✓
Pre-Induction Checklist — MSMAID
Gelb et al., Anesthesiology 2018 · WFSA/WHO endorsed
M
Machine
Complete standard machine check (APSF protocol). Backup ventilation + O₂ confirmed accessible.
S
Suction
Functional and within reach. Yankauer immediately available.
M
Monitors
SpO₂, NIBP, 3-lead ECG, EtCO₂, Temperature (standard). Adjuncts per case: arterial line, BIS/entropy, NMT (quantitative strongly recommended — ASA 2023).
A
Airway
Confirm primary + backup plan. Mask · ETT/LMA · VL + DL · bougie · stylet · tape. Optimize: sniff position, ramping PRN.
I
IV Access
Adequate gauge, number, flow confirmed. Lines flushed and labeled.
D
Drugs
Standard induction agents drawn + ASTM-labeled. Emergency meds accessible: epi, atropine, sux, vasopressors, Intralipid (if blocks planned).
Always know who to call for help
💧
Maintenance Fluids — 4-2-1
Holliday-Segar Rule
4 mL/kg/hr → first 10 kg2 mL/kg/hr → next 10 kg
1 mL/kg/hr → each kg >20 kg
22 kg40+20+2 = 62 mL/hr
70 kg adult40+20+50 = 110 mL/hr
🩸
Avg Blood Volume
Premature90–100 mL/kg
Term neonate80–85 mL/kg
Infant 1 yr75 mL/kg
Child70–75 mL/kg
Adult ♂70 mL/kg
Adult ♀65 mL/kg
ABL = EBV × (Hgb₀−Hgb_min) / Hgb₀
⏱
NPO Guidelines — ASA 2023
| Intake | Fast (hr) | Notes |
|---|---|---|
| Clear liquids | 2 | Water, pulp-free juice, black coffee, clear tea, carbonated drinks. Carbohydrate-containing clear liquids (e.g. Gatorade, maltodextrin drinks) included — reduce hunger/thirst vs. water alone; no added aspiration risk (ASA 2023) |
| Breast milk | 4 | Infants |
| Infant formula | 6 | |
| Non-human milk / light meal | 6 | Toast + clear liquid = light meal |
| Full / fatty meal | 8 | May need longer; clinical judgment |
| Chewing gum | No hold | ASA 2023: no evidence of increased aspiration risk; proceed per standard NPO. Inform patient to avoid swallowing excess saliva. |
| GLP-1 agonists (semaglutide, tirzepatide, etc.) | ⚠ See note | ASA 2023: Hold 1 day (daily) or 1 week (weekly) before elective procedures + standard fasting. SPAQI 2025 update: GI symptoms (nausea, vomiting, bloating) → treat as full stomach regardless of fasting; consider gastric US (POCUS) preop. Discontinuation may worsen glycemic control — individualize with endocrinology. No aspiration risk reduction if held <4–5 half-lives. |
GLP-1 Agonists (2024 Update)
Semaglutide, liraglutide, tirzepatide — ↓ gastric motility. Consider extended NPO or 24-hr hold before elective cases. Assess for gastroparesis risk. Point-of-care US gastric assessment emerging option. Individualize.Carbohydrate Loading — Endorsed ASA 2023
Clear carbohydrate drink (e.g., 50 g CHO) up to 2 hr pre-op: ↓insulin resistance, ↓PONV, ↓anxiety. Appropriate for elective non-diabetic adults.🧮
Drug Concentration Math
% → mg/mL% × 10
1% = 1:10010 mg/mL
0.25% bupiv2.5 mg/mL
0.5% bupiv5 mg/mL
0.75% bupiv7.5 mg/mL
2% lido20 mg/mL
1:200,000 epi5 mcg/mL
1:10,000 epi0.1 mg/mL
1:1,000 epi1 mg/mL
🫁
MAC Values (%)
| Agent | Adult | >60yr |
|---|---|---|
| Sevoflurane preferred | 2.0–2.6 | 1.4–1.7 |
| Isoflurane | 1.2 | 1.0 |
| Desflurane ⚠ Phasing out | 6.0–7.3 | 5.2 |
| Desflurane: GWP ~2500× CO₂; many institutions eliminating. Sevoflurane preferred. AHA 2025 endorses desflurane phase-out for climate/sustainability. | ||
| N₂O | 105% (adjunct only) | |
MAC awake ≈ 0.3 · MAC BAR ≈ 1.3–1.5 · N₂O ≈ 0.5 MAC equiv
Desflurane
~20× higher GWP vs sevo. FDA removed mask induction indication 2023. Use where available; favor alternatives.Airway Ultrasound
Difficult Airway Society 2015 · ASA 2022CRICOTHYROID MEMBRANE IDENTIFICATION
Technique
Linear probe, transverse, midline neck
Slide caudally from thyroid cartilage; CTM = hyperechoic flat line between thyroid and cricoid; mark before induction in anticipated difficult airway
Thyroid cartilage
Hypoechoic paired structures, inverted V
Acoustic shadow posterior; slide inferiorly to find CTM
CTM mark
Skin mark with pen before positioning
Critical for FONA (scalpel-bougie technique); identify in any predicted or known difficult airway
ETT CONFIRMATION
Tracheal ring sign
Transverse at suprasternal notch
Single ring with ETT = tracheal; two rings (snow globe sign) = esophageal — more sensitive than capnography in low-flow states
Bilateral lung sliding
Anterior chest bilaterally post-intubation
Bilateral sliding = bilateral ventilation; unilateral = mainstem → withdraw 1–2 cm; faster than auscultation in noisy ORs
Gastric ultrasound (pre-induction)
Grade 0 = empty bilaterally (antral CSA <340 mm²) → standard induction; Grade 1 = clear fluid one position only → consider modified RSI; Grade 2 = solid content or bilat clear fluid → RSI or awake; subcostal view, right lateral decubitus or supine, curvilinear probe
Neuraxial Ultrasound
ASRA 2023Paramedian sagittal oblique
Curvilinear, lateral to midline, cephalad tilt
Identify laminae (saw-tooth pattern), LFD complex (lig. flavum-dura); count levels from sacrum cephalad
Transverse interlaminar
Midline transverse between spinous processes
Spinous process acoustic shadow at top; identify interspinous space; measure depth skin to LFD complex
Depth to epidural space
Skin to LFD complex on US = Tuohy depth
Typical 4–8 cm; varies widely; critical in obese patients; reduces needle passes
Level identification
Count from sacrum (L5-S1 junction)
Tuffier's line ≈ L4; US significantly more accurate than palpation in obese / scoliotic / prior spine surgery patients
OB epidural pre-scan
Pre-procedure scan reduces needle attempts and complications; mark optimal site before positioning; high-value in difficult anatomy (obesity BMI >35, scoliosis, prior instrumentation)
Cardiac POCUS — Golden Spiral (5 Views)
ASE 2022 · SCA 2023PRE-INDUCTION ASSESSMENT
LVEF (eyeball)
Good (>55%) / moderate (30–55%) / poor (<30%); EPSS >8 mm = reduced EF; guides induction agent choice and dose titration
RWMA
Regional wall motion abnormality — hypo/akinesis in coronary territory; document pre-operatively; may change surgical or anesthetic plan
Pericardial effusion
RV diastolic collapse + RA systolic collapse + IVC plethora = tamponade physiology; absolute concern for neuraxial if hemodynamically significant
INTRAOPERATIVE HYPOTENSION DIFFERENTIAL
Hypovolemia
Hyperdynamic LV, kissing walls in systole, flat/collapsing IVC <1.5 cm — treat: volume
Vasodilation
Hyperdynamic LV, flat IVC — distributive pattern — treat: norepinephrine / phenylephrine
Cardiogenic
Poor EF, dilated LV, plethoric IVC >2.5 cm, B-lines — treat: inotropes, reduce volatile agent
Obstructive
RV strain (D-sign, McConnell), tamponade (effusion + RV collapse), PTX (absent sliding) — treat: cause
| IVC Diameter | Collapsibility | Interpretation |
|---|---|---|
| <1.5 cm | >50% | Hypovolemia — volume responsive |
| 1.5–2.5 cm | >50% | Borderline / likely responsive |
| 1.5–2.5 cm | <50% | Euvolemic |
| >2.5 cm | <50% | Elevated RAP / volume overload |
Vascular Access POCUS
Internal jugular
Short-axis transverse at neck
IJ lateral to carotid; compressible = vein; confirm wire in vein before dilation; dynamic tip visualization reduces complications
Subclavian / axillary
Infraclavicular, in-plane long-axis
Axillary vein medial to artery; real-time guidance reduces PTX risk vs landmark technique
Radial artery
Short-axis or long-axis at wrist
Pulsatile, non-compressible; long-axis improves first-pass success; high value in vasoconsticted/hypotensive patients
Femoral access
CFV medial to CFA at inguinal crease
Short-axis; compress to differentiate vein from artery; Doppler confirms venous flow; avoid below femoral bifurcation
Lung Ultrasound — OR Context
| Finding | Suggests | Action |
|---|---|---|
| Bilateral sliding + A-lines | Normal ventilation | Continue monitoring |
| Absent sliding (unilateral) | Mainstem ETT or PTX | Withdraw ETT 1–2 cm or needle decompression |
| B-lines bilateral | Pulmonary edema | Diuresis, reduce fluids, increase PEEP |
| Barcode sign (M-mode) | PTX confirmed | Decompress; find lung point to localize |
| Absent sliding post-CVC | Iatrogenic PTX | Chest tube vs needle per hemodynamics |
One-lung ventilation
Confirm absent sliding on operative side, present on ventilated side
More reliable than auscultation in noisy OR; dynamically verify DLT or bronchial blocker position
Post-intubation PTX check
After CVC or high-risk intubation
Bilateral anterior chest; absent sliding = PTX until proven otherwise; M-mode barcode confirms
⚠
Contraindications to Neuraxial
Absolute
- Patient refusal
- Coagulopathy: INR >1.5 · Plt <80×10⁹/L (ASRA 2023)
- Active therapeutic anticoagulation — see ASRA intervals below
- Skin infection at injection site
- Elevated ICP / mass lesion (herniation risk)
- Lack of resuscitation equipment or monitoring
Relative
- Hypovolemia — stabilize first
- Pre-existing neurologic disease — document baseline
- Severe AS/MS (↓ SVR → ↓ CO)
- Systemic infection (bacteremia) — individualize risk/benefit
- Indeterminate surgical duration
ASRA 2023 — Anticoagulant Hold Times (Neuraxial / Deep Block)
| Drug | Hold Before | Resume After |
|---|---|---|
| UFH prophylactic SC | 4–6 hr + nl aPTT | 1 hr |
| UFH therapeutic IV | 4–6 hr + nl aPTT | 1 hr |
| LMWH prophylactic | 12 hr | 4 hr |
| LMWH therapeutic | 24 hr | 4 hr |
| Warfarin | 5 days; confirm INR ≤1.5 before block (ASRA 5th ed) | After catheter removal |
| Dabigatran | 72–96 hr (CrCl-based); residual level <30 ng/mL acceptable | 6 hr |
| Rivaroxaban | 72 hr (high dose) / 24 hr (low); anti-Xa ≤0.1 IU/mL acceptable (ASRA 2025) | 6 hr |
| Apixaban | 72 hr (high) / 36 hr (low); anti-Xa ≤0.1 IU/mL acceptable (ASRA 2025) | 6 hr |
| Aspirin | No hold required | Immediately |
| Clopidogrel | 7 days | After catheter removal |
| Prasugrel | 7–10 days | 6 hr |
| Ticagrelor | 5–7 days | 6 hr |
| Cangrelor (IV) | 3 hr (ASRA); short-acting GP IIb/IIIa-like; hold infusion before block | 8 hr |
ASRA 5th ed (2022) + 2025 update: anti-Xa level calibrated to specific DOAC acceptable as alternative to fixed hold times. Plt threshold for neuraxial: ≥80×10⁹/L (ASRA 2023).
💉
Spinal Anesthesia — Agents
| Agent | Dose (mg) | Plain (min) | +Epi (min) | Notes |
|---|---|---|---|---|
| Chloroprocaine 3% short/amb | 30–60 | 60–80 | N/A | Fastest offset; ambulatory preferred |
| Bupivacaine 0.5% isobaric | 8–15 | 90–120 | 100–150 | Standard workhorse |
| Bupivacaine 0.75% hyperbaric OB | 8–12 | 90–120 | 120–180 | C/S standard: 10–12 mg typical |
| Ropivacaine 0.5–0.75% | 15–25 | 100–150 | — | ↓ cardiac toxicity vs bupiv |
| Tetracaine 0.5% | 6–20 | 90–120 | 120–240 | Long procedures |
| Lidocaine 2% TNS risk | 40–80 | 60–90 | 70–100 | Avoid spinal — use chloroprocaine instead |
Intrathecal Adjuncts
| Drug | Dose | Effect / Notes |
|---|---|---|
| Fentanyl PF | 10–25 mcg | Intraop analgesia; reduces LA dose needed |
| Morphine PF | 50–300 mcg | Postop pain; delayed respiratory depression 6–18 hr → monitor 18–24 hr |
| Hydromorphone PF | 50–100 mcg | Alternative to morphine; shorter monitoring window ~12 hr |
| Epinephrine | 100–200 mcg | ↑ duration 30–50%; use as test dose component |
| Clonidine | 15–75 mcg | ↑ duration; sedation; ↓ shivering. ⚠ BBW maternal hypotension/bradycardia |
| Dexmedetomidine | 3–10 mcg | Off-label; ↑ duration + sedation; hypotension/bradycardia risk |
Standard C/S Spinal Mix
Hyperbaric bupivacaine 0.75% 10–12 mg + fentanyl PF 10–15 mcg + morphine PF 100–150 mcg ± epi 100–200 mcg↓BP
Spinal Hypotension
Prevention
Co-load 500–1000 mL crystalloid at block placement (not pre-load). Preemptive phenylephrine infusion 25–50 mcg/min OR norepinephrine 0.05–0.1 mcg/kg/min started at block. Ondansetron 4 mg IV reduces vasovagal component.Treatment
- Phenylephrine 50–200 mcg IV bolus → infusion 25–100 mcg/min
- Norepinephrine 5–10 mcg IV bolus → infusion 0.05–0.1 mcg/kg/min — OB preferred (↓ reflex brady vs phenylephrine)
- Ephedrine 5–10 mg IV — prefer if bradycardia + hypotension coexist
- Atropine 0.5 mg IV for isolated bradycardia; low threshold for epi
- IV fluid bolus if hypovolemic component
- LUD if parturient
2024 OB Update
Norepinephrine now equivalent or superior to phenylephrine for OB spinal hypotension — better HR maintenance, similar neonatal outcomes. Consider as first-line where available.📋
Epidural — Levels & Dosing
| Indication | Level | Regimen |
|---|---|---|
| Thoracic / cardiac | T4–T6 | PCEA: 0.0625–0.1% bupiv + fentanyl 2 mcg/mL; 5 mL bolus/10 min lockout/8 mL/hr basal |
| Upper abdomen | T7–T10 | Same above |
| Lower abdomen / C/S / LE | T10–L2 | PIB 0.0625–0.1% bupiv 5–10 mL/30 min or PCEA 5 mL/10 min lockout |
| Labor analgesia | T10–L1 | PCEA: 0.0625% bupiv + fentanyl 2 mcg/mL; 5–8 mL bolus/15 min lockout/6–10 mL/hr basal |
Urgent C/S Top-Up from Existing Labor Epidural
2% lidocaine + epi 1:200,000 → 15–20 mL in 5 mL increments q3–5 min. Add NaHCO₃ 1 mEq/10 mL to ↑ speed. Onset 10–15 min. Alt: 0.5% bupivacaine 15–20 mL.PDPH Management
Conservative 24–48 hr: hydration, caffeine 300 mg PO. EBP gold standard: 15–20 mL autologous blood; 1 hr flat after. Cosyntropin 1 mg IV single dose — emerging evidence.💊
Local Anesthetic Properties — ASRA 2023
| Agent | Class | Onset | Plain (hr) | +Epi (hr) | Max Plain (mg/kg) | Max +Epi (mg/kg) |
|---|---|---|---|---|---|---|
| Lidocaine 1–2% | Amide | Fast | 1–1.5 | 2–3 | 4.5 (max 300 mg) | 7 (max 500 mg) |
| Bupivacaine 0.25–0.5% | Amide | Mod | 3–8 | 4–12 | 2.5 (max 175 mg) | 3 (max 225 mg) |
| Ropivacaine 0.2–1% | Amide | Mod | 3–8 | 4–10 | 3 (max 200–300 mg) | Similar |
| Levobupivacaine 0.25–0.75% | Amide | Mod | 3–8 | 4–12 | 2.5 (max 150 mg) | 3 (max 225 mg) |
| Mepivacaine 1–2% | Amide | Mod | 2–3 | 3–4 | 5 (max 400 mg) | 7 (max 550 mg) |
| Chloroprocaine 2–3% | Ester | Fast | 0.5–1 | 1–1.5 | 11 (max 800 mg) | 14 (max 1000 mg) |
| Procaine 1–2% | Ester | Fast | 0.5–1 | 0.75–1.5 | 7 (max 500 mg) | 9 |
| Tetracaine 0.5% | Ester | Slow | 3–6 | 4–8 | 1.5 | 2.5 |
| Prilocaine 2–4% | Amide | Fast | 1–3 | 2–4 | 6 (max 400 mg) | 8 |
⚠ Maximum Dose Caveats
Highly site-dependent. Intercostal = highest systemic absorption. Epidural > brachial plexus > femoral > sciatic. Reduce by 25–30% in elderly, hepatic failure, cardiac disease, low protein. These are absolute maximums — clinical doses are often much lower.Block Duration Adjuncts
Dexamethasone 8 mg IV (systemic > perineural for duration) · Dexmedetomidine 0.5–1 mcg/kg perineural (off-label; ↑ duration 3–6 hr) · Buprenorphine 0.3 mg perineural · Clonidine 75–150 mcg perineural (↓ BP risk)☠
Vascularity Hierarchy — LAST Risk
Highest → lowest systemic absorption:
Intercostal
→
Paracervical
→
Epidural
→
Brachial plexus
→
Femoral / Sciatic
→
Subcutaneous
→ See LAST tab for full treatment protocol
🚨 LOCAL ANESTHETIC SYSTEMIC TOXICITY — ASRA 2023
Delayed onset up to 60 min post-injection. Maintain vigilance. Stock Intralipid wherever regional anesthesia is performed.⚡
CNS Signs
- Perioral / tongue numbness
- Metallic taste, tinnitus
- Lightheadedness, visual Δ
- Agitation, confusion, slurred speech
- Muscle twitching → seizures
- Coma, respiratory arrest
💓
CV Signs
- Hypertension (early)
- QRS widening, PR prolongation
- Bradycardia, heart block
- Hypotension, ventricular arrhythmias
- VT/VF — resistant to std ACLS
- Cardiac arrest
Bupivacaine Warning
CV collapse may be FIRST sign — minimal CNS prodrome. Delayed onset >5 min reported with large depot injections. Ultrasound guidance reduces but does NOT eliminate LAST risk.🚑
LAST Treatment Algorithm — ASRA 2023
1
Stop Injection + Call for Help
Immediately stop LA. Announce LAST. Activate code team. Notify nearest ECMO center early if arrest seems likely.
2
Airway — 100% O₂
Maintain patent airway. 100% O₂ via NRB or BVM. Intubate if necessary. Hypoxia + acidosis ↑↑ cardiotoxicity. Avoid propofol for intubation if hemodynamically compromised.
3
Seizure Control — Benzos First
Benzodiazepines preferred. Small propofol doses acceptable if hemodynamically stable only.
Midazolam: 1–5 mg IV (titrate)
Lorazepam: 2–4 mg IV
Propofol: 0.5–1 mg/kg IV — only if CV stable
Phenobarbital: 15–20 mg/kg IV if refractory
Lorazepam: 2–4 mg IV
Propofol: 0.5–1 mg/kg IV — only if CV stable
Phenobarbital: 15–20 mg/kg IV if refractory
4
Intralipid 20% — Start Immediately
Do NOT delay for cardiac arrest. Use ideal body weight. Max cumulative ~12 mL/kg.
Bolus: 1.5 mL/kg IBW IV over 2–3 min
Infusion: 0.25 mL/kg/min (↑ to 0.5 mL/kg/min if refractory)
Repeat bolus × 1–2 for refractory arrest
70 kg example: ~105 mL bolus → ~18 mL/min infusion
Max cumulative: ≤12 mL/kg (≈ 840 mL for 70 kg)
Infusion: 0.25 mL/kg/min (↑ to 0.5 mL/kg/min if refractory)
Repeat bolus × 1–2 for refractory arrest
70 kg example: ~105 mL bolus → ~18 mL/min infusion
Max cumulative: ≤12 mL/kg (≈ 840 mL for 70 kg)
5
Cardiac Arrest — Modified ACLS
Key deviations from standard ACLS:
✅ Epinephrine: ≤1 mcg/kg IV boluses (↓ dose — large doses worsen VF + impair lipid resuscitation)
✅ Amiodarone 150 mg IV for refractory VT/VF
✅ Continue Intralipid throughout CPR
✅ Prolonged CPR — 60–90 min; recovery reported
❌ Avoid vasopressin — worsens outcomes in LAST
❌ Avoid Ca-channel blockers / beta-blockers
❌ Avoid lidocaine as antiarrhythmic
✅ Amiodarone 150 mg IV for refractory VT/VF
✅ Continue Intralipid throughout CPR
✅ Prolonged CPR — 60–90 min; recovery reported
❌ Avoid vasopressin — worsens outcomes in LAST
❌ Avoid Ca-channel blockers / beta-blockers
❌ Avoid lidocaine as antiarrhythmic
6
ECMO / Cardiopulmonary Bypass
Refractory arrest despite optimal resuscitation + LET → activate ECMO team. Best outcomes with early institution. ECMO provides circulatory support while LA redistributes.
7
Post-Event Monitoring ≥ 2 hr
Delayed recurrence reported. ICU admission recommended after severe LAST. Intralipid may interfere with: triglycerides, lipase, LFTs, some drug assays.
📋
LAST Prevention
- Use ultrasound guidance — ↓ incidence but does NOT eliminate risk
- Fractionated injection: 3–5 mL increments with 30–60 sec pauses
- Epinephrine test dose each increment: ↑HR >10 bpm = intravascular
- Aspirate before each injection
- Use minimum effective dose and concentration
- Prefer ropivacaine or levobupivacaine over bupivacaine for large-volume blocks
- Stock Intralipid 20% wherever blocks are performed
- High-risk patients: extremes of age, cardiac/hepatic disease, low protein, pregnancy
Intralipid Stocking (ASRA 2023)
20% Intralipid must be immediately available (≤60 sec) wherever large-volume regional anesthesia performed. Typical stocking: 4–6 × 250 mL bags or equivalent. IO administration acceptable if no IV access.Regional Anesthesia — General Principles
Use ultrasound guidance (standard of care). Fractionated injection. Epinephrine test dose. Have Intralipid stocked. Document pre-block neuro exam. New CPT codes effective Jan 1, 2025 for thoracic + lower extremity fascial plane blocks.UPPER EXTREMITY
Interscalene Block
C5–C6 (shoulder/prox humerus) · US-guided
Coverage
- Shoulder surgery, proximal humerus, AC joint
- C5–C6 (C7 variable)
- Spares: ulnar nerve (C8–T1), medial arm
Dosing
Volume15–20 mL
Bupivacaine 0.5%15–20 mL
Ropivacaine 0.5%15–20 mL
Continuous0.2% rop 5–8 mL/hr
Complications
- Phrenic nerve block (100%) → ↓ ipsilateral diaphragm — avoid in severe contralateral lung disease
- Pneumothorax (<1% US-guided)
- Horner syndrome (ptosis, miosis, anhidrosis)
- Recurrent laryngeal nerve block → hoarseness
- Vertebral artery injection (rare)
Notes
US: probe at neck; identify SCM, scalene muscles, C5/C6 roots between ASM/MSM. Low-volume (10 mL) reduces phrenic palsy. Superficial injection target.
Supraclavicular Block
C5–T1 (entire upper extremity below shoulder) · US-guided
Coverage
- Elbow, forearm, wrist, hand surgery
- All trunks of brachial plexus at compact point
- Fastest onset of brachial plexus approaches
Dosing
Volume20–35 mL
Bupivacaine 0.375–0.5%20–30 mL
Ropivacaine 0.5%20–30 mL
Complications
- Pneumothorax (~0.5–1% US-guided)
- Phrenic nerve (50–67% incidence)
- Vascular puncture (subclavian artery)
- Horner syndrome
Notes
US: lateral-to-medial needle approach above clavicle; target corner pocket of subclavian artery. "Corner pocket" injection most reliable. Deep block — high LAST risk site.
Infraclavicular Block
Cords of brachial plexus · Good for catheters · US-guided
Coverage
- Elbow to hand; proximal arm variable
- Lateral, posterior, medial cords
- Excellent catheter site (arm position maintained)
Dosing
Volume25–35 mL
Ropivacaine 0.5%25–30 mL
Continuous0.2% rop 5–8 mL/hr
Notes
US: probe below clavicle medial to coracoid; identify axillary artery. Target: posterior cord (U-distribution around artery). Deep — keep angle steep. Lower pneumothorax risk than supraclavicular.
Complications
- Vascular puncture
- Pneumothorax (rare)
- Phrenic nerve (uncommon)
Axillary Block
Musculocutaneous + terminal branches · Safest brachial approach
Coverage
- Forearm, wrist, hand (medial biceps/elbow variable)
- Four terminal branches: median, ulnar, radial + musculocutaneous separately
Dosing
Volume (total)30–40 mL divided
Per nerve5–10 mL each
AgentBupiv 0.25–0.5% or rop 0.5%
Notes
Safest approach — no pneumothorax, no phrenic nerve. Requires abduction. US: identify axillary artery; four injection approach (inject each nerve separately). Musculocutaneous in coracobrachialis muscle.
Complications
- Vascular puncture / hematoma
- Multiple injections required
Wrist Blocks
Median · Ulnar · Radial (superficial) · Hand surgery
| Nerve | Location | Volume | Coverage |
|---|---|---|---|
| Median | Medial to FCR tendon at wrist crease | 3–5 mL | Palmar thumb, index, middle, radial ring; thenar eminence |
| Ulnar | Medial to FCU, lateral to ulnar artery | 3–5 mL | Ulnar ring, little finger, hypothenar |
| Radial (superficial) | Subcutaneous ring lateral wrist/dorsum | 5–8 mL SC | Dorsal radial hand + thumb |
Use short-acting LA (lido 1–2% or mepivacaine) for outpatient procedures. Digital blocks: 1–2 mL each side of base of digit (avoid epi in digital blocks — controversial but widely practiced).
LOWER EXTREMITY
Femoral Nerve Block / Adductor Canal Block (ACB)
Knee analgesia · Motor-sparing ACB preferred for TKA
Femoral Nerve Block
Volume20–30 mL
AgentBupiv 0.25–0.5% or rop 0.2–0.5%
Continuous0.1–0.2% rop 5–10 mL/hr
⚠ Quad weakness → fall risk. Largely replaced by ACB for TKA.
Adductor Canal Block (Saphenous Block)
Volume15–20 mL
AgentRopivacaine 0.2–0.5%
TargetSaphenous + NIFP in adductor canal
Motor-sparing. Preferred for TKA — ↓ fall risk, allows PT. Often combined with IPACK.
Coverage
- FNB: Anterior knee + anteromedial thigh + medial leg
- ACB: Medial knee + medial leg (saphenous)
- For full knee coverage: ACB + IPACK + local infiltration
IPACK Block
Infiltration between popliteal artery and posterior knee capsule. Posterior knee pain coverage. Volume: 20 mL ropivacaine 0.2%. Target: space between PA and PCK under US.
Sciatic Nerve Block
Posterior thigh/leg/foot · Multiple approaches
Approaches
- Subgluteal — prone or lateral; 20–30 mL; foot/ankle/leg
- Popliteal — prone or lateral; 20–30 mL; foot/ankle (below knee); most common for ankle/foot
- Parasacral — hip/pelvis coverage + sciatic
Popliteal Dosing
Volume20–30 mL
Ropivacaine 0.5%20–25 mL
Bupivacaine 0.25–0.5%20–25 mL
Continuous0.2% rop 5–8 mL/hr
Coverage
- Posterior thigh (to knee), entire leg below knee, dorsal + plantar foot
- Split into tibial + common peroneal at popliteal fossa
- Inject proximal to bifurcation for most reliable block
Notes
Foot/ankle surgery: popliteal sciatic ± saphenous block. Ankle block (5-nerve) alternative for distal foot.
PENG Block / Fascia Iliaca Block
Hip analgesia · Motor-sparing · Hip fracture
PENG Block (Pericapsular Nerve Group)
TargetArticular branches femoral + accessory obturator nerves
Volume20 mL
AgentRopivacaine 0.2–0.375%
LandmarkIliopubic eminence / femoral head junction
Motor-sparing. Preferred for hip fracture, THA analgesia. Allows early PT. Often replaces femoral block for hip.
Fascia Iliaca Block
Volume30–40 mL
AgentBupiv 0.25% or rop 0.2%
CoverageFemoral + lateral femoral cutaneous + obturator (partial)
High-volume required for reliable 3-in-1 coverage. US-guided subfascial injection lateral to femoral nerve.
TRUNCAL
TAP Block — Transversus Abdominis Plane
Abdominal wall analgesia T6–L1 · Multiple approaches
Approaches & Coverage
- Lateral TAP — T10–L1; umbilical-level incisions, lower abdominal, C/S
- Subcostal TAP — T6–T10; upper abdominal, laparotomy
- Posterior TAP — T10–L1 with visceral component; laparoscopic
Dosing (per side, bilateral for most)
Volume / side15–20 mL
Ropivacaine 0.25–0.375%15–20 mL/side
Bupivacaine 0.25%15–20 mL/side
Total bilateral≤3 mg/kg (check LAST max)
Common Indications
- C-section (bilateral) — significant opioid sparing
- Laparoscopic cholecystectomy, appendectomy
- Colectomy, hysterectomy
- Hernia repair
Notes
Somatic analgesia only — does not cover visceral pain. Combine with IV acetaminophen, NSAIDs, ketorolac for optimal multimodal. CPT 64486–64489 (US bundled). Liposomal bupivacaine (Exparel) used by some for extended duration — institutional protocols vary.
Erector Spinae Plane (ESP) Block
Thoracic + abdominal analgesia · Versatile · Emerging evidence
Mechanism
LA injected between erector spinae muscle and transverse process → spreads to paravertebral space → blocks dorsal and ventral rami. Some visceral coverage via communicating rami.
Dosing
Volume / side20–30 mL
Ropivacaine 0.25–0.375%20–30 mL
Level (thoracic)T4–T5 for thorax / T7–T9 for upper abd
Level (lumbar)L2–L3 for lower abd/flank
Continuous0.2% rop 5–10 mL/hr
Indications
- Rib fractures (multiple)
- Thoracotomy (VATS/open) — alternative to PVB/epidural
- Breast surgery
- Laparoscopic / open abdominal surgery
- C-section — emerging alternative to TAP
Notes
Easier and safer than PVB — superficial target. Evidence shows comparable analgesia to TAP for some indications. Variability in spread. No CPT code yet (billed separately — institutional guidance).
Serratus Anterior Plane (SAP) Block
Lateral chest wall · Rib fractures · Thoracic surgery
Coverage
- T2–T9 lateral chest wall
- Long thoracic nerve (serratus), lateral cutaneous branches intercostal nerves
- Does NOT cover medial chest
Dosing
Volume20–30 mL
AgentRopivacaine 0.25–0.375%
TargetSuperficial to serratus (preferred) or deep
Indications
- Multiple rib fractures
- VATS / thoracic procedures
- Breast surgery (lateral)
- Chest tube analgesia
Notes
US-guided at midaxillary line, 4th–5th rib level. Superficial plane (between serratus and latissimus) preferred — ↓ pneumothorax risk. Safe, reproducible, effective for lateral chest pain.
PECS I & II Blocks
Breast surgery · Chest wall · Axillary dissection
PECS I
TargetBetween pect major and pect minor
Volume10 mL
CoverageLateral pectoral nerve → medial breast
PECS II
TargetBetween pect minor and serratus
Volume20 mL
CoverageIntercostobrachial, medial pectoral, lateral intercostals
Combined PECS I+II
- Mastectomy, lumpectomy, tissue expander
- Axillary node dissection coverage
- Total volume: 30 mL (10+20)
- Agent: Ropivacaine 0.25–0.375% or bupivacaine 0.25%
Notes
US-guided infraclavicular approach. Identify pec major, pec minor, serratus, ribs. Safe — superficial fascial planes. Effective opioid-sparing for breast surgery.
Thoracic Paravertebral Block (PVB)
Unilateral thoracic/chest analgesia · Thoracotomy
Coverage
- Unilateral somatic + visceral (T1–T12, one level at a time)
- Thoracotomy, mastectomy, rib fractures
- Epidural-equivalent for unilateral pain
Dosing
Single-level volume15–20 mL
Multi-level5 mL per level × 3–4 levels
AgentRopivacaine 0.375–0.5%
Continuous0.1–0.2% rop 5–8 mL/hr
Complications
- Pneumothorax (1–5%)
- Vascular puncture — high LAST risk (deep vascular site)
- Epidural spread → bilateral block
- Hypotension
Notes
US-guided: paramedian sagittal view. Needle tip just through costotransverse ligament. High LAST risk — treat as deep/vascular site per ASRA. ESB increasingly preferred for safety.
NEURAXIAL-ADJACENT
Lumbar Plexus Block (Psoas Compartment)
L1–L4 · Hip/knee/thigh · Deep — treat as neuraxial risk
Coverage
- Femoral + obturator + lateral femoral cutaneous nerves (L1–L4)
- Hip, anterior thigh, knee
- Combine with sciatic for full leg anesthesia
Dosing
Volume25–35 mL
Ropivacaine 0.5%30 mL
Max single dose~3 mg/kg (high-absorb site)
Complications
- Epidural spread (10–15%)
- Hematoma — treat as neuraxial for anticoag timing
- Renal/vascular puncture
- Quad weakness → fall risk
Notes
Deep block — ASRA treats same as neuraxial for anticoagulation. US-guided (probe transverse L4) or landmark + nerve stimulator. High-risk for LAST and epidural spread.
ASA/APSF/ESAIC 2023 — NMB Monitoring Standard
Quantitative neuromuscular monitoring at adductor pollicis (ulnar nerve stimulation) is the ONLY reliable method to confirm TOF ratio ≥0.9 before extubation. Clinical tests (head lift, hand grip, tongue depressor) do NOT reliably detect residual block. Residual NMB rate: 30–65% without quantitative monitoring.🔬
TOF — Depth Classification (ASA 2023)
Deep Block — PTC <10, TOF count = 0
1
2
3
4
Reversal
Sugammadex 4 mg/kg IV (PTC 1–2) or 16 mg/kg (immediate emergent reversal after roc 1.2 mg/kg). Neostigmine cannot reverse deep block.Moderate Block — TOF count 1–3
1
2
3
4
Reversal
Sugammadex 2 mg/kg IV (rocuronium/vecuronium) — recommended. Neostigmine NOT recommended at this depth.Shallow Block — TOF count = 4, ratio <0.4
1
2
3
4
Fade present on qualitative assessment
Reversal
Sugammadex 2 mg/kg IV recommended. Neostigmine 15–40 mcg/kg acceptable alternative with quantitative monitoring confirmation TOF ≥0.4.Minimal Block — TOF ratio 0.4–<0.9
1
2
3
4
Fade present on quantitative — not reliably detectable qualitatively
Reversal
Sugammadex 2 mg/kg (preferred, rocuronium/vecuronium) OR Neostigmine 15–40 mcg/kg + glycopyrrolate 0.01 mg/kg (acceptable alternative for minimal block). Cisatracurium: neostigmine only (sugammadex does not reverse).Adequate Recovery — TOF ratio ≥ 0.9
1
2
3
4
No Pharmacologic Reversal Needed
TOF ratio ≥0.9 confirmed by quantitative monitoring = adequate recovery. Safe to extubate. Note: Cannot reliably confirm ≥0.9 by qualitative (visual/tactile) assessment alone.💉
Reversal Dosing — Quick Reference
| Agent | Indication | Dose | Notes |
|---|---|---|---|
| Sugammadex preferred | Moderate (TOF 2+) | 2 mg/kg IV | Rocuronium / vecuronium only. Time to TOF ≥0.9: ~2–3 min |
| Sugammadex | Deep (PTC 1–2) | 4 mg/kg IV | Time to TOF ≥0.9: ~3–5 min |
| Sugammadex | Immediate/emergent | 16 mg/kg IV | After roc 1.2 mg/kg RSI; onset ~3 min. CICO rescue option. |
| Neostigmine minimal block only | TOF ratio 0.4–<0.9 | 15–40 mcg/kg IV (max 5 mg) | ALWAYS pair with glycopyrrolate 0.01 mg/kg or atropine 0.02 mg/kg. Time to TOF ≥0.9: 10–15+ min |
| Neostigmine | Cisatracurium (any depth) | 40–70 mcg/kg IV | Sugammadex does NOT reverse benzylisoquinoliniums |
| Glycopyrrolate | With neostigmine | 0.01 mg/kg IV | Ratio: glycopyrrolate 0.2 mg : neostigmine 1 mg |
Sugammadex Caveats
Only encapsulates aminosteroids (rocuronium, vecuronium). No effect on succinylcholine, atracurium, cisatracurium, benzylisoquinoliniums. Re-curarization rare but monitor ≥30 min. Caution in severe renal failure (accumulation of complex) — however, 2024 data show rocuronium+sugammadex superior to cis+neostigmine even in CrCl <30. QTc prolongation reported at 32 mg/kg doses. Pregnancy: crosses placenta → monitor neonate.Monitoring Best Practice (ASA 2023)
Use quantitative monitor (acceleromyography EMG preferred) at adductor pollicis (ulnar nerve). Calibrate before induction. Always confirm TOF ≥0.9 before extubation. Qualitative (visual/tactile fade) is unreliable — do NOT use as sole criterion for extubation.⏱
NMB Drug Duration Reference
| Drug | Type | Intubation Dose | Clinical Duration | Reversible With |
|---|---|---|---|---|
| Succinylcholine | Depolarizing | 1.5 mg/kg | 6–10 min | Spontaneous (pseudocholinesterase) |
| Rocuronium (RSI) | Aminosteroid | 1.2 mg/kg | 60–90 min | Sugammadex 16 mg/kg (immediate) |
| Rocuronium (standard) | Aminosteroid | 0.6 mg/kg | 30–45 min | Sugammadex 2–4 mg/kg |
| Vecuronium | Aminosteroid | 0.1 mg/kg | 25–40 min | Sugammadex 2–4 mg/kg |
| Cisatracurium | Benzylisoquinolinium | 0.15–0.2 mg/kg | 40–60 min | Neostigmine (hofmann elim.) |
| Atracurium | Benzylisoquinolinium | 0.5 mg/kg | 25–35 min | Neostigmine (hofmann elim.) |
| Pancuronium | Aminosteroid | 0.1 mg/kg | 90–120 min | Sugammadex (↓ use — renal accum.) |
Factors Prolonging NMB Duration
Hypothermia · Hypermagnesemia · Acidosis · Aminoglycoside antibiotics · Volatile anesthetics (potentiate) · Hepatic failure (aminosteroids) · Renal failure (pancuronium, vecuronium) · Pseudocholinesterase deficiency (succinylcholine)🚨
High / Total Spinal
- Rapid unexpected cephalad spread of block
- Numbness / paresthesia / weakness of upper extremities
- SOB, apnea, anxiety, nausea
- Bradycardia ± hypotension
- Loss of consciousness → cardiac arrest (total spinal)
Treatment
- Call for help, code cart, inform surgical team immediately
- If cardiac arrest: CPR + ACLS protocol
- Support ventilation — intubate if apneic
- Epi 10 mcg IV boluses for bradycardia/hypotension; titrate up
- Atropine 0.5 mg IV for mild bradycardia; low threshold for epi
- IV fluid bolus wide open
IF PARTURIENT
LUD immediately. Alert OB team. Prepare for perimortem C/S. Monitor fetal HR. If arrest → ACLS in Pregnancy protocol.🌡
Malignant Hyperthermia (MH)
Trigger Agents
- All volatile agents (sevo, iso, des, halothane)
- Succinylcholine
- SAFE: propofol, ketamine, opioids, benzos, NdNMBs, N₂O, local anesthetics
Early Signs
- ↑ EtCO₂ (first reliable sign)
- Masseter spasm / generalized rigidity
- ↑ HR, ↑ RR, hyperthermia (>1°C/5 min)
- Metabolic acidosis, ↑ K⁺, myoglobinuria
Treatment — MHAUS Hotline: 1-800-644-9737
1
Dantrolene — Immediately
2.5 mg/kg IV rapid bolus → repeat 2.5 mg/kg q5 min PRN (MHAUS/EMHG 2024: repeat full 2.5 mg/kg dose, not 1 mg/kg); max 10 mg/kg (up to 20 mg/kg if refractory). Maintenance post-crisis: 1 mg/kg IV q4–6h × ≥24h to prevent recrudescence (occurs in ~20% of cases, median 9h after crisis). Ryanodex 250 mg/5 mL DW (faster reconstitution than standard 20 mg/vial).
2
Discontinue All Triggers
Stop volatile agents. Switch to TIVA (propofol ± opioid). Hyperventilate 100% O₂ ≥10 L/min. Change circuit and soda lime when time permits.
3
Active Cooling
Ice to groin/axilla/neck. Cold IVF lavage. Cool body cavities if open. Stop cooling at 38.5°C (overshoot risk).
4
Treat Metabolic Consequences
Bicarb for acidosis. CaCl for hyperkalemia. Insulin + D50 for K⁺. Amiodarone for arrhythmias. UO >1 mL/kg/hr; alkalinize urine for rhabdomyolysis.
5
ICU — ≥24h Post-Crisis
Dantrolene 1 mg/kg IV q4–6h × ≥24h (MHAUS: bolus preferred over infusion; allows clinical reassessment at each interval). Recrudescence in ~20% — monitor for return of rigidity, ↑EtCO₂, ↑CK. Monitor: CK, BMP, UA q6h. CK peaks 12–24h. Oral dantrolene 4–8 mg/kg/day ÷ 4 doses × 1–3 days if transitioning off IV. Refer patient + family for RYR1 genetic testing (CHCT or DNA).
⚠
Anaphylaxis
Common triggers: Antibiotics · NMBDs (roc, sux) · Latex · Chlorhexidine · Contrast · Colloids · Opioids
1
Epinephrine — First and Only First Line
Arrest: 0.5–1 mg IV → ACLS. Hypotension/bronchospasm: 10–50 mcg IV q1–2 min. No IV: 300–500 mcg IM (anterolateral thigh). Infusion: 0.05–1 mcg/kg/min
2
Airway + 100% O₂
Intubate early if airway edema developing. Albuterol 2.5 mg neb for bronchospasm.
3
Volume + Vasopressors
1–2 L crystalloid IV rapidly. Vasopressin 0.03–0.04 units/min for epi-refractory hypotension. Norepinephrine infusion if needed.
4
Adjuncts (Secondary)
Diphenhydramine 25–50 mg IV · Famotidine 20 mg IV (H₂; ranitidine RECALLED — NDMA) · Methylprednisolone 125 mg IV · Glucagon 1–5 mg IV if beta-blocked
Rocuronium/Vecuronium Anaphylaxis
Sugammadex 16 mg/kg IV — encapsulates the antigenic NMBD, removes ongoing stimulus. Does NOT treat the anaphylaxis itself — still requires full anaphylaxis treatment.🫁
CICO — Cannot Intubate Cannot Oxygenate
CICO = Surgical Emergency — Declare It
1
Declare CICO — Call for Help
Max 3 laryngoscopy attempts total (including video). 2nd-gen SGA (i-gel, ProSeal LMA). If SpO₂ falling with no oxygenation after SGA → CICO declared.
2
Front of Neck Access (FONA) — Scalpel First
Preferred: Scalpel-bougie-tube technique (DAS 2015). Do NOT attempt needle cric as primary CICO in adults.
Scalpel cric: Horizontal stab incision through CTM → digital dilate → 6.0 cuffed ETT or trach tube
Commercial devices: Melker, Portex — only if trained
Needle cric + jet vent: temporizing bridge only (<45 min; barotrauma risk)
Scalpel cric: Horizontal stab incision through CTM → digital dilate → 6.0 cuffed ETT or trach tube
Commercial devices: Melker, Portex — only if trained
Needle cric + jet vent: temporizing bridge only (<45 min; barotrauma risk)
DAS 2015 · NAP4 · ASA 2022 Difficult Airway Practice Guidelines
K⁺
Hyperkalemia
| Mechanism | Drug | Dose | Onset |
|---|---|---|---|
| Membrane stabilize | Calcium chloride 10% first | 0.5–1 g IV over 2–5 min | Immediate |
| Membrane stabilize | Calcium gluconate 10% | 1–3 g IV over 10 min | 1–3 min |
| Redistribution | Regular insulin + D50 | 10 U + 50 mL D50W IV | 15–30 min |
| Redistribution | Sodium bicarbonate | 50–100 mEq IV | 15–30 min |
| Redistribution | Albuterol | 10–20 mg neb | 30 min |
| Elimination | Furosemide | 40–80 mg IV | 30–60 min |
| Elimination | Kayexalate / Patiromer | 15–30 g PO/PR or 8.4 g PO | Hours |
| Elimination | Hemodialysis | Definitive for severe/refractory | Rapid |
CaCl: ~3× elemental Ca²⁺ vs gluconate — prefer CaCl in arrest. Incompatible with NaHCO₃ in same line.
🍼
Post-Partum Hemorrhage (PPH)
EBL Thresholds
Vaginal: >500 mL · C-section: >1000 mL · Severe PPH: >1500 mL4 T's Etiology
Tone (atony 80%) · Trauma (lacerations/rupture) · Tissue (retained products) · Thrombin (coagulopathy)
| Drug | Dose | Route | Key Notes |
|---|---|---|---|
| Oxytocin 1st line | Rule of 3s: 3 U load over 30 sec → repeat q3min × 3 doses → 3 U/hr infusion up to 9 hr | IV/IM/IU | WHO: 10 U IM/IV. Do NOT rapid IV bolus → hypotension, coronary spasm |
| TXA early — all PPH | 1 g IV over 10 min; repeat × 1 after 30 min if continued bleeding | IV only | WHO 2023: recommended for ALL PPH. Give within 3 hr delivery. WOMAN trial: ↓ mortality 19%. Does not ↑ thrombosis. |
| Methylergonovine | 0.2 mg IM q5–10 min × max 2 doses; then q2–4 hr | IM preferred (avoid rapid IV) | CI: HTN, pre-eclampsia, Raynaud's, CAD. SE: HTN, coronary spasm |
| Carboprost (Hemabate) | 0.25 mg IM q15–90 min; max 2 mg/24 hr | IM or IU only | CI: asthma. SE: bronchospasm, N/V/D, flushing |
| Misoprostol | 600–1000 mcg | Buccal/SL/PR/PO | Onset 10 min buccal. SE: fever ≤38.5°C, shivering, N/V |
| Fibrinogen conc. (RiaSTAP) | 2–4 g IV; target fib >2 g/L | IV | DIC/AFE/major hemorrhage. ROTEM/TEG-guided preferred. 2 g ≈ 10–20 cryo units. |
Escalation
↑ IV access (2 large bore) · MTP activation · Cell salvage · CaCl 1 g q4U pRBC · Warm patient · POC coag (ROTEM/TEG) · IR embolization · Prepare for hysterectomyBP↑
Hypertensive Disorders of Pregnancy
Pre-Eclampsia
BP >140/90 ×2 (≥4 hr apart) after 20 wks + proteinuria OR any severe feature: BP >160/110, plt <100k, Cr >1.1, LFTs 2×ULN, pulmonary edema, new HA/visual changesSeizure Prophylaxis
Mg load4–6 g IV over 15–20 min
Mg infusion1–2 g/hr × 24 hr post-delivery — do NOT stop intraop
Mg toxicity↓ DTRs (4–5) → resp paralysis (6–7) → arrest (>10 mEq/L)
AntidoteCaCl 1 g IV or CaGluconate 2–3 g IV
Severe HTN (SBP ≥160 / DBP ≥110) — Treat within 15–30 min (OBLS 2024); ACOG: 60 min
| Drug | Dose | Notes |
|---|---|---|
| Labetalol 1st line | 20 mg IV; then 40–80 mg q10 min; max 300 mg. Infusion 1–2 mg/min | Avoid: severe asthma, bradycardia |
| Hydralazine 1st line | 5–10 mg IV q20 min; max 30 mg | Onset 15–20 min; unpredictable |
| Nifedipine IR 1st line | 10–20 mg PO; repeat 20 mg q30 min PRN; max 50 mg/episode | PO only — DO NOT give IV. OK with Mg (prior concern unfounded) |
| Nicardipine alt | 0.5–10 mg/hr IV infusion | Smooth/titratable; peripartum ICU preferred |
HELLP Syndrome
Hemolysis + ↑ LFTs + Plt <100k. Plt <50k → transfuse if C/S. GA if C/S — control BP at laryngoscopy (risk intracranial hemorrhage). No neuraxial if plt <80k.✂
Emergent GA for C-Section
ENSURE OB TEAM PREPPED & DRAPED BEFORE INDUCTION
- Pre-oxygenate: 3 min tidal breathing OR 8 vital capacity breaths 100% O₂
- Sodium citrate 0.3M 30 mL PO within 30 min of induction
- Left uterine displacement (wedge or manual)
- RSI with cricoid pressure (Sellick) — controversial but standard
| Drug | Dose | Notes |
|---|---|---|
| Succinylcholine | 1.5 mg/kg IV | Standard RSI agent |
| Rocuronium (RSI) | 1.2 mg/kg IV | Reverse with sugammadex 16 mg/kg if needed |
| Propofol | 2–2.5 mg/kg IV | Preferred if non-hemorrhagic |
| Ketamine | 1–2 mg/kg IV | Preferred if hemorrhage/hypotension or asthma |
| Etomidate | 0.3 mg/kg IV | Hemodynamically stable; single dose acceptable |
C/S Antibiotics — ACOG 2023
| Indication | Regimen |
|---|---|
| Standard | Cefazolin 2 g IV (3 g if ≥120 kg) within 60 min of incision |
| High-risk endometritis† | Cefazolin as above + Azithromycin 500 mg IV × 1 over 60 min (no re-dose) |
| PCN-allergic (IgE-mediated) | Clindamycin 900 mg IV + Gentamicin 5 mg/kg IV × 1 |
†High-risk: prolonged labor, prolonged ROM, multiple vaginal exams, chorioamnionitis, obesity. Redose cefazolin q4h if EBL >1500 mL.
👶
Pediatric Normal Parameters
| Age | Wt(kg) | HR | SBP | RR | LMA | Blade | ETT(mm) | Depth |
|---|---|---|---|---|---|---|---|---|
| Premature | <1 | 140–160 | 30–45 | 40–60 | 1 | Miller 0 | 2.5–3.0 | 6–8 cm |
| 0–1 mo (1–2 kg) | 1–2 | 130–140 | 35–55 | 30–50 | 1 | Miller 0 | 3.0 | 8 cm |
| 0–1 mo (2–3 kg) | 2–3 | 130–140 | 45–60 | 30–50 | 1 | Miller 0–1 | 3.5 | 9 cm |
| 0–1 mo (>3 kg) | >3 | 125–145 | 55–70 | 30–50 | 1 | Miller 0–1 | 3.5–4.0 | 10 cm |
| 1–6 mo | 4–6 | 120–140 | 65–80 | 24–30 | 1–1.5 | Miller 1 | 3.5–4.0 | 12 cm |
| 6 mo–1 yr | 6–10 | 110–130 | 70–90 | 22–26 | 1.5 | Wis 1.5 | 4.0 | 13 cm |
| 1–2 yr | 10–12 | 105–120 | 75–95 | 20–24 | 2 | Wis 1.5 | 4.5 | 14 cm |
| 2–4 yr | 12–16 | 95–115 | 80–100 | 18–22 | 2 | Mac 2 | 5.0 | 15 cm |
| 4–6 yr | 16–20 | 85–110 | 85–105 | 16–20 | 2–2.5 | Mac 2 | 5.5 | 16 cm |
| 6–8 yr | 20–30 | 80–100 | 90–110 | 16–20 | 2.5 | Mac 2 | 6.0 | 17 cm |
| 9–12 yr | 30–45 | 70–90 | 95–115 | 12–18 | 3 | Mac 2–3 | 6.5–7.0 | 18 cm |
| >14 yr | >50 | 60–80 | 100–130 | 10–16 | 4 | Mac 3 | 7.0 | 20–22 cm |
Quick Formulas
ETT uncuffed(Age÷4) + 4
ETT cuffed(Age÷4) + 3.5
ETT depth (lips)Age + 10 cm (or 3 × ETT size)
ETT depth (nose)(Height cm÷10) + 5
Weight >1 yr(Age × 2) + 8 kg
Low SBP (1–10 yr)70 + (Age × 2) mmHg
Neonatal Rules
MAP (mmHg) ≈ weeks PCA. By DOL 5: MAP = weeks PCA + 5. Neonatal 1-2-3 kg / 7-8-9 cm Rule (ETT depth at lip).🍬
Intraop Glucose — Infants & Neonates
Check glucose intraoperatively:
- Any NPO infant <6 months
- <44 weeks PCA (premature / IUGR / SGA)
- Born to diabetic mothers
- On TPN or D10W
- Sepsis, fever, or shock
- Long procedures (>2 hr)
- Suspected inborn errors of metabolism
Targets & Dosing
Neonate target: 50–150 mg/dL. Basal glucose requirement: 5–8 mg/kg/min. Run D5LR or D5NS at maintenance if concern. Check q30–60 min if supplementing. Adjust rate PRN.🔍
Rx
Surgical Antibiotic Prophylaxis — ASHP/IDSA/SHEA 2023
General Principles
Administer within 60 min of incision (120 min for vancomycin/fluoroquinolones). Redose at 1–2× drug half-life or EBL >1500 mL. Discontinue within 24 hr post-op (cardiac surgery: 48 hr). Single dose adequate for most procedures.| Drug | Adult Dose | Peds Dose | Redose Interval |
|---|---|---|---|
| Cefazolin 1st line most cases | 2 g IV (3 g if ≥120 kg) | 30 mg/kg IV (max 2 g) | q4h |
| Cefoxitin | 2 g IV | 40 mg/kg IV (max 2 g) | q2h |
| Cefuroxime | 1.5 g IV | 50 mg/kg IV (max 1.5 g) | q4h |
| Ceftriaxone | 2 g IV | 50 mg/kg IV (max 2 g) | q12–24h |
| Ampicillin-sulbactam | 3 g IV | 50 mg/kg amp IV | q2h |
| Pip-tazo | 3.375 g IV | 100 mg/kg pip IV | q2h |
| Clindamycin PCN-allergic alt | 900 mg IV | 10 mg/kg IV (max 900 mg) | q6h |
| Vancomycin MRSA/PCN allergy | 15–20 mg/kg IV (max 3 g); AUC/MIC-guided — target AUC 400–600 mg·h/L (ASHP/IDSA/SHEA 2020; trough-only monitoring no longer recommended) | 15 mg/kg IV | q6–12h |
| Gentamicin | 5 mg/kg IV × 1 (single dose preferred) | 2.5 mg/kg IV | q24h |
| Metronidazole colorectal | 500 mg IV | 15 mg/kg IV (max 500 mg) | q8h |
| Azithromycin OB add-on | 500 mg IV × 1 over 60 min only | — | Single dose — no redose |
Procedure-Specific Selection
| Procedure | Preferred | PCN Allergy Alternative |
|---|---|---|
| Cardiac / thoracic / vascular | Cefazolin 2 g | Vancomycin + gent |
| Orthopedic (implant) | Cefazolin 2 g | Vancomycin ± gent (MRSA risk) |
| Colorectal | Cefoxitin 2 g OR cefazolin + metronidazole | Clindamycin + gent or aztreonam |
| Appendectomy (uncomplicated) | Cefoxitin 2 g | Clindamycin + gent |
| Gynecologic | Cefazolin 2 g | Clindamycin + gent |
| C-section | Cefazolin 2–3 g ± azithromycin 500 mg | Clindamycin 900 mg + gent 5 mg/kg |
| Head/neck (clean-contaminated) | Ampicillin-sulbactam 3 g | Clindamycin + gent |
| Urologic | Cefazolin 2 g or TMP-SMX | Fluoroquinolone (watch resistance) |
| Neurosurgery (craniotomy) | Cefazolin 2 g | Clindamycin 900 mg |
🎨
ASTM D4774-24 / ISO 26825 — Verified Color Reference
ASTM D4774-24 — 9 Drug Classes (ASA / APSF Endorsed)
Standardizes user-applied syringe label colors in anesthesiology. Current standard: D4774-24. ISO 26825 covers 8 classes (excludes beta-blockers). Text is BLACK on background color for agonists. Antagonists use WHITE DIAGONAL STRIPES over the parent class color.
THE 9 OFFICIAL ASTM D4774-24 CLASSES
Yellow Class 1
INDUCTION AGENTS — propofol, etomidate, ketamine, thiopental, methohexital
⚠ Note: Benzodiazepines are a SEPARATE class (orange) — NOT grouped here
Orange Class 2
BENZODIAZEPINES — midazolam, diazepam, lorazepam
Orange + White Diagonal Stripes ANTAGONIST
Benzodiazepine antagonist — flumazenil
Fluorescent Red Class 3
NEUROMUSCULAR BLOCKING AGENTS — succinylcholine, rocuronium, vecuronium, cisatracurium, atracurium, pancuronium
⚠ Succinylcholine + Epinephrine use REVERSED PLATE (white text on red) per D4774 Fig. 3
Red + White Diagonal Stripes ANTAGONIST
NMB reversal agents — neostigmine, pyridostigmine, sugammadex, edrophonium
Blue Class 4
OPIOIDS — fentanyl, morphine, hydromorphone, sufentanil, remifentanil, meperidine, methadone, codeine, oxycodone
Blue + White Diagonal Stripes ANTAGONIST
Opioid antagonist — naloxone
Aqua / Teal Class 5
ANTIEMETICS — ondansetron, metoclopramide, droperidol, prochlorperazine, promethazine
Violet / Purple Class 6
VASOPRESSORS & HYPOTENSIVES — epinephrine, norepinephrine, phenylephrine, vasopressin, ephedrine, dopamine, dobutamine, nitroglycerin, nitroprusside, hydralazine, nicardipine
⚠ Epinephrine uses REVERSED PLATE (white text on violet) per D4774 Fig. 3
Gray / Silver Class 7
LOCAL ANESTHETICS — lidocaine, bupivacaine, ropivacaine, mepivacaine, chloroprocaine, tetracaine, prilocaine, levobupivacaine
Green Class 8
ANTICHOLINERGIC AGENTS — atropine, glycopyrrolate, scopolamine
Blue + White Diagonal Stripes Class 9
BETA-BLOCKERS — esmolol, labetalol, metoprolol, propranolol, atenolol
Added in D4774 revision; not in ISO 26825. Uses same base blue as opioid class but pattern only (no solid blue background)
Pocket Anesthesia Reference v4
ASRA · ASA · ACOG · ASHP · WHO 2023–2025
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