Pediatric Anesthesia
Basics
2013
Laura Downey, MD
Yun-Sheen Liu, MD
Julie Williamson, DO
LPCH Pediatric Anesthesia Rotation
Updated December 2013
NPO guidelines
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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 December 2013
Premedication
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IV Versed
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0.1 mg/kg midazolam for toddlers, up to
2 mg for children >5 years
Oral Versed – order 20-30min before case to be
Stranger anxiety
given by pre-op holding RNs
starts around 9
<6mo = usually no premed needed months of age
 6mo to 12y = oral premed (0.5 mg/kg up to 20 mg)
 Over 12y = IV in pre-op area
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LPCH Pediatric Anesthesia Rotation
Updated December 2013
Set Up: T-MSMAID
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Table
Machine
Suction
Monitors
Airway
IV
Drugs
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Table
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Bair Hugger
Shoulder Roll
3 lead EKG
Pulse Ox
Appropriate
sized BP cuff
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Special cable
for neonatal
cuffs
Pulse oximeter and BP cuff will be in patient’s
chart, and should stay on for PACU
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Machine
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Standard Machine
check
Monitor set to
Neonate or Pediatric
Mode
Reset alarms for age
appropriate vitals
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Suction
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Red rubber Rob Nell for little kids
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Yankauers may be in anesthesia machine or on
surgical shelves. Have available before
induction.
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Turn on suction
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Monitors
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BP cuff of appropriate size
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Pulse ox
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Neonatal cuffs require a separate cable
Avoid index finger to minimize corneal abrasions
post op
3 lead EKG
White lead on right
 Green lead is V5 and equivalent to red lead in adults
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LPCH Pediatric Anesthesia Rotation
Updated December 2013
Airway
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ETT (3)
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One half size bigger and
one half size smaller
Appropriate size stylet
Cloth Tape
Two laryngoscope blades
& handles
Oral airways
Flavored face mask
Cloth white tape to secure ETT
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Mepitec
Two Y-strips
Red rubber for suction
Eye tape:
 Paper tape > 1year
 Mepitec for <1 year
or fragile skin
For every case, the anesthesia techs will set up airway
equipment according to age of patient. While RN places
LPCH
Pediatric
Anesthesia
Rotation
monitors,
double
check
size of equipment.
Updated December 2013
ETT
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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 December 2013
Laryngoscope blades
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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 December 2013
Airway
AGE
Form
ula
Kg
32
week
s
Term
3 mo
6mo
12
mo
18
mo
2 yr
3 yr
5 yr
10 yr
2.0
3.5
5.0
6.0
8
11
13
15
20
40
5.5
ETT
size
(age/4)
+4
2.5
3.0
3.5
3.5
4.0
4.5
4.5
4.5
5.0
ETT
depth
ETT
size*3
7.5
9.0
10.5
10.5
12.0
13.5
13.5
13.5
15.0
Mil 0
Mil 0
Mil 0
Mil 1
Mil 1
Mil 1
Wis 1.5
Mac 1
Mil 1.5
Mac 1
Mil 1.5
Mac 2
Mil 2
Mac 23
1
1
1
1.5
1.5
2
2
2
2.5-3
Blade
LMA
LPCH Pediatric Anesthesia Rotation
Updated December 2013
LPCH Difficult Airway
Equipment
Glidescope
Storz CMAC system
Olympus FOB
LPCH Pediatric Anesthesia Rotation
Updated December 2013
IV
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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
One IV setup will be placed on a Mayo stand by
 Syringe with T-piece
techs for every case.
LPCH Pediatric Anesthesia Rotation
Updated December 2013
IV continued
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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 deair before injecting
Children <6m should have
dextrose infusion
Buretrol IV set for <2yo
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Microdripper for <12 yo
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LPCH Pediatric Anesthesia Rotation
Updated December 2013
Do you know the
incidence of PFO in
babies? Children? Adults?
Drugs
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Pyxis machine in OR
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Contains:
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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
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Omnicell in LPCH IR Suite
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LPCH Pharmacy (near OR 7):
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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 December 2013
Drugs
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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
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Epinephrine 10 mcg/cc
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Two syringes of saline flush
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Other emergency drugs
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Calcium Chloride
10cc of 100mg/cc
 10cc of 10mg/cc for small infants
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Sodium bicarbonate
8.4% 1 mEq/cc for patients >1 year
 Note dilute solution for infants
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Syringes of 5% albumin
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Induction Drugs
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Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM
Propofol – 3-5 mg/kg IV
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Time and date all syringes. Discard after 6 hours.
Rocuronium 0.6-1.2 mg/kg
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Dilute to 1 mg/cc for children <5 kg
LPCH Pediatric Anesthesia Rotation
Updated December 2013
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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
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Pain medications
IMPORTANT PERSONNEL
AND OR FLOW
LPCH Pediatric Anesthesia Rotation
Updated December 2013
ARC:
Anesthesia Resource Coordinator
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Makes daily schedule and
runs board: 1-9705
Holds emergency phone:  Olga Albert
1-9706
 Rebecca Claure (lead)
Monitors PACU
 Louise Furukawa
Assists with difficult
 Echo Rowe
inductions
 Jen Wagner
Must be notified (along
with OR desk) of any
changes in call or
LPCH Pediatric Anesthesia Rotation
scheduling
Updated December 2013
PARC:
Pediatric Anesthesia Resource Center
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All elective cases reviewed
Phone interview with families
Selected patients seen in-person
Will try to see inpatients and add-ons
Dr. RJ Ramamurthi is lead PARC
anesthesiologist
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Perioperative flow
Intake
• Vitals and NPO
verified
• Anesthesia NP
examines and
begins Careform
and PreOp note
Holding
• Patient changed into
gown
• Site marked, 24 hour
H&P, 1st timeout  GO
• Premed given
• Patient consented by
anesthesia team
• PreOp note signed by
attending
Operative
Location
OR
APU
MRI/CT
IR
ASC
Radiation Therapy
http://www.lpch.org/aboutus/news/releases/2009/ford.html
LPCH Pediatric Anesthesia Rotation
Updated December 2013
PostOp
PACU or ICU
(NICU, PICU,
CVICU)
IPASS Handoff
PostOp Note
Maneuvering the Paperwork
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Cerner Powerchart is LPCH EMR
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User name and Password are the same as for OB
EMR access from home is on LPCH intranet:
https://intranet.lpch.org
 Or may access from ether.stanford.edu
 Intranet password is different password than Cerner
 Choose LINKS from menu and Powerchart
 Sign into Cerner
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LPCH Pediatric Anesthesia Rotation
Updated December 2013
How do I find my schedule?
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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
Pediatric Anesthesia Rotation
name and number LPCH
and site
Updated December 2013
Finding information
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Old Anesthesia Records:
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Clinical Documents Tab:
(after 9/2009)
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OR and Procedure Notes
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Scanned Documents Tab:
(before 9/2009)
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Anesthesia Records,
Anesthesia Pre-Op
OR and Procedure Notes
Under ClinDocs, Care
Forms, Pre Anesthesia
NP note
ECHOS/EKG
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Clin Docs Tab
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Ancillary Documents
LPCH Pediatric Anesthesia Rotation
Updated December 2013
The Kanban Restocking System
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Clean/Dirty Areas
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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”
LPCH Pediatric Anesthesia Rotation
Updated December 2013
PACU Handoff
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Formalized sign-out by
surgeon, OR RN and
anesthesiologist to
PACU RN
For outpatients, IPASS is
in front page of chart
LPCH Pediatric Anesthesia Rotation
Updated December 2013
IPASS to ICU
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Parking on call
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After 4pm and on weekends or holidays, can park
in A lot on Welch and Quarry. Move car before
6am week days!
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Pain Call Duties
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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
LPCH Pediatric Anesthesia Rotation
Updated December 2013
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Case Tracking
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Passport
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Pedsanesthesia.stanford.edu
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Pedsanesthesia.stanford.edu
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Goals and objectives
Transplant – setup,
education
Mitochondrial disease
EB
Critical Airway
Pain
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Daily Feedback
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Crisis checklists
LPCH Pediatric Anesthesia Rotation
Updated December 2013
Code Cart
Code Cart
Broselow © Tape (ED only)
LPCH Pediatric Anesthesia Rotation
Updated December 2013