High Spinal & Total Spinal
Signs •Numbness, paresthesia, or weakness of UE’s
•Rapid unexpected rise of sensory block
•SOB, apnea, bradycardia, hypotension, or nausea/vomiting
•Loss of consciousness (LOC = total spinal), Cardiac arrest
Tx •Call for help & code cart, inform team
•If cardiac arrest: start CPR, refer to ACLS protocol
•Support ventilation. Intubate if necessary
•If significant brady or hypotension: 10mcg boluses epi,
↑prn, consider ACLS/pacing pads
•If mild brady can try atropine, low threshold for epi
•Give IV fluid bolus
•IF PARTURIENT: LUD, alert OB, prepare for possible C/S,
monitor fetal HR. If arrest, see ACLS in parturient
Pocket Anesthesia
Reference Card
Card design by providers from many institutions including:
Disclaimer: This card is intended to be educational in nature and is not a substitute for clinical
decision making based on the medical condition presented. It is intended to serve as an introduction
to terminology. It is the responsibility of the user to ensure all information contained herein is current
and accurate by using published references. This card is a collaborative effort by representatives of
multiple academic medical centers.
Maintenance Fluids - “4-2-1” Rule
4 mL/kg/hr: each kg up to 10 kg
2 mL/kg/hr: each additional kg to 20 kg
1 mL/kg/hr: each additional kg > 20 kg
Example: a 22 kg pt needs 40+20+2 = 62ml/hr)
Average Blood Volume (ABV)
Premature 90-100 ml/kg 1yo 75 ml/kg
Term 80 ml/kg Adult 70 ml/kg
Calculation of Drug Concentrations
Percentage solutions:
100% solution = 1g/ml
•To convert: multiply % by 10
Ratio solutions: Number before : = grams in
solution. Number after : = mls in solution.
•To convert ratio to g/ml divide grams by mls.
•1% solution = 1:100 = 10mg/ml
•0.005% = 1:200,000 = 0.005mg/ml or 5 mcg/ml
Allowable Blood Loss (ABL)
Est blood volume (EBV) = Kg x Average Blood Volume (ABV)
Allowable Blood Loss (ABL) = [EBV x (initial Hgb-final Hgb)]/initial Hgb
NPO Guidelines (Hrs)
Clears 2Formula, milk, light meal 6
Breast Milk 4Full meals 8
GENERAL ANESTHESIA KNOWLEDGE
EMERGENCIES
Hypotension in Spinal Anesthesia
Most pts. receiving spinal anesthesia will need vasopressor support.
Prevention •See contraindications
•Bolus 500-1000ml IVF at time of placement & consider preemptive
phenylephrine gtt.
Signs: •AMS: confusion, agitation, somnolence, unconsciousness
•Nausea, vomiting
•Inability for BP cuff to read
•Increased HR
Tx: •IV ephedrine 5-10mg or IV phenylephrine 50-100mg
•Will likely need phenylephrine infusion
•Pt positioning (left lateral + reverse trendelenburg)
Common Local Anesthetics for Spinal Anesthesia
~Dose, mg ~Duration w/ epi
Procedure <
90 min
Chloroprocaine 40-60 n/a
Lidocaine 2% 60-80 30-45
Lidocaine 5% (Avoid 2/2 TNS) 60-75 60-70
Procaine 75-200 45 60-75
Procedure >
90 min
Bupivacaine 0.05% or 0.75% (iso or
hyperbaric ) 5-20 90-110 100-150
Tetracaine 0.5% 5-20 90-120 120-240
NEURAXIAL ANESTHESIA
Common Adjuncts for Spinal Anesthesia
Epinephrine 0.1-0.2mg Morphine 50-300mcg
Fentanyl 10-25mcg Peak 2hr & 6-12hr: only for postop pain. Must monitor
24 hrs due to risk of delayed respiratory depression
Clonidine (caution black
box warning for maternal
hypoTN and bradycardia)
30-60 mcg
Common mix: 2.5-15 mg 0.5-0.75% hyperbaric bupiv +/- 10-15 mcg fentanyl +/-
100-150 mcg morphine +/- 50-100 mcg epinephrine
Key Points
•Uses: C/S, Gyn, Uro, Abdo & LE procedures
•High spinal is a significant cause of morbidity/mortality → see emergencies
•Monitor BP q1-5 min before, during, & after. Use standard monitors
•Ensure adequate IV access, vasoconstrictors & GA available
•Consider preloading with IVF (Avoid in pre-eclampsia)
•Consider starting vasopressor support at time of placement
•Ensure aseptic technique for placement
•Spread determined by: baricity, dose, volume, position, level of injection, ↓
CSF volume(↑ intra-abdominal pressure, pregnancy)
PPH EBL: Vaginal: > 500 mL, C-section: > 1000 mL
4 T’s: Tone/atony, Thrombin/coags, Tissue/retained placenta, Trauma/artery lac
Oxytocin/
Pitocin
(Syntocinon)
-Can be given: IM/IV/IU routes (WHO rec: 10 U IM/IV)
-Do NOT bolus IV rapidly
-Consider Rule of 3’s:
- Dose: 3 U load IV over 30 sec
- Consider repeat 3 U doses q 3 min for total 3 doses
- Infusion at 3 U/hr for up to 9 hr postop
- COMMUNICATE w/ OB TEAM re: TONE q 3 min
-SE: hypotension, N/V, coronary spasm
Methylergon
ovine/
Methergine
- Dose: 0.2 mg IM; q 5-10 min max 2 doses, then q 2-4 hr
- Avoid IV, but if IV, 0.2 mg/10 mL NS, give 2 mL q 1 min
- Relatively contraindicated if GHTN, HTN, Pre-E
- SE: HTN, seizures, HA, N/V, chest tightness
Hemabate/
Carboprost
- Dose: 0.25 mg only IM or IU q 15-90 min, Max 2 mg/24 hr
- Contraindicated in asthma
- SE: N/V, flushing, bronchospasm, diarrhea
Misoprostol/
Cytotec
- Dose: 600-1000 mcg buccal/PR (10 min onset)
- SE: temp ↑ to ~ 38.1, N/V, diarrhea
Tranexamic
Acid/TXA
- Consider for all PPH
- Dose: 1 g IV over 10 min, repeat x 1 after 30 min prn
Fibrinogen
concentrate/
RiaSTAP
- Consider for PPH w/ confirmed/suspected low fib state: (DIC, AFE,
abruption, major hemorrhage)
- 2 g fibrinogen = 2 vials RiaSTAP = 2-4 U FFP = 10-20 cryo U
- To ↑ fibrinogen 100 mg/dL, give 2-4 g fibrinogen conc
- Keep pt. warm
- Don’t forget CaCl
- Consider IR for uterine artery
embolization
- Call for help
- Consider MTP, cell salvage
- Consider POC testing/ROTEM
- Syntometrine = oxytocin + ergometrine
- Prepare for hysterectomy if bleeding still
uncontrolled (↑IV access, consider airway)
Post-Partum Hemorrhage
Urgent or Emergent C-Section & Emergent GA
For all: Pre-induction checklist
•Call for help, take AMPLE Hx, IV access, NaCit, pulse ox, LUD.
•Neuraxial preferred if time - plan determined by degree of urgency,
communication w/OB team, resources, & pt. condition
•If CS for fetal distress, ↑ O2 to baby: SPOILT-Stop oxytocin, Position-LUD, O2, IV fluid, Low
BP (give pressor), Tocolytics (terbutaline 250 mcg subQ, +/-NTG SL spray 400 mcg x2)
For Emergent GA:
•ENSURE OBs PREPPED AND DRAPED BEFORE INDUCTION
•Pre-oxygenate 4 breaths. RSI w/ cricoid:
•Meds: Sux 1.5 mg/kg w/ either: propofol 2-3 mg/kg or etomidate 0.2 mg/kg or
ketamine 1-2 mg/kg or thiopental 4-5 mg/kg
•Once ETT placement verified, INSTRUCT SURGEONS TO “CUT”
•Until cord clamp: High gas flow & 2 MAC. Try to avoid benzo/narcs
•After cord clamp: 0.5 MAC + 70% N2O or TIVA .Benzo/narcs OK
•When able: Timeout, Abx, OG, +/-NMB, +/- post-op TAP block or PCA
C-section Antibiotics
•Standard: Cefazolin 2 gm IV (3 g if > 120 kg) Q 4 hr
•PCN-allergic: Clindamycin 900 mg IV q 6 hr & Gentamicin 5 mg/kg IV once
•High-risk (discuss w/ OB): Cefazolin as above & Azithromycin 500 mg IV x 1 (Do
NOT re-dose azithro & infuse over 1 hr, faster risks local IV site rxn)
OBSTETRICS & OB EMERGENCIES
(Please see full OB pocket card for details)
Hypertensive Disorders
Pre-Eclampsia: BP > 140/90 x2 ≥ 20 wks, proteinuria, +/- organ dysfunct.
•Consider delivery
•Prevent seizure: Mg 4-6 g IV over 15-20 min + 1-2 g/hr gtt for 24 hr post
delivery (do NOT d/c in OR); (10 g IM load described if no PIV)
•Tx severe HTN (SBP > 155, DBP > 105): 1st line: Labetalol IV, hydralazine IV,
nifedipine PO and no IV (others okay if 1st line unavailable)
•Watch for Mg tox: ↓ DTRs, Resp/cardiac comp. Tx: CaCl 1g IV or CaGluc 1-3 g
IV
Eclampsia: Pre-E w/ Seizure
•Goal: prevent hypoxia, trauma, additional seizures.
•Tx HTN, eval for prompt delivery
•LUD/full lateral, O2, airway, +/- ETT (If intubation: control BP to avoid cerebral
hemorrhage)
•IV Mg load & gtt, as above
•If persistent/recurrent seizure: IV benzo (IM/IO okay)
•If severe HTN, tx as above
•Prepare for prompt delivery (NO neuraxial until rule out HELLP)
HELLP: hemolysis, ↑ LFTs, ↓ plt
•Tx: As above for seizure ppx, HTN, consider delivery (vaginal if able)
•If active bleeding, consider plt transfusion
•Prepare for delivery, likely GA if C-Section (Control BP to avoid cerebral
hemorrhage)
Normal Physiologic Parameters & Equipment
AGE KG HR MAP** RR LMA Blade ETT mm ETT@
Lips
0-1mo <1* 140’s 30 <60 1 Miller 0 2.5 7 cm*
0-1mo 1-2* 140’s 30’s <60 1 Miller 0 3.0 8 cm*
0-1mo 2-3* 130-140 30’s <60 1 Mil 0/Mil 1 3.5 9 cm*
0-1mo >3 130-140 40’s <60 1 Mil 0/Mil 1 3.5-4.0 10 cm
1-6 mo 4-6 130’s 50’s 24-30 1-1.5 Mil1/Wis1.5 3.5-4.0 12 cm
6mo-1yr 6-10 130’s 60’s 22-26 1.5 Wis 1.5 4.0 13 cm
1-2 yr 10-12 120’s 60’s 20-24 2 Wis 1.5 4.5 14 cm
2-4 yr 12-16 110’s 60’s 18-22 2 Wis1.5/Mac2 5.0 15 cm
4-6 yr 16-20 90-110 70’s 16-20 2 Mil 2/Mac2 5.5 16 cm
6-8 yr 20-30 90’s 70’s 16-20 2.5 Mil 2/Mac2 6.0 17 cm
9-12 yr 30-45 80 70-80’s 12-18 3 Mil/Mac 2-3 6.5-7.0 18 cm
>14 yr >50 75 70-80’s 10-16 4 Mil/Mac 2-3 7.0 20-22
Neonatal & Peds General Estimates
•The Neonatal “1-2-3(kg)/7-8-9(ETT@Lips)
Rule”
•For preterm & term newborns: MAP
equals the # of weeks post conceptual
age(PCA)!
•By day of life 5, MAP = # of weeks PCA + 5
•ETT Size: (Age/4) + 4 or 5th finger
size
•ETT Depth: [(Height in cm)/10]+ 5
or 3 x ETT Size
•Age + 11 cm at lip
Intraop Glucose for Infants and Neonates
For any NPO infant < 6mo & recommended for infants that are:
1. < 45 wks PCA*
2. Premature/IUGR/SGA*
3. Septic, have fever or shock*
4. Born to diabetic mothers*
*will have higher glucose requirement
5. On TPN or Glucose/D10
6. Suspected inborn errors of
metabolism/TCA cycle
7. Having long procedures
Typical basal glucose requirement: 5-8 mg/kg/min. If in doubt, start at 5, adjust prn.
PEDIATRICS & NEONATES
OBSTETRICS & OB EMERGENCIES
(Please see full OB pocket card for details)
*Redose Cefazolin/Clinda if EBL > 1500ml
Examples:
Anesthesia/Pre-Induction Checklist – MSMAID Gelb et al 2018
MMachine: □Complete standard machine check
□Ensure backup ventilation and O2 available
SSuction: □Confirm suction is available and working
MMonitors: □Standard: Pulse Ox, BP, EKG, Capnography, Temp
□Consider adjuncts: palpate pulse, auscultation, etc.
AAirway:
□Confirm appropriate plan and backup
□Prepare mask, ETT/LMA, laryngoscope/blades,
bougie, tape/tie
□Optimize intubation positioning (sniffing, ramp)
IIV: □Confirm adequate number & flow of IV’s
DDrugs: □Availability of standard & emergency meds
Always know who to call for help!
Epidural
Indication Level Drug and Dosing
Thoracic T4-T7 PCEA (bolus/lockout/rate/hr limit)
0.1% bupiv 5 mL/10 min/8 mL/32 mL
Abdominal T7-T12 PCEA (bolus/lockout/rate/hr limit)
0.1% bupiv 5 mL/10 min/8 mL/32 mL
Lower Abdominal,
C-Sections, Lower-Extremity
L1-L5 PIB 0.0625-0.1% bupiv + fentanyl 5-10 mL/30 min
PCEA 5-10 mL/10-15 min
Anaphylaxis Treatment
•Epinephrine: If cardiac arrest, 0.5-1.0
mg IV and begin ACLS. If hypotensive
or bronchospasm, 10-50 mcg IV
increments. 300mcg IM if no IV.
•Open IV fluids, albuterol
•Diphenhydramine 25-50mg IV,
ranitidine 50mg IV
•Hydrocortisone 100mg IV or
methylprednisolone 125mg IV
v 0.9
Kovacheva et al, Anesthesiology, 2015
Wikkelso et al, BJA, 2015
Hyperkalemia Tx
Medication Dose
Calcium 0.5-1g CaCl
Bicarbonate 25-50mEq
Insulin Regular 5-10 units IV
Glucose (D50) 25-50gm IV
Kayexalate 15-50g PO
Albuterol Puffs or neb PRN
Furosemide 40-80mg IV
Reproduced From: Difficult Airway Society 2015 guidelines for management of unanticipated difficult
intubation in adults
Frerk et al, British Journal of Anaesthesia, 2015
Contraindications to Spinal Anesthesia
•Coagulopathy: INR>2, platelets <80x109/L). History of anticoag use & bleeding
•Sepsis and/or hypovolemia
•Skin infection at injection site
•Elevated ICP, indeterminate neurologic disease
•Lack of emergency meds & equipment
•Relative: Infection away from injection site, unclear surgical duration
