APPENDIX 3: PEDIATRIC CRITICAL EVENTS CHECKLISTS

PEDIATRIC CRITICAL EVENTS CHECKLISTS

Reprinted with permission from the Society for Pediatric Anesthesia. Please refer to the following site for any updates to the checklist:

http://www.pedsanesthesia.org/newnews/Critical_Event_Checklists.pdf

AIR EMBOLISM (↓ETCO₂ ↓SaO₂ ↓BP)

Objective: Restore normal SpO₂, hemodynamic stability, and stop source of air entry.

✓ Call for help. Notify surgeon.

✓ Increase oxygen to 100%.

✓ Stop nitrous oxide and volatile agents.

✓ Find air entry point, stop source, and limit further entry.

• Flood wound with irrigation.

• Check for open venous lines or air in tubing.

• Turn off all pressurized gas sources (laparoscope, endoscope).

• Lower surgical site below level of heart (if possible).

• Perform Valsalva on patient using hand ventilation.

• Compress jugular veins intermittently if head or cranial case.

• Left side down once source controlled.

✓ Consider:

• Vasopressors (epinephrine, norepinephrine).

• Chest compressions: 100/min; to force air through lock, even if not in cardiac arrest.

✓ Call for transesophageal echocardiography (if available and/or diagnosis unclear).

ANAPHYLAXIS (RASH, BRONCHOSPASM, HYPOTENSION)

✓ Call for help.

✓ Increase oxygen to 100%.

✓ Remove suspected trigger(s).

• If latex is suspected, thoroughly wash area.

✓ Ensure adequate ventilation/oxygenation.

✓ Obtain IV access.

✓ If hypotensive, turn off anesthetic agents.

✓ Rapidly infuse NS or LR (10-30 mL/kg IV) to restore intravascular volume.

✓ Epinephrine (1-10 μg/kg IV as needed) to restore BP and ↓ mediator release.

• Epinephrine infusion (0.02-0.2 μg/kg/min) may be required to maintain BP.

✓ Adjuvants

• Beta-agonists (albuterol 4-10 puffs as needed) for bronchoconstriction.

• Methylprednisolone (2 mg/kg IV, max 100 mg) to ↓ mediator release.

• Diphenhydramine (1 mg/kg IV, max 50 mg) to ↓ histamine-mediated effects.

• Famotidine (0.25 mg/kg IV) or ranitidine (1 mg/kg IV) to ↓ effects of histamine.

✓ If anaphylactic reaction requires laboratory confirmation, send mast cell tryptase level within 2 hours of event.

COMMON CAUSATIVE AGENTS

Neuromuscular blockers, latex, chlorhexidine, IV colloids, antibiotics

BRADYCARDIA: UNSTABLE (BRADYCARDIA ± HEART BLOCK, HYPOTENSIVE WITH PULSES)

• Age < 30 days: HR < 100

• Age > 30 days < 1 year: HR < 80

• Age > 1 year: HR < 60

✓ Call for help and transcutaneous pacer.

✓ Hypoxia is common cause of bradycardia.

• Ensure pt is not hypoxic. Give 100% oxygen.

• Go to “Hypoxia” card if hypoxia persists.

✓ Stop surgical stimulation. If laparoscopy, desufflate.

✓ Consider:

• Epinephrine 2-10 μg/kg ...