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Pediatric Anesthesia Basics 2013

Pediatric Anesthesia Basics 2013. Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO. 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 . Premedication.

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Pediatric Anesthesia Basics 2013

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  1. Pediatric Anesthesia Basics2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated August 2013

  2. NPO guidelines LPCH Pediatric Anesthesia Rotation Updated August 2013 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

  3. Premedication LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  4. Set Up: T-MSMAID LPCH Pediatric Anesthesia Rotation Updated August 2013 Table Machine Suction Monitors Airway IV Drugs

  5. Table Pulse oximeter and BP cuff will be in patient’s chart, and should stay on for PACU LPCH Pediatric Anesthesia Rotation Updated August 2013 • Bair Hugger • Shoulder Roll • 3 lead EKG • Pulse Ox • Appropriate sized BP cuff • Special cable for neonatal cuffs

  6. Machine LPCH Pediatric Anesthesia Rotation Updated August 2013 Standard Machine check Monitor set to Neonate or Pediatric Mode Reset alarms for age appropriate vitals

  7. Suction LPCH Pediatric Anesthesia Rotation Updated August 2013 Red rubber Rob Nell for little kids Yankauers may be in anesthesia machine or on surgical shelves. Have available before induction. Turn on suction

  8. Monitors LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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 adults

  9. Airway 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. LPCH 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

  10. 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 August 2013

  11. 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 tech LPCH Pediatric Anesthesia Rotation Updated August 2013

  12. Airway LPCH Pediatric Anesthesia Rotation Updated August 2013

  13. IV One IV setup will be placed on a Mayo stand by techs for every case. LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  14. IV continued LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  15. 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 LPCH Pediatric Anesthesia Rotation Updated August 2013

  16. Drugs Have small syringes and needles available. Do not draw up for EVERY case. LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  17. Other emergency drugs LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  18. Induction Drugs LPCH Pediatric Anesthesia Rotation Updated August 2013 • 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

  19. Pain medications • RECTALacetaminophen30-40 mg/kg (single dose) • IVacetaminophendose 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 • Morphinesingle dose 0.1 mg/kg IV • Hydromorphone single dose 0.01mg/kg IV LPCH Pediatric Anesthesia Rotation Updated August 2013

  20. 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 LPCH Pediatric Anesthesia Rotation Updated August 2013

  21. 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! LPCH Pediatric Anesthesia Rotation Updated August 2013

  22. 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 LPCH Pediatric Anesthesia Rotation Updated August 2013

  23. 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 August 2013

  24. 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 August 2013

  25. The Kanban Restocking System LPCH Pediatric Anesthesia Rotation Updated August 2013

  26. Clean/Dirty Areas LPCH Pediatric Anesthesia Rotation Updated August 2013 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”

  27. PACU Handoff LPCH Pediatric Anesthesia Rotation Updated August 2013 Formalized sign-out by surgeon, OR RN and anesthesiologist to PACU RN For outpatients, IPASS is in front page of chart

  28. IPASS LPCH Pediatric Anesthesia Rotation Updated August 2013

  29. Parking on call LPCH Pediatric Anesthesia Rotation Updated August 2013 After 4pm and on weekends or holidays, can park in A lot on Welch and Quarry. Move car before 6am week days!

  30. Pain Call Duties LPCH Pediatric Anesthesia Rotation Updated August 2013 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

  31. To Enhance Your Experience… LPCH Pediatric Anesthesia Rotation Updated August 2013

  32. Case Tracking LPCH Pediatric Anesthesia Rotation Updated August 2013

  33. Passport LPCH Pediatric Anesthesia Rotation Updated August 2013

  34. Pedsanesthesia.stanford.edu LPCH Pediatric Anesthesia Rotation Updated August 2013

  35. Pedsanesthesia.stanford.edu • Goals and objectives • Transplant – setup, education • Mitochondrial disease • EB • Critical Airway • Pain LPCH Pediatric Anesthesia Rotation Updated August 2013

  36. Daily Feedback LPCH Pediatric Anesthesia Rotation Updated August 2013

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