pediatric anesthesia basics by a5vokX5v

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									Pediatric Anesthesia
       Basics
        2012
     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
   ETT (3)                                  Mepitec

        One half size bigger and
         one half size smaller
                                             Cloth Tape
        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
AGE     Form      32      Term    3 mo    6mo     12      18      2 yr      3 yr      5 yr      10 yr
        ula       week                            mo      mo
                  s
Kg                2.0     3.5     5.0     6.0     8       11      13        15        20        40




ETT     (age/4)   2.5     3.0     3.5     3.5     4.0     4.5     4.5       4.5       5.0       5.5
        +4
size

ETT     ETT       7.5     9.0     10.5    10.5    12.0    13.5    13.5      13.5      15.0
        size*3
depth

Blade             Mil 0   Mil 0   Mil 0   Mil 1   Mil 1   Mil 1   Wis 1.5   Mil 1.5   Mil 1.5   Mil 2
                                                                  Mac 1     Mac 1     Mac 2     Mac 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-piece
                        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
                                 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
   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
   PR 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 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                    GO!
     Room is ready



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

								
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