Transcript Pediatric anesthesia basics

Pediatric Anesthesia
Basics
2012
Laura Downey, MD
Yun-Sheen Liu, MD
Julie Williamson, DO
NPO guidelines
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Solids/formula = 6h
Breast milk = 4h
Clears = 2h
Older kids should be NPO after midnight
Chewing gum and candy are considered clear
liquids
Premedication
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IV Premed
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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
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Set Up: T-MSMAID
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Table
Machine
Suction
Monitors
Airway
IV
Drugs
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
Machine
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Standard Machine check
Monitor set to Neonate or Pediatric Mode
Reset alarms for age appropriate vitals
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
Monitors
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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
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Airway
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ETT (3)
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Two laryngoscope blades
Oral airways
Flavored face mask
Cloth white tape to secure ETT
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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
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Size based on the
child’s pinky or
(age/4) + 4
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Subtract 0.5 size for
cuffed tube
Have one half-size
smaller and larger
available
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Laryngoscope blades
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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
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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
 Syringe with T-piece
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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Drugs
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Pyxis machine in OR
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Contains:
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Access: 6 digit dictation number + password or fingerprint
LPCH Pharmacy (near OR 7):
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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:
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Sign out a green box for patients going for procedures in
Stanford Hospital (AMC, interventional radiology)
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
Other emergency drugs
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Calcium Chloride
10cc of 100mg/cc
 10cc of 10mg/cc
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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
Induction Drugs
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Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM
Propofol – 2-3 mg/kg IV
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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
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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
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Pre-op: Ground floor of LPCH outside OR
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Holding: 8 bed area in OR suite
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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
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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?.....
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GO stickers:
H and P from surgeon (with 24 hour update)
 Preoperative note from anesthesia signed by
attending
GO!
 Patient marked
 Room is ready
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First “time out” is done in pre-op at patient’s
bedside. Check MRN, birth date, allergies.
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 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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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
name and number and site
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