Paediatric Anaesthetic Emergency Data Manual PDF

PAEDIATRIC
ANAESTHETIC
EMERGENCY
DATA MANUAL
JAMES ARMSTRONG
HANNAH KING
CAMBRIDGE Medicine
18:28:28, subject to the Cambridge Core terms of use

CONTENTS
PAGE
• Preface 2
• Age-Per-Page guidelines 3
• Paediatric Cardiac Arrest Algorithm 20
A
• Newborn Cardiac Arrest Algorithm 21
R • Peri-Arrest Algorithms
R • Bradycardia 22
E • SVT 23
S • VT 24
• Peri-Arrest Drugs 25
T
• Treatment of Hyperkalaemia 26
T • Massive Haemorrhage 27
R
• Traumatic Brain Injury 28
A
U
• Children’s GCS 28
M • Burns 30
A • Radiology Guidelines 31
A
• Difficult Mask Ventilation 33
• Unanticipated Difficult Intubation 34
N
• Can’t Intubate, Can’t Ventilate 35
A • Malignant Hyperthermia 36
E • IV Dantrolene dosing 37
S • Severe Local Anaesthetic Toxicity 38
T • IV Intralipid dosing 39
H • Pain Management Guidelines 40
E • Antiemetics 41
T • Fluid Management 42
• Congenital Cardiac Disease 44
I
• CCD for Non-Cardiac Surgery 45
C • Common Syndromes & Congenital Conditions 46
M
• Anaphylaxis 54
E • Airway Emergencies 55
D • Septic Shock 56
I • Status Epilepticus 57
C • Life-threatening Asthma 58
A • Diabetic Ketoacidosis 59
L • DKA associated Cerebral Oedema 60
• Formulary 61
• Steroid replacement therapy 62
• Notes 65
• References 66

PREFACE
Anaesthetising children can be daunting for the trainee or non-specialist Consultant Anaesthetist.
The management of paediatric emergencies requires the rapid recall of multiple formulae,
drug doses and management guidelines for a multitude of clinical conditions. To provide
evidence-based care, clinicians require rapid access to national guidelines presented in a format
that enables easy comprehension and application to the clinical scenario.
This book began as a compilation of local treatment guidelines, collated for our anaesthetic
trainees. It quickly grew as new sections were added, becoming, we feel, a comprehensive
companion for dealing with paediatric emergencies. The aim of the book is to allow confident
patient management by non-specialist clinicians in stressful situations without needing to remem-
ber formulae, reducing potentially harmful errors.
The book is a collection of 23 flow chart management plans for life-threatening paediatric
crises. Topics included in the emergency management guidelines section are:-
• Cardio-pulmonary arrest – Including management of peri-arrest arrhythmia.
• Trauma – Traumatic head injury, massive haemorrhage and burns.
• Anaesthesia – Airway management algorithms, malignant hyperpyrexia, local anaesthetic
toxicity, analgesia and fluid management, anaesthetic implications of 50 common conditions
and syndromes.
• Medicine – Anaphylaxis, asthma, status epilepticus, sepsis and diabetic ketoacidosis.
The ‘age-by-page’ section provides pre-calculated drug doses and equipment selections for
children from birth to 12 years, ensuring rapid data access and reducing potentially harmful
errors.
This is not a textbook of paediatric anaesthesia. It is a comprehensive compendium covering
the management of a wide range of paediatric emergencies which provides a succinct summary of
management plans for trainees in many paediatric specialties.
We would like to acknowledge the contributions made by three anaesthetic trainees (Joy
Abbott, Helen Fenner and Katherine James) to the original local guidelines book and also to
Andrew Wignell (Paediatric pharmacist) who has checked all of the medication doses used and
our calculations.

.001
AGE : TERM
Wt : 3 – 3.5 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 80
A
OP Airway : Size : 000 ET Tube :
I
R Diameter : Cuffed: 2.5 – 3.0
W Uncuffed: 3.0 – 3.5
A LMA : Size : 1 Length (Oral) : 9 – 10 cm
Y
C
IV – Arrest
Defibrillation (4 J/kg) 20 J (10 microgram/kg)
0.4 mL (1 in 10,000)
A
R Atropine 100 microgram IM – Anaphylaxis
D (min) Adrenaline 0.4 mL (1 in 10,000)
(20 microgram/kg) (10 microgram/kg)
I
A Amiodarone 18 mg Nebulised – Croup 1.4 mL (1 in 1,000)
C (5 mg/kg) (0.6 mL of minijet) (400 microgram/kg)
F Crystalloids : Trauma (10 mL/kg): 35 mL Blood, FFP or

L Other (20 mL/kg) : 35 mL
70 mL Platelets (10 mL/kg)
U
I 10% Dextrose : (Hypoglycaemia) Mannitol 20% 4 – 8 mL
D 7 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)
Calculated Dose Volume to be

Drug (Dose) Neat or Dilution (mg/mL)
(3.5 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 3 – 15 mg 0.3 – 1.5 mL
Ketamine IV (2 mg/kg) NEAT (10 mg/mL) 7 mg 0.7 mL
D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 4 - 7 microgram 0.4 – 0.7 mL
R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 0.3 mg (Repeat PRN) 0.3 mL

Paracetamol IV (10 mg/kg) NEAT (10 mg/mL) 35 mg 3.5 mL
U
Suxamethonium (2 mg/kg) Dilute to 10 mg/mL 7 mg 0.7 mL
G
Rocuronium (1 mg/kg) NEAT (10 mg/mL) 3.5 mg 0.35 mL
S
Atracurium (0.5 mg/kg) NEAT (10 mg/mL) 2 mg 0.2 mL
Sugammadex (16 mg/kg) NEAT (100 mg/mL) 50 mg 0.5 mL
Tranexamic Acid (15 mg/kg) NEAT (100 mg/mL) 50 mg 0.5 mL
10% Calcium Chloride (0.2 mL/kg) NEAT 0.7 mL 0.7 mL
I Drug To Make Up in 50 mL Infusion Rate

N
F
Propofol (4 – 12 mg/kg/hr) NEAT (10 mg/mL) 2 – 6 mL/hr
U
S
Morphine (10 – 40 microgram/kg/hr) 3.5 mg (1 mg/kg) 0.5 – 2 mL/hr (1 mL/hr = 20 microgram/kg/hr)
I
Midazolam (60 – 240 microgram/kg/hr) 21 mg (6 mg/kg) 0.5 – 2 mL/hr (1 mL/hr = 120 microgram/kg/hr)
O
N Noradrenaline / Adrenaline 1 mg (0.3 mg/kg)
S
0.1 – 5 mL/hr (1 mL/hr = 0.1 microgram/kg/min)
(0.01 – 0.5 microgram/kg/min) in 5% Dextrose
3
.002
AGE : 3 months
Wt : 4 – 6 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 80
A
I
R Diameter : Cuffed: 2.5 – 3.0
A LMA : Size : 1 Length (Oral) : 11 cm
Y
C
IV – Arrest
0.5 mL (1 in 10,000)
A
R Atropine IM – Anaphylaxis
D
110 microgram Adrenaline 0.5 mL (1 in 10,000)
I

U
D 12 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(5.5 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 5 – 20 mg 0.5 – 2 mL
Ketamine IV (2 mg/kg) NEAT (10 mg/mL) 10 mg 1 mL
D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 5 – 10 microgram 0.5 – 1 mL

Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 80 mg 8 mL
U
Suxamethonium (2 mg/kg) Dilute to 10 mg/mL 10 mg 1 mL
G
Rocuronium (1 mg/kg) NEAT (10 mg/mL) 5 mg 0.5 mL
S
Atracurium (0.5 mg/kg) NEAT (10 mg/mL) 2.5 mg 0.25 mL

N
F
U
S
I
O
N Noradrenaline / Adrenaline 1.5 mg (0.3 mg/kg)
S
4
.002
AGE : 6 months
A
I
R Diameter : Cuffed: 3.0
W Uncuffed: 3.5
A LMA : Size : 1.5 Length (Oral) : 12 cm
Y
C
IV – Arrest
0.7 mL (1 in 10,000)
A
D
I

U
D 14 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(7 kg) given (mL)
D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 7 – 15 microgram 0.7 – 1.5 mL

U
G
S
Tranexamic Acid (15 mg/kg) NEAT (100 mg/mL) 100 mg 1 mL

N
F
U
S
Morphine (10 – 40 microgram/kg/hr) 7 mg (1 mg/kg) 0.5 – 2 mL/hr (1 mL/hr = 20 microgram/kg/hr)
I
O
S
5
.002
AGE : 9 months
A
I
Y
C
IV – Arrest
0.8 mL (1 in 10,000)
A
D
I

U
D 17 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(8.5 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 8.5 – 35 mg 1 – 3.5 mL
D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 10 – 20 microgram 1 – 2 mL

U
G
S

N
F
U
S
I
O
S
6
.002
AGE : 1 year
A
OP Airway : Size : 00 – 0 ET Tube :
I
W Uncuffed: 4.5
A LMA : Size : 2 Length (Oral) : 12.5 cm
Y
C
IV – Arrest
1.0 mL (1 in 10,000)
A
D
I

U
D 20 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(10 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 10 – 40 mg 1 – 4 mL
R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1 mg (Repeat PRN) 1 mL

U
G
Rocuronium (1 mg/kg) NEAT (10 mg/mL) 10 mg 1 mL
S
10% Calcium Chloride (0.2 mL/kg) NEAT 2 mL 2 mL

N
F
U
S
I
O
S
7
.002
AGE : 18 months
A
I
W Uncuffed: 4.5
A LMA : Size : 2 Length (Oral) : 12.5 – 13 cm
Y
C
IV – Arrest
1.1 mL (1 in 10,000)
A
D
I

U
D 22 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(11 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 10 – 45 mg 1 – 4.5 mL

U
G
S

N
F
U
S
I
O
S
8
.002
AGE : 2 years
A
I
W Uncuffed: 5.0
Y
C
IV – Arrest
1.2 mL (1 in 10,000)
A
D
I

U
D 24 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(12 kg) given (mL)

U
G
S
Sugammadex (16 mg/kg) NEAT (100 mg/mL) 200 mg 2 mL

N
F
U
S
I
O
S
9
.002
AGE : 3 years
A
I
W Uncuffed: 5.0
A LMA : Size : 2 Length (Oral) : 13cm
Y
C
IV – Arrest
1.4 mL (1 in 10,000)
A
D
I
C (5 mg/kg) (2.3 mL of minijet) (400 microgram/kg) (max)

U
I 10% Dextrose : (Hypoglycaemia) Mannitol 20% 17.5 – 35 mL
D 28 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(14 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
10
.002
AGE : 4 years
A
I
W Uncuffed: 5.5
Y
C
IV – Arrest
1.6 mL (1 in 10,000)
A
D
I

U
D 32 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(16 kg) given (mL)

U
G
S
Atracurium (0.5 mg/kg) NEAT (10 mg/mL) 10 mg 1 mL

N
F
U
S
I
O
S
11
.002
AGE : 5 years
A
I
W Uncuffed: 5.5
A LMA : Size : 2 – 2.5 Length (Oral) : 14.5 cm
Y
C
IV – Arrest
1.8 mL (1 in 10,000)
A
D
I
C (5 mg/kg) (3 mL of minijet) (400 microgram/kg) (max)

U
I 10% Dextrose : (Hypoglycaemia) Mannitol 20% 22.5 – 45 mL
D 36 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(18 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
12
.002
AGE : 6 years
A
I
W Uncuffed: 6.0
Y
C
IV – Arrest
2.5 mL (1 in 10,000)
A
D
I

U
D 50 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(25 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
13
.002
AGE : 7 years
A
I
W Uncuffed: 6.0
Y
C
IV – Arrest
2.8 mL (1 in 10,000)
A
D
I

U
D 56 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(28 kg) given (mL)
Propofol (1 – 4 mg/kg) NEAT (10 mg/mL) 30 – 115mg 3 – 11.5 mL
D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 30 – 55 microgram 3 – 5.5 mL

U
G
S

N
F
U
S
I
O
S
14
.002
AGE : 8 years
A
I
W Uncuffed: 6.5
Y
C
IV – Arrest
3.0 mL (1 in 10,000)
A
D Adrenaline 0.3 mL (1 in 1,000)
(20 microgram/kg) (max) (10 microgram/kg)
I

U
D 60 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(30 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
15
.002
AGE : 9 years
A
I
W Uncuffed: 6.5
A LMA : Size : 2.5 – 3 Length (Oral) : 16.5 cm
Y
C
IV – Arrest
3.4 mL (1 in 10,000)
A
D (max) Adrenaline 0.34 mL (1 in 1,000)
I

U
D 68 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(34 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
16
.002
AGE : 10 years
A
I
W Uncuffed: 7.0
Y
C
IV – Arrest
3.7 mL (1 in 10,000)
A
I

U
D 74 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(37 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
17
.002
AGE : 11 years
A
I
W Uncuffed: 7.0
Y
C
IV – Arrest
4.0 mL (1 in 10,000)
A
I

U
D 80 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(40 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
18
.002
AGE : 12 years
A
I
W Uncuffed: 7.5
Y
C
IV – Arrest
4.3 mL (1 in 10,000)
A
D (max) Adrenaline 0.43 mL (1 in 1,000)
I

U
D 86 mL (0.25 – 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S (2 mL/kg)

(43 kg) given (mL)

U
G
S

N
F
U
S
I
O
S
19
.002
PAEDIATRIC CARDIAC ARREST ALGORITHM
Open Airway & Give 5 Rescue Breaths

Check for Signs of Life
Take no more than 10 sec
Commence CPR
15:2
(Rate 100 – 120)
VF Asystole
Assess
Shockable Non-Shockable
Pulseless Rhythm PEA
VT
Adrenaline
DC Shock immediately &
4 J/kg then every 4 min
10 microgram/kg
IV or IO
Consider
4 Hs & 4 Ts Consider
Co
4 Hs & 4 Ts
Continue CPR Continue CPR

for 2 min for 2 min
Adrenaline after 3rd DC shock 4 Hs & 4 Ts

& then every alternate DC
shock Hypoxia Tamponade
10 microgram/kg IV or IO Hypovolaemia Toxic/Drugs
Hyperkalaemia Thromboembolic
Hypothermia Tension
Amiodarone after 3rd & 5th DC Pneumothorax
shocks only
5 mg/kg IV or IO
20
.003
NEWBORN CARDIAC ARREST ALGORITHM
Dry the baby A

Remove any wet towels & cover Birth
Start the clock or note the time R
R
GET E
Assess tone, breathing & heart rate S
30 sec
T
If gasping or not breathing:

Open the airway !
60 sec
Give 5 inflation breaths
Consider SpO2 monitoring
Re-assess
If no increase in heart rate
Look for chest movement HELP
If chest not moving: Acceptable pre-

ductal SpO2
Re-check head position
2 min 60%
Consider 2-person airway control & adjunct 3 min 70%
Repeat inflation breaths 4 min 80%
Look for a response 5 min 85% !
10 min 90%
When the chest is moving:

If HR is not detectable or slow (<60 bpm)
Start chest compressions 3:1
EARLY
Reassess HR every 30 sec

If HR is not detectable or slow (<60 bpm)
Consider venous access & drugs
21
.004
MANAGEMENT OF BRADYCARDIA
Bradycardia = HR <60 bpm or a rapidly falling HR with poor systemic perfusion

A
R
R
E
Shock
YES NO
S
Present?
T
Treat hypoxia Monitor &
Seek senior
& shock
advice
Vagal over If hypoxia & shock:

YES • High flow O2, intubation & ventilate
activity? • Volume expansion (20 mL/kg 0.9%
saline)
• If the above is ineffective give a bolus
ATROPINE of adrenaline 10 microgram/kg IV
NO (maximum dose 1 mg)
20 microgram/kg • If that is ineffective, commence an
infusion of adrenaline 0.05 – 2
microgram/kg/min IV
ADRENALINE If vagal stimulation:

10 microgram/kg • Treat with adequate ventilation.
• Give atropine 20 microgram/kg IV/IO
(minimum dose 100 micrograms
maximum dose 600 micrograms)
• The dose may be repeated after 5
Consider: min (maximum total dose of 1 mg in a
• Adrenaline infusion child and 2 mg in an adolescent).
• Pacing • If IV/IO access is unavailable,
atropine (40 microgram/kg) may be
administered tracheally, although
absorption into the circulation may be
unreliable
If poisoning, seek expert

toxicology help
22
.005
MANAGEMENT OF SVT
SVT in infants generally produces an HR > 220 bpm, and often 250 – 300 bpm
Shock
YES NO
Present?
Vagal
manoeuvre Vagal
(if no delays) manoeuvre
Establishing IV
access quicker ADENOSINE
than obtain YES 100 microgram/kg
defibrillator?
2 min
ADENOSINE
200 microgram/kg
NO
2 min
Synchronous DC ADENOSINE
(consider sedation) 300 microgram/kg
Shock 1 J/kg
Consider:
Synchronous DC ADENOSINE
(consider sedation) 400 – 500 micrograms/kg
Shock 2 J/kg (max 12 mg)
Synchronous DC shock
Or AMIODARONE
Consider Or other antiarrhythmics
AMIODARONE
23
.005
MANAGEMENT OF VT
Pulse
VF Protocol NO
Present?
YES
Shock
NO YES
Present?
AMIODARONE DC shock 1 J/kg

5 mg/kg (consider sedation)
Over 30 min
Consider:
Synchronous DC DC shock 2 J/kg
shock (consider sedation)
Seek advice
Amiodarone
Consider the following causes:

• Congenital heart disease
• Poisoning with tricyclic antidepressants, procainamide or quinidine
• Renal disease or another cause of hyperkalaemia
• Long QT syndrome
24
.005
PERI-ARREST DRUGS (1)
INDICATION ROUTE AGE/WEIGHT CAUTION
ADENOSINE IV bolus Birth – 12 yrs 12 – 18 yrs Heart block

Anti-arrhythmic 100 microgram/kg 3 mg Sick sinus
to terminate SVT Asthma
& to elucidate Increase after 2 min 6 mg Prolonged
mechanism to 200 microgram/kg then QT
of tachycardia 300 microgram/kg 12 mg
ADRENALINE IV bolus 1 month – 12 yrs 12 – 18 yrs

CPR 10 microgram/kg 1 mg
Low CO IV infusion 0.01 – 1 microgram/kg/min
AMIODARONE IV loading Birth – 18 years

Arrhythmias dose 5 mg/kg over 20 – 30 min (max dose 300 mg)
(if CPR give over 3 min)
IV infusion 300 microgram/kg/hr Do not

(max 1.5 mg/kg/hr as needed) exceed 1.2 g
In 5% glucose only in 24 hours
ATROPINE IV bolus Birth – 1 mth 1 mth – 12 yrs 12 – 18 yrs

Pre-intubation dose or 15 microgram/kg 20 microgram/kg 300 microgram – 1 mg
bradycardia induced by (min 100 microgram
vagal stimulation max 600 microgram)
CALCIUM GLUCONATE IV bolus Birth – 18 yrs Tissue

CPR when there is 0.3 mL/kg of 10% solution damage if
electrolyte disturbance or extravasates
septicaemia where there Max dose 20 mL (4.5 mmol)
is hypocalcaemia
FLECAINIDE IV bolus Birth – 18 yrs Avoid in

Treatment of resistant 2 mg/kg pre-existing
re-entry SVT, VEs or VT over 10 min Heart Block
Max dose 150 mg
25
.006
PERI-ARREST DRUGS (2)
INDICATION ROUTE AGE/WEIGHT CAUTION
FLUMAZENIL IV bolus Birth – 12 yrs 12 – 18 yrs Limited

Reversal of acute 10 microgram/kg 200 microgram experience
benzodiazepine overdose max 200 microgram of use in
(repeat as needed, up to 5 times) children
LIDOCAINE IV bolus Birth – 12 yrs 12 – 18 yrs

Antiarrhythmic 1 mg/kg 50 – 100 mg
VF or pulseless VT max 100 mg
Repeat every 5 min to a maximum dose of 3 mg/kg
MAGNESIUM SULPHATE IV bolus Birth – 1 month 1 month – 18 yrs

Treatment of Torsades Not 0.1 – 0.2 mmol/kg
de pointes Recommended max 8 mmol
NALOXONE Birth – 1 mth 1 mth – 12 yrs 12 – 18 yrs

Reversal of opioid IV bolus - 10 microgram/kg 10 microgram/kg
induced central & Then: Then:
respiratory depression 100 microgram/kg 2 mg Short half-
life
IV infusion 10 microgram/kg 5 – 20 microgram/kg/hr
SODIUM BICARBONATE Slow IV Birth – 18 yrs

Prolonged cardiac arrest 1 mL/kg of 8.4%
Followed by 0.5 mL/kg of 8.4% if needed
Metabolic acidosis 1 – 2 mmol/kg
Renal hyperkalaemia 1 mmol/kg
TREATMENT OF HYPERKALAEMIA (K+ > 6.5)

If arrhythmia: 0.5 mL/kg 10% Calcium Gluconate (max 20 mL)
Normal ECG: 2.5 – 10 mg Nebulised Salbutamol & Repeat serum K+
If K+ falling:
- 1 g/kg Calcium Resonium PO/PR & plan dialysis if necessary
If K+ remains high:
- Assess pH: <7.34 1 – 2 mL/kg 8.4% Sodium Bicarbonate & Repeat serum K+
>7.35 5 mL/kg/hr 10% Glucose & 0.05 units/kg/hr Insulin
(5 units/kg Insulin in 50 mL 0.9% saline. 1 mL/hr = 0.1 units/kg/hr)
26
.006
MANAGEMENT OF MASSIVE HAEMORRHAGE
Definition of Massive
Haemorrhage Activate Massive Haemorrhage
• Ongoing severe bleeding &
Protocol
received 20 mL/kg Red Cells or 40 Contact Haematologist (may be initiated by Blood Bank)
mL/kg of any fluid in preceding hour
• Signs of hypovolaemia +/- Haemorrhage
coagulopathy Resuscitate
control
Take blood & send samples to lab (by hand)

Dosing Guide
X Match, FBC, Coagulation, Fibrinogen, U+E, Ca2+ T
Red cells 10 – 20 mL/kg R
FFP/Octaplas 10 – 20 mL/kg A
Platelets 10 – 20 mL/kg Tranexamic Acid U
Cryoprecipitate 5 – 10 mL/kg M
(15 mg/kg IV bolus (max 1 g) then 2 mg/kg/hr infusion)
10% Calcium 0.2 mL/kg A
Chloride
Collect & Transfuse Red Cells (20 mL/kg)
Correct Acidosis & Hypothermia
Transfusion Targets
Hb: 80 – 100 g/L Reassess
Platelets: >75 x 109/L Enquire about available blood results but DO NOT WAIT
PT/PTT : <1.5x normal for results before transfusing
Suspected continued haemorrhage:
Fibrinogen: >1.5 g/L
Collect & Transfuse Pack 2
Ionised Ca2+: >1 mmol/L
Send repeat samples (including ABG, K+, Ca2+)
Transfusion Packs
Pack 1
Patient Still Bleeding?
Send for Transfusion Pack 3
Red Cells 20 mL/kg
(Group specific if possible or O Liaise with Consultant Haematologist
Rh D negative)
Pack 2
Red Cells 40 mL/kg Reassess
FFP 15 mL/kg Check available blood results
Platelets 15 mL/kg
Cryoprecipitate 15 mL/kg Suspected continued haemorrhage:
Pack 3 Transfuse Pack 3
Red Cells 40 mL/kg
Discuss with Consultant Haematologist
FFP 15 mL/kg
Platelets 15 mL/kg Further components require authorisation from
Cryoprecipitate 15 mL/kg Consultant Haematologist
27
.007
MANAGEMENT OF TRAUMATIC BRAIN INJURY (1)
Indicators of severe/time Other indications for intubation

critical injury
• Loss of protective laryngeal reflexes
• GCS <9 • Ventilatory insufficiency:
¾ hypoxaemia (PaO2 < 9 kPa in air or < 13
• Falling GCS
kPa in O2)
• Focal neurological deficit
OR
• Single dilated pupil ¾ hypercarbia (PaCO2 > 6 kPa)
• Depressed/open skull fracture • Spontaneous hyperventilation (PaCO2 < 4 kPa)
• CSF leak • Respiratory irregularity
T
R
A
U
M Children’s Glasgow Coma Scale Glasgow Coma Scale
A ( < 4 years) (4 – 15 years)
Response Score Response Score
Eye opening Eye opening
Spontaneously 4 Spontaneously 4
To verbal stimuli 3 To verbal stimuli 3
To pain 2 To pain 2
No response to pain 1 No response to pain 1
Best verbal/non-verbal response Best verbal response

Alert; babbles, coos words to usual ability
5 Orientated and converses 5
Smiles, fixes & follows
Less than usual words, spontaneous
4 Disorientated and converses 4
irritable cry, consolable
Cries only to pain, inconsolable 3 Inappropriate words 3
Moans to pain. Restless/agitated 2 Incomprehensible sounds 2
Best motor response Best motor response

Spontaneous or obeys verbal command 6 Obeys verbal command 6
Localises to pain or withdraws to touch 5 Localises to pain 5
Withdraws from pain 4 Withdraws from pain 4
Abnormal flexion to pain (decorticate) 3 Abnormal flexion to pain (decorticate) 3
Abnormal extension to pain (decerebrate) 2 Abnormal extension to pain (decerebrate) 2
28
.008
MANAGEMENT OF TRAUMATIC BRAIN INJURY (2)
• Intubate and ventilate

Airway • Oral ETT, secured with tape
& • Aim for: PaCO2 4.5 – 5.0 kPa
PaO2 ≥ 13 kPa
Breathing • C-spine immobilisation if suspected injury
• Aim for: Systolic ≥ 80 + (Age x 2) mmHg
• Adequate intravenous crystalloid resuscitation
Circulation • Continue maintenance fluids
• Noradrenaline if euvolaemic and CPP < (45 + Age) mmHg
• 15 minute neuro observations
• Sedate with Morphine and Midazolam to complete unresponsiveness to
noxious stimuli (see infusions below)
Disability • Maintain paralysis while transferring patient
& • Treat seizures with Phenytoin 20 mg/kg over 20 min (Phenobarbitone in
neonates)
Exposure • Discuss strategy for managing raised ICP with neurosurgeons
(in an emergency consider Mannitol 0.25 – 0.5 g/kg)
• Keep 36 – 37°C, cool if needed. Warm no faster than 0.5°C/hr
• Head up position 15 – 30°
• ICP < 20 mmHg
On-going • CPP > (45 + age) mmHg
Management • Blood glucose 6 – 8 mmol/L
• Serum sodium 140 – 150 mmol/L
• HB > 100 g/L
Drug Bolus dose Dilution for infusion Infusion rate

10 – 40 microgram/kg/hr
Morphine 0.1 mg/kg 1 mg/kg in 50 mL
(1 mL/hr = 20 microgram/kg/hr)
Midazolam 0.1 mg/kg 6 mg/kg in 50 mL
(1 mL/hr = 120 microgram/kg/hr)

Atracurium 0.5 mg/kg Neat (10 mg/mL) (1 mL/hr = (10,000/wt in kg) microgram/kg/hr)

Rocuronium 0.6 mg/kg Neat (10 mg/mL)
(1 mL/hr = (10,000/wt in kg) microgram/kg/hr)
Noradrenaline 0.3 mg/kg in 50mL 0.01 – 0.5 microgram/kg/min

N/A (1 mL/hr = 0.1 microgram/kg/min)
/ Adrenaline of 5% Dextrose
29
.008
MANAGEMENT OF BURNS
When indicated:-
A Indications for intubation
I ¾ Don’t delay, get senior help
R
• Airway burns ¾ Intubate with oral tubes (ideally
W • Inhalational injury cuffed)
A ¾ DON’T cut the ETT
Y
• Reduced or fluctuating conscious level GCS ≤ 8
¾ 100% oxygen until CO levels < 10%
F 4 mL/kg/% BSA
Parkland formula
L ¾ ½ in first 8 hr
(Hartmann’s solution)
U ¾ ½ in next 16 hr
I
PLUS Maintenance fluids (0.9% Saline/5% Dextrose) Aim for urine output > 1 mL/kg/hr
D
S ¾ 4:2:1 rule Treat shock with fluid boluses
O • Manage as trauma (consider C-spine & secondary survey) Indications for transfer to a Burns
T • Check carboxyhaemoglobin levels (normal < 5%) Centre:
H • Access – 2 x large bore IV or IO ¾ Ventilated patients
E • Analgesia – Paracetamol/opiates/Ketamine as indicated ¾ Burn area > 30% BSA
R • Insert NG tube ¾ Burn with poly-trauma
30
.009
RADIOLOGY INFORMATION (1)
Trauma CT Guideline
• Clinical suspicion of non-accidental injury
• Post-traumatic seizure but no history of epilepsy
• GCS < 14 (< 1 yr old GCS < 15) in the ED
• GCS < 15 at 2 hr post injury
Are NICE CT Head criteria • Open or depressed skull injury or tense fontanelle
met? (see blue box on right) • Any sign of basal skull fracture
• Focal neurological deficit
• If < 1 year, head bruise, swelling or laceration of > 5 cm
Any of:
• Loss of consciousness > 5 min
Yes No • Abnormal drowsiness
• Three or more discrete episodes of vomiting
• Dangerous mechanism of injury
• Amnesia (antegrade or retrograde) > 5 min
Any of:
• GCS < 13 on arrival
• Intubated
• Focal peripheral neurology Yes Yes No
• Paraesthesia in upper or lower limbs >1 factor 1 factor
• Other body areas being scanned for
head injury or multi-region trauma No head imaging
required
Yes No
Observe for min 4 hr
Assess for further risk
CT head & C-spine Neck factors:
(patient on scoop) tenderness? • GCS < 15
• Further vomiting
• Further abnormal drowsiness
No
Yes Assess C-spine
CT head only
(patient on scoop)
Any of:
• GCS < 13 on arrival
• Intubated
3-view • Focal peripheral neurology
C-spine X-ray • Paraesthesia in upper or lower limbs
• Other body areas being scanned for
head injury or multi-region trauma
Inadequate views or Adequate views &
abnormal findings normal findings No Yes
CT C-spine only No spine imaging Neck CT C-spine

Yes
(patient on scoop) required tenderness? (patient on scoop)
No
No spine imaging required

31
.010
RADIOLOGY INFORMATION (2)
Abdominal CT Guideline
BLUNT ABDOMINAL INJURY
RADIOLOGIST PERFORMED ULTRASOUND

IN RESUS WITH ONGOING RESUSCITATION
UNSTABLE STABLE
RESUSCITATE
10 mL/kg 0.9% Saline
ACT ON ULTRASOUND RESULTS
STABLE? YES
NO
Free fluid Solid
detected or organ Normal
RESUSCITATE
clinical concern injury scan
10 mL/kg 0.9% Saline or blood
e.g. handlebar
injury or lapbelt
STABLE? YES
NO
CT Abdomen
PAEDS CONSULTANT SURGEON

REVIEW, CONTINUE Hollow Solid organ
RESUSCITATION, PREP FOR organ injury or free
IMMEDIATE LAPAROTOMY injury fluid
Deteriorates clinically, reassess Admit for repeated observation
Only undertake scan if results will affect management plan for that day.
Contraindications (D/W Consultant if emergency):
Urgent MRI • FiO2 > 50%
Guidelines • PEEP ≥ 8
• Unstable cardiovascular status
32 • More than 1 inotrope infusion
.010
UNANTICIPATED DIFFICULT MASK VENTILATION
• Inability to maintain ventilation using face mask

Recognition • Give 100% oxygen
• CALL for HELP
• Optimise head position – chin lift/jaw thrust,

shoulder roll, neutral head position, adjust/remove
cricoid pressure, 2 person BMV
Immediate • Check equipment – circuit, mask, connectors,
management consider using a self-inflating bag
• Increase depth of anaesthesia – propofol 1st line
• Consider CPAP
• Insert oropharyngeal airway

• Treat cause e.g.
A
¾ Light anaesthesia – deepen anaesthesia
N
¾ Laryngospasm – PEEP
2nd stage A
¾ Gastric distension – NG tube E
management • Maintain anaesthesia S
¾ If paralysed, attempt intubation T
• If intubation unsuccessful, proceed to failed H
intubation algorithm E
- Insert supra-glottic airway device (LMA) T
I
¾ not more than 3 attempts
C
- Consider nasopharyngeal airway
Good airway Poor airway

• Continue with • SaO2 > 80% – consider:
3rd stage procedure adjusting/changing LMA,
bronchospasm/pneumothorax
management • SaO2 < 80% – attempt
intubation
¾ Successful – continue
¾ Unsuccessful – proceed to
failed intubation algorithm
33
.011
UNANTICIPATED DIFFICULT TRACHEAL INTUBATION
• Difficult direct laryngoscopy

• Satisfactory mask ventilation & oxygenation
Recognition • Give 100% oxygen & maintain anaesthesia (CPAP &
avoid gastric distension)
• CALL for HELP
• Direct laryngoscopy – Not > 4 attempts
• Optimise head position & laryngoscopy technique
(consider: using bougie, changing blade/ETT size)
• Remove/adjust laryngeal manipulation/cricoid
Immediate pressure
management • Consider inadequate paralysis
• If intubation successful confirm position with
ETCO2 & auscultation
A ¾ If in doubt – Remove ET tube
N FAILED INTUBATION with good oxygenation/mask
A ventilation:
E ¾ CALL for HELP if not arrived
S ¾ Insert supra-glottic airway device (SAD)
T e.g. LMA; 3 attempts max
H ¾ Consider use of indirect laryngoscope if
E experienced in use & available
T
Successful airway with SAD – consider safety of
I proceeding with surgery
C 2nd stage • Safe – proceed with surgery
management • Unsafe – postpone surgery & wake patient up
• If safe – consider 1 attempt of FOI via SAD
Failed oxygenation SaO2 < 90% with FiO2 1.0
• Convert back to MV, optimise positioning,
oxygenate & ventilate, apply CPAP, consider 2 person
BMV, manage gastric distension, reverse non-
depolarising muscle relaxant
¾ Successful – postpone surgery & wake up
¾ Unsuccessful – proceed to “can’t intubate can’t
ventilate” algorithm
34
.012
CAN’T INTUBATE, CAN’T VENTILATE (CICV)
• Failed intubation & inadequate ventilation

Recognition • Give 100% oxygen
• CALL for HELP
• FiO2 1.0, continue to attempt oxygenation &
ventilation
• Optimise head position – chin lift/jaw thrust
Immediate • Insert oropharyngeal airway or SAD
management • Ventilate with a 2 person BM technique
• Insert NG tube, if time permits (prevent gastric
distension)
¾ Wake patient up if SaO2 > 80%
2nd stage • Reverse with suggamadex (16 mg/kg) if
rocuronium/vecuronium used
management • Prepare for rescue techniques if patient
deteriorates
¾ SaO2 < 80% & falling +/- heart rate falling:
Specialist ENT ENT unavailable:
3rd
stage support available: • Percutaneous cannula
• Surgical cricothyroidotomy/transtracheal
management tracheostomy jet ventilation (pressure limited)
• Rigid ¾ Successful – continue at lowest
(Airway bronchoscopy & pressure settings until wake up
Rescue ventilate or definitive airway established
¾ Fail – perform surgical
Techniques) cricothyroidotomy/transtracheal
& insertion of ETT/tracheostomy
tube
Cannula cricothyroidotomy
- Extend neck (roll under shoulders), stabilise larynx with non-dominant hand, access
cricothyroid membrane with a 14/16G cannula aimed in a caudal direction, confirm position
by aspiration of air into saline-filled syringe
- Connect to either adjustable pressure limiting device set to lowest pressure OR O 2
flowmeter (flow (L/min) = child’s age in yr) and a 3-way tap
- Cautiously increase inflation pressure/flow rate to achieve adequate chest expansion. Wait
for full expiration before next inflation & maintain upper airway patency to aid expiration
35
.013
MANAGEMENT OF MALIGNANT HYPERTHERMIA
• Unexplained increase in EtCO2 with tachypnoea AND

Diagnosis • Unexplained tachycardia in non-paralysed patient AND
& • Unexplained increase in oxygen requirement
• Raised temperature often a late sign
Recognition
Previous uneventful anaesthesia does not rule out MH
• STOP all trigger agents

• Call for help
• Get MH box
Immediate • Install clean breathing system & hyperventilate with 100% O2
high flow
management
• Maintain anaesthesia with IV propofol
• Muscle relaxation (Non-depolarising agent)
• Abandon/finish surgery ASAP
• Give Dantrolene DANTROLENE
• Active cooling 2.5 mg/kg bolus
Treat: (Mix 20 mg in 60 mL → 7.5 mL/kg)
• Hyperkalaemia Then: 1 mg/kg repeat boluses
• Arrhythmias up to 10 mg/kg
• Metabolic acidosis Mix vials with water for
Monitoring & injection
• Myoglobinuria
treatment • DIC
Bloods: Monitoring
• CK • Core & peripheral
temperature
• ABG
• EtCO2, SpO2, ECG
• U&E’s & FBC
• Arterial BP & CVP
• Coagulation
• Transfer to Paediatric ICU
• Repeat Dantrolene as required
Follow up • Repeat CK
• Refer to MH unit at St James’s Hospital, Leeds (0113 206
5270. Emergency Hotline: 07947 609601)
36
.014
IV DANTROLENE DOSING FOR MH
1st BOLUS Additional Maximum

WEIGHT (mix 20 mg in 60 mL water BOLUS cumulative dose
for injection)
(Kg)
2.5 mg/kg = 7.5 mL/kg 1 mg/kg = 3 mL/kg 10 mg/kg = 30 ml/kg
1 7.5 mL 3 mL 30 mL
5 37.5 mL 15 mL 150 mL
10 75.0 mL 30 mL 300 mL
15 112.5 mL 45 mL 450 mL
20 150.0 mL 60 mL 600 mL
25 187.5 mL 75 mL 750 mL
30 225.0 mL 90 mL 900 mL
35 262.5 mL 105 mL 1050 mL
40 300.0 mL 120 mL 1200 mL
45 337.5 mL 135 mL 1350 mL
50 375.0 mL 150 mL 1500 mL
55 412.5 mL 165 mL 1650 mL
60 450.0 mL 180 mL 1800 mL
65 487.5 mL 195 mL 1950 mL
70 525.0 mL 210 mL 2100 mL
Remember to include Dantrolene solution volume in child’s total fluid

balance record
37
.014
MANAGEMENT OF SEVERE LOCAL
ANAESTHETIC TOXICITY
CNS: Sudden alteration in mental state or loss of consciousness with or

Diagnosis without seizures
& CVS: Cardiovascular collapse; conduction blocks, sinus bradycardia, asystole
and ventricular tachyarrhythmia
Recognition These may occur some time after injection
• Stop injection of local anaesthetic

• Call for help
Immediate • Give 100% oxygen and ensure adequate lung ventilation
• Confirm/establish venous access
management • Control of seizures: give benzodiazepine or thiopentone or propofol in
small incremental doses
• Monitor cardiovascular status throughout
• Start cardiopulmonary resuscitation as per protocol

• Manage arrhythmias as APLS protocol: may be refractory to standard
treatment
• Prolonged resuscitation may be necessary
• Consider treatment with lipid emulsion (See Page 39):
Local
Anaesthetic- 1. Give an intravenous bolus injection of intralipid 20% 1.5 mL/kg over 1 min
2. Follow immediately with an infusion rate of 15 mL/kg/hr
induced
3. Continue CPR to circulate intralipid
Cardiac 4. Repeat bolus 1 – 2 times at 5 min interval, if inadequate circulation
Arrest persists
Management 5. After another 5 min increase the rate to 30 mL/kg/hr if cardiovascular
stability is not restored or an adequate circulation deteriorates
6. Continue infusion until CVS stability or max. dose of intralipid is given
7. Review infusion rate every 15 – 20 min, reduce & stop when clinical
parameters allow
A maximum total dose of 12 mL/kg is recommended
Report all cases to National Patient Safety Agency and to the Lipid Rescue
site: www.npsa.nhs.uk & www.lipidrescue.org
Follow up If possible take blood samples into a plain tube (red top) & a heparinized
tube (green top) before and after lipid emulsion. Measure lipid and
local anaesthetic levels
38
.015
IV INTRALIPID 20% DOSING FOR LOCAL
ANAESTHETIC-INDUCED CARDIAC ARREST
BOLUS INFUSION Maximum

INFUSION Increase to
WEIGHT cumulative
30 mL/kg/hr
Intralipid 20%
if inadequate
dose
(Kg) Start at:
1.5 mL/kg IV
15 mL/kg/hr circulation
over 1 minute 12 mL/kg
persists
1 1.5 mL 15 mL/hr 30 mL/hr 12 mL
2 3.0 mL 30 mL/hr 60 mL/hr 24 mL
3 4.5 mL 45 mL/hr 90 mL/hr 36 mL
4 6.0 mL 60 mL/hr 120 mL/hr 48 mL
5 7.5 mL 75 mL/hr 150 mL/hr 60 mL
6 9.0 mL 90 mL/hr 180 mL/hr 72 mL
7 10.5 mL 105 mL/hr 210 mL/hr 84 mL
8 12.0 mL 120 mL/hr 240 mL/hr 96 mL
9 13.5 mL 135 mL/hr 270 mL/hr 108 mL
10 15.0 mL 150 mL/hr 300 mL/hr 120 mL
15 22.5 mL 225 mL/hr 450 mL/hr 180 mL
20 30.0 mL 300 mL/hr 600 mL/hr 240 mL
25 37.5 mL 375 mL/hr 750 mL/hr 300 mL
30 45.0 mL 450 mL/hr 900 mL/hr 360 mL
35 52.5 mL 525 mL/hr 1050 mL/hr 420 mL
40 60.0 mL 600 mL/hr 1200 mL/hr 480 mL
45 67.5 mL 675 mL/hr 1350 mL/hr 540 mL
50 75.0 mL 750 mL/hr 1500 mL/hr 600 mL
55 82.5 mL 825 mL/hr 1650 mL/hr 660 mL
60 90.0 mL 900 mL/hr 1800 mL/hr 720 mL
70 100 mL 1000 mL/hr 2000 mL/hr 840 mL
80 120 mL 1200 mL/hr 2400 mL/hr 960 mL
90 135 mL 1350 mL/hr 2700 mL/hr 1080 mL
100 150 mL 1500 mL/hr 3000 mL/hr 1200 mL
39
.015
PAEDIATRIC PAIN GUIDELINES (1)
MORPHINE FENTANYL
N.C.A. NEONATAL up to 12 wks To be used for renal patients requiring
Drug concentration = 10 microgram/kg/mL post-operative intravenous opiates
i.e. 0.5 mg morphine/kg/bodyweight diluted to
50 mL with 0.9% Saline OR
PUMP PROGRAMME
Loading dose = zero
Bolus dose = 0.5 mL Patients with inadequate analgesia
Lockout = 60 min
Background infusion = 0.5 – 1 mL/hr
with morphine
N.C.A. CHILDREN from 13 WEEKS
N.C.A. INFANT – 13 wks to 6 months
Drug concentration = 1 microgram/kg/mL
i.e. 50 microgram/kg bodyweight (max. 2500
i.e. 0.5 mg morphine/kg/bodyweight
microgram) = 1 mL NEAT fentanyl/kg
diluted to 50 mL with 0.9% Saline
PUMP PROGRAMME
bodyweight – diluted to 50 mL with 0.9% Saline
Loading dose = zero PUMP PROGRAMME
Bolus dose = 1 mL Loading dose = zero
Lockout = 30 min Bolus dose = 1 mL
Background infusion = 1 mL/hr Lockout = 30 min
Background infusion = 1 mL/hr
P.C.A. CHILDREN > 6 YEARS
N.C.A. CHILDREN from 6 months
i.e. 50 microgram/kg bodyweight (max. 2500
i.e. 1 mg morphine/kg/bodyweight
microgram) = 1 mL NEAT fentanyl/kg
(max. 50 mg) diluted to 50 mL with 0.9% Saline
PUMP PROGRAMME
bodyweight – diluted to 50 mL with 0.9% Saline
Loading dose = zero PUMP PROGRAMME
Bolus dose = 1 mL Loading dose = zero
Lockout = 30 min Bolus dose = 0.5 mL
Background infusion = 1 mL/hr Lockout = 6 – 10 min
Background infusion = 0.5 mL/hr
P.C.A. CHILDREN > 6 YEARS KETAMINE
i.e. 1 mg morphine/kg/bodyweight
PUMP PROGRAMME Drug concentration = 40 microgram/kg/mL
Loading dose = zero i.e. 2 mg Ketamine/kg bodyweight
Bolus dose = 1 mL
Lockout = 5 min
Background infusion = 0.2 mL/hr PCA
Indications : Pancolitis & risk of toxic megacolon
ORAL MORPHINE
Loading dose = 1 – 2 mL of solution
AGE DOSE INTERVAL Infusion 0 – 1 mL/hr
Bolus 0.5 – 1 mL
< 3/12 50 microgram/kg 6 hourly Lockout 10 – 30 min
Infusion
3/12 – 6/12 50 – 100 microgram/kg 4 hourly
Indications – scoliosis surgery or complex
6/12 – 1 yr 100 microgram/kg 4 hourly analgesia requirements
Loading dose = 1 – 2 mL of solution
1 yr – 2 yr 200 – 400 microgram/kg 4 hourly Infusion 0 – 5 mL/hr
> 2 yr 200 – 500 microgram/kg 4 hourly
Use lower end of dose range if using as codeine Must be discussed with a Consultant
replacement Anaesthetist
40
.016
PAEDIATRIC PAIN GUIDELINES (2)
LOCAL ANAESTHETICS OTHER DRUGS

ANTIEMETICS
EPIDURAL CHILDREN > 13 wks ONDANSETRON
0.15 mg/kg 8 hourly IV or PO Max = 4 mg
Drugs & concentration = 0.1% Levo-bupivacaine
+ Fentanyl 2 microgram/mL DEXAMETHASONE
0.15 mg/kg 8 hourly IV or PO Max = 4 mg
OR Plain 0.125% Levo-bupivacaine
Rate = 0.1 – 0.3 mL/kg/hr (maximum 15 mL/hr) ANALGESICS

PARACETAMOL – PO
EPIDURAL TROUBLE SHOOTING Under 13 weeks: loading dose 20 mg/kg then
20 mg/kg TDS. Max 60 mg/kg daily
1. Block but inadequate analgesia: Increase Over 13 weeks: loading dose 20 mg/kg then
rate within prescribed range OR change to plain 15 mg/kg QDS. Max 90 mg/kg or 4 g daily
L-bupivacaine plus NCA/PCA
PARACETAMOL – INTRAVENOUS
2. Inadequate/no block: Bolus 0.1 mL/kg of Preterm > 32 weeks: 7.5 mg/kg TDS. Max 25 mg/kg
0.25% L – bupivacaine, assess BP every 5 min daily
for 15 min Neonate: 10 mg/kg TDS. Max 30 mg/kg daily
Child body weight <50 kg: 15 mg/kg 4 hourly. Max
3. If NO improvement in block: Change to 60 mg/kg daily
NCA/PCA Child body weight >50 kg: 1 g 4 hourly. Max 4 g daily
Boluses – ONLY by members of anaesthetic IBUPROFEN (NSAID)

department or pain service <5 kg weight = Not recommended
Child over 5 kg body weight: 5 mg/kg QDS
REGIONAL BLOCK & WOUND CATHETERS (10 mg/kg severe pain) Max 2.4 g daily
Drug & concentration = 0.125% L-bupivacaine DICLOFENAC (NSAID)

<6 mths (postoperative pain) - Not recommended
Wound catheter infusions From 6 mths - 1 mg/kg TDS
Child 0 – 8 years - rate 0 – 2 mL/hr Max. daily dose = 150 mg for children >50 kg
Child 9 years and over - rate 0 – 5 mL/hr
NALOXONE – IV OR IM
Paravertebral 4 microgram/kg – stat dose Max 200 microgram
Rate = 0 – 0.2 mL/kg/hr (maximum = 10 mL/hr) (always prescribe with NCA/PCA)
Caudal analgesia CHLORPHENAMINE/PIRITON

Drug & concentration = 0.25% L-bupivacaine 0.1 mg/kg 8 hourly. Max 4 mg (PO) or 5 mg (IV)
Volume = 0.5 – 1.0 mL/kg single shot
Possible caudal additives: 1st choice for treatment of opiate-induced itch is
- Preservative-free S-ketamine: 0.5 mg/kg Ondansetron.
(for children > 12 months of age) Piriton may cause excessive drowsiness with opiates
- Clonidine: 1 microgram/kg
41
.016
FLUID MANAGEMENT (1)
Aim of peri-operative fluids is to replace deficit (starvation/dehydration),

provide ongoing maintenance requirements & replace intra-operative
losses (3rd space/blood loss)
Maintenance fluids
• NPSA alert 2007 – Only isotonic solutions should be used as maintenance fluids. Hypotonic
solutions may result in hyponatraemia due to retention of free water released after metabolism
of dextrose. Children are also prone to exhibiting syndrome of inappropriate anti-diuretic
secretion (SIADH) in response to pain, nausea/vomiting, pyrexia, sepsis, head injury
Pre- and post-operatively

• Appropriate fluid is the isotonic solution: 0.9% saline/5% Dextrose
• Children receiving IV fluids should have daily urea and electrolytes measured and ideally have
their weight checked daily.
• Post-operatively either give full maintenance OR restrict to 60 – 70% of maintenance plus
boluses of isotonic solutions as required to maintain urine output.
Intra-operatively
• The risk of hypoglycaemia developing in healthy children is unusual as blood glucose tends to
increase due to the stress response to surgery.
• Children at risk of hypoglycaemia include: Neonates
Those on TPN
Those with extensive regional analgesia techniques
• These patients should have their blood glucose recorded intra-operatively.
• Neonates should receive 10% Dextrose with added sodium chloride and those on TPN should
have this continued intra-operatively.
• The majority of children do not required Dextrose-containing solutions intra-operatively and
Ringer’s lactate/Hartmann’s solution or 0.9% saline are appropriate solutions.
Formula:
Body weight
Body weight Body weight
Formula 1st 10 kg Total
11 – 20 kg > 20 kg
(0 – 10 kg)
1000 mL + 1500 mL +
Holiday &
50 mL/kg/day 20 mL/kg/day mL per 24
Segar derived 100 mL/kg/day
For 2nd 10 kg For all kg over hours
formula
20 kg
40 mL + 60 mL +
4:2:1 formula 4 mL/kg/hr 2 mL/kg/hr for 1 mL/kg/hr for mL per hour
2nd 10 kg all kg over 20 kg
42
.017
FLUID MANAGEMENT (2)
Correction of fluid deficit

• Minimise fluid deprivation period – safe to have clear fluids up to 2 hours before surgery.
• Fasting deficit = number of hours fluids restricted x hourly maintenance . Replace 50% in
1st hour & 25% in 2nd & 3rd hours (Furman et al 1975)
• Assessment of dehydration from clinical signs is inaccurate. Best method uses difference
between current weight and accurate pre-morbid weight
• Correction of 1% dehydration requires 10 mL/kg of fluid
• Ringers lactate or 0.9% saline are appropriate fluids
Third space losses

• Replace with Ringers lactate or 0.9% saline
• Vary with procedure:
1 – 2 mL/kg/hr Peripheral & neurosurgery
4 – 7 mL/kg/hr Thoracic surgery
6 – 10 mL/kg/hr Abdominal surgery
Up to 50 mL/kg NEC surgery
• Replace NG/stoma losses with 0.9% saline
Blood loss
• Decision made on concept of an allowable blood loss (ABL) and estimated blood volume
(EBV):
• EBV: Neonate 80 – 90 mL/kg; Infant 80 mL/kg; Child 75 – 80 mL/kg; Adult 70 mL/kg
• ABL = EBV x (Hb (start) – Hb (lowest acceptable) )/Hb (start)
• Replace blood loss with crystalloid (ratio 3:1) or colloid (ratio 1:1) until transfusion limit
reached
Treatment of hyponatraemia – Na+ <135 mmol/L
• Early signs are non-specific. Often presents with seizures or respiratory arrest.
• First line treatment is an infusion of 3% saline until seizures stop or Na + >125 mmol/L (1
mL/kg will raise the Na+ by 1 mmol/L)
• Mmol of Na+ required = (130 – present Na+ ) x 0.6 x wt (kg)
• Once Na+ > 125 mmol/L then correction can be slower and fluid changed to 0.9% saline
• The asymptomatic child with a normal or increased fluid status should have their oral or IV
maintenance fluids reduced to 50%
Treatment of hypernatraemia – Na+ >150 mmol/L

• Develops due to restricted water intake, inability to respond to thirst, excessive water loss
or inappropriately made up infant feeds. Symptoms are more severe when hypernatraemia
develops rapidly, chronic hypernatraemia is generally well tolerated
• The degree of dehydration is often underestimated as circulating volume is maintained at
the expense of intracellular water
• Initial management involves a 20 mL/kg bolus of 0.9% saline to restore circulating volume
• Further correction should be done over 48 hours to prevent development of cerebral
oedema. Serum Na+ should not increase by more than 12 mmol/L/day. Maintenance fluids
must be run along-side correction fluids
43
.017
CONGENITAL CARDIAC DISEASE
• Most common birth defect (1 : 125 live births). > 90% survive to adulthood
• Present with the same elective & emergency conditions as other children
• In general, ↑ risk of morbidity, cardiac events and 30-day mortality
Normal Circulation with Shunt Surgical Palliation (Single Ventricle)
e.g. ASD, VSD, PDA
• Blood flows down pressure gradient: Multi-stage generation of ‘in series’ circulation
• L > R : ↑ Pulmonary flow (PBF) & ↓ systemic flow => • Ventricle supplies systemic circulation; pulmonary
systemic acidosis blood flow is via passive systemic venous return
• R > L : ↓ PBF & cyanosis Stage 1 (BT Shunt)
¾ Ensure adequate fluid loading (avoid long starvation) ¾ Most difficult to manage
¾ Minimise disruption to SVR:PVR ratio ¾ Balance between SVR & PVR CRITICAL
¾ Maintain normal/high CO2 & low FiO2
Persistent Parallel Circulation ¾ Monitor SpO2 (70 – 80%) & lactate
Stage 2 (Glenn Shunt)
e.g. Hypoplastic left heart, Complete AVSD ¾ SpO2 in mid-80s
• Pulmonary & systemic circulations freely communicate ¾ Aim to reduce load on RV
• Blood flow dependent on relative resistances in systemic & ¾ Often chronically cyanosed & polycythaemic
pulmonary circulations (SVR & PVR) ¾ Maintain preload & avoid hypovolaemia
¾ Best managed in specialist centre Stage 3 (Fontan Circulation)
¾ Monitor pre- and post- shunt & maintain preload ¾ SpO2 usually normal, ↓ if PVR increases
¾ Maintain SVR:PVR ratio: ¾ Essential that PVR remains low
¾ SVR : ↓with anaesthetics & ↑ with inotropes ¾ Maintain hydration & avoid ventilation if possible
¾ PVR : ↑ - ↓PaO2, ↑PaCO2, Nitrous Oxide ¾ Careful ventilation in long cases (see below)
↓ - ↑PaO2, ↓PaCO2, pharmacology
GENERAL ANAESTHETIC CONSIDERATIONS
INDUCTION:
- IV: Propofol : ↓↓SVR & MAP, ↑Right-to-Left shunt ⇒ ↓ SpO2
Ketamine : Minimal effect on SVR, PVR or MAP. Best agent in Pulmonary Hypertension
- Inhalational : Common choice, avoid prolonged 8% sevoflurane
MAINTENANCE:
- Isoflurane/Sevoflurane : Minimal effect on myocardial contractility or shunt fraction
- Avoid propofol
ANALGESIA:
- Fentanyl (+/- infusion) or regional techniques
OXYGEN:
- High FiO2: ↓PVR; can ↑ Left-to-Right shunt ⇒ ↓systemic perfusion & pulmonary oedema
VENTILATION:
- Consider spontaneous ventilation to aid pulmonary blood flow
- MUST avoid: hypoxia, hypercarbia & atelectasis (which ↑PVR & ↓PBF)
- If ventilating, avoid: High pressures; high PEEP & long inspiratory times
OTHER:
- Slight head-up & raising legs aids venous return & PBF
- Extreme care to avoid air bubbles in lines
44
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CCD FOR NON-CARDIAC SURGERY
• Children with CCD presenting for non-cardiac surgery are at increased risk
• Range of heart disease & variety of procedures make this hard to quantify
• Most important factors:
1) Physiological Status: 2) Complexity of Heart Disease:
• Cardiac Failure (Very high risk) Considered ‘complex’ if any of:
- Signs differ with age • Single ventricle physiology
- Tachypnoea, tachycardia, sweating & cool • Parallel circulation physiology
peripheries • Cardiomyopathy
• Pulmonary Hypertension • Aortic stenosis
- PAP >25 mmHg at rest ( or 30 mmHg on exercise)
- Clear predictor of morbidity
3) Type of Operation:
• Arrhythmias
• Cyanosis • Major vs. Minor
- Common in unrepaired or partially palliated • Elective vs. Emergency
- Chronic cyanosis affects most organ systems • Risk of blood loss
- Polycythaemia & coagulopathy main problem • Prolonged hospital stay
- Dehydration, fever & anaemia MUST be avoided
RISK CLASSIFICATION:
HIGH RISK INTERMEDIATE RISK LOW RISK
Physiologically poorly compensated +/-
presence of major complications:
¾ Cardiac Failure Physiologically normal or well Physiologically normal or well
¾ Pulmonary Hypertension compensated compensated
¾ Arrhythmias
¾ Cyanosis
Complex lesions Simple lesions Simple lesions

Major surgery (intra-peritoneal, intra- Major surgery (intra-peritoneal, intra-
Minor (or body surface)
thoracic or anticipated major blood thoracic or anticipated major blood
surgery
loss) loss)
Under 2 years Under 2 years Over 2 years
Emergency Emergency Elective
Pre-op hospital stay > 10 days Pre-op hospital stay > 10 days Pre-op hospital stay < 10 days
ASA IV or V ASA IV or V ASA I – III
SUGGESTED MANAGEMENT:
RISK ELECTIVE EMERGENCY
¾ Seek advice from PICU & surgeons about
High Transfer to specialist centre
possibility of transfer
¾ If impossible: advice from cardiologist &
Discuss with specialist centre cardiac anaesthetist re: peri-op management
Intermediate and consider transfer ¾ Transfer post-op as soon as stable
Manage locally
Low Manage at local hospital
If concerned, seek advice
45
.018
COMMON SYNDROMES & CONGENITAL CONDITIONS (1)
Anaesthetic
Syndrome Description Clinical features
considerations
Shortened tubular bones Often require smaller ETT
Commonest form of
Foramen magnum & spinal than age suggests
dwarfism.
stenosis may occur Caution with neck
1/25,000 live births
Sleep apnoea secondary to movements
Achondroplasia Defective fibroblastic
midface hypoplasia & IV access may be difficult
growth factor 3
brainstem compression Sleep apnoea – consider
affecting bone
Macrocephaly sleep studies and post-
formation
Hypotonia & lax skin operative care
Caution with GABA and

Appear normal at birth NMDA receptor active
Genetic defect in Mental retardation, drugs
Angelman syndrome maternal chromosome craniofacial abnormalities, Inhalational technique
(Happy puppet 15q drooling, ataxia, seizures, preferable
syndrome) 1/10 – 20,000 paroxysmal laughter, Risk of difficult
incidence muscle atrophy, vagal over intubation (progressive)
activity, thoracic scoliosis Consider anticholinergic
to overcome vagal tone
Mask ventilation may be
Mental retardation, difficult but intubation
hypoplastic maxilla, usually easy
exophthalmos, High incidence of URTI
1/50,000 live births craniosynostosis, fused complications. Increased
Apert syndrome Fibroblast growth cervical vertebrae, narrow incidence of
factor receptor 2 defect trachea with fused rings, bronchospasm
congenital heart disease, OSA – may need post-op
50% have raised ICP, CPAP
syndactyly Eyes susceptible to
damage – lubricate well
Muscle weakness (limb)
Cardiac problems including
Normal response to non-
conduction defects,
Charcot Marie Tooth depolarising muscle
Hereditary arrhythmias &
(Peroneal muscular relaxants
polyneuropathy cardiomyopathy
atrophy) Volatiles have been used
Potential association with
without problem
malignant hyperthermia
although doubtful
C – Coloboma
H – Heart defect Difficult airway and
A – Atresia choanae & intubation with
Mid-face hypoplasia &
clefts increasing difficulty as
micrognathia
R – Retarded growth & age increases
CHARGE association 75% have a congenital
development Reflux common
heart defect (commonest:
G – Genital hypoplasia Echo to assess CHD
Tetralogy of Fallot)
& renal abnormality Abdominal US for renal
E – Ear anomalies & anomalies
deafness
46
.019
Anaesthetic
considerations
Short stature,
microcephaly, facial
dysmorphism, Reflux common
dysmorphic limbs, Intubation may be
Cornelia de Lange hirsuitism, difficult. Consider FOI
Approx 1:40,000
syndrome developmental delay, Susceptibility to malignant
cardiac & renal hyperthermia has been
malformations, reported
characteristic low
pitched cry
Mental retardation,
characteristic cat-like
cry, microcephaly, broad
nasal bridge, Airway – Anticipate need
Chromosomal
micrognathia, may have for smaller ETT
Cri du Chat syndrome abnormality (5p deletion)
abnormal epiglottis and Intubation may be
1:15,000 to 1:50,000
small larynx. Small difficult
incidence of congenital
heart defects & renal
abnormalities
Mask ventilation difficult
but tracheal intubation
Chromosomal
Craniosynostosis & facial usually straightforward
abnormality leading to
hypoplasia (especially Post-op airway
premature closure of
maxilla) and obstruction may be a
Crouzon syndrome cranial sutures
exophthalmos. May problem. Airway access
Progressive condition
lead to raised may be limited by external
usually manifesting
intracranial pressure fixation devices for
before the age of 2
maxillary distraction. Eye
protection important
Severe cardiac
Anticipate difficult
malformations. Aortic
airway. Sterile techniques
arch abnormalities.
required as
Midface hypoplasia &
3rd and 4th brachial arch immunodeficient. Need
DiGeorge syndrome micrognathia. Absent
abnormalities irradiated blood, check
(Catch 22 syndrome) thymus and parathyroid
22q deletion calcium levels &
glands, low serum
supplement. Adrenaline
calcium leading to
may cause prolonged
tetany and seizures.
tachycardia
Immunodeficient
Developmental delay.
CCD (ASD / VSD / AVSD /
Careful airway and cardiac
PDA). Hypotonia,
assessment. Mask
atlantoaxial instability
Trisomy 21 ventilation may be
Down syndrome (12%). Micrognathia,
1 in 700 live births difficult. Consider small ET
large tongue, congenital
tube. Care with neck
subglottic stenosis,
extension
tonsillar hyperplasia &
OSA. Hypothyroidism
47
.019
Anaesthetic
considerations
Mental retardation,
May be difficult airway
Trisomy 18 hypotonia, renal
Edward’s syndrome & intubation
1 in 8,000 live births abnormalities & CCD.
Sux can cause rigidity
Micrognathia
Hyper-elastic & fragile
Difficult IV access
Ehlers-Danlos tissue. Dissecting aortic
Collagen abnormality Increased bleeding
syndromes aneurysms. May affect
Spont. pneumothorax
clotting, heart, lung & GI
Assess cardiac function.
Inhalation or SLOW IV
induction. Avoid ↑ PVR
(hypoxemia, hypercarbia,
Right-to-Left shunt acidosis or N2O) or ↓ SVR
Reversal of Left-to-Right
Eisenmenger Dyspnoea, fatigue, (high dose induction
shunt caused by
syndrome cyanosis, finger clubbing agents, SNP). Caution
pulmonary hypertension
& cardiac failure with IPPV (minimise
intra-thoracic pressure) &
fluid therapy (avoid
hypovolaemia or over
hydration)
Usually due to cystinosis
Impaired renal function,
Correct electrolyte and
acidosis, K loss,
Anaemia with renal acid-base abnormalities
Fanconi’s syndrome dehydration. Thyroid &
tubular acidosis Caution with renally
pancreatic dysfunction
excreted drugs
possible. May need renal
nd
transplant in 2 decade
Potentially difficult
Unilateral mandibular airway:- BMV may be
hypoplasia difficult. Tracheal
Oculoauriculovertebral
Chromosome 22 trisomy. intubation may be very
Goldenhar syndrome syndrome; hemifacial
20% have CHD difficult especially with
microsomia
Vertebral abnormalities bilateral disease or right
may limit neck extension sided TMJ & mandible
involved
Usually occurs in 1 – 2
year olds following a
prodromal GI infection. Assessment of
CVS (hypotension, respiratory function
Renal failure, haemolytic myocarditis, CCF), CNS Correct electrolyte, acid-
Haemolytic uraemic
anaemia and (drowsiness, seizures, base and coagulation
syndrome thrombocytopenia coma), respiratory- abnormalities
pulmonary insufficiency, Caution with renally
hepatosplenomegaly, excreted drugs
coagulopathy, decreased
platelet function
48
.019
Anaesthetic
considerations
Factor VIII deficiency Bleeding either
Infusions of recombinant
(Classic haemophilia type spontaneous or after
factor VIII 1 hr before and
Haemophilia A) minimal injury,
after surgery to maintain
X-linked recessive, haemarthrosis are
factor VIII activity ≥ 50%
incidence 1 in 10,000 common
Thrombocytopenia
Severe GI or intracranial Steroid cover many be
Autoimmune disease bleeding rare in children necessary due to steroid
Idiopathic
associated with presence Chronic ITP more likely in therapy
thrombocytopenia of antiplatelet factor children > 10 yr of age Avoid NSAIDs and IM
Treatment with high dose injections
steroids and γ-globulin
Still’s disease (systemic), Joint pain & stiffness,

Juvenile rheumatoid Steroid supplement
polyarticular or fever, rash,
arthritis required
pauciarticular forms lymphadenopathy, uveitis
Reduced cervical
Plan for a difficult
Congenital fusion of 2 or mobility. Associated with
Klippel-Feil syndrome intubation due to neck
more cervical vertebrae Arnold-Chiari
immobility
malformation & scoliosis
Multiple large freckles,
hypertelorism, deafness,
CHD, progressive Assess cardiorespiratory
Cardio-cutaneous hypertrophic function, monitor ECG
Leopard syndrome
syndrome cardiomyopathy, Intubation may be
arrhythmias, growth difficult
retardation, kyphosis,
genitourinary anomalies
Discuss with a
Congenital deafness and
cardiologist. GA may
cardiac conduction
precipitate arrhythmias.
defects (arrhythmias &
Pre-treat with B blockers
syncopal episodes),
Jervell-Lange-Nielsen to decrease risk. Avoid
Long QT syndrome serious arrhythmias (VF)
syndrome atropine and volatiles.
may occur under GA
TIVA with propofol and
ECG shows large T waves
remifentanil may be
and prolonged
optimal. Treat VF with
Q-T interval
lidocaine & defibrillation
Tall, thin usually male
Preoperative cardiac
patients, long fingers and
assessment required
face, high arched palate,
Intubation may be
Arachnodactyly joint instability including
difficult. Care needed to
Mutant gene on cervical spine,
prevent damage to C-
Marfan syndrome chromosome 15 causing kyphoscoliosis, pectus
spine or
connective tissue excavatum, spontaneous
temporomandibular
disorder pneumothorax (4%),
joint. Beware of
aortic root dilation
pneumothorax
causing incompetence or
Avoid hypertension
aneurysm
49
.019
Anaesthetic
considerations
Mental retardation,
Difficult airway
gargoyle facies, deafness,
management &
stiff joints, severe
Abnormal intubation – upper
coronary artery disease,
Muco- mucopolysaccharide airway obstruction due to
hepatosplenomegaly
polysaccharidosis metabolism with lymphoid tissue
Most die from
(Hurler’s, Hunter’s) progressive deposition in infiltration, micrognathia,
respiratory/cardiac
tissues short neck & limited
failure before 10 years of
movement of TMJ
age. Hunter’s less severe
than Hurler’s
Discus benefits vs risk
Inherited disorders of
Assess cardiac function
muscle due to
including ejection
abnormality/absence of
fraction, consider
the protein dystrophin
invasive monitoring
Progressive muscle Respiratory function tests
Duchenne – X linked
weakness of affected to help predicted need
recessive mutation on
muscle groups for post-op ventilation
chromosome 21,
(pseudohypertrophied) Prone to LRTI. Regional
incidence 1 in 3000 live
analgesia useful
male births
Duchenne – onset Suxamethonium
between 1 – 4 years, contraindicated – risk of
Becker – X linked
Muscular dystrophies wheelchair bound by 12 rhabdomyolysis, rigidity,
recessive, incidence 1 in
(Duchenne’s, Becker’s, years, cardiac hyperkalaemia, cardiac
60,000, later onset and
facioscapulohumeral) slower progression than involvement with arrest
hypertrophic Variable response to non-
Duchenne
cardiomyopathy and depolarising muscle
sudden death, scoliosis, relaxants. Reduction in
Facioscapulohumeral
mental retardation dose recommended
muscular dystrophy –
(30%), death from Significant myocardial
autosomal dominant,
cardiorespiratory failure depression with volatiles.
relatively benign, slowly
in 3rd decade NO proven link with MH
progressive, affects
but muscle damage &
abductors of upper arms,
hyperkalaemia may occur
facial muscles, winged
with volatiles, hence TIVA
scapula, sensorineural
often used
deafness, retinopathy
PHDU / PICU post-op
Muscle weakness may
cause respiratory failure.
Anticholinesterases cause
Presentation in childhood increased respiratory
or adolescence with secretions
Juvenile/autoimmune muscle Increased sensitivity to
Myasthenia gravis
myasthenia fatigability/weakness non-depolarizing muscle
either generalized or relaxants – intubate deep
limited to ocular muscles / topical lignocaine to
trachea
Avoid opiates & sedative
premedication
50
.019
Anaesthetic
considerations
Central core – hypotonia Central core disease &
at birth, proximal muscle King syndrome – treat
weakness, kyphoscoliosis, patients as MH
Inherited diseases of
joint hypermobility, short susceptible. Avoid all
muscle function
neck, mandibular trigger agents
hypoplasia. Symptoms Assess degree of muscle
Central core disease –
mild & non-progressive weakness preoperatively
autosomal dominant,
Closely associated with
gene mutation on
MH Nemaline rod – NO
chromosome 19 close to
Nemaline rod – association with MH
gene responsible for
weakness of proximal Prone to recurrent
Myopathies ryanidine receptor
muscles, facial, bulbar & aspirations & LRTI
(Central core, respiratory. Dysmorphic Assess respiratory
Nemaline myopathy –
nemaline myopathy, feature ( micrognathia, function & optimise with
autosomal recessive &
King syndrome) hypertelorism, high physio
dominant inheritance,
arched palate), cardiac Intubation may be
mutations on
abnormalities difficult
chromosome 1, 2 & 19
“Typical” – infantile Resistant to
hypotonia, non- suxamethonium but
progressive increased sensitivity to
King syndrome –
“Severe” – presents at non-depolarising muscle
myopathy, MH trait,
birth with severe relaxants
dysmorphic features
hypotonia, respiratory May need post-operative
(Noonan like)
failure, arthrogryposis, ventilation & respiratory
death in first few months complications are most
of life common cause of death
Short stature, web neck,
mild mental retardation Assess cardiac function
Turner’s characteristics CCD (pul. stenosis & Check coagulation &
Noonan syndrome without sex chromosome cardiomyopathy) renal function
abnormality Micrognathia, Possible difficult
hydronephrosis & intubation
platelet dysfunction
Multiple skin and mucosa
lesions. May affect other Intra-op blood loss may
organs, esp. pulmonary & be difficult to control
Osler-Weber-Rendu Hereditary haemorrhagic
hepatic AV fistula Difficult IV access
syndrome telangiectasia
Anaemia & systemic Assess pulmonary
emboli. Later, high function
output cardiac failure
Extreme care with
Fractures, blue sclera &
Osteogenesis positioning. Fragile teeth
Pathological fractures deafness. Scoliosis & lung
imperfecta & veins (difficult IV
pathology
access)
Mental retardation,
microcephaly, cleft Possible difficult
Trisomy 13
Patau’s syndrome lip/palate, micrognathia. intubation
1 in 10,000 live births
CCD (VSD). Polydactyly Assess cardiac function
Die in infancy
51
.019
Anaesthetic
considerations
Micrognathia,
Improves with growth
glossoptosis, cleft
Assess cardiac function
Pierre Robin lip/palate. More severe
1 in 8000 live births Intubation may be VERY
syndrome in neonate (may get
difficult. (Consider fibre-
airway obstruction)
optic)
CCD may be present
Neonate: Hypotonia & Hypoglycaemia risk
poor feeding Difficult IV access. OSA
Child: Hyperactive, common, may require
Prader-Willi syndrome Deletion 15q11 – q13
uncontrolled eating, post-op support
mental retardation Low grade pyrexia or
Cardiovascular failure hypothermia also seen
Assess renal function
Poor respiratory function
Absent abdominal Treat as full stomach
Prune Belly syndrome and cough
musculature Control ventilation,
Renal abnormalities
epidural useful post-op
Severe metabolic Abnormal LFTs, deranged
Largely supportive. Avoid
Reye’s syndrome encephalopathy & fatty clotting
liver-metabolised drugs
change in liver Raised ICP if untreated
Mental retardation,
Possible difficult
Autosomal recessive microcephaly, dwarfism,
Seckel syndrome ventilation, intubation
‘Bird-headed dwarfism’ micrognathia &
and IV access
prominent maxilla
Trait: (Low HbS levels Pre-op screening of at-
<50%) Sickling very risk groups
Abnormal Hb (HbS) which unlikely Crisis: Analgesia (PCA)
distorts in low O2 levels Disease: (HbS >50%) May Peri-op: Avoid prolonged
Sickle cell disease
(vaso-occlusive crisis or present with painful fasting, hydrate well, high
‘Sickling’) crisis, or sickle peri-op FiO2, keep warm, avoid
(lung infarction, acidosis. Extreme care
haemolysis & pain) with tourniquets
Central: CNS immaturity,
trauma, infection or Review sleep study
neoplasms. Normal Careful airway
muscle activity assessment, intubation
Obstructive: Obesity, may be difficult. Avoid
adenotonsillar hyper- sedating pre-med
Disorders of breathing
Sleep apnoea trophy or Pierre Robin Caution with opiates
during sleep
Response to CO2 reduced Post-op apnoea
Very sensitive to opiates monitoring
Mixed: Daytime HDU if: < 2 yrs, syndrome
somnolence, snore, affecting airway, CLD for
insomnia, fatigue, RDS, cor pulmonale
behavioural problems
Microcephaly, mental Care with asepsis. Use
Smith-Lemli-Opitz Inborn error of retardation & hypotonia muscle relaxants with
syndrome cholesterol synthesis Skeletal abnormalities, care, may have airway &
inc. micrognathia intubation problems
52
.019
Anaesthetic
considerations
Excessive growth in early
Care with asepsis and
childhood
positioning of head
Mild developmental
Soto’s syndrome Cerebral gigantism Hyperthermia has been
delay & macrocephaly
reported (not MH);
Poor immune function
monitor temperature
Hypotonia
Similar to Pierre Robin
Autosomal dominant Mid-face hypoplasia,
Stickler’s syndrome Airway may be VERY
mid-face disorder micrognathia, cleft palate
difficult
Port-wine stain over Glaucoma, mental Often multiple laser
Sturge Weber
Trigeminal nerve retardation, seizures & treatments. May affect
syndrome distribution hemiplegia larynx
Pre-op assessment of
Micrognathia, aplastic
Treacher-Collins cardiac function & airway
Mandibulofacial dysplasia zygoma, choanal atresia
syndrome May be VERY difficult
& cleft lip/palate
ventilation/intubation
Short stature, infantile
Assess cardiac & renal
genitalia, webbed neck
status
Turner’s syndrome XO females Possible micrognathia
Intubation may be
CCD (coarctation)
difficult
Renal anomalies
V – Vertebral (scoliosis)
A – Ano-rectal atresia Careful pre-op
C – Cardiac assessment of neonate
Non-random association T – Tracheoesophageal showing one or more
VATER/VACTERL
of defects (at least 3) fistula feature
E – oEsophageal atresia Cardiac & renal
R – Renal abnormalities assessment
L – Limb defects
Learning difficulties
(mild), small stature. CCD Assess cardiac function
22q11 micro-deletion
Velocardiofacial common (VSD, Tetralogy Airway may be difficult,
Very variable
syndrome of Fallot). Cleft lip/palate post-op apnoea monitor
presentation
Characteristic facial essential
features
Very variable. Cutaneous
Assess pulmonary,
lesions common. May
cardiac & renal function
Von Recklinghausen’s Café au lait spots (> 5), have tumours in larynx or Intubation my be
trachea. 50% have
Disease tumours in all parts of difficult
kyphoscoliosis. May have
Neurofibromatosis the CNS and peripheral Caution with neck
fibrosing alveolitis. Renal
type 1 nerves Effects of neuromuscular
artery dysplasia common
blocking drugs may be
1% have
prolonged
pheochromocytoma
Infantile spasms, May be difficult to
Seizures, neurological
psychomotor determine level of
West’s syndrome deficit & severe mental
developmental arrest & consciousness. BIS may
deficiency
hypsarrhythmia on EEG be unreliable
53
.019
MANAGEMENT OF ANAPHYLAXIS
Signs and symptoms

Diagnosis • Airway – Swelling, hoarseness, stridor
• Breathing – Tachypnoea, wheeze, desaturation
&
• Circulation – Pale, clammy, hypotension, tachycardia
Recognition • Disability – Drowsy
• Exposure – Rash
• Call for help
• High flow O2
Immediate
• Ensure airway secure
management
• Ensure IV access
• Lie flat & elevate legs
ADRENALINE
Intramuscular doses of 1:1000
• Under 6 years = 150 microgram IM (0.15 mL)
• Age 6 – 12 years = 300 microgram IM (0.3 mL)
• > 12 years = 500 microgram IM (0.5 mL)
Or Intravenous adrenaline (1:10,000)

Treatment • Titrate 1 microgram/kg boluses
• Repeat as required at 5 min intervals

IV FLUIDS
• STOP colloid - may be the cause!
• 20 mL/kg crystalloid bolus
IV CHLORPHENAMINE IV HYDROCORTISONE
Child under 6 months 250 microgram/kg 25 mg
6 months to 6 years 2.5 mg 50 mg
6 – 12 years 5 mg 100 mg
> 12 years 10 mg 200 mg
54
.020
MANAGEMENT AIRWAY EMERGENCIES
Anaesthesia for rigid bronchoscopy:
D/W ENT surgeon re: plan & check equipment
• Slow Gas Induction (sevoflurane in O2) vs. propofol TCI
Inhaled ¾ Avoid N2O
¾ Deep laryngoscopy and lignocaine spray to the cords
¾ Maintain spontaneous respiration
foreign ¾ ‘Short’ nasal ET tube to maintain gas delivery while scope being
passed
body • Pass Storz paediatric bronchoscope through the larynx & attach circuit to side
arm to maintain anaesthesia
• When FB is grasped the forceps & bronchoscope are withdrawn from the
trachea as a single unit, SV maintained via face mask or nasopharyngeal airway
until the bronchoscope is reintroduced & manoeuvre is repeated as necessary
• Monitoring – patient, chest movement, HR & SaO2. Often lose EtCO2/gas
analysis
• Toddler
• Possible complications – laryngospasm, bronchospasm, pneumothorax &
• Witnessed or arrhythmias
unwitnessed acute • End of procedure – back to face mask or nasopharyngeal airway & wake up
event ¾ May benefit from IV dexamethasone 0.1 – 0.25 mg/kg for laryngeal
• Inspiratory stridor oedema
¾ Need continuous SaO2 monitoring post-op
¾ Consider PHDU or PICU
• Maintenance of oxygenation, with SaO2 > 92%, using nasal cannula, head box
Bronchiolitis or humidified face mask O2
• Small, frequent oral feeds or NG feeds if RR >60/min or oral intake < 50%
• Children < 2 yrs expected
• Seasonal • Naso-pharyngeal suction
• Coryzal symptoms, • Indications for PHDU/PICU: Recurrent apnoeas
dry cough, apnoeas, Worsening respiratory distress
poor feeding Inability to maintain SaO2 > 92%
• PICU management – Intubate and ventilate
• Dexamethasone : 0.6 mg/kg PO
Mild/
• Budesonide
Croup moderate
: Nebulised 2 mg
(if not tolerating oral medication)
• 6 months – 6 yrs • Budesonide : (as above)

• Barking cough, • Adrenaline < 1 yr: 2.5 mL & 2.5 mL saline
inspiratory stridor (nebulised) >1 yr : 5 mL
Severe • Beware rebound worsening of symptoms M
• Symptoms often
worse at night • Dexamethasone : 0.6 mg/kg IV E
• +/- fever • Transfer to PICU/PHDU – Consider intubation (smaller than D
expected ET tube) I
C
• Leave in favoured position, administer oxygen in non-threatening manner
Epiglottitis • Call for senior help – Anaesthetist and ENT surgeon
A
Arrange transfer to theatre L
• 2 – 7 yr olds • Slow Gas Induction with sevoflurane & oxygen
• No prodromal illness, ¾ Maintaining spontaneous ventilation in the sitting position
toxic ¾ IV access once anaesthetised
• Drooling saliva • Usually requires a smaller than expected ETT
• Cherry red • Sedate and ventilate on PICU until a leak appears around the ETT
epiglottis/arytenoids • IV ceftriaxone or ampicillin
55
.021
MANAGEMENT OF SEPTIC SHOCK
Recognition: High flow O2 (SaO2 >95%)

• Fever, tachycardia & abnormal Establish IV or IO access
perfusion
Check blood sugar
• +/- tachypnoea/SpO2 < 95%, reduced
urine output, irritability,
lethargy/drowsiness, base deficit on
ABG, hypotension (late sign)
Initial resuscitation
COLD Shock ¾ Bolus 20 mL/kg 0.9% saline or 4.5% HAS until
• Capillary refill > 3 sec perfusion improves or lung crackles develop (may
• Reduced peripheral pulses need > 60 mL/kg)
• Cool mottled extremities ¾ Correct hypoglycaemia: 2 mL/kg 10% Dextrose
¾ Start antibiotics
• Narrow pulse pressure
WARM shock
• Flash capillary refill
• Bounding peripheral pulses Fluid refractory shock
• Warm extremities Call PICU SpR
Start: Dopamine up to 15 microgram/kg/min IV/IO
• Wide pulse pressure
Intubate & gain central access
(Use Ketamine/Fentanyl & Suxamethonium
IV Antibiotic Therapy ETT cuffed if possible, NG tube, urinary catheter)
• Child < 28 days
• Cefotaxime 50 mg/kg
• Gentamicin 4 mg/kg (over 3 min)
• Amoxicillin 100 mg/kg
For Cold Shock For Warm Shock
• Consider Aciclovir 20 mg/kg Add in central Adrenaline Add in central
• Child 28 days – 3 months if Dopamine resistant Noradrenaline
• Cefotaxime 50 mg/kg
• Gentamicin 7 mg/kg (over 30 min)
• Amoxicillin 50 mg/kg
• Child > 3 months old Catecholamine-resistant shock
• Ceftriaxone 80 mg/kg (slowly) Start Hydrocortisone (after D/W PICU)
M • Gentamicin 7 mg/kg (over 30 min)
E
D Coagulopathy
I • Treat with: 10 – 20 mL/kg
Transfer to PICU
(Check Ca2+ , Mg2+ , K+ )
C FFP/Octaplas
A • Low fibrinogen suggests DIC : give 5 –
L 10 mL/kg of Cryoprecipitate
Goals of Resuscitation
Dopamine
Restore:-
• To make up (for CENTRAL use):
Normal perfusion, normal HR, BP & RR (for age),
30 mg/kg in 50 mL 5% Dextrose
(1 mL/hr = 10 microgram/kg/min) normal mental status, UO > 1 mL/kg/hr & serum
lactate < 2
56
.022
MANAGEMENT OF STATUS EPILEPTICUS
• Confirm clinically that it

is an epileptic seizure: ¾ Airway
¾ Generalised convulsion ¾ High flow O2
lasting ≥ 30 min
or ¾ Check glucose
¾ Repeated convulsions
occurring over a 30 min
period without recovery of
consciousness between
convulsions Vascular access?
• Consider what pre-
NO YES
hospital treatment has
been received and modify
the protocol accordingly Midazolam
Lorazepam
0.5 mg/kg
• Buccal Midazolam may 0.1 mg/kg IV/IO
buccally
be given by ambulance
crew or parents in non-
hospital setting
10 MIN 10 MIN
YES
• If BM < 3.0 mmol/L Vascular Lorazepam
administer 2 mL/kg 10%
Dextrose access? 0.1 mg/kg IV/IO
• Paraldehyde 0.8 mL/kg YES

of 50:50 paraldehyde/olive
oil mixture PR may be
administered as directed by Phenytoin: 20 mg/kg by intravenous infusion over 20 min
senior staff (max 20 mL) OR (if on regular Phenytoin)
Phenobarbital: 20 mg/kg IV over 20 min
• Inform PICU &
Anaesthetic Teams when
considering loading with
Phenytoin
Rapid sequence induction with Thiopentone or Propofol
• Phenytoin administration
- Doses <500 mg in 50 mL Transfer to PICU
- Doses >500 mg in 250 mL
57
.023
MANAGEMENT OF ACUTE LIFE-THREATENING ASTHMA
• Reduced consciousness/agitated
Diagnosis • Silent chest
• Fatigue, exhaustion
& • Poor respiratory effort
Recognition • Cyanosis in air (SaO2 < 92% in air)
• PEFR < 33% expected
• High flow O2 to keep SpO2 > 92%
Immediate • Get senior help (Paeds SpR/Anaes SpR/PICU)
management • Establish IV or IO access
• Monitoring: ECG & SpO2
NEBULISERS
• Back-to-back salbutamol nebs (O2 driven)
– 2.5 mg under 5 years OR 5 mg over 5 years
• Ipratropium nebs (250 microgram) every 20 min in 1st hour
INTRAVENOUS INFUSIONS
• Salbutamol I.V. – Load over 5 min with:
- 5 microgram/kg if under 2 yr
Treatment OR
- 15 microgram/kg if over 2 yr (max 250 microgram)
• Aminophylline I.V. – Load with 5 mg/kg over 20 min then 1
mg/kg/hr
• Magnesium I.V. – 0.2 mmol/kg over 20 min
• Steroids – Hydrocortisone 4 mg/kg (max 100 mg)
• Crystalloid fluid boluses
Indications: Considerations:
• Cardiac or respiratory • Senior help
arrest • Consider RSI with ketamine
• Severe hypoxia & suxamethonium
INTUBATION • Deteriorating mental state • Lignocaine spray to cords
AVOID IF AT ALL • Progressive exhaustion • Cuffed ETT if possible
POSSIBLE • Aim Vt 6 – 8 mL/kg
• Avoid PEEP
CLINICAL JUDGEMENT • Long expiratory times
RATHER THAN BLOOD • Permissive hypercapnia
GASES • Consider paralysis
58
.024
MANAGEMENT OF DIABETIC KETOACIDOSIS
History - Polyuria, polydipsia, weight loss, abdominal pain, tiredness, vomiting,

confusion
Diagnosis Signs - Dehydration, kussmaul breathing, lethargy/drowsiness

Biochemical - Blood glucose >11 mmol/L, pH <7.3 or bicarbonate <15 mmol/L,
ketouria
• Airway & breathing - high flow oxygen
• Circulation - if shocked, give 10 mL/kg 0.9% sodium chloride, repeat up to 3
times
• Assess degree of dehydration
Immediate
• Mild (3%) – only just clinically detectable
management • Moderate (5%) – dry mucous membranes, reduced skin turgor
• Severe (8%) – above plus sunken eyes, poor capillary return
• 1% dehydration = 10 mL/kg deficit to be replaced over 48 hr
• Start IV fluid replacement with 0.9% saline and 20 mmol KCl in 500 mL bag
• Weigh (12 hourly) • Glucose, HbA1c
• Continuous ECG monitoring • U&Es
Monitoring • Hourly BP & urine output • Venous blood gas
• Hourly GCS until pH > 7.3 • Serum osmolality
& • Glucose ½ hourly for first 2 hr, then hourly until 4 – • Urine/blood ketones
Investigation 14 mmol/L, then 2 – 4 hourly thereafter • FBC
• Na⁺, K⁺ & ABG at 0, 2 & 6 hours • LFT
• Capillary blood glucose & ketones every 1 – 2 hr • Amylase
Calculate total volume requirement and plan to replace over 48 hours
Include: - Deficit – measured or assessed weight loss (1 kg = 1000 mL)
- Maintenance requirements
Fluid
- Continuing losses – replaced only if urine output or vomiting is excessive
management Subtract: - Any volume already received during resuscitation
Hourly rate = (48 hr maintenance + deficit) – resuscitation fluid already given
48
Commence insulin infusion an hour after starting IV fluids (50 units human soluble
insulin (Actrapid or Humulin S) per 50 mL 0.9% saline)
Infuse at rate of 0.1 units/kg/hour. An initial bolus should NOT be given
Aim for a gradual fall in glucose of ≈ 5 mmol/L/hr until it reaches 14 mmol/L. If the
rate of fall is > 5 mmol/L/hr, add glucose to the IV fluids
Insulin If despite increased glucose (up to 10%), blood sugar continues to fall rapidly or is <
4 mmol/L decrease insulin rate to 0.05 units/kg/hr
infusion DO NOT STOP INSULIN INFUSION
For BM < 4 give a bolus of 2 mL/kg of 10% glucose IV and add extra glucose to the IV
fluids, rather than reducing/stopping the insulin
If pH > 7.3 with stable blood sugars between 4 – 15 & receiving glucose containing IV
fluids, insulin infusion can be reduced to 0.05 units/kg/hr
59
.025
MANAGEMENT OF CEREBRAL OEDEMA
ASSOCIATED WITH DIABETIC KETOACIDOSIS
• Up to 1% of children with DKA develop cerebral oedema with

a high morbidity/mortality
• Signs – Headache, confusion, irritability or restlessness,
reduced conscious level, fits, increasing BP, slowing pulse,
papilloedema, abnormal posturing
Diagnosis • Risk appears to be increased if insulin is started within an
hour of starting IV fluids. Hence current recommendation to
defer the insulin infusion for at least 1 hour after starting
fluids
• If cerebral oedema is suspected inform the Paediatric
Consultant and PICU team
• Exclude hypoglycaemia and continue insulin infusion
• Give hypertonic saline (2.7%) 5 mL/kg over 5 – 10 min or
mannitol 1 g/kg stat (5 mL/kg 20% mannitol in 20 min) as
soon as possible
• Restrict IV fluids to ½ maintenance and plan to replace over
72 hours rather than 48 hours
• Continue management on PICU if not already there
Emergency • Intubate and ventilate to low normal pCO2 (4 kPa)
management • Exclude other diagnoses by CT scan (thrombosis, infarction or
haemorrhage)
• Consider intracranial pressure monitoring
• Repeated doses of mannitol (above dose 2 hourly) may be
needed to control intracranial pressure
• Close management of sodium is essential. If outside of the
range 140 – 150 mmol/L, discuss with paediatric
endocrinologist on-call. Assess the degree of dehydration
60
.025
FORMULARY (1)
DRUG INDICATION DOSE
Acyclovir Severe sepsis in under 28 day old 20 mg/kg
100 – 500 microgram/kg
Adenosine Management of SVT
(max 12 mg)
Cardiac arrest IV: 10 microgram/kg
Anaphylaxis IM: 10 microgram/kg
Adrenaline Croup/airway compromise Nebulised: 400 microgram/kg
Low cardiac output Infusion: 0.01 – 1 microgram/kg/min
- (0.3 mg/kg in 50 mL 5% Dextrose)
Alfentanil Short-term analgesia/Induction 10 microgram/kg
5 mg/kg
Aminophylline Life-threatening asthma
Then: 1 mg/kg/hr
5 mg/kg (max 1.2 g in 24 hr)
Amiodarone Arrhythmia management
Infusion: 300 microgram/kg/hr
Amoxicillin Severe sepsis 50 – 100 mg/kg
0.5 mg/kg
Atracurium Neuromuscular blockade
Infusion: 0.3 – 0.6 mg/kg/hr
Bradycardia 20 microgram/kg
Atropine (100 – 600 microgram)
Pre-medication (1 hr pre-procedure) 30 microgram/kg PO (max 900)
Benzyl-penicillin Early sepsis in neonates 50 mg/kg
Blood 10 – 20 mL/kg
Haemorrhage/low Hb (< 80 g/L)
(Packed Red Cells) (5 mL/kg will ↑ Hb by ~10 g/L)
Bupivacaine (levo-) Local anaesthetic 2 mg/kg
Calcium Chloride 10% Hypocalcaemia/Hyperkalaemia 0.2 mL/kg

Hypocalcaemia-induced cardiac arrest 0.3 mL/kg 10% solution (max 20 mL)
Calcium Gluconate Hyperkalaemia 0.5 mL/kg 10% solution (max 20 mL)
Calcium Resonium Hyperkalaemia 1 g/kg
Cefotaxime Severe sepsis 50 mg/kg
Ceftriaxone Severe sepsis 80 mg/kg
Cefuroxime Surgical prophylaxis 30 – 50 mg/kg

4 microgram/kg PO
Clonidine Pre-medication (1 hr pre-procedure)
2 microgram/kg Intranasal
Co-Amoxiclav Surgical prophylaxis 30 mg/kg
Codeine Analgesia (over 12 yrs only) 1 mg/kg/hr (max 60 mg)
Cryoprecipitate Low fibrinogen (< 1.5 g/L) 5 – 10 mL/kg
2.5 mg/kg
Dantrolene Malignant hyperthermia
Then: 1 mg/kg boluses
61
.026
FORMULARY (2)
Dexamethasone Anti-emetic 0.15 mg/kg
2 mL/kg
Hypoglycaemia
Dextrose 10% Then: 5 mL/kg/hr
Hyperkalaemia (with Insulin)
5 mL/kg/hr
Diazepam Muscle spasm 0.1 mg/kg QDS
Diclofenac Analgesia (> 6 months old) 1 mg/kg
Low cardiac output states
Dobutamine 5 – 15 microgram/kg/min
- 30 mg/kg in 50 mL 5% Dextrose
Severe sepsis with low cardiac output
Dopamine - 30 mg/kg in 50 mL 5% Dextrose (central) 5 – 15 microgram/kg/min
- 3 mg/kg in 50 mL 5% Dextrose (peripheral)
500 microgram/kg over 1 min
Esmolol Treatment of arrhythmias Then: 50 microgram/kg/min over
4 min
Fentanyl Analgesia/Induction of anaesthesia 1 – 2 microgram/kg
FFP/Octaplas Coagulopathy/Massive transfusion 10 – 20 mL/kg
2 mg/kg
Flecanide Resistant re-entry SVT, VEs or VT
(max 150 mg)
Flucloxacillin Surgical prophylaxis 25 mg/kg
Flumazanil Reversal of benzodiazepine 10 microgram/kg (max 200)
Furosemide Diuretic 1 – 2 mg/kg

Surgical prophylaxis 2 mg/kg
Gentamicin Severe sepsis 5 – 7 mg/kg
Bradycardia
Glycopyrolate 10 microgram/kg
Reversal of neuromuscular blockade
2nd line anaphylaxis 4 mg/kg
Steroid Replacement Therapy:

(if > 10 mg prednisolone (or equivalent) per
day)
- Minor surgery (e.g. hernia repair) Routine pre-op steroid dose
OR 1 – 2 mg/kg IV at induction
Hydrocortisone - Intermediate surgery (e.g. laparoscopic) Normal dose AND 1 – 2 mg/kg IV at

induction & 6 hourly for 24 hr
- Major Surgery (e.g. laparotomy) Normal dose AND 1 – 2 mg/kg IV at

induction & 6 hourly for 48 – 72 hr
If steroids stopped > 3 months ago – no
replacement needed
62
.026
FORMULARY (3)
Ibuprofen Analgesia (>5 kg) 5 mg/kg
Diabetic management
Insulin 0.05 – 0.1 units/kg/hr
Hyperkalaemia (with 10% Dextrose)
Intralipid 20% Local anaesthetic toxicity 1.5 mL/kg; Then: 15 – 30 mL/kg/hr
Ipratropium Asthma Nebulised: 250 microgram

Pre-medication (30 min pre-procedure) 6 mg/kg PO
(3 mg/kg if given with midazolam)
Ketamine Induction of anaesthesia 1 – 2 mg/kg
IM: 5 – 10 mg/kg
Lidocaine 2nd line VF or pulseless VT 1 mg/kg (max 100 mg)
Pre-medication (1 hr pre-procedure) 50 – 100 microgram/kg (max 4 mg)
Lorazepam Status epilepticus 0.1 mg/kg
Magnesium Sulphate Severe asthma/Torsades de pointes 0.1 – 0.2 mmol/kg (max 8 mmol)
0.25 – 1 g/kg
Mannitol 20% Raised ICP
(0.5 g/kg = 2.5 mL/kg)
300 mg/m2 over 10 min
Methyl-prednisolone Renal transplant
(max 500 mg)
Metronidazole Surgical prophylaxis 30 mg/kg

Pre-medication (30 min pre-procedure) 0.5 mg/kg PO (max 20 mg)
0.3 mg/kg buccal (max 5mg)
Midazolam Status epilepticus Buccal: 0.5 mg/kg
Sedation (6 mg/kg in 50 mL) Infusion: 60 – 240 microgram/kg/hr
Analgesia: IV: 0.1 mg/kg
Oral: 0.1 – 0.5 mg/kg
Morphine - Low dose (codeine replacement) < 1 yr: 50 – 100 microgram/kg PO
> 1 yr: 100 – 200 microgram/kg PO
Sedation (1 mg/kg in 50 mL) Infusion: 10 – 40 microgram/kg/hr
10 microgram/kg
Naloxone Reversal of opiates
Infusion: 5 – 20 microgram/kg/hr
Neostigmine Reversal of neuromuscular blockade 50 microgram/kg
Acute hypotension Infusion: 0.01 – 0.5
Noradrenaline - 0.3 mg/kg in 50 mL 5% Dextrose microgram/kg/min
Ondansetron Anti-emetic/Opiate-induced pruritus 0.15 mg/kg
Oral: 15 – 20 mg/kg
IV:
Paracetamol Analgesia - Prem > 32 weeks – 7.5 mg/kg TDS
- Neonate – 10 mg/kg QDS
- Child < 50 kg – 15 mg/kg QDS
Paraldehyde Status epilepticus PR: 0.8 mL/kg (max 20 mL)
63
.026
FORMULARY (4)
Phenobarbital Status epilepticus 20 mg/kg over 20 min
Phenylephrine Acute hypotension 1 microgram/kg
Phenytoin Status epilepticus 20 mg/kg over 20 min

Piperacillin
Septicaemia 90 mg/kg (max 4.5 g)
(with Tazobactam)
0.1 mg/kg
Piriton 2nd line anaphylaxis/Pruritus
(max 4 mg PO, or 5 mg IV)
Platelets Low platelets (< 75 x 109/L) 10 – 20 mL/kg

Induction of anaesthesia 1 – 4 mg/kg
Propofol Maintenance of anaesthesia Infusion: 4 – 12 mg/kg/hr
5 nanogram/kg/min
Prostin Opening/maintaining PDA in neonate
(max 100 nanogram/kg/min)
1 mg/kg
Rocuronium Neuromuscular blockade
Infusion: 0.3 – 1 mg/kg/hr
Nebulised: 2.5 – 10 mg
Salbutamol Asthma IV: 5 microgram/kg (Under 2 yr)
15 microgram/kg (Over 2 yr)
Saline 2.7% Raised intra cranial pressure 5 mL/kg
Sodium Bicarbonate Metabolic acidosis/Hyperkalaemia 0.5 – 1 mL/kg of 8.4% solution

Reversal of Rocuronium – Routine 2 – 4 mg/kg
Sugammadex Immediate 16 mg/kg
Suxamethonium Neuromuscular blockade 1 – 2 mg/kg
Teicoplanin Surgical prophylaxis 10 mg/kg over 30 min
Pre-medication (1 hr pre-procedure)
Temazepam 10 – 20 mg/kg
(Age: 12 – 18 yr)
Thiopentone Induction of anaesthesia 3 – 5 mg/kg

15 mg/kg
Tranexamic Acid Massive haemorrhage
Then: 2 mg/kg/hr
Vancomycin Surgical prophylaxis 15 mg/kg over 60 min

0.1 mg/kg
Vecuronium Neuromuscular blockade
Infusion: 0.8 – 1.4 microgram/kg/hr
64
.026
NOTES
65
References
• Weight information:
• 1 – 12 months = (0.5 x age in months) + 4
• 1 – 5 years = (2 x age) + 8
• 6 – 12 years = (3 x age) + 7
• UK – WHO growth charts – www.rcpch.ac.uk/growthcharts
• BNF for Children 2013 – 2014
• Advanced Paediatric Life Support. The Practical Approach. 5 th Edition
• Association of Anaesthetists of Great Britain and Ireland. Blood transfusion and the
anaesthetist: Management of massive haemorrhage. Anaesthesia 2010; 65: 1153-1161
• Major trauma and the use of tranexamic acid in children, RCPCH, November 2012
• Head injury: triage, assessment, investigation and early management of head injury in
infants, children and adults NICE Clinical Guideline 176, January 2014.
www.nice.org.uk/guidance/CG176
• “Emergency Management of Severe Burns”, course manual. Australian and New
Zealand Burn Association/UK version for the British Burn Association, 15 th Edition, June
2012
• Paediatric Airway Guidelines 2012 – The Guidelines Group, supported by the
Association of Paediatric Anaesthetists, the Difficult Airway Society and liaising with
the RCoA. Reproduced with permission
• Malignant Hyperthermia Crisis – AAGBI Safety Guideline 2013
• Management of severe local anaesthetic toxicity 2 – AAGBI Safety Guideline 2010
• Good Practice in Postoperative and Procedural Pain Management, 2 nd Edition.
APAGBI, July 2012
• APA consensus guideline on peri-operative fluid management in children v 1.1,
September 2007
• Resuscitation Council (UK) Emergency treatment of anaphylactic reactions. January
2008, annotated July 2012
• Bacterial meningitis and meningococcal septicaemia. NICE Clinical Guideline 102,
June 2010. www.nice.org.uk/guidance/CG102
• Management of status epilepticus NICE Clinical Guidelines CG137 (published 2011) .
www.nice.org.uk/guidance/CG137
• British Guideline on the Management of Asthma. SIGN & The British Thoracic Society,
revised May 2011
• DKA guidelines. British Society of Paediatric Endocrinology and Diabetes website.
www.bsped.org.uk
66
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PAEDIATRIC

18:28:28, subject to the Cambridge Core terms of use

18:28:30, subject to the Cambridge Core terms of use

18:28:32, subject to the Cambridge Core terms of use

Wt : 3 – 3.5 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 80

F Crystalloids : Trauma (10 mL/kg): 35 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 4 - 7 microgram 0.4 – 0.7 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 0.3 mg (Repeat PRN) 0.3 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 4 – 6 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 80

F Crystalloids : Trauma (10 mL/kg): 55 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 5 – 10 microgram 0.5 – 1 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 0.5 mg (Repeat PRN) 0.5 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 6 – 8 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 90

F Crystalloids : Trauma (10 mL/kg): 70 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 7 – 15 microgram 0.7 – 1.5 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 0.7 mg (Repeat PRN) 0.7 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 7 – 9 kg HR : 110 – 160 RR : 30 – 40 Systolic BP : 70 – 90

F Crystalloids : Trauma (10 mL/kg): 85 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 10 – 20 microgram 1 – 2 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 0.8 mg (Repeat PRN) 0.8 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 9 – 10 kg HR : 100 – 150 RR : 25 – 35 Systolic BP : 80 – 95

F Crystalloids : Trauma (10 mL/kg): 100 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 10 – 20 microgram 1 – 2 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1 mg (Repeat PRN) 1 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 10 – 11 kg HR : 100 – 150 RR : 25 – 35 Systolic BP : 80 – 95

F Crystalloids : Trauma (10 mL/kg): 110 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 10 – 20 microgram 1 – 2 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1 mg (Repeat PRN) 1 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 11 – 12 kg HR : 95 – 140 RR : 25 – 30 Systolic BP : 80 – 100

F Crystalloids : Trauma (10 mL/kg): 120 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 12 – 25 microgram 1.2 – 2.5 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1.2 mg (Repeat PRN) 1.2 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 11 – 15 kg HR : 95 – 140 RR : 25 – 30 Systolic BP : 80 – 100

F Crystalloids : Trauma (10 mL/kg): 140 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 15 – 30 microgram 1.5 – 3 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1.4 mg (Repeat PRN) 1.4 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 14 – 16 kg HR : 95 – 150 RR : 25 – 30 Systolic BP : 80 – 100

F Crystalloids : Trauma (10 mL/kg): 160 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 15 – 30 microgram 1.5 – 3 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1.5 mg (Repeat PRN) 1.5 mL

I Drug To Make Up in 50 mL Infusion Rate

Wt : 16 – 22 kg HR : 90 – 130 RR : 20 – 25 Systolic BP : 90 – 110

F Crystalloids : Trauma (10 mL/kg): 180 mL Blood, FFP or

Calculated Dose Volume to be

D Fentanyl (1 – 2 microgram/kg) Dilute to 10 microgram/mL 20 – 40 microgram 2 – 4 mL

R Morphine (0.1 mg/kg) Dilute to 1 mg/mL 1.8 mg (Repeat PRN) 1.8 mL