ANESTHESIOLOGY RESIDENT

SURVIVAL GUIDE

7 TH Edition
2014-2015

UC Davis Department of Anesthesiology & Pain Medicine

 UCDMC Telephone Numbers
Prefix 734- or 703- Chronic Pain ‐ Mureen 4.6688
Anesthesia Office (Joyce G) 4.5028 Dr. Bach Preop Clinic 2.6631
Bobbi Pane 4.5169 Cath Lab 3.2300
4.5630 CT 4.3495
OR Front Desk 3.6200 GI Lab 4.5505
Main PACU 3.6390 IR Board 3.2269
Middle PACU 3.6380 IR Suites 4.3669
Main OR Pre‐op 3.6370 Rad Pre‐Hold 3.2168
Acute Pain Desk 3.6374 MRI Pavillion 4.7959
Main Anesthesia WkRm 3.6188 MRI Main 4.8133
ABG 762.6033 Rad Onc 4.5820
Anesthesia Bunker 3.6182 Pharmacy Pavillion 3 3.6120
Anesthesia Lounge –front 3.7141 SICU 4.2848
Anesthesia Lounge –back 3.7140 CTICU 3.6141
OR Rm 21 3.6221 Burn T5 4.3636
OR Rm 22 3.6222 NSICU T5 4.3303
OR Rm 23 3.6223 CCU T6 4.2616
OR Rm 24 3.6224 MICU T6 4.2880
OR Rm 25 3.6225 MSICU T7 4.5680
OR Rm 26 3.6226 Peds D7 3.3070
OR Rm 27 3.6227 NICU D5 3.3050
OR Rm 28 3.6228 PICU East7 4.0880
OR Rm 31 3.6231 PICU T7 4.2994
OR Rm 32 3.6232 ER 4.3790
OR Rm 33 3.6233 Peds Coordinator 4.7824
OR Rm 34 3.6234 CSC Desk 4.6505
OR Rm 35 3.6235 CSC PACU 4.6508
OR Rm 36 3.6236 CSC Tech 4.3477
OR Rm 37 3.6237 CSC Rm 1 4.6507
OR Rm 38 3.6238 CSC Rm 2 4.2351
OR Rm 41 3.6241 CSC Rm 3 4.7425
OR Rm 42 3.6242 CSC Rm 4 4.7664
OR Rm 43 3.6243 Labor & Delivery 3.3030
OR Rm 44 3.6244 OB Resident Pager 762.6706
OR Rm 45 3.6245 OB Attending Pager 762.7696
OR Rm 46 3.6246 Code Resident Pager 762.6121
OR Rm 47 3.6247 Code Attending Pager 762.0090
OR Rm 48 3.6248 VOCERA 4.0775
Same Day Surgery 3.5300 Operator (Back Line) 4.6800

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31. Liver Transplant 95

Table of Contents 32. Vacation/Leave and Sick Leave 97
33. Research 98
Chapter Page 34. ACGME requirements 99
1. Introduction & Reminders 4 35. California State License & DEA Number 100
2. Websites & EMR Templates 5 36. Rotaplast 104
3. Call Responsibilities 6 37. ACLS Renewal 107
4. A Typical Day in the Main OR 7 38. Miscellaneous (Needlestick, Incident Reports) 108
5. NPO Guidelines and Preop Testing Recommendations 9 39. ASA Classifications & Algorithms 109
6. Post‐Anesthesia Care Unit 11 40. Notes 114
7. Code Box setup 14
8. Intubations on the Floor 15
9. Trauma Room Setup 17
10. Emergency and Trauma Anesthesia 19
11. Adult Drugs for General Anesthesia 22
12. Adult Drips 24
13. Perioperative Pain Service (Acute Pain) 25
14. Pediatric Anesthesiology 32
15. Obstetric Anesthesiology 44
16. Cardiac Anesthesiology 51
17. Thoracic Anesthesiology/Double Lumen ETTs 60
18. Endocarditis Antibiotic Prophylaxis 63
19. Pre‐Operative Clinic 64
20. Pacemakers/AICDs 66
21. Neuroanesthesiology 68
22. Kidney Transplant 75
23. Laparoscopic Gastric Bypass 76
24. Medical ICU Rotation 77
25. Pulmonary Critical Care Rotation 81
26. Chronic Pain Rotation 82
27. Pain Management and Common Opioid Conversions 84
28. Shriners Rotation 85
29. Same Day Surgery/Regional Rotation 89
30. Difficult Airway Rotation 90

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1. Introduction & Reminders
Anesthesiology residency at UCDMC is fun, educational, and stimulating. The core
strength of our program lies with our residents. This handbook is a testament to that— it
was created by residents, for residents in order to maximize our learning and to help
alleviate our anxieties. The guidance and occasional tongue‐in‐cheek advice contained
in the following pages are based on insights we’ve gained from our own (sometimes
painful) experiences. We hope that you can use this guide to your benefit.
Our residency is constantly evolving. Keeping up can be difficult. Please remember,
that as with any guide, we insist that this be a book of suggestions and ideas, and is not
guaranteed to be free of mistakes or even controversy. We have, however, tried to
make it complete. Always, always, always use your clinical judgment. Call your
attending. Alert the chiefs to any errors you may find so that we may continue our
tradition of residents helping other residents.
Friendly Reminders:
1) Always remember “The Golden Rule”…”DO unto others as you would have
others do unto you!”
Remember your obligation to your patient. It is our privilege to care for them.
Be courteous to your co-residents. If you are late, miss a shift, or don’t sign out
properly, you make more work for others
2) Schedule Requests
a. Due: 1st Friday of each block (first come, first served)
b. Submit: date requested, block #, rotation name, any special context
c. Requests on TRA and OBA are always difficult to accommodate.
d. The schedule is not official until announced by the chiefs, 2 months prior
to the start of the next block. DO NOT make inflexible plans prior to this.
3) ACGME allows a maximum of 20 days off each academic year. Absences due to
sick days will have to be taken out of future vacation time. Make-up days are not
allowed.
Regards,
Amir Amini & Alison Nielsen
2013‐2014 Chief Residents
4  5
3. Call Responsibilities
For the PACU/Code/6121 Resident
Respond to:
 PACU issues (36390. Don’t call back, just go there)
 Code Blue (announced overhead or page from front desk 36200)
 Floor intubations (semi‐elective, call comes from floor or ICU)
 Trauma (usually a call from 36200)
 Acute Pain management—calls on the 6915 pager
(epidurals/peripheral catheters/blood patches)
 Code C (6767‐911, go directly to Davis tower 3)
Take care of:
 Code box setup x3 (Pre‐Op (next to Acute Pain desk), Call Room,
Anesthesia tech room)
 Trauma room setup x2 (check in with the front desk for which rooms to set
up, sometimes changes throughout the day)
 Pre‐op evaluations
 Giving breaks (rare) and scheduled cases (minimal)
Extra/unofficial duties:
 Clean lounge (including fridge, especially if stinky, and get rid of old drug
syringes)
 Call Housekeeping 4‐3777 if need be (vacuum, change sheets)
 Plan social event at least once every two weeks
 Call Matt Jurach 4.5122 for problems with computers or printer
Weekend Post-op checks and notes:
 Patients that go directly to the ICU’s from the OR will need to be seen on the
following day since they do not get a post-op check note from the PACU
resident
 On the weekends, it is the PACU day resident’s job to see these ICU patients
 On the weekdays, it is the Late 2’s job to see these patients
 Use the note template “Anesthesia Post Op Assessment”
 CMS/Joint Commission requires that all patients undergoing anesthetics have
a post-op assessment.
Shift Times: Sign out ONLY if Patient Care is adequate
PACU/WED/Code Day - 07:00 ‐ 18:30
Late2 ‐ start at 14:00 and can potentially be kept until 04:00
Late11 ‐ start at 11:00 and can potentially be kept until 01:00
Peds, OB, Cardiac, Trauma, ICU ‐ see separate sections
6  7
2. Websites & EMR Templates
Home access for Lotus Notes (web based): hsmail.ucdmc.ucdavis.edu
Home access for EMR/Citrix: hsapps.ucdmc.ucdavis.edu and install the application.
Electronic Board: Click on SIS E‐Board icon in Citrix; call Joyce Schamburg @ 4‐8514
for help.
OR Schedule: Open Internet Explorer icon in Citrix. Type “OR” into address bar, click
‘Operating Room Schedule’ in the left column.
Smartsite: anesthesiasmartsite.org (use Kerberos log‐in and password) for assignments,
schedules, rotation information, announcements, exam scores.
Case Logs: www.acgme.org
Data Collection Systems -> Resident Case Log System - > Login (another password!)
Evaluations: www.e‐value.net
Can link to this without a password when emailed to do evaluations from Carolyn.
Patient Lists: https://ehandoff.ucdmc.ucdavis.edu (or just ‘ehandoff’ from the intranet)
Contact Jennifer Cano to set up account: 4-4270, or jennifer.cano@ucdmc.ucdavis.edu
Text page:  http://www.usamobility.com/send_a_message/
Type in pager as 916816XXXX
Favorite EMR Templates
In the Smart text icon, search for these, right click to make them a favorite.
Airway Assessment Procedure Note (for floor intubations) Anesthesia & Pain
Epidural/Peripheral Cath Progress Note Anesthesia Difficult Airway Notification
Anesthesia Nerve Blockade Procedure
Anesthesia Neuraxial Blockade Procedure
Anesthesia Operative Note
Anesthesia Pre Op Assessment
IPPROC AL/CL/PA Insertion (when you put in a line) Obstetric Anesthesia and
Analgesia Progress Note Obstetric Anesthesia Pre Op Screening
Obstetric Anesthesia Neuraxial Anesthesia Procedure
Pediatric Anesthesia Preoperative Note
To make your own custom templates and smart text/dot phrases:
Tools (under the EPIC tab in the top left) -> Smart Tool Editors -> My Smart Phrases
 
4. A Typical Day in the Main OR
Step 1: Preop the day before. Access the next day’s case schedule by typing “OR” into
any UCD intranet address bar. Use the “Patient Station” tab in EMR to look up your
patients. If they have been seen in preop clinic, there will be a note (Chart review ->
Encounters -> PSUSAC) that you can refer to for your full H&P. If they are inpatients,
you should go see them. If not, you should call them (especially important for difficult
cases or peds). Use the separate Citrix EKG icon or Echo/Treadmill icon if need be.
Page your attending to discuss your plans. Some will call you back, some won’t. To be
safe, always page.
Step 2: In the morning find your patient. The electronic board will say when the patient
was pre‐meded, sent for, and arrived in the PACU. Sometimes patients, especially
ICU/trauma/add‐on players, will be in the hallways. Isolation patients are in the isolation
bays.
Step 3: Talk to patient. Ask pre op nurse for a translator if needed. Go over the
Anesthesia Consent form with the patient and make sure you and the patient both sign
it. Make sure there is a surgical consent form (EMR or paper). Make sure surgeon
marks the patient. Do a physical exam. See diagram of dentition below.
Step 4: Write pre‐op orders using the EMR “Anesthesia Pre‐Op” order set (type
“Anesthesia Pre‐Op” or “133” to get the form). Peds has a separate order set.
Step 5: Write an H&P. Click the NOTES tab, then NEW NOTE. Then go to the Smart
Text icon and open up the template for the “Anesthesia Pre Op Assessment.” Fill out
template, put note type as “Progress” and add the attending as the cosigner. You may
free text what you like, especially adding specifications to your consent. Complete and
sign the Pre-Op note before going to the OR.
Step 6: If you place the IV yourself, tell the pre op nurse so that they can record it. Ask
for antibiotics.
Step 7: Make sure the flow sheet in the EMR is completed by Pre‐op nurse, Circulating
nurse, Surgeon (attending or fellow) and the anesthesiologist attending. If this is the first
case of the day, go back to the room at 0720 if you have not specifically been asked by
the circulating nurse not to. For other times talk to circulator to see if the room is ready
to bring the patient back. (cardiac room time is 0730)
Step 8: At the end of the case, place post‐op orders using the “Anesthesia Post‐Op”
order set. Fill out the “Anesthesia Operative Note” (template available in the Smart Text
icon), usually your attending starts this. Give report to the PACU nurse – name, age, wt if
pedi, allergies, pertinent medial hx, procedure, type of anesthesia,
narcotics/antiemetics/any special meds, abx including time, fluid totals, issues or PACU
tasks the nurse needs to do. The nurses also want your name. Introduce yourself, be
nice- they will treat you well or give you grief, depending on how you treat them!
 
Step 9: For ICU patients—You will transport these patients straight to the ICU if 1) you
feel the patient is stable and 2) they accept the patient. If the patient is intubated, carry:
intubating gear, self‐inflating ventilation bag (Ambu bag), induction meds, narcotics,
and vasopressors. Sign out to ICU nurse and intern/resident if they are around….and
stay until patient is stable. All pediatric patients need to be signed out to the pediatric
resident/fellow/attending and nursing all at once. See Peds section regarding sign out.
During the weekday, you will need to see these patients on POD#1 and complete an
“Anesthesia Post-Op Assessment” note in EMR. Friday and Saturday patients will be
seen by the weekend PACU day resident the following day (see Chapter 3).
Step 10: When transporting anyone around the hospital, always have at least a pulse
oximeter on them. Insist on it.
Numbering of dentition (http://sundds.files.wordpress.com/2009/03/1.jpg)
8  9
Medications on the Day of Surgery
 Take
o Cardiac medications (ex. Digoxin. Also see Antihypertensives below)
o Statins
o Narcotic pain medications
o Anti‐anxiety and anti‐psychotic medications
o Thyroid medications
o Birth control pills
o Eye drops
o Heartburn/reflux medications
o Anti‐seizure medications
o Asthma medications
o Steroids (oral and inhaled)
o Autoimmune medications (ex. Methotrexate)
 Special consideration needed
o Antihypertensives – continue (esp BBs), with the following exceptions:
 Hold diuretics, except HCTZ, Triamterene if taken for HTN
 Consider holding ACEI, ARBs if sequelae of hypotension is high
o Asprin/Plavix – continue unless bleeding risk outweighs thrombosis risk
o NSAIDs – in general, surgeons ask these to be held 7 days before surgery.
Note that Tylenol (non‐NSAID analgesia) is OK to continue
o Coumadin – Low thromboembolic risk, stop 5 days before surgery, check
INR. High risk, stop 4 days before and bridge with heparin/lovenox
o Dabigatran (Pradaxa) – Renally excreted, so depends on GFR. Low
thromboembolic risk, stop 2 days prior. If high risk, may need bridging.
o Anti‐depressants – continue except:
 MAOIs – traditionally held 2 wks before surgery, but now
considered low risk if continued. Rather, the anesthetic is altered
(avoid indirect sympathomimetics, meperidine).
o Insulin
 T1DM – take 1/3‐1/2 usual am long‐acting insulin (ex lente or NPH)
 T2DM – take 0‐1/2 usual am long‐acting/combo insulin
 Take ultra‐long acting insulins (glargine, Lantus) as usual
 Insulin pump should be at lowest basal rate (usually the pt’s
nighttime rate)
 Hold all intermittent regular insulin
 Pt should check BS on am of surgery and hold insulin if <100
 Oral hypoglycemics – take the evening before, but not the am of
surgery.
10  11
5. NPO Guidelines and PreOp Testing
NPO Guidelines: adult patients, elective surgery + GA/MAC/moderate sedation:
 Clear liquids* until 2 hours preoperatively
 Milk until 6 hours preoperatively
 All other food until 8 hours preoperatively
*Clear liquids: water, clear fruit juice (apple, cranberry OK, no orange juice),
carbonated beverages, ice, black coffee/tea (no milk/cream). No alcohol.
*Jello, broth, and candy require an 8 hour fast.
Routine Preoperative Testing
 Class A– minimally invasive, rarely associated with anesthetic morbidity, blood
administration, invasive monitoring, or post op ICU. Ex. cataract, arthroscopy,
tubal ligation, lap chole.
 Class B– moderately invasive, may require blood, invasive monitoring, or ICU.
Ex.CEA, TAH, spinal fusion w/ limited number of levels.
 Class C– highly invasive, frequently associated with blood transfusion, invasive
monitoring, and ICU care. Ex. open cardiac surgery, open aortic aneurysm,
fem‐pop, posterior fossa crani, extensive spinal fusion.
Healthy Patients (ASA I & II) <50 yrs old
Class A Procedure No testing
Class B Procedure Hct, blood T&S
Class C Procedure CBC, BUN/Cr, lytes, glc, T&C
Healthy Patients (ASA I & II) >50 yrs old
Class A Procedure Hct, ECG
Class B Procedure Above + ECG
Class C Procedure Above +ECG
Patients with Specific Disease History
HTN/CVS Disease ECG, Hct, BUN/Cr
Pulmonary Disease ECG
Diabetes Glc am of surg, ECG if >40y/o
Malignancy CBC, lytes, BUN/Cr
Bleeding d/o or FamHx bleeding CBC, INR, plts
Hepatitis BUN/Cr, lytes, LFTs, INR, plts
Renal Disease (CKD>2) BUN/Cr, lytes, ECG, CXR, plts
Patients with Specific Drug History
Diuretics lytes, BUN/Cr
Digoxin lytes, BUN/Cr, EKG
Steroids lytes, glc
Anticoagulants CBC, INR, plts
 
6. Post Anesthesia Care Unit
Daily PACU Rounds: Choose a time with L3 attending who starts at 7am, think of topics
to discuss (i.e. pain control, PONV, delayed awakening, etc) for learning.
***DISCUSS ANY COMLICATED PT WITH AN ATTENDING***
PACU sign out note:
Every patient must be evaluated and have an “Anesthesia Post-Op Assessment” (EMR
template) for D/C. Have the attending that finished the case cosign. At the minimum, it
must contain (Joint Comission requirements in bold):
1. Set of vitals with brief exam (BP, HR, RR, airway patency, mental status, temp)
2. Brief assessment of: pain, N/V, hydration, MAE, hemodynamics, +/‐
supplemental O2, etc.
3. Where the patient is being discharged (to home, wards, ICU, etc)
Consider adding Aldrete or PADSS scores to your note; see:
1. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995 Feb;7(1):89-91.
2. Chung F, et. al. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth.
1995 Sep;7(6):500-6.
3. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's
scoring system. Anesth Analg. 1999 May;88(5):1069-72.
For complicated patients, document: interventions, medications, labs/studies pending,
anesthesia attending you discussed things with. If a patient needs further management,
they may still be signed out as long as the surgeon/primary team agrees to continue
close follow up. DOCUMENT THIS! Example: “Surgeons aware of high drain output.
Plan to check coagulation panel and reimage with CXR. Discussed with Dr. ___. Pain
controlled, surgeons plan to continue PCA post op. Stable for to transfer to ICU. No
apparent anesthetic complications at this time.”
Sometimes the surgeons start writing their own orders and doing procedures on patients
still under PACU care. This is not acceptable- you are still responsible for the patient.
Talk to the surgeon and your attending, insist that the PACU nurse follow your orders,
and consider sign-out with a detailed note describing transfer and plan of care.
Signing out pediatric patients: Most pediatric anesthesiology faculty will want to sign out
their own patients. They may ask you to sign them out if they were a straightforward
case. If the pediatric patient had an adult anesthesiology staff, let the attending know
before signing out a patient under 2 years old.
Sign out orders (Do this first before the note): Under Periop tab・orderset view・orders.
D/C any anesthesia post-op orders, and order “Discharge from anesthesia”.
Additional Note: Any intubated, unstable or peds patient must be signed out to you by
the primary resident/CRNA. If residents/CRNA’s “forget” to let you know about them, call
them back and ask. Check CXR for ETT and central line placements. May need to
adjust. When in doubt, let someone know. Know your limitations, you are NOT alone!
Chain of commands: 1) primary anesthesia attending who did the case, 2) L3 attending,
3) board runner, 4) available/acute pain attending. Also let the primary team know.
 
Common Problems in the PACU: ‐Clonidine, Toradol (ask surgical team),
The majority of PACU patients will come in and out without incident. But for those that Generally, any Ketamine, Dexmedetomedine
need special attention because of the issues below, an integral part of your deviation from • Note: chronic pain patients can
management includes a review of the chart for PMH and co‐morbid conditions such as normal rate or have high requirements
cardiac/respiratory/chronic pain, as well as review of the anesthetic record for rhythm can
information on meds given, I/O, complications, etc. If the procedure was especially signify acute Anxiety • LOW DOSE benzo/ haldol/ ativan/
complicated, it is also acceptable to page the attending/ resident involved in the case. cardiac injury, (watch for apnea)
Please note this is NOT a comprehensive list. warranting a stat
12‐lead EKG Sympathetic Overactivity • Dx of exclusion. Control pain first.
Problem Possible Etiologies Intervention and appropriate Labetalol 5‐10 mg Q 15 min
(in order of likelihood) workup with Metoprolol 1‐2 mg Q 5 min
Hypoventilation/ Narcotic overdose • Check record for opiate doses immediate Hydralazine 5‐10 mg Q 15 min
Hypoxemia (Low RR, high Vt) • Consider Narcan 0.04 mg IV at a time, primary team (slow onset, long duration)
beware re‐narcotization involvement
Acidosis • Check ABG, assess ventilation
Low threshold Residual Neuromuscular • Nasal/oral airway
for ABG to assess Blockade • Check record for Tachycardia w/ Hypovolemia • Check record for fluids vs. UOP/EBL
pH,PO2, PCO2, relaxant/reversal doses given hypotension • Bolus 0.5‐1L crystalloid, reassess
Hct. (Rapid, shallow, • Test pt: 5‐sec head lift, grip ( smaller volumes in renal/CHF
uncoordinated) strength (twitch monitor is painful, avoid patients)
in awake pts) • Check Hct, consider PRBC tx
100% O2 and • Reversal if indicated
elevated head of • Reintubate and wait if indicated PE/PTX/Tamponade • Consider stat CT chest if suspect,
bed is almost call attending/primary
always indicated. Obstruction/ • Jaw thrust, chin lift
Airway edema/ • Nasal/oral airway, suction oropharynx Bradycardia w/ Excessive beta blocker • Stat EKG
Laryngospasm • Albuterol and/or racemic epi hypotension or cholinergic • Check records for medication hx /
Controlled • Decadron administration anesthetic
ventilation (bag • Poss OR take‐back for • Consider anticholinergics/pacing
mask vs. re‐ decompression
intubation) may • Sux 10‐20 mg (last resort for Intrinsic cardiac • Stat EKG, call attending/primary
be necessary in laryngospasm) w/ positive pressure abnormality team if significant findings
severe cases.
Atelectasis/Decreased • Stat portable upright CXR Other Acute cardiac injury • Review chart, stat EKG, lytes
FRC/ pulmonary edema/ • Incentive spirometry Arrhythmias vs. baseline abnormal • Support hemodynamics as needed
PTX/ PE • Stat CT chest if suspect PE, call • Call attending/primary if needed
attending/primary
Also see Chapter 3 for further responsibilities as the PACU resident:
Pain/Splinting • Treat with long‐acting narcotics  If you’re on during the weekend, you need to do post-op checks on ICU patients
(Rapid, shallow, • Consider epidural or intercostals block  Clean the lounge (cleaning the fridge, and getting rid of old drug syringes)
coordinated)  Call Housekeeping 4‐3777 if need be (vacuum, garbage, etc)
 Plan a social event at least once every two weeks
Cerebral Injury • Call primary team if suspec
 Call Matt Jurach 4-5122 for problems with computers or printer
 
7. Code Box Setup
Tachycardia w/ Pain • ↑ narcotic dose and/or frequency
HTN • Consider alternative medications

12  13 
   

There are three code boxes: one is in the PACU in the pre‐op area by the acute pain
resident computer, one is in PACU 3 by the PACU resident desk, and one is in the call
room for the PACU resident in the Pavilion basement. Always check all the code boxes
yourself at the beginning of the shift (regardless of whether or not they were used by
your predecessor) to ensure that they contain the following and place a yellow tie
indicating that it has been checked (a Joint Commission requirement). The yellow ties
can be found in the Pyxis in the anesthesia workroom under the name “yellow ties” as
well as all the other supplies for the code box.
 Airway equipment:
o Bougie taped on top of the box
o Long and short handles
o MAC 2, 3 & 4; Miller 1.5, 2, 3 blades
o Oral & nasal airways: various sizes
o Tongue blades, ETT ties, tape
o IV set up: tourniquet, IV catheters, normal saline syringes
o Micro cuff ETT: 6.5‐8.0 styletted w/syringes
o Regular cuff ETT: 6.5‐8.0 styletted w/syringes
o LMAs sizes 3 to 5
o ETCO2 indicator
o Cricothyroidotomy kit
 Drugs
o Drug bags are prepared by pharmacy, stocked daily, and located in the
Anesthesia Tech room. If the red pharmacy seal has been broken on the
drug bag on the code box, bring it to the tech room and swap it out for a
new, sealed bag. Place used bags on the shelf labeled “used” so that
pharmacy will restock them.
8. Intubations on the Floor
The process is essentially the same as a code, except that for codes you go directly to
the bedside and meet your attending there (paged separately). For regular intubations
you have time to call back, get more info, and notify your attending. Then, grab that box
and go!
The 5 steps to success:
Step 1: Assess (AS TIME PERMITS)
1. Quick history focused on suspected cause of respiratory distress/code
2. Chart review for allergies, prior intubation records, labs
3. Vitals, IV access, exam of heart, lungs, airway, degree of distress
Step 2: Set Up
1. SUCTION. Many times you’ll only see blood/vomit/secretions on the first DL and
will need to clear your view quickly
2. Ambu bag w/O2 for preoxygenation and post‐intubation ventilation. Usually there
will already be an RT ready to connect the vent.
3. Blade
4. Endotracheal Tube (Micro‐cuff tube if available)
5. ETCO2 indicator (it must be activated by pulling the tab)
6. Bougie, oral airways, tongue blade (with you or readily accessible)
7. Drugs of choice – usual cocktail is Etomidate and Rocuronium
Points to ponder:
 Use Succinylcholine with caution. In patients with chronic kidney disease, burns
or prolonged immobilization (ICU, wheel‐ chair, muscular dystrophy,
stroke/upper motor neuron lesion), Sux -> hyperkalemia -> cardiac arrest
 Remember, true code patients don’t need to be induced, just intubate!

8. NS flush to ensure your drugs actually make it into the patient

9. Gloves/Face mask (nothing worse than meningitic mucus coughed right onto
your face, so protect yourself!)
10. Stethoscope
Step 3: Position
1. OPTIMIZE the patient’s position ‐‐ Raise the bed, ramp up the obese, slide the
patient toward the head of the bed, remove the head board, etc.
2. Make sure you have suction! Can’t stress this enough!
3. Ask a nurse to assist with (and tell them how to) cricoid pressure for RSI
4. Preoxygenate as best you can (ambu bag must be squeezed to get O2 out!
There’s no passive flow like a non‐rebreather or our circuit in the OR)
Step 4: Intubate
1. Give drugs and FLUSH them in. Your attending will typically push the drugs, but
it’s good practice to tell him/her how much to give.
2. Describe what you see as you DL to allow your attending to facilitate
3. A view of the tube passing through the vocal cords is the best sign of a
successful intubation. Otherwise, you will have to go on indirect (a.k.a. less
reliable) measures—chest rise, auscultation, CO2 indicator, fogging.
14  15 
   
 4. Listen to ensure bilateral breath sounds. Mainstem intubation can be dangerous 9. Trauma Room Setup
in tenuous patients.
5. Hold the tube or tie it in place until secured by the nurse. They have a fancy tape
Perform the usual “MSMAID” check of the machine and equipment at each shift.
job they like to use.
Step 5: Reassess
Trauma Rooms are usually #34 or #35, check with board runner or charge nurse before
1. Give RT your temporary vent settings; these will probably be changed by the
setting up. Although difficult to accomplish during the day, as there are usually too
primary team. Check that a CXR has been ordered for tube placement.
many cases going, try to the best of your ability to have 2 trauma rooms set‐up.
2. Treat anesthesia induced hypotension with rescue drugs.
3. Pack up all syringes and blades/handles to take back to the workroom.
1. Airway equipment:
4. Restock the code box immediately. Intubations and codes come in pairs more
often than you might think.  Long and short handle (this will save you on obese/C‐collar patients)
5. Fill out EMR Template progress note “Airway Assessment”.  Mac 3 and 4 blades
 Size 8.0/7.5/7.0 ETT (with low pressure cuffs), styletted, tested, syringed
 Pink, Yellow, Green oral airways
Adult/Pediatric ETT and LMA Sizing*  Trach tie, tongue blade
 Humidivent
Size (mm)  Donut pillow with rubber facemask holder
Age Distance at Lip LMA Size  OGT (the one with the gentry valve) and lube
Uncuffed
Premature Newborn (1–2.5 kg) 2.5 10 cm  ALWAYS check for presence of: Bougie, Ambu bag, size 3,4,5 LMA
1
Term Newborn (2.5–4 kg) 3 11 cm 2. Other Monitors:
1–6 months (5–7 kg) 3.5 11 cm  Attach pulse oximeter sticker
1.5
6–12 months ( 7–10 kg) 4 12 cm  Attach BP cuff
2 years (12 kg) 4.5 13 cm  Load EKG pads on cables
4 years (14 kg) 5 14 cm 2  Temp probe
6 years (18 kg) 5.5 15–16 cm  Default ventilator settings: volume control 550 ml, rate 12, peep 5
8 years (24 kg) 6 16–17 cm  A‐line/CVP transducers connected, zeroed, flushed (techs will set this up)
2.5
10 years (30 kg) 6 17–18 cm 3. IV access:
12 years 6.5 18–20 cm 3  2 PIV sets (Tegaderm, 14/16/18G IV, alcohol, NS flush syringe with J loop,
Adult Female 7.0–7.5 20–21 cm 3‐4 Tourniquet, 4x4, clear tape).
Pregnancy 7 20–21 cm Unwise  A‐line set (A‐line kit, Chlorhexidine, sterile glove, 4x4, clear tape, Tegaderm, wrist
Adult Male 7.5‐8.0 21–22 cm 4‐5 bump)
 Central lines (MAC introducer, Double 14G), no triple lumens b/c they are
Adult Nasal Intubation 6.5‐7.5 Add 2‐3 cm N/A
suboptimal for acute resuscitation (usually will be on top of machine)
 Make sure the Level 1 infusers are plugged in and TURNED ON. This ensures
* Also see Pediatrics chapter for more detailed sizing info (w/ formulas)
that the heater is on and the air trap is functioning.

4. Drugs: All trauma drugs are restocked with prefilled syringes by pharmacy from 4-6
PM daily in the 4th drawer of the Pyxis machine in rooms 34 and 35. Check to see
that we have these essential drugs, and draw up those that are missing.
 Etomidate
 Rocuronium
 Epinephrine (pedi and adult concentration syringes)
 Ephedrine
 Phenylephrine

16  17 
   

 TXA (almost all major traumas with high blood loss will require this)
o Dosing: 10 mg/kg/hr bolus ( approx. 30 minutes), then 1mg/kg/hr for rest of
case
 Atropine
 Succinylcholine
 Sodium Bicarbonate
 Calcium Chloride/Gluconate
 Multiple bags of Plasmalyte
Rule (per pharmacy): All drawn up meds (by us) need to be redrawn at least every 24
hours. Drugs drawn up by Pharmacy have their own expiration dates.
All Drugs need to be labeled with drug name, concentration, date, time, and your initials
Note: Stow away drawn up trauma meds, a‐line/IV kits for the next night shift/day PACU
resident. They may walk away if left out (sad, but true).
10. Emergency and Trauma Anesthesiology
This is a month long rotation with 4 residents sharing four types of shifts. You will cover
holiday call for the main OR. No vacation is allowed, but limited schedule requests
(including edu days) can be made among the trauma service pool of 4 residents.
Trauma Day: M‐F you will be assigned to a room; start a regular OR day until relieved
by the boardrunner or by trauma swing/late person
Trauma Swing: start at 14:00 and should be available until 04:00
Tuesdays from 1400‐1600 may be at the CVC
Will cover emergencies (if they are present, if not you serve as a late person to
get your fellow residents out)
Trauma Night: Every day, start 18:00, end 07:00
Will cover PACU, codes, emergencies, and Acute Pain Service
Weekend Trauma Day: First case starts at 07:30; ends by 22:30 on Saturday and 20:30
on Sunday (remind Board Runner, especially if you are working the next day). If
you are relieved earlier than those times, you will remain first back up until then.
BACK UP CALL for weekend trauma is the cardiac call person. Although not
always possible, you will cover trauma/emergency cases.

If a patient comes emergently up to the main OR, you may not have time for much of a
pre‐op. Consent if possible, including blood products.

Quick questions to ask patient and/or family: (Mnemonic: AMPLE)

 Allergies
 Medications/illicit drugs
 PMH ‐ Broad screening questions such as “Do you have any health problems?”
may be all that time allows
 Last meal
 Environmental exposure (chemical, fire, etc.)

ALL TRAUMA PATIENTS HAVE A FULL STOMACH, regardless of what they tell you.
Induce with Rapid Sequence Induction (RSI)

TREAT ALL TRAUMAS WITH C‐SPINE PRECAUTIONS!

 Use in‐line stabilization (especially when removing C‐collar for intubation) and
bimanual cricoid pressure
 Always have an LMA and Bougie handy
 Consider fiberoptic intubation or Glidescope on standby

Other points to ponder during a trauma:

 IV Access: 2 large bore IV’s (14‐16 gauge is ideal) and/or central line
 A‐line (usually a good idea to help monitor pressures, draw ABGs, etc)
 OG tube/NG tube ON SUCTION (Only for selected trauma cases)

18  19 
   
  Caution: In the cases of basilar skull/facial fractures, it’s never a good idea to Fluid Management in Adult Traumas:
place an NG tube or nasal ETT as it can enter the cranium and cause severe
brain injury Blood Volume: Male: approx. 75 ml/kg, Female: approx. 65 ml/kg
 Level One/Belmont primed and turned on, with air trap device functional (it is to
your advantage to learn how to set these up yourself). Product Effect/Notes
PRBCs • Watch for dilutional thrombocytopenia/ decreased factors
General Fluid Management and Blood Product Replacement: with “massive transfusion” (approx. 1 blood volume).
In the case of trauma, the most likely cause of decreased BP is HYPOVOLEMIA. This is • Consider FFP/platelet replacement
best managed with Fluids, Fluids, Fluids.
 Crystalloids (LR, NS, Plasmalyte) are a 3:1 ml replacement for blood loss (i.e. FFP • Contains all clotting factors
EBL of 300ml = 900 ml of crystalloid, give or take) • Usual dose for massive transfusion 10‐15ml/kg.
o Beware of hyperchloremic metabolic acidosis with high volume infusions • Approx. 3‐8 ml/kg to reverse Coumadin.
of normal saline. It really happens! • Vitamin K requires adequate liver function and takes 6‐12
o Maintenance rates follow the 4‐2‐1 rule for both adults and peds: 4 ml/kg hours to work and weeks to re‐reverse
first 10 kg, 2 ml/kg next 10 kg, 1 ml for each additionall kg.
 Colloids (Hextend, 5%, Voluven, Albumin) and Whole Blood are a 1:1 ml Platelets • One unit should raise the platelet levels 5‐10K
replacement for blood loss. • DO NOT PRESSURE INFUSE — easily injured
 PRBC are a ½ ml to 1 ml replacement for blood loss, call for platelets and FFP or
cryoprecipitate early. Davis has a “massive transfusion protocol” for PRBC and Cryoprecipitate • Contains Factor VIII, XIII , vWF, and fibrinogen
FFP to be delivered in a refrigerator. Just ask for it if needed, and sign the pink • One unit/10 kg raises fibrinogen levels 50mg/dl
form the nurse needs to get it.
 Blood Universal donor: O negative r-Factor VII • Used in extreme cases, obtained from pharmacy.
 Plasma Universal donor: AB (NovoSeven) • Not a blood product (recombinant protein)
 All COLD blood products should be warmed via Hotline or Level One, esp. w/ • Consider after transfusing the above products in large
rapid infusion through a central line. Doing otherwise could lead to infusion of a amounts and coagulopathy still persists, or if no thawed
hyperkalemic, cold product straight to the heart leading to hypothermia and/or FFP immediately available
cardiac arrest. • Cost: Approx. $ 3‐5k/ vial.
 Send serial ABGs to follow the Hct, Lactate, Base Excess, Electrolytes. If time
allows, send a priority one DIC panel (blue and purple top tubes) to obtain an
INR, PTT, Platelet count, Fibrinogen (nl 150‐350 mg/dl) and D‐dimer (nl< 250).
 A patient’s calcium will probably need replacement when you give large volumes ***FOR FLUID MANAGEMENT/BLOOD PRODUCT INFO FOR PEDIATRIC TRAUMAS,
of blood products, due to chelation from the citrate preservative. REFER TO THE PEDIATRICS CHAPTER***

Caution: Calcium is an inotrope and can act like a pressor so it is usually prudent
to give it slowly (1 gram over 3‐5 minutes).

 Don’t forget TXA (tranexamic acid, antifibrinolytic)-shown to decrease necessary

blood transfusion in high blood loss trauma surgery.
 Above all, remember: we treat patients, not lab values. Pay attention to the
clinical picture and use your judgment. If you’re losing blood fast or the surgeon
says the patient looks “oozy”, hematocrits and INRs are just numbers.

20  21 
   

11. Adult Drugs for General Anesthesia Morphine

Scopolamine
0.5–1 mg/kg
0.3–0.6 mg
Below are medication guidelines based on healthy young adults (which you will have
3. Maintenance
noticed by now is NOT your typical UCD patient). Adjust prn.
Dexmedetomidine (Precedex) 0.007 (0.005‐0.01) mcg/kg/min
Ketamine (Ketalar) 0.5‐1.0 mg/kg q5–30 min (1–3 mg/kg loading)
1. Preop Medicines
Fentanyl (Sublimaze) 1–3 mcg/kg/hr (3–7 mcg/kg loading)
 Sedation:
Alfentanyl (Alfenta) 50–150 mcg/kg/min
Midazolam (Versed) 1–5 mg IM or IV (0.07 mg/kg)
Sufentanil (Sufenta) 0.007 (0.005‐0.1) mcg/kg/min
Lorazepam (Ativan) 0.5‐2 mg IV/IM/PO
D/C ~1/2 hr before end of case or your pt may remain apneic until postop.
Diazepam (Valium) 2–10 mg IV/PO
Propofol (Diprivan) 50–300 mcg/kg/min
Meperidine (Demerol) 25–150 mg IV/IM/PO (1‐1.8 mg/kg)
If analgesia needed, add remifentanil 50‐100 mcg to 20ml propofol.
Morphine 1‐4 mg IV/3–7 mg IM (0.1‐0.2mg/kg)
4. Neuromuscular Blockade
 GERD and Anti‐Emetics: Succinylcholine 1–1.5 mg/kg
Sodium citrate (Bicitra) 30 ml PO Mivacurium (Mivacron) 0.15–0.25 mg/kg
Famotidine (Pepcid) 20 mg PO or IV Atracurium (Tracurium) 0.4–0.5 mg/kg
Ranitidine (Zantac) 150 mg PO or 50 mg IV Cisatracurium (Nimbex) 0.1–0.2 mg/kg
Metoclopramide (Reglan) 5–10 mg PO or IV Rocuronium (Zemuron) 0.45–1 mg/kg
Promethazine (Phenergan) 12.5–50 mg IM, 12.5‐25 mg IV Vecuronium (Norcuron) 0.08–0.12 mg/kg
Scopolamine patch 0.4 mg x 72 hrs behind ear; onset ~4hrs Pancuronium (Pavulon) 0.08–0.12 mg/kg
o IMPORTANT: Document on anesthesia pre-op orders; record, and tell
primary team! CNS and other S/E’s can occur long after pt leaves PACU. 5. Reversal of Neuromuscular Blockade
o Avoid getting in eyes, yours or pt’s (mydriasis). Wear gloves when placing; Neostigmine (Prostigmine) 0.04–0.08 mg/kg
cover with ½ Opsite to prevent pt touching patch. Edrophonium 0.5–1.0 mg/kg
Glycopyrrolate (Robinul) 0.005–0.01 mg/kg (0.02 mg/1 mg Neostig)
 Awake Intubation: Atropine 0.01–0.02 mg/kg (0.014 mg/1 mg Edro)
Glycopyrrolate (Robinul) 0.2 mg/Adult (Anti‐sialogogue)
Dexmedetomidine (Precedex) 0.007 (0.005‐0.01) mcg/kg/min 6. Postop Nausea (Prevention and Treatment)
Load w/up to 1 mcg/kg over 10 min. Allow 10‐20min for effect. Ondansetron (Zofran) 4 mg/Adult
Lidocaine 4% nebulizer +/‐ nerve blocks Dexamethasone (Decadron) 8‐10 mg IV/Adult
Dolasetron (Anzemet) 12.5 mg IV/Adult
 Multimodal Pain Control:
Acetaminophen (Tylenol) 650‐1000 mg PO Refractory N/V:
1000 mg IV over 15min ( < 50 kg, 15 mg/kg) o Confirm patient has received Zofran if >6h after last dose
Celecoxib (Celebrex) 200 mg PO (contraind. if CKD, sulfa allergy) o 2nd line ‐ Phenergan 6.25‐25 mg IV (sedating but frequently effective)
Gabapentin (Neurontin) 300 mg PO, 1‐3 tabs o 3rd line ‐ Consider IV fluid bolus, up to 1L if no contraindications
Clonidine (Catapres) 0.1‐0.2 mg PO o Other options – Reglan 10 mg IV, Diphenhydramine (Benadryl) 12.5‐25 mg
IV (sedating but antiemetic properties), Decadron 4‐10 mg IV (but
2. Induction (doses are IV unless stated otherwise) immunosuppressive), Propofol 5‐10mg, Compazine 2.5‐5 mg IV (possible
Thiopental (Pentathol) 4 mg/kg CNS S/E’s).
Etomidate (Amidate) 0.3–0.4 mg/kg
Ketamine (Ketalar) 1–3 mg/kg (Ketamine “dart” IM 3‐5 mg/kg)
Propofol (Diprivan) 2 mg/kg
Midazolam (Versed) 0.25–0.35 mg/kg
Fentanyl (Sublimaze) 50–100 mcg/kg
Sufentanil (Sufenta) 5 mcg/kg

22  23 
   
12. Adult Drips – May need to be ordered from Pharmacy 13. Perioperative Pain Service (Acute Pain)
Medication Infusion Rate Mixture Concentration
Amiodarone Loading:150mg x10min 450mg/250ml 1.8 mg/ml Logistics: This is a 4 week rotation covering non‐OB neuraxial and peripheral nerve
1 mg/min x 6h blocks and catheters for the entire hospital. You share weekend rounding
0.5 mg/min x 18h responsibilities with the resident on Regional/ SDS. Attendings change weekly and
Dexmedetomidine +/‐0.007mcg/kg/min; 200mcg/50ml 4 mcg/ml include Drs. Aldwinkle, Furukawa, Macres, Pitts, Ramos, Devera, and Tautz. Keep an
load 1 mcg/kg x 10 min updated patient list on eHandoff.

Dobutamine 5‐20 mcg/kg/min 500mg/250 ml 2 mg/ml Before a Procedure:

Review the OR schedule the day before and discuss the blocks with your attending. In
Dopamine 2‐20 mcg/kg/min 400mg/250ml 1.6 mg/ml addition, make a list of blocks on the dry erase board in preop for the nursing staff
(these patients will get their IVs first)
Epinephrine 0.01‐0.1 mcg/kg/min 4 mg/250ml 16 mcg/ml  Talk to the patient for consent; check allergies, coags, plts.
 Talk to attending surgeon and make sure they are okay with the block (try and
Esmolol 50‐200 mcg/kg/min 2.5 gm/250 ml 10 mcg/ml talk to surgery resident the day before).
 Talk to the OR anesthesia resident about the plan; obtain midazolam and/or
Insulin 1‐10 Units/hr 250 Units/250 ml 1 Unit/ml fentanyl from them (or get it from the pre‐op pyxis yourself).
 Talk to OR RN (or pod RN when cannot locate OR RN) so they may do their
Isoproterenol 0.05‐0.1 mcg/kg/min 2 mg/250 ml 8 mcg/ml check before you sedate the patient.
 Confirm IV access and place monitors – EKG, pulse-ox, BP.
Labetalol 0.5‐2 mg/min 100 mg/100 ml 1 mg/ml  Turn on ultrasound machine, input patient information
 Set up block cart with:
Lidocaine 20‐50 mcg/kg/min 2 gm/250 ml 8 mg/ml o Sterile towels & 4x4 gauze
o Chloraprep x2
Magnesium 0.5‐1 gm/hr 1 gm/50 ml 20 mcg/ml o 5 ml of 0.5% lidocaine for skin infiltration
o Depending on block and attending, draw up 20 ml or 30 ml of
 0.25% ropivicaine
Milrinone 0.25‐0.75 mcg/kg/min 20 mg/100 ml 200 mcg/ml
 0.5% ropivacaine +/‐epinehrine
 1.5% mepivicaine +/‐epinehrine
Naloxone 1‐5 mcg/kg/hr 1 mg/100 ml 10 mcg/ml
o Stimuplex needle (if single‐shot block) or Continuplex needle (if catheter
planned).
Nitroglycerin (NTG) 0.1‐10 mcg/kg/min 50 mg/250 ml 200 mcg/ml
o +/‐U/S sleeve or tegaderm with lots of goop packets
Nitroprusside (SNP) 0.2‐10 mcg/kg/min 50 mg/250 ml 200 mcg/ml The Pain Bag: Should contain: 18G needles, 10ml saline bottles, EtOH wipes,
band‐aids, Tegaderms, benzoin swabs, silk tape, replacement catheters, alligator clips,
Norepinephrine 0.01‐0.1 mcg/kg/min 8 mg/ 250 ml 32 mcg/ ml and syringes. Drugs that you might want to grab before you round include: 2% lidocaine
(Levophed) bottles, 0.25% bupivacaine, 2% chloroprocaine, ephedrine, phenylephrine, atropine,
Phenylephrine +/‐0.1 mcg/kg/min 20 mg/250 ml 80 mcg/ml pedi bicarb, saline flushes. Do not keep drugs in the bag; CMS will be very unhappy.
(Neosynephrine)
Procainamide 1‐4 mg/ min 2 gm/250 ml 8 mg/ml Rounds: Assess pain level at rest and with movement, PRN narcotic use, PCA use
(attempts, injections, total dose), sleep pattern, ambulation/activity, ability to cough,
Remifentanil 0.025‐2 mcg/kg/min 1 gm/20 ml 50 mcg/ml anticoagulants and time given, diet status. Write daily progress notes using the
“Anesthesia and Pain Epidural/Peripheral Cath Progress Note” template on EMR
Sufentanil +/‐0.007 mcg/kg/min 250 mcg/20ml 12.5 mcg/ml

Vasopressin 0.04 Units/min 40 Units/250 ml 0.16 Units/ml

24  25 
   

Local Anesthetics for Regional Anesthesia 6. Write a procedure note in EMR. Use the template “Anesthesia Neuraxial Anesthesia
Procedure Note.”
Drug Duration (min) Max Dose (IV + topical + regional)
Lidocaine 30–60 5 mg/kg Peripheral Nerve Catheter:
Lidocaine w/ Epinephrine 120–180 7 mg/kg 1. Ropivacaine is frequently used in peripheral catheter infusions. Order is found under
Bupivicaine 120–240 2.5 mg/kg ropivicaine 0.2% for nerve block infusion. Start rate at 8ml/hr for most continuous
Ropivacaine 150‐360 epidural 3‐4 mg/kg catheters. Type in range of infusion up to 10ml/hr.
8‐12hrs PNB 2. See bolus guidelines under Epidural Catheters. The difference is that you can bolus
Tetracaine 120–240 1.5 mg/kg up to 20 ml total (in 5‐ml increments).
Chloroprocaine 15–30 8 mg/kg 3. Write a procedure note as above. Use the template “Anesthesia Nerve Blockade
Chloroprocaine w/Epi 30–60 10 mg/kg Procedure Note.”
Procaine 15–30 8 mg/kg
Procaine w/ Epi 30–60 10 mg/kg Pain Services:
1:1 = 1 gm/ml; 1:1000 = 1 mg/ml; 1:100,000 = 0.01 mg/ml = 10 mcg/ml 1. Pain Pharmacists (8 a.m. to 5 p.m.) ‐ 816‐1457
1% = 1:100 = 10:1000 = 10mg/ml 2. Primarily Mark Holtsman, Pharm.D. – Available for consults and management of
chronic pain pt medications on the floor/ICU
Spinal Anesthetic (Non‐OB): Must be preservative‐free. 3. Chronic Pain Service: 916‐OUCH (6824) ‐ Pain fellow on-call pager
Bupivacaine 0.75% in 8.25% dextrose (hyperbaric) 10‐15 mg 4. Acute (aka Perioperative) Pain Service: 816‐6915. Also covering non‐OB blood
Duration 90‐12 min plain, 100‐150 min w/epi patches, rib fracture epidurals, and pediatric epidurals.
Lidocaine 5% in 7.5% glucose (hyperbaric) 50‐75 mg 5. Regional Pain service: places blocks for the OR (same day surgery center)
Duration 60‐75 min plain, 60‐90 min w/epi
Tetracaine 1% 10 mg in 10% glucose (hyper‐) or +1 ml sterile water (hypo‐) Trouble‐shooting Catheters:
Duration 90‐120 min plain, 120‐240 min w/epi 1. The better we manage our catheters, the more convinced surgeons will be that they
benefit their patients, and the more we will get to do.
Spinal Adjuncts: 2. Trace the catheter from the patient’s skin to the pump. Many nurses are completely
Fentanyl 15 mcg‐25 mcg (0.3 ml of 50 mcg/ml) unfamiliar with these. Catheters have been found connected to IVs or not connected
Duramorph 0.2‐0.3 mg (0.4‐0.6 ml of 0.5 mg/ml) at all. Check the pump and confirm it is programmed correctly.
3. When you see a patient (even if you don’t do anything), WRITE A NOTE IN EMR. If
Epinephrine 0.1‐0.2 mg (0.1‐0.2 ml of 1 mg/ml)
it's not documented, it never happened.
4. If the catheter is broken, cut off the broken tip of the catheter at an intact, meta-
Epidural Catheter Anesthetic (Non‐OB):
reinforced portion and reinsert at the white connector (alligator clip). If white
1. Test dose in kit – lidocaine 1.5% + epi 1:200,000, total 5 ml.
connector broken then replace (connector in Anes Tech room).
2. Order infusion using Epidural Analgesia order set. Include in comments: "Page
5. Assessing block:
816‐6915 for all pain management questions."
a. Assess block bilaterally (unless peripheral block) using ice in a glove or bag to
3. Bolus while awaiting infusion and pump. Every dose is a test dose! Aspirate first and
assess temperature discrimination (sympathectomy level), metal tip of
give in max 5‐ml increments. Bupivacaine 0.125‐0.25% or Lidocaine 1‐2%
yellow/orange needle‐less needles to assess pinprick (sensory level), or
4. Start infusion intraop when pump and infusate arrive. To unlock pump keypad,
motor testing (motor blockade).
Anesthesia code is 777. Use volume of 90 ml; otherwise, infusion has a tendency to
b. Block onset is fastest at the sympathetic fibers. Level of sympathetic block is
run dry before replacement arrives.
≥ 2 more than sensory ≥ 2 more than motor. Need only a sensory block for
5. IMPORTANT: Call 6915 to sign out your epidural. The Pain Service can’t follow it if
pain control but may see hypotension due to sympathectomy or respiratory
they don’t know about it. If you are carrying 6915 after hours and find a catheter that
symptoms due to intercostal motor blockade.
is not on the list you were given, add it and sign it out in the morning. Report the
c. Don’t want a block ≥ T4; monitor for dyspnea and weakness, bradycardia, or
following info:
paresthesias in ulnar distribution, indicating block is getting too high. Place
a. Pt name, age, allergies, significant Hx (anticoagulants, other pain meds)
patient head‐ up w/ neck flexion and stop infusion until block subsides.
b. Level of placement, depth in epidural space and at skin
c. Infusate and rate
d. Attending surgeon and surgery performed
e. Any complications during placement
26  27 
   
 6. Postop Catheter Bolus Drugs: Patient had a level A. Infusion stopped, now or Check pump and connections all
a. 0.125‐0.25% bupivacaine: Onset~10min; don’t mix with bicarbonate before and now has earlier (e.g., delay the way to patient. Fix mechanical
b. 1% Lidocaine with bicarb (speeds onset): Mix 9ml of 1% Lido with 1 ml 8.4 % none receiving infusion bag) problems, bolus to achieve
(pediatric) bicarbonate 1 mEq/ml. Onset: ~5 min. adequate level, then restart
c. 2% Chloroprocaine: Onset ~3‐5 min B. Catheter migrated out infusion.
d. Can bolus with the infusate itself, but it takes longer for effect.
e. IV rescue drugs: Ephedrine 5 mg/ml or phenylephrine 0.1 mg/ml. 1. Pull out catheter and put patient
7. Procedure for bolusing: on PCA. Caution: Check coags
a. Determine whether you are dealing with a lumbar epidural, thoracic epidural, and anticoagulant dosing first!
or peripheral nerve catheter. 2. Early postop thoracotomies: If
b. Make sure the patient is monitored with BP cuff/SpO2. possible, replace epidural with
c. Tell patient that s/he may feel the cold solution going in. attending supervision
d. Expect it to feel more resistant than blousing meds into an IV.
e. Stop bolus immediately if there is any pressure or pain. Patient has a A. Catheter was always Bolus. If no effect, pull back
f. Bolus guidelines (in general, sympathectomy more likely with thoracic one‐sided level one‐sided, but may have catheter 1cm at a time and
epidurals): seemed bilateral initially re‐bolus.
i. Lumbar: bolus 5ml at a time, may repeat to max of 15‐20 ml 2/2 bolus spillover
ii. Thoracic: bolus 3‐5ml at a time, max 10 ml
iii. Peripheral: bolus 5‐10ml (usually with lido when checking function, B. Patient is lying on one Turn patient to the other side and
may using longer acting if topping up). side. Down side has good give bolus.
g. The aforementioned pressors are for when you are overzealous and drop the level; up side has little to
pt's BP. Stay 15‐20 minutes to reassess block, follow vital signs, and write no level
your note.
h. Tell the nurse you bolused the patient's catheter because they will monitor Patient might or Unable to adequately If pain appears inadequately
vital signs more frequently according to their protocol. might not have a assess block as patient controlled, try bolusing. If no effect
8. Common Epidural Catheter Problems, and What to Do: level gives inconsistent answers and everything else is ruled out,
pull out catheter (check coags!)
Findings Reason Solution and start PCA vs. prn IV/PO pain
Patient had a good Infusion rate too low Bolus and increase infusion rate meds per primary team.
block before; now
not covering Patient never had a Placing team cannot admit Try bolusing/pulling back, call
incision level and still has defeat? attending and replace catheter
none now (check coags!), or remove and
Patient has a partial A. Patient has chronic pain D/C narcotic from infusion and start PCA vs. prn IV/PO pain meds
or good block but in areas not covered by continue with local anesthetic per primary team.
after trouble‐ block only. Communicate with primary
shooting continues team. Offer to order or let them
to complain of pain B. Catheter does not order PCA vs. prn IV/PO narcotics
completely cover incision as indicated. Check chart for
home pain meds that need to be
continued.

28  29 
   

LMWH 0/0 3‐5 hrs 12+ hr PPx = enoxaparin (Lovenox) 30mg q12 or 40mg
Neuraxial Anesthesia in the Setting of Anticoagulation q24, dalteparin (Fragmin) 25‐50K q24
Agent PT/PTT Time to Duration Recommendations  Placement: delay until 10‐12 hrs after last
peak dose
Oral Anticoagulants  Start: q12 dosing contraind, may begin
Warfarin +++/0 4‐6 days 4‐6 days  Long term: document INR<1.2 before q24hr dosing 24hrs p catheter placement.
(less with placing block.  Removal: remove catheter 10‐12hrs after
loading)  Periop ppx: If 1 dose given in last 24hrs, last dose, start next dose 2 hrs later
safe to do block. If >1dose, or given > Therapeutic = enoxaparin 1mg/kg q12 or
24hrs ago, check for nl INR. 1.5mg/kg q24, daltaparin 100U/kg q12 or
 Keep INR at or below 3 while catheter in 200U/kg q24
place.  Delay placement ≥ 24hrs after last dose.
 Safe to remove catheter when INR <1.5  Therapeutic dosing contraindicated while
Antiplatelet Drugs catheter in place
ASA 0/0 Hours 5‐8 days  No increased risk of hematoma Additional Agents
NSAIDs 0/0 Hours 1‐3 days  No increased risk of hematoma Thrombolytics Streptokinase, Urokinase,  Neuraxial anesthesia is contraindicated.
Other Thenoyridines: ticlopidine (Ticlid) 14 days, clopidogrel (Plavix) 7 days TPA
Antiplatelets GP IIa/IIIb: abciximab (Rheopro) 48hrs, eptifibatide (Intergrilin) 8hrs, tirofiban Fondaparinux  Single shot neuraxial OK, catheters
(Aggrasstat) 8hrs contraindicated
Heparins Herbal Meds  No contraindication
Unfractionated 0/++ 1.5hrs 4‐6 hr Heparin subQ
Heparin  Not contraindicated, but heparin peaks
2hrs after SQ administration
 Check platelets before placement or
removal if >4 days on heparin.
 Removal: If q12, 1hr prior to next heparin
dose. If q8, skip one dose and dc 11hrs
after the last dose received.
Intraop IV Heparin
 No neuraxial if other coagulopathies also
present
 Start: delay for 1 hr after catheter
placement, more if difficult placement.
Therapeutic IV Heparin
 Placement: avoid block if ↑ PTT
 Removal: if pt on tx, remove 2‐4 hrs after
heparin dosing held and only after
documented normal PTT.

30  31 
   
14. Pediatric Anesthesiology Locker Code 543
Feel like you’re in that first CA1 month again? So much new stuff to learn. Your brain
will be exhausted. The good news is that the attendings on peds are all more than
willing to teach and guide you through it.
Welcome to pediatric anesthesiology. You will spend a minimum of two month‐ long
attachments on this service during your residency. During this rotation, you will become
an integral member of the pediatric anesthesia team, focusing primarily on the child and
family members. You will also interact with pediatric surgeons, Child Life Specialists,
PICU & NICU staff, nurses, and pediatricians. Working together, we provide patients
and their families with the best possible care through the University of California, Davis
Children’s Hospital. Dr. Niroop Ravula is the Residency Education Director for Pediatric
Anesthesiology and can be contacted via Vocera or pager 819-0853 to discuss issues at
any time.
Location/Personnel
The Children’s Surgery Center is located in the area formerly known as the University
Surgery Center, on the first floor of the hospital, down the hall towards the parking
garage from the “brick lobby” / Black Rhino coffee area. CSC has four OR’s and one
procedure room CSC #5. CSC #3 is situated so that parents in bunny suits may join
their children for certain types of cases. (Scrubs are required in CSC#1,2, and 4). There
is also a physician computer room (near the main PACU entrance), and a family
consultation room (just around the corner from the check‐in desk). The consultation
room is where Monday AM didactic sessions occur.
Downstairs from CSC, you can find locker rooms (bathrooms and showers, code 5-4-3),
as well as a break room (refrigerator, microwaves, coffee, and good cheer). The break
room is very close to the classroom where you have Monday afternoon lectures.
You will be assigned a faculty mentor for your pediatric rotation. If you haven’t already
met, please introduce yourself to the mentor as well.
Call Schedule
Each resident covers one “call week” on the pediatric rotation (Saturday 7 AM through
the following Saturday at 7 AM). We view this as seven 24‐hour shifts. You are expected
to be in the hospital each weekday at 10:00am; you will cover pre‐ops, post‐op checks,
urgent add‐on cases, unexpected sick calls/absences, or to relieve people for certain
obligations (e.g., the Wednesday morning cardiac conference, which is mandatory for
pediatric anesthesia fellows). Once cases are done, you are on typically home call (by
pager, within 30 min distance), until midnight so that you can return at 1000 the next
day. Pagers should still be on overnight in case of extreme emergent cases where the
resident may get called in.
Your call is not always linked with the pediatric anesthesiologist. Sometimes, you may
do pediatric cases while being supervised by the in‐house (Pavilion) call faculty. It is up
to them to decide whether or not to call in the pediatric anesthesiology attending as well.
32  33
 See the patient before giving any premedication – sometimes the situation has
changed since you spoke to them the night before!
 Besides writing the midazolam order in EMR, you must verbally communicate
with the pre‐op nurse – they may not realize that an order has been written or
know the appropriate time to administer the dose.
 Oral midazolam takes about 15‐20 minutes to work, so give it earlier rather than
later. But… it also wears off after about 45 min, so don’t give it TOO early.
 Consider adding oral acetaminophen (10‐15 mg/kg) to oral midazolam. It makes
the midazolam taste better, and has some opioid‐sparing synergy.
Room Turnover
Room turnovers in CSC are fast compared to the Pavilion. Don’t wait until you have set
up the room, examined the patient, and obtained consent before ordering the oral
premedication. If you do this, each case will be delayed while you are waiting for the
drug to take effect, and the time will add up by the end of the day! Think about giving
the midazolam (if appropriate) just after you drop the previous patient off in the PACU,
prior to the rest of your turnover tasks. Similarly, plan your early morning activities so
that your first pre‐medication is given by about 07:05 – 07:10 at the latest.
Keep moving at light‐speed. Gather everyone necessary for the “huddle” (circulator,
anesthesia attending, surgeon, and scrub nurse) and meet in the OR before bring
patient back to the OR.
Set‐Up
 Machine: usual check, set ventilator to pediatric settings for each patient
 Suction: pediatric size suction catheters
 Monitors: screen set for ‘pediatric’ or ‘neonate’, 3‐lead ‘puppy‐dog’ ECG stickers
(plug the green lead into the red hole) appropriate size pulse‐ox sticker and BP
cuff, and the special neonate BP cord, if needed.
 Airway: have range of 3 tubes (styletted, syringed, and tested), as well as a range
of oral airways and facemasks. Also, make sure an appropriately sized LMA is
available as an emergency airway. For most children younger than teenagers,
use a pediatric circuit/anesthesia bag.
 IV—For kids < 20 kg, use a 250 or 500 ml NS bag on Buretrol tubing with blue
Luer lock and pedi T‐piece. (The Buretrol will limit accidental IV fluid overdose.)
For kids > 20 kg, omit the Buretrol and use regular pedi ‘microdrip’ tubing. For IV
placement, get a tourniquet, 24/22 G IV, alcohol wipes, 4x4, and Tegaderm.
NOTE: In rooms with rapid turnover and short cases, set up your IV’s at the
beginning of the day.
 Drugs: weight‐based! Have succinylcholine and atropine ready with 22G needle
at the end of the syringe for emergency IM injection. Also, propofol is an
emergency airway drug in pediatrics – always have it ready. If you think you will
need it, also consider epinephrine in 3 dilutions: 100mcg/ml, 10 mcg/ml, 1
mcg/ml.
 Other: Underbody Bair Hugger blanket, French fry light (premies and newborns),
and increased room temp for small kids (< 5 yo).
34  35
You must follow the 10‐hour rule during your call week. When you finish in the
OR, don’t return until after a 10‐hour rest period. A few points about this rule:
 The 10‐hour rest doesn’t begin until ALL cases that night are finished. Rarely,
you may be called in multiple times during the same night.
 Per ACGME, the 10‐hour rule does NOT apply on weekends or holidays, since
call is “from home”.
 The 10‐hour rule is a valid reason to miss the Monday AM didactic session (see
below).
Call and Life: We appreciate that this week offers you some scheduling flexibility to do
things that normal people do during the day, like visiting doctors, dentists, and auto
mechanics. It’s usually OK to do these – just let us know in advance. You’re still
expected to be in the hospital during the remainder of your 24‐hour shift (taking into
account the 10‐hour rule). For example, tell us Monday or Tuesday that, “I need to visit
the dentist, so I’ll be busy on Wednesday from 10 – 12”.
Drugs
The OR’s in CSC share one Pyxis machine, with limited supplies. Therefore, you will
have to check out a drug kit from the Pavilion 3rd floor pharmacy. After hours and on
weekends/holidays, drugs kits may be checked out (and returned) at the 8th floor
pharmacy. The CSC PACU also has a Pyxis machine, with some (but not all) typical
anesthesia drugs (e.g., propofol, fentanyl, morphine, midazolam). If you only need a few
vials of medication for one case, you may consider obtaining them from this Pyxis.
Pre‐op and Consent
Please do your best to obtain a detailed anesthetic consent for all of your patients. The
consent is an important way to reassure parents, address their questions, and build
rapport. In pediatrics, consent issues are often more complex than they appear. For
example, the daily caregiver (grandparent, foster parent, etc.) with whom you speak on
the phone or who is staying with the child in the hospital often is NOT the legal consent
giver. The sooner we realize that a consent issue needs to be resolved, the quicker we
can mobilize resources (e.g., social workers) to avoid delaying or postponing cases.
One exception to the consent rule when you are in the “heme‐onc” room, doing sedation
for lumbar punctures and bone‐marrow biopsies. Here, you do not need to call your
patients the night before, for two reasons: (1) the final schedule is frequently changed
the day of the procedure; (2) most of these patients already have a “serial consent” in
the chart (verify with the pre-op nurse).
Premedication
Stranger anxiety starts at 6 months, peaks at 9 months and ends at 12 months.
Separation anxiety begins at 12 months and continues to 30 months. One way around
these sources of anxiety is to invite a parent to be present during induction of
anesthesia. However, oral midazolam (0.5‐0.75 mg/kg, max dose 20mg) is even more
effective than parental presence, and is often preferred. There are a few important
points to remember:
 
Educational Component
Monday morning didactics (6:10 – 6:50 AM in the CSC consultation room) are
mandatory, as are intra‐operative case discussions. Consequences of missing some or
all of these components may result in an unsatisfactory assessment, and leading the
didactics the following week. Please check the pediatric anesthesia SmartSite under
“resources” for up‐to‐date curriculum information.
The Transport and Handover of Intensive Care Patients
M.D. to M.D. communication is key, whether in person (for patients transferred from and
to the ICU) or by phone (for patients recovered in the PACU first before going to the
ICU). Patients admitted to the PICU or NICU should be seen on POD#1 with a post‐
operative note documented in the chart, either by the resident involved with the case,
or – if (s)he is unable – by the on‐call resident.
Transport must be planned in advance. Equipment should include:
 Airway equipment (mask, oral airway, LMA, endotracheal tube/laryngoscope)
 Ambu‐bag, in addition to Jackson‐Rees (Mapleson F)
 Oxygen tank (check the pressure)
 Drugs (resuscitation and sedation – typically propofol)
 Fluids and/or blood
 Warm blankets
Your attending will communicate with the PICU attending prior to transport. On arrival on
the PICU, the anesthesia team remains in charge of patient management, whilst the ICU
staff connects monitors and ventilator. Invasive lines must be zeroed, and NOT
sampled, so that the necessary hemodynamic information is readily visible.
Once the patient is deemed stable, the anesthesia resident will formally hand over the
patient to both intensivists (resident AND attending) and bedside RN. If someone is
missing or not listening, insist that they appear. Handover is to be done clearly,
succinctly and ONCE only. That way, everybody has the same information and we don’t
repeat ourselves. Your attending will be present to fill in any gaps. Once handover is
complete, the ICU team takes charge of the patient.
To facilitate this process, the anesthesia resident should prepare the handover report
fully prior to transport. WRITE IT DOWN IN FULL PRIOR TO PICU ARRIVAL. The
handoff for pediatric cardiac cases is more specialized; please discuss how it works with
your attending prior to arrival in the PICU.
 
Normal Pediatric Values According to Age Normal Intracardiac Pressures (mmHg)
Age HR BP RR Wt (kg) Blade (Miller) Newborn Child
Newborn 120-180 55-80 / 30-50 50-60 3.2 0 RA (mean) 0‐4 2‐6
6 mos 140-160 65-108 / 43-70 24-40 7.5 1 RV 65‐80 / 0‐6 15‐25 / 3‐7
12 mos 90-150 65-108 / 43-70 24-40 10 1 PA 65‐80 / 35‐50 15‐25 / 10‐16
2-3 yrs 80-130 78-113 / 45-78 24-32 12 1.5-2.0 PW (mean) 6‐9 8‐11
4-6 yrs 80-120 78-113 / 45-78 22-28 16-20 1.5-2.0 LA (mean) 3‐6 5‐10
6-8 yrs 75-110 80-120 / 53-82 20-24 20-24 2 LV 65‐80 / 0‐6 90‐110 / 65‐75
10-12 yrs 70-110 90-130 / 55-85 14-20 30-40 2-3
14-16 yrs 60-105 95-144 / 58-88 12-20 40-60 3 Central Venous Catheters
< 10 kg 4 Fr / 8 cm
Estimating weight (kg) ≈ 2 x age (yrs) + 8 (< 8 yo), or 3 x age (> 8 yo) 10-30 kg 4-5 Fr / 12 cm
> 30 kg 5 Fr / 15 cm
Blood pressure: Handy definition of hypotension:
MAP < post‐conceptual age (in weeks) for preterm babies Length of catheter to insert (assuming a LOW approach):
SBP < 60 (newborn) SBP < 70 (1 year‐old) [ Height (cm) / 10 ] – 1cm (ht < 100cm), or
SBP < 70 + 2 * age (age 2‐10 y) SBP < 90 (age > 10) [ Height (cm) / 10] – 2 cm (ht > 100 cm)

ETT and LMA Sizing NPO Guidelines

Size (mm) Distance at 2 hrs for clear liquids
Age LMA Size
Uncuffed Lip 4 hrs for breast milk
Premature Newborn (1–2.5 kg) 2.5 10 cm 6 hrs for formula
1
Term Newborn (2.5–4 kg) 3 11 cm 8 hrs for solids and non‐human milk
1–6 months (5–7 kg) 3.5 11 cm NOTE: 6 hours for a ‘light meal’ (non‐fatty foods like toast/crackers/dry cereal) is
1.5
6–12 months ( 7–10 kg) 4 12 cm acceptable to some practitioners, but this is not official UCDMC policy.
2 years (12 kg) 4.5 13 cm
4 years (14 kg) 5 14 cm 2 Allowable Blood Loss (MABL) Equation
6 years (18 kg) 5.5 15–16 cm MABL = wt(kg) * EBV * (original Hct – lowest acceptable Hct) / Average Hct
8 years (24 kg) 6 16–17 cm
2.5 Estimate of Circulating Volume
10 years (30 kg) 6 17–18 cm
12 years 6.5 18–20 cm 3 Age EBV (ml/kg)
14+ years 7.0+ 20-22 Preterm 100
Fullterm newborn 90
ETT Sizing Formulas (internal diameter in millimeters): For Peds (age > 2 yrs) Infant 80
School age 75
Uncuffed ETT: age (years) / 4 + 4 Adult 70
Cuffed ETT: age (years) / 4 + 3
For NICU pts: Current Gestational Age (weeks)/10 Estimated Blood Loss
4x4 sponge ~1ml blood – sponge looks red; can hold up to 10 ml if soaked
ETT Depth Formulas (in centimeters) Lap sponge ~10 ml blood – sponge looks red; can hold up to 100 ml soaked
Oral intubation = 3 X internal diameter (mm) or 12 + (Age/2)
Nasal intubation = 4 X internal diameter (mm) or 15 + (Age/2) Amount to Transfuse
NICU patient: wt (kg) + 6 mL of PRBC = (Desired Hct – current Hct) * EBV * weight(kg) / 60

36  37 
   

Bronchodilators and Emergency Airway Drugs

Blood Products/Fluids Drug Dose Notes
Product Dose Effect/Notes Albuterol puff 10‐20 puffs thru ETT Only about 10% gets to lungs
PRBC 10 ml/kg Incr. Hct 3‐5% or Hgb 1g/dl Albuterol 0.15 mg/kg in 2.5mL NS As frequently as Q 1 h
FFP 10 ml/kg Incr. all coag factors 30% (2.5mg/3ml)
Platelets 10 mL/kg Incr. count by 25K‐50K Racemic Epi 0.25‐0.5 mL in 3mL NS As frequently as Q 1 h
Cryoprecipitate 3‐5 ml/kg Incr. Fibrinogen 50 mg/dl (2.25%)
Factor VIII 1 unit/kg Incr. Plasma level 2% Isoproterenol 0.1 mcg/kg/min IV Increase to effect
Recombinant VIII 90 mcg/kg (max) Split into 2 – 3 smaller doses Dexamethasone 0.25 – 0.5mg/kg IV Max dose 10 mg
ddAVP (Vasopressin) 0.1‐0.2 mcg/kg Infuse slowly Methylprednisolone 1‐2 mg/kg IV/PO ) q 6‐12 hrs (max 4 mg/kg/day
NS or LR Bolus 20 ml/kg Repeat X 2‐3 for low BP Terbutaline 0.1 mg/kg neb, 10 mcg/kg Max dose 0.4 mg ‐ 0.75mg IV
Maintenance IV fluid 4 ml/kg/hr for first 10 kg Example: 33 kg child gets (40 IV/IM dose 2‐3 mcg/kg at a time
2 ml/kg/hr for next 10 kg + 20 + 3) = 63 mL/hr Magnesium sulfate 25‐50 mg/kg IV Max dose 2 g
1 ml/kg/hr each addl. kg
Dextrose 0.5 – 1 g/kg Hypoglycemia: Premedication
Infant: < 60 mg/dl Drug Dose (mg/kg) Onset Max Dose
Neonate: < 40 mg/dl Midazolam PO 0.5 ‐ 0.75 10 ‐ 20 min 20 mg
Midazolam IV 0.1 Fast
Resuscitation Midazolam IM 0.2 Fast
Drug Dose (mg/kg IV) Notes Midazolam nasal 0.2 10 ‐ 20 min
Atropine 0.02 (can give IM) ?minimum dose 0.1mg Clonidine PO 0.004 45 ‐ 60 min
Epinephrine (‘code dose’) 0.01 Or give 0.1 mg/kg via ETT
Epinephrine (‘hypotension’) 0.001 Induction Agents
Epinephrine (‘bronchospasm’) 0.001 Drug Dose (mg/kg)
Adenosine 0.1 (first dose) Repeat 0.2mg/kg (12 mg max) Propofol 2 – 3 mg/kg
Amiodarone 5 Max 300 mg Thiopental 4 – 6 mg/kg (reference only, no longer available)
Lidocaine 1–2 Can give via ETT Etomidate 0.3 mg/kg
Calcium chloride 10% 20 via central line Remifentanyl (intubation) 3 – 4 mcg/kg
Calcium gluconate 10% 50 via PIV or central line Ketamine IV 1‐2 mg/kg
Na-Bicarb 8.4% (1 mEq/mL) 1 – 2 mEq/kg for pH<7.2 Ketamine IM 2‐5 mg/kg
THAM 3 – 6 mL/kg Atropine 20 mcg/kg (MIN dose 0.1 mg)
KCl 0.5 mEq/kg Give over 1 hour Glycopyrrolate 10 mcg/kg
Insulin (regular) 0.1 unit/kg Can also give 0.1 unit/kg/hr
Muscle Relaxants: Use 1/5 loading dose for incremental dose
Cardioversion: Drug Dose (mg/kg)
External synchronized: 0.5‐1.0 J/kg, repeat up to 2 J/kg Rocuronium (normal) 0.6 (for neonates, use 0.3)
Rocuronium (RSI) 1.2 (for neonates, use 0.6)
Defibrillation: Cisatracurium 0.2
External: 2 J/kg, repeat up to 4 J/kg Vecuronium 0.1
Internal: Start with 1‐2 J then increase by 2 J Pancuronium 0.1
Succinylcholine IV 2
Succinylcholine IM 4

38  39 
   
Reversal Antiemetics
Drug Dose Drug Dose Notes
Neostigmine + Glyco 70 mcg/kg + 0.2mg glyco per 1mg neo Ondansetron 0.1 mg/kg Max dose 8 mg
Edrophonium + Atropine 0.25‐0.5 mg/kg + 5‐10 mcg/kg Metoclopramide 0.15 mg/kg
Naloxone 1 mcg/kg, titrate to effect; Can also give IM or via ETT Ranitidine IV 1.5 mg/kg Or 3 mg/kg PO
Flumazenil 1‐10 mcg/kg, titrate to effect Promethazine 0.25‐0.5 mg/kg q8 hr IV, IM or PO

Analgesics Anticonvulsants
Drug Dose Max Dose Drug Dose Notes
Fentanyl 1 – 2 mcg/kg Diazepam 0.2‐0.5 mg/kg Max 10 mg
Morphine (loading) 0.1 – 0.2 mg/kg Lorazepam 0.1 mg/kg Max 4 mg
Morphine (top‐up dose) 0.02 mg/kg q10‐15 min Midazolam 0.1 mg/kg Max 4 mg
Meperidine 1 mg/kg Phenobarbital 10‐20 mg/kg Max 40 mg/kg
Methadone 0.1 mg/kg q8‐12 hrs Phenytoin 10‐20 mg/kg Give over 10 minutes
Acetaminophen PO 10 mg/kg q4h 60 mg/kg/day for term infants
15 mg/kg q6h and preterm neonates > 32
weeks. Miscellaneous
Acetaminophen IV 10 mg/kg q4h 40 mg/kg/day for premies < Drug Dose
15 mg/kg q6h 32 weeks post conceptual Mannitol 0.25‐0.5 g/kg
Acetaminophen PR 20 mg/kg if < 6mo age. Furosemide 0.5‐1.0 mg/kg
90 mg/kg/day for others.
Peri-op:
Benadryl 0.5 ‐ 1 mg/kg
<2years: 10-12mg/kg Chloral hydrate PO 50 – 100 mg/kg
>2 years 15mg/kg Pentobarbital 2 mg/kg IV (max 6 mg/kg)
Ketorolac (> 6mo – 1 yo) 0.5 mg/kg q6 hrs 30mg Caffeine citrate 10 – 20 mg/kg IV
Oxycodone elixir PO 0.1 – 0.15 mg/kg
Codeine PO 0.5‐1.0 mg/kg q4‐6 hrs Infusions
Ibuprofen PO 10 mg/kg/dose q8h r 20 mg/kg/day Drug Dose Notes
Naloxone (itching) 0.5 – 1 mcg/kg Propofol 75‐300 mcg/kg/min
Nalbuphine (itching) 0.025 mg/kg IV q6 hr Propofol + Remifentanil Set pump for usual Dilute remifentanil to
(mixed in same syringe) propofol dose 0.01 mg/mL (1/1000th
Antibiotics propofol)
Drug Dose Max Dose Fentanyl 1‐3 mcg/kg/hr IV
Ampicillin 25‐50 mg/kg q6 hrs 2g Sufentanil 0.002‐0.008 mcg/kg/min 100 mcg / mL
Cefazolin 25‐30 mg/kg q8 hrs 2g Remifentanil 0.05‐2.0 mcg/kg/min
Ceftazidime 50 mg/kg q8 hrs 1g Dexmetetomidine 0.01 mcg./kg/min 4 mcg / mL
Cefotaxime 40 mg/kg q6‐8 hrs 2g Naloxone (itching) 0.25 mcg/kg/hr
Ceftriaxone 25‐50 mg/kg q12‐24 hrs
Ciprofloxacin 10 mg/kg q12 hrs Steroid Potency:
Clindamycin 10 mg/kg q8 hrs 600 mg Hydrocortisone (“Solu Cortef”): 20 mg
Gentamicin 2.5 mg/kg q8 hrs Infuse over 30 min Prednisone (4 x’s as strong): 5 mg
Metronidazole 10 mg/kg q6 hrs 500 mg Prednisolone (4 x’s as strong): 5 mg
Nafcillin 25‐50 mg/kg q6 hrs 2g Methylprednisolone (“Solumedrol”): 4 mg
Penicillin 20k‐50k units/kg q6 hrs 1 million units / dose Dexamethasone (30 x’s as strong): 0.75 mg
Tobramycin 2‐3 mg/kg
Vancomycin 10‐12.5 mg/kg q6 hrs 1g

40  41 
   

Cardiovascular Drugs Pediatric Regional Anesthesia

Drug Dose Notes Local Anesthestic Maximum Doses (mg/kg):
Heparin IV 350 units/kg (pedi bypass dose) Goal: ACT>400sec Lidocaine plain: 5 (1 mL/kg of 0.5% lidocaine)
Lidocaine + epi: 7
Protamine Equal volume(mL) to heparin 10 mg/mL Bupivicaine: 2.5 (1 mL/kg of 0.25% bupivacaine)
dose Ropivacaine: 2.5
Amicar (CPB) 75 mg/kg load over 10 min, Chloroprocaine: 15
75 mg/kg into CPB pump, then Tetracaine: 1
75 mg/kg/hr
Amicar (non-CPB) 100 mg/kg load, Caudal Anesthesia:
33 mg/kg/hr Prepare: 22 g angiocath, sterile prep & drape
Amiodarone load: 5 mg/kg over 10 min Max: 15 mcg/kg/min 0.125% bupivacaine, 0.25% Bupiv, or 0.2% ropiv with 1:200,000 epi
infusion: 5 mcg/kg/min Test dose: 0.1 ml/kg (check for tachycardia and T‐wave changes)
Procainamide 5‐15 mg/kg IV over 30 min Max: 80 mcg/kg/min Dose: 0.5‐1.0 ml/kg total given in increments.
infusion 20 mcg/kg/min Use 0.5 ml/kg for incisions below umbilicus; 1 mL/kg for supra‐umbilical.
Dopamine 2 – 20 mcg/kg/min Start @ 5
Dobutamine 2 – 20 mcg/kg/min Start @ 5 Epidural/Caudal Catheter:
Enalapril 5‐10 mcg/kg IV q 8‐12 hr Typicallly, use bupivacaine 0.1% +/‐ fentanyl or hydromorphone.
Epinephrine 0.05 mcg/kg/min Max maintenance dose: 0.4 mL/kg/hr (0.4 mg bupiv/kg/hr) – children > 6 mo
Norepinephrine 0.05 mcg/kg/min Max: 1 mcg/kg/min Max maintenance dose: 0.2 mL/kg/hr (children < 6 mo)
Phenylephrine 0.05 mcg/kg/min Max: 1 mcg/kg/min Note: Can establish block with higher doses, keeping in mid max dose of 2.5
Esmolol (bolus) 0.5 mg/kg IV over 1 min Repeat same dose
mg/kg. Sometimes, chloroprocaine infusions are used for neonates. If so, the
dose is 0.2 – 0.8 mL/kg/hr (using chloroprocaine 1% or 1.5%).
Esmolol (drip) 50 – 300 mcg/kg/min
Hydralazine 0.1 – 0.2 mg/kg IV/IM
Estimation of Epidural Space Depth (mm)
Isoproterenol 0.05 mcg/kg/min 18 + (1.5 x age in years), or use the simple rule 1 mm/kg
Propanolol 0.5‐1.0 mg/kg PO (q 6‐12 hr)
Labetalol 0.1‐0.4 mg/kg IV Intrathecal Morphine: 5-10 mcg/kg (max dose 300 mcg)
Magnesium 25 ‐ 50 mg/kg IV slow Max 2 g
Milrinone 0.5 mcg/kg/min Load 50 mcg/kg onto Intrathecal Dilaudid: divide intrathecal morphine dose by 5
pump. Max: 1 mcg /
kg / min Infusion rate (mL/hr) = 60 * pump rate (mcg/kg/min) * weight (kg) / concent(mcg/mL)
Nitroglycerine 0.5 – 4 mcg/kg/min
Nitroprusside 0.5 – 4 mcg/kg/min
Verapamil 50‐100 mcg/kg Not for kids < 1 year
Procainiamide load 5‐15 mg/kg over 30 min Max 750 mg
Procainiamide drip 20 – 80 mcg/kg/min Monitor BP and QT
Propranolol 0.05 – 0.1 mg/kg over 10 mins Max 10 mg
Prostaglandin E1 0.05 ‐ 0.1 mcg/kg/min
Tranexamic acid 10 mg/kg loading
0.02 - 0.1 mg/kg/min (adult)

42  43 
   
15. Obstetric Anesthesiology Drug Cart Code *135
Logistics:
There are 3 anesthesia residents on the rotation each block and a dedicated OB
anesthesia attending M‐F days.
Day Shift: 06:30 (07:00 on weekends/holidays) ‐ 18:00
Night Shift: 18:00 ‐ 06:30 (07:00 on weekends/holidays)
OR and Cart Set‐Up:
Each of the two ORs should have ephedrine, phenylephrine, succinylcholine, and 2%
lidocaine (20ml + 2ml pedi bicarb+1:200k Epi) ready. Always store these medications in
the narcotics drawer. Perform usual “MSMAIDS” setup and check/calibrate machine
each shift. Pressors and Lidocaine should be ready in each of the procedure carts. Lock
your carts when not in use. Record all blocks in eHandoff.
Anesthetic Consultations:
 Check patient’s chart ‐ age, GP, dilation, PIH, SROM, etc.
 Ensure pt is in labor or being induced. If an epidural is requested for a non-
laboring patient, inquire why it is needed and consult with your attending
 Obtain a Medical History and perform a focused physical exam. Airway, heart,
lung, back and pertinent systems based on history.
 If a patient has any reason to have low platelets or abnormal clotting, wait for
labs. In low risk patients with no history of bleeding, easy bruising, etc. there is no
need to wait for labs.
 Obtain completed and signed consent prior to placement of epidurals. Don’t
forget to consent for failure to provide pain relief/need for replacement!
 Page your attending for ALL procedures.
 Record H&P in EMR as “OB anesthesia Pre‐Op Screening”. Do the H&P and
consent as soon as you know a patient may need an epidural, that way it is ready
when she’s screaming in pain/there are 5 epidurals that need to be placed at
once/there is an emergency.
Labor Epidurals:
Remember the mantra “Every dose is a test dose.” Even well placed catheters may
migrate. Be sure to always inject in increments of no more than 3‐5mL at a time.
Document boluses with your initials on the paper chart. Document FHR, dilation, Pain
score, SpO2, RR, and sensory level. Write epidural orders and a procedure note in EMR
as “OB Anesthesia Neuraxial Procedure”.
Standard Epidural
Usually initiated at patient’s request. No specific cervical dilation required. Consists of
the test dose followed by an activation bolus and subsequently a continuous infusion.
Test Dose
3 ml 1.5% lidocaine with epi 1:200,000 (45 mg + 15 mcg) (in the kit)
44  45
Cesarean Delivery:
For scheduled sections, go to preop holding to see your patient. Provide BiCitra 30 ml
po and Reglan 10 mg IV. Make sure T&S is done. If urgent or emergent, quickly
reassess patient. You should get a T4 sensory level and record this time in the chart as
your “Anesthesia ready time”.
Epidural: (usually pre‐existing, though sometimes can place one)
2% lidocaine with bicarb 1 meq/ml 10:1 +/‐ epi 1:200K or
3% chloroprocaine +/‐ bicarb
Spinal: always check with attending, this often varies
0.75% bupivacaine 1.5‐2 ml (1.6 ml = 12 mg)
fentanyl 15‐25 mcg (0.3‐0.5 ml)
Duramorph 0.15‐0.3 mg (0.3‐0.6 ml of 0.5 mg/mL)
Treat hypotension w/ Phenylephrine or Ephedrine.
Maintain MAP at baseline. Low threshold for epi 1 ml of 10 mcg/ml
If emergent C/S: Check vitals, disconnect pump and begin dosing existing epidural
ASAP. Give 5 ml in patient room, 5 ml en route to the OR, and 5 ml upon arrival to the
OR. Transfer patient to OR table. Provide O2 and LUD. Check level and begin applying
monitors. Be prepared for GA.
If urgent (but not emergent) C/S: Begin dosing only in OR after monitors are applied.
Remainder as above.
Rescue Options for Inadequate Analgesia During C/S:
50% inhaled N20.
Versed/Fentanyl/Morphine.
Ketamine 10‐20 mg increments IV (up to total about 0.3‐0.5 mg/kg).
Consider GA.
Post Op
After delivery, if you haven’t already given some sort of neuraxial opioid, give epidural
Duramorph 1.5 to 3mg for post op analgesia. Remove epidural when pt rolled to move
off OR table (leave in place if additional procedures (ex. BTL) planned). Complete EMR
ordersets: 1) OB anesthesia post op PAR (akin to PACU orders) and 2) OB anesthesia
Acute Care (pain relief for the first 24 hours).
Uterotonics
Drug Dose Notes
Oxytocin (Pitocin) gtt 40 U/liter or pre-mixed May increase to 80 U/liter
30 U/500 ml
Methylergonovine 0.2 mg IM Watch for HTN, N/V, bronchospasm.
(Methergine) Systemic HTN is a relative
contraindication. Methylergonovine is
an ergot alkaloid
46  47
Before test dose, aspirate catheter (slowly with a 3 ml syringe!). It takes
approximately 10‐15 seconds of aspiration for blood to appear in the syringe and
you may collapse the vein if you aspirate too aggressive) Blood or CSF may be
observed sooner in the clear portions of the catheter. Between contractions,
bolus the lido with epi and ensure absence of increase HR, spinal block, or
neurological sx’s. If the patient has high blood pressure (preeclampsia or chronic
HTN) consider test dose without EPI.
Initiation
0.125‐0.25% bupivcaine 15ml +/‐ 50-100 mcg fentanyl, or
1% lidocaine +/‐ bicarb 10:1, 5‐15 ml +/‐ 100 mcg fentanyl
Give in 3‐5ml increments. Monitor BP and FHR closely. Bupivacaine has a slower
onset of analgesia, longer duration, less motor block and is preferred. Lidocaine
has a faster onset of analgesia, shorter duration. Note 0.1 ml of epi (1:1000) in 20
ml of local anesthetic makes a 1:200,000 dilution.
*Goal is pain control, not a specific level. If pain control not reached and level is
higher than T10, consult your attending, it may need a stronger solution or
replacement of the catether
Top off or bolus
0.125‐0.25% bupivicaine 5‐12 ml +/‐ fentanyl, or
1% lido 5‐12 ml + /‐ fentanyl 50-100 mcg
Continuous Infusion
5‐15 ml/hour of 0.1% bupivicaine + 2 mcg/ml of fentanyl
“Walking” Epidural
Epidural‐ fentanyl 50‐100 mcg and preservative free NS 5‐10 ml
Best done early in labor (e.g. <4cm dilation). Can be completed for anyone that requests
it. The test dose must be omitted until full activation of the epidural. No infusion until
conversion to standard epidural. Nurse must assist out of bed especially if test dose
given.
Combined Spinal‐Epidural (CSE)
Intrathecal dose ‐ fentanyl 10‐25 mcg +/‐
0.25% isobaric bupivacaine 0.8‐1 mL +/‐
Epidural dose ‐ 3 ml test dose and infusion.
Best done late in labor >8 cm dilation. Always use new vials and strict aseptic technique.
Test dose may be postponed until initiation of epidural. If uterine tachysystole occurs,
provide O2, LUD, sublingual NTG, call OBs (they sometimes give terbutaline).
Problem Epidurals:
Inadequate, one‐sided, or patchy analgesia. Refer to Acute Pain chapter for
troubleshooting information.
 
Carboprost (Hemabate) 0.25mg IM Watch for bronchospasm and HTN.
Asthma is an absolute
contraindication.
Misoprostol (Cytotec) 800mcg mucosal If buccal, suction before induction.
Any other route will be given by RN.
Hypertension & Pregnancy:
 Chronic HTN >140/90 present prior to pregnancy and dx’d @ <20wks
 Gestational HTN >140/90 and dx’d at >20wks
 Preeclampsia:
o HTN > 140/90, or increase SBP >30 or DBP >15 (2x 6hr apart)
o Proteinuria ‐ 300mg/24hr
 Severe Preeclampsia = Any of the following in presence of preeclampsia:
o SBP>160 or DBP>110
o Proteinuria > 5g/24hr, or 3+ to 4+ on UA
o Thrombocytopenia (<100K)
o Impaired liver function
o Pulmonary edema
o New-onset cerebral or visual disturbances
 HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets)
o 2‐12% of preeclampsia
o Risk Factors: nullip, fam hx, obesity, mult gest, prev preeclampsia
 Treatments:
o IVF resuscitation. Total < 125 ml/hr
o BP control (goal SBP<160 and DBP<110)‐ hydralazine 10mg IV q30min,
labetalol 20mg initial dose, then double dose q10min (max 300mg), acute
control w/esmolol, nitroprusside or NTG
o Magnesium: Loading dose 4-6 g, maintenance 1-2 g/hr. Therapeutic at
4‐7 mEq/L (5-9 mg/dL), loss of deep tendon reflexes >7mEq/L (9-12
mg/dL, respiratory depression 12-18 mg/dL (>10 mEq/L), and cardiac
arrest 24-30 mg/dL (>25 mEq/L). Prolonged neuromuscular blockade can
occur.
For C/S with Preeclampsia
Spinal or epidural technique. Spinal compared to epidural has no difference in pressure
changes or amount of pressors (Hood, Anesthesiology '99). Spinal needle may be less
traumatic. If no epidural in place, a spinal is preferable. Early epidural is ideal provided
platelets ok (>80K and not dropping, but can vary depending on attending).
Evaluation of Postpartum Patients:
 It is the resident’s responsibility to complete a postpartum check 24‐48 hrs
post‐procedure. If the day resident is too busy, the night resident should complete
as many as possible before 10 pm.
 Review the eHandoff list; convention has it that postpartum patients are tagged
with a ‘z’ in front of their last name. Only remove patients from the eHandoff list
once a postpartum evaluation and note has been completed.
 
  Use EMR template “OB Anesthesia/Analgesia Progress Note”. Write down the Post‐Dural Puncture Headache (PDPH):
procedure and anesthetic (ex. s/p NSVD with continuous labor epidural, or s/p  Bilateral, frontal, or occipital h/a. Postural, worse upright.
C/S with CSE, etc.)  Usually 24‐48 hr post, can be up to 7d.
 Make note of patient’s temperature and vital signs. Focused hx and physical  Can be associated with N/V, auditory sx, visual sx.
exam.  Rule out meningitis, mass effect, continued preeclampsia.
 Note pertinent negatives h/a, visual or auditory sx, fever, chills, backache, areas  Prevention: Cosyntropin 1 mg IV after delivery to patients with accidental dural
of numbness or weakness, bowel or bladder sx. Any positive signs or sx should puncture, may help. Discuss with attending
be fully documented and discussed with an attending.  Treatments: IV /PO fluids
 ALWAYS document that a neuro exam was done. Tylenol, opioids.
 Note whether they are breastfeeding (may change your pain medicine Caffeine 325mg po q4‐6 max 6/d
management). Caffeine Na benzoate 500mg iv in 1L NS (avoid in PIH or
seizure disorders as it lowers threshold)
Epidural blood patch

Epidural Blood Patch (EBP):

 80‐90% success rate with first treatment.
 Recurrence of headache up to 39% after successful EBP.
 Obtain signed consent.
 Do quick history of symptoms and neuro exam. Select more caudal interspace,
as blood spreads cranially.
 After epidural space identified with Tuohy, have assistant use 18G needle to
obtain 20 ml blood using strict aseptic technique. Inject up to 20ml blood. Stop if
any back or leg pain. Should work immediately.
 2 hr of recumbency, consider stool softener, cough suppressant.

OB Average Physiological Changes (Schnider, 4th Edition):

Blood volume +35%
Plasma volume +45%
RBC volume +20%
Cardiac output +40‐50%
Stroke volume +30%
HR +15‐20%
SVR ‐15%
MAP ‐15mm Hg
MAC ‐20‐30%
FRC ‐15‐20%
ERV ‐20%
RV ‐20%
VC No change
Minute ventilation +50%
Vt +40%
RR No Changfe or +
Oxygen consumption +20%
Closing volume decrease (may be below FRC)
GFR +50‐60%
BUN 6‐9mg/dL

48  49 
   

Cr 0.4‐0.6 Average Blood Loss

Vaginal delivery 500‐600ml

Cesarean delivery 1000ml
Autotransfusion‐ uterus 500ml

Normal Values for Umbilical Cord Blood:

pH PCO2 PO2 Bicarb
Arterial 7.28±0.5 49 18±6 22
Venous 7.35±0.5 38 29±6 20

APGAR: 0 1 2
Appearance blue part blue pink
Pulse none <100 >100
Grimace none grimace crying
Activity flaccid flexion active
Respiration none slow crying

5‐7: stimulation & 100% O2

3‐4: temporary PPV w/ mask and bag
0‐2: intubation +/‐ compressions

Post‐Partum Tubal Ligation

Check Hct and NPO status. May still be considered full stomach despite NPO. May use
epidural in situ or place spinal. Usually require similar dose of local as in C/S. Check
with attending whether Duramorph okay (not always needed given shorter case and
patients go home same day).

50  51 
   
16. Cardiac Anesthesiology
This is a 1-2 month rotation with 4 residents. Hours are long; pace yourself. You will
meet with Dr. Bhullar or Kowalczyk at the start of each block at 06:30am in PSSB for
information. Have your case logs done before the meeting. Each resident will also do a
5 minute echo presentation at Grand rounds, Dr. Bhullar or Kowalczyk will let you know
when it’s your turn. See SmartSite for echo directions. Have a USB drive to download
images from the echo machine and work with an attending that did the TEE exam. Work
with IT (Joyce Schamburg or Shaun Lane) to make sure the presentation works
Tuesday Morning. Do a dry run on the actual equipment it will be presented onHave a
USB drive to download images from the echo machine. Get books/videos form Carolyn
Murdock in PSSB.
Call: We gained back being allowed to be home during the day when on call (used to
have to stay in‐house all day). Don’t abuse this! Get here around 06:45‐07:00 to help
start heart cases and go over TEE. Go home after clearing with the cardiac attending on
call. You must be available (within 30 mins) for any urgent cardiac case throughout the
day. Coordinate what time you should call in/return to the OR with the cardiac attending
on call. You’ll have to relieve your fellow cardiac co‐residents in the afternoon, even if
it’s not a cardiac case. Suck it up, you’ll want it done for you too. You will be backup
weekdays after 0400, and on weekends- keep your pager on, stay within 30 minutes.
Cardiac Surgery/Heart Room Setup
Timing: Arrive at 5:45 am to begin setup. Patient in room at 7:30am after preop A‐line.
Turnover to surgeons at 8:00am.
Equipment in the room: set up by anesthesia tech
1. 4‐6 IV infusion pumps
2. 1 syringe pump (Kowalczyk prefers 2)
3. 4 pressure transducers with tubing (AP/PAP/CVP/anterograde pressure
monitoring line to come from surgeons)
4. Male to male connector for CVP and transducer (will connect to retrograde and
antegrade pressure monitoring line from surgeons)
5. Belmont (to be connected to white port of MAC introducer)
6. Continuous cardiac output Swan Ganz catheter and monitor (connected, and
flushed, give tech pt’s ht/wt/hct to calibrate)
7. 9 Fr MAC introducer
8. TEE machine with TEE probe and epi‐aortic probe (turn on, enter pt data)
9. 1 L NS bag with microdripper and multiinfusion portat the end of tubing (carrier
for drips)
10. 1 500 ml NS bag on Buretrol with 3 stopcocks at the end of tubing (to be
connected to VIP port of the PAC, Protamine will go into Buretrol after CPB,
Amicar will be connected to a stopcock; Kowalczyk does not use this)
11. Pacing box (often the tech forgets, get it yourself, make sure it turns on)
12. NIRS (near infrared spectroscopy) brain ox monitor. Sensors go on patient’s
forehead in pre-op. Obtain and set baseline before giving O2.
52  53
 Milrinone – premixed ziplock bag, program for 0.25 to 0.375 mcg/kg/min.
Improves diastolic dysfunction but can drop BP significantly, and may need
Norepi to offset lower BP.
 Phenylephrine – mix 2 10mg/ml vials into 250 ml NS bag (=80 mcg/ml), program
for 0.2 mcg/kg/min (range 0.1‐10).
 Epinephrine – rarely needed, mix 4 1mg/ml vials into 250 ml NS bag (16 mcg/ml),
program at 0.01 mcg/kg/min (range 0.01‐0.1).
 Vasopressin – rarely needed, mix 2 20 units/ml vial into 250 ml NS bag, program
for 1‐6 units/h.
 Insulin – For DM patients. Mix 250 units regular insulin (2.5 ml of 100 units/ml) in
250 ml NS bag (=1 unit/ml); program for 1‐10 units/hr. Double check dose with a
2nd person per guidelines.
 Dexmedetomidine gtt: for after off pump.
4. Which drips to prepare? – the following are just general suggestions
a. CABG – NTG to dilate vessels and decrease preload leading to decreased
wall tension + Norepi to support BP and for coming of bypass;
b. Stenotic valve – Phenyephrine as bolus or as infusion to preserve SVR
during induction, Norepi to support BP and for coming off bypass, have
Nitroprusside in the pump available: valve now open, ventricle still very
contractile; if stenotic valve combined with CABG, add NTG
c. Regurgitant valve – NTG or Nipride to decrease SVR, Norepi to support BP
and for coming of bypass
d. Aortic dissection – Nipride and Esmolol to control systolic BP and decrease
wall stress + Norepi to support BP
e. If decreased left or right ventricular function – Milrinone combined with
Norepi
f. If significant elevation of PAP preop possibly indicating RV failure, Epi may
be needed
5. Amicar (epsilon‐aminocaproic acid, antifibrinolytic): Fill 60 ml syringe with 60 ml
(3 vials) from Pyxis machine in POD 40. Program syringe pump for ml/hr, starting
rate 40 ml/hr x 1 hr (volume 40ml); after that finishes, you will reprogram for 4
ml/hr (volume 20 ml) for remainder of surgery. Connect to a stopcock on Buretrol
line; after Swan in, connect Buretrol line to white VIP and start infusion.
6. Tranexamic acid (i.e. TXA, antifibrinolytic): 10 mg/kg bolus over 20 minutes, 1-6.5
mg/kg/hr (if Amicar unavailable-check with attending)
7. Heparin: Have 5000 units ready for CABG cases if saphenous vein graft is
planned. The vein harvester will ask for it.
Preop Patient Care
1. Meet the pt: It is expected that you see all inpatients the day before, even for
Monday cases. The day of surgery confirm the consent, meds taken, NPO time
and physical findings. In pts after dental extractions, make sure the gums don’t
ooze and for pts after a recent cath, check that there is no excessive groin
hematoma (2 good reasons not to fully heparinize, 2 good reasons to cancel a
case for the surgeon). Also make sure the UA is clean, especially if valve
replacement.
54  55
Medications to set up:
1. Rescue drugs:
a. Atropine –1 mg
b. Phenylephrine – 100 mcg/ml or 80 mcg/ml (from 20 mg/250 ml NS bag)
c. Ephedrine – 5 mg/ml
d. Succinylcholine – 20 mg/ml
e. Epinephrine – 100 mcg/ml and 10 mcg/ml
f. CaCl2 - 10 ml (100 mg/ml)
g. NTG – one syringe of 10 mcg/mL
h. Nitroprusside – one syringe of 10 mcg/mL (only if hanging NTP drip)
2. Induction: attending specific, ask what they’d like prepared.
a. Dr. Fleming ‐ 5 mcg/kg Sufentanil into buretrol with 20‐30 ml NS and
infuse drug into peripheral i.v., Stimulate patient to breath, attach relaxant
(Roc) to Buretrol stopcock, once patient unresponsive administer relaxant
immediately and start ventilating once chest wall rigidity subsides.
b. Drs. Liu, Singh, Yao – Fentanyl 50‐250 mcg i.v. bolus, Lidocaine, low dose
Etomidate/PPF, high dose roc.
c. Dr. Kowalczyk – fentanyl 50-150 mcg, lidocaine, propofol 200 mg only, no
etomidate unless discussed previously
d. Vecuronuim + sufentanil may cause severe bradycardia
3. Drips:
a. Discuss drips with attending preop.
b. Set up in pumps and connect to stopcocks on R IV pole 1L NS
c. When preparing drips:
i. Label the bag with a printed label from the computer: the username
is cardiacanes and the password is the same
ii. Label name of the drug, dose of the drug in the diluent and
concentration of the drug, time and date, your initials
iii. Label the infusion pump, and the distal end of the line where it
connects to the stopcock
iv. Open all rollers, turn stopcocks to open
Make sure all infusions are connected in this fashion and ready to
go. When a hectic moment occurs, there will be not time to check
and big mistakes can happen.
d. Preparing Drips
Drips are mcg/kg/min except Vasopressin (units/min) and Insulin (units/hr)
 NTG – in top drawer of cart in a glass bottle, use vented IV tubing, program for 0.2
mcg/kg/min (range 0.2‐10).
 Nitroprusside – Mix one 50 mg/2 ml vial into 250 ml NS bag, cover bag with dark
plastic cover and label both; program for 0.2 mcg/kg/ min (range 0.1‐10).
 Norepinephrine – mix two 4mg/ml vials into 250 ml NS bag (=32 mcg/ml),
program for 0.05 mcg/kg/min (range 0.01‐0.1).
 Dopamine – premixed in ziplock bag, program for 5 mcg/kg/min (2‐10 “renal”,
10‐20 Beta, >20 alpha).
 
2. Arterial line in preop: The patient usually arrives 6:20‐6:30am. Make sure the
surgeon signed the preop checklist (otherwise page) before placing line. Ask your
circulating nurse to check the patient in. Use Versed and a lot of local lidocaine
for placement. Use the dominant hand for bypass cases (keep non-dominant
radial artery intact in case surgeons harvest for bypass). Use the distal end of the
A‐line tubing with stopcock and flush attached. After placing A‐line, connect
tubing and draw blood back, then flush with NS. Turn stopcock so that blood
won’t back up into tubing.
3. NIRS probes: Place on patient’s forehead before administering oxygen to record
baseline.
4. When leaving the patient, make sure the monitors are on and sedation has been
mentioned to the preop nurse
5. Blood: Make sure 4 units PRBCs are available in the fridge before incision, in low
Hct patients before induction.
6. Patient Transport: Patients with an intra aortic balloon pump will need to be
transported by resident and perfusionist from the ICU. Plan for this in the am.
In the OR
1. Monitors: Place EKGs lateral/posterior, +/- tegaderm as they tend to fall off when
wet. Place defibrillator pads. Set NIRS baseline before pre-oxygenation. Set
NIRS ‘induction’ event marker. Thorough preO2, watch end tidal O2.
2. After Intubation:
a. Your Attending or the Call Resident Will:
i. Tie (not tape) ETT
ii. Position and prep (widely with Chlorprep) for R IJ
iii. Lower FiO2 to have dark blood return
iv. Prepare TEE machine transducer as the US for line placement
v. For Kowalczyk, insert TEE probe before line placement
b. You Will:
i. Immediately head to wash your hands
ii. Gown and glove. Anesthesia tech will help you.
iii. Place FULL drape (pedi laparotomy drape)
iv. Check landmarks then put on ultrasound probe
v. Place RIJ MAC. Brown port down if R IJ, up if L IJ.
vi. 2 sutures through holes and one suture around the swan introducer
port (suture loop through the skin then tight around the catheter)
vii. Small Tegaderm on the site to keep sterile until prep
viii. Float Swan Ganz catheter with help of tech: always watch your
depth markings and A‐line and CVP tracings at the same time.
Always confirm balloon up/down as you need it.
ix. Connect 1L NS bag with drips to the brown port (VIP for Kowalczyk)
x. Check all connections (triple stopcock) for tight fit
xi. Connect buretrol with 3 stopcocks to white infusion port on Swan
Ganz (VIP; Kowalczyk does not do this).
xii. Connect Amicar or TXA to stopcock port and start infusing.
xiii. Change NIBP to q 1 hr after lines are placed
xiv. Tech will draw gas, baseline ACT and TEG.
 
 xv. Get antibiotics running.
xvi. Suction stomach with OG. (Kowalczyk does not do this)
xvii. Place TEE probe
xviii. Place shoulder roll
xix. Secure twisty bar (all cables/pipelines inside the bar)
xx. Make sure temp probe is connected to bladder
xxi. Pad all stopcocks before arms get tucked
xxii. Make sure that PIV and arterial line are still functional after tucking
xxiii. Take a big breath and continue to cope with the plethora of people
in your way of delivering patient care. Now the case can start!
3. Case Begins:
a. The attending, fellow and call resident will perform the TEE. Check it out
with them and catch up on charting. There will be lots of new stuff to chart /
less when on pump, ask the fellow/call resident to show you.
b. Check ETT tie for tension, loosen up PRN, patient can get edematous
c. Put 4X4 under tie and TEE tubing to avoid pressure sores
d. Make sure the EKG lead manifold is never under the head (it can cause
bad skin necroses after hrs of low perfusion)
e. When vein grafts are obtained laparoscopically have 5000 U Heparin
ready and give if asked. Blood loss during vein harvest can be substantial
depending on provider.
f. Prepare to give scrub nurse 20 ml blood shortly thereafter (to preserve the
harvested veins in). Draw from Aline and place in the two cups she sets
out for you on the sterile table.
g. Surgeon or nurse will hand you tubing for anterograde perfusion, which
you connect to the transducer on the very right (P4–purple on monitor), and
retrograde perfusion, which you connect through male‐to‐male connector
to second transducer from right (CVP – blue). Make sure connections are
correct; perfusionist uses them by color code. Some surgeons use only
one, ask your attending which one gets plugged where.
h. IMA takedown – the patient is suspended by a crank under the sternum.
Pad head further if dangling. Also, during IMA harvesting, the surgeon may
give Papaverine which will drop the BP.
i. Once the heart is exposed, pull back Swan a couple of cm so that it does
not get overwedged/rupture the PA when the heart gets moved around.
j. Observe progress of surgery – occasionally BP will drop because surgeon
is mechanically pressing on the heart, if drop significant, notify surgeon to
release pressure.
k. Once surgeons are ready the scrub nurse will hand you Heparin 350U/kg
(dose calculated by perfusionist), give it and say it out loud.
l. 3 minutes after administration of Heparin (set timer on the monitor) draw
1.5 ml blood and give to perfusionist to determine ACT (need >400 to go
on CBP).
4. Cannulation
a. Have attending in the room before going on bypass.
b. Get a face shield, blood may fly!
c. Check paralysis before surgeons start placing cannulas—not a good time
for the patient to move. Re-dose NMB if needed.
56  57
e. If HR low/valve surgery, surgeon will likely place pacemaker leads, which
you will connect to pacer box and test.
f. Turn back on the swan, pulse ox sound, vent, FGF, small amt agent.
g. Once everything looks good, perfusionist fills the heart and decreases
pump flow.
h. Once off pump and hemodynamic parameters look good, the surgeon will
ask scrub nurse to hand you Protamine (1mg/100Units heparin given).
Inject it into Buretrol (except Kowalczyk) and add NS to 100 ml line. Infuse
at full flow. Monitor patient for hypotension, allergic reaction, pulmonary
hypertension.
i. Let perfusionist and surgeon know when Protamine started and again
when it’s half way in. They cannot use pump suction from there on. Three
minutes after Protamine dose is in, draw an ACT and ABG.
j. Volume requirements immediately after CPB will be higher, due to
continuous bleeding in the field and less compliant heart. Monitor right and
left heart pressures carefully.
k. DIC panel and platelet count will be sent and numbers written on write
board, write down on anesthesia record, transfuse products.
l. Situation changes quickly. Pay attention when chest closed: grafts may get
kinked, BP may drop . . .
m. During post‐CPB time, titrate in opiates +/‐ dexmedetomidine drip.
n. As surgeons close, organize your lines, disconnect NIRS and Swan‐Ganz
monitor. Remove unused drips (except take Nipride gtt with you to ICU to
treat HTN immediately postop). Remove Amicar and Buretrol line, and cap
lines as needed. Remove TEE and insert OG if not in place. Cover IJ with
Op‐Site. Disconnect Belmont line at the very end and connect PIV line to
RIJ. Ready Ambu bag. Take pressors and intubating gear with you.
Untangle, untangle, untangle!
Whew! Sounds like a lot, but the fellow and call resident are around to help you. Once
you get the routine down, it becomes much less stressful.
Robotic Cardiac Cases
Patient
 Pain management‐ these patients usually benefit from a paravertebral block and
infusion catheter. D/W pain team day before and coordinate this. Remember it
may take them 30min to put one in and we do not want to delay the case.
 Arterial line ALWAYS in the right hand (the left hand is not favorable because it
hangs in a sling and left lung is down) may consider placing pulse oximetry
sticker on left side
 NIRS, TEE as usual
 Double lumen tube, left lung deflated. May use single lumen (OET 8.0) with Arndt
Bronchial Blocker, DLT is preferred.
 Patient usually extubated soon in the ICU‐ therefore may leave DLT in place‐but
inform ICU on ICU information sheet. Most respiratory therapist are used to the
DLTs now.
58  59
d. Be ready to hand surgeon or scrub the epi‐aortic echo probe, placing into
sterile sleeve. Page attending when surgeons request epi-aortic scan.
(Used to look for loose plaques before placing the aortic cannula.) When
done, they will hand you back the probe.
e. Aortic cannula: Always placed first. Make sure SBP 90‐100 mmHg to
avoid aortic dissection. Prepare to alter the BP with table position (reverse
Trendelenburg) and/or drugs (NTG) as needed immediately before
cannulation. (For Kowalczyk, use dilute NTG/NTP)
f. After aortic cannulation, decrease volatile anesthetic in expectation of BP
drop with upcoming venous cannulation. May need phenylephrine.
g. Anterograde cannula placed next (Dr Young). They’ll ask you to flush the
line (pull the pig tail on the transducer).
h. Retrograde cannula: needs to go into coronary sinus, surgeons may ask
for TEE guidance – make sure attending is present
i. Be prepared to hold respirations intermittently.
j. Write down aortic clamp times and bypass times on your anesthesia
record. Get this from the perfusionist.
5. Going on Bypass
a. Redosing meds (AlWAYS discuss w/ attg): benzodiazepine (rarely for
patients >70yo), sufentanil 50 to 200 mcg (depending on BP), and relaxant
(vecuronium 10 mg, rocuronium 100 mg, cisatracurium 20 mg). Re‐dose
after discussing with attending prn BP high or pupils dilated, and when
rewarming and patient reaches 32‐34°C.
b. Ventilation: Once on full bypass some surgeons like lungs off; Dr. Young
likes to keep ventilating until no pulsatile flow on A‐line. If in doubt, ask.
Once lungs off, run low flow O2 or air. Put vent on bypass mode.
c. Volatile anesthetic: turn off yours. Perfusionist runs sevoflurane while on
pump, (typically sets to 1% - verify he has volatile on); you can monitor ET
agent by setting up a sample line to the pump.
d. Monitors: Freeze TEE probe, suspend COO monitor (press and hold
‘silence’), share NIRS screen with perfusionist, silence pulse ox, stop all
drips and fluids (except Amicar, and NTG with Dr Liu)
e. Occasionally BP support with Norepi will be necessary on pump; the
perfusionist will ask you to start it.
f. Perfusionist will send off ABGs every 20 minutes – check glucose and treat
with bolus IV insulin if glucose >200-250 mg/dl (discuss w/ attg)
g. You should plan on needing more blood products and possibly milrinone
for longer bypass times.
h. Finally, you get to sit down! Don’t forget to redose drugs, especially when
rewarming (discuss w/ attg).
6. Coming Off Pump
a. Keep your attending informed (text page with ‘Rewarming’ and again with
‘Clamp off’) Attending should be in room to check TEE for air, function of
heart.
b. If CABG, start NTG once cross‐clamp off.
c. If radial artery used as graft, ask surgeon if they want diltiazem gtt.
d. If MAP low (less than 55–60), start Norepi and give fluids/blood.
 
 Shoulder roll to the inferior edge of the scapulae
 Defibrillator pads (commonly referred to as R2 pads) placement: Anterior:
between sternum and right nipple; Posterior: on left scapula
 Loose tuck of the left arm (in a sling off the edge), regular tuck of the right
 Position patient on left edge of the bed
 Right table tilt to 30 degrees
Special drugs
 Lidocaine drip ( 0.5 to 1 mg/min) may be asked. Get from Pharmacy
 Lidocaine 100 mg bolus syringes during the opening of the pericardial sack and
freeing of the target vessel
 Magnesium (1‐4 gm) for the same timeframe, especially with Dr. Boyd, careful
slow administration to avoid P‐R interval /QRS prolongation
 No Amicar unless we are going on pump. Discuss with attendings‐ some may
want half dose.
 Full heparinization (300 Units/kg) when indicated by the surgeon, goal ACT
above 400 sec
 ACT every 30 to 40 min, luckily the perfusionist reminds us
 Have Heparin available to redoes
 Phenylephrine gtt (not always but some times) to maintain root pressure without
increasing myocardial O2 consumption while not sacrificing C.O.
Room setup
 The robot takes up a lot of room to maneuver the elbows
 Discuss with anesthesia techs and mechanicians
 Belmont mounted on the single pole
 Klima mat™ (green gel) on the bed (liver transplant mat) and turned on to 39
degrees Celsius
 Push bed down into the room away from the anesthesia machine as far as
possible, it comes back to you anyways
 Fiberoptic behind you at the head of table next to the Pyxis machine – that way it
can be pushed out way when not needed.
 Straight bar to mount quadruple transducer setup, no twisty bar/Ether screen.
Monitoring
 Special attention to the fluid administration/avoidance of overload
 Consider adding SVV monitoring by Vigileo when PA Catheter not in place
 With CO2 chest insufflation hemodynamic derangements occur (tension pneumo
physiology), usually insufflation pressure is between 5 and 10 mmHg, mostly
around 8 mmHg
 May consider starting and inotrope in preparation, assure good fluid balance.
 The surgeon will want fully focused attention on the hemodynamics around the
insufflation time with rapid communication of changes in the patient
 Clear and loud communication regarding rhythm (especially during pericardial
opening and LAD preparation) and hemodynamics (systolic pressure less than
80‐90 mmHg) is important as the surgeon is blinded to the data in the console.
 
Most attendings will want to be text-paged when: giving CPB heparin, rewarming, pt.
temp at 36C, removing cross clamp, if considering pressors/inotropes/blood, drops in
NIRS or CI, and if glucose > 200 mg/dL.
60  61
i. Bilateral sounds- drop cuff and advance DLT
ii. Right‐sided sounds only- DLT in right bronchus
c. Unclamp tracheal lumen and clamp bronchial lumen. Confirm only
right‐sided breath sounds.
i. Absent or diminished sounds- DLT is too far down left bronchus
ii. Bilateral sounds- DLT not in far enough.
8. Confirm placement with bronchoscope:
a. Advance scope through tracheal lumen. Locate carina. Confirm DLT is
entering left bronchus. Inflate bronchial cuff and position DLT so that you
just barely see the upper edge of the blue cuff from your view in the
trachea.
9. Re‐confirm DLT or endobronchial blocker placement by scope after patient
lateral as they can shift with position change.
10. One‐lung ventilation (OLV) with left‐sided DLT:
a. If operating on left side (want left lung collapsed): Clamp bronchial (left)
tubing near breathing circuit connection and open vent.
b. If operating on right side (want right lung collapsed): Clamp tracheal
(right) tubing near circuit connection and open vent.
c. Set your ventilator for OLV settings BEFORE dropping the lung: 4-6ml/kg
tidal volume, increase respiratory rate to match two lung minute
ventilation; observe airway pressures after you drop the lung – unusually
high PIP may suggest ETT malposition (too deep into one bronchus)
Trouble‐Shooting
1. Lung is in interfering with surgical field:
a. Confirm you have appropriate tube clamped and vent open to allow air in
lung to escape. Be aware that even if you’ve done everything right, it can
take 30+ minutes for a lung to deflate on its own.
b. To speed deflation, place suction catheter (from DTL packet) into vent of
lung you want down, tape over catheter open side port.
c. Confirm there is no leak around bronchial cuff and DLT is in correct
position by breath sounds and bronch.
2. Hypoxemia:
a. Call your attending and tell the surgeon. They can help you trouble‐shoot,
guide you on how low a SaO2 to tolerate, and help you explain to the
surgeon why you aren’t providing optimal operating conditions.
b. Goal: Maximize hypoxic pulmonary vasoconstriction (HPV). To minimize
large (20‐ 30%) R to L shunt seen with OLV, minimize HPV inhibitors: low
FiO2; high/low mixed venous O2; hypocapnia and hyperventilation;
high/low PA pressures; high mean airway pressures, PIP, or PEEP;
vasodilators and vasopressors; volatile anesthetics; hypothermia; and
volume overload.
c. Check or try the following:
i. Confirm on 100% FiO2.
ii. Minimize one‐lung ventilation time.
iii. Confirm ventilating as intended; re‐scope; auscultate.
62  63
17. Thoracic Surgery/Double Lumen ETTs
Preop Considerations:
 Is there potential for airway compromise: anterior mediastinal mass, tracheal
deviation or compression, superior vena cava syndrome?
 Review preop CXR, CT, and PFTs and document patient’s pre-op O2 sat and
FiO2 requirements at home.
Set‐Up for DLT:
1. Anesthesia tech will bring the fiberoptic bronchoscope to the room.
2. Make sure the bronchoscope is ready (ask tech for help):
a. Turn on screen and confirm you have a picture.
b. Align pointer to straight up.
c. Use knobs to focus.
d. Perform white balance.
e. Have 1‐2 steps available to stand on.
3. Make sure clamp, defogger, and breakaway airways are available. Also
Hurricane spray (for Liu).
4. Endobronchial blocker set‐up and positioning (use with regular ETT):
a. Insert bronchoscope/blocker port between ETT and breathing circuit.
Insert bronchoscope, either with or without snare, visualize and guide the
blocker into position down the desired bronchus. Inflate blocker cuff under
direct visualization and confirm cuff stays in the correct bronchus, not
ballooning into carina (use +/‐ 8 cc air). After blocker correctly positioned
and balloon up, note depth and lock blocker in place by tightening plastic
cap, then remove snare wire and distal cap from blocker so lung can start
deflating (takes time).
5. Double‐lumen tube (DLT) set‐up:
a. You will usually use a left‐sided DLT.
b. DLT sizes—guidelines only. Know your patient’s height.
i. Men – 39 Fr for most, 41Fr above 6’
ii. Women – 37 Fr for most, 35 below 5’4”
c. The DLT comes with stylet inserted. Assemble extra tubing to form right
angle that will connect DLT to breathing circuit; don’t connect to DLT until
after intubation. Cap ends so that you can ventilate when everything is
connected.
d. Test balloons—12 mL syringe on tracheal, 3 mL on bronchial.
6. To intubate with DLT, hold DLT with curve up (anterior). After tip enters the
larynx, REMOVE STYLET, then rotate 90 degrees, e.g., 90 degrees left for a
left‐sided tube. Advance until depth marker reaches 29-31cm at the teeth (about
27 for 35Fr DLT) and connect to breathing circuit. Check for ETCO2.
7. Check placement of DLT (left‐sided protocol):
a. Inflate tracheal cuff (5‐10 ml). Confirm bilateral breath sounds.
i. Unilateral sounds- DLT is endobronchial- pull back DLT
b. Inflate bronchial cuff (1‐2 ml). Clamp tracheal lumen. Confirm only
left‐sided breath sounds.
 
iv. Consider bronchodilator (wheezing, tightness or patient uses one
pre‐op).
v. Adjust Vt. If high PAP (>30 mmHg), check tube position. If ok, drop
Vt to 4‐6 ml/kg and increase RR.
vi. Adjust PEEP.
vii. Adjust I:E ratios, usually to increase inspiratory time.
viii. Add continuous insufflation of O2 to collapsed lung: can connect
tubing from auxiliary O2 supply to collapsed lung vent port and run
at 1‐2L/min. Usually less interference with surgical field than CPAP.
ix. Periodically inflate collapsed lung (coordinate with surgeons).
x. Add CPAP to non‐dependent lung—most effective but least
preferred as it interferes with the surgical field. The CPAP bag
set‐up should be on the bronch cart or call anesthesia tech.
Bronchoscopy by Surgeon
 Intubate as usual with as large an ETT as possible (8.5 available in tech room).
You will change out ETT to DLT after bronchoscopy.
Mediastinoscopy
 Measure BP in the right arm as mediastinoscopy can compress the innominate
artery on the left. Pulse ox on left arm will tell you if they are compressing that
artery.
 Need good IV access, e.g., two large‐bore PIVs, as SIGNIFICANT bleeding can
occur.
 Complications can include reflex bradycardia from vagal stimulation,
hemorrhage, cerebral ischemia from innominate artery compression,
pneumothorax, venous air embolism, bleeding, and recurrent laryngeal or phrenic
nerve injury.
VATS
 Patient will be positioned laterally with operative side up. Usually works best to
place A‐line in dependent radial artery.
 MINIMIZE FLUIDS. Figure on 1.5‐2L for a typical VATS.
 Watch screen for bleeding. There are several major blood vessels in the vicinity;
one nick is all it takes to send you crashing onto bypass.
 May need an epidural pre‐op so ask surgeon.
Open Thoracotomy
 Plan on thoracic epidural for postop pain control and improved respiratory effort.
 May place epidural in PACU while waiting for room turn around.
 
18. Endocarditis Antibiotic Prophylaxis 19. Pre-Operative Clinic
The 2007 AHA guidelines (Prevention of Infective Endocarditis: Guidelines From the This is a one month rotation dedicated to seeing patients referred by their surgeons
American Heart Association) focus on dental and respiratory tract procedures. There are preoperatively. You will work with Dr. Huong Bach and preop nurses. By resident vote,
no specific guidelines regarding surgical incision; these guidelines can be applied on a you will also be the backup resident primarily for MICU/PCC, and otherwise as needed.
surgical case‐by‐case basis. Do not plan on leaving town for the weekends, and keep your pager on. Contact the
chiefs with questions.
Cardiac conditions for which antibiotic prophylaxis is recommended:
 Prosthetic cardiac valve or prosthetic material used for cardiac valve repair Directions to the Clinic:
 Previous IE First floor of the Ellison building, Suite 1701. (You can ask the front desk at 1700 where
 Congenital heart disease (CHD) only in the following categories: to go.) The entrance door is a single door in the back left corner of the 1700 waiting
o Unrepaired cyanotic CHD, including palliative shunts and conduits room with a yellow sign. Enter that door and turn to your left. The clinic door is the first
o Completely repaired congenital heart defect with prosthetic material or door on your right and is always open.
device, whether placed by surgery or catheter intervention, during the first
6 months after the procedure Daily
o Repaired CHD with residual defects at the site or adjacent to the site of a Show up on the first day of your rotation at about 8:45 so that Dr. Bach has some time
prosthetic patch or prosthetic device to go over the rotation and cardiac risk stratification for pre‐op patients. All other days
 Cardiac transplantation recipients who develop cardiac valvular disease you can show up at 9am. On a typical day you will likely leave by about 3. The nurses
will let you know when it slows down and you can go study‐ make sure you thank them.
Antibiotic prophylaxis recommendations: You’ll have a lot of freedom on this rotation so make the most of your educational time.
Regimen: Single Dose 30-60 min Before
Procedure Patients
Situation Agent Adults Children  For the first 1‐2 weeks of the rotation you will be shadowing Dr. Bach or the
Oral Amoxicillin 2g 50 mg/kg nurses while they see patients. Many patients she sees will need an ECG (Dr.
Unable to take oral Ampicillin OR 2 g IM or IV 50 mg/kg IM or IV Bach will show you how to do this). After seeing each patient she dictates her
medication Cefazolin OR 1 g IM or IV 50 mg/kg IM or IV note. For the first few days it is good to listen to her dictate, but after that, feel
Ceftriaxone free to do other things while she is dictating.
Allergic to penicillins or Cephalexin*† OR 2 g 50 mg/kg  Also during the first week, the nurses will show you how to use the computer to
ampicillin - Oral Clindamycin OR 600 mg 20 mg/kg write a pre‐op note. It is helpful to go through the entire process with one of
Azithromycin or 500 mg 15 mg/kg them, (from seeing the patient to charting/billing). Then start doing your own
Clarithromycin notes after the first or second day.
Allergic to penicillins or Cefazolin or 1 g IM or IV 50 mg/kg IM or IV  You will then spend the next weeks seeing interesting patients with Dr Bach or
ampicillin and unable to Ceftriaxone† OR seeing patients scheduled for the nurses on your own.
take oral medication Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
*Or other 1st‐ or 2nd‐generation oral cephalosporin in equivalent adult or pediatric dosage. Computer Access
†
Cephalosporins should not be used in an individual with a history of anaphylaxis, There are 4 computers where the nurses work, and computers in all exam rooms. The
angioedema, or urticaria with penicillins or ampicillin. nurses will let you use their computers when they are not using them or tell you which
one is best to use in the exam rooms.

EMR/Preop Steps:
The nurses will show you how to use EMR for clinic notes, but hopefully this will assist
you in the process...
1. Begin to log in to EMR
2. Change context to surgical admission center.
3. Click on "Schedule" to access patient list.
4. In upper left corner of the screen, change department to surgical admissions (if it
is not already that way).
64  65 
   

5. If you click on "BACH" under providers you will get Dr. Bach’s schedule. For the 20. Pacemakers (PM) and AICD’s
list of patients that will see the nurses (patients that you can see alone) go under
resources and click "NRSO, PSUSAC." When you take a patient, mark the name
PM information to obtain pre‐op (if available; which it sometimes isn’t):
with your “colored dot.” The nurses will show you how to do this.
6. Double clicking on any patients name on that list will take you to “visit navigator"  What was the indication for pacing?
where you will complete your patient's note.  PM make/model/serial# (may be apparent on CXR)
7. Using the nursing documentation list, starting at the top and going down is likely  Date of last interrogation
the easiest way to complete the visit documentation. o Interrogation ensures that battery life is OK, lead integrity is OK, and
8. RFV (reason for visit) – pre‐anesthesia screening sensing/pacing thresholds are appropriate
9. Review home meds – TRULY make sure these are up to date.  Is there a rate‐responsiveness function?
10. Vitals – enter current vitals (you take them), including wt and height o if so, this should be programmed off pre‐op
11. History – review patient medical/surgical history (this can be tedious, but do it! It  Is the patient pacer‐dependent?
will auto‐populate into your note) ASK IF BLOOD TRANSFUSIONS ARE OK. o i.e., what is their underlying HR, and what percentage of beats are paced
12. Progress note – use "HBC pre‐op" for your template, or create your own with beats
smart tools. Ask RNs for helpful smart phrases.  What happens when a magnet is placed over the PM?
13. Patient instructions: enter in smart phrase (dot phrase) ".insacadult" for the o Usually, but not always, this will convert it to asynchronous (non‐sensing)
pre‐op patient instructions (ex what meds to take/hold for surgery). pacing at a specific backup rate (70‐100 bpm)
14. Print the AVS and review it with the patient before they go. PLEASE go over
anesthesia risks, NPO instructions and which medications need to be taken or Possible indications for PM reprogramming pre‐op:
held and if you don’t know ask Dr. Bach. Make sure to tell the OSA patients bring  Rate responsiveness function (PM adjusts rate based on minute ventilation, QT
their CPAP/BiPAP machines on the day of surgery. interval, RV pressure, or other cues)
15. Before you send them on their way, make sure they have gotten labs (if ordered)  Special pacing indications (HOCM, dilated cardiomyopathy, peds)
and walk them out the door and SHOW them the lab waiting area.  Certain procedures:
o Major surgery close to the heart or generator site
Call: o Lithotripsy
You will be unable to take night call during the week so plan on 1‐2 weekend day calls. o ECT
o Succinylcholine use
Note for patients with pacemakers/AICDs: o MRI exposure
 See the pacemaker section for rep contact numbers.  If any of the above are present, this is an indication to call the rep to determine if
 Call the company representative for the pacemaker/AICD to arrange deactivation re‐programming is needed
or reprogramming the device for the day of surgery.
 Write this in the preop H&P along with the rep’s name and contact number. Steps to take peri‐op:
 It may also be helpful to know where the pacer is located, when installed and  On preop physical exam, locate the pacemaker on the patient
why, and CXR to look for placement.  Ask the anesthesia tech for a magnet.
 Ask patient to bring info card with them and tell them that pacemaker may need  Set your EKG monitor to ‘paced rhythm’ – a gray pacer spike will now denote
to be reprogrammed post op each paced beat
 Ask to have the bovie grounding pad placed as far from the pacer as possible, to
Resources and Reference: minimize interference
Jaffer A, Grant P. Perioperative Medicine: Medical Consultation and Co-Management.  If the patient’s pacemaker malfunctions intraoperatively, e.g., with Bovie use,
Online publication July 2012 place the circular magnet over the pacemaker and tape in place. This usually
(available on intranet at http://onlinelibrary.wiley.com/book/10.1002/9781118375372) converts the pacemaker to asynchronous pacing mode (e.g., DDD・VOO),
meaning it will pace at the preset ventricular rate rather than looking for an
electrical impulse and misinterpreting Bovie interference as myocardial electrical
activity.

66  67 
   
AICDs: 21. Neuroanesthesiology
 Distinguished by a larger, bulkier generator box, and/or defibrillator coils seen on
CXR You will have two one month rotations in the MOR with a dedicated team of
 Unlike pacemakers, AICD functions should be turned off preop and interrogated neuroanesthesia attendings. No vacation is allowed unless you have completed your
postop. This is to prevent the AICD from misinterpreting fasciculations, Bovie, ACGME requirements. Cases include craniotomies, cranioplasties, pituitary surgery,
postop shivering, etc., as VTach and shocking the patient. Contact the aneurysm clippings and coilings, deep brain stimulation surgery and lots of spine
appropriate rep or the EP nurse coordinator to arrange for this. surgery.
 Magnet placement will typically disable the AICD function, while leaving the
pacing function intact: however, you still need to call the rep, because at the very Reading the following will certainly not replace studying a textbook, but it will give you
least the battery life will need to be interrogated before the patient leaves the some practical advice regarding several case scenarios.
PACU.
Trauma Craniotomy/Aneursym Clipping
Pacemaker/AICD Reps: (Updated list available at Main OR front desk or call EP Major anesthetic goals:
nurse coordinator below)  Prevent increase in ICP/brain herniation
Manufacturer Contact Number Representative  Maintain cerebral perfusion (CPP = MAP – ICP or MAP – CVP)
Biotronik (866) 229‐4744 1st call
 Maintain tissue oxygenation
(916) 400‐4734 Larry Goldsmith
 Maintain serum osmolarity
(916) 281‐5923 Larry Okinaka
Frankie Carino  Reduce CMRO2 (sedation, seizure prevention, avoid hyperthermia)
(916) 335‐7891
 Maintain glycemic control
Boston Scientific (800 227‐3422 Paging service
 Beware venous air embolism
(previously Guidant/CPI)
Also Intermedics, AM, Arco  Keep up with the bleeding
Medtronic (800 435‐2597 Paging service Preoperative preparation (may not need everything listed for every case):
Also Vitatron, Edwards (916 955‐6916 (cell) Todd Moore  T & C at least 2 units, keep 2 units ahead
St. Jude Medical (800 722‐3423 Paging service  A‐line and Central Line supplies, with double setup, transducer at circle of Willis
Also Ventritex, Telectronis, (916) 960-9951 Terry Carlson o Required: A‐line and 2 large bore IVs. +/‐ Central line
Siemens‐ Elema, Cordis,  Pumps for TIVA or drips (plugged in!)
Diag/Medcor o Syringe pump for remifentanil or sufentanil
ELA 800‐352‐6466 Paging service o Sigma pump for most other drips (PPF, inotropes, etc.)
Cook 800‐457‐4500 Paging service  Meds to have available: Mannitol 50g x2, Lasix 20 mg x3, Dilantin 250 mg x4 in
20 mL syringe (Or alternatively Keppra from pharmacy), lots of Propofol,
UCD EP Nurse Coordinator 762‐8914 (pager) Debra Bradac, RN Dexamethasone
UCD Heart Center, Rm 2304 734‐2590  Non-depolarizing NMB (Sux only if airway risk > elevated ICP risk)
 Remifentanil, sufentanil or other opioid infusion per attending
 Dexmedetomedine infusion
 Phenylephrine 20 mg in 250 mL bag with microdrip tubing
 Normal Saline only (Watch for hyperchloremic acidosis; No hypoosmolar like LR
or glucose containing IVFs, surgeons may require hypertonic 3% saline)
 Osmolar pressure (rather than oncotic pressure) affects fluid shifts within the
brain. Hypoosmolar fluids can worsen cerebral edema)
 Standard Emergency drugs
 Set up for a 90 to 180 degree spin (circuit extensions usually not necessary)
 No need for a temperature probe as all Neuro patients get a temp-foley

Induction/Intubation:
 Beware pre-op opiates/benzos – hypoventilation can cause ICP increases

68  69 
   

 Deep induction with fentanyl + propofol, consider supplementation by mask w/
volatiles if not using TIVA
 Tape ETT (no ties- may impede venous return)
 Avoid ↑↑ BP or coughing with intubation! Will lead to increased ICP/herniation
 Avoid ↓↓ BP with induction! Causes decreased perfusion / worsening vasospasm
o Phenylephrine gtt titration as needed
 Set up for 90 or 180 degree spin. May also be prone or supine if posterior, head
may be elevated or slightly turned. Check neck for proper positioning.
 Note: All IV anesthetics to some degree reduce CBF and ICP (except ketamine).
All inhalational anesthetics cause some cerebral vasodilation/ increased ICP.
Avoid succinylcholine (can also increase ICP). See Charts from Lange below.
Intraoperative:
 If Mayfield pins are being placed, prevent an increase in BP by giving additional
boli of e.g. Remi or Propofol (ideally have your a-line in place)
 Send baseline ABG, and repeat roughly hourly (check with attg)
 Hyperventilation often used to decrease PaCO2 to 25‐30 (less than 25 provides
little added benefit and compromises CBF). Use PaCO2, as ETCO2 can be
inaccurate depending on lung function/A‐a gradient. So check an ABG!
 PEEP: some avoid it to improve venous drainage, but prevention of atelectasis
and good oxygenation is vital, therefore use a PEEP of 5
 PaCO2- low-normal. Do not routinely hyperventilate- record if surgeon requests.
 TIGHT BP CONTROL! SBP 120‐150 (or as dictated by pt’s baseline)
o Note that for aneurysm, induced hypotension may be used to reduce risk
of rupture and to facilitate clipping.
 Remi gtt 0.2 mcg/kg/min or Sufentanil 0.007 mcg/kg/min to start, increase PRN
(Baxter syringe pump)
 Phenylephrine gtt w/ microtubing PRN hypotension (if using triple pump, 0.5‐1
mcg/kg/min)
 Volatiles at 0.5‐0.7 MAC or TIVA to minimize interference with SSEP/MEP
 Patient must not buck or cough! Extracranial brain herniation and cervical fracture
while in Mayfields has happened. Deep induction, lidocaine prior to DL and
continual muscle relaxation are all useful measures to take.
 Surgeon may request steroids (although per CRASH trial in Lancet 2004 and
2005, no benefit in survival in head injury patients)
 If surgeon requests, load Dilantin 1000 mg slowly (over 30 min to 1 hour) at start
of case (Baxter pump). Note high infusion rate can cause refractory hypotension.
 Depending on operating conditions, may also be asked to give Lasix and/or
Mannitol to decrease brain volume. Load Mannitol slowly to avoid hypotension
(more effective if BBB intact). Monitor UOP!
 Treat vasospasm w/ triple H (Hypervolemia, Hemodilution, Hypertension). Also
add Nicardipine / Nimodipine as needed.
 Osmolar, not oncotic, pressure primarily affects fluid shifts within the brain.
Hypo‐osmolar IVF can worsen cerebral edema and increase ICP. Glucose‐ 0.1mg/ml. Change the concentration setting on Baxter pump so you don’t
containing IVF can induce hyperglycemia which worsens injury. Therefore,
NORMAL SALINE ONLY or colloid.
 Hypothermia is under much discussion at present, not much evidence in support
out there (IHAST II study by Todd etc. 2005). Balance risk/benefit and discuss
with your attending and surgeons.
 Usually maintanence with sevoflurane (Bedforth 2000)
Key events during the operation:
 Mayfield pins: Give Fent, Remi and/or Propofol bolus to avoid patient stimulation
and accompanying HTN/ increased ICP
 Before aneurysm clipping: Propofol and ↑MAC to get burst suppression/↓CMRO2
 After aneurysm clipping: Increase BP to above baseline to allow adequate
perfusion from collateral circulation
 Continuously monitor EBL, esp. during aneurysm clipping, as can perforate artery
and lead to catastrophic hemorrhage
Emergence:
 Avoid hypercapnia as a way to achieve spontaneous ventilation
 Avoid coughing/straining or bucking during extubation (consider keeping Dex
and/or Remi on board; iv. Lidocaine/Nipride/beta blocker)
 Long acting opioids are to be used sparingly to allow prompt wake up and
neurological assessment (Consider Dex, iv Acetaminophen)
 Antiemetics!!
Post-op
 Do a post-op check up to evaluate how well you have been doing with pain
control, antiemesis, fluid management (in spine cases: when were they
extubated, signs of renal impairment, facial pressure sores?)
Total Intra Venous Anesthesia (for neural monitoring cases such as craniotomy, spines)
 Benefits include: faster return of higher cognitive function to facilitate early
neurological assessment, intact cerebral autoregulation, stable hemodynamics,
lower incidence of nausea/vomiting to avoid the increase in ICP, decreased ICP,
and increased CPP (Cole et al, 2007).
 Will need two PIVs and possibly a central line (a good time to practice
subclavians), arterial line with Vigileo flowtrac
 TIVA runs through an extremity PIV only and stopcocks should be placed close to
the IV port and visible to anesthesia staff
 Get the TIVA set (three stopcocks OR microbore infusion manifold) from tech
room and one‐way (check valved) Y piece connector.
 Have tracheal lidocaine, propofol (200 mcg/kg/min and titrate down by 50mcg
every 10 minutes until about 100 mcg/kg/min),
 Remifentanil (bolus for intubation 1‐2 mcg/kg then there is a wide range for
infusion but 0.2 mcg/kg/min okay to start), and dexmeditomidine (start at 0.007
mcg/kg/min and titrate up) ready
o Propofol 1000mg bottles are in Pod 20 and 30 Pyxis – get lots of them for
long crani; can hang bottle on Sigma pumps with vented tubing
o Remi 1mg vials in OR Pyxis. 1mg vial x2 (2mg) into 20ml syringe makes
have to refill as often. Put triple stop cock at end of syringe for refills.

70  71 
   
  Dexmedetomedine: 0.007 mcg/kg/min, no positive data on use in spinal cord
injury but seems to blunt hemodynamic response (increased SBP) in
craniotomies with little side effects (Becker, et al. 2008)
 Ask anesthesia tech for three pumps, anode tubes with secure tape or tie, arterial
line or double set up (+/‐ Vigileo)
 PRBC and colloid (albumin) available
 Do a baseline ABG
Traumatic brain injury:
 The major anesthetic goal is to prevent secondary brain damage
 Potentially significant blood loss (ideal Hct is 30)
 They may ask for iv Keppra (circulator will bring it)
 Keep CPP >50 mmHg
SAH:
 Consider an awake a-line to have optimal BP control during induction; discuss
your BP aim with Neurosurgeon before you start
 vasospasms may be treated with triple H therapy (hypervolemia, hemodilution,
hypertension)
 have Phenylephrine drip as well as Nimodipine drip set up before case starts
 Aneurysm clipping: make sure that you have at least 2 units of blood in the room.
 Just prior to the clipping you might be asked to drop the BP to reduce the risk of
rupture (Propofol bolus, Adenosine) Call your attending into the room!
 If the aneurysm ruptures you might encounter a catastrophic hemorrhage. You
might have to drop the BP fast and furious in order for the surgeons to visualize
the rupture and be able to clip it. Then think about hanging blood/volume.
Pituitary Surgery:
 Make sure you know the patient’s hormone status and whether the patient will
need a stress dose of steroids
 Joint procedure with ENT. Use an oral RAE
 Neurosurgeons may place a lumbar drain and take a fat graft from the abdomen.
 Every hour check an ABG and calculate your ins and outs. Have a close eye on
your electrolytes. (Remember SIADH, D.i, cerebral salt wasting)
 Ensure that throat pack has been removed at the end of the procedure
 Make sure that the patient does not pull on the foley that is left in the nose for
packing.
 Sedation with Propofol +/- Dex (no further Midazolam)
 Be aware that you have limited access to the head for airway rescue, have nasal
prongs with etCO2 available
 Low threshold for A-line, keep Systolic BP <130mmHg
 Inform yourself about the medications that you can give without interfering with
the success of the procedure (MER-micro electrode recordings)
Spinal Surgery: laminectomy, fusions, sciolisis repair
 Will need two PIVs and possibly a central line (a good time to practice
subclavians), arterial line (with Vigileo flowtrac is optional, send baseline ABG)
 May need TIVA or run low MAC on volatiles for neuromonitoring
 May be supine or prone; slight reverse-T reduces risk of post-op visual loss
 Face pillow needs 30 minutes to expand. Check eyes and face frequently
because of pressure ulcers when laying prone (may want to consent patient for
facial damage or blindness preop) and document on anesthesia record
 Patient may have chronic pain preoperatively, so plan on a multi‐modal approach
(ie. ketamine, methadone, surgeon may do intrathecal duramorph or fentanyl)
 PRBC and colloid (albumin) available, +/- platelets, FFP, Amicar or TXA
 Loss of signals is an emergency. You are expected to call your attending to the
room STAT. Consider raising the MAP, optimize Hct, paO2, temperature,
anesthetics etc.
Pain procedures: baclofen pump, intrathecal pumps
 Lateral or prone positioning, usually short cases (LMA if no contraindications)
 Chronic pain patients so need to know their medications, when last taken, and
plan accordingly
 A representative is around to help program these pumps
 Beware of baclofen withdrawal in PACU (from miscalculation of dose: agitation,
diaphoresis, spasticity, rigidity, hyperreflexia, tachycardia, hypertension,
respiratory depression, hyperthermia, and rhabdomyolysis. Treatment: refilling of
the pump, IV diazepam, physostigmine, and supportive care. (Salazar 2008,
Muller‐Schwefe 1998)
 Beware also of baclofen overdose: CNS depression with coma, and diminished
DTRs. Treatment is supportive. Stop pump. Call primary team to investigate. May
require securing airway and mechanical ventilation.

Deep Brain Stimulation Surgery:

 A headframe will be placed in pre-op by the neurosurgeon before the patient
goes to the CT scanner. The nurse will administer iv. Midazolam. The patient
needs to be checked in by anesthesia before this happens
 The OR Table will already be at 180
 Careful positioning of the patient while they are awake (patients are off their
meds and can have significant tremor)
72  73 
   

Potential Problems: LANGE, Clinical Anesthesiology, Fourth Edition, Chapter 25. Neurophysiology &
Venous air embolism, brisk bleeding, moving while in Mayfield pins, pneumocephalus, Anesthesia, Table 25-3. Effect of anesthetic agents on evoked potentials.
slow surgeons, lots of time to position, sterile and draped equipment that you can bonk SSEP VER BAER
your head on, prone positioning, disconnection of TIVA, and long long days. Agent Amp Lat Amp Lat Amp Lat
Nitrous oxide ↓ ± ↓ ↑ ± ±
LANGE, Clinical Anesthesiology, Fourth Edition, Chapter 25. Neurophysiology & Halothane ↓ ↑ ± ↑ ± ↑
Anesthesia, Table 25-1. Comparitive effects of anesthetic agents on cerebral physiology Isoflurane ↓ ↑ ↓ ↑ ± ↑
Agent CMR CBF CSF CSF CBV ICP Barbiturates ± ± ↓ ↑ ± ±
Production Absorption Opioids2 ± ± ± ± ± ±
Halothane ↓↓ ↑↑↑ ↓ ↓ ↑↑ ↑↑ Etomidate ↑ ↑
Isoflurane ↓↓↓ ↑ ± ↑ ↑↑ ↑ Propofol ↓ ↑ ↓ ↑
Desflurane ↓↓↓ ↑ ↑ ↓ ↑ ↑↑ Benzodiazepines ↓ ±
Sevoflurane ↓↓↓ ↑ ? ? ↑ ↑↑ Ketamine ± ↑
Nitrous Oxide ↓ ↑ ± ± ± ↑ ↑, increase; ↓, decrease; ±, little or no change; ?, unknown; SSEP, somatosensory
Barbiturates ↓↓↓↓ ↓↓↓ ± ↑ ↓↓ ↓↓↓ evoked potentials; VER, visual evoked response; BAER, brainstem auditory evoked
Etomidate ↓↓↓ ↓↓ ± ↑ ↓↓ ↓↓ response; Amp, amplitude; Lat, latency.
Propofol ↓↓↓ ↓↓↓↓ ? ? ↓↓ ↓↓ 2
At very high doses, can decrease the latency and decrease the amplitude of SSEP
Benzodiazepines ↓↓ ↓ ± ↑ ↓ ↓
Ketamine ± ↑↑ ± ↓ ↑↑ ↑↑
Opioids ± ± ± ↑ ± ± Glasgow Coma Scale
Lidocaine ↓↓ ↓↓ ? ? ↓↓ ↓↓ Eye opening Spontaneous 4
↑, increase; ↓, decrease; ±, little or no change; ?, unknown; CMR, cerebral metabolic To Speech 3
rate; CBF, cerebral blood flow; CSF, cerebrospinal fluid; CBV, cerebral blood volume; To Pain 2
ICP, intracranial pressure. None 1

Motor Response To verbal command 6

Localizes pain 5
Withdraws 4
Decorticate 3
Extensor 2
None 1

Verbal Response Oriented 5

Confused 4
Inappropriate 3
Sounds 2
None 1

Didactics- New for this year, so still evolving and subject to changes. Currently Friday
mornings, 0630-0650 in the cafeteria. Look for "Neuroanesthesia" on SmartSite, then
click on "resources", where you find a folder titled "Friday Case Discussions". There
should be an article and some questions for discussion.

74  75 
   
22. Kidney Transplant
Need: Central line.
Do Not Need: No epidural. NO A‐line (Rule of thumb: No A‐line on any ESRD patients).
No Hextend. No LR. Avoid Morphine or Demerol including postop, even if new kidney is
working fine. Avoid rocuronium unless indicated for modified RSI induction.
Set‐up: Clamp for Foley (from circulating RN). Single set‐up for CVP, Single syringe
pump, U/S for central line placement. Mannitol. Have several vials of Lasix in room.
1. Methylprednisolone and Thymoglobulin should be with patient’s preop Abx; if not
there, find them! Methylprednisolone is given after induction as
immunosuppressant and pre‐treatment for Thymoglobulin.
2. Thymoglobulin should go through your central line and must be run on a 22
micron filter (available in middle PACU supply room); run on pump at about 43
ml/hr. Fever, HTN, Tachycardia are common side effects noted with
thymoglobulin, especially if methylprednisolone not given upfront. Consider using
Dexmedetomidine infusion to help with post‐op HTN and Tachycardia.
3. Goal CVP is 10‐12 mmHg to encourage new kidney’s UOP. Give NS to get it
there.
4. Hang bag of mannitol. Shortly before reperfusion, surgeon will tell you how much
mannitol to give (typically 12.5 ‐ 25g). Will also tell you if/how much Lasix needed.
5. Circulator will set up a bag of NS+Abx on your IV pole which is connected to
Foley. Surgeon will direct you on when to clamp Foley, when to infuse fluids into
bladder, when to unclamp Foley, and when to start counting Foley output as
UOP.
Kidney/Pancreas Transplant
Kidney Transplant with the following mods:
 May need A‐line; avoid side of AV fistula/graft.
 Goal CVP 10‐15 mmHg intraop as well as postop.
Have insulin and Dextrose 50% available. Check glucose q30min intraop, q10min for
first hour after reperfusion, then q30min. Keep glucose <300 but do not try to drive
below 150, as there can be a dramatic decrease after reperfusion.
Afterhours in PACU
Renal transplant patients arriving in PACU after 1800-1900 will stay until 0700 the
following morning before sign-out- this was decided on by the transplant service to
prevent apnea, etc. on the floor.
76  77
24. Medical ICU
Team Structure
2 teams: 1 Medicine, 1 ED/Anesthesia. Each team consists of two senior residents, one
junior resident, and 2 interns. The anesthesia team has two seniors (ED resident and
CA‐1 or CA‐2), junior resident (CA‐1) and two interns (FP and ED). There is a
pulmonary/critical care fellow that is the authority on the team. Most big decisions go
through him/her.
Because the Senior/Junior designation is sometimes arbitrary, residents in the past
have switched roles after 2 weeks to balance; check with the prior MICU anesthesia
team, and clear with IM first.
Schedule Basics
Call schedule:
 www.amion.com
 Login: ucdim00 (zero‐zero)
 On top of page, click on “call”
 Use blue arrows at top of page to find your month. Your name will be listed under
“MICU‐res”
(Typically for Anesthesia/ED team, the 1st call will be Monday, but the senior that
day will be an ED resident)
Just like intern year, call the current resident the day before you start to get a sign‐out
on the patients you will be inheriting. Patient lists are maintained on the web site
“eHandoff” (You can type this into the intranet). To obtain a login, contact Jennifer Cano
(4‐4270).
Rounds: Start on Tower 6 MICU at 7:30, and last 2‐5 hours, depending on how much
pain your attending wants to inflict that day.
Call Structure: This has changed recently because of the new ACGME work hours for
interns. It’s confusing to think about, but fairly straightforward after actually being in the
MICU for a day or two. Q4 call for the senior resident, which, because of the team
structure, ends up being Q2 call for the team as a whole. Any patient that comes in after
6AM on your call day is fair game. You also carry the Code Blue pager on your call day.
Senior Resident (ED and CA‐1 or CA‐2) (2):
 Schedule of q4, 24‐h call with every 4th day off.
 Work in a supervisory roll
 Should know all patients on the team
 Help out Juniors and Interns with procedures/notes as needed
 Write “Brief admission note” on all new admission/transfers that are admitted by
interns
 Present all patients admitted with overnight intern on post call day.
78  79
23. Laparoscopic Gastric Bypass
Preop:
 Confirm bougie and difficult airway equipment available as needed.
 Optimize intubating conditions (don’t be ashamed to build a ramp).
 Set up Hotline to use with the second PIV you will start.
 Consider need for GERD pre‐tx, may check preop BS if pt has DM.
 If patient has CPAP machine with them, ask preop nurse to get it ready for patient
postop (has to have a safety check before use).
Induction:
 Pre‐oxygenate! Take this step seriously, and give it time. May use the black
mask strap and give 100% O2 from the minute your patient is on the bed.
 If RSI not indicated, place OPA + have short handle laryngoscope.
 The surgeon usually wants Decadron 10 mg along with preop Abx.
Intraop:
 IVF: Expect to give 4‐6L crystalloid during the case. Give 2‐3L+ early to attenuate
responses to CO2 insufflation and position changes.
 Positioning: Get into the habit of checking BP immediately after dramatic position
changes, especially reverse trendelenburg, and treat appropriately.
 Severe hypotension: Let surgeon know. Level patient, then slowly increase to
steep RT as BP tolerates. Bolus IVF. Consider pressors but surgeons don’t
prefer.
 UOP: Patients frequently have very low UOP with CO2 insufflation. This markedly
improves postop if you have kept up with IVF.
Pain Control:
 Breathing comes first! Most patients do well with short‐acting narcotics titrated in
during the case (e.g., the fat‐loving fentanyl up to 10 mcg/kg IBW) or
dexmeditomidine gtt. Avoid long‐acting narcotics intraop and order small doses
postop.
 Check with surgeon about giving Toradol at end of case—usually okay, but not if
they had increased intraop bleeding.
Emergence/Postop:
 It’s all about breathing! Reverse T‐burg to assist respiratory effort.
 Consider nasal +/‐ oral airway until patient awake enough to object.
 Transport to PACU in RT position.
 Let patient’s PACU nurse know if patient has CPAP machine to use (know
settings).
 
Junior Resident (CA‐1) (1):
 Responsibilities
o Pick up patients from the overnight admissions that the Senior resident will
present on rounds.
o Manage daytime procedures for the team
o Independently manage admissions during the day if things are busy
 Schedule
o 1 overnight call/week (Saturday or Sunday)
o Days off will alternate between one week with Friday off and another with
Saturday off (depending on call cycle of senior resident)
Intern (FP and ED) (2):
 Day Shift (5:30 am ‐ 6 pm)
o 2 interns, one from each team
o When team is on call, intern will do admission while being supervised by
senior resident
o Day shift Interns will have either Saturday or Sunday off. Night Shift (5:30
pm ‐6 am)
o Intern for on call team does admissions with Senior resident
o Other intern does cross‐cover with close supervision from senior resident
 Night shift Interns will have both Sat and Sun off.
Admissions/Transfers: All admission and transfer orders are done in EMR. There are
specific ICU order sets (“MICU Admission”) you can use. Try to clarify code status on
EVERY patient! To obtain the H&P and progress notes templates, look up “Critical Care”
under the “Smart Text” options. That for transfer summaries is “IM Transfer Summary”,
although many times your fellow Medicine residents will have their own preformed notes
that you may be able to share.
Call rooms: To get the call room keys, call the IM housestaff office x47080. Call room is
in the hallway between Davis 5 and Tower 5 and tricky to find. As you walk towards
Davis tower there is a set of bathrooms on the left hand side just before the Davis tower.
There is a door to the left as you face the bathroom door. Enter that door using your call
room key and then there are a bunch of call rooms all in one place. Look for the sign that
says MICU resident (first door on the right). There is also a staff bathroom across from
the MICU. The code is 415.
Non‐call days: Sign‐out now occurs at 5:30 PM every day, to the senior resident on call
that day and to your team’s night intern for cross cover issues. If your team is on call
that day, then the resident will be you or the ED resident.
Typical Admissions (not a complete list)
 Airway issues on the floor leading to intubation or Full‐face BIPAP: Usually
caused by oversedation, worsening of pulmonary function from PNA, or
exacerbation of CHF or COPD. Important: Nasal BIPAP can stay on the floor.
 Code Blue / other major hemodynamic instability on the floor needing closer
monitoring and/or vasoactive drips
 
  DKA: large amounts of NS with insulin gtt, goal to decrease glucose by ~100/hr.
Don’t forget to start D5NS when glucose reaches 200‐250, and then titrate down
the insulin rate.
 EtOH w/drawal: Ativan gtt vs. Valium ATC. Thiamine/Folate/MVI.
 GI Bleed: Get GI to scope ASAP to determine need for ICU vs. floor. General
plan: CBC Q4, PPI BID or gtt, +/‐ octreotide gtt for esophageal bleed
 Sepsis/FUO: Pan culture, then broad‐spectrum Abx, HD support
 Brain death/organ donor: Followed by the ICU Fellow only!
 Ventilator management for other services: usually followed by Pulmonary Critical
Care fellow but you may become primary if decided between the fellow and
attending
 End stage cancer: where code status needs to be addressed
 Liver Cirrhosis
Questionable Admissions
Blocking isn’t allowed unless a Fellow/Attending approves it. Most fellows will take the
conservative approach and accept patients. Bottom line, if you don’t protect your
service, nobody will. So, if in your honest clinical judgment, and after you see the
patient, you feel that the ICU isn’t appropriate discuss it with your fellow and make that
known to any potential turfers. Be diplomatic but firm in your interactions, and if they
accept your argument, do keep a close eye on that patient in case things change. Also,
keep in mind that many potential ICU admits can be effectively managed on the floor by
the hospitalist. If you think your patient qualifies, have the ED contact them (or talk to
them yourself) so they can do a quick consult. Above all, keep patients safe. If that
means taking admit #12 at 5AM, so be it.
Important: transfers from other facilities have already been accepted by the MICU
attending by the time you hear about them, so don’t try to turf these!
Lines and Intubations
You can’t put in central lines above the diaphragm without first being observed by an
attending or fellow and “signed off” in the official book. Do this early in the rotation to
avoid inconvenience later. Full drape/gown/ultrasound are mandatory for all lines.
Procedures like arterial and central lines and intubations need to be documented (i.e.
procedure note) into the EMR.
Fellows like to do the intubations but if you feel like it might be difficult, call the 6121.
Intubations by the ICU fellows/attendings can be traumatic for your patient and you; if
you want to be there for airway back up, then stay; if it’s too awful to see, it’s okay to
walk away from the bedside. (But be within hearing distance to call 6121 to the rescue if
it becomes a flail!)
Days Off
Senior residents get Q4 off, typically the post‐post call day. Junior residents get 1 day
off a week, typically Friday or Saturday.
80  81
25. Pulmonary Critical Care Rotation
Team Structure: One team: you, your fellow, your attending and perhaps another
resident from one of the surgery subspecialties.
Daily Schedule Basics:
Hours: Show up b/w 7‐8 depending on how may pts and how long it takes you to pre‐
round. Round with attending at 9am. Finish rounding 10‐11ish. Write notes.
Chill/read/didactics with attending (depending on attending), +/‐ conference (schedule
below), +/‐ procedures if you want them. Leave usually by 5pm. Typically no call, no
weekends, and holidays off; this will usually depend on the service census and your
fellow.. If your weekends are off, you will be in the anesthesia PACU weekend call pool.
Conferences: Tues 1:30 chest conference (go over old cases). Thursday morning 7am
their equivalent of grand rounds. Thurs afternoon either path rounds or cxr rounds.
Types of Patients: Most of the patients you see are neuro/neurosurg, gyn, ortho and
ENT patients. The ortho patients are usually run‐of‐the‐mill ICU patients and we become
primary. The other services have more experience with ICU care so we typically get
consulted when there are more complicated issues but we remain in a secondary
consultant role. The CTICU patients are co‐managed by the surgery and your
attendings but your fellows do not get involved. There is opportunity to follow these
cardiothoracic pt’s depending on your attending and your motivation level.
Resident Expectations: much like any other inpatient service ‐ i.e. see consults, present,
write notes, communicate with primary team, etc. Lots of opportunity for procedures.
Ask to do bronchoscopy to improve skills at FOB intubations in OR.
Topics to read prior rotation: There is no syllabus per‐se. Most of the issues surround
vent management, when to extubate, neurologic catastrophes, antibiotic management,
fluid management, etc.
First Day: get sign out and contact info for the fellow from the previous anesthesia
resident if there was one. Otherwise, find out who your fellow will be from the Internal
Medicine/Critical Care Coordinator. It’s a good idea to contact your fellow the night
before.
Overall: Great rotation. Lots of 1:1 teaching, opportunities for procedures and time to
read.
82  83
Midnight Rounds
At least one of the two residents (or both of you) along with the intern need to do
midnight rounds on every patient on the MICU service. You will go to each unit and
round with the charge nurse. Most of the time, it will simply involve modifying orders as
the nurses request. It’s also a good time to check off things on your “To Do” list that
other teams have signed out to you. Lastly, “midnight” rounds don’t have to be at
midnight. It’s usually a good idea to do them as soon as you have the chance in case
you get slammed throughout the night.
RADIOLOGY DICTATION
Many times a final read on a scan shows up as “dictated but not transcribed” on EMR.
Rads will give you a hard time if you call them for these, so the best thing is to listen to
the dictation yourself:
 Dial 40180
 When it answers, dial 99999
 Wait a few seconds, then dial #1
 Wait a few more seconds, then dial 00000
 Wait yet a few more seconds, then dial the accession number of the specific scan
(NOT THE MR NUMBER). Dictation will play back. Dial 3 to rewind.
 
26. Chronic Pain
This is a one month chronic pain rotation that is usually divided into two‐one week
blocks and one‐two week block. Mureen Darrington is the Pain Fellowship Coordinator
and also works with the residents and medical students on this rotation. She is very
helpful, and you can go to her with questions. Her office is on the 3rd floor of the Ellison
building in the Pain Medicine department (Suite 3020, 916.734.6688). Report to her at
0800 on your first day for orientation.
One of the attendings (likely Dr. Naileshni Singh) will tell you what is expected of you on
this rotation. The attending (or Mureen) will add you to the Pain SmartSite list so you
can get access to articles and the AMA pain modules. You should print out the opioid
conversion scale for the UCD Pain department from SmartSite. A question bank is
available on SmartSite as well for your perusal.
The block is broken down into one week segments. Week 1: Pain Pharmacy and Cancer
Clinic; Week 2: Outpatient Clinic; Week 3: Procedure Clinic; and Week 4: Outpatient or
Procedure Clinic.
Written Requirements
 Read through the 12 AMA modules: http://www.ama-cmeonline.com/pain_mgmt/
 Do 40-45 minute Powerpoint oral presentation on a subject of either your or your
attendings’ choosing on the last Friday of the rotation. You should pick this
subject your first week, although Dr. Singh will usually pick a topic for you. Ask
the fellows and try to focus on a specific topic to make your life easier.
 Do a computer exam on the last Wednesday of the rotation (arrange through
Mureen). This exam typically takes a half day and is based on opioid conversions
and the AMA modules. It is very useful for board review.
The Schedule
 Basically every day starts at 0745 for lecture in the 3rd floor conference room.
Then there is also a noon lecture: Mondays consist of a chapter review,
Tuesdays present a non-cancer case, Thursdays a cancer case and Fridays an
interventional case. Wednesdays may or may not have a guest lecturer.
 The day ends anywhere between 4:00‐6:00 pm for inpatient or procedures and
3:00‐5:00 for clinic. Attend Grand Rounds on Tuesday mornings. Weekends are
off but expect to do at least one weekend code day because of the less strenuous
requirements on this rotation.
 Since you don’t work weekends, plan on working 1‐2 weekend PACU shifts.
Inpatient
The inpatient service is a consult service and mainly includes patients with cancer pain;
but patients with chronic pain and other pain syndromes are often managed as well. You
can work out with the fellow how involved you will be. Sometimes they will do all of the
EMR entries and you will just help to gather information for rounds. For the progress
note, calculate how much PCA or other narcotics they’ve gotten over the last
 
24 hours. You can use the RN Pain Management section of the EMR Flowsheet for 27.Pain Management and Opioid Conversion
PCA totals but often times you have to check the machine itself to be accurate. Convert
that to oral morphine equivalents. The fellow receives calls about the new consults. You
Equianalgesic dosing
usually go with the fellow to see the new consults. They have to do a complete H&P .
Be advised, there are many different conversion tables, and conversions vary greatly
The fellows are in contact with the attendings all day regarding patients. The attendings
with dose/day.
however don’t come to round until after their clinic is over (if at all)….so you could be
waiting.
Convert Everything to Morphine Equivalents
PO (mg) Analgesic IV/IM/SC
Outpatient
Clinic supposedly starts at 8:00 but patients don’t get roomed until about 8:30. You will 30 Morphine 10
see patients with the fellows and attendings. You may be asked to do the physical 20 Hydrocodone -
exam. Physical exam includes: heart and lungs, sensation to pin prick, motor strength, 20 Oxycodone -
Faber’s test, Gaenslen’s test, Spurling’s test, straight leg raise, flexion/extension/lateral 10 Oxymorphone 1
bending of the spine, examination of the hip joint and reflexes (may do both upper and 4 Hydromorphone 1.5
lower extremities depending on patient’s complaints). Please review the origin of the - Fentanyl* 0.1
reflexes. You will probably need to look up imaging studies. You are usually not asked 200 Codeine -
to see patients by yourself. The fellows or attendings will typically write the note. 300 Meperidine 75
*The dosing ratio of fentanyl above applies to acute or opioids naïve dosing
Procedures
Alas! The procedures section! This will consist of either 1) watching, 2) pretending you Neuraxial Morphine Conversions
are interested, 3) setting up the tray for the fellow, and 4) getting to do it yourself with PO IV Epidural Intrathecal
some help from either an attending or fellow. You are technically not allowed to perform 30 mg 10 mg 1 mg 0.1 mg
procedures without the attending present. The main procedures done are trigger point
injections, lumbar epidural or caudal steroid injections, and medial branch blocks. Learn Morphine to Methadone Equianalgesic Dose Ratio (EDR)
how to set up the trays. Always wear lead & glasses in the room. Oral Morphine Equivalents Morphine : Methadone EDR
0 – 100 mg/day 4:1 (ie, morphine 4 mg = methadone 1 mg)
Things to Study 101 – 300 mg/day 10:1 (ie, morphine 10 mg = methadone 1 mg)
1. Spinal cord and vertebral anatomy, dermatomes >301 mg/day 15:1 (ie, morphine 15 mg = methadone 1 mg)
2. Lange chapters on Opioids‐ uses, dosing, side effects. Opioid conversions.
3. Neuropathic agents like neurontin and lyrica‐ uses, dosing, and side effects
4. Ketamine and other drugs used for multimodal pain relief. Methadone PO Methadone IV
5. The keywords assigned to you. 1 mg 0.8 mg
6. Physical exam for chronic pain evaluation.
7. Indications for blocks. Fentanyl Transdermal (TD) Patch Conversion
8. Imaging such as fluoroscopy and ultrasound. IV Drug Patch
25 mcg Fentanyl 25 mcg/hr
1 mg Morphine 1 mg/hr IV

The conversion ratio above applies for patients on chronic opioid therapy. An easy way
to remember the conversion of morphine IV to fentanyl TD is as follows:
 total amount of IV morphine for 24 hours = dose of the fentanyl transdermal patch
per hour.
o Example: 50 milligrams IV morphine over a 24 hour time period = 50
micrograms per hour fentanyl TD patch.

84  85 
   

28. Shriners Children’s Hospital
Attendings:
Dr. John Scavone (chief 590‐6045) Dr. Sunny Tumber (590‐6041)
Dr. Matson (590‐6043) Dr. Sampaguita Tafoya
Anesthesia Tech: Larnell Madison or one of the other technicians‐arrives usually at
6:30‐ 6:40am to bring drug box into your room
Secretary: Laura (453‐2066)‐needs to have drug test sent to her no earlier than 30 days
prior, but no later than one week before the start date of the rotation; invalid if done
otherwise
Locations:
ORs and Burn ICU‐ 4th Floor
Cafeteria (Important Info) ‐ 2nd Floor (You get $5 for Breakfast; $7 for Lunch, just tell
the cashier you’re a resident). They are strict on this so carry some cash with you.
Otherwise there is free coffee there all of the time
Inpatients (3 South and North)‐ 3rd Floor
Anesthesia Office‐ 7th Floor
Pharmacy‐ 3rd Floor‐no code needed to enter; open until 7pm. If after 7pm, you may
leave your drug box in the OR and one of the anesthesia techs will return it. Make sure
the form is accurate and signed.
Before the rotation starts, you should complete:
1. Shriner Paperwork: You can find it on CRC (look under GME Coordinators) or it
will be in your mailbox. Once you complete it, send it to Laura.
2. Drug Testing‐> Call US HEALTHWORKS ‐ 451‐4580 LOCATED AT: 1675
ALHAMBRA BLVD. #B. WALK IN BASIS ONLY, THEY DO NOT TAKE APPTS.
ALLOT ABOUT 45MIN TO 1 HOUR TO COMPLETE THIS. Contact person from
the Shriners for Drug Testing is Jayne Kimmel 453‐2060
3. There are no longer any parking permits allotted to residents, so lot 14 is the
closest place to park. There is a bike locker in the Shriner’s parking lot (code
2524)
General Expectations: You have to dress professionally every day, including the first
day (shirt and tie/the female equivalent, no white coat required, but definitely
appreciated by Dr. Scavone). Dr. Scavone likes pen tips that are 0.5 mm or less, but
know that he wants you to use the pen he gives you. Also, they must let you out for
Monday classes and Tuesday Grand Rounds, and any other required lectures. So
Tuesday you can go straight to Grand Rounds, but it might be helpful to set up your
room first, as cases will likely have started before you get back!
Computer Training: All Orders are done on the computer. They have an equivalent to
our EMR Order Entry. Dr. Scavone’s secretary will schedule your computer training for
the training for the first Monday or Tuesday of the rotation. The training lasts about 4
hours. Yes, you do have to go back to the ORs once it is done.
Daily Activities: (Including the first day)
Burn Rounds are no longer required nor expected, but you still may be asked by Dr.
Scavone or Dr. Tumber to attend the ICU portion at some point during the rotation if
there is a patient of interest. We don’t write any notes. Burn Rounds start at 6:25 AM in
the Burn ICU on the 4th floor. They usually finish around 6:45‐50 AM.
Locker:
We have a locker identified by “Anesthesia resident.” Since there are 2 residents every
month now, one of you will have to ask Dr. Scavone or the resident previous to you
which additional locker is okay to use. You can also share. Bring your own lock to
secure belongings.
Preparing for Cases:
1. You’ll do your PreOps the day before (weekends are a little different and will be
discussed later) ONLY if they are inpatients. The Pre Op form is pretty simple.
The first few Pre Ops on your first day will be done by the Attending, so pay close
attention because after that, it is up to you to do them. Most patients have had
surgery at Shriner before, so take a look at the previous Anesthesia workup (will
make things easier for you). Don’t forget to sign just below the Consent portion
after you are done with your evaluation. Any cases that say “SDS” or “AM
Admission” on the board get seen the day of surgery in the Pre Op room.
Any cases that say “In Patient” you will Pre Op for the next day. This will be
stated on the schedule. Again, review the old chart (if you don’t see it, ask the
clerk to show you where it is).
The schedule is usually out around 12‐1pm and is available at the front desk.
Sometimes they don’t list the anesthesia resident on the schedule, either
because it has not been decided, or they have forgotten to write in on the board.
If Dr. Scavone or Dr. Tumber has not told you by the time the next day’s schedule
is on the board, ask whoever is running the board for that day.
Note: Patients that are inpatient are located either on 3 South, 3 North, or the
Burn ICU.
2. You only follow one attending or room per day. Generally, there are 3 ORs
running. Generally, 3 of the attendings are staffing rooms and 1 is floating
around. Drug boxes are usually found in the rooms in the morning, as the
anesthesia tech will generally have already placed it there. If not, you can find it
in the Anesthesia Workroom and take it to the OR yourself to start setting up. You
will have to learn their Anesthesia cart and workroom. The Carts are usually
stocked and things aren’t missing like some other places you are familiar with.
The anesthesia tech almost always checks the machine and sets up an IV kit and
bag. (This means that you generally are responsible for only the drugs and the
airway stuff.) Cart lock code is 1225.

86  87 
   
 3. Drugs: Have Ephedrine (5mg/ml) and Atropine (0.4mg/ml) for rescue (for all
attendings except Dr Devera). Epinephrine is generally not drawn up in the
morning as it is at the CSC, unless you expect to use it, i.e. a tenuous patient.
Some of the doses for drugs you will use: Glyco 5 mcg/kg, Remifentanil
2‐3mcg/kg. Abx: Usually Kefzol (30 mg/kg) except for Burn cases. All Patients,
pretty much, will get Decadron (0.25mg/kg) and Zofran (0.1mg/kg).
They rarely use NDNMB and don’t even mention Sux. Dr Devera is the only one
who likes to also give Reglan for LMAs, in increments of 2.5, 5 or 10 mg. Also
have the other drugs drawn up (Propofol and Fentanyl). All Attendings run
fentanyl infusions at 2mcg/kg/hr for longer cases (usually those greater than 1
hour), so attach fentanyl (50 mcg/ml) in a 2 or 5 cc syringe to the extension tubing
found in top R side of cart and hook it to the pump. Their infusion pumps are the
same as ours and have a library for most of the drugs they run.
Pre/Intra/Post Op:
1. PreOp room: For PO Versed, they will use 0.75mg/kg (Max of 20mg), but as
many children are repeat patients, look at the anesthetic records for previous
doses used and titrate appropriately. (You need to write for this on the computer
or give a verbal order to the Preop RN, which you will then have to sign). For IVs,
it’s the same thing as the CSC (too young, they get an inhaled induction and then
an IV). Dr. Scavone will emphasize the importance of an IV for those you can
place PreOp. He will show you how he does it several times before allowing you
to do one. This is normal. All Attendings there have a lower threshold for taking
over IVs, but most will let you place them yourself early on.
2. IntraOp: The usual cases include Ortho (Especially Spine cases for scoliosis
patients), Burn (STSGs, room gets hot) and Urology. For Ortho cases, most times
you will do a peripheral nerve block under nerve stimulator/ US guidance. All are
done asleep. The attendings will walk you through it. You should learn the set up
for Nerve blocks because they have it all set up before the patient enters the
room. Nerve block equipment is the last drawer in cart, stimuplex needles come
in 1,2 or 4”. They use 0.25% bupivacaine or 0.5 % ropivicaine – a quick way to
calculate max dose for bupivacaine is to convert their wt in kg into ml, and for
ropivicaine is to do the same, and then divide by 2. EG: 20 kg kid can have a
maximum of 20ml of 0.25% ropiv or 10 ml of 0.5% ropiv. All Central lines are
done under US. They are very particular about the Anesth record, so stay on top
of it. Do NOT induce or extubate by yourself. You will do a lot of deep extubations
(ie. MAC >2‐3, suctioning (or OGT suction), oral airway, chin lift). Have someone
show you how to order ABGs via the EMR‐type in “BLOOD” and make sure to
order the co‐0x blood arterial order
3. PostOp: All orders are done on the computer. This includes the PostOp orders.
Record PACU vitals, give report, and complete the Post op Note (it is at the
bottom of the PreOp Form). Usually, you do three checkboxes (ie. No dental
damage, etc.). (Also make sure that you have signed the PreOp portion too). If
not, the chart comes back to you to sign. If you are dropping a patient off in the
88  89
29. Same Day Surgery/Regional
Ah! Vacation, or the closest thing to private practice you will ever see. SDS is located
near the Ellison bldg and has 4 Ors. You are almost always in room 3 or 4 with the ortho
cases. The goal is to get the resident out of their OR case to do blocks for the next case
and cases scheduled in the other ORs that also require blocks. The board‐runner will
help you with the blocks. Dr. Aldwinckle is the main anesthesiologist over there. He will
also send you an introduction email the week prior to your starting.
Cases: Ortho‐knees, shoulders, hand/CTRs, rarely eye.
Pyxis: You will have access to a Pyxis (which is also your anesthesia cart) that you will
use to take medications out for each patient under their name. This is a different Pyxis
name from the one you use in the main OR. You should try to obtain your pyxix access
by contacting Guy Neal through Vocera. He will give you your login and password. The
anesthesia tech over there also has instructions to help you with this. It is probably a
good idea for you to come a little earlier to get this straightened out. You will waste the
drugs in the Pyxis with a licensed individual such as an RN just like in the main OR.
Block Cart: This cart contains everything you need for the blocks. In the beginning of
the day, draw up the local anesthetic for the day (typically everyone uses 0.5% ropiv,
but Dr. Tautz may prefer 0.25% ropiv). You may have add ons as well. You may want to
set up block kits with sterile towels, lidocaine, ropivacaine, chloroprep, and the needles
(esp w/ Dr. Macres).
Daily: Show up at 6‐6:15 am to setup. Set up the block cart. The anesthesia tech or you
bring the ultrasound and block cart out to the preop area. It is expected that the patient
is in the room by 7:20 am. Mondays and Fridays are usually the busiest block days.
Days end around 2:00‐5:00 pm.
Major Blocks: interscalene, femoral, sciatic, popliteal. No catheters or rarely spinals. All
are usually ultrasound‐guided.
NOTE: No vacation is allowed on this rotation and if you must miss one day then let the
schedulers (chiefs) and the MOR board runner know so that you may have a
replacement! Very important! The Same Day Surgery is one of the few hospital
institutions to receive the highest rating among all institutions in the nation. This is Dr.
Moore’s pride and joy, so it is up to us to help maintain that reputation.
90  91
ICU, you need to talk to the ICU attending in charge for a signout (you will have to
page them sometimes) and write a post op anesthesia note on the preop form.
4. At the End of the Day: If you have extubated your last patient deep with an oral
airway, the attending or you cannot leave the hospital until it is out. You will be
responsible for filling out the Drug Sheet associated with your Drug Box. It is
done differently than our pink sheets so have someone show you how to do it.
Once that is done, you can take it to the Pharmacy. (Make sure to sign at the
bottom). Don’t forget to Pre Op your “In Patients” for the following day before
going home. You should plan on preoping all the inpatients and not just the
resident cases. If you are in a room late, you can work it out with your
co‐resident, if they are done early, to help out with pre‐ ops. Nonetheless, all
inpatients have to have their pre‐ops done, even if they are not YOUR patients.
For weekends see below
Call System:
Each resident is on home call every other day and weekends alternating. You can
decide how you want to split them. You will fill out Calendar with the resident call
schedule and give a copy to Dr Scavone’s secretary. During your call days/weekends,
you have to keep your pager on you 24/7. You will rarely get called in (I think they get
called in 5‐6 times per year). If you do get called in, they respect our residency hour
rules, so you will be off the following day if you get any night calls.
Pre-Op for Monday Cases (Weekend Responsibilities)
Pre Ops for Monday cases are done after 2pm by the call resident (that’s when patients
arrive for admission) on Sunday. You will have to do ALL of the Pre Ops for the patients
on the schedule (not just the cases you are doing). There are 4 Sundays for the Month,
so each of you will be responsible for 2 Sundays. A good way to do it is whatever
Friday you are on home call, you can also be responsible for the weekend call and
Sunday Pre Ops. That is only a suggestion, it is ultimately up to you. CALL 453‐2146
(staffing office) or 453‐2000 (main line and ask for patient’s floor) to see if the patient
has arrived because sometimes they come late. Also call the floor and talk to the
patient’s nurse and tell them to have the patient in the room when you come by. CHECK
the patient’s location on Friday to see if they are already in house‐if so, you can do your
preops in the late afternoon on Friday so that you don’t have to come in on Sunday.
Don’t worry about the first Monday’s PreOps. The residents prior to you should have
taken care of them. This also means that you should expect to do the preops for the
incoming residents on the last Sunday.
 
30. Difficult Airway Rotation
This rotation is in the Main Operating Room and is 2‐4 weeks MOR (with some weekend
call) divided into Basic and Advanced. The objective is to practice multiple airways
techniques with a dedicated attending.
There is also a textbook which is required: Management of the Difficult and Failed
Airway to read entirely throughout the rotation (you may check this book out from Dr.
Rivera). Get a primer with the anesthesia tech to learn the setup of the fiberoptic bronch
cart. And BE PROACTIVE when it comes to trying different techniques. You are the
one that can best ensure the depth of your experience.
Case types: Many of these cases are ENT types of cases. Medications to have on hand:
remifentanil, dexmedetomidine, dexamethasone
Other items to have handy: nebulized lidocaine (pre‐op), lubricants
Equipment/Techniques:
1. Fiberoptic cart with multiple size ET tubes, suction hooked up to the suction port,
lidocaine available to spray the vocal cords
2. McGrath laryngoscope
3. Glidescope
4. AirQ intubating LMA
5. Transtracheal blocks‐ (Need 4% lido)
6. Lightwand
7. Bougie
8. Jet ventilation
9. Surgical airway‐ via simulator, etc.
10. LMA
Note: Vacation is allowed on this rotation but you probably don’t want to miss any days!
You may be scheduled for weekend call.
Background (from Dr. Phat Giang’s senior project)
Elements of an Airway examination
 Mallampatti score
 Thyromental distance
 Neck range of motion
 Teeth protrusion
 Tongue size
 Jaw protrusion
 Hard palate arch
 Underpalate density
Four dimensions of a Difficult Airway
1. Difficult Bag‐Mask ventilation – MOANS
 
 a. Mask Seal – bushy beards, crusted blood, or disruption of lower facial
continuity
b. Obese – BMI > 26.
c. Aged ‐ >55, due to loss of muscle and tissue tone of upper airway
d. No teeth – face tends to cave in. Consider leaving dentures in place
e. Snores or Stiff – look for h/o OSA
2. Difficult laryngoscopy – LEMON
a. Look externally – look for small mandible, large mandible, buck teeth, high
arched palate, short neck, lower facial disruption
b. Evaluate 3‐3‐2 – assess adequacy of mouth opening (open one’s mouth
with three of one’s own finger breadths), length dimension of mandibular
space (thyromental distance greater than 3 finger breadths), and position
of larynx relative to base of tongue (2 finger breadths between tip of
mentum and mandible‐neck junction)
c. Mallampati Class – I‐IV
d. Obstruction – three cardinal signs are muffled voice, difficulty swallowing
secretions and stridor.
e. Neck Mobility – achieve “sniffing” position
3. Difficult Extraglottic device ‐ RODS
a. Restricted Mouth opening
b. Obstruction
c. Disrupted or distorted airway
d. Stiff lungs or cervical spine
4. Difficult Cricothyrotomy ‐ SHORT
a. Surgery/disrupted airway
b. Hematoma or infection
c. Obese/access problem
d. Radiation
e. Tumor
Airway techniques/Equipment
**Note: all suggested doses are for a standard 70 kg person. Adjust volumes according
to patient size
Eschmann Tracheal Tube Introducer (Bougie)‐ 60 cm long tube with a 35‐degree angle
bend. Useful when the glottic opening cannot be clearly seen using a laryngoscope.
The bougie can be directed anterior to the epiglottis and advanced into the trachea. May
railroad ETT over bougie.
Glidescope video laryngoscope‐ Modified plastic MAC blade attached to a LCD video
display. The Glidescope blade should be introduced into the mouth in the midline
position and maintained in the midline as it is rotated around the tongue. A special rigid,
preformed stylet should be used with the glidescope as this stylet mimics the shape of
the blade and will aid in ETT placement
McGrath laryngoscope‐ is a portable wireless laryngoscope with single use blades. The
flat screen monitor of the McGrath is mounted on the handle and displays a line‐of‐sight
92  93
d. Preparation for an oral intubation involves anesthetizing the tongue, soft
palate, tonsillar pillars, and pharynx. Although many methods are
available, the most commonly performed techniques at UCD are the
aerosolized atomized local anesthetic or the nebulizer (started for 15‐ the patient inhales. A total of 10 mL should be used.
30min in pre‐op) connected to a mouthpiece.
3. Open up the airway
a. If an oral intubation is planned, use a breakaway airway (found in the cart)
of appropriate length. If topical anesthesia is adequate, the patient’s
reflexes should be blunted and the patient will not gag. An alternative is to
have an assistant use a 4x4 gauze to grab hold of the tongue and pull
straight up towards the ceiling.
b. Suction the oral pharynx with a yankaur to clear secretions.
4. Line up the fiberoptic shaft
a. The goal is to keep the shaft of the bronchoscope as straight as possible.
Have the bed lowered all the way and stand on lifts if needed. Hold the
bronchoscope handle in your right hand with the thumb on the lever and
your index finger on the suction knob. With your left hand, stabilized the
lower portion of the shaft and insert the tip midline through the breakaway
airway (or nares with nasal intubations). As you hit the back of the mouth,
the epiglottis (or sometimes the glottis) should come into view. If you are
“lost,” try flexing the shaft tip. A jaw thrust maneuver may be helpful lifting
up the collapsed soft tissue. Once the epiglottis is in view, dive
underneath it to visualized the vocal cords.
5. Advance the shaft and tube
a. Advance the shaft pass the cords until you can see the carina. Avoid
contacting the carina as this is one of the most sensitive areas and may
induce coughing. Use your left hand or an assistant to advance the ETT to
an appropriate depth. If the ETT meets resistance, a 90 degree counter‐
clockwise rotation for oral intubations and clockwise for nasal intubations
will improve success.
Methods of Oral Topicalization
1. Aerosol Atomizer
Device can be found in the tech room and consists of a glass reservoir holding
the local anesthetic, a nozzle assembly, and standard oxygen tubing. 7 mL of 4%
lidocaine can be used. Connect the oxygen tubing to 8 L/min O2. Ask the patient
in inhale deeply as you spray the mouth, and posterior pharynx. This device can
also be used nasally.
2. Nebulized Lidocaine
7 mL of 4% lidocaine can be put into a standard nebulizer and connected to a
mouthpiece. Instruct the patient to take deep breaths through the mouth in order
to obtain proper localization of the deeper structures below the vocal cords and
into the trachea. Nasal localization can be achieved with a facemask and
instructing the patient to inhale deeply through the nose.
3. Trans‐Oral Drip
Have the patient gargle 5 mL of 2% lidocaine. Once the mouth is properly
94  95
view. Check the McGrath when you pick it up because it is not uncommon for the
batteries to run out right as you DL. Also make sure the connection between the blade
and the handle/camera has good contact. Sometimes you can use and alcohol wipe to
improve the signal transmission.
Air‐Q Intubating LMA‐ disposable hypercurved intubating laryngeal airway that resists
kinking and has a removable airway connector. A larger mask cavity allows blind
intubation using standard ETTs (sizes 5.5‐8.5 mm). LMA removal following intubation is
accomplished using the removal stylet. An alternative to the blind insertion is the use of
a fiberoptic scope through the Air‐Q LMA.
Lightwand‐ Consists of three parts: a reusable handle, a flexible wand, and a stiff,
retractable stylet. Relies on transillumination of the tissues of the anterior neck to
demonstrate the location of the tip of the ETT. The ETT/lightwand combination is
inserted blindly. If it enters the glottic opening, a well‐defined circumscribed glow can be
readily seen below the thyroid prominence. If in the esophagus, the glow is diffuse
and cannot be readily seen under ambient lighting condition. If in the vallecula, the light
glow is diffuse and slightly above the thyroid prominence. This is the reason this device
should not be used with room lights off.
Awake Fiberoptic Intubation
1. Setting up the fiberoptic scope
a. Ask an anesthesia tech to bring in a fiberoptic cart to the room
b. Ideally, the cart should be on the left side of patient, because the cables all
insert on the left side of the bronchoscope handle when held properly.
c. Check that the lights, camera, and suction actually all work.
d. Lubricate the fiberoptic shaft with a small amount of gel. Dap a bit of
defogging solution on the shaft tip
e. Slide an appropriate size ETT over the bronchoscope. Smear lubricant
over the cuff and distal end of the ETT.
f. Connect the suction tubing to the suction port.
g. If color is off, perform a white balance using clean 4x4 gauze.
h. Just prior to use, turn on the light source. This is often left off.
2. Preparing the Patient
a. Proper topical airway anesthesia is essential to a successful awake
fiberoptic intubation
b. Prior to any airway anesthesia, an antisialogogue should be used to
decrease secretions and increase the effectiveness of the local anesthetic.
0.2‐0.4 mg of glycopyrolate IV is a good choice.
c. Preparation for a nasal intubation involves use of a topical vasoconstrictor
to minimize risk of bleeding. At UCD, afrin spray (found in the pixis in both
the pre‐op area and the tech room) is used. The nasal muscosa is
anesthetized with lidocaine dripped in using a 20G IV catheter or sprayed
using an atomizer (2‐3 ml of Lido 2%). Now, progressively dilate both
nares with bigger nasal airways that have been well‐lubricated with
lidocaine jelly.
 
anesthetized and the gag reflex blunted, fill a syringe with 10 mL 2% lidocaine
connected to a 14 G angiocath. Using a 4x4 guaze or a tongue depressor to
move the tongue, slowly trickle 1‐2 mL of Lidocaine in the back of the throat while
4. Transtracheal Block
Attach a 22 G needle to a syringe containing 4 mL of 2% lidocaine (or 4%).
Identify the midpoint of the cricothyroid membrane just cephalad to the cricoid
cartilage. Direct the needle posteriorly, perpendicular to the floor. The needle is in
the trachea when a sudden loss of resistance is felt. The position of the needle is
confirmed by aspirating air through the syringe. Injection should occur at the start
of inspiration in order to induce coughing and spread the local anesthetic down
into the trachea and up towards the vocal cords. The upper airway will also need
to be anesthetized either using a glossopharyngeal block, local anesthetic gargle,
or another method outline above.
5. Fiberscope “Spray-As-You-Go” Technique
Once the oral mucosa has been properly anesthetized, the fiberoptic scope can
be inserted until the vocal cords are visualized. 4 mL of 4% lidocaine is injected
through the fiberoptic injection port during inspiration to induce cough and spread
of the local anesthetic.
6. Superior Laryngeal Block (external approach)
With the patient supine and the head extended, the skin of the neck is retracted
caudad over the thyroid cartilage. The hyoid bone (freely mobile bony structure
cephalad to the thyroid cartilage). A syringe containing 2‐3 mL lidocaine 2%
connected to a 22 gauge needle is used. The needle is inserted until it rests on
the lateral portion of the hyoid bone. It is then withdrawn slightly and walked off
the hyoid bone in a caudal direction. The needle is then advanced and passed
through the thyrohyoid membrane, which should be felt as a slight resistance.
The syringe is then aspirated, and the lidocaine is injected. The procedure should
be repeated on the opposite side.
Sedation/Adjuncts during an Awake Fiberoptic Intubation
The goal is to produce a calm and cooperative patient who remains responsive to
commands. A variety of drugs are available.
1. Midazolam ‐ 1‐6 mg, titrated to effect.
2. Remifentanil‐ If used in conjunction with topical anesthesia, a bolus dose of 0.75
mcg/kg followed by and infusion of 0.075 mcg/kg/min is a good starting dose.
3. Dexmedetomidine‐ Dose depends on whether it is used as a sole agent or in
conjunction with another method. If used in conjunction with good topical
anesthesia, a bolus of 1 mcg/kg over ten minutes followed by an infusion of 0.01
mcg/kg/min is an appropriate dose.
 
31. Liver Transplant
Although the program is currently inactive, this topic is a good one to review for boards.
That is why we kept the chapter in the Survival Guide. Read Jaffe 3rd edition pp.
547‐558 to see what you’re potentially in for. Some of the main concepts to keep in
mind: the three stages of liver transplantation, drug dosing with liver disease, PA
catheters, CO/SVR, mixed venous O2, TEGs, coagulopathies, fluid/blood product
resuscitation, etc.
Drugs
 Usual rescue drugs plus epi.
 RSI induction; o/w cisatracurium for muscle relaxation, 6+ vials.
 Fentanyl (plan on several grams) vs. sufentanil.
 Have insulin, dextrose, and sodium bicarbonate available. Generally heparin is
not used despite going on bypass.
 Most patients are encephalopathic, so +/‐ preop benzo’s.
 Consider preop metoclopramide/famotidine/Bicitra.
 Methylprednisolone 1 gram is typically given on arrival to the OR.
Drips ‐ Vary on a case‐by‐case basis, but at minimum:
 CaCl2 in 60ml syringe on a syringe pump, starting rate 1 gm/hr.
 Mannitol should be started after induction at 25‐35 mL/hr.
 Phenylephrine gtt (80 mcg/ml) should be loaded into the Baxter pump.
 THAM 500cc should be hung on a minidrip for possible piggyback infusion during
the anhepatic phase of the procedure, when metabolic acids are not metabolized
and pH can plummet.
 Some attendings use e‐aminocaproic acid routinely, others only if primary
fibrinolysis is diagnosed w/TEG.
Be prepared for rapid pressor administration when the graft liver is first perfused (epi,
Neo, norepi if needed).
Fluids/ Products
 Albumin 5% ‐ Order or pick up 6‐12 500 ml bottles from Pharmacy.
 Plasmalyte is crystalloid of choice; total crystalloid typically limited to 1‐2 liters.
 Have 10 units PRBC and 2‐4 FFP available in fridge and checked.
 Cryo and platelets will usually be needed. Don’t give platelets until AFTER veno‐
venous bypass is discontinued; most attendings give platelets slowly and do not
put them through the Belmont or Level One to avoid possible
damage/inactivation.
Lines
 Peripheral IV (1 or 2)
 Right radial A‐line on FloTrac and Vigileo monitor
 Two central lines:
96  97
32. Vacation/Leave and Sick Leave
The ABA limits time away from the program to 20 days. Other programs may allot 15
days of vacation and 5 days of sick leave. Our program has been kind enough to allow
us to use our sick days as vacation days. Most of the time, this translates to 4 weeks of
vacation since we usually also try to reserve the weekends before and after your week
of leave. However, this is not always guaranteed.
Unfortunately, this means that if you become sick (which never happens, right?
Residents are superhuman…) it will need to come out of your total annual ABA specified
20 days of time away. Should you become sick, please call, in order of priority: the
Board Runner (3‐6182 and/or their pager), Bobbi (4‐5169), and one of the chiefs.
Shooting Drs. Singh and Sandhu an e‐mail will also cover your bases.
Vacation and educational days are not allowed on: MICU, Pulm/Critical Care, OB,
Trauma, Chronic Pain, Shriners, Same Day Surgery, and Pre-op Clinic. For cardiac and
peds, if it is your first time on and you have 2 blocks back to back, you can take 1 week
out in your second month. If you are on Neuro, you can take time only if your ACGME
requirements have been met for neuro cases (typically 2 months).
Lastly, as you enter your CA-3 year and anticipate that you will need interview time for
fellowships or job searching, reserve aside a week of vacation and only request for 3
weeks.
98  99
o R IJ Mac introducer and Swan‐Ganz. Most liver failure patients will show
high CO/low SVR.
o R subclavian percutaneous introducer sheath. One Cordis will be attached
to the Belmont, the other to a Level One.
o Foley temp probe
NO LINES ON THE PATIENT’S LEFT SIDE, since veno‐venous bypass, if done,
will be left femoro‐axillary.
Induction
 WARM THE ROOM before induction and aggressively maintain normothermia.
Apply Bair Hugger(s) before/as your patient loses lash reflex. Remember,
platelets go on strike when they get cold and you definitely want some platelet
function on these cases.
 Plan on RSI or some modification thereof.
 Start giving FFP early if the patient is coagulopathic preop.
Labs
 These patients often have low sodium. This will normalize 2/2 albumin’s sodium
concentration and factor administration. Keep central pontine myelinolysis in
mind and check for it in the ICU next day.
 Send an ABG and TEG as soon as the A‐line is in.
 Surgical DIC panels will be sent as needed.
 You will typically aim for a HCT of about 33 throughout the case.
Record Keeping
 Practical suggestion—Make columns on a blank page for albumin, crystalloid,
PRBC, Cellsaver, FFP, cryo, and platelets. Use tally marks when something is
given and tally totals at the end.
 Document time results received with DIC panel results.
For more info, also refer to former resident Satsimran Thind’s liver transplant manual
(his senior project) located in the resident’s lounge.
 
33. Research
Dedicated research months (from 1‐6) can be arranged in the CA‐3 year by finding a
mentor, submitting a research proposal, and asking the Program Director. Plan ahead
for this! You need to demonstrate that:
 You have a study protocol that you will follow
 You have received IRB approval for anything that may require it
 Your ACGME required case numbers have been, or are very close, to being met
Of course you can always perform research at any time in concert with your clinical
education. If you’re interested, you can always discuss the topic with your mentor and
he/she can point you in the right direction. If you’re looking for topics, feel free to contact
any of the following attendings, who often have active projects that could use resident
involvement:
Clinical: Basic Science:
Dr. Fleming Dr. Liu
Dr. Klein
Dr. Rivera
Dr. Dhamrait
Dr. Ravula
 
34. ACGME Requirements
35. California State License and DEA number
Please note, these were made effective July 2008 (still current 9/2012) and may change
or differ depending on when you started. Check with the Program Director. California State License
 http://www.acgme.org/acWebsite/RRC_040/040_prIndex.asp Fortunately, GME will sponsor the payment for your California medical license. You
 www.acgme.org: Review Committees -> Anesthesiology -> Prog Requirements have a choice. Submit the application materials and payment yourself and then give the
receipt to the GME office so that they can reimburse you. OR you can submit the
Procedure/Rotation Required Numbers Notes application materials directly to the GME office and they will submit what you give them
OB 40, Vaginal 2 one-month rotations, must along with the payment to the medical board. Please respect the due dates in order to
20, C-section show involvement in high get full reimbursement.
risk cass
Pediatrics 100, < 12 yo 2 one-month rotations The process does require a number of steps which are outlined below. If you get lost, a
20 , < 3 yo great resource to help you is Marcia Pereira at the GME office in the basement of the
5, < 5 mo Pavilion (near the call rooms). Her contact information is 916‐734‐7797 and email is
Cardiothoracic 20, Cardiac surgery 2 one-month rotations, marcia.pereira@ucdmc.ucdavis.edu. Part I will get the application process going.
Vascular 20, Intrathoracic majority cardiac with CPB, Submit that part first and then work on Part II afterwards.
20, Major Vascular vascular access excluded
Neuro 20 intracerebral (incl. 2 one-month rotations, Note that you do have to renew every 2 years. When you renew as a CA‐3, the renewal
endovascular) majority must be open fee is NOT paid for by GME.
Epidural 40, Epidural used as If CSE, count as spinal as
Anesthesia/Analgesia anesthetic or for analgesia. well as epidural For U.S. ‐ M.D.:
Includes C-sections PART I Due: 7/31/13
Trauma/Burns 20, with complex, threatening Include patients with > 20%  Initial Application Fee $ 491.00
injury TBSA burns  Obtain Application, LiveScan Form & LiveScan Locations:
Spinal 40, including C-sections If CSE, count as spinal as http://www.medbd.ca.gov/applicant/additional_info.html
well as epidural  Complete L1A‐L1E
PNBs 40  If you need one, obtain picture from Medical Illustration in the Ticon III Bldg ‐ call
Pain 20 patients evaluated for At least 3 months in pain 4‐2133 take form to them for placement
acute, chronic, or cancer pain med; May include 1 month  Get L1E Notarized (GME does not have a notary)
each of: chronic pain,  Complete LiveScan
regional, and peri-op  ONLY Submit completed application (Forms L1A‐L1E, Livescan & Notary) to
Acute Post Op Pain Documented involvement in See above; not less than 1 GME (Education Building – Suite 4202).
acute post-op pain week at a time  Applications & UCDHS check for application fee ($491) will be sent to the
Pre-Op Total of 4 weeks Not < 1 week at a time Medical Board by the GME Office.
Airway Management Significant experience Incl FOB, lung isolation
PACU Total 0.5 month OK to carry code pager; not
< 1 week at a time PART II Due: 09/30/13
ICU 4 months; max 2 before CA- Critical care anesthesiologist  Reduced License Fee $ 416.50
1,Each rotation min 1 month involvement = 2 mos min.  L2 form is sent to medical school for completion. Also request official medical
Ancillary Sufficient experience school transcripts to be sent directly to the Board (address on form). Call first to
Misc Significant exp with CVP, PAC Excluding BIS see if there is a fee.
insertion + TEE, neuro  L3A and L3B are sent to your internship program. Make sure the program signs
monitoring, EEG; May do in the 2 boxes.
remaining CBY req. rotations  L4 to current program.
All residents should be ACLS  Once you know you passed USMLE Step III ‐ Request USMLE transcripts from
current the Federation of State Medical Boards ‐ https://secure.fsmb.org/trol/
100  101 
   

 Request 2 transcripts: 1 to medical board, 1 to yourself ‐ same cost
 Residents should have all documents to the Board by 09/30/13.
 The CA Medical Board will mail residents a letter/invoice requesting the final
$416.50 reduced license fee payment. It is the responsibility of the resident to
obtain and provide this letter/invoice to GME. GME will submit the license fee
directly to the Medical Board.
For D.Os:
PART I Due: 7/31/13
 Initial Application Fee $ 249.00
 Obtain Application, LiveScan Form: http://www.ombc.ca.gov/forms_pubs/
 Complete OMB1 (GME does not have a notary)
 Obtain picture from Medical Illustration in Ticon III Bldg ‐ call 4‐2133 and then
take form to them for placement
 Get last page Notarized
 Complete LiveScan
 Copy of Diploma
 D.O. applicants are required to have passed COMLEX – Step III.
 Applications & UCDHS check for application fee ($251) will be sent to the
Osteopathic Board by the GME Office .
PART II Due: 09/30/13
 Prorated License Fee $? (will be determined by OMB)
 Form OMB 2, Written Examination Verification & Cerfified Offical Osteopathic
CollegeTranscripts ‐ instruction:
http://www.ombc.ca.gov/forms_pubs/application_pkg.pdf
 The OBM requires all documents be submitted in order to issue residents a
letter/invoice requesting the final license fee. When you received the request to
pay the pro‐rated fee for your license, forward this document to GME and
payment will be processed on your behalf.The following is information on how
you can achieve some of the steps above.
USMLE exams and transcripts
1. Register for and take Step 3 immediately. This is going to take a long time given it
takes weeks to get your scheduling permit, and you need to find two consecutive
days that you are free to take it. I don't think the testing center is open on
Sundays either (though you should DEFINITELY check on that). Also, there is
only one testing center in all of Sacramento so that limits your options too.
2. If you've taken Step 3 and have your score, go to the fsmb.org website and go to
"Examination Services", then click on "Transcripts". Fill out the online USMLE
transcript request and list the California Medical Board as the recipient.
Important: don't request a transcript until you actually have a Step 3 score in
hand, or you'll have to send another one later to include Step 3. Cost is $50.
Medical School Documentation
1. Contact your medical school registrar and request an official transcript to be sent
directly to the Medical Board of California.
2. Send your school Form L2, which they should complete and send directly to the
Medical Board.
3. Request a CERTIFIED copy of your medical school diploma to be sent to the
Medical Board. This copy must bear some kind of school seal on it that tells the
Medical Board it is a certified copy. Your own Kinko's photocopy won't cut it. If
your school won't do that for you, you can also take your original diploma to the
Medical Board office to have it verified.
Internship Documentation
Send Forms L3A and L3B to your internship Program Director to sign and notarize
saying you satisfactorily completed intern year. He/She must sign in two spots on L3B,
otherwise it will be returned. He/She should send the forms directly to the Medical
Board.
Anesthesia Documentation
Give Form L4 to Joyce Groen or Bobbi Pane to have Dr. Moore sign and notarize saying
you are currently in an accredited training program. This must be done because the
GME will only reimburse you a reduced licensing fee, which applies to all applicants who
are currently enrolled in a residency. If you don't get that form signed, your application
fees will be much higher, and GME won't reimburse you all of that. The forms should
end up back in your mailbox in a week or two.
Deadlines
There is a strict September 31 deadline to do all of the steps above, and handing in
these forms after that deadline will forfeit your reimbursement. This means you don't
have to fork over any money on your own, but it also means you have to make sure form
L4 is signed by Dr. Moore. Also, the Board will notify you if items are missing. Don’t
argue with them, just resubmit.
DEA Number Procurement
Note: You can only do this if you already have an actual California Medical License.
1. Checking to see if you have a license number (assuming you haven’t gotten the
card yet)
a. Go to http://www.medbd.ca.gov/Lookup.htm
b. At bottom of page, click "Continue Search"
c. Type in your name, click "Find"
d. If everything's gone through, you should see a number next to your
name‐‐you're licensed!
2. Applying for your DEA number
a. www.deadiversion.usdoj.gov/drugreg/reg_apps/onlineforms_new.htm
b. Click on “New applicant”, "DEA‐224" (this is the application for
practitioners) then “Begin Application Process”, “Business
category/Activity” is practioner

102  103 
   
 c. As you're filling out the form, you'll get to a part where it asks if you qualify
for exemption‐‐you DO!
d. Check the box‐‐this waives the $551 fee you'd otherwise have to pay.
e. On the next page, put down UC Davis Med Center as the institution, and
Dr. Moore as your Certifying Official.
f. Next, you'll get to the page that asks for your license number. Type it in.
g. Where it asks for a state controlled substance license number, check “N/A”
h. It will ask you which schedules you want to qualify for.
i. You will have to fill out everyplace with a ***
j. The application should take 4‐6 weeks to process, assuming everything
goes well.
104  105
 Extra Tegaderms, trauma scissors, tape and your own stethoscope.
 Food you like in case your stomach doesn’t agree with the local fare.
Granola/power bars, instant oatmeal/cereal, and instant coffee are good choices.
(Note: some countries, like China, don’t have coffee!)
 Camera to capture the sweetest moments!
 Toys and stickers for kids are optional. The PACU nurses will have toys to
distract kids but it is helpful to have your own.
 Gifts for the visiting country’s OR personnel are not required but greatly
appreciated. I would recommend bringing a small token, like printed scrub hats
for the nurses
The Rotaplast team will bring laryngoscopes, endotracheal tubes, medications,
monitors, vaporizers with sevoflurane, syringes, needles, and IV start kits. The Rotaplast
team will contract with the hosting hospital in order to obtain IV fluids and narcotics.
Your team and your schedule:
There are about 25‐30 people on the team, both medical and non‐medical volunteers.
The medical team consists of pediatricians, anesthesiologists, surgeons, circulating
nurses, PACU nurses, and an equipment person who runs the sterilizer and works with
all things electrical. There is a mission director who is in charge of the whole mission, as
well as a medical director (usually a surgeon) who directs the cases to be done. The
non‐medical volunteers are Rotarians who pay their own way and raise money to fund
the trip. They are a great resource. One of them is the Quartermaster, who will help you
with currency exchanges and anything else you might need done while you’re stuck in
the operating room. Another non‐medical volunteer will be in charge of keeping the
medical records: one for the hosting hospital and another for Rotaplast.
You will be scheduled into the pre‐op clinic, OR, and post‐op clinic. Pre‐op clinic is 1‐2
days. This will be your chance to evaluate the patient’s airway and see if there are any
potential risks to providing anesthesia. Once you have a list of appropriate cases, the
head nurse and medical director will create a schedule. Operative days vary between 4‐
8 days. You will spend your last 1‐2 days in the post‐op clinic. Anesthesiologists are
generally not required to be at post‐op clinic but it is a good opportunity to see the
results of your good work.
Preparing for the trip:
 Review some pediatric anesthesia before going.
 Review local anesthetic toxicity doses and circuits (you may need to create one).
Basic anesthetic plan:
 No pre‐op PO versed. Bring child back to the OR for mask induction.
 Start an IV. Deepen patient with the inhaled anesthetic. Intubate. This is usually
done without a muscle relaxant, but it is available if you need it.
 Consider giving an optional bolus of dexmedetomidine 0.5 mg/kg up front to
“smooth out” the anesthetic. Titrate in narcotics (usually short‐acting fentanyl) as
needed. Give antibiotics, steroids, and an anti‐emetic (usually Zofran).
106  107
36. Rotaplast
Expect the unexpected, and be flexible!
Rotaplast is an offshoot organization from the Rotary Club, a non‐profit volunteer group
committed to providing free reconstructive surgery for cleft lip/palate and burns to
children and (occasionally) adults in developing countries.
Dr. Fleming sends an e‐mail each year regarding open positions on teams going to
different locations. The e‐mail will specify the country and dates. NOTE: You will have to
use two weeks of your vacation to go to these trips. Unfortunately, there is no
negotiation on this point due to ABA regulations. (See section 32 on Vacation/Leave.) If
you are interested, contact Dr. Fleming or look on www.rotaplast.org to find out about
possible trips. Contact him as early as possible once you figure out when and where you
would like to go as the highly desired locations fill quickly. If he finds you an open spot,
proceed to the application form. Keep in mind that your trip may be canceled or
rescheduled in the event of political turmoil or epidemics, such as swine flu.
Once you have been accepted, you will need to provide several documents:
 Medical volunteer application found on the website.
 A letter of endorsement from Dr. Fleming.
 Your passport. You might possibly need to send your original passport, which is a
little nerve‐racking but it will eventually be returned.
 Proof of vaccinations like Hep B and others…check with Employee Health to see if
you have them already. Additional vaccines may be needed depending on the
country you are visiting. Optional but recommended: make an appointment with
the UC Davis Travel Clinic. (You will need a referral from your PCP, which may
take approximately 2 weeks so plan appropriately.) Get a prescription for
Ciprofloxacin!
What you need to take:
 Khaki pants/skirt, a white shirt and a blue blazer to wear on the day of your
journey. Borrow if you don’t want to buy one, or go to a thrift store
 3‐4 sets of scrubs and one nice outfit for the goodbye/thank you dinner.
(Otherwise, travel light.)
 Pocket money, and to contribute to tips, etc. Your transportation, housing and
most of your food will be paid for by the Rotary Club/Rotaplast International. Most
countries have ATMs that allow you to withdraw directly from your account in that
specific country’s currency. These have heavy fees, so beware.
 Your resident handbook or peds cards for a helpful reference.
 Laptops and international cell phones are optional. Some cell phone companies
will activate an international rate for you if you call them in advance. Some hotels
have wireless connection, although this is not always guaranteed.
 A fanny pack. As unfashionable as it might seem, it is helpful for tucking all your
supplies in.
 Waterless hand sanitizer gels, cold medicine (you will need it!), ciprofloxacin.
 
 Decide ahead of time whether to extubate deep or awake. (Your goal is to avoid
coughing and undoing the sutures).
 Suction, suction, suction. Expect a lot of bleeding in the oropharynx, especially if
the case is a cleft palate repair.
 Extubate with the patient on their side.
 Be vigilant about obstruction, stridor and wheezing as you transport the child to
the PACU.
 Endotracheal tubes and oral RAE are reused after being cleaned with bleach. Do
not be surprised by this.
Rewards of trip:
 The kids are absolutely adorable, and the families are extremely grateful.
 You get at least one day of sight‐seeing in a different country.
 You get to know other like‐minded, altruistic volunteers. There will be a hospitality
suite where the team can relax with beverages and snacks at the end of each
gratifying day.
 And, finally, to paraphrase Dr. Divakar Joshi, Class of 2009: You feed your soul.
 
37. ACLS Renewal
All residents need to have current ACLS certification. This certification expires every
TWO years. The department is pretty good at monitoring this and they will USUALLY
set up your ACLS certification for you. There is a Saturday course that is offered every 6
months and if you are due, you will be notified and signed up for the course. Keeping on
top of your own ACLS status is not a bad idea either as the renewal course is only half a
day. But if you do let your certification expire for more than one month, you will have to
complete the full day course. Jennifer Meyer at the Center for Virtual Care (Sim Suite) at
734‐4708 is also a good resource if you have other questions.
38. Miscellaneous
Needlestick or Blood/Body Fluid Exposure
Report exposures as soon as possible after the incident. You can find the application to
do this by going to any generic UC Davis computer (in the PACU, ORs, SICU, or the
floor). Go to the desktop and find the “EE” icon. It stands for Employee Exposure. It will
open up a window that will allow you to create a profile and log in. Once you’ve done
this, fill out the form.
The charge nurse for patient’s location (PACU, ICU, etc.) can help make sure the lab
slips print out and patient’s blood gets drawn (blue top and yellow top tube).

Incident Reporting
Report incidents that “may potentially or actually result in injury, harm, or loss to any
patient, visitor, student, volunteer, or employee..”
 From UCD Intranet Home Page, go to On‐The‐Job Resources > Clinical
>Incident Reporting System
 Create profile/log in and fill out form.
 Alternatively, one can also reach the same incident report site by typing either
“IR” or “incident” in the the url tab of any computer connected to the UCDMC
intranet

108  109 
   

39. ASA Physical Status Classifications & Algorithms

ASA PS Preoperative Coments, Examples
Category Health Status
ASA PS 1 Normal healthy No organic, physiologic, or psychiatric disturbance;
patient excludes the very young and very old; healthy with
good exercise tolerance
ASA PS 2 Patients with mild No functional limitations; has a well‐controlled
systemic disease disease of one body system; controlled
hypertension or diabetes without systemic effects,
cigarette smoking without chronic obstructive
pulmonary disease (COPD); mild obesity,
pregnancy
ASA PS 3 Patients with Some functional limitation; has a controlled disease
severe systemic of more than one body system or one major system;
disease no immediate danger of death; controlled
congestive heart failure (CHF), stable angina, old
heart attack, poorly controlled hypertension,
morbid obesity (BMI > 35), chronic renal failure;
bronchospastic
disease with intermittent symptoms
ASA PS 4 Patients with Has at least one severe disease that is poorly
severe systemic controlled or at end stage; possible risk of death;
disease that is a unstable angina, symptomatic COPD, symptomatic
constant threat to CHF, hepatorenal failure
life
ASA PS 5 Moribund patients Not expected to survive > 24 hours without surgery;
who are not imminent risk of death; multiorgan failure, sepsis
expected to syndrome with hemodynamic instability,
survive without hypothermia, poorly controlled
the operation Coagulopathy
ASA PS 6 A declared brain‐dead patient whose organs are being removed for
donor purposes

110  111 
   
Laryngospasm Algorithm Malignant Hyperthermia (Adapted from MHAUS guideline, May 2008, www.mhaus.org)
Hampton-Evans et al. Pediatric Laryngospasm. Pediatric Anesthesia: 18,303-07 MH Hotline: (800) 644-9797 Outside the US: (315) 464-7079
MHAUS Phone: 1-800-986-4287 (607-674-7901)
PO Box 1069 (11 East State Street) Fax: 607-674-7910
Sherburne, NY 13460-1069 Email info@mhaus.org

Diagnosis vs. Associated Problems

Signs of MH:
 Increasing ETCO2
 Trunk or total body rigidity
 Masseter spasm or trismus
 Tachycardia/tachypnea
 Mixed Respiratory and
Metabolic Acidosis
 Increased temperature (may
be late sign)
 Myoglobinuria
Sudden/Unexpected Cardiac
Arrest in Young Patients:
 Presume hyperkalemia and
initiate treatment (see #6)
 Measure CK, myoglobin,
ABGs, until normalized
 Consider dantrolene
 Usually secondary to occult
myopathy (e.g., muscular
dystrophy)
 Resuscitation may be difficult
and prolonged
Trismus or Masseter Spasm with Succinylcholine
 Early sign of MH in many patients
 If limb muscle rigidity, begin treatment with dantrolene
 For emergent procedures, continue with non-triggering
agents, evaluate and monitor the patient, and consider
dantrolene treatment
 Follow CK and urine myoglobin for 36 hours.
 Check CK immediately and at 6 hour intervals until
returning to normal. Observe for dark or cola colored urine.
If present, liberalize fluid intake and test for myoglobin
 Observe in PACU or ICU for at least 12 hours

Acute Phase Treatment

1. GET HELP. GET DANTROLENE –
Notify Surgeon
 Discontinue volatile agents and
succinylcholine.
 Hyperventilate with 100% oxygen at
flows of 10 L/min. or more.
 Halt the procedure as soon as possible;
if emergent, continue with non-triggering
anesthetic technique.
 Don’t waste time changing the circle
system and CO2 absorbant.
2. Dantrolene 2.5 mg/kg rapidly IV
through large-bore IV, if possible
To convert kg to lbs for amount of
dantrolene, give patients 1 mg/lb (2.5
mg/kg approximates 1 mg/lb).
 Dissolve the 20 mg in each vial with at
least 60 ml sterile, preservative-free
water for injection. Prewarming (not to
exceed 39º C.) the sterile water may
expidite solublization of dantrolene.
However, to date, there is no evidence
that such warming improves clinical
outcome.
 Repeat until signs of MH are reversed.
 Sometimes more than 10 mg/kg (up to
30 mg/kg) is necessary
 Each 20 mg bottle has 3 gm mannitol for
isotonicity. The pH of the solution is 9.
3. Bicarbonate for metabolic acidosis
 1-2 mEq/kg if blood gas values are not
yet available.
4. Cool the patient with core temperature
>39ºC, Lavage open body cavities,
stomach, bladder, or rectum. Apply ice to
surface. Infuse cold saline intravenously.
Stop cooling if temp. <38ºC and falling to
prevent drift < 36ºC.
5. Dysrhythmias usually respond to
treatment of acidosis and hyperkalemia.
 Use standard drug therapy except
calcium channel blockers, which may
cause hyperkalemia or cardiac arrest in
the presence of dantrolene.
6. Hyperkalemia – Treat with
hyperventilation, bicarbonate,
glucose/insulin, calcium.
 Bicarbonate 1-2 mEq/kg IV.
 For pediatric, 0.1 units insulin/kg and 1
ml/kg 50% glucose or for adult, 10 units
regular insulin IV and 50 ml 50%
glucose.
 Calcium chloride 10 mg/kg or calcium
gluconate10-50 mg/kg for life-
threatening hyperkalemia.
 Check glucose levels hourly.
7. Follow ETCO2, electrolytes, blood
gases, CK, core temperature, urine output
and color, coagulation studies. If CK
and/or K+ rise more than transiently or
urine output falls to less than 0.5 ml/kg/hr,
induce diuresis to >1 ml/kg/hr and give
bicarbonate to alkalanize urine to prevent
myoglobinuria-induced renal failure. (See
D below)
 Venous blood gas (e.g., femoral vein)
values may document hypermetabolism
better than arterial values.
 Central venous or PA monitoring as
needed and record minute ventilation.
 Place Foley catheter and monitor urine
output.

Post Acute Phase

A. Observe the patient in an ICU for at least 24
hours, due to the risk of recrudescence.
B. Dantrolene 1 mg/kg q 4-6 hours or 0.25
mg/kg/hr by infusion for at least 24 hours. Further
doses may be indicated.
C. Follow vitals and labs as above (see #7)
• Frequent ABG as per clinical signs
• CK every 8-12 hours; less often as the values
trend downward
D Follow urine myoglobin and institute therapy to prevent myoglobin
precipitation in renal tubules and the subsequent development of Acute Renal
Failure. CK levels above 10,000 IU/L is a presumptive sign of rhabdomyolysis
and myoglobinuria. Follow standard intensive care therapy for acute
rhabdomyolysis and myoglobinuria (urine output >2 ml/kg/hr by hydration and
diuretics along with alkalinization of urine with Na-bicarbonate infusion with
careful attention to both urine and serum pH values).
E Counsel the patient and family regarding MH and further precautions; refer
them to MHAUS. Fill out and send in the Adverse Metabolic Reaction to
Anesthesia (AMRA) form (www.mhreg.org) and send a letter to the patient and
her/his physician. Refer patient to the nearest Biopsy Center for follow-up.

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ASRA Checklist for Treatment of Local Anesthetic Systemic Toxicity

40. Notes
http://www.asra.com/checklist-for-local-anesthetic-toxicity-treatment-1-18-12.pdf

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 Amrik Singh, M.D., Resident Program Director
Charandip Sandhu, M.D., Assistant Program Director
Roberta Pane, Education Manager
Devon Burnett, Residency Coordinator
Peter G. Moore, M.D., Ph.D., Professor and Chair

UC Davis Department of Anesthesiology & Pain Medicine

4150 V Street, Suite 1200 PSSB
Sacramento, CA 95817
T 916-734-5028 F 916-734-7980