Neuromuscular Scoliosis Spinal Fusion — Anesthesia Team Preoperative Preparation — Clinical Pathway

Neuromuscular Scoliosis Spinal Fusion Clinical Pathway — ICU, Inpatient, Outpatient Specialty Care

Anesthesia Team Preoperative Preparation

Anesthesia team should review the patient’s medical history on the day before admission, formulate a plan and order appropriate equipment using a level II form in the preoperative navigator and medications using the Anesthesia PHL General Requisitions Order Set.

Room Preparation

Utilize Preoperative Navigator Level II Forms
  • LR macrodrips x 2
  • Microdrip/buretrol as infusion carrier with 4 stopcocks at distal end of IV near the T-piece connection
  • Hotline
  • A-line, central line set-up (double transducer) — if planning on central line
  • 2-D Ultrasound for arterial line and vascular access
  • Vascular access tray:
    • Radial arterial catheter kit:
      • Children 10-30 kg: 2.5 Fr x 5 cm
      • Children and adolescents > 30 kg: 3 Fr x 5 cm
    • Central line sizing:
      • Children 10-40 kg: 5.0 Fr 8-12 cm
      • Children and adolescents > 40 kg: 5-7 Fr 12-15 cm
    • Note: Large, flat arm boards available for arterial line placement are located outside OR 11 by the ice machine in the central hallway.
  • 5 infusion pumps
  • Point-of-care-testing:
    • I-stat and HemoCue®
    • Consider sending confirmatory blood gas to laboratory for lactate level
  • Prone pillow (blue pillow or headrest with mirror, per attending preference)
  • Bair Hugger™ (lower body, upper body and under-table)

IV Bolus Medications

Utilize Anesthesia PHL General Requisitions Order Set
  • Acetaminophen:
    • 15 mg/kg, max 1000 mg
  • Tranexamic Acid:
    • 30 mg/kg over 10 min, max 2000 mg
  • Methadone:
    • Dispensed as a 10 mg/ml syringe

Infusions

Utilize Anesthesia PHL General Requisitions Order Set
Hypnotic/Analgesic Agents
  • Propofol:
    • 100-250 mcg/kg/min
    • See Epic dosing guide, pictured below

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  • Remifentanil:
    • 0.1-0.2 mcg/kg/min
    • Determine concentration using infusion ordering guide, pictured below

    • © 2024 Epic Systems Corporation
  • or
  • Fentanyl:
  • Ketamine:
    • 0.1-0.2 mg/kg/hr
    • Discuss with attending anesthesiologist
    • Consider for patients with global delay, respiratory insufficiency and/or severe neuromuscular scoliosis — GMFCS IV-V
Vasoactive Agents

Discuss options with attending anesthesiologist

Order concentration appropriate for patient size and vascular access
  • Nicardipine:
    • 0.5-2 mcg/kg/min
  • Phenylephrine:
    • 0.06 mg/ml concentration
    • 0.1-0.3 mcg/kg/min
  • and/or
  • Norepinephrine:
    • 0.05-1 mcg/kg/minute, titrate to desired effect
  • and/or
  • Epinephrine:
    • 0.01-1 mcg/kg/minute, titrate dosage to desired effect
Other
  • Tranexamic acid:
    • 100 mg/ml infusion 10 mg/kg/hr