scrubs, out-of-wear, footwear, accessories, and more, you'll be looking sharp, feeling good, and ready to take on anything. 2026 is here, so let's do this. 15% off your first order at wearfigs.com with a code FIGsRX. That's wearfigs.com code F-I-G-S-R-X. Hello and welcome back to A-CRACK, I'm Jed Wolplaw, and I am so thrilled that we for the first time ever have, as I'm sure you just noticed, music for A-CRACK. Now let me tell you a little bit about this development because it's very exciting. This theme music was composed specifically and originally for A-CRACK by a fantastic anesthesiologist named Dr. Dennis Quo. Dennis is a pain fellow at UCSD. He did his anesthesiology residency there prior to being a fellow. And in addition to being an anesthesiologist, he is also a pianist, a composer, and a music producer. When Dennis was in med school, he started creating original music to help promote a relaxing environment for himself and for his friends to study. And then he actually did a really cool thing. He created a place for this. He called it the study music project, and over the years since he did that, he's had tens of millions of hits on YouTube from students all over the world who use this as a way to relax while they're studying, and they really love his music. You can check out all of his music on his website, which is studymusicproject.com. That's studymusicprojectalloneword.com, or you can search the study music project on YouTube, and you'll find music to help you relax and focus. So I couldn't be more thrilled to have Dennis' music as the new and first ever theme music for ACRAC. Alright, let's get started with the show. I am thrilled to have with me today a first time guest on the show and a truly wonderful colleague here at Hopkins, Dr. Bomi Mershan, who is an assistant professor of pediatric anesthesia here at Johns Hopkins and a fantastic person she's involved in all kinds of really interesting stuff. But I invited her here today to kind of do a basic overview of some of the important things to think about in clinical pediatric anesthesia. And this came from a bunch of listener requests when listeners were kind of thinking, "You know, gee, I don't do this very often, but I do it sometimes," and it'd be really nice to have kind of a basic primer or overview. And I thought Bomi would be fantastic for this, so Bomi, thank you so much for agreeing to come on the show. Thank you, Chad, for this wonderful invitation, and I'm happy to be here. Awesome. Alright, so let me just ask you right up front. I mean, you know, you hear people joke about this, but really, you know, kids, adults, is there really that much of a difference, I mean, you often, you know, kind of just think, like, if you do weight-based dosing, that's it, right? Kids are just like little adults. So that's a really common misconception, and kids are not little adults. There's a lot of physiologic differences, and a more important difference would be the psychological difference that we see in kids. And so the pre-operative and post-operative issues that come up will be very important, and we'll talk about that in the later questions. But one thing, size really does matter, and it depends also on the age. And so some of the really kind of key points for everyone to think about are positioning, especially for intubation. So kids have relatively bigger heads for their body. They have relative macroglossia, so when you're intubating, you have to be mindful of that. And so positioning of their heads. So most of the time in kids, you will need shoulder rolls, as opposed to like a roll or lifting of their head to get that nice sniffing position. So big heads and large tongues. Yes. Okay. And so little different. You're thinking often, you know, we might ramp an adult, put some pads under their head in order to get their external auditory meadus lined up with their sternal notch, but in kids, it's going to be more of a shoulder roll. Absolutely. Okay. And also think about the blades that you're using, right? And so a lot of times, most people are pretty familiar with the MAC, the curved blades. But I would recommend practicing on adults with more of the straight blades. And that way you can get more apt with the straight blades, because those I think are more helpful in kids, especially the younger you are. And really practicing good positioning and prepping the child for intubation. So moving the tongue out of the way, really moving the tongue out of the way, I don't actually go midline when I put the blade in. I actually come from the side, really push the tongue out of the way as you're straightening the blade. And remember, their epiglottis is also floppy or short, and it's harder to catch. Yep. All right. So those are some important things to keep in mind. Let's start like way at the beginning. Let's say that you've got a patient, a kid who you're taking to the OR, what about the basic H&P? Is there anything that you want to know about in a kid or that you're doing in your physical exam that's different than you would do in an adult? Yes. So I have about three things that I would say are kind of the things that you want to hone in on. So number one, you have to remember the preop eval is actually quite similar to adults, right? And the same systems from a physiologic standpoint. But what you want to really focus on and really have eyes to see and be dynamic in is how can I psychologically prep the patient and the family very well for what's going to happen. And I think that's going to really determine not only parental satisfaction, but the experience of the child from beginning to end when you're taking care of them. So that's really what you want to think about is how can I psychologically help this family because it's a family unit, not just the child, to have as good of an experience as they can during this scary time. Yeah, that's really interesting because it's unique in our practice, right? That when you're taking care of a kid, you actually have kind of two patients. So you have the parents and the kid, right, where it's for an adult. You just have the adult. Right, absolutely. So that's important. You have to think differently, probably, about how to psychologically prepare each one of them. Absolutely, absolutely. So in terms of systems standpoint, one is really make sure that you understand the MPO guidelines for kids. So the official guidelines that are, I think, kind of some people are trying to change is, breast milk is four hours, clears is still two, solids is still eight. But there's two things that kids do that or eat that adults don't breast milk and formula. So formula is considered six hours, so it's like a light meal, so don't forget that. There is a movement now in the pediatric anesthesia community to try to allow for clears, I think similar to adults, actually up to an hour. But that, you know, some people are hesitant to adopt that right now because it's not official ASA guidelines, so it's institution dependent. Okay. Interesting. So we'll keep our eye out for any changes there. Yes. The next thing that's really big and controversial and very hard to deal with in the pizza population is your eyes. Kids are sick all the time, especially in this day and age of day care and being around kids who are constantly sick, so how do you deal with URIs? That's a kind of a gray box. You know if someone has a fever and a cough boom, you know, you're going to cancel or postpone that elective surgery. And then you have the well patient, but what if you do, what if you have a patient who's kind of in that in between? So we consider URIs when you say of current URI or in the last two weeks prior to the surgery date. Do you want to ask about that? Do you have any symptoms of a cold? Did you have a runny nose, a cough, a fever in the last two weeks? So we know the literature supports that kids who have a current URI or have had a URI in the last two weeks prior to surgery, they have increased risk of A.A.E.s. And those are called, that's, sorry, stands for adverse airway events. So that includes anything from coughing, wheezing, luringus pasms, broncus pasms, increased secretions, oxygen requirements or desaturations, post-exturbation group, and then obviously the scary or the most concerning thing would be requiring intubation post procedure. So they're at higher risk for all those things by virtue of having had either an active URI or anytime in the past couple of weeks? Absolutely. Just a couple of statistics, if you've had a URI within the last 30 days prior to surgery, there has been shown to have an increase, two to three times increased risk of luringus pasm, as well as prolonged emergence. I've taken care of so many kids whose, you know, parents say they've had a mild cold or they're fine or they come with, you can just see the beginnings of a cold and the emergence time has increased significantly because they've had secretions and it takes longer for them to be able to breathe well on their own. So here's my question. Bomi is that, you know, I have a one year old who always has a URI, right? So if it takes 30 days for that risk to go down, I don't think she's ever had a period of 30 days without, you know, any of those symptoms. So, you know, she essentially then would, if we said we have to wait until 30 days after the symptoms, she would never get to have her surgery if she needed one. So we must, we must proceed if it's just some mild symptoms, right? Absolutely. So you have kids who actually have colds because they have issues. So they need ear tubes. They have fluid in their ears all the time. They need tonsil surgery. So in that case, they would never be able to do that. But the risk of not having the surgery is going to outweigh the benefit of waiting. And so in those cases, I think this is why it's kind of a gray box. But I do proceed knowing that there's an increased risk and you proceed with caution, but you tell the parents and it's actually, and I will say, bronchial hyperreactivity, even from a common cold actually lasts about two to four weeks. And then if you've had a pneumonia, it's actually six to eight weeks. So the recommended time of waiting is at least two weeks from common cold, if you can, before from the time not there well, wait another two weeks until you schedule the surgery. If they've had pneumonia, I would actually wait at least eight weeks if you can. So things like pneumonia or, like you said, originally feverers and major cough or concern for lower airway infection, these things, we would not want to proceed with an elective surgery. But a basic clear ryanoreal mild cough sneezing, that kind of thing, a lot of kids are like you said, they're either going to have it all the time or they aren't going to stop having it till they get their procedure. So that kind of thing we might proceed as long as we let the parents know there is increased risk. Absolutely. And I'm always aware of that. And so you might say, you know what? I'm going to intimidate this child and suction them out and that actually helps. I'm going to administer bronchodilator before they wake up, et cetera, et cetera. Right. Okay. So, you know, kids I wanted to just mention who actually have pre-existing lung disease from prematurely. If they have second hand smoke exposure, which is actually very high risk, about ten times higher risk, kids who have second hand exposure and a URI, ten times higher risk of an adverse airway event, people, kids who have asthma, especially those that are not well controlled, and kids who are just having airway surgery, even if they don't have a cold, they're already at increased risk for ACE. So there's a couple of questions that come out of this. So what type of airway do I use then, right? And so there has been shown that the risk does increase with the type of airway that you use. So if you use a face mask with no instrumentation of the airway, that actually will help decrease your risk. So in ear tubes, using face mask, providing volatile anesthetic through just gas and through a mask is actually probably the ideal thing to do. Because you're not irritating, you're not actually touching the core or it's irritating the airway, okay? Exactly. And then an LMA is the next on the list in terms of providing less risk, obviously, because it's a supra-galotic airway. Right. But then there's also the risk of that increased secretions and causing luring spasm. So it's kind of a balance of risk. And then obviously, an endotracheal tube is the highest risk, however, I will say sometimes you will choose to actually put an endotracheal tube for the very fact that you have control of the airway. So if they bronchospasm, you can control it, you can suction them out. And also, it pretty much takes away the risk of luring spasm at least while they're under, while those surgeries happening. And so again, it's that's what the literature says, but it's also a clinical judgment. Right. Interesting. Great. So, Bonnie, when you're thinking about the things you want to know in that H&P, things you want to keep in mind, what else do you want to know? Yes. So post-op apnea is actually something that anesthesia providers should really think about because there's a risk even in full-term infant. So you have a patient, the surgeon doesn't know. They bring a patient for surgery. You actually have to calculate how many weeks they are post-conceptually. So if you have a full-term baby who is born after 38 weeks, the risk of apnea is still there actually. And it decreases based on the literature after 45 weeks, right? So if you are born at 40 weeks, you have to be at least a month out before you can consider outpatient surgery. If you're born at 38 weeks, you still have to calculate that. So it might be recommended to either educate your surgeons about the timeframe for when they should schedule their surgery or you have to let them know. And you have to also see what the policy is. Every children's hospital or every hospital that takes care of kids should have a policy in terms of outpatient surgery recommendations. And this is, when we say post-op apnea, we mean at some point post-operatively, they just could stop breathing. So they need to be monitored. Exactly. And what's the window like there could stop breathing any time within the first 24 hours? Yeah, so usually the risk is highest in the first 6 to 8 hours and then it decreases. And so I would think of it just as like a 23 hour opt or overnight admission. It's really the nighttime when you, even with all the anesthetic out, you would say, they're still at risk for post-op apnea. For premature infants, this is where it gets tricky. So what you find in the literature is that after about 52 to 60 weeks in terms of their brain, they're more mature that they can coordinate their breathing. Each hospital, I will say, is different though. Some hospitals are less conservative and they will say, if you're at least 52 weeks, you're fine. Our hospital is more conservative and we actually say you have to be at least 60 weeks post-conceptual age before you can have outpatient surgery so that you just have to look at your hospital policy. Okay. Interesting. All right. Now let's go to like the pre-op, you're there, you've got, you're in pre-op with your kid and one of the things that comes up a lot I think is, do we give POversed or any other pre-medication to help come a kid who might be really nervous or agitated down. What's your take on that? Should we be giving POversed? If so, how much and how do we decide? Sure. So this is where you have to really have eyes to assess the psychological dynamic of the family when they come and as you know, each family is different as well as each kid is different. So you can, you can really tell a lot just from a face to face. So always make it a habit to assess your families when you're in the pre-op area, don't necessarily rely on let's say your secondary providers who are there, your support staff. If you have residents or fellows or CRNAs, so I really have my hands and eyes open and talk to the families and so you'll find parents who are much more nervous than the child. And as you know, that kind of anxiety translates to the child as well. So you have to think about, do I allow the parents to come back? It depends again on your policy and also your personal preference for that. You will also see how the child is in pre-op, a lot of times you can tell they're kind of anxious. And then you have to decide, do I give them the POverset, right? And I engage the parents very actively in this. You have to acknowledge that the parents know the child the best. And you offer it to them say, do you think that giving them an oral medication that helps relax them will help them with the mask? And a lot of times the parents have very clear kind of ideas about this. Because they don't want any additional meds. Sometimes they actually do want the medication. And so I first engage the parent. A lot of times kids go two ways in terms of kids who've had lots of surgeries, who've been at the hospital a lot. They either go on the extreme of, I can handle this, I'm fine, I know exactly what works for me. And in that case, I engage the child and say, what works for you? Kids who, the other extreme are kids who kind of develop a little bit of a PTSD to the hospital environment. And so just being in the hospital itself, knowing they have to have surgery, creates a lot of anxiety for them. So in that case, I will always offer a POverset. The other thing you want to ask actually are, in this special population, do you want an IV? Some kids actually want an IV because they understand that they don't like the way they feel when they have a mask induction. And some kids, even in their teenage years, having had lots of surgeries, refuse an IV. And so that takes more negotiation. So if you decide that you're going to give POverset, and I should say, sorry, I said VERSET and we've been using that term, but I realize our international listeners use the generic name of Midaslan. So when we say VERSET, we're talking about Midaslan. Yeah, so if you're using an oral sedative in the liquid form, because that's most common in our population here for kids, the dose you can use is 0.5 to 1 milligram per kilo with the max dose of 20 milligrams. Our formulation here, it comes in a liquid concentration of 2 milligrams per ml. And so that would be about 10 CCs. Things to think about, right? If you're ready to head back, that's a large volume. POverset or sorry, PO Midaslan takes about 15 to 30 minutes to actually work. You'll see some of the effects, you know, they'll seem a little bit out of it earlier than that. The leak effect is actually around 15 to 30 minutes. And so you have to plan this early. You have to tell the parents we have to give it now. You can't give it too early because it's short acting. It's only about an hour long. So you don't want to give it too early, you don't want to give it too late. You also have to think about volume. If there's an aspiration risk, because you're ready to head back right now, then you have to either postpone delay, and you really feel like it's beneficial versus, hey, you don't want mom and dad. I think we have other methods of getting the child to the mask induction. So it's a lot of factors to consider. I would say personally, if you're under two years of age, you don't really need it because they don't actually have yet the capacity to form long-term memories. And so a lot of that, you know, these young kids that need ear tubes and such, I don't typically offer that in the first place. Okay. Yeah. So if you're going to use it, it's going to be 0.5 to 1 makes per kick. So you've got a 10 kilogram kid, you're somewhere in the 5 to 10 milligram dose range. You also probably want to take into account the fact that I remember as a resident doing this, that a lot of these kids are going to spit part of it out or they're not going to get it all. Yes. But you still would assume they're getting what you're giving and give them the one you wouldn't go above the 1 milligram per kilogram. I know. I wouldn't. It's just volume, and that's a lot. And then if you have a short surgery, it's going to prolong their pack you stay or their emergence as well. And so, yeah, and I usually say if they're over four, that's when you can inform these long term memories. And if it's going to be very traumatic, I would seriously consider using it or not. One thing that is actually really great now that we have it is intranasal dexmenitomidine. It's painless. You don't have to worry about the kids spitting it up. It doesn't really necessarily rely on the patient's cooperation, right? Because it's really a small volume. So what we use is 200 milligrams per ml, the dose again is about 0.5 to 2 milligrams per kilo. Hey folks, that's actually micrograms per kilo, micrograms, and the way that makes it up is 200 micrograms per ml. So, it's a really tiny volume. It comes or you should use a little nasal atomizer and boom, boom, it squirts and it works very well. So that's a great option if your hospital allows that. And that's really interesting. How does that compare to medazolam? Does it give you similar effects? Is it a little different in some way? It might make them seem a little bit less loopy, quote unquote, in terms of the medazolam. I think it causes less dizziness. So dexmenitomidine is a great sedative. It preserves breathing. And the only thing to watch out for, obviously, is some bradycardia that you can see. So in that 0.5 to 2, that's a fairly wide range. What's your go to? Do you start kids somewhere in the middle of that? Do you pick one, for example, or what's your go to dose? So I will go, my go to dose is actually 0.5 to 1. I think 2 milligrams. Again, that's micrograms, not milligrams, micrograms per kilo. Times is good. If you're only using intranasal dex, let's say for an MRI, you don't want to place an IV, you don't want them under general anesthesia for whatever reason, something that's kind of painless and not estimulating something quick. You just need it, so 2 milligrams per kilo, I think would be great for that. Again, folks, that's 2 micrograms per kilo, 2 micrograms per kilo, not milligrams. But if you're just using it for a sedative, I would say 0.5 to 1 milligram per kilo. I are on the side of 1 milligram per kilo. And that's micrograms per kilo, not milligrams, micrograms per kilo. You can also use it in combination with medazolam. Let's say you want to just give a little bit of pio medazolam, less volume, you want something a little bit quicker on board, and then you have the medazolam kicking in, so you can give 0.5 of presidex, intranasal dexmenitomidine, and then maybe 0.5 milligrams per kilo of pio medazolam, so it works great in combination as well. That's great. Okay, very cool. Are there other meds you've given pre-opera or is it pretty much choosing between those two? I would say that. So now that we have eras protocols that percolate down to children, so any of those pio meds that work for post-op pain, I think give it pio tylenol, you have to worry about pio tylenol, and if you're giving pio medazolam, volume is quite large, and so other than the sedatives or the pain medications, those are kind of what I limit in terms of pre-op medications. Great. All right. Think about some kids, as you said, will get an IV and be induced just like an adult with an IV induction, others, and I think the unique thing with kids is the idea of an inhaled induction. How, one thing you already mentioned is you can ask the kid if they're old enough to have that discussion, and they may have a preference. In the absence of that or with a baby or a smaller kid, a toddler, are they all getting inhaled inductions or how do you decide who gets an IV and who gets induced? So you want to think about the type of surgery and also the level of surgery that you're providing. So if the child is coming for an urgent or emergent surgery, IV has, you know, is the safest thing to have, in terms of healthy kids getting elective surgery, how do you delineate? So it really depends on the child. So around, I would say, even eight that might be a little bit young, but I actually assess the maturity of the child, and especially if they've had multiple surgeries, they can kind of tell you, yeah, I prefer an IV. However, if it's like their first time getting surgery, I start around nine to 11 years old or older than nine to 11 years old to ask about IV placement. And I do offer it because what you find in the operating room, mask inductions for kids, I think older than about 10 to 12, what I find is it's very difficult. They get very physically kind of aggressive as you're going through stage two. And it just takes such a long time because their lung capacity is so big, right? And so it just, it takes a long time to go under. The parents are uncomfortable. They're scared of what's happening. And so when they're around nine, definitely when they're around 11, I pretty much tell them that this is the best thing for them. And usually they're amenable to at least one time. So I negotiate one try. So I negotiate with them say, hey, let us try one once. And then if we can't get it, let's talk about the other option of how to get you under anesthesia. So I spend time with them. And if you find that there's a much greater benefit. So a child who has an M.H. risk, malignant hyperthermia risk, you want an IV. That's obvious. And if they just cannot tolerate it, then I will go to Plan B, which is nitrous oxide or PO sedatives to be able to facilitate the IV placement. Okay. Great. So that's really good stuff. You mentioned before that you'll, you know, another decision of pediatric anesthesiology has to make is whether to bring the parents back for induction. And you said that this is partly at least a question of the comfort of the provider. Anything else that goes into that, obviously, the preference of the parents is something. If you're comfortable with it, they would also need to be comfortable with it. Is there any, you know, do we know, is it better, is it worse, does it not matter in terms of the kid? Right. So the research has not shown that there is increased efficacy if parents are actually there. Because there's a lot of, you know, underlying, you know, stuff, emotional and relationships that happen prior to the surgery. So it's not like you can fix it in one try. So the research I shown, the efficacy of parental presence is uncertain in terms of decreasing child anxiety. But we know that parental satisfaction goes way up if you allow the parents to come back. So some things to think about, what is your hospital's policy? Our hospital here allows at least one parent to come back. Other hospitals don't allow any parents. That's it. And so they employ a lot of PO sedatives, pretty much to every child. Here we kind of do it by case by case because we allow the parents to come back. So some exceptions. For big surgeries, major surgeries where the risk is higher for a comorbidity to occur or, you know, it's going to be a long day. I actually offer both parents to come back because I think it's good to see the parents for the parents to see their child, both of them. And so they can, you know, have a proper kiss, you know, and make sure that their child is safe. So it reassures them. For urgent and emergency cases, you know, a lot of times we have the parents accompanying the child to the OR from the emergency room. In that case, I either have them say they're goodbyes outside the operating room. Or if they come into the operating room, I let, I give them time, let's say, if we just putting the pulse ox on, or right before, you know, give them a little bit of time to say goodbye if there's time, you know, obviously if it's in an emergency case, all hands, you know, are on deck and all bets are off in that situation. So I would just say you just have to have really eyes to see the situation and it really varies. The most important thing to say is the anesthesia provider needs to be really much in tune and able to change with the situation. I've had kids that are totally fine. They come into the room and then they totally decompensate completely out of the blue unexpected. And in that case, you have to be really creative. And so some of the things that I will tell you guys in terms of things you can do, if the child decompensates and we'll get into monitors in the next few questions, but you want to be creative. So sometimes we've had them, you know, pull the blanket over like a tent, like a sleep over and you don't bring the mask in, but you plan to bring the circuit in, you just have to allow for more time. The nitrous is there, you know, and they're going to get more and more sleepy and then you gently put it on. If the child is sleeping, I actually do what's called a steel technique, steel induction technique. So again, you're bringing it closer and closer to their face as they're breathing the nitrous. We turn on music for them shows. So just be really creative to change your technique. I sometimes allow the parents to hold the child in a chair, give them a bear hug I call it, and then a mask in that way. And then sometimes you just have to go for it's better to quickly put them to sleep them prolong the misery of such. And so sometimes I'll go immediately to 100% with CIVO and no nitrous. And so you know, it's hard to tell you exactly what to do in every situation, but really just keep your eyes open. Yeah. Okay. So it sounds like, you know, you're going to want to know your hospital policy about parents coming back. You're going to want to know your own comfort level. And of course, talk to the parents about their comfort level, think about the procedure and then make a decision. And then as you said, you know, these things can change in real time. So being creative and kind of making that call and that's going to come in time and with practice and experience. Yes. All right. This came from a listener question. Someone's all of a sudden not used to doing kids. You get a kid. One of the most basic things you got to decide is what endotracheal tube size do you use? How was there a good rule of thumb? You recommend people keeping mine. Yes. So this is really important when I'm teaching too is I always ask them, how do you know what size to pick for an ET tube and where do you place it? Where do you tape it? And so the easy equation to remember, there is an equation is age over four plus three for cuffed size tubes, age over four plus four for uncuffed. And you want to have a couple of sizes again, because, you know, depending on the child, if they've been intubated, they have subglotic stenosis or they have some craniofacial issues. You might have to go smaller as well. So a couple of sizes up and down from the number that you get from doing the equation. If you're in a bind and you just completely forget what size to get the size of the tube that matches the size of the patient's fifth finger. So they're pinky. That's a great way to remember if you just don't know and you forgot. I will say in terms of cuffed or uncuffed in this day and age with micro cuffed tubes, I would always err on the side of using a cuffed tube because it's easy to control. You can always have the balloon down or put, you know, the air up depending on what you need and how your ventilation is. Great. All right. So we're always going to go for a cuffed tube. If we've got them, age over four plus three is the formula. And we're going to keep that in mind. All right. And then you mentioned also, you know, again, with adults, it's pretty, you've got a lot of room. So watch that thing go in and as long as you don't jam it in too far and, you know, in my mind, if I'm at 20, 21, I'm never going to be right, mainstreamed unless I've got a very short adult, not so easy in kids, right? So how do you decide where to tape it? Great question. So the rule of thumb here is size of the ET tube times three. And that's been proven in the literature after, you know, hundreds, thousands of measurements. And so the size of the ET tube times three, I will say you cannot substitute listening and watching the chest rise. And so in the smaller you are, it's, it's like millimeters of a difference. So if you're at nine and a half and then you're nine and three quarters, boom, your mainstime. And so you really want to listen bilaterally and adjust your tube accordingly, if you're just doing a direct laryngoscopy. So absolutely. But the rule of thumb is age, I'm sorry, size of the ET tube times three. Great. So if I've got a 40 tube, it's going to supposedly the, my guideline is I'm going to tape it at about 12th, but certainly I'm going to listen and make sure that I've got bilaterally pressed down. Yes. All right. You mentioned before and let's revisit monitors. So my memory is that, you know, very different than adults who we fully monitor up before induction in kids, we often don't, right? We would put on maybe a pulse ox before an inhaled induction. So tell me a little more. What's your practice? Sure. Ideally, all monitors should go on before induction. However, you, you know, as we've talked about some kids, just won't tolerate it. You see a changing situation where you thought you could do monitors or at least a pulse ox. So the first thing to do is if the child allows you to do it, is put the pulse ox on. But I will say if you have a very healthy child, who is just emotionally not able to handle being in the operating room, there's been plenty of times where I don't even put any, a single monitor on what you want to do is get this kid under safely and quickly and then put the monitors on. And so in our operating room, we actually have a lot of help. So if I'm not, you know, by myself, I have a resident or see on it. I also have two nurses at least and even the surgical team to help. And so you're going to just employ your help. Your main focus is get them quickly and safely induced. Because they don't tolerate a mask. If they don't tolerate a monitor before you do the mask induction, I say and they're healthy. And you know, there are obviously, you know, their vital signs are fine. I say just quickly go to the mask induction in whatever situation I've masked kids in the wagon, you know, sitting down right beside them. And so, you know, in that case, it's going to be hard. But as soon as, you know, they're getting a little bit under their, you know, distracted, they're sedated, then I employ my help and say, hey, can you quickly put the pulse ox on et cetera? All right. So then at some point, whether they're partially or fully induced, you're going to then get on whatever monitors you didn't already get on, pulse ox, blood pressure, et cetera. Okay. Let's talk about an inhaled induction because we rarely, if I ever do that in adults. So I remember really the options were CVO alone or CVO plus nitrous. How do you decide which to do whether to use nitrous or not? Sure. Sure. So I will say, you know, just think back to basic physiology of the respiratory system, right? So you understand that the younger you are or you have lung disease, your FRC, your functional residual capacity is less, right? And so, in smaller kids, it's really important to use 100% oxygen with CVO flooring. That's it. And so, usually if they're under about four, again, the whole long-term memory is important, they're not going to remember. What you want to do is not have them desaturate while you're putting them under. And so, in those cases, I would say generally 100% oxygen is, what you want to think about is how much oxygen can I provide without having them desaturate? Premium babies? No question. 100%. Babies. No question. So, probably between about two to four, I still use 100% with CVO. And the reason not to use the nitrous there is because, obviously, if you use 70% nitrous, you can only have 30% oxygen. Exactly. So, you want the oxygen in those little kids. Right. Right. Okay. If they're older and you can engage them in games, and so I do a lot of introducing, you know, the balloon game, they're going to blow up the balloon. They're going to be like astronauts. If you can engage them, obviously starting with nitrous is much better because CVO is quite pungent still. And so, if, you know, I draw on the balloon, if you can engage them, there's time, you can put a pulse oxon, and then you start with just nitrous and you have to remember, you actually have to wait at least, I would say 30 seconds to a minute for the nitrous to really take it to effect, especially if you don't have a good seal on the face. And then, you know, then I kind of prep them and say, oh, you know, you're going to smell a dinosaur fart or it's going to smell like nail polish, and then you're going to, I actually just go straight to 8%. Some people will say the tight trade up, but I say, you know, they're going to be smelling in any way as you might as well want you want them to get, get to sleep under. Now, there's a really nice technique you can use for older kids. So let's say the child refuses the IV. So if they're at least eight or nine, they can actually follow instructions and you can practice with them. I do what's called a three breath induction technique. And that requires the child to be able to take at least three vital capacity breaths. And so I actually practice this with them in the pre-op area. And so, you know, I just say, take the biggest deep breath you can. You're going to hold it for three seconds and then you're going to exhale. What this requires you to do is actually prime the circuit with 70% nitrous and 8% Civo. You do want to utilize the second gas effect. And so you have to have it prepped and so a good kind of workflow you can do is you get into the OR as you're checking them in, as you're putting the monitors on, you know, you actually close the circuit and prime it with high flows. And then you tell them as soon as I put the mask on the face, you're going to take the biggest deep breath you can. And I've had kids go to sleep with two vital capacity breaths. And so this is really nice for older children to avoid this kind of crazy stage to, you know, thrashing about. And so this actually gets them really sleep, really to sleep quickly. The parents are happy. They give them a kiss and they go out. And then you'll see more of the stage to action happening. Great. All right. So another thing that comes up, I think, in kids, it's different than adults is a question about whether succinyl colon is safe to use. We think that in the absence of MH risk and adults, it's pretty safe. Kids, there's some concern, right? So it's still very controversial. And so I would say if you have a strong indication for to perform a rapid sequence intubation, use it absolutely. And even in other unique situations, the theoretical risk of an undiagnosed malignant hypothermia condition or a muscular dystrophy, it doesn't at the time outweigh the risk of aspiration. Asperation risk is very real, right? And usually by the time you're three or four, maybe even younger, or especially in older kids in this day and age, in America, or in any place where you have established health care, routine health care for kids, you're going to pretty much know if your child has in muscular dystrophy. And so I will say, just use your clinical judgment in terms of the risk of aspiration and also the trauma or the risk of not doing a rapid sequence intubation. That being said, you also understand that you can do a modified RSI, get the same intubating conditions with high dose rachuronium. And now with Sugamodex, you have very rapid reversal potential of rachuronium. So in this day and age, what you do, have Sugamodex around, do you still use succinyl-colonium kids? I still use succinyl-colonium. So if I'm working, I get a trauma patient or I get a patient who, even though they've been NPO, they came in for a trauma, like an elbow fracture or some kind of orthopedic fracture, I still will use succinyl-colon if I find that the risk again or the benefit outweighs the risk. And especially in these short procedures, elbows, if you're just doing a procutaneous pinning at last, maybe 30 minutes, and you might not want to sit around if you've given high dose rachuronium. And even with Sugamodex, you're thinking about the risk of Sugamodex as well with high dose Sugamodex, you understand there's a higher risk of side effects and such. So I still am a proponent of using succinyl-colonium. There's no consensus on the safety of Sugamodex. So the FDA has a contraindication, but it's not a black box warning. And so, but you know, you still have to understand there are serious side effects with hypochalemic cardiac arrest. So even if you don't have MH or muscular dystrophy, make sure you check the labs. If you feel that you might have to use Sugamodex, check the labs because sometimes you might have labs. And sometimes if it's over five, potassium levels over five, then I'm much more wary about using it because you can have it even in healthy kids if you have just a high potassium to start with. Now, if you are going to give Sugamodex, do you give atropine with it? So I actually, again, there's no consensus. Some of my older colleagues always do. I find that I don't. I actually just monitor them, and so I follow their heart rate. If you have an IV in place, you can quickly give atropine or even glycopyrily. If you're concerned really is the bradycardia that results. So even if you don't use succinocholine, just doing direct laryngoscopy, especially in younger children, babies, premature babies, you can just get a bradycardia from direct laryngoscopy. So you might consider, you know what, I will prophylaxically sometimes give atropine to premature babies for intubation as well. So you know, the question that the controversy is also, what dose? Some people use a blanket, doesn't matter 20 micrograms. Doesn't matter if you're really, or 20 micrograms per kilo. Some people just say, I'm going to give 0.2 milligrams of atropine, no matter the age or no matter the weight. I tend to use more of a weight-based. And so I say 20 mikes per kilo. Okay. So you say you don't use it with succs just by virtue of using succsinocholine, but you do sometimes for premature kids, or even little ones because of the concern of bradycardia with the laryngoscopy, you have 20 mikes per kilo of atropine. Right. And Down syndrome kids are notoriously very sensitive to induction period. So mask induction, IV induction, they will, you'll see a significant profound bradycardia. So those kids, the Down syndrome kids are the ones that I actually really have atropine on a needle. I give it submentally or intramuscularly. Great. All right. What about maintenance? So, you know, we often are going to use C-Vo for an inhaled induction. Do you just continue C-Vo? Do you switch to ISO? Are there kids you use T-Va and how do you decide? So in this case, I actually follow what you do. Just follow your general anesthetic technique that you do. You can actually use any gases. I use a lot of desfloring as well. Some people will say that desfloring, you know, can worsen, you know, metabolic issues if you have them. So, some people don't use it. But I think any gas is fine. And it, again, depends on your comfort level and what you're doing the case for. So I think you just follow your general guidelines for how you would manage kind of any anesthetic. So you're thinking also about P-O-N-V. So teenagers who are coming for routine outpatient surgery, they're at much higher risk for P-O-N-V. I use a lot of T-Va in those cases. And that's post-op nausea and vomiting. Yes. And T-Va, because of the propyl, being a little less risk for post-op nausea. And it also, again, just like adults, it depends on the type of surgery if you're doing any neural monitoring for spines, et cetera, et cetera. So one thing to note is we do, in P, it's a lot more deep excavations than awake. But you can achieve, what's the philosophy of deep excavation is you want them to be under general anesthesia when you take the tube out. They need to be spontaneously breathing. So you can achieve stage three anesthesia with any anesthetic. So it's really a multimodal type of technique that you're going to use. Great. All right. We've touched on this, but we really, unlike adults, in kids, we use weight-based dosing. What do we want to keep in mind? Antibiotic dosing, other drugs, any rules of thumb? I mean, the obvious one being just check and make sure you're giving a weight-based dose. But what do you tell people to be careful of? Oh, so, you know, we get a lot of trainees, patients, sorry, providers who are not familiar with P's. And so the main thing is hypervigilance. And so everything that you give, you have to have a reason for and also the right dose. And so, you know, you're not going to just give all of the big white syringe, right? And so you want to do everything weight-based. So antibiotics, we have a really nice perioperative surgical prophylaxis dosing chart for P's. And so I tell everyone, make sure you always double check, even for adults because, you know, a lot of it depends on creatinine clearance as well. And so I say, always use the dosing chart, unless you've been doing this for years and hundreds of cases, you're not going to remember all of it. There's a lot of different things to remember. And we also have a nice pediatric dosing chart for all of the drugs. And so what good practices before every case, because every kid weighs a different weight, we actually have the residents or even the CRNAs, and even the attendings will write out if, you know, to remember or have it in your mind, this kid weighs X kilo. So for propofol, sucks, atropine, you know, anceph or sephazolan or clindamycin, I'm going to use this medication. So it's there for you. So I would just say, use a good dosing chart. You can find a lot of them online if you don't have access to it. Great. All right. So you touched before on extubating deep. So you mentioned that when we extubate deep, one of the things is to obviously make sure they are indeed deep. What is, why would we even want to do that? What's the advantage of extubating deep versus awake? So part of it is, you know, the type of surgery you're doing. So if you're doing, you know, plastic surgery on the face or airway surgery or things that would really be not beneficial for the kid to kind of thrash about and be coughing or agitated. And so those are general principles that I think you can apply to any type of surgery or patient. But, you know, especially in kids, right, because they're, you know, they can have emergence delirium, which we'll talk about later, deep extubation might be preferable, sorry. And so, and also for emergence delirium, you might say, you know what? I think it's better if they just kind of come out of it slowly as opposed to, you know, waking them up really quickly. And so that might be an indication. I will say as a rule of thumb, you know, the younger you are, the more immature your brain is. So I don't for any surgery really extubate deep if you're under probably around four. Okay. If you, if you feel that the benefit of deep extubation is so much more than the risk of, you know, having an air, airway event or any problems, I would say just make sure you have, you are equipped with how are you going to handle this child? If you deep extubate and they suddenly stop breathing or they, you know, going to learn luringus spasm. And sometimes you also have to weigh if they're having surgery on the face and you are not able to rescue them with a mask, with positive pressure ventilation through a mask, you have to think about that too. And so if you're thinking about that, you're like, well, of course I'm not going to deep extubate in that case, right? So oral airways are your friends, positive pressure or things like that. I will say in this age, dexmenatomidine has really kind of changed the landscape of being able to provide a much more sophisticated emergence, especially in kids. It really helps with emergence delirium. It really helps with a nice extubation. And so sometimes you, you could titrate in some dexmenatomidine in the beginning and the middle at the end of the case before you extubate. So you do kind of a nice extubation where they're breathing on their own, but they're comfortable, but then you've turned off all the gas in that case. So they're not technically under general anesthesia, but it's a, it's more of like a deep sedation. Right. Okay. Interesting. Dexmenatomidine can make this a little easier. All right. Do, if you choose to extubate deep versus awake to the rates of luringospasm differ? So that's a really good question. It doesn't. It actually doesn't. All right. So it's not worth that is not a reason to decide to do it or not. Right. And you know, because you can learn, luringospasm at any point, you can luringospasm right after an awake extubation in the OR, but then there's also the chance that you're going to luringospasm on the way to the pack you, which is dangerous and, you know, not ideal as well. Luringospasm in the pack as well. So it doesn't change. It's just a matter of what your clinical judgment is based on the type of surgery and also the patient. Great. So let's talk about luringospasm. Sure. You know, certainly something we worry about in kids and adults too, but it's more common in kids. I think, how do we treat it if it happens? Yes. So the similar principles, right? What is the point of, or what happens during luringospasm? Your vocal cords close and you are not oxygenating, ventilating well. So the two things to remember, immediate positive pressure, aggressive positive pressure, because you need to break it and then increase your depth of anesthesia. You should have a working IV, so be able to give propyl. So when you're giving positive pressure, turn on 8% CIVO, but you have to remember if they're in spasm, you're not going to be able to adequately deliver in the beginning the CIVO. So you can't just rely on gas. You have to have another method. So you're going to ask somebody or you're going to push a large dose of propyl and induction dose or even more, you need to get them to relax their cords to open. So those are your two things, immediate, aggressive positive pressure, increase your depth of anesthesia. And what I say is if you're going to do a deep excavation or even an awake excavation, what I do immediately after excavation is I place my stethoscope or my procordial stethoscope and monitor closely over the trachea for airflow. You're going to catch that much quicker. You're going to catch it in seconds as opposed to trying to look at the chest. Is it rising? I can't tell. Is it just they're belly moving and waiting for the sats to drop because you've probably given them 100% oxygen prior to excavation. So the thing, three things, then I guess, immediate positive pressure, if it happens, increase your depth of anesthesia and monitor very closely before it happens to make sure you can treat it right away. And do you ever get to a point where those things don't work and then you need to give muscle relaxing? I'm rarely. I personally never give in succinocholine to break luringospasm because I am aggressive. I treat it very early and I'm watching it for very early. I think when people get in trouble is they don't expect it and they're not monitoring closely. So when you take the tube out, immediately listen over the trachea, keep your mask on, apply positive pressure. So even if you have a child who's breathing well, as soon as you take the, you know, endotracheal tube out, I actually give them some positive pressure. So if they cough or if they're breathing, they're actually breathing against some positive pressure and it keeps their air way open. Great. All right. You mentioned before emergence delirium. This is something that certainly can happen and anyone seems to be more common in kids. You mentioned that precedent or dexmetatomidine is kind of a neat way to or a more modern way to try to reduce the risk of emergence delirium. Are there other things we should keep in mind to try to prevent this from happening or to treat it if it does happen? Yes. So propyl fall has been shown to be effective small boluses, any type of opioid, so fentanyl, whatever you have on hand, but just know, you know, the lasting effects of it if you're using fentanyl versus morphine versus delotted. So any of those three kind of medications are actually quite good and those are readily available, hopefully, so at least propyl fall is readily available. So always have, you know, a syringe of propyl fall either in line as you're going to the pack you or have it in your pocket, so you can give that. So what is emergence delirium? Quickly, it's, you know, thrashing, disorientation, crying and screaming. So it's a state where you can't really direct them, you know, you can't say, hey, everything's okay, they're just really disoriented and so, you know, they're really out of it is kind of how I would, they're inconsolable, they don't recognize the parents, they don't recognize where they are, they are being very irrational. It occurs more often in children, 10 to 20 time percent more than in adults and one thing to remember is if you're under six, it's very high. So any kid under six, you're going to have a risk of increased emergence delirium. And so, any, any IV adjunct is fine, ketamine, if you have ketamine, opioids like we talked about and prosthetics or dexmenatomidine is very useful. Okay, great. And then of course, this goes away in time, it's just can be a disturbing time, right? Yeah, yes, it does go away in time as they're emerging from the anesthesia. So some, there's some, you know, theories on why do kids get it in terms of is it because of the type of volatile agent that you're using, is it the more insoluble, it just comes out too quickly and then they're really disoriented. Right. So some people will say, you know, isoflorine is better to do, for, to treat or to prevent emergence delirium, you know, just a deep excavation help more. So it, there's nothing proven, but you just have to remember it's common, it's high and then how do you treat it? Yep. Great. All right. So some of our regional anesthesia, my understanding is, you know, basically any of the blocks you would do in an adult, you can do any kid. The one difference is that in kids, from my experience, you do a lot of cartels. Sometimes even, correct me if I'm wrong, but I think you might place a cartel and thread it up. So instead of doing an epidural, you would just do a cartel and thread it quite a ways. Tell me a little bit about that. Why do we do so many cartels and kids? Is there a reason we prefer those and do you ever do a regular epidural instead of a cartel? Absolutely. So I will say in this one area, regional anesthesia, kids are like small adults. Okay. And a lot of, you know, their nerves are in the same area, right? But it's a lot of times easier because they're smaller and you can visualize them much easily, much more easily than in adults. But what's really different is I will say more drug dosing and the pharmacokinetics and dynamics are different in children and adults. So it's really important to not use the same type of dosing regimen that you would use in adults because their kidneys and livers are much more or less mature than adults. And so I have a reference that I can provide in terms of dosing. Great. We can post that in the show notes. Okay. Perfect. And so cartels are, I will say, performed a lot, especially in younger kids because the cartel space is very easily accessible. And in one sense, it's safer, right? Because your spinal cord will terminate way above your sacral space. But you have to be careful to know that the dural sac will still terminate in the sacral area. So S2 to S3. So you have to still be careful that you could cause an interethical injection. But in terms of nerve roots coming out, that's going to terminate way above the cartel space. So it's really great easy to access for single shots and for procedures under the umbilicus. So in that case, if you're doing like a hernia, you know, some, a lot of time circumcisions to any of those orthopedic procedures, you just need something to help them get through this, you know, this period, but it's an outpatient thing or they're going to just spend a few hours on the floor. Then a single shot cartel is very nice. However, I will say that coddle epidural placement. So let's say you're doing a thoracotomy or something that's higher than the umbilicus, you know, a lot of my colleagues will place coddle epidural cathars. They'll start in the coddle space and then measure up to where they want the tip of the catheter to go, you know, that has some risk. Sometimes it doesn't end up where you want it to be. It coils at the bottom. Sometimes it's really hard to place it actually will not go. And so I actually tend to place a lot of regular epidurals. Thoracic epidurals, I think, are much higher risk, especially in younger kids. And so in that case, maybe you want to err on the side of caution and do coddle epidural because those are much safer. However, for even younger kids who are getting, let's say, belly abdominal surgery or kind of longer bladder surgeries that need epidurals, the advantage of having just placing a regular lumbar epidural is that it's out of the bottom area. So if when they, you know, have bowel movements, the risk of contamination infection is much less. So a regular lumbar epidural, I do them all the time. Okay. And when you say thoracic epidurals are a lot higher risk, just because in general thoracic epidurals are or is there anything about in kids specifically, why you worry about the space, it's just harder to access, it's going to be very shallow, you know, there's blood vessels and all that stuff. And so I think it's just much higher risk on top of being a higher risk, generally. Gotcha. Okay. Great. How about pressers? Let's say a kid is hypotensive. Certainly in adults, I think people may have their own approaches, but in general, the most common approach with a hypotensive adult is to try pushing some phenylaphron or phenylaphron and, you know, maybe occasionally pushing that when needed. If it doesn't work or it's happening a lot, then maybe you go to a presser infusion, whether phenylaphron or norepinephrine. What about kids? Is that the same or different? So you have to remember in healthy children with healthy hearts and healthy lungs, the number one reason for hypotension is what? It's Iatrogenic, right? It's from our anesthetic and it's from them being NPO. And so I tend to say, don't reach for those. It's very common for our residents and providers who work a lot in the adults to immediately go for phenylaphron, which is very reasonable to do, right? Because a lot of adults have pre-existing coronary artery disease. You can't give them a lot of fluids, but in kids it's really different. If you have a healthy heart, if you're just healthy in general, you need fluid, right? And so you need to increase your cardiac output. It's inadequate resuscitation. So fluid should be your first line before pressors. Good rule of thumb, if you can't remember all of the equations and such. Give them a 20cc per kilobolus. That actually will fix a lot of problems. You're making up for their NPO deficit and then you're also compensating for the vasodilation that occurs. One thing could be maybe you're over-drugging them quote-unquote. So maybe your volatile anesthetic concentration is too high. You're overdosing them on anesthetic, right? Or you've given them a big dose of an opioid. So you know that's going to cause some hypotension. You've given them a dose of dexmenotomony that's going to cause hypotension. But really the general rule of thumb is fluids, fluids, fluids first. If you need to use a pressor because you have persistent hypotension, then you need to look outside just like in adults as well. Is it bleeding? That you're not seeing. That you're not, you know, a lot of the blood is on the sponges that you're not accounting for. It's not in the suction canister. You know, also it's the child themselves, right? So if you're a premature baby, if you have cerebral palsy, those kind of patients actually are very sensitive to anesthetics. So even a little bit of anesthetic will cause them to be hypotensive. So they tend to use need more fluids as well. So if you need a pressor, I actually we do start with phenyl effort or a fedron for us just like in adults. You want to just give one or two CCs of that. That's a big dose. And you also, so you say, how do you know what to give first? I also do look at the heart rate. So if their heart rate is low, it's a healthy teenager. You know, I do sometimes a combination of a little bit of phenyl effort and a little bit of a fedron, or I start with a fedron first. So in terms of dosing phenyl effort, you start with 5 to 10 mics per kilo as a general role for a fedron, it's 0.2 to 0.3 milligrams per kilo because as you know, the syringes are phenyl effort is in micrograms and a fedron is in milligrams. Yep. Okay. And so, for example, the syringes we have in adults are 100 mics per ml. Do you dilute that for kids? And if so, to what 10 mics per ml or what do you do? Yeah. So an easy dilution is take one CC of the 100 mics of phenyl effort and then dilute it in 9 CCs to make 10 mics. I think that's a really good rule of thumb. Another thing you could do, very simply, if you don't have time to dilute or you want to do it this way, is just put one CC of the 100 mics of phenyl effort or the 5 milligrams of a fedron and you put it in a one CC syringe, right? So one CC syringe is 0.1 CC for each tick mark and that equates to the same. Right. So you give one, yeah, one aliquot. Exactly. One aliquot. When we think about volatile dosing, that's a little different in only in a sense that kids have higher max, right? Mac is higher for kids than it is for adults. And so you want to take that into account. Is there a typical, like if you're doing a two year old, do you generally think, oh, you know, if my machine doesn't adjust for age, right? If my monitor is only telling me the Mac value based on a 40 year old man, we want to be what, do we talk about like a 1.3, 1.4 kind of, is that your general go to? So you know, I, so you, you give anesthesia in a multimodal fashion, right? So sometimes you don't need that much volatile anesthetic because you're doing other things. You're giving opioids or they have a regional block on board and so, or anything is synergistic. If you're running propyl fall along with it ketamine or prosthetics or dexmenotominated infusions, those are very synergistic to your gas. And so, you know, what does the textbook say say the Mac values really increase to its maximum value between one to six months of age for any of the gases. But you know, even for me, it's going to be hard to remember like all this stuff. And so I tend to just do, I guess what you would do for adults, like just think about the multimodal. And so I tend to adjust the gas based, I guess, on their blood pressure heart rate. And sometimes they need more, sometimes they need less. And so, if you, I guess, need numbers, you can look at the textbook, but I do use a lot more clinical judgment. So sometimes I'm using a very low Mac, 0.5 to 0.6 because I have all this other, you know, anesthetic analgesic on board. Yeah. Great. Bohemian, this has been fantastic. And we've covered a lot of great stuff. Anything you think we left out that we should cover before we go. So generally, I know it's a lot of stuff, right? I can't kind of give you every little nuanced comment, you know, with all my, with all my years of doing this and not being able to do this regularly. I will say just quickly, you know, the general rule of thumb that I give to even my residents and to my CRNs and people that are coming in that are, you know, kind of fearful of doing kids is, you just really need to be meticulous. I think maybe much more so than in general adults, not that you aren't, but meticulous attention to detail, hyper vigilance, everything needs to be weight-based and size-based because what do we do in kids in Peds, you're taking care of premiums that are less than one gram to a teenager's who are adult size. And so everything that you're doing, every drug you're giving, every procedure you're doing, even the size of the NG tube, you have to really think about the patient. And so I find that we're really honing the detailed aspect of the art of anesthesia for a lot of our residents because, you know, they're coming from adult land where it's, you're kind of giving very similar doses to everybody. And so thinking about the dynamic response to the psychological part of a lot of the care that we're giving, you know, with parents and children as well. And, you know, the finally I just tell, you know, my fellows and my residents, you know, if you're committed to and you operate with the philosophy of just be the kind of doctor that you would want for yourself or for your child or for your loved one who's on the table, you know, that's going to be a really good philosophy to provide the best and safest care for the patients. Awesome. Very wise words. Bomi, thank you so much for coming on the show. Thank you so much. All right. That was awesome. I hope everyone learned as much as I did from Bomi. If you have anything to add, comments, questions, go to the website at crack.com, ACCRAC.com. You can leave a comment that everyone can learn from. Let us know how do you take care of kids? Is there anything we left out that you think everyone should know? We can all learn from you as well. If you are a fan of the show, please consider going to iTunes and leaving a comment and a rating. It really helps others find the show and if you're interested in supporting the making of the show, please consider going to patreon.com/acrack. That's P-A-T-R-E-O-N dot com slash ACCRAC where you can become a patron of the show. Even if it's just a couple of dollars that you pledge, it makes a big difference and we really appreciate it. If you prefer to donate when and where you like, you can also go to paypal dot me slash acrack that's paypal dot me slash ACCRAC where you can donate whenever you like. Thank you so much to those of you who are already patrons and have already made donations and of course a big shout out to Brian Park for making some great outlines for a variety of the episodes and you'll see more of those pop up. All right. That is it for today for the ACRAC podcast and Dr. Bowie Mershan. I'm Jed Wolfall. Thanks for listening. Remember what you're doing out there every day is really important and valued.