Pediatric Anesthesia Basics 2013

Pediatric Anesthesia Basics

2013Laura Downey, MDYun-Sheen Liu, MD

Julie Williamson, DOLPCH Pediatric Anesthesia Rotation

Updated August 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 August 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 areaLPCH Pediatric Anesthesia Rotation

Updated August 2013

Set Up: T-MSMAID Table Machine Suction Monitors Airway IV Drugs

LPCH Pediatric Anesthesia Rotation Updated August 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


Machine Standard Machine check Monitor set to Neonate or Pediatric

Mode Reset alarms for age appropriate

vitals


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


Monitors BP cuff of appropriate size

Neonatal cuffs require a separate cable

Pulse ox

3 lead EKG White lead on right Green lead is V5 and equivalent to red

lead in adultsLPCH Pediatric Anesthesia Rotation

Updated August 2013

ETT (3) One half size bigger and one half size smaller Appropriate size stylet

Two laryngoscope blades 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


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.


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 August 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


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-pieceOne IV setup will be placed on a Mayo

stand by techs for every case.LPCH Pediatric Anesthesia Rotation

Updated August 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 August 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

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


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.


Other emergency drugs Calcium Chloride

10cc of 100mg/cc 10cc of 10mg/cc

Sodium bicarbonate 8.4% 1 mEq/cc for patients >1 year Note dilute solution for infants

Syringes of 5% albuminLPCH Pediatric Anesthesia Rotation

Updated August 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 <1 years


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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Flow of the OR Pre-op: Ground floor of LPCH outside OR

Patient admitted to Pre-op Intake where NPs see patients and start care form/preop note

Holding: 8 bed area in OR suite Patients brought to holding when <30 min until case

start

Need GO sticker before you can leave holding. 1st timeout in holding

OR 7 main ORs MRI/CT suites on ground floor APU – outpatient procedures on 1st floor LPCH

PACU: next to holding area ICUs are all on 2nd floor LPCH


May I have a GO?..... GO stickers:

H and P from surgeon (with 24 hour update)

Preoperative note from anesthesia signed by attending

Patient marked Room is ready

First “time out” is done in pre-op at patient’s bedside. Check MRN, birth date, allergies.

GO!


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 access from ether.stanford.edu Intranet password is different password

than Cerner Choose LINKS from menu and

Powerchart Sign into Cerner


https://intranet.lpch.org/index.html;jsessionid=DEF5C75ED7CA97A2C80AC3C8E34F180C.Ext1

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


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


The Kanban Restocking System


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”


PACU Handoff Formalized sign-out by surgeon, OR

RN and anesthesiologist to PACU RN For outpatients, IPASS is in front

page of chart


IPASS


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!


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


To Enhance Your Experience…


Case Tracking


Pass

port


Pedsanesthesia.stanford.edu


Pedsanesthesia.stanford.edu

Goals and objectives

Transplant – setup, education

Mitochondrial disease

EB Critical Airway Pain


Daily Feedback


Pediatric Anesthesia Basics 2013

Documents

iv setup

ett sizeage4

npo guidelinessolidsformula

ett depthett size

mdyunsheen liu

mdjulie williamson

iviv supplies

small babiesalcohol