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Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013
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Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Dec 17, 2015

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Page 1: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Pediatric Anesthesia Basics

2013Laura Downey, MDYun-Sheen Liu, MD

Julie Williamson, DOLPCH Pediatric Anesthesia Rotation

Updated December 2013

Page 2: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH 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

Page 3: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 4: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Set Up: T-MSMAID

Table Machine Suction Monitors Airway IV Drugs

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 5: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 6: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 7: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 8: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 9: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH 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

Page 10: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

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

Page 11: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 12: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH 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

Page 13: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

LPCH Difficult Airway Equipment

LPCH Pediatric Anesthesia Rotation Updated December 2013

GlidescopeStorz CMAC systemOlympus FOB

Page 14: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

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

Page 15: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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?

Page 16: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

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

Page 17: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 18: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 19: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH 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

Page 20: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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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Page 21: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

IMPORTANT PERSONNEL AND OR FLOW

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 22: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

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

Page 23: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 24: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 25: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

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

Page 26: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 27: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 28: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

The Kanban Restocking System

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 29: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 30: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 31: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

IPASS to ICU

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 32: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 33: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 34: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

To Enhance Your Experience…

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 35: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Case Tracking

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 36: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Pass

port

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 37: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Pedsanesthesia.stanford.edu

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 38: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO 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

Page 39: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Daily Feedback

LPCH Pediatric Anesthesia Rotation Updated December 2013

Page 40: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Crisis checklists

LPCH Pediatric Anesthesia Rotation Updated December 2013

In OR!

iPhone

App!

Page 41: Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013.

Code Cart

Code CartBroselow © Tape (ED only)

LPCH Pediatric Anesthesia Rotation Updated December 2013