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Pediatric Sedation Outside the Operating Room

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  • 1. PEDIATRIC SEDATION OUTSIDE OF THE OPERATING ROOM New York Marriott Downtown, New York City September 28-29, 2013 Weekend Sedation Conference Exploring the Current Practice and Frontiers of Sedation Across The Specialties Friday, September 27, 2013 Option 1: Full-Day Sedation Symposium: The Fundamentals of Sedation: Reviewing the Basics Bridging the Specialties Option 2: Full-Day High Fidelity Pediatric Sedation Simulation Workshops Course Director Keira P. Mason, MD Director, Fundamentals of Sedation Symposium Mark G. Roback, MD Director, Sedation Simulation Workshops James Fehr, MD Abstracts Deadline JULY 1, 2013 www.PediatricSedationConference.com Featuring SaturdayKeynote Speaker Bonnie St. JohnOlympic Athlete and Bestselling Author Featuring Sunday Keynote Speaker Stewart L.Cohen,Esq. Sedation Mishaps Reviewed by Medical Malpractice Attorney
  • 2. Planning Committee Dear Colleagues and Friends: It is our pleasure to welcome you to the 2013 Pediatric Sedation Outside of the Operating Room weekend conference, optional Friday symposium entitled The Fundamentals of Sedation: Reviewing the Basics, Bridging the Specialties, and optional Friday High Fidelity Pediatric Simulation Workshops. This year we are presenting a unique, enriching, and exciting conference. As always, we have a diverse group of internationally and nationally rec- ognized speakers from a variety of disciplines. We are grateful to all the speakers and to each and every attendee. We have attendees from multi- disciplines (emergency medicine, dental medicine, hospital medicine, inten- sive care medicine, pediatrics, anesthesiology, nursing, oncology, cardiology, radiology, hospital administration). Over the years, 17 countries have been represented (including Italy, the Netherlands, Israel, Canada, Australia, Hong Kong, New Zealand, Japan, Indonesia, South Africa, and Singapore). The spe- cialized tracks, round table luncheons, and open forums enable us to share our experiences, ideas, and challenges. The Planning Committee presents a conference which we hope will interest specialists from every discipline and setting. We have also organized the program to allow time for questions and to encourage you to participate in a lively exchange of ideas. The full day of high fidelity sedation simulation has had overwhelming en- rollment and feedback. In response to the attendee’s requests, we have continued with this full day of simulation which will be led by multi-specialty experts. Your thoughts and comments are invaluable in planning future courses. Feel free to approach myself, the Course Coordinator, or any member of the Plan- ning Committee with your suggestions. On behalf of the entire faculty, myself, and the Course Coordinator, I would like to invite you to attend “Pediatric Seda- tion Outside of the Operating Room.” We hope that you find the course and workshops both educational and enjoyable. Sincerely, Keira P. Mason, MD Course Director Welcome Letter Keira P. Mason, MD Michael Stabile, MD James Fehr, MD Doug Carlson, MD Baruch Krauss, MD Morton Rosenberg, DMD David Rothman, DDS Mark Roback, MD Educational Grants This program is supported in part by educational grants from the following: Exhibitors The following company has provided in-kind support for the course Bronze
  • 3. Keynote Speakers Bonnie St. John Olympic Medal Winning Athlete and Best-Selling Author Harnessing Your Inner Strength to Achieve Success Hailed as “one of the five most inspiring women in America” by NBC Nightly News, Bonnie St. John challenges audiences to question their own limitations and shows them how to re-energize their lives to achieve peak performance. Bonnie St. John is the first African-American to win medals in Winter Paralympic competi- tion as a ski racer. In the 1984 Winter Paralympics in Innsbruck, Austria, St. John won a bronze medal in the slalom, a bronze medal in the giant slalom, and was awarded a silver medal for overall performance thereby earning her the distinction of being the second fast- est woman in the world on one leg in that year. At the 2002 Paralympics in Salt Lake City, Utah, St. John was asked to speak during the opening ceremonies. Partner of Cohen, Placitella and Roth. Won a landmark $25 million case, recognized as one of the Top 100 Verdicts in the United States. President, Brain Injury Associa- tion of Pennsylvania. Vice President, United Cerebral Palsy of Philadelphia. Multimil- lion dollar recoveries in medical and hospital malpractice cases. Stewart L. Cohen, Esq. St. John had her right leg amputated above the knee when she was 5 years old. Despite this challenge, she went on to excel. She graduated magna cum laude from Harvard University in 1986, was awarded a Rhodes Scholarship. St. John also worked in the White House during the Clinton administration as a Director for the National Economic Council. Learning from our Mistakes: Sedation Mishaps Reviewed by A Medical Malpractice Attorney St. John has written and published six books including a #1 best seller, How Great Women Lead. In February 2007, St. John was hon- ored at the White House by President George W. Bush who said: “[Bonnie St. John] is the kind of person that you really want to be around, and the kind of person that shows that individual courage matters in life.” She has been featured extensively in local, national, and international media, including: the New York Times, People Magazine, the Today Show, and CNN. I was ahead in the slalom. But in the second run, everyone fell on a dangerous spot. I was beaten by a woman who got up faster than I did. I learned that people fall down, winners get up, and gold medal winners just get up faster. — Bonnie St. John
  • 4. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties4 International Faculty National Faculty Anthony Absalom, MBChB, FRCA, MD Professor of Anesthesia University Medical Center Groningen Groningen, Netherlands Eduardo A. Alcaino, BDS (Hons), MDSc, FRACDS Visiting Specialist in Pediatric Dentistry Westmead Centre for Oral Health Sydney Dental Hospital IAPD President Elect (Representative of Nations) Specialist Clinical Associate University of Sydney Sydney,Australia Maria Sammartino, MD Assistant Professor, Anesthesia and Intensive Care Catholic University of Sacred Heart (UCSC) Rome, Italy Douglas Stewart, DMD Program Director, Grad Diploma in Clinical Dentistry Clinical Associate Professor, Clinical Dentistry (Sedation) University of Sydney Sydney,Australia Mike R. J. Sury, FRCA, PhD Consultant Pediatric Anaesthetist Great Ormond Street Hospital for Children Honorary Senior Lecturer in Anaesthesia PORTEX Unit of Paediatric Anaesthesia Institute of Child Health University College of London London, England Iqbal Ahmed, MD, FRCA Director, Anesthesia Residency Program Interim Director, Pediatric Anesthesia Assistant Professor and Chief Pediatric Cardiac Anesthesia Tufts University School of Medicine Boston, MA Dean B. Andropolous, MD, MHCM Professor of Anesthesiology and Pediatrics Baylor College of Medicine Chief of Anesthesiology Texas Children’s Hospital Thomas Anthony Anderson, MD, PhD Instructor in Anesthesia Department of Anesthesia, Critical Care Pain Medicine Massachusetts General Hospital Nelson Aquino, CRNA, MS Department of Anesthesia, Boston Children’s Hospital Somaletha T. Bhattacharya, MBBS Instructor in Anesthesia Department of Anesthesia, Critical Care Pain Medicine Massachusetts General Hospital Douglas W. Carlson, MD Professor of Pediatrics Washington University Chief, Division of Pediatric Hospital Medicine St. Louis Children’s Hospital Maureen Carrier, RN, BSN Department of Radiology Boston Children’s Hospital Jerry Chao, MD Assistant Professor of Anesthesia Albert Einstein College of Medicine Department of Anesthesiology Montefiore Medical Center Joseph Cravero, MD Professor of Anesthesia Harvard Medical School Boston Children’s Hospital Yasmeen Daud, MD Assistant Professor of Pediatrics Washington University Division of Pediatric Hospital Medicine St. Louis Children’s Hospital Jennifer L. Dearden, MD Instructor in Anesthesia Harvard Medical School Boston Children’s Hospital Anesthesia Director, Dana Farber Cancer Institute Dayna Downing Simulation Specialist Children’s Medical Center Dallas,TX James J. Fehr, MD Associate Professor of Anesthesia and Pediatrics Washington University Director, Saigh Pediatric Simulation Center St Louis Children’s Hospital Lynne R. Ferrari, MD Associate Professor of Anesthesia Harvard Medical School Chief, Perioperative Anesthesia Services Boston Children’s Hospital Gerald A. Ferretti, DMD Professor and Chair of Pediatric Dentistry School of Dental Medicine Case Western Reserve University Division Chief, Pediatric Dentistry Rainbow Babies Children's Hospital Eric Fleegler, MD, MPH Harvard Medical School Boston Children’s Hospital Roberta Forman, RN, BSN, MHA Department of Radiology Boston Children’s Hospital Kim P. Hamlin, MD Assistant Professor of Pediatrics Washington University Division of Pediatric Hospital Medicine St. Louis Children’s Hospital Timothy Horeczko, MD, MSCR Assistant Professor of Emergency Medicine UC Davis School of Medicine Director, Pediatric Advanced Life Support UC Davis Medical Center Robert (Bo) M. Kennedy, MD Professor of Pediatrics Washington University Associate Director, Educational Affairs, Emergency Services St. Louis Children’s Hospital Monica E. Kleinman, MD Associate Professor of Anesthesia Harvard Medical School Clinical Director, Medical/Surgical Intensive Care Unit Medical Director,Transport Program Boston Children’s Hospital
  • 5. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties 5 National Faculty Babu Koka, MBBS Clinical Director, Perioperative Anesthesia Assistant Professor of Anesthesia Harvard Medical School Boston Children’s Hospital Ronald Kosinski, DMD Assistant Professor School of Dental Medicine, SUNY at Stony Brook Chief, Division of Pediatric Dentistry Schneiders Dental Baruch Krauss, MD, EdM Associate Professor of Pediatrics Harvard Medical School Director, Inpatient Sedation Service Department of Emergency Medicine Boston Children’s Hospital Calvin Kuan, MD, FAAP Attending Physician Pediatric Intensive Care Unit Children’s Hospital and Research Center Oakland Clinical Associate Professor Pediatric Cardiac Anesthesia Lucile Packard Children’s Hospital Stanford University School of Medicine Jerrold Lerman, MD, FRCPC, FANZCA Clinical Professor of Anesthesia Women and Children's Hospital of Buffalo State University of New York Mohamed Mahmoud, MD Associate Professor of ClinicalAnesthesia and Pediatrics Director, Radiology Anesthesia and Sedation Cincinnati Children’s Hospital Medical Center Timothy W. Martin, MD, MBA Professor of Anesthesiology Vice Chair for Education Administration Department of Anesthesiology Arkansas Children’s Hospital UAMS College of Medicine Chief, Division of Pediatric Anesthesia Arkansas Children’s Hospital Keira P. Mason, MD Associate Professor of Anesthesia Harvard Medical School Director, Radiology Anesthesia and Sedation Boston Children’s Hospital Kai Matthes, MD, PhD Assistant Professor of Anesthesia Harvard Medical School Department of Anesthesia Boston Children's Hospital Edward Michna, MD, JD Assistant Professor of Anesthesia Harvard Medical School Director, Pain Trials Center Brigham and Women’s Hospital Manchula Navaratnam, MBChB, FRCA, Clinical Assistant Professor of Anesthesia Pediatric Cardiac Anesthesia Lucile Packard Children’s Hospital Stanford University School of Medicine Anna Maria Onisei, MD Assistant Professor of Anesthesiology UAMS College of Medicine Associate Medical Director PULSE Center Arkansas Children’s Hospital Randy Prescilla, MD Instructor in Anesthesia Harvard Medical School Boston Children’s Hospital Ricardo A. Quiñonez, MD, FAAP Assistant Professor of Pediatrics Section of Hospital Medicine Co-Director Pediatric Hospital Medicine Fellowship Program, Baylor College of Medicine Texas Children’s Hospital Sharon L. Redd, MD Assistant Professor of Anesthesia Harvard Medical School Clinical Director, Day Surgical Unit Boston Children’s Hospital Mark G. Roback, MD Professor of Pediatrics Emergency Medicine University of Minnesota Medical School Director, Division of Emergency Medicine Amplatz Children’s Hospital David L. Rothman, DDS Past-President, California Society of Pediatric Dentistry Diplomate,American Board of Pediatric Dentistry Practice Limited to Infants, Children, Adolescents and Persons with Disabilities San Francisco, CA Echo Rowe, MD Clinical Assistant Professor Department of Anesthesia Lucile Packard Children’s Hospital Stanford University School of Medicine M. Saif Siddiqui, MD Associate Professor of Anesthesiology UAMS College of Medicine Director, Radiology Sedation and Anesthesia Arkansas Children's Hospital Michael Stabile, MD, MBA Adjunct Clinical Professor of Anesthesia Vanderbilt University Medical School Chief of Anesthesia Council Operation Smile International Michele Trinka, MSN, RN, CCRN, PCCN Program Manager, Simulation Lab Clinical Educator, PALS/PEARS/ACLS Children’s Medical Center Dallas,TX Robert A. Veselis, MD Professor of Anesthesia Director, Neuroanesthesiology Research Laboratory Associate Attending Anesthesiologist, Memorial Sloan-Kettering Cancer Center, Cornell Medical School Jennifer Wagner, MD Clinical Assistant Professor Department of Anesthesia Lucile Packard Children’s Hospital Stanford University School of Medicine Michael Webb, DDS, MEd Private Practice, Center for Pediatric Dentistry and Sedation Pediatric Dentistry Dental Anesthesiology Richmond,VA Sarah Wiser, MD Department of Anesthesia Newton Wellesley Hospital Vanessa Young, RN, BA Senior Research Nurse Coordinator Department of Anesthesiology, Boston Children’s Hospital Steven Zgleszewski, MD Assistant Professor of Anesthesia Harvard Medical School Anesthesia Director, Gastroenterology Procedure Unit Boston Children’s Hospital Shannon Zhang, MD, MS Instructor in Anesthesia Department of Anesthesia, Critical Care Pain Medicine Massachusetts General Hospital John Zhong, MD Clinical Assistant Professor UT Southwestern Medical Center Staff Anesthesiologist Children’s Medical Center Dallas,TX Judith Zier, MD, FAAP Assistant Clinical Professor Pediatric Critical Care Children's Hospitals and Clinics of Minnesota
  • 6. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties6 Saturday, September 28, 2013 Weekend Conference: Day 1 Exploring the Current Practice and Frontiers of Sedation Across The Specialties Course Director: Keira P. Mason, MD 6:30 – 7:00 AM Early Registration 7:00 – 8:15 AM Registration/Breakfast OR SMALL, OPEN FORUM, INTERACTIVE ROUND TABLE DISCUSSIONS (Optional; Each limited to 15; Pre-Registration and Fee Required; Breakfast Provided) Propofol, Sedation, and Non-Anesthesia Delivery Models: Douglas Carlson,MD,DeanAndropolous,MD,Ricardo Quinonez,MD Difficult Airway Workshop: Basic: Jennifer Dearden, MD (Leader), Iqbal Ahmed, MD,Thomas Anthony Anderson, MD, Nelson Aquino, MD Sarah Wiser, MD, Shannon Zhang, MD 8:30 – 8:45 AM 8:45 – 9:45 AM 9:45 – 10:00 AM Welcome Address: Keira P. Mason, MD Keynote Address: Bonnie St. John: Harnessing Your Inner Strength to Achieve Success Question and Answer Panel 10:00 – 10:20 AM Book Signing and Morning Break 10:20 – 10:50 AM Obesity: Clinical Assessment and Should the Dosages be Altered? Jerrold Lerman, MD SEDATION PROGRAMS THAT WORK: AN IN-DEPTH EXPLORATION Moderator: Keira P. Mason, MD 10:50 – 11:10 AM 11:10 – 11:40 AM 11:40 – 12:15 PM 12:15 – 12:30 PM Do Sedation Outcomes Differ Amongst Specialty Providers? Joseph Cravero, MD Multi Specialist Tiered Sedation Delivery Method: Nuts and Bolts, Politics, Billing, Tier, and Triage Dean Andropolous, MD Incorporating Safety Strategies into a Sedation Service Douglas Carlson, MD and Michael Stabile, MD Panel Discussion: Joseph Cravero, MD, Dean Andropolous, MD, Douglas Carlson, MD, Michael Stabile, MD, Jerrold Lerman, MD 12:30 - 2:00 PM Lunch on Your Own OR SMALL, OPEN FORUM, INTERACTIVE ROUND TABLE DISCUSSIONS (Optional; Each limited to 15; Pre-Registration and Fee Required; Lunch Provided) Ketamine: Bo Kennedy, MD, Mark Roback, MD Hospital Medicine: Douglas Carlson, MD, Ricardo Quinonez, MD CHALLENGES IN SEDATION MANAGEMENT Moderator: Kai Matthes, MD 2:00 – 2:25 PM 2:25 – 2:55 PM 2:55 – 3:25 PM 3:25 – 3:40 PM Obstructive Sleep Apnea: Diagnosis, Evaluation and Sedation Management Lynne Ferrari, MD Sedation for the Developmentally Challenged: Autism and Spectrums David Rothman, DDS Sedation Literature of 2012: Important, Novel and Interesting Contributions Timothy Martin, MD Panel Discussion: Lynne Ferrari, MD, David Rothman, DDS,Timothy Martin, MD 3:40 - 4:00 PM Afternoon Break 4:00 - 4:20 PM 4:20 - 4:50 PM 4:50 - 5:20 PM 5:20 - 5:30 PM Sedation, Amnesia, Memory: Exploring the Effect of Different Sedatives Robert Vesselis, MD Nitrous Oxide: Clinical Applications Explored Bo Kennedy, MD Expanded Roles of Ketamine Mark Roback, MD Panel Discussion: Robert Vesselis, MD, Bo Kennedy, MD, Mark Roback, MD 5:30 - 8:00 PM Complimentary Cocktail Reception (Faculty,Attendees and Sponsors) * Program changes/substitutions may be made without notice.
  • 7. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties 7 Sunday, September 29, 2013 Weekend Conference: Day 2 Exploring the Current Practice and Frontiers of Sedation Across The Specialties Course Director: Keira P. Mason, MD 7:00 - 8:15 AM Breakfast/ Registration OR SMALL, OPEN FORUM, INTERACTIVE ROUND TABLE DISCUSSIONS (Optional; Each limited to 15; Pre-Registration and Fee Required; Breakfast Provided) Dexmedetomidine: Keira Mason, MD, Mohamed Mahmoud, MD Difficult Airway Workshop: Advanced: Small, hands-on, one-on-one interaction with faculty to review, practice and improve advanced airway skills: A unique opportunity to trial advanced airway equipment. Jennifer Dearden,MD (Leader),IqbalAhmed,MD,ThomasAnthonyAnderson,MD,NelsonAquino,CRNA,SarahWiser,MD,Maria Sammartino,MD,Shannon Zhang,MD 8:30 – 8:45 AM 8:45 – 9:30 AM 9:30 – 9:45 AM 9:45 – 10:15 AM 10:15 – 10:45 AM Introduction, Report and Update of Adverse Event Sedation Reporting Tool Keira P. Mason, MD Keynote Address: Learning from our Mistakes: Sedation Mishaps Reviewed by a Medical Malpractice Attorney Stewart Cohen, JD Question and Answer Panel Using Simulation to Improve Sedation Outcome and Training James Fehr, MD Target Controlled Intravenous Infusion: A Look to the Future of Precise, Sedation Delivery Methods: A- Live, Hands-on Simulation and Demonstration Kai Matthes, MD, Anthony Absalom, MBChB, FRCA, MD 10:45 - 11:00 AM Morning Break EXPLORING THE FRONTIERS OF SEDATION Moderator: Mark Roback, MD 11:00 - 11:25 AM 11:25 - 11:50 PM 11:50 - 12:15 PM 12:15 - 12:45 PM 12:45 - 1:00 PM Reviewing Different Sedation Scales: Pros and Cons. Ease of Use and Applicability? Dean Androplous, MD Dexmedetomidine: Clinical Applications, Limitations and Future Use Keira Mason, MD Clinical Application of Inhaled Sevoflaurane for Sedation Michael Sury, MD What's New in Sedation and Analgesia? Jerrold Lerman, MD Panel Discussion Dean Andropolous, MD, Keira Mason, MD, Michael Sury, MD, Jerrold Lerman, MD 1:00 - 2:30 PM Lunch on Your Own OR SMALL, OPEN FORUM, INTERACTIVE ROUND TABLE DISCUSSIONS (Optional; Each limited to 15; Pre-Registration and Fee Required; Lunch Provided) Nitrous: Bo Kennedy, MD, Judy Zier, MD Ask the Expert: Lunch with a Medical Malpractice Attorney: Stewart Cohen, JD 2:30 - 5:30 PM Concurrent Afternoon Tracks You may attend and combine any of the three tracks. Pre-registration is not required. TRACK A Integration Track: Multi-Specialty Based Case Scenarios for Interactive Discussion and Learning Moderator: Robert Kennedy, MD, Mark Roback, MD, David Rothman, DDS,Yasmeen Daud, MD, Maureen Carrier, RN BSN Mohamed Mahmoud, MD, Saif Siddiqui, MD Keira Mason, MD This interactive workshop with faculty from multi-specialties will present a unique, case-based approach to procedural sedation, with individual- ized sedation recommendations and management guidelines by procedure and setting.This is an open-forum setting which allows active en- gagement of all participants with direction and sharing of sedation faculty which represents an expertise across all sedation specialties. Empha- sis will be placed on both the art and the science of procedural sedation.Topics will include: determining when sedation is needed, determining the type and level of sedation required for each intervention, combining non-pharmacologic techniques for managing acute anxiety and pain with pharmacologic sedation, discussion of individual agents for sedation and analgesia, guidelines for preparation, management, and discharge of sedated patients, monitoring guidelines, sedation for mentally handicapped and psychiatric patients, and medicolegal aspects of pediatric seda- tion. Case studies and clinical scenarios will be emphasized. Participants are encouraged to bring cases from their practice for discussion. TRACK B Innovations in Sedation Moderator: Baruch Krauss, MD 2:30 - 3:00 PM 3:00 - 3:20 PM 3:20 - 3:50 PM 3:50 - 4:20 PM 4:20 - 4:40 PM 4:40 - 5:00 PM 5:00 - 5:30 PM NPO Status and Sedation Risk; Guidelines, Facts, Fiction and Outcome Mark Roback, MD Clinical Application of BIS Monitoring for Sedation Anthony Absalom, MBChB, FRCA, MD An Advanced Review of Capnography Baruch Krauss, MD Development and Implementation of a Non-Anesthesia Delivered Nitrous Program Judith Zier, MD PALS Monica Kleinman, MD Distraction Techniques Baruch Krauss, MD Panel Discussion Mark Roback, MD, Anthony Absalom, MBChB, FRCA, MD, Baruch Krauss, MD, Judith Zier, MD, Monica Kleinman, MD TRACK C Hospital Medicine Moderator: Douglas Carlson, MD 2:30 - 3:00 PM 3:00 - 3:30 PM 3:30 - 4:15 PM 4:15 - 4:45 PM 4:45 - 5:30 PM The Hands-On Practical Aspects of Nitrous Oxide Application and Utility Judith Zier, MD Approaches to Developing, Maintaining and Credentialing Sedation Skills Douglas Carlson, MD Picking the Right Sedation Drugs and When to Refer Ricardo Quinonez, MD Options and Strategies to Maximize Billing and Reimbursement for Sedation Douglas Carlson, MD Case Presentations: Decision Making for Safe, Effective and Efficient Sedations Douglas Carlson, MD, and Ricardo Quinonez, MD
  • 8. September 28-29, 2013 Weekend Course Overview Target Audience This conference is intended for physicians, dentists, registered nurses, nurse practitioners, nurse anesthetists, pharmacists, advanced practice nurses and health care administrators. Specifically, the healthcare professionals have represented the specialties of anesthesiology, radiology, emergency medicine, hospital medicine, pediatrics, dental medicine, dental anes- thesiology, intensive care medicine and gastroenterology. Course Description This annual conference entitled, Pediatric Sedation Outside the Operating Room, is taught by multi-specialists, renowned in pediatric sedation, from both the United States and internationally. This course offers both didactic lectures and panel discussions. Optional hands-on airway workshops in both basic and advanced airway skills is also offered. Small round table discussions with the faculty and afternoon concurrent tracks provides the attendee with an opportunity for discourse and interactive discussions. The field of sedation continues to evolve and policies, recommendations and Center for Medicaid and Medicare Service guidelines change in response to the health care environment. Currently, sedation guidelines and recommendations differ between specialty societies: For example, the American Society of Anesthesiologists (ASA) guidelines on deep sedation are not concurrent with those of the American Society of Gastroenterology nor American College of Emergency Physicians. Sedative agents, delivery methods and routes of delivery are changing as new techniques and outcomes continue to be explored and presented. This course is designed to fill the practice gaps created by this combination of evolving practice guidelines, differing practice standards among specialty societies, and continuing advances in sedation medicine and technology by updating and reviewing state-of-the-art techniques for safe and effective delivery of sedation. This conference is intended to improve learner competence and performance by reviewing not only the basics of sedation but also updating the registrant to current, evolving and state-of-the art practice (i.e. knowledge). The hands-on workshops on airway management and patient simulation using mannequins will allow the learner to apply this competence to their everyday practice (i.e. performance) and prepare for the rare, unanticipated emergencies. Being prepared for emergencies as well as for the more common adverse events, the learner will be able to be better equipped to improve patient outcome. This confer- ence is to increase the participant’s breadth of knowledge of pediatric sedation along with elaborate on ways to improve and track patient outcomes. Learning Objectives At the end of this course, participants will be able to: • Attain a comprehensive knowledge of current sedation practice. • Describe recent changes in guidelines, regulations, and policies. • Understand current on-going and future developments and initiatives in the field of sedation. • Preview sedation systems and initiatives which are in development. • Justify the role of High Fidelity Simulation in sedation training and practice. • Have met faculty and attendees from both the United States and abroad to develop a global exposure to the many facets of sedation practice. • Complete an in-depth review of physiologic monitoring and develop an appreciation of the role and interpretation of capnography. • Participate in an open forum clinical based case-studies to obtain a comprehensive appreciation to sedation alternatives proposed by faculty from different specialties. • Utilize the hands-on experience attained in the airway workshops to better manage airway emergencies and be able to teach their colleagues that which they have learned. Call For Abstracts Deadline for Submission of Abstracts: July 1, 2013 Detailed submission guidelines, abstract submission form, and disclosure form can be found at: www.PediatricSedationConference.com Abstracts are blindly reviewed by the abstract committee. Presenting authors will be notified if their abstract is chosen for poster display at the September 28-29, 2013 weekend conference.
  • 9. A NEW COURSE OFFERING! A Comprehensive Review of the Essentials of Pediatric Sedation This one-day course is a comprehensive introduction and review of the fundamentals of pediatric sedation. This offers a unique opportunity to update your knowledge in the format of didactic sessions, open forum question-and-answers and clinical case reviews. An optional hands-on workshop will provide personalized one-on-one faculty attention to gain hands-on experi- ence using manikins to practice basic airway resuscitation skills. This course is designed to provide a review of topics related to the safe and effective delivery of minimal, moderate and seda- tion by inhalation, enteral, and parenteral routes of administration. This course is intended to be an introduction and review of the up-to-date policies and guidelines governing sedation. The topics will include physiological monitoring, airway evaluation, the etiology and management of central and obstructive apnea, patient assessment, discharge and recovery guidelines, risk factors for adverse events, emergency preparedness, non-pharmacologic techniques and the basic pharmacology of commonly used sedatives. Clinical case presentations will be presented in an interactive format to maximize discussion, collaborative sharing of ideas and consideration of all options. Case studies will include challenging and complex situations. Question and answer sessions will provide participants with forums to ask questions and discuss specific issues with course faculty. This new course will feature recognized leaders and faculty from different specialties, all leaders in the field of sedation. The attendee will have the opportunity to gain hands-on experience learning airway techniques to rescue patients from deep seda- tion, including manikin practice with face masks and ambu bag along with the insertion of nasal and oral airways in a personal- ized setting with manikins and real equipment. Learning Objectives At the end of this course, participants will be able to: • Understand current rules and regulations regarding minimal, moderate and deep sedation. • Outline the pharmacology and clinical application of commonly utilized sedatives. • Weigh advantages, disadvantages, efficacy and adverse events associated with different sedative options. • Evaluate complex and challenging sedation scenarios and formulate a plan. • Comprehend the risk factors for sedation-related adverse events. • Provide a comprehensive review of patient evaluation including airway assessment, relevant medical history and vital signs necessary to evaluate patients as appropriate sedation candidates. • Review the discharge criteria and available recovery guidelines for discharge home following sedation. • Understand the role and application of capnography. • Prepare for unanticipated emergency situations. • Summarize the clinical and physiologic occurrences which herald an ensuing adverse event. Full-Day Sedation Symposium The Fundamentals of Sedation: Reviewing the Basics Bridging the Specialties Friday, September 27, 2013 OPTION 1:
  • 10. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties10 7:15 - 8:15 AM 8:15 - 8:30 AM Registration and Breakfast Welcome and Introduction Keira Mason, MD, Mark Roback, MD 8:30 - 12:00 PM SEDATION OUTSIDE THE OR: GETTING STARTED Moderator: Mark Roback 8:30 - 9:00 AM Mark Roback, MD Define Sedation, Distinguish Sedation from Analgesia and Amnesia The Sedation Continuum: Guidelines for Assessing Sedation Depth,Accompanying Risks and An Objective Look at the Limitations of the Continuum The Sedation “Set Up”: Space, Personnel, Physiologic Monitors, Equipment and Resuscitation Supplies 9:00 - 9:20 AM Jennifer Dearden, MD The Pediatric Airway: Anatomy, Hallmarks of Increased Risk, Strategies for Preparation and Management 9:20 - 10:10 AM Timothy Horeczko, MD Essentials of Pediatric Physiology and Anatomy and their applications to sedation Physiological Monitoring: Interpreting the EKG, Pulse Oximeter and Capnograph 10:10 - 10:30 AM Keira P. Mason, MD Patient Selection:The“Pearls”of Pre-SedationAssessment: How toAssessWho isAppropriate for Sedation andWhenTo a Consult with Specialists? Return to Pre-Sedation State and Readiness for Discharge- Discharge Criteria: Different Options and Scoring Assessment Tools 10:30 - 11:00 AM David Rothman, DDS Management of Challenging Patients: Autism, Obesity and the Neurologically Challenged 11:00 - 11:30 AM Morning Break 11:30 - 12:00 PM Timothy Horeczko, MD and David Rothman, DDS Non-Pharmacologic Strategies for Behavior Management: Expert Approaches 12:00 - 1:00 PM Lunch on Your Own OR Optional Airway Lunch Optional Lunch: Difficult Airway Workshop: Basic (Medical and Dental) Pre-Registration and Fee Required | Seaport (3rd Floor) Small, hands-on, one-on-one interaction with faculty to review, practice and improve advanced airway skills. This is a unique opportunity to trial advanced airway equipment, including but not limited to video laryngoscopy, fiberoptic intubation, supraglottic airway devices, and surgical cricothyroidotomy using porcine tracheas. Jennifer Dearden, MD (Leader), Thomas Anthony Anderson, MD, PhD, David Gozal, MD,Tim Horeczko, MD, Babu Koka, MD Mohamed Mahmoud, MD, Steven Zgleszewski, MD, Marina Sammartino, MD SYMPOSIUM SCHEDULE Friday, September 27, 2013 Optional Full-Day Sedation Symposium: The Fundamentals of Sedation: Reviewing the Basics, Bridging the Specialties Course Director: Keira P. Mason, MD Director, Fundamentals of Sedation Symposium: Mark Roback, MD This full-day course provides an overview of sedation administered outside the OR and is directed toward a multidisciplinary audience that includes physicians, dentists, nurses, hygienists, students and trainees.The morning session “sets the stage” for successful sedation and challenges the participants to consider their goals for sedation and how best to achieve them. Introductory sedation lectures and the Pediatric Airway Workshop are directed toward both medical and dental personnel.The remainder of the session targets medical- or dental- specific groups to reflect particular interests and practice. In the afternoon, case scenarios will be presented with the intent to foster vigorous discussion of options for sedation and best practice models.The day will reach a conclusion with Sedation Jeopardy to test your sedation knowledge and poise under pressure. Please remember to phrase your answer in the form of a question.
  • 11. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties 11 CHOOSE EITHER SESSION TO ATTEND Medical Session Dental Session 1:00 - 1:30 PM Pharmacology of Sedation: A Broad Review of Sedatives Analgesics and Adjuncts Timothy Horeczko, MD (Moderator/Lecturer) • A Pharmacologic Review of Commonly Used Medication Dental Pharmacology and Adjunctive Behavior Management Techniques in Pediatric Dentistry David Rothman, DDS (Moderator/Lecturer) • Oral “Conscious Sedation” agents • Local Anesthetics: Pharmacology, physiology, administration risks, and outcome • Papuse board- the controversy 1:30 - 2:00 PM Pharmacology of Sedation: A Broad Review Timothy Horeczko, MD (Moderator/Lecturer) • Emergency and Resuscitation Medications: Protocols, Options and Routes of Administration Inhalation Sedation: Nitrous Oxide Eduardo Alcaino, DDS (Lecturer) • Pharmacology and Physiology • Clinical indications • Contraindications and adverse events • Administration techniques 2:00 - 2:30 PM Rescue: Managing Sedation Adverse Events Mark Roback, MD (Moderator/Lecturer) • Risk factors and predictors of Adverse Events • Management and approach • Special populations Minimal and Moderate Sedation: Oral, Intravenous and Alternate Routes David Rothman, DDS (Moderator/Lecturer) • Definitions • Qualifications, guidelines and policies • Necessary equipment and supplies • Routes of administration • Sedative options: pharmacology, physiology, clinical indications outcomes 2:30 - 3:00 PM How to Design, Implement and Fund a Safe and Efficient Sedation Service: Douglas Carlson, MD (Moderator/Lecturer) • Training recommendations • Privileges and credentialing • Set-up and personnel Deep Sedation: Oral, Intravenous and Alternate Routes Michael Webb, DDS • Definitions • Qualifications, guidelines and policies • Necessary equipment and supplies • Routes of administration • Sedative options: pharmacology, physiology, clinical indications outcomes 3:00 - 4:30 PM Case Studies in Pediatric Sedation Mark Roback, MD, Bo Kennedy, MD, Douglas Carlson, MD Keira Mason, MD Cases presented from multi-specialty sedation venues with an open forum approach to explore techniques at evaluation, planning and patient management. Extensive QA time allotted 3:00 - 3:30 PM Preparation and Anticipation of Dental Sedation Emergencies Ron Kosinski, DMD • Setting up emergency protocols, policies and procedures • Emergency equipment and training • Review of Pediatric CPR, PALS and ACLS 3:30 - 4:30 PM Case Studies and Panel Discussion David Rothman, Eduardo Alcaino, Ron Kosinski 4:30 - 5:30 PM Sedation Jeopardy — A Unique and Entertaining Learning Format Joint Medical and Dental Session: Mark Roback, MD Closing Remarks and Open Forum Feedback: Mark Roback, MD * Program changes/substitutions may be made without notice. Friday, September 27, 2013 Optional Full-Day Sedation Symposium: The Fundamentals of Sedation: Reviewing the Basics, Bridging the Specialties
  • 12. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties12 Pediatric Sedation Hands-On Simulation is now recognized by the American Society of Anesthesiologists (ASA) in the “October 20, 2010 statement on granting privileges for deep sedation to non-anesthesiologist sedation practitioners.” Although this seda- tion conference provides AMA PRA Category 1 Credits™ for the didactic and simulator portions, this does not imply endorsment by the ASA. The ASA does not endorse nor certify any sedation-related training curriculum. This course is intended for practitioners providing IV moderate sedation and deep sedation and offers an educational high fidel- ity simulation experience to provide skills for successful recognition and management of sedation-related complications. This unique and challenging program provides a clinical simulation experience that addresses the proper assessment and manage- ment of complications associated with moderate sedation, deep sedation. Following a brief introduction explaining essential principles, participants will demonstrate appropriate patient management on human patient simulators. (Laerdal SimMan). This full-day simulation workshop will provide each registrant with six clinical scenarios intended to improve individual skills as well as to impart an understanding of a team approach to crisis resource management. Each registrant will become part of a small team which will will rotate together through each of the six scenarios over the course of the day. The scenarios are intended to improve individual skills as well as the team’s reactions and responses. Effective post-simulation debriefings will integrate criti- cal performance feedback, promote reflective practice, and augment future performance. The full-day of high fidelity simulation scenarios are taught by national and internationally recognized faculty of simulation experts and aims to provide participants with knowledge and skills to recognize and manage sedation-related emergencies. Course registration is limited to provide each registrant with an optimal, educational hands -on experience. There will be an optional “working” lunch which offers the opportunity to have a hands-on experience with personalized faculty attention using manikins to develop and improve airway skills. Two airway workshops will be offered: Basic and Advanced. The Basic Airway Workshop is intended to solidify skills at delivering positive pressure ventilation using a face mask and ambu bag along with the insertion of naso and oral airways. The Advanced Airway Workshop offers the opportunity to place laryngeal mask airways, intubate and use new state-of-the-art airway equipment. 1. Medical simulation is a highly adaptable tool for evaluating individual knowledge and team performance. 2. Medical simulation can improve patient safety by raising an individual’s awareness of their practice and by enhancing team cohesion and performance. 3. Simulation provides a safe arena for learning and evaluation, trains with actual equipment used in the clinical realm, and provides for repetition and reflection. 4. Medical simulation should be educational,reflective and fun. Learning Objectives At the end of this course, participants will be able to: • Discuss the importance of simulation context and physical setting. • Explain the importance of human-factors leading to and in the management of crisis. • Anticipate and prepare for the management of rare events. • Summarize the components of a simulation based learning encounter. • Comprehend the advantages of simulation-based learning. • Acquire an understanding of how simulation may be incorporated into credentialing and training of sedation care providers. • Establish and demonstrate appropriate components of an adequate primary assessment. • Develop an algorithm for the recognition and management of various anatomical and pathological causes of airway obstruction. • Create a differential diagnosis for the etiology of respiratory depression and understand the different management techniques. • Describe and demonstrate appropriate management of cardiovascular compromise. • Demonstrate proficiency in directing a team during a crisis. High Fidelity Pediatric Sedation Simulation Workshop Objectives Friday, September 27, 2013 OPTION 2:
  • 13. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties 13 6:30-7:30 AM Registratio and Breakfast (Included) 7:30-8:30 AM Introduction: Simulation in the 21st Century Integration into Sedation Training James Fehr, MD 8:30-9:30 AM 9:30-10:30 AM Scenario 1 Scenario 2 10:30-11:00 AM Break 11:00-12:00 PM Scenario 3 12:00-1:00 PM Lunch OR Optional Difficult Airway Workshop OPTIONAL LUNCH: Difficult Airway Workshop: Basic (Pre-registration and fee required) Small, hands-on, one-on-one interaction with faculty to review, practice and improve advanced airway skills. This is a unique opportunity to trial advanced airway equipment, including but not limited to video laryngoscopy, fiberoptic intubation, supraglottic airway devices, and surgical cricothyroidotomy using porcine tracheas. Jennifer Dearden, MD (Leader) Thomas Anthony Anderson, MD, PhD, David Gozal, MD,Tim Horeczko, MD, Babu Koka, MD, Mohamed Mahmoud, MD Steven Zgleszewski, MD 1:00-2:00 PM 2:00-3:00 PM 3:00-4:00 PM Scenario 4 Scenario 5 Scenario 6 4:00-4:30 PM Closing Remarks and Debriefing/Interactive Feedback Moderator and Leader of Simulation Workshops James Fehr, MD Anesthesia Directed Scenario Disruptive Parent, Distraction of Provider Leading to Cardiac Arrest from Unrecognized Apnea Kai Matthes, MD (Leader), Sharon Redd, MD, Roberta Forman, RN, BSN, MHA Dental Medicine Directed Scenario Aspiration of a Crown Calvin Kuan, MD (Leader), Jen Wagner, MD Manchula Navaratnam, MBChB, FRCA, Jerry Chao, MD, Echo Rowe, MD Emergency Medicine Directed Scenario Resistance to Sedatives Leading to Apnea Robert Kennedy, MD (Leader) Hospital Medicine Directed Scenario Anaphylaxis Yasmeen Daud, MD (Leader), Kim Hamlin, MD Post Sedation Recovery Event Scenario Respiratory Depression in Recovery John Zhong (Leader), Michele Trinka, MSN, RN, CCRN, PCCN, Dayna Downing Procedural Sedation Scenario Laryngospasm Anna Maria Onisei, MD, Saif Siddiqui, MD (Leader) Friday, September 27, 2013 Full-Day High Fidelity Pediatric Sedation Simulation Workshops Course Director: Keira P. Mason, MD Director, Sedation Simulation Workshops: James Fehr, MD Program changes/substitutions may be made without notice. CONFERENCE SCHEDULE A unique opportunity for small groups to actively engage with registrants and faculty from multi-specialties: all faculty have simulation expertise to present 6 sedation scenarios with detailed debriefing after each- scenarios will review skills which include: Assessment and Management of Anaphylaxis, Over Sedation, Respiratory Depression, Cardiovascular Collapse,Aspiration, Laryngospasm, Disruptive Behavior. Participants will spend one hour in each of the six scenarios.
  • 14. Pediatric Sedation Outside of The Operating Room 2013 Theme Exploring The Current Practice and Frontiers of Sedation Across The Specialties14 Registration Information Reduced Weekend Course Tuition Fee for four or more attendees from the same hospital/institution: $649 per person. This reduced tuition fee only includes the weekend course. (In order to receive this discount, please contact the HMS-DCE office at (617) 384-8600.) Registration by credit card (VISA or MasterCard) can be made at: www.pediatricsedationconference.com Registration by check (draft on a United States bank), please make payable to Harvard Medical School and mail with registration form to Harvard Medical School– Department of Continuing Education, PO Box 417476, Boston, MA 02241-7476. Telephone or fax registration is not accepted. Registration with cash payment is not permitted. Upon receipt of your paid registration an email confirmation from the HMS-DCE office will be sent to you. Be sure to include an email address that you check frequently.Your email address is used for critical information including: registration confirmation, evaluation and certificate. Inquiries By phone 617-384-8600, Monday-Friday, 10 AM to 4 PM (EST) or by email at: hms-cme@hms.harvard.edu. Online Information To register or view activity information online, visit: www.pediatricsedationconference.com To ensure proper registration, please add the first three characters of the source code found above your name on the mailing panel. Disclosure Policy Harvard Medical School (HMS) adheres to all ACCME Essential Areas, Standards, and Policies. It is HMS’s policy that those who have influenced the content of a CME activity (e.g. planners, faculty, authors, review­ers and others) disclose all relevant financial relationships with commercial entities so that HMS may identify and resolve any conflicts of interest prior to the activity.These disclosures will be provided in the activity materials along with disclosure of any commercial support received for the activity. Additionally, faculty members have been instructed to disclose any limitations of data and unlabeled or investigational uses of products during their presentations. Refund Policy A handling fee of $60 is deducted for cancellation. Refund requests must be received by postal mail, email or fax one week prior to this activity. No refunds will be made thereafter. Course Location All sessions for this course will be held at New York Marriott Downtown, 85 West Street at Albany Street, New York, NY 10006. (Telephone: 1-877-513-6305) This course is designed to meet one or more of the following Ac- creditation Council of Graduate Medical Education competencies: * Patient care * Medical knowledge * Practice-based learning and improvement * Interpersonal and communication skills * Systems-based practice ACGME Competencies The Harvard Medical School is accredited by the Accredi- tation Council for Continuing Medical Education to provide continuing medical education for physicians. The Harvard Medical School designates this live activity for a maximum of 27.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity This course is currently pending approval for AANA, nurs- ing CEU, ACEP category 1, and Risk Management credits. Accreditation Accommodation / Travel This year there are only a limited number of hotel rooms available at the New York Marriott Downtown Hotel. Many of the hotels are already in a sold-out situation. Please reserve hotel space early. A limited number of rooms have been reserved at the New York Marriott Downtown, 85 West Street at Alba- ny Street, New York, NY 10006 (Telephone: (877) 513-6305) until September 1, 2013. Please specify that you are enrolled in this course to receive a reduced deluxe standard room rate of $299 per night Single/ Double. Hotel arrange­ments can also be made online at: www.pediatricsedationconference.com/ html/accomodation.html. Please do not pur­chase non-refundable airline ticket(s) until you have received an email from our office confirming your paid registration. For airline reservations contact the HMS Travel Desk toll free 1-877-4-HARVMD (1-877-442-7863) Monday - Friday 9 AM - 8 PM (EST). From outside the U.S., Canada and Virgin Islands, please call 617-559-3764.
  • 15. September 28-29, 2013 Two Day Weekend Course: Exploring the Current Practice and Frontiers of Sedation Optional Breakfast Breakout Panels: Difficult Airway Workshop: Basic Propofol, Sedation and Non-Anesthesia Delivery Models Dexmedetomidine Difficult Airway Workshop: Advanced Optional Lunch Breakout Panels: Hospital Medicine Ketamine Nitrous Oxide Ask the Expert: Lunch with a Medical Malpractice Attorney $749 (USD) $100 (USD) $50 (USD) $50 (USD) $100 (USD) $100 (USD) $100 (USD) $100 (USD) $100 (USD) Reduced Weekend Course Tuition Fee for four or more attendees from the same hospital/institution: $649 per person.This reduced tuition fee only includes the weekend course. (In order to receive this discount, please contact the HMS-DCE office at (617) 384-8600.) Friday, September 27, 2013 Option 1: Full-Day Simulation Workshop Option 2: Fundamentals of Sedation: Reviewing the Basics Bridging the Specialties Lunch on your own OR Optional Lunch: Difficult Airway Workshop: Basic $679 (USD) $549 (USD) $100 (USD) TOTAL $ ________ (USD) Print Name Clearly — All Fields Required First ___________________________ Middle Initial ________ Last _____________________________________________________________ Mailing Address _______________________________________________________________________________________________________ City ____________________________ State _________________ Zip Code ____________ Country __________________________________ Daytime Phone (_____) ___________________________ Fax Number (_____) ___________________________________________________ Email Address _________________________________________________________________________________________________________ Please note Your email address is used for critical information about the course including: registration confirmation, course evaluation and certificate. Please be sure to include an email address you check daily or frequently. □Please check if you wish to be excluded from receiving email notices of future Harvard Medical School Department of Continuing Education programs. Profession ________________________________ Degree ____________________________________________________________________ Primary Specialty (Physicians Only) ___________________________________________________________ Board Certified: Yes □ No □ Professional School Attended (Physicians only) □Harvard Medical School □U.S. Medical School □International Year of Graduation ____________ Please select up to two breakfast panels and/or two lunch panels. Panels are limited to 15; assignments are made in the order received. Pediatric Sedation Outside of the Operating Room Course# 331418BREAKFASTLUNCH 9/27 9/28 9/29 Difficulty Airway Workshop: Basic – $100 (USD) Propofol, Sedation and Non-Anesthesia Delivery Models – $50 (USD) Dexmedetomidine – $50 (USD) Difficult Airway Workshop: Advanced – $100 (USD) Difficulty Airway Workshop: Basic – $100 (USD) Nitrous Oxide – $100 (USD) Ask the Expert: Lunch with a Medical Malpractice Attorney – $100 (USD) Hospital Medicine – $100 (USD) Ketamine – $100 (USD)
  • 16. Non-profit Org. U.S. Postage PAID Nashua, NH Permit No. 375 PEDIATRIC SEDATION OUTSIDE OF THE OPERATING ROOM September 28-29, 2013 Weekend Sedation Conference Exploring the Current Practice and Frontiers of Sedation Across The Specialties Friday, September 27, 2013 Option 1: Full-Day Sedation Symposium: The Fundamentals of Sedation: Reviewing The Basics Bridging the Specialties Option 2: Full-Day High Fidelity Pediatric Sedation Simulation Workshops New York Marriott Downtown, New York City BACK BYPOPULAR DEMANDOptional FULL-DAY High Fidelity Pediatric Sedation Simulation Workshops New Multispecialty Directed ScenariosLIMITED ENROLLMENTSEPTEMBER 27, 2013 Harvard Medical School Department of Continuing Education P.O. Box 825 Boston, MA 02117-0825 Abstracts Deadline July 1, 2013 Course Director Keira P. Mason, MD Director, Sedation Symposium Mark G. Roback, MD Director, Sedation Simulation Workshops James Fehr, MD For more details please visit us at www.PediatricSedationConference.com Source Code:

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