Anesthesiology CA1

Survival Guide
Created by David Hutchinson &
Caitlin Gray

2021 revisions by Lida Esfandiary,

Bryan Stevens, and Jack Schneck
 TABLE OF CONTENTS
Phone Numbers 3 POSTOPERATIVE
PREOPERATIVE 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

2
 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

3
 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

4
ASA CLASSIFICATION
ASA PS Adult examples, including, but not limited
Definition
classification to:
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 Examples include (but not limited to): ruptured
survive without the operation 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

5
PREOPERATIVE CARDIAC ASSESSMNT ALGORITHM FOR CAD

Source: https://www.ahajournals.org/doi/full/10.1161/cir.0000000000000106
6
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
7
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

8
 FDA Anesthesia Apparatus Checkout
Recommendations, 1993
This checkout, or a reasonable equivalent, should be conducted before 10. Check Initial Status of Breathing System
administration of anesthesia. These recommendations are only valid for a. Set selector switch to "Bag" mode.
an anesthesia system that conforms to current and relevant standards and b. Check that breathing circuit is complete, undamaged and
includes an ascending bellows ventilator and at least the following unobstructed.
monitors: capnograph, pulse oximeter, oxygen analyzer, respiratory c. Verify that CO2 absorbent is adequate.
volume monitor (spirometer) and breathing system pressure monitor d. Install breathing circuit accessory equipment (eg,
with high and low pressure alarms. This is a guideline that users are humidifier, PEEP valve) to be used during the case.
encouraged to modify to accommodate differences in equipment design 11. Perform Leak Check of the Breathing System
and variations in local clinical practice. Such local modifications should a. Set all gas flows to zero (or minimum).
have appropriate peer review. Users should refer to the operator manual b. Close APL (pop-off) valve and occlude Y-piece.
for specific procedures and precautions. c. Pressurize breathing system to about 30cmH2O with O2
Emergency Ventilation Equipment flush.
*1. Verify Backup Ventilation Equipment is Available & d. Ensure that pressure remains fixed for at least 10 seconds.
Functioning. e. Open APL (pop-off) valve and ensure that pressure
decreases.
High Pressure System
*2. Check O2 Cylinder Supply Manual and Automatic Ventilation Systems
a. Open O2 cylinder and verify at least half full (about 1000 12. Test Ventilation Systems and Unidirectional Valves
psi). a. Place a second breathing bag on Y-piece.
b. Close cylinder.
b. Set appropriate ventilator parameters for next patient.
*3. Check Central Pipeline Supplies c. Switch to automatic ventilation (Ventilator) mode.
a. Check that hoses are connected and pipeline gauges read d. Turn ventilator ON and fill bellows and breathing bag with
about 50psi. O2 flush.
e. Set O2 flow to minimum, other gas flows to zero.
Low Pressure System f. Verify that during inspiration bellows delivers appropriate
*4. Check Initial Status of Low Pressure System tidal volume and that during
a. Close flow control valves and turn vaporizers off. expiration bellows fills completely.
b. Check fill level and tighten vaporizers' filler caps. g. Set fresh gas flow to about 5 L/min.
*5. Perform Leak Check of Machine Low Pressure System h. Verify that the ventilator bellows and simulated lungs fill
a. Verify that the machine master switch and flow control and empty appropriately without sustained pressure at end
valves are OFF. expiration.
b. Attach "Suction Bulb" to common (fresh) gas outlet. i. Check for proper action of unidirectional valves.
c. Squeeze bulb repeatedly until fully collapsed. j. Exercise breathing circuit accessories to ensure proper
d. Verify bulb stays fully collapsed for at least 10 seconds function.
e. Open one vaporizer at a time and repeat "c" and "d" as k. Turn ventilator OFF and switch to manual ventilation
above. (Bag/APL) mode.
f. Remove suction bulb, and reconnect fresh gas hose. l. Ventilate manually and assure inflation and deflation of
*6. Turn On Machine Master Switch artificial lungs and appropriate feel of system resistance
and all other necessary electrical equipment. and compliance.
*7. Test Flowmeters m. Remove second breathing bag from Y-piece.
a. Adjust flow of all gases through their full range, checking
for smooth operation of floats and undamaged flowtubes. Monitors
b. Attempt to create a hypoxic O2/N2O mixture and verify 13. Check, Calibrate and/or Set Alarm Limits of all Monitors
correct changes in flow and/or alarm. Capnograph - Pulse Oximeter -O2 Analyzer Respiratory
Volume Monitor (Spirometer)-Pressure Monitor with High and
Scavenging System Low Airway Pressure Alarms
*8. Adjust and Check Scavenging System
a. Ensure proper connections between the scavenging system Final Position
and both APL (pop-off) valve and ventilator relief valve. 14. Check Final Status of Machine
b. Adjust waste gas vacuum (if possible). a. Vaporizers off
c. Fully open APL valve and occlude Y-piece. b. b. APL valve open
d. With minimum O2 flow, allow scavenger reservoir bag to c. c. Selector switch to “Bag”
collapse completely and verify that absorber pressure d. All flowmeters to zero (or minimum) e. Patient suction
gauge reads about zero. level adequate
e. With the O2 flush activated, allow the scavenger reservoir e. Breathing system ready to use
bag to distend fully, and then verify that absorber pressure
gauge reads < 10 cm H2O.
*If an anesthesia provider uses the same machine in successive cases,
Breathing System the steps on a gray background need not be repeated or may be
*9. Calibrate O2 Monitor abbreviated after the initial checkout.
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 This FDA checklist can be downloaded at
O2. http://vam.anest.ufl.edu/fda-checklist4fold.doc
d. Verify that monitor now reads greater than 90%.

9
 INTRAOPERATIVE
DIFFICULT AIRWAY ALGORITHM

Source: https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918684&_ga=2.2541053
57.487275535.1586370830-786737438.1566664741
10
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
11
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 • Mainstem intubation
mismatch • Bronchospasm
• Anaphylaxis
• Mucus plug
• Aspiration
Diffusion • Pulmonary edema, fibrosis, emphysema – usually chronic
impairment
Low FiO2 • Hypoxic FiO2 gas mixture; may have to go to alternative O2 source (tank)
Increased O2 • MH
demand • 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 • For pneumothorax
Decompression

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

12
Suggested algorithm for management of hypoxia

Reference: Pocket Anesthesia

Alveolar Gas Equation:

Alveolar – arterial (A-a) Gradient:

A-a Gradient = PAO2 – PaO2

13
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 • Central depression of medullary respiratory center
Ventilation • 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 • Exogenous CO2
production • 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.

14
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 Cstat = Vt / (Pplat – PEEP)

flow
• Based on plateau pressure
Dynamic Compliance • Measured in the presence of gas Cdyn = Vt / (Ppeak – PEEP)
flow
• Based on peak pressure

Increased PIP Increased PIP

Normal Plateau Elevated Plateau
Things that increase airway resistance and Things that reduce lung compliance increase both peak and
peak pressure, so dynamic compliance curve plateau pressure, so both static and dynamic compliance
shifts to the right and flattens. Plateau fall.
pressure and static compliance are unchanged.
Mechanical Alveolus
• Kinked circuit • Atelectasis
• Faulty inspiratory valve • Edema
Endotracheal tube • Aspiration
• Kinked • Restrictive lung disease
• Mucus plug Pleural space
• Depth • Tension pneumothorax
• Esophageal • Pleural effusion
Conducting airways Chest wall
• Bronchospasm • Obesity
• Paralytic weaning off
• Surgeon leaning on chest
• Narcotic-induced rigidity

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

15
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)

16
HYPOTENSION

BP = CO × SVR

HR × SV

Rate Preload
Rhythm Afterload
Contractility
Preload: volume of blood at end Afterload: resistance the heart Contractility: the hearts force of
diastole must overcome to eject blood pumping
Absolute hypovolemia • Vasodilation (sepsis, • Ischemia
• Hemorrhage anaphylaxis) • Arrhythmias
• Diuresis • Drugs (anesthetics) • CHF
• Bowel prep • Sympathectomy (spinal, • Iatrogenic (beta-blockers)
• NPO status epidural) • 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

17
HYPERTENSION

Primary Hypertension Secondary Hypertension

• Long-standing HTN (no known • Pain/surgical stimulation (inadequate anesthesia; usually
cause, 70%-95% of HTN) associated with tachycardia unless beta-blocked)
• Specific disease processes • Incision
• Preeclampsia • Distended bladder
• Kidney failure • 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

18
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

19
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.?
Episoaked 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

20
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.

21
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.

22
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

23
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
24
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

25
NONTHROMBOTIC EMBOLISM

Fat Embolism Amniotic Fluid Embolism

● Associated with traumatic fracture of the femur, ● Currently pregnant or within 48 hours of delivery
pelvis, tibia, and after intramedullary nailing and ● Multiparity, abruption, intrauterine fetal death,
femoral/knee arthroplasty. tumultuous labor, oxytocin or prostaglandin
● Bone marrow biopsy, bone marrow transplant, CPR, hyperstimulation, C-section, manual removal of the
liposuction, median sternotomy placenta
Signs Signs
● Pulmonary dysfunction is earliest to manifest, 75% of ● Respiratory distress (51%), can lead to ARDS
patients; progresses to respiratory failure in 10% ● Hypotension (27%), can lead to cardiovascular
● Nonpalpable petechial rash in chest, axilla, collapse
conjunctiva, and neck ● Coagulopathy (12%)
● Other nonspecific findings: tachycardia, pyrexia, renal ● Seizures
changes, jaundice ● Nausea
Diagnosis Diagnosis
Gurd’s and Wilson’s criteria Clinical diagnosis: classic triad: hemodynamic and
● One major and four minor criteria respiratory compromise accompanied by DIC
• Major criteria: petechial rash, respiratory ● Currently pregnant or within 48 hours of delivery
insufficiency, cerebral involvement ● One or more of: hypotension, respiratory distress,
• Minor criteria: tachycardia, fever, retinal changes, DIC,or coma and/or seizures
jaundice, renal signs, thrombocytopenia, anemia, ● Absence of other medical explanations
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
Treatment Treatment
Supportive care AOK treatment:
• Management of ARDS ● Atropine: vagolysis
• Management of hemodynamic instability ● Ondansetron: block serotonin receptors, vagolysis
• Transfusions/bronchodilators to improve ● Ketorolac 30 mg: block thromboxane production
oxygenation Treatment for coagulopathy: FFP,
• ECMO in severe cases cryoprecipitate/fibrinogen concentrate, and
• Very high mortality in patients with sickle cell disease 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/
26
Local Anesthetic Systemic Toxicity -- LAST

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

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

27
BURN

Source: Illinois Department of Public Health, Hospital Preparedness Program

28
FLUIDS

29
TRANSFUSION THERAPY

30
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/

31
ACID/BASE

32
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

33
 POSTOPERATIVE
Postoperative Nausea
and Vomiting--PONV

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

34
Source: https://www.anzca.edu.au/documents/2014-consensus-guidelines-for-the-management-of-po.pdf

35
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/

36
DELAYED AWAKENING

OTHER SPECIFIC CONDITIONS

37
38
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/

39
 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 5 mL 1 mg/mL 1-4 mg Given w/ glycopyrrolate
Sugamadex 2 mL-5mL 100 mg/mL 2-4 mg/kg 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 500 μg/mL N/A 1 mg/kg/hr
Dobutamine 1,000 μg/mL 250 mg in 250 mL of D5W or NS 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
40
ANALGESICS

41
Source: https://com-dom-hemonc.sites.medinfo.ufl.edu/files/2013/07/Pain.pdf
42
ADRENERGIC AGONISTS AND VASOPRESSORS

BETA BLOCKERS

PROPHYLACTIC ANTIBIOTIC ADMINISTRATION, GENERAL GUIDELINES

Common Antibiotics
Dose
<120 kg
Drug >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 1g 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
43
 ALGORITHMS
Adult Cardiac Arrest Algorithm (AHA guidelines) – 2018 update

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

44
Adult Cardiac Arrest Circular Algorithm – 2018 update

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

Emergency and ACLS Medications - Adult Dosing

Medication Indication IV Dose ETT Dose
Adenosine SVT 6-mg bolus, repeat dose 12 mg
Amiodarone SVT, VT/VF, Afib 150-300 mg, then 1 mg/min
Atropine Asystole, Bradycardia 1 mg for asystole, 0.5 mg for brady 2 mg
Dantrolene Malignant Hyperthermia 2.5 mg/kg q 5min up to 10 mg/kg
Diltiazem Afib w. RvR 0.25 mg/kg bolus, 5-15 mg/hr infusion
Epinephrine Pulseless VT/VF 1 mg q 3 min 2-2.5 mg
Flumazenil Benzodiazepine toxicity 0.2 mg q 1 min up to 1 mg
Glucagon Beta-blocker toxicity 5 mg bolus, 1-10 mg/hr infusion
Lidocaine Refractory VT, PVCs 1-1.5 mg/kg, 15-50 μg/kg/min infusion 2-3 mg/kg
Magnesium Torsades de pointes 1-2 g
Naloxone Opioid toxicity 0.2 mg q 2min up to 2 mg
Vasopressin Pulseless VT/VF 40 units 80 units

45
Source: https://www.acls.net/images/algo-postarrest.pdf

46
Source: https://www.acls.net/images/algo-acs.pdf

47
Source: https://www.acls.net/images/algo-bradycardia.pdf

48
Source: https://www.acls.net/images/algo-tachycardia.pdf

49
Source: https://www.acls.net/images/algo-stroke.pdf

50
Pediatric Cardiac Arrest Algorithm – 2018 Update

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

51
Neonatal Resuscitation Algorithm – 2015 Update

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

52
 PEDIATRICS
Pediatric Airway Equipment

Weight Oral Suction ETT ETT @ lips DL blade LMA

(kg) Airway Catheter (uncuffed) (cm)
(mm) (Fr) mm
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 IM: 4 mg/kg (of succinylcholine); IV: 1 mg/kg
(80 mg/0.4 mg) (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)
53
 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

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