A Practice of Anesthesia for Infants and Children

CJ Coté MD, J Lerman MD, BJ Anderson MB ChB

Pocket Reference Guide
Note that the drug doses and management decisions presented are those that are commonly recommended; each child’s care must be individualized according to the
child’s underlying medical and surgical conditions. All drug doses should be double checked before administration so as to avoid errors.

RESUSCITATION
Oxygen ventilate with 100% oxygen
Epinephrine (Adrenaline) 1 μg/kg to treat hypotension IV; 10 μg/kg IV for cardiac arrest; repeat every 3-5 minutes as needed
Atropine 20 μg/kg IV (for symptomatic bradycardia); maximum dose 1 mg for child and 2 mg for adolescent
Bicarbonate 1-2 mEq/kg IV to be guided by blood gas analysis
Calcium Chloride 10-20 mg/kg IV (0.1-0.2 mL/kg of a 10% solution)
Calcium Gluconate 30-60 mg/kg IV (0.3-0.6 mL/kg of a 10% solution)
Adenosine (Adenocard) 100 μg/kg rapid IV bolus and flush (maximum 6 mg ); second dose 200 μg/kg (maximum 12 mg)*
Lidocaine 1 mg/kg IV then followed by 20-50 μg/kg/min by infusion pump
Amiodarone (Cordarone) 5 mg/kg IV, maximum 300 mg for ventricular fibrillation and/or ventricular tachycardia
Procainamide (Pronestyl) 5 to 15 mg/kg IV loading dose over 30-60 minutes, then 20-80 μg/kg/min by infusion pump. ECG monitoring
required. Caution: hypotension and prolonged QT interval may occur particularly when combined with amiodarone
Magnesium 25-50 mg/kg IV for Torsades de Pointes (maximum dose 2 grams)
*Reduce by half if administering through a central line or for patients who have had a heart transplant.

VASOACTIVE DRUGS CARDIOVERSION/DEFIBRILLATION (EXTERNAL)

Note that all are administered by IV infusion pump; consider invasive arterial pressure monitoring
cardioversion For supraventricular/ventricular tachycardia
Dopamine 1-20 μg/kg/min; titrate to effect 0.5 joules/kg SYNCHRONOUS; repeat up
Dobutamine 1-20 μg/kg/min; titrate to effect to 2 joules/kg
defibrillation For ventricular fibrillation/ventricular
Epinephrine (Adrenalin) 0.1-1 μg/kg/min; titrate to effect tachycardia 2 joules/kg ASYNCHRONOUS;
Isoproterenol (Isuprel) 0.1-1 μg/kg/min; titrate to effect repeat up to 4 joules/kg
Norepinephrine (Levophed) 0.1-1 μg/kg/min; titrate to effect
Phenylephrine (Neo-Synephrine) 0.1-1 μg/kg/min; titrate to effect
Milrinone (Primacor) 50-100 μg/kg loading dose followed by RULE OF SIXES
0.25-1 μg/kg/min infusion
0.1 μg/kg/min = 0.6 mg/100 mL administered as body weight
Nitroprusside (Nipride) 0.5-10 μg/kg/min; titrate to effect; observe for (kg) in mL/hr
signs of cyanide toxicity
1 μg/kg/min = 6 mg/100 mL administered as body weight (kg)
Nitroglycerine (NitroQuick) 1-10 μg/kg/min; titrate to effect in mL/hr
Prostaglandin E1 0.01-0.1 μg/kg/min (Note that apnea may occur 10 μg/kg/min = 60 mg/100 mL administered as body weight (kg)
and intubation is often required with doses in mL/hr
>0.05 μg/kg/min)
20 μg/kg/min = 120 mg/100 mL administered as body weight
Vasopressin (Pitressin) 0.0001 to 0.001 units/kg/min (kg) in mL/hr

HYPERKALEMIA TREATMENT
ANAPHYLAXIS
Search for cause, especially latex allergy; remove source if possible Intervention Dose
Oxygen Ventilate with 100% oxygen Calcium chloride 5-10 mg/kg/dose IV; repeat until normal
sinus rhythm
Epinephrine 1 μg/kg IV to treat hypotension/bronchospasm;
(Adrenaline) repeat with increasing doses every 3-5 minutes as Calcium gluconate 15-30 mg/kg/dose IV; repeat until
needed; may need continuous infusion normal sinus rhythm
Fluid bolus 20 mL/kg balanced salt solution; repeat as necessary Hyperventilation
Phenylephrine 0.1 μg/kg/min IV; titrate to effect if inadequate Albuterol (Ventolin, Proventil) by inhalation administered with a spacer
(Neo-Synephrine) response to epinephrine Salbutamol 5 μg/kg IV over 15 minutes
Hydrocortisone 2-3 mg/kg IV Glucose + insulin glucose (0.5-1 g/kg) with insulin (0.1 U/
Diphenhydramine 1-2 mg/kg IV kg) given IV over 30-60 minutes
Ranitidine (Zantac) 1.5 mg/kg IV Kayexalate 1 g/kg (up to 40 g) q4hr (PO, PR, per
gastric tube)

LARYNGEAL MARK AIRWAY (CLASSIC) ETT SIZE (mm ID) DISTANCE OF

INSERTION (cm)
Weight Cuff Volume Largest ETT that will Uncuffed Cuffed
EVEN WITH GUMS
(kg) Size (mL) fit through LMA
Preterm 2.5
<5 1 4 3.5 uncuffed Preterm (<1000 6-7
(<1.5 kg)
grams)
5-10 1.5 7 4 uncuffed Preterm 3
Preterm (<2000 7-9
10-20 2 10 4.5 uncuffed (1.5-3 kg)
grams)
20-30 2.5 14 5 uncuffed Full-term 3
Full-term ~10
neonate
30-50 3 20 6 cuffed neonate
1 year 4 3-3.5
50-70 4 30 6 cuffed 1 year ~11
2 years 5 4-4.5
70-100 5 40 7 cuffed 2 years ~12
>2 years Age/4 + 4 0.5-1.0
>100 6 50 7 cuffed 16 years ~18
(or 4.5) smaller
than ≥20 years ~20-21
uncuffed
ETT*
*Assure leak with deflated cuff at 20-40 cm H2O PIP.

LARYNGOSCOPE BLADES INDUCTION AGENTS DURATION OF E-CYLINDER

(APPROXIMATE SIZE) OXYGEN SUPPLY
IM Rectal
Wis- IV (mg/kg) (mg/kg) (mg/kg) Non-SI units SI units
Age Miller Hipple Macintosh Propofol 2-3 mg/kg IV Time (in minutes) Time (in
Preterm 0 (Diprivan) = 1/3 × tank minutes) =
pressure (pounds/ tank pressure
Full-term 0 Ketamine 1-2 3-12 5-10
square inch)/ (kPa)/(23 ×
neonate (Ketalar)
oxygen flow rate oxygen flow
Term-2 years 1 1 Etomidate 0.2-0.3 (L/min) rate (L/min))
(Amidate)
2-6 years 1.5 1-2
Thiopental 4-6 20-30
6-10 years 2 NA 2
Methohexital 1-3 20-30
>10 years 2 or 3 NA 2 or 3

NEUROMUSCULAR BLOCKING DRUGS

Succinylcholine 2-3 mg/kg IV for <1 year; 1-2 mg/
(Anectine)* kg IV; 4-5 mg/kg IM or 1-3 mg/kg
intralingual (submental) for >1 year
Rocuronium 0.3 mg/kg in neonates = ~30-45
(Zemuron) min, 0.6 mg/kg in children =
~30-45 min duration, 1.2 mg/kg in REVERSAL AGENTS/ANTAGONISTS
children for rapid sequence
Neostigmine (Prostigmin) 0.02-0.05 mg/kg + atropine 0.02 mg/kg or glycopyrrolate 0.01 mg/kg
intubation = ~75 min duration
Edrophonium (Enlon) 0.3-1 mg/kg + atropine 0.02 mg/kg or glycopyrrolate 0.01 mg/kg
Vecuronium 0.1 mg/kg IV
(Norcuron) Sugammadex 2 mg/kg for reversal of rocuronium
Pancuronium 0.05-0.1 mg/kg IV Physostigmine (Antilirium) 0.01-0.03 mg/kg followed by infusion 0.03 mg/kg/hr to treat
(Pavulon) cholinergic syndrome
Cisatracurium 0.1 mg/kg IV neonates; 0.1-0.2 mg/ Naloxone (Narcan) 0.25-0.5 μg/kg, additional doses titrated to effect; up to 100 μg/kg
(Nimbex) kg older children (maximum 2 mg) may be needed for respiratory arrest; must observe
child for recrudescence. May also give the effective dose IM to
Atracurium 0.5 mg/kg IV
prevent recrudescence
(Tracrium)
Flumazenil (Romazicon) 10 μg/kg/dose, titrate to effect; must observe child for minimum of 2
*Pretreatment with anticholinergic recommended. hours after antagonism

ANALGESICS
Non-Opioids
Acetaminophen oral/rectal (Tylenol) Non-IV routes (Tylenol): 10-15 mg/kg PO every 4-6 hours or 30-40 mg/kg PR loading dose, then
Acetaminophen IV (OFIRMEV) (Pro-Dafalgan) 20 mg/kg PR every 6 hours (maximum 75 mg/kg/24 hr)
IV routes: 15 mg/kg paracetamol IV every 6 hours or 30 mg/kg propacetamol every 6 hours
(with only 15 mg/kg of the prodrug in neonates)
Ibuprofen (Advil) 10 mg/kg PO every- 6 hours (max 800 mg)
Ketorolac (Toradol) 0.5 mg/kg up to 15 mg <50 kg; 0.5 mg/kg up to 30 mg >50 kg, IV, IM, PO every 6 hours
Ketamine (Ketalar) 0.25-1 mg/kg every 8-10 minutes IV as needed
Opioids
Codeine 0.5-1.5 mg/kg PO/IM every 6 hours
Fentanyl (Sublimaze) 0.5-2 μg/kg; greater doses up to 100 μg/kg for cardiac or other major cases
Hydromorphone (Dilaudid) 0.015 mg/kg IV every 3-4 hours
Morphine 0.05-0.1 mg/kg IV every 3-4 hours (postoperative analgesia infusion 5-20 μg/kg/hr)
Remifentanil (Ultiva) 0.05-0.15 μg/kg/min (may need larger doses for brief periods); continuous infusion may cause
hypotension and bradycardia
 OPIOID CONVERSION APPROXIMATIONS SEDATIVES
Morphine (1 mg) is equivalent to:
Chloral hydrate 50-100 mg/kg maximum 2 grams in divided
IV (mg) PO (mg) doses (PO or PR)
Codeine ~12-13 ~20 Dexmedetomidine 0.3-2 μg/kg loading dose infused over 10
Fentanyl (Sublimaze) ~0.01 (10 μg) ~0.02 (20 μg) (Precedex) minutes followed by 0.7 to 1 μg/kg/hr

Hydromorphone (Dilaudid) ~0.15 ~0.75 Pentobarbital 2 mg/kg IV every 10 minutes up to 6 mg/kg

Oxycodone (OxyContin) ~2-3

Methadone ~1 ~1.5
Tramadol (Ultram) ~10 ~15

ANTIBIOTICS ANTIHISTAMINES
Antibiotic (IV)* 1st week 1-4 weeks >4 weeks IV (mg/kg) PO (mg/kg)
postnatal postnatal postnatal
(>2000 grams) Diphenhydramine (Benadryl) 1-1.25 1-1.5
Ampicillin 50 mg/kg 25-50 mg/kg 25-50 mg/kg Ranitidine (Zantac) 1.5 2-5
(Omnipen) every 8 hours every 6 hours every 4-6 hours
Famotidine (Pepcid) 0.5 0.5
Ampicillin/ 25-37.5 mg/kg
Sulbactam every 6 hours
(UNASYN)
Cefotaxime 50 mg/kg 50 mg/kg 50 mg/kg every
(Claforan) every 8-12 every 6-8 6-8 hours
hours hours
Cefazolin (Ancef) 20 mg/kg 20 mg/kg 16-33 mg/kg
every 12 hours every 8 hours every 8 hours ANTIEMETICS
(up to 3 grams)
IV (mg/kg) PO (mg/kg)
Ceftriaxone 50 mg/kg 50-75 mg/kg 50-75 mg/kg
(Rocephin) every 24 hours every 24 every 12-24 Dexamethasone 0.0625-0.15 (max 10-15 mg)
hours hours
Metoclopramide (Reglan) 0.15 0.15
Cefuroxime 25-50 mg/kg 25-50 mg/kg 25-50 mg/kg
(Zinacef) every 12 hours every 12 every 8 hours Ondansetron (Zofran) 0.05-0.1 up to a maximum 0.1 up to
hours total dose of 4 mg 4 mg
Clindamycin 5 mg/kg every 10 mg/kg 10 mg/kg every Tropisetron (Navoban) 0.1-0.2
(Cleocin) 8 hours every 8 hours 6-8 hours
Gentamicin†‡ 4 mg/kg every 4 mg/kg 2-2.5 mg/kg
24 hours every 24 every 8 hours
hours ANTICHOLINERGICS
Metronidazole 7.5 mg/kg 15 mg/kg 7.5 mg/kg IV (mg/kg) PO (mg/kg)
(Flagyl) every 12 hours every 12 every 6 hours
hours Atropine 0.02 (20 μg/kg) 0.02-0.03
Nafcillin (Unipen) 25 mg/kg 25 mg/kg 25-50 mg/kg Scopolamine 0.01 (10 μg/kg)
every 8 hours every 6 hours every 6 hours
Glycopyrrolate 0.01 (10 μg/kg)
Piperacillin/ 37.5-75 mg/kg
Tazobactam (Zosyn) every 6 hours
Ticarcillin 75 mg every 50-75 mg/kg 33-50 mg/kg
(Timentin) 8 hours every 6 hours every 4 hours
DIURETICS
Vancomycin 15 mg/kg 15 mg/kg 10-15 mg/kg
(Vancocin)†§ every 12 hours every 8 hours every 8 hours Chlorothiazide (Diuril) 10-15 mg/kg PO every 12 hours
*For preterm infants, check with pharmacy. Furosemide (Lasix) 1-2 mg/kg/dose PO/IM/IV
†
Monitoring blood levels recommended. Spironolactone (Aldactone) 1 mg/kg PO every 8-12 hours
‡
0-4 weeks, <1200 g, 2.5 mg/kg every 18-24 hours; <1000 g 3.5 mg/kg every
24 hours. Mannitol 0.25-0.5 g/kg IV (slowly to avoid hypotension)
§
Should generally be administered by infusion pump over 60 minutes.

ANTIHYPERTENSIVES TRANSFUSION SHORT CUTS

Adrenergic Dose Whole blood 6 mL/kg Increases hemoglobin 1 g/dL
receptor PRBCs 4 mL/kg Increases hemoglobin by 1 g/dL
Captopril 0.05-0.25 mg/kg every 6 hours PO or NG Platelets 5-10 mL/kg increases platelet count by
(Capoten) 50,000-100,000/mm3
Hydralazine 0.1-0.2 mg/kg IM/IV every 4-6 hours Fresh Frozen 10-15 mL/kg Factor levels increase by
Esmolol β1 100-500 μg/kg IV over 1-5 minutes; Plasma ~15-20 percent
(Brevibloc) 50-100 μg/kg by infusion pump up to Cryoprecipitate 1-2 units/kg Increases fibrinogen by
300 μg/kg/min ~ 60-100 mg/dL
Labetalol α 1, β 1, and 0.1-0.4 mg/kg IV every 5-10 minutes until
(Trandate) β2 desired effect
SPECIAL PROBLEMS
Atenolol β1 1-2 mg/kg/day PO up to 3 mg/kg in single
(Tenormin) or divided doses until desired effect Diabetes Insipidus
Propranolol β 1 and β 2 0.05-0.1 mg/kg/ dose IV every 10 Dilute polyuria (urine osmolality <250 mOsm/L, >2 mL/kg/hr), hypernatremia
(Inderal) minutes; titrate to effect; maximum single (sodium >145 mEq/L) with serum hyperosmolality (>300 mOsm/L)
dose 10 mg; hypotension may occur in
infants; (1-2 mg/kg PO every 6 hours) DDAVP (desmopressin) 1-10 mU/kg/hr (0.0025-0.025 μg/kg/hr), titrate to effect
(4 μg = 16 IU)
Nitroprusside 0.5-10 μg/kg/min by infusion pump;
(Nipride)& titrate to effect; may cause precipitous von Willebrand Disease (VWD)
Nitroglycerin decrease in blood pressure; arterial line Desmopressin (DDAVP) 0.3 μg/kg IV once 30 minutes preoperatively
(NitroQuick) recommended
(See above) Amicar 100 mg/kg IV or PO 1 hour preoperatively, then every 4-6 hours
depending on the type of VWD

LOCAL ANESTHETICS (VOLUME ADJUSTED

FOR NERVE BLOCKS) SBE REGIMEN FOR DENTAL SURGERY

Conversion from percent to mg/mL: concentration (percent) Route Antibiotic dose

× 10 = mg/mL Oral Amoxicillin 50 mg/kg PO
With epinephrine IV (unable to take oral Ampicillin, Cefazolin or Ceftriaxone
Maximum doses Plain mg/kg (1 : 200,000) mg/kg medication) 50 mg/kg IV
Lidocaine 5 7 Oral (allergy to penicillins) Cephalexin 50 mg/kg or Clindamycin
20 mg/kg or Azithromycin 15 mg/kg
Bupivacaine 2.5 3
PO
Levobupivacaine 2.5 3
IV (allergy to penicillins Cefazolin or ceftriaxone 50 mg/kg or
Ropivacaine 2.5 3 and unable to take oral clindamycin 20 mg/kg IV
medication)

MIDAZOLAM DOSING ACCORDING TO ROUTE OF For complete listing of SBE indications for other surgeries/procedures, see www.
utoronto.ca/kids/sbe.htm
ADMINISTRATION (APPROXIMATE EQUIVALENCE)
MIDAZOLAM
Onset Peak effect NORMAL HEMODYNAMIC INDICES AND WEIGHT
Route mg/kg (minutes) (minutes) Mean systolic blood pressure (mm Hg) in preterm and term infants
Intravenous 0.05-0.15 immediate 3-5 Gestational
Intramuscular 0.1-0.2 3-5 10-20 age at birth Day 1 of life Day 10 of life
Orogastric 0.25-0.75 5-15 10-30 24 41 52
Nasal 0.1-0.2 3-5 10-15 28 44 62
Rectal 0.75-1 5-10 10-30 32 50 69
36 56 76
40 63 83
Mean Weight
KETAMINE DOSING ACCORDING
heart rate range
TO ROUTE OF ADMINISTRATION
Normal blood (beats/ 10th-90th
Route mg/kg Age pressure (mm Hg) minute) percentile
Intravenous 1-2 Mean Mean
Intramuscular 2-10 systolic diastolic
Oral 3-6 Preterm 55-75 35-45 120-170
Nasal 2-4 0-3 months 65-85 45-55 100-150 2.5-7.5
Rectal 5-10 3-6 months 70-90 50-65 90-120 4.8-9.5
6-12 months 80-100 55-65 80-120 6.5-12.5
1-3 years 90-105 55-70 70-110 8.75-17
3-6 years 95-110 60-75 65-110 15.5-25
FLUID AND BLOOD
Maintenance Fluids (balanced salt solution) 6-12 years 100-120 60-75 60-95 17-55
12-20 years 110-135 60-75 55-85 30-86
For neonates and infants <6 months: 4 mL/kg/hour first 10 kg, 2 mL/kg/hour
10-20 kg, 1 mL/hour for each kg above 20 Simple formula to predict weight from age:
<8 years: weight (kg) = 2 × age + 9
Perioperatively for infants and children >6 months: 10-40 mL/kg over 1-4 hours
≥8 years: weight (kg) = 3 × age

BLOOD PRODUCTS

EBV × (child’ s hematocrit − minimum accepted hematocrit ) 700 × ( 42 − 25) 700 × 17

MABL = MABL = = = 285 mL
Child’ s hematocrit 42 42
e.g., 10-kg child with a hematocrit of 42% who could be hemodiluted to a hematocrit of ~25%
(assuming EBV = ~ 70 mL/kg)
EBV, Estimated blood volume; MABL, maximal allowable blood loss.

PRBC TRANSFUSION

Volume of PRBCs = (35 − 23) × (70 × 10) 12 × 700

Volume of PRBCs to be transfused = =
( desired Hct − present Hct ) × estimated blood volume (70 mL/kg × 10 kg) 60 600
Hematocrit of PRCBs =~ 140 mL PRBCs
e.g., a 10-kg child with a hematocrit of 23 who you wish to
(35 − 23) × (70 × 10)
= transfuse to a hematocrit of 35
60
= 140 mL PRBCs