Anesthesiology CA1

Survival Guide

Created by David Hutchinson &

Caitlin Gray

2021 revisions by Lida Esfandiary,

Bryan Stevens, and Jack Schneck

2

TABLE OF CONTENTS

Phone Numbers PREOPERATIVE

3 POSTOPERATIVE PONV

34-35

Airway Exam 4 Respiratory and Airway Problems 36

ASA Classification 5 Hypertension 36

Preoperative Cardiac Assessment 6 Delayed Awakening 37

Algorithm OTHER SPECIFIC CONDITIONS

ASA Guidelines for Fasting 7 Hypovolemia 37

Pre-Induction Checklist 8 Bleeding 37

Premedication – Adult 8 Sepsis 37

FDA Anesthesia Apparatus 9 Myocardial Infarction 37

Checkout, 1993 Arrhythmias 37

INTRAOPERATIVE Drugs 38

Difficult Airway Algorithm 10 Pulmonary Embolism 38

Techniques for Difficult Intubation/ 11 Congestive Heart Failure 38

Difficult Ventilation Anaphylaxis 38

Cormack-Lehane Laryngoscopy 11 Aspiration 38

Grades Upper Airway Obstruction/Stridor 38

Hypoxia 12-13 Pneumothorax/Hemothorax/ 38

Hypercarbia 14 Pleural Effusion

Elevated PIP 15-16 PACU Discharge Criteria 39

Bronchospasm 16 DRUGS

Hypotension 17 Common Drugs 40

Hypertension 18 Analgesics 41-42

Bradycardia 19 Adrenergic Agonists and 43

Tachycardia 20 Vasopressors

Anaphylaxis 21 Beta-blockers 43

Hypothermia 22 Prophylactic Antibiotics 43

Hyperthermia 22 ALGORITHMS

Malignant Hyperthermia 23 Adult Cardiac Arrest Algorithm – 44

Delayed Emergence 24 2018 Update

Venous Air Embolism 25 Adult Cardiac Arrest Circular 45

Nonthrombotic Embolism 26 Algorithm

LAST 27 Emergency ACLS Medications 45

Burn 28 Immediate Post-Cardiac Arrest 46

Fluids 29 Algorithm

Transfusion Therapy 30-31 Acute Coronary Syndromes 47

Acid/Base 32-33 Algorithm

Bradycardia with a Pulse Algorithm 48 Tachycardia with a Pulse 49 Algorithm

Suspected Stroke Algorithm 50 Pediatric Cardiac Arrest Algorithm 51 Neonatal Resuscitation Algorithm 52 PEDIATRICS

Pediatric Airway Equipment 53 Pediatric Drugs 53-54 SET-UP

Basic and Cardiac Set-Up 55-56

3

PHONE NUMBERS

Contact Information for VA Attendings Awoniyi, Caleb 850-264-7337, 352-363-9301

Bauerfeind, Julia 352-204-7434

Endredi, Jozsef 352-639-0799, 813-731-7785

Goldstein, Chris 352-325-1196

Hegland, Dustin 352-359-3860

Soberon, Jose 786-247-2749, office extension 10-3581

Sulek, Cheri 352-359-5460

Urdaneta, Felipe 352-246-3449, 352-413-5469

Other Important Numbers

North Tower AOD 494-4990

South Tower AOD 260-7638

HVN Tower AOD 256-9151

APS 494-1496

APS Fellow 219-5453

Preop Phone 260-8884

Trauma Phone 494-4331

HVN OR charge nurse 494-4892

NT OR charge nurse 494-4891

ST OR charge nurse 494-4890

NT Pre-Op 682-7617

ST Pre-Op 260-8884

4

PREOPERATIVE

AIRWAY EXAM

• Patient features: facial hair, small mouth, arched/high palate, short neck, thick neck, protruding teeth

• Mallampati Classification

o Class I: Soft palate, entire uvula, faucial pillars o Class II: Soft palate, major part of uvula, faucial pillars

o Class III: Soft palate, base of uvula

o Class IV: Only hard palate

• Mouth opening/interincisor gap (ideally >3 cm)

• Thyromental distance (ideally >6.5 cm)

• Mandibular protrusion

Source:

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918684&_ga=2.254105357.487275535.1586370

830-786737438.1566664741

5

ASA CLASSIFICATION

ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol

use

ASA II A patient with mild systemic disease Mild diseases only without substantive

functional limitations. Examples include (but

not limited to): current smoker, social alcohol

drinker, pregnancy, obesity (30 < BMI < 40),

well-controlled DM/HTN, mild lung disease

ASA III A patient with severe systemic disease Substantive functional limitations; one or

more moderate to severe diseases. Examples

include (but not limited to): poorly controlled

DM or HTN, COPD, morbid obesity (BMI

≥ 40), active hepatitis, alcohol dependence or

abuse, implanted pacemaker, moderate

reduction of ejection fraction, ESRD

undergoing regularly scheduled dialysis,

premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents

ASA IV A patient with severe systemic disease as a Examples include (but not limited to): recent constant threat to life (< 3 months) MI, CVA, TIA, or CAD/stents,

ongoing cardiac ischemia or severe valve

dysfunction, severe reduction of ejection

fraction, sepsis, DIC, ARD, or ESRD not

undergoing regularly scheduled dialysis

ASA V A moribund patient who is not expected to

survive without the operation

Examples include (but not limited to): ruptured

abdominal/thoracic aneurysm, massive trauma,

intracranial bleed with mass effect, ischemic

bowel in the face of significant cardiac

pathology, or multiple organ/system

dysfunction

ASA VI A declared brain-dead patient whose

organs are being removed for donor

purposes

*The addition of “E” denotes Emergency surgery (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part).

Source: https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

ASA PS

classification Definition

Adult examples, including, but not limited

to:

6

PREOPERATIVE CARDIAC ASSESSMNT ALGORITHM FOR CAD

Source: https://www.ahajournals.org/doi/full/10.1161/cir.0000000000000106

7

ASA GUIDELINES for Preoperative Fasting/Pharmacologic Recommendations

Source:

https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2596245&_ga=2.258879631.487275535.1586370

830-786737438.1566664741

8

PRE-INDUCTION CHECKLIST

M Machine check, including ventilatory settings

S Suction on with catheter in place

M Monitors on patient (blood pressure cuff, pulse oximetry, ECG, ETCO2 detector, temperature probe)

A Airway equipment (oral/nasal airway, face mask, stylets, ET tube, laryngoscope with working bulb)

I IV access for administering drugs and giving fluids

D Drugs, including induction agents, muscle relaxants, resuscitation drugs

S Special equipment, including video laryngoscopes, arterial lines, prone view, BIS, NG tube

PREMEDICATION – Adult

Anxiolysis/Amnesia Versed 1-2 mg IV (when rolling to the OR); DO NOT give to elderly without checking with attending

Analgesia Fentanyl 25-50 mcg doses

PONV Scopolamine transdermal patch (when you see patient in preop) -Ensure you warn patients of side effects

Antacids Sodium citrate (PO) 10-20 mL

Anticholinergics Glycopyrrolate 0.2 mg (useful for drying oral secretions)

Pre-op interview The best premedication is a good pre-op interview that builds rapport and confidence with the patient and the family

9

FDA Anesthesia Apparatus Checkout

Recommendations, 1993 This checkout, or a reasonable equivalent, should be conducted before

administration of anesthesia. These recommendations are only valid for

an anesthesia system that conforms to current and relevant standards and

includes an ascending bellows ventilator and at least the following

monitors: capnograph, pulse oximeter, oxygen analyzer, respiratory

volume monitor (spirometer) and breathing system pressure monitor

with high and low pressure alarms. This is a guideline that users are

encouraged to modify to accommodate differences in equipment design

and variations in local clinical practice. Such local modifications should

have appropriate peer review. Users should refer to the operator manual

for specific procedures and precautions.

10. Check Initial Status of Breathing System

a. Set selector switch to "Bag" mode.

b. Check that breathing circuit is complete, undamaged and

unobstructed.

c. Verify that CO2 absorbent is adequate.

d. Install breathing circuit accessory equipment (eg,

humidifier, PEEP valve) to be used during the case.

11. Perform Leak Check of the Breathing System

a. Set all gas flows to zero (or minimum).

b. Close APL (pop-off) valve and occlude Y-piece.

c. Pressurize breathing system to about 30cmH2O with O2

flush. d. Ensure that pressure remains fixed for at least 10 seconds.

e. Open APL (pop-off) valve and ensure that pressure

decreases.

Manual and Automatic Ventilation Systems

12. Test Ventilation Systems and Unidirectional Valves

a. Place a second breathing bag on Y-piece.

b. Set appropriate ventilator parameters for next patient.

c. Switch to automatic ventilation (Ventilator) mode.

d. Turn ventilator ON and fill bellows and breathing bag with

O2 flush. e. Set O2 flow to minimum, other gas flows to zero.

f. Verify that during inspiration bellows delivers appropriate

tidal volume and that during

expiration bellows fills completely.

g. Set fresh gas flow to about 5 L/min.

h. Verify that the ventilator bellows and simulated lungs fill

and empty appropriately without sustained pressure at end

expiration.

i. Check for proper action of unidirectional valves.

j. Exercise breathing circuit accessories to ensure proper

function.

k. Turn ventilator OFF and switch to manual ventilation

(Bag/APL) mode.

l. Ventilate manually and assure inflation and deflation of

artificial lungs and appropriate feel of system resistance

and compliance.

m. Remove second breathing bag from Y-piece.

Monitors

13. Check, Calibrate and/or Set Alarm Limits of all Monitors

Capnograph - Pulse Oximeter -O2 Analyzer Respiratory

Volume Monitor (Spirometer)-Pressure Monitor with High and

Low Airway Pressure Alarms

Final Position

14. Check Final Status of Machine

a. Vaporizers off

b. b. APL valve open

c. c. Selector switch to “Bag”

d. All flowmeters to zero (or minimum) e. Patient suction

level adequate

e. Breathing system ready to use

This FDA checklist can be downloaded at

http://vam.anest.ufl.edu/fda-checklist4fold.doc

*If an anesthesia provider uses the same machine in successive cases,

the steps on a gray background need not be repeated or may be

abbreviated after the initial checkout.

Emergency Ventilation Equipment

*1. Verify Backup Ventilation Equipment is Available &

Functioning.

High Pressure System *2. Check O2 Cylinder Supply

a. Open O2 cylinder and verify at least half full (about 1000

psi). b. Close cylinder.

*3. Check Central Pipeline Supplies

a. Check that hoses are connected and pipeline gauges read

about 50psi.

Low Pressure System

*4. Check Initial Status of Low Pressure System

a. Close flow control valves and turn vaporizers off.

b. Check fill level and tighten vaporizers' filler caps.

*5. Perform Leak Check of Machine Low Pressure System

a. Verify that the machine master switch and flow control

valves are OFF.

b. Attach "Suction Bulb" to common (fresh) gas outlet.

c. Squeeze bulb repeatedly until fully collapsed.

d. Verify bulb stays fully collapsed for at least 10 seconds

e. Open one vaporizer at a time and repeat "c" and "d" as

above.

f. Remove suction bulb, and reconnect fresh gas hose.

*6. Turn On Machine Master Switch

and all other necessary electrical equipment.

*7. Test Flowmeters

a. Adjust flow of all gases through their full range, checking

for smooth operation of floats and undamaged flowtubes.

b. Attempt to create a hypoxic O2/N2O mixture and verify

correct changes in flow and/or alarm.

Scavenging System

*8. Adjust and Check Scavenging System

a. Ensure proper connections between the scavenging system

and both APL (pop-off) valve and ventilator relief valve.

b. Adjust waste gas vacuum (if possible).

c. Fully open APL valve and occlude Y-piece.

d. With minimum O2 flow, allow scavenger reservoir bag to

collapse completely and verify that absorber pressure

gauge reads about zero.

e. With the O2 flush activated, allow the scavenger reservoir

bag to distend fully, and then verify that absorber pressure

gauge reads < 10 cm H2O.

Breathing System *9. Calibrate O2 Monitor

a. Ensure monitor reads 21% in room air.

b. Verify low O2 alarm is enabled and functioning.

c. Reinstall sensor in circuit and flush breathing system with

O2. d. Verify that monitor now reads greater than 90%.

10

INTRAOPERATIVE DIFFICULT AIRWAY ALGORITHM

Source: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918684&_ga=2.2541053 57.487275535.1586370830-786737438.1566664741

11

TECHNIQUES FOR DIFFICULT INTUBATION/DIFFICULT VENTILATION

Source: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918684&_ga=2.2541053

57.487275535.1586370830-786737438.1566664741

CORMACK-LEHANE LARYNGOSCOPY GRADES

Grade I: Full view of vocal cords

Grade IIA: Partial view of vocal cords

Grade IIB: View of arytenoids and epiglottis

Grade III: Only epiglottis visible Grade IV: Neither the epiglottis nor glottis seen

12

HYPOXIA

Initial Response

• Increase to 100% FiO2 high flow, look at other vitals

• Work from patient to machine (or vice versa):

• Listen to lungs: atelectasis, bronchospasm, mucus plug, mainstem intubation, pneumothorax

• Check ETT: kinked, patient biting tube, patient extubated, cuff leak

• Check circuit: disconnect at ETT or at machine

• Check machine: inspiratory and expiratory valves, bellows, FiO2, MV

• Check monitors: pulse ox waveform, EtCO2, gas analyzer

• Hand ventilate: feel compliance or leaks, recruitment maneuver

• Suction ETT

• Call for HELP if worsening or no clear cause. Communicate to surgical team.

Differential Diagnosis

Hypoventilation • Low TV/RR or MV

• High or low EtCO2

• High PIP

• Circuit leaks

• Kinked/obstructed ETT

• Poor chest rise

• Patient bucking ventilator

Shunt/VQ mismatch

• Mainstem intubation

• Bronchospasm

• Anaphylaxis

• Mucus plug

• Aspiration

Diffusion impairment

• Pulmonary edema, fibrosis, emphysema – usually chronic

Low FiO2 • Hypoxic FiO2 gas mixture; may have to go to alternative O2 source (tank)

Increased O2

demand • MH

• Thyrotoxicosis

• Sepsis

Artifact • Poor waveform: cold extremity, light interference, cautery, dyes, extremity movement

Depending on likely diagnosis, consider:

Recruitment breaths • Caution if hypotensive

Bronchodilators • Albuterol MDI

• Volatile anesthetics (except for Desflurane)/Ketamine

Increase FRC • Head up (if bp stable), desufflate abdomen

Needle

Decompression • For pneumothorax

Source: http://web.stanford.edu/dept/anesthesia/em/semv3.1_digital.pdf

13

Suggested algorithm for management of hypoxia

Reference: Pocket Anesthesia

Alveolar Gas Equation:

Alveolar – arterial (A-a) Gradient:

A-a Gradient = PAO2 – PaO2

14

HYPERCARBIA

• Caused by inadequate ventilation or increased CO2 production • Can lead to respiratory acidosis, increased pulmonary artery pressure, and/or increased intracranial pressure

Differential Diagnosis

Inadequate

Ventilation • Central depression of medullary respiratory center

• Opioids, barbiturates, benzodiazepines

• Neuromuscular depression

• Muscle relaxants

• Phrenic nerve paralysis

• Low minute ventilation

• Inappropriate ventilator settings

• Altered respiratory mechanics in spontaneously ventilated patients

• Equipment problems

• Ventilator malfunction

• Leak in breathing circuit

• Increased airway resistance

• Bronchospasm

• Severe COPD

• Upper airway obstruction

• Pneumoperitoneum with CO2

• ET tube issue

• Kinked ETT

• Endobronchial intubation

• Rebreathing of exhaled gases

• Exhausted CO2 absorber • Inadequate fresh gas flows

Increased CO2

production • Exogenous CO2

• Insufflation during laparoscopy

• Reperfusion

• Release of tourniquet, removal of cross-clamps

• Hypermetabolic states

• Malignant hyperthermia

• Sepsis

• Thyrotoxicosis

• Fever/shivering

• Seizures

• IV sodium bicarbonate administration

Investigations / Treatments

• Assess oxygenation and airway

• Ensure appropriate ventilator settings; increase minute ventilation; increase fresh gas flow

• Check CO2 absorber

• Consider checking ABG to confirm capnography

• Ensure muscle relaxant reversal, residual narcotic/anesthetic effect (if increased CO2 during emergence)

• Treat secondary causes, such as shivering, malignant hyperthermia, thyroid storm, etc.

Source: Freeman BS. Hypocarbia and Hypercarbia. Chapter 142. Anesthesiology Core Review.

Part One: BASIC Exam.

15

ELEVATED PIP

Initial Response:

1. ABCs (100% FiO2, switch to bag, hand ventilate, verify EtCO2)

2. Address most common diagnoses, auscultate bilaterally (bronchospasm [wheezing], endobronchial intubation [check tube depth- neck flexion can increase tube depth by 2 cm], mucus plug)

If Unresolved:

3. Sweep from machine, circuit, ETT, lungs, chest wall

4. Suction ETT

5. Go through systematic differential of possible causes. Assess if plateau elevated or just PIP.

Static Compliance • Measured in the absence of gas

flow • Based on plateau pressure

Cstat = Vt / (Pplat – PEEP)

Dynamic Compliance • Measured in the presence of gas

flow • Based on peak pressure

Cdyn = Vt / (Ppeak – PEEP)

Increased PIP

Normal Plateau

Increased PIP

Elevated Plateau

Things that increase airway resistance and

peak pressure, so dynamic compliance curve

shifts to the right and flattens. Plateau pressure and static compliance are unchanged.

Things that reduce lung compliance increase both peak and

plateau pressure, so both static and dynamic compliance

fall.

Mechanical

• Kinked circuit

• Faulty inspiratory valve

Endotracheal tube

• Kinked

• Mucus plug

• Depth

• Esophageal

Conducting airways

• Bronchospasm

Alveolus

• Atelectasis

• Edema

• Aspiration

• Restrictive lung disease

Pleural space

• Tension pneumothorax

• Pleural effusion

Chest wall

• Obesity

• Paralytic weaning off

• Surgeon leaning on chest

• Narcotic-induced rigidity

• Pulmonary emboli do not change resistance or compliance, so both curves are unchanged.

16

Peak airway pressure made up from:

1. Alveolar pressure present at the beginning of the breath (PEEP)

2. Elastic recoil of the lung and chest wall (pulmonary compliance – static pressure)

3. Inspiratory flow resistance

Source: https://healthjade.net/peak-inspiratory-pressure/

BRONCHOSPASM

Signs

● Increased PIP

● Wheezing

● Increased expiratory time ● Increased ETCO2, upsloping ETCO2 waveform

Management

● Assess oxygenation (FiO2 100%) and airway

● Initially switch to manual ventilation

● If put back on ventilator, appropriate settings

o Lower RR (6-8/min), longer expiratory times (I:E 1:3 or 1:4)

o VCV with TV 6 cc/kg, peak airway pressure < 40 cm H2)

o Minimal PEEP

● Deepen anesthetic (volatiles act as bronchodilator, exception is Desflurane)

● Ketamine (bronchodilator)

● Inhaled beta 2-agonist (albuterol)

● Consider IV Steroids (hydrocortisone 100 mg IV) ● Consider epinephrine if severe (start with 10 mcg IV)

17

HYPOTENSION

BP = CO × SVR

HR × SV

Rate Preload Rhythm Afterload

Contractility

Preload: volume of blood at end

diastole

Afterload: resistance the heart

must overcome to eject blood

Contractility: the hearts force of

pumping

Absolute hypovolemia

• Hemorrhage

• Diuresis

• Bowel prep

• NPO status

• Vasodilation (sepsis,

anaphylaxis)

• Drugs (anesthetics)

• Sympathectomy (spinal,

epidural)

• Ischemia

• Arrhythmias

• CHF

• Iatrogenic (beta-blockers)

• Anesthetic effect Relative hypovolemia

• Increased intra-abdominal pressure (insufflation)

• Increased thoracis pressure

(pneumothorax)

• Surgical IVC compression

• Positional (Reverse

Trendelenburg)

Management

• Open IV fluids, place in Trendelenburg

• Room sweep

• Confirm BP (examine cuff for fit, check other site for BP)

• Check EtCO2 (drop in EtCO2 would support real drop in BP)

• Check EKG

• Check ventilator for increased PIP

• Check surgical field: hemorrhage, CO2 insufflation, retraction

• Consider fluid status examine arterial line (or pulse ox) waveform for variation

• Ensure IV site isn’t infiltrated

• Decrease anesthetic agents

• Vasopressors

• Phenylephrine

• Ephedrine

• Vasopressin

18

HYPERTENSION

Primary Hypertension Secondary Hypertension

• Long-standing HTN (no known cause, 70%-95% of HTN)

• Specific disease processes

• Preeclampsia

• Kidney failure

• Pain/surgical stimulation (inadequate anesthesia; usually associated with tachycardia unless beta-blocked)

• Incision

• Distended bladder

• Tourniquet pain

• ETT stimulation

• Hypoxia, hypercarbia

• Intracranial pathology (increased ICP)

• Endocrine problems (pheochromocytoma, Cushing syndrome,

hyperthyroidism)

• Alcohol withdrawal

• Malignant hyperthermia

• Inadvertent drug administration

• Illicit drug use (amphetamines, cocaine)

Management

Cuff Error • Check size of cuff and placement

• Surgeon leaning on cuff?

Surgical Stimulation • Increase depth of anesthesia

• Opioids

Full Bladder • Check Foley

Improve oxygenation/ventilation • Check FiO2, EtCO2

Medications • Alpha/beta adrenergic-blocking agents (labetalol 5-10 mg IV)

• B-adrenergic-blocking agents (metoprolol 1-5 mg IV)

• Vasodilators (hydralazine 2.5-5 mg IV, NTG gtt at 30-50

ug/min IV) • Ca channel blockers (diltiazem 5-10 mg IV)

Other things to consider • Drug contamination (e.g., epi-soaked gauze in surgical field)

• Elevated ICP

• Malignant hyperthermia

• Hypervolemia

19

BRADYCARDIA

Etiologies

● Hypoxia

● Acute MI (especially inferior wall)

● Sick sinus syndrome

● Drugs

● Succinylcholine (especially in peds)

● Anticholinesterases (neostigmine)

● Beta blockers

● Calcium channel blockers

● Digoxin

● Synthetic narcotics (fentanyl, remi, alfenta, sufenta)

● Alpha-2 antagonists (dexmedetomidine)

● Increased vagal tone/reflexes

● Visceral traction (spermatic cord)

● Laparoscopic insufflation

● Brainstem manipulation

● Carotid body manipulation

● Valsalva

● Oculocardiac reflex

● Elevated ICP Treatment

● Ensure adequate oxygenation and ventilation

● Stable vs. unstable? MAP decreased by >20%? EtCO2 decreased? Weak or absent pulse?

● Stable: glyco (start 0.2 mg), ephedrine (5-10 mg)

● Unstable: atropine (0.5 mg) or epi (50 mcg); transcutaneous pacing for severe or refractory

● Remove offending stimulus! Desufflate abdomen, release ocular traction Further work-up

● EKG: Sinus brady vs. heart block

20

TACHYCARDIA

Stable vs. Unstable?

Unstable → ACLS guidelines Stable → Check EKG, changes indicative of ischemia?

Differential Diagnosis

● Inadequate depth of anesthesia: Check that vaporizer is filled, IV is not infiltrated (if during TIVA)

● Inadequate analgesia

● Hypovolemia/hypotension: Check PPV, fluid responsiveness

● Hypoxemia/hypercarbia: FiO2, EtCO2

● Hyperthermia: Is warmer on too high?

● Drugs: Did patient miss beta blocker dose? Have you given glycopyrrolate, atropine, ephedrine, etc.?

Epi soaked gauze on the field?

● Myocardial ischemia? Check EKG

● Endocrine: pheochromocytoma, thyrotoxicosis

● Hypermetabolic state: trauma patient, burn patient, malignant hyperthermia

● Unusual events: tension PTX, embolism, sepsis

Treatment

● If light anesthesia: anesthetics to deepen

● If inadequate analgesia: opioids

● Hypovolemia: fluids

● Can patient tolerate tachycardia? Does the patient need the tachycardia to maintain hemodynamic

stability?

● Can administer B-blocking agents

● Metoprolol 1-5 mg IV

● Esmolol 5-10 mg IV

● Labetalol 5-10 mg IV if HTN as well

● If stable, SVT/Afib

● May start with beta blockade as above

● Consider amiodarone 150 mg in 100-cc bag as loading dose (over 10 minutes) followed by 1 mg/min

infusion

21

ANAPHYLAXIS

Clinical manifestations

● Cardiovascular: tachycardia, hypotension, dysrhythmias

● Respiratory: bronchospasm/wheezing, dyspnea, laryngeal edema, hypoxemia, pulmonary edema

● Dermatologic: rash, facial edema

Etiologies

● Muscle relaxants (succinylcholine, rocuronium, atracurium)

● Latex (gloves, tourniquets, Foley catheters)

● Antibiotics (penicillin, B-lactams)

● Hypnotics (propofol, thiopental)

● Colloids (dextran > albumin > HES)

● Opioids (morphine, meperidine)

● Other (sugammadex, chlorhexidine) Treatment

● STOP OFFENDING AGENT

● Notify surgeon and your attending; call for help!

● 100% FiO2

● Ensure adequate IV access

● Rapidly infuse IV fluid (10-30 mL/kg IV) to restore intravascular volume

● If hypotensive, turn off anesthetic agents; consider amnestic agents (ketamine, midazolam)

o Inhaled anesthetics cause vasodilation

o Narcotic infusions suppress sympathetic response

Drugs:

● Epinephrine (1-10 mcg/kg IV as needed) to restore BP and decrease mediator release

o Epi gtt (0.02-0.2 mcg/kg/min) may be required to maintain BP

● Beta-agonists (albuterol) for bronchoconstriction

● Methylprednisolone (2 mg/kg IV, MAX 100 mg) to decrease mediator release

● Diphenhydramine (1 mg/kg IV, MAX 50 mg) to decrease histamine-related effects

● Famotidine (0.25 mg/kg IV) or ranitidine (1 mg/kg IV) to decrease effects of histamine

● If anaphylactic reaction requires laboratory confirmation, send mast cell tryptase level within 2 hours of

event

Source: Previous Anesthesia Pocket Survival Guide, Dr. Shaik and Dr. Gonzalez

Source: http://ether.stanford.edu/ca1_new/Final-%202018%20CA-

1%20Tutorial%20Textbook.Smartphone%20or%20Tablet.pdf

Source: Kim BA, Yang SW. Anaphylaxis. Chapter 105. Anesthesiology Core Review. Part One:

BASIC Exam.

22

HYPOTHERMIA

Sources of heat loss

● Redistribution: initial decrease in core temperature because of redistribution of heat to the peripheral

compartment; most common etiology of hypothermia in the first hour after induction of anesthesia; not

heat loss per se, just redistribution of heat

● Radiation: main mechanism of heat loss in the OR; vasodilation and cutaneous blood flow to body

surfaces exposed to cold OR environment

● Conduction: dissipation of heat from warm to cool objects that are touching

● Convection: heat loss to airflow surrounding the patient

● Evaporation: heat loss through vaporization (gas exhalation, exposed viscera) Prevention

● ASA standard: “Every patient receiving anesthesia shall have temperature monitored when clinically

significant changes in body temperature are intended, anticipated, or suspected.”

● Skin surface warming (Bair Hugger) for 30 minutes prior to induction of anesthesia has been shown

to prevent redistribution hypothermia

● Bair Hugger in OR (upper body ± lower body)

● Warm IV fluids

● Lower gas flows

● Ensure patient’s head is warm (via Bair Hugger, place warm blankets around head, etc.)

● Increase temperature of OR

Source: Patel R, Hawkins K. Hypothermia, Chapter 102. Anesthesiology Core Review. Part

One: BASIC Exam.

Source: Sessler DI, Schroeder M, Merrifield B, Matsukawa T, Cheng C. Optimal

duration and temperature of prewarming. Anesthesiology. 1995;82:674–81.

HYPERTHERMIA

Etiology

● Drug reactions

o Serotonin syndrome (SSRIs, MAOIs, amphetamines)

o Neuroleptic malignant syndrome (antipsychotic medications)

o Sympathomimetic toxicity (amphetamines, cocaine)

o Anticholinergic syndrome (antihistamines, antipsychotics, TCAs)

● Transfusion reactions

● Infections

● Exogenous heating sources (forced air warming, fluid warming devices, cardiopulmonary bypass)

● Endocrine: pheochromocytoma, thyroid storm

● Pulmonary: atelectasis, PE, aspiration

● CNS: seizures Treatment

● Remove external warming devices

● Active cooling strategies: forced air cooling, fluid infusions

● Focused treatment depending on diagnosis

Source: Edwards C. Nonmalignant Hyperthermia. Chapter 103. Anesthesiology Core Review.

Part One: BASIC Exam.

23

MALIGNANT HYPERTHERMIA

MH Hotline: 1-800-644-9737 (1-800-MH-HYPER)

Signs

● Hypermetabolism: increased CO2 production, increased O2 consumption, metabolic acidosis

● Increased sympathetic activity: increased HR, increased BP, arrhythmias

● Muscle damage: masseter muscle rigidity, increased serum CK, increased K+, myoglobinemia

● Hyperthermia: fever, diaphoresis

*Nearly 50% of patients with MH have had prior uneventful anesthetic (where they were exposed to

triggering agent)

Treatment

● Call for help

● Get Malignant Hyperthermia (MH) Kit

● Stop procedure if possible

● Stop volatile anesthetic. Transition to non-triggering anesthetic. Consider changing circuit and soda lime.

● Request chilled IV saline

● Hyperventilate patient to reduce CO2: 2-4 times patient’s minute ventilation; 100% FiO2

● Dantrolene 2.5 mg/kg IV every 5 minutes until symptoms resolve

o Assign dedicated person to mix dantrolene (20 mg/vial) with 60 mL of sterile water

● Bicarbonate 1-2 mEq/kg IV for suspected metabolic acidosis; maintain pH >7.2

● Cool patient if temperature >39 °C

o NG lavage with cold water

o Apply ice externally

o Infuse cold saline IV

o Stop cooling if temperature <38 °C

● Hyperkalemia treatment

o Ca gluconate 30 mg/kg IV or Ca chloride 10 mg/kg IV

o Sodium bicarbonate 1-2 mEq/kg IV

o Regular insulin 0.1 units/kg IV (MAX 10 units) and 0.5 g/kg dextrose (MAX 50 mL D50)

● Dysrhythmia treatment: standard antiarrhythmics; do NOT use calcium channel blocker

● Send labs: ABG or VBG, electrolytes, serum CK, serum/urine myoglobin, coagulation

● Place Foley to monitor urine output; ABG, central line

● Call ICU to arrange disposition

Source: Previous Anesthesiology Pocket Survival Guide, Dr. Shaik and Dr. Gonzalez.

Source: OpenAnesthesia keywords: MH Presentation, Malignant Hyperthermia, Malignant

Hyperthermia - periop mgmt

24

DELAYED EMERGENCE

Management

Drug Effects

● Ensure anesthetic agents are OFF

● Reverse neuromuscular blockade as appropriate. Check for return of TOF/tetanus with peripheral nerve

stimulator. Pseudocholinesterase deficiency?

● Consider narcotic reversal

o 40 mcg naloxone IV repeat q2 mins up to 0.2 mg

● Too much midazolam?

o Flumazenil 0.2 mg q1min up to 1 mg

● Excess cholinergics such as scopolamine. Physostigmine 1.25 mg IV can reverse cholinergic effects

(e.g., scopolamine) and possibly anesthetic agents

● Alcohol or other drug intoxication

Metabolic Derangements

● Check blood glucose, ABG, and electrolytes

o Hypo/hyperglycemia?

o Hypoxia? Assess pulse ox

o CO2 narcosis from hypercarbia? Assess EtCO2. Obtain ABG?

o Electrolyte abnormalities? Hyponatremia?

o Acidosis?

● Check patient’s temperature; actively warm if hypothermic

Neurologic Disorder

● If no correctible abnormalities, concern for neurological event?

o Postictal?

o Consider head CT scan, neurology/neurosurgery consult to rule out possible CVA

o Increased ICP?

Source: http://ether.stanford.edu/delayed_emergence.html

Source: https://www.cambridge.org/core/books/postanesthesia-care/signs-and-

symptoms/B3160878057B599C56AE65B8A215DF30/core-reader

Source: Open Anesthesia, Delayed emergence: differential diagnosis

25

VENOUS AIR EMBOLISM

Background

● At-risk surgeries: sitting position (crani, most commonly in surgery in the posterior fossa), C-

sections during uterine exteriorization, any surgery in which the operative field is above the heart

● Adult lethal volume of air entrained as acute bolus: 3-5 mL/kg in adults (~200-300 mL) Signs

● If patient is awake (e.g., awake crani), first sign will be coughing

● Decreased EtCO2

● Oxygen desaturation

● Altered mental status, wheezing Sensitivity of modalities for VAE detection – most to least sensitive

● TEE (most sensitive)

● Doppler (L or R parasternal, between 2nd and 3rd rib, mill-wheel murmur)

● EtCO2 and/or PA pressure

● Cardiac output and/or CVP

● Blood pressure, EKG (RV strain pattern, ST depression), stethoscope (least sensitive)

Treatment

● Prevention of further air entrainment: notify surgeon to flood/pack surgical field, lower surgical site if

possible

● 100% FiO2; ensure NO nitrous oxide

● Supportive treatment (pressors PRN)

● Aspiration of air from R atrium – intuitive solution, although this has very questionable success rates

● Hyperbaric oxygen therapy?

Source: https://www.openanesthesia.org/venous_air_embolism/

Source: Mirski MA et al. Diagnosis and Treatment of Vascular Air Embolism. Anesthesiology

2007; 106:164-77. http://www.sarasotaanesthesia.com/reading/monthlyarticles/Anes_Jan07_VenouseAir.pdf

26

NONTHROMBOTIC EMBOLISM

Fat Embolism Amniotic Fluid Embolism

● Associated with traumatic fracture of the femur, pelvis, tibia, and after intramedullary nailing and femoral/knee arthroplasty.

● Bone marrow biopsy, bone marrow transplant, CPR,

liposuction, median sternotomy

● Currently pregnant or within 48 hours of delivery

● Multiparity, abruption, intrauterine fetal death, tumultuous labor, oxytocin or prostaglandin

hyperstimulation, C-section, manual removal of the

placenta

Signs Signs

● Pulmonary dysfunction is earliest to manifest, 75% of patients; progresses to respiratory failure in 10%

● Nonpalpable petechial rash in chest, axilla, conjunctiva, and neck

● Other nonspecific findings: tachycardia, pyrexia, renal

changes, jaundice

● Respiratory distress (51%), can lead to ARDS

● Hypotension (27%), can lead to cardiovascular collapse

● Coagulopathy (12%)

● Seizures ● Nausea

Diagnosis Diagnosis

Gurd’s and Wilson’s criteria

● One major and four minor criteria

• Major criteria: petechial rash, respiratory

insufficiency, cerebral involvement

• Minor criteria: tachycardia, fever, retinal changes,

jaundice, renal signs, thrombocytopenia, anemia,

high ESR, fat macroglobinemia

Schonfeld’s criteria

● Need a score of 5 or greater

• Petechiae = 5, X-ray chest diffuse infiltrates = 4,

Hypoxemia = 3, Fever = 1, Tachycardia = 1, Tachypnea = 1, Confusion = 1

Clinical diagnosis: classic triad: hemodynamic and

respiratory compromise accompanied by DIC

● Currently pregnant or within 48 hours of delivery

● One or more of: hypotension, respiratory distress, DIC, or coma and/or seizures

● Absence of other medical explanations

Treatment Treatment

Supportive care

• Management of ARDS

• Management of hemodynamic instability

• Transfusions/bronchodilators to improve

oxygenation

• ECMO in severe cases • Very high mortality in patients with sickle cell disease

AOK treatment:

● Atropine: vagolysis

● Ondansetron: block serotonin receptors, vagolysis

● Ketorolac 30 mg: block thromboxane production Treatment for coagulopathy: FFP,

cryoprecipitate/fibrinogen concentrate, and

antifibrinolytics

Source: Shaikh, N. Emergency management of fat embolism syndrome J Emerg Traum Shock. 2009 Jan- Apr; 2(1): 29-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700578/

Source: https://behindthedrape.wordpress.com/2016/11/21/clinical-update-on-amniotic-fluid-embolism/

Source: https://www.pulmonologyadvisor.com/home/decision-support-in-medicine/pulmonary-

medicine/nonthrombotic-pulmonary-embolism-air-amniotic-fluid-fat-tumor/

27

Local Anesthetic Systemic Toxicity -- LAST

Source: https://www.nysora.com/foundations-of-regional-anesthesia/complications/local-

anesthetic-systemic-toxicity/

Background

• Inadvertent IV injection, vascular uptake

from local spread

• Bupivacaine is more lipophilic and has

greater affinity for voltage-gated sodium

channels; greatest cardiotoxic profile

Signs

• Perioral numbness, tinnitus, metallic

taste, agitation dysarthria, confusion

• Seizures, coma

• CV derangements: HTN, tachycardia

followed by bradycardia and hypotension

→ ventricular arrhythmias and asystole

• The majority of adverse events occur

within 1 minute after injection of LA

Risks

• Type and dose of LA; more lipophilic =

increased risk of toxicity

• Site of injection. Absorption of LA

highest to lowest: IV > tracheal >

intercostal > caudal > paracervical >

epidural > brachial plexus > sciatic

• Extremes of age

• Preexisting cardiac disease can make

patients more prone to arrhythmogenic

and myocardial depressant effects

• Liver/kidney failure, malnutrition or

anything resulting in a decreased

albumin

Treatment

• Stop local anesthetic injection

• Lipid emulsion resuscitation: 1.5 mL/kg

bolus of 20% intralipid, infusion at 0.25

mL/kg/min (mac 0.5 mL/kg/min). May

repeat loading dose × 3

• If pulseless, CPR, <1 mcg/kg

epinephrine; avoid vasopressin • Treat seizures with benzodiazepines • May require prolonged resuscitation

28

BURN

Source: Illinois Department of Public Health, Hospital Preparedness Program

29

FLUIDS

30

TRANSFUSION THERAPY

31

Calculating Allowable Blood Loss

Estimated allowable blood loss = EBV × (Hinitial – Hlow)/Hinitial

Hinitial = initial Hct Hlow = final lowest acceptable Hct

Estimated blood volume (EBV) = weight (kg) × average blood volume

Source: https://aneskey.com/electrolytes-transfusion-therapy/

32

ACID/BASE

33

Acid--Base Guide by Dr. Gallagher

pH = 7.40

PCO2 = 40

CO2 + H20 → H+ HCO3

Acute: pCO2: 10 torr → HCO3 up 1

pCO2: 10 torr → HCO3 down 2

Chronic: pCO2: 10 torr → HCO3 up 4-6

pCO2: 10 torr → HCO3 down 4-6

Surgical Patient Changes:

Metabolic Acidosis: Metabolic Alkalosis:

Hypoperfusion – Lactic Acidosis GI Losses

Hyperchloremia Hypochloremia

Renal Tubular Iatrogenic

Ketoacidosis Blood – Large volume

To Solve Acid Base Problem: 1) Determine the pCO2

2) Based on the pCO2 determine what the HCO3 should be

3) If actual HCO3 is greater than determined HCO3 → metabolic alkalosis

4) If actual HCO3 is less than determined HCO3 → metabolic acidosis

Pure Respiratory Acidosis/Alkalosis:

Every pCO2 changed of 10 torr changes pH by 0.08 Ex: pCO2 50 → pH 7.32

pCO2 30 → pH 7.48

Henderson Equation

Used to validate numbers for acid-base determination

[H+] = 24 × pCO2

HCO3 pH 7.55 [H+] = 25

pH 7.50 [H+] = 30

pH 7.40 [H+] = 40

pH 7.30 [H+] = 50 pH 7.20 [H+] = 60

1) If values calculated on right side of the equation are within 4-5 of the [H+], then probably correct

2) If values calculated on the right side of the equation are >5 from [H+], then probably wrong

3) Calculations of acid base work best the closer in time ABG and BMP are collected

34

Postoperative Nausea

and Vomiting--PONV

POSTOPERATIVE

Risk Factors:

• Patient factors

o Female gender

o History of PONV or motion sickness

o Non-smoking status

o Younger age

• Anesthetic factors

o Volatile anesthetics

o Longer duration of anesthesia

o Perioperative opioid use

o Nitrous oxide use

• Surgical factors

o Abdominal procedures

o Gynecological/breast surgery

o ENT surgery

o Strabismus surgery

o Urologic surgery

35

Source: https://www.anzca.edu.au/documents/2014-consensus-guidelines-for-the-management-of-po.pdf

36

RESPIRATORY AND AIRWAY PROBLEMS

Respiratory Insufficiency: Diagnosis & Management

1. Assess Airway, Breathing, Circulation

2. ↑ delivered FiO2, ↑ flow rate and consider non-rebreather or shovel mask 3. Consider jaw thrust/chin lift, placement of oral/nasal airway

4. Consider positive-pressure ventilation with bag-valve mask

5. Consider intubation vs. noninvasive ventilation (CPAP/BiPAP)

6. Review patientt history, OR and postop course, fluid status, and medications administered

7. Consider ABG, chest X-ray (rule out pneumothorax/pulmonary edema)

HYPERTENSION

• Treat underlying cause, resume home antihypertensives

• For initial treatment, consider:

o Labetalol 5-40 mg IV bolus q 10 minutes

o Hydralazine 2.5-20 mg IV bolus q 10-20 minutes

o Lopressor 2.5-10 mg IV bolus Source: https://aneskey.com/management-and-discharge/

37

DELAYED AWAKENING

OTHER SPECIFIC CONDITIONS

38

39

PACU DISCHARGE CRITERIA

Common Discharge Issues (Anesthesiology 2002;96:742–752)

• Passing of urine is not a mandatory requirement

• Ability to drink and retain fluids is not mandatory

• There is no minimum PACU stay period

• Escort is needed if patient received any sedation

Source: https://aneskey.com/management-and-discharge/

40

DRUGS COMMON DRUGS * Denotes medication that needs to be diluted when drawn-up

Intravenous Agents

Medication Syringe Usual Conc. Dose Notes

Induction Agents / Adjuncts

Etomidate 20 mL 2 mg/mL 0.2-0.3 mg/kg Typical induction 14-20 mg

Propofol 20 mL 10 mg/mL 2-3 mg/kg Typical induction: 120-200 mg

Fentanyl 5 mL 50 μg/mL 1-1.5 μg/kg Typical induction 100-150 μg

Ketamine 5 mL 10 mg/mL 1-2 mg/kg Multimodal induction: 15-30 mg

Lidocaine 5 mL 10 mg/mL 0.5-1 mg/kg Typical induction: 50 mg

Midazolam 3 mL 1 mg/mL 1-2 mg Typical pre-medication: 2 mg

Neuromuscular Blocking Agents / Reversal Agents

Cisatracurium 10 mL 2 mg/mL 0.1 mg/kg

Rocuronium 5 mL 10 mg/mL 0.6-1.2 mg/kg Typical intubation: 30-50 mg

Succinylcholine 10 mL 20 mg/mL 1-1.5 mg/mL RSI: 100-150 mg

Vecuronium 10 mL 1 mg/mL 0.1 mg/kg Typical intubation: 5-10 mg

Glycopyrrolate 5 mL 0.2 mg/mL 0.2-0.9 mg Given 1 mL:1 mL with neostigmine

Neostigmine

Sugamadex

5 mL 2 mL-5mL

1 mg/mL 100 mg/mL

1-4 mg 2-4 mg/kg

Given w/ glycopyrrolate 2 mg/kg if 2 twitches; 4 mg/kg if 0 twitch

Antiemetics

Metaclopramide 3 mL 10 mg/mL 10 mg Slow IV push or in IV bag

Ondansetron 3 mL 2 mg/mL 4 mg

Vasoactive Agents

Ephedrine* 10 mL 5 mg/mL 5-10 mg Single dilution

Phenylephrine* 10 mL 67-100 μg/mL 50-100 μg Double dilution

Vasopressin* 20 mL 1 unit/mL 1 unit Single dilution

Esmolol 10 mL 10 mg/mL 10-30 mg

Labetalol 10 mL 5 mg/mL 5-15 mg

Metoprolol 5 mL 1 mg/mL 1-5 mg

Other Agents

Dexamethasone 3 mL 2 mg/mL 4-8 mg

Intravenous Infusions

Medication Usual Conc. Preparation Starting Dose

Clevidipine

Dobutamine

500 μg/mL 1,000 μg/mL

N/A 250 mg in 250 mL of D5W or NS

1 mg/kg/hr 2-20 μg/kg/min

Dopamine 1,600 μg/mL 400 mg in 250 mL of D5W 5-20 μg/kg/min

Epinephrine 16 μg/mL 4 mg in 250 mL of D5W or NS 0.01-0.2 μg/kg/min

Nicardipine 0.1 mg/mL 25 mg in 250 mL NS 5-15 mg/hr

Nitroglycerine 200 μg/mL 50 mg in 250 mL D5W or NS 0.1-1 μg/kg/min

Norepinephrine 16 μg/mL 4 mg in 250 mL of D5W or NS 0.01-0.2 μg/kg/min

Phenylephrine 100 μg/mL 10 mg in 100 mL NS 0.1-1.5 μg/kg/min

Vasopressin 1 unit/mL 100 units in 100 mL NS 0.03-0.04 units/min

Dexmedetomidine 5 μg/mL 200 μg in 40 mL NS 0.1-0.7 μg/kg/hr

Propofol 10 mg/mL N/A 20-300 μg/kg/min

Remifentanyl 50 μg/mL 1 mg in 20 mL NS 0.1-1.5 μg/kg/min

Sufentanil 5 μg/mL 50 μg in 10 mL NS 0.1-1.5 μg/kg/hr

41

ANALGESICS

42

Source: https://com-dom-hemonc.sites.medinfo.ufl.edu/files/2013/07/Pain.pdf

43

ADRENERGIC AGONISTS AND VASOPRESSORS

BETA BLOCKERS

PROPHYLACTIC ANTIBIOTIC ADMINISTRATION, GENERAL GUIDELINES

Common Antibiotics

Drug

Dose

<120 kg >120 kg

Delivery Mode

Re-dosing Interval (hrs)

Cefazolin 2 gm 3 gm Bolus 3

Cefuroxime 1.5 gm 2.25 gm Bolus 4

Cefoxitin 2 gm 2 gm Bolus 2

Vancomycin 15 mg/kg Infusion (60-120 min) 12

Clindamycin 900 mg Infusion (10-60 min) 6

Ciprofloxacin 400 mg Infusion (60 min) 12

Levofloxacin 500 mg Infusion (60 min) 12

Metronidazole 0.5-1 gm Infusion (30-60 min) 12

Gentamicin 2.5-5 mg/kg Infusion (30-60 min) 12

Piperacillin-tazobactam 3.375 gm Infusion (10-60 min) 2

Ertapenem 1 g Infusion (10-60 min) 8 to 12

*Dosing will vary depending on the clinical situation/surgery performed – check hospital protocols and

antibiotic resource guides prior to administration. In general: For surgeries requiring skin incisions:

• Cefazolin is the preferred agent (or vancomycin in cases with MRSA)

For GI surgeries (distal gut) and GU surgeries:

• Cefoxitin is the preferred agent

• Cefazolin + Metronidazole for penicillin allergy

• Clindamycin + Gentamicin or Clindamycin + Ciprofloxacin

44

ALGORITHMS Adult Cardiac Arrest Algorithm (AHA guidelines) – 2018 update

Source: https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000613

45

Adult Cardiac Arrest Circular Algorithm – 2018 update

Source: https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000613

Medication

Adenosine

Indication

SVT

IV Dose

6-mg bolus, repeat dose 12 mg

ETT Dose

Amiodarone SVT, VT/VF, Afib 150-300 mg, then 1 mg/min

Atropine

Dantrolene

Asystole, Bradycardia

Malignant Hyperthermia

1 mg for asystole, 0.5 mg for brady

2.5 mg/kg q 5min up to 10 mg/kg

2 mg

Diltiazem

Epinephrine

Afib w. RvR

Pulseless VT/VF

0.25 mg/kg bolus, 5-15 mg/hr infusion

1 mg q 3 min

2-2.5 mg

Flumazenil

Glucagon

Benzodiazepine toxicity

Beta-blocker toxicity

0.2 mg q 1 min up to 1 mg

5 mg bolus, 1-10 mg/hr infusion

Lidocaine

Magnesium

Refractory VT, PVCs

Torsades de pointes

1-1.5 mg/kg, 15-50 μg/kg/min infusion

1-2 g

2-3 mg/kg

Naloxone

Vasopressin

Opioid toxicity

Pulseless VT/VF

0.2 mg q 2min up to 2 mg

40 units

80 units

Emergency and ACLS Medications - Adult Dosing

46

Source: https://www.acls.net/images/algo-postarrest.pdf

47

Source: https://www.acls.net/images/algo-acs.pdf

48

Source: https://www.acls.net/images/algo-bradycardia.pdf

49

Source: https://www.acls.net/images/algo-tachycardia.pdf

50

Source: https://www.acls.net/images/algo-stroke.pdf

51

Pediatric Cardiac Arrest Algorithm – 2018 Update

Source: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000612

52

Neonatal Resuscitation Algorithm – 2015 Update

Source: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000267

53

Pediatric Airway Equipment

PEDIATRICS

Weight

(kg)

Oral

Airway (mm)

Suction

Catheter (Fr)

ETT

(uncuffed)

mm

ETT @ lips

(cm)

DL blade LMA

Neonate <1 40 6 2.5 6 Miller 0 1

Neonate 1-2 40 6 2.5-3.0 7 Miller 0 1

Neonate 2-3 40 6 3.0 8 Mil 0/Mil 1 1

Neonate >3 40 6 3.0-3.5 9-10 Mil 0/Mil 1 1

1-6mo 4-6 40-50 8 3.0-3.5 11 Mil 1/Wis 1.5 1-1.5

6mo-1yr 6-10 50 8 3.5-4.0 11 Wis 1.5 1.5

1-2yr 10-12 50 8 4.0-4.5 11-12 Wis 1.5 2

2-4yr 12-16 60 8 5.0 13-14 Wis 1.5/Mac 2 2

4-6yr 16-20 70 10 5.5 14-15 Wis 1.5/Mac 2 2

6-8yr 20-30 80 10 6.0 15-16 Mil 2/Mac 2 2.5

9-12yr 30-45 80 12 6.5-7.0 16-18 Mil/Mac 2-3 3

>12yr >50 80 12 7.0 20-22 Mil/Mac 2-3 4

Uncuffed ETT size: (age/4) + 4; Cuffed ETT size: (age/4) + 3.5, ETT depth <1yr: Wt/2 + 8, >1yr: age/2 + 12. The

Neonatal “1-2-3/6-7-8” Rule (1 kg: tape at 6 cm, etc.). ALWAYS have available airway equipment one size above

and below calculated. (Credit to Drs. Shaik and Gonzalez for this chart and the medication charts following.)

Pediatric Drugs

Emergency Drugs: PEDIATRIC

Epinephrine 10 mcg/kg IV; infusion: 0.02-0.5 mcg/kg/min Anaphylaxis: IM: 10 mcg/kg every 5-15 min; IV: 1 mcg/kg, titrate for response

Atropine 20 mcg/kg IV (min 0.1 mg)

Succ + atropine dart (80 mg/0.4 mg)

IM: 4 mg/kg (of succinylcholine); IV: 1 mg/kg (1 cc = sux 16 mg + atropine 80 mcg)

Adenosine Initial bolus: 0.1 mg/kg IV Repeat dose: 0.2 mg/kg IV (max 12 mg)

Amiodarone 5 mg/kg IV

Calcium chloride 5-20 mg/kg IV (usual dose 10 mg/kg) For central line administration

Calcium gluconate 15-100 mg/kg IV (usual dose 30 mg/kg) Can be given via PIV

Dantrolene 2.5 mg/kg IV (max 10 mg/kg)

Dexamethasone 0.1-0.5 mg/kg IV

Dextrose (D25W/D50W) 0.5-1 gr/kg IV

Diphenhydramine 0.5-1 mg/kg IV, IM, or PO

Dopamine 2-20 mcg/kg/min IV infusion

Ephedrine 0.1-0.3 mg/kg IV

Racemic epi 2.25% 0.05 mL/kg in NaCl 0.9% 3 cc (nebulized)

Flumazenil 10 mcg/kg IV

Naloxone 10 mcg/kg IV (give divided doses)

Phenylephrine 1-10 mcg/kg IV For TOF hypercyanotic spells, NOT for routine tx of hypotension in children

Sodium bicarbonate 1 mEq/kg IV

Magnesium sulfate 25-50 mg/kg IV (max 2 gr)

Premedication: PEDIATRIC

Midazolam PO: 0.5 mg/kg (max 20 mg); IV: 0.05-0.1 mg/kg (max 2 mg)

Ketamine PO: 6-10 mg/kg; IV 0.5-1 mg/kg; IM: 3 mg/kg

Dexmedetomidine Intranasal: 1 mcg/kg (undiluted, 100 mcg/cc solution)

54

Induction Agents: PEDIATRIC

Propofol 2-3 mg/kg IV Maintenance: ~250 mcg/kg/min

Ketamine 1-3 mg/kg IV

Etomidate 0.3 mg/kg IV

Thiopental 5-6 mg/kg IV (currently not available in the US)

Methohexital 1 mg/kg IV

Muscle Relaxants: PEDIATRIC

Rocuronium 0.6-1.2 mg/kg IV

Vecuronium 0.1 mg/kg

Succinylcholine 1-3 mg/kg (neonates require doses at the higher end)

Cisatracurium 0.15 mg/kg

Opioids: PEDIATRIC

Fentanyl IV: 1-5 mcg/kg; Intranasal: 2 mcg/kg. If used as main anesthetic (e.g., CDH repair in NICU): 25-50 mcg/kg

Morphine 0.05-0.1 mg/kg IV

Remifentanil Bolus: 0.25-1 mcg/kg IV; Infusion: 0.05-0.2 mcg/kg/min IV

Sufentanil 0.5-1 mcg/kg IV; Infusion: 0.05-0.2 mcg/kg/hr IV

Hydromorphone 0.005-0.01 mg/kg IV

Oxycodone 0.1 mg/kg PO

Analgesics: PEDIATRIC

Acetaminophen Neonates: 20-30 mg/kg PR

Children 3-25 kg: 30-40 mg/kg PR; 10-20 mg/kg PO

Children >25 kg: 15 mg/kg IV. Maximum per day: 60 mg/kg

Ketorolac 0.5 mg/kg IV (max 30 mg)

Ibuprofen 10 mg/kg

Antiemetics: PEDIATRIC

Ondansetron 0.1-0.15 mg/kg IV (up to 4 mg)

Dexamethasone 0.5 mg/kg IV (up to 8 mg)

Metoclopramide 0.1 mg/kg IV (up to 10 mg)

Common Antibiotics: PEDIATRIC

Ampicillin 50 mg/kg IV

Ampi/sulbactam (unasyn) 25-50 mg/kg IV

Cefazolin 25-30 mg/kg IV

Cefotaxime 25-50 mg/kg IV

Ciprofloxacin 7.5-10 mg/kg IV

Ceftriaxone 25-50 mg/kg IV

Clindamycin 15 mg/kg IV

Gentamicin 2 mg/kg IV

Metronidazole 7.5 mg/kg IV

Zosyn 50-100 mg/kg IV (usual dose: 75 mg/kg)

Vancomycin 15 mg/kg IV

Source: Dr. Shaik and Dr. Gonzalez

55

56