1. Pediatric Anesthesia Basics 2012 Laura Downey, MD Yun-Sheen Liu, MD Julie Williamson, DO

2. NPO guidelines Solids/formula = 6h Solids/formula = 6h Breast milk = 4h Breast milk = 4h Clears = 2h Clears = 2h Older kids should be NPO after midnight Older kids should be NPO after midnight Chewing gum and candy are considered clear liquids Chewing gum and candy are considered clear liquids

3. Premedication IV Premed IV Premed 0.5mg/kg Versed for toddlers, up to 2 mg of IV Versed for children >5 years 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 Oral Medication – 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

4. Set Up: T-MSMAID Table Table Machine Machine Suction Suction Monitors Monitors Airway Airway IV IV Drugs Drugs

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

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

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

8. Monitors BP cuff of appropriate size BP cuff of appropriate size Pulse ox Pulse ox 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

9. Airway 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 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

10. ETT Size based on the child’s pinky or (age/4) + 4 Size based on the child’s pinky or (age/4) + 4 Subtract 0.5 size for cuffed tube Subtract 0.5 size for cuffed tube Have one half-size smaller and larger available Have one half-size smaller and larger available

11. Laryngoscope blades for babies up to 3 months: Miller 0 for babies up to 3 months: Miller 0 for babies aged 3 months to 18 months: Miller 1 for babies aged 3 months to 18 months: Miller 1 for 18 month- 3 years: Miller 1.5, Mac 1, Wisc 1.5 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 3-5 years: Miller 1.5, Mac 2, Wisc 1.5 for >5 years: Miller 2, Mac 2-3 for >5 years: Miller 2, Mac 2-3 Note: Mac 4 is not standard in room. You will need to request one from tech Note: Mac 4 is not standard in room. You will need to request one from tech

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

13. 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

14. 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 Buretrols are currently out of stock. 250cc bags for patients <5 yo or syringe pump for IVF for infants.

15. Drugs Pyxis machine in OR Contains: Emergency drugs, opioids, induction agents Note that ketamine comes in 100mg/ml (for IM injection) and 10mg/ml Albumin, Crystalloid, Dextrose Access: 6 digit dictation number + password or fingerprint 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 Stanford Main OR Pharmacy: Sign out a green box for patients going for procedures in Stanford Hospital (AMC, interventional radiology)

16. 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.

17. Other emergency drugs Calcium Chloride Calcium Chloride 10cc of 100mg/cc 10cc of 100mg/cc 10cc of 10mg/cc 10cc of 10mg/cc 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

18. 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 – 2-3 mg/kg IV Propofol – 2-3 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, dilute to 1 mg/cc for children <1 years Rocuronium 0.6-1.2 mg/kg, dilute to 1 mg/cc for children <1 years

19. Pain medications PR acetaminophen 30-40 mg/kg (single dose) PR 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 10 mcg/kg IV Hydromorphone single dose 10 mcg/kg IV

20. Flow of the OR Pre-op: Ground floor of LPCH outside OR Patient admitted to Pre-op where NPs see patients and often start care form 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 7 main ORs MRI/CT suites on ground floor APU – outpatient procedures on 1 st floor LPCH PACU: next to holding area ICUs are all on 2 nd floor LPCH

21. May I have a GO?..... GO stickers: H and P from surgeon (with 24 hour update) Preoperative note from anesthesia signed by attending Patient marked Room is ready First “time out” is done in pre-op at patient’s bedside. Check MRN, birth date, allergies. GO!

22. 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

23. 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

24. 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