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117 Resident Handbook
Updated January 2001
Pediatric Anesthesia
RESIDENT HANDBOOK
Written, Compiled, and Edited by
Michael L. Schmitz, M.D.
Copyright
Resident Survival Handbook © 2000
The University of Arkansas for Medical Sciences
Arkansas Children’s Hospital
April, 2000
Resident Handbook 116
TABLE OF CONTENTS
Page #
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Introduction
Preoperative Evaluation & Management
A. Gather Information
Verbal & recorded history
Optimize medical therapy
Recognize stress on family
B. NPO
How long and for what?
Timing
Infants & neonates
Transpyloric feeding tubes
C. Premedication
Premed or not to premed?
Mode of administration
Uncooperative patients
Behavioral intervention
Informed Consent
Method of interaction
What to tell the child
Special Techniques
Reassurance
The Operating Room & Monitoring
Induction & Maintenance of Anesthesia
A. Clinical monitoring
B. Airway & ventilation
C. Fluids
D. Conduct of the anesthesia team
PACU
Postoperative Visit
Pain Management
Conclusion
i.
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X.
Page #
Appendices:
Appendix A--Common Drug Dosages
Appendix B--Fluid Replacement
Appendix C--Airway Equipment
Appendix D--Blood Components
Appendix E--Pain Management Guidelines
Appendix F--QI Chart Requirements
Appendix G-- Outline of Preop Note
Appendix H--Machine/Room Preparation
Appendix I--Inhaled Anesth Characteristics
Appendix J--Normal Vital Signs
31
Appendix K--Adrenocorticosteroids
Appendix L--Laboratory Values
36
Appendix M--Malignant Hyperthermia
Appendix N-- Preparation Protocol For MH
Sensitive Cases
Appendix O--Dermatomes
Appendix P--CV Drug Infusions
Appendix Q--Pulmonary Gas Exchange
Appendix R--Compressed Gas Characteristics
Appendix S--Resuscitation
Appendix T--SBOS for Pediatric Patients
Appendix U--Body Surface Area Nomogram
Appendix V--Initial Fluid Therapy/Burns
Appendix W--ASC NPO Instructions
Appendix X--Policy/Lower RT Infections
Appendix Y--Caudal Handout
Appendix Z--Breaks and Lunch Relief
Appendix AA--Sickle Cell Transfusion Protocol 61
Appendix BB--Endocarditis Prophylaxis
62
Appendix CC--ACH Staff
Appendix DD--Miscellaneous Phone Numbers
Appendix EE--Formulary
Appendix FF--Regional Anesthesia
ii.
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1 Resident Handbook
I. INTRODUCTION
This manual is intended to serve as a guide for residents who are
rotating in pediatric anesthesia at Arkansas Children’s Hospital.
It is my intention that the information contained in this manual
will reduce the stress associated with being a new resident on this
rotation. It is by no means meant to be a comprehensive reading
of all one needs to know about pediatric anesthesia. Contained in
it are nuts and bolts information assembled to facilitate getting
the usual work of the day finished.
Remember, if you are ever unsure of the manner in which to
proceed, talk to an attending, especially for activities outside
the OR.
“It is my belief that the attending anesthesiologist should be
apprised of all procedures done by residents while at Arkansas
Children’s Hospital. This certainly includes procedures in the
operating room, as well as significant procedures out of the
operating room, such as intubating patients in the intensive care
unit, the burn unit, or the neonatal intensive care unit. If there is
any question in your mind about whether or not you should call
your attending, please err on the side of making them aware of
what is going on in the hospital.”
Raeford E. Brown, Jr., M.D.
December 14, 1994
II. PREOPERATIVE EVALUATION & MANAGEMENT
A. THE GATHERING OF INFORMATION
VERBAL HISTORY: The resident must play an active role
in gathering all the pertinent information in an organized
manner that is essential for the preoperative evaluation. The
best circumstance occurs when the resident during the
preoperative evaluation will also be the resident performing
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the anesthesia. The work-up consists of a medical history
which includes: history of present illness, past medical
history, past surgical and anesthesia history, allergies,
medications, a brief review of systems, such as has the child
had a recent URI or other acute illness on top of the present
illness. A family history of anesthetic complications, a social
history which includes use of alcohol, recreational drugs, and
sexual activity. Often the tendency is to forget that when one
is at a children’s hospital there are teenagers who engage in
recreational drug activities or who smoke, drink, or are
sexually active. Usually a urine or serum beta HCG screen is
obtained for any postmenarchal female patient. This is more
reliable than taking an accurate sexual history from a
teenaged person.
RECORDED HISTORY: Also important in gathering
information is the review of old medical records. These
records may be requested to the anesthesia work room or to
the floor where the child is admitted. A brief scan of these
records will reveal whether that child had any anesthetic
difficulties during previous surgical procedures. Information
may also be obtained from the hospital computer system.
Information such as echo cardiogram reports, dictation’s
from prior chest x-ray’s, CT scans, or MRI scans may be
available there also. All residents will have a password to
access the hospital system for this information. The
information may be printed in hard-copy form by specifying
“OR2.2” behind the command “print on.” This information
will then be printed on the OR work room printer.
OPTIMIZE MEDICAL THERAPY: In addition to
gathering and organizing information, it is also essential to
optimize the patient’s medical therapy. This may include
prophylactic nebulizer treatments for an asthmatic, SBE
prophylaxis, or stress-dose steroid administration.
Depending on the medical therapy, the anesthesia resident
may chose not to write for this alone, but may consult with
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the attending anesthesiologist and/or the staff of the service
to which the patient belongs.
ESTABLISH RAPPORT: It is essential that the
preoperative visit be used to establish rapport between the
child and the anesthesiologist, as well as between the family
and the anesthesiologist. It is best when the child has a sense
of trust when they separate from their family and enter a
room full of strangers. This may be facilitated with an
established relationship with the anesthesiologist, who may
be the only person in the OR they have met previously.
Active resistance to the anesthesia process by the child due to
behavioral distress can be hazardous to the child as well as
the anesthesiologist. The child needs to be reassured that
they will be taken care of and be given medicine for pain and
for anxiety. They also need to be reassured they will be able
to see their parents again soon.
RECOGNIZE STRESS ON FAMILY: Often times, the
patient and the family are very anxious during the
preoperative period. It is during the preoperative visit that
reassurance and information may be relayed to the patient
and family to allay anxiety. It is unfair to the family for
them to miss out on the preoperative evaluation. Families
that are extremely stressed may also require a very patient
and empathetic approach to their situation.
B.
NPO
How long a child is made NPO is dependent upon many
considerations. The age of the patient is important because
metabolic rates are different, and the frequency in which
they eat is markedly different. For example, a neonate may
breast feed every 2-3 hours whereas a 7 month-old child
take formula every 4-6 hours. What kinds of food or fluids
are being taken in is also important to gastric emptying.
Solid food tends to stay in the stomach longer than noncarbonated, clear liquids. Our present guidelines are as
follows:
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Inpatients
ASC Patients
Infants
0-6 mon
formula/food  4 hr
clear liquids 2 hr
See Appendix
Children
6 mon-2 yr
food  6 hours
clear liquids 2 hr
Children
> 2 yr
food8 hr
clear liquids 2 hr
V
Clear liquids are acceptable in quantities of  8 ounces
within the 2 or 3 hours prior to surgery.
TIMING: It is important to note that the OR schedule is
extremely variable and just because a patient is scheduled at
4:00 pm does not mean that they will not be advanced on the
schedule. They may actually go to the OR at noon or even
7:30 a.m. If it is unclear exactly when the patient will come
to the operating room, as it usually is, then the resident
should either consult with their staff about when to make the
child NPO or make the child NPO for the earliest possible
OR time. Feeding orders can always be changed the morning
of the surgery if it looks like the case will go later in the day.
All Dr. Bower’s inpatients for ENT surgery should be NPO
for solids and nonclear liquids after midnight.
INFANTS & NEONATES: Infants and neonates have
limited glycogen stores and require more frequent feeding.
Certainly, newborn infants and babies that are small for
gestational age or premature may require an IV glucose
source. These babies could possibly become hypoglycemic
during an NPO period of even a few hours. For these
instances, consultation with the attending anesthesiologist
would be appropriate. This may also be applicable to
children with certain types of metabolic disorders
characterized by impaired glucose homeostasis mechanisms.
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TRANSPYLORIC FEEDINGS: In general, patients with
transpyloric feeding tubes have had the feedings discontinued
for 2 hours prior to surgery. This is meant to minimize
accumulation of fluids in the stomach that may reflux back
through the pylorus from the duodenum. When evaluating a
patient with a transpyloric feeding tube, it is important to
document that the tube indeed still is in the duodenum and is
transpyloric. This may be done by checking a recent (ie,
within 24-48 hours) chest x-ray or KUB. When minimal
interruption of feeding is essential, such as with burn
patients, it is acceptable to order a film to confirm that the
feeding tube is still beyond the pyloric sphincter.
C. PREMEDICATION
TO PREMED OR NOT TO PREMED?: When assessing
children preoperatively, one must decide first of all if they
need premedication or not. Teenagers who have been to the
operating room on a number of occasions, may feel entirely
comfortable entering the OR without any premedication at
all. However, the majority of teenagers and children, just as
with adults, do require some type of anxiolysis prior to
entering the operating room environment. Anxiolysis need
not always be pharmacological. (See Behavioral Intervention,
below)
MODE OF ADMINISTRATION: The mode of
administration of premedication is important for both reasons
of cost and stress to the patient. Medications which are given
PO require larger dosages due to the first pass effect of
hepatic extraction and are therefore, more expensive.
Medications given IV, IM, or SC require lower doses and are
less expensive, but frequently are more stressful to the
patient since they need a “shot.” In appropriate patients, we
typically give midazolam PO at a dose of 0.5 mg/kg (up to a
maximum of 15 mg) 15-30 minutes prior to entering the
operating room. If the patient already has an IV in place, we
typically use midazolam by the intravenous route.
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 Cook, D. Ryan and Peter J. Davis: "Pharmacology of Pediatric
Anesthesia" SMITH'S ANESTHESIA FOR INFANTS AND
CHILDREN Fifth Edition, Mosby 1988
 Fisher, Quentin A., et. al. Postoperative Voiding Interval and
Duration of Analgesia Following Peripheral or Caudal Nerve
Blocks in Children. Anesthesia and Analgesia 1993;76:173-177
 Gunter, Jowl B., et. al. Optimum Concentration of Bupivacaine
for Combined Caudal-General Anesthesia in Children.
Anesthesiology 1991;75:57-61.
 Rice, Linda Jo and Raafat S. Hannallah: "Pediatric Regional
Anesthesia" SMITH'S ANESTHESIA FOR INFANTS AND
CHILDREN Fifth Edition, Mosby 1988
 Sartorelli, Kennith H., et. al. Improved outcome Utilizing Spinal
Anesthesia in High-Risk Infants. Journal of Pediatric Surgery
1992;27:no.8 1022-1025
 Sethna, Navil F. and Charles B. Berde: "Pediatric Regional
Anesthesia" GREGORY'S PEDIATRIC ANESTHESIA Second
Edition, Churchill-Livingston 1989
 Sethna, Navil F. and Charles B. Berde: "Pediatric Regional
Anesthesia" GREGORY'S PEDIATRIC ANESTHESIA Third
Edition, Churchill-Livingston 1994
 Small, George A. Brachial Plexus Block Anesthesia in Children.
Journal of the American Medical Association 1951;147:17 16481651.
 Verghese, M. D., et. al. Pediatric Caudal Anesthesia: Volume vs.
Concentration As Determinants Of The Level Of Blockade.
Anesthesiology ASA Abstracts 1992,77:3A A1157.
109 Resident Handbook
any other block to cause toxicity. Being careful to not exceed the
recommended safe total doses of anesthetics, and utilizing
epinephrine containing solutions should attenuate the chances of
this occurring.
 subarachnoid/total spinal block
this is more likely with the paravertebral approach, as the dura
invests the rib heavily, especially in children. This can be avoided
by not injecting too close to the vertebral bodies.
 infection
 hematoma
INFILTRATION ANESTHESIA
The use of either pre-incisional or post-incisional infusion of local
anesthetics greatly decreases the requirements in the immediate post
operative period for narcotics and other analgesics. The concept of
pre-emptive analgesia is too broad to cover here, but may indicate
that infusion prior to incision may also decrease the long term
narcotic/analgesic requirements by ablating the development of pain
pathways. Most surgeons are happy to inject local anesthetics to help
with their patients postoperative pain control. Remember to assist the
surgeon with maximum dose recommendations and note the total
doses administered to avoid toxic reactions. Regional anesthesia is
one of the most satisfying techniques to the patient, surgeon (they
like happy patients) and anesthesiologists, and once mastered are
easy and safe to perform. Happy "blocking", but always be safe first
for the patient's sake.
REFERENCES:
 Alifimoff, James K. and Charles J. Cote: "Pediatric Regional
Anesthesia" in Cote, Ryan, Todres, and Goudsouzian's A
PRACTICE OF ANESTHESIA FOR INFANTS AND
CHILDREN Second Edition, Saunders 1992
 Arnett, Robert M., et. al. Effectiveness of 1% lidocaine dorsal
penile nerve block in infant circumcision. American Journal of
Obstetrics and Gynecology 1990;163:3 1074-1078.
 Broadman, Lynn M. Pediatric Regional Anesthesia Clinical
Anesthesia Updates 1992;3:2 1-14.
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Dosages vary and are dependent upon what other drugs the
patient has on board and if the patient has a history of
adverse reaction to benzodiazepines. An intravenous dose of
midazolam of 0.075 to 0.15 mg/kg may be considered for a
healthy patient who has received no respiratory depressant
medications.
UNCOOPERATIVE PATIENTS: There will be
circumstances such as with mentally retarded young adults or
teenagers where administration of an oral premed or
placement of an IV is impossible. Sometimes premedication
to these patients may be given via the SC or IM route
utilizing midazolam or another drug such as ketamine in a
dose of 2 - 4 mg/kg. The attending anesthesiologist should
be notified of these instances so that a plan of action can be
formulated.
BEHAVIORAL INTERVENTION: Something that the
resident will experience at Children’s Hospital is a concept
known as behavioral intervention. Children are very
distractible and may have considerably less anxiety when
they are busy with an activity. The Division of Pediatric
Anesthesia has purchased a number of behavioral
intervention tools (which the child sees as toys) to be used in
distracting children during times in which they need an IV
placed or need to be separated from parents or taken into a
strange environment. Such behavioral intervention tools
include toys that make music, storybooks, bubble blowers,
head phones, etc. Behavioral intervention is not a substitute
for premedication, but an adjunct. However, some children
may not require premedication if provided with behavioral
intervention. Selection of premedication and behavioral
intervention is an art to be learned by the anesthesiologist
who provides for pediatric patients. We encourage residents
to learn as much about it as they can during this rotation.
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Technique
III. INFORMED CONSENT
METHOD OF INTERACTION: When speaking with families
and patients about the risks and benefits of anesthesia, it is
important to use the appropriate tone. By this, I mean taking care
not to sound cold and calculating speaking with an already
frightened patient and family. One’s approach to explanations of
risks and benefits needs to be modified to the level of anxiety and
educational background of the parent and child.
WHAT TO TELL THE CHILD: It is best to involve the child
in the discussion about the anesthesia and in the description of
exactly what will happen to them when they come down to the
operating room area. Children of school age should be asked if
they have any questions or fears about the anesthesia since they
feel they are part of the decision making process. It is especially
important to reassure the child that they will not “wake up”
during the procedure, and that they will awaken at the end of the
procedure. Children are most afraid of pain when presenting for
a procedure. It is important that accurate explanations of what
will be done both when the child is awake and asleep be given to
the family. For instance, the knowledge that the IV will be
placed when the child is asleep is especially comforting to the
child.
SPECIAL TECHNIQUES: Discussion of invasive monitoring
and regional anesthetic techniques as well as postoperative pain
control measures that may be instituted by the Pain Management
Service should be discussed. Parents’ opinions about
postoperative pain management should be sought.
REASSURANCE: Most importantly, the family needs to be
assured that good care will be taken of their child in the operating
room. Frequently, this is the only time during their child’s illness
that the parent is not allowed to be with them. Parents also need
to be assured that an attending pediatric anesthesiologist will be
present during their child’s anesthetic.
Technique of posterior intercostal nerve block.
Either a paravertebral or mid axillary block can be performed.
Perpendicular to the middle of the rib wall, insert the needle and
advance until the rib is contacted. Walk the needle inferiorly and
carefully advance until the needle is walked off the rib. Further
advancement of the needle by 2-3 mm should be met with a distinct
pop. Aspirate and inject the local anesthetic.
Medications
Each intercostal nerve block anesthetizes 1-3 dermatomes on either
side. Use 0.08 ccs of epinephrine containing local anesthetic for each
block, being careful not to exceed the total safe amount of local
anesthetic.
Complications
 pneumothorax
is more likely with the midaxillary approach than the
paravertebral, but it is usually small and does not often require
treatment. A post-block chest film is indicated in all patients who
receive intercostal nerve blocks.
 systemic toxicity
for reasons mentioned above, this procedure is more likely than
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All attempts will be made to answer the parents’ questions about
the anesthesia prior to coming to the operating room.
TABLE.: Recommended Doses for Penile Block in Infants and Children
Study
Soliman & Tremblay
Bacon
Kirya & Werthmann
Carlsson & Svenssor
104
Lau
a
Plain Anesthetic
Solution
Age
4 months-8 years
3-12 months
1-5 years
6-12 years
13-40 years
2-3 days
1-15 years
2-5 years
6-10 years
Bupivacaine 0.25%
Bupivacaine 0.5%
Bupivacaine 0.5%
Bupivacaine 0.5%
Bupivacaine 0.5%
Lidocaine 1%
Bupivacaine 0.25%
Bupivacaine 0.5%
Bupivacaine 0.5%
Duration of
Analgesia
Dose
0.54 mg/kg (mean)
1 ml
3 ml
4 ml
5-7 ml
0.5 ml
0.38 mg/kg (mean)
2.5 ml
5 ml
a
6 hr
6 hr
6 hr
6 hr
6 hr
30 min
4-24 hr
6-12 hr
6-12 hr
Maximum of 12.5 mg.
Complications
There has never been a serious complication reported from
performing the subcutaneous ring block to date. The following are
potential or reported complications with both techniques;
 pressure induced compression of the dorsal penile vessels
 infection
 hematoma
 intravascular injection
 gangrene of the tip of the glans very rare
INTERCOSTAL NERVE BLOCKS
These blocks are ideal for postoperative analgesia for thoracotomy
patients, patients who have had upper abdominal procedures, and
patients with rib fractures. Intercostal nerve blocks optimizes
postoperative pulmonary function superiorly to narcotics alone, but
there is a higher and more rapid resorption of local anesthetic than
with any other nerve block. The plasma concentration rate of rise of
local anesthetic is even more rapid in children than adults, so addition
of vasoconstrictors is imperative, as well as limiting the total dose of
local medication.
Anatomy
The intercostal nerves traverse on the inferior aspect of the rib in a
neurovascular bundle with the intercostal artery and vein. The rib is
invested with both dura posteriorly and pleura antero-posteriorly.
IV. THE OPERATING ROOM AND MONITORING
When the patient comes to the holding area, it is important that
the chart be checked for new information about the patient that
may be pertinent to the anesthetic. It is also very important that
the patient’s identification bracelet be checked and confirmed,
especially if the anesthesiologist providing the anesthetic is not
the same person as did the preoperative examination. The
anesthesiologist taking care of the child will have personally
checked the equipment needed for induction and maintenance of
anesthesia. This includes suction, monitoring devices, and all
other equipment.
The degree of monitoring is modified based on the child’s
clinical condition and the surgical procedure. For all cases, basic
monitoring is essential and includes:









observation of patient’s color and chest movements
auscultation of heart tone and breath sounds
palpation of the arterial pulse (occasionally)
a precordial stethoscope
continuous ECG
temperature
inspired or expired oxygen concentration and alarms
intermittent blood pressure monitoring
exhaled carbon dioxide monitor
In addition, all children except for those having the briefest of
procedures should have an intravenous line placed which allows
replacement of the fluid deficit and allows for rapid and reliable
drug administration.
Arterial cannulation may be beneficial under circumstances
where one anticipates extensive or sudden blood loss or fluid
shifting. It is also important for patients who are medically
unstable and require continuous rather than intermittent
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penile nerve block
measurement of blood pressure. It is also useful in patients that
require frequent blood sampling during the surgical procedure
especially for those patients with difficult vascular access.
Central venous pressure monitoring is used less often but may be
quite useful in cases involving extensive blood loss and fluid
repletion. Pulmonary artery occlusion pressures obtained with
the Swan-Ganz catheter are rarely used at this hospital.
However, they are indicated in cases where the dynamics of the
heart cannot be predicted merely by measurement of preload
(CVP) and afterload (systemic blood pressure).
The urinary catheter can provide good data regarding the
intervascular volume status of the patient. It also allows some
prediction regarding organ perfusion since it is a measurement of
kidney perfusion. It is quite useful for procedures that are very
long which would otherwise result in a full and distended bladder
or procedures in which blood loss is extensive and verification of
fluid repletion may be obtained by measuring urine output.
Most importantly the focus of monitoring should be on the
appearance of the child. Frequently residents in training spend
too much time looking at the monitors and trying to interpret the
monitors rather than looking across the screen directly at the
patient.
V. INDUCTION AND MAINTENANCE OF ANESTHESIA
Penile block. A 23- to 25-gauge needle is inserted in the midline, 1 cm above the symphysis pubis at an
angle of 30º and directed caudad. After piercing the penile fascia (0.5-1.0 cm) and negative aspiration for
blood, 1 to 4 ml of local anesthetic without epinephrine is injected.
Using a 22 gauge short bevel needle, the needle is inserted
perpendicular to the skin above the symphysis pubis and walked
inferiorly and directing the tip of the needle 2-3 mm laterally in a
sagittal plane until off the bone and a pop is felt. Inject one-half of
the medication. Then perform the same block directing the needle to
the other side using the same needle hole. Alternatively, give one
injection in the midline in the same manner. Although a fascial plane
separates the two penile nerves, this technique is as effective as the
two injection technique.
A. CLINICAL MONITORING
The cliché statement, “the child is not merely a small adult,”
is based on significant differences that are found in the
physiology and behavior of the child when compared to the
adult. This is especially true of the newborn. Many of the
differences that are seen in the physiology of the infant and
child are based on the much higher metabolic rate of the
child in comparison with the adult. As a result, anesthesia
Medications
*DO NOT USE EPINEPHRINE CONTAINING SOLUTIONS!!!*
 Bupivacaine 0.5% without epinephrine 0.1 ml/kg/side
OR
 Lidocaine 1.0% without epinephrine 0.1 ml/kg/side
105 Resident Handbook
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induction and maintenance vary considerably from what is
seen in adult patients. Also, behavioral differences in
children may require a change in the plan of induction of
anesthesia at the last minute.
PENILE NERVE BLOCK
The penile nerve block has many of the same benefits of the
ilioinguinal/iliohypogastric nerve blocks in comparison to the caudal
block. It is an ideal block to supplement general anesthesia for
circumcision and hypospadius repair with benefits being a decreased
requirement for general anesthetics, quicker emergence time,
decreased recovery time, earlier discharge from the hospital,
decreased requirements for postoperative pain medications, no
delayed mobility or micturition, decreased total dose of local
anesthetic in comparison to a caudal, and decreased nausea and
vomiting. It is often used as the sole anesthetic for circumcisions
done in newborns.
The most important clinical monitors during the induction
period are the senses of the anesthesiologist. During
induction, the pediatric anesthesiologist is constantly
observing the depth and symmetry of chest excursion, the
color of the lips, oral mucosa and nail beds, as well as
sometimes capillary refill. This provides information
regarding ventilation and perfusion. In addition, the
anesthesiologist is listening to the quality of the heart tones
and the breath sounds through a precordial stethoscope which
provides immediate information about heart rate and rhythm.
The intensity of heart sounds gives some indication of
cardiac output and changes in the intensity of heart sounds
relate changes in cardiac output. In a similar manner,
ventilation may be assessed. As a result arrhythmia’s,
hypovolemia, anesthetic overdose, and airway obstruction
may immediately be detected. When blood pressure
monitoring devices fail, palpation of an arterial pulse can
provide information confirming adequacy of cardiac output
and heart rate. Peripheral temperature may also be assessed
by merely touching the patient.
Anatomy
The 2 dorsal penile nerves are branches of the pudendal nerve (S2-4)
that emerge from the pelvis covered by Buck's fascia under the
symphysis pubis. They run alongside the dorsal penile arteries and
veins deep to Buck's fascia. They provide sensory innervation to the
glans and most of the shaft of the penis except the most proximal and
scrotal portions (which are innervated by branches of the
genitofemoral and ilioinguinal nerves).
Technique
There are two techniques to block the penile nerves:
subcutaneous ring block - local
anesthetic is injected circumferentially
around the shaft of the penis with a small
(27 or 30 gauge needle)
Penile nerve block via the subpubic space approach in children.
B.
AIRWAY AND VENTILATION
Infants and children have many unique characteristics
regarding their airway in comparison with the adult. The
infant and child’s airways are more prone to obstruction. A
pediatric anesthesiologist is attuned to this propensity for
obstruction and is adept at relieving causes of obstruction.
Most morbidity and mortality in pediatric anesthesia is
related to inadequacy of ventilation.
A comparison between the neonatal and the adult airway
reveals five areas of major difference.
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1) The tongue. The tongue of the infant is relatively large in
proportion to the oral cavity. This results in two
problems. The first is that the tongue more easily
obstructs the airway in the neonate, and the second is that
the tongue is more difficult to manipulate and displace to
the side with a laryngoscope blade.
2) The position of the larynx. The adults larynx is located
anterior to C4-5. However, the infant’s larynx is higher
in the neck at approximately C3-4. This rostral
displacement of the larynx in infants results in the tongue
being closer to the roof of the mouth. The more superior
location of the larynx and tongue creates more difficulty
in visualization of the glottis. A straight laryngoscope
blade allows better visualization of the glottis in
neonates.
3) The epiglottis. In the adult, the epiglottis is broad and it’s
axis is parallel to that of the trachea. When looking at
the infant’s epiglottis, one finds that it is narrower,
shorter, and is angled away from the axis of the trachea.
This angulation causes the epiglottis to fold down
posteriorly over the glottic opening when visualized
through the laryngoscope. As a result, it is beneficial to
lift the epiglottis with the laryngoscope blade in order to
view the glottic opening.
4) Vocal folds. In the adult, the axis of the vocal folds is
perpendicular to that of the trachea. This means
basically that the vocal folds sit flat on top of the trachea
at a right angle. In the infant, the vocal folds are
angulated such that they slant inferiorly at the anterior
attachment. This angulation often results in the tip of the
endotracheal tube becoming caught at the anterior
commissure of the vocal fold.
5) The subglottic area. The most narrow portion of the adult
airway is the rimaglottidis. This means that any
endotracheal tube that is able to pass through the glottis
will pass into the trachea easily since the trachea has a
larger diameter than the rimaglottidis. However, in the
Ilioinguinal and iliohypogastric nerve blocks. The anterior superior iliac spine is palpated and a point 1.0 to 1.5 cm cephalad
and toward the midline is located. A 22-gauge needle is passed through the external and internal oblique muscles, and 1 to
5 ml of local anesthetic is deposited in a fanlike fashion cephalad toward the umbilicus, medially, and caudad toward the
groin. Just before removal from the skin, another 0.5 to 1.0 ml of local anesthetic is injected subcutaneously to block the
iliohypogastric nerve.
Using a 22 gauge short bevel needle, place it one of the patient’s
width of their 5th finger medial and inferior to the anterior superior
iliac crest perpendicular to the skin and advance until either a pop is
felt or bone is met. If bone is met, withdraw 1-2 mm, aspirate and
inject in a column to the skin about 2/3 of the local. Next, inject the
remainder in a subcutaneous cuff towards the umbilicus using the
same needle hole.
Medications
Each set of nerves can be consistently and successfully blocked with
bupivacaine 0.5% with epinephrine in a dose of 1 mg/kg/side.
Complications
 infection
 rare, transient paresis of the quadriceps muscles manifested as difficulty walking from femoral nerve blockade.
This adverse affect can be decreased or abolished by using 0.25%
instead of 0.5% bupivacaine.
 rare, transient paresthesia in the cutaneous distribution of the
femoral nerve
103 Resident Handbook
need for postoperative narcotics), earlier ambulation without the risk
of motor blockade from a caudal, and lower doses of local anesthetic
than a caudal thus decreasing the risk of systemic toxicity. In
addition, there is practically no risk of intravascular injection.
Anatomy
The ilioinguinal (L1) supplies cutaneous sensory innervation to the
scrotum and inner thigh. The iliohypogastric (T12-L1) supplies
cutaneous innervation above the inguinal ligament. The sensory area
supplied by these nerves receives a small contribution from the
genital branch of the genitofemoral nerve. Both nerves pass in a
plane between the transversus abdominus and the internal oblique
muscles. The ilioinguinal becomes superficial at the inguinal ring
and the iliohypogastric nerve becomes superficial earlier in its course
and is located subcutaneously in the abdominal wall just lateral to the
anterior superior iliac spine.
Technique
Resident Handbook 12
child, this is not the case. The narrowest portion of the
child’s airway is the cricoid cartilage which is a
nondistendible structure. This means that although an
endotracheal tube may pass easily through the cords, it
may fit tightly at the level of the cricoid cartilage. A
tight fitting endotracheal tube may result in subglottic
edema and narrowing of the airway. One mm of edema
in an adult subglottic area may narrow the airway by
44%. However, in an infant 1 mm of edema, given the
narrow diameter of the airway at this point, may reduce
the cross sectional area by 75%.
6) Obligate nasal breathing. Another peculiarity pertinent to
breathing in infants is that infants are obligate nasal
breathers. This means that the infant preferentially
breaths through its nose during periods of quiet
respiration. At these times, the tongue actually rests
against the roof of the mouth resulting or oral airway
obstruction. Coordination of respiratory and oral
function continues to develop in the infant for the first
3 - 5 months of life. After 3 - 5 months of age, the infant
is able to coordinate breathing adequately through the
mouth. This is why young infants with nasal obstruction
due to URIs may have difficulty sleeping. If the nasal
passages are obstructed, the only way they can breath is
by opening their mouth and crying.
C. FLUIDS
Diagram showing the course of ilioinguinal and iliohypogastric nerve, the landmarks, and the
needle insertion site.
Fluid management is especially important in the infant and
child. Infants and children have a relatively large surface
area given their blood volume. As a result, insensible losses
of fluids are relatively greater. As a result, the increase in
venous capacitance that occurs from vasodilatation and the
losses of blood during the surgical procedure may be more
significant in a dehydrated infant or child. Repletion of fluid
deficits must be done carefully. Occasionally, the liter of IV
fluid that is hung above the OR table is actually greater in
mass than the entire patient.
13 Resident Handbook
Resident Handbook 102
Needless to say, fluid overload may occur easily from
unregulated intravenous fluid infusion. For this reason,
children who come to the operating room routinely, have
their IV fluids placed and run through a Travenol® pump.
of local from the lateral malleolus to the extensor hallucis longus
tendon anteriorly and medially.
Replacement of fluid deficits should be done in a carefully
measured and planned manner. Deficit fluids are given in
addition to maintenance fluids, fluids to accommodate the
increase in venous capacitance, and fluids for evaporative,
“third space,” and blood losses. Typically, in the first hour
of anesthesia care, 1/2 of the fluid deficit is administered,
plus the maintenance fluid rate plus replacement for blood
loss. In the second and third hour of anesthesia care, 1/4 of
the fluid deficit is given per hour. This results in
replenishment of the fluid deficit within a three hour period.
Certainly if upon induction of anesthesia, the child appears to
be tachycardic due to dehydration, a fluid bolus may be
given. Frequently lactated Ringer’s or normal saline is given
in boluses of 10-20 cc/kg over 20-30 minutes. Laparotomy
may require 4-10 cc/kg/hr of crystalloid solution beyond
maintenance fluid to replace third space losses into
manipulated viscera and evaporative losses.
Many different local anesthetics can be used. Two suggested dose
regimens are:
Calculation of fluid deficit is used for periods of time up to 8
hours. I do not believe it is worth while calculating fluid
deficits for periods greater than 8 hours since most of our
patients have endogenous antidiuretic hormone (ADH). If
more fluid replenishment is needed beyond the 8 hour deficit,
this is done based on clinical observation of the patient’s
vital signs in the operating room.
D. CONDUCT OF THE ANESTHESIA TEAM
During the surgical procedure, communication must be open
between the anesthesiologist and the surgeon in order to
anticipate changes in the child’s physiological status that may
be induced by the surgical procedure. Cooperation between
the anesthesiologist and the surgeon is essential to best care
for the patient.
Medications;
Lidocaine 1.0% or 1.5% with/without epinephrine
6 mg/kg total dose (approximately 1 mg/kg/nerve)
Bupivacaine 0.25% or 0.5% with/without epinephrine
3 mg/kg total dose (approximately 0.5 mg/kg/nerve)
Complications
 pressure ischemia
a theoretical complication from injecting large amounts of local
anesthetic into fascial planes with limited space for diffusion.
Compartment syndromes with severe muscle loss have been
described in adults, but not children as of yet.
 hematoma
 infection
 neuropathy
OTHER PERIPHERAL NERVE BLOCKS
ilioinguinal and iliohypogastric nerve blocks
This block was reported first by Shandling and Steward in children in
1980. These nerves are major branches of the lumber plexus. These
blocks are good for analgesia for procedures such as inguinal hernia
repair, varicocele repair, testicular biopsy, and orchiopexy. These
blocks do not abolish the visceral pain from peritoneal traction or
exploration and manipulation of the spermatic cord and testicles.
Nevertheless, they allow for a decreased MAC during the surgery,
excellent postoperative analgesia with few complications, markedly
decreased postoperative analgesic requirements, a decreased
incidence of postoperative nausea and vomiting (most likely from
decreased requirements for intraoperative narcotics and the decreased
101 Resident Handbook
deep peroneal nerve (anterior tibial nerve)
A branch of the sciatic nerve (contributions from L4-S2), it is found
deep to the extensor retinaculum, next to anterior tibial artery on the
anterior surface of the distal end of the tibia between the tibialis
anterior and the extensor hallucis longus tendons at the level of the
medial malleolus. It innervates the adjacent joints and skin between
the first and second toes. It is blocked by placing the needle
lateral to the extensor hallucis longus until contact with the tibia is
made. Alternatively, the needle can be placed just lateral to the
extensor hallucis longus tendon on the dorsal aspect of the foot just
medial to the dorsalis pedis until bone contact is made. The needle is
withdrawn 1-2 mm, aspiration is performed and the injection made if
no blood is returned.
posterior tibial nerve
Another branch of the sciatic nerve, it is found deep under the flexor
retinaculum posterior to the pulsation of the posterior tibial artery at
the upper level of the medial malleolus. It innervates the skin and
muscles of the plantar surface of the foot. It is blocked by injection
posterior to the pulsation of the posterior tibial artery and advanced
until a pop is felt or contact with bone is made. After negative
aspiration for blood, injection of the local anesthetic is done.
sural nerve
A branch of the sciatic nerve, it is a cutaneous nerve that supplies
sensation to the lateral side of the foot and lateral side of the little
toe, as well as the heel. It is blocked by injecting a subcutaneous cuff
of local from the lateral malleolus to the Achilles tendon.
superficial peroneal nerve
Also a branch of the sciatic nerve, it supplies sensory innervation to
the dorsum of the foot. It is blocked by injecting a subcutaneous cuff
Resident Handbook 14
Based on the high metabolic rate of infants and children,
rapid response times are needed by the anesthesiologist. This
is what makes pediatric anesthesia such a challenging
subspecialty since not only does the anesthesiologist need to
know exactly what to do, but must make decisions and act in
an immediate fashion. Most often the actions concern airway
management. When residents experience difficulty in the
operating room the call needs to go out immediately to the
attending anesthesiologist for help if the attending
anesthesiologist is not present in the room.
When transferring the care of the patient to a colleague, it is
essential that information be relayed in an efficient and clear
manner regarding the nature of the surgery, the child’s
underlying disease conditions, the anesthetic management
and plan, and the tabulations of fluid and blood replacement.
All drugs should be labeled clearly by name and
concentration before turning the case over to another
anesthesiologist.
If the child’s condition warrants close attention by the
anesthesiologist during the procedure, it is acceptable to
forego documentation on the anesthetic record until a later,
more pertinent time. There is no need to risk patient
endangerment for purposes of documentation.
VI. THE PACU
Transport of the child to the PACU is done with care and
attention to patency of the airway, adequacy of ventilation, and
perfusion. Appropriate monitoring is utilized during this
transport. Frequently, this monitoring amounts to observation of
the child utilizing the anesthesiologist’s own senses of sight,
hearing, and touch. Pediatric patients are frequently placed on
their side for transport so that if emesis occurs, it will likely exit
the mouth and be less likely to enter the lungs. A hand is usually
placed over the patient’s mouth and nose, frequently while
providing a small amount of chin lift for airway support
15 Resident Handbook
during transport. This allows the anesthesiologist to feel air
movement in and out of the patient’s airway.
On arrival in the PACU, the PACU nurse is given a clear and
concise summary of the patient’s medical problems and the
surgical procedure that has occurred. It is also important to relay
specific information regarding the adequacy of the patient’s
airway and the expectations for needs for pain control. Orders
are written for fluid management and pain control, but also may
include other drug administration, blood tests, or oxygen
administration.
Resident Handbook 100
Complications





systemic toxicity
sciatic nerve injury or dysesthesia
delayed neuropathy
hematoma formation
infection
ANKLE BLOCK
For patients not going to the PACU, but rather directly to the
PICU or NICU, observe the following.*
1. Patients that are taken directly to the PICU are taken there at
the discretion of the attending anesthesiologist. It is that
person’s responsibility to ensure that at least twenty minutes
warning is given to the medical and nursing staff so that
equipment and personnel can be coordinated.
2. It is often in the best interest of patient care that direct
communication between the attending anesthesiologist and the
attending intensivist take place to resolve issues of medical
management.
3. Morbidity associated with transport is high. Communication
between the parties concerned is necessary to reduce the risk
of injury to the patient.
* Raeford E. Brown, Jr., M.D.
March 3, 1995
VII. THE POSTOPERATIVE VISIT
It is essential that the resident visit the child and family in the
postop period (within 48 hours) to assess the child’s experience
of the anesthesia procedure and to note any postoperative
complications that may have occurred. It is not adequate to
Ankle block. Block of the ankle generally requires five separate nerves to be blocked.
Three nerves can be blocked from the dorsal aspect of the foot (A) and two on either
side of the Achilles tendon (B). (Sites of injection are indicated by the circles with dots).
The ankle block is indicated for procedures on the plantar and dorsal
aspects of the foot. Discomfort associated with multiple injections
make this procedure objectionable to most awake pediatric patients.
It can be safely and easily be performed on anesthetized patients,
though. Block of the ankle requires anesthetizing five nerves:
saphenous nerve
The only branch of the femoral nerve distal to knee, it is found
subcutaneously and innervates the medial calf, proximal medial half
of the foot, and the metatarsophalangeal joint of the great toe. It is
blocked by a subcutaneous injection of anesthetic around the
saphenous vein anterior to the medial malleolus.
99 Resident Handbook
Anterior Approach
Resident Handbook 16
merely review the patient’s chart without speaking to the family
or the child since not all information is recorded on the chart.
A note needs to be placed in the child’s chart about the
postoperative visit. If no postoperative visit is performed, and
the child has had postoperative difficulties, the family may
assume that no one from the anesthesia department cares about
what happened to their child since the anesthetic was over.
Given that anesthesiologists have very little limited contact with
patients and their families it is important to utilize every
opportunity to establish rapport and communication with
families and patients so that the anesthesiologist is recognized
as a physician in their eyes. This is the only way the public will
ever come to know the important role that the anesthesiologist
plays as a physician, not technician, in the care of patients in
the operating room.
VIII. PAIN MANAGEMENT
(A and B) Sciatic nerve block (anterior approach). With the patient in a supine position, a line is drawn from the anterior iliac
spine to the pubic tuberosity (line 1). The greater trochanter is located, and another line is drawn parallel to the first (line 2). A
perpendicular line is dropped from line 1 at a point one third the distance laterally from the pubic tuberosity to the anterior iliac
spine (broken line 3). (C and D) A needle is inserted at the intersection of line 2 and the perpendicular line (in A, circle with
dot) until bone is encountered. The needle is redirected off the edge of the femur to the approximate posterior margin of the
femur (A), and after negative aspiration for blood, ease of injection is ascertained. Resistance to injection indicates that the
needle is within muscle or fascial bundle; the needle should be advanced until there is minimal resistance to injection or until a
paresthesia is elicited.
With the patient supine and the lower extremity in a neutral position,
draw a line from the anterior superior iliac crest to the pubic
tuberosity and a parallel line from the greater trochanter medially.
One-third from the median upper line, draw a perpendicular line
connecting the two parallel lines. The point of injection is on the
cross point on the line drawn from the greater trochanter. Insert a 22
gauge short bevel needle until the bone is contacted. Withdraw the
needle slightly and direct it medially and posteriorly until the
posterior margin of the femur in contacted. With a nerve stimulator
you may elicit motor activity identical to the above approach. After
aspiration, injection of medication should not meet any resistance. If
resistance is felt, the injection is either in the fascial plane or the
body of the muscle.
While on call, you will be responsible for carrying the pain
beeper (#405-6079) and responding to all calls. Most of these
calls will be from in-house sources regarding needs of patients on
the pain service or notification of new consults. Occasionally, a
parent of an outpatient with a chronic pain syndrome may call for
advice.
It is imperative that the staff person on pain call be notified
immediately of all interactions and interventions that have to do
with management of pain patients.
Inpatients should be assessed and examined prior to contacting
the on-call staff for the pain service. All patients should be seen
prior to alterations in therapy.
Please Inform The Pain Attending Of Any Pain Management Regimen
Changes Made Regarding A Patient While On ACH Rotation.
Michael L. Schmitz, M.D., Director Pediatric Pain Management
17 Resident Handbook
Guidelines for pain control modalities such as epidural infusions
and patient-controlled analgesia (PCA) pumps are outlined in
Appendix E.
Resident Handbook 98
Posterior Approach
IX. CONCLUSION
Once again, this manual is meant to be a guide, not a definitive
reading of essentials for pediatric anesthesiology. I appreciate all
comments for subsequent revision and improvement of this
manual which may make it more useful to the anesthesia
residents and fellows rotating at Arkansas Children’s Hospital in
Pediatric Anesthesia.
(A) Static nerve block (approach of Labat). The patient is
placed in a lateral position with the lower leg extended and the
upper leg, the one to be blocked, flexed; a line is drawn from
the greater trochanter of the femur to the posterior superior
iliac spine (line 1). A second line is drawn from the greater
trochanter to the coccyx (line 2). Line 1 is bisected, and a
perpendicular line is drawn from that point to line 2 (broken line
3); the point at which the perpendicular broken line intersects
line 2 (circle with dot) is the point of needle insertion. (B and C)
A 22-gauge needle is advanced perpendicular to the skin until
it strikes bone, or if the patient is awake, a paresthesia is
elicited.
Place the patient in the lateral decubitus position with the leg to be
blocked uppermost and flexed so the foot is at the popliteal fossae of
the dependent leg. This stretches the nerve so that it does not roll.
Make a mark on the greater trochanter of the femur and the posterior
superior iliac crest and connect the dots. Next make a line from the
greater trochanter to the sacral hiatus. From the midpoint of the first
line draw a perpendicular line to the second line. This is the point of
injection. Using a 22 gauge short bevel or a 3 1/2 inch 22 gauge
spinal needle (depending on the size of the patient) with a nerve
stimulator, advance the needle perpendicular to the skin until
dorsiflexion of the foot is seen. Aspirate and incrementally inject the
medications.
97 Resident Handbook
Complications
 accidental intravascular injection
aspiration for blood during incremental injections is strongly
indicated.
 hematoma formation
 temporary or permanent nerve injury
 infection
 sparing of the obturator and/or LFCN
SCIATIC NERVE BLOCK
The sciatic nerve is made from branches from L4-S3 and supplies
motor innervation to the extensor muscles of the hip and to flexors of
the knee and ankle. It supplies sensory innervation to the skin over
the back of the thigh and leg, extending from the sacrum to the
dorsum of the foot. It is often performed in conjunction with the
saphenous nerve block for anesthesia for the foot, or in conjunction
with the femoral, obturator, and/or the lateral femoral cutaneous
nerve for anesthesia for the lower extremity.
Resident Handbook 18
X. APPENDICES
APPENDIX A: COMMON DRUG DOSAGES
BENZODIAZEPINES



INDUCTION AGENTS









Medications
This nerve block is not well studied in children, but those that have
done a number of these suggest have used of 0.6-1.0 ml/kg of 0.5%
bupivacaine with/without epinephrine and have not observed toxic
levels of bupivacaine.
pentothal 3-6 mg/kg IV
propofol (Diprivan) 2-2.5 mg/kg IV
etomidate (Amidate) 0.2-0.3 mg/kg IV
ketamine (Ketalar) 1-2 mg/kg IV
MUSCLE RELAXANTS
Induction Doses:
Anatomy
The sciatic nerve emerges from the anterior aspect of the sacrum
through the great sciatic foramen and passes anterior to the piriform
muscle and through the sciatic notch posterior to the quadriceps
femoris muscle.
midazolam (Versed) 0.5 mg/kg po (max 15 mg) 15-30 minutes prior to
entering operating room, or
0.075 to 0.15 mg/kg IV/IM up to 5 mg maximum.
lorazepam (Ativan) 0.1 mg/kg po/IV up to 1-2 mg total.
diazepam (Valium) 0.3-0.5 mg/kg po 30 min. prior to anesthesia



succinylcholine 1-1.5 mg/kg IV for > 6 months of age
- 2 mg/kg IV for < than 6 months of age
- 5 mg/kg IM
rapacuronium (Raplon) 2 mg/kg for children, 1.5 mg/kg for adults
mivacurium (Mivacron) 0.3 mg/kg IV in two divided doses of
0.15mg/kg
rocuronium (Zemuron) 0.6-0.9 mg/kg IV
cisatricurium (Nimbex)
- 0.1mg/kg (child)
- 0.2 mg/kg (adult)
atracurium (Tracrium) 0.5 mg/kg IV
vecuronium 0.1 mg/kg IV
pancuronium 0.1 mg/kg IV
ANTICHOLINERGICS
Technique
There are several techniques of placing the sciatic nerve block, of
which the two most common ones are described below:

atropine 20 mcg/kg IV/IM, maximum 1.0 mg

glycopyrrolate (Robinul) 8-10 mcg/kg IV up to 0.6 mg per dose
19 Resident Handbook
ANTICHOLINESTERASE 

edrophonium 1 mg/kg IV

neostigmine 70 mcg/kg IV up to 5 mg maximum per dose
NARCOTICS
 morphine 0.1 mg/kg IV usually divided into about 3 doses every
5-10 minutes PRN in the PACU
 fentanyl 1 mcg/kg IV per dose for pain control. For anesthesia:
- 1-2 mcg/kg IV
- Low dose
- 5 mcg/kg IV
- Moderate dose
- 7-10 mcg/kg IV
- High dose
 hydromorphone (Dilaudid) 20 mcg/kg IV usually divided into 3
doses in the PACU for pain control and given every 5-10 minutes
PRN
 meperidine (Demerol) 1-1.5 mg/kg IM/IV
 codeine 0.5-1.0 mg/kg PO every 4 hours PRN pain
 oxycodone 0.05-0.10 mg/kg PO every 4 hours PRN pain
NSAIDS
 acetaminophen (Tylenol) 15 mg/kg PO/PR q4H or 20 mg/kg
PO/PR q6H.
 ketorolac (Toradol) 0.9-1.0 mg/kg IV/IM loading dose, then 0.5
mg/kg
- IV/IM every 6 hours up to no more than 5 days of treatment
- 10 mg PO every 6 hours up to no more than 5 days of
treatment
REVERSAL AGENTS
 flumazenil (Mazicon) 0.1-0.3 mg IV every 1-2 minutes to effect.
Reassess etiology of sedation after 0.5 mg administered.
 naloxone (Narcan) 1 mcg/kg IV/IM per dose. Titrate dose to
effect.
ANTIEMETICS
 metoclopramide 0.15-0.25 mg/kg PO/IV up to 10 mg q6H.
 droperidol 20-75 mcg/kg IV up to 1.25 mg qH6
 ondansetron (Zofran) 0.05 mg/kg IV up to 4.0 mg total q6-8H
 phenergan 0.25-0.5 mg/kg IM/PR q6H
Resident Handbook 96
caudad and 2 cm lateral to the anterior superior iliac crest. Advance
the needle perpendicular fashion through the skin until a pop is felt.
Inject the local in a fan fashion in a sagittal plane. Note that there is
no motor innervation of this nerve, so a peripheral nerve stimulator is
not useful.
Medications
Use of 0.25 mg/kg of 0.25% bupivacaine or 1 mg/kg of 1% lidocaine
without epinephrine will usually provide an adequate block.
Complications
This block is one of the safer blocks to perform in terms of having a
low incidence of complications. Since no major arteries travel with
the nerve at this location, risk of hematoma formation or
intravascular injection is remote. The two greatest risks are:
 temporary or permanent nerve injury
 infection
INGUINAL PARAVASCULAR NERVE BLOCK
This is an excellent block for analgesia for surgical procedures on the
anterior surface of the thigh. It has not been evaluated in children,
and is rarely used. It blocks the femoral, lateral femoral cutaneous,
and obturator nerves (L1-5).
Technique and Medications
Similar to a femoral nerve block (see above) but after the second pop
is felt, instead of directing the needle in a perpendicular plane, direct
the needle cephalad at a 30-45 degree angle up the femoral sheath,
applying distal pressure during the injection of medication to promote
cephalad flow. Although not established in children, use of 0.5 ml/kg
of 0.5% bupivacaine with/without epinephrine has been successfully
performed and shown to provide 2-4 hours of analgesia.
95 Resident Handbook
bupivacaine
lidocaine
0.5% with/without epinephrine
0.2-0.3 ml/kg (1-1.5 mg/kg) maximum 10 ccs.
onset 15-20 minutes, duration 2-4 hours
1.0% with/without epinephrine
0.2 ml/kg (2 mg/kg)
onset 10-15 minutes, duration 30-40 minutes
Complications
 accidental intravascular injection
aspiration for blood during incremental injections is imperative
 Hematoma formation
 Temporary or permanent nerve injury
 infection
 pseudoaneurysm formation
a delayed and unusual complication
LATERAL FEMORAL CUTANEOUS NERVE BLOCK
The lateral femoral cutaneous nerve (LFCN) supplies sensory
innervation to the skin on the anterolateral side of the thigh to the
knee. This nerve block is mainly used to supplement femoral and
sciatic nerve blocks, to relieve tourniquet pain, or for analgesia for
skin donor graft sites. In combination with the femoral nerve block it
is ideal for muscle biopsy for patients with suspected malignant
hyperthermia susceptibility, muscular dystrophy, and other
neuromuscular disorders--and may allow one to avoid general
anesthetic agents.
Anatomy
The LFCN is formed from branches from L2 and L3. It emerges
from the lateral border of the psoas muscle and passes obliquely
under the fascia iliaca to enter the thigh 1 - 2 cm medial to the
anterior superior iliac spine.
Technique
After a sterile preparation, place a 22 gauge short bevel needle 2 cm
Resident Handbook 20
MISCELLANEOUS
 caffeine benzoate 20 mg/kg IV q24H
 Hespan maximum 20 cc/kg per 24 hours
 cefazolin (Ancef Kefzol) 20 mg/kg IV q8H
CAUDAL NERVE BLOCK
 bupivacaine maximum 2.5 mg/kg. Concentrations used 0.125 0.5% bupivacaine with 1:200,000 epinephrine. Volume 0.5 cc/kg
for an extremity, 1 cc/kg for surgical site below umbilicus. 1.4
cc/kg for a T4 level. Note for higher levels, lower concentrations
of bupivacaine are used and will result in less total analgesia. For
most surgical procedures, 0.75-1.0 cc/kg up to 20 cc maximum of
0.25% bupivacaine with 1:200,000 epinephrine. Bupivacaine
caudals generally provide 4-6 hours of analgesia.
 butorphanol 30 mcg/kg ED up to 1.0 mg. Note: butorphanol
usually provides for 8-12 hours of analgesia. It usually is added to
a bupivacaine solution for caudal administration.
APPENDIX B: FLUID REPLACEMENT
MAINTENANCE FLUIDS




First 10 kg
Second 10 kg
For 20-50 kg
> 50 kg
4cc/kg/hr
2 cc/kg/hr
1cc/kg/hr
0.5 cc/kg/hr
Deficit = Maintenance fluid rate x # of hours NPO (max 8 hours)
DEFICIT REPLACEMENT
 First hour
 Second hour
 Third hour
1/2 of fluid deficit plus maintenance
1/4 of fluid deficit plus maintenance
1/4 of fluid deficit plus maintenance
21 Resident Handbook
Resident Handbook 94
 Fourth hour and beyond maintenance fluid
Replacement of blood loss with crystalloid solutions.
 crystalloid = 3 x blood loss
Femoral nerve block.
Note that the femoral
nerve lies lateral to the
femoral artery. The
appropriate dose of
local anesthetic is
administered while
maintaining pressure on
the nerve sheath distal
to the site of injection
just below the inguinal
ligament; local
anesthetic is thus
forced proximally and
all three femoral nerve
branches can often be
blocked with a single
injection.
Replacement of blood loss with colloid solutions
 colloid solution = 1 x blood loss
Fluid boluses for mild to moderate hypovolemia
 crystalloid 10-20 cc/kg over 20 minutes
 colloid 10 cc/kg over 20 minutes
APPENDIX C: AIRWAY EQUIPMENT
INTERNAL DIAMETER OF ENDOTRACHEAL TUBES
AGE
Premature Infant
1000 gm
1000-2500 gm
SIZE
Neonate to 6 mo
3.0-3.5 mm
6 mo to 1 yr
3.5-4.0 mm
1-2 yr
4.0-4.5 mm
Beyond 2 yr
Age (yrs) + 16
4
2.5 mm
3.0 mm
Technique
THE SIZE OF LARYNGOSCOPE BLADES
AGE
Premature
Neonate
Neonate-2 yr
2-6 yr
6-12 yr
Over 12 yr
Miller
0
0
1

2
3
Wis-Hippel



1.5


McIntosh




2
3
After sterile preparation, identify the femoral artery pulse 1 - 1.5 cm
below the inguinal ligament. Using a 22 gauge short bevel needle,
enter the skin in a perpendicular fashion just lateral to the pulsation
(remember the order in from the genitalia laterally vein, artery, nerve
[VAN]). Advance the needle until two distinct pops are felt. If using
a nerve stimulator, watch for quadriceps contractions (but not
sartorius contractions, which indicate the needle has not been
advanced far enough). Aspirate and inject the medication in 0.5 - 2
cc increments, depending on the size of the patient.
Medications
There are at least two safe medication schemes for femoral nerve
blocks:
93 Resident Handbook
Femoral Nerve Block
The femoral nerve block is indicated for relief of quadriceps muscle
spasm, pain free manipulation of middle third femoral shaft fractures,
and to augment other lower extremity blocks. This block can be
performed as either a single shot or continuous block.
Anatomy
The femoral nerve is made of contributions from L2, 3, and 4 and
supplies motor innervation to the quadriceps and sartorius muscles,
sensory to the medial ligament of the knee joint, overlying skin of the
anterior aspect of the thigh, and to the periosteum of the femoral
shaft. The saphenous nerve is the only continuation of the femoral
nerve below the knee and supplies sensory innervation to the medial
aspect of the calf, the proximal medial half of the foot, and the
metatarsophalangeal joint of the great toe. The femoral nerve passes
in the groove between the psoas major and the iliac muscles and
enters the thigh under the inguinal ligament lying anterior to the
iliopsoas muscle and immediately lateral to the femoral artery.
Resident Handbook 22
FORMULAS FOR DEPTH OF INSERTION OF
ENDOTRACHEAL TUBE
1. Age (years)  2 + 12
2. Weight (kg)  5 + 12
APPENDIX D. BLOOD COMPONENTS
COMPONENT DOSE REFERENCE SHEET
NEONATES:
Maintenance Transfusions:
 RBC: 10 cc/kg (body weight) (should raise Hct by 3%)
 FFP: 10 cc/kg (contains 1 international unit of Coag Factor
activity per cc)
 PLT: 10 cc/kg (should raise Plt ct by 60,000)
 PP: 10 cc/kg (should raise Plt ct by 200,000)
 Cryo: 0.5 bags/kg (should raise fibrinogen by 150 mg/dl AND raise
Factor VIII activity by 75%)
For Surgery: 50-100 cc in aliquot bag
If order is placed for 1 unit, aliquot into 2 bags before issue
NON-NEONATES:
Therapeutic Transfusions:
 RBC: 10-15 cc/kg (should raise Hct by 3%)
 FFP: 10 cc/kg (contains 1 international unit of Coag Factor
activity per cc)
 PLT: 10 cc/kg or 1 unit/10 kg (should raise Plt count by 60,000)
 PP: 10 cc/kg (should raise Plt ct by 200,000)
 Cryo: 0.5 bags/kg (should raise fibrinogen by 150 mg/dl AND raise
Factor VIII activity by 75%)
Hemophilia A or von Willebrand patients should receive the
appropriate pharmacy product ... NOT Cryo.
Femoral nerve block. Diagram showing the course of the needle piercing fascia lata
and iliaca.
23 Resident Handbook
HEM/ONC patients 1 or 2 pp usually - may need to Reduce
Volume if pt is volume sensitive or because of ABO incompatible
units.
Trauma: (Emergency Released 0 negs)
Age:
0-5 years
1-2 units in transport box
5-10 years
2-4 units in transport box
>10 years
> 4 units in transport box
Burns:
Pediatrics: as above
Adults: as many units as are ordered ...Verify use of FFP before
thawing, many times it is only to be on hold.
APPENDIX E: PAIN MANAGEMENT GUIDELINES
A. EPIDURAL REGIMENS
Epidural Medications (Most Commonly Used)
 Bupivacaine
 Butorphanol (Stadol)
 Fentanyl
 Morphine
Resident Handbook 92
decrease the risk of CNS toxicity from intravascular injection
but not cardiac toxicity.
Complications;
 convulsions more likely when using the transarterial approach. Must
carefully aspirate every 1-3 ccs prior to injecting the next volume
of anesthetic.
 dysrhythmias
usually related to systemic absorption of epinephrine containing
solutions or intravascular injection of either local alone or local
containing epinephrine.
 hematoma
 direct nerve injury
 intravascular injection
 pneumothorax
more likely with the supraclavicular and interscalene approaches
than the axillary approach.
 infection
LOWER EXTREMITY PERIPHERAL NERVE BLOCKS
Most Common Combination Infusion Combinations &
Concentrations
 Fentanyl 0.0005% (5 mcg/ml) + Bupivacaine 0.075%
(750 mcg/ml)
 Morphine 0.005% (50 mcg/ml) +
Butorphanol 0.001% (10 mcg/ml)
 Morphine 0.005% (50 mcg/ml) +
Butorphanol 0.001% (10 mcg/ml) +
Bupivacaine 0.075% (750 mcg/ml)
 Morphine 0.005% (50 mcg/ml) +
Butorphanol 0.001% (10 mcg/ml)
(Bupivacaine and Fentanyl are used when the end of the epidural
catheter is near the affected dermatomes.)
The sensory innervation of the lower extremity is presented. Note that anesthesia of
the lower extremity requires block of the femoral nerve (A) (and its branches) as well
as the sciatic nerve (B).
91 Resident Handbook
Characteristic movements of the fingers, wrist, and elbow in response to nerve stimulation. (Cousins MJ,
Bridenbaugh PO (eds); Neural Blockade in Clinical Anesthesia and Management of Pain, 2nd ed, p. 406.
Philadelphia, JB Lippincott, 1988)
Technique
Resident Handbook 24
Dosages for boluses (usually to precede infusions)
 Bupivacaine: 1cc/kg (up to 10 cc, usually) of 0.25% Bupivacaine
with 1/200,000 epinephrine for pain control in the conscious
patient.
 Morphine 50-60 mcg/kg (up to 5 mg, maximum) in combination
with Butorphanol 10-12 mcg/kg (up to 1 mg, maximum),
respectively.
 A combination of the above two regimens.
 Fentanyl 0.5-1.0 mcg/kg--only if the patient is under your direct
observation for the next hour.
Dosages for Infusion
 Bupivacaine 7.5-15 mcg/kg/hr
 Butorphanol 1-1.2 mcg/kg/hr
 Fentanyl 1 mcg/kg/hr
 Morphine 5 mcg/kg/hr
(Simplified: 2 cc/10 kg/hr for the Fentanyl/Bupivacaine solution
listed above, and 1 cc/10 kg/hr for any of the
Morphine/Butorphanol±Bupivacaine solutions listed above)
As in axillary blocks in adults, one can use the transarterial, intrasheath, or nerve stimulator techniques to perform this block. Since
the block in children is usually performed after the child has received
a general anesthetic, the nerve paresthesia approach is not useful.
Often the axillary sheath can be palpated in children.
B. PCA REGIMENS
(Usual starting doses for patients pushing their own
PCA buttons)
Medications
 Morphine:
Several dosing regimens have been suggested for use in brachial
plexus anesthesia. The most important factor appears to be the
volume of anesthetic injected, rather than the concentration. The
three most commonly used agents are lidocaine, mepivacaine, and
bupivacaine. When using 1% mepivacaine or lidocaine the suggested
volume is 0.7 cc/kg; for 0.5% bupivacaine it is slightly lower at 0.6
ml/kg. Campbell and colleagues showed that using 2-3 mg/kg of
bupivacaine in a total volume of 0.6 ml/kg allowed an adequate block
without producing toxic levels. The addition of 1:200,000
epinephrine may decrease the rate of vascular absorption and
potential for toxicity. Some believe that bupivacaine should be
avoided for brachial plexus anesthesia given in the axilla because of a
higher risk of intravascular injection. The administration of
benzodiazepines pre- or intra-operatively may also
Background:
Bolus:
Lockout:
Max.
boluses/hr:
 Hydromorphone
(Dilaudid)
Background:
Bolus:
Lockout:
Max
boluses/hr:
15 mcg/kg/hr
(maximum 1.0 mg)
15 mcg/kg
(maximum 1.0 mg/hr)
8-10 minutes
4-6
3 mcg/kg/hr
(maximum 0.2 mg)
3 mcg/kg
(maximum 0.2 mg/hr)
8-10 minutes
4-6
25 Resident Handbook
 Fentanyl
Resident Handbook 90
Background:
Bolus:
Lockout:
Max
boluses/hr:
 Meperidine
(Demerol)
6-8
Background:
Bolus:
Lockout:
Max
boluses/hr:
0.2 mcg/kg/hr
(maximum 10 mcg)
0.3 mcg/kg
(maximum 15 mcg)
5 minutes
110 mcg/kg/hr
(maximum 7.5 mg/hr)
110 mcg/kg
(maximum 7.5 mg)
8-10 minutes
4
(Consult with staff always since normeperidine toxicity is an
issue).
C. NARCOTIC INTERCONVERSION TABLE
Narcotic
Morphine
Hydromorphone
Meperidine
Methadone
Fentanyl
Sufentanil
Alfentanil
Nalbuphine
Buprenorphine
Codeine phosphate
Oxycodone
Anileridine
Levorphanol tartrate
Oxymorphone
Diamorphine
Pentazocine
IM/IV Dose
10 mg
2 mg
75 mg
10 mg
750-1,250 mcg
150-250 mcg
5,000 mcg
10-15 mg
0.3 mg
25 mg
2 mg
1.5 mg
5-8 mg
60 mg
PO Dose
20-30 mg
7.5 mg
300 mg
20 mg
130 mg
10-15 mg
75 mg
4 mg
10-15 mg
180 mg
UPPER EXTREMITY PERIPHERAL NERVE BLOCKS
brachial plexus block;
There are three techniques of blocking the brachial plexus in adults
(axillary, supraclavicular, and interscalene), but the axillary approach
is the most used and safest in smaller patients because it is easier to
perform, does not require an awake patient, and has less risk of
blocking the phrenic or recurrent laryngeal nerves (as these are much
more proximal to the injection site with supraclavicular and
interscalene blocks), or causing a pneumothorax. Block of the
phrenic nerve in small patients can lead to postoperative respiratory
failure as infants and small children are heavily reliant on the
diaphragm for normal respiration. This block has to date not been
extensively used or studied in the pediatric population.
Anatomy
The brachial plexus is made of nerve contributions from C5-T1. The
nerve sheath for the brachial plexus in the axilla contains the median
nerve anteriorly, the ulnar nerve posteriorly, and the radial nerve
posterolaterally in relation to the axillary artery. In addition,
blockade of the musculocutaneous nerve (in the belly of the
coracobrachialis muscle that supplies the sensation to the medial
forearm) and the inter-costobrachial nerve (subcutaneously) must be
done as these nerves are frequently not located in the axillary sheath
at this level.
The anatomic relationships of
the brachial plexus are
presented. Note that the
fascial sheath envelops the
nerves and the axillary artery
and vein; the
musculocutaneous nerve lies
within the body of the
coracobrachialis muscle.
Local anesthetic injected
within the sheath (on either
side of the axillary artery)
produces a satisfactory block.
89 Resident Handbook
Resident Handbook 26
 sympathetic blockade
in infants and children, sympathetic blockade is not usually
associated with significant hypotension or bradycardia
Lumbar and Thoracic Epidurals
Lumbar and thoracic epidural anesthesia are not as well studied in
children, but are easy to do and with good outcomes. The benefits
and complications are similar to those for caudal epidural blockade.
While many pediatric anesthesiologists will place a lumbar epidural
in patients after they have received a general anesthetic, most
recommend only doing thoracic epidurals in awake patients to elicit
signs of neural stimulation. Also remember the anatomy of the spinal
cord and where it terminates in the infant compared to the adult.
Below are listed two dosing regimens for lumbar epidural blockade:
TABLE: Equations for Determining Doses of Local Anesthetic Solution for Lumbar Epidural Blockade
Study
a
b
Patient Age
(years)
Ruston
0-10
Bromage
4-20
Equation
0.5 +
(weight in lb)
2
Anesthetic Solution
Lidocaine 1% + epinephrine
1:200,000
a
0.106 + (years x 0.075)
b
Lidocaine 2% + epinephrine
1:200,000
Dose in total milliliters
Dose in milliliters per spinal segment
Despite the above table, no formula or dose schedule predictably
ensures the desired level of lumbar or thoracic epidural block for
infants or children. As in adults, neither height, age, nor weight is a
reliable predictor of anesthetic level. A study by Schulte and Rahlfs
seems to correlate best between the age of the child and dermatomal
effects of local anesthesia. Their formula is:
Volume per spinal segment = 0.1 X age (in years)
Also, in children under the age of 5 years, the epidural fat is
compliant enough to pass a styletted caudal catheter to the
appropriate lumbar or thoracic level, thus avoiding the risks of
placing thoracic catheters in small patients. Although lumbar and
thoracic epidurals can be placed safely in small children and infants,
hey should only be performed by those expert in the technique, as the
risks are much greater in children.
D. Other Control Measures for Pain










Tens unit
Relaxation therapy
Distraction techniques or introduced coping mechanisms
NSAID's (see Appendix A).
codeine 0.5-1.0 mg/kg PO Q4° PRN pain.
oxycodone 0.05-0.10 mg/kg PO Q4° PRN pain.
MS Contin, methadone, other PO narcotics--consult staff
amitriptyline (Elavil) or other TCA's--consult staff
fluoxetine (Prozac) or other SSRI's--consult staff
anticonvulsants (phenytoin, carbamazepine, valproate, etc.)-consult staff
 clonidine (alpha-2 agonist)--consult staff
APPENDIX F: QI CHART REQUIREMENTS
I. PRE-ANESTHETIC EVALUATION:
1. Complete medical and surgical history, including
ASA status
2. Complete physical exam, including vital signs (HR, RR,
BP, Temp, Weight)
3. Appropriate lab data recorded (if no labs, put "NR")
4. Anesthetic plan is recorded
5. Your signature
II. INTRA-OP RECORD:
1. Reevaluation
2. Equipment check
3. ID and consent checked
4. Monitors recorded
5. ECG at least every 15 min
6. SpO2 at least every 15 min
7. ETCO2 at least every 15 min
8. Temperature at least every 15 min
9. Anesthetic drugs and dosage recorded
10. BP recorded at least every 5 min
11. Type and amount of fluids and blood recorded
12. IV site recorded
13. IV size recorded
14. Pt reassessed at end of case and given PAR score
27 Resident Handbook
III. POST-OP NOTE/CONSULT:
EVERY patient must have a post-op note written, after leaving
the recovery room but before 48 hours post-op. This should
involve more than circling "NONE" for complications. Essentially
all out-patients get a post-op note because they can't be discharged
without it. However, many inpatients never have a documented
post-op visit, especially emergency cases done at night and on
weekends, burn unit patients, and patients who return directly to
an ICU bed post-op.
APPENDIX G: OUTLINE OF PREOP NOTE
A preop note should fulfill these functions:
1. It carries the heading “Anesthesia Preop Note”
2. It reviews the important problems presented by the patient. This
can be done by a series of numbered paragraphs. With very
complex patients, it may help to organize problems by organ
system (ie Cardiovascular, Pulmonary, Neuro, etc.) This outline
should include the expected or feared consequences of each of
these problems. It should tell how each problem will be handled.
3. List allergies and medications
4. Physical exam: height / weight / vital signs
Evaluation should be directed toward:
a) Airway: dentition; range of motion of TMJ and cervical
spine, mouth opening, ability to see the uvula; distance
between thyroid cartilage and chin; position of trachea
(midline or deviated)
b) Heart and lungs; rales; wheezing, rhonchi, murmurs, S3, S4;
bruits
c) IV access, Allens test, needle insertion sites for regional
anesthesia or invasive monitoring should be inspected for
local infection, evidence of prior trauma or deformity
5. Pertinent laboratory values
6. Assignment of one of the ASA Physical Status Classes:
 Class I - healthy patient
 Class II - mild systemic disease

Resident Handbook 88
bupivacaine. In fact, in children under the age of 5, 0.25%
bupivacaine with epinephrine can give up to 22 hours of analgesia
with minimal motor effects. A benefit of administering only narcotic
or non-narcotic analgesics is the absence of motor or autonomic
block, less morbidity associated with an inadvertent intravascular
injection, and up to 36 hours of analgesia. Frequently 0.1-0.15 mg/kg
of a 0.5 mg/kg solution of morphine is used. Higher doses than this
greatly increases the incidence of delayed respiratory depression, and
with all centrally administered narcotics, the patient should receive
monitored continuous care for at least 24 hours post-administration.
Complications
The failure rates of caudal blockade range between 2-29%. The rate
is usually attributed to inadequate volume or concentration of local
anesthetic, inexperience of the performer, or abnormalities of the
sacral anatomy. In experienced hands, the failure rate is very low.
Other reasons for failure include:
 misplacement of local anesthetic into the bone marrow
(which may present as an intravascular-type injection reaction)
 periosteal injection
 injection into the posterior sacral ligaments
 injection into a decoy hiatus
 injection into the anterior sacral wall or the pelvis
 injection into a lateral foramen
(which may demonstrate itself as a partial block).
 lower extremity muscle weakness
the inability to walk for up to 6 hours is seen in up to 31% of
patients when 0.5% bupivacaine is used
 urinary retention
 intravascular injection
 subarachnoid injection
 infection
meningitis, cellulitis, arachnoiditis, epidural abscess, hematoma
 temporary or permanent neurologic injury
while this is a risk, I have never read of or heard of an infant or
child with this complication. In addition, many colleagues I have
questioned have not either.
87 Resident Handbook
Resident Handbook 28
the needle is in the caudal canal. Aspirate, administer a test dose, and
if negative inject in small increments (as described above.)
Medications
TABLE: Equations for Determining Doses of Local Anesthetics for Pediatric Caudal Anesthesia
Study
Spiegel
Patient Age
41
2 days-14 years
Fortuna & Santos
56
Schulte-Steinberg &
54
Rahlfs
Lourey &
51
McDonald
Takasaki et al
53
0-10 years
7 weeks - 12 years
8 months-10 years
0-7 years
<8 kg
Dose
Lidocaine or tetracaine
b
(ml)
& procaine variable
% and combination
10 mg/kg
Lidocaine 0.5-2.0%
12.5 mg/kg
Lidocaine 0.5-2.0%
0.056 + (years x
Lidocaine 1% with
c
0.097)
epinephrine 1:200,000
3-4 mg/kg
Lidocaine 1%
4+
Da - 15
2
1 mg/kg
c
(kg x 0.078) - 0.17
>8 kg
Satoyoshi &
42
Kamiyama
55
Melman et al.
28 days -11 years
0-4 years
Local Anesthetic
Solution
(% weight in volume)
b
D - 13 (ml)
4 mg/kg or 1.6
ml/kg
Level of
Analgesia
T4 - T 2
T12
T10
Not mentioned
Bupivacaine 0.2%
Lidocaine 1% with
epinephrine 1:200,000
Lidocaine 1.5% with
epinephrine 1:200,000
Bupivacaine 0.20.375%
Bupivacaine 0.25% with
epinephrine 1:200,000
T4-T5
T4-T5
a
D = The distance from C 7 to the sacral hiatus, in centimeters.
Total dose.
c
Dose in milliliters per spinal segment.
b
Three important variables determine the quality, duration and extent
of a caudal block: volume, total dose, and concentration of local
anesthetic. Usually local anesthetics are used in the caudal space, but
narcotics and non-narcotic analgesics (ex. clonidine, Stadol) have
also been used with good success in infants and children. Extensive
literature exists reporting multiple successful formulas for
determining the amount of local anesthetic to use to obtain certain
dermatoma levels. There is no agreement whether the age, weight, or
height is the best criteria for determining the dose of anesthetic to use
though. A study by Schulte-Steinberg and Rahlfs states that using
Lidocaine 1%, Mepivacaine 1%, or Bupivacaine 0.25% 0.1
ml/segment per year of life in prepubertal children is a reliable
method for determining anesthetic dose. I usually use 0.25%
bupivacaine with 1:100,000 or 1:200,000 epinephrine 0.5-0.75 cc/kg
for sacral levels, 1 cc/kg for lumbar levels, and 1.25 cc/kg for
thoracic levels with a maximum dose of 20 ccs. There is no
additional benefit for analgesia in giving higher concentrations of
 Class III - severe systemic disease that limits activity but is
not incapacitating
 Class IV - incapacitating systemic disease that is a constant
threat to life
 Class V - moribund patient not expected to survive 24 hours
with or without operation
 E
- If the procedure is performed as an emergency
7. It may ask for further studies, therapy or consultation
8. It documents informed consent to the planned anesthetic
9. It is signed legibly by an anesthesiologist
APPENDIX H: ANESTHESIA MACHINE CHECK-OUT
AND IMMEDIATE PRE-ANESTHESIA
PREPARATION: SHORT FORM
Room
1. Table Trendelenburg and is locked
2. Suction and catheter or Yankauer, scavenger
Machine
3. Battery test appropriate to machine: power on: machine attached
to power outlet.
4. GASES - correct gases in correct yokes and tanks: hoses correct
5. All valves closed: ensure full range of flows without sticking or
erratic behavior
6. O2 - adequate reserve in cylinders
(If piped O2 to be used - 500 psi on one
(If cylinder O2 to be used - 500 psi in one; 1500 psi in 2nd
7. N2O adequate reserve in cylinders - 740 psi in each cylinder
8. Turn off all cylinders; leave tank wrench on closed O2 cylinder
9. FAIL-SAFE/O2 RATIO:
a) O2 1.5 LPM:N2O > 5 L/M. Check: charge In O2 flow alarm
b) If not (a), check fail-safe:run N2O, disconnect O2 supply;
bring O2 pressure to zero. Check N2O shut-off for alarm.
10. Vaporizers: labeled, not empty or full, caps closed, shut off
when done
11. LOW PRESSURE SYSTEM - Check for leaks: (expect some
OHIO machines): open the vaporizer to be used. Turn on
O2 flow 300/min/min: route O2 flow through vaporizer;
Resident Handbook 86
29 Resident Handbook
Anatomy
occlude gas delivery tubing; listen for leaks, ensure that
rotameters fall slowly and then bounce back when
occlusion is released.
12. Place anesthesia bag on circuit elbow; fill ventilator bellows;
turn on ventilator to check ventilation function
BREATHING CIRCUIT
13. OXYGEN ANALYZER: Turn on and calibrate. Connect to
anesthesia circuit.
14. Soda lime is present and not exhausted.
15. Reservoir bag, corrugated tubing and Y-piece, elbow connector
16. Uni-directional valves competent and patent
17. Check circuit for leaks; 40 cm of H2O for 5 seconds; no inflow;
no pressure decrease
18. Release pressure by pop-off. Proper sequence; no connections
broken after leak test.
AIRWAY
19. Masks of appropriate sizes: oral and nasal airway
20. LARYNGOSCOPE and spare
21. Endotracheal tube and spare - check cuff, proper size
22. Lubricant and stylette
23. Proper pillow for patient’s head
MONITORING (Locate, turn on, calibrate, etc. as needed)
24. Precordial or esophageal stethoscope
25. EKG
26. Blood pressure cuff, Dinamap or equivalent
27. Temperature monitoring device
28. Pulse oximeter
29. CO2 analyzer
DRUGS & IV’s
30. Thiopental or other IV hypnotic
31. Atropine, glycopyrrolate
32. Succinylcholine
33. Extra syringes and needles
34. IV Set, IV Supplies
35. Supplies specific for the case
36. Check availability of blood products as indicated
The sacrum is a triangular bone formed by the fusion of five sacral
vertebrae. Ossification is incomplete at birth and it continues to
ossify until eight years of age. The sacral hiatus is an opening into
the sacral canal formed by the failure of fusion of the fifth sacral
vertebral arches. Remnants are prominent sacrally and are referred to
the cornua on either side of the hiatus. The opening is covered by the
sacrococcygeal membrane. The sacral hiatus is easily palpated in
infants and prepubertal children. A prominent sacral fat pad develops
during puberty that may obscure normally prominent cornua. There
is a large variation in the anatomy secondary to the frequent
occurrence of developmental defects which accounts for a portion of
failed blocks. Because of the relative stability of the anatomical
landmarks, this block can be easily performed in either the lateral
decubitus or prone position. In small infants and neonates, recall that
the dural sac may end as low as S3, and the sacrum is narrower and
flatter, so advancement of the needle more than 2-5 mm may result in
a total spinal anesthetic. Also, the epidural fat in newborns and
children less than five years is gelatinous, spongy, and less compact.
There is less resistance to the cephalad spread of local anesthetics,
and a styletted catheter can easily be passed to the lumbar or low
thoracic vertebrae in these patients.
Technique
The caudal block is performed in either the lateral decubitus or prone
position. Identify the tip of the coccyx, then with the index finger
move cephalad until locating the sacral hiatus, which is felt as a
depression in the bone. Superior and on either side of the hiatus, the
sacral cornua are palpable. Mark the cornua and the tip of the coccyx
and draw a triangle. Draw a perpendicular line from the base of the
triangle to the apex, and divide this line into thirds. The caudal most
intersection marks where the needle is to be inserted, and the other is
the center of the sacral hiatus. Advance the needle at a 25 degree
angle to the skin with the bevel facing down (to avoid piercing the
anterior sacral wall--which is the most common reason to aspirate
blood) until a pop is felt. Then drop the hub of the needle to 15
degrees and advance 2 millimeters more to assure that the bevel of
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85 Resident Handbook
 total spinal usually demonstrated as apnea with no change in the blood
pressure or heart rate. In neonates, the rate of administration of
the local does affect the level, whereas in adults it does not.
Several cases of total spinals have been reported following rapid
administration of usually safe doses of anesthetics.
 epidermoid tumors none reported in anyone who has received a spinal as an infant, ...
so far.
Caudal block
The caudal block is the most frequently utilized regional anesthetic in
infants and children for lower abdominal, upper abdominal, and
lower extremity procedures. There is available data on
pharmacokinetics and pharmacodynamics in all age groups, so drug
doses are known. Well defined landmarks, simplicity, safety, ease of
performance, less postoperative agitation secondary to excellent
analgesia, decreased incidence of nausea and vomiting, earlier
resumption of activities, and more rapid emergence from general
anesthesia from a decreased use of narcotics all make this a superb
anesthetic adjunct to general anesthesia.
Sites of misplacement of local
anesthetics for caudal block
anesthesia. Note that injection
may be made into bone marrow
(A), into subperiostium (B), into
posterior sacral ligaments (C),
into a false “decoy” hiatus (D),
into the anterior sacral wall and
possibly out into the pelvis (E), or
into a lateral foramen, producing
a limited block (F). (Cousins MJ,
Bridenbaugh PO [eds]: Neural
Blockade in Clinical Anesthesia
and Management of Pain, 2nd ed.
Philadelpia, JB Lippincott, p.
378. 1988)
APPENDIX I. INHALED ANESTHESIA
CHARACTERISTICS
31 Resident Handbook