Pediatric Anesthesia/Pediatric Pain
Locations: The layout of LPCH can be confusing, so it may be useful to
utilize the PACU central location as an orienting point. Preop area lies
between the PACU and the main LPCH hallway. The two PICUs are straight
through the double doors you see to the right of the PACU. If you exit out
the front entrance of the preop reception area you may take the stairs or
elevators up to the wards (3North, South, East, and West) or if you go right
out the same ped reception area front entrance door and following the
hallway around to the left you will pass the Pain Service Office on your left
(Sandy Sentivany-Collins, RN, CNS); continuing past her office you will
come to the entrance of the NICU at the end of that hall. Find the APU by
taking the stairs or elevators outside the preop area to the first floor, go right
out of the elevators, and the entrance is in that hall on the right as you walk
toward the adult hospital.
Clinical Duties
Usually children come into the preop clinic and will be evaluated by the
pediatric anesthesia nurse practitioner. Inpatients should be preop’d by the
resident staff. Some patients come in the morning of surgery for the first
time. Regardless of which occurs, it is your responsibility to perform an
evaluation and obtain consent from a parent/guardian prior to commencing
the anesthetic. Preoperative charts can be found the evening prior to surgery
in the LPCH PACU, and you can always obtain up to the minute laboratory
data, Xray reports, and dictations by accessing the LPCH Meditech
computer network at LPCH. If you have a home computer and modem, you
can access Meditech from home, too. See our administrative assistant to
obtain an application for an ID and a password for Meditech.
The on-call resident picks up operating room cases starting at 1700, but I
encourage residents to finish their own cases if they are likely to finish by
1800 for the sake of continuity, professionalism, and to foster good relations
with the surgeons.
Night/Pain Service week: You will be excused from the OR typically
around 3pm to round on pain patients until about 3:30-4:00pm. Then return
to the OR to finish your room, relieve day schedule pediatric residents, and
work until all peds cases are finished; you are the on-call resident until 7am
the next morning. During this period of your rotation you will learn to
manage the post op epidurals and all other pain issues. Peds epidural
management is very different than the adult. You will rely on Sandy early in
this rotation to familiarize yourself with the department style of
management.
Misc. Notes on Our Clinical Practices
More detailed information can be found at:
http://pedsanesthesia.stanford.edu/guide/guideline-preop.pdf.
Please read this prior to your rotation.
In examining the child, first auscultate the heart and lungs, then check vital
signs and examine the airway, assess the likely ease of vascular access, and
examine the spine if an epidural or spinal block is anticipated. Determine if
the pt’s condition has changed since the last preop evaluation. If the night
before surgery, write NPO orders (see guidelines below), and the next AM
double check NPO status.
Before you go into the operating room with the child, please know the
child’s name, his weight, the proper ETT size, and familiarize yourself with
doses of resuscitation medications, that are printed on the “Code” sheet in
the medical record.
General NPO guidelines
Age
Solid/milk/formula
Clear liquids/breast milk
All ages
6 hrs
3 hrs
Clears = water, clear juice drinks, popsicles, Pedialyte.
Solids = candy, chewing gum, juice w/ pulp, milk/formula
Typical child anxiety concerns in AM (some focused reassurance useful)
6 months-6 yrs
Fear of strangers, fear of separation
6-12 yrs
Pain
≥12 yrs
Loss of control (embarrassment)
Inductions.
Virtually all children from 6 months to ~10 years require some degree of
pharmacologic sedation prior to separating from their parents and going to
the OR. We make liberal use of midazolam given orally in doses of 0.5
mg/kg to obtain preoperative sedation, even in "full-stomach" situations.
This dose rarely if ever produces unconsciousness, but usually produces a
cooperative child. Please call the PACU (7-8700) to have your next patient
premedicated 10-20 minutes prior to the end of the previous case to facilitate
fast turn over times.
If the child already has an IV, then midazolam 0.1 mg/kg should be
administered. If an IV induction is anticipated, then please consider using
EMLA cream on the IV site, remembering that one hour of application is
required for adequate local anesthesia.
Intravenous Lines.
Please place T-Pieces on all lines. Please use Buretrols for children under 12
months of age, and micro-drip chambers on children under 10 years of age.
All children under 10 years of age should also have arm boards on the limb
with the IV. IV sites should be dressed with a sterile transparent dressing
and tape. Please do not use plastic "eye" tape on immunosuppressed
patients.
Glucose containing solutions
should not be routinely used in the OR. Administer D2LR to children less
than 6 months of age or to children who are malnourished by mixing 2
grams of glucose (4cc of D50W) to every 100cc of LR in the Buretrol.
Otherwise, LR is our standard IV solution. Do not use NS in big cases
during which large quantities of crystalloid are administered. This has been
associated with postoperative metabolic acidosis in our population. A good
alternative to NS is Normosol, which is compatible with blood products as it
does not contain calcium.
Regional Anesthesia.
Our pediatric surgeons have come to expect certain clinical practices. For
example, regional anesthesia is used whenever practical to minimize
intraoperative drug requirement and to smooth the postoperative course.
Most often, this means performing lumbar or caudal epidural blocks, with or
without catheters, but other commonly used techniques include the use of
intrathecal opioids for cardiac surgery and spine fusions, and the use of
thoracic epidural anesthesia for virtually all thoracotomies and upper
abdominal surgery. Brachial plexus anesthesia is commonly used during
hand surgery, especially for children with epidermolysis bullosa. Please
consult one of the pediatric anesthesiologists as needed for recommendations
regarding regional anesthesia, and for assistance in placing blocks.
Invasive Vascular Lines.
When central venous catheters are inserted, the placement of the catheter tip
must be confirmed with a portable chest radiograph in the operating room at
the time of line placement. The purpose of this is to assure safe and
appropriate placement of the line and to avoid the need to re-suture central
lines in awake uncooperative children. CVP catheter tips should not be
allowed to remain in the right atrium, but should ideally lie in the SVC or at
the SVC-RA junction. Peripheral arterial lines are usually secured using
benzoin and ¼" Steri-Strips rather than suture, with a sterile transparent
occlusive dressing and tape over the Steri-Strips. Femoral lines are secured
using suture. All children with invasive lines should be transported to the
ICU with the lines attached to pressurized infusion bags, to maintain line
patency.
Fiberoptic Intubations.
There is a pediatric fiberoptic intubation cart that is kept in the OR. The cart
includes two bronchoscopes, a video camera and monitor, and a color video
printer. This equipment is only for the use of the personnel in pediatric
anesthesia under the supervision of one of the pediatric anesthesia faculty
members or fellows. There are two Olympus bronchoscopes: 3.5mm
(smallest ETT size 4.5 mm) and 2mm (smallest ETT size 3.0mm).
After discussion with your attending, you are encouraged to use the
fiberoptic equipment to intubate normal children to become facile in its use.
After using a bronchoscope, please place the entire ‘scope in the blue basin
kept on the cart, and fill the basin with 1 bottle of sterile water. If the 3.5mm
‘scope was used, suction a few cc’s of water through the ‘scope to remove
blood and secretions from the suction channel. Park the cart outside your
operating room, and call the telephone number printed on the basin for the
cart to be picked up and the ‘scope to be cleaned. Nights and weekends the
equipment will be cleaned by the anesthesia technicians.
If you get the cart from the APU for your use, you are responsible for
assuring that it was cleaned and returned to the APU.
PICU/NICU Interface
Patients transported from an ICU to the operating room should be
accompanied by an anesthesiologist, and often by both the attending and
resident/fellow.
At the end of the case, the ICUs must receive a 45 minute heads up
telephone call from you or your resident/fellow. Call the ICU, ask to speak
with the nurse who will take care of the child, and tell her ventilator settings
or oxygen therapy to expect, what lines to be ready for, what drips are being
used, etc. Make sure they get called again about 10-15 minutes prior to
leaving the operating room for a final notice. The circulator can make this
final phone call.
When you take a child to the PICU or NICU, keep all invasive lines attached
to pressure bags and transducers to maintain line patency. They can use your
transducers and bags, saving considerable money.
Sign out should be made to the ICU bedside nurse and to the ICU resident
staff. Speak directly with the ICU attending in unusual circumstances or
when you have special concerns about the operating room-PICU transition
and the ongoing care of the child.
Pain Service
All children treated with epidurals and PCA are managed by the pediatric
pain management service. At the end of the case, remember to page the pain
service nurse (Sandy Sentivany, beeper 1-8779), and tell them about the
patient and what ongoing therapy you’ve planned. Always call the pain
attending if you’re unsure of protocols or have questions about what is
appropriate or what works.
Useful Phone Numbers and Beepers
Peds Anesthesia Administrative
3-5728
Office
PACU Preop Area
7-8700
PACU Postop Area
7-8701
PICU
7-8850
NICU
7-8800
Peds Inpatient Pain Service Office
7-8057
Peds Inpatient Pain RN (Sandy
Sentivany)
Peds Outpatient Pain Service
Office
Peds Outpatient Pain RN (Chris
Almgren)
Beeper 18779,
4-5338
Beeper 28521, 415-607-4298
____________________________________________________________
Basic Pediatric Clinical Skills and Information
Peds OR Setup: Set-up early with special vigilance to detail. Be ready
to bring pt. to room by 7:15 am.
Standard machine checkout (See MSMAIDS Section II, page 10)
Additionally, be sure all machine and monitors are at age specific settings (A
common error is not resetting the BP cuff to PEDS setting).
Endotracheal tubes: Place on the machine the predicted sized w/ one size
above and one size below. Use of stylet is attending specific, but always
have a stylet on the machine. Open only the ETTs you plan on using (a good
practice is to open the predicted size plus one size below predicted w/ stylet
in place).
IV Bags: 500cc of LR should be hung with using a Buretrol and microdrip
for children less than 10 yrs. or under 30 kg. Place a stopcock at end of
Buretrol and an extension added to the stopcock. Finally, place a Tconnector on the end. It is important to remove all bubbles in the line by
tapping the injection ports. Prepare an IV boat for each case and include
multiple different sized catheters. If you feel you need instruction, on your
first few days inserting an IV, don’t hesitate to ask your attending to
demonstrate their particular method.
Drug Set-up (routine case)
Sux: 1cc or 5cc syringe (this is attending specific)
Atropine: 0.4 mg (1cc syringe for neonates and premies).
Propofol: 10mg/kg available
For major cases:
Epinephrine: in appropriate dilution (100mcg/cc and 10mcg/cc
syringes drawn-up.
Calcium chloride: if anticipating massive blood transfusions.
Thermoregulation standards: always make sure room is warm, Bair hugger
is in place, and warming lights are available.
Special: anything else such as blood warmer, a-line set-up etc.
Commonly used med doses
Premeds
Oral midazolam 0.5mg/kg
Rx’s Intubating doses
Propofol 2-4 mg/kg
Succinylcholine 4-6 mg/kg (if Sux used: precede with atropine 0.01mg/kg
for children <6 years of age)
Rocuronium 1 mg/kg
Fluid Maintenance
Preinduction bolus: Less than 3 yrs.= 10ml/kg; Greater than 3 yrs= 20ml/kg
Intraop maintenance: 4ml/kg/hr
TIVA
Mix remifentanil 0.2mg into a 20cc vial of propofol to a final concentration
of 10 µg/kg (note that is 1/1000th the concentration of the propofol). The
usual maintenance dose of this combination is 75-150 µg/kg/min of propofol
(=0.075-0.150 µg/kg/min of remi).
Postop Orders
Premie’s: always 24hr admit
Fluid 2cc/kg/hr; morphine 0.05-0.1mg/kg IV; Tylenol 30mg/kg PR;
ondansatron 0.1mg/kg
Transport
Jackson-Reese circuits or oxygen masks for all patient transports to the
recovery room.
Peds PACU
Report (see adult reporting to PACU nurse pg.27)
Peds formulas for quick reference
Spinal cord ends
Premature S1-2
Neonate L3-4
8Yrs- adult L1-2 (15% L2-3)
Airway Facts
Newborn = obligate nasal breathers
Tongue = large
Head = large occiput (blue towel roll under shoulders/ none under head)
Larynx = more cephalad C3-4 (adult C6)
Narrowest point of airway = C4 (cricoid cartilage)
Vocal cords = angled more anterior than adult
Ett Size by Age
LMA
Age
Size (+/- .5)
Size Wt.
Inflation Vol
Premie
2.5
1
<6.5kg
2-4cc
NB
3.5
2
6.5-20
<10
6-12mths
4.0
2.5
20-30
<15
1-2yr
4.5
3
>30 (Female adult) <20
> 2yrs ETT size = (16 + age)/ 4
4
Adult male
<30
Or, ETT size = length or height/20
Cuffed ETTs are available down to 3.0mm size.
Laryngoscope Blades
Age
Type/Size
Preme
Miller 0
NB-4yrs
Miller 1 or WH 1.5
> 4yrs
Miller 2 or Mac 2
Large child Mac 3
Wt. for Age Simple formula
NB
3kg
6 mths
6kg (2X birth wt.)
1yr
10kg (3X birth wt.)
>
then 2kg per yr
[or Wt.= (Age X 2) + 9]
Vital Signs for Age
Age Hr
RR
BP
NB
140
50
65/40
Hb/Hct*
16/55
1mth 160
6mth 140
40
35
90/50
90/50
16/30
13/35
1yr
2yr
3yr
100
100
100
30
25
25
95/60
95/60
95/60
12/35
12/35
12/35
80ml/kg
“
“
8yr
12yr
80
75
20
20
100/65
115/70
12/40
12/40
70ml/kg
“
Blood Vol.
90ml/kg
“
“