Just-Doses-Cross-Referenced Flashcards
Heparin:
Infusion Rate:
Cath Lab:
ACT for PCI w/ and w/o IIb/IIa glycoprotein drugs:
Pre-Bypass ACT:
bolus & infusion: 5,000-10,000 units then 15-18 units/kg/hr
target aPTT of 50-80secs. Adjust by about 2 units every 6 hours.
Cath Lab: 70-100 units/kg IV
ACT Cath Lab: 250-300 secs w/ IIb/lla drugs 200-250secs.
Measure ACT 3-5 minutes after the initial bolus, then periodically (every 30 minutes) during the procedure.
If ACT is below target, administer additional 2,000-5,000 units of heparin IV as needed.
If ACT is above target, hold further doses.
Pre-Bypass: >450 secs
Routine Diagnostic Angiography: Lower doses of heparin (50-70 units/kg IV bolus) are sufficient to prevent clot formation on catheters and guidewires
Protamine Sulfate:
normal dose:
for Hearts:
Normal: 1-1.5 mg per 100 USP units of heparin; not to exceed 50 mg
Hearts: 300- 400mg - give over 10-15 minutes.
Insulin drip (Hearts):
DKA:
Hearts drip: 140–180 mg/dL is the most commonly accepted target to minimize risks of hypoglycemia while maintaining glycemic control.
Starting the Insulin Infusion:
Initial Bolus: If blood glucose >200 mg/dL, administer 4-6 units IV as a bolus before starting the drip.
Initial Drip Rate: Start at 1-2 units/hour and titrate based on glucose measurements.
Titration Based on Blood Glucose:
Measure blood glucose every 30 minutes to 1 hour until stable, then every 1-2 hours.
Blood Glucose (mg/dL) Action
< 70 Stop infusion. Administer 25–50 mL D50 IV and recheck in 15 minutes.
70–140 Decrease rate by 0.5–1 unit/hour.
140–180 Maintain current rate.
180–250 Increase rate by 1–2 units/hour.
> 250 Increase rate by 2–4 units/hour and consider an additional bolus of 4–6 units.
DKA: Initial Rate: 0.1 units/kg/hr (6.8 units/hr for 68 kg). Bolus 10 units Regular insulin
Adjust rate based on hourly blood sugar checks, targeting 140-180 mg/dL to avoid exacerbating ICP with hypoglycemia. Make sure patient is not hypokalemic prior to drip.. normally hyper bc of acid.
Phenylephrine
Bolus:
Drip:
Bolus: 50-150mcg
drip: 10-200mcg/min most common is 40-80mcg/min or 0.05-1mcg/kg/min
Vasopressin
Drip:
Bolus:
onset:
Drip: 0.03 units/min
Bolus: 1-2 units - Dilute in 10 mL syringe. If patient is hypocalcemic then other vasoactive drugs will not work as well and this is a good option.
onset: 10-15 min
Calcium Chloride:
Cardiac Arrest:
Hyperkalemia:
Hypermagnesemia (Might see in Preeclampsia):
Arrest: 1-2 gm.. for peds 20mg/kg (max 2gm)
Hyperkalemia: 1gm can also use calcium Gluconate if don’t have central line.
Hypermagnesemia: 1 gm
Increases BP and Cardiac Contractility
Adenosine (SVT):
Adult:
Peds:
Adult: 6mg then 12mg (everyone just gives 12mg)
Peds: 0.1mg/kg then 0.2mg/kg
Epinephrine:
Drip:
Bolus:
Dirty Epi (post code)
Peds Anaphylaxis:
Peds Arrest:
Drip: 0.02- 0.3mcg/kg/min (same as norepi)
Bolus: 5-10 mcg (same as norepi) - anaphylaxis
Dirty: put 1 mg in 250cc bag.. roll open and titrate to effect. typically around 16mcg/min
Peds Anaphylaxis: 10mcg/kg IM
Peds Arrest: 10mcg/kg IV or 100mcg/kg ETT
Albuterol
Optimize- pre-op:
Intra-op (bronchospasm)
pre-op: 2-4 puffs
intra-op: 10 puffs reassess and re-dose if need q3 min
Amiodarone (arrest) - VF and pulselessVT
1st:
2nd:
1st: 300mg
2nd: 150mg
Atropine:
Arrest:
Brady:
Peds:
Arrest: 1mg q 3-5 min (max 3mg)
Brady: 0.5mg
Peds: 0.02mg/kg ETT 0.04-0.06mg/kg
Carboprost (hemabate)
Pregnant Hemmorage dose:
Caution w/
250 mcg IM not IV !!!!!!!!!!!!
just give whole vial
caution w/ asthmatics -> may cause severe bronchospasm.. try Methylergonovine (Methergine) first
Codeine
Dose:
Age appropriateness:
15-60mg PO/IM/SQ
don’t give to peds < 12 years old
Dantrolene MH
dose:
2.5mg/kg adults and peds
use 60mL syringes..
For a 78kg patient this would be about 10 syringes (200mg) of 60mL syringes containing 20mg of Dantrolene with a total volume of 600mL
Dexmedotomidine
Loading Dose:
Infusion:
receptor:
How produce analgesia:
Loading (adults & peds): 0.5-1 mcg/kg/min over 10 min.
infusion: 0.2-1.5 mcg/kg/HR
receptor: a2 agonist
analgesia: block substance P in dorsal horn
reconstitute to get a concentration of 4mcg/mL mix in 48mL bag 200mcg/2 mL vial
Use some push doses 4mcg or about 0.5mcg/kg for emergence with PEDs and adults for smoother awake extubations.
The sedative effects may peak within 10-15 minutes and gradually taper off over 30-60 minutes.
Diazepam
Adults:
Peds:
Adults: 5-10mg IV
Peds: 0.2- 0.3 mg/kg IV
How to treat Bronchospasm?
How to recognize:
Check the Circuit for Disconnection:**
- Inspect all components of the breathing circuit for loose connections, kinks, or dislodged tubing. Start at the patient’s airway (ETT placement and cuff) and systematically follow the circuit back to the ventilator.
- Characteristic shark-fin waveform on the capnography monitor may indicate airway obstruction or bronchospasm. Auscultate wheezing
- ** 100% fiO@ and increase the flows to 10-15L.. ( 1L of 100% fiO2 is not = to 100% O2)
-
Administer Bronchodilators:
-
Albuterol (Beta-2 Agonist):
- Administer 8-10 puffs via a metered-dose inhaler (MDI) through the ETT. Connect the MDI to the circuit and deliver the puffs while ventilating.
**REASSESS AND RE-ADMINISTER IF NEEDED Q3 MIN - Beta-2 agonists act by relaxing bronchial smooth muscle, relieving bronchospasm.
- Epinephrine 10-50 mcg IV or 10mcg/kg subcutaneously
- Administer 8-10 puffs via a metered-dose inhaler (MDI) through the ETT. Connect the MDI to the circuit and deliver the puffs while ventilating.
-
Albuterol (Beta-2 Agonist):
-also Terbutaline if severe (adult): 5-10mcg/kg IV q15 (max 250mcg).
-
Adjust Ventilation Settings: OR MANUALLY VENT IS BETTER- prevent air trapping
- Decrease Respiratory Rate (RR): To prevent air trapping and allow for adequate expiration.
- Increase the Expiratory Time (I:E Ratio): Ensure a longer expiratory phase to minimize dynamic hyperinflation.
-
Deepen Anesthesia:
-
Volatile Agents:
- Sevoflurane is the preferred volatile anesthetic for asthma patients due to its bronchodilatory properties and minimal airway irritation.
-
Additional Medications:
- Administer Propofol or Ketamine:
- Propofol: Sedative-hypnotic that can reduce bronchial tone indirectly. 0.5–1 mg/kg IV.
- Ketamine: 0.5-1 mg/kg IV for bronchodilation via NMDA receptor antagonism.
- Administer Propofol or Ketamine:
-
Volatile Agents:
-
Anti-inflammatory Agents:
- Dexamethasone (4-8 mg IV): Reduces inflammation and stabilizes the airway, although effects may take several hours.- give pre-op to asthma patients
- Hydrocortisone (100 mg IV): Another option for reducing airway inflammation. – same give pre-op to asthma patents.
-
Other Supportive Measures:
- Manual ventilation if auto-PEEP (positive end-expiratory pressure) is suspected to avoid barotrauma.
Magnesium @ 2gm IV over 20 min (works w/ asthma as well -prob just add it if patient has asthma).
HyperKalemia Tx:
how to recognize:
Calcium: 0.5-1g CaCl (give first)
Bicarbonate: 25-50mEq
Insulin Regular: 5- 10 units
Glucose (D50): 25- 50gm
Kayexalate: 15-50g PO (probably won’t be able)
Albuterol: 10 puff or neb
Furosemide: 40-80mg IV
Tall peaked T- waves, hypotension
DIPHENHYDRAMINE
Adult:
Peds:
Adult: 25-50mg IV (for anaphylaxis do 50)
Peds: 0.5-1mg/kg
Dopamine:
Renal dose (fuck the rest):
1-4mcg/kg/min
ERGOMETRINE (Methergine)- for refractory post-partum hemorrhage.
dose:
Considerations:
dose: 0.2mg IV/IM slow (whole vial)
considerations: HTN, PVD
if history of hypertension consider Hemabate first
Dobutamine:
infusion:
0.5-20 mcg/kg/min
Ephedrine
Adults:
Peds:
Adults: 5-10mg (max 50mg) q 3-5 min
Peds: 0.1-0.2mg/kg (max 25mg)
Esmolol (brevibloc):
Bolus:
Drip:
Induction:
Bolus (adults & peds): 0.5mg/kg but most do 10-20mg up to 80mg.
Drip: 50-300mcg/kg/min
Induction: 100-150mg, 2 min before laryngoscopy
Norepinephrine
Bolus:
Drip:
Bolus: 5-10mcg
drip: 0.02-0.3 mcg/kg/min (same as epi) can go as high as 2mcg/kg/min but probably need an additional pressor before then.
Etomidate:
Induction dose:
0.2- 0.3 mg/kg
Fentanyl
bolus:
infusion:
Off:
Bolus: 1-3mcg/kg but most do 25- 100mcg
Infusion: 25-200mcg/hr or 1-3mcg/kg/hr for easy memory (use with caution, long- context sensitive half life).
off: 45- 60 min before end of procedure
DKA management
How to recognize:
Bolus 10 units
Start IV insulin drip @ Initial Rate: 0.1 units/kg/hr (6.8 units/hr for 68 kg).
keep running IV until anion gap closed < 12 if BS < 200 and anion gap is still above 12 then start D5w & 1/2 NS and keep the insulin infusion running. Switch to subq insulin when anion gap has closed.
Make sure patient is not borderline hypokalemic before starting insulin (rare but important). If so , replace K+ first.
regonition: Kussmal’s Breathing, acidotic, BS > 400
Ischemic Event
How to recognize:
Tx:
- Recognition:
o Monitor ECG for signs of myocardial ischemia:
ST depression and/or T-wave inversion
Hypotension and tachycardia (or inappropriate bradycardia in some cases).
GET A 12 LEAD!!!
- Management:
o Restore Coronary Perfusion Pressure (CPP):
Begin with Phenylephrine drip:
Start at 10 mcg/min and titrate up to 200 mcg/min to increase BP and improve coronary perfusion.
o Control Heart Rate:
Administer Esmolol for HR control:
Give a 10 mg IV bolus.
Start Esmolol drip at 50 mcg/kg/min, titrate to a maximum of 250 mcg/kg/min as needed to achieve optimal HR (typically < 80 bpm).
o Improve Coronary Flow:
Initiate Nitroglycerin drip to dilate coronary arteries:
Start at 0.2 mcg/kg/min and titrate every 3 minutes by increments of 0.1.. so rang is 0.2-1.5 mcg/kg/min, or 10-200mcg/min can give a bolus of 10-50 mcg while starting drip. (note nitroprusside is the same dosing but has slightly longer effect). - Additional Supportive Measures:
o Increase FiO₂ to 100% and increase flows to 10L to optimize oxygen delivery.
o Ensure adequate volume status:
Administer balanced salt solution or colloids as needed for preload optimization.
o Consider reducing volatile anesthetic depth if hypotension persists. - Monitor:
o Continuously monitor ECG for resolution of ischemic changes.
o Assess BP, HR, and rhythm frequently after adjustments to therapy.
Venous Air Emboli
How to recognize:
Tx:
What cases are most common:
most common: Neruo where lesion is above heart.
- Venous Air Embolism (VAE):
o Signs: Sudden hypotension, decreased EtCO₂, or mill-wheel murmur on precordial Doppler .
o Management:
Notify surgeon to flood the surgical field.
Place patient in left lateral decubitus and Trendelenburg position.
Aspirate air through central venous catheter if in place.
100% O2
Start Inotrope support and fluid bolus. (patient may have distended jugular veins, sign of Right heart not pumping).
Administer epinephrine (100- 300 mcg IV) for cardiovascular collapse. or Epi drip @ 0.02-0.3mcg/kg/min or
Use Dobutamine 2-20 mcg/kg/min as it has less decrease on SVR than Milrinone).
Pulmonary Hypertension Crises
How to recognize:
Tx:
Recognition: Hemodynamic Indicators:
Increased Pulmonary Artery Pressure (PAP): Elevated readings from a pulmonary artery catheter. (normal is 25/10)
Systemic Hypotension: Due to RV failure reducing cardiac output.
Increased Central Venous Pressure (CVP - 2-6): Reflecting RV overload.
Decreased Cardiac Output (CO- 4-8L/min norm) or Index (CI- 2.5-4L norm): Measured via PAC or other hemodynamic monitors.
Right Ventricular Dysfunction:
Tachycardia: Attempt to compensate for decreased cardiac output.
Jugular Venous Distension (JVD): From RV overload.
RV strain on ECG: Right axis deviation, peaked P waves, or RBBB.
Respiratory Changes:
Hypoxemia: Worsening oxygen saturation despite adequate ventilation.
Increased Peak Airway Pressures: Secondary to pulmonary vasoconstriction (HPV) and reduced lung compliance.
Clinical Signs:
Cyanosis, cool extremities, and signs of poor perfusion.
Sudden onset of dyspnea or desaturation.
TX:
Immediate Interventions
Oxygenation:
Administer 100% FiO₂ to optimize oxygen delivery and reduce hypoxic vasoconstriction.
Optimize Ventilation:
Maintain normocapnia or mild hypocapnia (PaCO₂: 35-40 mmHg) to avoid acidosis-induced vasoconstriction.
Avoid high PEEP as it can impair venous return to the RV.
Pulmonary Vasodilators
Inhaled Nitric Oxide (iNO):
Dose: Start at 20 ppm (10-40 ppm), titrate based on PAP and systemic BP response.
Rationale: Selective pulmonary vasodilation reduces RV afterload without systemic hypotension.
Intravenous Prostacyclin (Epoprostenol):
Dose: Start at 2-4 ng/kg/min, titrate up to 20-40 ng/kg/min based on response.
Rationale: Reduces PVR and has anti-platelet effects to reduce microvascular thrombosis.
Sildenafil or Tadalafil:
Consider oral or IV formulations if available for chronic PH management, though less effective in acute crises.
Inotropic Support:
Dobutamine: Start at 2-5 mcg/kg/min (infusion range is 0.5- 20 mcg/kg), titrate for improved RV contractility and cardiac output.
Milrinone: Loading dose of 25-50 mcg/kg over 10 minutes, then infusion at 0.125–0.75 mcg/kg/min. Avoid in severe hypotension due to vasodilatory effects (greater SVR & PVR reduction than dobutamine).
Epi is also an option.
Vasopressors:
Norepinephrine: Start at 0.02 mcg/kg/min, titrate to maintain systemic perfusion and RV coronary perfusion.
Avoid RV Afterload Increases:
Treat systemic hypotension carefully to maintain RV perfusion pressure while avoiding excessive increases in PVR.
Address Precipitating Factors
Hypoxia: Increase oxygenation.
Hypercapnia or Acidosis: Optimize ventilation and administer sodium bicarbonate (50mEq) if severe acidosis (pH <7.2).
Pain or Agitation: Administer analgesia (e.g., fentanyl) or anxiolytics to blunt sympathetic stimulation.
Bolus fluid cautiously, if CVP is low < 8mmHg then probably ok.. do slowly (10 min), if worsens situation then stop immediately
Massive Hemorrhage
Tx:
SPECIAL EQUIPMENT / INVASIVE LINES
* Arterial Line (Radial or Femoral): Continuous blood pressure monitoring and frequent arterial blood gas analysis.
REASONING: Critical for managing hemodynamic instability and guiding resuscitation.
- Large Bore Peripheral IVs (14-16G x 2): For rapid administration of fluids and blood products.
REASONING: Ensures adequate access for massive transfusion. - Rapid Infuser (e.g., Level 1 or Belmont): For rapid administration of warmed blood products and fluids.
REASONING: Critical for managing massive hemorrhage and maintaining normothermia. - TEG- monitor ACTs
Activate Massive Transfusion Protocol - Call for HELP
Fluids Administered:
Start with 1-2 L crystalloid; transition rapidly to blood products.
Massive Transfusion Protocol (MTP): Ratio-based resuscitation (1:1:1 or 2:1:1 RBC:FFP).
- Blood Products: Begin with 2 units of O-negative blood, then switch to type-specific once available. Continue with a 1:1:1 ratio of PRBCs:FFP:platelets
COMPONENTS
The three components of MTP are:
1. Packed Red Blood Cells (PRBCs): Replaces lost red blood cells to restore oxygen-carrying capacity.
2. Fresh Frozen Plasma (FFP): Provides clotting factors to help correct coagulopathy.
3. Platelets: Replenishes platelet count to aid in clot formation.
* 1:1:1 Ratio (PRBCs:FFP): This means for every unit of PRBCs given, one unit of FFP and one dose of platelets are also administered. This approach aims to provide a balanced replenishment of red cells, plasma, and platelets.
* 2:1:1 Ratio (PRBCs:FFP): This means for every two units of PRBCs given, one unit of FFP and one dose of platelets are administered. This approach might be used initially to rapidly restore oxygen-carrying capacity while still addressing coagulopathy.
- First Cooler:
o 2 Units of O-Negative PRBCs
o 4 Units PRBCs
o 4 Units FFP
o 1 Six-Pack Platelets
o Cryoprecipitate: As indicated by laboratory results and clinical assessment.
o Use the Belmont rapid transfuser/warmer or pressure bag. Set blood transfusion tubing up with a fluid warmer(s).
o 100% O2 & increase flows lower volatile concentration.
o Actively warm the patient. Bair Hugger where you can
Calcium Gluconate: 1-2 g IV after every 4-6 units of PRBCs.
Calcium Chloride: 1 g IV (preferred for acute hypocalcemia or cardiac instability).
- Laboratory Monitoring: After the first cooler, draw blood for TEG, CBC, ABG, and CMP. Repeat as necessary to guide further blood product administration.
Active Coagulation Monitoring with TEG/ROTEM:
Incorporate thromboelastography (TEG) or ROTEM to guide targeted blood product administration:
FFP: For prolonged clotting time. ACT > 140
Platelets: For low MA (maximum amplitude) < 50 .
Cryoprecipitate: For low fibrinogen levels (<1.5 g/L). FIBTEM MCF low (ROTEM) or K time > 3 min (TEG) or @ angle < 53 (TEG)
Laboratory monitoring should include TEG, CBC, fibrinogen, ABG, ionized calcium, and lactate.
Cryoprecipitate and Fibrinogen Replacement:
Indication: Use cryoprecipitate if fibrinogen is <1.5-2 g/L.
Dose:
Cryoprecipitate: 1 bag per 10 kg body weight (usually 10-15 bags).
Fibrinogen Concentrate: 3-4 g IV for rapid correction.
If Coagulopathy is suspected give 1g TXA over 10 min
Vasopressor support
Thyroid Storm
Recognition:
Management:
- Thyroid Storm:
Signs: Fever, tachycardia, hypertension, arrhythmias.
Management:
Esmolol drip for HR and BP control. 50-300mcg/kg/min or 10-40mg boluses (drip better)
Propylthiouracil (PTU) 200-400 mg NG to inhibit thyroid hormone release.
Hydrocortisone 100 mg IV to block peripheral conversion of T4 to T3. - Hemodynamic Instability:
o Treat hypotension with Phenylephrine boluses (50-100 mcg IV- rare).
o Avoid ephedrine or other agents that can exacerbate tachycardia.
Anaphylaxis
Recognition:
Tx:
- 100% fiO2 & increase flows
- Balanced salt solution or colloid - often rapid infusion of 1 - 4 lL !!! required.
- Epinephrine (initial dose 10 - 100 mcg IV): reassess and redose if needed q3 min
o Beta adrenergic effect inhibits degranulation of mast cells and causes bronchodilation.
o Alpha effect causes vasoconstriction. - Diphenhydramine (initial dose 50 - 100 mg IV): Blunts histamine effects.
- Albuterol Inhaler (initial dose 10 puffs per ETT): For bronchospasm.
- Phenylephrine (initial dose 25-100 mcg IV): Raises BP through alpha-adrenergic effect.
- Corticosteroids - Methylprednisolone (40-60mg): 4x more potent than hydrocortisone.
o Enhances beta effects of Epinephrine.
o Inhibits production of leukotrienes.
o Reduces complement system activation.
Methylene Blue for refractory hypotension: 10-50mg IV
Aortic Stenosis Management
plan:
Maintain Preload, Afterload, and Sinus Rhythm:
Preload: Ensure adequate volume to maintain ventricular filling.
Afterload: Avoid hypotension as the heart relies on systemic vascular resistance (SVR) for forward flow.
Sinus Rhythm: Preserving atrial contraction is critical for diastolic filling in a non-compliant left ventricle. (Have pads on, quickly cardiovert any A-fib!!!)
Induction Plan
Medications to Administer:
Etomidate 0.2-0.3 mg/kg IV: Preserves SVR with minimal myocardial depression.
Fentanyl 2-5 mcg/kg IV: Blunts sympathetic response to intubation.
Rocuronium 0.6-1.2 mg/kg IV: For muscle relaxation.
Rapid Response to Hypotension:
Administer Phenylephrine 100 mcg IV bolus to quickly restore afterload if hypotension occurs.
Maintaneance Phase: (keep MAP > 70)
Anesthetic Agents:
Sevoflurane 0.5-0.7 MAC: Maintain lower MAC to reduce myocardial depression and maintain SVR.
Supplement with Remifentanil infusion (0.05-0.2 mcg/kg/min) to achieve adequate analgesia and further reduce MAC requirements.
Avoid Nitrous Oxide: Prevents hemodynamic compromise.
Ventilation Settings:
Avoid hyperventilation; maintain normocapnia (EtCO₂ 35-40 mmHg) to avoid decreasing preload.
Fluid Management:
Use crystalloids judiciously to maintain preload without causing volume overload.
Avoid rapid boluses; use a controlled infusion if needed, guided by CVP or PAC monitoring.
Vasopressor Support:
Start a Phenylephrine infusion (0.05-0.1 mcg/kg/min) 40-80mcg/min is most common dose and titrate to maintain MAP > 70 mmHg.
Emergence Phase
Extubation Criteria:
Ensure hemodynamic stability (MAP > 70 mmHg).
Confirm adequate spontaneous ventilation and airway reflexes.
Neuromuscular Reversal:
Use Sugammadex to avoid bradycardia associated with neostigmine.
Postoperative PONV Prophylaxis:
Ondansetron 4 mg IV at the end of surgery
Special Considerations for Aortic Stenosis
Hypotension Management:
Use Phenylephrine (50-100 mcg IV) or titrate infusion to maintain afterload.
Avoid ephedrine, as tachycardia worsens diastolic filling.
Tachycardia Management:
Esmolol 0.5 mg/kg (10-40mg) IV bolus or infusion for HR > 90 bpm.
Avoid Fluid Overload:
Monitor urine output and CVP to guide fluid resuscitation.
Intraoperative Dysrhythmias:
**Treat atrial fibrillation aggressively with cardioversion (100 -200 joules) and amiodarone 150mg.
How to Manage Difficult Airway
Vortex Principle:
Get Help First, try adjuncts w/ the 3 techniques
Three Airway Techniques:
Face mask ventilation.
Supraglottic airway (e.g., LMA).
Endotracheal intubation.
no more than 3 attempts per technique - Oxygenation is key, if you cannot oxygenate at the end of the vortex and are unable to reverse the patient to wake up THEN…make sure you have an extra set of hands, place a foam roll under the shoulders to expose the neck, adjust lighting and start an emergency cricothyrotomy.
Airway Optimization Strategies - FOR EVERY PHASE CONSIDER OXYGENATION, ADJUNCTS, SWITCHING PROVIDERS, AND MUSLCE RELAXANTS for optimal position.
- Face Mask Ventilation
Seal: Ensure a tight seal by adjusting head position, mask grip, or using a two-person technique (two handed). (JAW THRUST).. Try a new mask size.
Airway Adjuncts: Insert an oropharyngeal (OPA) or nasopharyngeal (NPA) airway to reduce obstruction.
Pressure: Increase positive pressure ventilation (PPV) cautiously, using PEEP or CPAP if needed.
- Supraglottic Airway (SGA)
Placement: Ensure correct placement of the SGA.
Size: Switch to a larger size if ventilation is inadequate. if 3 go 4. Also you can switch to a different type of LMA.
Position: Adjust head/neck alignment or reposition the device.
- Endotracheal Intubation- more Paralysis ??
Positioning: Optimize the sniffing position for better glottic visualization. (Try different blade, different size).
Video Laryngoscopy: Use if direct laryngoscopy fails or is predicted to fail. (Fiberoptic if available as well)
Bougie: Insert to facilitate tube passage.
External Manipulation: Apply BURP (Backward, Upward, Rightward Pressure) on the larynx.
REVERSE PARALYTICS w/ SUGGAMADEX 16mg/kg - WAKE THE PATIENT UP
DON’T KEEP DOING THE SAME SHIT, GET HELP AS SOON AS YOU RECOGNIZE YOU CANNOT OXYGENATE PATIENT ACCORDING TO ORIGINAL PLAN.
Quick Airway Assessment
steps:
Past History:
Look for conditions like OSA, prior difficult intubation, or airway surgery.
Facial Features (Predictors of Difficult Mask Ventilation):
Beard: Often requires RSI; difficult to achieve a seal.
Edentulous (No teeth): Increases difficulty in mask ventilation.
Jaw protrusion limitation: Predicts difficulty with both bag-mask ventilation and intubation.
Airway Exam (Predictors of Difficult Intubation):
Mallampati Score: Class 3-4 predicts difficulty.
Neck Extension: Limited extension (<35°) is predictive of difficulty.
Thyromental Distance (TMD):
Normal: >6.5 cm (~3 fingerbreadths).
Difficulty: <6 cm.
Inter-incisor Distance (Mouth Opening):
Normal: >4 cm (~3 fingerbreadths).
Difficulty: <3 cm.
Neck Circumference:
Normal: <40 cm.
Predicts difficult intubation if >43 cm (especially in obese patients).
Methylene Blue
Dose for refractory hypotension w/ anaphylaxis
10-50mg IV
Mechanism of Action
Inhibits Nitric Oxide (NO)-Mediated Vasodilation:
Anaphylaxis triggers the release of mediators like histamine and nitric oxide, which lead to profound vasodilation and decreased systemic vascular resistance (SVR).
Methylene blue inhibits guanylate cyclase, reducing cyclic GMP (cGMP) production and counteracting nitric oxide’s vasodilatory effects.
This restores vascular tone and improves blood pressure.
Acts as a Vasopressor Adjunct:
It directly promotes vasoconstriction and enhances the effectiveness of other vasopressors like norepinephrine and phenylephrine.
When to Use Methylene Blue
Consider methylene blue in patients with:
Refractory hypotension that does not respond to epinephrine, fluids, and standard vasopressors.
Evidence of severe distributive shock due to anaphylaxis.
Indigo Carmine
Dose:
Use Case:
Dose: The entire vial 5mL of 0.8% (40mg) IV push
half life: 4-5 min excreted via kidneys may cause transient HTN.
Urological Procedures:
Indigo carmine is commonly used during surgeries involving the urinary system to visualize the ureters and confirm their patency or to detect injury.
It is filtered by the kidneys and excreted in the urine, producing a blue-colored output that helps surgeons identify ureteral function and integrity.
Gynecological Procedures:
Used to ensure ureteral patency after pelvic surgeries like hysterectomy or to evaluate possible urinary tract injury.
Other Uses:
Can aid in identifying fistulas or leaks in the urinary tract.
Occasionally used for dye-based localization during other procedures.
Glycopyrrolate (Robinul)
dose:
peds:
adults: 0.2mg per mg of Neostigmine
peds: 15mcg/kg IV or 4mcg/kg IM
Hydralazine
dose:
peds:
onset:
duration:
dose: 5-10mg
peds: 0.1-0.2mg/kg q4
onset: 10-20 min
duration: 3-6 hours
Hydrocodone
dose:
Peds:
adults: 20-40mg PO
Peds: 0.2mg/kg PO
Hydrocortisone (stress dose)
Adult:
Peds:
indications:
Adult: 100mg IV, then 25-100mg IV every 6-8 hours. (depending on stress of surgery).
Peds: 0.1-0.2mg/kg q4 hr
Indications for Stress-Dose Hydrocortisone
Known Adrenal Insufficiency:
Primary adrenal insufficiency (e.g., Addison’s disease).
Secondary adrenal insufficiency (e.g., pituitary dysfunction).
Chronic Steroid Use:
Patients on long-term steroids (prednisone ≥5 mg/day for >3 weeks) may have suppressed adrenal glands and cannot produce sufficient cortisol in response to stress.
Acute Adrenal Crisis:
Hypotension unresponsive to fluids and vasopressors.
Features of adrenal crisis, such as weakness, confusion, or hypoglycemia.
Major Surgical Procedures or Trauma:
Especially in patients with known or suspected adrenal insufficiency undergoing:
Major surgeries (e.g., open abdominal, thoracic, or vascular surgery).
Significant trauma or sepsis.
Hydromorphone
Bolus dose:
Bolus Peds:
infusion:
onset:
duration:
Adults: 0.5-2mg IV
Peds: 5-10 mcg/kg IV prn
infusion: 0.5-4mg/hr
onset: 5-15 min
duration: 2-4 hrs
LAST tx:
Adult & Peds: LAST: 1.5 mL/kg followed by infusion 0.25 mL/kg/min up to 0.5 mL/kg/min (IDBW)
start CPR, bolus 20% intralipid @ 1.5mL/kg. Repeat bolus q3-5 min and double infusion if still unresponsive.
Continue infusion until hemodynamically stable.
Max total dose 8mL/kg
Ketamine:
Induction:
Maintenance (intra-op):
post op:
epidural:
spinal
Duration:
Induction: 0.5-2mg/kg give w/ Midazolam
Maintenance and sub anesthetic dose (analgesia): 0.2-0.5 mg/kg IV or 0.1-0.5mg/kg/hr
Post op sedation and analgesia:
1-2 mg/kg/hr (also used for ped heart case)
Neuraxial analgesia:
Epidural: 30 mg
intrathecal/spinal/ subarachnoid: 0.1-0.3mg/kg
Duration: 10-20 min
Ketorolac (Toradol)
dose:
Use in Neck Surgeries?:
dose: 15-30mg Q6hrs
neck: NO, use ofirmev, as NSAIDs are prone to cause bleeding and hematoma.. no good in neck cases.
Avoid in renal failure or CR > 1, avoid w/ Ashtma patients and Cox allergies.
You know you’re not allergic to the COX ; -)
This is not Tramadol, which is an opioid!
Lidocaine:
Induction & Arrest :
Infusion (analgesia):
Max dose Plain:
Max w/ epi:
duration:
induction & arrest: 1-1.5mg/kg (Max 100mg)
infusion: 0.5-3 mg/kg/hr IV - usually 1mg/kg/hr for MAGA
plain: 5mg/kg
w/ epi: 7mg/kg
duration: 60-120 min
Don’t go over 300mg total without epi or 500mg total w/ epi
Lorazepam:
Adult:
Peds:
Adult: 1-4mg IV
Peds: 0.1mg/kg IV
MAGNESIUM SULFATE
Asthma Dose & Multimodal pain dose:
Pre-eclampsia dose:
Peds:
Torsades:
Adult: Asthma & pain: 2 gm IV over 20 min;
Eclampsia/preeclampsia: Load 4-6 gm IV, infusion 1-2 gm/hr IV;
TdP: 1-2 gm IV, infusion 0.5-1 gm/hr IV
Peds: Asthma: 25-75 mg/kg (max 2 gm) IV over 20min;
TdP: 25-50 mg/kg/dose (max 2 gm) IV
TdP = Torsades de Pointes
Laryngospasm
Tx:
Recognition:
Recognition: Upper airway obstruction; inspiratory stridor, Typically on emergence), O2 sats drop
TX: Turn APL valve to 40-70, (positive pressure). increase flows, Tight mask seal with jaw thrust and Larson’s maneuver (two handed).
If doesn’t work then Succinylcholine 10-20 mg IV or 3-4mg/kg IM in kids without IV access.
Meperidine:
dose:
12.5mg for post op shivering
Mechanism: Meperidine has a unique anti-shivering property mediated by its action on kappa-opioid receptors and potential inhibition of the shivering reflex in the hypothalamus.
Dexmedetomidine works as well to widen shiver threshold
METHYLERGONOVINE/ METHERGINE
Adult: 0.2 mg IM; repeat q 5-10min max 2 doses for PPH
METHYLPREDNISOLONE
adults:
anaphylaxis:
Peds:
Adult: Asthma: 40-80mg IV;
Anaphylaxis: 125mg IV
Peds: Asthma: 1mg/kg IV; Anaphylaxis: 1-2mg/kg IV
METOCLOPRAMIDE (Reglan)
adults:
Peds
Adult: 10-20 mg IV/PO, repeat 5-10 mg q6hr prn
Peds: 0.1-0.15 mg/kg IV/PO q6hr prn
MIDAZOLAM
Adult:
Peds:
Adult: 0.5-4 mg IV
Peds: 0.1-0.2 mg/kg IV, 0.5 mg/kg PO/PR
MISOPROSTOL
Adult: 1mg PR
used for inducing and PPH
MORPHINE SULFATE
onset:
duration:
adult:
Peds:
Adult: 1 - 10 mg IV/IM
Peds: 0.05-0.1 mg/kg IV/IM
onset: 10-20 min
duration: 4-5 hrs
NALOXONE
dose:
onset:
duration:
dose: 40-80 mcg (less than the 2mg giving to people who OD.. we don’t want to reverse all analgesia).. reassess and redose if needed
onset: 1-5 min
duration: 30 min !!! (shorter than opioids)
NEOSTIGMINE
Adult & Peds: 0.04-0.07 mg/kg IV (max 5 mg)
Add atropine IV 0.5-1 mg (adults), 20 mcg/kg (peds) w/ edrophonium
NITROGLYCERIN
Bolus:
Infusion:
duration
Bolus: 10-50mcg
Adult: Infusion: 10-200 mcg/min IV or 0.1-1.5mcg/kg/min
(Note these doses are the same for nitroprusside)
Peds: 0.5-20 mcg/kg/min IV Infusion
duration: 3-5 min
Nitroprusside
Bolus:
Infusion:
duration
Bolus: 10-50mcg
Adult: Infusion: 10-200 mcg/min IV or 0.1-1mcg/kg/min
(Note these doses are the same for nitroglycerin)
Peds: 0.5-20 mcg/kg/min IV Infusion
duration: 1-10 min (longer duration than nitro)
ONDANSETRON
Adult: 4-8 mg IV, repeat q4-8hr prn
Peds: 0.15 mg/kg IV; repeat q6-8hr prn
OXYCODONE
Adult: 5-15 mg (or higher depending on opioid tolerance), repeat q3-4hr prn
Peds: 0.1 mg/kg PO; repeat q3-4hr prn
OXYTOCIN (PITOCIN)
Adult: standard 20 units (2 vials ) in a L.. sec, consider repeat dosing and infusion
Should be in a Liter, just roll it open in the event of PPH
PARACETAMOL (ACETAMINOPHEN)
Adult: 500-1000 mg IV/PO, repeat q4-6 prn (max 3-4 gm/day)
Peds: PO/IV: 10-15 mg/kg, repeat q6h prn,
PR: 40 mg/kg x 1, Max: 75 mg/kg/24 hour
PHENOBARBITAL/ PHENOBARBITONE
Adult & Peds: Status epilepticus: 15-20 mg/kg IV, may repeat 5-10 mg/kg in 10min prn x 1
Make sure you dilute, this shit is a vesicant!!
PHENYLEPHRINE
Bolus:
Infusion:
Adult: 40-100 mcg IV q1-2min prn;
Infusion 10-200 mcg/min
PROCHLORPERAZINE (anti-psychotic & anti-emetic)
Adult: 5-10 mg IV/IM/PO q3-6 hrs prn (max 40 mg/day)
Peds: 0.1-0.15 mg/kg PO/IM/IV q6-8h prn (max 10 mg/dose
PROMETHAZINE
Adult: 6.25-25 mg PO/PR q4-6hr prn
Peds: 0.2-0.5 mg/kg PO/PR q6-8h
Max 25 mg/dose (do not give if < 2 yo)
vesicant; good rescue drug (if puking)
PROPOFOL
Induction:
MAC:
TIVA:
Induction: 1.5-2.5mg/kg
MAC: 25-100mcg/kg/MIN
TIVA: 100-300mcg/kg/MIN
RANITIDINE (zantac)
Adult: 50 mg IV; 150-300 mg PO
Peds: 1 mg/kg IV; 2.5 mg/kg PO
Antihistamine and Antacid
It can treat and prevent heartburn. it can also treat stomach ulcers, gastroesophageal reflux disease (GERD), and conditions that cause too much stomach acid.
REMIFENTANIL
Bolus:
Infusion TIVA:
Infusion MAC/Awake Fiberoptic:
duration:
Adult & Peds: Bolus: 0.5-1 mcg/kg IV; 50mcg bolus common
Infusion (adjunct w/ prop or volatile): 0.05 - 2 mcg/kg/min IV
MAC/Fiber: 0.025-0.1 mcg/kg/min .. Keep resp > 10 (Titrate by 0.01, do not even bolus 1cc of propofol w/ this setup bc of apnea) prop running at 50mcg/kg/min for MAC.
duration: 5-10 min
ROCURONIUM
duration:
Adult: 0.6-1.2 mg/kg IV (t1⁄2 = ~60 min)
Peds: 0.9-1.2 mg/kg IV
duration: 35-75 min
SCOPOLAMINE
Adult & Adolescents: 1 patch q72hr
Peds: 6 mcg/kg IV (max 0.3 mg)
SODIUM CITRATE (Bicitra)
Adult: 15-30mL PO q6h prn
Peds ≥ 2 yo: 1-1.5 mL/kg q6-8h prn (max 30 mL/dose)
SODIUM BICARBONATE
Adult: 50-100 mEq IV prn (1”Amp” of 50 mL 8.4% = 50 mEq)
Peds: 1-2 mEq/kg IV
SUCCINYLCHOLINE/ SUXAMETHONIUM
IV
IM
IV: 1-1.5mg/kg
IM: 3-4mg/kg
SUFENTANIL
Bolus:
Infusion:
Duration:
Adult: Analgesia: 5-10mcg bolus
Infusion: 0.2-0.5mcg/kg/hr common is 0.3mcg/kg/hr -> 0.2 -> 0.1 as the case progresses.
Turn off 15-30 min before the end of case
duration: 1-1.5 hrs
SUGAMMADEX
Adult: 2 TOF Twitches: 2 mg/kg;
0 TOF, 1-2 PTC (post tetanic): 4 mg/kg;
Immediate emergent reversal : 16 mg/kg
TERBUTALINE
Bronchospasm dose:
Tocolysis dose:
5-10mcg/kg IV
Bronchospasm:
IV Dose:
5-10 mcg/kg IV every 15-30 minutes, titrated based on response.
Maximum single dose: 250 mcg.
Tocolysis:
IV Dose:
5-10 mcg/kg IV every 15-30 minutes, titrated for uterine relaxation.
Alternatively, a continuous infusion can be initiated at 2.5-10 mcg/min, titrated as needed.
Maximum infusion rate: 80 mcg/min.
Tocolysis is a medical procedure that uses medications to delay preterm birth by relaxing uterine muscles and suppressing contractions
THIOPENTAL/ THIOPENTONE
IV: 4 mg/kg (technically 3-6)
***re-dose after 30 min d/t rapid redistribution
TRAMADOL
Adult: 25-100 mg PO q4-6h prn
Peds: not recommended in children < 12 yo
TRANEXAMIC ACID
Adult: 1 g IV (over 10 min!!!!!), repeat x 1 after 30 min prn
If someone tells you to just push it, hand the stick to them and say be my guest..
You don’t want to be the one to blame for a PE.. (just because they haven’t had one yet doesn’t mean it’s safe).
VASOPRESSIN
drip:
bolus:
Adults: (shock) 0.03 - 0.04 units/minute drip
Bolus: Can bolus 0.5- 1 units, (might need bolus in acute setting if patient is hypocalemic, as this will hinder other vasoactive medications from working).
Peds: (shock) Infusion: 0.002 units/kg/min IV
VECURONIUM
onset:
duration:
Adult & Peds: (induction) 0.1 mg/kg IV (t1⁄2 = ~ 65 min)
0.8-1.7 mcg/kg/min drip
onset: 2-3 min
duration: 45-90 min
Isoproterenol
drip:
when would you use:
drip: 1-20mcg/min
when: Third degree heart block to keep CO up (which will maintain BP).
This is a temporary fix while you pace the heart or whatever else is needed.
Milrinone:
Bolus:
Drip:
Loading dose of 25-50 mcg/kg over 10 minutes, then infusion at 0.125–0.75 mcg/kg/min. Avoid in severe hypotension due to vasodilatory effects
increase cAMP and HR, contractility
Metroprolol
dose:
duration:
Intravenous (IV) Dose:
Initial Dose: 1-5 mg IV bolus, administered slowly
Titration: Repeat every 5 minutes as needed, up to a maximum of 15 mg in most settings.
Onset:
1-2 minutes after IV administration.
Duration:
duration: 5-8 hours for IV doses (depending on patient metabolism and other factors).
Clevedipine
bolus:
Onset:
Duration:
Drip:
CCB
Bolus: 50-100mcg
Onset: 1 min
Duration: 5- 15 min
drip: 1-16mg/hr
ultra short acting
Nicardipine (Cardene)
Use:
drip:
duration:
Use: HTN and angina
drip: 1-15mg/hr
Titration: Increase by 2.5 mg/hour every 5-15 minutes to achieve the desired blood pressure.
Duration:
The effects last 15-30 minutes after discontinuation, depending on the duration of infusion.
Use Cases in the OR Setting
Intraoperative Hypertension:
Effective for rapid control of elevated blood pressure during surgery, especially in neurosurgical, vascular, or cardiac cases.
Preferred when precise and titratable blood pressure management is needed.
Postoperative Hypertension:
Used to stabilize blood pressure in the immediate postoperative period, particularly in high-risk patients.
Hypertensive Emergencies:
Nicardipine is a go-to agent for controlling hypertensive crises due to its rapid action and titratability.
Neurosurgery:
Useful in managing blood pressure to prevent secondary brain injury (e.g., during aneurysm clipping or craniotomies).
Cardiac Surgery:
Helps reduce afterload without significant myocardial depression, which is ideal for patients with impaired cardiac function.
Diltiazem (Cardizem) CCB
Indications:
drip:
drip: 5-15 mg/hr; titrate by 5mg/hr
indications: Control rapid ventricular response from Afib/flutter, PSVT, HTN, Harvesting radial grafts (CABAG- stops arterial spasm), Angina (PO)
ONLY USE IF VENTRICULAR RATE > 100
Methadone
dose:
duration:
dose: 0.2-0.3mg/kg
duration: 1-2 days, NMDA effects
Dexamethasone (Decadron)
dose:
Peds:
onset:
duration:
dose: 4-8mg
Peds: 0.2-0.5mg/kg (max 20mg)
onset: 10-30 min
duration: 2-10 hrs
antiemetic steroidal, anti-inflammatory.
Halperidol
dose:
use:
dose: 1-5mg
use: antiemetic
anti-DA, QT prolongation
Olanzapine
dose:
dose: 2.5-10mg PO
anti-DA
Aprepitant (Emend)
dose:
onset:
NK1 Neurokinin Receptor Antagonist
dose: 40mg more for chemo like 100mg
onset: give 3 hours before induction
constraceptives will not work as well for 28 days
SPINAL
Bupivacaine 0.5-0.75%
dose (T10)
dose(T4)
onset:
duration:
T10: 10-15mg @ 0.75% solution would be 1.3-2cc
T4: 12- 20mg @ 0.75% solution would be 1.6- 2.6 cc
onset: 4-8 min
duration: 130-220 min + 20-50% w/ epi
SPINAL
Ropivacaine 0.5-1%
dose (T10):
dose(T4):
onset:
duration:
T10: 12-18 mg @ 0.5% solution would be 2.4-3.6cc
T4: 18-25mg @ 0.5% solution would be 3.6-5cc
onset: 3-8 min
duration 80- 210 min ( less than bupivacaine (slightly less lipophilic)
Common Adjuncts for Spinal Anesthesia
Common Adjuncts for Spinal Anesthesia
Epinephrine: 0.1-0.2mg
Morphine : 50-300mcg (Max 300)
Fentanyl: 10-25mcg
Peak 2hr & 6-12hr: only for postop pain. Must monitor 24 hrs due to risk of delayed respiratory depression
Clonidine: 30- 60 mcg (caution black
box warning for maternal hypoTN and bradycardia)
Common mix: 2.5-15 mg 0.5-0.75% hyperbaric bupiv +/- 10-15 mcg fentanyl +/- 100-150 mcg morphine +/- 50-100 mcg epinephrine
Epidural
Thoracic (T4-T7):
Abdominal(T7-T12):
Lower Abdominal, C-Section, LE (L1-L5):
T4-T7: PCEA (bolus/lockout/rate/hr limit)
0.1% bupiv 5 mL/10 min/8 mL/32 mL
T7-T12: PCEA (bolus/lockout/rate/hr limit)
0.1% bupiv 5 mL/10 min/8 mL/32 mL
L1-L5: PIB 0.0625-0.1% bupiv + fentanyl 5-10 mL/30 min
PCEA 5-10 mL/10-15 min
Defasciculating Dose of Rocuronium
Dose: 0.03–0.06 mg/kg IV (ideal body weight).
For an average 70 kg patient, this equates to 2-4 mg IV.
This is the way to go over awake fiber-optics in penetrating eye injury according to studies apparently.
