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Pediatric Anesthesia Basics
2013Laura Downey, MDYun-Sheen Liu, MD
Julie Williamson, DOLPCH Pediatric Anesthesia Rotation
Updated December 2013
NPO guidelines
Solids/formula = 6h
Breast milk = 4h Clears = 2h Older kids and
outpatients should be NPO after midnight
Chewing gum and candy are considered clear liquids
LPCH Pediatric Anesthesia Rotation Updated December 2013
Premedication
IV Versed 0.1 mg/kg midazolam for toddlers, up
to 2 mg for children >5 years
Oral Versed – order 20-30min before case to be given by pre-op holding RNs <6mo = usually no premed needed 6mo to 12y = oral premed (0.5 mg/kg
up to 20 mg) Over 12y = IV in pre-op area
LPCH Pediatric Anesthesia Rotation Updated December 2013
Stranger anxiety starts around 9 months of age
Set Up: T-MSMAID
Table Machine Suction Monitors Airway IV Drugs
LPCH Pediatric Anesthesia Rotation Updated December 2013
Table
Bair Hugger
Shoulder Roll
3 lead EKG
Pulse Ox Appropriat
e sized BP cuff Special
cable for neonatal cuffs
Pulse oximeter and BP cuff will be in patient’s chart, and should stay on for PACU
LPCH Pediatric Anesthesia Rotation Updated December 2013
Machine
Standard Machine check
Monitor set to Neonate or Pediatric Mode
Reset alarms for age appropriate vitals
LPCH Pediatric Anesthesia Rotation Updated December 2013
Suction
Red rubber Rob Nell for little kids
Yankauers may be in anesthesia machine or on surgical shelves. Have available before induction.
Turn on suction
LPCH Pediatric Anesthesia Rotation Updated December 2013
Monitors
BP cuff of appropriate size Neonatal cuffs require a separate cable
Pulse ox Avoid index finger to minimize corneal
abrasions post op 3 lead EKG
White lead on right Green lead is V5 and equivalent to red
lead in adultsLPCH Pediatric Anesthesia Rotation
Updated December 2013
ETT (3) One half size bigger and one half size smaller Appropriate size stylet
Two laryngoscope blades & handles Oral airways Flavored face mask Cloth white tape to secure ETT
Two Y-strips Red rubber for suction Eye tape:
Paper tape > 1year Mepitec for <1 year or fragile skin
Mepitec
Cloth Tape
LPCH Pediatric Anesthesia Rotation Updated December 2013
For every case, the anesthesia techs will set up airway equipment according to age of patient. While RN places monitors, double check size of equipment.
Airway
ETT
Size based on the child’s pinky or (age/4) + 4
Might need to size ½ down if cuffed
Have one half-size smaller and larger available
Oral and nasal RAE boxes are available from the techs.
LPCH Pediatric Anesthesia Rotation Updated December 2013
Laryngoscope blades
Preemie: Miller 00 Neonate to 3 months: Miller 0 3 months to 18 months: Miller 1 18 month- 3 years: Miller 1.5, Mac 1,
Wisc 1.5 3-5 years: Miller 1.5, Mac 2, Wisc
1.5 >5 years: Miller 2, Mac 2-3 Mac 4 is not standard in room. You
will need to request one from techLPCH Pediatric Anesthesia Rotation
Updated December 2013
AirwayAGE For
mula
32 weeks
Term
3 mo
6mo 12 mo
18 mo
2 yr 3 yr 5 yr 10 yr
Kg 2.0 3.5 5.0 6.0 8 11 13 15 20 40
ETT size
(age/4) +4
2.5 3.0 3.5 3.5 4.0 4.5 4.5 4.5 5.0 5.5
ETT depth
ETT size*3
7.5 9.0 10.5 10.5 12.0 13.5 13.5 13.5 15.0
Blade
Mil 0 Mil 0 Mil 0 Mil 1 Mil 1 Mil 1 Wis 1.5Mac 1
Mil 1.5Mac 1
Mil 1.5Mac 2
Mil 2Mac 2-3
LMA
1 1 1 1.5 1.5 2 2 2 2.5-3
LPCH Pediatric Anesthesia Rotation Updated December 2013
LPCH Difficult Airway Equipment
LPCH Pediatric Anesthesia Rotation Updated December 2013
GlidescopeStorz CMAC systemOlympus FOB
IV IV supplies – in kidney basin
mini tourniquet – cut to half width for small babies Alcohol pads 20, 22, 24g PIV catheters Opsites 2x2 gauze Paper tape for additional reinforcement Scissors Arm board Syringe with T-piece
One IV setup will be placed on a Mayo stand by techs for every case.
LPCH Pediatric Anesthesia Rotation Updated December 2013
IV continued Debubble all buretrols
and IV sets. Green clip should be left in open position A bubble is a bullet to
the brain – Boltz Draw back on syringes
to de-air before injecting
Children <6m should have dextrose infusion
Buretrol IV set for <2yo
Microdripper for <12 yo
LPCH Pediatric Anesthesia Rotation Updated December 2013
Do you know the incidence of PFO in babies? Children? Adults?
Drugs Pyxis machine in OR
Contains: Emergency drugs, opioids, induction agents Note that ketamine comes in 100mg/ml (for IM
injection) and 10mg/ml for IV Albumin, Crystalloid, Dextrose
Access: 6 digit dictation number + password or fingerprint
Omnicell in LPCH IR Suite
LPCH Pharmacy (near OR 7): Call to have drips made for big cases – 721-
2731. Can be ordered in advance under “Anesthesia OR drips” in Cerner.
10mcg/ml pre-made Epinephrine sticks available
LPCH Pediatric Anesthesia Rotation Updated December 2013
Drugs Emergency Drugs
Sux 4-6 mg/kg on IM needle
Atropine 0.02 mg/kg on IM needle
Ephedrine 10cc of 5mg/cc
Phenylephrine 1 syringe of
100ug/cc 1 syringe of 10ug/cc
Epinephrine 10 mcg/cc
Two syringes of saline flush
Have small syringes and needles available.
Do not draw up for EVERY case.
LPCH Pediatric Anesthesia Rotation Updated December 2013
Other emergency drugs
Calcium Chloride 10cc of 100mg/cc 10cc of 10mg/cc for small infants
Sodium bicarbonate 8.4% 1 mEq/cc for patients >1 year Note dilute solution for infants
Syringes of 5% albuminLPCH Pediatric Anesthesia Rotation
Updated December 2013
Induction Drugs
Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM
Propofol – 3-5 mg/kg IV Time and date all syringes. Discard
after 6 hours. Rocuronium 0.6-1.2 mg/kg
Dilute to 1 mg/cc for children <5 kg
LPCH Pediatric Anesthesia Rotation Updated December 2013
Pain medications RECTAL acetaminophen 30-40
mg/kg (single dose) IV acetaminophen dose is age
dependent: 10mg/kg <2 years. 15 mg/kg >2 years. Re-dose Q 6 hours. Slow push/infusion over 15 minutes.
Toradol 0.5 mg/kg IV or IM Fentanyl single dose 0.5 to 1 mcg/kg,
dilute to 1 mcg/cc for babies, 10 mcg/cc for children<10 years
Morphine single dose 0.1 mg/kg IV Hydromorphone single dose
0.01mg/kg IV
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ARC:Anesthesia Resource
Coordinator Makes daily
schedule and runs board: 1-9705
Holds emergency phone: 1-9706
Monitors PACU Assists with
difficult inductions Must be notified
(along with OR desk) of any changes in call or scheduling
Olga Albert Rebecca Claure
(lead) Louise Furukawa Echo Rowe Jen Wagner
LPCH Pediatric Anesthesia Rotation Updated December 2013
PARC:Pediatric Anesthesia
Resource Center All elective cases reviewed Phone interview with families Selected patients seen in-person Will try to see inpatients and add-
ons Dr. RJ Ramamurthi is lead PARC
anesthesiologist
LPCH Pediatric Anesthesia Rotation Updated December 2013
Perioperative flow
• Vitals and NPO verified
• Anesthesia NP examines and begins Careform and PreOp note
• Patient changed into gown
• Site marked, 24 hour H&P, 1st timeout GO
• Premed given• Patient consented
by anesthesia team
• PreOp note signed by attending
ORAPU
MRI/CTIR
ASCRadiation Therapy
PACU or ICU(NICU, PICU,
CVICU)IPASS HandoffPostOp Note
LPCH Pediatric Anesthesia Rotation Updated December 2013
http://www.lpch.org/aboutus/news/releases/2009/ford.html
Intake HoldingOperative Location PostOp
Maneuvering the Paperwork
Cerner Powerchart is LPCH EMR User name and Password are the same
as for OB EMR access from home is on LPCH
intranet: https://intranet.lpch.org Or may access from ether.stanford.edu Intranet password is different password
than Cerner Choose LINKS from menu and
Powerchart Sign into Cerner
LPCH Pediatric Anesthesia Rotation Updated December 2013
How do I find my schedule?
In Cerner: Choose compass icon
(Explorer Menu) Open Main Menu
Folder Open Perioperative
Services Folder Choose Perioperative
Schedule In Gray Box:
Surgery All Areas Bookshelf: Choose LPCH Perioperative All Areas Bookshelf
View Master View Execute This generates the
daily schedule with Anesthesia Attending, Resident, Patient name and number and site
LPCH Pediatric Anesthesia Rotation Updated December 2013
Finding information Old Anesthesia
Records: Clinical Documents
Tab: (after 9/2009) OR and Procedure
Notes Anesthesia
Records, Anesthesia Pre-Op
Scanned Documents Tab: (before 9/2009)
OR and Procedure Notes
Under ClinDocs, Care Forms, Pre Anesthesia NP note
ECHOS/EKG Clin Docs Tab
Ancillary Documents
LPCH Pediatric Anesthesia Rotation Updated December 2013
Clean/Dirty Areas
Remove gloves and foam hands before touching Pyxis or clean supply cart
Top of anesthesia machine is a “dirty” zone and will be completely cleared between cases.
Lower side tray is considered “clean”
LPCH Pediatric Anesthesia Rotation Updated December 2013
PACU Handoff
Formalized sign-out by surgeon, OR RN and anesthesiologist to PACU RN
For outpatients, IPASS is in front page of chart
LPCH Pediatric Anesthesia Rotation Updated December 2013
Parking on call
After 4pm and on weekends or holidays, can park in A lot on Welch and Quarry. Move car before 6am week days!
LPCH Pediatric Anesthesia Rotation Updated December 2013
Pain Call Duties
Signout with attending and pain NPs 2pm M-F
NP pager 18779 – Chris Almgren or Summer Hayes. Refer pain calls/consults received during business hours to NPs
Weekends contact pain attending the day before to arrange time to round
Expectation: Routine pediatric perioperative pain management
LPCH Pediatric Anesthesia Rotation Updated December 2013
Pedsanesthesia.stanford.edu
Goals and objectives
Transplant – setup, education
Mitochondrial disease
EB Critical Airway Pain
LPCH Pediatric Anesthesia Rotation Updated December 2013