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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:


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).


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.


Neuromuscular blockers, latex, chlorhexidine, IV colloids, antibiotics


  • 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 ...

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