N.B. Avoid giving drugs intramuscularly (IM) if possible. IM injections are painful and children do not like them. If IM drugs are necessary and more than one has to be given, combine them in the same syringe whenever possible.
Drugs for Premedication
Atropine: IV-0.02 mg/kg at induction (maximum dose, 0.6 mg); IM-0.02 mg/kg 30 to 60 minutes preoperatively (maximum, 0.6 mg). PO-same dose, 60 to 90 minutes preoperatively.
Glycopyrrolate: 0.01 mg/kg IV or IM.
Midazolam (Versed): 0.5 to 0.75 mg/kg PO, or 0.2 mg/kg intranasally, or 1.0 mg/kg PR, or 0.1 mg/kg IM, or 0.05 to 0.1 mg/kg IV (in a monitored area).
Clonidine: 4 µg/kg oral, or 1 to 2 µg/kg intranasal.
Dexmedetomidine: 2.5 µg/kg oral or 1 µg/kg intranasal. ( N.B. No data on neurotoxicity for intranasal injection)
Lorazepam (Ativan): for adolescents, 1 to 2 mg PO.
Midazolam/ketamine mixture: 0.3 to 0.5 mg/kg midazolam plus 2 to 6 mg/kg; ketamine plus 0.02 mg/kg atropine PO (This combination may result in considerable sedation—use in a monitored setting).
Antacids: H 2 -Histamine blocking agents
Cimetidine: 10 mg/kg PO, or 30 mg/kg PR, or 5 mg/kg IV.
Ranitidine: 2 to 5 mg/kg PO, or 1.5 mg/kg IV or IM.
Sodium citrate: 0.4 ml/kg PO.
Drugs to Speed Gastric Emptying
Metoclopramide: 0.15 mg/kg IV. ( Note: Atropine blocks the effect of metoclopramide and should be withheld until induction of anesthesia.)
Topical local anesthetics
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.
Amethocaine Gel (Ametop): Tetracaine (4%). Apply to skin 45 minutes before procedure. Cover with occlusive dressing. Caution: not recommended for infants < 1 month.
Ela-Max (4% Lidocaine): Apply to skin 30 min. before procedure. Cover with occlusive dressing.
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.
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.
Etomidate : 0.25 to 0.3 mg/kg
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
Propofol (Diprivan): infants 1.5 to 2 mg/kg, children 2.5 to 3.5 mg/kg.
Ketamine: 2 mg/kg IV or 4 to 8 mg/kg IM (plus atropine 0.02 mg/kg IM/IV)
Drugs for Intubation
Succinylcholine: infants, 2 mg/kg IV; older children, 1 mg/kg IV or 4 to 5 mg/kg IM.
Rocuronium: 0.3 to 1.2 mg/kg IV.
( N.B. Large doses of rocuronium in infants may result in prolonged blockade)
Vecuronium: 0.1 mg/kg IV.
( NB: Do not inject rocuronium or vecuronium immediately after thiopental; thiopental precipitates and may occlude IV.)
Cis- atracurium: 0.1 to 0.2 mg/kg.
Pancuronium: 0.1 mg/kg.
Topical lidocaine for laryngeal spray: maximum dose 4 mg/kg.
Fentanyl: Bolus doses 1 to 2 μg/kg IV prn
IV infusion for major surgery; loading dose 5 μg/kg, infuse at 2 to 4 μg/kg/hr.
Hydromorphone: 0.01-0.02 mg/kg IV
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.
Remifentanil: IV loading dose—0.5 to 2 µg/kg.
IV Infusion—0.05 to 0. 3 µg/kg/min.
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
Usual route of administration IV; only administer IM succinylcholine in emergency situation.
Give initial and repeat doses preferably as indicated by nerve stimulator, especially in infants (whose response to these drugs is extremely variable).
Remember that potent volatile agents (especially sevoflurane and isoflurane) reduce the dose requirement of nondepolarizing drugs.
Infusion rates are given as a guide only and should be modified as indicated by neuromuscular blockade monitoring.
Cis -atracurium: initial dose 0.1 mg/kg, repeat dose 0.03 mg/kg.
Infusion: loading dose 0.1 mg/kg, infusion at 2 to 3 μg/kg/min.
Pancuronium: initial dose 0.06 to 0.1 mg/kg; repeat doses should not exceed one sixth of the initial dose.
Rocuronium: initial dose 0.3 to 1.2 mg/kg, incremental doses 0.15 mg/kg;
Infusion: rate: 10 to 12 μg/kg/min.
Vecuronium: loading dose 0.1 mg/kg, incremental doses 0.02 mg/kg.
Infusion rate 0.1 mg/kg/hr.
Antagonism of Neuromuscular Blockade
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
Atropine 0.02 mg/kg, followed by edrophonium 1 mg/kg.