Pediatric Anesthesia

at Yale New-Haven Hospital

YNHH Pediatric Orientation

Welcome to Pediatrics! Here are some tips and guidelines that will hopefully make your orientation into the Pediatric Surgery Center at YNHH Children’s Hospital enjoyable and successful!

• There are six operating rooms.

• Anesthesia services are also provided off floor in locations such as MRI, Cardiac Cath lab, CT, X-ray, nuclear medicine, radiation therapy and the Special Procedure’s room. – For these off-floor cases, an off-floor cart should be

set up.

– The anesthesia tech will deliver an anesthesia machine and set it up.

Cases**Assignments are posted on Epic. Your

name will be on Epic next to your

preceptor’s name. Please look up your

patients the night before.

• The first case of the AM should be in the

room and started by 0730 (by 0830 on

Fridays).

• You should plan to see your patient around

0700.

• Some children receive PO midazolam

(0.5mg/kg) in the holding area

(administered by 0715, max dose 20mg).

Premedication and Induction

• Please communicate with staff if a premed is needed.

• Remember if it is given, allow time for it to take effect.

• This can greatly decrease anxiety when used appropriately.

• After receiving meds, these children are occasionally put in the PACU holding area on a stretcher for observation and safety.

• Most cases are mask inductions. Children who will tolerate an IV may receive an IV induction or a combination of both. (Refer to IV setup)

Pregnancy Testing

• Any child over the age of 10 must submit a urine sample.

• If pt can not, then we do a blood draw and send to lab.

• Sometimes I-STAT available to conduct a pregnancy test.

Pediatric Preoperative NPO

Guidelines• No solid foods (including milk, formula,

candy, and chewing gum) after midnight.

• Clear liquids may be taken until two (2) hours before surgery. Clear liquids include:

– water, pedialyte, and apple juice.

• Other Liquids:

– Formula may be given until six (6) hours before surgery.

– Breast milk may be given until four (4) hours before surgery.

– Clear liquids may be given until two (2) hours before surgery.

OR Set Up for Infants and Children

• Suction:

– Always have a Yankauer available.

– 14fr soft suction catheters are also useful for

suctioning oropharynx.

– Make sure small suction catheters are

available (6fr, 8fr, 10fr) for use with smaller

ETTs.

• Circuits:

– Pediatric circuits are available and may be

used for children < 40kg.

– Adult systems are used for larger children.

OR Set Up for Infants and Children

• Oxygen:

– All patients are transported to the PACU with

O2, Jackson Reese, and a pulse oximeter.

Monitors

• Extra BP cuffs are located in the

anesthesia work room.

• Precordial stethoscopes

• Temperature probes

• Pulse oximeter probes: soft, tape

pulse oximeter probes are available

Laryngoscope Blades

BLADE AGE

Miller 0 preterm babies and

neonates

Miller 1 neonate - 2 years

Miller 2 3 years and older

Wis-Hipple 1.5 2-5 years

MacIntosh (MAC)

2

3-6 years

MacIntosh (MAC)

3

7 years and older

Oral Airways

Age Size

Preterm 000, 0, 4.5

0 – 3 months 5.0

3 – 12

months

5.5, 6.0

1 – 5 years 6.0, 7.0

> 5 years 7.0, 8.0

Face Masks

Available in a range

of sizes, from premie

to small adult

Aromas for mask

induction available

Endotracheal TubesAge Size (ID)

Premies < 2 kg 2.5

Premies > 2 kg 3.0

0 – 6 months 3.0 – 3.5

6 – 12 months 3.5 – 4.0

1 – 2 years 4.0 – 5.0

> 2 years (Age in years + 16) ⁄ 4

Insertion distance estimate ~

age in years + 10

**be sure to check for = BBS and

leak!

As per our waste

reduction initiative,

please open only

ONE ETT for your

patient. For

infants, you may

have other sizes at

the ready on top of

the anesthesia

machine

UNOPENED.

Laryngeal Mask Airways (LMAs)Size Weight

1 < 6.5 kg

1.5 6.5 – 10 kg

2 10 – 20 kg

2.5 20 - 30 kg

3 > 30 kg

4 Small adult

5 Large adult

Air-Q LMAs

Emergency Medications Set Up

• Epinephrine:

– Draw up two syringes• Dilute one to 100 mcg/cc

• Dilute one to 10 mcg/cc (double dilute method)

Emergency rescue dosage is 10 mcg/kg**

• Succinylcholine:

– 2mg/kg IV

– 4mg/kg IM

• Atropine: 0.02 mg/kg

• An intravenous induction agent should ALWAYS be available for use.

Emergency Medications & Syringe

Set Up

Induction Agents and Non-depolarizers

Drug Dosage

propofol 2 – 3 mg/kg

thiopental 4 – 6 mg/kg (For Board

Review)

ketamine 1 mg/kg IV; 3-5 mg/kg IM

vecuronium 0.1 mg/kg

rocuronium 0.6 – 1.2 mg/kg

atracurium 0.6 mg/kg

pancuronium 0.1 mg/kg (For Board

Review)

Common Opioid Analgesics

• morphine

– 0.1mg/kg IV

• fentanyl 1-2 mcg/kg

– may draw up in a TB syringe

• every 0.1cc is 5 mcg

– Intranasal fentanyl

• 2 mcg/kg drawn up in a TB syringe

• administer half the dose in each nostril.

• commonly used during mask only cases, and

cases where there is no IV access (i.e. PE tubes)

Intravenous set-up• T - pieces are used to connect the IV catheter to

the intravenous tubing.

– assemble a 10cc saline flush syringe + three way stopcock + T-piece

• A burette set is used for infants and small children under 10kg.

• It is very important to keep the IV tubing bubble-free.

– Use three way stopcocks.

– ***Make sure IV connections are tight.

• Typical cases use LR 500ml on microdrip tubing, with a K-52 extension tubing attached

• Glucose containing solutions (D5LR) should be considered for maintenance in young infants and during long cases.

Intravenous set-up items

IV start kit with T-piece and flush 3-way stopcock and T-piece

K-52 extension tubingPrimary IV microdrip set

Burette set

Intravenous caveats

• Please tape IV so the RN in PACU can see the site. Cloth tape and a tegaderm work best. Arm boards are available for padding as well.

• Please do not start IV in the exam room. If it is clinically relevant and you need to start an IV, please let the nurses know so that the patient can be moved to the PACU and placed on a stretcher.

Warming Techniques

• Warming blankets are on each OR table

and should be turned on in the morning.

• Bair Huggers are available with blankets of

varying sizes.

• Radiant heat lamps are used for neonates

and infants.

Parental Presence During Induction

• Parents often accompany their child into the operating room and then, are present for induction.

• It is patient, situation, and anesthesiologist specific. There are times that parental presence is not appropriate. Check with your Preceptor.

• If the parent does come back to the OR, they must put on gown, mask and hat before entering. Make sure the parent knows what to expect. As soon as the child loses consciousness, they are asked to leave the OR.

PEDI PACU: HELPFUL HINTS

• Remember to bring fentanyl with you to the PACU- it is helpful to have pain medication on hand.

• Bring emergency drugs and propofol with you to the PACU as well in case of Laryngospasm.

• Try not to stimulate the child in the PACU. It is helpful to decrease movement and touching, to provide for a quiet emergence. The less stimulating the environment is the better!

• Remember to give report to the RN before leaving to use the computer. Return pulse ox to OR, you will need it for your next case.

PACU Orders

• Your Preceptor will place PACU orders through EPIC.

• Please medicate patients intraoperatively for pain and nausea-it makes for a better PACU stay for the child.

Common PACU Orders

• Ondansetron IV 0.1mg/kg/dose

• Dimenhydrinate IV 12.5 to 25mg

• Reglan IV 0.1 -.15 mg/kg/dose

• Morphine IV 0.05 - 0.1mg/kg/dose – For T+A use intraoperatively

• Fentanyl IV 1-2 mcg/kg/dose

• Midazolam IV 0.05mg to 0.2mg/kg/dose

• Acetaminophen PO 10-15 mg kg/dose

• Ketorolac IV 0.5-1mg/kg/dose

• Lortab po 0.135mg/kg/dose

• Dexmedetomidine IV 0.5-1 mcg/kg

Professional Behavior

• Please arrive in a timely manner each day to set up for your cases.

• Look up your cases the night before.

• Communicate with myself or your preceptor if you have any questions.

Contact information• Pediatric Clinical Coordinator

– Brett Morey, CRNA

Contact: 518-542-9902 E-mail: brett.morey@ynhh.org

• CRNA Manager

– Holly Robins, CRNA

Contact: 203-688-6963 E-mail: holly.robins@ynhh.org

• In the event of illness, please contact Brett

Medication Route Calculation Dose Dose in ml

atropine

(0.4 mg/ml)

IM/IV 0.02 mg X

_____ kg = _______ mg _______ ml

glycopyrrolate

(0.2 mg/ml)

IV 0.004 mg X

_____ kg = _______ mg

(max 0.1 mg)

_______ ml

epinephrine

(10 mcg/ml)

(100 mcg/ml)

IV, sq(CPR)

(bronchospasm)

10 mcg X

_____ kg =

2 mcg X

_____kg =

_______ mcg _______ ml

_______ ml

succinylcholine

(20 mg/ml)IV

IM

2 mg X ____ kg

=

4 mg X ____ kg

=

_______ mg

_______ mg

_______ ml

_______ ml

Resuscitation worksheet

Pt age ______

Wt (kg) _____Defibrillate with 2j X _____ kg = _____ j