Looks like we got ourselves a Bleeder


The Post-Partum Hemorrhage: Notes from Anesthesiology Core Review Part Two Advanced Exam

most common cause of blood loss in OB practice
leading cause of fetal and maternal M&M globally
definition: bleeding w/in 6wks of delivery
->500ml for vaginal, >1000ml for c/s
-decrease of 10% in hct from admission
-often underestimated!
Uterine blood flow = 700ml/min
-get good access fast
Uterine Atony
2-5% of all deliversies
cause of >90% of pp hemorrhage
results from failure of uterus to contract
risk factors:
-long labor (+oxytocin)
-placenta: retained, accreta, increta, percreta
-poor perfused myometrium
-drugs: inhalationals, oxytocin, tocolytics
Management of Atony
Oxytocin to contract uterus
-rapid: hypotension, decrease svr, tachy (rare card collapse), chest pain, ischemia, anaphylaxis
-ECG changes resolve spontaneously
-similar to ADH, so watch for water intox. so never give with hypotonic solution!
Ergot Alkaloids
-0.4mg – methylergonovine IM only
-10 minutes to action, lasts 3-6hrs
-vasoconstrictive -> HTN, avoid with pre-eclempsia.eclampsia
-if given IV -> intense vasoconstric -> siezures, CVA, retinal detach – MI
-Common ade: nausea vomiting
-2 dose then move on
-increase calcium -> myosin kinase

-carboprost = 15-methyl prostaglandin f2alpha given 260ucg IM
-increase force/interval of contraction
-also don’t give IV
-side effects: diarrhea, HTN, fever, flush, tachy
-bronchospasm, pulmonary vasoconstriction – so careful with asthmatics
-Misoprostol (prostaglandin E1) oral, rectal intrauterine also effective, side effect hypothermia
Retained Placenta

1-3 in 100 deliveries

result: uterus unable to fully contract –> bleeding

Need for uterine relaxation to explore and fix

GA -> 1MAC+ Inhalational

IV or sublingual Nitorglycerin
-100 ug works in 30-45seconds
-60-90 seconds return to baseline, may need redosing
-tx hypotension with phenylephrine

The Abnormal Placenta

Normal interface between placenta and uterus : Decidua basalis
When that’s missing -> uteri gets implanted
Placenta Accreta = ON myometrium
Placenta Increta = IN myometrium
Placenta Perceta = through and to other organs!
Bleeding serious complication and common
1:2000 births have accreta
-prior c/s
-placenta previa
-more c/s higher risk

If known beforehand, discuss plan about possible hysterectomy
-this can incur massive blood loss
-cell saver, think general anesthesia, secure airway, arterial line
-also consider prophylactic internal iliac balloon catheters in IR preop

Genital Trauma

lacerations of cervix, vagina, perinuem most common injuries of childbirth
if continued hypotension: think retriperitoneal hematoma!
-CT or MRI, tx with ex lap

help along repair with IV meds, neuraxial continuation, or nitrous oxide, think low dose ketamine too

Why Shiver?

Girlfriend To Stay Underneath Blanket For Next 5 Months
Girlfriend To Stay Underneath Blanket For Next 5 Months

Notes from Truelearn and UpToDate on Shivering in OB

Shivering during labor

  • 10-20% of laboring patients without epidural, 30-55% with epidural
  • multifactorial
  • hormonal changes: less progesterone than normal cycle results in less NE -> less augmentation of core temps
  • immunological reaction to fetomaternal transfusion
  • use of Misoprostol
  • possibly non-thermogenic: bursting tremor similar to clonus
  • Epidural shivering from central hypothermia and peripheral vasoconstriction
  • First hour with an epidural: core heat -> periphery 2/2 neuraxial blunt autonomic thermoregulatory below level of blockade, vasodilation causes redistribution of heat

Prevention and Treatment

  • Warming prior to epidural/spinal placement can decrease shivering
  • Warming after shivering
  • Dopaminergic/seretonergic pathway drugs can reduce shivering (25mg IV Meperidine (demerol), clonidine, tramadol, ketamine, dexmedatomidine)


What is OSA? Why does OSA matter? And does STOP BANG help us truly identify OSA?

OSA is:

  • cessation of airflow >10sec, 5+x/hr + 4% desat in SaO2
  • definitions vary, but >15x /hr is diagnostistic
  • dx by polysomnography
  • Apnea/hypopnea index (AHI), which is derived from the total number of apneas and hypopneas divided by the total sleep time (mild up to 15, severe >30)


Obstructive Sleep Apnea (OSA) matters because:

  • harder to intubate, harder to ventilate
  • increased prevalance of cardiac disease: Afib, arrhythmias, stroke, CHF, cardiomyopathy, pulmonary hypertension, CAD
  • periop complications higher, including airway obstruction, hypoxemia, atelectasis, pneumonia
  • more sensitive to respiratory depressant effect of opioids and hypnotics

Source: http://www.ncbi.nlm.nih.gov/pubmed/18339794

Is STOP BANG Helpful?

The literature shows…

“The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs.”

See: http://www.ncbi.nlm.nih.gov/pubmed/18431116

And what are these complications?

Mostly pulmonary, with a few possible cardiac events mixed in as noted in this study in Chest, cited in Miller’s 8th edition( http://journal.publications.chestnet.org/article.aspx?articleid=1085863#t4)


Variables ODI4% Age, yr Sex BMI, kg/m2 Type of Surgery Complication
ODI 4%< 5 0.2 27 F 46.7 Laparoscopic gastric bypass surgery Transient episodes of unspecified tachyarrhythmia during the first 3 postoperative days
3.0 52 F 59.4 Laparoscopy with conversion to open ventral herniorrhaphy and adhesiolysis Hypoxemia treated with supplemental oxygen and BPAP
ODI 4%≥ 5 5.5 49 F 26.2 Total abdominal hysterectomy and right salpingoophorectomy cystoscopy with placement of ureteral catheters Hypoxemia was observed on postoperative day 3 and treated with oxygen supplementation; atelectasis was noted
6.0 49 F 39.1 Total abdominal hysterectomy and bilateral oophorectomy Intraperitoneal bleeding was treated with embolization
6.2 39 F 44.9 Laparoscopic gastric bypass surgery Intraperitoneal bleeding which resolved without surgery
7.6 61 M 33.5 Sigmoid colon resection Hypoxemia and hypotension.
12.9 64 M 37.0 Mitral valve replacement Hypotension and junctional escape rhythm
13.0 57 M 38.9 Laparoscopic colonic polypectomy Atelectasis
14.5 58 F 41.6 Total abdominal hysterectomy and bilateral oophorectomy Atelectasis
18.6 62 M 37.3 Left inguinal herniorrhaphy Wheezing observed which required treatment with bronchodilators
24.6 49 F 28.1 Total abdominal hysterectomy and bilateral oophorectomy Pneumonia
26.3 53 F 47.9 Gastric bypass surgery GI bleeding
31.9 50 M 29.6 Radical prostatectomy Hypoxemia treated with CPAP
34.1 62 F 31.4 Total abdominal hysterectomy and bilateral oophorectomy Atelectasis
34.2 69 M 36.9 Laparoscopic right hemicolectomy Pulmonary embolism; superior mesenteric vein thrombosis
36.4 55 F 49.5 Exploratory laparotomy, adhesiolysis, small bowel resection, partial hepatic resection, gastric bypass Chest pain (MI was ruled out)
82.4 66 F 46.8 Total abdominal hysterectomy and bilateral oophorectomy Hypoxemia treated with CPAP


F = female; M = male; BPAP = bilevel positive airway pressure. See Table 1 for abbreviation not used in the text.

lefort !

A nice rundown of Anesthetic considerations available at Continuing Education in Anesthesia, Critical Care and Pain (2014): http://ceaccp.oxfordjournals.org/content/early/2013/06/28/bjaceaccp.mkt027.full

A few of the key points:

  • Nasal intubation preferred, and smooth extubation is essential
  • Watch out for local anesthestic toxicity, and they use lots of epinephrine
  • PONV is critical to avoid – use copious anti-emetics and go for TIVA
  • Remifentanil helps smoothen anesthetic and smoothens extubation
  • P/O ICU is historical, blood loss is minimal
  • Severe malocclusion can be intubation difficult
  • Surgeons prefer induced hypotension to minimize bleeding, remi helps this
  • Know post-op if patient will have wired jaw (clippers at bedside in pacu)
Quite the jaw thrust
Quite the jaw thrust (from Elsevier, via article cited)

Dry Lungs?

Fluid in Thoracic Surgery: Time to move overthrow Immortan Joe?
Fluid in Thoracic Surgery: Time to overthrow Immortan Joe?

The Classic Teaching from Miller 8th Edition ch 66 Anesthesia for Thoracic Surgery

Total positive fluid balance in the first 24-hour perioperative period should not exceed 20 mL/kg.

For an average adult patient, crystalloid administration should be limited to less than 3 L in the first 24 hours.

No fluid administration for third-space fluid losses during pulmonary resection.

Urine output greater than 0.5 mL/kg/h is unnecessary.

If increased tissue perfusion is needed postoperatively, it is preferable to use invasive monitoring and inotropes rather than to cause fluid overload.

And so the above was also consistent with the clinical teaching at my institution. Keep them dry, regardless of whether it was a wedge resection, lobectomy or esophagectomy (I haven’t had the pleasure of a pneumonectomy yet).

But further reading in Barash (Clinical Anethesia Fundamentals), calls this into question in ch 34 Anesthesia for Thoracic Surgery, with the following one liner broadside:

“Fluid management for all thoracic procedures should follow either a restricted or a goal-directed protocol. However, recently, concerns about acute kidney injury have called into question the strategy of fluid restriction in thoracic surgery.”

And later in the same chapter, a “Did You Know?” sidebar reinforces the same point, specifically mentioning esophageal surgery and the controversy around restrictive fluid management.

When asked about this in the operating room, the Thoracic Surgery team even indicated that anesthesiologists in this practice are being too restrictive, especially with the esophagectomies (which are for the most part, abdominal surgery).

So what is one to make of this?

Digging into the literature, there was a nice summary of the controversy and recent data at Current Opinion in Anaesthesiology  (doi: 10.1097/ACO.0b013e32835c5cf5) from a team of anesthesiologists at Yale. The article provides a nice run down on the basis of the fluid restrictive strategies (mainly studies from the 198os) and how these studies were performed before the advent of lung protective ventilation strategies (6-8cc/kg and use of peep). They do agree that fluid restriction in Pneumonectomy is logical:

In pneumonectomy, the whole cardiac output will be directed to the remaining lung. This volume in the presence of a decreased vital capacity may overwhelm the remaining lung’s protective mechanisms resulting in a rise in the pulmonary capillary filtration pressure.

However, this may not be the case in lesser lung resections, with a restrictive therapy threatening to cause Acute Kidney Injury. In fact, the belief that renal injury is low in thoracic surgery appears misplaced, as old data only counted kidney injury if patients required renal replacement therapy. Newer evidence shows thoracic patients are at higher risk of AKI than previously thought and that this may cause increased M&M in the longer term.

The authors then go on to promote a Normovolemia and Goal-Directed fluid therapy regiment. One study showed a simple normovolemia method of replacing ongoing losses and use of maintenance fluids i/o and post-op until PO intake, reduced both AKI and extravascular lung water (EVLW). The goal-directed therapy targets Cardiac Index through either Thermodilution, PiCCO, Transesophageal Doppler, SVV or PPV.  The authors point out that while controversy remains, there is some evidence showing no increase in EVLW with goal-directed fluid therapy when lung protective ventilation strategies are used.

The remainder of the article goes into the colloid vs. crystalloid debate, which is beyond the scope of this post, and it appears there is no evidence of which is better to use in thoracic surgery (potential for future research questions!).

So in conclusion, it appears that Dry Lungs may not be the Best Lungs and Best Kidneys for Thoracic Surgery.

Renal Replacement Therapy – Considerations

Indications for Renal Replacement Therapy (notes from TrueLearn)

-broad term : hemodialysis, peritoneal dialysis, hemofiltration, renal transplant
-CRRT is over 24hrs, best for HD unstable patients

Chronic Renal Failure indications
-fluid overload
-uremic symptoms
-GFR criteria

Indications in ICU patient
-pulmonary edema unresponsive to diuretics
-uncompensated metabolic acidosis (ph35, creatinine >400, hyperkalemia >6.5

Succ will raise K same as normal patient
watch fluid status and hemodynamics
avoid nephrotoxic agents (some a/b, nsaids)

Pediatric Anesthesia Reference Guide

In my dream the Lord did come to me, and He was a shape. It was He Who Walks Behind the Rows.
In my dream the Lord did come to me, and He was a shape. It was He Who Walks Behind the Rows.

UCSF once had an excellent PDF of the essentials to pediatric anesthesia (doses, tube sizes, etc), but that has since been lost to the internet. In searching for a replacement, I came across the Open Anesthesia page on peds, and it has just about everything!

Check it out here: https://www.openanesthesia.org/pediatric_anesthesia_anesthesia_text/

Note that when waking a patient up on precedex (deep) use 0.3mcg/kg as your dose and be sure to extubate deep (1 mac) .

Another reference site is found at Stony Brook, which is a bit more specific to drug doses, see here: https://medicine.stonybrookmedicine.edu/anesthesiology/teaching/peds-drug-dosages

In the interest of internet information preservation, the full text of the website is below:

Pediatric Anesthesia (Anesthesia Text)


Anesthesia-related morbidity and mortality is higher in infants than adults, as well as in younger compared to older children. In particular, airway complications are more likely in very young infants. Critical events are highest in infants < 2 kg [Tay et. al. Paediatr Anaesth 11: 711, 2001]

Preoperative Checklist

Warm the room, peds Bear hugger, overhead warming lights, age appropriate headrest and monitors. IV setup in room. See patient early to determine need for premedication needs. For latex precautions, use latex free gloves, black bag on circuit, latex-free IV setup (clear masks are OK, as are ETT, LMA, and pink tape)

  • Warm the room
  • Peds Bair hugger
  • Overhead
  • Warming lights
  • Age appropriate headrest and monitors
  • IV setup in room
  • See patient early to determine need for premedication needs
  • For latex precautions, use latex free gloves, black bag on circuit, latex-free IV setup (clear masks are OK, as are ETT, LMA, and tape)

Pediatric Airway

The tongue is relatively larger, thus making a disproportionate contribution to airway obstruction and moving the glottis anteriorly (especially in children with craniofacial abnormalities, NMJ or CNS disease, tumors, hemangiomas, or URIs). Flexion of an infant’s head may collapse the airway

Pediatric patients often have less pulmonary reserve than adults, and require significantly more oxygen intake, thus they are prone to apnea during direct laryngoscopy

The larynx in infants is located at C3-4 (as opposed to C4-5 in adults). The infant epiglottis is large but short and narrow, possibly making a direct view of the larynx easier than in an adult. Note that the posterior commissure is relatively cephalad, predisposing the anterior sublaryngeal airway to trauma from the ETT. The narrowest portion of the infant airway is the cricoid cartilage, which can lead to resistance after passing an ETT through the cords

Cuffed vs. Uncuffed ETT

In 2009 a multicenter study comparing Microcuff tubes to uncuffed tubes in 2246 children showed that rates of tube exchange were 2.1% with cuffed compared with 30.8% for conventional tubes (p < 0.0001), and that rates of post-extubation stridor were equal in both groups. Furthermore, the cuff significantly improved the accuracy of the ET monitor. Anesthesia providers could ventilate with an average cuff pressure of 10 cm H20 [Weiss M et al. Br J Anaesth 103: 867, 2009].

Pediatric Endotracheal Tube Size

Age Internal Diameter (mm) Depth (cm)
Preterm 2.5 6 – 8
Term 3.0 9 – 10
6 months 3-3.5 10
1 – 2 years 4.0 10 – 11
3 – 4 years 4.5 12 – 13
5 – 6 years 5.0 14 – 15
10 years 6.0 16 – 17

Pediatric Endotracheal Tube Depth

For preemies and neonates (cm) = weight (in kg) + 6 For 1 year or older (cm) = age + 10 cm

Pediatric Airway Equipment

Age Miller Blade
< 32 weeks 00
Term 0 (< 3 kg)
3-18 mo. 1 (3-10 kg)
> 18 mo 2 (> 12 kg)

Pediatric LMA Size

LMA sizes ~ weight (kg) / 20 + 1 (round to nearest 0.5)

Organ Systems


Fetal circulation displays 1) increased PVR 2) decreased Qpulm 3) decreased SVR 4) RtoL shunting through foramen ovale. Hypoxemia or acidosis in the newborn can cause a return to fetal circulation

Neonatal hearts are relatively non-compliant and thus stroke volume is relatively fixed – they rely entirely on heart rate to manage cardiac output

Murmurs, abnormal heart sounds, dysrhythmias, and cardiomegaly are all important when noted in a newborn. EKG, CXR, and echo are therefore often required

Normal Physiologic Variables

Age BP (mmHg) HR (/min) RR (/min) Hct (%)
1 kg 45/30 120 – 180 40 – 50
2 kg 55/35 110 – 180 40 – 50
3 kg 65/40 100 – 180 40 – 60 45 – 65
Neonate 75/45 100 – 180 35 – 55 45 – 65
6 mo. 85/50 80 – 180 30 – 50 30 – 40 (nadir)
1 year 95/55 80 – 130 20 – 30 34 – 42
10 year 110/60 60 – 100 20 35 – 43
Adult 110/60 60 – 100 15 40 – 50


Hypotension is a late finding in pediatric patients (children may maintain a normal blood pressure until 35% of blood volume is lost). Tachycardia is sensitive but not specific indicator. Prolonged capillary refill (> 2 seconds), especially when combined with tachycardia, is more specific, although it may be difficult to measure. Cold skin and decreased urine output may be present. Weak pulses, mottling, cyanosis, and impaired consciousness may all precede hypotension. In fact, hypotension is an ominous sign in pediatric patients

Hypovolemia in Pediatrics: Signs

  • Tachycardia: sensitive but not specific. Resolution may help guide therapy
  • Delayed Capillary Refill: specific if > 2 seconds
  • Others: weak pulses, mottling, cyanosis, and impaired consciousness (may all precede hypotension), cold skin, decreased urine output
  • Hypotension: late finding. OMINOUS



The lung is not fully formed at birth, and increases from 20 MM alveoli to 300 MM by 18 months of age. Newborn ribcages are particularly compliant and have a circular (non-ellipsoid) configuration as well as a horizontal (non-oblique) insertion of the diaphragm, all of which lead to inefficient diaphragmatic contraction. Worse, full-term infant diaphragms only have 25% type I (slow twitch) fibers, as opposed to 55% in adults

FEN/Renal System


Newborns have decreased GFR, decreased ability to excrete solid material, and decreased ability to concentrate urine (ie conserve water). Adult values of GFR are reached between 12 and 24 months of life

Age (weeks) Urine Output (ml/h)
20 5 cc/hr
30 18 cc/hr
40 50 cc/hr

This limited renal resorptive function explains the “physiologic” decrease in bicarbonate (and corresponding acidosis) in newborns (pH 7.26-7.29 at birth, 7.37 at 24h, 7.40 at 1 week)

Estimated blood volume changes with age – at term, the body is 78% water, and adult proportions are not reached until between 9 and 24 months.

Infants have higher plasma chloride and lower bicarbonate (and pH). In the first ten days of life, normal K values may be as high as 6.5 mEq/L. This drops to 3.5-5.5 mEq/L after 2-3 weeks of life. Water exchange is also negative during the first week of life due to limited intake. Infants are at high risk for both over and under hydration


Maintenance Requirements in Children

Weight (kg) Maintenance Requirements in Children (mL/hour)
0-10 4 (mL/kg)
11-20 40 + 2 (mL/kg)
> 20 kg 60 + 1 (mL/kg)

Replacement of Losses

Procedure Insesnsible losses
Non-invasive (inguinal hernia, clubfoot) 0-2 cc/kg/hr
Mildly invasive (uteteral reimplantation) 2-4 cc/kg/hr
Moderately invasive (bowel reanastamosis) 4-8 cc/kg/hr
Significantly invasive (NEC) > 10 cc/kg/hr


Intraoperative Glucose Infants: 4 mg/kg/min = 240 mg/kg/hr maintenance requirements D5 = 50 mg/mL Delivery of D5 @ > 4 mL/kg/hr may lead to hyperglycemia


At birth, full term infants have 18-20 g/dL of hemoglobin, 75% of which is HgF (which normalizes by 3-6 months). Hgb will naturally decrease as the infant progresses, reaching a nadir as low as 9-10 g/dL (avg 11.2 g/dL) around 2 months of age [Harriet Lane, 16th ed. CV Mosby, 2002]. In premature infants, however, the nadir may be as low as 6-7 g/dL at 3 or 4 months of age

Cross matched blood should be available for newborn surgery. Assessment of clotting function should be considered because prothrombin as well as factors II, VII, and X are limited in young livers


Caudal Block

  • Equipment: 22g B-bevel needle (or angiocath)
  • Drugs: 0.25% bupivacaine or 0.2% ropivacaine +/- morphine 25 ucg/kg or hydromorphone 6 ucg/kg
  • Desired level and volume:
    • Sacral Block: 0.5 ml/kg
    • Midthoracic Block: 1.25 ml/kg

Complicating Issues in Peds

Upper Respiratory Tract Infection

Children recovering from URI are at increased risk for respiratory complications. For short procedures via mask, the increased risk is minimal. If reactive airways accompany the infection, the effects of URI may last 2-7 weeks. In particular, those who already have asthma, bronchopulmonary dysplasia, < 1 yoa, sickle cell, or live in a household of smokers are at high risk, suggesting a “two hit” phenomena [Tait et. al. Anesthesiology 95: 299, 2001]. Bronchial hyperreactivity may last as long as 7 weeks after URI [Collier et. al. Am Rev Resp Dis 117: 47, 1978]. Note that in these patients MASK anesthetics have significantly lower complications than LMA or ETT

If an ETT tube is required, the risk of anesthesia in an infant can be increased as much as 10-fold when compared to an infant with no URI and which does not require ETT. Risk of an LMA are about halfway between those of a facemask and an ETT

Postoperative Croup (< 3 hrs after extubation)

IV decadron 0.25 – 0.5 mg/kg Racemic epinephrine 0.25-0.5 mL of 2.25% solution in 2.5 ml NS

Outpatient Surgery

Inguinal herniorrhaphy, hypospadias repair, and various orthopedic procedures are performed on an outpatient basis in the pediatric population. LMA + caudal block (1 mg/kg 0.125-0.25% bupivacaine) can provide excellent postoperative pain control and lower the anesthetic requirements. A more dilute anesthetic may be used to maintain ambulation

Ex-Premature Infant

Post-operative apnea is always a concern, however it is impossible to fully develop a monitoring protocol [Cote et. al. Anesthesiology 82: 809, 1995]. Apnea is rare after 48 weeks of conceptual age, but the incidence is not zero. The decision of whether or not to admit an ex-premature infant s/p surgery must be individualized. The most conservative approach would be to admit all infants younger than 60 weeks post-conception but this is often impractical. Note that many of these children have chronic lung conditions that last as many as ten years (mostly secondary to reactive airway disease). Hepatic and renal function, as well as developmental delay may also occur.

Cote combined data from eight prospective studies (255 patients) to develop an algorithm based on gestational age, post-conceptual age, apnea at home, size at gestational age, and anemia [Cote CJ et. al. Anesthesiology 82: 809, 1995]. Cotes data showed that the incidence of apnea following inguinal hernia repair did not fall below 5% until gestational age reached 35 weeks and post-conceptual age reached 48 weeks, and that the incidence of apnea following inguinal hernia repair did not fall below 1% until gestational age reached 32 weeks and post-conceptual age reached 56 weeks (or post-gestational 35 weeks with post-conceptual 54 weeks). Any infant that exhibits apnea, has a history of apnea, or is anemic, should not undergo outpatient surgery.


Maintenance Requirements in Children

Weight (kg) Maintenance Requirements in Children (mL/hour)
0-10 4 (mL/kg)
11-20 40 + 2 (mL/kg)
> 20 kg 60 + 1 (mL/kg)

Replacement of Losses

Procedure Insesnsible losses
Non-invasive (inguinal hernia, clubfoot) 0-2 cc/kg/hr
Mildly invasive (uteteral reimplantation) 2-4 cc/kg/hr
Moderately invasive (bowel reanastamosis) 4-8 cc/kg/hr
Significantly invasive (NEC) > 10 cc/kg/hr

Intraoperative Glucose

Infants: 4 mg/kg/min = 240 mg/kg/hr maintenance requirements D5 = 50 mg/mL Delivery of D5 @ > 4 mL/kg/hr may lead to hyperglycemia

Medications for Children

Preoperative Medication in Children

PO Nasal IV IM
Midazolam 0.5 – 1.0 mg/kg 0.05 – 0.10 mg/kg
Fentanyl 1 – 3 ucg/kg
Morphine 0.05 – 0.10 mg/kg
Sufentanil 0.25 – 0.5 ucg/kg
Ketamine 2-4 mg/kg 4-6 mg/kg

Resuscitation Medication in Children

  • Epinephrine = 10-100 ucg/kg for arrest (100 ucg/kg in ETT), 1-4 ucg/kg for hypotension
  • Atropine = 0.01 – 0.02 mg/kg (0.3 mg/kg in ETT) – actual dose 0.1 – 1 mg
  • Adenosine = 0.1 mg/kg (max dose 6 mg)
  • Lidocaine = 1-1.5 mg/kg
  • SCh = 2-3 mg/kg
  • Rocuronium 1 mg/kg
  • Calcium chloride = 10-20 mg/kg (dilute to 10 mg/cc or else veins will sclerose, try to give centrally if possible)
  • Bicarbonate = 1 mEq/kg (dilute to 1 mEq/cc or else veins will sclerose)
  • Naloxone = 0.1 mg/kg
  • DEFIBRILLATION = 2 J/kg (can increase up to 4 J/kg)

Preoperative Medication in Children

  • Midazolam 0.05-0.1 mg/kg IV (0.5-1 mg/kg PO, 15 mg max)
  • Methohexital 1-2 mg/kg IV (25-30 mg/kg PR, 500 mg max)
  • Ketamine 1-2 mg/kg IV, 10 mg/kg IM, 5-8 mg/kg PO
  • Sodium Pentothal 1-2 mg/kg IV (separation), 4-6 mg/kg IV (induction)
  • Propofol 0.1-1 mg/kg IV (separation), 2-4 mg/kg IV (induction)
  • Etomidate 0.2-0.3 mg/kg IV

Antibiotic Doses in Children

  • Cefazolin 25 mg/kg q6-8h up to 1-2 grams
  • Cefotaxime 20-30 mg/kg q6h
  • Ampicillin 50-100 mg/kg q6h up to 3 grams
  • Gentamicin 2-2.5 mg/kg q8h (must monitor serum levels, longer interval in renal impairment)
  • Clindamycin 5-10 mg/kg q6-8h up to 900mg
  • Mezlocillinn 50-100 mg/kg q6h up to 2g
  • Vancomycin 10 mg/kg q6h up to 1g

Other Useful Medication in Children

  • Glycopyrrolate 0.01 mg/kg IV, IM, ETT (max 0.4 mg)
  • Morphine 0.05 – 0.1 mg/kg IV (max 0.4 mg/kg)
  • Fentanyl 1-5 ucg/kg IV
  • Ketorolac 0.5 mg/kg IV
  • Tylenol 20 mg/kg PO, 40 mg/kg PR, IV 10-15mg/kg
  • Zofran 0.05-0.15 mg/kg
  • Droperidol 20-25 ucg/kg
  • Dexamethasone 0.1-0.5 mg/kg for pain, N/V prophylaxis
  • Neostigmine 0.07 mg/kg
  • Dexamethasone 0.5-1 mg/kg for tracheal edema
  • Solumedrol 1 mg/kg IV
  • Dexmedatomidine (Precedex) 0.3-0.5mcg/kg slowly at end of case prophylaxis for emergence delerium


Smith’s Anesthesia for Infants and Children, 8th Edition. Chapters 5, 30, 39 (TABLE 30-5)


G E Rasmussen, C M Grande Blood, fluids, and electrolytes in the pediatric trauma patient. Int Anesthesiol Clin: 1994, 32(1);79-101 [PubMed:8144255]

Insulin Pumps and Infusions

Insulin Action Review!
Insulin Action Review!


Nice quick reference from the Joslin Diabetes Center and Clinic on management of perioperative blood glucose in patients undergoing surgery, a few things to note:

  • Insulin pumps can be maintained at basal rate throughout surgery
  • Maintenance IVF need NOT have dextrose
  • If starting insulin infusion, give fluids with a substrate, e.g. D5W at 40 ml/hr or D10W at 20 ml/hr
  • if MAJOR surgery start infusion and track throughout case (a line)
  • i/o generally check BG every 2hrs
  • 24hr glucose if on infusion should be 50g
  • Protocols vary by institution for bolus/infusion rates, generally follow local guides (this sheet has one)

See: http://www.joslin.org/Inpatient_Guideline_10-02-09.pdf for more details!