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
