Pediatric dosing

[pinkMD12]

I am in PP and most of my colleagues use only sevoflurane for bmt & adenoids - very rarely use propofol or fentanyl. I normally induce with gas, use 2mg/kg propofol to intubate and titrate in 1mcg/kg fentanyl before case in done. Sometimes I even use up to 4mg/kg in older kiddos if they’re light when I go to put the tube in. I’ve been told by multiple more senior colleagues that might be too much. What do other folks do?
Also, full disclosure these cases are 15-20 minutes at most.
Thanks.

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[Justice4all]

Any difference in total OR time to your colleagues? Unlikely. Keep doing what you are doing!

 

[deleted162650]

Kids that get only sevo are nightmares in PACU. Some opioid really helps smooth things out. Skip the oral pre-med too (unless the kid is really losing their S in preop).

Titrate fent to RR/etCO2. I don’t have a pre-conceived dose in mind, but 1mcg/kg as soon as the IV is in is a reasonable starting point.

 

[dhb]

Kids that get only sevo are nightmares in PACU.

Not the ones that get only sevo and clonidine (and maybe some other stuff but not fentanyl)

 

[2010houston]

For bmt + adenoids I usually:
- no propofol usually *if* they’re deep enough by the time we have an IV, otherwise a little (?prob 2mg/kg)
-0.1mg/kg morphine
-adjuncts- precedex 0.5mcg/kg, dexameth, Tylenol maybe, toradol - most of our ENTs ok w toradol if adenoids only.
I think sevo only for adenoids sounds a bit like a pacu disaster. Why fent instead of morphine? Either fine but I feel like morphine maybe gives a longer pain free period....


For BMT only I do IM fent + ketorolac.

 

[IlDestriero]

My recipe for BMT Adenoids is the same as for T&A-
0.5mg/kg midazolam premed.
Sevo/N2O mask induction.
1mg/kg propofol for DL.
Morphine 0.06mg/kg
Zofran 0.1mg/kg
Dexamethasone 0.5mg/kg
Put on low RR Pressure Support to let ETCO2 rise, O2 off (air up to blow off O2 to less than 30% by start of adenoids sevo dial about 3%).
By end of case (10-20m) they should be triggering the vent.
If I’m going to extubate awake I turn the Sevo off when they start cooking the adenoids.
When they are done PS off. Turn bed
morphine 0.04mg/kg
+/- Toradol 0.5mg/kg
Extubate deep, OPA in, to pacu.
Or extubate awake after ~5min.
I tend to extubate deep in the main hosptial and awake in the ASC where I may not be available for pacu complications. We are direct providing 100% at the ASC.
I usually write for tylenol p.o. In the PACU but you can give it IV if there's time.

 

[deleted162650]

Not the ones that get only sevo and clonidine (and maybe some other stuff but not fentanyl)

A) Sevo + clonidine is not “only sevo”

B) My personal experience is that a2 agonists are great adjuncts to opioids and allow significant dose reduction of the narcotic, but a2’s by themselves don’t really do much. This opinion is shared by the PACU nurses at one of our big local children’s hospitals.

 

[pinkMD12]

This was brought up because I had a laryngospasm in pacu - probably extubated deep and maybe too much stimulation by nurses. Unsure of what happened as this was brought up during m&m several months later. Anyway case resulted in bmv in pacu not reintubation. Also some concerns from nurses my patients arrive too sleepy.
This is a free standing asc and I’m new so that probably plays a large part in this.
Thanks for everyone’s response. I’m always learning from folks on this site.

 

[deleted162650]

You just need to be more aggressive about getting rid of the sevo earlier if you’re giving adjuvants.

 

[IlDestriero]

Of course your patients arrive too sleepy if the local standard is sevo wearing off and patient sitting up and screaming 2 minutes after drop off. Please give my kids opiates.

 

[Southpaw]

This was brought up because I had a laryngospasm in pacu - probably extubated deep and maybe too much stimulation by nurses. Unsure of what happened as this was brought up during m&m several months later. Anyway case resulted in bmv in pacu not reintubation. Also some concerns from nurses my patients arrive too sleepy.
This is a free standing asc and I’m new so that probably plays a large part in this.
Thanks for everyone’s response. I’m always learning from folks on this site.

You’re getting a little flack because 1) you’re new and 2) you’re doing things a little different. A RN can’t treat your deep extubation the same as the screaming bloody murder awake kid w sevo only.

It’s not a stretch to say she caused the laryngospasm if she’s in the habit of not leaving the kid the F alone until they wake on their own. Regardless, you’ll need to adjust. Like @SaltyDog said, just get the sevo off quick when using adjuvants.

I’ve had older partners use sevo only. Those kids wake up friggin awful.

 

[deleted697535]

Yeah the problem here is likely the new environment plus pacu is not used to deep extubations.

RN pacu evaluation of the quality of staffs cases is an horrendous measure. It's mostly driven by their like or dislike of you socially.

Learn their names, crack a few jokes, buy them coffee and muffins a few times and I guarantee you your reports will flourish regardless of your anesthetic.

In a new place that I don't know the pacu I don't think I'd do many deep extubations. Id probably ask the others what they do and copy that for a while til you find your rhythm

 

[deleted9493]

For kids <10 yo getting T&A:
- premed .75mg/kg midazolam (max 20mg)
- sevo induction
- 2mg/kg propofol with IV
- 1 mcg/kg of dexmedetomdine and fentanyl in buretrol
- decadron/zofran
- add ketorolac if only removing adenoids
- extubate deep

 

[dhb]

For kids <10 yo getting T&A:
- premed .75mg/kg midazolam (max 20mg)
- sevo induction
- 2mg/kg propofol with IV
- 1 mcg/kg of dexmedetomdine and fentanyl in buretrol
- decadron/zofran
- add ketorolac if only removing adenoids
- extubate deep

See them the next day for discharge

 

[deleted9493]

See them the next day for discharge

Not at all! They’re in recovery for 30 minutes, regardless...might as well make it a quiet 30 minutes.

 

[DrOwnage]

My recipe for BMT Adenoids is the same as for T&A-
0.5mg/kg midazolam premed.
Sevo/N2O mask induction.
1mg/kg propofol for DL.
Morphine 0.06mg/kg
Zofran 0.1mg/kg
Dexamethasone 0.5mg/kg
Put on low RR Pressure Support to let ETCO2 rise, O2 off (air up to blow off O2 to less than 30% by start of adenoids sevo dial about 3%).
By end of case (10-20m) they should be triggering the vent.
If I’m going to extubate awake I turn the Sevo off when they start cooking the adenoids.
When they are done PS off. Turn bed
morphine 0.04mg/kg
+/- Toradol 0.5mg/kg
Extubate deep, OPA in, to pacu.
Or extubate awake after ~5min.
I tend to extubate deep in the main hosptial and awake in the ASC where I may not be available for pacu complications. We are direct providing 100% at the ASC.
I usually write for tylenol p.o. In the PACU but you can give it IV if there's time.

How do you turn off the gas that early and still technically extubate "deep." What ET sevo are you usually considering as deep? I mean I guess it depends on the flow, and you're putting them on spontaneous shortly thereafter so their not breathing off much.

 

[dchz]

Yeah the problem here is likely the new environment plus pacu is not used to deep extubations.

RN pacu evaluation of the quality of staffs cases is an horrendous measure. It's mostly driven by their like or dislike of you socially.

Learn their names, crack a few jokes, buy them coffee and muffins a few times and I guarantee you your reports will flourish regardless of your anesthetic.

In a new place that I don't know the pacu I don't think I'd do many deep extubations. Id probably ask the others what they do and copy that for a while til you find your rhythm

This is the one thing that we should learn during residency. But few learned it.

 

[dhb]

Not at all! They’re in recovery for 30 minutes, regardless...might as well make it a quiet 30 minutes.

Jk, i think clonidine is the best silencer, i do give paracetamol and ketorolac.

 

[abolt18]

This is one the things that we should learn during residency. But few learned it.

The main advice I give to new residents starting in the OR is "learn people's names, say please and thank you, ask people about their real lives outside of work and people will be happy to see you and they'll go out of their way to help you if you need something. It will make your life much better and your working environment overall more pleasant."

It doesn't take much real effort, but it certainly pays off.

 

[Arch Guillotti]

Skip the oral pre-med too (unless the kid is really losing their S in preop).

How do you give an oral premed to a kid that is losing it?

 

[deleted162650]

How do you give an oral premed to a kid that is losing it?

You tell them they can go home if they drink this.

If the kid is calm, they don’t need a pre-med.

 

[Arch Guillotti]

You tell them they can go home if they drink this.

If the kid is calm, they don’t need a pre-med.

Yeah kids are great at reasoning when under stress.

Ones who are calm prep always go to sleep so easily.

 

[IlDestriero]

How do you turn off the gas that early and still technically extubate "deep." What ET sevo are you usually considering as deep? I mean I guess it depends on the flow, and you're putting them on spontaneous shortly thereafter so their not breathing off much.

If I’m extubating them deep, I don’t turn the gas off until they’re done. I turn the gas off if I plan to wake them up.

 

[IlDestriero]

You tell them they can go home if they drink this.

If the kid is calm, they don’t need a pre-med.

I don’t like that approach for younger kids as they often keep it together just long enough to get to the OR and then they get scared no matter what you’re doing, go mental, screaming and crying, etc. It makes for a less than smooth induction and may set you up for airway issues from the secretions, etc.

 

[deleted162650]

Yeah kids are great at reasoning when under stress.

Ones who are calm prep always go to sleep so easily.

I don’t like that approach for younger kids as they often keep it together just long enough to get to the OR and then they get scared no matter what you’re doing, go mental, screaming and crying, etc. It makes for a less than smooth induction and may set you up for airway issues from the secretions, etc.

Kids get a hospital issued iPad or my phone to watch their favorite show rolling back. YouTube is better than Versed (more addictive too). Distraction is the best medicine.

Some kids will lose it when the mask comes out. Even then, I’d rather deal with 30 seconds of crying on induction than 30 minutes in PACU ‘cuz they’re still drunk and disoriented on PO midaz after a 15 minute case. I haven’t had any secretion related issues on induction.

I couldn’t tell you the last time I gave premed to a pediatric ENT case.

I do think midaz premed is a good idea for the kids that are frequent flyers. It helps future anesthetics if they don’t remember the last one.

 

[AdmiralChz]

Kids are just little adults, folks!

 

[Endee]

Precedex in kids is *chef's kiss.* When I worked at our local children's hospital, we did a lot of propofol+precedex TIVA general anesthetics, towards the end of the case, we'd turn off the propofol, reverse, leave the precedex on, extubate when SV returned, and just turned off the precedex right before we'd go to PACU. Not a single emergence delerium.

I saw a paper once that suggested the threshold precedex dose for reducing the incidence of emergence delirium to zero with sevo anesthesia was 0.3mcg/kg total. I do 0.3-0.5mcg/kg a lot for the pedi cases where I am now. Usually can totally avoid opioids (however, we don't do major stuff where I work now, just things like dental, circs, ENT).

 

[deleted162650]

Kids are just little adults, folks!

I know you were joking, but for routine pediatric cases this is true. The reason people run into problems with kids is because they run these f***ed up “pediatric” anesthetics. Try running on an adult on sevo only with no opioid/propofol/etc and they’ll L-spasm and wake up like s**t too.

Run your pedi cases like an adult case. Give ‘em some opioid, get rid of the gas, and watch your L-spasm incidence go way down and your emergence delirium disappear.

Precedex in kids is *chef's kiss.* When I worked at our local children's hospital, we did a lot of propofol+precedex TIVA general anesthetics, towards the end of the case, we'd turn off the propofol, reverse, leave the precedex on, extubate when SV returned, and just turned off the precedex right before we'd go to PACU. Not a single emergence delerium.

I saw a paper once that suggested the threshold precedex dose for reducing the incidence of emergence delirium to zero with sevo anesthesia was 0.3mcg/kg total. I do 0.3-0.5mcg/kg a lot for the pedi cases where I am now. Usually can totally avoid opioids (however, we don't do major stuff where I work now, just things like dental, circs, ENT).

There’s nothing magical about precedex. My emergence delirium incidence is zero and my preceded dose is 0.0mcg/kg. They key is waking them up with 0.0% sevo on board and not 0.2%. You can do that with precedex, or you can do it with a little nitrous/opioid/prop.

 

[Endee]

Of course, wasn't suggesting it's magical or it's the only way to get the desired result. I just find that its a very nice drug that relatively easily accomplishes a nice calm emergence. It's also nice to help get opioid reduction, since a lot of procedures aren't that painful afterwards or theyre controllable with just local.

I know you were joking, but for routine pediatric cases this is true. The reason people run into problems with kids is because they run these f***ed up “pediatric” anesthetics. Try running on an adult on sevo only with no opioid/propofol/etc and they’ll L-spasm and wake up like s**t too.

Run your pedi cases like an adult case. Give ‘em some opioid, get rid of the gas, and watch your L-spasm incidence go way down and your emergence delirium disappear.




There’s nothing magical about precedex. My emergence delirium incidence is zero and my preceded dose is 0.0mcg/kg. They key is waking them up with 0.0% sevo on board and not 0.2%. You can do that with precedex, or you can do it with a little nitrous/opioid/prop.

 

[dhb]

They key is waking them up with 0.0% sevo on board and not 0.2%. You can do that with precedex, or you can do it with a little nitrous/opioid/prop.

Waking up on propofol is almost like falling asleep.

 

[Hoya11]

I know you were joking, but for routine pediatric cases this is true. The reason people run into problems with kids is because they run these f***ed up “pediatric” anesthetics. Try running on an adult on sevo only with no opioid/propofol/etc and they’ll L-spasm and wake up like s**t too.

Run your pedi cases like an adult case. Give ‘em some opioid, get rid of the gas, and watch your L-spasm incidence go way down and your emergence delirium disappear.




There’s nothing magical about precedex. My emergence delirium incidence is zero and my preceded dose is 0.0mcg/kg. They key is waking them up with 0.0% sevo on board and not 0.2%. You can do that with precedex, or you can do it with a little nitrous/opioid/prop.

nitrous, IMO, is the worst offender for delirium for all comers

after a long propofol infusion you can cover up its delirious effects but i dont find the need to use it with good sevo timing

 

[deleted162650]

nitrous, IMO, is the worst offender for delirium for all comers

Just about every pedi dental practice in the US would disagree with you.

 

[deleted162650]

Waking up on propofol is almost like falling asleep.

It’s almost as good as when a surgeon asks “Can you wake them up deep?”

 

[Hoya11]

Just about every pedi dental practice in the US would disagree with you.

'Nitrous alone, good, not really what im talking about as just puffing a little nitrous is not going to get anyone through anything requiring GA
Nitrous as emerging from propofol infusion OK
Nitrous plus sevo based general anesthetic plus opiate --> emergence delirium

 

[WholeLottaGame7]

+/- midaz 0.5mg/kg depending on age/baseline anxiety state
Nitrous/sevo induction
2-3mg/kg propofol + 1mcg/kg fentanyl
15mg/kg IV tylenol
+/- precedex 0.5-1 mcg/kg depending on baseline anxiety state
Gas off early, prop prn for resident clean-up
Extubate awake-ish (less than 0.2-0.3% sevo at least)
Toradol by surgeon preference

I also try not to give midaz if at all possible, it definitely burns you on the back end for the shorter cases. Sometimes it's the only way to get the kid back without a major production, however. As @SaltyDog said, iPads/phones/YouTube are wonderful inventions.

I have at least one colleague that goes high-dose precedex in lieu of narcotics. In a perfect world, I like that plan. The problem with precedex is that it's a lazy PACU RN's dream, they can just sit on a kid forever while they sleep. Also the issue of how long the drive home is and how the kid will be monitored on the way. Don't love the idea of a sleepy kid post-tonsillectomy in a carseat in the back for 2-3 hours.

If you're doing healthy kids with motivated PACU RNs, I think it's reasonable.

 

[nimbus]

I know you were joking, but for routine pediatric cases this is true. The reason people run into problems with kids is because they run these f***ed up “pediatric” anesthetics. Try running on an adult on sevo only with no opioid/propofol/etc and they’ll L-spasm and wake up like s**t too.

I’ve been doing this with non painful cases like Afib ablations and have had no problems with laryngospasm. Old folks are conversant before leaving the room. The other upside is that I’m not chasing blood pressure the whole case. It’s beautiful.

 

[deleted162650]

Old folks

This is why you can get away with it in EP lab.

 

[nimbus]

This is why you can get away with it in EP lab.

I do all my EP cases that way. Younger people just need more sevo.