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APPENDIX 3

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PEDIATRIC CRITICAL EVENTS CHECKLISTS

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

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AIR EMBOLISM (↓ETCO2 ↓SaO2 ↓BP)

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

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Call for help. Notify surgeon.

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✓ Increase oxygen to 100%.

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Stop nitrous oxide and volatile agents.

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

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  • 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.

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✓ Consider:

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  • Vasopressors (epinephrine, norepinephrine).

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

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

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ANAPHYLAXIS (RASH, BRONCHOSPASM, HYPOTENSION)

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Call for help.

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Increase oxygen to 100%.

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✓ Remove suspected trigger(s).

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  • If latex is suspected, thoroughly wash area.

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✓ Ensure adequate ventilation/oxygenation.

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✓ Obtain IV access.

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✓ If hypotensive, turn off anesthetic agents.

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

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

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

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✓ Adjuvants

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  • 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.

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

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COMMON CAUSATIVE AGENTS

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Neuromuscular blockers, latex, chlorhexidine, IV colloids, antibiotics

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

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  • Age < 30 days: HR < 100

  • Age > 30 days < 1 year: HR < 80

  • Age > 1 year: HR < 60

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Call for help and transcutaneous pacer.

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Hypoxia is common cause of bradycardia.

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

  • Go to “Hypoxia” card if hypoxia persists.

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Stop surgical stimulation. If laparoscopy, desufflate.

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✓ Consider:

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  • Epinephrine 2-10 μg/kg IV.

  • Chest compression if ↓ pulses.

  • Atropine (0.01-0.02 mg/kg IV) if vagal etiology.

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✓ Assess for ...

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