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Introduction to Anesthesia at UCLA

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					            Introduction to Anesthesia at UCLA
Index:
   A Typical day
   NPO Guidelines
   Basic Formulary
   Extubation Criteria
   Blood/Respiratory Gas Values
   Cardiac Anesthesia
         Adults
             1. Cardiac Adult Setup
             2. Cardiac Adult Drug Infusions
         Pediatric
             1. Cardiac Pediatric less than 10kg
             2. Cardiac Pediatric greater than 10kg
             3. Cardiac Pediatric Drug Infusions
         Circulatory Parameters
   Jules Stein Eye Institute
      1. Strabismus Surgery
   Liver Transplant
   Obstetrics at UCLA
      1. OB Anesthesia
      2. OB at Cedars
   PACU
   Acute Pain at UCLA
      1. Epidurals
      2. IV/PO
      3. PCA
      4. Transdermal
   Pediatric Anesthesia
   Pediatrics at CHLA
   Santa Monica
         Santa Monica Protocols
             1. TEE
             2. MRI
             3. GI Lab
             4. CT Scan
             5. Cardioversion
             6. Pacemaker
             7. Brain Spect
   Team Captain
   Call Responsibilities
   Email Addresses
   CA-3 Requirements

A Typical Day
Actually, there is no such thing at UCLA. Each day will be different, but this is the general flow of the OR:

      6-6:15 Arrive at UCLA, change into scrubs ( or are wearing them in ). Pick up drug pack at the OR
      pharmacy.
      6-7:00 Set up anesthesia cart and machine check. Call workroom 5-1132 for special equipment (
      fiberoptic, LMAs, etc.) or Call Blood Gas Lab at 5-5070 for Aline, CVP or swan setup.
      7-7:15 See patient in the SAU Surgical Admitting Unit ( across from PTU ), check consents, start IV,
      give premed
      7:15 Move Pt to OR. Request help from RN or Orderlies if neccessary.
      7:30 Monitors on, PreO2.....Induce Pt. Surgery starts.
      11:30-3pm Half hour lunch breaks by covering attending.
      5pm If you are relieved from the room before this, great but this is the usual time for getting out.
      Finish the anesthesia and drug record, turn in the drug pack to pharmacy, and get schedule for
      tomorrows cases.

After the OR.... Do the preops (at PTU) and postops. All inhouse patients should be seen inhouse and
consented. If the pt was evaluated by preop clinic, there is a "yellow line" (anesthesia H&P) in the folder
and also scanned into the computer system. Otherwise the preop evaluation needs to be done by computer
search. Call the patient and get any other bit of history necessary. The PTU also has a list with the patient's
phone numbers where they can be reached that night. Finally, call your attending and discuss the anesthetic
plan.

Note: The Post-OP check is very important. See them in 48 hours and write a small note in the chart to
document the visit. For Example: Pt. POD #2 s/p GETA for lap Chole. Pt doing well. No apparent
complication from anesthesia.

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NPO Guidelines
Ingested Material/Minimum Fasting Period

      Clear liquids 2 h
      Breast milk 4 h
      Infant formula 6 h
      Non-human milk 6h
      Light meal 6h

Summary of Fasting Recommendations to Reduce the Risk of Pulmonary Aspiration:

These recommendations apply to healthy patients who are undergoing elective procedures. They are not
intended for women in labor.

Following the guidelines does not guarantee a complete gastric emptying has occurred.

The fasting periods noted above apply to all ages.

Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black
coffee.

Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered
when determining an appropriate fasting period.

A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may
prolong gastric emptying time. Both the amount and type of foods ingested must be considered when
determining an appropriate fasting period.

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Basic Formulary

from R.H. Steadman's lecture.

Induction Agents:

      Thiopental (25mg/cc; dose 2-4mg/kg): barbiturate; gold standard; contraindicated in patients with
      acute intermittent porphyrias
      Propofol (10mg/cc; 1-2.5mg/kg):decrease SVR; mild antiemetic effects
      Etomidate (2mg/cc; 0.3mg/kg): minimal hemodynamic effects; increase incidence of nausea/vomiting
      and movement during induction;
      Ketamine (10mg/cc, and 100mg/cc; 1-2mg/kg): associated with sympathomimetic response, i.e. good
      for hypovolemic pts and pts with bronchospasm

Inhalation Agents;

      Nitrous oxide (MAC 105%; blood/gas partition coeff: 0.47): least potent
      Isoflurane (MAC 1.15%; blood/gas partition coeff: 1.4): least potent cardiac depressant
      Sevoflurane (MAC 2.08%; blood/gas partition coeff: 0.65): more rapid onsent and offset than Iso; less
      pungent, thus better for inhalational induction.
      Desflurane (MAC 6-8%; blood/gas partition coeff: 0.42): fast onset/offset than Sevo; sympathetic
      stim w/ rapid increases; airway irritant at lower concentrations.

Narcotics

      Morphine (10 mg/cc; analgesic: 0.05-0.2mg/kg)
      Hydromorphone (2mg/cc; diluted to 0.2mg/cc; analgesic: 0.01-0.03mg/kg)
      Meperidine (100mg/cc; analgesic: 0.2-0.5mg)
      Fentanyl (50 mcg/cc; analgesic:1-3 mcg/kg)
      Remifentanil (dilute to 25 to 50 mcg/cc; analgesic dose 0.05-0.1mcg/kg/min; anesthesia: 0.5-
      1mcg/kg/min)
      Alfentanyl (dilute to 100mcg/cc; analgesia 3-8mcg/kg; anesthesia: 0.5-3mcg/kg/min)

Muscle Relaxants

      Succinylcholine (20mg/cc; dose: 1-1.5mg/kg)
      Cisatracurium (2mg/cc; dose: 0.2mg/kg)
      Pancuronium (1mg/cc; dose 0.1mg/kg)
      Rocuronium (10mg/cc; dose 0.6-1mg/kg)
      Vecuronium (1mg/cc; dose 0.1mg/kg)

Muscle Relaxant Reversal
      Neostigmine/Glycopyrrolate (Neo: 1mg/cc; dose: 50-70mcg/kg; Glyco:0.2mg/cc; dose 20mcg/cc)
      Edrophonium/Atropine (Edro: 10mg/cc; dose 0.5-1mg/kg; atropine: 0.4mg/kg; dose 20mcg/kg)

Sedatives

      Midazolam (1 and 5mg/cc; dose: 1-5mg/70kg)
      Propofol (10mg/cc; sedative dose: 25-100mcg/kg/min)

Cardiovascular Drugs

      Ephedrine (dilute to 5mg/cc; dose:5-10mg/70kg)
      Pheynylephrine (dilute to 40 to 100mcg/cc; dose: 50-200mcg/70kg)
      Epinephrine (dilute to 10 to 100mcg/cc; dose 10-100mcg/70kg; 1000mcg for arrest)
      Atropine (0.4mg/cc; dose 0.4-0.8mg/70kg)

Antiemetics

      Droperidol (dose: 0.5mg/70kg)
      Ondansetron (dose: 4mg/70kg)
      Dolansetron (dose: 12.5mg/70kg)

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Extubation Criteria:
      Head lift, Grip
      NIF < -25 torr
      RR < 30
      TV > 5 cc/kg
      VC > 10 cc/kg
      PaO2 > 65 on FiO2 < .40
      PaCO2 < 50 torr
      Resting MV < 10 l/min
      Level of Consciousness OK
      Muscle Relaxants OK
      TV/RR > 10

Things to do prior to Extubation:Â

      Patient either deep or awakeÂ
      Patient either breathing or easy to ventilate manuallyÂ
      Oral airway in place
      Pharynx suctioned
      Cuff deflated
      Lungs manually inflated with 100% O2
      Succinylcholine available.

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Blood/Respiratory gas values
Art. Oxy Sat. (SaO2) 96-100%
Mixed Venous Oxy Sat (SvO2) >70% <80%
pH 7.35 - 7.45
PaCO2 35-45 mmHg (4.7-6.0 kPa)
PaO2 75-100mmHg (10.0-13.3 kPa)
Art O2 content(CaO2) 18-21 ml O2/dl vol%
Alv-Art diff for O2 ( A - a DO2)
at FiO2 = .21 5-25 mmHg
at FiO2 = 1.0 <150 mmHg
Shunt fraction(Qs/Qt) 3-8%
Dead space fraction (Vd/Vt) <.35
Oxygen consumption (VO2) 3-4 ml/kg/min
Co2 production (VCO2) 3-4 ml/kg/min
Oxygen transport (QO2) 12-16 ml/kg/min
Respiratory Quotient(RQ) .7-1.0
Tidal Volume (Vt) 6-8 ml/kg
or short 500 - 1000 ml
Respiratory rate (f) 8-16/min
Respiratory static compliance (Cst,rs)
70-100 ml/cm H2O
Respiratory system resistance (Rrs)
< 3 cmH2O/L/s

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Cardiac Anesthesia UCLA
Book: A Practical Approach to Cardiac Anesthesia Hensley/Martin

Extremely challanging rotation. You will be tired everyday and exhausted by the end of the month. Come in
early (1hr first day) to set up all the drips. This is rotation to get comfortable with lines, ionotropes, echo,
nitric oxide: cool.

Focus on the echo after the basics.

NEVER look on the main OR schedule. Cardiac schedule is behind the OR front desk or in the anesth
library. Even then the cases will change at whim at any time. Always come to the OR by 6:15 even if no
cases scheduled. Ask Dr. Sopher.

Blood Gas lab will be prepared with triple setup/swan kit; call them to request echo. Attnd will help with
ehco type and +/- nitric oxide. They also deliver the christmas tree for infusion pumps. There is a person
devoted to running cardiac case ABGs to the lab.

Turn on continuous cardiac monitor: it takes a while to warm up. Calibrate to Pt - Attnd will show.

Double check infusion pump settings. No air in IV lines, esp pediatric cases.

Finish charting at bypass. Be alert at opening of sternum, closure of chest, initiation of bypass and coming
off bypass.
EBL usually not documentable.

Bring intubation and emergency drugs with you during transport since patients can code anywhere or
anytime.

Pager may not work in room 23.

There is a lot of equipment,lines,and people - hope you are not claustrophobic.

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Cardiac Adult Setup
Drugs

  1.    fentanyl 50 mcg/ml in 20ml syringe ( from 50ml)
  2.    midazolam 1 mg/ml in 10 ml syringe
  3.    pancuronium 1mg/ml in 10 ml syringe
  4.    calcl 100 mg/ml in 10 ml syringe ( 2)
  5.    phenylephrine 100mcg/ml in 10 ml syringe (2)
  6.    NTG 100 mcg.ml in 10ml syringe (2)
  7.    Epi^ 100 mcg/ml in 10ml syringe
  8.    Epi 10 mcg/ml in 10 ml syringe
  9.    Ancef 1gm in 10mg syringe second dose given post CPB
 10.    Available in room succ, atropine,lidocaine, ephedrine, heparin stp protamine

Peripherals

   1.   1NS blood pump connected to 2 stopcocks with 33" ext.
   2.   1 NS blood pump to HOTLINE with 2 stopcock (cordis)
   3.   1 60ml D5W/NS syringe pump to 60" ext with 4 stopcock
   4.   4 syringe pumps available in room
   5.   airway equipment scope,blades,ett,sylets,suction
   6.   triple setup transducer
   7.   heparinized syringes (ABGs)

Miscellanies

   1. Dopamine and NTG gtt
   2. TEE, epicardial probes

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Cardiac Adult Standard Drug Infusion Setup
DRUG/ concentration mix / final/ dose loading/ infusion rate

AMIODARONE
no dilution/ 50 mg/m final / 150mg load / 60 mh/hr infusion
*Infuse 60 mg/hr over the first 6 hrs and 30 mg/hr over the next 18 hrs.
AMRINONE
no dilution/ 5 mg/ml final l/ 1.5 mcg/kg load/ 5-15 mcg/kg/min infusion

APROTININ
no dilution/ 10,000 U/ml final/ 100-200ml load/ 25-50 ml/hr infusion

** Test dose = 1cc. Wait five min, then give loading dose over 20min. Load bypass pump with another
dose. Drip is continued throughout CBP and until skin closure.

BRETYLIUM
0.5gm/50cc conc/ 10mg/ml final/ no load/ 1-4mg/min infusion

DILTIAZEM
no dilution/ 5mg/ml final/ 0.25mg/kg load/ 5-15mg/hr infusion
***Loading = 0.25mg/kg over 2 min, if inadequate give 0.35mg/kg 15 min later.

DOBUTAMINE
250mg/50cc conc/ 5mg/ml final/ no load/ 2-20mcg/kg/min

DOPAMINE
400mg/50cc conc/ 8mg/ml final/ no load/ 3-10mcg/kg/min

EPINEPHRINE
1mg/50cc conc/ 0.02mg/gl final/ no load/ 0.01-0.5 mcg/kg/min

ESMOLOL
2.5 gm/50cc/ 50mg/ml final/ 0.5mg/kg load/ 50-300 mcg/kg/min infusion (ICU conc 10mg/cc - 2.5g/250cu)

FENTANYL
500mcg/50cc/ 0.01mg/cc final/ no load/ 1-3 mcg/kg/hr infusion

ISOPROTERENAL
1mg/50 cc/ 0.02 mg/ml final/ no load/ 0.02-0.1 mcg/kg/min

LIDOCAINE
no dilution/ 40mg/ml final/ no load/ 0.25-0.75 mcg/kg/min
****4% bottles are available from pharmacy for infusion

MILRINONE
no dilution/ 1mg/ml final/ 50mg/kg load/ 0.25-0.75 mcg/kg/min

PHENYLEPHRINE
10 mg/50cc/ 0.2mg/ml final/ no load/ 0.2-2 mcg/kg/min

NICARDIPINE
25mg/50cc/ 0.5mg/ml final/ no load/ 5-15 mg/hr

NOREPINEPHRINE
4mg/50cc/ 0.08mg/ml final/ no load/ 0.01-0.2 mcg/kg/min

NITROGLYCERIN
50mg/50cc/ 1 mg/ml final/ no load/ 0.5-5 mcg/kg/min
NITROPRUSSIDE
50mg/50cc/ 1mg/ml final/ no load/ 0.5-5 mcg/kg/min

PGE
0.5mg/50cc/ 0.01mg/ml final/ no load/ 0.03-2 mcg/kg/min

PROCAINAMIDE
1gm/50cc/ 20mg/ml final/ no load/ 1-4mg/min

PROPOFOL
no dilution/ 10mg/ml final/ no load/ 10-50 mcg/kg/min

                                               Return to Index

Pediatric (Less than 10 kg)
Drugs

  1.    fentanyl 10mcg/ml in 10ml syringe
  2.    fentanyl 50 mcg/ml in 3 ml syringe
  3.    midazolam 1 mg/ml in 2 ml syringe
  4.    pancuronium 1 mg/ml in 3 ml syringe
  5.    cacl 25-50 ml/ml in 10 ml syringe (2)
  6.    phenylephrine 100 mch/ml in 10 ml syringe (2)
  7.    phenylephrine 10 mcg/ml in 10 ml syringe
  8.    NTG 100 mcg/ml in 10 ml syringe (2)
  9.    Epi 10 mcg/ml in 10 ml syringe
 10.    Epi 1 mcyh/ml in 10 ml syringe
 11.    Ancef 1 gm in 10 ml syringe ( second dose post CPB)
 12.    Atropine 0.4mg/cc in 3 cc
 13.    Available : succ,lido,ephed,heparin,stp,protamine

Periferals

   1.   1 NS buretrol connected to 2 stopcocks, 33" ext
   2.   1 NS blood pump to hotline 2 stopcocks, NOT connect to pt.
   3.   WARM flush syringes
   4.   1 60ml D5W ( D10 for neonates, less than 6mo), 60" ext 5 stopcocks, 60" ext
   5.   5 syringe pumps in room
   6.   airway equipment : mill 0.1.1.5, ett 2.5-4, suction
   7.   triple transducer setup
   8.   4 heparinized syringes ABG
   9.   5 ml NS/albumin flush

Miscellanies

   1. discuss drip conc with attnd. The drip rate at the lowest commonly used dose should be at least 1
      ml/hr
   2. dopamine ( 2mg/ml)(1/4 stnd)
   3. NTG (0.25mg/ml) ( ≈ stnd)
   4. Dobutamine 1 mg/ml (1/5 stnd)
   5. No dilution for epinephrine, PGE, Isoproterenol, same gtt premade as ICU
   6. pediatric TEE for children over 3-4 kg
   7. bairhugger with u blanket

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Pediatric (Greater than 10 kg)
Drug

  1.    fentanyl 50 mcg/ml in 20 ml syringe ( from 50ml )
  2.    midazolam 1 mg.ml in 10 ml syringe
  3.    pancuronium 1 mg.ml in 10 ml syringe (2)
  4.    phenyl 100 mcg/ml in 10 ml syringe (2)
  5.    phenyl 10 mcg/ml in 10 ml syringe
  6.    NTG 100 mcg/ml in 10 ml syringe (2)
  7.    Epi 10 mcg.ml in 10 ml syringe
  8.    Epi 1 mcg/ml in 10 ml syringe
  9.    Ancef 1 gm in 10 ml syringe
 10.    Atropine 0.4mg/cc in 3 cc syringe
 11.    Available : succ, lido,ephed,heparine,stp, protamine

Peripherals

   1.   1 NS buretrol connect 2 stopcocks, 33" ext
   2.   1 NS blood pump to hotline , 2 stopcocks ( CVP)
   3.   1 60ml D5W , 60" ext, 5 stopcocks, 60 " ext.
   4.   5 syringe pumps in room
   5.   airway equipment : scope, ett suction with pediatric tip
   6.   4 heparinized syringes ABG

Miscellanies

   1.   drip rate lowest 1 ml/hr
   2.   dopamine 4 mg/ml
   3.   NTG 0.5 mg/ml
   4.   Dobutamine 2.5 mg/ml
   5.   (all 1/2 stnd)
   6.   pediatric TEE for children under 15 kg
   7.   upper body / Corrie cover bair hugger.

Heparin
2.5-3 mg/kg (250-300 U/kg) concentration 1 mg/ccor 100 U/cc
surgery to r atrial appendage or SVC
ACT check baseline and 3-5 min post dose.
ACT > 400
Protamine (perfusionist calculates)
Reversal of heparin = 3 mg/kg after CPB
Slow infusion over 5-10 min . watch for anaphylaxis, hypotension, dysrythmias
Notify perfusionist at start ( close off pump suckers when half is in)
ACT check 3-5 in after infusion
Repeat dose 0.5 - 1.0 mg.kg every 15-30 min
Maintain ACT < 150
Pump blood needs more.

Hematocrit
^Neonate and residual cyanotic conditions ^30-40%
^Acyanotic children and healthy adult >24%
^Adults with severe ischemic disease 28-30%

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Cardiac Pediatric Standard Drug Infusion Setup
Drug/ Concentration Mix/ Loading dose/ Infusion rate

** For neonates and small infants the above drug concentration may need to be further diluted to allow
infusions that run at a minimum of 1 cc/hr.

AMIODARONE
300mg in 50cc NS syringe/ 6mg/ml final/ 5mg/kg load/ 5mcg/kg/min infusion

AMRINONE
125mg in 50cc/ 2.5 mg/ml final/ 0.75mg/kg over 3 min load/ 3-10mcg/kg/min infusion

APROTININ
no dilution/ 10,000U/ml final / 20,000U/kg load/ 10U/kg/ml infusion
*test dose = 1cc; wait 5 min, then give loading dose over 20min. Load bypass pump with another loading
dose. Drip is continued throughout CPB until skin closure.

BRETYLIUM
250mg/50ccNS/ 5mg/ml final/ 5 mg/kg load

DOBUTAMINE
125mg/50cc / 2.5mg/ml final/ no load/ 2-20 mcg/kg/min infusion

DOPAMINE
80mg in 50ccNS/ 1.6 mg/ml final/ no load/ 2-20 mcg/kg/min infusion

EPINEPHRINE
1mg/50cc/ 0.02 mg/ml final/ no load/ 0.01-0.5 mcg/kg/min infusion

ESMOLOL
2.5gm in 50cc/ 50mg/ml final/ 0.5mg/kg load/ 50-300 mcg/kg/min infusion

FENTANYL
500mcg in 50cc/ 0.01 mg/cc final/ no load/ 1-3 mcg/kg/hr infusion

ISOPROTERENOL
0.5 mg in 50cc NS/ 0.01mg/ml final/ no load/ 0.02-0.1 mcg/kg/min infusion

LIDOCAINE
400mg in 50cc NS/ 8 mg/ml final/ 1 mg/kg load/ 20-50 mcg/kg/min infusion
MILRINONE
12.5mg in 50cc NS/ 0.25mg/ml final/ 50 mcg/kg load/ 0.25-0.75 mcg/kg/min infusion

PHENYLEPHRINE
2mg in 50ccNS/ 0.04mg/ml final/ no load/ 0.2-2 mcg/kg/min infusion

NOREPINEPHRINE
2mg in 50cc NS/ 0.04 mg/ml final/ no load/ 0.01-0.2 mcg/kg/min infusion

NITROGLYCERIN
25mg in 50cc NS/ 0.5mg/ml final/ no load/ 0.5-5 mcg/kg/min infusion

NITROPRUSSIDE
25mg in 50cc NS/ 0.5mg/ml final/ no load/ 0.5-5mcg/kg/min infusion

PGE
0.5 ng in 50cc/ 0.01 mg/ml final/ no load/ 0.03-2 mcg/kg/min infusion

PROCAINAMIDE
1 gm in 50cc/ 20mg/ml final/ no load/ 1-4 mg/min infusion

PROPOFOL
no dilution/ 10mg/ml final/ no load/ 10-50 mcg/kg/min infusion

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Circulatory Parameters/Equations
Systolic pressure (SP) 100-140 mmHg

Diastolic pressure (DP) 60-90 mmHg

Pulse pressure (SP-DP) 30-50 mmHg

Mean art pressure (BP,mmHg)
= (SP + 2DP) / 3 at normal heart rate

Heart rate 60-90 / min

Stroke vol 50-100 ml

Stoke index (SI)
= SV / body surface area (BSA)
= 35-50 ml/m2

Right atrial pressure (Pra) 2-8 mmHg

Pulm systolic P 16-24 mmHg

Pulm diast P 5-12 mmHg

Pulm Pulse P 8-15 mmHg
Mean Pulm art P (Ppa) 9-16 mmHg

Mean Pulm capillary wedge P (Ppw) 5-12 mmHg

Cardiac output 4-6 L/min
= Qt = SV x HR

Cardiac index 2.5-3 L/min/m2
= CI = Qt / BSA

Systemic vasc resist
10 - 15 mmHg/L/min
(to convert to c.g.s.units multiply x80)
900 - 1200 dyne/s/cm5
= SVR = ( MAP - Pra ) / Qt

Pulm vasc resist
1.5-2.5 mmHg/L/min
( 120-200 dyne/s/cm5 )
= PVR = ( Ppa - Ppw ) / Qt

Venous return (VR) 4-6 L/min
= ( Pms - Pra ) / Rvr
where Pms is mean syt pressure
10-15 mmHg
where Rvr is resistance to venous return 1-2 mmHg/L/min

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Jules Stein Eye Institute
Rapid turnover. Busy days : Prepare All IV and drugs in advance.

Avoid taping the eye !

Protocol for IV sedation. (M.Keyes)

      PreO2 or supplement O2 before bolus
      Mix 8 cc DIRPIVAN/propofol with 1000mcg Alfentanil (t=10ml)
      Give bolus of Alfentanyl based on age:
            <50 y/o 5 mcg/kg
            50-70, 4 mcg/kg
            >70, 3 mcg/kg
            (or 1 cc per kg)
      then run alfentanyl infusion at 0.75 mcg/kg/min stop the infusion when retrobulbar block is done. Be
      prepared for apnea after bolus. may need to support the airway.

Supply room is in the back. No support staff to turnover room. Circuits are in bins between the rooms.
Claim an anesthesia cart in the hallway and drug trays are in the supply room. Controlled drugs get
delivered sometimes late by roving pharm dude.
                                               Return to Index

Jules Stein Inst. Strabismus Surgery
By Mary Keyes, MD

Children

   1.   Premedication 0.5mg/kg midazolam PO or PR
   2.   Induction: Mask with sevoflurane
   3.   Airway: LMA (if OK PMHx)
   4.   Maintenance: Diprivan/propofol Infusion at 150mcg/kg/min, taper to 100 and then 50 for the last 10-
        15 min
  5.    60%N2O and O2
  6.    Narcotics: fentanyl 2-3 mcg/kg
  7.    Muscle relaxants: optional, pefer not
  8.    Analgesics: tylenol 20 mg/kg PR post induction
  9.    Antiemetics: zofran 100 mcg/kg if +history/motion sickness
 10.    Post OP analgesia: fentanyl 0.5-1 mcg/kg iv q 5-10 min. prn

Adults

   1.   Premedication: midazolam 1-2mg IV
   2.   Induction: propofol 1.5-2 mg/kg
   3.   Airway: LMA unless contraind.
   4.   Maintenance: same as above - propofol infusion
   5.   Muscle relaxants: Optional
   6.   Analgesics: ketoralac 30-60mg iv/im
   7.   Antiemetics: zofran 4 mg if +PMHx
   8.   Post op Analgesia: same as above

                                               Return to Index

Liver Transplant Setup
Lines:

        cordis with PA cath
        cordis
        large periferal IV
        arterial line
        chain gang of stopcocks for infusions with dedicated infusion pump at 10 cc/hr NS (or buretrol)

Meds:

        epinephrine 10 mcg/cc and 100 mcg/cc
        ephedrine 10mg/ml
        Lidocaine 1%
        x2 CaCl 100mg/cc
        x2 Bicarb
      x2+phenylephrine 100mcg/cc
      Induction meds: RSI
            succinylcholine
            thiopental/propofol; regular doses
            fentanyl
      Paralysis: Cisatracurium
      Drips:
            Dopamine 1 cc (80mcg of 400mcg/5cc) in 50cc NS-conc 1.6 mcg/cc
            Calcium 100mg/cc at 1 gm/hr
            Amicar bolus 3-4 gm(75mg/kg) then run at 1-2 g per hr in adults.
            PGE 1-0.01 mcg/kg/min
            Dextran run at 0.5 cc/kc/hr. give promit first(20ml/70kg) (if surgeons request it)
            OKT3-5mg/100ml over 1 hr

Replacement:

      1.5
      Platelets for oozing or <100K
      Cryoprecipitate for fibrinogen <100
      Amicar for fibrinolysis
      Protamine 50 mg bolus (used in cardiac)

Pediatric Cases

      Keep PT 18-20
      Hct 25-28
      Insulin infusion
      Dextran infusion

Coagulation Labs

      PT 11.1-12.9-extrinsic
      PTT 22.9-33.8-intrinsic
      Plt 140-440
      thrombin time <20

                                               Return to Index

Malignant Hyperthermia

Henry Rosenburg,M.D.
Philadelphia, Pennsylvania - 1997
Intro : Denborough and Lovell

Diagnosis of true MH :

   1. Hypermetabolic response to volatile agents and /or succinycholine
   2. An inherited component
   3. Muscle destruction
Etiology/Pathos :
uncontrolled increase in intracellular calcium levels

Genetics:
AD heterogenic disorder - controll of intracellular ca levels is a complex # genes

Clinical Presentation:
Increasing ETCO2, acidosis, muscle, rigidity, rhabdomyolysis,hyperkalemia,
tachycardia,tachypnea,arrhythmia, and death monitor core temperature in any procedure >20min.

ALL INHALATIONAL ANESTHETICS AND SUCCINYLCHOLINE, ARE TRIGGERS FOR MH
(Nitrous is not a trigger). No other drugs appera to be triggers, including propofol and ketamine.

Succinylcholine with masseter m. rigidity "jaws of steel"

50% Pt with MMR are MH susceptible

Sudden cardiac arrest with MH tiggers

      check undiagnosed myopathy (Duchenne's)
      check hyperkalemia
      succ reserved for full stomach/EM
      50% with unexplained ^ in CK also MH

MH like disorders:

      hyperthermia, acidosis
      myoglobinuria, arrhythmias
      cardiac arrest

Disorders char. by hypertherm, acidosis, rhabdo, NOT MH, myopathies

      MAO inhibitors and Meperidine interactions
      cocaine tox(esp with alcohol)
      heat stroke serotonin synd.
      water soluble contrast agent in CSF
      status elepticus
      hypoxic encephalopathy
      pheochromocytoma

Mimics of MH

      sepsis, thyroid storm, pheochromocytoma, iatrogenic overheating

Treatment of MH:

      Immediate discontinue of trigger agents, hyperventilation, administration of dantrolene in doses of 2.5
      mg/kg repeated prn to signs of MH, cooling by all routes availabel (esp. NG lavage), treatment of
      hyperkalemia. (don't use CA blockerswith dantrolene : potentiates hyperkalemia with combo)
      Additional muscle biopsy, tests for sepsis, urine monitor for myoglobinuric renal failure

Testing for MH:
sensitivity ~100%, false positive 15-20%

MHAUS :
32 S. Main St. PO Box 1069
Sherburne, NY 13815
1-800-98-MHAUS
Fax on demand : 1-800-440-9990
http://www.gasnet.med.yale.edu/
http://www.mhaus.org/
HOTLINE # : 1-800-MH-HYPER

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Neuro Anesthesia
Attendings:

      Van de Wiele
      Rubinstein
      Ziv
      Nadjat-Haiem

Get comfortable for an extremely long case: good chair, extra blankets, warm bottle, something to
read.(something to eat).

Intubation is incredibly important secondary to ICP and intracranial bleeding issues. It's considered bad
form to rupture an aneurysm before craniotomy. Intubation needs to be smooth with hemodynamic control -
generous narcotics,esmolol, nitroglycerin, nitroprusside.

Maintaining an airway when the pt's head is very far away needs vigilance, a secure ETT(mastisol), a
surgeon who will notify you if he moves the head. Pts have been extubated while their head was still open
and in the mayfield! Do not put an oral airway for long case - has been associated with tongue edema.

Neurosurgeons may desire and specify a particular range for pt's BP and ETCO2. During spine cases,
orthopods usually want hypotension while neurosurgeons want near nl.

Rubinstein does most central lines via subclavian route.

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Neuro Anesthesia setup
For induction:

      Thiopental 3-5 mg/kg
      Fentanyl 3-10 mcg/kg
      Rocuronium 1 mg/kg
      Lidocaine 1-1.5 mg/kg

After induction:
      Mannitol 1-1.5gm/kg at skin incision over 20 min. Check foley and iv is OK. Check UOP, K,and
      osmolatiy before and after mannitol.
      Consider Lasix 0.5-1 mg/kg

Maintenance:

      Low dose isoflurane 0.4%ish
      Nitrous oxide
      Fentanyl drip at 1-3 mcg/kg/hr
      Dilantin: beware of hypotension and bradycardia. dilantin load 10-20 mg/kg at 50 mg/min

Barbituate coma:

      Thiopental loading dose of 10 mg/kg
      Thiopental drip at 10mg/kg/hr
      Thiopental bolus of 75mg prn EEG burst
      EEG goal is 1 burst per 10 seconds

Typical parameters :

      ETCO2 between 25-30
      CVP between 10-12
      MAP as specified by surgeon/attnd
      Osmolarity 295-310 , avoid >320

Head Trauma:

      Keep cerebral perfusion pressure
      >70mmhg , SBP >120
      CPP=MAP-ICP
      CVP goal = 10
      ICP goal < 20mmhg
      SVO2 > 55%

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Obstetrics at UCLA
There are 2 OR rooms that get routinely used and one that is more for minor procedures. The rooms must be
ready at all times for a crash c-section. Everyday draw fresh succinylcholine/ephedrine; ready to draw-
etomidate . Setup IV and airway also. Monday am - you may need to restock cart.

Call room is at the end of the back hallway of the OB suite. The closest bathroom is too far away.

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OB Anesthesia
Analgesia for labor:

   1. Bolus-5-10cc 0.25% bupiv w/fent 100mcg: 3cc test dose - wait 4min - check sens, then 5cc test dose
      -wait 2min - check for intravascular - then the rest.
   2. Give 15% BV/minimum 1L w/epid
   3. Infus:.0625% bupiv w/fent 2mcg/cc at 7-10cc/h early labor. If active labor - give 5cc inj of 0.0625%
      to enhance block.

HOW TO MAKE LABOR INFUSIONS:

If using older Baxter pumps (50cc total volume):

Conc       bupiv.25%                fent50/cc          saline
0.1%            20cc                  2cc                28cc
0.0625%         12.5                   2                 35.5
0.05%           10                     2                 38

If using new PCEA pumps:
Get 100cc NS bag, add 35cc of 0.25% Bupiv + 5cc Fentanyl (50mcg/cc); total volume of 140cc. Set rate to
10cc/hr, bolus dose 5-6cc, interval 12min, max 4 demands/hr.

Anesthesia for vaginal delivery: T10

Epidural-
2% Lido w/epi 10-14cc bolus

Spinal-
5% Lido in 7.5%D-0.6-0.8cc (30-40mg)
or.....
0.75%bupiv in 7.5%D 0.8-0.9cc (6-7mg)

GA - see below for details
RSI,thiop or ket w/succ,iso (up to 4%)
for uterine relax (100mcg NTG too),
then N2O/narcs ASAP; after baby out, reduce volatile(<0.5 MAC) since it relaxes uterus = increases
bleeding

Anesthesia for C-Section

General facts:

   1. npo 8hrs
   2. LR, bloodpump, 16g iv
   3. Fluids: deficit-125cc/hr npo, maintenance- 8-10cc/kq/hr, EBL -4cc/cc >700cc, for regional-volume
      expan-30%BV
   4. Polycitra 30cc
   5. T&S,HCT
   6. Uterine tone:
         1. Pitocin 30-40u/L into IV bag after delivery. Add 20-30u/L to bottles. Hypotension w/bolus.
         2. Methergen 0.2mg IM. Can cause N/V. IV can cause extreme HTN.
         3. Hemabate 0.25mg IM q15-30min prn up to 2mg-can cause V/Q mismatch, bronchospasm,
            hypox. Careful with asthmatics!

Epidural anesthesia: T2-T4 level:
   1.   Rapid infus 30% BV - min 2000cc LR
   2.   2%lido w/epi 1:200k 20-25cc (may add fent 100mcg, HCO3 2cc 1:10vol)
   3.   Top off dose @60-75 min
   4.   20 min before end- 5-7cc top off if not given recently, 4mg duramorph.

Spinal anesthesia-T4 level

   1. 30% LR bolus as w/epid
   2. hyperbar bupiv 0.75% 1.5-2cc w/fent 20mcg + duramorp 0.2mg=0.4cc +/- epi 0.1 mg.

Post Duramorph Orders

   1.   Received ---- @ -----
   2.   RR q 1hr until ----- (24h)
   3.   Record sedation q 1h until----(24h) 0=none, 1=arousable, 2=not arous.
   4.   Call anesth resident or team captain for RR<8, sed=2, itch, N/V,pain
   5.   No IV analgesia/sedation w/o anest approval until----(24h)
   6.   IVF until ----, or as per OB team.

General Anesthesia

   1. R hip wedge
   2. Pre-O2 w/4-5 deep breaths
   3. RSI thiop 4mg/kg + succ 1.5-2mg/kgw/cricc; may use ketamine 0.75mg/kg or etom 0.3mg/kg,
      vecuronium 0.1-0.2 mg/kg, no rocuronium.
   4. when OB's ready to start, intub w/ 6.0-7.0 ETT, then incis OK
   5. 50%nitr + 0.75 iso (no overpress) @ flow 10L/min
   6. CO2~30torr
   7. After deliv-D/C iso, nitr to 67%, add narcotics
   8. End: D/C nitr, leave on vent @ 10L/min until awake. Extubate fully awake.

Anesthesia for Preeclampsia

   1.   Severe-fluid preload=500cc for deliv 1000cc for c-section. Do not correct deficit.
   2.   Mild or chronic HTN - normal fluids
   3.   Regional anesth technique of choice
   4.   Coags-chk plts on all, chk PT/PTT if severe preec or if plts < 100k
   5.   Awake a-line if GA-RSI- alfent 30mck/kg + thiop 2mg/kg + succ, maintain w/narcs.
   6.   For HTN -labetalol, NTG, nitropruss. NO esmolol becausec of fetal brady

Cerclage anesthesia

   1. Spinal - do block in lateral, no sitting
         1. lido 5% in 7.25%D 1.2-1.5cc- dilute w/equal CSF
         2. bupiv 0.75% in 8.25D 1.5-2.0cc
   2. GA - nitr/narcs/40% O2 min/RSI

Postpartum Tubal ligation anesthesia

   1. Epidural-T4 level: lido 2% w/epi 22-25cc
   2. Spinal: lido 5% 1.2-1.5cc or bupiv 0.75% 1.6-2.0cc
Retained Placenta anesthesia:
Same as for vaginal delivery. For uterine relaxation - use IV NTG

Placenta accreta = prepare for blood loss

        0.04% of all pregnancies
        5% in previa
        24% in previa w/prior c-section
        40-60% in previa w/3-4 c-sections

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Obstetrics at Cedars
The OB service at Cedars is especially busy. You will do between 8-15 epidurals and 2-4 c-sections in a
24hr shift. Unlike UCLA nurses, Cedars nurses turn pumps off, pull epidural catheters, and determine when
a patient gets epidural.

OB attending: 0211

OB Resident: 1314

Standard Dosages:

   1.   Intermitten bolus: bupiv .25% 6-9ml,with 50-100mcg fentanyl
   2.   Pushing dose: bupiv .125% w/fent 100mcg, 14ml (bupiv .25% 7cc + fentanyl 2cc + NS 5cc)
   3.   Delivery dose: (baby's head + episiotomy) 1.5%chloropro +/- bupiv0.125% 12-15ml
   4.   Infusion bag: bupiv 0.0625%/fent 2mcg/cc : NS 100ml + 15ml bupiv 0.5% + 5ml fentanyl 50mcg/ml,
        infuse at 10-14ml/hr. If no narcotics in infusion, run at 18-20cc/hr.

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PACU

#1 responsibility : sign out patients from the recovery room.
#2 responsibility : do yellow lines and consents for the T.C
#3 responsibility : get coffee and breakfast in the morning

Anticipate post op complications and pain management. PACU person may be the only circulating lunch
relief on busy days.

End of the day: day T.C has to wait to pass on to night T.C; sign out with night T.C.

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Acute Pain at UCLA
This is now a 4 week rotation. Two residents and the pain fellows share call responsibilities. Call is from
home.
Pain room # 112-5355
pager 93600
phone 70315

pain office 67608

house phone 61328

clinic 41841

OB 73136

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Pain (EPIDURALS)
Dosages:
give bolus dose 30mins - 1h prior to leaving the OR w: 100mcg fent + 3-5cc 0.125-0.25 bupiv and start the
infusion at the same time

THORACIC

   1. 0.0625-0.125% bupiv 4-10cc/hr
   2. 0.25% bupiv 4-8cc/h for refact
   3. dilaudid 0.1-0.4 iv q2 prn btp

ABDOMEN

   1. 0.0625-0.125% bupiv + 0-5mcg/cc fent @6-14cc/h
   2. 0.25% bupiv + 0-5mcg/cc fen @ 6-10cc/h refract

LOWER EXTREMITY

   1. 0.0625-0.125% bupiv + 0-5mcg/cc fent @ 8-14cc/h
   2. 0.25% bupiv + 0-5mcg/cc fent @8-14cc/h refract

Benefits:

   1.   Dec. bleeding intraop
   2.   Dec. incidence of constipation
   3.   Dec. sedation
   4.   Dec. confusion
   5.   Improve resp. function
   6.   Faster recovery rate
   7.   Dec. incidence of phantom limb pain
   8.   Better analgesia


** dec. the need for po opioids on d/c

Risks:
     1.   Nerve damage
     2.   Paralysis
     3.   Hypotension
     4.   Bradycardia
     5.   Motor weakness
     6.   Sensory deficit
     7.   Itching
     8.   Sedation

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Pain (IV/PO)
IV

     1. Robaxin (methocarbamol)
              250-750 ivpb q4-8hr prn spasm
              avg. 500mg iv q8h
     2. Ativan
              0.5-2mg iv qhs-q8 prn sleep/anx
              don't mix with other sleep/anxiol
     3. Toradol
              15-30mg iv q8 x24-72hrs
              don't use on pt's w/ulcers, RF, CHF, ASA allergy
              pt w/epidurals, limit to 15mg iv q8 x3days

MS/MYOFASCIAL PAIN

     1. Baclofen
              5-20mg po qhs-qid prn
              avg 5mg po tid
              max 20mg po qid
     2. Robaxin
              250-750mg po qhs-q4hr prn
              avg 500 mg po q8hr

NEUROPATHIC

     1. Neurontin 100-400mg po qhs-qid
     2. Mexilitine 150mg po qid
     3. Dilantin 50 mg po tid

ANTI-INFLAMMATORIES

     1. Celebrex 100-200mg po qd-bid
     2. Vioxx 25-50 mg po qd

PURE OPIOIDS

     1. Oxycodone tab/elixir
             5-20mg po q3-6hr prn mild pain
         10-30mg po q3-6hr prn moderate
         15-40mg po q3-6 prn severe
  2. MSO4 tab/elixir: 10-30 mg po q4-8hr prn

ANXIOLYTICS/SLEEP AIDS

  1. Ativan 0.5-2mg poq8/qhs
  2. Klonopin 0.5-2mg po q8/qhs

OPIOID/ACETAMINOPHEN MIX

  1. Vicoden: 5mg hydrocodone/500; 1-2 tab po q4-6 (max 8 tabs/day)
  2. Wygesic: 65mg propoxyphone/650; 1 tab po q6 prn (max 5 tabs/day)
  3. T#3 30mg codeine/300; 1-2 tabs po q4-6 (max13 tabs/d)

**max dose for acetaminophen 4g/d

MEDS NOT ON THE FORMULARY

  1. Norco 10/325 (10mg hydroco/325)
           1-2 tab po q4 max 12 tabs/day
  2. Ultram 50mg
           1-2 tab po q6
           max 400mg qd
           max 300mg qd for renal pts
           don't use on pts w/h/o seizures
  3. Actiq 200-1600mcg units - ask the attending.

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Pain (OPIOIDS =ANALGESIC DOSE)
FENT 50MCG = MS 1MG

MS 10MG =

METHA 10MG =

DILAUDID 1.5 MG =

MEPERIDINE 75 MG =

LEVORPHANOL 2MG =

PO dose 1/3 of IV dose

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Pain (PCA Settings)
1. MSO4
demand (bolus): 1-5mg IV
frequency: q3-10mins
basal rate: none-1mg/hr(8pm-6am)
hour max dose: 8-35mg

2. Dilaudid
bolus: 0.1-0.6mg IV
frequency: q3-10mins
basal: 0-0.2mg/hr (8pm-6am)
max: 1.5-10mg/hr

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Pain (TRANSDERMAL)
Fentanyl patch

      25-100mcg/hr, change q3days
      Takes 12hrs to begin taking effect
      See full effect in 24-72hrs
      Wait 3days before changing dose
      Takes 12hrs for effect to dissipate after removal

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Pediatric Anesthesia
Vital Signs:
typical BP in children 1-10yrs = 90mmHg + (child's age in yrs x2)mmHg
lower BP limits in children 1-10yrs = 70mmHg + (child's age in yrs x2)mmHg

Approximate weight

      28 wks = 1kg +/- 100g/wk from 22-30wks
      1 yr: 1/2 age(months plus 4kg)
      1 yr to puberty: 2 x age in yrs plus 10kg

Endotracheal Tube Recommendations:

      Uncuffed tubes for children under 10yrs
      Tube leak 15-20cm
      Tube size(mm): for children older than 2 yrs, (Age/4) + 4
      Length of insertion: 3 x tube internal diameter (mm)


Reservoir bags: newborn 0.5L; 1-3 yrs 1.0L; 3-5 yrs 2.0L greater than 5yrs 3.0L

LMA sizing: Â

      < 5 kg = 1
      5-10 kg = 1.5
      10-20 kg = 2
      20-30 kg = 2.5
      30-50 kg = 3

Fluids:

      4+2+1 rule (4cc/kg 1st 10 kg,Â
      2cc/kg 2nd 10 kg,Â
      1cc/kg after that) per hour

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Pediatrics at CHLA

Children's Hospital of Los Angeles

Generally, the busiest month is September and the busiest times are during holiday / vacations (SUMMER).

Directions from UCLA: Take 10 E (stay in L lane), 110 N (avoid exits to downtown 6th-1st), 101N via R
side exit ramp, exit 101N on Vermont, go North on Vermont (R turn), R on Sunset. Childrens visitor lot at U
driveway and parking across the street. Park in visitor lot and ticket validated for first and last day.

Bring: Check book

Immunization record (TB w/i 3 mo)

Your own scrubs.

Orientation is 6:30 am. Newbies usually begin at outpatient. Parking/ID/Ect. will be done during lunch.

OR logistics: Cases start at 7:30. Case schedule prelim is in the supply room behind the OR board. If Pt is
SDA (same day admit) no need to call pt or preop; RN will fill in preop when pt arrieves. You/Attnd will
consent and discuss before each case. It Pt is inpt, you need see the pt, fill their "yllw" line, consent, and
discuss case with attnd. All post ops are done by the on call person.

Call: The bane of call are all the postop checks of the day. Get the check list from recovery room after last
case. Add on cases for next day need to be seen. That list is at front desk. Otherwise expect 6-8 hrs of sleep.
You will carry the Pain service pager, but expect rare and easy to fix pages. Leave the post op list and
copies of the preops in the supply room.

Pearl of the MO: Agreement of the residents/RN students - everybody fills/signs the post op check form for
their patients. The person on call only has to check on the pt and need only to modify the note if there is a
complication (time consuming to find charts and the form).

Food: Stipend of ~$75 and $20 McDonald gift dollars.

There are RN anesth trainees now (~2-3).there may actually be fellows there.

Finally, be very accurate (even down to the every 1 mcg of fentanyl) with drug accounting since they are
very strict with record keeping.

Lectures every am at 6:30.
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Santa Monica
1250 16th St just south of Wilshire Blvd. OR located on the 4th floor of southeast section / Pavilion of
hospital.

Prefirst day. OR schedule is online. No preopcharts and usually no MR #. Check computer of info if have
MR or call patient. Cases can start late and usually are ASA I or II. Get parking permit from Coco.

First day: Setting up the room is similar to Jules Stein : nothing is where you think it is and you have to set
up most things yourself. Pharmacy open around 6:50 - 7:00 am. Get ID on 2nd floor volunteer / security
office 11am - 2 pm M,W,F, later on during the day.

Tips:

        Cafeteria food is free.
        319-xxxx
        amb care unit 94825
        nursing staff office 94745
        OR front desk 94650
        PACU 93232
        pharmacy 94808 (pgr 737-5098)
        PCA pgr213-963-6597/310-319-7291

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Santa Monica Protocols
General Rules:

All the paper work is located in one of the drawers on the Off –Site Anesthesia Cart. Remember to leave
the top copy of the anesthesia record with the chart, take all other copies back to the fourth floor and place
in the bin in the PACU.

If patient is an in-patient PLEASE consent the patient the night before. May need to get the patient’s
Power of Attorney, if patient is obtunded.

Questions: please page Dr. Philip Levin 14364


Protocol for T.E.E. Sedation
T.E.E. sedations are given either in the in-patient’s room or in the T.E.E. procedure room. To discover
where the T.E.E. will be, please call Cardiology (extension 9-4805) or you can call the O.R. scheduler
(extension 9-4587).

Please take Off-site Anesthesia Cart with (+/-) a Propofol infusion pump to cardiovascular services. Take
the Pavilion Elevators (elevators nearest the O.R.s) to the 2nd floor. Follow the signs to the cardiovascular
services room 2109.
Anesthesia normally consists of Propofol infusion or boluses (+/-) fentanyl, alfentanil.

Protocol for M.R.I. Scan Sedation:
The M.R.I. Scan is located in room 1150. Take the Pavilion Elevators (near the O.R.s) to the 1st floor.

Take the Off-site Anesthesia Cart with a Propofol infusion pump.

Protocol for G.I. Lab Sedation:
Patients getting GI procedures do not normally have an Anesthesiologist. Either the patient has many
multiple medical issues and the GI specialist is uncomfortable performing the sedation without us, or they
attempted the procedure and they were unable to complete.

Please take Off-site Anesthesia Cart with a Propofol infusion pump to the GI Lab. Take the Pavilion
Elevators (elevators nearest the O.R.s) to the 2nd floor. Follow the signs to the G.I. Lab room 2126.

Protocol for C.T. Scan Sedation:
The C.T. Scan is located in room 279. Take the Tower Elevators (near the cafeteria) to the 2nd floor. Follow
the signs to Radiology. Go through the double doors, to the end of the hallway, room 279 is on the right.

Take the Off-site Anesthesia Cart with a Propofol infusion pump.

Protocol for Cardioversion Sedation:
Cardioversions are usually done in one of the patient rooms on one of the in-patient floors. To discover
where the cardioversion will be, please call Cardiology (extension 9-4805) or you can call the O.R.
scheduler (extension 9-4587).

Usually do not need to take the off-site anesthesia cart. They will have an ambubag already there and a
crash cart for emergency drugs. No versed usually necessary. Usually all you need is a 20 cc syringe of
Propfol mixed with some lidocaine. Usually a 5-7cc bolus is all that is needed. Bring paperwork, you will
need an Anesthesia preoperative assessment, and an Anesthesia record. Remember to leave the top copy of
the anesthesia record with the chart, take all other copies back to the fourth floor and place in the bin in the
PACU.

Protocol for Pacemaker Sedation in the Cardiac Cath:
Often the Cardiac Cath staff likes to get the patient on the O.R. bed and get them prepped and draped before
we get there. They appreciate it, if we get the Anesthesia consent and do the Anesthesia preop assessment
the night before on in-patients.

Please take Off-site Anesthesia Cart with a Propofol infusion pump to the Cardiac Cath O.R.s. Take the
Pavilion Elevators (elevators nearest the operating rooms) to the 3rd floor. Go through the Cataract
operating rooms (O.R. 11 and 12) to the door, which leads to the cardiac Cath.

Usually they expect Monitored Anesthesia Care for these procedures, with a Propofol infusion.

Protocol for Brain Spect Scan Sedation:
  1. Patients getting Brain Spect Scans are frequently C.P. children or patients with brain damage that will
     be receiving hyperbaric oxygen therapy. They will be getting a Brain Spect scan on two separate
     occasions (weeks apart). The first will be prior to therapy and the second will be post therapy. We
     would like to give the same Anesthetic agents for both sedations if at all possible.
  2. Please call the patient/ patient's family the night before. Many of these patients have allergies, which
     may change your anesthetic plan.
  3. The patient will be admitted in A.C.U. on the day of surgery. They will have an I.V. started there
     without sedation.
  4. The patient will be transported at 13:30, from A.C.U. to Nuclear Medicine Suite 2124j. We are to
     meet the patient there. (Take the elevators closest to the Operating Rooms go down to the second
     floor, follow sign to Nuclear medicine). They are usually scheduled at 13:30 to give us time to set up.
     We actually expect the scan to be started around 14:00.
  5. Nuclear Medicine has a monitor that has EKG, blood pressure and pulse-oximeter capabilities. They
     have a suction canister and an Oxygen wall source. A crash cart will be available for emergencies. If
     you want a monitor with EtCO2 capability it can be found at the Cardiac Cath lab, on the third floor.
     You can ask to borrow it and you must return it.
  6. Please check for a short form H&P on the chart, which must be done within 30 days prior to the
     sedation.
  7. Most of these patients do very well with propofol sedation (unless the patient is allergic to egg whites
     or soy products), remember to bring an infusion pump. Propofol 100-300 Mcg/Kg/min usually works
     well. Usually you do not need to intubate these patients. If you feel you need to, please obtain the
     Anesthesia Machine from Radiology. Remember to bring an LMA with you, if you feel you would
     like to use it (rarely needed).
  8. Please keep the patient asleep until the very end, because if the patient moves, the entire spect scan
     will have to be redone. Once the scan starts, it takes approximately 35 minutes to complete.
  9. Bring the Anesthesia cart for off sites with you (located by O.R. Pharmacy).
 10. After the sedation, we are expected to bring the patients to the P.A.C.U. to recover, and then they will
     be sent home.

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Team Captain Ext : 310-267-0023
Day: Switch of T.C officially begins 7 am but be there by 6:30, just in case. Check with Attending running
the board - help may be needed to start a room. Scan the add on cases; most may have been seen by night
T.C with yellowlines /consents. All add on cases are T.C's responsibility. Try to see off site cases (i.e. MRI,
peds sedation, IR), but most of us see main OR cases before. Ask charge nurse or attending running the
board which add on cases will go first and try to see those patients ASAP.

Finally, set up for TRAUMA in room 10: basic airway set up, two IV's (one on a hotline), syringes labeled
for induction and emergency drugs, but not necessarily drawn up.

Lunch relief: List the perdiems, lone attendings on the board. List the free residents - head RN will help you
figure out free rooms. Request help from PACU if needed.

Code Blue/Floor Intubations:

      Figure out how to use the elevator key to get to Code Blues ASAP. There is nothing more painful
      than hearing getting paged overhead continuously while waiting to get to the 10th floor from the
      basement.
      Be prepared for a difficult airway!
      You are alone and bad things can happen.
      Call attending running the board if it is your first time.
      Get brief history from senior resident and/or attending running code.
      Consider asking someone what the patient's potassium is (just in case you need to give sux).
      The most helpful person is the Respiratory Tech. Although trying to help, most people will hinder you
      unintetionally (i.e. medical students should not be doing their first intubation there).
      Do not forget to document your intubation so that if the patient ever needs to get intubated, others will
      be aware of any difficulties and response to medications.

Preparation (in your fanny pack):

      LMA 3-4. Eschmann stylette, medium tube exchanger.
      Etomidate and Succinylcholine.
      Optional: NTG/Phen stick from pharm or pressors of discretion.

At BEDSIDE: emergency airway tray. Suction. Have the RN #1 inject the meds (make sure drugs are
flushed in) and RN #2 hold cricoid pressure . PreO2 if possible - maskable?.

What Drugs to give:

      Crash intubation needs nothing but tube and O2.
      If pt. awake but unstable, consider just 2mg of Midazolam alone
      Else, titration is Key: use small doses of etomidate 5-10cc(10-20mg), muscle relaxants are usually not
      needed - Sux 1-3 cc(20-60mg) (K+ OK?, ?ICP).


Confirm BBS and ETCO2(+yellow).

Trauma level 3 in ER:

Be ready to help ER with airway management. Take over if they are in trouble or difficult airway.
Warning: ER residents will mutilate the airway before handing it over to you. ER attendings have a set
mentality of pancuronium 1mg defasciculation dose before Sux. Update the Attending running the board and
OR front desk ASAP: coming to the OR stat, coming to the OR in a few hrs, or stable and not going to the
OR.

                                               Return to Index

The Call Schedule
Call is not a pleasant experience no matter what your specialty is. There is nothing easy or pleasant about it.
Fortunately, it is a great time to learn new things and apply yourself to difficult situations. Expect to work
hard when on call, realizing that unlike any other specialty, you will get the next call day off (unless home
call).

DEFINITION OF CALL RESPONSIBILITIES

Overnight call.
From 7am to 7 pm the next day. The only exception is Wednesdays, when you are expected to remain in-
house until 8 am, because of grand rounds. On weekends, plan on arriving at 6:30. You may have a case to
start at 7am. There is nothing worse than being post-call and having to stay late because a fellow resident is
late. Expect almost a regular workday on Saturdays: there are scheduled cases.

Night T.C :
Responsible for many things:

   1.   Assisting call attnd with coordiation of cases and distribution of work force.
   2.   Floor intubations
   3.   ER trauma
   4.   PACU signouts
   5.   Add on yellow lines and consents. Make sure everybody gets dinner and those who are not needed
        can go home.

1st call: Overnight call usually taken by a senior resident. Primarily responsible for handling the more
complicated cases in the OR.

2nd call: Overnight call usually taken by the junior resident. Primarily responsible for handling the more
basic cases in the OR.

OB call: Overnight call usually taken by a senior resident. Covers OB service. May be asked to help in the
OR if things get busy.

A call weekday: Junior residents stays late assisting in cases until discretion of call attending. There doesn't
seem to be a cap on how late the A person is held; there should be (say latest 8-9pm...). The next day,
resident is assigned to PES.

A call weekend: The first back up resident. You will be called in if there are too many cases for the call
team to handle. KEEP PAGER ON. Recommend 30 min. driving distance. Can be called in anytime from
7am to 7pm the next day. Usually, expect to assist on cases Sat am and expect not to be called back or in at
night. A call covers the liver transplants on Sun and some holidays.

B call: Same as the A person, except you are the second backup resident.

K call: Usually a 2 week rotation. come in at 3 pm and stay until cases can be handled by the call team. This
call can last until 7am but usually does not go past 12. Sometimes it is insanely easy : in at 3pm gone by
5pm.

Note : It is bogus to be backup and called in to do yellow lines on the weekend - let T.C know this should
this happen.

                                                Return to Index

Emailings
There are the mass email enablers. They are self explainatory...

AnesClinStff@mednet.ucla.edu

AnesExPhy@mednet.ucla.edu
anesres@mednet.ucla.edu

crna@mednet.ucla.edu

AllEveryone@mednet.ucla.edu

If you need to email faculty, go to www.mednet.ucla.edu/dept/directory.html

                                             Return to Index

CA-3 Requirements
Board Requirement by Jan of 3d yr:
Critical Care 2 mo
Cardiothoracic anesthesia 1mo
Neuroanesthesia 1mo
Obstetric 1mo
Pediatrics 1mo
Pain 1mo
PACU 2 contiguous weeks

ACGME Residency Requirement
Vaginal delivery 40 cases
C-section 20 cases
Children < 12 100 cases
Children < 1 yr 15 cases (must include < 45 weeks post conseption)
Cardiopulmonary bypass 20 cases
Major vascular 20 cases
Intrathoracic noncardiac 20 cases
Craniotomy 20 cases (must include intracerebral vascular)
Epidural 50 blocks (include C-section)
Major trauma 10 cases
Spinal blocks for surgery 50 cases
Periferal nv blocks 40 blocks
Nv blocks for pain management 25 blocks
http://www.acgme.org for requirements
American Heart Association for ACLS/PALS certification

                                             Return to Index

				
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