Drugs for Premedication

Drugs to Speed Gastric Emptying

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  Metoclopramide: 0.15 mg/kg IV. ( Note: Atropine blocks the effect of metoclopramide and should be withheld until induction of anesthesia.)

Topical local anesthetics

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  EMLA (eutectic mixture of local anesthetics): Prilocaine (2.5%) and Lidocaine (2.5%). Apply to skin 60-90 min. before procedure. Cover with occlusive dressing. Caution: metabolism of prilocaine may result in methemoglobinemia in neonates: limit application to 1 gm EMLA cream over 10 cm ² skin.

  
  
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  Amethocaine Gel (Ametop): Tetracaine (4%). Apply to skin 45 minutes before procedure. Cover with occlusive dressing. Caution: not recommended for infants < 1 month.

  
  
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  Ela-Max (4% Lidocaine): Apply to skin 30 min. before procedure. Cover with occlusive dressing.

  
  
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  S-Caine Patch: Eutectic mixture of 70 mg lidocaine and 70 mg tetracaine in each patch. Apply 20 min. before procedure. Cover with occlusive dressing.

Induction Agents

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  Thiopental sodium (Pentothal): neonates (younger than 1 month), up to 3 to 4 mg/kg; infants (1 month–1 year), up to 7 to 8 mg/kg; children, up to 5 to 6 mg/kg.

  
  
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  Etomidate : 0.25 to 0.3 mg/kg

  
  
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  Methohexital: up to 2 mg/kg IV or 15-25 mg/kg of a 1% or 20-30 mg/kg of a 10% solution PR

  
  
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  Propofol (Diprivan): infants 1.5 to 2 mg/kg, children 2.5 to 3.5 mg/kg.

  
  
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  Ketamine: 2 mg/kg IV or 4 to 8 mg/kg IM (plus atropine 0.02 mg/kg IM/IV)

Drugs for Intubation

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  Succinylcholine: infants, 2 mg/kg IV; older children, 1 mg/kg IV or 4 to 5 mg/kg IM.

  
  
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  Rocuronium: 0.3 to 1.2 mg/kg IV.

  
  
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  ( N.B. Large doses of rocuronium in infants may result in prolonged blockade)

  
  
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  Vecuronium: 0.1 mg/kg IV.

  
  
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  ( NB: Do not inject rocuronium or vecuronium immediately after thiopental; thiopental precipitates and may occlude IV.)

  
  
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  Cis- atracurium: 0.1 to 0.2 mg/kg.

  
  
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  Pancuronium: 0.1 mg/kg.

  
  
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  Topical lidocaine for laryngeal spray: maximum dose 4 mg/kg.

Maintenance

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  Fentanyl: Bolus doses 1 to 2 μg/kg IV prn

  
  
  
  
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    IV infusion for major surgery; loading dose 5 μg/kg, infuse at 2 to 4 μg/kg/hr.

  
  
  
  
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  Hydromorphone: 0.01-0.02 mg/kg IV

  
  
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  Morphine: 10 to 100 μg/kg IV or intravenous infusion (for children older than 5 years of age); loading dose 100 μg/kg over 5 minutes, infusion at 40 to 60 μg/kg/hr.

  
  
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  Remifentanil: IV loading dose—0.5 to 2 µg/kg.

  
  
  
  
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    IV Infusion—0.05 to 0. 3 µg/kg/min.

  
  
  
  
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  Acetaminophen: 30 to 40 mg/kg single dose PR followed by 20 mg/kg q6h (maximum daily dose 90 to 100 mg/kg)

Neuromuscular Blocking Drugs

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  Usual route of administration IV; only administer IM succinylcholine in emergency situation.

  
  
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  Give initial and repeat doses preferably as indicated by nerve stimulator, especially in infants (whose response to these drugs is extremely variable).

  
  
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  Remember that potent volatile agents (especially sevoflurane and isoflurane) reduce the dose requirement of nondepolarizing drugs.

  
  
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  Infusion rates are given as a guide only and should be modified as indicated by neuromuscular blockade monitoring.

  
  
  
  
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    Cis -atracurium: initial dose 0.1 mg/kg, repeat dose 0.03 mg/kg.

    
    
    
    
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      Infusion: loading dose 0.1 mg/kg, infusion at 2 to 3 μg/kg/min.

    
    
    
    
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    Pancuronium: initial dose 0.06 to 0.1 mg/kg; repeat doses should not exceed one sixth of the initial dose.

    
    
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    Rocuronium: initial dose 0.3 to 1.2 mg/kg, incremental doses 0.15 mg/kg;

    
    
    
    
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      Infusion: rate: 10 to 12 μg/kg/min.

    
    
    
    
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    Vecuronium: loading dose 0.1 mg/kg, incremental doses 0.02 mg/kg.

    
    
    
    
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      Infusion rate 0.1 mg/kg/hr.

    
    

  
  

Antagonism of Neuromuscular Blockade

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  Atropine 0.02 mg/kg or glycopyrrolate 0.01 mg/kg mixed with neostigmine 0.05 mg/kg-administer slowly; use a nerve stimulator to monitor effect; OR

  
  
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  Atropine 0.02 mg/kg, followed by edrophonium 1 mg/kg.