what's up everybody my name is max feinstein and i'm an anesthesia resident at the mount sinai
hospital in new york city in this video i'm going to be showing you how a pediatric anesthesiologist
sets up an operating room to prepare for surgery if you find this video interesting and helpful
i'd really appreciate it if you liked it and subscribe to the channel let's dive in
fundamentally speaking the basic setup for pediatric anesthesia is the same as for
adult anesthesia in the sense that we use the same mnemonic to help us remember all of the
different components of the setup specifically that's MS-MAIDS which stands for machine
suction monitor airway IVdrugs and S for special which is just a designation that we use for
any special pieces of equipment that we need for that case the equipment used in pediatric
anesthesia however is quite different from that of adult surgery so there's actually a separate
cart full of equipment that we use at our hospital which is where i'm going to be getting all of the
equipment from today and as i go through this video i'll show you a side-by-side comparison
because the size difference between the adult and pediatric equipment is quite striking
the first component of my machine check is actually going around to the back of the machine
opening up the back up oxygen tank and making sure that there's an adequate amount of oxygen
in the event that there's a catastrophic failure of the oxygen supply from the main hospital system
and then i come around to the front of the machine check to make sure that the volume is adequate
and then make sure i go around back and close the oxygen tank because
if it's left open it could leak and then if i really needed it there wouldn't be any oxygen left
next i make sure that i have my appropriately sized circuit
tubing which for pediatric cases there are actually a range of different tubing sizes
and for this case i'm going to be using the second smallest tubing that we
have available but there's one that's even smaller that's made for neonates
next up i'm going to do a machine check, and i always do this for all my adult cases but it's
especially important for pediatrics cases where you're changing the equipment that you're using
because when you do a machine check it takes into consideration how much volume is in the
circuit that you just put on and so you need to have an accurate assessment of that volume
when you're doing any kind of case and especially a pediatrics case
so i'll go ahead and do a full machine check here
the last part of my machine setup is going and dialing in the patient's age to my ventilator
and making sure that i've got the ventilator set to the mode that i'd like
when i get the case started which in this case is going to be pressure
control ventilation which is very commonly used for pediatrics cases
the S in the mnemonic stands for suction and so in this case i'm picking out
one of our smallest suction catheters that we have and you can see by comparison
it's significantly smaller than the suction used for adult cases
the second M in the mnemonic stands for monitors and in this case there's quite
a bit of changing around that i need to do from my adult setup
i'll start by changing out the EKG cable because instead of using a five lead EKG
for an adult i'm going to be using a 3 lead EKG with the infant EKG lead setup
next up is a pulse oximeter and we have a lot of different sizes available for pediatrics cases
and the one i'm going to use here is one of the smallest sizes that we have
next up is a blood pressure cuff and we actually have even smaller blood pressure
cuffs than the one that i'm using for this particular setup but i think this should
be appropriate if not for the patient's arm then probably for the patient's leg
i'm also going to have a thermometer ready to go and in this case i'm using
an esophageal temperature probe which is going to go down the patient's esophagus
the last component of my monitor setup is making sure that i've got my cable connected to capture
in tidal capnography which refers to getting a sense of how much CO2 the patient is breathing off
the A in the mnemonic stands for airway and so i'll start by making sure i've got
several different endotracheal tubes that i think will work for this patient
but since i'm not exactly sure what the best size is going to be i want
to make sure i've got a backup option that's a different size
i'm going to go ahead and put what's called a stylet inside the endotracheal tube
that gives it a little bit of rigidity so as i'm intubating the patient i can
navigate the tube through the vocal cords and then once it's where it needs to be
i'll go ahead and remove the stylet i also want to make sure to test the cuff on the endotracheal
tube to make sure that it doesn't have any punctures and will stay inflated when i need it to
next i'm going to have several different intubating blades and you'll notice that these
are both straight blades which are also called Miller blades which are used most commonly in
pediatrics cases particularly with very young children and i want to make sure that i've got
several sizes available just in case the first time i go to take a look it's not the right size
blade and i need to get something else i want to have it right on hand next to me ready to go
other components of my airway setup include several oral airways in case i'm having
difficulty ventilating the patient with a mask and i need to prop open their airway a little more
and i also want to make sure i've got eye tape available so i can protect their eyes
from corneal abrasions. make sure that i've got tube tape available so that i can tape
my tube down and so that won't go anywhere and additionally i want to make sure that i've got
several different options for masks that i can fit over the patient's nose and mouth
and lastly i want to make sure that i've got a heat and moisture exchanger which
is a device that helps keep heat inside of the breathing circuit because that can actually be
a big source of loss of heat which is very important for me to keep track of during surgery
as with my adult cases i want to make sure that i've got working
self-inflating resuscitation bags and for pediatrics it's important to make sure you
have a couple different sizes available depending on what the patient size is
the "i" in the mnemonic stands for IV
and as you'll see the 24 gauge IV that we typically use for pediatric cases is
significantly smaller than say an 18 gauge IV that's commonly used in adult anesthesia
perhaps the most important part of setting up for a pediatric anesthesia case is making sure
that there's absolutely no air that's inside of the IV tubing. the reason for that is that some
kids can have undiagnosed septal wall defects meaning a hole in their heart that goes from
one side to the other and if an air bubble were to get introduced into that hole and go across to the
other side of the heart it may end up going to the brain and causing a stroke that's called a
paradoxical embolism and it's incredibly important that we de-air our IVs to avoid paradoxical emboli
the D in the mnemonic stands for drugs and this is probably the other most important
part of the setup here is making sure that i've got the appropriate emergency drugs available
for resuscitation if there's a problem like anaphylaxis or laryngospasm specifically there
are two drugs that i always have drawn up ready to go on intramuscular syringes just in case i don't
have IV access. those drugs are succinylcholine and atropine and it's important to make sure that
the dose that i have drawn up is the dose that is specific to the patient who i'm taking care of
because in the event that there's an emergency there is no time to calculate
weight-based dosing and i need to have my drugs available and ready to go within arm's reach
the last part of my drug setup is topping off my volatile gas cartridge and pediatric patients
can go through a lot of volatile gas so it's important to make sure that this is ready to go
the S in the mnemonic stands for special and there are two very special things that i do
in all pediatric cases. one is going over to my thermostat and turning it up. operating
rooms are typically quite cold but for pediatrics cases because the kids can
become very cold quickly it's important to make sure that the entire room is warm
the other part of my setup is making sure that i've got an age appropriate hat on!
i should mention that pediatric anesthesiology is a board certified subspecialty within
anesthesiology which requires an additional year of fellowship training after completing residency
and i should mention that i myself am very interested in pursuing pediatric anesthesiology
so if you're a program director and you'd like to have me at your program please send me an email!
well that wraps up this video i hope you found it interesting and if you have any feedback i'd
love to read it in the comments below thanks very much for watching i'll see you next time