5-156
for the pediatric population.
Table 5-10: Dosing Guidlines for IV Agents
Drug Loading Dose Incremental Dose Infusion Dose
Amnestics
Propofol 1.0 - 2.5 mg/kg 0.25 - 1.0 mg/kg 75 - 200 mcg/kg/min
Midazolam 50 - 150 mcg/kg 5 - 10 mcg/kg 0.25 - 1 mcg/kg/min
Analgesics
Fentanyl 2.0 - 4.0 mcg/kg 0.25 – 1.0 mcg/kg 0.02 - 0.1 mcg/kg/min
Sufentanil 0.2 - 0.6 mcg/kg 0.1 - 0.15 mcg/kg 0.003 - 0.01 mcg/kg/min
Ketamine 0.5 - 2.0 mg/kg 0.5 - 1.0 mg/kg 10 - 40 mcg/kg/min
Muscle Relaxants
Intubating Dose
Vecuronium 0.08 - 0.1 mg/kg 0.01 - 0.015 mg/kg 0.8 - 1.2 mcg/kg/min
Succinylcholine 1 - 2 mg/kg 20 mg boluses 0.25 - 0.5 mg/kg/min
What To Do:
- Conduct pre-operative system check (Table 5-11).
- Induce general anesthesia with selected medications (loading doses listed on Table 5-10).
- Secure the airway and ensure adequate oxygenation and ventilation of the patient.
- Initiate maintenance infusions of selected medications (Table 5-10).
- Monitor the patient vigilantly and titrate infusions. If a patient has not responded to surgical stimulation
during the previous 10-15 minutes, and a substantial increase in the level of surgical stress is
not imminent:
a. Reduce the infusion rate by 20%.
b. If the patient subsequently begins to respond to surgical stimulation:
· Increase the infusion rate to a setting between the original rate and the reduced rate (or
approximately a 10% reduction from the original setting) and
· Administer a bolus equivalent to the amount of drug the infusion will provide during
the next 5-minute period. - General considerations when employing continuous infusion techniques:
a. Using a powered infusion pump will ensure continuous infusion, providing optimal control and ideal
effect-site concentration.
b. Use small-bore tubing for the medication infusion and place as close to the IV cannulation site as
possible.
c. Check carrier fluid and connections often. Empty carrier IVs will result in emergence from anesthesia
or overdose.
d. Limit the use of muscle relaxants: determine titration of infusion rates based on the usual clinical signs
of anesthetic depth (lack of movement, stable blood pressure and heart rate, regular respiratory
rate and rhythm). Overzealously using muscle relaxants blinds the practitioner to some of these signs,
necessitating the delivery of positive-pressure ventilations throughout the procedure.
e. Force downward titration: This is the most critical consideration when rapid post-surgical recovery is
required. Review section 5.b.
What Not To Do:
Contraindications: Other than allergic reaction to the selected medication, there are no absolute contraindica-
tions to this technique.
Complications:
- Compatibility concerns: All drugs being infused through a single access line MUST be compatible. This
compatibility applies to not only the anesthetic agents, but also other medications (antibiotics) that might
be administered during the course of an anesthetic. - False sense of security: Practice vigilant downward titration to avoid overdosing the patient but provide
adequate levels of anesthesia at the same time. Remain constantly aware of your patient’s vital signs. - Awareness: Avoid overuse of muscle relaxants, which can mask the purposeful movement usually