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SRNA Orientation Checklist

Here 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, thats 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. IVs. 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 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 dont 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 dont 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. OBrien, MD Douglas G. Ririe, MD Leah C. Templeton, MD T. Wesley Templeton, MD Contributions by Pamela Wofford, CRNA Chief Nurse Anesthetist for Pediatric Anesthesia

Table of Contents OR Set-up for Pediatric Cases and Guidelines for the Pediatric OR .........................................1 Assignment ..................................................................................................................................1 Pre-ops .........................................................................................................................................1 Surgeon Specific Requests...........................................................................................................1 General Information on How the Pediatric OR is Expected to Function ....................................1 Off-site Anesthesia.......................................................................................................................2 General Location of Supplies.......................................................................................................3 OR Set-up for Pediatric Cases .....................................................................................................3 Pertinent Issues in the Pediatric OR.............................................................................................5 PACU...........................................................................................................................................6 Scholastic Goals for Pediatric Rotation .........................................................................................7 Issues of Prematurity....................................................................................................................7 Issues Related to the Neonatal Patient .........................................................................................7 Issues Related to the Infant ..........................................................................................................7 ENT Concerns Related to the Pediatric Patient ...........................................................................7 Congenital Heart Disease.............................................................................................................8 Anesthetic Drugs and the Pediatric Patient..................................................................................8 Regional Anesthesia.....................................................................................................................8 Common Disease States in Pediatric Patients..............................................................................8 Preoperative Evaluation of the Pediatric Patient .........................................................................9 History of Present Illness .............................................................................................................9 Past Medical History....................................................................................................................11 Family History .............................................................................................................................11 Allergies.......................................................................................................................................11 Medications..................................................................................................................................12 Review of Systems.......................................................................................................................12 Physical Exam..............................................................................................................................12 Labs..............................................................................................................................................13 Special Concerns in the Pediatric Patient......................................................................................14 Asthma .........................................................................................................................................14 Upper Respiratory Infection ........................................................................................................14 Diabetes........................................................................................................................................14 Seizures ........................................................................................................................................15 Sickle Cell Disease ......................................................................................................................15 Cerebral Palsy ..............................................................................................................................16 Congenital Heart Disease.............................................................................................................16 Genetic Syndromes ......................................................................................................................17 Premedication...................................................................................................................................18 Guidelines for Premedication ......................................................................................................18 Versed ..........................................................................................................................................18 Ketamine ......................................................................................................................................19 Atropine .......................................................................................................................................19

Intraoperative Considerations in Pediatric Anesthesia................................................................20 Monitoring ...................................................................................................................................20 Induction ......................................................................................................................................20 Access ..........................................................................................................................................21 Airway..........................................................................................................................................21 Positioning ...................................................................................................................................23 Maintenance of Anesthesia ..........................................................................................................23 Fluid Maintenance .......................................................................................................................24 Transfusion Therapy in Children .................................................................................................24 Emergence....................................................................................................................................25 Care of the Pediatric Patient Postoperatively ...............................................................................26 Postoperative Analgesia...............................................................................................................26 Postoperative Nausea and Vomiting in Children.........................................................................27 Specific Cases: Strategies, Concerns, and General Guidelines....................................................28 ENT Cases ...................................................................................................................................28 General Surgery ...........................................................................................................................30 Urogenital Surgery.......................................................................................................................31 Orthopedic Procedures.................................................................................................................33 Plastic Surgery .............................................................................................................................33

1 Welcome to the pediatric anesthesia rotation. This packet provides a list of scholastic goals, a guideline for operating room (OR) set-up, a description of the operation of the pediatric OR, and a brief outline of some of the key issues in pediatric anesthesia. The reading text for the rotation is A Practice of Anesthesia for Infants and Children by Cot et al. The text is available from Dr. Tim Smith and should be returned prior to completing the rotation. Although it would be ideal to read the entire text, the following chapters are recommended. First month: chapters 2, 4, 7, 8, 9, 11, 12, 15, 25, 27, 30 Second month: chapters 3, 10, 13, 14, 16, 17, 18, 19, 20, 22, 29 Third month: chapters 5, 6, 21, 22, 23, 24, 26, 28, 31, 32 OPERATING ROOM (OR) SET-UP FOR PEDIATRIC CASES AND GUIDELINES FOR THE PEDIATRIC OR I. Assignments Assignments are posted on the bulletin board outside the Medical Directors office (Tim Smith, MD) II. Pre-ops Pre-ops can be found either in the pediatric waiting room (Surgical Family Waiting); or after 17:00, locked in the room next to the OP copier. A code is needed for that door. Ask Pam Wofford if you do not yet have code access (713-5341). Replace charts in the same order in which they were found. Some pre-ops and consents are done in the holding room the day of surgery. Inpatient pre-ops and extra schedules are posted on the bulletin board outside of the Medical Directors office. 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. III. Surgeon Specific Requests Dr. Kirse likes to see his patients/families in the holding room before you take the patient to the OR. Dr. Glazier requests limited traffic in and out of his room with VP shunts. Dr. 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. IV. General Information on How the Pediatric OR is Expected to Function Keep a neat and orderly workplace. No one should be cleaning up after you. Do not use the floor as a waste basket. Monitor cables should be hung from the IV poles at the end of the case: BP cuff, pulse ox, EKG, a-line cable, temp, BIS, and so forth. Be cost conscious. Do not be wasteful.

2 Please keep the carts neat. Return any extra supplies that you bring with you into the room to the workroom by the end of the day. 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, and in the D-cells at the end of the day. Janie Dull is our only Anesthesia Technician, and is here to help everyone. She is not expected to pick-up after you, turn over your room, or restock your room. Most of the time Janie, and whoever is PRN, will help with these chores, but the final responsibility is yours. Outside sites must be cleaned and restocked in the same fashion as the main Peds OR. If you are free, please help in the rooms to rapidly turnover cases. Gloves: Use clean gloves and remove them immediately after they are soiled. DO NOT TOUCH ANYTHING WITH DIRTY GLOVES, i.e., IV tubing, regulating gas valves, breathing bag, etc. Remember that the purpose of wearing gloves is to protect yourself and others from patients bodily fluids. Avoid contamination of anything with dirty gloves. End of day cleaning: Use TBQ in the spray bottle to wash machine, monitors (except the face of the screen), lines, IV poles, chair, ploss cart, blood warmers, Bair hugger, and any anesthesia equipment that comes in contact with the patient and/or floor. Leave a clean suction liner, tubing, and Yankauer set-up. Fill volatile agents. Discard soda lime at the end of the day each Friday. Replace soda lime each Monday morning be sure to check for circuit leaks after soda lime is replaced. Empty the trash and replace the plastic trash bag. Trash goes in the dirty utility room across the hall from OR 39. Syringes and needles: Clean syringes ONLY may be thrown in the trash can (NO BLOOD, NO NEEDLES). Otherwise, use the needle box to discard. Absolutely NO trash allowed in the needle boxes. LMAs/Laryngoscope blades: LMAs are in a locked cabinet in the anesthesia workroom. Only Janie Dull and Pamela Wofford have keys to this cabinet. If Janie has gone for the day, dirty LMAs should be placed in the container on the sink in the workroom. NO TBQ on LMAs, so please do not put them in the sink. Disposable LMAs are also in the workroom. Laryngoscope blades can be placed in the sink in the workroom to be cleaned and processed. Laryngoscope bulbs should be checked before each use. Take the time to locate the laryngoscope bulbs in the workroom and change at least one while you are here. Stylets are one-time use only throw them away. V. Off-site Anesthesia These include MRI, Radiation Oncology, Peds Cath Lab, CT, and Specials. It is necessary to take a stretcher, transport monitor with appropriate cables, and full O2 tank (located in first stage Peds PACUs soiled utility room, if needed) with you to whichever site you are assigned. Please return all these items to the PACU after they have been cleaned. Monitors should be plugged in. Please let the Peds PACU staff know if the O2 tanks need replacing or are unacceptable.

3 D-cells and gas machines are located in MRI and in Radiation Oncology. For all other sites, check with Pam or Janie regarding D-cell and machine availability. When in the MRI, remove anything metal that is on your person, including stethoscopes, credit cards, keys, badges, pagers, jewelry, and so forth. VI. General Location of Supplies It is a good idea to familiarize oneself with the anesthesia workroom. 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. Halothane vaporizer: ask Pam or Janie if you would like to use. Laryngoscope blades and McGill forceps: next to the sink on the counter in the workroom. Difficult Airway Cart: in the hallway outside of OR #36 Malignant Hyperthermia supplies: in the main OR anesthesia workroom Pod B (not Peds OR). 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), rubber bands, waterproof tape, hyperinflation bags (, 1, 2, and 3 liter), some of the smaller nasal airways and some gloves (sterile and non-sterile). VII. 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. They are intended to provide a more standardized (we hope), less vague, and more cost effective routine in preparation of the OR for d\pediatric cases. Circuit: A pediatric circle system or Bain system is acceptable for children under 30 kg. Children above this weight may be managed with a standard adult circle system. An appropriate sized artificial nose should be immediately available. 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. Suction: A Yankauer suction tip should be available for all cases; however, a 14-Fr. Suction catheter is more appropriate for infants and neonates. Warming: The room itself should be warmed in advance as follows: Newborn and small neonatal children: 80 F

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. When time does not allow for his, a radiant warmer (french-fry lights) can be obtained from the PACU. These are also often useful for those cases involving a long post-induction prep time for obtaining vascular access. Warming blankets are useful for cases for children under 10 kg. Pediatric Bair huggers are available for prolonged cases such as the craniofacial repairs. Chemical warming pads are to be used for transport of all infants being returned to the NICU. Miscellaneous: Infants and neonates are easier to manage with a head ring. The circular foam head ring may be cut longitudinally or a hole cut in the plain foam pads for small infants and neonates. Additionally, be certain that the cushions under the sheets are close enough together to prevent the childs shoulders from dropping into a gap between them, thus complicating airway management. Monitors: Pediatric standard monitors are only different from adults in size. 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. Temperature monitoring is not necessary for short cases such as BTTs and PDLs. Airway: For ALL cases, appropriate sized ETTs, the predicted size plus a half size larger and a half size smaller, along with appropriate sized oral airways should be immediately available on top of the ploss cart. Additional endotracheal tube sizes beyond the half size variation just described should be in the room. This may require particular confirmation in the case of oral and nasal RAE tubes. Oral RAE tubes are preferred for palate and cleft lip repairs. A standard ETT is acceptable for tonsils and adenoids. Nasal RAE tubes are preferred for dental cases. IVs: T-connectors are required for every case. Neonates: Buretrol solution set. Consider having an additional pump set up to infuse maintenance fluids with a glucose solution. Those coming from the NICU generally have this in place already and this is usually continued throughout the case, with an additional buretrol set up for fluid boluses.

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. Hot Line Use: Reserve for longer cases (>1.5 hr) or when you anticipate the need for large volumes of fluid or blood product warming. 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. This requires flushing immediately prior to hooking up to an IV. Drugs: Standardized doses are not necessary or desirable for most cases. The practice of drawing up exact predicted doses of medications frequently leads to scrambles when additional medication needs to be given. Of course, knowledge of the appropriate doses of each medication for each child is expected in every case. If your attending requests standard doses in a single syringe, have an additional dose easily available in an appropriate size syringe. Other than epinephrine for ASA III and greater infants and neonates, it is also not necessary to dilute drugs. For each case, draw up the following in the smallest syringe which will hold the appropriate amount: Atropine: 2 ml Succinylcholine: at least 4 mg/kg, in case IM injection is needed Narcotics: as discussed with the attending. VIII. Pertinent Issues in the Pediatric OR NPO Guidelines: 2 hours clear liquids 4 hours breast milk 6 hours formula, non-fatty meal It is especially important that an OR nurse be available to check the patient in before transporting to the OR or, at the very least, prior to induction. Be QUIET during induction and emergence. Children become over-stimulated easily.

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. Also, the anesthesia charge form needs to be filled out completely, including CPT code(s). Please do not use abbreviations on your forms for anything. Make sure that your printed computerized record is placed in the patients chart. If you remove an armband, it is your responsibility to replace it. As a member of the multidisciplinary team, you must participate in the time-out before incision is made. This means you verbally agree on the correct patient, correct procedure, correct site, correct side, correct position, and the availability of implants/equipment. Please DO NOT transport any NICU or PICU patient with unlabeled syringes. Also, as a reminder, ALL SYRINGES must be labeled with the drug, dosage, date, time, and your initials. 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. If you should choose to use these syringes either during your rotation through pediatric anesthesia or while on-call, they MUST be replaced by you. There also is an aline bag, transducer, and pressure bag available. Again, if used please replace. XI. PACU You are responsible for the patient until a PACU nurse has accepted the patient. Nurses will be connecting the patient to monitors and assessing, so wait until you have their full attention to begin report. Be attentive to all children at all times. Keep a hand physically on a child to ensure maximum safety until you have given report and turned the patient over to PACU. The PACU nurse needs your signature on the PACU flow sheet before you leave to start your next case. It is helpful if someone could call the PACU to tell them you are on the way to PACU. Please coordinate this with the OR staff.

7 SCHOLASTIC GOALS FOR PEDIATRIC ROTATION I. Issues of Prematurity A. Discuss the physiologic transitions of neonatal circulation at birth. B. Discuss the presentation, diagnosis, and treatment of necrotizing enterocolitis and the anesthetic concerns related to surgical intervention. C. What is retinopathy of prematurity and how is it treated? How are these patients managed in the OR? D. How is temperature regulated in the premature infant? What measures are taken to help maintain body temperature? E. Discuss apnea of prematurity. At what gestational age does the risk for apnea of prematurity measurably decrease? F. Discuss the sequelae of prematurity. II. Issues Related to the Neonatal Patient A. What is gastroschisis? Discuss any associated anomalies. What are the anesthetic concerns for patients with gastroschisis? B. What is an omphalocele? Discuss any associated anomalies. What are the primary anesthetic concerns for these patients? C. Discuss the different types of tracheoesophageal fistulas. How is the endotracheal tube positioned in these patients? What are the intraoperative concerns for these patients? D. What is a myelomeningocele? Discuss the timing of the surgical repair of the myelomeningocele. How do you position this patient safely for surgery? E. What is a congenital diaphragmatic hernia? Discuss any associated anomalies. Discuss the anesthetic management of these patients. What are the intraoperative concerns? III. Issues Related to the Infant A. What is pyloric stenosis? Discuss the preoperative evaluation of these patients. What is your plan for induction and maintenance of general anesthesia in these patients? B. Discuss by system the physiologic differences between the infant and the older child. IV. ENT Concerns Related to the Pediatric Patient A. Discuss at least 10 differences between the pediatric and the adult airway. B. Discuss the anesthetic management of the pediatric patient who presents with a foreign body in the airway. What are your primary concerns? C. Discuss the management of patients who present for BTT. How do you manage their pain? What is emergence delirium? How is emergence delirium treated? D. Discuss the management of patients who present for T&A. Discuss the management of the patient who presents with a bleeding tonsil. E. Discuss at least five syndromes associated with a difficult airway. Discuss a rational approach to the difficult airway in the pediatric patient.

8 V. Congenital Heart Disease A. Discuss the pathophysiology of the following lesions: Tetralogy of Fallot, ASD, VSD, and coarctation of the aorta. B. Discuss the intraoperative management of PDA ligation. VI. Anesthetic Drugs and the Pediatric Patient A. Discuss the differences in MAC in the neonatal, infant, childhood periods B. Discuss local anesthetic toxicity in the pediatric patient. How does one assess for intraoperative local anesthetic toxicity. Calculate the maximum dose of 0.25% bupivacaine for a 14-kg patient. C. Discuss the use of succinylcholine in the pediatric patient. 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. Regional Anesthesia A. 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. Are there any contraindications to placing a caudal? B. Discuss the use of both lumbar and thoracic epidurals in children. 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. Common Disease States in Pediatric Patients A. Discuss the anesthetic concerns related to the patient with Trisomy 21. 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. Discuss your anesthetic plan for the patient with muscular dystrophy who presents for an appendectomy. C. 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.

9 PREOPERATIVE EVALUATION OF THE PEDIATRIC PATIENT One must include all aspects of the standard preoperative evaluation. In pediatric anesthesia, the parents and the old chart serve as the two primary sources of information. HPI, PMH, Family History, and PE must all be obtained. Key issues pertinent to the pediatric ROS, that differ from an adult, are discussed in this section of the syllabus. Always remember to address the following issues in your preop evaluation: birth history, last PO intake, any recent URI or other viruses, LMP for females, and a discussion of any other concomitant medical problems. I. History of Present Illness When taking the HPI in a pediatric patient one must obtain all information regarding current illness, medications, and previous hospitalizations pertaining to the current issue. In addition to frequently asked questions, the following is a list of key issues pertinent to the pediatric HPI. In addition to this small list, please see the section on Special Concerns in the Pediatric Patient. This section provides a broader overview of additional topics. In many cases, the birth history is directly related to the HPI. Below is a brief guideline regarding obtaining a birth history. A. Birth History 1. Full-Term: estimated gestational age 37 weeks in this country. In some other developed countries full-term is defined as EGA 36 weeks. 2. Mode of Delivery is important. NSVD vs. C-section and the circumstances surrounding the delivery 3. Preterm: <37 weeks Prematurity has a number of sequelae. These include, but are not limited to, the following: 1. Bronchopulmonary Dysplasia (BPD) 2. Cerebral Palsy (CP) 3. Apnea and Bradycardia of prematurity 4. Intraventricular Hemorrhage (IVH) 5. Retinopathy of Prematurity (ROP) B. URI 1. There are a number of review articles written on this topic. The presence of any URI symptoms puts the patient at increased risk for pulmonary complications. What is a pulmonary complication you rightfully ask? In most articles studying the impact of URI on pediatric patients undergoing surgery, a pulmonary complication is defined as one or more of the following: laryngospasm, bronchospasm, desaturation, and breath-holding. However, 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.

10 2. During the physical exam, it is important to listen for wheezing and to distinguish lower airway noises from upper laryngeal sounds. Many mild cases of asthma will appear only in the setting of a URI, and you will see a number of patients who carry a diagnosis of asthma but are not on medication, and simply use an albuterol inhaler when they get a URI. 3. How does one decide to postpone a case? Many factors must be considered when answering this question. Additionally, 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, 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, one must seriously consider whether or not it is worth proceeding or perhaps the case should be postponed. 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. In situations where the patient is actively wheezing, the case is usually postponed, and aggressive asthma treatment initiated. Remember, 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. Many children have persistent and frequent URIs. However, if a lower respiratory infection is present one should not be lulled into performing the anesthetic just because of a recent previous cancellation. For example, it is likely a child may return for a rescheduled procedure with another cold or a significant URI. Do not simply proceed because they have been canceled once before and they have traveled from a significant distance. This justification serves only the convenience of the family and surgeon. To proceed if the patient is truly ill is potentially harmful. 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, during the surgery, and certainly postoperatively. There is a large list of comorbidities that can potentiate or further contribute to respiratory complications in these patients. Some of the significant ones include, but are not limited to, Downs syndrome, significant asthma, palliated congential heart disease, CP, BPD, and muscular dystrophies. Not to state the obvious . . . but . . . more invasive surgeries such as open or laparoscopic intra-abdominal cases, intracranial cases, spine surgery, thoracotomies, heart surgery versus minor procedures such as BMTs, inguinal hernias,

11 circumcision, and syndactyly repair will affect the final decision concerning postponement. B. LMP in menstruating females DO NOT be afraid to ask. If you have any concern whatsoever do not be afraid to ask for a urine sample for B-Hcg. This information is important and must be addressed. II. Past Medical History A. A thorough history should be obtained. Always remember to address issues related to prematurity, syndromes, and chronic illnesses such as childhood cancers. In this section, the medical history must be obtained. Prior surgeries or other experiences with sedation or general anesthesia must be discussed. B. Look at old records if possible. Make it a priority, especially in syndromic children or others known to have a potential for anesthetic complications. The old chart is key for information regarding the airway, difficult IV access, intraoperative hemodynamic instability, etc. Parents are not a reliable source for obtaining the entire anesthetic history, especially in ill children. Additionally, if the surgery is reasonably contemporaneous you can look at what ETT size was used. In addition, the old chart allows for continuity of care in children who have undergone multiple procedures, such as pulse dye laser. 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. The old chart allows knowledge of the premed used as well as pain control requirements. In some situations parental presence at induction is allowed. It is good to know ahead of time as the parent may likely have similar expectations for the upcoming procedure. III. Family History Always evaluate for a family history of malignant hyperthermia and the presence of pseudocholinesterase deficiency. Parents will often add that they get nauseated or that they take awhile to wake up. At this point, just clarify and redirect. IV. Allergies Internalize these and always recite prior to giving antibiotics. Always be aware of the specter of latex allergy especially in patients with myelomeningoceles, tethered cords, urogenital abnormalities, and other chronic illnesses. The pediatric OR area is NOT a latex free environment. Specifically, the white cloth tape, blue coban, gloves, and rubber bands all contain latex. Please be advised that there are two types of brown coban. The internal aspect of the roll reads LF for latex-free brown coban. All other brown coban contains latex. Please take necessary precautions for latex allergic patients and always alert the room staff.

12 V. Medications Review the med list and the time of last intake. Patients from the NICU should have a cover sheet in the chart with this information. It is important to review the medications given on the floor and the dosing schedule. Know the prescribed antibiotics and the time of the last dose. If patients are taking narcotics look at doses and length of usage to estimate the intraoperative needs. VI. Review of Systems The pediatric ROS is unique, and a section entitled Special Medical Concerns in Pediatric Anesthesia addresses the key topics. Please refer to this section. For a brief overview of the ROS, you may refer to the Table 4-2 in the Cot text. VII. Physical Exam A complete physical should be performed. Observation is a tool that must be used to perform the physical exam in children. 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. Do Not Forget . . . obtaining an exact weight in kilograms is essential, as medications are dosed according to weight in kilograms. The size of the patient can also give you a great deal of insight into the global picture of a childs overall physiologic health. Children with significant underlying systemic pathology do not grow normally. So what is normal? Here are a couple of useful numbers: Children should weigh around 10 kg at 1 year of age. Children should weigh around 20 kg at 5 years of age. There is a much larger spread at 5 years of age, but classically a 1 year old should weigh around 10 kg. 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). A. Vital Signs note any fever or variation from normal in vital signs for the childs age group. Always note temperature, HR, RR, and BP if applicable. B. Airway a detailed exam should be performed. 1. Most children will have relatively easy airways 2. The vast majority of children do not require a styletted ETT. The routine use of a stylet may introduce the possibility of further trauma. 3. Most infants and toddlers are not cooperative with an airway exam; however, one should obtain an overall impression of the facies (normal vs. abnormal). Specifically, the

13 presence or absence of mandibular hypoplasia, facial asymmetry, and extreme macroglossia must be appreciated during the preop exam. 4. Remember to evaluate dentition and remark on any loose or missing teeth. 5. 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. Lungs 1. Obviously listen . . . 2. Wheezing usually gets postponed 3. Some children may have loud breathing as a result of some upper airway pathology/variant . . . these children are not wheezing they simply have loud upper airway noises even though they do not carry an official diagnosis of laryngomalacia. Heart 1. Obviously listen . . . 2. Many murmurs have been heard before but may not have been commented on. Always discuss the murmur with the parents and inquire as to the history. Based on the history, the attending anesthesiologist will determine the need for a formal consult. Good clinical acumen, careful history, and conversation with the patients pediatrician probably go a long way in this situation. A murmur first noted preoperatively in a child <1 year of age should be considered for formal evaluation. Undiagnosed cyanotic/structural heart disease is one of the most common causes of unexplained death in children <1 year of age. Abdominal Evaluate for any apparent abnormality, including the presence of a G-tube or large surgical incisions. Extremities Again, observe. Address any obvious abnormalities.

C.

D.

E. F.

VIII. Labs The need for laboratory studies is case specific and should be discussed with the attending.

14 SPECIAL CONCERNS IN THE PEDIATRIC PATIENT I. Asthma There is a large continuum here in terms of the true degree of pathology. Many patients carry a diagnosis of asthma, but do not require regular medication, and use an inhaler only with URIs. These patients are typically at low-risk for intraoperative bronchospastic events, assuming they do not currently have a URI. Beware though, if they have an ongoing URI, or if they have had one recently. Next there is the subset of patients on multiple medications with multiple ER visits because of bronchospastic events that required nebulizers, pulse dose steroids. These patients are certainly at more risk than the above patients. If these patients are medically optimized they will typically tolerate GA and surgery without further preoperative optimization. The peak flow value is important information in the older asthmatic patient. 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. If this history exists, it should be taken very seriously and further clarified. Recent documentation of a visit to his/her pulmonologist in preparation for surgery is certainly appropriate. Frequently in these severe cases, patients will receive a short course of steroids prior to going to the OR. Patients who are actively wheezing should be postponed in most cases, unless there is a truly compelling reason to proceed. II. Upper Respiratory Infection (URI) As outlined earlier in the section on preoperative evaluation of the pediatric patient. III. 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. These patients must be managed carefully throughout the perioperative course. A. Check glucose while in holding. B. These patients should be the first case of the day. C. Always inquire about ongoing glucose control, and be aware of the potential for significant metabolic derangements prior to and potentially during surgery. Obviously a balance must be maintained such that the patient is neither hypoglycemic nor significantly hyperglycemic, and potentially headed down the road toward ketoacidosis and dehydration. D. Preoperative insulin regimens are frequently handled by the patients endocrinologist. If questions arise, do not hesitate to contact the endocrinologist preoperatively, intraoperatively, or postoperatively.

15 E. If preop insulin is managed by the anesthesia team, typically the patient will take half their insulin dose on the morning of surgery. F. One should seriously reconsider proceeding to elective surgery in the presence of a blood glucose >250, and appropriate glucose control with insulin should be instituted. G. In the event of intraoperative hypoglycemia, glucose containing solution should be initiated. Always discuss with the attending before initiating such treatment. H. An appropriate IV insulin dose to start with in children is probably around 0.05-0.1 u/kg, but this is only a start and further consultation with an attending is necessary. The titration of insulin to achieve the desired glucose value over time while closely following intraoperative blood sugars is probably warranted. IV. Seizures A. Seizures in children may be a result of some significant CNS injury early in life or may be idiopathic in an otherwise normal child. Documentation of regular follow-up with a neurologist can be very helpful in allaying your concerns prior to coming to the OR. B. In taking a history a few points in particular are important: 1. When he/she has a seizure what does the child look like? 2. When was their last seizure? How often do they occur? 3. Are they on medications to control their seizures? If yes, when were the last medication levels drawn? 4. Always be wary if the parents state that the childs seizure pattern has changed recently (1 wk-6 mo), and be sure this has been addressed. In this situation a determination of anti-seizure medication levels should be considered. 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. V. Sickle Cell Disease (SCD) A. It is important to obtain a preoperative Hgb in patients with either sickle cell disease (HgbSS) or trait (HgbSs). These patients can obviously be significantly anemic preoperatively. B. There is at least one study published in the New England Journal of Medicine that showed a benefit in this patient population with aggressive transfusionup to an Hgb of at least 10. C. Patients who have experienced several SS crises are typically treated with narcotics at the time of a crisis. Thus, the intraoperative narcotic requirements for these patients are frequently higher than normal. This is important to note when planning the anesthetic and postoperative pain interventions. D. Maintenance of hydration, adequate oxygenation, and normothermia are essential in managing these patients. A working IV and pulse oximetry are essential. E. For procedures requiring an intraoperative tourniquet, discuss the plan and maximum time for which the tourniquet can be safely inflated with surgeon preoperatively. F. Standard spectrophotometric pulse oximetry techniques have been validated in these patients and likely reflect the true saturation.

16 VI. Cerebral Palsy (CP) A. This is probably one of the more common diagnoses we see at a tertiary care facility, as these patients present for a number of different types of surgeries/procedures. B. CP specifically refers to a non-progressive motor disability frequently characterized by spasticity and ultimately secondary contractures. CP does not necessarily imply mental retardation/disability, although frequently that is the case. C. CP patients frequently have persistent reflux disease. In the past, many practitioners advocated a rapid sequence induction in these patients; however, during the past 10 years there has been a paradigm shift, and most practitioners who deal with these patients regularly are fairly comfortable proceeding with a mask induction, followed by IV placement and ultimately intubation. VII. Congenital Heart Disease A. It is important to obtain a clear history and understanding of the patients cardiac lesion before proceeding to the OR. Clarify points concerning the etiology of the lesion and the palliative/corrective surgeries that may have been performed. 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. 1. Does he/she tire easily? 2. Does he/she keep up with peers or does he/she get fatigued before their friends when playing? B. What about infants who are unable to communicate or exercise? Eating is the most active thing neonates and infants do. So when taking a history directed at the functional status of an infant or neonate some questions to ask may be: 1. Does he/she sweat when feeding? 2. Does he/she turn blue or appear in distress when feeding? 3. Always inquire about growth. Children in heart failure do not grow appropriately, frequently appearing thin and wasted in addition to potentially being cyanotic. Thus, always be on the lookout when you hear the term failure to thrive sometimes abbreviated FTT. C. Assess rhythm. Be aware many of these children may have pacemakers. Look at the EKG. D. Listen to the heart. Frequently you will here a murmur. Continue practicing auscultation. A study from the University of Chicago revealed that pediatricians identified pathologic from non-pathologic murmurs only about 50% of the time. Pediatric cardiologists were able to distinguish the difference around 90% of the time. You will begin to appreciate that pathologic murmurs typically have a slightly higher pitch than their benign flow murmur counterparts. Sometime you will hear the term Stills murmur These are benign flow murmurs and are of no clinical consequence. E. Pay close attention to medications. Frequently these kids will be on digoxin, ACE inhibitors, and diuretics. Obviously these drugs have many potential sequelae, but in combination be aware of the interaction between digoxin and hypokalemia secondary to diuretic therapy. Obtain lab values when indicated. F. Get a room air SpO2.

17 G. Look for a note from a pediatric cardiologist if the child is on any medications or has anything more significant than an ASD, VSD, or PDA corrected in the distant past (>1 yr). The note will frequently state precisely the lesion, any surgical interventions, and the need for SBE prophylaxis will be addressed. H. A few SBE pearls: 1. M&Ts do not require prophylaxis. 2. T&A does require prophylaxis. 3. Direct laryngoscopy does not require prophylaxis; however, any airway manipulation debridement or rigid bronch probably warrants SBE prophylaxis. 4. Isolated Repaired VSDs and ASDs, do not require prophylaxis after 6 months. 5. The American Heart Associations website contains the most recent guidelines on regimens, dosing, and what types of procedure require what type of antibiotics. VIII. Genetic Syndromes There are many genetic syndromes in pediatrics that deserve attention. However, the scope of this discussion is limited, and a full understanding of these syndromes requires continual selfeducation. Always remember the presence of the difficult airway with many genetic syndromes. A few references are the Online Mendelian Inheritance in Man website. This site can be found via any server by typing OMIM. The information on the website was compiled at Johns Hopkins. The site is a database that has information regarding human genes and genetic disorders. There is also a text in the Peds PACU on genetic syndromes by Smith. Ask any attending or PACU nurse for the reference.

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. First one must determine if a premed is necessary. If a premed is desired, many medications may be used. Versed is used most frequently, but many of the options are addressed in this section. I. Guidelines for Premedication A. Children <6-10 mo of an age typically do not require a premed, as they do not tend to have separation anxiety. B. Between 10 mo and 7-8 yr of age children frequently require premedication. This is especially true for those who are going to have multiple procedures in the future. It is best to minimize the level of anxiety in these patients. C. The ultimate determination is subjective and multifactorial. The length of the surgery must be considered. For example, the peak effect of a versed premed given to a child for a short procedure, such as myringotomy and tubes, may occur postoperatively. If a parent requests a premed, it is probably a good idea to give the medication. Although the child may appear calm, children can change their emotional state very quickly. II. Versed A. Versed is commonly used as a premedication. Below are a few recommendations when giving PO, intranasal, IM, or IV versed. Always counsel the patients caregiver to hold the patient after a versed premed or let the patient rest on the bed. Children frequently become unsteady and can easily fall or stumble if allowed to ambulate. Verseds amnestic properties frequently are present after a few minutes even though the child does not appear to be completely anxiety free. Do not rush an oral premed. The onset of action may be as long as 15-20 min. If one has gone to the trouble of giving it, one might as well wait a few minutes and reap the benefit of having a cooperative child on induction. B. PO versed 0.5-1.0 mg/kg up to 20 mg. 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.e., T&A, M&T). Probably best to consult the attending. The holding room nurses are good at giving oral medications if your technique is not working well. Often the parents will assist as well. C. IM versed 0.1 mg/kg. This often looks and sounds more gruesome than it is. 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. A discussion with the parents is helpful when making the decision to use an IM injection. Simply ask if the child is likely to take PO with success. If the answer is no, take time to explain the need for the IM injection and proceed. Use the concentrated 5 mg/1 ml form from the pharmacy. D. Giving an injection in the pediatric population requires HELP. The nurses are available to help hold a child. It is best to allow the parents to step aside during the injection. However, many parents may want to restrain the child. If this is the case, always have an extra staff person in the room in addition to yourself. Give the injection in the deltoid after prepping with EtOH because blood flow is significantly higher in the deltoid than the thigh, and as a

19 consequence of this uptake is significantly faster. Also, dress the site with a band-aid. The parents will appreciate your attention to detail as they are used to seeing a band-aid placed on their child after a shot. The down side to an IM injection is really the pain on injection. The upside, however, is a significantly faster and reliable onset of versed. The crying following the injection will typically fade into a carefree state of sedation over the course of minutes (frequently <5). E. Intranasal Versed 0.3 mg/kg F. Versed may be given in IV titrated doses up to 0.1-0.3 mg/kg. III. Ketamine A. Ketamine is a dissociative anesthetic. It is useful in and should be reserved for the most recalcitrant of patients. It can be especially useful in larger children who are mentally disabled and unable to understand and comply with caregivers. Ketamine may be given PO, IM, or IV. B. Although postoperative hallucinations and nightmares are more common in adults following the administration of ketamine, it is important to consider the use of versed in addition to ketamine. C. 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. In larger doses the effect of ketamine will last a long time and will lead to an unending stream of drool. Always discuss the need for ketamine with the attending prior to administration. The drug is frequently administered in the holding room with the parents present. You must counsel the parents regarding the presence of nystagmus. It is important to warn parents that the child may appear awake even though they are sedated following the administration of the drug. Also, be sure to move the patient to a recumbent position on the stretcher sooner rather than later. D. PO ketamine may be dosed 5-10 mg/kg. The same issues apply. E. IV ketamine ketamine is rarely given IV as a premed. VI. Atropine A. 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. B. This is a reasonable approach in healthy infants and children with few, if any, comorbidities who are undergoing elective surgery with an anesthetic being administered by experienced pediatric providers. However, atropine is useful as a premed if there is any concern of bradycardia or stimulation of vagal reflexes. Atropine, 0.02 mg/kg IM or IV should always be given prior to succinylcholine. The minimum dose for atropine is 100 mcg IM or IV. C. If you think that atropine is needed, it is important to discuss this with your attending. You will be amazed at how fast an infant will become bradycardic and arrest when faced with a hypoxic event related to airway compromise.

20 INTRAOPERATIVE CONSIDERATIONS IN PEDIATRIC ANESTHESIA. While the components of a case are similar in both pediatric and adult patients, the delivery of anesthesia requires attention to a different subset of variables. I. Monitoring A. There is no better monitor in pediatric anesthesia than the provider. You must constantly watch the patient and listen! Your eyes and ears serve as the best monitors. On induction children will move around interrupting any useable signal from your pulse oximeter. ECG signals will generally be maintained. During induction, the best monitor you have is observation of the chest rise and fall. Should hypoxia occur that is not detected by pulse oximetry, a color change in the lips is noted around a saturation of 88%. Just remember to look at the patient! B. Standard monitoring applies for all pediatric cases. Of note, infant BP cuff tubing is white and found in the top drawer of the anesthesia machine. This tubing is generally reserved for infants <5 kg. C. The monitoring of temperature is critical in very young pediatric patients. Premature babies and infants are at increased risk for hypothermia because of their increased surface-tovolume ratio and increased thermal conductance, among many other reasons. The job of the anesthesiologist is to warm the room preoperatively and to maintain the patients body temperature throughout the procedure. During induction and IV placement, the room temperature should also be maintained and the patient covered to minimize heat loss. The room temperature must be maintained if the patients temperature is low. Heating blankets and fluid warmers may also be necessary. D. The need for additional monitoring is determined on a case-by-case basis, and should be discussed with the attending prior to the case. II. Induction A. Inhalational Induction 1. This is the induction method of choice in most pediatric patients especially those <10 years of age. Monitors are placed prior to induction as necessitated by the situation. 2. Inhalation inductions carry the obvious benefit of avoiding IV placement in a crying toddler. It is dramatically easier to place an IV in a completely still, venodilated youngster. 3. Older children may still be candidates for an inhalational induction but certain issues arise because of their size, including a longer time spent in stage two of anesthesia. While they are in stage two, they may move or wiggle around, sometimes in fairly dramatic fashion. This will pass . . . the most important thing here is to maintain a patent airway and restrain them appropriately. 4. There are different techniques used for inhalational inductions. A mixture of 70/30 nitrous/oxygen vs. 100% oxygen may be used along with either an incremental increase in sevoflurane with every third breath or an initial dose of 8% sevoflurane. There exist rationales for all approaches; these should be discussed with your attending prior to coming back to the OR.

21 B. IV Induction 1. IV induction is used in older children. Most children 12 will tolerate the placement of an IV preoperatively. It is also used in RSI, and in those patients who already have a functioning IV in situ. 2. A preoperative IV allows for ease in the administration of a premedication. 3. IV inductions are preferable in older children. 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. All induction agents may be used in children; however, propofol and thiopental are used most commonly. C. IM Induction - Ketamine is useful for IM induction but is rarely indicated. D. Rectal - Methohexital inductions have been performed in the past, but this is mostly of historic note. Down sides included the obvious . . . it could be messy . . . and onset was fairly slow relative to other methods of induction III. Access A. The presence of a functioning IV prior to the start of the procedure is essential. Do not accept less than certainty when placing an IV or using a pre-existing IV. Always ensure adequate function of the IV. B. A few valuable questions to ask when assessing the function of the IV. 1. Can you flush the catheter with ease? 2. Are you able to obtain blood return from the catheter? 3. Does the site appear to have infiltrated? C. Significant and unrealized infiltration of an IV in a baby or toddler can be very dangerous. Do not accept less than absolute certainty from yourself. D. In infants, blind IV sites including the saphenous vein, interns vein, antecubital vein, and the vein above the fourth metacarpal are frequently used. E. Practice saphenous IVs when you can. You can catheterize veins you cannot see; it just takes practice and proper technique. Ask for guidance if youre unsure of landmarks and techniques. IV. Airway Successful intubation of the pediatric patient requires that one understands the many differences that exist between the pediatric and adult airway. A. Differences in the pediatric/neonatal airway and the adult airway. In pediatric patients the following is true: 1. Flatter faces 2. Larger occiput in relation to body size 3. Macroglossia 4. Edentulous (neonatal and infants) 5. Omega shaped epiglottis 6. Less cartilaginous epiglottis 7. Cephalad orientation of larynx relative to the adult 8. Larynx of a child is funnel shaped secondary to the narrow cricoid cartilage

22 9. The cricoid cartilage is the narrowest portion of the childs trachea versus the glottis in the adult. 10. 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. Trachea is shorter and more compliant. 12. Major conducting airways are also significantly more compliant. 13. More acute angle at branching of mainstem bronchi than is seen in an adult. 14. Alveoli are significantly less mature. 15. Chest wall is significantly more compliant. 16. 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. 3-4 ml of oxygen/kg in an adult). 17. FRC is the same on a per kilogram basis. Closing capacity is increased. B. Choosing the right endotracheal tube There exist many opinions about the sizes and types of endotracheal tubes used in children. This exposure to different opinions will allow for the development of your personal preferences. 1. The narrowest portion of the pediatric airway is the cricoid cartilage. 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. Many anesthesiologists continue to use only uncuffed tubes until children are between 5-7 years of age. 2. A more recent approach to the use of uncuffed tubes restricts their use to children <2 years of age. However, many anesthesiologists use cuffed tubes in most pediatric patients, including premature infants and neonates. 3. Uncuffed ETT formula age / 4 + 4 = ETT internal diameter. This applies to children >1 year of age. Recommendation for children <1 year of age are listed below. i. Neonate/Young Infant (0-4 mo): 3.5 ii. Infant (4-10 mo): 4.0 iii. Older Infant (>10 mo): 4.5 4. Cuffed ETT formula is age / 4 + 3 = ETT internal diameter. This applies to children >1 year of age. Recommendations for children <1 year of age are listed below. i. Neonate/Young Infant (0-4 mo): 3.0 ii. Infant (4-10 mo): 3.5 iii. Older Infant (>10 mo): 4.0 5. Regardless of whether you use a cuffed or uncuffed ETT, it imperative to document a leak. WHY? WHAT OPERATIVE FACTORS HAVE BEEN ASSOCIATED WITH POSTOPERATIVE CROUP? HOW DO YOU TREAT IT? C. Intubating blade choice in the pediatric patient. Again, there are many opinions and personal preferences to which you will be exposed. Take the opportunity to use all of the pediatric blades as you work with different attendings. Below is a list of suggestions. This is not to say that other blades cannot be used to intubate smaller children; they simply may not give ideal intubating conditions.

23 MIL 0: Neonates/Preemies MIL 1: 0-2 yr MAC 1: 6 mo-4 yr WIS 1.5: 2-6 yr MAC 2: 2-12 yr MIL 2: >12 yr MAC 3: >12 yr D. Syndromes associated with the difficult airway. 1. Hurlers Syndrome 2. Gauchers Syndrome 3. Treacher Collins 4. Pierre Robin Sequence 5. Whistlers Syndrome 6. Downs Syndrome 7. Hunters Syndrome 8. Goldenhars Syndrome 9. Angelmans Syndrome V. Positioning A. Children in general are significantly more flexible than their adult counter parts. B. Exceptions to the above remark are those children with spastic neuromuscular disease states in which there are contractures present. It may be challenging to find a comfortable appearing position, especially if the patient is being turned lateral or prone. Prior to the induction of anesthesia, pay close attention to the patients range of motion to ensure safe positioning. C. Always pad every pressure point to avoid nerve injury. D. Caution must be used when placing monitors on children. None of the monitoring wires should lie on the baby in such a way that an impression will be left. Parents do not like to see marks of any kind on their child, and once they are satisfied that their child has survived their surgery, they will start looking for every bruise, blister, tape abrasion, ECG lead mark, etc. VI. Maintenance of Anesthesia A. After induction of anesthesia any one of the 3 available inhalational anesthetics may be appropriate for maintenance. Remember, you do not have to use sevoflurane for the whole case just because it is a kid or because you used it on induction. All of the available agents may be used in children for maintenance. B. Narcotic requirements can very greatly depending on the procedure, patient etc. C. It is probably best to exercise some caution in administering larger doses of narcotics to children <6 mo of age. In this population it is typical to administer a reasonable amount of narcotic intraoperatively. Narcotic is then titrated following emergence and extubation. Otherwise you may delay the patients emergence or worse cause a significant respiratory complication in the PACU. D. In children <7 yr of age, the use of spontaneous ventilation to guide the administration and titration of narcotics is not a particularly good technique for a variety of reasons.

24 1. Emergence is almost always delayed because of the decreased minute ventilation and reduced clearance of volatile anesthetics. 2. Children, for reasons that are unknown, will frequently continue to breathe even when they are hypocarbic. 3. There is little consistency in how different children will respond on emergence. Many frequently become at least briefly agitated and then settle down. E. When using a regional technique, such as a caudal, 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. Remifentanil infusions may be used in many surgical procedures involving neonates. Remifentanils 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. Postoperatively there is minimal residual sedation. Following the procedure, a smaller dose of any given narcotic may be adequate to control the infants pain. VII. Fluid Maintenance A. Isotonic crystalloid solutions are most often used intraoperatively. B. Neonates (especially <2 wk) old should probably have some component of dextrose in their isotonic crystalloid solution (D5%LR, D5%NS, D10LR). C. A good rule of thumb in running/calculating/maintenance fluids and routine deficits is the 42-1 rule. 4 ml/hr for the first 10 kg, 2 ml/kg/hr for the next 10 kg, and finally 1 ml/kg/hr for each additional kg. D. A good ballpark number for most routine/outpatient procedures is a total of 20 ml/kg (deficit + replacement) within the first 1-2 hr. E. These are not hard and fast rules, and obviously the operative context will greatly impact your fluid management. Some larger abdominal procedures in a neonate may necessitate as much as 10-20 ml/kg/hr. VIII. Transfusion Therapy in Children In most circumstances, children will tolerate a significant degree of anemia so we tend to be more conservative overall in transfusing them. With this in mind there are no absolute transfusion trigger points. However, a 4-kg infant does not need to lose much blood before they may become anemic. It is important to remain extremely vigilant and always acknowledge a surgeons admission of blood loss. A. 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. A good rule of thumb for transfusing: 10 ml/kg of PRBCs will raise the childs Hgb 1 gm/dl.

25 C. We typically (do not dilute) PRBC prior to administration as is often done in adult anesthesia. D. Infants and small children will get hypothermic very quickly if you do not take measures to warm the blood prior to administration. E. Blood also should be passed through a filter prior to administration F. 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). Calcium chloride (10-20 mg/kg) or calcium gluconate (15 mg/kg) will quickly chelate the citrate and improve hemodynamic stability. This tends to be much less of a factor in larger pediatric patients with significantly larger intravascular circulating volumes. G. 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. H. If DIC or hepatic dysfunction is present, a coagulopathic state may develop sooner. IX. Emergence A. Adult extubation criteria obviously must be somewhat adjusted given that young children and infants are unable to follow commands. B. Unique criteria for extubation in infants through toddlers are the following: hip flexion, adequate spontaneous regular respiratory pattern, grimace, eye opening, and purposeful movement. Children sometimes will wake up and appear to have emerged from anesthesia and immediately go back to sleep after coughing on the ETT briefly. If several of the above extubation criteria are met, it is less likely that this will occur. C. Everyone extubates prematurely at some point. In the setting of premature extubation, the incidence of laryngospasm in children is significantly higher than in adults. The important issue is to quickly address the laryngospasm. If CPAP fails do not persist. Know the dose of succinylcholine and atropine and be prepared to reintubate the child if necessary, i.e., an appropriate laryngoscope and ETT should be available. D. Set yourself up for success. Extubate children with the head of the bed turned toward you such that you can easily access the childs airway if necessary on emergence. This may sound paranoid until you try to: close the APL valve, apply, CPAP, turn the bed, get to the IV, and administer atropine and succinylcholine rapidly as the child becomes hypoxic and bradycardic. The 30 seconds you save will be well worth it. One day you may be the only anesthesiologist in that room. E. Once extubated, the patient should be transferred to the PACU with oxygen. On arrival in the PACU, the anesthesiologist should assist the PACU nurses with the placement of monitors, and evaluation of the patient should occur prior to report. Always relay pertinent information regarding the patient to the PACU nurses. Do not forget to evaluate all vital signs, including temperature and to provide adequate postoperative analgesia.

26 CARE OF THE PEDIATRIC PATIENT POSTOPERATIVELY I. Postoperative Analgesia As with all anesthetics, one must begin planning for postoperative analgesia prior to the onset of the case. In pediatrics, NSAIDs, narcotics, and regional techniques are all important aspects of postoperative pain management. A. Acetaminophen Rectal acetaminophen is frequently used in doses of no more than 40 mg/kg. It is important to give this dose at the onset of the anesthetic. Between 60-180 min are required to achieve peak blood levels. A dose of 20 mg/kg every 6 hr is prescribed following the initial dose. B. Ketorolac Ketorolac may be used alone for postoperative pain, for example with dental procedures, or it may be used as an adjuvant to narcotics. The dose is 0.5 mg/kg IV or IM. One concern with ketorolac is the potential for platelet function inhibition, especially in children having tonsillectomy. Ketorolac is not commonly prescribed during an anesthetic for tonsillectomy or other procedures with an increased likelihood for postoperative bleeding. To ensure safety, simply inform the surgeons that you are going to give ketorolac with their agreement. C. IV Narcotics IV narcotics are frequently used postoperatively. A standardized form is available for ordering postoperative narcotics. Fentanyl and morphine are used most commonly. When dosing narcotics, one must examine the patients need for pain medication and intervene with a safe but adequate dose. In many cases, narcotics must be titrated to safely achieve adequate pain control. D. Regional Anesthesia Both caudal and epidural anesthesia are used safely in children. Caudal anesthesia is frequently performed for urologic or orthopedic procedures in young children. Many different techniques exist for the placement of a caudal and epidurals. During the rotation, you will be exposed to these different techniques. 1. Caudal anesthesia In general, a caudal anesthetic is performed by placing local anesthetic at the level of the sacral hiatus. Once the sacral hiatus is identified, the needle is advanced cephalad at a 45 angle until a pop is felt. The pop signifies advancement through the sacrococcygeal ligament and into caudal space. The needle should then be leveled and positioned parallel to the patients back. The needle is then advanced 1-2 mm. Most commonly 0.125% bupivacaine with 1:200,000 epinephrine is used for the caudal. Once in the caudal space, a test dose is performed to rule out intravascular injection and intrathecal injection. First aspirate, check for the presence of heme. If heme is present, the needle must be removed. If the aspirate is clear, a 1 ml test dose may be given. The test period should last 1 full min. During this period of time, 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, which occur with intravascular bupivacaine injection. 2. Epidural anesthesia is performed infrequently in our pediatric population secondary to the inherent risks of performing a block on a patient under anesthesia. Certain thoracotomy procedures, spine procedures, and Wilms tumor resections are the procedures for which an epidural is most commonly performed.

27 II. Postoperative Nausea and Vomiting (PONV) in Children The management of PONV remains a controversial topic. This issue should be addressed with the attending prior to the case, such that adequate medications can be given intraoperatively. A. Below are the pediatric anesthesia departmental guidelines on PONV: 1. All patients 1 year of age, who have an IV, receive a general anesthetic, have a surgical procedure, and do not have a contraindication should receive dexamethasone 150 mcg/kg to max of 8 mg. 2. Patients 1 year of age who are at high-risk of PONV (history of PONV or high-risk surgical procedure, i.e., adeno-tonsillectomy, dental extraction, herniorrhaphy, laparotomy, laparoscopy, middle ear surgery, orchiopexy, strabismus, craniotomy) should receive, in addition to dexamethasone, ondansetron 0.1 mg/kg up to 2 mg. 3. Antiemetic prophylaxis and treatment of neonates and infants will be at the discretion of the anesthesiologist. 4. PACU rescue should be at the discretion of the anesthesiologist and may include higher doses of ondansetron; droperidol for patients in whom it is felt the potential benefits outweigh the risks, and others. B. Risk factors for PONV in children include: 1. Sight of surgery (ENT, abdominal, strabismus) 2. History of motion sickness 3. Female gender 4. Prior history of PONV C. Below are doses for commonly used antiemetics. 1. Odansetron 100 mcg/kg 2. Decadron 150 mcg/kg maximum dose of 8 mg. 3. Droperidol 50-75 mcg/kg potential second level rescue in PACU. Note: Dr. Glazier requests that his patients DO NOT receive droperidol. 4. Metoclopramide 0.15-0.25 mg/kg D. Additional strategies for decreasing PONV 1. Always remember to decompress the stomach following induction. This serves to empty the stomach of its contents and relieve gastric distention that can be a factor in PONV. 2. The use of nitrous oxide can be a contributor to PONV, as are all the inhalational agents. In cases of severe PONV, one may consider TIVA as the primary anesthetic.

28 SPECIFIC CASES: STRATEGIES / CONCERNS / GENERAL GUIDELINES The outline below is meant as a guideline for those starting their pediatric anesthesia rotation. There exist many stylistic differences between attendings. This section covers the procedures commonly performed in the pediatric ORs. There are, of course, many other procedures not addressed below. I. ENT Cases A. M&T 1. Maintain spontaneous ventilation. 2. An oral airway may be placed following induction. The oral airway will allow you to maintain a patent airway without CPAP even when the head is turned. 3. Emergence delirium is common in the pediatric population and occurs most frequently when sevoflurane is used for short cases. At this time there are no specific SPA (Society of Pediatric Anesthesia?) guidelines on the prevention of emergence delirium. The studies designed to address emergence delirium show a reduction in emergence delirium in patients who receive 2 mcg/kg total of intranasal fentanyl. These patients also typically receive 40 mg/kg of rectal acetaminophen. 4. Following the procedure, parents should be counseled not to re-dose the acetaminophen for at least 4 hours. Plasma levels of rectal acetaminophen will typically not peak for up to an hour after placement. In female children, please ensure proper rectal placement of acetaminophen and avoid accidental vaginal placement of the suppository. Also, the parents should be warned that the next bowel movement might have a white color secondary to the placement of the acetaminophen. 5. For short cases such as M&T and laser procedures, the bed will be turned. For quick cases, please take time to layer the OR beds with waterproof pads and green sheets, i.e., 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, and so forth, so all you need to do is to remove a green sheet and pad between each case. B. T&A 1. Many of these children come to the OR with diagnoses of obstructive sleep apnea (OSA). It is essential to realize that most of these children have not had a formal sleep study. The diagnosis is based parental description of the child asleep (i.e., snoring, loud breathing, etc.) coupled with a physical exam that shows large tonsils in the office. 2. It is appropriate and safe to sedate most children presenting for T&A, even in the presence of a diagnosis of OSA. However, in the presence of documented severe sleep apnea, the patient must be sedated in the presence of a vigilant anesthesiologist, as one would for any adult patient with severe OSA. 3. These children tend to be between 2-12 years of age although frequently they are <8, and because of this they may be more anxious than younger children who remain oblivious or older children who may be more stoic. Frequently these children may need a premedication.

29 4. Either an IV or an inhalational induction may be performed depending on the patients size and medical history. 5. The use of muscle relaxant is not mandatory. Discuss this with your attending. 6. Either a straight ETT or an oral RAE tube may be used. 7. Fentanyl and morphine are both acceptable, although the kinetics of morphine will allow pain control to extend significantly further into the postoperative period. 8. These patients all receive Decadron 0.5 mg/kg up to 8 mg to reduce airway swelling. It may also have the benefit of lowering the incidence of PONV. 9. Discuss ondansetron prophylaxis with your attending. 10. These patients will typically stay overnight in Day Hospital. 11. These patients frequently have worse obstruction in the first 24 hr post-procedure, even with relief of the anatomic obstruction. The explanation for this remains unclear but probably relates to some discoordination of the oropharyngeal musculature. This potential must be considered when dosing post-operative pain medications. 12. Postoperatively they can re-bleed and may need to come back emergently to the OR in which case they will get a RSI. C. Direct Laryngoscopy 1. Probably in no other operative arena is communication between anesthesia and surgery more vital than in this one. 2. 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). 3. If there is any question about safe management of the airway during induction, consider having the ENT present at the time of induction of anesthesia. 4. These children typically will tolerate premedication. 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. 5. Maintenance of spontaneous ventilation is paramount, so be careful in ASSISTING the child and make sure you are not ventilating the child. This is further amplified in patients who have received a premed. They can rapidly lose their drive to breathe if assisted too much, and this will make the operative course much more difficult. There is an art to maintaining spontaneous ventilation, so do not be discouraged if things do not go smoothly the first time around. 6. After induction and placement of the IV, the anesthesiologist performs laryngoscopy, and a disposable atomizer is used to spray the vocal cords with either 1% or 4% lidocaine. ENT will give you the atomizer. 7. The table is then turned 90, and ENT establishes a mask airway. Pay close attention because often the ENT resident may not be as skilled at this as you are. 8. Once the child is appropriately deep, ENT will laryngoscopy and/or perform a rigid bronchoscopy. The circuit is attached to the bronchoscope and/or the laryngoscope using a 3.0 9-mm ETT adapter. 9. Continue to insufflate as the child continues to breathe spontaneously inhaling additional oxygen and sevoflurane.

30 10. It is important to monitor the depth of anesthesia especially with a rigid bronchoscope in the trachea. One of the best indicators is the depth and pattern of respirations. Patients that are lighter tend to have a rocking pattern to their respirations. Patients that are deeper tend to have a shallower pattern of respiration that appears more relaxed. 11. 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. 12. These children will frequently wake up without an ETT. 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. 13. These procedures typically do not require narcotics for pain control postoperatively, although sometimes it may lessen the incidence of emergence delirium postoperatively. 14. Laryngoscopy and debridement for HPV requires special mention. i. Ask the parents how the child has been feeling and evaluate any change in symptoms since the last procedure, i.e., more hoarse/less hoarse than usual. ii. Because these children have been to the OR several times, it is good to ask the parents how thing have gone in the past. iii. Beware of sedating these children preoperatively. They can obstruct in holding secondary to their disease process. This does not mean that these children should not receive premedication; it just means it should be administered judiciously. iv. Wear gloves!!! v. The presence of HPV in the airway is thought to occur secondary to exposure as they pass through the birth canal. vi. Typically these children will wax and wane into their early teenage years. According to Dr. Kirse, the decrease in papillomas during the teenage years may be medicated by a hormonal alteration that shuts off papilloma formation. II. General Surgery A. Pyloric Stenosis 1. Without a doubt this case is fair game on both the written and oral boards. 2. Incidence 1:500 live births. 3. This is a medical emergency not a surgical emergency. Historically, these patients were rushed to the OR before rehydration and many did very poorly. These babies are frequently significantly dehydrated and have both intravascular and overall free water deficits. Accordingly, they need to be adequately resuscitated and hydrated prior to coming to the OR. 4. The primary physiologic derangement is dehydration with attendant metabolic disorders. The classic metabolic disorders associated with this are a hyponatremic, hypokalemic, hypochloremic metabolic alkalosis. Why arent these patients hypernatremic typically? 5. Preoperative optimization must begin with appropriate resuscitation using an isotonic solution in the setting of severe intravascular volume depletion, followed by the administration of a hypotonic crystalloid solution to replete the free water deficit. Additionally most people will look to see an increase in the serum potassium >3.0. 6. These patients will, and must have an IV prior to coming to the OR. NOTE: MAKE SURE THIS KINKED, TENUOUS 24G ANGIOCATH HANGING BY ONE PIECE OF

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. 7. Many practitioners will suction the stomach with the child awake prior to doing a RSI. 8. It is worthwhile to consider the administration of atropine prior to induction. 9. There exist varying opinions on the use of succinylcholine in pediatric patients, except in an emergency setting. You must discuss and clearly understand the plan for intubation. All attendings in the peds OR have a different style. Some may perform a textbook RSI, while others may perform a modified RSI with rocuronium. Awake intubation in these patients is also an option, although rarely utilized. 10. Frequently, narcotics are not dosed during the procedure. The surgeon will usually inject with local anesthetic. B. Lap Nissen/Open Nissen+G-tube 1. There is a spectrum of ages that present for this procedure. Most children will present <5 years of age. 2. Although these children do have reflux disease, it is unnecessary to perform a rapid sequence. The true concerns related to reflux disease are chronic aspiration, ongoing inflammation, and recurrent pneumonia. 3. A single good IV is necessary, typically in the upper extremities because lower extremity IVs may get in the way of positioning the patient. 4. Intraoperatively be aware of the consequences of pneumoperitoneum (i.e., on ventilation, preload, UOP, etc.) 5. Operative time is typically between 2-4 hr. 6. At some institutions they will use a rubber bougie to gauge the tightness of the rap. Here we simply use an OG tube. III. Urogenital Surgery A. Hypospadias Repair 1. These are typically young, otherwise healthy males between 6 mo and 4 yr. The procedures vary greatly in length and complexity. 2. Mask induction 3. A single IV is sufficient. This is actually a good case to attempt blind saphenous lines. Frequently a caudal anesthetic may be performed and the IV site in the foot will not be as bothersome to the child. 4. After agreement from the surgeon, a caudal anesthetic may be performed. 5. LMA/ETT. Patient may be intubated deep or with the aid of a relaxing agent. 6. Patients typically will go home postoperatively. B. Inguinal Hernia Repair 1. These patients have the potential to be very young former preemies. 2. Be careful to look at the estimated conceptual age at birth and calculate their current estimated conceptual age. Pre-term patients <60 wk post-conceptual age are considered at risk for postoperative apnea and bradycardia.

32 3. A caudal is frequently performed for this procedure. In babies at risk for postoperative apnea and bradycardia, the use of a caudal diminishes the need for narcotics. 4. There is a significant operative time difference between female and male children. The male will be more time-consuming secondary to the need for identification of the vas deferens and spermatic cordal structures. 5. Beware of access problems, especially if they are former residents of a NICU. 6. Although it is institutionally dependent, some practitioners advocated doing spinals in expremies who are at risk for apnea/bradycardia following general anesthesia. An anesthesiologist experienced with the technique should perform this. Typically a circulating nurse or other anesthesia provider holds the patient in a sitting position with their back to the practitioner. The back is prepped, local infiltrated, and a 22-G 1.5 stylleted needle is inserted at L4-5, L5-S1. With free flow of CSF, lidocaine is injected. The subarachnoid space in infants <60 wk ECA is typically <1.5 cm from the skin. Once in place, the patient is allowed to lay supine, and IV access is then obtained typically in the lower extremity of these infants. These patients will not become hypotensive because there is very little resting sympathetic tone. As a result, there is little clinical relevance to the sympathectomy. One of the caveats of this technique though, is that the surgeon must be fairly efficient, as the block will typically last 45 min to 1 hr, no matter what type of local anesthetic is used. The reasons for this are unknown at this time. 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. Also, if narcotics are used, the patient is considered to be at risk for postoperative apnea and bradycardia. There has been no difference in the incidence of postoperative apnea and bradycardia between GA and spinal anesthetic in the presence of narcotic supplementation. C. Circumcision 1. Although this case may be appropriate for mask management of the airway, the airway is frequently secured with an ETT, or an LMA is placed in older children. 2. Caudal may be appropriate; however, a penile block is often sufficient in young infants. 3. A single IV is necessary. 4. Rectal acetaminophen is often given. 5. In very young infants avoid anything over and above minimal narcotics. Consider Toradol. Discuss with your attending. D. Ureteral Reimplantation 1. A ureteral reimplantation is an abdominal procedure for the treatment of vesicoureteral reflux. During the procedure, the ureter/ureters are reimplanted into the bladder. 2. Children are typically between 5- and 8-years-old. 3. A Pfannenstiel incision is typically performed. 4. One IV is sufficient. 5. The surgeons have requested that no nitrous be used for these procedures because of the potential decrease in operative exposure.

33 6. Blood loss is typically minimal. 7. Some practitioners will do a caudal for the procedure. 8. All these patients receive Toradol. This helps dramatically with bladder spasms that are often the most painful part of this procedure. These children are also at risk for PONV. IV. Orthopedic Procedures There is a large spectrum of orthopedic procedures that are performed. Many of these children have CP or congenital bony malformations that necessitate the need for surgery. A caudal may be considered on a case-by-case basis for lower extremity procedures. V. Plastic Surgery A. Craniosynostosis 1. These children frequently have facial as well as cranial abnormalities. One must perform a complete airway exam despite the fact that the children are frequently uncooperative. Always consult prior anesthetic records if possible. 2. IV access is a must: at least two IVs that run well, preferably two 20s, or two 22s, or a 22 and 20. 3. An A-line is a must. The A-line allows for frequent lab studies. 4. A large amount of blood loss is frequently associated with this surgery, and judging the blood loss accurately is extremely difficult. Blood should be in the room and CHECKED prior to commencing this operation. A hot line should also be checked and ready for immediate use. 5. Blood loss is typically steady, though it can be accelerated if a sinus is violatedthis does happen, so you will need to be prepared. 6. It is extremely easy to get behind in these cases. Beware of this; start to give blood a little earlier rather than later. 7. Most of these patients can be extubated postoperatively; however, occasionally they may need to remain intubated. 8. Pay close attention to temperature; a large amount of room temperature fluid is frequently administered to these children. Also, ensure that the blood is effectively warmed prior to administration, when possible. B. PDL of AVM 1. These cases frequently are quick enough that a mask is adequate. 2. There is usually no need for an IV. 3. Analgesics include rectal acetaminophen, IM Toradol, and/or intranasal fentanyl (1-2 mcg/kg). 4. It is worth mentioning that many of these patients will come for this procedure multiple times. Always ask the parents how things went during the last procedure. The parents may have expectations (i.e. premed, PONV) of which you should be aware. Please read the old chart to see if how things have been done previously. 5. These procedures are fairly short, and the postoperative pain is comparable to sunburn. Therefore, if a premed is necessary, consider the use of adjuvant narcotic with caution, as the use of other benzo and narcotic may significantly prolong the postoperative recovery.

34 C. Burn Surgery 1. The room should be warmed and remain warm throughout the procedure. Also, blood needs to be in the room and CHECKED before surgery begins. 2. A preoperative Hct and other chemistries are necessary before coming to the OR. 3. 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. 4. Excessive IV access is the rule. 5. An A-line is never a bad idea, but you must also gauge the extent of debridement and grafting. In many cases you will need to sample blood, and an A-line or central line will be necessary. 6. It is extremely difficult to calculate an exact blood loss, and it is extremely easy to get behind. It is often necessary to transfuse empirically, i.e., if it looks like they are beginning to bleed at all, it is probably a good idea to begin transfusing in situations with a low starting Hct. If blood loss is brisk, even in a healthy child, do not wait for changes in vital signs or to check an Hgb before initiating resuscitation. In extreme situations, if you wait the child will most assuredly be extremely hemodynamically unstable before you get your results. 7. Sometimes it will be necessary to ask the surgeon to stop so that you can catch up with the volume.