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MSC - Anesthesiology - Pediatric - Preoperative [5077]

MSC - Anesthesiology - Pediatric - Preoperative [5077] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Anesthesiology - Pediatric - Preoperative [5077]
Medications
Analgesics - Oral [135351]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension - NOTE: Suggested dose 15 mg/kg
(Maximum 650 mg/dose) [43991]
15 mg/kg, Oral, ON CALL For 1 Doses
Administer {arrival/on-call:2000140} No more than 4 grams
acetaminophen per 24 hours for Adults or 15 mg/kg per dose
for Peds < 40 kg.
NOTE: Suggested dose 15 mg/kg (Maximum 650 mg/dose)
Pre-Op Day Of Procedure
acetaMINOPHEN (TYLENOL) tab - NOTE: Suggested
dose 15 mg/kg (Maximum 650 mg/dose) [34149]
Oral, ON CALL For 1 Doses
Administer {arrival/on-call:2000140} No more than 4 grams
acetaminophen per 24 hours for Adults or 15 mg/kg per dose
for Peds < 40 kg.
Pre-Op Day Of Procedure
acetaMINOPHEN (TYLENOL) chew tab - NOTE:
Suggested dose 15 mg/kg (Maximum 650 mg/dose)
[34147]
Oral, ON CALL For 1 Doses
Administer {arrival/on-call:2000140} No more than 4 grams
acetaminophen per 24 hours for Adults or 15 mg/kg per dose
for Peds < 40 kg.
Pre-Op Day Of Procedure
acetaMINOPHEN (TYLENOL) disintegrating tab -
NOTE: Suggested dose 15 mg/kg (Maximum 650
mg/dose) [64412]
Oral
Administer {arrival/on-call:2000140} No more than 4 grams
acetaminophen per 24 hours for Adults or 15 mg/kg per dose
for Peds < 40 kg.
Pre-Op Day Of Procedure
Sedatives (Single Response) [135355]
midazolam (VERSED) syrup - NOTE: Suggested dose
0.5 mg/kg (Maximum 20 mg/dose) [60487]
0.5 mg/kg, Oral, ON CALL For 1 Doses
Administer {arrival/on-call:2000140}
NOTE: Suggested dose 0.5 mg/kg (Maximum 20 mg/dose)
Pre-Op Day Of Procedure
Block Sedation Medications [137269]
midazolam (VERSED) injection RANGE [750056] 1-4 mg, Intravenous, PRN For 5 Doses, Sedation
IV Push Rate 1 mg/minute. Give every 1 minute as
needed.
Pre-Op Day Of Procedure
FENTanyl (SUBLIMAZE) injection RANGE [750047] 25-50 mcg, Intravenous, PRN For 5 Doses, pain
Give every 2-4 minutes as needed.
for 1 Minutes, Pre-Op Day Of Procedure
alfentanil (ALFENTA) injection [44052] 50-400 mcg, Intravenous, PRN For 5 Doses, pain
Give every 2 minutes as needed per anesthesiologist
instructions during regional block only. May be repeated 1-
5 times.
Pre-Op Day Of Procedure
Anti-emetics [135356]
diphenhydramine (BENADRYL) injection - Maximum
Dose = 25 mg [36790]
1 mg/kg, Intravenous, ONCE For 1 Doses, for 1 Minutes, Pre-
Op Day Of Procedure
meclizine (ANTIVERT) tab [47269] 25 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of Procedure
metoclopramide (REGLAN) injection [39626] 0.15 mg/kg, Intravenous, ONCE For 1 Doses, Pre-Op Day Of
Procedure
ondansetron (ZOFRAN) injection [132824] 0.1 mg/kg, Intravenous, ONCE For 1 Doses, for 3 Minutes,
Pre-Op Day Of Procedure
ranitidine (ZANTAC) injection - Maximum Dose = 50 mg
[760215]
1 mg/kg, Intravenous, ONCE For 1 Doses, for 5 Minutes, Pre-
Op Day Of Procedure
ondansetron (ZOFRAN ODT) disintegrating tab -
Maximum Dose = 4 mg [64224]
4 mg, Oral, ONCE For 1 Doses, Pre-Op Day Of Procedure
Respiratory [135363]
albuterol 2.5 mg/3 mL neb soln [34314] 2.5 mg, Nebulization, ONCE For 1 Doses, Pre-Op Day Of
Page 1 of 2
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:08 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Procedure
Self-administer Medications [81204]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer and use own supply of the
following medications: ***
Pre-Op Day Of Procedure
Laboratory
Laboratory - Pregnancy Test [137635]
Obtain pregnancy test if female between menarche & menopause and any of: (1) surgery is pelvic, renal, or intra-
abdominal, (2) patient had unprotected intercourse, (3) patient missed menses, (4) patient says she "could" be pregnant.
HCG, QUAL, URINE, POC [HCPREGPOC] ONCE For 1 Occurrences, Routine
If Conditional, What Condition?
Pre-Op Day Of Procedure
Page 2 of 2
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:08 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org