Pediatric Anesthesia Basics 2012

Pediatric Anesthesia Basics2012 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO

NPO guidelines Solids/formula = 6h Breast milk = 4h Clears = 2h Older kids should be NPO after midnight Chewing gum and candy are considered clear liquids

Premedication • IV Premed • 0.5mg/kg Versed for toddlers, up to 2 mg of IV Versed for children >5 years • Oral Medication – 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

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

Table • Bair Hugger • Shoulder Roll • 3 lead EKG • Pulse Ox • Appropriate sized BP cuff • Special cable for neonatal cuffs

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 • Pulse ox • 3 lead EKG • White lead on right • Green lead is V5 and equivalent to red lead in adults

Airway Mepitec Cloth Tape • 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

ETT • Size based on the child’s pinky or (age/4) + 4 • Subtract 0.5 size for cuffed tube • Have one half-size smaller and larger available

Laryngoscope blades • for babies up to 3 months: Miller 0 • for babies aged 3 months to 18 months: Miller 1 • for 18 month- 3 years: Miller 1.5, Mac 1, Wisc 1.5 • for 3-5 years: Miller 1.5, Mac 2, Wisc 1.5 • for >5 years: Miller 2, Mac 2-3 • Note: Mac 4 is not standard in room. You will need to request one from tech

Airway

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

IV continued Buretrols are currently out of stock. 250cc bags for patients <5 yo or syringe pump for IVF for infants. • 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

Drugs • Pyxis machine in OR • Contains: • Emergency drugs, opioids, induction agents • Note that ketamine comes in 100mg/ml (for IM injection) and 10mg/ml • 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 • Stanford Main OR Pharmacy: • Sign out a green box for patients going for procedures in Stanford Hospital (AMC, interventional radiology)

Drugs Have small syringes and needles available. Do not draw up for EVERY case. • 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

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% albumin

Induction Drugs • Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM • Propofol – 2-3 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 • PRacetaminophen 30-40 mg/kg (single dose) • IVacetaminophen 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 10 mcg/kg IV

Flow of the OR • Pre-op: Ground floor of LPCH outside OR • Patient admitted to Pre-op where NPs see patients and often start care form • Holding: 8 bed area in OR suite • Inpatients are brought to holding when <30 min until case start • Patients too big to carry out of pre-op are brought to holding for premed • Need GO sticker before you can leave 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

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

Pediatric Anesthesia Basics 2012