1 Air Embolism

2 Anaphylaxis
3 Anterior Mediastinal Mass
4 Bradycardia
5 Bronchospasm

Pedi Crisis 6-7 Cardiac Arrest

8 Difficult Airway
9-10 Fire: Airway / OR
11 Hyperkalemia
12 Hypertension, Acute
CRITICAL EVENTS
13 Hypotension
CHECKLISTS 14 Hypoxia
For use in the peri-anesthesia setting
15 Intracranial Pressure

Call for help! 16

17
Laryngospasm
Local Anesthetic Toxicity

Code Team ___________ 18 Loss of Evoked Potentials

PICU ___________ 19 Malignant Hyperthermia

Fire ___________ 20 Massive Hemorrhage

Overhead STAT ___________ 21 Myocardial Ischemia

ECMO ___________ 22 Pulmonary Hypertension

23 Tachycardia
Notify surgeon/team 24 Tamponade, Cardiac

Use expert clinical judgment when using this 25 Tension pneumothorax

and all emergency manuals.
26 Transfusion Reaction
Revision Nov 2020. Formatted June 2020. Available at: 27 Trauma
http://www.pedsanesthesia.org/wpcontent/uploads/2018/03/SPACriticalEventsChecklists.pdf
28 Maternal OB Hemorrhage
 Air Embolism ↓ EtCO2 ↓ SaO2 ↓ BP, mill-wheel murmur
1
 Notify team, stop nitrous oxide and volatile agents. Increase O2 to 100%
 Stop air entrainment: Find air entry point, stop source, and limit further entry
 Ask surgeon:
- Flood wound with irrigation/soaked saline dressing
- Stop all pressurized gas sources, e.g. laparoscope, endoscope
- Place bone wax or cement on exposed bone edges
• Check for open venous lines or air in IV tubing

Air Embolism
• Position surgical site below heart, head down, lateral (if possible)
 Consider:
• Compress jugular veins intermittently if head or cranial case
 If hypotensive:
• Give EPINEPHrine 1-10 MICROgrams/kg IV, consider infusion EPINEPHrine 0.02-1
MICROgrams/kg/min IV or NOREPInephrine 0.05-2 MICROgrams/kg/min IV
• Chest compressions: 100-120/min to force air through lock, even if not in cardiac arrest
• If available, call for TEE/US. Consider ECMO
 If cardiac arrest, see ‘Cardiac Arrest’ card

 Consider Differential (Partial)

• Embolus (fat, thrombotic, cement, amniotic fluid)
• Anaphylaxis
• Local anesthetic systemic toxicity
Revision Oct 2020
 Anaphylaxis Rash, bronchospasm, hypotension
2
 Increase O2 to 100%, evaluate ventilation Common causative agents:
• Neuromuscular blockers
 Remove suspected trigger(s) • Latex
• If latex is suspected, thoroughly wash area • Chlorhexidine
 If HYPOtensive, turn off anesthetic agents • IV colloids
• Antibiotics

Indications Treatments

To restore intravascular NS or LR, 10-30 mL/kg IV/IO, rapidly

volume

Anaphylaxis
To increase BP and  EPINEPHrine 1-10 MICROgrams/kg IV/IO, as needed or
reduce mediator release 10 MICROgrams/kg IM q5-15 min as needed
 May need EPINEPHrine infusion 0.02-1 MICROgrams/kg/min IV
 If BP remains low, give Vasopressin 10 MILLIunits/kg IV
To reduce histamine- DiphenhydrAMINE 1 mg/kg IV/IO (MAX 50 mg) or
mediated effects Famotidine 0.25 mg/kg IV (MAX 20 mg)

To reduce mediator MethylPREDNISolone 2 mg/kg IV/IO (MAX 100 mg)

release
To reduce Albuterol (Beta-agonists) 4-10 puffs, repeat as needed
bronchoconstriction

Revision Nov 2020

 Send tryptase within 3 hours
 Consider Differential (partial):
• Severe bronchospasm from URI or underlying condition: go to ‘Bronchospasm’ card
• Air, fat, thrombotic, or cement embolus: go to ‘Air Embolism’ card
• Sepsis: support BP, antibiotics
Anterior Mediastinal Mass
3

Intra-operative Treatments
Airway Collapse Cardiovascular Collapse
 Increase O2 to 100%  Increase O2 to 100%

Anterior Mediastinal Mass

 Increase FiO2  Give fluid bolus
 Add CPAP for spontaneous ventilation;  Reposition to lateral or prone
add PEEP for controlled ventilation  Ask surgeon for sternotomy and
 Reposition to lateral or prone elevation of mass
 Ventilate via rigid bronchoscope  Consider ECMO

Preoperative Considerations
High Risk Factors Anesthetic Plan
 Etiology:  Perform surgery under local
• Hodgkin’s and non-Hodgkin’s anesthesia, if possible
lymphoma  Pre-treat with irradiation or
 Clinical signs: corticosteroids

• Orthopnea, upper body edema,  Maintain spontaneous ventilation

stridor, wheezing and avoid paralysis

 Imaging findings:  Ensure availability of fiberoptic and

rigid bronchoscope
• Tracheal, bronchial, carinal, or
great vessel compression; SVC or  Cardiopulmonary bypass or ECMO
RVOT obstruction; ventricular  Type and cross and sternal saw (for
dysfunction; pericardial effusion surgeons) available
Revision June 2018
 Bradycardia
4
 Definition: Age < 30 days HR < 100

≥ 30 days < 1 yr < 80 Instructions for PACING

≥ 1 yr < 60 1. Place pacing ECG

electrodes AND pacer pads
 If hypotensive, pulseless, or poor perfusion: start chest on chest per package
compressions. See ‘Cardiac Arrest’ card instructions
• Give EPINEPHrine 10 MICROgrams/kg IV 2. Turn monitor/defibrillator
• Call for transcutaneous pacer (see inset) ON, set to PACER mode
- Start pacing, when available 3. Set PACER RATE (ppm) to

Bradycardia
 Confirm NSR. If heart block or slow junction/ventricular, call EP desired rate/min. (Can be
adjusted up or down based
 If NOT hypotensive or pulseless: on clinical response once
pacing is established)
Etiology Treatment
4. Increase the milliamperes
Hypoxia  Increase O2 to 100%
(mA) of PACER OUTPUT
(most  Ensure ventilation until electrical capture
common)
 See ‘Hypoxia’ card (pacer spikes aligned with
QRS complex; threshold
Vagal  Atropine 0.01-0.02 mg/kg IV normally 65‐100mA)
Surgical  Stop stimulation 5. Set final mA to 10mA
Stimulation  If laparoscopy, desufflate above this level
Ca-Channel  Calcium chloride 10-20 mg/kg IV or 6. Confirm pulse is present
Blocker Calcium gluconate 50 mg/kg IV
Overdose 7. Must change pacing pads
 If ineffective, Glucagon as dosed below hourly to avoid burns
Beta-Blocker  Glucagon 50 MICROgrams/kg IV, then
Overdose 0.07 mg/kg/hour IV infusion
(MAX 5 mg/hr)
• Check blood sugar Revision June 2018
 Bronchospasm
↓ EtCO2, upslope stage III EtCO2
↑ airway pressures, ↓ SpO2
5
Intubated Patient Non-Intubated Patient
 Increase FiO2 to 100%  If ETT in, go to ‘Intubated Patient’ column on
 Auscultate the chest: this card (at the left)
• Equal breath sounds?  Administer supplemental oxygen
• Endobronchial ETT?  Auscultate the chest, differentiate from
• Wheezing? stridor/extrathoracic airway obstruction
 Check ETT:  Consider inhaled albuterol (with spacer)
• Kinked? 2.5-5 mg. If severe, 5-20 mg/hr inhaled

Bronchospasm
• Secretions/blood in ETT? Needs suctioning?  Consider chest radiograph
 Consider albuterol 2-10 puffs, repeat as needed
 Consider IV steroids:
 Consider deepening anesthetic methylprednisolone 1 mg/kg IV (MAX 60 mg)
 If needed, give ketamine 1-2 mg/kg IV or dexamethasone 0.15-0.25 mg/kg (MAX 16
 If severe, consider mg)
EPINEPHrine 1-2 MICROgrams/kg IV (MAX 1 mg)
 If severe, consider EPINEPHrine
 Consider IV steroids: methylprednisolone 2 mg/kg IV 1-2 MICROgrams/kg IV (MAX 1 mg) or
(MAX 60 mg) or dexamethasone 0.15-0.25 mg/kg 10 MICROgrams/kg
(MAX 16 mg) subcutaneous/intramuscular (MAX 0.5 mg)
 Consider chest radiograph
 If severe, consider ICU and/or advanced airway
 For refractory bronchospasm, consider magnesium management.
sulfate 50-75 mg/kg (MAX 2 grams) bolused over 20
minutes, (CAUTION, may cause hypotension)

Differential Diagnosis
 Endobronchial intubation  Pulmonary edema
 Mechanical obstruction of ETT  Tension pneumothorax

Revision Oct 2018

• Kinking  Aspiration pneumonitis
• Solidified secretions or blood  Pulmonary embolism
• Overinflation of tracheal tube cuff  Persistent coughing and straining
 Inadequate depth of anesthesia  Asthmatic attack
 URI/tobacco exposure  Anaphylaxis
 Foreign body
 Cardiac Arrest Pulseless cardiac arrest
6
 Notify team, designate team leader, call for help and code cart/defibrillator
 Increase O2 to 100%. Turn off anesthetics. Start timer
 If ETT, 100-120 chest compressions/min + 10 breaths/min. Avoid hyperventilation
 If no ETT, 15:2 compression:ventilation ratio (100-120 chest compressions/min + 8 breaths/min)
 For chest compressions, maximize EtCO2 > 10 mmHg (see next card for more details):
• Switch compressor every 2 min
• Use sudden increase in EtCO2 for ROSC, Do NOT stop compressions for pulse check
 Obtain defibrillator. Attach pads. If VF/VT, shock 2 joules/kg. Continue chest compressions for 2
minutes

Cardiac Arrest
 Assign roles. Designate a scribe/recorder. Notify family. Continue with items in yellow box
Repeat sequence below until return of spontaneous circulation:
 If still in VF/VT, shock 4 joules/kg q2 min (up to 10 joules/kg on subsequent shocks)
 Resume chest compressions immediately regardless of rhythm
 EPINEPHrine 10 MICROgrams/kg IV q 3-5 min while in arrest (MAX 1 mg)
• If still no ROSC after second dose of EPINEPHrine, activate ECMO (if available)
 Check pulse & rhythm q 2 min during compressor change
 Check for reversible causes (Hs and Ts) early and often (see table below)
 Lidocaine 1 mg/kg bolus (MAX 100 mg); may repeat (total: 2 doses) OR amiodarone 5 mg/kg
bolus; may repeat (total: 3 doses)
 Repeat sequence in this box until return of spontaneous circulation

Hs and Ts: Reversible Causes

Revision June 2020

• Hypovolemia • Tension Pneumothorax
• Hypoxemia • Tamponade (Cardiac)
• Hydrogen ion (acidosis) • Thrombosi
• Hyperkalemia/Hypoglycemia • Toxin (anesthetic, β-blocker)
• Hypothermia • Trauma (surgical or nonsurgical bleeding)
 Cardiac Arrest: Supine/Prone Chest Compressions 7
 Chest compression instructions (see previous card for full CPR instructions):
• Place patient on backboard, maintain good hand position; if prone, see instructions below

Supine/Prone Chest compressions

• Maximize EtCO2 > 10 mmHg with force/depth of compressions
• Allow full recoil between compressions
• Switch compressor every 2 min
• Use sudden increase in EtCO2 for ROSC, Do NOT stop compressions for pulse check

Prone: Prone:
Children/Adolescents Infants

Compress with encircling

 If no midline incision: technique:
Compress with heel of
hand on spine and  If no midline incision:
second hand on top thumbs midline

 If midline incision:
Figure 1
thumbs lateral to incision

Figure 3
 If midline incision:
Compress with heel of
each hand under
scapula

Figure 2

Mar 2018
Figure 1: From Dequin P-F et al. Cardiopulmonary resuscitation in the prone position: Kouwenhoven revisited. Intensive Care Medicine, 1996;22:1272

Revision
Figure 2: From Tobias et al, Journal of Pediatric Surgery, 1994:29, 1537-1539
Figure 3: Original artwork by Brooke Albright-Trainer, MD
 Difficult Airway, Unexpected 8
 Increase O2 to 100% and maintain continuous oxygen flow during airway management
 Call for help, surgical airway expert and cart, rigid bronchoscope and tracheostomy kit

Difficult Airway, Unexpected

 If unable to mask ventilate, ask for 2-handed assistance and:
• Insert oral and/or nasal airway
• If unsuccessful, insert supraglottic airway (e.g., LMA)
• Decompress stomach with orogastric tube
• Consider reversing rocuronium or vecuronium with
sugammadex (16 mg/kg). Call to obtain if not in OR.

 If able to re-establish pt spontaneous ventilation:

• Consider awakening patient Alternative
• Consider reversal of neuromuscular blocker Approaches for
Intubation
 After two attempts: change providers and consider • Different blade
alternative approaches to intubation (see table)
• Re-position head
 If macroglossia (e.g. Beckwith-Wiedemann, Pierre-Robin), • Different provider
or mediastinal mass, consider prone or lateral position
• Video-laryngoscope
 If still unable to ventilate: • Bougie
• Younger children: Emergency non-invasive airway • Intubating LMA
such as rigid bronchoscopy • Fiberoptic scope
• In older children: Jet ventilation or emergency • Intubating stylet
invasive/surgical airway such as cricothyrotomy • Blind oral
or tracheostomy • Blind nasal
Revision May 2019
 Fire: Airway Fire in tracheal tube, circuit, canister
9

 Simultaneously:
• Disconnect circuit from tracheal tube then remove tracheal tube
• Stop all gas flow (O2, N2O)
• Remove sponges and other flammable materials from airway
• Pour saline into airway
 Re-intubate and re-establish ventilation
• If intubation difficult, don’t hesitate to obtain surgical airway

Airway Fire
 Consider bronchoscopy to assess for thermal injury
• Look for tracheal tube fragments
• Remove residual material
 Impound all equipment and supplies for later inspection
 Maintain ventilation. Assess for inhalation injury
 Consider input from ENT, pulmonary, plastic surgery
 Consider PICU
 Shut off gases to affected OR if fire not self-contained
Picture from ECRI: www.ecri.org
• Verify gases are not shut off to adjacent rooms

Revision May 2019

 OR Fire (non-airway)
Fire in OR, equipment smoke,
fumes, flash/fire on patient
10

 Simultaneously:
• Stop flow of medical gases
• Remove drapes and all burning and flammable material from patient
• Make one attempt to extinguish fire by pouring saline on fire
 If fire not extinguished on 1st attempt, use CO2 fire extinguisher
 If fire persists:
• Activate fire alarm
• Remove patient from OR

OR Fire
• Confine fire by closing all OR doors
• Turn off O2 gas supply to OR
 Maintain ventilation. Assess for inhalation injury
 Consider input from ENT, pulmonary, plastic surgery
 Consider PICU Picture from ECRI: www.ecri.org

 Shut off gases to affected OR if fire not self-contained

• Verify gases are not shut off to adjacent rooms
 Impound all equipment and supplies for later inspection

Revision May 2019

 Hyperkalemia K+ > 6 mEq/L
11
Treatment:
 If hemodynamically unstable, start CPR/PALS Manifestations:
 Hyperventilate with 100% O2 • Tall peaked T
 Calcium gluconate 60-100 mg/kg or calcium chloride 20 mg/kg IV • wave
Heart block
• Directly visualize site to avoid infiltration • Sine wave
• Flush tubing after calcium administration • V fib or asystole
 Stop K+ containing fluids (LR/RBC); switch to NS

Hyperkalemia
 Dextrose IV 0.5-1 g/kg and insulin IV 0.1 Unit/kg (MAX 10 units)
 Albuterol puffs or nebulized, once cardiac rhythm stable

 Sodium bicarbonate IV 1-2 mEq/kg

 Furosemide IV 0.5-1 mg/kg
 Consider terbutaline 10 MICROgrams/kg load,
then 0.1-10 MICROgrams/kg/min
 If cardiac arrest > 6 min, activate ECMO (if available)
 Dialysis if refractory to treatment
 If transfusion required, use washed or fresh RBC
From: Slovis C, Jenkins R. BMJ 2002

Causes of Hyperkalemia:
 Excessive intake: massive or “old” blood products, TPN, cardioplegia, KCl infusion
 Shift of K+ from tissues to plasma: crush injury, burns, succinylcholine, malignant
hyperthermia, acidosis
 Inadequate excretion: renal failure
 Pseudohyperkalemia: hemolyzed sample, thrombocytosis, leukocytosis
Revision Mar 2018
 Hypertension, Acute Sustained high blood pressure refractory
to treating reversible causes
12
 In pediatrics, hypertension is almost always treated by
addressing likely causes such as light anesthesia or Hypertensive Blood Pressure Range*
measurement error: Age (yr) Systolic Diastolic
newborn >97 >70
• Ensure correct BP cuff size: cuff bladder
width ~ 40% of limb circumference 1-3 >105 >61
4-12 >113 >86
• Ensure arterial line transducer is at level of heart

Hypertension, Acute
- Consider placing arterial line if not already present
* CAUTION: Anti-hypertensive drugs are almost never needed for routine pediatric cases. These
medications are used almost exclusively for specialized cardiac, neurosurgical, or endocrine
(pheochromocytoma) cases. Consult an expert before use. Rule-out increased ICP.

Action Drug (IV Dosing)

Direct smooth muscle  Sodium nitroprusside 0.5-10 MICROgrams/kg/min

relaxation  HydrALAZINE 0.1-0.2 mg/kg (adult dose 5-10 mg)
β-Adrenergic  Esmolol 100-500 MICROgrams/kg over 5 min, then
blockade 25-300 MICROgrams/kg/min
 Labetalol (also α effect) 0.2-1 mg/kg q 10 min; 0.4-3 mg/kg/hour (infusion)

Calcium channel  niCARdapine 0.5-5 MICROgrams/kg/min

blockade  Clevidipine 0.5-3.5 MICROgrams/kg/min
D1-dopamine agonist  Fenoldopam 0.2-0.8 MICROgrams/kg/min

Revision Feb 2020

 Consider Differential (Partial):
• Light anesthesia (consider • Hypoxemia • Thyroid Storm
vaporizer or infusion pump • Arterial line transducer too • Pheochromocytoma
empty or malfunctioning) low or BP cuff too small • Drug Error
• Hypercarbia • Withdrawal (EtOH or opioid)
 Hypotension Sustained low blood pressure with patient at risk for
end-organ hypoperfusion, typically > 20% below baseline
13
 Ensure oxygenation/ventilation Age < 5th% Systolic BP (mmHg)*
* Numbers
Preemie 47– 57
 Turn anesthetic agents down or off are only a
0 – 3 mo 62 – 69 guide and
vary for
 Check cuff size and transducer position 3 mo – 1 yr 65 – 68 individual
patients and
1 – 3 yr 68 – 74
 Consider placing arterial line if not already present situations
4 – 12 yr 70 – 85
 Give appropriate treatment (see table below) > 12 yr 85 – 92

↓ Preload ↓ Contractility ↓ Afterload

 Hypovolemia/hemorrhage  Negative inotropic drugs  Drug-induced vasodilation

Hypotension
 Vasodilation (anesthetic agents)  Sepsis
 Impaired venous return  Arrhythmias  Anaphylaxis
Causes

 Tamponade  Hypoxemia  Adrenal crisis

 IVC compression (prone,  Heart failure (ischemia)  Hypocalcemia
obese, surgical)  Hypocalcemia/blood product  Thyroid crisis
 Pneumothorax/ administration
pneumoperitoneum/PE
 Increased PIP or PEEP
 Expand circulating blood  Start inotrope if needed:  Start vasopressor if needed:
volume (administer fluids DOPamine 2-20 phenylephrine 1-20
rapidly, consider PRBCs and MICROgrams/kg/min IV infusion, MICROgrams/kg IV bolus, then
albumin) or phenylephrine 0.1-2
 Trendelenberg position EPINEPHrine 1-10 MICROgrams/kg MICROgrams/kg/min IV infusion,
Treatment

IV bolus or
 Place or replace IV;
consider intraosseous line then EPINEPHrine 0.02-1 norepinephrine 0.05-2

Revision Feb 2020

MICROgrams/kg/min IV infusion MICROgrams/kg/min IV infusion

 Calcium chloride 10-30 mg/kg IV or  Go to ‘Anaphylaxis’ card, if

Calcium gluconate 50 mg/kg IV appropriate.

 Review ECG (rhythm, ischemia),  Administer steroids for adrenal

send ABG, Hgb, electrolytes crisis
 Hypoxia ↓ SpO2
14
 Turn FiO2 to 100%
 Confirm presence of end-tidal CO2, look for any changes in capnogram
 Hand-ventilate to assess compliance
 Listen to breath sounds
 Consider DOPE: displacement, obstruction, pneumothorax, equipment failure
 Check:
• ETT tube position and patency. Correct if mainstem or supraglottic, suction to rule out mucous plug,
secretions, or kink
• Consider circuit integrity: kink in circuit or ETT, bronchspasm, obstruction, mucous plug
• Pulse oximeter: try new probe or changing placement
• Check BP and HR

Hypoxia
• Consider recruitment maneuvers
• Consider deepening anesthetic or muscle relaxant if patient-ventilator asynchrony
 Further assessment: Draw blood gas. Perform bronchoscopy, CXR, TEE, ECG
 Consider Differential Diagnosis. If airway cause suspected, see appropriate table below
YES, Airway Cause IS Suspected NO, Airway Cause is NOT Suspected
Lungs Drugs/Allergy
 Bronchospasm/atelectasis  Recent drugs given
 Aspiration  Allergy / anaphylaxis (see ‘Anaphylaxis’ card)/dose error
 Pneumothorax  Methylene blue/dyes or methemoglobinemia
 Pulmonary Edema
ETT Circulation
 Mainstem intubation  Embolism – air (see ‘Air Embolus’ card), fat, CO2,
pulmonary, septic, MI, CHF, cardiac tamponade
 Mucous Plug

Revision Feb 2020

 ETT kinked or dislodged  Severe sepsis
Machine
 Right to left intracardiac or intrapulmonary shunt
 Ventilator settings: RR, TV, I:E ratio,  If associated with hypotension, see ‘Hypotension’ card
auto-PEEP
 Machine malfunction
 Increased Intracranial Pressure ICP > 20
15
 If GCS < 9, respiratory distress, hemodynamic instability: MAP to optimize CPP
• Secure airway Age (yrs) MAP
• Provide sedation prior to transport

Increased Intracranial Pressure

0-4 >45
 Keep PaCO2 30-35 mmHg and PaO2 > 80 mmHg 5-8 >55
 Maintain cerebral perfusion pressure >8 >60
(discuss goal CPP with team)
 Discuss target ICP with neurosurgery, will often want ICP < 20
 Use vasopressors (phenylephrine or NOREPInephrine) as needed to maintain BP and CPP.
 Consider head of bed at 30⁰
 Hypertonic saline (3% saline via central venous catheter) 1-5 mL/kg over 20 min,
then 0.1-2 mL/kg/hour; goal ICP <20 mmHg
• Monitor serum sodium
• Keep osmolarity <360 mOsm/L
 If hypertonic saline not available, can give mannitol 0.25-1 g/kg, over 20 minutes to decrease ICP
 Consider furosemide 1-2 mg/kg (starting MAX 20 mg) to decrease ICP
 Consider seizure prophylaxis: Keppra (levetiracetam) 10-30 mg/kg IV (MAX 2500 mg)
 Consult with neurosurgery colleagues about draining CSF directly or via ventriculostomy
 Refractory elevated ICP treatment, consider:
• Barbiturate coma
• Paralysis with non-depolarizing agent
 AVOID:
• Compression of neck vessels
• Hyperthermia

Mar 2018
Revision
• Hyperglycemia & dextrose containing solutions (maintain glucose level < 200 mg/dL)
 Loss of EtCO2 due to vocal cord closure,
Laryngospasm often during stage 2 anesthesia
16
Signs and Symptoms
 Inspiratory stridor, accessory muscle use, sternal retractions, paradoxical chest
movement, airway obstruction, ↓SpO2, ↓HR, loss of EtCO2
Treatment
 Notify team to cease stimulation/surgery
 Give 100% O2, evaluate ventilation
 Apply CPAP and jaw thrust

Laryngospasm
 Confirm or establish adequate IV access
 Deepen anesthesia with IV and/or inhaled agents. Consider propofol 1-3 mg/kg
 Give succinylcholine 0.1-2 mg/kg (if no IV: 2-4 mg/kg IM)
 If bradycardia, give atropine 0.02 mg/kg IV (if no IV: 0.04 mg/kg IM)
 Consider direct laryngoscopy to secure the airway and/or suction
 Avoid further patient stimulation during stage 2 anesthesia
 If further airway instrumentation needed, consider airway topicalization with
lidocaine
 Monitor for negative pressure pulmonary edema (pink frothy secretions). If
present, consider ETT, PPV, PEEP, ICU
Differential Diagnosis

Revision June 2018

 Circuit disconnect or obstruction
 Upper airway obstruction
 Lower airway obstruction/bronchospasm
 Hypotension, rhythm disturbance,
Local Anesthetic Toxicity altered consciousness, seizures
17
 Stop local anesthetic
 Request Intralipid kit Intralipid Dosing
 Secure airway and ventilation  Bolus Intralipid 20% 1.5 mL/kg
 Give 100% O2 over 1 min
 Start infusion 0.25 mL/kg/min

Local Anesthetic Toxicity

 Confirm or establish adequate IV access.
 Confirm & monitor continuous ECG, BP, and SaO2  Repeat bolus every 3-5 min up to
4.5 mL/kg total dose until
 Seizure treatment: circulation is restored
• Midazolam 0.05-0.1 mg/kg IV
• Be prepared to treat resultant hypoventilation  Double the rate to 0.5 mL/kg/min
if BP remains low
 Treat hypotension with small doses of  Continue infusion for 10 min after
EPINEPHrine 1 MICROgram/kg hemodynamic stability is restored.
 Avoid propofol, vasopressin, calcium channel  MAX total Intralipid 20% dose: 10
blockers and beta blockers mL/kg over first 30 min
 Start Intralipid therapy (see inset box)
 If cardiac instability occurs:
• Start CPR/PALS
- Continue chest compressions (lipid must circulate). May need prolonged compressions
 Consider: alert nearest cardiopulmonary bypass/ECMO center & ICU if no ROSC after 6 min
 Monitor and correct acidosis, hypercarbia and hyperkalemia
 Monitor for recurrence for 4-6 hours following the event
 Consider Differential (partial):
• Anaphylaxis: go to Anaphylaxis card
• Air, fat, thrombotic, or cement embolus: go to Air Embolism card
Revision Feb 2020
 Loss of Evoked Potentials Management of signal
changes during spine surgery
18
 Notify all members of health care team. Call a “time out"

 Loss of evoked potentials (EP) requires definitive steps to re-establish perfusion/remove

mechanical cause; MEP loss for > 40 min may increase possibility of long term injury
• Assure the presence of attending surgeon, attending anesthesiologist, senior neurologist
or neurophysiologist, and experienced nurse

Loss of Evoked Potentials

• Each service: review situation, report on management and corrective actions taken
- Surgeon: rule out mechanical causes for loss/change including traction weights
- EP technologist: rule out technical causes for loss/change
- Anesthesiologist: assure no neuromuscular blockade is present; reverse NMB if
necessary

 Check patient positioning (neck, upper and lower extremities)

 Review the anesthetic and consider improving spinal cord perfusion by modifying:
• Mean arterial pressure: MAP > 65 mmHg using ePHEDrine 0.1 mg/kg IV (MAX 10
mg/dose) and/or phenylephrine 0.3-1 MICROgrams/kg IV (MAX 100
MICROgrams/dose), with repeated doses as needed
• Hemoglobin: if anemic, transfuse RBC to improve oxygen delivery
• pH and PaCO2: ensure normocarbia or slight hypercarbia (↑ I/E ratio, ↓ PEEP)
• Temperature: ensure normothermia
• Check for “unintended” drugs given (e.g. neuromuscular blocker)
• Decrease depth of anesthetic and ensure N2O is under 50%

Revision Feb 2020

 Discuss feasibility of a useful wake-up test:
• Patient is appropriate candidate if capable of following verbal commands
 Consider high-dose steroid if no improvement:
• MethylPREDNISolone 30 mg/kg IV over one hour, then 5.4 mg/kg/hour IV for 23 hours
 Malignant Hyperthermia ↑ Temp ↑ HR ↑ CO2 acidosis
19
 Get MH Cart, dantrolene, and help
 Notify team and stop procedure, if possible
MH hotline 1‐800‐644‐9737
 Stop volatile anesthetic, succinylcholine.
 Attach charcoal filter. Turn O2 flow to 10 L/min
 Hyperventilate patient to reduce EtCO2

Malignant Hyperthermia
 Give dantrolene 2.5 mg/kg IV, rapidly, through large bore IV if possible, every 5 min until symptoms
resolve. May need up to 10 mg/kg (if no response at this dose, consider alternative diagnoses)
• Dantrium/Revonto: Assign dedicated person to mix these formulations of
dantrolene (20 mg/vial) with 60 mL non-bacteriostatic sterile water
• Ryanodex: 250 mg is mixed with 5 mL non-bacteriostatic sterile water
 Transition to non‐triggering anesthetic
 Give sodium bicarbonate 1-2 mEq/kg IV for suspected metabolic acidosis
 Cool patient:
• Apply ice externally to axilla, groin and around head
• Infuse cold saline intravenously
• NG and open body cavity lavage with cold water
• Stop cooling when temperature < 38o C
 Hyperkalemia treatment:
• Calcium gluconate 30 mg/kg IV or calcium chloride 10 mg/kg IV;
• Sodium bicarbonate 1‐2 mEq/kg IV;
• Regular insulin 0.1 units/kg IV (MAX 10 units) and dextrose 0.5-1 g/kg IV
 VT or afib treatment: Do NOT use calcium channel blocker; give amiodarone 5 mg/kg
 Send labs: ABG or VBG, electrolytes, serum CK, serum/urine myoglobin, coagulation
 Place urinary catheter, maintain UO > 2 ml/kg/hr
 If cardiac arrest occurs, begin CPR & consider ECMO, see ‘Cardiac Arrest’ card
 If no response after 10 mg/kg dantrolene, consider other dx: sepsis, NMS, serotonin synd., myopathy,
pheochromocytoma
 Call ICU to arrange disposition. For post-acute management, see: http://www.mhaus.org
Revision Mar 2018
 Massive Hemorrhage Replacement > half total blood volume
(TBV) per hour or TBV < 24 hours
20
 Notify Blood Bank immediately, send blood sample
for type and cross Treatment

Transfusion: Massive Hemorrhage

 Activate institutional pediatric massive  HCT < 21% or Hgb < 7:
transfusion protocol. Consider • 4 ml/kg PRBC increases Hct by
RBC : FFP : Platelets = 2:1:1 or 1:1:1 3%
• Use un-crossmatched O negative PRBCs and AB+  Platelet count < 50,000 (< 100K
plasma until
for brain injury), rapid TEG-MA <
crossmatched blood available
54mm:
• Consider intraoperative blood salvage
(e.g., Cell Saver) • 10 ml/kg apheresed platelets
increases platelet count by 30 –
 Obtain additional vascular access if needed 50k
 Watch for hyperkalemia, if needed give calcium  INR > 1.5 (or > 1.3 brain injury),
gluconate 60 mg/kg or calcium chloride 20 mg/kg
rapid TEG-ACT >120 sec:
while directly visualizing IV site (if peripheral)
• 10ml/kg plasma increases
 Warm the room coagulation factors by 20%
 Send labs/perform point of care testing q 30 min:
CBC, platelets, PT/PTT/INR, fibrinogen, rapid TEG,  Fibrinogen < 100 mg/dL or rapid
ABG, Na, K, Ca, lactate TEG-angle<66°, k value >120 sec:

 Blood product administration: • 10 ml/kg cryoprecipitate

increases fibrinogen by 30-50
• Use 140 micron filter for all products mg/dL
• Use a blood warmer for RBC and FFP
transfusion (NOT for platelets)  Refractory hemorrhage
• Consider use of rapid transfusion pumps • Consider factor VIIa, up to 90
• Monitor ABG, electrolytes, and temperature MICROgrams/kg
 When under control: call blood bank to terminate
Revision Mar 2018
 Myocardial Ischemia ST changes on ECG
21
Treatment:
 Improve O2 Supply:
• Increase O2 to 100%
• Correct anemia
• Correct hypotension
 Decrease O2 Demand:

Myocardial Ischemia
• Reduce heart rate
• Correct hypertension
• Restore sinus rhythm
Recognition
 Drug therapy (rarely needed in peds, consult a
pediatric cardiac expert):  ST depression >0.5 mm in any lead

• NitroGLYCERIN 0.5-5 MICROgrams/kg/min  ST elevation >1 mm (2mm in

precordial leads)
• Consider heparin infusion 10 Units/kg bolus,
 Flattened or inverted T waves
then 10 Units/kg/hour
 Arrhythmia: VF, VT, ventricular
Potential Causes: ectopy, heart block
 Severe hypoxemia Diagnostic studies
 Systemic arterial hypo- or hypertension  12-lead ECG:
• II, III, aVF for inferior (RCA)
 Marked tachycardia
• V5 for lateral ischemia (LCx)
 Severe anemia
• V2, V3 anterior ischemia (LAD)
 Coronary air embolus  Compare to previous ECGs
 Cardiogenic shock  Request Pediatric Cardiology
 Local anesthetic toxicity consult and echocardiogram

Revision Mar 2018

 Pulmonary Hypertensive Crisis Increased PVR
22
Initial Management
 Give 100% O2 Call stat for inhaled nitric oxide (iNO) 20-40 ppm. Reduced O2 saturation may
not be immediate

Pulmonary Hypertensive Crisis

 Consider stat TEE and ECMO
 Deepen anesthetic/sedation, consider fentanyl 1 MICROgram/kg or ketamine 0.5-1 mg/kg
 Administer muscle relaxant
 If poor perfusion, consider chest compressions early
Hypotension Management
 If hypotensive, give vasopressin 0.03 units/kg bolus, then:
• To maintain perfusion:
Vasopressin 0.17-0.67 milliunits/kg/minute = 0.01 to 0.03 units/kg/hour
or
NOREPInephrine 0.05-0.3 MICROgrams/kg/min
Ventilation
 Ventilate with low airway pressures & long expiratory phase to maintain adequate tidal
volume, avoid atelectasis and preserve FRC. Maintain normocapnia or mild hypocapnia. PEEP
may worsen pulmonary hypertension
Further Management
 Administer isotonic fluid judiciously to achieve normovolemia and to reduce acid load, correct
acidosis with sodium bicarbonate
 Maintain NSR and AV synchrony
 Temperature: ensure normothermia
Crisis Management
 If cardiac arrest occurs or is imminent, give epinephrine 1-10 MICROgrams/kg

Nov 2020
Revision
 If cardiac arrest occurs, begin CPR and call for ECMO as CPR may be ineffective if no
intracardiac communication
 Tachycardia, unstable Tachycardia associated with hypotension
23
 Call for defibrillator and code cart. Typically infant >=220 bpm, child >=180 bpm
 Place patient on backboard. Attach defibrillator pads
 Give 100% O2, stop anesthetic agents, notify team, consider cardiology consult
 If NO pulse present: start CPR/PALS; go to ‘Cardiac Arrest’ card


Tachycardia, unstable
If pulse present: administer appropriate treatment (see table below)

Treatment
Narrow complex: Torsade de Pointes:
p waves present SVT, tachyarrythmia Wide complex polymorphic VT with
before every QRS prolonged QT
 Probably sinus  Consider vagal  Amiodarone  Magnesium sulfate
tachycardia maneuvers 5 mg/kg IV bolus 25-50 mg/kg IV/IO
over 20-60 min (MAX 2 g)
 Identify and treat  Adenosine: 1st dose
underlying etiology 0.1 mg/kg IV, rapid OR  Lidocaine 1 mg/kg IV
push (6 mg MAX); (MAX 100 mg)
2nd dose 0.2 mg/kg  Procainamide 15
IV (12 mg MAX) mg/kg IV bolus  Sodium bicarbonate
over 30-60 min (for quinidine-related
 Synchronized SVT) 1 mEq/kg IV
cardioversion: OR
 Temporary pacing
0.5-1 joule/kg,  Synchronized (see ‘Bradycardia’
additional shocks cardioversion: card)
@ 2 joules/kg
0.5-1 joule/kg,
additional shocks
@ 2 joules/kg

Revision Mar 2018

Tamponade, Cardiac
Tamponade physiology occurs when increased
pericardial pressure impairs diastolic filling
24
Signs & Symptoms
 Beck’s Triad: muffled heart tones, distended neck veins, decreased systolic blood pressure
 Pulsus Paradoxus: cyclic inspiratory decrease in systolic BP of more than 10mmHg
 Electrical Alternans: cyclic alteration in magnitude of p waves, QRS complex & t-waves
 Typical presentation of acute tamponade = sudden hypotension, tachycardia & tachypnea; patient
may be unable to lie flat
Diagnosis

Tampondade, Cardiac
 Echocardiography/ultrasound: diastolic compression or
collapse of RA/RV, leftward displacement of ventricular
septum, exaggerated increase in RV size with reciprocal
decrease in LV size during inspiration

Treatment - imaging is key in deciding treatment

 Pericardiocentesis awake/local for large effusions prior
to GA
 Surgical for postoperative tamponade (cause is often
local collections of clotted blood)

Anesthetic Considerations
 Progressive decrease in SV with an increased CVP  systemic hypotension  cardiogenic shock
 Goals: maintain sympathetic tone and CO via  HR and contractility/fluid bolus prn
• Induction: Ketamine (1-2 mg/kg IV), muscle relaxant
• If CV collapse: EPINEPHrine 0.05-0.1 MICROgrams/kg IV bolus or infusion (0.01-0.1
MICROgrams/kg/min)
• Access: Large bore PIV; arterial line ideal but should not delay treatment in hemodynamically
unstable patient
• Avoid: cardiac depression, vasodilation,  HR;  airway pressure (will  venous return) so may
need small tidal volumes or hand ventilation

Differential Diagnosis
 CHF, PE
 If pulsus paradoxus: respiratory distress, airway obstruction, COPD, PE, RV infarction
First Published Nov 2018
 Tension Pneumothorax
↑ HR ↓ SpO2 ↓ BP tracheal
deviation, mediastinal shift
25
 Stop N2O; increase O2 to 100%
 Perform immediate needle decompression,
then chest tube placement
Needle
 Needle decompression: decompression
Chest tube

Tension Pneumothorax
• 2nd rib space superior to 3rd rib, mid-clavicular line
- 14-16g angiocath for teens/adults
- 18-20g angiocath for infants/children Downloaded from:
http://www.uwhealth.org/images/ewebeditpro/
 Secure airway with endotracheal tube uploadimages/5384_Figure_1.jpg

 Reduce positive ventilation pressure

Lung Ultrasound Instructions
 Consider CXR, lung ultrasound, transillumination to  High frequency probe, place
confirm diagnosis (see inset) longitudinally on chest, 2nd
intercostal space. Slide probe
 Administer vasopressors for circulatory collapse downwards to observe pleural
 Chest tube insertion sliding

• 5-6th intercostal space, mid-axillary line • If see pleural

sliding, 100%
 If no improvement in hemodynamics after a rush of positive predictive
air, consider: value no
pneumothorax
• Needle decompression of contralateral side
• Presence of pneumopericardium • If no pleural
Pic: No PTX sliding, consider
• Scan both lungs with ultrasound or pneumothorax,
transillumination to evaluate for alternate side or ARDS, fibrosis,
insufficiently decompressed pneumothorax acute asthma,
pleurodesis
Revision Feb 2020
 Transfusion Reactions Reactions may occur with any type of blood product
26
For All Reactions:
 Stop transfusion
 Disconnect donor product and IV tubing
 Infuse normal saline through clean tubing
 Examine blood product ID; determine correct pt

Transfusion Reactions
 Send product to Blood Bank
 Determine the type of reaction:

Hemolytic Non-Hemolytic Anaphylactic

Hemoglobinemia, ↓ BP, bronchospasm, Erythema, urticaria,
hemoglobinuria, DIC, ↓ BP, pulmonary edema, angioedema, bronchospasm,
Signs

↑ HR, bronchospasm fever, rash tachycardia, shock

 Furosemide 1-2 mg/kg IV  Treat fever  Support airway and

(MAX 40 mg) circulation as necessary
 Treat pulmonary
 Mannitol 0.25-1 g/kg edema  EPINEPHrine
1-10 MICROgrams/kg IV
 Support BP to maintain  Observe for signs of
Treatment

renal perfusion hemolysis  DiphenhydrAMINE

1 mg/kg IV (MAX 50 mg)
 Maintain urine output at
least 1-2 mL/kg/hour  MethylPREDNISolone
2 mg/kg IV (MAX 60 mg)
 Prepare for cardiovascular
instability  Maintain intravascular
volume
 Send blood and urine
sample to laboratory

Revision June 2020

 Trauma Initial management of trauma
27
Set-up prior to patient arrival to OR:
 Assemble team and assign roles
 Estimate weight and prepare emergency drugs
 Warm the room
 Gather equipment:
• Airway supplies
• Line placement and monitoring devices
• Fluid warmer/rapid infusion device
• Code cart with programmed defibrillator

Trauma
 Type and cross blood products. Activate massive transfusion protocol if indicated
On patient arrival to OR:
 Maintain c-spine precautions for transport
 Secure/confirm airway (often aspiration risk, unstable c-spine)
 Ensure adequate ventilation (maintain PIP < 20 cm H20)
 Obtain/confirm large-bore IV access (central or intraosseous if peripheral unsuccessful)
 Assess hemodynamic stability.
• If hypovolemic, pre-induction fluid bolus recommended: 20 mL/kg LR or NS (repeat x
2) and/or 10 mL/kg RBCs or 20 mL/kg whole blood
 Arterial and central venous line placement if indicated
 Maintain normothermia

Revision June
 Monitor and treat associated conditions

2020
• Anemia, coagulopathy, acidosis, electrolyte derangements
 Continuously assess for undiagnosed secondary and/or developing injuries, blood loss
MATERNAL CRISIS
 Loss of >500mL after vaginal
MATERNAL Postpartum Hemorrhage birth, or >1,000mL after
cesarean delivery
28

 ATTENTION: This checklist is for ADULT-SIZED maternal Treatment

MATERNAL Postpartum Hemorrhage

patients ONLY
ADULT MATERNAL Uterotonics:
 Prepare for crystalloid and blood product resuscitation
 Oxytocin ADULT DOSE 3-5 Units
 Obtain vascular access with 2 large-bore IVs rapid infusion, then start 40
Units slow infusion
 Call Blood Bank to activate Massive Transfusion with
PRBC:FFP:platelet in a 4:2:1 ratio. Ask blood bank to  Methylergonovine (Methergine)
prepare next round when each round is picked up. ADULT DOSE 0.2mg IM NOT IV,
may repeat in 2 hours (AVOID
• Give calcium chloride ADULT DOSE 200-500mg/Unit in HTN and pre-eclampsia)
PRBCs, in separate line. Monitor for hyperkalemia
 Carboprost (Hemabate) ADULT
• Consider giving tranexamic acid early DOSE 0.25mg IM NOT IV, may
repeat q 15 minutes up to 8
• If refractory hemorrhage, consider fVIIa and doses (AVOID in asthma,
cryoprecipitate or fibrinogen concentrate pulmonary hypertension)
 Give uterotonics  Misoprostol ADULT DOSE 800-
 Call for rapid transfuser or pressure bags 1000 MICROgrams rectal

 Warm room, patient and fluids (NOT platelets)

Hemostatics:
 Send CBC, PT/PTT/INR, fibrinogen, calcium, K, ABG
 Tranexamic acid ADULT DOSE 1g
IV
Obstetric Interventions Consider
 If low fibrinogen, give
• Intrauterine balloon • Arterial line cryoprecipitate ADULT DOSE 10
units or fibrinogen concentrate
• External uterine • If awake, convert to
compression sutures general anesthesia  If refractory hemorrhage,
consider factor VIIa 90
• Uterine artery ligation • Embolization in IR
MICROgrams/kg, up to 3 doses
• Hysterectomy • TEG/ROTEM monitoring
Revision Dec 2018