Basic Peds Guide

Warning: pretty much everything listed below is an approximation. Real situations require flexibility and adaptability.

Premedication Midazolam 0.5 mg/kg PO - allow 15 minutes for onset Ketamine 2-10 mg/kg IM - you should rarely need to do this Airway Devices
Laryngoscope Blades Age Miller Wis-Hipple Preterm 0 Term Noenate 0-1 Term to 2 years 1 1 2-6 years 1.5 6-10 years 2 Over 10 years 2 or 3 Uncuffed ETT Size Age/Size Tube < 1.5 kg 2.5 <3 kg 3 Term neonate 3.5 1 year 4 2 years 4.5 Age/4 + Above 2 years 4 Macintosh Insertion Depth at gums/teeth <1 kg 6 to 7 <2 kg 7 to 9 Term neonate 10 1 year 11 2 years 12 16 years 18

1 or 2 2 2 or 3

Cuffed tubes should generally be at least 0.5 smaller size than the appropriate uncuffed tube. When setting up, prepare a tube of the expected size, a tube 0.5 size larger than expected, and a tube 0.5 size smaller than expected.

LMA check packaging and select the size based on the child's weight Induction Drugs Propofol 2-3 mg/kg you may need significantly more, so have a bunch ready Non-depolarizer of some sort (Roc or Vec) Succ IM dose: 4-5 mg/kg Atropine 0.02 mg/kg Additional drugs as indicated Warming blankets should be used, consider radiant warmers for the smaller babies. IV bag and tubing without bubbles: Consider using a buret in the IV tubing to help avoid large fluid boluses in kids less than 20 kg. Consider using a dextrose containing maintenance fluid for babies. Consider using a dead space adapter if you have a 3.5 ETT or smaller. Kids will generally need lower ventilatory pressures, but expect to use a higher respiratory rate (15-30 breaths/minute).

Attendings preferences will vary with regard to: Caudal solutions and equipment Preferences for or against specific sedatives/analgesics like dexmedetomidine Whether you should draw Succ/atropine up and put an IM needle on the syringe or whether just having the pre-packaged syringe out is good enough. When you should consider adding dextrose to the IV solution. Anything and everything else you can imagine Inhalation induction It is generally safe to proceed with an inhalation induction in children. Inhalation induction becomes less feasible as children approach adult size because it takes longer to reach deep anesthesia (more time in stage 2). Therefore, large kids may get an IV in holding and undergo an IV induction. Airway obstruction Premedication will help with separation from the parents. / Laryngospasm Try not to allow the child to look back at their parent as you 100% oxygen carry/wheel him/her off. Try to avoid long, drawn-out Chin lift, jaw thrust separations. When you enter the OR never leave the child Oral airway unattended. At all times someone must ensure that the child does CPAP not fall off the OR table. The pulse-ox should be connected prior Drugs to initiating an inhalation induction. If the child is not crying and you dont think the child will start crying once the mask goes on, you may try to begin the induction with 70% nitrous and zero sevo. If the child tolerates the nitrous you can increase the sevo 2% every 5-6 breaths until you reach 8%. If the child starts crying during induction increase the sevo to 8%. If the child is crying, begin the inhalation induction with 70% nitrous and 8% sevo with the goal of go2ing to sleep ASAP. Support the airway as the child deepens. Once entering stage 2, using 5 cm H20 on the APL will help maintain a patent airway. Avoid squeezing the bag if possible, as this may trigger laryngospasm at this most critical time. If airway obstruction/laryngospasm develops you must quickly identify the problem and begin treatment. Place an IV. Your attending may trade places with you to let you do this. When you are sure the child is deeply anesthetized or once the IV is in, switch to 100% oxygen. You might or might not administer drugs prior to laryngoscopy. After the airway device is in place remember to turn down the sevo to normal levels.

Caudal block Caudal Read about this ahead of time. Discuss what drugs you 22g b-bevel needle will give ahead of time. Remember this is going in the epidural t-connector space, so maintain sterility. Sterile gloves Unfold sterile gloves wrapper to establish a sterile field. Prep solution Open the t-connector onto the sterile filed. Prep the site with Drugs your prep solution. Your assistant should hold the b-bevel needle and the drug syringe. Put on the sterile gloves. Assistant should remove the blue cap from the b-bevel needle and hold it up for you. You will screw the leur lock of the tconnector on to the needle. Withdraw the needle as your assistant retains the cap of the needle. In a similar fashion (assistant holding drug syringe) attach the other end of the tconnector to the drug syringe. Put the need in the caudal space and inject the drugs incrementally with periodic aspiration.