1. science
2. medicine
3. surgery

Clinical Site Resource Manual
The Children’s Hospital of Alabama
Nurse Anesthesia Program
School of Health Related Professions
The University of Alabama at Birmingham
TABLE OF CONTENTS
Section 1
CLINICAL SITE RESOURCE MANUAL
A.
Location and Directions / 3
B.
Phone and Fax Numbers / 3
C.
Pictures of Personnel / 4
D.
Faculty Anesthesiologist / 5
E.
Faculty Nurse Anesthetist / 5
F.
Rotation Requirements / 6
G.
Additional Information / 7
H.
Clinical Objectives / 8
I.
Specific Information for Children’s Hospital/ 9-23
J.
Demographics of Clinical Site / 24
2
Children’s Hospital of Alabama
- Clinical Orientation Handout Location
Hospital:
1600 7th Avenue South
Birmingham, AL 35233
205 / 939-9246
Directions to Clinical Site
Head west on University Blvd.
(from the RMSB Building)
Anesthesia Department / Operating Room
Anesthesia Office:
2nd floor hospital
205 / 783-3143 or 3350
205 / 783-3195 (FAX)
Anesthesia Lounge::
2nd floor hospital
205 / 783-3350
Main OR Desk:
2nd floor hospital
205 / 783-3400
David Neal, CRNA
Nurse Anesthesia Resident
Manager:
(beeper)
E-mail: nealsrus@bellsouth.net
The Children’s Hospital of Alabama was established to render
Description of Clinical Site health care to the Birmingham community and the surrounding
area, specifically for children. It is a privately owned institution, and
is used as a primary teaching facility for the UAB Department of
Pediatrics. The mission of Children’s Health System is to provide
the finest pediatric health services to all children in an environment
that fosters excellence in research and medical education.
Children’s Health System will be an advocate for all children and
work to educate the public about issues affecting children’s health
and well-being.
It is a 225 bed hospital that cares for medical and surgical cases for
newborns to 19 years of age. The type of surgical cases performed
include a variety of procedures ranging from orthopedic to general
surgery. Pediatric heart cases are performed at UAB.
3
Blanche Lowery, Chief CRNA
David Neal, CRNA, NARM
4
Department of Anesthesia Clinical Faculty
Physicians
Chief of Anesthesiology:
Staff Anesthesiologists:
Juan Gutierrez
Brock, Kathryn
Bryant, Paty
Buckmaster, Mark
Cox, Jerry
Defreese, Travis
Greve, Mark
Laborde, Patricia
Long, Gary
Siegel, Richard
Yonfa, Alfonso
Nurse Anesthetists
Chief Nurse Anesthetist:
Blanche Lowery
Nurse Anesthesia Resident
Manager:
David Neal
Staff Anesthetists:
Allison, Lisa
Amdall, Karen
Boone, Myra
Clay, Barry
Brasher, Clifford
Byers, Corinne
Cahoon, Terri
Caddell, Cynthia
Culpepper, Resa
Dunn, Rhonda
Farris, Dede
Fields, Barbara
Fullman, Lisa
Hairston, Susan
Harris, Chris
Johnson, Carol
Key, Pam
Klein, Elaine
Knight, David
Leader, Deanna
Leaf, Donna
Ledbetter, Elisa
Logan, Leeann
Milligan, Rita
Morrissette, Nita
Paternostro, Connie
Paz, Dannelle
Anesthesia Technicians
5
Rotation Requirements
1.Be on duty at 0600.
2.Scrub suits, mask, cap, and new shoe covers are required in the O.R. Lab coats are to
be worn over scrubs at all times, when leaving the O.R. suite. Mask, cap, and shoe covers
are to be removed when leaving the O.R. suite.
3.See Robbie for a locker and to have your picture made.
4.Assignments are posted the afternoon before the scheduled surgery at the O.R. desk.
5.The large anesthesia board contains the scheduled cases for the next day.
6.Set up anesthesia cart and room according to the instructions of your clinical
instructor.
7.You are expected to see your first patient of the day preoperatively. An adequate
and correct pre-op should be written on this patient. This information should then
be revealed to the MDA and CRNA reponsible for this patient. Pre-op medication
should be ordered, this includes any medicaton the patient takes on a regular basis
such as pulmonary, or cardiac medication. If sedation or medication for the patient’s
diabetes is required, contact the attending MDA and/or CRNA to help you decide on
the optimal medication and dose.
8.You are to go to the One Day Surgery Unit after your room is set up and the first
patient scheduled for your room has been seen. In the morning before the scheduled
cases are to begin, you will be expected to perform pre-op evaluations on the One
Day Admissions. MDAs and CRNAs will be available to help you in decision
making.
9.You are expected to discuss each anesthetic care plan with the attending CRNA and
MDA before the beginning of each case.
10.On arrival to the PACU, wait for the R.N. to supply vital signs before giving your
report.
11.Your location while on duty must be known by the clinical instructor or clinical
coordinator at all times.
12.In case of illness, a call must be made to the hospital and to the Nurse Anesthesia
Program to report your absence before 0600. You must speak to someone in the Anesthesia
Department. The number is 939-9246 or 939-5246.
13.Narcotic sign outs are made througth your clinical instructor or clinical coordinator
at all times.
14.Professional behavior and dress is expected at all times. (See your student handbook
for dress code.)
15.An in-depth anesthesia orientation will be provided prior to your first day at your
clinical rotation.
16.Any surgical procedure or anesthetic technique that you are not familiar with should
be investigated prior to the scheduled procedure. This information should be
discussed with the assigned clinical instructor.
6
17.This clinical rotation is a service rendered to patients from the private sector of the
community. Expedient turnover itme for the anesthesia team is expected. If you are
having difficulty in setting up your room between cases, it is your responsibility to
discuss this problem with the clinical instructor to get recommendations to decrease
the amount of time to set up your room.
18.Courtesy to all staff and patients is expected at all times.
19.Every effort is made to provide the student with constructive evaluations during this
rotation. Problems that cannot be resolved by the clinical instructor are referred to
the clinical coordinator.
20.The student will receive a written performance evaluation at the termination of the
rotation.
21.If your room finishes early, check to see if any cases have been moved to your room.
If not, check with the charge CRNA to see if help is needed with in-house preOps.
22.Do not take any equipment or supplies from another room without first asking the
person assigned to that room.
Additional Information
1. The cafeteria is located on the first floor. Meals are reasonably priced and you are free to go
there with a lab coat cover during your 15 minute breaks or 30 minute lunches. Additionally, free
coffee and a refrigerator are located in the surgery lounge on the 2nd floor.
2. Student parking is available on the street and through UAB Transportation Services.
3. Anesthesia inservices and conferences will be posted in the CRNA call room. Usually
conferences are held the first 2 Fridays of each month at 6:00 am in the 2nd floor auditorium.
You will be expected to attend and participate. A 10 minute presentation on a topic approved by
the clinical coordinator will be expected from each student during his/her rotation
7
Clinical Objectives
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Set-up and use the specific types of anesthesia circuits used in pediatric anesthesia;
i.e., Bain, Jackson Reese, infant circle.
Demonstrate how to use the humidifier-heater with the anesthesia circuits.
Demonstrate the use of the warming equipment; i.e., infrared lamps, heating blanket,
room thermostat.
Demonstrate the set up for a routine pediatric case.
Demonstrate the use of all the types of monitoring equipment; i.e., EKG, temperature,
blood pressure, TCPO2.
Demonstrate application of monitoring devices in pediatric i.e., procordial steth,
EKG, blood pressure, temp.
Demonstrate the technique for starting IV’s on the pediatric patient, and perform
venipunctures successfully.
Demonstrate the technique for intubation of the trachea and perform 20 successful
intubations.
Perform inhalation inductions on children.
Demonstrate how to manage the pediatric airway with a mask.
Estimate the blood volume, fluid deficit, and maintenance fluid requirements for
children of all ages, according to guidelines given in pediatric anesthesia manual
for Children’s Hospital.
Calculate the appropriate preoperative medication dosages for children of all ages,
according to guidelines given in pediatric anesthesia manual for Children’s Hospital.
Plan the anesthetic mangement for an ASA I, II, or III patient undergoing an
elective procedure.
Perform pre and post operative assessments on children.
Assess the status of children for normalcy of growth, maturation, hydration, airway,
respiratory, cardiac, and neurological function.
Report abnormal findings to the clinical instructor.
Maintain hydration and normothermia during surgery.
Demonstrate, by calculation and usage of, a knowledge of the pharmacology of the
anesthetic and adjunct drugs given in the pediatric anesthesia a manual for Chiildren’s
Hospital.
Recognize post-opeartive problems common to children, i.e., laryngeal edema,
retching on emergence, injury to limbs for thrashing on emergence , etc.
Calculate the normal tidal volume, dead space. and minute volume on the pediatric
patient.
Recognize the range of normal vital signs, (heart rate, blood pressure, respiration) in
children.
Participate in the respiratory therapy care of the pediatric patient.
Communicate, verbally and physically with the children to allay their fears of
anesthesia and surgery.
Demonstrate, by holding and/or playing with children, the rapport and trust that is
helpful in induction of anesthesia.
rev12/5/97
8
NPO and LAB GUIDELINES
NPO GUIDELINES
* FOR ANESTHESIA
* NO solids/milk/formula 7 hrs
* Breast milk until 4 hrs prior to surgery
* Clear liquids until 2 hours prior to surgery for completely healthy
patients, unless otherwise directed by anesthesia
* FOR “SEDATION”
INDIVIDUALIZED NPO ORDERS MAY BE DIRECTED BY THE PHYSICIAN
WHO ADMINISTERS THE ACTUAL SEDATIVE.
PRE-OP LAB GUIDELINES
* HEALTHY / AT LEAST 1 YEAR OLD / MINOR PROCEDURE
(see list of “minor” procedures on next page)
* Sickle cell screen documented for African-Americans
* Lab per request of physician
* ALL OTHER PATIENTS
* Sickle cell screen documented for African-Americans
* CBC
* Lab per patient’s needs and physician’s request
ANESTHESIA WILL ACCEPT DATA FROM ANY ACCREDITED LAB.
SICKLE CELL DATA MAY BE OBTAINED FROM THE PRIMARY CARE
PHYSICIAN, PUBLIC HEALTH DEPARTMENT, OR STATE LAB.
9
CHILDREN’S HOSPITAL SURGICAL SERVICES
GUIDELINES TO MINOR PROCEDURES
APPROPRIATE FOR MINIMAL PRE-OP LAB
HEALTHY PATIENTS ONLY/AT LEAST ONE YEAR OLD
ADENOIDECTOMY
CAST CHANGE (including spica cast change)
CAUTERY OF NASAL SEPTUM
CIRCUMCISION
CLEFT LIP REPAIR
CLUB FOOT REPAIR
COLONOSCOPY (with or without biopsy/ with polypectomy)
CYSTOSCOPY
DRESSING CHANGE
DUODENOSCOPY
ESOPHAGO-GASTRO-DUODENOSCOPY (with foreign body removal/ with
schleratherapy)
ESPHAGOSCOPY
EVALUATION UNDER ANESTHESIA (eyes/nose/rectum/scrotum/vagina, etc.)
EXCISION BAKER/S CYST
EXCISION OF CHALAZION
EXCISION OF SKIN LESION
EYE EXAMINATION/EYE PROBE
EYE TENSION MEASURES
FINE NEEDLE BIOPSY
FINGERNAIL/TOENAIL REMOVAL
FLEXIBLE BRONCHOSCOPY
FRENULECTOMY
GASTROSCOPY
INCISION AND DRAINAGE (simple)
INGUINAL HERNIORRAPHY
LYSIS OF LABIAL/PENILE ADHESION
MANIPULATION OF SIMPLE FRACTURE
MEOTOTOMY
MYRINGOTOMY (with or without ear tubes)
ORCHIOPEXY (simple, not intra-abdominal)
PERCUTANEOUS ENDOSCOPY GASTROSTOMY
PILOIDAL CYST REMOVAL/REPAIR
PROCTOSCOPY
REMOVAL OF EAR TUBES
REMOVAL OF EAR LOBE KELOIDS
REMOVAL OF FOREIGN BODY
REMOVAL OF K-WIRE
REMOVAL OF SUTURES
REMOVAL SKIN LESION
REPAIR OF NAIL BED INJURY (simple)
10
SIMPLE SUTURE OF LACERATION
SIGMOIDOSCOPY
TEAR DUCT PROBE
UMBILICAL HERNIORRAPHY
URETHRAL DILATATION
VAGINAL EXAMINATION
PRE ANESTHETIC EVALUATION PROCEDURE
A.
The Patient's Chart
1.
Check history and physical.
2.
Check blood work
3.
Check operative and anesthesia consent forms for properly signed and informed
consent .
4.
Check vital signs - all documented.
5.
Check height and weight of patient.
6.
Check preoperative orders of surgeon.
7.
Check other pertinent lab work and x-ray findings.
8.
Check any outpatient or old chart records. Request them to be sent to the OR
with the present record.
B.
Visit with parent and child. Discussion should include:
1.
Child's immediate surgery problem.
2.
Complete account of all past illnesses, medical and surgical.
3.
Previous anesthesia history and report of possible or actual anesthesia associated
complications.
4.
Allergy status - medication and other substances.
5.
If patient is on any type of medication.
6.
Child's neonatal status: premature, full term, jaundice, etc. If premature, then
you need to know: (1) gestational age at birth (2) length of NICU stay (3)
intubated/ventilated and length of time (4) question of apnea after discharge.
7.
Emotional status of child.
8.
Medical, surgical, or anesthesia problems in the immediate family of the child
which may be pertinent; Abnormal Pseudocholinesterase, Sickle Cell Disease, or
Muscle Disease.
9.
Explanation of anesthesia technique and agents to be used in anesthetizing the
child.
10.
Make certain the parent or responsible person understands and agrees to
anesthesia, and team concept of anesthesia delivery.
11.
Explanation of anesthesia technique to the child.
12.
Explanation of premedication and mode of administration.
13.
Explanation of N.P.O. time.
14.
Recovery room procedure following surgery.
15.
Examination of child - pulmonary and cardiac status, airway and teeth.
C.
Anesthesia Pre-op Record
1.
Fill out as much as possible.
a.
Pre op evaluation - diagnosis and medical history.
b.
Allergies, bleeding tendencies, medications, drug sensitivities.
c.
Previous anesthesia history, date, agent, complications.
d.
Family anesthesia history.
11
e.
f.
g.
h.
i.
D.
Physical status: Airway, Heart, Lungs
Evaluate physical status - ASA number.
C.B.C., other pertinent lab work.
All pertinent data collected during interview.
Date and time of anesthesia evaluation and signature.
Progress Notes For Pre-ops Done On In-house Patients.
1.
Pre Anesthesia note heading with date and time.
2.
Note that anesthesia was discussed and explained to parents and child and
that they are in agreement with the anesthesia care plan, including team
concept.
3.
A.S.A. evaluation of the condition of patient coming to anesthesia.
4.
Signature, date and time
Pediatric Anesthesia
Pre-Anesthesia Emotional Preparation of the Child
Fears of Children:
1. Unknown
2. Hurt of Mutilation
3. Death
4. Separation from parents
Ways to Help Children Cope
1. Explanation
2. Rehearsal of experience
3. Acquaintance with anesthesia providers
4. Avoiding traumatic separation from the parent
5. Allowing the child to express his feeling
OBJECTIVES OF PRE-OP MEDICATION
The objectives of giving a pre-op medication are to:
1.
Produce tranquillity
2.
Provide for a smooth induction
3.
To prevent vagal reflex responses (and secretions) and to prevent bradycardia
4.
To provide for relief of pain pre and post operatively
The means of accomplishing this are controversial and no set method has been
determined. Here, patients are evaluated individually for pre operative. Pre-op medications are
given on the basis of weight as follows and are administered approximately 1/2 to 1 hour prior to
surgery:
If the patient is on Dilantin or Phenobarbital for seizure, these medications are also given
prior to surgery at the patient's normal dosage. Orders are written as verbal orders from the
MDA responsible for the child. Any child not ASA I or II or any in-house patient is evaluated
by consultation with the staff MDA for premedication.
12
PRE-OP DRUG DOSAGES
Anticholinergic PO: double IM dose
Atropine:
0.01 - 0.02 mg/kg IM
Barbs:
4 - 8 mg/kg PO (maximum 150 mg)
Demerol:
1 mg/kg IM
Diazepam:
0.2 mg/kg PO (maximum 10 mg)
DPT:
Heavy sedation
2 mg/pound
1 mg/pound
1 mg/pound
Demerol:
Phenergan:
Thorazine:
Droperidol:
(Inapsine)
Glycopyrrolate:
Light sedation
1 mg/pound
0.5 mg/pound
0.5 mg/pound
0.1 mg/kg IM (maximum 5 mg)
(should be used in conjunction with a narcotic)
.005 - 0.01 mg/kg
Hydroxyzine:
3 - 5 mg/lb. PO (maximum 150 mg)
Lorazepam:
0.05 - 0.1 mg/kg IM or 0.3 - 0.5 mg PO
Midazolam:
0.2 - 0.5 mg/kg PO (maximum dose: 15 mg)
Morphine:
0.1 mg/kg IM (maximum 15 mg)
Promethazine:
0.5 mg/kg (maximum 50 mg)
Propulsid
0.15 - 0.3 mg/kg PO
Reglan:
0.15 mg/kg PO; 0.1 mg/kg IV
Zantac:
2.0 mg/kg PO; 1 mg/kg IV
13
INDUCTION DRUG DOSAGES
Alfentanyl:
500 mcg/ml
Procedure Length
Induction
Maintenance
Short (under 30 min.)
8 - 20 mcg/kg
3 - 5 mcg/kg
Medium (30 - 60 min.)
20 - 50 mcg/kg
5 - 15 mcg/kg
Long (over 1 hour)
up to 80 mcg/kg
1 mcg/kg/min.
(infusion)
Atracurium:
0.3 - 0.5 mg/kg IV (0.1 mg/kg maint)
Cisatracurium:
0.1 mg/kg IV
Droperidol:
Primary agent - 0.1 mg/lb. IV
Etomidate:
0.2 - 0.3 mg/kg IV
Fentanyl:
3 - 10 mcg/kg IV
Innovar:
1 cc/25 lb. IV
Ketamine:
1 - 2 mg/kg IV
Lorazepam:
0.05 - 0.1 mg/kg (up to 4 mg) IV
Meperidine:
3 - 5 mg/kg IV
Methohexital:
IM - 2 -10 mg/kg (not FDA approved)
Midazolam:
0.2 mg - 0.5 mg/kg IV
Mivacurium:
0.2 mg/kg IV
Morphine:
0.3 mg - 0.5 mg/kg IV
Pancuronium:
.06 - 0.1 mg/kg IV (maint 1/3 initial dose)
14
Antiemetic - 0.005 - 0.02 mg/kg IV
6 - 10 mg/kg IM
Rectal - 20 mg/kg PR
0.15 mg/kg IM
Pentothal:
IV - 1 - 5 mg/kg IV
Propofol:
1.5 - 2.5 mg/kg IV bolus
Remifentanil:
Induction: 0.5 - 1 mcg/kg/min. IV
Maintenance Infusion dose range (mcg/kg/min)
N2O: 0.1 - 2
Forane: 0.05 - 2
Propofol: 0.05 - 2
Supplemental bolus dose of 1 mcg/kg
Rocuronium
0.6 - 1 mg/kg IV
Succinycholine:
Rectal - 20 -25 mg/kg PR
1 - 2 mg/kg IV
3 - 4 mg/kg IM
Sufentanyl:
1 - 2 mcg/kg (up to 8 mcg/kg) IV
Vecuronium:
.08 - 0.1 mg/kg (.01 - 0.15 mg/kg maint) IV
rapid sequence: priming .015 mg/kg followed by 0.3 mg/kg
REVERSAL DRUG DOSAGES
Atropine:
0.02 - 0.04 mg/kg
Flumazenil:
initial dose 0.01 mg/kg (max. 0.2 mg)
subsequent doses 0.005 - 0.01 mg/kg (max 0.2 mg)
maximum cumulative total of 1 mg
Naloxone:
.01 mg/kg IV or IM
Physostigmine:
0.04 mg/kg (max 2 mg)
Neostigmine:
Robinul:
0.06 mg/kg (may repeat X 1)
0.08 mg/kg (for up to 6 months of age)
(Glycopyrrolate)
0.015 - 0.02 mg/kg (max 0.6 mg)
Tensilon: (Edrophonium)
0.5 - 1 mg/kg IV
ADJUNCT - MEDS
CaCl:
3 - 10 mg/kg
Ca Gluconate:
50 - 100 mg/kg for "floppiness"
(up to 150 mg/kg in neonates)
Decadron:
0.5 mg/kg IV
Ondansetron
0.15 mg/kg IV
15
Steroid Equivalent Dose
SoluMedrol
Hydrocortisone
Decadron
Prednisone
40 mg
100 mg
4 mg
20 mg
Dopamine:
1 - 10 mg/kg min.
NaHCO3:
kg wt X base deficit X 0.2 - 0.5 mg (ECF compartment) give 1/2 this dose
and repeat gases
DO NOT PUSH IN BABIES - CAUSES IVH - GIVE IN SOLUSET - IF HAVE TO
PUSH GIVE NO MORE THAN 1 MG/KG/MIN.
Hespan:
initial: 5 cc/kg
maximum: 10 cc/kg
Bupivicaine:
caudal block - 0.25%
(.05 cc times # of segments desired block times kg wt)
Allowable Lidocaine:
5 mg/kg without Epi
7 mg/kg with Epi
Allowable Bupivicaine:
1 - 2 mg/kg without Epi
2 - 3 mg/kg with Epi
16
SIZES OF ENDOTRACHEAL TUBES FOR VARIOUS AGES
AGE
APPROXIMATE WEIGHT
INTERNAL DIAMETER
premature to newborn
newborn to 6 months
6 to 18 months
18 months to 2.5 yrs 2.5 to 4
years
4 to 6 years
7 to 9 years
10 to 12 years
1.0 - 2.0
2.0 - 6.0
6.0 -10.0
10.0 - 13.0
14.0 - 20.0
20.0 - 30.0
30.0 - 45.0
45.0 - 60.0
2.5
3.0, 3.5
3.5, 4.0
4.0, 4.5
4.5, 5.0, 5.5
5.5, 6.0, 6.5
6.5, 7.0
7.5, 8.0, 8.5
Endotracheal tubes without cuffs are used until approximately 8 years of age when a 6.0 cuffed
endotracheal tube should be adequate.
FORMULAS TO CALCULATE ENDOTRACHEAL TUBE SIZES
Internal Diameter (I.D.) = 16 + age - for children over 6 months
4
GUIDELINES FOR TAPING DISTANCE
OROTRACHEAL TUBES
ORAL LENGTH CM
Premature
Newborns
6 months
9 months
12 months
8 cm
9 cm
10 cm
11 cm
12 cm
1 year up = 12 + age (years)
2
Nasotracheal Tubes - Premature 3 cm + oral length
4 cm + oral length
17
IV FLUIDS
Maintenance Fluids:
0 -10 kg
4 cc/kg/hr
10 - 20 kg
40 cc + 2 cc/kg/hr for > 10 kg
20 kg or more
60 cc + 1 cc/kg/hr > 20 kg
Calculate fluid deficit by determining maintenance fluids for body weight and multiply by
number of hours patient has been NPO. Give one half of deficit in first hour, 1/4 second hour
and 1/4 the third hour.
Example:
weight =
42 kg
NPO =
2300
Anesthesia start time = 0800
Maintenance = 82 cc/hr
NPO X 9 hours
82 cc/hour X 9 hours = 738 cc EFD
Estimated Fluid Deficit (EFD) Replacement:
1st hour
:
369 cc + 82 cc = 451 cc
2nd hour:
184.5 cc + 82 cc = 266.5 cc
3rd hour:
184.5 cc + 82 cc = 266.5 cc
Maintenance fluids and fluid for both 3rd space loss and EBL should be
given hourly.
Total fluid per hour should not exceed 20 cc/kg unless indicated.
Urine output should be .5 - 5 cc/kg/hr.
18
PEDIATRIC ANESTHESIA FORMULAS
RAISE HCT:
Multiply percent rise times kg weight then multiply by PC (1.5) or WB (2.5)
CALCULATED BLOOD LOSS DOWN TO 30 HCT:
Present HCT minus 30, multiply this by EBV, then divide this by present HCT.
FFP OR 5% ALBUMIN FOR VOLUME EXPANSION:
Give 1/3 amount of PRBC's that have been given
RBC VOLUME:
Take HCT as decimal and multiple by BV
PLASMA VOLUME:
Subtract RBC volume from EBV
ESTIMATED BLOOD VOLUME:
Preemie = 90 - 95 cc/kg
6 month - 2 years = 85 cc/kg
2 - 6 years = 80 cc/kg
6 - 12 years = 75 cc/kg
> 12 years = 70 - 75 cc/kg
post puberty = 65 cc/kg
< 2 years = 50+ hct X kg. wt.
19
MONITORING
It is important that the six (6) major vital sign parameters be monitored in the pediatric
patient. They are: blood pressure, pulse, respiration, EKG, temperature, and SaO2.
At the Children's Hospital, these parameters are routinely monitored on every patient that
is given an anesthetic. The modes of monitoring may differ with the specific patient and/or
procedure, but nevertheless, these are the required monitors used.
Each operating room and anesthetic machine is capable of monitoring blood pressure by
cuff. Direct arterial line monitoring can also be used.
Anesthesia is not begun until a pre-cordial stethoscope and/or the EKG monitor is in
place. If there is an indication for it, an esophageal stethoscope may be used. The EKG
monitors are used on all patients and there is a monitor in every operating room.
Not only are respiration’s monitored by the administering anesthetist, but the O2
concentration is continuously monitored by an O2 analyzer on each anesthesia machine. These
analyzers are calibrated each morning before the first case. Oxygen saturation is monitored on
each patient with the pulse oximeter.
Each patient's temperature is monitored by some means; either an esophageal or rectal
probe, axillary probe, oropharyngeal probe, or the skin temperature is monitored by a TempStrip.
RESPIRATORY DATA
Infants and Children
Weight (kg)
Age
Dead Space
Tidal Volume
Resp. Rate
3.2
4.5
6.4
9.4
13.6
20
36
43
Newborn
3 months
6 months
1 year
2-3 years
4 years
8 years
10 years
6
9
12
20
27
40
70
85
20
30
45
65
90
130
240
275
50
50
50
40
30
30
27
20
Premature Infants
2 cc/kg 5 - 17 50 - 70
20
GUIDELINES FOR NORMAL VITAL SIGNS
AGE SPECIFIC
NORMAL HEART RATES FOR CHILDREN
AGE
RESTING AWAKE
RESTING
SLEEPING
EXERCISE FEVER
100 - 180
100 - 220
00 - 160
80 - 200
UP TO 200
UP TO 200
80 - 150
70 - 120
UP TO 200
70 - 110
60 - 90
UP TO 200
55 - 90
50 - 90
UP TO 200
NEWBORN
1 WEEK - 3
MONTHS
3 MONTHS - 2
YEARS
2 YEARS - 10
YEARS
10 YEARS TO
ADULT
NORMAL RESPIRATORY RATES IN CHILDREN
AGE
RATE (BREATHS/MINUTES)
NEWBORN
1 TO 11 MONTHS
2 YEARS
4 YEARS
6 YEARS
8 YEARS
10 YEARS TO 12 YEARS
14 YEARS TO 18 YEARS
30 - 60
26 - 40
20 - 30
23
21
20
19
18 - 20
AVERAGE BLOOD PRESSURES IN CHILDREN
AGE
AGE
NEWBORN
5 MONTHS
5 MONTHS TO 1
YEAR
1 YEAR TO 2 YEARS
2 YEARS TO 4
YEARS
BLOOD PRESSURE FOR
RANGE
AVERAGE
54 / 38 TO 90 / 70
72 / 35 TO 110
/68
72 / 38 TO 109/72
70 / 44
80 / 46
72 / 39 TO 110/72
73 / 40 TO 111 / 72
99 / 64
92 / 55
21
89 / 60
4 YEARS TO 6
YEARS
6 YEARS TO 8
YEARS
8 YEARS TO 10
YEARS
10 YEARS TO 12
YEARS
12 YEARS TO 14
YEARS
14 YEARS TO 16
YEARS
16 YEARS TO 18
YEARS
76 / 40 TO 113 / 73
95 / 56
78 / 42 TO 116 / 75
97 / 58
82 / 44 TO 120 / 76
100 / 60
86 / 47 TO 123 / 80
105 / 63
90 / 45 TO 128 / 82
109 / 63
95 / 47 TO 133 / 85
114 / 65
100 / 50 TO 136 / 86
115 / 68
POST OPERATIVE ANESTHESIA PROCEDURES
I.
Post - Anesthesia Note within 24 - 72 hours
Note: This note is never written before the patient is discharged from PACU (Recovery
Room)
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Record general condition of patient.
Fully reacted from general anesthesia.
Vital signs, temperature, pulse, respiration, and blood pressure checked.
Evidence of nausea.
Evidence of stridor, cough, croup sounds, or any chest involvement.
Examination of patient's chest.
Verbal discussion on any anesthesia complications with parent & child.
Note that there were no anesthesia complications noted.
Preface anesthesia note: “Post Anesthesia Note”.
Sign anesthesia note, date, and time.
22
ANESTHESIA CART
TOP OF CART:
a) alcohol sponges
b) drug labels
c) different sizes of tape
d) 3 X 3 sponges
e) tourniquets
f) temp strips
DRAWER #1:
a) resuscitation drugs
b) anesthetic adjunct drugs
DRAWER #2:
a) laryngoscope
b) intubation equipment
c) nasal airways
d) oral airways
e) Magill forceps
f) racine adapters
g) tongue blades
h) stylets
I) peripheral nerve stimulator
DRAWER #3:
a) Endotracheal tubes - 2.5 - 8.0 mm ID uncuffed
DRAWER #4:
a) IV catheter
b) syringes
c) needles
DRAWER #5:
a) IV fluids and sets
BOTTOM:
a) masks
b) head rests
c) 0.5 liter and 2 liter bags
d) inhalation agents
e) pulse oximeter probes
BUCKETS:
There are 5 "buckets" on the sides of the cart containing:
a) suction catheters (5 Fr. - 14 Fr.)
b) gloves
c) 5.5 - 9.0 cuffed ETTs
d) Levin, salem sump and oxygen catheters
e) Esophageal stethoscopes
f) blood administration equipment
g) resuscitation drug guidelines
h) axillary temperature probes
i) stationery
23
Demographics of Clinical Site
Maximum # students clinical site is able to accomodate
Maximum # junior students clinical site is able to accommodate
Maximum # senior students clinical site is able to accommodate
Hands-on Regional Experience
¾
Spinals
¾
Epidurals
¾
Axillary blocks
¾
Supraclavicular blocks
¾
Bier blocks
¾
Other
Nurse Anesthesia Resident Inserts
Central Lines
Commonly
Occasionally
Rarely
Never
Commonly
Occasionally
Rarely
Never
Commonly
Occasionally
Rarely
Never
Commonly
Occasionally
Rarely
Never
Internal Jugular Vein
Subclavian Vein
Antecubital Vein
Pulmonary Artery Catheter
Clinical experience includes:
Mask Inductions for adults
Maintenance of GA via a face mask
Placement and management with LMA
Nurse Anesthesia Resident Administers
Drugs During Induction
Taking In-house call is an option
Yes
Afternoon
Night
24
No
25
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