ABA Pediatric Anesthesiology cheat sheet

Nil per os: clear liquids 2 h, breast milk 4 h, infant formula/nonhuman milk 6 h, light meal 6 h before elective anesthesia (2-4-6-8 rule).

Preoperative fasting does not require routine gastric decompression or routine antacid; aspiration risk is highest in neonates, bowel obstruction, and delayed gastric emptying.

Estimated blood volume: neonate 85-90 mL/kg, infant 75-80 mL/kg, child 70-75 mL/kg; allowable blood loss = EBV x (Hct_initial - Hct_target)/Hct_initial.

Maintenance crystalloid (4-2-1 rule): 4 mL/kg/h for first 10 kg, 2 mL/kg/h for next 10 kg, 1 mL/kg/h for each kg beyond 20.

Postanesthetic care discharge criteria: stable vital signs, patent airway, adequate oxygenation on room air, controlled pain, no ongoing bleeding, and return to baseline consciousness.

Prolonged fasting in infants increases risk of hypoglycemia and dehydration; point-of-care glucose is checked before induction in neonates and ex-premature infants.

Anesthesia-related cardiac arrest is more common in infants under 1 year; respiratory events (laryngospasm, airway obstruction) are the leading cause of perioperative morbidity in children.

Parental presence at induction reduces child anxiety but does not reduce emergence delirium; premedication with midazolam 0.5 mg/kg oral is an alternative.

Neonatal MAC for volatile agents is lower than in infants: MAC of sevoflurane is about 3.3% in neonates, 2.5-3.0% in infants, and 2.0-2.5% in older children.

Total body water is high in neonates (about 75-80% of body weight), increasing the volume of distribution of water-soluble drugs and requiring larger mg/kg loading doses.

Neonatal glomerular filtration rate is low (about 30-40% of adult value) and matures by 6-12 months; renally cleared drugs have prolonged elimination.

Fetal hemoglobin and lower 2,3-DPG shift the oxyhemoglobin dissociation curve left; P50 in neonates is about 19-20 mmHg versus 26-27 mmHg in adults.

Neonatal hepatic clearance is immature; cytochrome P450 activity reaches adult levels by 6-12 months, prolonging half-lives of many drugs.

Succinylcholine is relatively contraindicated in children with undiagnosed myopathy because of hyperkalemic cardiac arrest risk; routine use in healthy children is avoided.

Propofol clearance is high in children (higher weight-adjusted than adults), so children require larger mg/kg induction and infusion doses.

Infants have a higher resting oxygen consumption (about 6-8 mL/kg/min) and smaller functional residual capacity, causing rapid desaturation during apnea.

In unrepaired tetralogy of Fallot, increases in pulmonary vascular resistance or decreases in systemic vascular resistance worsen right-to-left shunt; maintain SVR and avoid hypovolemia and high airway pressures.

In left-to-right shunt lesions (VSD, PDA), avoid agents that decrease SVR disproportionately; increasing SVR reduces shunt fraction.

Children with upper respiratory infection have increased risk of laryngospasm and bronchospasm; elective surgery is generally deferred for 2-4 weeks after resolution.

In children with sickle cell disease, maintain hydration, oxygenation, and normothermia; avoid tourniquets and hypothermia that promote sickling.

In Duchenne muscular dystrophy, avoid succinylcholine and volatile agents because of rhabdomyolysis and hyperkalemia risk; total intravenous anesthesia is preferred.

Children with congenital heart disease and Eisenmenger physiology are at high risk from decreases in SVR; maintain systemic vascular resistance and avoid air embolism.

In pyloric stenosis, correct hypochloremic, hypokalemic metabolic alkalosis and dehydration before induction; the stomach should be decompressed.

Children with obstructive sleep apnea are at increased risk of postoperative respiratory depression; opioid-sparing techniques and monitoring are used.

Pediatric airway differences: large head, short neck, large tongue, long floppy epiglottis, anterior larynx, and narrowest point at the cricoid ring in younger children.

Uncuffed endotracheal tube size (mm ID) = (age in years/4) + 4; cuffed tube size is typically 0.5 mm smaller.

Endotracheal tube depth (cm at lip) = 3 x tube internal diameter (mm) in children older than 2 years.

Laryngospasm management: 100% oxygen with CPAP, deepen anesthesia, and if persistent, succinylcholine 0.5-2 mg/kg IV or 4 mg/kg IM.

Cuffed tubes are acceptable in infants and children when cuff pressure is kept below 20-25 cmH2O and tube size is appropriate.

The pediatric epiglottis is omega-shaped and floppy; a straight (Miller) blade is often preferred in neonates and infants.

Pediatric respiratory rate decreases with age: neonate 40-60, infant 30-40, toddler 24-30, school age 18-24, adolescent 12-18 breaths/min.

Foreign body aspiration presents with unilateral wheeze and is managed with rigid bronchoscopy; do not force ventilation past the obstruction.

Caudal block is the most common pediatric regional technique; landmark is the sacral hiatus at the level of S4; dose by volume: 1.25 mL/kg for sacral, 1 mL/kg for lumbar, 0.5 mL/kg for thoracic spread.

Maximum bupivacaine dose in children is 2-2.5 mg/kg (0.5 mL/kg of 0.25%); levobupivacaine and ropivacaine have similar or slightly higher maximums.

Test dose with epinephrine 1:200,000 (0.1 mL/kg) detects intravascular injection; do not rely on heart rate alone in children under anesthesia.

Ilioinguinal/iliohypogastric block covers inguinal hernia repair and orchiopexy; landmark is medial to the anterior superior iliac spine.

Penile block with 0.25% bupivacaine (without epinephrine) provides postoperative analgesia for circumcision.

Multimodal analgesia: acetaminophen 10-15 mg/kg q6h (max 75 mg/kg/day) and ibuprofen 5-10 mg/kg q6-8h are first-line in children.

Codeine and trampoline are avoided in children under 12 years because of ultrarapid CYP2D6 metabolism and respiratory depression risk.

Neonates and infants have immature pain pathways but demonstrate pain responses; regional and opioid analgesia should be titrated with apnea monitoring.

Pediatric basic life support compression-to-ventilation ratio: 30:2 for single rescuer, 15:2 for two rescuers; compression depth is one-third of chest AP diameter.

Epinephrine dose in pediatric cardiac arrest is 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO; repeat every 3-5 minutes.

Defibrillation in children: 2 J/kg first shock, 4 J/kg second shock, and 4-10 J/kg for subsequent shocks.

Fluid bolus in pediatric shock is 10-20 mL/kg isotonic crystalloid, reassessing after each bolus; 20 mL/kg is used in septic shock with caution in cardiac disease.

Pediatric early warning scores and capnography monitoring reduce unrecognized respiratory events; capnography is standard during sedation.

Weight-based dosing errors are reduced by standardized color-coded length-based tapes and double-checking high-alert medications.

Hypoglycemia in children is treated with 0.5-1 g/kg dextrose (2-4 mL/kg of D10 or 1-2 mL/kg of D25) in neonates and children.

Anaphylaxis in children: epinephrine 0.01 mg/kg IM (max 0.5 mg) of 1:1000 into the anterolateral thigh, repeated every 5-15 minutes as needed.

Fasting intervals: 2 h clear liquids, 4 h breast milk, 6 h formula and light meal; prolonged fasting increases hypoglycemia risk in infants.

Estimated blood volume: neonate 85-90 mL/kg, infant 75-80 mL/kg, child 70-75 mL/kg.

Allowable blood loss = EBV x (initial Hct - target Hct)/initial Hct.

Maintenance fluid 4-2-1 rule: 4 mL/kg/h first 10 kg, 2 mL/kg/h next 10 kg, 1 mL/kg/h beyond 20 kg.

Respiratory adverse events are the leading cause of pediatric perioperative morbidity; infants under 1 year are at highest risk.

Premedication with oral midazolam 0.5 mg/kg reduces anxiety without delaying discharge in ambulatory surgery.

Neonates and ex-premature infants require postoperative apnea monitoring after general anesthesia.

MAC of sevoflurane is highest in infants (about 3.0-3.3%) and lower in neonates and older children.

Neonates have high total body water (75-80%), increasing volume of distribution and mg/kg loading doses of water-soluble drugs.

GFR is about 30-40% of adult values at birth and reaches adult levels by 6-12 months.

Fetal hemoglobin shifts the oxyhemoglobin curve left; P50 is about 19-20 mmHg in neonates versus 26-27 mmHg in adults.

Hepatic CYP450 activity matures by 6-12 months, prolonging elimination of many drugs in neonates.

Succinylcholine is avoided in children with suspected myopathy because of hyperkalemic cardiac arrest risk.

Infants have higher oxygen consumption (6-8 mL/kg/min) and smaller FRC, causing rapid desaturation during apnea.

Tetralogy of Fallot: avoid increases in pulmonary vascular resistance and decreases in systemic vascular resistance, which worsen right-to-left shunt.

Left-to-right shunts (VSD, PDA): avoid disproportionate falls in SVR; maintain systemic vascular resistance.

Upper respiratory infection: defer elective surgery for 2-4 weeks after resolution because of laryngospasm and bronchospasm risk.

Sickle cell disease: maintain hydration, oxygenation, and normothermia; avoid tourniquets and hypothermia.

Duchenne muscular dystrophy: avoid succinylcholine and volatile agents; total intravenous anesthesia is preferred.

Pyloric stenosis: correct hypochloremic, hypokalemic metabolic alkalosis and dehydration before induction.

Eisenmenger physiology: avoid decreases in SVR and air embolism; maintain systemic vascular resistance.

Uncuffed ETT size (mm ID) = (age/4) + 4; cuffed size is typically 0.5 mm smaller.

ETT depth at lip (cm) = 3 x internal diameter (mm) in children older than 2 years.

Pediatric airway: large head, short neck, large tongue, floppy omega-shaped epiglottis, anterior larynx, narrowest at cricoid.

Laryngospasm: 100% oxygen with CPAP, deepen anesthesia, then succinylcholine 0.5-2 mg/kg IV or 4 mg/kg IM if persistent.

Cuffed tubes are acceptable in infants if cuff pressure is kept below 20-25 cmH2O.

Normal respiratory rate: neonate 40-60, infant 30-40, toddler 24-30, school age 18-24, adolescent 12-18 breaths/min.

Foreign body aspiration: unilateral wheeze; manage with rigid bronchoscopy and avoid forcing ventilation past the obstruction.

Caudal block: landmark sacral hiatus at S4; volume 1.25 mL/kg for sacral, 1 mL/kg for lumbar, 0.5 mL/kg for thoracic spread.

Maximum bupivacaine dose in children is 2-2.5 mg/kg (0.5 mL/kg of 0.25%).

Test dose epinephrine 1:200,000 (0.1 mL/kg) detects intravascular injection; heart rate changes are unreliable under anesthesia.

Ilioinguinal/iliohypogastric block covers inguinal hernia repair and orchiopexy; landmark medial to the anterior superior iliac spine.

Penile block with 0.25% bupivacaine without epinephrine provides analgesia for circumcision.

Acetaminophen 10-15 mg/kg q6h (max 75 mg/kg/day) and ibuprofen 5-10 mg/kg q6-8h are first-line multimodal analgesia.

Codeine and tramadol are avoided in children under 12 years because of ultrarapid CYP2D6 metabolism and respiratory depression.

Pediatric CPR compression-to-ventilation ratio: 30:2 single rescuer, 15:2 two rescuers; compression depth one-third of chest AP diameter.

Epinephrine in pediatric cardiac arrest: 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO every 3-5 minutes.

Defibrillation: 2 J/kg first shock, 4 J/kg second shock, 4-10 J/kg subsequent shocks.

Fluid bolus in pediatric shock: 10-20 mL/kg isotonic crystalloid, reassessing after each bolus.

Anaphylaxis: epinephrine 0.01 mg/kg IM (max 0.5 mg) of 1:1000 into the anterolateral thigh.

Hypoglycemia: 0.5-1 g/kg dextrose (2-4 mL/kg D10 or 1-2 mL/kg D25).

Capnography and length-based color-coded tapes reduce unrecognized respiratory events and weight-based dosing errors.