page air embolism - venous 1 operating theatre 2

Operating TheatreCrisis Manual

Please do NOT remove this book from theatreYour colleagues may need it in an emergency

Version 2.2, June 2016

Adapted with permission from the OR Crisis Checklists at www.projectcheck.org/crisis.

All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the materials lies with the reader.

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Air Embolism - Venous

Anaphylaxis

Bradycardia - Unstable

Cardiac Arrest - Asystole/PEA

Cardiac Arrest - VF/VT

Failed Airway

Fire - Airway

Fire - Non-airway

Haemorrhage

High Airway Pressure

Hypotension

Hypoxia

Local Anaesthetic Toxicity

Malignant Hyperthermia

Tachycardia - Unstable

Trauma

TURP Syndrome

Obstetrics - Haemorrhage

Paediatrics - Doses

SUSPECTED EVENT PAG

E

Bronchospasm

Important Phone NumbersL2 Duty Anaesthetist 23322L3 Duty Anaesthetist 23634Obstetric Anaesthetist 23470Theatre Co-ordinator 23565Tech Co-ordinator 23813Blood Bank 98472/98470MTP attendant 24082Operator (emergency) 99777

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1 Air Embolism - VenousDecreased end-tidal CO2, decreased oxygen saturation, hypotension, tachycardia, ECG changes

1 Callforhelpandadefibtrolley Ask: “Who will be the crisis leader?”

2 Turn FiO2 to 100%

3 Inform the Surgeon

4 Turnoffnitrousoxide

5 Stop source of air entry Fill wound with irrigation Lower surgical site below level of heart if possible Stop all pressurised gas sources Search for entry point (including open venous lines, pulsed lavage and laparoscopic insufflation gas) Consider intermittent jugular vein compression if head or cranial case

6 Consider... Positioning patient with left side down once ongoing air entry controlled • Continue appropriate monitoring while repositioning Placing bone wax or cement on bone edges Aspiration of air from a central line Valsalva maneuver Transoesophageal echo (TOE) if diagnosis unclear Chest compressions, even if not in cardiac arrest, to force air through right ventricle Use of vasopressors / inotropes

7 Use ETCO2 to monitor progression and resolution of embolus, and for assessment of adequate cardiac output

Critical CHANGESIf PEA develops: go to Checklist 5If VT/VF develops: go to Checklist 6

DRUG DOSES and treatmentsAdrenaline 5 – 200 mcg IV bolusDobutamine 5mcg/kg/min, increase by

5mcg/kg/min every 10 minutes as required

Consider noradrenaline infusion

1

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2 AnaphylaxisHypotension, bronchospasm, high peak-airway pressures, decrease or lack of breath sounds, tachycardia, urticaria

Common CAUSATIVE AGENTSNeuromuscular blocking agentsAntibioticsLatex productsIV contrast

DRUG DOSES and treatmentsAdrenaline IV Bolus 20 – 200 mcg if pulse IV Bolus 1mg if no pulse, repeat as necessary

Infusion 3mg/50mL 3-40mL/hr

Vasopressin IV Bolus 1 – 2 units Infusion 2 units/hourHydrocortisone IV Bolus 100 mg IVGlucagon IV Bolus 1 – 2 mg IV q5minSalbumatol IV Bolus 100-200mcg

Critical CHANGESIf PEA develops: go to Checklist 5If VT/VF develops: go to Checklist 6

1 Callforhelpandthedefibtrolley Ask: “Who will be the crisis leader?”2 GettheAnaphylaxisBox(L2 ramp or L3 PACU) Anaphylaxis cards are located in appendix of this manual (Note: separate Adult and Paeds cards)3 If cardiac arrest give 1mg IV adrenaline If PEA: go to Checklist 5 If VT/VF: go to Checklist 6 4 Remove possible triggers including latex, chlorhexidine and colloid5 Ensure airway established/secure Turn FiO2 to 100% and consider turning down volatile agent6 Ensure large bore IV access7 Give rapidIVfluidbolus of 2L warmed crystalloid (20ml/kg) and repeat as required8 Give adrenaline bolus Grade 2 (moderate) reactions 20mcg Grade 3 (life threatening) reactions 100-200mcg IV bolus If no IV access 500mcg IM (lateral thigh) q5min9 If >3 boluses of adrenaline required then start adrenaline infusion 3mg Adrenaline in 50mL start at 3mL/hr!0 If not responding refer to “Refractory Management” card (in Appendix)!1 Consider... Other diagnoses: see “Differential Diagnosis” card Terminating surgical procedure ICU/HDU admission Caution with extubation if airway oedema!2 Once stable use “Post Crisis Management” card Consider IV steroids and oral antihistamine (IV antihistamines not recommended) Trypase levels at 1, 4 and > 24 hours (red top tube) 2

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3 Bradycardia - UnstableHR < 50 bpm with hypotension, acutely altered mental status, shock, ischaemic chest discomfort, or acute heart failure


2 Turn FiO2 to 100% Verify oxygenation/ventilation adequate

3 Give Atropine 0.6mg IV (may repeat up to 3mg)

4 Stop surgical stimulation (if laparoscopy, desufflate)

5 Ifatropineineffective: Start adrenaline infusion - or - Start transcutaneous pacing

6 Consider... Turn off volatile anaesthetics if patient remains unstable Call for expert consultation (e.g. Cardiologist) Assessing for drug induced causes (e.g. beta blockers, calcium channel blockers,

digoxin) Call for cardiology consultation if myocardial infarction suspected (e.g. ECG changes)

TRANSCUTANEOUS PACING instructions1. Place defibrillatorpads front and back2. Connect 3-lead ECG from defibrillator to the patient3. Press PACER button on defibrillator4. Set PACER RATE (ppm) to 80/minute

(adjust based on clinical response once pacing is established)

5. Start CURRENT at 60mA and increase until electrical capture (pacer spikes aligned with QRS complex)

6. Set final milliamperes 10 mA above initial capture level7. Confirmeffectivecapture • Electrically: assess ECG tracing • Mechanically: palpate femoral pulse (carotid pulse unreliable)

During RESUSCITATION

Airway: Assess and secureCirculation: • Confirm adequate IV or IO access

• Consider IV fluids wide openIf PEA develops, go to Checklist 5

Critical CHANGES

Beta-blocker Glucagon: 2 – 4 mg IV pushCalcium channel blocker Calcium chloride: 1 g IVDigoxin: Digoxin Immune FAB; consult pharmacy for dosing

DRUG DOSES and treatments

OVERDOSE treatments

Atropine 0.6 mg IV, may repeat up to 3 mg totalAdrenaline 2-20mL/hr (4mg in 40mL)

3

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4 BronchospasmIncreased airway pressures, wheezing on auscultation, slowly increasing slope on capnogram

1 Callforhelpandadefibtrolley Ask: “Who will be the crisis leader?”2 Turn FiO2 to 100%3 Stop surgical stimulation (if laparoscopy, desufflate)4 Deepenvolatileanaesthetic(preferablysevoflurane)5 AdjustI:Eratiotoallowadequateexhalationtime6 ExcludeendobronchialintubationorkinkedETT Suction ETT7 If haemodynamic instability Consider anaphylaxis (hypotension, tachycardia, rash) go to Checklist 2 Consider gas trapping • Disconnect circuit and allow adequate exhalation Consider pneumothorax8 Administer inhaled salbumatol Use MDI and elbow with red adaptor or 50mL syringe9 If severe consider IV adrenaline!0 Consider other bronchodilators and adjuncts Ketamine, hydrocortisone, inhaled adrenaline, magnesium!1 Consider arterial line and performing an ABG

DRUG DOSES and treatmentsSalbutamol IV bolus 250mcg Infusion 5-25mcg/minAdrenaline IV bolus 10-100mcg Infusion 5mg in 50mls @ 3-30mls/hrKetamine IV bolus 0.2-1.0mg/kgHydrocortisone IV bolus 100mgMagnesium IV slow 10mmol over 10 minutes

Critical CHANGESIf CARDIAC ARREST: Asystole/PEA: go to Checklist 5 VF/VT: go to Checklist 6If ANAPHYLAXIS: go to Checklist 2

4

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5 Cardiac Arrest - Asystole/PEANon-shockable pulseless cardiac arrest

Asystole PEA

During CPRAirway: • Bag-mask sufficient (if ventilation adequate)Circulation: • Confirm adequate IV or IO access

• Consider IV fluids wide openAssign roles: • Chest compressions, Airway, Vascular access,

Documentation, Defib trolley, Time keeping

Local anesthetic: Intralipid 1.5mL/kg bolus go to Checklist 14Beta-blocker: Glucagon 2 – 4 mg IV push Calcium channel blocker: Calcium chloride 1 g IV

Adrenaline: 1 mg IV, repeat every 2nd cycleDRUG DOSES and treatments

TOXIN treatment

1 Callforhelpandadefibtrolley Ask: “Who will be the crisis leader?” Say: “The top priority is high-quality CPR”2 Turn FiO2to100%,turnoffvolatileanaesthetics3 Start CPR and assessment cycle... Perform CPR • “Hard and fast” about 100 compressions/minute • Ensure full chest recoil with minimal interruptions • 8 breaths/minute, do not overventilate Give Adrenaline • Give 1mg IV immediately • Repeat 1mg IV adrenaline every 2nd cycle (3-5 minutes) Assess every 2 minutes • Change CPR compression provider • Check ETCO2 If: <1.3kPa (10mmHg), evaluate CPR technique If: Sudden increase to >5kPa (40mmHg), may indicate return of spontaneous

circulation • Check rhythm: if rhythm organised check pulse If: Asystole/PEA continues: - Resume CPR and assessment cycle (restart Step 4) - Read aloud Hs and Ts (see list in right column) If: VF/VT - Resume CPR - go to Checklist 6

Hs & Ts• Hydrogen ion (acidosis)• Hyperkalaemia• Hypothermia• Hypovolaemia

• Hypoxia• Tamponade (cardiac)• Tension pneumothorax• Thrombosis

(coronary/pulmonary)

• Toxin (local anesthetic, beta blocker, calcium channel blocker)

HYPERKALEMIA treatmentCalcium chloride: 1g IV slowInsulin: 10iu actrapid IV with 50mls of 50% dextroseSodium Bicarbonate 8.4% (if pH<7.2): 1-2mmol/kg slow IV push (1ml=1mmol)

5

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6 Cardiac Arrest - VF/VTShockable pulseless cardiac arrest

VF VT

During CPRAirway: • Bag-mask sufficient (if ventilation adequate)Circulation: • Confirm adequate IV or IO access

• Consider IV fluids wide openAssign roles: • Chest compressions, Airway, Vascular access,

Documentation, Defib trolley, Time keeping

1. Place DefibrillatorPads on chest and connect to defib2. Turn defibrillator ON, and select ENERGY LEVEL Lifepak 20: 360 J3. Press CHARGE while continuing CPR4. Say “Stand clear”, check everybody is clear then press the

SHOCK button

DEFIBRILLATOR instructions

1 Callforhelpandadefibtrolley Ask: “Who will be the crisis leader?” Say: “The top priorities are high-quality CPR and early defibrillation”2 Turn FiO2to100%,turnoffvolatileanaesthetics3 Start CPR and assessment cycle... Perform CPR • “Hard and fast” 100-120 compressions/minute • Ensure full chest recoil with minimal interruptions • 8 breaths/minute, do not overventilate Defibrillate as soon as possible • Charge defibrillator prior to stopping to check rhythm • Resume CPR immediately after shock and continue for further 2 minutes before

reassessing Give Adrenaline • Give 1mg IV Adrenaline after 2nd shock • Repeat every 2nd cycle (3-5 minutes) Give amiodarone for refractory VF/VT • Give amiodarone 300mg after 3rd shock Assess every 2 minutes • Change CPR compression provider • Check ETCO2 If: <1.3kPa (10mmHg), evaluate CPR technique If: Sudden increase to >5kPa (40mmHg), may indicate return of spontaneous

circulation • Treat reversible causes, consider reading aloud Hs & Ts • Check rhythm: if rhythm organised check pulse If: VF/VT continues: Resume CPR and assessment cycle If: Asystole/PEA: go to Checklist 5

Amiodarone 300 mg IV/IO Magnesium 1 to 2 g IV/IO for Torsades de Pointes

Adrenaline 1 mg IV, repeat every 3 – 5 mins.


ANTIARRHYTHMICS

Hs & Ts• Hydrogen ion (acidosis)• Hyperkalaemia• Hypothermia• Hypovolaemia

• Hypoxia• Tamponade (cardiac)• Tension pneumothorax• Thrombosis

(coronary/pulmonary)

• Toxin (local anesthetic, beta blocker, calcium channel blocker)

6

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7 Failed Airway2 unsuccessful intubation attempts by an airway expert

1 Callforexperiencedanaesthetichelp Ask: “Who will be the crisis leader?”2 Assignstafftogetdifficultairwaykitandavideolaryngoscope3 Bag-mask ventilate with100%Oxygen4 Ensure monitoring with SpO2, ECG and ETCO2

5 Is ventilation adequate?

Consider awakening patient or alternative approaches to secure airway...

• Operation using LMA, face mask • Video laryngoscope • LMA as conduit to intubation • Return to spontaneous ventilation • Different blades • Intubating bougie/stylet • Fiberoptic intubation • Light wand • Retrograde intubation • Blind oral or nasal intubationIf awakening patient, consider: • Awake intubation • Do procedure under regional/local • Cancel the case

Implement surgical airway

Ventilation remains NOT ADEQUATE

Optimize ventilation • Manipulations (head & neck, larynx, device) • Adjuncts - oral/nasal airway, bougie, introducer, laryngoscope • Size/Type • Suction/O2 flow • Muscle tone - paralyse or reverse Check equipment • Using 100% O2 • Capnography • Circuit integrity

UseVortexapproach(also see appendix)

Prepare for surgical airway (prep neck, get surgical airway kit, call for surgeon)

Ventilation NOT ADEQUATE Switch list if ventilation

status changes

Ventilation ADEQUATE

FaceMask

LMA ETT

7

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8 Fire - AirwayEvidence of fire (smoke, odour, flash) in a patient’s airway

1 Callforhelpandactivatefirealarm Ask: “Who will be the crisis leader?”2 Get the fireextinguisher and fireblanket 3 Attempttoextinguishfire Turn off medical gases Disconnect ventilator Remove endotracheal tube Remove flammable material from airway Pour saline into airway4 Afterfireextinguished Re-establish ventilation using self-inflating bag with room air • If unable to re-establish ventilation go to Checklist 6 • Avoid N2O and minimize FiO2 Confirm no secondary fire • Check surgical field, drapes and towels Assess airway for injury or foreign body • Assess ETT integrity (fragments may be left in airway) • Consider bronchoscopy5 Assess patient status and devise ongoing management plan Reintubate early if significant risk of airway trauma6 Save involved materials/devices for review

8

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9 Fire - Non-airwayEvidence of fire (smoke, odour, flash) on patient or drapes or anywhere in the theatre complex

1 Callforhelpandactivatefirealarm Ask: “Who will be the crisis leader?”

2 Get the fireextinguisher and fireblanket

3 Attempttoextinguishfire

FIRST ATTEMPT Avoid N2O and minimize FiO2 Remove drapes / all flammable materials from patient Extinguish burning material with saline or saline soaked

gauze DO NOT use • Alcohol-based solutions • Any liquid on active electrical equipment (laser,

diathermy, anaesthesia machine etc.) Fire PERSISTS after 1 ATTEMPT Use fire extinguisher (safe in wounds) or fire blanket

Fire STILL PERSISTS Evacuate patient (if risk allows) Close theatre door Turn OFF gas supply to room4 Afterfireextinguished Maintain airway Assess patient for injury at site of fire, and for inhalational

injury if not intubated Confirm no secondary fire • Check surgical field, drapes and towels

5 Assess patient status and devise ongoing management plan6 Save involved materials/devices for review

Each theatre becomes autonomous` Two decisions need to be made • Do we need to evacuate? • If yes, can we safely evacuate ourselves and the patient within 5

minutes? Immediate evacuationFor an intubated patient with open cavity transport may not be in the

best interests of patient or staffThe safest evacuation for staff and patients may be to cease operating

and leave the patient in theatreONLY if time allows: • Surgical team to obtain haemostasis and cover wound • Anaesthetic team to isolate anaesthetic machine and ventilate with

low flowsNon-immediate evacuation (theatre not immediately threatened) Consult with floor fire wardenEach theatre should be preparing and planning for evacuation If not safe for scouts to move to warden then evacuation MUST

commence

THEATRE COMPLEX FIRE

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10 HaemorrhageAcute massive bleeding

SPECIAL PATIENT POPULATIONSObstetrics: go to Checklist 19Trauma: go to Checklist 17 Consider damage control resuscitation Consider TXA: 1g IV (caution if >3 hrs post trauma)Non-surgical uncontrolled bleeding despite massive transfusion • Consider giving Recombinant Factor VIIa: 90 mcg/kg IV - Surgical bleeding must first be controlled - use with CAUTION in patients at risk for thrombosis - DO NOT use when PH is < 7.2

DRUG DOSES and treatmentsHYPOCALCEMIA treatmentCalcium Chloride 10% 1g IV slow (repeat PRN)

HYPERKALEMIA treatmentCalcium chloride 1g IV slowInsulin 10iu actrapid IV with 50mls of 50% dextroseSodium Bicarbonate 8.4% 1-2mmol/kg slow IV push (1ml=1mmol)(if pH<7.2)

1 Call for help Ask: “Who will be the crisis leader?”2 OpenIVfluidsandensureadequateIVaccess3 Turn FiO2 to 100% and turn down volatile anaesthetics4 Consider 3 units of O Neg blood from L2 blood fridge5 Activate Massive Transfusion Protocol Call Blood Bank (98472 or 98470) Call MTP Attendant (24082) or designate Theatre HCA as MTP

attendant Assign one person as primary contact for blood bank6 Request rapid infusion device (e.g. Level one)7 Discuss management plan between surgical, anaesthetic and nursing

teams8 Keep patient warm9 Send urgent blood tests ABG / CBC / COAG, at times suggested by MTP Consider using TEG!0 Consider... Cell saver if non-malignant, non-contaminated Senior surgical support Electrolyte disturbances (hypocalcaemia and hyperkalaemia) Uncrossmatched type O blood if crossmatched blood not available Damage control surgery (pack, close, resuscitate) Discussion with transfusion medicine specialist (via blood bank)!1 Notify blood bank once decision made to cease Massive Transfusion Protocol

Transfusion GoalsMAP: >50mmHg but do not normalise until surgical control >70mmHg if head injuryHb: >70g/LFibrinogen: >2.0g/LPlatelets: >75 x 109/LCalcium: >1.0mmol/L

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11 High Airway PressurePersistently increased PAWP >40cmH20, hypoxaemia, inadequate tidal volume

DRUG DOSES and treatmentsBRONCHOSPASMSalbutamol Bolus 250mcg Infusion 5-25mcg/minAdrenaline Bolus 10-100mcg Infusion 5mg in 50mls @ 3-30mls/hr

PULMONARY OEDEMAFrusemide Bolus 20mg IVGTN Infusion 50mg in 50mls @ 1-20mL/hrAirway Ensure adequate PEEP

1 Call for help Ask: “Who will be the crisis leader?”2 Inform surgeon and stop stimulation3 Turn FiO2 to 100% 4 Switch to manual ventilation5 Ventilate patient with ambubag connected to O2 outlet at >10L/min If airway pressures normal go to CIRCUIT PROBLEM If high airway pressures remains go to PATIENT PROBLEM

Ventilate with ambubag Replace/repair circuit/machine Administer alternate anaesthesia

(consider starting TIVA)

Ensure patent airway • Laryngospasm • Confirm ETT/LMA position • Pass suction catheter down ETT • Check/replace filter Consider causes of reduced airway/chest

compliance • Bronchospasm/anaphylaxis see critical changes box • Inadequate muscle relaxation/depth of

anaesthesia • Pulmonary oedema • Aspiration • Atelectasis • Pneumothorax • Malignant hyperthermia • Abnormal patient anatomy Consider chest x-ray

Critical CHANGESIf CARDIAC ARREST: Asystole/PEA: go to Checklist 5 VF/VT: go to Checklist 6If ANAPHYLAXIS: go to Checklist 2If BRONCHOSPASM: go to Checklist 4If MALIGNANT HYPERTHERMIA: go to Checklist 15

If PATIENT PROBLEM6 If CIRCUIT PROBLEM

or

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12 HypotensionUnexplained drop in blood pressure refractory to initial treatment

DRUG DOSES and treatmentsEphedrine 3-9 mg IV, repeat as neededMetaraminol 0.5-2.0mg IV, repeat as neededAdrenaline Bolus 10-100mcg IV Infusion 2-20mL/hr (4mg in 40mL)Noradrenaline Infusion 2-20mL/hr (4mg in 40mL)

1 Call for help Ask: “Who will be the crisis leader?”2 Check... Pulse Blood pressure Equipment Heart rate and rhythm • If BRADYCARDIA go to Checklist 3 • If VF / VT go to Checklist 6 • If PEA go to Checklist 5 • If other UNSTABLE TACHYCARDIA, go to Checklist 163 RunIVfluidswideopen4 Give vasopressors and titrate to response MILD hypotension: give ephedrine or metaraminol SIGNIFICANT/REFRACTORY hypotension: Give

adrenaline bolus, consider starting adrenaline infusion

5 Turn FiO2 to 100% and turn down volatile anaesthetics6 Inspectsurgicalfieldforbleeding • If BLEEDING, go to Checklist 107 Consider actions... Place patient in Trendelenburg position Obtain additional IV access Place arterial line Echocardiography if refractory or significant

hypotension

8 Consider causes... Operativefield • Mechanical or surgical manipulation • Insufflation during laparoscopy • Retraction • Vagal stimulation • Vascular compression Unaccounted blood loss • Blood in suction canister • Bloody sponges/gauzes • Blood on the floor • Internal bleeding Drugs / Allergy • Anaphylaxis go to Checklist 2 • Recent drugs given • Dose error • Wrong drug • Drugs used in the surgical field

(i.e., intravascular injection of local anesthetic drugs)

Respiratory• Increased PEEP• Hypoventilation• Hypoxia go to Checklist 13• Persistent hyperventilation• Pneumothorax• Pulmonary oedemaCirculation• Air embolism go to Checklist 1• Malignant hyperthermia go to Checklist 15• Bone cementing (methylmethacrylate

effect)• Myocardial ischaemia• Emboli (pulmonary, fat, septic, amniotic,

CO2)• Severe sepsis• Tamponade

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13 HypoxiaUnexplained oxygen desaturation

1 Call for help Ask: “Who will be the crisis leader?”

2 Turn FiO2 to 100% at high flow rates Confirm FiO2 = 100% on gas analyser Confirm presence of end-tidal CO2 and changes

in capnograph morphology

3 Hand ventilate to assess compliance

4 Listen to breath sounds

5 Check... Blood pressure, peak airway pressure, pulse ET tube position and patency Pulse oximeter placement Circuit integrity: look for disconnection, kinks,

holes6 Consider actions to assess possible

breathing issue... Take a blood gas Suction ETT (to clear secretions) Remove circuit and use ambu-bag Bronchoscopy

7 Consider causes... Is an Airway / Breathing issue suspected?

Circulation• Embolism - Pulmonary embolus - Air embolism, go to Checklist 1 - Other emboli (fat, septic, CO2,

amniotic fluid)• Heart disease - Congestive cardiac failure - Coronary heart disease - Myocardial ischaemia - Cardiac tamponade - Congenital / anatomical defect• Severe sepsis• If hypoxia associated with

hypotension, go to Checklist 12Drugs / Allergy• Recent drugs given• Dose error / allergy / anaphylaxis• Dyes and abnormal haemoglobin

(e.g. methaemoglobinaemia, methylene blue)

NO airway issue suspected YES airway issue suspected

Airway / Breathing• Aspiration• Atelectasis• Bronchospasm go to Checklist 4• Hypoventilation• Obesity / positioning• Pneumothorax• Pulmonary oedema• Right mainstem intubation• Ventilator settings, leading to auto-PEEP

Additional DIAGNOSTIC TESTS• Fibreoptic bronchoscope• Chest x-ray / image intensifier• ECG• Transoesophageal echo

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14 Local Anaesthetic ToxicityAltered mental status, severe agitation, seizures, cardiovascular collapse associated with recent local anaesthetic injection or infusion

Intralipid 20% Immediately giveBolus: 1.5ml/kg over 1 minute (for 70kg patient give 100ml) - then-Infusion: Start at 15ml/kg/hr (for 70kg patient start infusion at 1000ml/hr)After 5 minutes: • If cardiovascular stability has not been restored, or • If an adequate circulation deteriorates - then - • Give a maximum of two repeat boluses (same

dose as initial bolus) • Double the infusion rate to 30ml/kg/hr (2000ml/hr for 70kg patient) • Do not exceed maximum cumulative dose of

12ml/kg (840ml for 70kg patient)


Critical CHANGESIf CARDIAC ARREST: Asystole/PEA: go to Checklist 5 VF/VT: go to Checklist 6

1 STOP injecting local anaesthetic


3 Maintain airway • If necessary secure with an endotrachael tube

4 Deliver100%oxygen

5 Ensure adequate ventilation • Hyperventilation may help in the setting of metabolic acidosis

6 ConfirmorestablishIVaccess

7 Control seizures • Use midazolam, thiopentone or propofol in small, incremental doses

8 Give Intralipid 20% IV • Immediate bolus followed by an infusion • Propofol is NOT a suitable substitute

9 Consider... • Conventional therapies to treat hypotension, bradycardia or tachyarrhythmias • Lignocaine should NOT be used as an anti-arrhyhthmic therapy • Use standard protocols for treatment of arrhythmias, recognising they may be

very refractory to treatment • Arterial blood gas

During CARDIAC ARREST• Continue Intralipid infusion• Recovery from LA induced cardiac arrest may take >1 hour• Consider use of cardiopulmonary bypass14

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15 Malignant HyperthermiaIn the presence of a triggering agent: unexpected, unexplained increase in end-tidal CO2, unexplained tachycardia/tachypnoea, prolonged masseter muscle spasm after suxamethonium. Hyperthermia is a late sign

TRIGGERING AGENTS

• Inhalational (volatile) anesthetics• Suxamethonium

DIFFERENTIAL diagnosis

Cardiorespiratory• Hypoventilation• Sepsis

Endocrine• Thyrotoxicosis• Pheochromocytoma

Iatrogenic• Exogenous CO2

source (e.g., laparoscopy)

• Overwarming• Neuroleptic

Malignant Syndrome

Neurologic• Meningitis• Intracranial bleed• Hypoxic

encephalopathy • Traumatic brain

injury

Toxicology• Radiologic contrast

neurotoxicity• Anticholinergic syndrome• Cocaine, amphetamine,

salicylate toxicity• Alcohol withdrawal


Dantrolene • 2.5 mg/kg IV every 5 minutes until symptoms subside

• May require up to 30mg/kg • Mix each ampoule with 60ml

sterile water Bicarbonate • 1 – 2 mmol/kg, slow IV push • For suspected metabolic

acidosis

HYPERKALEMIA treatmentCalcium chloride 10 mg/kg IVInsulin 10iu actrapid IV with 50ml

of 50% dextrose

1 Call for help and the MH Trolley Ask: “Who will be the crisis leader?”2 Assigndedicatedpersontostartmixing

dantrolene3 Turnoffvolatileanaestheticsand transition to

non-triggering anaesthetics • DO NOT delay treatment to change circuit

or CO2 absorber4 Turn FiO2 to 100% at flows of ≥ 10L/min5 Hyperventilate patient 6 Request chilled IV saline7 Terminate procedure if possible8 Give Dantrolene • (9 ampoules is ~2.5mg/kg for a 70kg patient)9 Give bicarbonate for suspected metabolic

acidosis (maintain pH >7.2)!0 Treat hyperkalaemia, if suspected!1 Treat dysryhthmias, if present • Standard antiarrythmics acceptable: • DO NOT USE calcium channel blockers

!2 Send urgent blood tests... • Arterial blood gas • Electrolytes • Serum creatine kinase (CK) • Serum / urine myoglobin • Coagulation profile!3 Initiate supportive care Consider cooling patient if temperature

> 38.5°C: • STOP cooling if temperature < 38°C • Lavage open body cavities • Nasogastric lavage with cold water • Apply ice externally • Infuse cold saline intravenously Place urinary catheter, monitor output Call ICU

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16 Tachycardia - UnstablePersistent tachycardia with hypotension, ischaemic chest pain, altered mental status or shock


2 Turn FiO2 to 100% and turn down volatile anaesthetics

3 Analyse rhythm • If wide complex, irregular: treat as VF, go to Checklist 6 • Otherwise prepare for cardioversion

4 Prepare for immediate synchonised cardioversion 1. Sedate all conscious patients unless deteriorating rapidly 2. Turn monitor/defibrillator ON, set to defibrillator mode 3. Place DefibrillatorPadson chest 4. Engage synchronization mode (black SYNC button) 5. Look for triangular sense maker on the R-waves indicating synchronization mode 6. If sense markers are incorrect attach defib ECG and select an alternate lead to display

5 Cardiovert at appropriate energy level 1. Determine appropriate energy level using Biphasic Cardioversion table at right; begin with lowest energy level and progress as needed 2. Select energy level and press CHARGE button 3. Ensure all staff members clear of patient 4. Press and hold SHOCK button 5. Check monitor; if tachycardia persists, increase energy level 6. Engage synchronization mode after delivery of each shock

6 Consider adjuctive drug therapy

7 Consider cardiology consultation

CONDITION ENERGY LEVEL (progression)

Narrow complex, regular 50 J 100 J 150 J 200 J

Narrow complex, irregular 100 J 150 J 200 J

Wide complex, regular 120 J 150 J 200 J

Wide complex, irregular Treat as VF: go to Checklist 6

BIPHASIC CARDIOVERSION energy levels

During RESUSCITATION Airway: • Assess and secureCirculation: • Confirm adequate IV or IO access

• Consider IV fluids wide open

If cardioversion needed and impossible to synchronize shock, use high-energy unsynchronized shocks

Defibrillation settings:Lifepak 20 360 J

If CARDIAC ARREST: Asystole/PEA: go to Checklist 5 VF/VT: go to Checklist 6

Critical CHANGES

DRUG DOSES and treatmentsAmiodarone 150mg, slow IVEsmolol 10-20mg, repeat as neededAdenosine 6mg rapid IV bolus, increase up to 12mg boluses

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MAJOR TRAUMA IN INTERVENTIONAL RADIOLOGYInterventional radiology should have a difficult airway kit and a blood warmer presentAdditional resources suggested to take include:• Drug trolley, Level One, videolaryngoscope, ultrasound

DAMAGE CONTROL RESUSCITATIONIndications include >10u RBC, acidosis, pH <7.2, core temp <35°C, operative time >90 min, coagulopathy, lactate >5mmol/L• <C> ABC resuscitation (<C> = catastrophic bleeding)• Permissive hypotension (MAP>50mmHg, consider>70mmHg if head injury)• Limitation of crystalloid with early use of blood and blood products• Early use of TXA• Damage control surgery: • Immediate control of surgical haemorrhage and contamination, abdominal

packing and temporary closure. Aim for surgery <90 min • Transfer to ICU for rewarming, correction of coagulopathy and

haemodynamic stabilisation • Planned return to theatre 6-48 hours later for definitive treatment

1 Notificationofmajortraumacase Early discussion with and involvement of consultant medical staff Decide on most appropriate location for resuscitation/surgery • Acute theatre / OT 2 / interventional radiology Consider anaesthetic review in ED and potential need for imaging Allocate sufficient personnel (anaesthetists and technicians)2 Preparation of theatre Warm theatre to ≥25°C Check anaesthetic machine and airway equipment Consider moving an anaesthetic emergency trolley into theatre Prepare IV fluid warmers (Level One and blood warmer) Prepare drugs - induction/resuscitation. Consider Ketamine Communicate with blood bank (98472 or 98470)3 Patient arrival Patient identification if possible Place monitors (SpO2, BP, ECG) Consider 3 units of O Negative blood in L2 blood fridge Consider initiating Massive Transfusion Protocol (MTP) • Phone blood bank 98472 or 98470 and MTP attendant 24082 Ensure large bore IV access • Ideally 2x ≥16g peripheral cannula. • Consider intraosseous access Apply Bair Hugger blanket if able Start pre-oxygenation while surgeon ‘preps and drapes’4 Induction of anaesthesia Rapid sequence with c-spine stabilisation as appropriate Surgery to commence once ETT placement confirmed by CO2 Consider further IV access (central line, PA sheath, arterial line) Place urinary catheter and orogastric tube. Administer appropriate antibiotics

17 TraumaMajor trauma with threat to life or limb

5 Ongoing resuscitation Do baseline labs, ABG, TEG and G&S (if not already done) Use MTP if appropriate and cease when no longer required Target urine output 0.5-1mL/kg/hr Consider cell saver if no contamination Consider TXA (1g IV bolus) if bleeding and <3 hours from injury Consider calcium chloride 1g Consider higher MAP target in TBI (MAP>70mmHg)6 Post-operative placement ICU vs HDU vs Ward Low volume ventilation (6mL/kg)

17

START


18 TURP Syndrome (N.B. may also occur during or following a hysteroscopy)

Restlessness, headache, progressing to profound CNS depression and CVS instability, during or following the use of hypotonic irrigation fluid

1 Call for help Ask: “Who will be the crisis leader?” 2 Terminate surgery as quickly as possible3 Maintain airway • If necessary secure with endotrachael tube4 Administer100%orhighflowO2 and turn down any volatile anaesthetics 5 Support circulation if required • Use standard vasopressors/inotropes (e.g. metaraminol/ephedrine)6 Control any seizures with incremental doses of midazolam7 Give Frusemide 10-20mg IV to initiate a diuresis8 Insert arterial ± central venous lines and take urgent blood samples for • ABG • Electrolytes • Hb • Serum osmolality9 Optimal treatment depends on the patients serum sodium and osmolality • If hyponatraemic and has significant hypoosmolality or symptoms of

cerebral oedema then give hypertonic saline • If hyponatraemic but serum osmolality near normal (>275mosml/kg)

then consider haemodialysis!0 Monitor serum Na, Hb and osmolality frequently!1 If perforated viscus (eg bladder) consider surgical drainage!2 Consider admission to ICU or HDU


Frusemide 10-20mg IVMannitol 20% 100ml

HYPERVOLAEMIA

Hypertonic saline 23.4% (20ml ampoules): • Contains [Na] 4mmol / ml • Bolus of 15ml will raise serum [Na] by 2-3mmol/l • Can repeat 15mL bolus a further 1-2 times at 10 minute

intervals if required • Consider infusion of 15ml/hrSodium bicarbonate 8.4%: • Contains 1mmol sodium / ml • Infusion of 60ml/hr will raise serum [Na] by ~2mmol/l/hr • Reduce infusion rate once severe symptoms resolved or serum

[Na] >125mmol/l• Avoid overcorrection of hyponatraemia/hypoosmolality

HYPONATRAEMIA

SYMPTOMS• Symptoms result from one or more of: hypervolaemia,

hyponatraemia, hypoosmolality and glycine toxicity. • Glycine induced diuresis and loop diuretics may contribute to

a natriuresis and worsen hyponatraemiaSevere symptoms include:• Transient blindness • Persistent nausea / vomiting• Severe headaches • Seizures• Coma • Respiratory arrest• Pronounced hypotension (drop in SBP >50mmHg)

18

START


19 Obstetrics - HaemorrhageAcute massive bleeding in a pregnant or recently post-partum patient

DRUG DOSES and treatmentsUTEROTONICSSyntocinon IV Bolus 3-10iu Infusion 10iu/hrSyntometrine IM 0.5mg ergometrine (1ml)Carboprost IM 250mcg (1ml)

1 Call for help, ensure senior anaesthetic and obstetric support Ask: “Who will be the crisis leader?”2 OpenIVfluidsandensureadequateIVaccess3 If under GA, turn FiO2 to 100% and Turn down volatile anaesthetic Consider changing to TIVA4 Activate Massive Transfusion Protocol (copy in Appendix) Call Blood Bank (98472 or 98470) Call MTP Attendant (24082) Assign one person as primary contact for blood bank5 Consider empiric administration of cryoprecipitate (1unit/30kg) Aim for fibrinogen >2.0g/L6 Request rapid infusion device (e.g. Level one)7 Discuss management plan between obstetric, anaesthetic and

nursing teams Administration of uterotonics • IV Syntocinon, IM Ergometrine, IM Carboprost Consider using Cell Saver • Use ordinary suction for amniotic fluid • Transfuse using leukodepletion filter Consider TXA (1g IV)8 Keep patient warm9 Send urgent blood tests ABG / CBC / COAG, at times suggested by MTP Consider using TEG

!0 Consider... Early involvement of vascular and/or radiological services Electrolyte disturbances (hypocalcaemia and hyperkalaemia) Uncrossmatched type O blood if crossmatched blood not available Damage control surgery: go to Checklist 17 Discussion with transfusion medicine specialist (via blood bank)!1 Notify blood bank once decision made to cease Massive Transfusion

Protocol

FURTHER TREATMENT OPTIONSNON-SURGICAL UNCONTROLLED BLEEDING despite massive transfusion of blood products• Consider giving Recombinant Factor VIIa: • 90 mcg/kg IV • Surgical bleeding must first be controlled • use with CAUTION in patients at risk for

thrombosis • DO NOT use when PH is < 7.2

OBSTETRIC/SURGICAL• Intrauterine balloon• B-Lynch suture• Uterine and hypogastric artery

ligation• Aortic cross-clamp

RADIOLOGICAL• Embolisation of pelvic vessels

POTENTIAL CAUSES• Tone• Tissue/retained placenta• Trauma/laceration• Thrombin

19


20 Paediatrics - Doses & CalculationsWeight (kg) Dose 10kg 12kg 14kg 16kg 18kg 20kg 25kg 30kg 35kg 40kg

RESUSCITATIONDefibrillation 4J / kg 40J 48J 56J 64J 72J 80J 100J 120J 140J 160J

Adrenaline IV (arrest) 10mcg/kg 100mcg 120mcg 140mcg 160mcg 180mcg 200mcg 250mcg 300mcg 350mcg 400mcg

Atropine IV 20mcg/kg 200mcg 240mcg 280mcg 320mcg 360mcg 400mcg 500mcg 600mcg 600mcg 600mcg

SuxamethoniumIV 2mg/kg 20mg 24mg 28mg 32mg 36mg 40mg 50mg 60mg 70mg 80mg

SuxamethoniumIM 4mg/kg 40mg 48mg 56mg 64mg 72mg 80mg 100mg 120mg 140mg 160mg

DRUGSFentanyl 1-2mcg/kg 10-20mcg 12-24mcg 14-28mcg 16-32mcg 18-36mcg 20-40mcg 25-50mcg 30-60mcg 35-70mcg 40-80mcg

IV Morphine 0.1mg/kg 1.0mg 1.2mg 1.4mg 1.6mg 1.8mg 2.0mg 2.5mg 3.0mg 3.5mg 4.0mg

Propofol 3-4mg/kg 30-40mg 36-48mg 42-56mg 48-64mg 54-72mg 60-80mg 75-100mg 90-120mg 105-140mg 120-160mg

Atracurium 0.3-0.5mg/kg 3-5mg 3.6-6mg 4.2-7mg 4.8-8mg 5.4-9mg 6-10mg 7.5-12.5mg 9-15mg 10.5-17.5mg 12-20mg

Rocuronium 0.6mg/kg 6mg 7.2mg 8.4mg 9.6mg 10.8mg 12mg 15mg 18mg 21mg 24mg

Fluid IV bolus 10ml/kg 100ml 120ml 140ml 160ml 180ml 200ml 250ml 300ml 350ml 400ml

Fluid IV maintenance Holliday-Segar 40ml/hr 44ml/hr 48ml/hr 52ml/hr 56ml/hr 60ml/hr 65ml/hr 70ml/hr 75ml/hr 80ml/hr

AIRWAYLMA Unique 2 2.5 3

ETT size cuffed: Age/4 + 3.5ETT size uncuffed: Age/4 + 4ETT distance from lips: 12+age/2Weightestimate: 2x(age+4)

20

© Waikato District Health Board 2014 – TM08/14 V11

Team leader responsibilities• Team leader should be a registrar or

consultant• Activate protocol by ringing both Blood

Bank 98472 and MTP Attendant 24082• For each state “I am activating the Massive

Transfusion Protocol”• State the patient’s name, NHI and location

as well as your name• Use the designated MTP Attendant to collect

each pack of blood products as required• Notify the Coag Lab and send Coag

requests• Assess patient continuously for ongoing

need for MTP• Make a decision to cancel MTP and

inform both Blood Bank and MTP Attendant immediately

Blood Bank responsibilities• Ensure X-match sample processed ASAP

after O negative release• Send MTP cancellation card and MTP

protocol in pack one• Notify NZBS medical officer after issuing

MTP pack four• Thaw next pack in advance and await

request/collection• Ensure supply of platelets

Contacts• Blood Bank Ext 98470 or 98472 Pager 20072

• MTP Attendant Phone 24082

• Coagulation Lab Ext 98459 Pager 20073

• Duty anaesthetist Pager 23322

Additional treatment thresholds• If PR > 1.5 or APTT > 40 consider additional

4 units FFP• If fibrinogen < 2.0 g/L give additional 3U

Cryoprecipitate • If platelets < 75x109/L consider additional

unit of platelets• If ionized Ca++ < 1 mmol/L give 6.8 mmol

Calcium Chloride (1 ampoule)

Adult Massive Transfusion Protocol (MTP)

REQUEST, DELIVER AND TRANSFUSE AS BELOW:

MTP PACk ONE2U RBC and 2U FFP

MTP PACk TWO4 RBC4 FFP

3U Cryoprecipitate

MTP PACk THREE4 RBC4 FFP

1U Platelets

MTP PACk FOUR4 RBC4 FFP

3U Cryoprecipitate

And alternate 3 and 4Reassess need and notify

Blood Bank and MTP Attendant if stopping.

Sign and give attendant MTP cancellation card to

return to Blood Bank

G2732HWF

MTP Attendant responsibilities• MTP Attendant to collect first blood pack

from Blood Bank immediately• MTP Attendant to collect blood packs only

as instructed by team leader or delegate• MTP Attendant to stay with Massive

Transfusion until it is cancelled at which time they will return the signed MTP cancellation card to Blood Bank

Massive bleeding with either shock or abnormal coagulopathy

Ensure delivery of X-match specimen to Blood Bank

Blood Bank to check patient has received 3 RBC. If yes send MTP pack one. If no send 3 units RBC first.

Give 3 units type specific RBC or 3 units O negative

Request urgent blood

Ring Blood Bank AND MTP Attendant to activate Massive Transfusion Protocol

Consider further Tranexamic

acid 1g

Check coags/platelets/CBC/

ABG/Ca++


ABG/Ca++


ABG/Ca++

Repeat every 30 mins

Tranexamic acid 1g

(Caution if >3 hours post trauma)

Absence of tachycardia or cutaneous signs does not exclude anaphylaxisAnaphylaxis is usually rapid in onset but is occasionally delayed

Skin and MucosaHives, flushing, erythema, urticaria, swelling head and neck or peripheries

• Direct Histamine Release• Venous obstruction• Head down position• C1-esterase deficiency (Angioedema only)• Mastocytosis• Cold induced anaphylaxis

Generalised mucocutaneous signs: Erythema, Urticaria+/- Angioedema

Australian & New Zealand Anaesthetic Allergy Group

ANZAAG Australian & New Zealand Anaesthetic Allergy Group

ANZAAG Anaphylaxis during Anaesthesia

Differential Diagnosis Card

Appendix 5 ANZAAG-ANZCA Perioperative Anaphylaxis Management Guidelines version 2 May 2016. The scientific rationale and evidence base for the recommendations on this card is explained in more detail at www.anzca.edu.au and www.anzaag.com © Copyright 2016 – Australian and New Zealand College of Anaesthetists, Australian and New Zealand Anaesthetic Allergy Group. All rights reserved.

Possible Causes & Actions

Cardiac Arrest

• Hypoxia• Hypovolaemia• Hypo/hyperkalaemia/metabolic disorders• Hypo/hyperthermia• Tension pneumothorax (Decompress)• Tamponade• Toxins• Thrombosis: pulmonary or coronary

High Airway Pressure/ Airway Compromise

Dyspnoea, wheeze, stridor, difficulty inflating lungs• Circuit malfunction Check using Self Inflating Bag• Misplaced/kinked Airway device Check with suction catheter/Consider changing device• Tension pneumothorax Decompress• Exacerbation of Asthma Treat as per Refractory Management• Foreign Body Consider bronchoscopy• Acid aspiration Consider bronchoscopy

Hypotension

• Hypovolaemia• Sepsis• Drug overdose• Vasodilation by drugs• Neuraxial blockade• Embolism: Thrombotic, Air or Amniotic • Vasovagal

Mild (Grade 1)

Moderate (Grade 2)

Life Threatening (Grade 3)

Arrest (Grade 4)

Moderate – Multi-organ manifestation may include: • Hypotension, tachycardia• Evidence of bronchospasm, cough, difficult ventilation • Mucocutaneous signs

Life Threatening and requiring immediate and specific treatment: • Severe hypotension• Bradycardia or tachycardia, arrhythmias• Severe bronchospasm, and/or airway oedema• Cutaneous signs may be absent, or present only after correction of hypotension

Cardiopulmonary Arrest

DR

S

AB

C

D

IF Adult CARDIAC ARREST Pulseless Electrical Activity, PEA

Danger and Diagnosis Response to stimulus

Send for help and organise team

Check/Secure AirwayBreathing - 100% oxygen

Rapid fluid bolusPlan for large volume resuscitation

Adrenaline BolusRepeat as neededPrepare Infusion

• ALS GUIDELINES for non-shockable rhythms• 1 mg I.V. Adrenaline, Repeat 1 - 2 minutely prn• Immediately start CPR. Elevate legs. 2 L Crystalloid

• Unresponsive hypotension or bronchospasm• Remove triggers e.g. chlorhexidine, synthetic colloid• Stop procedure. Use minimal volatile if GA

• Call for Help and Anaphylaxis box• Assign a designated Leader and Scribe• Assign a Reader of the cards

• Consider early intubation: airway oedema• Confirm FiO2 100%

• If hypotensive: Elevate legs• Bolus 2L Crystalloid, Repeat as needed• Large bore I.V. access. Warm I.V. fluids if possible

I.M. Adrenaline (Adult) No I.V. access or haemodynamic monitoring OR awaiting Adrenaline Infusion1:1000 1mg/mL500 mcg lateral thighEvery 5 minutes prn

Adrenaline INFUSION (Adult) >3 boluses of Adrenaline start infusionCan be administered peripherally

3 mg Adrenaline in 50 mL saline Commence at 3 mL/hr = 3 mcg/min Titrate to max. 40 mL/hr = 40 mcg/min(Infusion rate 0.05 - 0.5 mcg/kg/min)

If NOT RESPONDING see ‘Refractory Management’

Moderate (Grade 2)


Initial I.V. Adrenaline Bolus (Adult) Dilution 1 mg in 10 mL = 100 mcg/mL• Give dose below every 1-2 minutes prn• Increase dose if unresponsive

20 mcg = 0.2 mL

100-200 mcg= 1-2 mL


Anaphylaxis during Anaesthesia

Immediate Management



ANZAAG

Adults 12+

Request more help • Consider calling arrest code • May require assistance with fluid resuscitation



ANZAAG

Adults 12+

Resistant Bronchospasm• Continue Adrenaline Infusion • Consider: - Airway device malfunction - Circuit malfunction - Tension pneumothorax (decompress) • Add alternative bronchodilators

Triggers removed?• Chlorhexidine including impregnated CVCs• Synthetic Colloid disconnect and remove • Latex remove from OR

Monitoring • Consider Arterial line• Consider TOE/TTE

Adult RecommendationsSalbutamol • Metered Dose Inhaler 12 puffs (1200 mcg)• I.V. bolus 100-200mcg +/- infusion 5-25mcg/min

Magnesium 2 g (8 mmol) over 20 minutes

Consider Inhalational Anaesthetics and Ketamine

Pregnancy

Consider other diagnoses

• Manual Left Uterine Displacement• Caesarean within 4 minutes if arrest or peri-arrest

See ‘Differential Diagnosis Card’ in Anaphylaxis Box

Resistant Hypotension• Continue Adrenaline Infusion• Additional I.V. fluid bolus 50 mL/kg• Add second vasopressor• Consider CVC• Cardiac bypass/ECMO if available

Anaphylaxis during Anaesthesia

Refractory Management


Once stable refer to ‘Post Crisis Management’

Adult RecommendationsNoradrenaline Infusion 3 – 40 mcg/min(0.05 - 0.5 mcg/kg/min) and/or

Vasopressin bolus 1- 2 units then 2 units per hour

If neither available use either Metaraminol or Phenylephrine Infusion

Glucagon 1- 2 mg I.V. every 5 min until responseDraw up and administer I.V. (Counteract β blockers)

DR

S

AB

C

D

IF Paediatric CARDIAC ARREST Pulseless Electrical Activity, PEA

Danger and Diagnosis Response to stimulus

Send for help and organise team

Check/Secure AirwayBreathing - 100% oxygen

Rapid fluid bolusPlan for large volume resuscitation

Adrenaline BolusRepeat as neededPrepare Infusion

• ALS GUIDELINES for non-shockable rhythms• 0.1 mL/kg of 1:10,000 (10 mcg/kg) I.V. Adrenaline• Repeat 1-4 minutely prn• Immediately start CPR. 20 mL/kg Crystalloid

• Unresponsive hypotension or bronchospasm• Remove triggers e.g. chlorhexidine, synthetic colloid• Stop procedure. Use minimal volatile if GA

• Call for Help and Anaphylaxis box• Assign a designated Leader and Scribe• Assign a Reader of this card

• Intubate early: airway oedema CVS/Respiratory compromise • Confirm FiO2 100%

• If hypotensive: Elevate legs• Bolus 20 mL/kg Crystalloid, Repeat as needed• Large bore I.V. Access. Warm I.V. fluids if possible

I.M. Adrenaline (Paediatric)No I.V. access or haemodynamic monitoring OR awaiting Adrenaline Infusion1:1000 1mg/mL lateral thigh< 6 years = 0.15 mL (150 mcg)6-12 years = 0.3 mL (300 mcg)Every 5 minutes prn

Paediatric Adrenaline InfusionCommence infusion as soon as possibleCan be administered peripherally

1 mg Adrenaline in 50 mL (20 mcg/mL) Commence at 0.3 mL/kg/hr (0.1 mcg/kg/min) Titrate to max. 6 mL/kg/hr (2 mcg/kg/min)

Initial I.V. Adrenaline Bolus (Paediatric) Dilution 1 mg in 50 mL = 20 mcg/mL• Give dose below every 1-2 minutes prn• Increase dose if unresponsive


Moderate (Grade 2)

0.1 mL/kg2 mcg/kg

0.2-0.5 mL/kg4-10 mcg/kg

IF NOT RESPONDING see ‘Paediatric Refractory Management’Appendix 2 ANZAAG-ANZCA Perioperative Anaphylaxis Management Guidelines version 2 May 2016. The scientific rationale and evidence base for the recommendations on this card is explained in more detail at www.anzca.edu.au and www.anzaag.com © Copyright 2016 – Australian and New Zealand College of Anaesthetists, Australian and New Zealand Anaesthetic Allergy Group. All rights reserved.




Immediate Management

Paediatric 0-12

Request advice/help • Contact local/regional paediatric service• Consider calling arrest code

Resistant Bronchospasm• Continue Adrenaline Infusion • Consider: - Airway device malfunction - Circuit malfunction - Tension pneumothorax (decompress) • Add alternative bronchodilators

Triggers removed? • Chlorhexidine including impregnated CVCs• Synthetic Colloid disconnect and remove • Latex remove from OR

Monitoring • Consider Arterial line• Consider TOE/TTE

Paediatric RecommendationsNoradrenaline infusion 0.1 - 2 mcg/kg/min0.15 mg/kg in 50 mL run at 2 - 40 mL/hrand/or

Vasopressin infusion 0.02 - 0.06 units/kg/hr1 unit/kg in 50 mL2 mL bolus then 1 - 3 mL/hr

Glucagon 40 mcg/kg I.V. to max 1mg

Consider other diagnoses See ‘Differential Diagnosis Card’ in Anaphylaxis Box

Resistant Hypotension• Continue Adrenaline Infusion• Additional I.V. fluid bolus 20 - 40 mL/kg• Add second vasopressor• Consider CVC





Refractory Management

Once stable refer to ‘Post Crisis Management’

Paediatric 0-12

Paediatric RecommendationsSalbutamol • Metered Dose Inhaler (100 mcg/puff)6 puffs < 6 years, 12 puffs > 6 years

• I.V. Infusion as per local paediatric protocol

Magnesium sulfate 50% (500 mg/mL)50 mg/kg to max 2 g over 20 minutes(0.1 mL/kg 50% solution= 50 mg/kg)

Aminophylline 10 mg/kg over 1 hour (max 500 mg)

Hydrocortisone 2 - 4 mg/kg (max 200 mg)

Once Situation is Stabilised

Consider Steroids

Consider ORAL Antihistamines

I.V./I.M. Antihistamines

Investigations

Observations

Consider: Proceed/Cancel/Postpone SurgeryPostoperative ICU/HDU monitoring

Dexamethasone 0.1 - 0.4 mg/kg (Paediatric maximum 12 mg)Hydrocortisone 2 - 4 mg/kg (Paediatric maximum 200 mg)

Consider Oral non-sedating Antihistamines when patient able to take oral medications

NOT RECOMMENDED

Letter with Patient: Reaction Description + Agents UsedRefer Patient for Testing and Allergy Assessment

For referral form & to locate nearest testing centre go to www.anzaag.com

• Monitor closely for 6 hours • Consider 24 hours ICU/HDU if moderate to severe • Anaphylaxis may persist for >24 hours despite

aggressive treatment





Post Crisis Management

• Tryptase at 1 hour, 4 hours and > 24 hours Send to laboratory for processing ASAP If >1 hour to laboratory then refrigerate Use serum (SST) or plain tube

• Other investigations as clinically indicated• Coagulation screen if proceeding with surgery

page air embolism - venous 1 operating theatre 2

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