Welcome to the Pediatric Anesthesia Rotation. We hope that you will enjoy this experience while learning as much about our special “little people” as you can. This guide is meant to provide you with a quick introduction to the rotation, what is expected of you and how you will be evaluated, and some didactic material that covers topics you are expected to study during the rotation.

Important personnel to know are your pediatric anesthesia attending staff: Drs. Anna Crnkovic, Melissa Ehlers, Archana Mane and Helena Oechsner. Colleen Savage and Laura Igoe, RNP are our nurse practitioners in the pediatric holding/recovery area, and Wendy Reamer, RN and Gail Cashin, RN are the nurses which you will most frequently deal with in the pediatric recovery area.

A typical day performing pediatric anesthesia:

Check your cases the night before on the schedule. Pediatric patients who are ASA III-V SHOULD have been prescreened by Colleen or Laura (and those sheets are kept in Peds PACU, ask someone over there to show you where) although we do not always get the notification that they are a “sick” child ahead of time.

The morning of the case, set up your room appropriately. Different things to consider include:

1. Hypothermia prevention – different maneuvers include warming the room, setting up french-fry lights, placing a Bair Hugger on the bed, warm blankets

2. Machine set-up – is this machine appropriate for this size patient? Perform routine check-out. Is the bag size appropriate for your patient?

3. Monitors – disposable (pediatric) pulse ox, appropriate size BP cuff, pediatric EKG stickers (you can find them in the pediatric tackle boxes which are kept in the anesthesia supply room – make sure that you have one of these boxes in your room for every peds case).

4. Airway equipment – oral airways selected, appropriate size ETT (4 + age/4) plus one size larger and smaller, (if using cuffed tube, subtract 0.5 from above formula), ETT stylet, pedi laryngoscope handle + blades, mask (a few different sizes), LMA (if appropriate for case), eye tape and ETT tape ready to use

5. IV equipment – A pediatric IV setup should be brought to your OR by the anesthesia tech, but if they forget, they are kept in the anesthesia equipment room. Multiple 22 and 24g angiocaths, tourniquet, tegaderm, alcohol pads/chlorhexidine swabs, arm board, tape for IV.

6. Medications – always have a syringe of atropine (1cc) and a syringe of succinylcholine ready but kept in the top drawer of the anesthesia cart. (A reminder: ALL drugs in the top drawer are assumed to be clean; NEVER put dirty drugs in this location). Also have 1ml syringes of Fentanyl, appropriate-sized syringes of propofol (thiopental for babies), and muscle relaxant (vecuronium or rocuronium is used for the majority of pediatric cases, if used at all).

7. Caudal equipment (when appropriate) – Epinephrine added to 0.25% Bupivicaine, sterile gloves, chloraprep swab stick, 22 or 20g angiocath, syringe to draw up dose + needle, sterile label, sterile drape (use same one as in block room)

8. Miscellaneous (when appropriate), 22g short bevel needles for ilioinguinal block, central lines/arterial line catheters + transducer, continuous caudal catheter

Once the OR room is prepared, go and see the first patient, who should arrive by shortly after 7 AM. Perform an H&P if not already done (use the “Pediatric Surgery/Anesthesia H&P, see link to this below) decide on whether or not to give a premedication and whether or not you will invite the parent to accompany their child to the OR (see articles about this subject in this handout, also check with your attending when necessary). If you are giving a premed, use Versed 0.5mg/kg po from the pyxis (use the intranasal form which is 5mg/ml) which you should mix with Tylenol to make it taste better. When you are ready (and sure that the surgeon is available), check with the room first and your attending, then proceed back to the OR. Children without an IV already in place will almost always have an inhalation induction (once they reach age 8, start to think about offering them an IV induction instead), but if they are coming from the floor with an IV, an IV induction will usually be performed.

We are lucky enough to now have at least one nurse practitioner (if not two) who will see pediatric patients in the holding area for us and fill out a modified H&P, as well as giving premeds and taking care of parental consents. Occasionally Colleen will be away on vacation or at conference (and Laura is only part-time), so you may need to help prepare patients later in the day as well. Don’t forget that you must also write an H&P for ALL patients regardless of any other H&Ps that may be on the chart.

After your case is finished, you will accompany your patient to the pediatric PACU (always with oxygen!) where you will hand over care of your patient to the nurses there.

Sample copy of the peds anesthesia H&P:

K:\Public\Ehlers-public\Pediatric Anesthesia History & Physical.doc

Pediatric Anesthesia Rotation Evaluation:2nd year: Written exam, individual evaluations by attending anesthesiologists 3rd year: Oral exam, individual evaluations by attending anesthesiologists, portfolio of cases

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Topics to be covered during these two years will include 2nd year:

Dosing of emergency drugs – atropine, succinylcholine, epinephrine

Physiologic differences between infants and children as compared to adults

K:\Public\Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\MELISSA Physiologic differences between infants.doc

Down Syndrome – anesthetic implications :

Pyloric Stenosis:

ScienceDirect - Seminars in Pediatric Surgery : Current management of hypertrophic pyloric stenosis

\\Amc09\vol1\Practice\Anest\Shared\Public\Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\PYLORIC STENOSIS.doc

Open eye injuries/oculocardiac index:

K:\Public\Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\00000542-200404000-00045eyeinjuries.pdf

(see editorials on sux and open eye)

Tonsillectomy/Adenoidectomy/Bleeding Tonsil

IV fluid/glucose requirements in children/Blood volume/Allowable Blood loss/ECF/TBW

Pediatric NPO guidelines

Pediatric PACU issues – implications/treatment of vomiting/pain/apnea

Discharge criteria for infants & justification

Caudal anesthesia – techniques, complications, when to use

Institutional policy on child abuse, minors of Jehovah’s witnesses, latex allergy, infection control(insert word doc), http://www.med.unipi.it/patchir/bloodl/bmr/legal.htm , http://intranet.amc.edu/nursing/files/LATEX.pdf

Pre-operative sedation – methodology and reasoning

3rd year:

Newborn/Neonatal resuscitation: An Advisory Statement From the Pediatric Working Group of the International Liaison Committee on Resuscitation -- Kattwinkel et al. 103 (4): e56 -- Pediatrics

Pediatric Advanced Life Support: Part 12: Pediatric Advanced Life Support -- 112 (24 Supplement): IV-167 -- Circulation

Practice two pediatric megacodes at: MDChoice Pediatric Advanced Life Support Simulator

Malignant Hyperthermiamalignant hyperthermia.pdf

Additional suggested reading material:

Manual of Pediatric Anesthesia. By David Steward