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- May 30, 2008
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tonsillectomy and adenoidectomy, that is.
this is a basic procedure, but turnover time and keeping surgeons, patients, nurses, and families happy and impressed with your smoothness is an art. i see a LOT of variability within my group. my recipe is still evolving - i still learn new tricks often and my routine is not set in stone.
here's my current recipe (i'd love to see some others' recipes and hear opinions...):
i pull all meds at the beginning of the day
1. minimize premed usage but give it if necessary (i have cartoons and video games on my phone)
2. mask induction (n2o, sevo straight to 8, get em deep during IV (usually by the circulator)
3. if kid acts nice during induction, no meds for intubation. cuffed oral rae. most kids just keep right on breathing...
4. sevo maintenance (decreasing setting during case; 8, 4, 3, 2...). n20 OFF - maintain spont ventilation throughout procedure. 0.3% fio2 (2L/min).
5. morphine 50-150ug/kg IV depending on the rr/mv
6. decadron 0.5mg/kg up to 8mg, zofran 0.1mg/kg
7. IV tylenol - 15mg/kg (i push this in)
7.5. IVF 10-20mL/kg - LR
8. volatile off (flows 2L/min) when surgeon gives 3 minute warning.
9. "awake" extubation - if airway/breathing is minimal trouble/risk factors during case, i extubate when kid wakes up or when etsevo is 0.3 - whichever comes first.
we have great pacu nurses and our surgeons are fast and dry.
if the kiddos have severe OSA (or morbid obesity) and/or periop agitation or h/o emergence delirium i sometimes substitute or replace morphine with dexmedetomidine 50-200ug/kg IV.
if kiddos have borderline URI's, asthma, or give me any trouble with induction, i may give some propofol with induction/intubation to minimize bronchospasm and i may extubate more on the awake side (or deep side sometimes).
this is my current recipe but i am flexible still and try to be open to trying new things...
what do you guys do?
this is a basic procedure, but turnover time and keeping surgeons, patients, nurses, and families happy and impressed with your smoothness is an art. i see a LOT of variability within my group. my recipe is still evolving - i still learn new tricks often and my routine is not set in stone.
here's my current recipe (i'd love to see some others' recipes and hear opinions...):
i pull all meds at the beginning of the day
1. minimize premed usage but give it if necessary (i have cartoons and video games on my phone)
2. mask induction (n2o, sevo straight to 8, get em deep during IV (usually by the circulator)
3. if kid acts nice during induction, no meds for intubation. cuffed oral rae. most kids just keep right on breathing...
4. sevo maintenance (decreasing setting during case; 8, 4, 3, 2...). n20 OFF - maintain spont ventilation throughout procedure. 0.3% fio2 (2L/min).
5. morphine 50-150ug/kg IV depending on the rr/mv
6. decadron 0.5mg/kg up to 8mg, zofran 0.1mg/kg
7. IV tylenol - 15mg/kg (i push this in)
7.5. IVF 10-20mL/kg - LR
8. volatile off (flows 2L/min) when surgeon gives 3 minute warning.
9. "awake" extubation - if airway/breathing is minimal trouble/risk factors during case, i extubate when kid wakes up or when etsevo is 0.3 - whichever comes first.
we have great pacu nurses and our surgeons are fast and dry.
if the kiddos have severe OSA (or morbid obesity) and/or periop agitation or h/o emergence delirium i sometimes substitute or replace morphine with dexmedetomidine 50-200ug/kg IV.
if kiddos have borderline URI's, asthma, or give me any trouble with induction, i may give some propofol with induction/intubation to minimize bronchospasm and i may extubate more on the awake side (or deep side sometimes).
this is my current recipe but i am flexible still and try to be open to trying new things...
what do you guys do?
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