Pediatric Off Site Anesthesia

Table setup

Bair hugger

Shoulder roll

3 lead EKG

Pulse Ox

Appropriate sized BP cuff

Special cable for neonatal cuffs
Glucose (25 % or 50 %)

Monitor set to Neonate or Pediatric Mode




Glycopyrrolate, 0.2 mg/ml

Tetracaine, 0.45 %, 49 ml

Succinyl choline


Epinephrine 10 mcg/cc

Ephedrine 10 cc of 5 mg/cc

Phenylephrine (1 syringe of 100ug/cc, 1 syringe of 10ug/cc)

Succinylcholine (4–6 mg/kg on IM needle)

Calcium Chloride (10 cc of 100 mg/cc, 10 cc of 10 mg/cc)

Sodium bicarbonate (8.4 % 1 mEq/cc for patients >1 year)

Ketamine – (0.5–5 mg/kg IV, 3–5 mg/kg IM)

Propofol – (2–3 mg/kg IV)

Rocuronium (0.6–1.2 mg/kg, dilute to 1 mg/cc for children <1 years)

Two syringes of saline flush

Lidocaine, 1 %, 50 ml

Lidocaine, 2 %, 50 ml

Xylocaine, 2 %, Jelly

Xylocaine, 5 %, ointment

Xylocaine prep 4 %, for topical spray

Drawer One: Preps

Alcohol prep

Oxymetazoline hydrochloride spray (Afrin)

Atomizer spray

Silicone lubricant

Catheter, 22-gauge angio × 1 in.

Stopcocks, three way

Gauze, 3 in. by 3 in.

Syringes, 3 cm [3]

Tongue depressors

Needle, 25-gauge × 3.5 in. spinal

Needles, 19-gauge, 1.5 in.

Albuterol Multi dose Inhaler

Cetacaine Spray

Eye-tape (Paper tape >1 year, Mepitec for <1 year or fragile skin)

Tega derm

Drawer Two: Laryngeal mask airways, suction catheters

No. 1 laryngeal mask (neonate/infants)

No. 2 laryngeal mask (babies/children)

No. 2.5 laryngeal mask (babies/children)

No. 3 laryngeal mask (children/small adults)

Laryngeal mask tube extensions

Yankauer suction tips

Catheter, suction, 8 F, pediatric
Drawer Three: Blades, Handles

Magill forceps (small)

Magill forceps (large)

Laryngoscope handle (regular)

Laryngoscope handle (short)

Macintosh blade no. 2 (child)

Miller blade no. 0 (Infants <3 months)

Miller blade no. 1 (children 3 months to 18 months)

Miller blade no. 1 (children 3–5 years)

Miller blade no. 2 (children >5 years)
Drawer Four: Retrograde set and transtracheal jet ventilation (TTJV)

0.035 × 145 cm guidewire

Needle, epidural with catheter

Catheter, 14-gauge intravenous (IV) (TTJV)

Nerve hooks

Catheter, red rubber, Robinson urethral

Clamps, Kelly

Sutures, silk

Needle, 18-gauge thin-wall

Surgical blade

Drawer Five: Airways and tube exchangers

Airway, Berman oral, 100 mm

Airway, Berman oral, 90 mm

Airway, Berman oral, 80 mm

Nasopharyngeal airway, 26 F

Nasopharyngeal airway, 28 F

Nasopharyngeal airway, 30 F

Nasopharyngeal airway, 32 F

Nasopharyngeal airway, 34 F

Catheter, 14-gauge × 2 in.

Catheter, 16-gauge × 2 in.

Catheter, 18-gauge × 2 in.

Needle, Benumof transtracheal (Cook)

Endotracheal Tube Exchanger

Syringes, 20 cc

Tube Exchanger Jet Ventilation Adapters

Drawer Six: Endotracheal tubes and lighted stylets

2.5–5.5 mm, uncuffed (Size based on the child’s little finger or (age/4) + 4)

3.0–6.0 mm, cuffed (Subtract 0.5 size for cuffed tube)

Stylet, pediatric

Lighted stylet

Lighted stylet, Laerdal, disposable stylets

Lighted stylet, Laerdal, handle

Drawer Seven: specialty blades, and miscellaneous

Patil-Syracuse mask for FOB, appropriate pediatric size

Bronch swivel elbow

Bullard blade, adult

Bullard blade, small

CO2 analyzer, Easy Cap, disposable


Airway, Ovassapian

Tubing, O2 supply

Airway, Williams, 10 cm

Airway, Williams, 9 cm

Tubing, suction connection

Augustine guide

WuScope, small

Belscope, small

  • See Table 21.2 for a pediatric offsite anesthesia checklist.

    Table 21.2
    Check list for pediatric off-site anesthesia

    Are two sources of O2 and a suction available?

    Is the lighting sufficient?

    Is Emergency Cart Available?

    Are there enough electrical sockets available?

    Is help readily available?

    Standard machine check

    Reset machine alarms for age appropriate vitals

    Turn on machine suction

  • Anesthesiologists are part of a multi-disciplinary team in pediatric off-site anesthesia, they must take a holistic approach towards patient care.

  • NPO status

    • Challenging to have a young patient NPO for a procedure or scan especially if it is scheduled later in the day.

    • Consider the ASA guidelines [19] when instructing families when the patient should stop eating or drinking. See Table 21.3.

      Table 21.3
      ASA fasting guidelines [19]

      Fasting required


      2 h

      Clears (e.g. water, clear juice without pulp, CT contrast)

      4 h

      Breast milk

      6 h

      Infant formula, nonhuman milk, light meal, juice pulp

      Consider 8 h

      Fatty meal

    • Excessive fasting for patients who are not at an increased risk for aspiration may have excessive preoperative discomfort [20, 21].


      • Propofol

        • One of the mainstays for intravenous sedation by anesthesia providers.

        • It can provide significant amnesia and sedation for procedures but does not provide analgesia. It can be used safely by an anesthesia provider with an expertise in airway management.

        • It has a lower risk of postoperative nausea and vomiting.

        • Bolus 1 mg/kg and repeat with 0.5 mg/kg as needed [22]. Also can consider an infusion of 100–200 mcg/kg/min for longer procedures [23].

      • Ketamine

        • Unique sedative that is frequently used for pediatric sedation. Unlike most sedatives, ketamine causes an increase in sympathetic drive, which often results in an increase in heart rate and blood pressure. Furthermore, it preserves the respiratory drive better than many other agents.

        • Ketamine may cause hallucinations and dysphoric effects that may last beyond the immediate period of sedation. Consider administering midazolam to prevent emergence dysphoria [23].

        • Consider using an anticholinergic prior to the administration of ketamine due to an increase in oral secretions.

        • Cardiac depression can occur especially in the setting of an already activate sympathetic drive.

        • Postoperative nausea and vomiting is not uncommon.

        • Bolus 1–2 IV or 3–4 mg/kg IM or 5–8 mg/kg can be used for general anesthesia induction [23].

      • Dexmedetomidine

        • Dexmedetomidine is a newer sedative agent that has analgesic properties. It is an alpha-2 agonist similar to clonidine.

        • It does not carry the same level of respiratory depression found in many other agents.

        • Dexmedetomidine is associated with bradycardia, especially when administered as a bolus. It should be given slowly over 10 min. An anticholinergic may be necessary for treatment of the bradycardia.

        • Bolus 2 mcg/kg loading dose over 10 min and infuse at 0.2–1 mcg/kg/h.

        • There is evidence that a bolus of 0.5–1 mcg/kg of can decrease the incidence of emergence delirium [24].

      • Midazolam

        • Midazolam is a versatile sedative agent with many routes of administration.

        • It is a short-acting amnestic agent. It is one of the most commonly used benzodiazepines in pediatrics.

        • A paradoxical reaction can occur especially in children.

        • Oral dose 0.5–0.75 mg/kg (maximum of 20 mg), rectal 0.25–0.5 mg/kg, intranasal 0.2–0.5 mg/kg, intravenous 0.025–0.05 mg/kg, intramuscular 0.1–0.15 mg/kg [23, 24]

      • Fentanyl

        • Fentanyl is a synthetic opioid that is commonly used in both adult and pediatric populations for short acting pain relief.

        • Caution must be used because it will have a synergistic effect when used with other sedative agents, especially in regards to apnea.

        • Dose 1–2 mcg/kg IV with a titration to effect.

      • Remifentanil

        • Remifentanil is an ultra short-acting opioid that has been become more popular recently for pediatric sedation.

        • Similar to all opioids, there is a significant risk of apnea.

        • It has very limited amnestic effects.

        • Dose 0.1 mcg/kg/min infusion with a titration to effect [23].

      • Nitrous Oxide

        • Nitrous oxide is one of the oldest anesthetic agents yet its use is still prominent in today’s practice.

        • As a non-pungent inhaled anesthetic, it is one of the best-tolerated agents for induction of anesthesia in pediatric patients.

        • Drawbacks include a reduction in inhaled oxygen concentration in order to administer it, an association with postoperative nausea and vomiting, and the potential to expand any airspaces (e.g. pneumothorax). There is also a controversy as to whether nitrous oxide’s inactivation of plasma homocysteine via vitamin B12 inactivation with prolonged exposure could have hematologic complications for pediatric patients [25].

      • Volatile Anesthetics

        • Inhaled volatile anesthetics have been used extensively in children.

        • Most anesthesia providers use sevoflurane for their pediatric patients because of its less odorous smell for inhaled induction and better bronchodilation to prevent reactive airway complications.

        • When considering the use of volatiles for pediatric patients outside of the operating room, the availability of proper anesthesia equipment and scavenging system may preclude their use.

      • Succinylcholine

        • As the only clinically used depolarizing neuromuscular blocking agent, succinylcholine has a very important role in pediatrics. It has the shortest onset and ultra-short duration of action, which can both be very useful for airway management, especially when rapid sequence intubation is required.

        • There is an increased risk of succinylcholine use in pediatrics due to the possibility of undiagnosed muscular dystrophy that may cause a hyperkalemic response. Therefore, it is not recommended to use succinylcholine routinely.

        • Dose 1–3 mg/kg IV for intubation conditions, 4 mg/kg intramuscular

      • Anticholingerics

        • Because children’s hemodynamics are much more heart rate dependent than adults, anticholinergics are critical to have available as a rescue medication during pediatric sedation procedures.

        • Children can have high vagal tone and respond to noxious stimuli with profound bradycardia.

        • Atropine and glycopyrrolate are useful due to their mechanism of action as a competitive inverse agonist of the muscarinic acetylcholine receptors.

        • Atropine dose 10–20 mcg/kg IV, 20–30 mcg/kg intramuscular

        • Glycopyrrolate dose 4 mcg/kg IV

      • Ondansetron

        • Ondansetron is one of the most effect anti-emetic agents with a good safety profile within the pediatric population.

        • Dose of 0.1 mg/kg (up to 4 mg) has been found to significantly decrease postoperative nausea and vomiting as well as speed up home readiness in outpatient surgical settings [26].

      • Local Anesthetics

        • Local anesthetics may be used for pain control once sedation has been begun.

        • Toxic doses of local anesthetics are calculated based on dose per body weight. Therefore, increased vigilance is warranted for young pediatric patients.

        • Local anesthetics bind sodium channels in the peripheral nervous system, but larger doses can lead to central nervous system and cardiovascular system toxicity. This can result in severe and or even life threatening arrhythmias and death.

        • Toxicity may also occur with direct intravascular injection.

        • Injection with epinephrine can decrease systemic absorption through vascular constriction and therefore increases the toxic dose of the local anesthetic.

        • Toxicity levels: Plain Lidocaine 5 mg/kg, Lidocaine with epinephrine 7 mg/kg; Plain Bupivacaine 2 mg/kg, Bupivacaine with epinephrine 3 mg/kg, Plain Mepivicaine 5 mg/kg, Mepivacaine with epinephrine 6 mg/kg; Ropivacaine with or without epinephrine 3.5 mg/kg

      Pediatric Off-Site Anesthesia in a Non-pediatric Hospital

      • Children may come to an adult hospital if particular services like advanced radiation treatment options are not available in the pediatric hospital or if a pediatric unit is too far [27].

      • Biggest issue is unfamiliarity of the personnel with the requirements of a child and the uncomfortable feeling associated with it.

      • Equipment and supplies may not be available readily or at all.

      • Best solution is to have enough personnel in the department enlisted to handle these cases. These individuals should keep themselves up to date on pediatric anesthesia literature.

      • A pediatric cart and its supplies need to be checked and updated on periodic basis.

      • Areas that have these cases (radiology, ER etc.) should have periodic meetings with the dedicated anesthesia personnel and occasional debriefings after the procedures.

      • Policies & Procedures of these departments may need to be modified to accommodate the needs of children, e.g. allowing the parents or care givers presence during the procedure.

      • Nursing personnel may need to be trained and certified to take care of these children, especially recovery room nurses.

      Radiological Scans and Nuclear Medicine Scans

      • Radiological scans and nuclear medicine scans require immobility that young or developmentally delayed children may not be able to do without anesthesia. They all require a peripheral IV or central line access.

      • Common off-site pediatric procedures requiring anesthesia and sedation are as follows:

        • Diagnostic radiology: CT, MRI, Bone Scan

        • Cardiovascular interventions: Angiography, Cardiac catheterizations

        • Radiation Oncology

        • Diagnostic & interventional procedures: Bronchoscopy, Eye examination, Endoscopy, Ultrasound, Transesophageal echo

        • Diagnostics exams: Lumbar puncture, Bone marrow aspiration, Biopsy, Evoked potentials


      • MRI is the most common pediatric offsite procedure requiring sedation/anesthesia.

      • A relatively longer scan in duration.

      • No radiation is emitted but the anesthesia provider must monitor from outside the room in zone III or zone IV. Monitors and the patient should be easily viewed from a distance, either directly or via video camera [28].

      • The anesthesia department should properly label equipment for the MRI as safe, unsafe or conditional. All equipment must be safe for use in the MRI suite [28].

      • Fully monitor the patient vitals including capnography. There may be EKG or pulse oximetry artifact from the MRI magnetism.

      • The patient and staff need to be screened for the presence of metal [28].

      • If a patient does not have a peripheral IV or central line access prior to the procedure, the anesthesia provider can induce with sevoflurane by mask. An IV is required for contrast administration. Once access is established, the anesthesia provider can continue with a general anesthetic with either LMA or ETT or can convert to an infusion such as propofol.

      • If a patient has a peripheral IV or central line, consider propofol sedation if the patient is an acceptable candidate. Bolus propofol until the patient is adequately sedated and then begin an infusion. A dexmedetomidine infusion is also acceptable but requires a slow bolus and can cause bradycardia. Give supplemental oxygen via nasal cannula.

      • Place ear plugs in the patient after the patient is sedated.

      Nuclear Medicine Scan

      • Nuclear medicine scans that a pediatric patient may need sedation for include Positron emission tomography (PET), CT scan, MIBG scan, and renal scan.

      • Nuclear medicine scans vary in length. PET scans are relatively short while MIBG scans are relatively long. They require no movement.

      • These children are injected before the scan so a peripheral IV or central access will be needed. The timing of the scan may need to be coordinated with the injection time.

        • PET/CT scans require PO contrast. The patient should be sedated after 2 h since the contrast is considered a clear liquid.

        • For both PET and PET/CT scans, the glucose analog tracer is injected intravenously approximately 45 min before scanning.

        • MIBG scans require an injection a day prior.

      • Consider a propofol infusion with supplemental oxygen via nasal cannula if the patient is a candidate for MAC. Fully monitor the patient’s vitals along with capnography.

      • Except when a CT scan is being performed as part of the scan, the anesthesia provider is able to monitor in close proximity to the patient.

      • The radioactive injection for MIBG scans is eliminated in the urine. Care must be taken if the patient urinates during the procedure.

      • SPECT (single-photon emission computed tomography) is a technique in nuclear medicine to map blood flow. It can be used to identify a seizure source since that is where the maximum blood flow is during a seizure activity.

      • A radioactive tracer is injected during the SPECT scan. The tracer usually contains radioactive technetium (Tc 99). The local tracer concentration peaks in the brain tissue about 2 min after injection, remains constant for about 2 h, and degrades with a half-life of 6 h.

      • An Ictal SPECT scan is taken during the seizure and an interictal scan when no seizure is there. The ictal and inter-ictal images are then compared to each other and to MRI and analyzed.

      CT Scan

      • There is a 2 h wait after PO CT contrast ingestion per NPO guidelines [19].

      • A peripheral IV or central access is required for IV contrast administration.

      • These are relatively short scans that emit ionizing radiation, so that the anesthesia provider must be monitoring from a distance.

      • Propofol is an ideal medication if the patient is a MAC candidate. Consider giving small boluses until the patient is adequately sedated. Can also consider sedation with midazolam. Give supplemental oxygen via nasal cannula. Fully monitor the patient along with end tidal CO2.

      • Consider general anesthesia if the scan is an emergency, if the patient is not NPO, has head trauma, cardiac or respiratory instability or if there is a need for breath holding during the scan [29].

      • Because of the short duration, children over 3 or 4 years old may be able to do the scan without anesthesia with parental presence. Parents can stay with the patient wearing lead for protection.

      • Give supplemental oxygen via nasal cannula with end tidal CO2 monitoring.

      Pediatric Off-Site Anesthesia for Radiation Oncology

      • Working in the pediatric radiation therapy suite presents a unique range of challenges to the anesthesiologist. The anesthesia provider has to deliver anesthesia for a wide variety of complex conditions in a remote location where the patient is not directly observable during the procedure.

      • Anesthesiologists are part of a multi-disciplinary team in radiation oncology, taking a holistic approach towards patient care.

      • Radiation therapy uses x-rays, gamma rays or protons to either lessen or completely destroy the cancer cell burden. Intensitymodulated radiotherapy (IMRT) is the technique used in radiation-oncology involving photons [30].

      • Proton therapy is the latest advancement in radiation therapy. It reduces the collateral radiation compared to the traditional photon based methods of radiation [31]. A typical session of proton therapy might run much longer as compared to the traditional techniques thus necessitating a change in anesthetic plan.

      • The main goal in radiotherapy is to target a specific area so maximum dose can be delivered to the cancer tissue while the surrounding normal tissue is unaffected. As the side effects of radiation are directly proportional to the total dose, extraordinary effort is made to treat the tumor with minimum possible dose delivered to a localized area.

      • Ideally to do so, the child should be as immobile as possible throughout the procedure. This is almost impossible for children under the age of four who are frightened in the unfamiliar environment.

      • Children between ages of 4–8 can be managed without sedation if they are able to understand the explanation provided by the care giver. For such older kids, it might be helpful to use play therapy [32] prior to the procedure and allowing them to speak to their guardians via microphone during the procedure.

      • Anesthesia is rarely required at age of 8 years and beyond [33].

      • Child is evaluated by an anesthesiologist few days prior to start of the treatment to assess any comorbidities, primary effects of the tumor (Table 21.4), as well as the secondary effects of chemo or radiation therapy.

        Table 21.4
        Primary diagnosis of 512 children undergoing radiation therapy (Duke University Medical Center) [33]


        Distribution of total Patients undergoing radiation therapy (%)

        Primary effects/anesthetic considerations

        Primary CNS tumor


        CNS tumors accounted 29 % of all malignancies in children <15 years of age

        There is a potential for raised ICP. Factors that raise ICP should be considered such as hypoxia, hypercapnia and volatile anesthetic-induced increase in CBF



        Anesthetic management of retinoblastoma patients is unremarkable, but retinoblastoma caused by 13q deficiency might be associated with difficult intubation due to macroglossia [34]



        Neuroblastoma is the most common extracranial solid cancer in childhood

        It most frequently originates in one of the adrenal glands, but can also develop in nerve tissues elsewhere in the body

        Treatment therapies include surgery, radiation therapy, hematopoietic stem cell transplantation and biological-based therapy. Their effect of these treatment therapies should be considered

        Acute leukemia


        Patients with leukemia receive a course of chemotherapy which should be reviewed. Common anesthetic concerns of such patients include tumor lysis syndrome, coagulopathies, myelosuppression, Infection associated with neutropenia. The chemotherapeutic drugs used must be reviewed and their possible side-effects and interactions noted



        Embryonal rhabdomyosarcoma, the most common type, usually occurs in children under 6 years of age

        Alveolar rhabdomyosarcoma occurs in older children and is less common

        Chemotherapy is generally given to all rhabdomyosarcoma patients. These drugs can cause anemia and neutropenia

        Wilms’ tumor


        In addition to the ‘routine’ issues, consequences of paraneoplastic phenomena should be considered, such as hypertension and coagulopathy, of proximal IVC or atrial extension of tumor thrombus, and of preoperative and previous treatment with chemotherapeutic drugs [35]

      • There is currently insufficient data available to guide routine pre-anesthetic testing in children with cancer. The choice of diagnostic laboratory or diagnostic examination should be guided by the patient’s specific history, physical examination and the nature of the procedure [36].

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    • Aug 26, 2017 | Posted by in Uncategorized | Comments Off on Pediatric Off Site Anesthesia

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