Department of Anaesthesia University of Cape Town Additional Information Disclaimer: The information is supplied in good faith and is believed to be accurate at the time of editing, but errors may be present. The contributors, editors, Dept. of Anaesthesia and University of Cape Town do not accept liability for any consequences arising from the information supplied. It is incumbent on the reader to verify the accuracy and suitability of any information prior to clinical use. Essential drugs & doses Volatiles MAC (%) Induction agents mg kg-1 Halothane 0,75 Propofol Adults 1,5 - 2,5 (1 - 1,5 in elderly) Enflurane 1,7 Children 2,5 - 3,0 Isoflurane 1,2 Thiopentone 3 - 5 Sevoflurane 2 Etomidate 0,2 - 0,3 Desflurane 6 Ketamine Induction IV 1 - 2 N2O 105 IM 5 - 10 Analgesia IV 0,2 - 0,4 Muscle relaxants mg kg-1 (adult bolus) Opiates -1 Suxamethonium 1 - 2 (100) Morphine 0,1 mg kg -1 Pancuronium (Pavulon®) 0,1 (6) Fentanyl (Sublimaze®) 1- 3 µg kg -1 Vecuronium (Norcuron®) 0,1 (6) Sufentanil (Sufenta®) 0,1 - 0,2 µg kg -1 -1 Rocuronium (Esmeron®) 0,6 - 1,0 (50) Remifentanil (Ultiva®) 0,05 - 0,5 µg kg min 50 mg ml-1 Atracurium (Tracrium®) 0,5 (30) -1 Cisatracurium (Nimbex®) 0,15 (10) Alfentanil (Rapifen®) 10 µg kg up to 30 µg kg-1 (To ↓ intubation response) Mivacurium (Mivacron®) 0,15 (10) -1 Repeat doses are 20 % of the original dose Tilidine (Valoron®) drops 1 mg kg (1 drop = 2,5 mg) Reversal of muscle relaxants Antagonist to opiates -1 -1 -1 Neostigmine with either 40 µg kg (2,5 mg) Naloxone (Narcan®) 2 - 10 µg kg dose -1 Glycopyrrolate (Robinul®) 8 µg kg (0,4 - 0,6 mg) 0,4 mg amps Titrate to effect and follow with -1 -1 -1 if necessary or 20 µg kg (1 - 1,2 mg) Dilute to 10 - 20 ml 10 µg kg hr Atropine Oral premedicants mg kg-1 IV sedatives mg kg-1 Midazolam (Dormicum®) Kids 0,5 max. 7,5 mg Midazolam 0,1 - 0,3 Adults 7,5 - 15 mg Diazepam 0,1 - 0,2 Diazepam (Valium®) 5 - 10 mg (Total dose) Antagonist to benzodiazepines Trimeprazine (Vallergan®) 2 - 3 (Children > 1 yr) Flumazenil (Anexate®) 0,2 mg q 1 min max. 1 mg Repeat q 20 min x 3 Droperidol (Inapsin®) 0,1 - 0,2 max. 5 mg All 2 hours pre-op., except Midazolam - 30 min pre-op. Resuscitation Bolus Local anaesthetics Max. safe dose mg kg-1 Ephedrine 5 - 10 mg (Titrate to effect) Lignocaine (Xylocaine®) 3 (or 7 with adrenaline) Phenylephrine 50 μg (Titrate to effect) Bupivacaine (Marcaine®) 2- 2,5 (Paediatrics) Adrenaline Arrest 1 mg q 4 min Local anaesthetic induced cardiac arrest - ® -1 CVS collapse 50 - 100 μg (Ttrate) Intralipid 20 % 1,5 ml kg and follow with -1 -1 0,25 ml kg min infusion Atropine Arrest 1 mg q 4 min max. 3 mg Bradycardia 0,2 - 0,5 mg (Titrate) Additional information Anti-emetics Paeds (Adult) Antibiotics Paeds (Adult) -1 -1 Dexa- / Beta- methasone 0,15 mg kg (8 mg) Cefazolin (Kefzol®) 50 mg kg max 1 g(1 - 2 g) -1 Droperidol (Inapsin®) 15 μg kg (0,5 - 1 mg) Co-amoxiciclav (Augmentin®) (1,2 g) -1 -1 Ondansetron (Zofran®) 0,1 mg kg (4 / 8 mg) Ampicillin 50 mg kg (1 g) -1 -1 Granisetron (Kytril®) (1 mg) Gentamycin 5 mg kg (5 mg kg ) -1 Metoclopramide (Maxolon®) (10 mg) Metronidazole (Flagyl®) 7,5 mg kg (500 mg) -1 Prochlorperazine (Stemetil®) (12,5 mg IMI)Clindamycin 20 mg kg (600 mg) For penicillin-allergic patients All IV except for Prochlorperazine - IM Antidysrhythmics Diuretics -1 -1 Lignocaine 1 - 2 mg kg Furosemide (Lasix®) 0,1 - 0,6 mg kg -1 Amiodarone (Cordarone®) 300 mg loading over 1 hr then Mannitol 20 % & 25 % 0,25 g kg -1 900 mg day infusion Adenosine 6 mg rapidly – If no effect, repeat after 1 - 2 min rapidly 12 mg Non-opiate Analgesics Verapamil (Isoptin®) 2,5 - 10 mg slowly (Titrate) NSAIDs Paeds (Adult - mg) -1 Ibuprofen (Brufen®) 5- 10 mg kg (200 - 400) Miscellaneous -1 Diclofenac (Voltaren®) 1- 2 mg kg PR (50) slowly over 1 min and follow -1 Oxytocin 2,5 iu Indomethacin (Indocid®) 0,5 - 1 mg kg PR(25 - 50) with infusion if needed -1 ® -1 10 - 20 iu l (Titrate to effect) Ketorolac (Toradol ) 0,5 mg kg IV (30 IV) ® -1 Ergometrine 100 μg slowly over 5 min or 200 Parecoxib (Rayzon ) 1 mg kg IV (40 IV) - 500 μg IM Paracetamol Sodium citrate 30 ml PO (30 min pre-op) Oral / IV 20 / 15 mg kg-1 (1 g) -1 Ranitidine (Zantac®) 300 mg PO (2 hr pre-op) Rectal 40 mg kg Bronchospasm Hypertension ® ↑ Volatiles All are bronchodilators Labetalol (Trandate ) 5- 10 μg bolus -1 ® -1 Salbutamol 0,2 - 1,2 mg hr Esmolol (Breviblock ) 0,2 - 0,5 mg kg bolus -1 (5 mg in 50 ml = 100 μg ml -1 -1 MgSO4 30 - 60 mg kg Rate = 2 - 12 ml hr ) -1 Hydrallazine (Nepresol®) 0,5 - 1 mg min -1 Ketamine 0,1 - 1 mg kg (25 mg in 200 ml N Saline) -1 -1 Propofol 10 - 20 mg bolus Glyceryl trinitrate 0,5 - 2 µg kg min (50 mg in 50 ml = 1 mg ml-1 Hydrocortisone 100 mg -1 Rate = 2 - 8 ml hr ) Essential equipment ETT sizes Length cm LMAs Vol Size mm Oral Nasal Size ml Paediatrics Premature 2,0 - 2,5 5 - 7 6 - 9 Infants < 5 kg 1 4 Term - 6 / 12 3,0 - 3,5 8,5 - 10 10,5 - 12 Infants 5 - 10 kg 1 ½ 7 6/ 12 - 1 year 3,5 - 4,0 10 - 11 12 - 14 Children 10 - 20 kg 2 10 1- 2 years 4,0 - 4,5 11 - 12 14 - 15 Children 20 - 30 kg 2 ½ 14 2- 4 years 4,5 - 5,0 12 - 14 15 - 17 Children / Adults > 30 kg 3 20 4 - 6 years 5,0 - 5,5 14 - 15 17 - 19 Adult females > 50 kg 4 30 6 - 8 years 5,5 - 6,0 15 - 16 19 - 20 Adults > 75 kg 5 40 8- 12 years 6,0 - 7,0 16 - 18 20 - 22 Adult males > 100 kg 6 50 Adults Females 7,0 - 7,5 18 - 22 24 - 26 Males 7,5 - 8,0 20 - 24 25 - 28 Formula: (Age / 4) + 4 (Age / 2) + 12 (Age / 2) + 15 2 Additional information Ventilation and breathing circuits Ventilator settings Fresh gas flows Spontaneous Controlled -1 Tidal volume 6 - 8 ml kg Magill system 1 x MV 2,5 x MV -1 Respiratory rate Adult 10 - 15 b min Bains system 2 - 3 x MV 1 - 1,5 x MV -1 Neonate 30 b min T-piece system 3 x MV 1,5 x MV Children < 6 yr or < 20 kg PEEP 3 - 10 hPa Minute volume Adult 70 ml kg-1 min-1 I : E ratio (R R dependant) 1 : 1,5 to 1 : 20 Inspiratory time 0,5 - 1,5 sec Premature - adult Intra-operative fluids Crystalloids + colloids Blood products -1 -1 Paediatric 4 : 2 : 1 rule 4 ml kg for 1st 10 kg - Packed cells 4 ml kg (↑ Hb 1 g dl-1) -1 -1 for maintenance 2 ml kg for next 10 kg - Whole blood 8 ml kg (↑ Hb 1 g dl-1) -1 e.g.: 27 kg child = 67 ml hr -1 -1 1 ml kg for each kg > 20 kg - FFP 10 - 30 ml kg and 16 kg child = 52 ml hr-1 -1 body weight Platelets 1 ml kg (↑ platelets by 5 000) Rehydration of deficit 1,0 ml kg-1 x hours NPO Maintenance 1,0 ml kg-1 hr-1 -1 -1 Replacement of 0 - 8 ml kg hr operative losses (depending on surgery) Replacement of blood losses 10 % loss Crystalloids (3 : 1) 10 - 20 % loss Colloids (1 : 1) Blood or clear colloids depends on starting Hb and transfusion trigger for patient Useful web pages Department of Anaesthesia at UCT .. www.anaesthesia.uct.ac.za/anaesuct.htm South African Society of Anaesthetists ...................................... www.sasaweb.com Resuscitation Council of South Africa ........................................ www.resuscitationcouncil.co.za World Anaesthesia Society (Updates in Anaesthesia) .............. www.worldanaesthesia.org The Association of Anaesthetists of Great Britain & Ireland ... www.aagbi.org Royal College of Anaesthesia ...................................................... www.rcoa.ac.uk Anaesthesia Education Website (Australian) ............................. www.anaesthesiamcq.com Australia and New Zealand College of Anaesthetists ............... www.anzca.edu.au The American Society of Anesthesiologists .............................. www.asahq.org GASnet Anesthesiology Homepage (virtual textbook) ............. anestit.unipa.it/HomePage.html New York School of Regional Anaesthesia ................................ www.nysora.com European Society of Regional Anaesthesia ............................... www.esraeurope.org 3 Additional information Guide to pre-operative investigations Test → Ward U / Cr & Blood FBC CXR ECG Urine PFTs Other Patient category ↓ Hb Elecs sugar Healthy pt. for minor surgery + Age > 60 yr or major surgery + + + Surgical blood loss > 600 ml + Diabetes, well-controlled, + + + < 40 yr and minor surgery Diabetes, well-controlled, + + + + + > 40 yr or major surgery Major abdominal surgery + Major vascular surgery + + + + + + Cardiovascular disease + + + + Limiting respiratory disease + + + + Renal impairment + + + + Liver disease with LFTs, INR, + + + + + + right heart failure Albumin Thoracotomy + + + Morbid obesity BMI > 35 + + + + + + Steroid (pred > 10 mg day-1) + + Females of child-bearing age + Pregnancy Additional notes: All cases must be fully clerked. Further tests may be necessary on clinical grounds. CXRs < 1 year old need not be repeated unless there is a change in symptoms ECG < 6 months old need not be repeated if symptoms stable. U / Cr & Elecs need not be repeated if normal in previous 3 months & no new diuretics / therapy.