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) Two laryngoscope blades Oral airways Flavored face mask Cloth white tape to secure ETT One half size bigger and one half size smaller Appropriate size stylet Two Y-strips Red rubber for suction Eye tape: Paper tape > 1year Mepitec for <1 year or fragile skin Mepitec Cloth Tape 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 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 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 deair before injecting Children <6m should have dextrose infusion Buretrol IV set for <2yo Microdripper for <12 yo Drugs Pyxis machine in OR Contains: Access: 6 digit dictation number + password or fingerprint LPCH Pharmacy (near OR 7): Emergency drugs, opioids, induction agents Note that ketamine comes in 100mg/ml (for IM injection) and 10mg/ml Albumin, Crystalloid, Dextrose 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 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 Patient admitted to Pre-op where NPs see patients and often start care form 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 GO! Patient marked 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 Scanned Documents Tab: (before 9/2009) Anesthesia Records, Anesthesia Pre-Op OR and Procedure Notes Under ClinDocs, Care Forms, Pre Anesthesia NP note ECHOS/EKG Clin Docs Tab Ancillary Documents