PEDIATRIC ANESTHESIOLOGY RESIDENT HANDBOOK 2017/2018

1. Introduction and Helpful Hints:

Welcome! Patients presenting for pediatric operations are challenging, diverse and
provide a unique experience for residents. Many of the cases will be unlike anything
you’ve seen so far in your training in anesthesiology, so you will surely develop new
skills and insights. We hope you find your pediatric anesthesia rotation challenging and
rewarding.

The majority of the pediatric cases are done in the pediatric OR’s near the Children’s
Health Center. You will find most of the equipment you'll need in those rooms. There
are portable carts with peds equipment if you find yourself in a room that does not
usually have children. The anesthesia tech can bring one to you. If you are unsure, ask
us!

A list of topics to read about and discuss with the attendings during your rotation is
included in this handbook. In addition, check out a copy of Ron Litman’s Pediatric
Anesthesia textbook from Allison Wright, the Pediatric Anesthesia Administrative
Assistant (her desk is outside of Allison Ross’ office in HAFS building). Read it and
return it in a timely fashion so that other residents will not miss out.

During your rotation, you are required to present a topic at our pediatric anesthesia
conference (each Thursday at 4 p.m. in HAFS conference room). You will be assigned a
time to do this. Dr. Einhorn is in charge of organizing this conference. Ask faculty for
assistance in completing this or if you need help coming up with ideas.

We expect the reading, clinical teaching, and conferences will prepare you well for taking
care of children in the operating room as well as preparing you for the pediatric portions
of both your written and oral boards in Anesthesiology.

2. Clinical Expectations



1. Residents should be capable of performing a thorough preoperative
evaluation of children with special reference to specific pediatric
considerations.

2. Residents should formulate a plan (and a back up plan!) for premedication,
induction, maintenance, emergence, and postoperative pain management
for their patients.

3. Always discuss your cases preoperatively with the attending
anesthesiologist. They are expecting to hear from you the day before your
scheduled cases.

4. The operating room should be fully prepared (for the day) before bringing
the first patient into the room. The patient should similarly be prepared
for anesthesia so we can start promptly.

5. Residents are required to perform postoperative checks to determine if
there are any anesthetic complications or parental questions. If you are
unable to do this in a timely fashion, you are similarly required to let
your attending know so that other arrangements can be made.

6. Ask questions. We don’t expect that you will know everything. Also,
bring your list of topics to the OR and ask your attending to review
one of them with you!
 3. Core Didactic Goals of the Pediatric Anesthesia Rotation

Topic

□ Pre-operative assessment
□ NPO guidelines
□ Pediatric anesthetic circuits
□ Fluid requirements
□ Blood administration and dosing
□ Induction techniques
□ Neonatal and pediatric physiology
□ Pediatric pharmacology
□ Pediatric advanced life support
□ Neonatal surgical emergencies:
□ Gastroschisis
□ Omphalocele
□ CDH
□ TEF
□ NEC
□ Myelomeningocele
□ Pyloromyotomy
□ Anesthetic concerns for preemies and neonates
□ Anesthetic concerns with a URI
□ Anesthetic management of a “bleeding tonsil”
□ Foreign body management
□ Croup vs. epiglottitis
□ Strabismus
□ Hydrocephalus
□ Caudal - doses, drugs, indications/contraindications, complications
□ Post-operative pain management options
□ Malignant Hyperthermia/AIR (Anesthesia-Induced Rhabdomyolysis)
□ Cardiac
□ Cyanotic congenital cardiac diseases
□ PDA
□ Tetrology of Fallot
□ Scoliosis
□ “Common” syndromes at Duke
□ Hurlers
□ Pierre Robin

 4. Recommended references:

1. Baum and O’Flaherty. Anesthesia for genetic, metabolic, and dysmorphic
syndromes of childhood, 2007 (copy is in the CHC anesthesia office)

2. Gregory. PEDIATRIC ANESTHESIA. 2012

3. Davis. SMITH'S ANESTHESIA FOR INFANTS AND CHILDREN. 2017

4. Cote A Practice of Anesthesia in Infants and Children. 2013

5. THE HARRIET LANE HANDBOOK. 2017 (you may remember this from
medical school-it is good for doses of non-anesthetic drugs and basic pediatric
care)

5. Preoperative evaluation


A. Psychological appearance. A preop visit is the quickest way to evaluate the
behavior of the child and therefore, the preferred (planned) method of
anesthesia induction for the child.

B. History. Although the child's history may be unremarkable, there are a
large number of children at Duke that are veterans to the system and who
have extensive medical records. A complete history in pediatrics should
include the following conditions that will affect anesthetic management:

1. Prematurity and its implications (including residual lung disease, difficult IV
access, apnea, etc.)
2. Any associated anomalies?
3. Congenital heart disease and type of repair, if any.
4. Neurologic problems (often prolongs wake-up time unless
baseline mental status observed and considered)
5. Recent URI-important factor in scheduling of elective cases.

This is by no means a complete list, but hits a few of the high points most often missed
by the non-pediatrician.

C. Physical Exam:
1. Overall
2. Airway with loose teeth (age 5 is a good age to start asking)
3. Cardiac (murmurs?)
4. Lungs (wheeze, rhonchi, rales?)
5. Visible veins
D. Labs:
Indicated by age and planned surgery. Generally speaking, otherwise
healthy children undergoing elective surgery do not need routine labs drawn. Many of the
children we take care of have multi-system disorders and may be undergoing procedures
with the potential for blood loss. Consider pre-op labs in these patients. Blood can often
be drawn after the child is asleep (e.g. type and screen. Although remember the
automated system the blood bank currently uses take 45 minutes!). Discuss this with your
attending. You MUST think about pregnancy potential in teenage girls! Ask about
last menstrual period (that’s a medical question, not a social or lifestyle question and so a
reasonable place to start the conversation). Consider a beta-HCG if there is any question
of pregnancy. Again, ask you attending if you’re not sure. The preop holding nurses will
generally make sure urine HCG is ready for outpatient girls when appropriate, but an
order must be placed in EPIC (needs to be STAT). For inpatients that you see, THIS IS
YOUR RESPONSIBILITY!

E. A few definitions:
1. Neonate: up to one month of age
2. Infant: up to one year of age
3. Premature infant: #1 or #2, born before 37 weeks gestation



6. Premedication, NPO Status

Premedication prior to anesthesia is useful to alleviate anxiety and induce a calm state to
allow for a smoother mask induction or IV placement. Amnesia is also a common and
often desirable side effect.

The choice to premedicate a child is based upon several factors:
1. Your attending-some like it, some don't like it, and some patients
don't need it.
2. Age of the patient. Children <6 months of age do not yet have
separation anxiety and are not accompanied into the O.R. by their
parent. They are also not routinely premedicated. When children
are older than 6-12 months of age, there are a variety of methods and
reasons for premedication, including:

-Anxiety (of the patient: not you or the parent!).
-The planned surgery, the child's expectations, and previous
anesthetic experience.
-Ease of separation from parents
-Ease of IV placement

3. Heart disease. SBE prophylaxis is still considered “premedication” for

example if the child requires a dose of Ampicillin or Cefazolin prior to a
nasal intubation for dental care.

Most commonly administered Premedications:

Midazolam:
Usual dose is 0.5 mg/kg PO (usual max 10-15mg), 20-30 minutes before induction.
Midazolam (as currently formulated) tastes bitter pretty terrible. We are basically giving
an oral dose of the concentrated IV form of the drug (5mg/mL). There are many ways to
administer it to minimize cruelty to the child (we're trying to help them, remember?).
Flavored syrup helps cover it up. A syringe is probably the best bet rather than in a cup.
Some children will spit out their premed no matter what you do. Parents are an important
resource in determining when this is likely to occur. The pre-op nurses will give it if you
tell them about it and put an order into Maestro Care for it (Look for the 5mg/mL form of
the drug-it’s in the “Preop Peds” order set). Nasal midazolam (0.3-0.5 mg/kg) is also
effective (skip the flavored syrup please) but quite noxious so not commonly used.

Dexmedetomidine:
Can be given as a premedication intra-nasally (1-2 mcg/kg) using the concentrated form
of the drug from pharmacy (not the IV form we usually give). Unfortunately, it takes
around 45 minutes to really work so it takes some planning.


The following is one of the most important things you will read today:
NPO orders for elective pediatric surgery
We use the ASA standard to determine this. For any age child, this means the minimum
acceptable time from ingestion is the following:

*Clear liquids 2 hours
Breast milk 4 hours
Formula, non-human
milk, #light meal 6 hours
Fatty foods 8 hours

*Clear liquids are water, apple juice, sprite, or other "see-through" sodas.
#The ASA says a “light meal” is toasted bread. Yum.

Be aware that these guidelines were intended for healthy patients undergoing outpatient
procedures. Many of our patients do not fit into these categories and this should be
taken into consideration. For example, patients with bowel issues (obstruction, short-gut,
etc.) may still be at risk for aspiration even though NPO, just like in adults. Also,
remember that fatty foods take longer to transit the stomach and 8+ hours is
probably a more appropriate fasting time if, for example, your patient stopped by
Bojangles for a biscuit on their way to the hospital.

Inpatients with intravenous lines should still adhere to the stricter NPO rules with
maintenance fluid being administered by IV during the fasting period. You are
responsible for double checking that NPO orders have been submitted in Maestro
Care on inpatient children prior to scheduled procedures. When doing so, keep in
mind that changes in the OR schedule sometimes occur. Be conservative, but reasonable.
If you have any questions, ask.
7. The Duke Children’s Health Center

The Children’s Health Center (CHC) is a facility that contains most of the pediatric
subspecialty clinics, including the surgical clinics. It also houses the preoperative and
PACU areas for children and overall is a terrific environment for children. All patients
with a pediatric surgeon will pass through this facility on the day of their surgery, as will
select children of non-pediatric surgeons. Most children will also have their preoperative
screening evaluation in the CHC by a member of the Preoperative Screening Unit team.
The pediatric anesthesia attendings review these preoperative evaluations and will
therefore often know about the patients before you do. You should still electronically
review the charts of outpatients on the day before surgery and be prepared to discuss the
anesthesia plans with your assigned attending the day/night before.

Get set up for the whole day before it begins. Many peds cases are short and you may
find that your OR has 5-6 cases or more in a day! You will often not have the time or
inclination to go to PACU, back to the pharmacy, back to the room to setup, back to
preop, and then back to the OR with the patient. If your room is pretty much ready for the
next patient when you leave for the PACU, you can page your tech to turnover, drop the
patient off in PACU, take the O2 tank to the next patient’s bed space in preop, talk to the
family and basically be ready to head into the OR for the next case after a quick check of
the OR setup. The preop nurses will give oral midazolam if they have an order for it (and
hopefully your attending did this before you got there!).

When setting up, have stuff ready but don’t open a bunch of things up that may not be
used. Trying to minimize waste and save the environment will help the kids you care for
have a better world to grow up in. Win-win.

There is a pharmacy in the CHC (first floor) so that families can get prescriptions filled
and an Einstein’s Bagels (T-level) so they can fill their stomachs as well.


8. Guidelines for operating room preparation

You may be doing a large number of cases in a relatively short period of time. The
bottom line is that you must start your set-up early in the morning for the cases you will
be doing over the day to avoid delays in between the cases. The set-ups need to be age-
appropriate and a variety of sizes of equipment and drugs will help to facilitate turnover
time. Have IV setups available for the whole day before you start your first case.

Anesthesia machine: Do your usual checkout and prepare your machine and circuit for
the size of your first patient.

Circuits: We use pediatric circle system for infants and children. The peds circuit (with
the smaller 1 liter bag) is a good choice for kids <30kg). Rarely, premature infants and
older children with significant lung disease will require an ICU ventilator. IV anesthesia
will be required in these cases.

Masks: Have two different sizes available for each patient at your fingertips.
Oral airways: Ditto. The one that looks too big usually fits.

Endotracheal tubes: Choose the size you feel is appropriate for your patient and also lay
out a size larger and one smaller (both unopened) so that you can change your plan easily
even with the scope in the mouth.
Guidelines for cuffed tubes:
Age Internal Diameter
Preemie 2-2.5mm
Term 3.0
3-9 mos. 3.5
9-12 mos. 4.0
18-24 mos. 4.0- 4.5
>24 mos. (age/4) + 3.5

You can actually measure the cuff pressure if you do use a cuffed ETT. There are
devices for this in the peds OR’s.






 Correct depth of the endotracheal tube is easy to remember in infants:
Remember: "1-2-3/7-8-9" at the lips
1 kg => 7 cm depth
2 kg => 8 cm depth
3 kg => 9 cm depth

Larger infants and children...Tube size (ID) X 3 or Age + 11

Laryngoscope blades: It is often easier to use a straight blade in children less than 1 year
old (ask your attending why). Nevertheless, keep a backup (unopened) on your machine
for each case.

Laryngeal Mask Airway (LMA): Sizes exist to allow use with any age child (perhaps
excluding premature infants). Beware: the smaller the child, the more labor-intensive the
LMA can be. Choosing the right size and getting the proper fit are the keys to success with
the LMA. Sizing guidelines are as follows:

Size Weight Maximum Cuff Volume
#1 newborn up to 5 kg up to 4 ml
#1.5 5-10 kg up to 7 ml
#2 10-20 kg up to 10 ml
#2.5 20-30 kg up to 14 ml
#3 >30 kg up to 20 ml

Drugs:

1. Atropine in 1ml syringe with a 22g needle.
2. Succinylcholine in syringe large enough to hold 4 mg/kg
(the IM dose used in an emergency) with a 22g needle.
3. Nondepolarizing drug of choice (if needed) in appropriately sized
syringe. We usually use Rocuronium.
4. Syringes of flush to push meds, salvage IVs, etc.
5. Propofol in the room, drawn up in a volume to allow 3+ mg/kg
6. Analgesic (Fentanyl, morphine or ketorolac as indicated)
7. Ketamine. Used for some cases but rarely.
8. Epinephrine 10 mcg/mL, 100mcg/mL (and 1 mcg/mL for <10kg) (on Omnicell)
9. Lidocaine in syringe large enough for 2 mg/kg

Does all of this seem like a lot to remember? There’s a “cheat sheet” in each of the Peds
OR’s that outlines this for your reference.
Note:
With the exception of antibiotics, choose the appropriate size syringes based on the patient’s
weight and expected dosing then fill up your syringes with drug. In other words, don’t
put a single dose of medication in a syringe (partially filled)! A full syringe means it’s
clean. A half filled syringe looks used. Since we often do so many cases, this helps keep it
safe for all the children. The Codonics machine makes labels for you. Scan the vials and
voila! Use it!

IV fluids: Use a buretrol IV setup for all children < 30 kg. Set up your fluids with a
buretrol, stopcock with extension and t-piece. NOTE: Larger children (>8y.o., 30kg) do not
need the buretrol in most cases and should get a regular IV drip (not a minidrip). Fill the
buretrol to no more than 10 ml/kg to avoid flooding your tiny patients.

Be sure to clear lines of bubbles of air as children often have undiagnosed septal defects.

Please keep track of the fluids you put into the buretrol by writing the amount on the side
of it (see discussion and picture below on how to do this).

Regarding IV’s, please make every attempt to keep stopcocks capped when not in use and
to clean needleless connections with an alcohol wipe EVERY TIME you administer a
drug. Many of our patients have central lines that are at risk of getting
contaminated/infected and a sizable number of these patients are immunocompromised for
a variety of reasons. If you get in the habit of maintaining an aseptic technique for every
IV and every drug administration, you will protect those at low risk and those at high risk
for infection. Dr. Eck is a germophobe and is watching you. J
Note on resuscitation drugs:
Our faculty have agreed that epinephrine should be available for resuscitation. In order to
keep it safe, the epinephrine should be prepared as outlined:

1. Epinephrine 100 mcg/mL already exists in the Omnicell in a brown-colored box.

The pharmacy also makes two concentrations of epinephrine for use in children. At
Duke North, have the 10 mcg/mL concentration for any peds case. When
appropriate (e.g. small kg wt/preexisting conditions/current health status of child),
also obtain a 5mL syringe of 1mcg/mL epinephrine from pharmacy.
2. Don’t dilute your own epinephrine! Flush syringes are to NEVER be used.
3. The syringes should be placed in the emergency drug holder that attaches to
the anesthesia machine. If you are in a non-peds room, put them on the top
left of the Omnicell (not on the anesthesia machine with other drugs).

To be clear, DON’T DO THIS!:
Adding any drug to a prefilled saline flush syringe, no matter how it’s labelled
is a setup for a medication error when someone grabs it thinking it is flush.
Dilute drugs in separate, clean syringes and label appropriately.
Pediatric Anesthesia Guidelines for Room Preparation

Endotracheal Tubes
Calculate the size expected based on age
Have that tube, one size larger, and one size smaller
Stylet tubes that are < size 3.5
Straight blades are typically used for children < 1 y.o.
Drugs
For ALL cases, have succinylcholine and atropine drawn up in syringes with 22
gauge needles for possible IM use. Place these on the anesthesia machine.
Other drugs are to be drawn up on an individual case basis
Syringes
Use 1 cc syringes if patient weighs < 5 kg
Pay attention to weight and max doses to determine when to use 3 vs. 5 cc
syringes for other pediatric cases
Circuits
Use pediatric circle system for all cases < 30 kg
Fluids
Buretrols should be used for all children <30kg (regular drip if >30kg)
Fill the buretrol to no more than 10 cc/kg
There should be at least 1 dextrose-containing solution for neonates/ICN babies,
running on an infusion pump.

Monito
Monitors

Note there are two types of disposable pulse ox probes to use according to the weight of the
patient:




Do not draw up needless drugs or use expensive supplies such as special endotracheal
tubes without reason. Be prepared for all cases for the day to avoid delays. If there are
any questions, ask your attending.

CLEAN UP AFTER YOURSELF!

Before you leave for the day, please make sure to discard or restock any disposable
supplies that you prepared and did not use. Leave the OR space clean and tidy. Don’t
expect others to clean up after you!

If you pulled extra equipment into the OR that is not normally stocked in there (e.g.
epidural or central line kits), that needs to be restocked outside of the OR itself, make
sure those items are placed in the designated space for restocking.
 9. Fluid and blood replacement

Here’s how to do the fluids in the OR with the Maestro Care record:

Start each bag of fluid in the record with “New Bag” note to indicate that you’ve started
the IV.

Put a piece of tape on the buretrol noting the amount of fluid you put in to start (100 cc
for example but no more than 10cc/kg). When it’s empty, fill it again to whatever
amount you choose. Cross out the first amount and write in the second. Document
each of these increments in the Maestro Care record for each IV separately. If you do
this every time you fill the buretrol, you will easily know what you have given just by
looking at the buretrol. If you keep a running total on outside of the buretrol(s), you
will always know how much fluid you have given, even if you have more than one IV.

Basically, you are keeping track of the fluids separately and putting each aliquot into the
Maestro Care record. Anyone coming into the room can immediately tell without having
to scroll around the record and fluids are unlikely to be “lost” in the record. If you don’t
keep track this way, you will likely not be able to keep track of how much you’ve given,
especially with infants because unlike with adults and older children, you can’t just look
at the bag and tell how much you’ve given with any precision. In the photo above, 250
mL have been administered so far.

1. Maintenance IV fluids:
4 ml/kg 0-10 kg plus
2 ml/kg 10-20 kg plus
1 ml/kg >20 kg

2. Suitable boluses are 10cc/kg at a time. Use Crystalloid, plasmanate (or other Colloid).

3. Each 1-1.5ml/kg of pRBC's will raise the Hct by about 1%.

4. 1 unit/10kg of platelets will raise the count by 20-25,000.



To estimate blood replacement
Vol of PRBCs = [(decimal)Desired Hct - Current Hct] x Est Blood Vol x 1.5
Example (6 month old, 7 kg), Hct 20 and goal Hct is 30:

Vol of PRBCs = [(0.3 – 0.2) x (80mL/kg x 7 kg) x 1.5]

= [0.1 x 560mL x 1.5)
= 84 mL

Estimated blood volumes

preemie = 100 ml/kg 1 year = 75 ml/kg
term = 90 ml/kg children = 70 ml/kg
6 mo. = 80 ml/kg adult = 65 ml/kg

10. Clinical Pointers

Induction techniques
Inhalation: O2, N2O, Sevoflurane
IV: Propofol, Ketamine
Know pediatric doses!
IM: Ketamine

Maestro Care
There are two Macros to use for pediatric cases. “Peds General” and “Peds
Mask”. Don’t use “Pediatrics” as that was a default from EPIC and does not work well
with our standard practice.

Monitors
ASA standards should be followed. It is often pointless to apply all the monitors
before induction in small children, as they tend to tear them off. More cooperative
children and newborns may have them applied before induction. Do the best you can. A
pulse oximeter may be your best bet if you can only get one monitor on. Keep in mind
that esophageal stethoscopes may not be appropriate in certain types of surgery e.g. ENT
and Plastic repair of airways. In this case you could insert a rectal one. Please don’t do
this in immunocompromised patients! Skin temps will probably suffice for many cases

Notes on induction:
1. Young children often have an inhalational induction in order to prevent the trauma
associated with needle placement of an IV. Most would agree that the safest anesthetic
is one in which IV access is available in the event of an emergency. In other words, we
are sacrificing a margin of safety to do an inhalational technique for induction. In the
vast majority of cases, this does not present a problem and induction proceeds smoothly.
In older children (usually 8-10 years old), always consider placement of an IV prior to
anesthesia. Oral premedication and/or EMLA cream (placed at least an hour before the
IV is put in) can often facilitate this. Also, any patient who is considered to have a full
stomach, significant GE reflux, or is at risk for MH should be considered for an IV
induction (just as in adults). Also, if you have an IV use it! Even if it’s a kid!

2. Sevoflurane stinks! (even at 1%). N2O doesn’t smell so much. Consider using just
N2O and O2 for the first 30-60 seconds of your induction and then add the Sevoflurane in
when the child is “stunned”. This will make you look slick and the child is less likely to
come back the next time afraid of the mask. This is especially important in non-
premedicated children. Note that there are a bunch of flavored Lip-smackers and scented
oils around for putting inside the mask to improve the smell. Letting a child choose a
flavor may help to feel more involved and therefore may help with cooperation.

3. Parental presence in the OR: In order to help alleviate children's anxiety, we
sometimes allow parents to accompany their kids into the OR until they are unconscious.
Keep in mind that parental presence is intended to provide a calming influence on the
child and may not be necessary. We do not do this for the parent’s sake. Many parents
do far less well than their children do with induction of anesthesia but may believe they
are abandoning their child if they don't go into the OR. We try to encourage those
parents who do not want to or who we feel will not do well not to accompany their child
to the OR. In the case of rapid sequence induction for example, it is probably best for
parents not to come to the OR as the time taken to get them out of the room is more time
for desaturation to occur. We have asked the preop screening nurses and nurses in the
preop holding area to not discuss accompaniment to the OR so that only the anesthesia
team decides whether parents come back to the OR. If you decide to let a parent come
back, let the preop nurse know so she can have them receive the appropriate attire. The
decision of the appropriateness of parental presence during induction is ultimately that of
the attending anesthesiologist and is final.

Notes on maintenance:
We most often use narcotic, inhalational, relaxant technique as in adults. We tend
to use Rocuronium for most cases, as its effect in slightly increasing heart rate is
beneficial in children who may rely on heart rate to maintain cardiac output. Keep in
mind that children may excrete inhalational agents faster. Do not try to awaken too early,
as a squirming child is hard to sew up. Also, don't be fooled into thinking that keeping
the Sevoflurane at 3% until the drapes come down is O.K. This is part of the art of
Pediatric Anesthesia!!!



Common problems
Laryngospasm, can be broken by gentle CPAP and/or bagging. Call for
immediate help, as this can be lethal. Stat pages are the room number + 911. A call to
660-7337 will alert the pediatric anesthesia faculty in the OR that day. Make this call
from the OR phone since the caller ID will alert the team where to come. Better yet,
have the circulator call. If positive pressure mask ventilation isn’t working, you may
need 1/4 dose sux IV or standard dose sux IM. Rocuronium can also be given if sux is
contraindicated and can also be used IM. It will last longer though, especially if given
IM. Also, remember the intraosseous route if there is ever an emergency and no IV. We
have Easy IO devices in the peds carts in Ped1 and Ped2.

Hypotension is often a late sign in pediatric patients, especially neonates.
Tachycardia may be a better indicator of fluid status. Potent inhalational agents can
depress cardiac output markedly in small babies, although this is less common with
agents such as Sevoflurane.


Regurgitation/Vomiting and/or gastro-esophageal reflux are very common less
than one year of age. It's important to realize that gastric distention is almost universal
after mask ventilation. Consider passing an OG tube and remove the air you put in
once the child is intubated.



11. ICU Transport

We are often called upon to care for infants and children from either the Intensive Care
Nursery (ICN-which houses newborn and premature infants), the Pediatric Intensive
Care Unit (PICU) or Pediatric Cardiac ICU (PCICU), all of which are located on the
fifth floor of the main hospital. This will require transport to and from the operating
rooms with potentially unstable patients and necessitates great care, vigilance and
preparation. Generally speaking, we transport patients from the ICU to the OR unless
they are not intubated and they are stable, in which case the nurse can bring them down to
preop holding. We transport all intubated patients, unstable patients and post-op patients
(with and without an endotracheal tube).


When preparing to transport an intensive care patient, consider what equipment and drugs
you would need if you had an event during transport and remember that the elevator
could break down between floors (thankfully, this is a very rare event). A few
suggestions:

1. Oxygen tank (full)
2. Means of administering positive pressure ventilation.
3. Laryngoscope blade and appropriately sized endotracheal tubes
4. Drugs: Atropine
SUX
Epinephrine
Dexmedetomidine
Propofol
Fentanyl (take with you what's left from the case)
5. Transport monitor with pulse oximeter. Never transport without one. We have
designated monitors that we use to transport to PICU and PCICU. It uses the same
module that the ICU’s use so when you arrive in intensive care, they simply remove the
module from the monitor and plug it into their own monitor. This saves time/effort and
keeps the patient monitored more continuously.

6. We have a specific process for handoffs in the PICU. There is a form that needs to be
filled out (look for the blank ones in the pocket on the side of the anesthesia cart). There
are also detailed descriptions of the process available there too. The whole point of this
new process is to improve communication. Please ask your attending about this before
you make your first trip to the PICU.

We hope that this handout will provide you with most of the day-to-day basics of
pediatric anesthesia at Duke and will help improve your experience. The pediatric
anesthesia faculty want your education and to be excellent and for you to have fun caring
for children. Please feel free to let us know if you have any concerns. Good Luck!!


Please pick up a card from Allison Wright with all the important numbers that you
can attach to your ID badge while on the peds rotation.

Pediatric Anesthesia Faculty and Important numbers

Faculty __________Pager ________Cell________
Wads Ames 0066 919-636-0935
Guy Dear 1559 919-906-5652
John Eck 4355 919-971-5486
Lisa Einhorn 2805 410-218-8026
Nate Greene 9968 206-601-2012
Mayumi Homi 9137 919-609-8172
Eddie Jooste 8070 917-361-8683
Kelly Machovec 9484 919-619-1212
Allison Ross 4069 919-815-7670
Brad Taicher 5798 215-432-1975
Annie Udani 9949 314-740-6140




CHC Preop holding area 668-4331
CHC PACU 668-4333
Allison Wright (peds assistant) 681-4877





Basic Pediatric Anesthesia (CA-2)
Goals and Objectives

1. COMPETENCE IN PATIENT CARE
Residents must be able to provide patient-centered care that is compassionate,
appropriate, and effective for the treatment of health problems and the promotion
of health.

Goal: The resident gathers essential and accurate information about the patient.
1. Residents should be capable of performing a thorough preoperative evaluation of
children with special reference to specific pediatric considerations.
2. Resident accesses all available data, including pt record, old anesthetic records,
and electronic record.
3. Resident interviews patients with an appreciation for their developmental level
and/or age.

Goal: The resident will make informed decisions about diagnostic and therapeutic
interventions based on patient information and preferences, up-to-date scientific
evidence, and clinical judgment.
1. Resident utilizes the appropriate lab tests and imaging studies to evaluate surgical
and anesthesia risk and interprets the results in consultation with attending staff.
2. Resident manages co-existent medical disease pre, intra-, and post-operatively

Goal: Develop and carry out patient management plans.
1. Resident formulates a plan for premedication, induction, maintenance, emergence,
fluid management and postoperative pain management for their patients and is
able to present the plan to the attending anesthesiologist in an organized and
succinct manner.
2. Selects and establishes appropriate monitoring techniques each patient
3. Equipment set-up and cart preparation are complete and appropriate
4. Executes the anesthetic plan in a facile and skilled manner, including induction,
maintenance and emergence from anesthesia.
5. Plans and orders post-operative analgesia regimen.
6. Recognizes and responds appropriately and in a timely manner to significant
changes in the patient’s condition.
7. Develops rational approaches to premedication of children and parental presence
at induction

Goal: The resident will perform competently the medical and invasive procedures
relevant to pediatric anesthesia
1. Resident demonstrates proficiency in performing airway management in infants
and children, including at least 30 endotracheal intubations and 10 laryngeal mask
airway (LMA) placements.





2. Demonstrates competence in venous cannulation in infants and children,
including at least 20 IV catheter insertions in children less than 10 years of age

2. COMPETENCE IN MEDICAL KNOWLEDGE
Residents must demonstrate knowledge about established and evolving biomedical,
clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the
application of this knowledge to patient care and the education of others.

Goal: Demonstrate an investigatory and analytic approach to clinical problem
solving and knowledge acquisition.
1. Resident demonstrates an analytical approach to the acquisition and application of
knowledge by utilizing evidence-based medicine skills to answer clinical
questions.
2. Initiates a discussion with the subspecialty director at the beginning of the rotation
to address prescribed as well as individual learning objectives
3. Consult with faculty to devise anesthetic plans tailored to individual patients
4. Discuss with the faculty the pediatric anesthesia topics compiled in the resident
handbook and to submit the completed documentation form at the end of the
rotation.

Goal: The resident will know and apply the basic and clinically supportive sciences,
which are appropriate for pediatric anesthesiology. (For an outline of the expected
knowledge base see separate curricula)
1. Resident demonstrates application of adequate general medical knowledge
relevant to the pediatric patient population, including medical comorbidities such
as prematurity.
2. Develops anesthesia-specific knowledge base including key concepts of basic
pediatric physiology and pharmacology, appreciation for the key differences
between adult and pediatric patients
3. Develops and maintains a willingness to be a life-long learner
4. Attends and presents a topic/s at Pediatric conference.

3. COMPETENCE IN PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents must be able to investigate and evaluate their patient care practices,
appraise and assimilate scientific evidence, and improve their patient care practices.

Goal: Analyze practice experience and perform practice-based improvement
activities using a systematic methodology.
1. Resident implements strategies, along with the patient care team, to improve
patient care practice.

Goal: Locate, appraise, and assimilate evidence from scientific studies
1. Resident is able to apply new knowledge to clinical situations.





2. Attends and presents a topic/s at Pediatric conference.



4. COMPETENCE IN INTERPERSONAL AND COMMUNICATION SKILLS
Residents must be able to demonstrate interpersonal and communication skills that
result in effective information exchange and teaming with patients, their patients
families, and professional associates

Goal: The resident will communicate effectively to create and sustain a therapeutic
and ethically sound relationship with patients and families.
1. Identifies self and other members of the health care team and explains role
appropriately to patient and/or care givers/family members
2. Respects patient/family dignity and confidentiality in perioperative discussions
3. Uses language and terminology appropriate to the developmental/educational
level of the patient and/or caregivers/family members
4. Obtains written informed consent, using knowledge and judgment, explains
anesthetic management to patients and families such that the plan and its risks,
benefits and alternatives are understood

Goal: Use effective listening skills and elicit and provide information using effective
nonverbal, explanatory, questioning, and writing skills.
1. Uses effective listening skills to elicit information
2. Maintains complete, accurate and legible anesthesia records
3. Pre-operative and post-operative notes and orders are legible and accurately
written, including date, time ,signature, and institutionally approved abbreviations

Goal: Work effectively with others as a member or leader of a health care team or
other professional group.
1. Contacts division for rotation information at least a week prior to rotation
2. Interacts with staff in a professional and courteous manner
3. Reviews cases and educational goals pre-operatively with anesthesia attending,
night before for scheduled cases
4. Demonstrates the ability to discuss patient care issues with the surgical team in a
collegial, non-confrontational manner



5. COMPETENCE IN PROFESSIONALISM
Residents must demonstrate a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.

Goal: Demonstrate respect, compassion, and integrity; a responsiveness to the needs
of patients and society that supersedes self-interest; accountability to patients,





society, and the profession; and a commitment to excellence and on-going
professional development.
1. Interacts with patients and families in a compassionate manner
2. Indicates self-awareness and a knowledge of one’s own limits by recognizing the
need for guidance and supervision, requesting assistance appropriately
3. Demonstrates a commitment to on-going professional development through
regular attendance at division conferences and reading medical literature
4. Is open to and responds favorably to constructive criticism and feedback by
improving behavior and/or skills

Goal: Demonstrate a commitment to ethical principles pertaining to provision or
withholding of clinical care, confidentiality of patient information, informed
consent, and business practices.
1. Adheres to the laws and rules governing the confidentiality of patient information
2. Obtains proper informed consent from patient or family member/legal guardian,
recognizing the situational need for determining competence



6. COMPETENCE IN SYSTEMS-BASED PRACTICE
Residents must demonstrate an awareness of and responsiveness to the larger
context and system of health care and the ability to effectively call on system
resources to provide care that is of optimal value.

Goal: The resident will understand the reciprocal impact of personal professional
practice, health care teams, and the health care organization on the
community/society.
1. Requests and gives help when needed
2. Demonstrates respect, support and understanding to team members
3. Demonstrates respect, support and understanding to team members
4. Helps prioritize tasks and setting of team goals