Pediatric Gastroenterology (Presby Tower)

Authors: Joseph Sisk MD, Tracye Carter, CRNA

Surgeons: Altaf, Grunow, Marshall, Palle, Shaukat, Steele, Talathi, Tung

ORs: Procedure Room #3

Last Update: 5.21.21

Workroom:

• is a physician's workroom and a break room across from the GI suite.

  • • The code for the doors is 9876#

Restroom:

• There is a restroom across from the GI suite.

Pre-Op:

• Check-In

  • • Pre-OP, patients will be brought back to a bay and checked in by a Peds Nurse. They will obtain an HCG at this time, if indicated.

• COVID tests

  • • If done at OSH, are in the patient folder at the nursing desk in pre-op.

• Premedication

  • • Pre-op oral versed is available if ordered. The pre-op nursing is able to administer this.

• IV Access

  • • Nurses may place pre-op PIVs, but I found myself offering nitrous oxide to those that needed awake IVs.

• Glucometer

  • • PNCU has a glucometer that may be used if needed

• Centricity EMR

  • • Centricity Pre-Ops will be skeletonized by our PAs but require completion by the attending.

    • At present, the only computer with Centricity on it is in the PNCU or Procedure room. They are working to get it installed in the Pre-Op/PACU area.

    • Centricity currently defaults to PNPTCLP006 which is in the back of PNCU.

      • • • This should be updated to print on the printer in pre-op/PACU (PNPTCLP005) soon.

Setup:

• Gas Supply

  • • There is a pipeline O2 supply.

    • Both Nitrous Oxide and Air supply comes from tanks on the back of the machine.

      • • • These must be turned on and off each day.

• Monitor and Ventilator Defaults

  • • Most of the monitors and anesthesia machines currently default to adult settings.

      • • • This means the secondary gas is air and the default vent setting is a TV of 500ml.

Intra-Op:

• The procedure room setup has the same supplies as the GI Suite at OCH.

• Locating the case in Centricity

  • • For vitals to transmit, assign the case to:

      • • • Unit: EOR

          • Room E.ORGI3

Post-Op:

• Extubation:

  • • Awake v Deep

      • • • Deep extubations can be done if indicated.

          • It is recommended that the attending anesthesiologist remain with the patient in PACU while the CRNA turns over over the room.

          • Do not roll back to the procedure room with the next patient until the previous emerges from Anesthesia and no longer has their oral airway in place.

          • Consider having both providers carry an emergency drug bag on them.

• The patients are recovered by Peds nurses who are familiar with deep extubations

• The Pre-Op and PACU bays are tight spaces.

  • • Consider ordering IV fluids to be TKO or saline locked so the nurses do not need to use a pump.

• Consider ordering acetaminophen for PACU as these patients will not receive Tylenol premedication.

Turnovers:

• Anesthesia Techs:

  • • Our pediatric anesthesia techs have done a super job ensuring we have adequate supplies

    • It is helpful to have the circulator call the Presby anesthesia techs when they call report to PACU.

      • • The adult techs did their best to arrive in a timely fashion but most of the turnover will fall on the CRNA.

        • The time it takes the attending to recover the child in PACU provides the extra time to get this done.

        • Because the adult techs are not made privy to the patient information on the tracker, they are unfamiliar with the age of the patient, the appropriate sized equipment.

        • Consider having the techs work to sanitize the anesthesia station and empty the trash while you perform a patient-appropriate set-up yourself.

        • For the older patients that require an adult circuit, the techs have pre-made packs filled with:

1. A Circuit

2. Suction

3. Blue towels

4. Maks

5. Tongue depressor

6. Oxygen facemasks for transport

7. BP cuff, pulse ox, electrodes

8. Trash bag

9. Some miscellaneous items

· These packets are located outside the GI suite and have proved to be quite helpful. You will still have to set out your own airway equipment and pediatric monitors.

• Please deposit used blades in the designated biohazard labeled bin.

o The GI nurses will return them to the peds side for sterile processing.

Medications:

• The procedure room Pyxis has our standard peds medications including precedex

• There is a central pyxis in PNCU which contains dilute epinephrine

Equipment availability:

• Code Cart

  • • The Peds-to-Adult Code cart is in Pre-Op/PACU

• PACU Airway Cart

  • • There is a pediatric basic airway cart in Pre-Op/PACU

      • • • This contains Mapleson Circuits, OPAs, LMAs, etc.

• Mapleson Circuits

  • • These are located in the Pre-Op/PACU Airway Cart

    • Individual PACU bays also have Mapleson circuits at bedside

• Malignant Hyperthermia Cart

  • • The MH Cart is in PNCU

• Video Laryngoscope/Ultrasound

  • • Presby Anesthesia techs can quickly bring us an ultrasound or video laryngoscope if requested

    • There is a Glidescope on this floor which is shared with Cath Lab

• Communication

  • • Cell service in the Peds GI area appears adequate

• Replacement Nitrous Oxide/Air cylinders

  • • The Techs told can quickly provide new Nitrous Oxide and Air cylinders if called.

Emergency Assistance:

• There are adult Anesthesia providers working in the Adult GI section of the PNCU

• Important Phone Numbers

  • • • OUMC Airway Phone

        • • (405) 417-0094

      • Presby Boardrunner

        • • (405) 271-0721

      • Presby 24hr Anesth tech hotline

        • • (405) 248-7160

      • Anesthesia Tech on Duty

        • • (405) 209-7701

Workflow:

• Overall, the workflow is similar to MRI

• The Anesthesia Attending should review the charts prior to the start of the day.

  • • Update all COVID tests.

• Nursing will room the patients and check them in.

• Assess for pre-medication need early.

  • • Tell nurse if it is ordered.

• Identify IV plan ASAP.

• Induce as you would in GI

• Consider seeing the next patient as the case proceeds.

  • • If not, it can be done after the case.

• Extubate as you would in GI.

  • • If deep, the attending should stay with the patient until the Oral Airway is out while the CRNA turns over the room.

• Roll back with the next patient only after Oral Airway is out.

Work in Progress:

• Centricity needs to be installed on computers in Pre-Op/PACU. Ideally on the nursing computer and a COW.

• Procedure Room #3 needs a narcotics waste receptacle

• The Anesthesia Machine Vent and Monitors need to be configured to Pediatric Settings as default

• Pre-OP/PACU vitals monitors should be configured to Pediatric Settings as default