To build rapport:
When you meet kids in preop you want to be at their height. I’m 6 feet tall, which can be scary to kids, so I always kneel next to the bed when talking to them/parents and examining them. You want to be at their height or lower to be less threatening. Have something kids will like (cartoon character name badge holder, stethoscope accessory, and/or scrub cap). If kids are afraid of you examining them, either fake examine the parent first (stethoscope on mom or dad) to show it doesn’t hurt. Either that or do something silly like put your stethoscope on their knee and ask them if that’s where it goes. Bonus points for Disney+ on your phone.
One of the toughest thing about peds is learning the weight-based dosing cold. Always look up a drug dose before you give it. On my first peds rotation I almost gave 800 mg of IV Tylenol to a baby before I caught myself and I’ve been paranoid ever since. Now I know the drugs cold, but an app like LexiComp can really help you with the dosing. You NEED to know weight-based dosing of emergency drugs (how much IM or IV sux would you give for laryngospasm, how much epi in a code?) Everything else you can learn over time and look up. If you don’t know something, always ask your attending. I like trainees who ask lots of questions; the ones who show up on their first peds anesthesia rotation with the attitude that “I’ve got this” are the ones who terrify me.
Getting a feel for normal vitals is also important. HR of 50 in a teenager is probably fine; HR of 50 in a neonate means it’s chest compressions time.
As for IV sizes, < 1 yo a 24 g is usually plenty (and 22 g is a volume line). For most pre-pubescent cases that you’re not expecting a lot of bleeding a 22 is normally fine. IVs in chunky babies can be really tough and are usually deeper than you’re used to. If you’re having trouble finding something, the saphenous is usually pretty good. If a kid is a chronic patient and has few IV sites, scan with ultrasound for the saphenous just below the knee as most people will not have gone there before. Don’t poke until the kids have gone through stage two (you’ll heart the heart rate go up initially with mask induction, wait until it goes back down before stimulating the child) or you may have to remember your IM sux dosing.
I know this will make me sound like one of THOSE peds anesthesiologists but NEVER push a bubble into any kid, especially a small one. I let my IVs bleed back before hooking up to tubing, and if they don’t bleed back I fill the hub with saline using the safetied needle from my angiocath or another angiocath. When you attach a new syringe to a manifold, draw back to pull any bubbles into the syringe and always push drugs with the plunger aligned up (so that bubbles rise away from the manifold). You really can cause a stroke or MI in a baby with a small air bubble.
Watch how much fluid you’re giving. It’ll depend on the case, size and npo time to determine how much you should be giving but remember the general rule for calculating maintenance fluids: 4 cc/kg/hr for the first 10
Kg + 2 cc/kg/hr for the next 10 kg + 1 cc/kg/hr for anything more than that. So the maintenance rate on a 15 kg kid is 10*4 cc/kg/hr + 5*2 cc/kg/hr = 50 cc/hour.
ETT sizes: 4 + age (years)/4 for uncuffed (though you should almost never use an uncuffed tube). For cuffed subtract 1/2. So for a 1 year old it would be 4+1/4 - 1/2 = 3.75, so use a 3.5 cuffed. Typical depth is usually ~ 3 times the ETT size (for that kid it would be about 3.5*3 = 10.5 cm).
For neonates (in uncuffed ETT sizes):
< 1 kg gets a 2.5, 1-2 kg gets a 3, 2+ kg gets a 3.5. Estimated depth in cm is 6 + weight in kg. A 2.5 kg kid should be able to have a 3.5 uncuffed (3.0 cuffed) at 8.5 cm. Ask your attending to show you how to find appropriate depth with mainstemming and how to figure out how much air goes in a cuffed.
Neonate: Miller 0, infant Miller 1, toddler Wisconsin (or Miller) 1.5. Tiny preemie might need a Miller 00.
Epi fixes a lot of problems.
