Protocols: pediatric patients

1. Vasopressors
2. Hyerkalemia
3. Hypoglycemia
4. Electrolytes imbalance
5. Temperature regulation
6. Regional anaesthesia
7. Blood pressures
8. Acute perioperative pain
9. Access for postoperative events- delirium
10. Postoperative adverse events
11. Difficult airway
12. Drug dosage
PREOPERATIVE FASTING PROTOCOL

Clear fluid- 1 hour

Allow dextrose water 5% till one hour of surgery
Breast milk- 4 hour
Light breakfast- 6 hour
Formula milk and non human milk- 6 hour
Heavy/ full meal- 8 hours or more
Premedication Protocol
IV cannula in situ- 0.5-1mg/kg ketamine IV and 0.05mg/kg
midazolam
No IV cannula- oral trichlophos 50mg/kg at least 30 minutes
preferably 45 minutes before entering to OT
Syp midazolam available - 0.5mg/kg oral midazolam

syrup phenargan- 12.5 to 25mg , adult 50 mg..(5mg per pound)

contraindicated below 2 year.(oral and tablet form)
Ketamine- 4 – 5mg/kg plus glycopyrollate 0.02mg/kg i.m. plus
midazolam .05mg/kg
Put monitor- Attach pulse oximetry after sedating the child and
monitor the child till he comes to OT
IV fluid therapy Protocol
1. Surgery- herniotomy, hydrocele, circumcision,
cystoscopy,or any sx lasting <1 hour duration
Fasting for clear fluid < 3hour duration- no need of
replacing the fasting deficit
Start fluid RL @4-6ml/kg/hour
Prolonged fasting- correct with RL@10ml/kg over
15minutes followed by maintenance requirement
2. Major surgery
Prolonged fasting- correct with RL@10ml/kg over
15minutes followed by maintenance requirement
Maintenance fluid- 10ml/kg/hour (8-15ml/kg/hour)
Volume therapy (replacement of blood losses with
crystalloid or colloid) - 10ml/kg/hour
Hypotension- bolus therapy-10-20ml/kg
Blood/ plasma/platelets- 10ml/kg
Colloid- use of 4%albumin @10ml/kg (can prepare by
diluting 20%albumin in saline).(HES 130 repeated boluses
of 5-10 ml/kg). moderate total dose 10-20 ml/kg.
Monitor hourly blood sugar
3. If blood sugar< 90mg/dl in infants undergoing major
surgery-1-2.5% dextrose maintenance @5mg/kg/min
4. Neonates undergoing surgery- RL with 1% dextrose as
maintenance fluid (40ml RL + 5ml 10% dextrose) or 2ml of
25% dextrose or
 Start one infusion of RL @10ml/kg/hour
Other infusion of 10% dextrose @5mg/kg/minute (4-
6mg/kg/min)
5. Neonates in first 2-3 days of life(<1kg – 5%D, >1kg- 10%D)
10%dextrose @5mg/kg/min
Volume therapy with RL depending on vitals
6. Neonates coming from NICU for surgery
Continue fluid prepared in ICU at maintenance rate and
volume therapy with RL
 Intravenous fluid protocol

✓
 A balanced isotonic electrolyte solution with 1–2.5%
glucose should be used for the background infusion.

✓ The background infusion may be initiated with an

initial infusion rate of 10 mlkg1 h1 and be adjusted to
the actual requirement during the further course
(target: normal ECFV).
✓ Prolonged fasting- correct with RL@10ml/kg over
15minutes followed by maintenance requirement

✓ For shorter surgeries (<1 h) without relevant tissue trauma

(e.g. inguinal herniotomy, circumcision), a background
infusion containing glucose is not necessarily required in
children beyond neonatal age with short preoperative
fasting times if the children are allowed to drink and eat
again soon after the surgery .
✓ Exception- In children who are admitted to the operating
theater in a catabolic state (e.g., after long-fasting times)
or who have high metabolic rates or low glycogen reserves
for developmental reasons or due to disease (e.g.,
premature infants, small neonates, parenteral nutrition,
liver disease), the infusion rate or glucose concentration of
the background infusion should be increased
✓ HES, third-generation products with a molecular weight of
130 000 Da (HES 130), which are associated with fewer
adverse reactions, should also be the preferred choice in
children

✓ In neonate two infusion should be prepared. One infusion

containing RL with 1 - 2.5% dextrose @ maintenance rate
and other infusion containing plain RL for additional fluid
requirement.

✓ In patients with circulatory instability - balanced

electrolyte solutions can be given as repeat-dose infusions
of 10–20 mlkg1 until the desired effect is achieved
(maximum volume, e.g., three times 10–20 ml/kg to avoid
interstitial fluid overload)
 Vasopressors Protocol
Pediatric vasopressor calculation- stock solution
preparation
Noradrenaline/ adrenaline dose: 0.05- 3mcg/kg/min
e.g. A 10 kg baby noradr to be started @ 0.1mcg/kg/min
Noradr requirement in 24 hours= 0.1mcg*60*24*10=
1440mcg= 1.4mg
So take 1.4 mg Adr/ Noradr plus 10.6 ml dextrose/NS
Total volume will be 12 ml
If start @0.5ml/hr= 0.1mcg/kg/min
Formula- for infusion @ .1 ugm/kg/min
Total dose of Noradrenaline /adrenaline for 24 hrs (mg)
= {0.144 x Weight} = ml adrenalin (x)
X ml adrenalin + (12-X)ml NS = 12ml volume
Start @ .5 ml/hr

Dopamine dose= 5-20mcg/kg/min

10 kg baby dopamine= 5mcg/kg/min
dopamine requirement in 24 hours= 5*10*60*24= 72mg
so take 1.8ml of dopamine and 10.2 ml saline=12 ml start
@0.5ml/hour
Spinal/epidural/ peripheral nerve block dosage

1) Spinal
Bupivacaine hyperbaric 0.5%
<5kg= 0.5 - 1mg/kg
5-15kg= 0.4mg/kg
>15kg= 0.3mg/kg
Adjuvant –
Morphine – 10-20 mcg/kg

2) Caudal block-
Armitage formula- 0.2%ropivacaine or
0.25%bupivacaine plain
Sacral dermatome- 0.5ml/kg
Lumbar dermatome- 1ml/ kg
Lower thoracic- 1.25ml/kg

3) Lumbar / thoracic epidural

Loading dose- 0.2%ropivacaine or 0.25%bupivacaine plain
Lumbar epidural- 0.5ml/kg
Thoracic epidural-0.3ml/kg
Top-up dose- 0.25ml/kg every 4-6 hour

Continuous epidural
<3 months= 0.2mg/kg/hr
3 months to 1 yr= 0.3 mg/ kg/hr
>1 yr= 0.4 mg/ kg/hr

Adjuvants
Clonidine = 1-2mcg/kg
In infusion = 0.01 mcg/kg
Not recommended - < 3 month /< 10kg

Morphine= 30-50mcg/kg
Fentanyl=1-1.5 mcg/kg

Test dose –
Epinephrine = 0.5mcg/kg (0.1ml/kg of a 1:200000) to a
maximum dose of 15mcg or total up to 3 ml (lignocaine
with epinephrine)
Positive test-
Increase HR- >10 bpm
Increases systolic BP > 15mmhg
Change in T wave amplitude by 25%

Depth of epidural space

Neonate = 1cm
Child 10-25 kg = 1mm/kg
Children >25 kg = 0.8 + (0.05 x weight)
Or 1+ (0.15 x age in year)
Maximum allowable dosage
Bupivacaine - 2mg/kg(Miller), 3mg/kg(Smith)
<6 month- decrease maximum allowable dose by 30%
(1.5mg/kg)
Ropivacaine – 3mg/kg
o.1% Ropin –in neonates and young infants or when wide
dermatomal spread is required
Lignocaine – 5mg/kg
Lignocaine with adrenaline- 7mg/kg
In < 6 month 3 mg/kg

Peripheral nerve block

1) Head and neck block
a) Supraorbital and Supratrochlear nerve block-
1 to 2ml 0.2% to 0.5% Ropivacaine (per side)

b) Infraorbitalnerve block-
0.5 to 1ml 0.2% to 0.5% Ropivacaine (per side)

c) Superficial cervical plexus block-

0.1 to 0.2ml/kg 0.5% Ropivacaine
2) Trunk Block
a) Paravertibral nerve block-
Bolus - 0.25 to 0.5 mL/kg per side of
ropivacaine (0.2% to 0.5%, maximum dose
3 mg/kg)
Continuous infusion- 0.5 mg/kg/hr in children

b) Intercostals nerve block-

0.1 to 0.15 ml/kg per level ropivacaine
0.2% or bupivacaine 0.25%, with a
maximum of 3 ml per level

c) Transversus abdominis plane block

0.3 ml/kg to 0.5 cc/kg of 0.2%
ropivacaine or 0.25% bupivacaine. Ropivicaine
0.5% can be used.

d) Rectus sheath block

0.1 ml/kg to 0.2 ml/kg per side of
0.2% ropivacaine or 0.25% bupivacaine

e) Ilioinguinal/Iliohypogastric Nerve Block

0.1 to 0.4 ml/ kg of 0.2% ropivacaine or 0.25%
bupivacaine is used.
f) Penile block
0.1 ml/kg of 0.2% ropivacaine or 0.25%
bupivacaine at each site.

UPPER-EXTREMITY NERVE BLOCKS

Interscalene Nerve Block- 0.1-0.4 cc/kg of 0.2%

ropivacaine or 0.25% bupivacaine

Supraclavicular Nerve Block- 0.2 to 0.4 cc/kg 0.2%

ropivacaine or 0.25% bupivacain
Axillary Nerve Block- 0.2 to 0.4 cc/kg 0.2%
ropivacaine or 0.25% bupivacaine

LOWER-EXTREMITY NERVE BLOCKS

lumbar plexus block (psoas compartment block)- 0.3
to 0.5 cc/kg of 0.2% ropivacaine or 0.25%,
bupivacaine
Fascia Iliaca Compartment Block-
0.75 cc/kg - weigh < 20 kg
0.5 cc/kg - weight > 20 kg of 0.2% ropivacaine or
0.25% bupivacaine, ( total of 30 cc.)

Femoral Nerve Block-

0.2 and 0.3 cc/kg of 0.2% ropivacaine or 0.25%
bupivacaine . Ropivicaine 0.5% can also be used.

Lateral Femoral Cutaneous Nerve Block- 0.2 cc/kg (up to

5 to 10 cc) of 0.2% ropivacaine or 0.25%
bupivacaine

Obturator Nerve Block-.

Adult - 5 to 10 cc around each nerve . In
Children - 0.2 cc/kg per nerve of 0.2% ropivacaine
or 0.25% bupivacaine.
Saphenous Nerve Block-
Adult - 5 to 10 cc of 0.2% ropivacaine or 0.25%
bupivacaine
Children - 0.2 cc/kg

Sciatic Nerve Block- 10 cc of 0.2% ropivacaine or

0.25% bupivacaine
In younger patients- 0.3 to 1 cc/kg of 0.2%
ropivacaine or 0.25% bupivacaine .

Ankle Block- . For each nerve, 1 to 2 cc of local

anesthetic
Hyperkalemia - management
Treatment of Mild Hyperkalemia
- Decrease dietary K+ burden
- Discontinue K+-containing medications or K+-sparing diuretics
- Eliminate conditions that favor hyperkalemia: Acidosis, sodium
restriction
- Treatment of moderate to severe hyperkalemia

To Reverse Membrane Effects

- 10% Calcium gluconate - 100 to 200 mg/kg per dose(1 – 2 ml/kg/dose)

To Produce Transcellular Shifts

- Sodium bicarbonate- 1 to 2 mmol/kg per dose
- Glucose, 0.3 to 0.5 g/kg as 10% glucose solution with insulin, 1 unit
per 4 to5 g glucose IV (4 to 5 ml/kg of 10% glucose with 0.1 unit/kg
insulin)
- Albuterol by nebulizer
- Hyperventilation

To Remove Potassium
- Kayexalate, 1 g/kg per dose PO or enema
- Furosemide, 1 mg/kg per dose IV
- Dialysis (hemodialysis or peritoneal dialysis)
- Hemofiltration (continuous arteriovenous hemofiltration or continuous
venovenous hemofiltration with or without dialysis)
BLOOD PRESSURE
Hypoglycemia –
Newborn

D1 - <40 mg/dl

D2 - <45mg/dl

D3 - <50 mg/dl

Management – 2 ml/kg of 10% D

Older children > Neonate

Blood sugar - < 54 mg/dl

t/t- 1 ml of 50% D

or

2 ml of 25% D

Or

5 ml of 10% D
 Local Anaesthetic Systemic Toxicity (LAST)

Avoid – B blockers, vasopressin, CCB’S, lignocaine and other

local anaesthetics
Anaphylaxis
Epinephrine for
Intramuscular (preferred)- 0.01mg/kg (1: 1000 )
If refractory
iv – infusion- 0.1 ug/kg titrated up to 1 ug/kg (1:1,00,000 )
(bolus- 1-5ug/kg)
Pain management
✓ Dosage of most synthetic opioids should be decreased in neonates during
the first 2‐4 weeks of life (and for premature neonates until at least
44 weeks post conceptual age).
✓ The dose of opioids (dose/kg) should be similar to older infants and
children after 6 months of age (considering underlying health and previous
exposure to opioids).

✓ (Reference:The Society for Pediatric Anesthesia recommendations for the use of opioids in children during
the perioperative period, Joseph P. Cravero)
Postoperative nausea vomiting

Eberhart risk score for ponv in paediatrics

reference-
Fourth Consensus Guidelines for the Management of Postoperative Nausea
and Vomiting
Electrolytes imbalance-

Calcium-

Hypocalcaemia- t/t- calcium gluconate

symptomatic

Newborn children

2 ml/kg/dose 6hrly 1-2ml/kg single dose

(8 ml/kg/day) (max 10-30ml)

Prophylactic – 4ml/kg

for hyperkalemia – 1-2ml/kg/dose