Paediatric Anaesthesia Handbook PDF

Nottingham University Hospitals
NHS Trust
PAEDs
Paediatric
Anaesthetic
Emergency Data
sheets
Editors: J. Armstrong, H. King
Contributors: J. Abbott, H. Fenner,
K. James
© ARMSTRONG & KING SEPTEMBER 2013

CONTENTS
PAGE
• Age-Per-Page guidelines 3
A • Paediatric Cardiac Arrest Algorithm 21
• Newborn Cardiac Arrest Algorithm 22
R
• Peri-Arrest Algorithms
R • Bradycardia 23
E • SVT 24
S • VT 25
T • Peri-Arrest Drugs 26
• Treatment of Hyperkalaemia 27
T • Massive Haemorrhage 28
R
• Traumatic Brain Injury 29
A
U
• Children’s GCS 29
M • Burns 31
A • Radiology Guidelines 32
• Difficult Mask Ventilation 35
A • Unanticipated Difficult Intubation 36
N • Can’t Intubate, Can’t Ventilate 37
A • Malignant Hyperthermia 38
E • Severe Local Anaesthetic Toxicity 39
S
• IV Intralipid dosing 40
T
• Pain Management Guidelines 41
H
• Antiemetics 42
E
• Fluid Management 43
T
• Congenital Cardiac Disease 45
• CCD for Non-Cardiac Surgery 46
I
• Renal transplants 47
C
• Advice on when to call a consultant 48
• Common Syndromes & Congenital Conditions 49
M • Anaphylaxis 59
E • Airway Emergencies 60
D • Septic Shock 61
I • Status Epilepticus 62
C • Life threatening Asthma 63
A
• Diabetic Ketoacidosis 64
L
• DKA associated Cerebral Oedema 63
• Formulary 66
• Notes 70
• Contact Numbers 71
• References 72
NHS Trust
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
C 1.4 mL (1 in 1,000)
(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 Mannitol 20 % 4 – 8 mL
D
10% Dextrose : (Hypoglycaemia) 7 mL
(2 mL/kg) (0.25 - 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S
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
U Paracetamol IV (10 mg/kg) NEAT (10 mg/mL) 35 mg 3.5 mL

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 50mL 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
© ARMSTRONG & KING SEPTEMBER 2013 3
NHS Trust
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
W Uncuffed: 3.0 – 3.5
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
C 2.2 mL (1 in 1,000)

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

(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

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 © ARMSTRONG & KING SEPTEMBER 2013
NHS Trust
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
I
C 2.8 mL (1 in 1,000)

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

(7 kg) given (mL)
D Fentanyl (1-2 microgram/kg) Dilute to 10 microgram/mL 7 – 15 microgram 0.7 – 1.5 mL
U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 70 mg 7 mL

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
NHS Trust
AGE : 9 months

A
I
W Uncuffed: 3.5 – 4.0
Y
C IV – Arrest
0.8 mL (1 in 10,000)
A
I
C 3.4 mL (1 in 1,000)

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

(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

G
S

N
F
U
S
I
O
S
NHS Trust
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
I
C 4.0 mL (1 in 1,000)

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

(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

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
NHS Trust
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
I
C 4.4 mL (1 in 1,000)

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

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

G
S

N
F
U
S
I
O
S
NHS Trust
AGE : 2 years
Wt : 11 – 12 kg HR : 95 – 140 RR : 25 – 30 Systolic BP : 80 - 100

A
I
W Uncuffed: 5.0
Y
C IV – Arrest
1.2 mL (1 in 10,000)
A
I
C 4.8 mL (1 in 1,000)

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

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

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

N
F
U
S
I
O
S
NHS Trust
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
I
A Amiodarone 70 mg Nebulised – Croup 5.0 mL (1 in 1,000)
C
(5 mg/kg) (2.3 mL of minijet) (400 microgram/kg) (max)

U
I Mannitol 20 % 17.5 – 35 mL
D
(2 mL/kg) (0.25 - 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S

(14 kg) given (mL)

G
S

N
F
Propofol (4-12 mg/kg/hr) NEAT (10 mg/mL) 5 - 16 mL/hr
U
S
I
O
S
NHS Trust
AGE : 4 years

A
I
W Uncuffed: 5.5
Y
C IV – Arrest
1.6 mL (1 in 10,000)
A
I
C

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

(16 kg) given (mL)

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

N
F
U
S
I
O
S
NHS Trust
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
I
C
(5 mg/kg) (3 mL of minijet) (400 microgram/kg) (max)

U
I Mannitol 20 % 22.5 – 45 mL
D
(2 mL/kg) (0.25 - 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S

(18 kg) given (mL)
Propofol (1-4 mg/kg) NEAT (10 mg/mL) 18 – 72 mg 2 - 7 mL
D Fentanyl (1-2 microgram/kg) Dilute to 10 microgram/mL 20 – 40 microgram 2 - 4 mL

G
S

N
F
U
S
I
O
S
NHS Trust
AGE : 6 years

A
I
W Uncuffed: 6.0
Y
C IV – Arrest
2.5 mL (1 in 10,000)
A
I
C

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

(25 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
AGE : 7 years

A
I
W Uncuffed: 6.0
Y
C IV – Arrest
2.8 mL (1 in 10,000)
A
I
A Amiodarone 140 mg Nebulised – Croup 5 mL (1 in 1,000)
C

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

(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

G
S

N
F
U
S
I
O
S
NHS Trust
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
C

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

(30 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
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
A Amiodarone 170 mg Nebulised – Croup 5 mL (1 in 1,000)
C

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

(34 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
AGE : 10 years

A
I
W Uncuffed: 7.0
Y
C IV – Arrest
3.7 mL (1 in 10,000)
A
I
C

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

(35 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
AGE : 11 years

A
I
W Uncuffed: 7.0
Y
C IV – Arrest
4.0 mL (1 in 10,000)
A
I
C

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

(40 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
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
C

U
I Mannitol 20 % 53 - 107 mL
D
(2 mL/kg) (0.25 - 0.5 g/kg) (0.5 g/kg = 2.5 mL/kg)
S

(43 kg) given (mL)

G
S

N
F
U
S
I
O
S
NHS Trust
PAEDIATRIC CARDIAC ARREST ALGORITHM
Open Airway & 5 Rescue Breaths

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

NHS Trust
NEWBORN CARDIAC ARREST ALGORITHM
Dry the baby

Remove any wet towels & cover Birth
Start the clock or note the time
GET
Assess tone, breathing & heart rate 30 sec
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

NHS Trust
MANAGEMENT OF BRADY
ARRHYTHMIAS
Bradycardia = HR <60 bpm or a rapidly falling HR with poor systemic perfusion
Shock
YES NO
Present?
Treat hypoxia Monitor &

Seek senior
& shock
advice
Vagal over If hypoxia & shock:

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

• Treat with adequate ventilation.
10 microgram/kg
• Give atropine 20 microgram/kg IV/IO
(minimum dose 100 micrograms
maximum dose 600 microgram)
• 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).
• If IV/IO access is unavailable,
• Pacing atropine (40 microgram/kg) may be
administered tracheally, although
absorption into the circulation may be
unreliable
If poisoning, seek expert

toxicology help

NHS Trust
MANAGEMENT OF SVT
SVT in infants generally produces an HR > 220 bpm, and often 250 – 300 bpm
Shock
YES NO
Present?
Vagal
Vagal
manoeuvre
(if no delays)
manoeuvre
Establishing IV Adenosine
access quicker
than obtain
YES 100 microgram/kg
defibrillator?
2 min
Adenosine
200 microgram/kg
NO 2 min
Adenosine
300 microgram/kg
Synchronous DC
Shock 1 J/kg
Consider:
Adenosine 400 – 500 microgram/kg
Synchronous DC (max 12 mg)
Shock 2 J/kg Synchronous DC shock
Or Amiodarone
Or other antiarrhythmics
Consider
Amiodarone

NHS Trust
MANAGEMENT OF VT
NO Pulse
VF Protocol
Present?
YES
Shock
NO YES
Present?
Amiodarone 5 mg/kg DC shock 1 J/kg

Over 30 min
Consider:
Synchronous DC shock DC shock 2 J/kg
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

NHS Trust
PERI-ARREST DRUGS (1)

INDICATION ROUTE AGE / WEIGHT CAUTION
ADENOSINE IV bolus Birth - 12 yrs 12 - 18 yrs Heart block

Antiarrhythmic 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 1.2g
In 5% glucose only in 24 hours
ATROPINE IV bolus Birth - 1mth 1 mth - 12yrs 12 - 18 yrs

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

NHS Trust
PERI-ARREST DRUGS (2)

INDICATION ROUTE AGE/WEIGHT CAUTION
FLUMAZENIL IV bolus Birth - 12yrs 12 - 18yrs 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 – 12yrs 12 - 18yrs

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 – 18yrs

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

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 – 18yrs

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)

NHS Trust
MANAGEMENT OF MASSIVE HAEMORRHAGE
Definition of Massive Activate Massive Haemorrhage

Haemorrhage Protocol
Contact Haematologist (may be initiated by Blood Bank)
• Ongoing severe bleeding &
received 20 mL/kg Red Cells or 40
mL/kg of any fluid in preceding hour Haemorrhage
Resuscitate Control
• Signs of Hypovolaemia +/-
coagulopathy
Take blood & send samples to lab (by hand)
Dosing Guide X Match, FBC, Coagulation, Fibrinogen, U+E, Ca2+
Red cells 10 - 20 mL/kg
FFP / Octaplas 10 - 20 mL/kg
Platelets 10 - 20 mL/kg Tranexamic Acid
Cryoprecipitate 5 - 10 mL/kg (15 mg/kg IV bolus (max 1 g) then 2 mg/kg/hr infusion)
10% Calcium 0.2 mL/kg
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 form
Cryoprecipitate 15 mL/kg Consultant Haematologist

NHS Trust
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:
 hypoxaemia (PaO2 < 9 kPa on air or < 13 kPa on O2)
• Falling GCS
or
• Focal neurological deficit
 hypercarbia (PaCO2 > 6 kPa)
• Single dilated pupil
• Spontaneous hyperventilation (PaCO2 < 3.5 kPa)
• Depressed/open skull fracture • Respiratory irregularity
• CSF leak
Children’s Glasgow Coma Scale ( < 4 years) Glasgow Coma Scale (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

NHS Trust
MANAGEMENT OF TRAUMATIC BRAIN INJURY (2)
• Intubate and ventilate

Airway • Oral ETT, secured with tape
& • Aim for: PaCO2 4.5 – 5.0 kPa
PaO2 ≥10 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
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
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MANAGEMENT OF BURNS
A Indications for intubation When indicated:-

I  Don’t delay, get senior help
R
• Airway burns
 Intubate with oral tubes (ideally cuffed)
W • Inhalational injury
A
 DON’T cut the ETT
Y
• Reduced or fluctuating conscious level GCS ≤ 8  100% oxygen until CO levels < 10%
F 4 mL/kg/% BSA
Parkland formula
L  ½ in first 8 hr
(Hatmann’s solution)
U  ½ in next 16 hr
I
PLUS Maintenance fluids (0.9% Saline / 5% Dextrose) Aim for urine output > 1 mL/kg/hr
D
S  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 carboxyhaemaglobin levels (normal < 5%) Centre:
H • Access – 2 x large bore IV or IO  Ventilated patients
E • Analgesia – Paracetamol / opiates / Ketamine as indicated  Burn area > 30% BSA
R • Insert NG tube  Burn with poly-trauma

NHS Trust
Paediatric Trauma CT Guideline

Are NICE CT Head criteria met?
 Loss of consciousness more than 5  Dangerous mechanism of injury
min  GCS lower than 14, (GCS lower than
 Amnesia (antegrade or retrograde) 15 if less than 1 year old) in the ED
more than 5 min  Open or depressed skull injury or
 Abnormal drowsiness. tense fontanelle
 Three or more discrete episodes of  Any sign of basal skull fracture
vomiting  Focal neurological deficit
 Clinical suspicion of non-accidental  If less than 1 year, head bruise,
injury swelling or laceration of more than 5
 Post-traumatic seizure but no history cm
of epilepsy
Age 10 or older Yes Age below 10 yrs No
Any of:
Neck imaging
• GCS lower than 8 on arrival
• Strong suspicion of C-Spine injury needed?
Yes No Lateral C-spine

Lateral C- XR
spine XR
Inadequate
Inadequate Adequate views?
views views
CT head & CT head only CT C-spine only

C-spine (with (with patient (with patient
patient on scoop) on scoop) on scoop)
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MRI Guideline
Only undertake scan if results will affect
management plan for that day.
Contraindications (D/W Consultant if emergency):
• FiO2 > 50%
• PEEP ≥ 8
• Unstable Cardiovascular status
• More than 1 inotrope

NHS Trust
Paediatric Abdominal CT Guideline

BLUNT ABDOMINAL INJURY
RADIOLOGIST PERFORMED ULTRASOUND
IN RESUS WITH ONGOING RESUSCITATION
UNSTABLE Is the patient stable? STABLE
Resuscitate
10 mL/kg 0.9% Saline
Stable? Yes Act on Ultrasound Results
No
Free fluid
Resuscitate detected or Solid
Normal
10 mL/kg 0.9% Saline or Blood clinical concern organ
scan
e.g. handlebar injury
Stable? Yes injury or lapbelt
No
CT Abdomen
•PAEDS CONSULTANT
SURGEON REVIEW Solid
Hollow
•CONTINUE RESUSCITATION organ
organ
•PREP FOR IMMEDIATE injury or
injury
LAPAROTOMY free fluid
Deteriorates clinically, reassess Admit for repeated observation

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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
Immediate • Get MH box (Kept in All Recovery areas & MRI)
• Install clean breathing system & hyperventilate with 100% O 2
management high flow
• Maintain anaesthesia with IV propofol
• Abandon/finish surgery ASAP
• Give dantrolene DANTROLENE
• Active cooling 2.5 mg/kg bolus
Treat: Then 1 mg/kg repeat boluses
• Hyperkalaemia up to 10 mg/kg
• Arrhythmias Mix vials with water for
Monitoring & • Metabolic acidosis injection
treatment • Myoglobinuria Monitoring
• DIC • Core & peripheral
Bloods temperature
• CK, ABG, U&Es, FBC, • EtCO2, SpO2, ECG
coagulation • Arterial BP & CVP
• 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)

NHS Trust
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
• Prolong resuscitation maybe necessary
• Consider treatment with lipid emulsion (see over):
Local
Anaesthetic 1. Give an intravenous bolus injection of intralipid 20% 1.5 mL/kg over 1 min
induced 2. Follow immediately with an infusion rate of 15 mL/kg/hr.
Cardiac 3. Continue CPR to circulate intralipid
Arrest 4. Repeat bolus 1 – 2 times at 5 min interval if inadequate circulation persists
5. After another 5 min increase the rate to 30 mL/kg/hr if cardiovascular
Management
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
If possible take blood samples into a plain tube (red top) & a heparinized
Follow up tube
(green top) before and after lipid emulsion. Measure lipid and local
anaesthetic levels

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IV INTRALIPID 20% DOSING FOR LOCAL ANAESTHETIC

INDUCED CARDIAC ARREST
WEIGHT BOLUS INFUSION INFUSION Maximum

In kg Intralipid 20% Start at: Increase to cumulative
1.5 mL/kg IV 15 mL/kg/hr 30 mL/kg/hr dose
over one minute If inadequate 12 mL/kg
circulation
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
70kg 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

NHS Trust
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) = 1mL 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 Drug concentration = 40 microgram/kg/mL
(max. 50 mg) diluted to 50 mL with 0.9% Saline i.e. 2 mg Ketamine / kg bodyweight
PUMP PROGRAMME
Loading dose = zero
(max. 100 mg) diluted to 50 mL with 0.9% Saline
Bolus dose = 1 mL PCA
Lockout = 5 min Indications – pancolitis & risk of toxic megacolon.
Background infusion = 0.2 mL/hr Loading dose = 1 – 2 mL of solution
ORAL MORPHINE Infusion 0 – 1 mL/hr
AGE DOSE INTERVAL Bolus 0.5 – 1 mL
Lockout 10 – 30 min
3/12 – 6/12 50 – 100 microgram/kg 4 hourly Infusion
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 yrs 200 – 400 microgram/kg 4 hourly Infusion 0 – 5 mL/hr
> 2 yrs 200 – 500 microgram/kg 4 hourly Must be discussed with a Consultant Anaesthetist

NHS Trust
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
ANALGESICS
Rate = 0.1 – 0.3 mL/kg/hr (maximum 15 mL/hr) PARACETAMOL – PO
Under 13 weeks: loading dose 20 mg/kg then
20 mg/kg TDS. Max 60 mg/kg daily
EPIDURAL TROUBLE SHOOTING
Over 13 weeks: loading dose 20 mg/kg then
15 mg/kg QDS. Max 90 mg/kg or 4 g daily
1. Block but inadequate analgesia: Increase
rate within prescribed range OR change to plain
PARACETAMOL – INTRAVENOUS
L-bupivacaine plus NCA / PCA
Preterm > 32 weeks: 7.5 mg/kg TDS. Max 25 mg/kg
daily
2. Inadequate / no block: Bolus 0.1 mL/kg of
Neonate/Infant <10kg : 10 mg/kg TDS. Max 30
0.25% L- bupivacaine, assess BP every 5 min for
mg/kg daily
15 min
Child body weight <50 kg: 15 mg/kg 4 hourly. Max
60 mg/kg daily
3. If NO improvement in block: Change to NCA /
Child body weight >50 kg: 1g 4 hourly. Max 4 g daily
PCA
IBUPROFEN (NSAID)
Boluses – ONLY by members of anaesthetic
<5 kg weight = Not recommended
department or pain service
Child over 5 kg body weight: 5 mg/kg QDS
(10 mg/kg severe pain) Max 2.4 g daily
REGIONAL BLOCK / WOUND CATHETERS
DICLOFENAC (NSAID)
Drug & concentration = 0.125 % Levo-bupivacaine <6 mths (postoperative pain) Not recommended
From 6 mths = 1 mg/kg TDS
Wound catheter infusions Max. daily dose = 150 mg for children >50 kg
Child 0 – 8 years - rate 0 – 2 mL/hr
Child 9 years and over - rate 0 – 5 mL/hr NALOXONE – IV OR IM
Children under 12 yrs of age - 1 microgram / kg
Paravertebral 12 yrs and older - 1 – 3 micrograms / kg
Rate = 0 – 0.2 mL/kg/hr (maximum = 10 mL/hr) Max 200 microgram
(always prescribe with NCA / PCA)
Caudal analgesia
Drug & concentration = 0.25 % L-bupivacaine CHLORPHENAMINE / PIRITON
Volume = 0.5 – 1.0 mL/kg single shot 0.1 mg/kg 8 hourly. Max 4 mg (PO) or 5 mg (IV)
Possible caudal additives:-
- Preservative free S-ketamine: 0.5 mg/kg 1st choice for treatment of opiate induced itch is
(Children > 12 months of age ) Ondansetron.
- Clonidine: 1 microgram/kg Piriton may cause excessive drowsiness with opiates

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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 lactate / Hartmann’s solution or 0.9% saline are appropriate solutions.
Formula
Holliday & Segar Oh

Body weight (kg) 4:2:1 rule
(1957) (1980)
1 – 10 4 mL/kg/day 4 mL/kg/hr 4 mL/kg/hr
40 mL/hr + Above + 2 mL/kg/hr

10 – 20 20 + (2 x kg) mL/hr
2 mL/kg/hr >10kg for 2nd 10kg
60 mL/hr + Above + 1 mL/kg/hr

>20 40 + ( 1 x kg) mL/hr
1 mL/kg/hr > 20kg for all kg over 20kg

NHS Trust
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: 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+ >125mmol/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.

NHS Trust
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)
 Ensure adequate fluid loading (avoid long starvation)  Most difficult to manage
 Minimise disruption to SVR:PVR ratio  Balance between SVR & PVR CRITICAL
 Maintain normal/high CO2 & low FiO2
Persistent Parallel Circulation  Monitor SpO2 (70 – 80%) & lactate
Stage 2 (Glenn Shunt)
e.g. Hypoplastic left heart, Complete AVSD  SpO2 in mid-80s
• Pulmonary & systemic circulations freely communicate  Aim to reduce load on RV
• Blood flow dependant on relative resistances in systemic &  Often chronically cyanosed & polycythaemic
pulmonary circulations (SVR & PVR)  Maintain preload & avoid hypovolaemia
 Best managed in specialist centre Stage 3 (Fontan Circulation)
 Monitor pre- and post- shunt & Maintain preload  SpO2 usually normal, ↓ if PVR increases
 Maintain SVR:PVR ratio:  Essential that PVR remains low
 SVR : ↓with anaesthetics & ↑ with inotropes  Maintain hydration & Avoid ventilation if possible
 PVR : ↑ - ↓PaO2, ↑PaCO2, Nitrous Oxide  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

NHS Trust
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 peripheries • Parallel circulation physiology
• Pulmonary Hypertension • Cardiomyopathy
- PAP >25mmHg at rest ( or 30mmHg on exercise) • Aortic stenosis
- Clear predictor of morbidity
• Arrhythmias
3) Type of operation:
• Cyanosis
- Common in unrepaired or partially palliated • Major vs. Minor
- Chronic cyanosis affects most organ systems • Elective vs. Emergency
- Polycythaemia & coagulopathy main problem • Risk of blood loss
- Dehydration, fever & anaemia MUST be avoided • Prolonged hospital stay
RISK CLASSIFICATION:
HIGH RISK INTERMEDIATE RISK LOW RISK
Physiologically poorly compensated +/-
presence of major complications:
 Cardiac Failure Physiologically normal or well Physiologically normal or well
 Pulmonary Hypertension compensated compensated
 Arrhythmias
 Cyanosis
Complex lesions Simple lesions Simple lesions
Major surgery (intra-peritoneal, intra- Major surgery (intra-peritoneal, intra-
Minor (or body surface) surgery
thoracic or anticipated major blood loss) thoracic or anticipated major blood 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
 Seek advice from PICU & surgeons about
High Transfer to specialist centre
possibility of transfer
 If impossible: advice from cardiologist &
Discuss with specialist centre and cardiac anaesthetist re: peri-op management
Intermediate consider transfer  Transfer post-op as soon as stable
Manage locally
Low Manage at local hospital
If concerned, seek advice
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ANAESTHETIC GUIDELINES FOR PAEDIATRIC

RENAL TRANSPLANT
Preoperative Assessment Monitoring

• Hypertension • Routine non-invasive BP, ECG. SpO2,
• Electrolytes – K⁺, Na⁺, Mg⁺. EtCO2, core temp
• If K⁺ >6 dialyse pre-surgery • Invasive monitoring
• Degree of anaemia – chronic anaemia • CVP (Essential)
well tolerated, only transfuse if Hb < 7 • Arterial line in children ≤ 5 years
g/dL • Urinary catheter
• Volume status – hypo / hypervolaemic • NO IV cannula in non-dominant
forearm as may be used for a fistula in
the future.
Intra-operative Management
• Induction technique is tailored to the medical condition of the patient with the
intention of protecting against aspiration and minimizing cardiovascular changes.
• Avoid hypothermia & vasoconstriction by using warm air blowers and warmed fluids
• Provide analgesia either using a fentanyl NCA / PCA or an epidural infusion.
• Fluid management
• Correct underlying hypovolaemia with 0.9% Saline or colloid
• 30 min prior to vascular unclamping volume load the patient:
• Child ≤5 years aim for a CVP 15 – 20
• Child ≥6 years aim for a CVP 12 – 14
• Aim for a systolic BP > 100 mmHg
• An adult kidney can sequester 200 – 300 mL of blood, which is a significant
proportion of the young child’s circulating blood volume
• Remainder of surgical time aim for a CVP 10 – 15
• Following ureteral anastomosis urine production can be monitored. Replace urine
volume every 30 min mL for mL with crystalloid to prevent dehydration from urea /
mannitol induced osmotic diuresis.
• Children ≤5 years may require a period of post-operative ventilation as they are
predisposed to develop pulmonary oedema due to aggressive fluid management.
• Additional peri-operative medications:
At induction:
Methylprednisolone 300 mg/m2 slow IV over 10 min(max 500 mg)
Co-amoxiclav 30 mg/kg (max 1.2 g)
At time of arterial anastomosis:
Mannitol 0.5 to 1 g/kg IV (max 25 g)
Frusemide 1-2 mg/kg over 5 min
MANNITOL 1 G/KG = 5 mL/KG OF 20% SOLUTION (200 mg/mL)

NHS Trust
ADVICE ON WHEN TO CALL A CONSULTANT
• To discuss any concerns
• For all neonates & babies under 1 year
• Emergency removal of airway foreign bodies children under 4 years
• Emergency intubation in young children with a compromised airway

i.e. croup, epiglottis, facial burns
• The following burns patients:

• Children under 5 yrs with a burn requiring IV resuscitation (i.e.
>10% TBSA) going to theatre acutely.
• Children under 10 yrs going to theatre acutely for debridement
& skin graft , escharotomy or fasciotomy
• Children under 10 yrs with airway compromise or potential
airway compromise from the burn injury as above
• Children under 10 yrs with concomitant burn injury and other
trauma
• ASA 3 and above patients, under 5 yrs requiring surgery
• All neurosurgical patients under 5 yrs requiring urgent surgery
• Children requiring urgent surgery for intracranial bleeds under 10 yrs
• Children requiring urgent surgery for major trauma incl. shooting/

stabbing under 10 yrs
• Renal transplants in children under 5 yrs old

• In older children the patient should be discussed , but if the 3rd
on-call or adult anaesthetist is happy & aware of the anaesthetic
protocol (intranet & desk-top of theatre computers), they can
manage the case.
• Complex problems with paediatric pain management and safeguarding

issues should be discussed

NHS Trust
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
Mental retardation, drugs.
Angelman syndrome Genetic defect in craniofacial abnormalities, Inhalational technique
maternal chromosome
(Happy puppet drooling, ataxia, seizures, preferable.
15q.
syndrome) paroxysmal laughter, Risk of difficult
1/10-20,000 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

NHS Trust

CONDITIONS (2)
Anaesthetic
considerations
C – Coloboma
H – Heart defect Difficult airway and
A – Atresia choanae & Mid-face hypoplasia & intubation with
clefts micrognathia. increasing difficulty as
R – Retarded growth & 75% have a congenital age increases
CHARGE association
development heart defect Reflux common
G – Genital hypoplasia & (commonest: Tetralogy Echo to assess CHD
renal abnormality of Fallot) Abdominal US for renal
E – Ear anomalies & anomalies
deafness
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 catlike cry,
microcephaly, broad
Chromosomal nasal bridge, Airway – Anticipate need
abnormality (5p micrognathia, may have for smaller ETT.
Cri du Chat syndrome
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
usually manifesting
intracranial pressure. external fixation devices
before the age of 2
for maxillary distraction.
Eye protection important.

NHS Trust

CONDITIONS (3)
Anaesthetic
considerations
Severe cardiac
Anticipate difficult
malformations. Aortic
airway. Sterile
arch abnormalities.
techniques required as
Midface hypoplasia &
3rd and 4th brachial arch immunodeficient. Need
DiGeorge syndrome micrognathia. Absent
abnormalities irradiated blood, check
(Catch 22 syndrome) 22q deletion thymus and parathyroid
calcium levels &
glands, low serum
supplement. Adrenaline
calcium leading to tetany
may cause prolonged
and seizures.
tachycardia
Immunodeficient
Developmental delay.
CCD (ASD / VSD / AVSD /
PDA) Careful airway and
Hypotonia, atlantoaxial cardiac assessment. Mask
instability (12%) ventilation may be
Down syndrome Trisomy 21
Micrognathia, large difficult. Consider small
tongue, congenital ET tube. Care with neck
subglottic stenosis, extension
tonsillar hyperplasia &
OSA. Hypothyroidism
Mental retardation,
May be difficult airway &
hypotonia, renal
Edward syndrome Trisomy 18 intubation
abnormalities & CCD.
Sux can cause rigidity
Micrognathia
Hyperelastic & fragile
Difficult IV access.
Ehlers-Danlos tissue. Dissecting aortic
Collagen abnormality Increased bleeding.
syndrome 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’s 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)

NHS Trust

CONDITIONS (4)
Anaesthetic
considerations
Usually due to cystinosis.
Impaired renal function,
Correct electrolyte and
acidosis, K loss,
Anaemia with renal acid-base abnormalities.
Fanconi dehydration.Thyroid &
tubular acidosis Caution with renally
pancreatic dysfunction
excreted drugs.
possible. May need renal
transplant in 2nd 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
Assessment of
prodromal GI infection.
respiratory function.
CVS (hypotension,
Correct electrolyte, acid-
Renal failure, haemolytic myocarditis, CCF), CNS
Haemolytic uraemic base and coagulation
anaemia and (drowsiness, seizures,
syndrome abnormalities.
thrombocytopenia coma), respiratory-
Caution with renally
pulmonary insufficiency,
excreted drugs.
hepatosplenomegaly,
coagulopathy, decreased
platelet function .
Factor VIII deficiency Bleeding either Infusions of recombinant

(Classic haemophilia type spontaneous or after factor VIII 1 hr before
Haemophilia A) minimal injury, and after surgery to
X-linked recessive, haemarthrosis are maintain factor VIII
incidence 1 in 10,000 common activity ≥ 50%
Thrombocytopenia.
Severe GI or intracranial
Steroid cover many be
Autoimmune disease bleeding rare in children.
necessary due to steroid
Idiopathic associated with Chronic ITP more likely in
therapy.
thrombocytopenia presence of antiplatelet children > 10 yr of age.
Avoid NSAIDs and IM
factor Treatment with high
injections
dose steroids and γ-
globilin.

NHS Trust

CONDITIONS (5)
Anaesthetic
considerations
Joint pain & stiffness,
Still disease (systemic),
Juvenile rheumatoid fever, rash, Steroid supplement
polyarticular or
arthritis lymphadenopathy, required.
pauciarticular forms
uveitis
Reduced cervical
Plan for a difficult
Congenital fusion of 2 or mobility. Associated with
Klippel-Fiel intubation due to neck
more cervical vertebrae Arnold-Chari
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-Nielson 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 chromasome 15 causing kyphoscoliosis, pectus
spine or
connective tissue excavatum, spontaneous
temporomandibular
disorder pneumothorax (4%),
joint. Beware of
aortic root dilation
pneumothorax. Avoid
causing incompetence or
hypertension.
aneurysm

NHS Trust

CONDITIONS (6)
Anaesthetic
considerations
Mental retardation,
Difficult airway
gargoyle facies,
management &
deafness, stiff joints,
intubation – upper
severe coronary artery
airway obstruction due
Muco- disease,
to lymphoid tissue
polysaccharidosis hepatosplenomegaly.
infiltration,
(Hurlers, Hunters) Most die from
micrognathia, short neck
respiratory / cardiac
& limited movement of
failure before 10 years of
TMJ.
age. Hunters less severe
than Hurlers.
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.
Respiratory function
Duchenne – X linked Progressive muscle tests to help predicted
recessive mutation on weakness of affected need for post-op
chromosome 21, muscle groups ventilation. Prone to
incidence 1 in 3000 live (pseudohypertrophied). LRTI. Regional analgesia
male births useful.
Duchenne – onset Suxamethonium
Becker – X linked between 1 – 4 years, contraindicated – risk of
Muscular dystrophies recessive, incidence 1 in wheelchair bound by 12 rhabdomyolysis, rigidity,
(Duchennes, Becker, 60,000, later onset and years, cardiac hyperkalaemia, cardiac
facioscapulohumeral) slower progression than involvement with arrest.
Duchenne. hypertrophic Variable response to
cardiomyopathy and non-depolarising muscle
Facioscapulohumeral sudden death, scoliosis, relaxants. Reduction in
muscular dystrophy – mental retardation dose recommended.
autosomal dominent, (30%), death from Significant myocardial
relatively benign, slowly cardiorespiratory failure depression with volatiles.
progressive, affects in 3rd decade NO proven link with MH
abductors of upper arms, but muscle damage &
facial muscles, winged hyperkalaemia may
scapula, sensorineural occur with volatiles,
deafness, retinopathy hence TIVA often used.
PHDU / PICU post-
operatively.

NHS Trust

CONDITIONS (7)
Anaesthetic
considerations
Muscle weakness may
cause respiratory failure.
Anticholinesterases cause
Presentation in childhood increased respiratory
or adolescence with secretions.
Juvenile / autoimmune muscle fatigability / Increased sensitivity to
Myasthenia Gravis
myasthenia weakness either nondepolarizing muscle
generalized or limited to relaxants – intubate deep
ocular muscles. / topical lignocaine to
trachea.
Avoid opiates & sedative
premedication.
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 dominent, Closely associated with
gene mutation on MH.
Nemaline rod – NO
chromosome 19 close to
association with MH.
gene responsible for Nemaline rod – weakness
Myopathies Prone to recurrent
ryanidine receptor. of proximal muscles,
aspirations & LRTI.
(Central core, nemaline facial, bulbar &
Assess respiratory
myopathy, King Nemaline myopathy – respiratory. Dysmorphic
function & optimise with
syndrome) autosomal recessive & feature ( micrognathia,
physio.
dominant inheritance, hypertelorism, high
Intubation may be
mutations on arched palate), cardiac
difficult.
chromosome 1, 2 & 19. abnormalities.
Resistant to
“Typical” – infantile
suxamethonium but
hypotonia, non-
increased sensitivity to
King syndrome – progressive.
non-depolarising muscle
myopathy, MH trait, “Severe” – presents at
relaxants.
dysmorphic features birth with severe
May need post-operative
(Noonan like) hypotonia, respiratory
ventilation & respiratory
failure, arthrogryposis,
complications are most
death in first few months
common cause of death.
of life.

NHS Trust

CONDITIONS (8)
Anaesthetic
considerations
Short stature, web neck,
mild mental retardation. Assess cardiac function
Turner’s characteristics
CCD (pul. stenosis & Check coagulation &
without sex
Noonan syndrome cardiomyopathy). renal function
chromosome
Micrognathia, Possible difficult
abnormality
hydronephrosis & intubation
platelet dysfunction
Multiple skin and
mucosa lesions. May
Intra-op blood loss may
affect other organs, esp.
be difficult to control.
Hereditary haemorrhagic Pulmonary & hepatic AV
Osler-Wendu Rendu Difficult IV access.
telangiectasia fistula. Anaemia &
Assess pulmonary
systemic emboli. Later,
function.
high output cardiac
failure
Extreme care with
Fractures, blue sclera &
Osteogenesis positioning. Fragile teeth
Pathological fractures deafness. Scoliosis &
imperfecta & veins (difficult IV
lung pathology
access)
Mental retardation,
microcephaly, cleft Possible difficult
Patau syndrome Trisomy 13 lip/palate, micrognathia. intubation.
CCD (VSD) Polydactyly Assess cardiac function
Die in infancy
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
airway obstruction). CCD
fibre-optic)
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
Obesity leading to CV
hypothermia also seen
failure
Assess renal function.
Poor respiratory function
Absent abdominal Treat as full stomach.
Prune Belly syndrome and cough. Renal
musculature Control ventilation,
abnormalities
epidural useful post-op

NHS Trust

CONDITIONS (9)
Anaesthetic
considerations
Severe metabolic Abnormal LFTs, deranged
Largely supportive. Avoid
Reyes syndrome encephalopathy & fatty clotting. Raised ICP if
liver metabolised drugs.
change in liver untreated
Mental retardation,
Possible difficult
microcephaly, dwarfism,
Seckel Autosomal recessive ventilation, intubation
micrognathia &
and IV access
prominent maxilla
Trait: (Low HbS levels Pre-op screening of at
<50%) Sickling very risk groups.
Abnormal Hb (HbS) unlikely Crisis: Analgesia (PCA)
which distorts in low O2 Disease: (HbS >50%) May Peri-op: Avoid prolonged
Sickle cell disease
levels (vaso-occlusive present with painful fasting, hydrate well,
crisis or ‘Sickling’) crisis, or sickle peri-op high FiO2, keep warm,
(lung infarction, avoid acidosis. Extreme
haemolysis & pain) care 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: <2yrs, syndrome
somnolence, snore, affecting airway, CLD for
insomnia, fatigue, RDS, cor pulmonale.
behavioural problems
Microcephaly, mental Care with asepsis. Use
Inborn error of retardation & hypotonia. muscle relaxants with
Smith-Lemli-Opitz
cholesterol synthesis Skeletal abnormalities, care, may have airway &
inc. micrognathia intubation problems
Excessive growth in early
Care with asepsis and
childhood. Mild
positioning of head.
developmental delay &
Sotos Cerebral gigantism Hyperthermia has been
macrocephaly. Poor
reported (not MH);
immune function.
monitor temperature
Hypotonia
Similar to Pierre Robin.
Autosomal dominant Mid-face hypoplasia,
Stickler Airway may be VERY
mid-face disorder micrognathia, cleft palate
difficult

NHS Trust

CONDITIONS (10)
Anaesthetic
considerations
Port-wine stain over Glaucoma, mental Often multiple laser
Sturge Weber Trigeminal nerve retardation, seizures & treatments. May affect
distribution hemiplegia. larynx
Per-op assessment of
Micrognathia, aplastic cardiac function &
Mandibulofacial
Treacher Collins zygoma, choanal atresia airway. May be VERY
dysplasia
& cleft lip/palate difficult ventilation /
intubation
Short stature, infantile
genitalia, webbed neck. Assess cardiac & renal
Turners XO females Possible micrognathia, status. Intubation my be
CCD (coarctation). Renal difficult
anomalies
V – Vertebral (scoliosis)
A – Ano-rectal atresia
Careful pre-op
C – Cardiac
assessment of neonate
Non-random association T – Tracheoesophageal
VATER/VACTERL showing one or more
of defects (at least 3) fistula
feature. Cardiac & renal
E – oEsophageal atresia
assessment.
R – Renal abnormalities
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

lesions common. May Assess pulmonary,
have tumours in larynx or cardiac & renal function.
Café au lait spots (>5),
Von Recklnghausen trachea. 50% have Intubation my be
tumours in all parts of
Neurofibromatosis kyphoscoliosis. May have difficult. Caution with
the CNS and peripheral
type 1 fibrosing alveolitis. Renal neck. Affects of
nerves
artery dysplasia neuromuscular blocking
common. 1% have drugs may be prolonged.
pheochromocytoma
Infantile spasms, May be difficult to
Seizures, neurological
psychomotor determine level of
West syndrome deficit & severe mental
developmental arrest & consciousness. BIS may
deficiency
hypsarrhythmia on EEG be unreliable

NHS Trust
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

NHS Trust
MANAGEMENT AIRWAY EMERGENCIES

Anaesthesia for rigid bronchoscopy: D/W ENT surgeon re: plan & check equipment
• Slow Gas Induction (sevoflurane in O2) vs propofol TCI
 Avoid N2O
 Deep laryngoscopy and lignocaine spray to the cords
Inhaled  Maintain spontaneous respiration
 ‘Short’ nasal ET tube to maintain gas delivery while scope being passed
foreign • Pass Storz paediatric bronchoscope through the larynx & attach circuit to side arm
to maintain anaesthesia.
body • 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
• Toddler bronchoscope is reintroduced & manoeuvre is repeated as necessary
• Monitoring – patient, chest movement, HR & SaO2. Often lose ETCO2 / gas analysis
• Witnessed /
• Possible complications – laryngospasm, bronchospasm, pneumothorax &
unwitnessed acute arrhythmias
event • End of procedure – back to FM or nasopharyngeal airway & wake up
• Inspiratory stridor  May benefit from IV dexamethasone 0.1 – 0.25 mg/kg for laryngeal
oedema
 Need continuous SaO2 monitoring post-op
 Consider PHDU or PICU
• Maintenance of oxygenation with SaO2 > 92% with nasal cannula / head box or
Bronchiolitis humidified face mask O2
• Small, frequent oral feeds or NG feeds if RR >60/min or oral intake < 50% expected
• Children < 2 yrs • Naso-pharyngeal suction
• Seasonal • Indications for PHDU / PICU: Recurrent apnoeas
• Coryzal symptoms, Worsening respiratory distress
dry cough, apnoeas, Inability to maintain SaO2 > 92%
poor feeding • PICU management – Intubate and ventilate
• Dexamethasone : 0.6 mg/kg PO
Mild /
• Budesonide : Nebulised 2mg
Croup moderate (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
• Symptoms often Severe • Beware rebound worsening of symptoms
worse at night • Dexamethasone : 0.6 mg/kg IV
• +/- fever • Transfer to PICU / PHDU – Consider intubation (smaller than
expected ET tube)
Epiglottitis • Leave in favoured position, administer oxygen in non-threatening manner

• Call for senior help – Anaesthetist and ENT surgeon
• 2 – 7yr olds Arrange transfer to theatre
• No prodromal • Slow Gas Induction with sevoflurane & oxygen,
illness, toxic  Maintaining spontaneous ventilation in the sitting position
• Drooling saliva  IV access once anaesthetised
• Cherry red • Usually requires a smaller than expected ETT
epiglottis / • Sedate and ventilate on PICU until a leak appears around the ETT
arytenoids • IV ceftriaxone or ampicillin
NHS Trust
MANAGEMENT OF SEPTIC SHOCK

High flow O2 (SaO2 >95%)
Recognition: Establish IV or IO access
• Fever, tachycardia & abnormal perfusion Check Blood Sugar
• +/- tachypnoea / SpO2 < 95%, reduced
urine output, irritability / lethargy /
drowsiness, base deficit on ABG,
hypotension (late sign) Initial resuscitation
Cold shock  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  Correct hypoglycaemia: 2 mL/kg 10% Dextrose
 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
IV Antibiotic Therapy (Use Ketamine / Fentanyl & Suxamethonium
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
• Consider Aciclovir 20 mg/kg For Cold Shock For Warm Shock
• Child 28 days – 3 months Add in central Adrenaline Add in central
if Dopamine resistant Noradrenaline
• Cefotaxime 50 mg/kg
• Amoxicillin 50 mg/kg
Catecholamine resistant shock
• Child > 3 months old
Start Hydrocortisone (D/W PICU)
• Ceftriaxone 80 mg/kg (slowly)
Coagulopathy Transfer to PICU

• Treat with 10 – 20 mL/kg FFP / Octaplas (Check Ca2+ , Mg2+ , K+ )
• Low fibrinogen suggests DIC : give 5 – 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
normal mental status, UO > 1 mL/kg/hr & serum
(1 mL/hr = 10 microgram/kg/min)
lactate < 2

NHS Trust
MANAGEMENT OF STATUS EPILEPTICUS

NICE Clinical Guidelines CG137 (published 2011)
• Confirm clinically that it

is an epileptic seizure:  Airway
 Generalised convulsion  High flow O2
lasting ≥ 30 min
or
 Check glucose
 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
0.1 mg/kg IV / IO
• Buccal Midazolam may buccally
be given by ambulance
crew or parents in non- 10 MIN 10 MIN
hospital setting
YES
• If BM < 3.0 mmol/L Vascular Lorazepam
administer 2 mL/kg 10% 0.1 mg/kg IV / IO
Dextrose
access?
• 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 Transfer to PICU
- Doses <500 mg in 50 mL
- Doses >500 mg in 250 mL

NHS Trust
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 5mg 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
Treatment under 2yr OR 15 microgram/kg if over 2yr (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
Considerations:
Indications: • Senior help
• Cardiac or resp 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
• Aim Vt 6 – 8 mL/kg
POSSIBLE
CLINICAL JUDGEMENT • Avoid PEEP
RATHER THAN BLOOD • Long expiratory times
GASES • Permissive hypercapnia
• Consider paralysis

NHS Trust
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 Sodium chloride 0.9%, 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/ 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 wt 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

NHS Trust
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 does 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

NHS Trust
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 12mg)
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)
Alfentanyl Short term analgesia / Induction 10 microgram/kg
Aminophylline Life threatening asthma 5 mg/kg; Then 1 mg/kg/hr
5 mg/kg
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
20 microgram/kg
Atropine Bradycardia
(100 – 600 microgram)
Benzyl-penicillin Early sepsis in neonates 50 mg/kg
10 – 20 mL/kg
Blood Haemorrhage / low Hb (<80 g/L)
(5 mL/kg → ↑ 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

NHS Trust
FORMULARY (2)
Co-Amoxiclav Surgical prophylaxis 30 mg/kg
1 mg/kg/hr
Codeine Analgesia (over 12 yrs only)
(max 60 mg)
Cryoprecipitate Low fibrinogen (<1.5 g/L) 5 – 10 mL/kg
Dantrolene Malignant hyperthermia 2.5 mg/kg
Dexamethasone Anti-emetic 0.15 mg/kg
Hypoglycaemia 2 mL/kg; Then: 5 mL/kg/hr

Dextrose 10% Hyperkalaemia (with Insulin) 5 mL/kg/hr
Diazepam Muscle spasm 0.1 mg/kg
Diclofenac Analgesia (> 6 months old) 1 mg/kg
Low cardiac output states

Dobutamine - 30 mg/kg in 50 mL 5% Dextrose
5 – 15 microgram/kg/min
Severe sepsis with low cardiac output

Dopamine - 30 mg/kg in 50 mL 5% Dextrose (central) Infusion: 5 – 15 microgram/kg/min
- 3 mg/kg in 50 mL 5% Dextrose (peripheral)
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
10 microgram/kg
Flumazanil Reversal of benzodiazepine
(max 200)
Furosemide Diuretic 1 – 2 mg/kg
Surgical prophylaxis 2 mg/kg

Gentamicin Severe sepsis 5 – 7 mg/kg
Bradycardia / Reversal of neuromuscular
Glycopyrolate blockade
10 microgram/kg
Hydrocortisone 2nd line anaphylaxis 4 mg/kg

NHS Trust
FORMULARY (3)
Ibuprofen Analgesia (>5 kg) 5 mg/kg
Diabetic management
Insulin Hyperkalaemia (with 10% Dextrose)
0.05 – 0.1 units/kg/hr
Intralipid 20% Local anaesthetic toxicity 1.5 mL/kg; Then: 15 – 30 mL/kg/hr
Ipratropium Asthma Nebulised: 250 microgram
Ketamine Induction of anaesthesia 1 – 2 mg/kg

1 mg/kg
Lidocaine 2nd line VF or pulseless VT
(max 100 mg)
Lorazepam Status Epilepticus 0.1 mg/kg

0.1 – 0.2 mmol/kg
Magnesium Sulphate Severe asthma / Torsades de pointes (max 8 mmol)
0.25 – 0.5 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 7.5 mg/kg

Buccal: 0.5 mg/kg
Status Epilepticus
Midazolam Sedation (6 mg/kg in 50 mL)
Infusion: 60 – 240
microgram/kg/hr
Analgesia Oral: 0.1 – 0.5 mg/kg
Morphine IV: 0.1 mg/kg
Sedation (1 mg/kg in 50 mL) Infusion: 10 – 40 microgram/kg/hr
Under 12 - 1 microgram / kg
12 yrs+ - 1 to 3 micrograms / kg
Naloxone Reversal of opiates
Max 200 microgram
Infusion: 5 – 20 microgram/kg/hr
Neostigmine Reversal of neuromuscular blockade 50 microgram/kg
Acute hypotension
Noradrenaline - 0.3 mg/kg in 50 mL 5% Dextrose
Infusion: 0.01 – 0.5 microgram/kg/min
Ondansetron Anti-emetic / Opiate induced puritis 0.15 mg/kg

Oral: 15 – 20 mg/kg
IV: Prem > 32 weeks – 7.5 mg/kg
Paracetamol Analgesia
Neonate – 10 mg/kg
Child < 50 kg – 15 mg/kg
NHS Trust
FORMULARY (4)
PR: 0.8 mL/kg
Paraldehyde Status Epilepticus
(max 20 mL)
Phenobarbital Status Epilepticus 20 mg/kg over 20 min
Phenylephrine Acute hypotension 1 microgram/kg
Phenytoin Status Epilepticus 20 mg/kg over 20 min
0.1 mg/kg
Piriton 2nd line anaphylaxis / Puritis
(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 2yr)
15 microgram/kg (Over 2yr)
Saline 2.7% Raised Intra Cranial Pressure 5 mL/kg
Sodium Bicarbonate Metabolic acidosis / Hyperkalaemia 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
Thiopentone Induction of anaesthesia 3 – 5 mg/kg
Tranexamic Acid Massive haemorrhage 15 mg/kg; 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

NHS Trust
NOTES

NHS Trust
CONTACT NUMBERS
784-1050 Theatre 64668 /

1st On-Call Th 1 64253 CCOT 780-6339
/ 70795 Co-ordinator 784-3344
784-1051 Trauma Paeds Pain
2nd On-Call 784-3017 Th 2 64234 780-6527
/ 70088 Co-ordinator Team
Adult
784-3051 784-3019
3rd On-Call ODA Th 3 64232 Pain 780-6546
/ 70087 / 70793
Team
61181 /
Haematology Th 7 64235
784-1340
Paeds 780-6741 63660 / QMC
Blood Bank Th 10 63308 61195
Surg SpR / 70786 784-1340 Anaes
Theatre
PICU SpR 784-3152 MASSIVE TRANSFUSION 63243 City Anaes 55637
Reception
Neurosurg 784-3412 784-1342 Theatre 63105 /
FROM ED
SpR / 70079 ‘CODE 911’ Recovery 63304
FROM 2222 CHN
ENT 70082 57199
THEATRES ‘MH in Th X’ Switch
ITU On- 784-3014 Clinical 63059 / 63879 / Royal
ED Resus *3068
Call / 70767 Chemistry 784-1360 66665 Derby
Surgical 63101 / Paediatric 61148 / 01522
784-3400 X-ray Lincoln
SpR 784-1300 ED 61149 512512
61232 /
CT3 66750 PICU KMH *3064
63422
Radiology 62502 / 63350 /
784-1312 CT4 70446 PHDU Porters
(Head) 69041 63211
Radiology 64120 /
784-1313 MRI 63067 NICU Security 63335
(Body) 65057
Radiology 64413 / 62758 / 690 +
784-1311 Neuro X-Ray AICU Wards
(MSK) 65850 62762 ward no

NHS Trust
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 2012-2013
• Resuscitation Council (UK) Emergency treatment of anaphylactic reactions. January 2008,
annotated July 2012.
• Advanced Paediatric Life Support. The Practical Approach. 5th Edition
• British Guideline on the Management of Asthma. SIGN & The British Thoracic Society, revised
May 2011
• Malignant Hyperthermia Crisis – AAGBI Safety Guideline 2011
• Paediatric Airway Guidelines 2012 – The Guidelines Group, supported by the Association of
Paediatric Anaesthetists, the Difficult Airway Society and liaising with the RCoA
• DKA guidelines. British Society of Paediatric Endocrinology and Diabetes website.
www.bsped.org.uk
• “Emergency Management of Severe Burns”, course manual. Australian and New Zealand Burn
Association / UK version for the British Burn Association, 15th Edition, June 2012
• Management of Status Epilepticus, NICE Clinical Guidelines CG137 (published 2011)
• Head Injury: triage, assessment, investigation and early management of head injury in infants,
children and adults. NICE Clinical Guideline 56, September 2007
• Bacterial meningitis and meningococcal septicaemia. NICE Clinical Guideline 102, June 2010.
www.nice.org.uk/guidance/CG102
• 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
• Good Practice in Postoperative and Procedural Pain Management, 2nd Edition. APAGBI, July
2012
• APA consensus guideline on peri-operative fluid management in children v 1.1 September 2007
• Management of severe local anaesthetic toxicity 2 - AAGBI Safety Guideline 2010

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Nottingham University Hospitals

© ARMSTRONG & KING SEPTEMBER 2013

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

U Paracetamol IV (10 mg/kg) NEAT (10 mg/mL) 35 mg 3.5 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 55 mg 5.5 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 70 mg 7 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 85 mg 8.5 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 150 mg 15 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 165 mg 16.5 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 180 mg 18 mL

I Drug To Make Up in 50mL 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

U Paracetamol IV (15 mg/kg) NEAT (10 mg/mL) 210 mg 21 mL

I Drug To Make Up in 50mL 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