Pedi Case Preparation Flashcards
Cath lab set up for GA
- ETT
- 0.1 mg/kg versed
- 1 mcg/ kg fentanyl
- 1 mg/kg rocuronium
+/- propofol - inhalation agent is poorly tolerated
- precedex 0.5-1 mcg/kg bolus
- room air O2 as Pulmonary artery pressure will be measured so we have to mimic the normal condition PT is in
Prepare pressors
- phenylephrine 100 mcg/kg
- epinephrine 10 mcg/kg
Surgeon assess Right IJ, no aline needed
Take right ventricle biopsy, watch for arrhythmia, if puncture RV cardiac tamponade
Watch for bradycardia when surgeon assess coronary artery tree bc the SA node is right at branching point of R coronary tree
Watch for pulm air embolism like phenomenal when pulm artery balloon dilation and stent placement. Treat electrolyte disarrangement and low HCO3 accordingly
After 5 years of heart transplant most PT develop coronary art dz
Cath lab set up for MAC
- 0.1 mg/kg versed
- 1 mcg/ kg fentanyl
- 0.5-1 mcg/kg precedex bolus
- 0.5 mcg/kg/hr precedex gtt
room air O2 as Pulmonary artery pressure will be measured so we have to mimic the normal condition PT is in
- congenital Cardiac pt grown up presents for card cath: MAC with versed, fentanyl and abx if intervention needed
Solumedrol for liver transplant
10 mg/kg solumedrol
Cleft palate repair
Oral RAE cuffed tube taped to lower jaw. Straight connector on circuit.
Concern for post-op obstruction. Surgeons will place tongue stitch to retract tongue if Pt obstructs. Will go to ICU post-op for airway watch.
Use Ketamine and/or Precedex and minimal narcotics to decrease respiratory depression post-op. Glycopyrrolate early in case to decrease secretions.
Hold tube when removing throat packing, ETT may be dislodged with packing.
May have significant amount of blood in posterior pharynx, suction thoroughly.
Avoid crying, screaming, coughing on wake-up. Do not place oral or nasal airway post-op. Use tongue stitch to open airway if needed.
May be associated with chronic otitis requiring tympanostomy tubes. May also be associated with Peirre-Robin and Treacher-Collins.
Infraorbital nerve block with 0.5-1.5 ml of ropi w epi
Central venous catheter for different age group
Typical central venous catheter choices:
- 0 – 1 months of age use 4 Fr 5cm Double lumen catheter
- 2 months – 2 years of age use 4 Fr 8cm Double lumen catheter
- 2 years - 10 years of age use 5 Fr 8cm Triple lumen catheter
- more than 12 yo or > 40 kg use 7 Fr
- adults 7 Fr 15 cm triple lumen catheter
Increased size = increased complications
Increased lumens = increased complications
- when do CVP for neonate <5 kg, use ultrasound to identify IJ then poke through and through then drop US probe and withdraw needle slowly and aspirate as we withdraw- this technique increases success
Radial artery catheter size
Radial arterial catheter choices:
● < 6 months of age or < 5kg use 24 gauge angiocath
● 6 months - 8 years of age or < 30kg use 22 gauge angiocath
● > 8 years of age or > 30kg use 20 gauge angiocathu
Brachial artery catheter size
Brachial arterial catheter choices:
● < 2kg not recommended
● 2-5 kg weight use 24 gauge angiocath
● > 5 kg weight use 22 gauge angiocath
Femoral artery catheter size
Femoral and axillary arterial catheter choices:
● < 6 months of age or < 10 kg use 2.5 Fr 5 cm single lumen catheter
● 6 months – 12 years of age or 10-50 kg use 3 Fr 8 cm single lumen catheter
● > 12 years of age or > 50 kg use 4 Fr 12 cm single lumen catheter
Tethered cord release setup
If SSEP and MEP monitoring:
- half TIVA and 1/2 Gas
- sufentanyl or remifentanyl and propofol gtt
- sufentanyl 5mcg/ml runs at 0.2 mcg/kg/hr
- remifentanyl 40 mcg/ml at 0.2 mcg/kg/hr
- 2 large IV
- type and screen
- OG and esophageal temp probe, bite block
- prone position
- no neuromuscular blockade
Large parietal tumor resection craniotomy
- lateral position with head turning
- GAET nad OG and esophagus temp probe and bite block
If SSEP and MEP monitoring
- TIVA no gas no neuromuscular blockade
- 2-3 large IV
- aline
- central line
- type and cross 4 PRBC 2 FFP 2 platelets 1 cryoprecipitate
- levophed gtt at 0.05 mcg/kg/min
- propofol gtt 100 mcg/kg/min
- Ketamine gtt 3-5 mcg/kg/min
- remifentanyl 40 mcg/ml at 0.2 mcg/kg/min
- calcium gluconate 30mg/kg
- bicarbonate
Bicarb = weight x BD x 0.25 or 1mEq/kg
- use plasmalyte for fluid
Dilaudid
- Dilaudid 3mcg/kg IV bolus
- dilaudid gtt 1-4mcg/kg/hr
Can increase to 6 mcg/kg/hr with permission from acute pain service
-
T and A set up
- Oral RAE
- LTA lidocaine
- no rocuronium
- inhalation induction, IV insertion, propofol, fentanyl, decadron 0.5mg/kg, Tylenol, +/- antinausea depending on age
- no toradol
- fentanyl 1 mcg/kg
- Keep spontaneously ventilation
Craniopharyngioma case setup (pituitary adenine) endoscopic, transnasal approach
Or poster clival chordoma resection via transnasal approach
Ssep monitor
- half TIVA (precedex, sufentanyl gtt), half gas
\+ precedex 0.5 mcg/kg/hr
\+ sufentanyl (0.2-0.5 mcg/kg/hr)
Sufentanyl 5mcg/ml
Stop sufentanyl 40 mins before end of case
\+ rocuronium gtt 0.6 mg/kg/ hr
- GAET, aline, 2 large IV
- istat, hemocue, glucometerMitochondrial disease and propofol
The following anesthetic plan has been safe to use in mitochondrial pts:
- mitochondrial dz pt may manifest as respiratory failure, cardiac depression, conduction defect, dysphasia, hypotonic myopathy.
- continue all home Med to day of surgery, avoid prolonged fasting.
- Variable by disease, but general rule is to avoid infusions. A bolus or two (ie, for intubation or laryngospasm) is fine
- Avoid physiologic stress (fasting/hypoglycemia, volume depletion, hypothermia, hypoxia etc etc).
- small IV boluses of propofol, benzodiazepines, or ketamine;
- continuous infusion of dexmedetomidine;
inhalation of sevoflurane; and
bolus dosing or continuous infusion of short- or ultrashort-acting opioids (fentanyl, sufentanil, alfentanil, or remifentanil).
- avoid LR as mitochondrial pt has impaired lactate metabolism
- avoid morphine (2/2 resp depression)
- tylenol but no repeated Tylenol dose (metabolism depends on liver)
- toradol (NSAIDs) okay
- unsure how long to monitor pt in PACU till pt returns to baseline b4 discharge
Smith protocol for posterior spine fusion for scoliosis
- propofol gtt 200mcg/kg/min
- precedex gtt 0.5 mcg/kg/hr
- lidocaine gtt 40 mcg/kg/min
- ketamine gtt 8 mcg/kg/min
- nicardipine gtt 0.5-1 mcg/kg/min
- TXA bolus 30mg/kg then TXA gtt 5-10 mg/kg/hr
- SSEP and MEP monitors
- Induction: if IV induction - GAET, bite block, propofol 3mg/kg and ketamine 1mg/kg.
- Tylenol IV 15 mg/kg prior to flipping, redose q6hr
- 2 hours into the case, decrease ketamine to 4, precedex to 0.2
- stop ketamine and precedex gtt after final pedicle screw is placed
- one hr before case ends, methadone 0.1 or less mg/kg (0.05 mg/kg probably enough)
- turn propofol and lidocaine gtt off at time of last neuro monitors done. Start N2O/O2 (70/30% or as tolerated to keep SpO2 >95%)
- switch to PSV get pt spontaneously breathing
- intermittent propofol bolus for conclusion surgery
- istat, hemocue, glucometer to check hourly labs, type and cross 2 uPRBC
Junctional epidermal bullosa
- complications from EB Hyper metabolic state FTT/ malnutrition/ growth retardation Infection Oropharyngeal scarrings Esophageal stricture Dilates cardiomyopathy: ?Chronic inanition, iron overload, low carnitine levels, selenium deficiency. Laryngotracheal Scarring
- avoid shearing force on skin
- compressive force on skin is better tolerated
- A special EB kit is kept in the Anesthesia Workroom that contains:
i. Coban® wrap, Webril®, Ace® wrap, etc.
ii. Silicon-based dressings and “adhesives” Molnlycke® products such as Mepitac, Mepitel, Mepilex, Mepiform
iii. Ocular lubricants (methylcellulose-based preferred)
iv. Emollients such as Aquaphor®, or Albolene®, Vaseline gauze.
v. Surg-o-Flex® bandaging
vi. Gel Defib pads to assist in the adhesion of ECG electrodes
Bicarb dose liver transplant
- 1mEq/kg bicarbonate
CDH repair congenial diaphragmatic hernia
- kiddo usually goes to OR already intubated
- gtt \+ epinephrine \+ milrinone \+ dopamine \+ D5 water
- aline, pre ductal and post ductal O2 probes, 2 IV
- pt is 90 degree turned from you
- lateral decubitus position
- istat, hemocue, glucometer - check ABG q 1 hr
- May need to hyperventilate to overcome rise in etCO2 or high frequency oscillation ventilation
- gentle ventilation- peak inspiratory pressure <= 25, PEEP <= 5, permissive hypercapnia
Modified Smith protocol for posterior thoracic spine fusion in 400lbs pt 16 yo M
- due to concern of large BMI and delayed emergence in posterior thoracic spine fusion, modified protocol used:
- propofol gtt 100-150 mcg/kg/min
- precedex gtt 0.2 mcg/kg/hr
- lidocaine gtt 10 mcg/kg/min
- ketamine gtt 4 mcg/kg/min
- Remi fentanyl 0.2 mcg/kg/min, [remifent] = 40 mcg/ml
- methadone 0.025 mg/kg one hour before case conclusion
- nicardipine gtt 0.5-1 mcg/kg/min
- TXA bolus 30mg/kg then TXA gtt 5-10 mg/kg/hr
- phenylephrine gtt 60 mcg/ml concentration
- phenylephrine gtt 10-25 mcg/min
- SSEP and MEP monitors
- Induction: if IV induction - GAET, bite block, propofol 3mg/kg and ketamine 1mg/kg.
- Tylenol IV 15 mg/kg prior to flipping, redose q6hr
- 2 hours into the case, decrease ketamine gtt to 2, precedex gtt to 0.1
- stop ketamine and precedex gtt after final pedicle screw is placed
- one hr before case ends, methadone 0.025 or less mg/kg
- turn propofol and lidocaine gtt off at time of last neuro monitors done. Start N2O/O2 (70/30 or as tolerated to keep SpO2 >95%)
- switch to PSV get pt spontaneously breathing
- intermittent propofol bolus for conclusion surgery
- istat, hemocue, glucometer to check hourly labs, type and cross 2 uPRBC
Nuss protocol UPMC
- T5-6 paraveterbral nerve block catheters, bolus w 0.5% ropi 15 ml per side (do not exceed 3mg/kg)
- PVB catheters places prior to surgery under sedation or GAET
- ketamine 1 mg/kg, decadron 8 mg IV, on induction. Intraoperatively, another ketamine 1mg/kg
- tylenol 15mg/kg, toradol 0.5 mg/kg max at 15 mg at end of case
- opioids as per providers
- PVB should be bolused w 0.2% ropi 5-8 ml per side at end of surgery with or without clonidine up to 2mcg/kg
- POD 0
+ PVB 0.2% ropi 7-8 ml/kg per side with clonidine 1mcg/kg infusion
+ intermittent bolus 0.2% ropivacaine up to 1/2 continuous infusion rate (ml) q 4 hours, clinical bolus 4 ml per side q 180 mins
+ do not exceed 0.5 mg/kg/hr total
+ PCA dilaudid: demand 0.5 mcg/kg q 8 mins, Clinician bolus 7 mcg/kg q 30 mins
+ PCA ketamine 0.1 mg/kg/ hr
+ tylenol 15 mg/kg/6 hr max 1000 mg q 6hra
+ diazepam 0.05 - 0.1 mg/kg q 4 hrs PRN muscle spasm
+ nalbuphine 0.02 mg/kg/6 hrs PRN itching
+ naloxone PRN apnea
+ zofran 0.1 mg/kg/6 hrs PRN
+ reglan 0.2 mg/kg max 10 mg PRN
+ flexeril 5-10 mg PO BID POD 1
Anesthesia for pig tail chest tube placed in pediatric pt?
- MAC with versed, fentanyl, ketamine, precedex and a bit of propofol
- if not GAET
NEC setup
- IV push line
- IV insertion for drugs
- aline for frequent ABG then adjust vent setting accordingly
- rocuronium, fentanyl, versed, bicarbonate, albumin 5%, pRBC
- emergency drugs
How to do BMT bilateral ear tubes in MH susceptible pt?
- Do not do at surgery center without MH capability
- do a nontriggering anesthestic. PO versed, nasal Dex, IM ketamine, ect.
- Get an IV in case you need Roc or prop. No need to use sux or volatiles. First case start with a flushed machine.
BMT when to put IV?
- less than 2 yo may be May be not IV, give toradol IM
- older than 2 yo yes IV
Subclavian CVL insertion
Start from sternal notch, go 2/3 lateral of clavicle then go lateral 1 cm more - needle insertion point going toward sternal notch
Will hit clavicle, then walk off clavicle, then aspirate as going toward sternal notch - should hit subclavian vein on this projection
1: 100,000 epinephrine is ?? mcg/ml?
1: 200,000 epi how to prepare?
1: 100,000 epi = 10 mcg/ml epi = 0.1 ml of not diluted 1 mg epi in 10 ml of solute
- 1:200,000 epi for nerve block: 0.05 ml of 1mg epi undiluted onto 10 ml of ropivacaine 0.2% = 5 mcg/ml of epi
Mitochondrial myopathy pt
- Avoid LR as they may at base line have elevated lactic acidosis
- mitochondrial myopathy pt- only brief fasting period, give them glucose infusion, no LR fluid
- May want to avoid propofol but they are not at risk for propofol infusion syndrome
- propofol can cause cardiac arrest
Congenital diaphragmatic hernia repair
- PT is usually intubated prior to Coming to OR
- Mark sure it’s cuff tube. May need to fiber optic the fiber optic scope to right main stem and push the single lumen ETT to right main stem to collapse the left lung for surgeon to operate.
- a line
- 1 preductal pulse ox and 1 post ductal pulse ox, keep preductal ox 90-95%
- 2 good IV
- heating lamp, bear hugger
- check glucose preop, intraop, run d10 NS or d10 LR
- have milrinone, epinephrine gtt available
- allow permissive hypercapnia ET CO2 50-60, PIP 25 before CO2 inflation, when CO2 inflation started then PIP can be 25 + pressure of CO2 inflation
- PVC with ~ 10ml/kg, RR 40-42 to keep ET CO2 50-60
- nitric oxide NO 10-20 ppm available
- after sx transfer to NICU intubated
- make a medicine line
- pt is moved down turn 90 degree and right lateral decubitus
Hirschsprung dz sweson procedure to reconnect rectum to colon
- GETA with 2 good IV
- heating lamp, bait hugger
- check Blood glucose q 90 mins
- run D10 NS or D10 1/2 NS
- do caudal before sx start
- if neonate ends up not having colostomy, then can repeat caudal with half dose of initial ropivacaine 0.2% diluted with equal amount of normal saline to make it 0.1% ropivacaine concentration
- if neonate ends up having colostomy then caudal catheter maybe?!?
- if too young kid (2 weeks old) with unrepaired transitional balanced AV canal, run dopamine 5mcg/kg/min and milrinone 0.2-0.4 mcg/kg/min from the start - if pressure fine then stop it
Anesthesia for eeg placement grind for refractory seizures (stereo electroencephalogram SEEG
- inhalation induction then 2 PIV then ET tube then half MAC of gas plus TIVA (propofol/ roc) and fent bolus PRN
- decadron/zofran/tylenol
Ped epidural/caudal rate?
- for <40 kg
- epidural/caudal gtt
+ bupivacaine 0.0625% +/- 1-2 mcg/ml fentanyl
- age < 4months old: 0.1-0.3 ml/kg/hr
Max dose 0.2mg/kg/hr
- age > 4 months old: 0.1-0.7 ml/kg/hr
Max dose 0.5mg/kg/hr
+ bupivacaine 0.125% with or without fentanyl- not to be used for < 10 kg pts
+ bupivacaine 0.1% or ropivacaine 0.1% with fentanyl 2mcg/ml
- age < 4 months old: calculate max dose per hour then divide by concentration to get rate
- age > 4 months old: calculate max dose per hour then divide by concentration to get rate
Anesthesia for Epiglottis
- have one of the parents with the kid to OR room, have ENT or general surgeon in room standby for trach
- inhalation induction with sevoflurance/ nitrous oxide, once kid starts falling asleep have parent leave
- place IV, give atropine or glycopyrrolate, give 20-40 ml/kg LR or NS bolus bc these kids are dry
- versed 0.1 mg/kg, ketamine IV 2-4 mg/kg
- keep kid spontaneous ventilating then DL or videoscope with glidescope with oral ETT or nasal ETT
Lumbar/ thoracic epidural block
- infant to child < 7 yo: 20 gauge 40-50 mm needle Touhy or Crawford
- child > 7-8 yo: 18 gauge 90-100 mm needle Touhy or Crawford
Spinal anesthesia in peds
- use 22 G spinal needle or Whitacre needle
- hyperbaric tetracaine 1mg/kg (1% tetracaine and 10% dextrose)
- isobaric bupivacaine 1mg/kg w 1:100,000 epinephrine
- last 1-2 hrs
Cystic fibrosis Peds case
- preop - ask about their fitness, how much exercise tolerance bc fitness is positive predictor of survival in cystic fibrosis
- ask how much secretion, how thick or thin of their secretion, if bronchodilator helps, how often bronchodilator needed?
- look for echo (pulm HTN, RVH, Cor pulmonale)
- CXR, PFT, hepatic function (PT, INR as they are vit K malabsorption), ? Diabetes
- give inhaled hypertonic saline 7% preop prior to induction and immediately post op will help lots to mobilize and clear secretion
- low fresh gas flow intraop to minimize drying of secretion
- avoid NMB or opioid if possible
- watch out if aminoglycosides abx used as that will prolong NMB - confirm reversals at end of case
Double lumen tubes and one lung ventilation in peds
- DLT 26 = 6.5 ETT
- DLT 28 = 7.0 ETT
- DLT 32 = 8.0 ETT
- DLT youngest age can use is 8 yo
- do not exceed 50 cm H2O Peak inspiratory pressure (20 for 2 lungs)
- TV 8-10 ml/kg
- high respiratory rate
- FiO2 1.0
- maintain PaCO2 45-60
- if desat, check position of DLT with fiber optic scope.
- if still desat, add 10 cm H2O CPAP to non-dependent lung
- if not improve, two lung ventilation
- in VATS video assisted thoracoscopy, CO2 insufflation used, make sure surgeon doesn’t over pressure ie > 10 mmHg bc it will shift mediastinum, cause suddenly bradycardia due to bezold jarisch reflex, cause hypotension
Cancer peds - no decadron?
- oncologists don’t like cancer pts get steroid like decadron bc it will lead to tumorlysis ( hyperkalemia, calcium metabolism problems, electrolyte abnormalities), alter the tumor anatomy making it hard for diagnosis
Williams syndrome kid is always a red flag kid - why?
Williams syndrome = Williams Beuren syndrome
- Williams syndrome kid has generalized cardiac problem - Supra aortic stenosis, pulm stenosis, and coronary arteries problems too
- they can code on inhalation induction
- without a cardiac cath you have no info of the coronary artery problem
- treat kids w Williams syndrome as a hypertrophic cardiomyopathy kids - don’t inhalation induce them, have fluid load, phenylephrine available to push the coronary perfusion pressure up
- pre Med versed with Williams kids so that you can place IV without inhalation induction but nitrous oxide is ok for iv insertion
- the Williams kids and Fontan kids are 2 population that will easily have cardiac arrest on induction - small versed with small etomidate OR mix ketamine with propofol if you have no etomidate and go VERY VERY SLOW - avoid tachycardia and hypotension
Diaphragmatic hernia repair
- 2 PIV
- a line
- regular ETT with regular intubation
- bronchial blocker (Cook BB size 5 for 5 yo pt), use fiber optic scope to guide Bronchial blocker (tied to fiber optic scope) to your lung which will be isolated then let go of the BB and withdraw fiber optic scope back to check if BB at right position
- once confirm the desired location of BB, deflate BB and check with fiber optic scope to make sure BB balloon not herniating incorrectly
- then deflate BB balloon to bilateral ventilate pt, reposition to lateral decubitus then check BB position and isolate lung and check again
Options for lung isolation in peds?
Lung isolation in peds
- 0-6 months old: single lumen trecheal
Chiari II malformation repair?
- inhalation induction, 2 PIV insertion, video laryngoscope/fiber optic intubation with propofol and precedex
- neuromonitors SSEP, BAER can run 1/2 TIVA 1/2 gas with 2 TOF for NMB
- TIVA propofol, Remi fentanyl 40mcg/ml at 0.2 mcg/kg/min
- prone position
- surgeon opens dura and patch dura to free up CSF flow
TEF case
- keep newborn spontaneously ventilated
- inhalation induction, PIV insertion then glycopyrrolate then spray vocal cord with lidocaine LTA, propofol ketamine prn, intubate with 3.0 cuff ETT (smallest size cuff ETT that fiber optic can pass through is 3.0)
- aline (24 g endocath) and additional PIV with ultrasound aid
- then hand PT to surgical team for them to do rigid bronchoscope to identify the location and size of tracheal esophageal fistula
- once surgical team done, Anesthesiologist places Fogarty catheter 3F a few cm pass the vocal cord then place the 3.0 cuff ETT side by side to it. Pass the fiber optic scope down to where fistula is, adjust the Fogarty catheter to the fistula then inflate the Fogarty balloon up to seal the fistula site.
- pass the ETT past the fistula site then inflate cuff with aid of fiber optic scope
- pt is left side lateral decubitus for right thoracotomy. Can have epidural or paraveterbral block at end of case
- hand ventilation white time to keep hypercapnia down (ET CO2 can be in 100s) if ventilator could not do job until fistula is ligated
- then can do SIMV PC- VG (SIMV pressure control volume guarantee) to ventilate after fistula is ligated
- do i stat, glucometer and hemocue
- 0-6 month newborn is 3.0 cuff ETT
- 6-12 months is 3.5 cuff ETT
- older than 1 yo is 4.0 cuff ETT
- 2PIV, aline, 2 pulse oximetry (right upper extremity, one in lower extremity)
- if want to left intubated ETT turn head to right sided and advance ETT blindly to isolate right lung
- will experience desat frequently with compression of right lung by surgeon. Inform surgeon so they can get out and you can ventilate
- depend on practice may extubate at end of case but commonly stay intubated for few days
Inguinal hernia repair no laparoscopic
- lma or ETT without NMB
EGD colonoscopy for peds
- infants less than 10 kg EGD: ETT or LMa
- infants > 10 kg or older: shared airway, IV anesthesia
Awake fiber optic intubation in infants?
- hold the infant down, precedex, ketamine, glycopyrrolate
- do nasal fiber optic intubation
- if infants have many abnormal syndromes and cannot do gas or propofol or sux: do remifentanyl, ketamine and precedex for maintenance anesthesia
Kidney transplant
- 2 PIV, aline, CVP cath - do monitor CVP
- Campath, famotidine, tylenol, Benadryl,
- upper: epinephrine, phenylephrine, dopamine gtt
- type and cross: PRBC, FFP, platelet
- istat, hemocue, glucometer q1 hr
- calcium gluconate, bicarbonate
- cisatracurium prefer
EGD in peds when to ETT ?
- ETT when < 10 kg as may not tolerate scope well, the scope presses on the trachea and child develops strider
- ETT when child has craniofacial abnormally
T&a
Adenotonsillectomy:
- Premedication: midazolam or precedex
- Induction: Mask
- Access: PIV x 1
- Meds: upon obtaining IV administer
• decadron 0.5mg/kg (max 10-12 mg), glyco 5 mcg/kg and an opioid
• opioid: fentanyl 1mcg/kg OR morphine 0.05-0.1 mg/kg OR dilaudid 5mcg/kg
• induce inhaled agent and above opioid, do not generally need propofol or rocuronium
Airway: Use Oral Rae +- LTA lidocaine
- Maintenance:
• Keep patient on PSV
• Administer IV Tylenol and Zofran, ask about toradol if adenoid only
• Ask ENT to drop an OG and place nasal trumpet
- Emergence:
• Consider deep extubation deep if severe asthma or less than severe OSA, awake if severe
- Other considerations:
• Admit for if less than 3 y/o or severe OSA
• Watch out for negative pressure pulmonary edem
Supraglottoplasty
Supraglottoplasty:
- Induction: use inhaled agent to deepen anesthetic, bolus precedex 0.5 mcg/kg
- Maintenance: propofol 150mcg/kg/min and precedex 0.4mcg/kg/hr
- Airway: Maintain SV with natural airway
Cleft lip/palate
Cleft Lip/Palate:
- Positioning: usually 180 degrees, may need extension for circuit
- Access: PIV x 1
- Airway: Oral Rae
- Analgesia:
• Infraorbital block performed by surgeon provides coverage for lip
• Usually require 4-6 mcg/kg fentanyl for additional coverage of palate - Emergence: usually awake given age, precedex gtt for smooth and calm recovery
Rigid bronchoscope
Rigid Bronchoscopy:
- Induction: inhaled with sevo
- Access: PIV x 1
- Airway: SV with natural airway, can usually connect circuit to side port
- Maintenance:
• propofol bolus 1-2mg/kg then infusion 200-400 mcg/kg/min
• LTA with lidocaine to glottis helps reduce anesthetic requirements
Cranial vault reconstruction
Facial orbital Advancement (FOA)
Cranial Vault Reconstruction (FOA):
Patients: Either idiopathic effecting a single suture or associated with a syndrome
. Apert-syndactyly, Phiffer-large flat thumb/big toes, Crouzon-nothing)
• If part of a syndrome look for midface hypoplasia and difficult mask ventilation
• Usually repaired before 2 y/o
Airway: standard ETT, sutured to gingiva or reinforced with tape and tegaderm, have straight and accordion connectors
• expect difficulty ventilating with midface hypoplasia
Access: PIV x 2 , arterial line and have blood in the room
Labs: Baseline gas and repeat q1hrs, blood loss is greatest with the scalp reflection and bone flap removal, minimal after removal of supraorbital rim (aka bandeau)
Precedex gtt 0.5 mcg/ kg/hr so we can lower MAC of volatile anesthetics
Analgesia: IV Tylenol, discuss toradol, consider sufentanil infusion or intermittent boluses of fentanyl or low dose dilaudid
Meds: consider TXA bolus (10mg/kg) bolus followed by infusion 10mg/kg/hr
Emergence: awake extubation for FOAs, keep facial bipartition and Le Forte 3 intubated for 1-2 days
Spring assisted cranioplasty
Spring-Assisted Cranioplasty
Patients: Either idiopathic or syndromic, usually performed at 4-6 months of life
Positioning: usually supine
Airway: usually supine with Oral Rae vs straight ETT
• expect difficulty ventilating with midface hypoplasia
Access: PIV x 2 , potential risk for massive blood loss of VAE with unintentional access of superior sagittal sinus
Analgesia: IV Tylenol, discuss toradol, intermittent boluses of fentanyl or low dose dilaudid
- emergence: awake extubation
BMT
Myringotomy Tubes:
Induction: inhaled induction with maintenance of SV and a natural airway
Access: +/- PIV x 1
Analgesia:
• IV or PR Tylenol 15-40/kg
• IM toradol 0.5mg/kg max 15 mg
Considerations:
• IN: precedex 2 mcg/kg at the start of the case
• Minimize neck movement with AAI in patients with Trisomy 21, consider LMA placement and rotating the bed laterally
Inguinoscrotal procedures: including hernia,
hydrocele and orchiopexy
Induction: mask induction
Access: PIV x 1, better tolerated in lower extremity
Maintenance/Analgesia: caudal ropi 0.2% 1cc/kg max 15 cc, IV Tylenol, discuss toradol
Airway: consider LMA with caudal, or ETT if less than 1 year or procedure is laparoscopic
• If intubating consider a small dose of propofol or muscle relaxant (0.2-0.3mg/kg)
Emergence: watch for hypotension, reverse and extubate awake or deep
Dr. Cladis’s approach for test dosing:
• Ropi 0.2% with epi 5mcg/ml (made 50 mcg/10 cc of ropi)
• Perform test dose which is generally 0.5mcg/kg of epi
• look for increase HR 10 bpm, SBP >15, or peaked T waves
Dose 0.7 cc/kg for sacral procedures
Foreign body
Foreign Body:
Induction: inhaled induction with 100% O2 and 8% sevo, lidocaine LTA and turn the bed for rigid scope by ENT
Considerations:
• Can control ventilation, no differences in adverse events
• Always check CXR before induction
• If FB is esophageal and passed into stomach or small bowel, RSI and ETT
• If FB is in the airway, maintain SV per above
Dental procedure
Dental:
If no extractions: dentist unlikely to perform nerve block for analgesia
• Induction: mask, then apply Afrin pledgets in both nares
• Access: PIV x 1
• Airway: nasal intubation with Magill’s and DL or shoulder roll and McGrath
• Meds: consider decadron 0.1 mg/kg, IV tylenol, discuss toradol
• Emergence: consider deep extubation
If dental extractions: dentist is likely to perform nerve block for analgesia
• Consider adding fentanyl boluses for analgesia, OG suctioning and awake extubation
Hidden IV insertion sites?
- saphenous = medial maleolus rolls your thumb anterior and pins to skin
- between 4th and 5th finger there is a vein
- intern vein
Less than 6 months old what size tube?
- < 6 months old 3.0 cuff ETT
- 6 months < age < 12 months old: 3.5 cuff ETT
- > 12 months old 4 cuff ETT
Less than 60 weeks postconceptual age with laparoscopic procedure, no opioid intraop?
- less than 3 months old or 60 weeks post conceptual age and laparoscopy procedure will not be in pain. No narcotics unless have to
Bicarbonate deficit calculation?
Bicarb deficit (mEq) = Total body weight (kg) x [0.4 + (2.4/[HCO3-]) x target change in [HCO3-]
Pericardial centesis for 22 months old male with Kawasaki dz and pericardial effusion
- versed 0.1-0.2 mg/kg, ketamine 4 mg/kg into multiple small doses
- fentanyl 1-2 mcg/kg
- precedex 0.5-1 mcg/kg
- keep spontaneously breathing
- type and screen/ type and cross
- keep fast full tight
- MAC CASE
Cochlear implant
- precedex bolus 0.5 mcg/kg then precedex gtt 0.5 -> 0.3 mcg/kg -> 0.2 mg/kg in a few hours, leave gtt on till deep extubation
- +/- propofol gtt
- facial nerve monitor
- 1/2 MAC of gas, decadron 0.1 mg/kg, zofran, Benadryl for anti nausea
- scopolamine patch
- fentanyl bolus PRN
- monitor ESRT evoked stapedius reflex threshold
+ volatile anesthetics abolish stapedius reflex in dose dependent fashion
+ propofol doesn’t affect ESRT so TIVA May be preferred - facial nerve monitor so no NMB
Kasai
- GAET, 2PIV, a line, epidural catheter, periodic istat, hemocue and glucometer
Airway, rigid bronch set up
- 100% FiO2 pre-oxygenation
- keep PT spontaneously ventilated
- then add sevoflurance 8%
- PIV, versed, glycopyrrolate 5mcg/kg, lidocaine LTA, varieties of ET tubes cuffed and uncuffed for ENT surgeon
- give propofol, precedex bolus
- hook up breathing circuit to rigid bronch/ suspension
- decadron 0.5 mg/kg
- tylenol, zofran if applicable
Glidescope blade size in peds
- Glidescope blade 0: < 1.5 kg
- Glidescope blade 1: 1.5 - 3.6 kg
- Glidescope blade 2: 1.8 - 10 kg
- Glidescope blade 2.5: 10-28 kg
Glaucoma PT and scopolamine patch
- scopolamine batch is contraindicated in glaucoma pts
- Atropine/ glycopyrrolate is okay in glaucoma pts
Ped burn PT fluid resuscitation
- parkland fluid for first 24 hrs
Crystalloid (ml/kg) = 4 x % burn x kg - Brook fluid for first 24 hrs
Colloid (ml/kg) = 0.45 x % burn x kg
Crystalloid (ml/kg) = 1.5 x % burn x kg - half of fluid infuse in first 8 hrs, rest Infuse next 16 hrs guided by PT response
- these formulas may underestimate fluid needed for < 10 kg babies
Premedication first Ped
- oral versed
+ 1-6 yo: 0.75 mg/kg (larger dose smaller kid)
+ > 6 yo: 0.5 mg/kg max 20 mg - intranasal versed - bitter aftertaste for days
+ 0.1-0.2 mg/kg - intranasal sufentanil - PONV
+ 2-3 mcg/kg - oral ketamine
+ 5-6 mg/kg - IM ketamine
+ 2-4 mg/kg - precedex PO/intranasal - 60-90 min onset
+ 1 mcg/kg
When should child receive glucose containing solution?
Child should receive glucose containing solution:
- neonates ie <= 1 month old - D10
- infants ie <= 1 yo - use D5 if preterm, cachectic
- < 1 yo if have other comorbidities that ref flag to hypoglycemic
- if receiving TPN then continue with D10
Treatment of Hypoglycemic in peds?
- 2-4 ml/kg D10 (200-400 mg/kg) bolus for hypoglycemia
- then 5-8 mg/kg/min D10 infusion = 0.05 - 0.08 ml/kg/min = 3-5 ml/kg/hr D10
Pt with uncuffed trach to OR
- change uncuffed trach to a cuffed trach or a flexible ETT to facilitate ventilation
Pediatric glidescope size
GVL 0 for < 1.5 kg
GVL 1 for 1.5–3.6 kg
GVL 2 for 1.8–10 kg
GVL 2.5: 10-28 kg
However, selecting the next size smaller than recommended for that weight child may provide a better view by allowing more ability to manipulate the angle and depth of the blade in the small pediatric mouth (1,2). You should optimally have both sizes available and be ready to switch blades if the first one doesn’t give a good view.
https://airwayjedi.com/2020/01/13/intubating-with-a-pediatric-glidescope/
Bladder extrophy
- GAET
- involves position change from prone to supine
- 2 large PIV upper extremities
- a line upper extremity
- long case, large fluid shift, check electrolytes and labs frequently
- caudal epidural catheter
- post op prefer PT not moving at all due to all delicates surgical work
Determine the tracheotomy tube size
- internal diameter of trach = (age x 0.3) + 3.5
- internal diameter of trach = (weight x 0.08) + 3.1
Advice please.
Hypothetical 27yo M scheduled for lap chole tomorrow with Leigh Syndrome. He’s wheel-chair bound, contracted with a short neck. High aspiration risk with PEG tube in place and OSA.
Plan is to nebulized with lidocaine and use ketamine and precedex during induction so I can keep him spontaneously breathing then using glidescope to make sure he’s not a difficult airway before using Rocuronium (no cisatracurium at our hospital). Intraoperative plan is to use propofol with remifentanil. NS only, no LR. Pre-op lactic acid and chem 7 for baseline levels.
Any other suggestions? Advice? TIA!
Suggest zero sedation, fully topicalize, awake fiberoptic. If too difficult to do oral with contractures, consider nasal approach. Vent peg tube. Would have glidescope in room in case you need glide/fiberoptic combo.
