1. Pediatric Anesthesia Basics 2013 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO LPCH Pediatric Anesthesia Rotation Updated December 2013

2. NPO guidelines Solids/formula = 6h Solids/formula = 6h Breast milk = 4h Breast milk = 4h Clears = 2h Clears = 2h Older kids and outpatients should be NPO after midnight Older kids and outpatients should be NPO after midnight Chewing gum and candy are considered clear liquids Chewing gum and candy are considered clear liquids LPCH Pediatric Anesthesia Rotation Updated December 2013

3. Premedication IV Versed IV Versed 0.1 mg/kg midazolam for toddlers, up to 0.1 mg/kg midazolam for toddlers, up to 2 mg for children >5 years 2 mg for children >5 years Oral Versed – order 20-30min before case to be given by pre-op holding RNs Oral Versed – order 20-30min before case to be given by pre-op holding RNs <6mo = usually no premed needed <6mo = usually no premed needed 6mo to 12y = oral premed (0.5 mg/kg up to 20 mg) 6mo to 12y = oral premed (0.5 mg/kg up to 20 mg) Over 12y = IV in pre-op area Over 12y = IV in pre-op area LPCH Pediatric Anesthesia Rotation Updated December 2013 Stranger anxiety starts around 9 months of age

4. Set Up: T-MSMAID Table Table Machine Machine Suction Suction Monitors Monitors Airway Airway IV IV Drugs Drugs LPCH Pediatric Anesthesia Rotation Updated December 2013

5. Table Bair Hugger Bair Hugger Shoulder Roll Shoulder Roll 3 lead EKG 3 lead EKG Pulse Ox Pulse Ox Appropriate sized BP cuff Appropriate sized BP cuff Special cable for neonatal cuffs 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

6. Machine Standard Machine check Standard Machine check Monitor set to Neonate or Pediatric Mode Monitor set to Neonate or Pediatric Mode Reset alarms for age appropriate vitals Reset alarms for age appropriate vitals LPCH Pediatric Anesthesia Rotation Updated December 2013

7. Suction Red rubber Rob Nell for little kids Red rubber Rob Nell for little kids Yankauers may be in anesthesia machine or on surgical shelves. Have available before induction. Yankauers may be in anesthesia machine or on surgical shelves. Have available before induction. Turn on suction Turn on suction LPCH Pediatric Anesthesia Rotation Updated December 2013

8. Monitors BP cuff of appropriate size BP cuff of appropriate size Neonatal cuffs require a separate cable Neonatal cuffs require a separate cable Pulse ox Pulse ox Avoid index finger to minimize corneal abrasions post op Avoid index finger to minimize corneal abrasions post op 3 lead EKG 3 lead EKG White lead on right White lead on right Green lead is V5 and equivalent to red lead in adults Green lead is V5 and equivalent to red lead in adults LPCH Pediatric Anesthesia Rotation Updated December 2013

9. ETT (3) ETT (3) One half size bigger and One half size bigger and one half size smaller one half size smaller Appropriate size stylet Appropriate size stylet Two laryngoscope blades Two laryngoscope blades & handles & handles Oral airways Oral airways Flavored face mask Flavored face mask Cloth white tape to secure ETT Cloth white tape to secure ETT Two Y-strips Two Y-strips Red rubber for suction Red rubber for suction Eye tape: Eye tape: Paper tape > 1year Paper tape > 1year Mepitec for <1 year Mepitec for <1 year or fragile skin or fragile skin Mepitec Cloth Tape LPCH Pediatric Anesthesia Rotation Updated December 2013 For every case, the anesthesia techs will set up airway equipment according to age of patient. While RN places monitors, double check size of equipment. Airway

10. ETT Size based on the child’s pinky or (age/4) + 4 Size based on the child’s pinky or (age/4) + 4 Might need to size ½ down if cuffed Might need to size ½ down if cuffed Have one half-size smaller and larger available 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

11. Laryngoscope blades Preemie: Miller 00 Preemie: Miller 00 Neonate to 3 months: Miller 0 Neonate to 3 months: Miller 0 3 months to 18 months: Miller 1 3 months to 18 months: Miller 1 18 month- 3 years: Miller 1.5, Mac 1, Wisc 1.5 18 month- 3 years: Miller 1.5, Mac 1, Wisc 1.5 3-5 years: Miller 1.5, Mac 2, Wisc 1.5 3-5 years: Miller 1.5, Mac 2, Wisc 1.5 >5 years: Miller 2, Mac 2-3 >5 years: Miller 2, Mac 2-3 Mac 4 is not standard in room. You will need to request one from tech Mac 4 is not standard in room. You will need to request one from tech LPCH Pediatric Anesthesia Rotation Updated December 2013

12. Airway AGEForm ula 32 week s Term3 mo6mo12 mo 18 mo 2 yr3 yr5 yr10 yr Kg 2.03.55.06.081113152040 ETT size (age/4) +4 2.53.03.5 4.04.5 5.05.5 ETT depth ETT size*3 7.59.010.5 12.013.5 15.0 Blade Mil 0 Mil 1 Wis 1.5 Mac 1 Mil 1.5 Mac 1 Mil 1.5 Mac 2 Mil 2 Mac 2- 3 LMA 1111.5 2222.5-3 LPCH Pediatric Anesthesia Rotation Updated December 2013

13. LPCH Difficult Airway Equipment LPCH Pediatric Anesthesia Rotation Updated December 2013 Glidescope Storz CMAC system Olympus FOB

14. IV IV supplies – in kidney basin IV supplies – in kidney basin mini tourniquet – cut to mini tourniquet – cut to half width for small babies half width for small babies Alcohol pads Alcohol pads 20, 22, 24g PIV catheters 20, 22, 24g PIV catheters Opsites Opsites 2x2 gauze 2x2 gauze Paper tape for additional Paper tape for additional reinforcement reinforcement Scissors Scissors Arm board Arm board Syringe with T-piece Syringe with T-piece One IV setup will be placed on a Mayo stand by techs for every case. LPCH Pediatric Anesthesia Rotation Updated December 2013

15. IV continued Debubble all buretrols and IV sets. Green clip should be left in open position Debubble all buretrols and IV sets. Green clip should be left in open position A bubble is a bullet to the brain – Boltz A bubble is a bullet to the brain – Boltz Draw back on syringes to de- air before injecting Draw back on syringes to de- air before injecting Children <6m should have dextrose infusion Children <6m should have dextrose infusion Buretrol IV set for <2yo Buretrol IV set for <2yo Microdripper for <12 yo Microdripper for <12 yo LPCH Pediatric Anesthesia Rotation Updated December 2013 Do you know the incidence of PFO in babies? Children? Adults?

16. Drugs Pyxis machine in OR Contains: 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 Omnicell in LPCH IR Suite LPCH Pharmacy (near OR 7): 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

17. Drugs Emergency Drugs Emergency Drugs Sux 4-6 mg/kg on IM needle Sux 4-6 mg/kg on IM needle Atropine 0.02 mg/kg on IM needle Atropine 0.02 mg/kg on IM needle Ephedrine 10cc of 5mg/cc Ephedrine 10cc of 5mg/cc Phenylephrine Phenylephrine 1 syringe of 100ug/cc 1 syringe of 100ug/cc 1 syringe of 10ug/cc 1 syringe of 10ug/cc Epinephrine 10 mcg/cc Epinephrine 10 mcg/cc Two syringes of saline flush Two syringes of saline flush Have small syringes and needles available. Do not draw up for EVERY case. LPCH Pediatric Anesthesia Rotation Updated December 2013

18. Other emergency drugs Calcium Chloride Calcium Chloride 10cc of 100mg/cc 10cc of 100mg/cc 10cc of 10mg/cc for small infants 10cc of 10mg/cc for small infants Sodium bicarbonate Sodium bicarbonate 8.4% 1 mEq/cc for patients >1 year 8.4% 1 mEq/cc for patients >1 year Note dilute solution for infants Note dilute solution for infants Syringes of 5% albumin Syringes of 5% albumin LPCH Pediatric Anesthesia Rotation Updated December 2013

19. Induction Drugs Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM Ketamine – 0.5-5 mg/kg IV, 3-5 mg/kg IM Propofol – 3-5 mg/kg IV Propofol – 3-5 mg/kg IV Time and date all syringes. Discard after 6 hours. Time and date all syringes. Discard after 6 hours. Rocuronium 0.6-1.2 mg/kg Rocuronium 0.6-1.2 mg/kg Dilute to 1 mg/cc for children <5 kg Dilute to 1 mg/cc for children <5 kg LPCH Pediatric Anesthesia Rotation Updated December 2013

20. Pain medications RECTAL acetaminophen 30-40 mg/kg (single dose) RECTAL acetaminophen 30-40 mg/kg (single dose) IV acetaminophen dose is age dependent: 10mg/kg 2 years. Re-dose Q 6 hours. Slow push/infusion over 15 minutes. IV acetaminophen dose is age dependent: 10mg/kg 2 years. Re-dose Q 6 hours. Slow push/infusion over 15 minutes. Toradol 0.5 mg/kg IV or IM 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 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 Morphine single dose 0.1 mg/kg IV Hydromorphone single dose 0.01mg/kg IV Hydromorphone single dose 0.01mg/kg IV LPCH Pediatric Anesthesia Rotation Updated December 2013

21. IMPORTANT PERSONNEL AND OR FLOW LPCH Pediatric Anesthesia Rotation Updated December 2013

22. ARC: Anesthesia Resource Coordinator Makes daily schedule and runs board: 1-9705 Makes daily schedule and runs board: 1-9705 Holds emergency phone: 1-9706 Holds emergency phone: 1-9706 Monitors PACU Monitors PACU Assists with difficult inductions Assists with difficult inductions Must be notified (along with OR desk) of any changes in call or scheduling Must be notified (along with OR desk) of any changes in call or scheduling Olga Albert Rebecca Claure (lead) Louise Furukawa Echo Rowe Jen Wagner LPCH Pediatric Anesthesia Rotation Updated December 2013

23. PARC: Pediatric Anesthesia Resource Center All elective cases reviewed All elective cases reviewed Phone interview with families Phone interview with families Selected patients seen in-person Selected patients seen in-person Will try to see inpatients and add-ons Will try to see inpatients and add-ons Dr. RJ Ramamurthi is lead PARC anesthesiologist Dr. RJ Ramamurthi is lead PARC anesthesiologist LPCH Pediatric Anesthesia Rotation Updated December 2013

24. Perioperative flow Vitals and NPO verified Anesthesia NP examines and begins Careform and PreOp note Patient changed into gown Site marked, 24 hour H&P, 1 st timeout  GO Premed given Patient consented by anesthesia team PreOp note signed by attending OR APU MRI/CT IR ASC Radiation Therapy PACU or ICU (NICU, PICU, CVICU) IPASS Handoff PostOp Note LPCH Pediatric Anesthesia Rotation Updated December 2013 http://www.lpch.org/aboutus/news/releases/2009/ford.html IntakeHolding Operative Location PostOp

25. 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 may access from ether.stanford.edu Intranet password is different password than Cerner Choose LINKS from menu and Powerchart Sign into Cerner LPCH Pediatric Anesthesia Rotation Updated December 2013

26. 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 LPCH Pediatric Anesthesia Rotation Updated December 2013

27. Finding information Old Anesthesia Records: Clinical Documents Tab: (after 9/2009) OR and Procedure Notes Anesthesia Records, Anesthesia Pre-Op Scanned Documents Tab: (before 9/2009) OR and Procedure Notes Under ClinDocs, Care Forms, Pre Anesthesia NP note ECHOS/EKG Clin Docs Tab Ancillary Documents LPCH Pediatric Anesthesia Rotation Updated December 2013

28. The Kanban Restocking System LPCH Pediatric Anesthesia Rotation Updated December 2013

29. Clean/Dirty Areas Remove gloves and foam hands before touching Pyxis or clean supply cart 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. Top of anesthesia machine is a “dirty” zone and will be completely cleared between cases. Lower side tray is considered “clean” Lower side tray is considered “clean” LPCH Pediatric Anesthesia Rotation Updated December 2013

30. PACU Handoff Formalized sign-out by surgeon, OR RN and anesthesiologist to PACU RN Formalized sign-out by surgeon, OR RN and anesthesiologist to PACU RN For outpatients, IPASS is in front page of chart For outpatients, IPASS is in front page of chart LPCH Pediatric Anesthesia Rotation Updated December 2013

31. IPASS to ICU LPCH Pediatric Anesthesia Rotation Updated December 2013

32. Parking on call After 4pm and on weekends or holidays, can park in A lot on Welch and Quarry. Move car before 6am week days! 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

33. Pain Call Duties Signout with attending and pain NPs 2pm M-F 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 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 Weekends contact pain attending the day before to arrange time to round Expectation: Routine pediatric perioperative pain management Expectation: Routine pediatric perioperative pain management LPCH Pediatric Anesthesia Rotation Updated December 2013

35. Case Tracking LPCH Pediatric Anesthesia Rotation Updated December 2013

36. Passport

37. Pedsanesthesia.stanford.edu

38. Pedsanesthesia.stanford.edu Goals and objectives Transplant – setup, education Mitochondrial disease EB Critical Airway Pain LPCH Pediatric Anesthesia Rotation Updated December 2013

39. Daily Feedback LPCH Pediatric Anesthesia Rotation Updated December 2013

40. Crisis checklists LPCH Pediatric Anesthesia Rotation Updated December 2013 In OR! iPhone App!

41. Code Cart Broselow © Tape (ED only) LPCH Pediatric Anesthesia Rotation Updated December 2013