Pediatric Preoperative Evaluation, Set Up, and Anesthetic Induction Techniques Flashcards
infants less than ___ months have highest rate of adverse events
one month
what encompasses the adverse events experienced by the pediatric population (5)
bradycardia secondary to hypoxia and high inhalation anesthetic concentration
respiratory complications (bronchospasm, laryngospasm, apnea)
cardiac arrest
medication related
equipment rerlated
wake up safe initiative
dedicated to better outcomes for children receiving anesthetic care and to the education of our members in improvement science
newborns are classified as
1-28 days old
infants are classified as
up to end of first year
small children are classified as
2-5 years
school aged children are classified as
6-14 years
adolescents are classified as
14-18 years
preoperative psychological preparation for the surgery can include
child life specialists, videos, hospital tours. basic objective is to explain to child and parents proceedings and bond with child
psychological aspects of anesthesia for children 0-6 months
not usually upset by separation from parents, prolonged separation may impair parent child bonding
psychological aspects of anesthesia for children 6 months to 4 years
separation anxiety, fear of hospitalization. may show regressive behavior
psychological aspects of anesthesia for children that are school aged
less upset by separation from parents, asks questions, involved, wants choices, more concerned with surgical procedure and its possible effects on body image
psychological aspects of anesthesia for adolescents
fear the process of narcosis, the loss of control, waking up during surgery, pain of surgery. value modesty, HCG testing in females
psychological aspects of anesthesia for parents
provide explanation of what to expect
assent versus consent
assent is the minor agreeing with what the parents are consenting to. if the patient does not want the spine surgery and is in her teens, but the parents do- and she is old enough to understand the implications-cancel that case so they can talk more
what two medications should you consider alternatives or patient education for with young females
aprepitant and sugammadex
parental presence during induction may not be appropriate in certain circumstances including
adequate preoperative sedation achieved
parents level of anxiety is too high
language barrier
emergency/RSI cases
anticipated difficult airway or unstable patient
pregnant mother (due to nitrous oxide exposure)
-bunny suits, hat, shoe covers, and masks are required for the patients entering the OR’s
interview and physical exam preoperatively includes
information from EMR, parents, child NPO status current weight lungs/heart auscultation evaluation of airway, inquire about loose teeth PMH/previous anesthetics/MH recent URI's or fevers cigarette exposure in home possibility of pregnancy allergies and current medications
NPO guidelines
clear liquids 2h
breast milk 4h
formula/non human milk/light meal 6h
fatty foods 8h
review of childs history: age
gestational, conceptional, birth history, maternal pregnancy history
consider preoperative hemoglobin on
neonates, premature infants, cardiopulmonary disease, known hematologic dysfunction, anticipated major blood loss during surgical procedure
the child with URI is at increased risk for
laryngospasm, bronchospasm, post intubation croup, atelectasis, PNA, and desaturations
for a child with a URI, consider which airways
ETT if possible, LMA considered.
for a child with a URI, consider rescheduling how far out:
2-4 weeks for URI’s and 6-8 weeks for lower respiratory infections
some reasons to postpone elective surgery includes
febrile, elevated WBC, productive/purulent sputum, getting worse, acutely ill, malaise, tachypnea, wheezing
PPV and infection spreading
may help spread infection from upper to lower airways
what happens to tracheal mucociliary flow under GA
that and pulmonary bacteriocidal activity decreased by GA
management of child under anesthesia with URI
adequate hydration and oxygenation
reduce secretions, limit airway manipulation
bronchodilators (beta 2 agonists) for wheezing
anticholinergics (inhibits cholinergic mediated bronchospasm)
muscle relaxants for laryngospasm
heart murmur may be detected in up to ____ of pediatric patients
50%
children ages 2-6 have what kind of murmur?
stills murmur, a functional systolic murmur
if the patient has a new onset murmur our murmur that is creating one of the following symptoms, a cardiologist should see the patient before proceeding with surgery
difficulty feeding, SOB
poor exercise tolerance, cant match peers
family hx of CHD
cyanotic episodes
abnormal peripheral pulses
unequal blood pressures in upper versus lower extremities (coarctation)
oral premedication and infants younger than 6-12 months
not usually necessary because they usually separate from their parents just fine
midazolam PO dose and max dose, and onset
.5mg/kg PO (usual max dose 20mg)
15-30 minutes prior to induction
midazolam PO special considerations
may prolong time to discharge, careful sedating a child with congenital heart disease, increased ICP, OSA, sepsis, trauma, or suspected difficult airway
nasal premedication meds and doses include
midazolam .2mg/kg nasal
ketamine 3mg/kg nasal
dexmedetomidine 1-2mcg/kg nasal
pediatric monitoring set up
BP, ECG (3 lead, 5 lead if cards patient), pulse ox weight based, capnography, temperature, neuromuscular function, SHOULDER ROLL
BP cuff sizes range from
1-5
normal vital signs for a premature infant
HR 120-170
BP 55-75/25-45
MAP 40-55
how to calculate MAP
2/3 diastolic plus 1/3 systolic
normal vital signs for 0-3 months
HR 100-150
BP 65-85/45-55
MAP 52-65
normal vital signs for 3-6 months
HR 90-120
BP 70-90/50-65
MAP 57-73
normal vital signs for 6-12 months
HR 80-120
BP 80-100/55-65
MAP 63-77
normal vital signs for 1-3 years
HR 70-110
BP 90-105/55-70
MAP 67-82
what does set up for the pediatric case include
mask (one size bigger and one size smaller, 3 total)
ETT (one size above and one size below calculated ETT)
blades
appropriately sized breathing circuit, BP cuff, ECG, SpO2
appropriate syringe sizes for weight based dosing
IM needles
warming devices
shoulder roll
sevoflurane first in line and topped off
IV set ups
soft ETT suction appropriate for ETT size
appropriate OG size
types of blades used in pediatrics include (5)
mac miller robert shaw wis hipple phillips
LMA mask size, max cuff volume, largest ETT internal diameter for neonates/infants up to 5kg
mask size 1
max cuff volume 4ml
largest ett ID 3.5
LMA mask size, max cuff volume, largest ETT internal diameter for infants 5-10kg
1.5 LMA
up to 7mL cuff volume
largest ETT ID 4
LMA mask size, max cuff volume, largest ETT internal diameter for infants/children 10-20kg
LMA 2
up to 10ml cuff volume
4.5 ETT ID largest
LMA mask size, max cuff volume, largest ETT internal diameter for children 20-30kg
LMA 2.5
up to 14mL cuff volume
5 ett largest ID
use straight blade in pedes cases less than ____ (age)
one year old
how to ensure head is positioned and supported correctly for induction
shoulder roll (caution in patients with potential unstable cervical spine)
what to check especially in children before induciton
loose teeth!!! be sure to return safely to mom
ID of cuffed ETT sizes for pedes: premature
2-2.5
ID of cuffed ETT sizes for pedes: term
3
ID of cuffed ETT sizes for pedes: 3-9 months
3-3.5
ID of cuffed ETT sizes for pedes: 9-18 months
3.5-4
ID of cuffed ETT sizes for pedes: 18-36 months
4-4.5
ID of cuffed ETT sizes for pedes: >36 months
(age/4)+3.5=cuffed size
approximate depth for 1, 2, 3 kg
7, 8, 9cm at lips
approx depth for >3kg
ID of tube x3
set up: emergency medications
atropine .4mg/mL, 22g IM needle
succinylcholine 3mL syringe and 22g needle
epi 100mcg/mL and 10mcg/mL (and 1mcg/mL if <10kg)
propofol (and another stick), and muscle relaxant of choice (commonly rocuronium)
dont forget flush syringes
set up: equipment to have available
masks, OPA, blade, temp probe, cocoon warmer, NG/OG, peds anesthesia circuit for kids <30kg
IVF set up for <30kg
use buretrol, double stopcock, extension and t piece. fill to 10mL/kg, write amount on the side, and expel all air bubbles
IVF set up for >30/kg
use macro drip tubing
1L pedes circuit bags for how many kg or less
30kg or less
are there neonate circuit bags
yes ask anesthesia tech for them
afirin in nasal intubation and children <2
cannot administer afirin in this age group to avoid HTN
inhalation induction agent, method
sevoflurane is agent of choice. place mask gently over childs nose and mouth. with administration of N2O and O2 for 1-2 minutes. sevoflurane then introduced and increased 6-8%. once general anesthesia achieved, decrease sevoflurane to 4-5%. IV is then placed following stage 2 but prior to instrumentation of aw. consider 100% FiO2 during this time
IV induction of anesthesia is most
reliable and rapid
may place an IV under ____ in older children or with the help of
N2O or with help of topical anesthetics like EMLA or ethyl chloride spray
IV induction is necessary when
inhalation induction is contraindicated (difficult aw, full stomach, cardiac instability)
ideally, all children should be pre oxygenated with 100% oxygen before IV induction but this is not always possible.
IM induction may be indicated in
uncooperative children who refuse other routes of sedation (commonly utilized is concentrated (100mg/mL) IM ketamine)
development of laryngospasm during inhalation induction
IM induction should happen in which muscle
vastus lateralis
two most commonly accessed veins are
superficial dorsal hand veins off basilic vein and saphenous vein at ankle
neonates IV gauge size
24g
infants IV gauge size
24-22g
children IV gauge size
22-20g
buretrol (metered chamber) in <30kg pearls
10-20mL/kg bolus and fluid calculations
availability and options of colloids
record each aliquot separately
inspect all tubing and all junctions and expel any air
close roller clamp between IV bag and chamber.
arterial line size for >2 years and <2 years
22g for >2 years
24g for <2 years
seldingers technique
baby wire for alines, can use in 24 gauge IV’s
how to tape a pediatric ett
pants split technique
caudal anesthesia is what type of regional technique
epidural anesthesia. can do a continuous catheter
benefits of caudal anesthesia
intraoperative and postoperative analgesia
reduction in systemic opioid requirements and side effects
reduction in anesthesia requirements
procedures to utilize caudal anesthesia
circumcision inguinal herniorrhaphy hypospadias anal surgery club foot erpair other sub umbilical procedures
contraindications to caudal anesthesia
infection around site, coagulopathy, anatomic abnormalities, parental refusal
what are the 3 caudal landmarks
sacral hiatus and 2 PSIS’s
how to perform caudal anesthesia
performed under GA. lateral decubitus with knees and hips flexed our cat position. place IV gatherer (22g <2 years, 20g >2 years, 18g if threading epidural catheter) at 45 degree angle. feel sudden give as needle advances through sacrococcygeal ligament. reduce angle of needle. still do test dose with .5mcg/kg epi.
caudal dosing for genital and anal surgery
.5-.75mL/kg (.5mL/kg sacral)
caudal dosing for lower abdomen and extremity surgery
1mL/kg (dosing for sacral up to low thorax)
caudal dosing for abdominal incision
1-1.25mL/kg (1.25mL/kg sacral to mid thorax dosing
caudal additives: epinephrine
test dose .5mcg/kg
increase duration is theory
theoretical neurological complications
caudal additives: clonidine
close 1-2mcg/kg
increase in duration of epidural by 2-3 hours
increased sedation scores, potential for hypotension and respiratory depression in some infants
maximum doses of lidocaine
5mg/kg, 7mg/kg with epinephrine
maximum doses of bupivicaine
2.5mg/kg, 3mg/kg
maximum doses of ropivicaine
2.5mg/kg, 3mg/kg
maximum doses of epinephrine with LA
5mcg/kg
traveling post anesthesia: consider having these available
appropriately sized ambu bag
oxygen source (blow by v face mask v nasal cannula)
monitoring (pulse ox only v ecg and/or BP)
emergency medications (atropine, succinylcholine, epinephrine)
pain medications
treatment for emergence delirium (dexmedetomidine, propofol, fentanyl)
lateral position
