SRNA Orientation Checklist

SRNA Orientation ChecklistHere is checklist for student to student orientation. Please arrange time to meet with your fellow student to make your transition a smooth one. We are glad you are here and will work hard to make this rotation a successful one for you. PEDS OR Student/Student Orientation List DAY BEFORE Schedule Location- Outside CRNA office Inpatient Pre-Ops are in folder in counter in holding room Outpatient pre-ops in John Galt just like IP/OP Many say acdos on schedule, anesthesia consent day of surgery. Look up in Carecast, that’s all you can do. MORNING SETUP Feel free to set up the night before, but beware of the possibility that a case may be done in your room overnight and your stuff will be gone. The call person will not replace what you had laid out. Check OR board for changes/messages Location of common items needed: Volatiles (you will need more than one bottle of SEVO for the day), Yellow foam Masks Circuits Reusable and disposable LMAs (disposables are under the counter in the workroom) Transport monitors + cables O2 Tanks Green towels to be placed under shoulders for intubation. IV’s. Have one set up for each case of the day before first case starts. (We usually do not start an IV on BTT or PDL cases, but have at least one ready to go in case of an emergency.) Use a T-piece on all IVs, and an extension with stopcock on all but adult IV sets. Buretrol for children up to 4-5 years. Label amount of fluid in Buretrol Micro drip with cookies extension for children 5-10 year IV start box (located in D-cell) on foot of bed. Check for adequate tourniquets (small and big), dressings and each size IV Size appropriate monitors attached to monitor cables- SpO2, BP, ECG, precordial and temperature probe laid out on bed.. Warming devices Room thermostat Super-heat button. Learn how to use. Under-body warming blankets, when to use Setup and operation of warmer- attach to blanket, unclamp ports, turn on, then fill with sterile water from d-cell to fill line. Heat Packs for NICU transports (in same room as yellow foam across from OR board) Monitor Packets for fast turn over cases. (ecg, temp, SpO2, precordial sticker) with appropriate mask for each case ready first thing. Anesthesia Cart Keep neat, minimal clutter Appropriate size syringes for emergency drugs (3mL and 5mL of Sux for smaller children) Atropine in 1mL syringe Epi dilutions 1:100mcg, 1:10 mcg and 1:1 mcg (Check with CRNA, if children are older and not very ill, you might be able to omit) Find slide out part of anesthesia cart Multiple ETT sizes, use the formula age/4+4 then go down ½ size if you are using a cuffed tube. You will use a cuffed ETT in most cases. Machine Check vital sign alarms are appropriate for age (under alarm settings) Check BP inflation pressure set for neonate, child, adult (under monitor setup) Appropriate mask and circuit Suction- if small child may use flexible suction catheter, or any size child may use to clear secretions/ remove residual PO versed Make sure you have lots of Sevo HOLDING ROOM Schedule location How to find location of patient Check paperwork as you would in IP/OP PO versed cups Old chart location PO versed doses, length of time from administration to going back to room CHECK with attending to be sure they are ready for you to go back! Very important! Waiting area for parents INDUCTION Induction routine SpO2, precordial and Mask IV start Drug administration Airway MAINTENANCE Common narcotic doses for different types of surgery MAC levels of gases EMERGENCE Extra time to breathe off induction sevo PSV Pro at end of case Sx oropharynx, possibly down to stomach Deep vs. awake extubation Awake extubation signals (they don’t follow commands) Stage II signals How to call for turnover PACU Often transport with pt on side Keep hand on pt in case they move SpO2 and respirations are first priority Location for anesthesia charge forms STOCKING You must look at each shelf and drawer and count each item on the D-cells, anesthesia cart and don’t forget the anesthesia machine drawers. The lists for stocking are attached to the D-cell and ploss cart. You cannot just take in what you plan to use and think you do not have to stock. There is only one tech in PEDS- if your room is not turned over when you return from PACU, just turn it over yourself. After 3 you can call IP techs. PDLs and BTTs Describe specific setups and routines for these cases Pediatric Anesthesia Rotation Department of Anesthesiology Wake Forest University School of Medicine Winston-Salem, North Carolina (336) 716-4498 Joseph R. Tobin, MD, Professor and Section Head Timothy E. Smith, MD, Medical Director, Pediatric ORs FACULTY Loren A. Bauman, MD W. Gavin Elliott, MD James J. O’Brien, MD Douglas G. Ririe, MD Leah C. Templeton, MD T. Wesley Templeton, MD Contributions by Pamela Wofford, CRNA Chief Nurse Anesthetist for Pediatric Anesthesia ..........................................7 Issues of Prematurity.........................9 History of Present Illness ......................13 Special Concerns in the Pediatric Patient............................................................................................................................................16 Congenital Heart Disease...............................................................................................................15 Sickle Cell Disease ............19 .....................11 Allergies..........................................................................................3 OR Set-up for Pediatric Cases ................12 Review of Systems....2 General Location of Supplies................7 Issues Related to the Neonatal Patient ......................................................................................................................................8 Anesthetic Drugs and the Pediatric Patient.............................................................................................................................18 Guidelines for Premedication ...................7 Issues Related to the Infant .............................1 Surgeon Specific Requests...................................................................................................................................16 Genetic Syndromes ............................................................................................................................................................7 Congenital Heart Disease.........................................................................................12 Physical Exam........................5 PACU...................1 Pre-ops ......................................................................................................19 Atropine ........................................................................1 Off-site Anesthesia......................................................................................1 Assignment .........................................................................................................................................................................................................................7 ENT Concerns Related to the Pediatric Patient ................................................................................................................................................................................................................................................14 Seizures ...........................................................................................................................................9 Past Medical History..........................................11 Medications..............................................................................................................18 Ketamine .................................................................................................................................................................................................................................................11 Family History .................................................................14 Asthma ................................8 Preoperative Evaluation of the Pediatric Patient ..........12 Labs.........................................................................................................................................14 Upper Respiratory Infection ..........................................................................1 General Information on How the Pediatric OR is Expected to Function .......................................................................................................................................................................17 Premedication...............................................................................................................18 Versed ...................................................................................................................................................................................6 Scholastic Goals for Pediatric Rotation ....................................................................................................................................................................................................................15 Cerebral Palsy ...8 Regional Anesthesia..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................8 Common Disease States in Pediatric Patients....................................................................................................................................................................................................................................................................14 Diabetes...................................................................................................................................................................................................................3 Pertinent Issues in the Pediatric OR...................................................Table of Contents OR Set-up for Pediatric Cases and Guidelines for the Pediatric OR ......................................................................................................................................... ...........................................................................................................27 Specific Cases: Strategies....................31 Orthopedic Procedures...............................................................20 Access ..Intraoperative Considerations in Pediatric Anesthesia..................................................................................................................................................................28 General Surgery .....................................................................................................28 ENT Cases ............................................................................... and General Guidelines.............26 Postoperative Nausea and Vomiting in Children......................................................................................................................................................................................................................................................................................................................33 ............................................................................................................................23 Fluid Maintenance ............................................................................................................................................................................26 Postoperative Analgesia................................................................................................................................................................................................................................................21 Airway.................................................24 Transfusion Therapy in Children ............................................................................20 Induction ...........................................................................21 Positioning ....... Concerns...24 Emergence......23 Maintenance of Anesthesia ...................................................20 Monitoring .33 Plastic Surgery .........................................................................................................................................................................................................................................................................................................................30 Urogenital Surgery.......................................................................25 Care of the Pediatric Patient Postoperatively .......................................................................... 24. 6. 13. Ask Pam Wofford if you do not yet have code access (713-5341). 27. No one should be cleaning up after you. a guideline for operating room (OR) set-up. Dr. locked in the room next to the OP copier. 22. Dr. The reading text for the rotation is A Practice of Anesthesia for Infants and Children by Coté et al. a-line cable. Glazier requests limited traffic in and out of his room with VP shunts. 8. temp. pulse ox. . 19. David prefers to start before 7:00 am – if you are assigned in her room PLEASE make sure the OR staff are in the room and ready BEFORE you go back. 28. 31. Do not be wasteful. Inpatient pre-ops and extra schedules are posted on the bulletin board outside of the Medical Director’s office. 4. A code is needed for that door. Do not use the floor as a waste basket. This packet provides a list of scholastic goals. 30 Second month: chapters 3. IV. MD) II. Tim Smith and should be returned prior to completing the rotation. 18. the following chapters are recommended. 21. and a brief outline of some of the key issues in pediatric anesthesia. and so forth. 9. Some pre-ops and consents are done in the holding room the day of surgery. Kirse likes to see his patients/families in the holding room before you take the patient to the OR. 26. 15. Assignments Assignments are posted on the bulletin board outside the Medical Director’s office (Tim Smith. BIS. 16. III. 14. 25. The text is available from Dr. 22. EKG. 12. Pre-ops Pre-ops can be found either in the pediatric waiting room (Surgical Family Waiting). Surgeon Specific Requests Dr. 32 OPERATING ROOM (OR) SET-UP FOR PEDIATRIC CASES AND GUIDELINES FOR THE PEDIATRIC OR I. Replace charts in the same order in which they were found.1 Welcome to the pediatric anesthesia rotation. 29 Third month: chapters 5. or after 17:00. a description of the operation of the pediatric OR. All inpatient pre-ops should be done before anyone leaves for the day and in-house pre-ops can be posted on the assignment board. Although it would be ideal to read the entire text. 23. 11. 17. General Information on How the Pediatric OR is Expected to Function Keep a neat and orderly workplace. 10. First month: chapters 2. Be cost conscious. 20. 7. Monitor cables should be hung from the IV poles at the end of the case: BP cuff. breathing bag. Monitors should be plugged in. Radiation Oncology. Only Janie Dull and Pamela Wofford have keys to this cabinet. Please let the Peds PACU staff know if the O2 tanks need replacing or are unacceptable. She is not expected to pick-up after you. turn over your room. monitors (except the face of the screen). will help with these chores. Please return all these items to the PACU after they have been cleaned. Gloves: Use clean gloves and remove them immediately after they are soiled. blood warmers. ploss cart. and any anesthesia equipment that comes in contact with the patient and/or floor. NO TBQ on LMAs. Avoid contamination of anything with dirty gloves. use the needle box to discard. Disposable LMAs are also in the workroom. . or restock your room. Leave a clean suction liner. and is here to help everyone. IV poles. End of day cleaning: Use TBQ in the spray bottle to wash machine. so please do not put them in the sink. but the final responsibility is yours. Laryngoscope blades can be placed in the sink in the workroom to be cleaned and processed. etc. Empty the trash and replace the plastic trash bag. Absolutely NO trash allowed in the needle boxes.. It is necessary to take a stretcher. please help in the rooms to rapidly turnover cases. and in the D-cells at the end of the day. Syringes and needles: Clean syringes ONLY may be thrown in the trash can (NO BLOOD. and Yankauer set-up. DO NOT TOUCH ANYTHING WITH DIRTY GLOVES. if needed) with you to whichever site you are assigned. IV tubing. lines. Outside sites must be cleaned and restocked in the same fashion as the main Peds OR. V.e. Laryngoscope bulbs should be checked before each use. Stylets are one-time use only – throw them away. LMAs/Laryngoscope blades: LMAs are in a locked cabinet in the anesthesia workroom. Bair hugger. If Janie has gone for the day. Remember that the purpose of wearing gloves is to protect yourself and others from patients’ bodily fluids. Otherwise. Trash goes in the dirty utility room across the hall from OR 39. i. Return any extra supplies that you bring with you into the room to the workroom by the end of the day. dirty LMAs should be placed in the container on the sink in the workroom. Fill volatile agents. and whoever is PRN. Most of the time Janie. Replace soda lime each Monday morning – be sure to check for circuit leaks after soda lime is replaced. and full O2 tank (located in first stage Peds PACUs soiled utility room. and Specials.2 Please keep the carts neat. regulating gas valves. transport monitor with appropriate cables. If you are free. Cleaning and turnover – each anesthesia provider is responsible for turning over his/her own room between cases and for restocking supplies both in the ploss carts. Peds Cath Lab. chair. tubing. Janie Dull is our only Anesthesia Technician. NO NEEDLES). Take the time to locate the laryngoscope bulbs in the workroom and change at least one while you are here. Off-site Anesthesia These include MRI. Discard soda lime at the end of the day each Friday. CT. 2. a 14-Fr. Latex-free supplies: all supplies should be latex-free with the exception of brown unmarked coban (Note: If the coban is marked on the inside with LF then it is latex-free). When in the MRI. Glucometer: cabinet behind nurses’ desk in the holding room Baxter Pumps: on the counter in the workroom Baxter tubing: in the cassettes Volatile agents: on counter in the workroom & bottom of the ploss carts. VII. Warming: The room itself should be warmed in advance as follows: Newborn and small neonatal children: 80° F . For all other sites. pagers. hyperinflation bags (½. and 3 liter). Suction catheter is more appropriate for infants and neonates. credit cards. An appropriate sized “artificial nose” should be immediately available. and so forth. 1. keys. Suction: A Yankauer suction tip should be available for all cases. Difficult Airway Cart: in the hallway outside of OR #36 Malignant Hyperthermia supplies: in the main OR – anesthesia workroom Pod B (not Peds OR). They are intended to provide a more standardized (we hope). including stethoscopes. Circuit: A pediatric circle system or Bain system is acceptable for children under 30 kg. VI. remove anything metal that is on your person. Halothane vaporizer: ask Pam or Janie if you would like to use.3 D-cells and gas machines are located in MRI and in Radiation Oncology. Laryngoscope blades and McGill forceps: next to the sink on the counter in the workroom. Children above this weight may be managed with a standard adult circle system. badges. less vague. jewelry. however. rubber bands. OR Setup for Pediatric Cases The following suggestions for the setup for pediatric cases represent consensus views of the attendings in the section of pediatric anesthesia. General Location of Supplies It is a good idea to familiarize oneself with the anesthesia workroom. and more cost effective routine in preparation of the OR for d\pediatric cases. check with Pam or Janie regarding D-cell and machine availability. some of the smaller nasal airways and some gloves (sterile and non-sterile). Note that the infant-sized “nose” does NOT fit properly in the mask and should be placed either after intubation or placed between the circuit elbow and the circuit itself. waterproof tape. along with appropriate sized oral airways should be immediately available on top of the ploss cart. IVs: T-connectors are required for every case. Neonates: Buretrol solution set. A standard ETT is acceptable for tonsils and adenoids. Chemical warming pads are to be used for transport of all infants being returned to the NICU. This may require particular confirmation in the case of oral and nasal RAE tubes. Warming blankets are useful for cases for children under 10 kg. Consider having an additional pump set up to infuse maintenance fluids with a glucose solution. . appropriate sized ETTs. with an additional buretrol set up for fluid boluses.4 Infants to 6 months: 6 months to 2 years: 78° F 76° F The room may be warmed rapidly by pushing the superheat button. Those coming from the NICU generally have this in place already and this is usually continued throughout the case. Since the child is often moved down the bed after induction. it is helpful to attach the monitors to the sheet over the warming blanket so the child and monitors along with the warming blanket may be moved simultaneously. When time does not allow for his. Nasal RAE tubes are preferred for dental cases. Oral RAE tubes are preferred for palate and cleft lip repairs. Monitors: Pediatric standard monitors are only different from adults in size. a radiant warmer (“french-fry lights”) can be obtained from the PACU. be certain that the cushions under the sheets are close enough together to prevent the child’s shoulders from dropping into a gap between them. Airway: For ALL cases. the predicted size plus a half size larger and a half size smaller. Additional endotracheal tube sizes beyond the half size variation just described should be in the room. Pediatric Bair huggers are available for prolonged cases such as the craniofacial repairs. thus complicating airway management. Miscellaneous: Infants and neonates are easier to manage with a head ring. Temperature monitoring is not necessary for short cases such as BTTs and PDLs. The circular foam head ring may be cut longitudinally or a hole cut in the plain foam pads for small infants and neonates. These are also often useful for those cases involving a long post-induction prep time for obtaining vascular access. Additionally. VIII. it is also not necessary to dilute drugs. Be QUIET during induction and emergence. Children become over-stimulated easily. at the very least. in case IM injection is needed Narcotics: as discussed with the attending. Hot Line Use: Reserve for longer cases (>1. Of course. Pertinent Issues in the Pediatric OR NPO Guidelines: 2 hours – clear liquids 4 hours – breast milk 6 hours – formula. have an additional dose easily available in an appropriate size syringe. draw up the following in the smallest syringe which will hold the appropriate amount: Atropine: 2 ml Succinylcholine: at least 4 mg/kg. Other than epinephrine for ASA III and greater infants and neonates. Drugs: Standardized doses are not necessary or desirable for most cases. If your attending requests standard doses in a single syringe. You will note that after the setup of IVs in the morning they will tend to have bubbles collect in the line in spite of meticulous removal at setup. . prior to induction. knowledge of the appropriate doses of each medication for each child is expected in every case.5 hr) or when you anticipate the need for large volumes of fluid or blood product warming. This requires flushing immediately prior to hooking up to an IV. For each case. non-fatty meal It is especially important that an OR nurse be available to check the patient in before transporting to the OR or. The practice of drawing up exact predicted doses of medications frequently leads to scrambles when additional medication needs to be given.5 Infants-5 years: Buretrol with extension set and T-connector with LR >5 years: Microdrip IV setup with extension set and T-connector with LR For cases where substantial blood loss is anticipated. include a double stopcock in the system so that connection of a hot line fluid warmer is more easily accomplished. Please do not use abbreviations on your forms for anything. correct site. correct side. so wait until you have their full attention to begin report. Nurses will be connecting the patient to monitors and assessing. if used please replace. Keep a hand physically on a child to ensure maximum safety until you have given report and turned the patient over to PACU. correct procedure. they MUST be replaced by you. If you should choose to use these syringes either during your rotation through pediatric anesthesia or while on-call. dosage. and the availability of implants/equipment. As a member of the multidisciplinary team. including CPT code(s). The PACU nurse needs your signature on the PACU flow sheet before you leave to start your next case. ALL SYRINGES must be labeled with the drug. as a reminder. you must participate in the “time-out” before incision is made. XI. Make sure that your printed computerized record is placed in the patient’s chart. date. correct position. There also is an aline bag. . it is your responsibility to replace it.6 Please LOOK at every form and make sure the labels match the patient and that each layer of the duplicate/triplicate forms have a label. the anesthesia charge form needs to be filled out completely. Also. This means you verbally agree on the correct patient. If you remove an armband. Again. Also. Please DO NOT transport any NICU or PICU patient with unlabeled syringes. transducer. Room 37 has a small cassette next to the IV tray in the D-cell with labeled syringes in the event of an emergency or trauma. and pressure bag available. PACU You are responsible for the patient until a PACU nurse has accepted the patient. It is helpful if someone could call the PACU to tell them you are on the way to PACU. Be attentive to all children at all times. and your initials. Please coordinate this with the OR staff. time. Issues Related to the Infant A. Discuss the management of patients who present for T&A. Discuss by system the physiologic differences between the infant and the older child. Discuss at least 10 differences between the pediatric and the adult airway. What is pyloric stenosis? Discuss the preoperative evaluation of these patients. Discuss the sequelae of prematurity. ENT Concerns Related to the Pediatric Patient A.7 SCHOLASTIC GOALS FOR PEDIATRIC ROTATION I. How is temperature regulated in the premature infant? What measures are taken to help maintain body temperature? E. What is an omphalocele? Discuss any associated anomalies. What is retinopathy of prematurity and how is it treated? How are these patients managed in the OR? D. C. What is gastroschisis? Discuss any associated anomalies. Discuss the presentation. Discuss the management of patients who present for BTT. Discuss the physiologic transitions of neonatal circulation at birth. . Discuss apnea of prematurity. B. What is a myelomeningocele? Discuss the timing of the surgical repair of the myelomeningocele. B. How do you position this patient safely for surgery? E. Issues Related to the Neonatal Patient A. Issues of Prematurity A. What are your primary concerns? C. What are the intraoperative concerns? III. Discuss the anesthetic management of these patients. How is the endotracheal tube positioned in these patients? What are the intraoperative concerns for these patients? D. Discuss the anesthetic management of the pediatric patient who presents with a foreign body in the airway. II. What are the anesthetic concerns for patients with gastroschisis? B. What is your plan for induction and maintenance of general anesthesia in these patients? B. diagnosis. What is a congenital diaphragmatic hernia? Discuss any associated anomalies. What are the primary anesthetic concerns for these patients? C. How do you manage their pain? What is emergence delirium? How is emergence delirium treated? D. Discuss a rational approach to the difficult airway in the pediatric patient. and treatment of necrotizing enterocolitis and the anesthetic concerns related to surgical intervention. IV. At what gestational age does the risk for apnea of prematurity measurably decrease? F. Discuss the management of the patient who presents with a bleeding tonsil. Discuss at least five syndromes associated with a difficult airway. Discuss the different types of tracheoesophageal fistulas. E. Discuss the use of both lumbar and thoracic epidurals in children. Anesthetic Drugs and the Pediatric Patient A. Is it safe to perform these procedures in the anesthetized patient? How would you manage the postoperative care of a pediatric patient with an epidural? VIII. Regional Anesthesia A. and coarctation of the aorta. Discuss the pathophysiology of the following lesions: Tetralogy of Fallot. B. Discuss the use of succinylcholine in the pediatric patient. What are common concerns in patients who present with cerebral palsy? Describe your anesthetic plan for a 2-year-old patient with cerebral palsy undergoing a left tendon release. Why does a black box warning exist for the use of succinylcholine in this population? What are the contraindications to using succinylcholine in the pediatric patient? VII. Common Disease States in Pediatric Patients A.25% bupivacaine for a 14-kg patient. . C. childhood periods B. What are the cardiac lesions associated with this genetic anomaly? What concerns are present regarding the airway of these patients? Is IV access a concern? B. infant. How does one assess for intraoperative local anesthetic toxicity. ASD. Discuss local anesthetic toxicity in the pediatric patient. Calculate the maximum dose of 0. VI. For what procedures is a caudal anesthetic indicated? What are the landmarks for placing a caudal? Discuss the standard practice of placing a caudal anesthetic. Congenital Heart Disease A. Discuss the intraoperative management of PDA ligation. C. Discuss the differences in MAC in the neonatal. Discuss your anesthetic plan for the patient with muscular dystrophy who presents for an appendectomy. Discuss the anesthetic concerns related to the patient with Trisomy 21. Are there any contraindications to placing a caudal? B. VSD.8 V. Mode of Delivery is important. any recent URI or other viruses. the evidence does not suggest that there is a significant outcome measure such as death or postoperative mechanical ventilation that is affected by the presence of a URI or URI symptoms in a low acuity outpatient ENT and general surgery. C-section and the circumstances surrounding the delivery 3. What is a pulmonary complication you rightfully ask? In most articles studying the impact of URI on pediatric patients undergoing surgery. the birth history is directly related to the HPI. The presence of any URI symptoms puts the patient at increased risk for pulmonary complications. LMP for females. that differ from an adult.9 PREOPERATIVE EVALUATION OF THE PEDIATRIC PATIENT One must include all aspects of the standard preoperative evaluation. In pediatric anesthesia. . Retinopathy of Prematurity (ROP) B. In addition to this small list. the following is a list of key issues pertinent to the pediatric HPI. These include. History of Present Illness When taking the HPI in a pediatric patient one must obtain all information regarding current illness. A. In some other developed countries full-term is defined as EGA ≥36 weeks. Always remember to address the following issues in your preop evaluation: birth history. PMH. In addition to frequently asked questions. Key issues pertinent to the pediatric ROS. the following: 1. Family History. Bronchopulmonary Dysplasia (BPD) 2. and previous hospitalizations pertaining to the current issue. are discussed in this section of the syllabus. a pulmonary complication is defined as one or more of the following: laryngospasm. In many cases. However. I. last PO intake. 2. desaturation. There are a number of review articles written on this topic. and a discussion of any other concomitant medical problems. Preterm: <37 weeks Prematurity has a number of sequelae. NSVD vs. Below is a brief guideline regarding obtaining a birth history. Full-Term: estimated gestational age ≥37 weeks in this country. and breath-holding. URI 1. bronchospasm. but are not limited to. Birth History 1. HPI. and PE must all be obtained. please see the section on Special Concerns in the Pediatric Patient. medications. Intraventricular Hemorrhage (IVH) 5. This section provides a broader overview of additional topics. Cerebral Palsy (CP) 3. Apnea and Bradycardia of prematurity 4. the parents and the old chart serve as the two primary sources of information. or is there a decrease in activity level? Has he/she been having any other symptoms such as GI distress etc? If the parents answer yes to these questions. thoracotomies. BPD. and certainly postoperatively.10 2. more invasive surgeries such as open or laparoscopic intra-abdominal cases. heart surgery versus minor procedures such as BMTs. if a lower respiratory infection is present one should not be lulled into performing the anesthetic just because of a recent previous cancellation. Additionally. and muscular dystrophies. simple questions directed at the parents about the functional status of their child are usually very helpful • • • • • • Has he/she been having fevers? Has he/she been coughing a lot? Does he/she seem sick to you? Has he/she been eating and sleeping normally? Has he/she been playing normally. it is important to listen for wheezing and to distinguish lower airway noises from upper laryngeal sounds. if the symptoms and findings on physical exam are consistent with a lower respiratory infection then it is probably safest to postpone the case for 4-6 weeks. For example. it is likely a child may return for a rescheduled procedure with another cold or a significant URI. and simply use an albuterol inhaler when they get a URI. 3. Many children have persistent and frequent URIs. and aggressive asthma treatment initiated. This justification serves only the convenience of the family and surgeon. . inguinal hernias. . In your physical exam it is important to listen for wheezing and to distinguish lower airway noises from upper laryngeal sounds. People who are wheezing usually get postponed unless there is a truly compelling reason to proceed. There is a large list of comorbidities that can potentiate or further contribute to respiratory complications in these patients. CP. but . Always take into consideration the extent of the surgical procedure the child is about to undergo and other significant comorbidities that may adversely affect the pulmonary status of the patient on induction. intracranial cases. . spine surgery. Some of the significant ones include. To proceed if the patient is truly ill is potentially harmful. . one must seriously consider whether or not it is worth proceeding or perhaps the case should be postponed. In situations where the patient is actively wheezing. Many mild cases of asthma will appear only in the setting of a URI. palliated congential heart disease. significant asthma. . Not to state the obvious . and you will see a number of patients who carry a diagnosis of asthma but are not on medication. Down’s syndrome. During the physical exam. However. the case is usually postponed. Remember. during the surgery. but are not limited to. Do not simply proceed because they have been canceled once before and they have traveled from a significant distance. How does one decide to postpone a case? Many factors must be considered when answering this question. Please take necessary precautions for latex allergic patients and always alert the room staff. Look at old records if possible. gloves. Specifically. In addition. and other chronic illnesses. All other brown coban contains latex. blue coban. Many times the family may have specific expectations because of what happened during the previous anesthetic and how it may have been an improvement over previous experiences. Please be advised that there are two types of brown coban. Family History Always evaluate for a family history of malignant hyperthermia and the presence of pseudocholinesterase deficiency. if the surgery is reasonably contemporaneous you can look at what ETT size was used. just clarify and redirect.11 circumcision. Allergies Internalize these and always recite prior to giving antibiotics. etc. Make it a priority. urogenital abnormalities. and syndactyly repair will affect the final decision concerning postponement. The old chart allows knowledge of the premed used as well as pain control requirements. tethered cords. the medical history must be obtained. and rubber bands all contain latex. difficult IV access. Parents are not a reliable source for obtaining the entire anesthetic history. In some situations parental presence at induction is allowed. Always remember to address issues related to prematurity. It is good to know ahead of time as the parent may likely have similar expectations for the upcoming procedure. LMP in menstruating females – DO NOT be afraid to ask. At this point. In this section. II. such as pulse dye laser. III. The old chart is key for information regarding the airway. The pediatric OR area is NOT a latex free environment. intraoperative hemodynamic instability. Parents will often add that they get nauseated or that they take awhile to wake up. the white cloth tape. syndromes. If you have any concern whatsoever do not be afraid to ask for a urine sample for B-Hcg. Always be aware of the specter of latex allergy especially in patients with myelomeningoceles. . Prior surgeries or other experiences with sedation or general anesthesia must be discussed. B. especially in syndromic children or others known to have a potential for anesthetic complications. and chronic illnesses such as childhood cancers. IV. B. A thorough history should be obtained. the old chart allows for continuity of care in children who have undergone multiple procedures. Past Medical History A. The internal aspect of the roll reads LF for latex-free brown coban. Additionally. especially in ill children. This information is important and must be addressed. RR. Physical Exam A complete physical should be performed. HR. the . one should obtain an overall impression of the facies (normal vs. It is important to review the medications given on the floor and the dosing schedule. A. Children with significant underlying systemic pathology do not grow normally. . Most children will have relatively easy airways 2. . Note that the presence of any infection or questionable physical finding of exam should be addressed with the attending at the time it is noticed. B. 3. If patients are taking narcotics look at doses and length of usage to estimate the intraoperative needs. Specifically. • Children should weigh around 20 kg at 5 years of age. • There is a much larger spread at 5 years of age. and a section entitled Special Medical Concerns in Pediatric Anesthesia addresses the key topics. Observation is a tool that must be used to perform the physical exam in children. Patients from the NICU should have a cover sheet in the chart with this information. VII. Know the prescribed antibiotics and the time of the last dose. Most infants and toddlers are not cooperative with an airway exam. The above weights serve as a guideline and should allow you to estimate a weight in an emergency situation or to attempt to assess whether the child is potentially failure to thrive (FTT). however. The routine use of a stylet may introduce the possibility of further trauma. 1. Please refer to this section. So what is normal? Here are a couple of useful numbers: • Children should weigh around 10 kg at 1 year of age. Do Not Forget . Vital Signs – note any fever or variation from normal in vital signs for the child’s age group. and BP if applicable. VI. you may refer to the Table 4-2 in the Coté text. as medications are dosed according to weight in kilograms. but classically a 1 year old should weigh around 10 kg. Review of Systems The pediatric ROS is unique. For a brief overview of the ROS.12 V. The size of the patient can also give you a great deal of insight into the global picture of a child’s overall physiologic health. abnormal). The vast majority of children do not require a styletted ETT. Airway – a detailed exam should be performed. obtaining an exact weight in kilograms is essential. Always note temperature. Medications Review the med list and the time of last intake. C. 4. Undiagnosed cyanotic/structural heart disease is one of the most common causes of unexplained death in children <1 year of age. Extremities – Again. Always discuss the murmur with the parents and inquire as to the history. Good clinical acumen. Some children may have loud breathing as a result of some upper airway pathology/variant . . Based on the history. D. Obviously listen . careful history. F. Obviously listen . 5. and conversation with the patient’s pediatrician probably go a long way in this situation. Children presenting for repair of cleft lip and/or palate and those with syndromes known to be associated with difficult airways should be closely evaluated. these children are not wheezing they simply have loud upper airway noises even though they do not carry an official diagnosis of laryngomalacia. Labs The need for laboratory studies is case specific and should be discussed with the attending. and extreme macroglossia must be appreciated during the preop exam. Wheezing usually gets postponed 3. 2. Address any obvious abnormalities.13 presence or absence of mandibular hypoplasia. . A murmur first noted preoperatively in a child <1 year of age should be considered for formal evaluation. . facial asymmetry. Abdominal – Evaluate for any apparent abnormality. Heart 1. . VIII. the attending anesthesiologist will determine the need for a formal consult. . observe. 2. including the presence of a G-tube or large surgical incisions. E. Lungs 1. . Many murmurs have been heard before but may not have been commented on. . Remember to evaluate dentition and remark on any loose or missing teeth. Diabetes Diabetes in pediatric patients most commonly represents a significant deficiency or complete absence of insulin as opposed to the pathophysiology of adult onset diabetes which more is usually a result of insulin resistance. A. patients will receive a short course of steroids prior to going to the OR. III. D. These patients are certainly at more risk than the above patients. . or if they have had one recently. if they have an ongoing URI. Upper Respiratory Infection (URI) As outlined earlier in the section on preoperative evaluation of the pediatric patient. Many patients carry a diagnosis of asthma. intraoperatively. The peak flow value is important information in the older asthmatic patient. pulse dose steroids. These patients should be the first case of the day. If this history exists. it should be taken very seriously and further clarified. Beware though.14 SPECIAL CONCERNS IN THE PEDIATRIC PATIENT I. Preoperative insulin regimens are frequently handled by the patient’s endocrinologist. Asthma There is a large continuum here in terms of the true degree of pathology. assuming they do not currently have a URI. and potentially headed down the road toward ketoacidosis and dehydration. Recent documentation of a visit to his/her pulmonologist in preparation for surgery is certainly appropriate. Frequently in these severe cases. These patients are typically at low-risk for intraoperative bronchospastic events. unless there is a truly compelling reason to proceed. and be aware of the potential for significant metabolic derangements prior to and potentially during surgery. or postoperatively. II. If these patients are medically optimized they will typically tolerate GA and surgery without further preoperative optimization. These patients must be managed carefully throughout the perioperative course. and use an inhaler only with URIs. Patients who are actively wheezing should be postponed in most cases. Always inquire about ongoing glucose control. Next there is the subset of patients on multiple medications with multiple ER visits because of bronchospastic events that required nebulizers. but do not require regular medication. do not hesitate to contact the endocrinologist preoperatively. A preoperative nebulizer treatment or a dose of albuterol in the holding area is reasonable for these patients It is unusual to elicit a history of a prior ICU admission or intubation and mechanical ventilation as a result of asthma. C. Check glucose while in holding. B. Obviously a balance must be maintained such that the patient is neither hypoglycemic nor significantly hyperglycemic. If questions arise. C. If preop insulin is managed by the anesthesia team. discuss the plan and maximum time for which the tourniquet can be safely inflated with surgeon preoperatively. Patients who have experienced several SS crises are typically treated with narcotics at the time of a crisis. When was their last seizure? How often do they occur? 3. In taking a history a few points in particular are important: 1.15 E. glucose containing solution should be initiated. and appropriate glucose control with insulin should be instituted. F. but this is only a start and further consultation with an attending is necessary. Seizures A. Sickle Cell Disease (SCD) A. when were the last medication levels drawn? 4. One should seriously reconsider proceeding to elective surgery in the presence of a blood glucose >250. This is important to note when planning the anesthetic and postoperative pain interventions. These patients can obviously be significantly anemic preoperatively. Maintenance of hydration. An appropriate IV insulin dose to start with in children is probably around 0. V. typically the patient will take half their insulin dose on the morning of surgery. Always be wary if the parents state that the child’s seizure pattern has changed recently (1 wk-6 mo). Always discuss with the attending before initiating such treatment. When he/she has a seizure what does the child look like? 2. IV. E. There is at least one study published in the New England Journal of Medicine that showed a benefit in this patient population with aggressive transfusion—up to an Hgb of at least 10. It is important to obtain a preoperative Hgb in patients with either sickle cell disease (HgbSS) or trait (HgbSs). D. B. A working IV and pulse oximetry are essential. The titration of insulin to achieve the desired glucose value over time while closely following intraoperative blood sugars is probably warranted. If it has not been addressed it may be wise to postpone an anesthetic and refer the child to his/her neurologist for further work-up/follow-up to make sure all appropriate measures have been to optimize this patient for the anesthetic. G. Standard spectrophotometric pulse oximetry techniques have been validated in these patients and likely reflect the true saturation.1 u/kg. In the event of intraoperative hypoglycemia. the intraoperative narcotic requirements for these patients are frequently higher than normal. Are they on medications to control their seizures? If yes. Documentation of regular follow-up with a neurologist can be very helpful in allaying your concerns prior to coming to the OR. H. F. For procedures requiring an intraoperative tourniquet.05-0. . and normothermia are essential in managing these patients. Seizures in children may be a result of some significant CNS injury early in life or may be idiopathic in an otherwise normal child. adequate oxygenation. and be sure this has been addressed. In this situation a determination of anti-seizure medication levels should be considered. B. Thus. CP patients frequently have persistent reflux disease. Clarify points concerning the etiology of the lesion and the palliative/corrective surgeries that may have been performed. You will begin to appreciate that pathologic murmurs typically have a slightly higher pitch than their benign flow murmur counterparts. but in combination be aware of the interaction between digoxin and hypokalemia secondary to diuretic therapy. Obtain lab values when indicated. Does he/she keep up with peers or does he/she get fatigued before their friends when playing? B. as these patients present for a number of different types of surgeries/procedures. Be aware many of these children may have pacemakers. Sometime you will hear the term “Still’s murmur” These are benign flow murmurs and are of no clinical consequence. A study from the University of Chicago revealed that pediatricians identified pathologic from non-pathologic murmurs only about 50% of the time. Thus. What about infants who are unable to communicate or exercise? Eating is the most active thing neonates and infants do. Does he/she sweat when feeding? 2. Congenital Heart Disease A.16 VI. Pediatric cardiologists were able to distinguish the difference around 90% of the time. followed by IV placement and ultimately intubation. Cerebral Palsy (CP) A. CP does not necessarily imply mental retardation/disability. Frequently you will here a murmur. Does he/she tire easily? 2. It is important to obtain a clear history and understanding of the patient’s cardiac lesion before proceeding to the OR. and most practitioners who deal with these patients regularly are fairly comfortable proceeding with a mask induction. during the past 10 years there has been a paradigm shift. Continue practicing auscultation. frequently appearing thin and wasted in addition to potentially being cyanotic. Assess rhythm. and diuretics.” C. B. So when taking a history directed at the functional status of an infant or neonate some questions to ask may be: 1. D. . Obviously these drugs have many potential sequelae. Listen to the heart. always be on the lookout when you hear the term “failure to thrive” sometimes abbreviated “FTT. This is probably one of the more common diagnoses we see at a tertiary care facility. C. Look at the EKG. Get a room air SpO2. In the setting of palliated complex congenital heart disease. always search for a recent echo and/or try to get an exercise tolerance history from the parents. E. In the past. 1. many practitioners advocated a rapid sequence induction in these patients. although frequently that is the case. Pay close attention to medications. Always inquire about growth. however. ACE inhibitors. Children in heart failure do not grow appropriately. Frequently these kids will be on digoxin. Does he/she turn blue or appear in distress when feeding? 3. VII. F. CP specifically refers to a non-progressive motor disability frequently characterized by spasticity and ultimately secondary contractures. 17 G. and a full understanding of these syndromes requires continual selfeducation. 3. the scope of this discussion is limited. Genetic Syndromes There are many genetic syndromes in pediatrics that deserve attention. . Isolated Repaired VSDs and ASDs. Ask any attending or PACU nurse for the reference. The note will frequently state precisely the lesion. However. Look for a note from a pediatric cardiologist if the child is on any medications or has anything more significant than an ASD. VSD. A few references are the Online Mendelian Inheritance in Man website. 4. dosing. H. T&A does require prophylaxis. The information on the website was compiled at Johns Hopkins. Always remember the presence of the difficult airway with many genetic syndromes. and the need for SBE prophylaxis will be addressed. or PDA corrected in the distant past (>1 yr). VIII. The site is a database that has information regarding human genes and genetic disorders. and what types of procedure require what type of antibiotics. 2. Direct laryngoscopy does not require prophylaxis. any surgical interventions. This site can be found via any server by typing OMIM. 5. There is also a text in the Peds PACU on genetic syndromes by Smith. do not require prophylaxis after 6 months. The American Heart Association’s website contains the most recent guidelines on regimens. M&Ts do not require prophylaxis. however. A few SBE pearls: 1. any airway manipulation debridement or rigid bronch probably warrants SBE prophylaxis. If the answer is no. This often looks and sounds more gruesome than it is. PO versed 0. M&T). Guidelines for Premedication A. At 1 mg/kg the sedative effect is going to last well over an hour so be aware of this when using this higher dose in shorter cases (i. Simply ask if the child is likely to take PO with success. IM. as they do not tend to have separation anxiety. However. the peak effect of a versed premed given to a child for a short procedure. Below are a few recommendations when giving PO.5-1. For example. The onset of action may be as long as 15-20 min. or IV versed. The nurses are available to help hold a child. It is best to minimize the level of anxiety in these patients. C.1 mg/kg. Do not rush an oral premed. Versed is used most frequently. B. Versed A. This is especially true for those who are going to have multiple procedures in the future. It is best to allow the parents to step aside during the injection. always have an extra staff person in the room in addition to yourself. Although the child may appear calm. many parents may want to restrain the child. and as a . The length of the surgery must be considered. Giving an injection in the pediatric population requires HELP. Use the concentrated 5 mg/1 ml form from the pharmacy. Probably best to consult the attending. Give the injection in the deltoid after prepping with EtOH because blood flow is significantly higher in the deltoid than the thigh. intranasal.e. I. If a premed is desired. one might as well wait a few minutes and reap the benefit of having a cooperative child on induction. Between 10 mo and 7-8 yr of age children frequently require premedication. it is probably a good idea to give the medication. Always counsel the patient’s caregiver to hold the patient after a versed premed or let the patient rest on the bed. such as myringotomy and tubes. B. The ultimate determination is subjective and multifactorial. take time to explain the need for the IM injection and proceed.0 mg/kg up to 20 mg. First one must determine if a premed is necessary. This is a good approach in the highly agitated child who refuses to take PO or is likely to spit half of it on the mother. children can change their emotional state very quickly. Often the parents will assist as well. If one has gone to the trouble of giving it. T&A. Versed is commonly used as a premedication. If a parent requests a premed.. Versed’s amnestic properties frequently are present after a few minutes even though the child does not appear to be completely anxiety free. Children <6-10 mo of an age typically do not require a premed. D. may occur postoperatively. A discussion with the parents is helpful when making the decision to use an IM injection. IM versed 0. If this is the case. C. many medications may be used.18 PREMEDICATION Premedication is an important aspect of preparing the patient for surgery and medication must be given in a timely manner to ensure an adequate effect preoperatively. but many of the options are addressed in this section. The holding room nurses are good at giving oral medications if your technique is not working well. II. Children frequently become unsteady and can easily fall or stumble if allowed to ambulate. PO ketamine may be dosed 5-10 mg/kg. It is useful in and should be reserved for the most recalcitrant of patients. The parents will appreciate your attention to detail as they are used to seeing a band-aid placed on their child after a shot. IM ketamine – a premedication dose is typically 2-3 mg/kg although some would say one can give as much as 5-7 mg/kg. Note that the induction dose of IM ketamine is 5-10 mg/kg. You must counsel the parents regarding the presence of nystagmus. is a significantly faster and reliable onset of versed. Also. dress the site with a band-aid. Atropine. B. However. be sure to move the patient to a recumbent position on the stretcher sooner rather than later. If you think that atropine is needed. Always discuss the need for ketamine with the attending prior to administration. You will be amazed at how fast an infant will become bradycardic and arrest when faced with a hypoxic event related to airway compromise. B. it is important to discuss this with your attending. Atropine A. The minimum dose for atropine is 100 mcg IM or IV. It is important to warn parents that the child may appear awake even though they are sedated following the administration of the drug.3 mg/kg. Also. IM. It can be especially useful in larger children who are mentally disabled and unable to understand and comply with caregivers. Versed may be given in IV titrated doses up to 0. comorbidities who are undergoing elective surgery with an anesthetic being administered by experienced pediatric providers. The down side to an IM injection is really the pain on injection. The same issues apply. IV ketamine – ketamine is rarely given IV as a premed. The upside. The crying following the injection will typically fade into a carefree state of sedation over the course of minutes (frequently <5). Ketamine may be given PO. VI. In larger doses the effect of ketamine will last a long time and will lead to an unending stream of drool. Intranasal Versed – 0. D.1-0. atropine is useful as a premed if there is any concern of bradycardia or stimulation of vagal reflexes.19 consequence of this uptake is significantly faster.3 mg/kg F. Ketamine A. or IV. Although postoperative hallucinations and nightmares are more common in adults following the administration of ketamine. III. The drug is frequently administered in the holding room with the parents present. however. C. C. Ketamine is a dissociative anesthetic. . it is important to consider the use of versed in addition to ketamine. E. if any. 0. E.02 mg/kg IM or IV should always be given prior to succinylcholine. This is a reasonable approach in healthy infants and children with few. The practice of routinely giving anticholinergics prior to induction in children and infants has evolved to the extent that many practitioners now advocate giving it on a PRN basis. There is no better monitor in pediatric anesthesia than the provider. Standard monitoring applies for all pediatric cases. Heating blankets and fluid warmers may also be necessary. It is dramatically easier to place an IV in a completely still. infant BP cuff tubing is white and found in the top drawer of the anesthesia machine. a color change in the lips is noted around a saturation of 88%. D. Of note. Inhalational Induction 1. venodilated youngster. This is the induction method of choice in most pediatric patients especially those <10 years of age. the best monitor you have is observation of the chest rise and fall. and should be discussed with the attending prior to the case. Monitors are placed prior to induction as necessitated by the situation. Just remember to look at the patient! B. the delivery of anesthesia requires attention to a different subset of variables. This will pass . There exist rationales for all approaches. these should be discussed with your attending prior to coming back to the OR. During induction and IV placement. 2. the room temperature should also be maintained and the patient covered to minimize heat loss. sometimes in fairly dramatic fashion. While they are in stage two. . Older children may still be candidates for an inhalational induction but certain issues arise because of their size. The job of the anesthesiologist is to warm the room preoperatively and to maintain the patient’s body temperature throughout the procedure. including a longer time spent in stage two of anesthesia. There are different techniques used for inhalational inductions. The monitoring of temperature is critical in very young pediatric patients. 4. C. On induction children will move around interrupting any useable signal from your pulse oximeter. This tubing is generally reserved for infants <5 kg. You must constantly watch the patient and listen! Your eyes and ears serve as the best monitors. While the components of a case are similar in both pediatric and adult patients. During induction. I. Should hypoxia occur that is not detected by pulse oximetry. Premature babies and infants are at increased risk for hypothermia because of their increased surface-tovolume ratio and increased thermal conductance. Monitoring A. . Induction A. they may move or wiggle around. Inhalation inductions carry the obvious benefit of avoiding IV placement in a crying toddler. among many other reasons.20 INTRAOPERATIVE CONSIDERATIONS IN PEDIATRIC ANESTHESIA. The need for additional monitoring is determined on a case-by-case basis. . The room temperature must be maintained if the patient’s temperature is low. A mixture of 70/30 nitrous/oxygen vs. the most important thing here is to maintain a patent airway and restrain them appropriately. II. 3. ECG signals will generally be maintained. 100% oxygen may be used along with either an incremental increase in sevoflurane with every third breath or an initial dose of 8% sevoflurane. A few valuable questions to ask when assessing the function of the IV. B. Larynx of a child is funnel shaped secondary to the narrow cricoid cartilage . Can you flush the catheter with ease? 2. 3. Omega shaped epiglottis 6. however. In infants. Practice saphenous IVs when you can. Less cartilaginous epiglottis 7. You can catheterize veins you cannot see. Do not accept less than absolute certainty from yourself. Access A. Do not accept less than certainty when placing an IV or using a pre-existing IV. Does the site appear to have infiltrated? C. Significant and unrealized infiltration of an IV in a baby or toddler can be very dangerous. Airway Successful intubation of the pediatric patient requires that one understands the many differences that exist between the pediatric and adult airway. D. . blind IV sites including the saphenous vein.Ketamine is useful for IM induction but is rarely indicated. A preoperative IV allows for ease in the administration of a premedication. and in those patients who already have a functioning IV in situ. C. and onset was fairly slow relative to other methods of induction III. E. IV inductions are preferable in older children. IV Induction 1. it just takes practice and proper technique. antecubital vein. but this is mostly of historic note. it could be messy . Flatter faces 2. intern’s vein. 2. Most children ≥12 will tolerate the placement of an IV preoperatively.21 B. . Ask for guidance if you’re unsure of landmarks and techniques. A. . Always ensure adequate function of the IV. Differences in the pediatric/neonatal airway and the adult airway. All induction agents may be used in children. Down sides included the obvious . 1. . Are you able to obtain blood return from the catheter? 3. In pediatric patients the following is true: 1. It is also used in RSI. Cephalad orientation of larynx relative to the adult 8. Edentulous (neonatal and infants) 5. IV. The uptake and the increased size of children in this age group results in an extended period in stage two which is avoided by using the appropriate dose of an induction agent. IM Induction . IV induction is used in older children. The presence of a functioning IV prior to the start of the procedure is essential. Rectal . and the vein above the fourth metacarpal are frequently used. D.Methohexital inductions have been performed in the past. propofol and thiopental are used most commonly. Larger occiput in relation to body size 3. Macroglossia 4. Recommendation for children <1 year of age are listed below. 16. However. Neonate/Young Infant (0-4 mo): 3. Recommendations for children <1 year of age are listed below. More acute angle at branching of mainstem bronchi than is seen in an adult. Choosing the right endotracheal tube There exist many opinions about the sizes and types of endotracheal tubes used in children. 3-4 ml of oxygen/kg in an adult). 17. 10. 13. Alveoli are significantly less mature.0 iii. Uncuffed ETT formula age / 4 + 4 = ETT internal diameter. it imperative to document a leak.22 9. Trachea is shorter and more compliant. Axis of vocal cords relative to the long axis of the trachea is different as a result of the anterior attachment being more caudad relative to the posterior attachment of the vocal cords 11. 1. Older Infant (>10 mo): 4. 2. 15. The cricoid cartilage is the narrowest portion of the child’s trachea versus the glottis in the adult. many anesthesiologists use cuffed tubes in most pediatric patients. Again. For many years practitioners advocated using uncuffed tubes to increase the internal diameter of the ETT as a means of decreasing the resistance to gas flow related to the ETT. This applies to children >1 year of age. The narrowest portion of the pediatric airway is the cricoid cartilage. Respiratory variations in the child that are important to note: oxygen consumption is dramatically higher on a per kilogram basis (6-7 ml of oxygen/kg vs.5 ii. Infant (4-10 mo): 4. 3. B. Take the opportunity to use all of the pediatric blades as you work with different attendings.5 4. This applies to children >1 year of age. they simply may not give ideal intubating conditions. Below is a list of suggestions. including premature infants and neonates.5 iii. WHY? WHAT OPERATIVE FACTORS HAVE BEEN ASSOCIATED WITH POSTOPERATIVE CROUP? HOW DO YOU TREAT IT? C. Intubating blade choice in the pediatric patient. A more recent approach to the use of uncuffed tubes restricts their use to children <2 years of age. i. . This is not to say that other blades cannot be used to intubate smaller children. Many anesthesiologists continue to use only uncuffed tubes until children are between 5-7 years of age. there are many opinions and personal preferences to which you will be exposed. Major conducting airways are also significantly more compliant. Neonate/Young Infant (0-4 mo): 3.0 ii. Closing capacity is increased. 14. Infant (4-10 mo): 3. Regardless of whether you use a cuffed or uncuffed ETT. Older Infant (>10 mo): 4. i. Chest wall is significantly more compliant. 12.0 5. This exposure to different opinions will allow for the development of your personal preferences. Cuffed ETT formula is age / 4 + 3 = ETT internal diameter. FRC is the same on a per kilogram basis. Positioning A. D. Whistler’s Syndrome 6. ECG lead mark. Pierre Robin Sequence 5. In this population it is typical to administer a reasonable amount of narcotic intraoperatively. 1. patient etc. C. All of the available agents may be used in children for maintenance. Maintenance of Anesthesia A. tape abrasion. Hunter’s Syndrome 8. they will start looking for every bruise. B. It may be challenging to find a comfortable appearing position.23 MIL 0: Neonates/Preemies MIL 1: 0-2 yr MAC 1: 6 mo-4 yr WIS 1. especially if the patient is being turned lateral or prone. Prior to the induction of anesthesia. Syndromes associated with the difficult airway. After induction of anesthesia any one of the 3 available inhalational anesthetics may be appropriate for maintenance. None of the monitoring wires should lie on the baby in such a way that an impression will be left. Caution must be used when placing monitors on children. Children in general are significantly more flexible than their adult counter parts. Goldenhar’s Syndrome 9. Remember. blister. Otherwise you may delay the patient’s emergence or worse cause a significant respiratory complication in the PACU. etc. . and once they are satisfied that their child has survived their surgery. Always pad every pressure point to avoid nerve injury. pay close attention to the patient’s range of motion to ensure safe positioning. the use of spontaneous ventilation to guide the administration and titration of narcotics is not a particularly good technique for a variety of reasons. Angelman’s Syndrome V. It is probably best to exercise some caution in administering larger doses of narcotics to children <6 mo of age. Gaucher’s Syndrome 3. C. Narcotic requirements can very greatly depending on the procedure. B. Narcotic is then titrated following emergence and extubation. Exceptions to the above remark are those children with spastic neuromuscular disease states in which there are contractures present.5: 2-6 yr MAC 2: 2-12 yr MIL 2: >12 yr MAC 3: >12 yr D. D. Parents do not like to see marks of any kind on their child. VI. In children <7 yr of age. Down’s Syndrome 7. you do not have to use sevoflurane for the whole case just because it is a kid or because you used it on induction. Treacher Collins 4. Hurler’s Syndrome 2. Remifentanil infusions may be used in many surgical procedures involving neonates. and finally 1 ml/kg/hr for each additional kg. . Some larger abdominal procedures in a neonate may necessitate as much as 10-20 ml/kg/hr. Transfusion Therapy in Children In most circumstances. E. A good rule of thumb for transfusing: 10 ml/kg of PRBCs will raise the child’s Hgb 1 gm/dl. A. D10LR). These are not hard and fast rules. When using a regional technique. E. However. 3. Neonates (especially <2 wk) old should probably have some component of dextrose in their isotonic crystalloid solution (D5%LR. 4 ml/hr for the first 10 kg. Fluid Maintenance A. With this in mind there are no absolute transfusion trigger points. a smaller dose of any given narcotic may be adequate to control the infant’s pain. Emergence is almost always delayed because of the decreased minute ventilation and reduced clearance of volatile anesthetics. Following the procedure. B. Isotonic crystalloid solutions are most often used intraoperatively. Blood volumes (ml/kg) are different at different ages: Preterm infants: 90-100 ml/kg Term infants: 80-90 ml/kg One-year-old: 70-80 ml/kg Older children: 70 ml/kg B. for reasons that are unknown. and obviously the operative context will greatly impact your fluid management.24 1. D. A good rule of thumb in running/calculating/maintenance fluids and routine deficits is the 42-1 rule. Children. will frequently continue to breathe even when they are hypocarbic. children will tolerate a significant degree of anemia so we tend to be more conservative overall in transfusing them. it is probably reasonable to withhold narcotics until incision to determine if the block is going to function adequately both for the surgery and in the postoperative period. F. VIII. A good ballpark number for most routine/outpatient procedures is a total of 20 ml/kg (deficit + replacement) within the first 1-2 hr. such as a caudal. 2. Remifentanil’s favorable pharmacokinetic profile and the fact that it can provide intense analgesia and presumably sympatholysis in these patients during surgery make it a good choice in this setting. C. VII. 2 ml/kg/hr for the next 10 kg. D5%NS. a 4-kg infant does not need to lose much blood before they may become anemic. Postoperatively there is minimal residual sedation. Many frequently become at least briefly agitated and then settle down. It is important to remain extremely vigilant and always acknowledge a surgeon’s admission of blood loss. There is little consistency in how different children will respond on emergence. C. Once extubated. Infants and small children will get hypothermic very quickly if you do not take measures to warm the blood prior to administration. Extubate children with the head of the bed turned toward you such that you can easily access the child’s airway if necessary on emergence. Calcium chloride (10-20 mg/kg) or calcium gluconate (15 mg/kg) will quickly chelate the citrate and improve hemodynamic stability. E. Blood also should be passed through a filter prior to administration F. a coagulopathic state may develop sooner. On arrival in the PACU. The important issue is to quickly address the laryngospasm. D. The 30 seconds you save will be well worth it. Adult extubation criteria obviously must be somewhat adjusted given that young children and infants are unable to follow commands. turn the bed. grimace. adequate spontaneous regular respiratory pattern. including temperature and to provide adequate postoperative analgesia. . H. One day you may be the only anesthesiologist in that room. Know the dose of succinylcholine and atropine and be prepared to reintubate the child if necessary. If DIC or hepatic dysfunction is present. This tends to be much less of a factor in larger pediatric patients with significantly larger intravascular circulating volumes. Unique criteria for extubation in infants through toddlers are the following: hip flexion. B. and purposeful movement. Emergence A. D.e. CPAP. IX. In the setting of premature extubation. the anesthesiologist should assist the PACU nurses with the placement of monitors. This may sound paranoid until you try to: close the APL valve. an appropriate laryngoscope and ETT should be available. apply. and administer atropine and succinylcholine rapidly as the child becomes hypoxic and bradycardic. E. Everyone extubates prematurely at some point. it is less likely that this will occur.25 C. eye opening. the incidence of laryngospasm in children is significantly higher than in adults. Be aware of the specter of citrate toxicity especially in the setting of rapid transfusion of a significant amount of blood to a small child (<10 kg). Patients will typically not become coagulopathic as a result of dilution of platelets or factors until you begin to approach an EBL of 2 blood volumes. G. the patient should be transferred to the PACU with oxygen. get to the IV. Always relay pertinent information regarding the patient to the PACU nurses. We typically (do not dilute) PRBC prior to administration as is often done in adult anesthesia.. Set yourself up for success. Do not forget to evaluate all vital signs. If CPAP fails do not persist. If several of the above extubation criteria are met. i. and evaluation of the patient should occur prior to report. Children sometimes will wake up and appear to have emerged from anesthesia and immediately go back to sleep after coughing on the ETT briefly. Caudal anesthesia is frequently performed for urologic or orthopedic procedures in young children. When dosing narcotics. Many different techniques exist for the placement of a caudal and epidurals. To ensure safety. and Wilm’s tumor resections are the procedures for which an epidural is most commonly performed.125% bupivacaine with 1:200. Between 60-180 min are required to achieve peak blood levels. First aspirate. narcotics must be titrated to safely achieve adequate pain control. During this period of time. simply inform the surgeons that you are going to give ketorolac with their agreement. D. you will be exposed to these different techniques. Regional Anesthesia – Both caudal and epidural anesthesia are used safely in children. a test dose is performed to rule out intravascular injection and intrathecal injection.000 epinephrine is used for the caudal. The test period should last 1 full min. and regional techniques are all important aspects of postoperative pain management. Postoperative Analgesia As with all anesthetics.5 mg/kg IV or IM. the needle must be removed. In pediatrics. 1. IV Narcotics – IV narcotics are frequently used postoperatively. one must listen to the heart rate for a change of >30 bpm and look at the ECG for the presence of peaked T waves. The needle is then advanced 1-2 mm. During the rotation. In many cases. Once the sacral hiatus is identified. . Ketorolac is not commonly prescribed during an anesthetic for tonsillectomy or other procedures with an increased likelihood for postoperative bleeding. C. 2. B. the needle is advanced cephalad at a 45° angle until a “pop” is felt. or it may be used as an adjuvant to narcotics. check for the presence of heme. The “pop” signifies advancement through the sacrococcygeal ligament and into caudal space. Once in the caudal space. One concern with ketorolac is the potential for platelet function inhibition. a caudal anesthetic is performed by placing local anesthetic at the level of the sacral hiatus. one must examine the patient’s need for pain medication and intervene with a safe but adequate dose. Most commonly 0. Acetaminophen – Rectal acetaminophen is frequently used in doses of no more than 40 mg/kg. If the aspirate is clear. for example with dental procedures. Certain thoracotomy procedures. a 1 ml test dose may be given. A dose of 20 mg/kg every 6 hr is prescribed following the initial dose. The dose is 0. Epidural anesthesia is performed infrequently in our pediatric population secondary to the inherent risks of performing a block on a patient under anesthesia. narcotics. NSAIDs. Ketorolac – Ketorolac may be used alone for postoperative pain. A standardized form is available for ordering postoperative narcotics. which occur with intravascular bupivacaine injection. A. Caudal anesthesia – In general. especially in children having tonsillectomy. The needle should then be leveled and positioned parallel to the patients back. spine procedures.26 CARE OF THE PEDIATRIC PATIENT POSTOPERATIVELY I. If heme is present. It is important to give this dose at the onset of the anesthetic. one must begin planning for postoperative analgesia prior to the onset of the case. Fentanyl and morphine are used most commonly. in addition to dexamethasone. 4. strabismus.. This serves to empty the stomach of its contents and relieve gastric distention that can be a factor in PONV. 4.1 mg/kg up to 2 mg. craniotomy) should receive. 3. and others. Below are doses for commonly used antiemetics. Below are the pediatric anesthesia departmental guidelines on PONV: 1. A. 1. Metoclopramide 0. who have an IV. one may consider TIVA as the primary anesthetic. dental extraction. adeno-tonsillectomy. middle ear surgery. i. strabismus) 2. laparotomy. herniorrhaphy. Antiemetic prophylaxis and treatment of neonates and infants will be at the discretion of the anesthesiologist. Patients ≥1 year of age who are at high-risk of PONV (history of PONV or high-risk surgical procedure. 3. B.25 mg/kg D. receive a general anesthetic. droperidol for patients in whom it is felt the potential benefits outweigh the risks. Sight of surgery (ENT. The use of nitrous oxide can be a contributor to PONV. 2. Additional strategies for decreasing PONV 1. PACU rescue should be at the discretion of the anesthesiologist and may include higher doses of ondansetron. Glazier requests that his patients DO NOT receive droperidol. orchiopexy. as are all the inhalational agents. Female gender 4. have a surgical procedure. .e. abdominal. History of motion sickness 3. This issue should be addressed with the attending prior to the case. Prior history of PONV C. All patients ≥1 year of age. such that adequate medications can be given intraoperatively. Always remember to decompress the stomach following induction. Odansetron 100 mcg/kg 2. Decadron 150 mcg/kg maximum dose of 8 mg. laparoscopy. and do not have a contraindication should receive dexamethasone 150 mcg/kg to max of 8 mg. Risk factors for PONV in children include: 1. Note: Dr. 2.27 II. Postoperative Nausea and Vomiting (PONV) in Children The management of PONV remains a controversial topic. In cases of severe PONV.15-0. Droperidol 50-75 mcg/kg potential second level rescue in PACU. ondansetron 0. For quick cases. 3. if you have 5 pulse dye laser cases then put a waterproof pad over the green sheet followed by another green sheet/waterproof pad/green sheet.28 SPECIFIC CASES: STRATEGIES / CONCERNS / GENERAL GUIDELINES The outline below is meant as a guideline for those starting their pediatric anesthesia rotation. I. B. the bed will be turned. At this time there are no specific SPA (Society of Pediatric Anesthesia?) guidelines on the prevention of emergence delirium.. These children tend to be between 2-12 years of age although frequently they are <8. snoring. 4. so all you need to do is to remove a green sheet and pad between each case. These patients also typically receive 40 mg/kg of rectal acetaminophen. the patient must be sedated in the presence of a vigilant anesthesiologist. However. 2. It is essential to realize that most of these children have not had a formal sleep study. T&A 1. The oral airway will allow you to maintain a patent airway without CPAP even when the head is turned. Following the procedure. of course. the parents should be warned that the next bowel movement might have a white color secondary to the placement of the acetaminophen. It is appropriate and safe to sedate most children presenting for T&A. and so forth. in the presence of documented severe sleep apnea. even in the presence of a diagnosis of OSA. Emergence delirium is common in the pediatric population and occurs most frequently when sevoflurane is used for short cases. Many of these children come to the OR with diagnoses of obstructive sleep apnea (OSA). There are. M&T 1. The diagnosis is based parental description of the child asleep (i. 2. loud breathing. please ensure proper rectal placement of acetaminophen and avoid accidental vaginal placement of the suppository. Frequently these children may need a premedication. as one would for any adult patient with severe OSA. Also. etc. An oral airway may be placed following induction..) coupled with a physical exam that shows large tonsils in the office. For short cases such as M&T and laser procedures. The studies designed to address emergence delirium show a reduction in emergence delirium in patients who receive 2 mcg/kg total of intranasal fentanyl. There exist many stylistic differences between attendings. many other procedures not addressed below. 3. please take time to layer the OR beds with waterproof pads and green sheets. parents should be counseled not to re-dose the acetaminophen for at least 4 hours. In female children. 5. Maintain spontaneous ventilation.e. i. and because of this they may be more anxious than younger children who remain oblivious or older children who may be more stoic. Plasma levels of rectal acetaminophen will typically not peak for up to an hour after placement. .e. ENT Cases A. This section covers the procedures commonly performed in the pediatric ORs. These patients all receive Decadron 0. 7. Pay close attention because often the ENT resident may not be as skilled at this as you are. the anesthesiologist performs laryngoscopy. Either a straight ETT or an oral RAE tube may be used. 5. The explanation for this remains unclear but probably relates to some discoordination of the oropharyngeal musculature. Postoperatively they can re-bleed and may need to come back emergently to the OR in which case they will get a RSI. This is further amplified in patients who have received a premed. The circuit is attached to the bronchoscope and/or the laryngoscope using a 3. so be careful in “ASSISTING” the child and make sure you are not ventilating the child. They can rapidly lose their drive to breathe if assisted too much.5 mg/kg up to 8 mg to reduce airway swelling. The use of muscle relaxant is not mandatory. 6. even with relief of the anatomic obstruction. consider having the ENT present at the time of induction of anesthesia.29 4.0 9-mm ETT adapter. 12. Discuss ondansetron prophylaxis with your attending. Discuss this with your attending. 9. Direct Laryngoscopy 1. and a disposable atomizer is used to spray the vocal cords with either 1% or 4% lidocaine. 10. and ENT establishes a mask airway. ENT will laryngoscopy and/or perform a rigid bronchoscopy. It may also have the benefit of lowering the incidence of PONV. 11. 3. although the kinetics of morphine will allow pain control to extend significantly further into the postoperative period. The table is then turned 90°. These children typically will tolerate premedication. C. 5. It is essential that the procedure be specifically defined in your mind prior to coming to the OR (flex bronch before/spontaneous ventilation/laser/debridement/does the ENT surgeon anticipate difficulty). and this will make the operative course much more difficult. 2. 7. 6. Probably in no other operative arena is communication between anesthesia and surgery more vital than in this one. 8. Once the child is appropriately deep. After induction and placement of the IV. These patients frequently have worse obstruction in the first 24 hr post-procedure. If there is any question about safe management of the airway during induction. ENT will give you the atomizer. Continue to insufflate as the child continues to breathe spontaneously inhaling additional oxygen and sevoflurane. Maintenance of spontaneous ventilation is paramount. There is an art to maintaining spontaneous ventilation. 9. This potential must be considered when dosing post-operative pain medications. It is imperative to be judicious and in some cases make sure that someone (NOT THE PARENT) is watching the child after administration of a premed because it may overly sedate them leading significant respiratory embarrassment. . 4. 8. Either an IV or an inhalational induction may be performed depending on the patient’s size and medical history. Fentanyl and morphine are both acceptable. so do not be discouraged if things do not go smoothly the first time around. These patients will typically stay overnight in Day Hospital. Preoperative optimization must begin with appropriate resuscitation using an isotonic solution in the setting of severe intravascular volume depletion. i. hypochloremic metabolic alkalosis. This does not mean that these children should not receive premedication.30 10. These procedures typically do not require narcotics for pain control postoperatively. Laryngoscopy and debridement for HPV requires special mention. 3. the decrease in papillomas during the teenage years may be medicated by a hormonal alteration that “shuts off” papilloma formation.0. Without a doubt this case is fair game on both the written and oral boards. 12. followed by the administration of a hypotonic crystalloid solution to replete the free water deficit. 4. Additionally most people will look to see an increase in the serum potassium >3. It is always a good idea to have a size-appropriate syringe of propofol ready in case of unanticipated movement secondary to stimulation in the presence of light anesthesia. 14. it just means it should be administered judiciously. it is good to ask the parents how thing have gone in the past. It is important to monitor the depth of anesthesia especially with a rigid bronchoscope in the trachea. They can obstruct in holding secondary to their disease process. This is a medical emergency not a surgical emergency. Beware of sedating these children preoperatively. These patients will. These babies are frequently significantly dehydrated and have both intravascular and overall free water deficits. Incidence 1:500 live births.. they need to be adequately resuscitated and hydrated prior to coming to the OR. Pyloric Stenosis 1. i. Do not be afraid to place an oral airway while the child is deep to hopefully eradicate the need for CPAP to maintain a patent upper airway as the child emerges. Because these children have been to the OR several times. Ask the parents how the child has been feeling and evaluate any change in symptoms since the last procedure. these patients were rushed to the OR before rehydration and many did very poorly. Wear gloves!!! v. The primary physiologic derangement is dehydration with attendant metabolic disorders. iii. These children will frequently wake up without an ETT. The classic metabolic disorders associated with this are a hyponatremic. ii. and must have an IV prior to coming to the OR. Typically these children will wax and wane into their early teenage years. Patients that are lighter tend to have a rocking pattern to their respirations. Kirse. hypokalemic. General Surgery A. 6. Why aren’t these patients hypernatremic typically? 5. II. although sometimes it may lessen the incidence of emergence delirium postoperatively. more hoarse/less hoarse than usual. According to Dr. Patients that are deeper tend to have a shallower pattern of respiration that appears more relaxed. NOTE: MAKE SURE THIS KINKED. vi. Historically. One of the best indicators is the depth and pattern of respirations. 11. 2. Accordingly. TENUOUS 24G ANGIOCATH HANGING BY ONE PIECE OF .e. The presence of HPV in the airway is thought to occur secondary to exposure as they pass through the birth canal. 13. iv. These are typically young. Lap Nissen/Open Nissen+G-tube 1. . These patients have the potential to be very young former preemies.e. Mask induction 3. 9. although rarely utilized. 2. 2. 6. Frequently. Patients typically will go home postoperatively. The surgeon will usually inject with local anesthetic. Pre-term patients <60 wk post-conceptual age are considered at risk for postoperative apnea and bradycardia. Urogenital Surgery A. After agreement from the surgeon. It is worthwhile to consider the administration of atropine prior to induction. Many practitioners will suction the stomach with the child awake prior to doing a RSI. At some institutions they will use a rubber bougie to gauge the tightness of the rap. Here we simply use an OG tube.31 TAPE UNDERNEATH 2” OF BANDAGES THAT RUNS FINE WHEN ATTACHED TO AN IV PUMP STILL REMAINS WITHIN THE LUMEN OF A VEIN BEFORE INDUCING GENERAL ANESTHESIA WITH SUBCUTANEOUS THIOPENTAL AND SUCCINYLCHOLINE. III. B. Intraoperatively be aware of the consequences of pneumoperitoneum (i. narcotics are not dosed during the procedure. on ventilation. B. otherwise healthy males between 6 mo and 4 yr. You must discuss and clearly understand the plan for intubation. typically in the upper extremities because lower extremity IVs may get in the way of positioning the patient. 10. 5. Patient may be intubated deep or with the aid of a relaxing agent. 6. Most children will present <5 years of age. UOP. preload. LMA/ETT. Although these children do have reflux disease. a caudal anesthetic may be performed. Be careful to look at the estimated conceptual age at birth and calculate their current estimated conceptual age. The true concerns related to reflux disease are chronic aspiration. Some may perform a textbook RSI. There exist varying opinions on the use of succinylcholine in pediatric patients. The procedures vary greatly in length and complexity. except in an emergency setting. 4. and recurrent pneumonia. All attendings in the peds OR have a different style. A single IV is sufficient.. 4.) 5. 8. Hypospadias Repair 1. it is unnecessary to perform a rapid sequence. Inguinal Hernia Repair 1. 2. while others may perform a modified RSI with rocuronium. A single good IV is necessary. ongoing inflammation. Frequently a caudal anesthetic may be performed and the IV site in the foot will not be as bothersome to the child. This is actually a good case to attempt blind saphenous lines. Awake intubation in these patients is also an option. There is a spectrum of ages that present for this procedure. 3. etc. Operative time is typically between 2-4 hr. 7. A Pfannenstiel incision is typically performed. 4.5 cm from the skin. Rectal acetaminophen is often given. D. 4. A single IV is necessary. as the block will typically last 45 min to 1 hr. A caudal is frequently performed for this procedure. especially if they are former residents of a NICU. the use of a caudal diminishes the need for narcotics. 5. In very young infants avoid anything over and above minimal narcotics. The back is prepped. a penile block is often sufficient in young infants. These patients will not become hypotensive because there is very little resting sympathetic tone. There has been no difference in the incidence of postoperative apnea and bradycardia between GA and spinal anesthetic in the presence of narcotic supplementation. local infiltrated. With free flow of CSF. The subarachnoid space in infants <60 wk ECA is typically <1. 6. the airway is frequently secured with an ETT. some practitioners advocated doing spinals in expremies who are at risk for apnea/bradycardia following general anesthesia.and 8-years-old. An anesthesiologist experienced with the technique should perform this. is that the surgeon must be fairly efficient. the ureter/ureters are reimplanted into the bladder. 5. no matter what type of local anesthetic is used. 2. C. During the procedure. however. Discuss with your attending. In babies at risk for postoperative apnea and bradycardia. 4. Beware of access problems. Although it is institutionally dependent. and IV access is then obtained typically in the lower extremity of these infants. lidocaine is injected. Caudal may be appropriate. Consider Toradol. if narcotics are used. 2. There is a significant operative time difference between female and male children. One of the caveats of this technique though. L5-S1. One IV is sufficient. Children are typically between 5. Typically a circulating nurse or other anesthesia provider holds the patient in a sitting position with their back to the practitioner. the patient is allowed to lay supine. and a 22-G 1. 3. or an LMA is placed in older children. Note: One should not pick up the baby by the legs while this spinal is setting up (to place the grounding pad on the baby) as this can lead to a total spinal with cephalad spread of the local anesthetic. As a result. 5. Ureteral Reimplantation 1. Once in place. Although this case may be appropriate for mask management of the airway. 3. A ureteral reimplantation is an abdominal procedure for the treatment of vesicoureteral reflux. Also. The surgeons have requested that no nitrous be used for these procedures because of the potential decrease in operative exposure. the patient is considered to be at risk for postoperative apnea and bradycardia. The male will be more time-consuming secondary to the need for identification of the vas deferens and spermatic cordal structures. there is little clinical relevance to the sympathectomy.5” stylleted needle is inserted at L4-5. . The reasons for this are unknown at this time.32 3. Circumcision 1. so you will need to be prepared. if a premed is necessary. and the postoperative pain is comparable to sunburn. 3. IV. Always ask the parents how things went during the last procedure. premed. Craniosynostosis 1. Most of these patients can be extubated postoperatively. 7. All these patients receive Toradol. These cases frequently are quick enough that a mask is adequate. Blood should be in the room and CHECKED prior to commencing this operation. Orthopedic Procedures There is a large spectrum of orthopedic procedures that are performed. occasionally they may need to remain intubated. Plastic Surgery A. and/or intranasal fentanyl (1-2 mcg/kg). These children frequently have facial as well as cranial abnormalities. PDL of AVM 1. Therefore. a large amount of room temperature fluid is frequently administered to these children. B. A large amount of blood loss is frequently associated with this surgery. 8. One must perform a complete airway exam despite the fact that the children are frequently uncooperative. V. 8. preferably two 20s. and judging the blood loss accurately is extremely difficult. Blood loss is typically minimal. though it can be accelerated if a sinus is violated—this does happen. IV access is a must: at least two IVs that run well. Many of these children have CP or congenital bony malformations that necessitate the need for surgery. Blood loss is typically steady. It is worth mentioning that many of these patients will come for this procedure multiple times. consider the use of adjuvant narcotic with caution. 7. 2. This helps dramatically with bladder spasms that are often the most painful part of this procedure. however.e. There is usually no need for an IV. 5. ensure that the blood is effectively warmed prior to administration. The parents may have expectations (i. 5. A hot line should also be checked and ready for immediate use. as the use of other benzo and narcotic may significantly prolong the postoperative recovery. These children are also at risk for PONV. An A-line is a must. . IM Toradol. The A-line allows for frequent lab studies. A caudal may be considered on a case-by-case basis for lower extremity procedures. 2. 3. 6. Some practitioners will do a caudal for the procedure. Beware of this. Always consult prior anesthetic records if possible. Also. or two 22s. or a 22 and 20. PONV) of which you should be aware. Pay close attention to temperature. start to give blood a little earlier rather than later. Analgesics include rectal acetaminophen. 4. 4. It is extremely easy to get behind in these cases. Please read the old chart to see if how things have been done previously. These procedures are fairly short.33 6. when possible. . 5. i. If blood loss is brisk.e. It is extremely difficult to calculate an exact blood loss. Also. Sometimes it will be necessary to ask the surgeon to stop so that you can catch up with the volume. An A-line is never a bad idea.34 C. and it is extremely easy to get behind. In extreme situations. In many cases you will need to sample blood. There needs to be a clear understanding in your mind of the extent of surgical debridement and the size of the area to be grafted. 7. blood needs to be in the room and CHECKED before surgery begins. Burn Surgery 1. 3. It is often necessary to transfuse empirically. 2. and an A-line or central line will be necessary. if it looks like they are beginning to bleed at all. 4. Excessive IV access is the rule. 6. A preoperative Hct and other chemistries are necessary before coming to the OR. but you must also gauge the extent of debridement and grafting.. do not wait for changes in vital signs or to check an Hgb before initiating resuscitation. The room should be warmed and remain warm throughout the procedure. if you wait the child will most assuredly be extremely hemodynamically unstable before you get your results. it is probably a good idea to begin transfusing in situations with a low starting Hct. even in a healthy child.