Welcome to the Pediatric Anesthesia Rotation. We hope that you will enjoy this experience while learning
as much about our special “little people” as you can. This guide is meant to provide you with a quick
introduction to the rotation, what is expected of you and how you will be evaluated, and some didactic
material that covers topics you are expected to study during the rotation.
Important personnel to know are your pediatric anesthesia attending staff: Drs. Anna Crnkovic, Melissa
Ehlers, Archana Mane and Helena Oechsner. Colleen Savage and Laura Igoe, RNP are our nurse
practitioners in the pediatric holding/recovery area, and Wendy Reamer, RN and Gail Cashin, RN are the
nurses which you will most frequently deal with in the pediatric recovery area.
A typical day performing pediatric anesthesia:
Check your cases the night before on the schedule. Pediatric patients who are ASA III-V SHOULD have
been prescreened by Colleen or Laura (and those sheets are kept in Peds PACU, ask someone over there to
show you where) although we do not always get the notification that they are a “sick” child ahead of time.
The morning of the case, set up your room appropriately. Different things to consider include:
1.
2.
3.
4.
5.
6.
7.
8.
Hypothermia prevention – different maneuvers include warming the room, setting up french-fry lights,
placing a Bair Hugger on the bed, warm blankets
Machine set-up – is this machine appropriate for this size patient? Perform routine check-out. Is the
bag size appropriate for your patient?
Monitors – disposable (pediatric) pulse ox, appropriate size BP cuff, pediatric EKG stickers (you can
find them in the pediatric tackle boxes which are kept in the anesthesia supply room – make sure that
you have one of these boxes in your room for every peds case).
Airway equipment – oral airways selected, appropriate size ETT (4 + age/4) plus one size larger and
smaller, (if using cuffed tube, subtract 0.5 from above formula), ETT stylet, pedi laryngoscope handle
+ blades, mask (a few different sizes), LMA (if appropriate for case), eye tape and ETT tape ready to
use
IV equipment – A pediatric IV setup should be brought to your OR by the anesthesia tech, but if they
forget, they are kept in the anesthesia equipment room. Multiple 22 and 24g angiocaths, tourniquet,
tegaderm, alcohol pads/chlorhexidine swabs, arm board, tape for IV.
Medications – always have a syringe of atropine (1cc) and a syringe of succinylcholine ready but kept
in the top drawer of the anesthesia cart. (A reminder: ALL drugs in the top drawer are assumed to be
clean; NEVER put dirty drugs in this location). Also have 1ml syringes of Fentanyl, appropriate-sized
syringes of propofol (thiopental for babies), and muscle relaxant (vecuronium or rocuronium is used
for the majority of pediatric cases, if used at all).
Caudal equipment (when appropriate) – Epinephrine added to 0.25% Bupivicaine, sterile gloves,
chloraprep swab stick, 22 or 20g angiocath, syringe to draw up dose + needle, sterile label, sterile
drape (use same one as in block room)
Miscellaneous (when appropriate), 22g short bevel needles for ilioinguinal block, central lines/arterial
line catheters + transducer, continuous caudal catheter
Once the OR room is prepared, go and see the first patient, who should arrive by shortly after 7 AM.
Perform an H&P if not already done (use the “Pediatric Surgery/Anesthesia H&P, see link to this below)
decide on whether or not to give a premedication and whether or not you will invite the parent to
accompany their child to the OR (see articles about this subject in this handout, also check with your
attending when necessary). If you are giving a premed, use Versed 0.5mg/kg po from the pyxis (use the
intranasal form which is 5mg/ml) which you should mix with Tylenol to make it taste better. When you are
ready (and sure that the surgeon is available), check with the room first and your attending, then proceed
back to the OR. Children without an IV already in place will almost always have an inhalation induction
(once they reach age 8, start to think about offering them an IV induction instead), but if they are coming
from the floor with an IV, an IV induction will usually be performed.
We are lucky enough to now have at least one nurse practitioner (if not two) who will see pediatric patients
in the holding area for us and fill out a modified H&P, as well as giving premeds and taking care of
parental consents. Occasionally Colleen will be away on vacation or at conference (and Laura is only parttime), so you may need to help prepare patients later in the day as well. Don’t forget that you must also
write an H&P for ALL patients regardless of any other H&Ps that may be on the chart.
After your case is finished, you will accompany your patient to the pediatric PACU (always with oxygen!)
where you will hand over care of your patient to the nurses there.
Sample copy of the peds anesthesia H&P:
K:\Public\
Ehlers-public\Pediatric Anesthesia History & Physical.doc
Pediatric Anesthesia Rotation Evaluation:
2nd year: Written exam, individual evaluations by attending anesthesiologists
3rd year: Oral exam, individual evaluations by attending anesthesiologists, portfolio of cases
:
Topics to be covered during these two years will include
2nd year:
Dosing of emergency drugs – atropine, succinylcholine, epinephrine
Physiologic differences between infants and children as compared to adults
K:\Public\
Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\MELISSA Physiologic differences between infants.doc
Down Syndrome – anesthetic implications :
Pyloric Stenosis:
ScienceDirect - Seminars in Pediatric Surgery : Current management of hypertrophic pyloric stenosis
\\Amc09\vol1\
Practice\Anest\Shared\Public\Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\PYLORIC STENOSIS.doc
Open eye injuries/oculocardiac index:
K:\Public\
Ehlers-public\Peds Anesthesia Rotation\CA-2&3 rotation\00000542-200404000-00045eyeinjuries.pdf
(see editorials on sux and open eye)
Tonsillectomy/Adenoidectomy/Bleeding Tonsil
IV fluid/glucose requirements in children/Blood volume/Allowable Blood loss/ECF/TBW
Pediatric NPO guidelines
Pediatric PACU issues – implications/treatment of vomiting/pain/apnea
Discharge criteria for infants & justification
Caudal anesthesia – techniques, complications, when to use
Institutional policy on child abuse, minors of Jehovah’s witnesses, latex allergy, infection control
(insert word doc), http://www.med.unipi.it/patchir/bloodl/bmr/legal.htm ,
http://intranet.amc.edu/nursing/files/LATEX.pdf
Pre-operative sedation – methodology and reasoning
3rd year:
Newborn/Neonatal resuscitation: An Advisory Statement From the Pediatric Working Group of the
International Liaison Committee on Resuscitation -- Kattwinkel et al. 103 (4): e56 -- Pediatrics
Pediatric Advanced Life Support: Part 12: Pediatric Advanced Life Support -- 112 (24 Supplement): IV167 -- Circulation
Practice two pediatric megacodes at: MDChoice Pediatric Advanced Life Support Simulator
Malignant Hyperthermia
malignant hyperthermia.pdf
Additional suggested reading material:
Manual of Pediatric Anesthesia. By David Steward