To the Editor: 

We would like to commend Fehr et al.  for their article that addresses simulation-based assessment for pediatric anesthesia skills.1We agree that a multiple scenario-based education and assessment of skills required to manage a pediatric anesthesia crisis are helpful in educating anesthesia residents.

We have a few questions for the authors to clarify their study.

In the scoring system, did the authors give consideration to the sequence in which the trainees performed items on the checklist? We believe this is important. For example, in a bronchospasm scenario, we believe administering 100% oxygen at the beginning of the crisis is more important than having it done toward the end of the crisis management. Did timing of performance of an action by the trainee affect the score they received?

Having previous exposure to pediatric anesthesia simulation could improve the trainees' performance and their comfort level in the simulated setting.2Did the trainees have previous exposure to pediatric simulation before their 2-h session described in the study?

Some of the scenarios seem to have less discrimination between the trainees with less than 2 months or those with more than 2 months of pediatric training. These scenarios, i.e. , malignant hyperthermia, bronchospasm, and accidental extubation, are common to both the pediatric and adult anesthesia experience. Could this have a role in their lack of discrimination?

Interestingly, there is a lack of difference in performance between anesthesia fellows and residents. This could also mean that these scenarios would be less discriminating for pediatric anesthesia practitioners. Was there any feedback from the fellows and experienced residents that some of the tasks were not necessary for the management of the crisis scenarios? Such feedback could help tailor the items in the checklist on which future trainees would be scored while participating in these crisis management scenarios.

Fehr JJ, Boulet JR, Waldrop WB, Snider R, Brockel M, Murray DJ: Simulation-based assessment of pediatric anesthesia skills. ANESTHESIOLOGY 2011;115:1308–15
Park CS, Rochlen LR, Yaghmour E, Higgins N, Bauchat JR, Wojciechowski KG, Sullivan JT, McCarthy RJ: Acquisition of critical intraoperative event management skills in novice Anesthesiology residents by using high-fidelity simulation-based training. ANESTHESIOLOGY 2010;112:202–11