Acute Hemorrhage in the Pediatric Patient
Definition
Acute hemorrhage in the pediatric patient is the acute loss of a large volume of blood and can be either overt or covert.
Overt
Can be visualized in the surgical field, on sponges, or in the suction containers
Covert
No outward sign of bleeding (e.g., retroperitoneal hemorrhage, blood loss hidden in the drapes)
Etiology
Bleeding from a large blood vessel (artery or vein) secondary to surgery, trauma, or disease
In pediatrics, massive blood loss is > 2 to 3 mL/kg/min or 50% of blood volume over 3 hours
Underlying coagulopathy or therapeutic anticoagulation
Loose connection in the IV, central line, or arterial line, leading to potentially hidden blood loss
Typical Situations
Major trauma
Procedural
Vascular, cardiac, thoracic, or major abdominal surgery
Major orthopedic surgery
Injury to fetus during delivery or cesarean section
Interventional radiologic or cardiac catheterization procedure
Covert hemorrhage is more likely where the surgical field is obscured by drapes or is distant from the anesthesia professional
Coagulopathy, either acquired or therapeutic
Occult blood loss (e.g., GI tract, long bone fractures, or into the retroperitoneal space)
Acute hemorrhage may be a delayed complication of an earlier injury or invasive procedure
Prevention
Identify and correct coagulopathy early
Identify, institute prophylaxis for, and treat other potential bleeding sites (e.g., GI ulcers, fractures in acute trauma)
In children, anticipate the need for massive transfusion and obtain adequate IV access prior to start of procedure
Establish an institutional MTP
Manifestations
Overt
Blood in surgical field
Blood on surgical sponges, on the drapes, and on the floor
Increased suction noise
Accumulation of blood in suction containers
Surgeon comments or concerns about bleeding, volume status, or transfusion
Changes in vital signs (decreased BP, increased HR)
Covert
Changes in vital signs
Increased HR (or decreased HR if severe)
Decreased BP
Decreased CVP
Change in pulse oximeter reading due to poor perfusion
Physical examination if accessible
Increased RR if breathing spontaneously
Poor peripheral perfusion or capillary refill time
Poor pulses
Expanding soft tissue, abdomen, or thigh (i.e., retroperitoneal bleed, or long bone fracture)
Change in neurologic examination, bulging fontanelle, anisocoria (i.e., intracranial bleed)
Decreased NIRS monitor reading
Inadequate filling of ventricle on TEE or TTE
Decreased urine output
Increased fluid requirement above what is expected
Little or transient BP response to IV fluid bolus or vasopressor administration
Laboratory studies
Unexplained decreasing hematocrit
Increasing metabolic acidosis on ABG
Similar Events
Hypotension (see Event 96, Hypotension in the Pediatric Patient )
Anesthetic or vasodilator overdose (see Event 72, Volatile Anesthetic Overdose )
Any cause of shock (see Event 91, Anaphylaxis in the Pediatric Patient , and Event 13, The Septic Patient )
Cardiac failure
Cardiac tamponade (see Event 18, Cardiac Tamponade )
Pulmonary hypertension
PE (see Event 21, Pulmonary Embolism )
Arrhythmias
Progressively inadequate volume replacement due to bleeding, insensible losses (e.g., urine, evaporative losses), or third spacing
Occlusion of venous return by compression of IVC by surgical packing, pneumoperitoneum, or retraction
Tension pneumothorax (see Event 35, Pneumothorax )
Management
Special pediatric considerations
IV access may be challenging, especially in young infants
Small-gauge IV catheters (24 and 22 g) typically placed in infants and young children may not withstand infusions of large volumes
Anticipate the need for transfusion and obtain adequate IV access prior to the start of the procedure
CVP line or cut-down may be necessary, especially if rapid volume administration is anticipated
Ensure that air bubbles are not injected into the patient
These may result in paradoxical air emboli to the heart or brain
All IV tubing must be meticulously debubbled
Special care should be taken with pressurized rapid-infusion devices
Hyperkalemia
Children are at much greater risk of morbidity from hyperkalemia than adults
Arrhythmias and cardiac arrest can occur in young children, particularly those with congenital heart disease
Older blood and blood that has been irradiated may contain dangerously elevated levels of K +
Employ strategies to minimize the risk of hyperkalemia from transfusion of RBCs
Use freshest RBCs
Use washed RBCs
Slow rate of RBC transfusion if possible
Monitor serum K + levels and ABGs frequently and initiate treatments if K + rises over 4.5
Diuretics, Ca 2+ , NaHCO 3 , Kayexalate, dialysis
Acidemia increases extracellular K + levels
Hypocalcemia
Secondary to transfusion of citrate-phosphate-dextrose-adenine (CPDA) blood products
CPDA present in higher levels in FFP than RBCs
Avoid hypothermia
Hypothermia will exacerbate coagulopathy and platelet dysfunction
Warm blood products
Preoperative
Send type and cross (especially if two samples are needed) before surgery as samples may be difficult to obtain in children without central venous or arterial access
Communicate the potential for significant bleeding and need for blood products with the blood bank
Extra time may be required to locate appropriately matched products for patients with antibodies
Determine acceptable values for HR and BP based on the child’s age
Determine blood volume and “allowable” blood loss based on patient weight and hematocrit
Intraoperative
Inform the surgeon of the problem
Initial treatment
Deliver 100% O 2
Consider reducing volatile anesthetic agents
Administer 10 to 20 ml/kg IV bolus of non–dextrose-containing isotonic fluid (e.g., saline, LR, 5% albumin, or blood) and watch for HR and BP response. Repeat as necessary to maintain adequate preload
Administer IV bolus of vasopressor (e.g., ephedrine, epinephrine, phenylephrine), carefully titrated to clinical effect
Vasopressors temporize the situation while administering IV fluids
Treatment of hypovolemic shock with vasopressors alone, without replacing volume, increases the risk of severe end organ damage
Additional monitoring data may help guide volume replacement
Consider placement of an arterial line for ABG and BP monitoring
Consider TEE or TTE examination for cardiac function and ventricular filling
Consider placement of a CVP line
If patient is not responding to initial therapy, or major fluid resuscitation is necessary
Call for help
Inform all team members of the situation and plans for resuscitation
Anesthesia professional’s role
Primary anesthesia professional should focus on leading and coordinating team members
Obtain additional IV access if necessary
Consider IO line early if IV access is difficult
Place arterial line if appropriate
Monitor patient hemodynamics and level of anesthesia
Operate rapid transfusion devices or push blood
Help to draw ABG and labs
Sugeon’s role
Identify and control source of bleeding
Surgeons may have to pause surgery
To allow anesthesia professional access to the patient to place an IV, CVP line, or arterial line
To allow time for volume replacement
To perform a necessary procedure (e.g., place a difficult CVP line or perform a cut-down for IV access)
Nurses’ role
Call for more nursing and tech help
Charge nurse may help coordinate resources
Order and arrange transport of blood products from blood bank
Help to check and administer blood or blood products
Ensure that a rapid infuser system is available
Set up cell saver if indicated
Consider activating MTP if available
Monitor venous access lines and sites
Check all IV and central lines for loose connections and leaks
Check IV site frequently for soft tissue infiltration, especially when fluid is being infused under pressure, as opposed to a drip IV set
For massive transfusion of blood or blood products
Activate MTP if available
Notify blood bank of situation and anticipated needs as they may need to seek out additional sources of products
Order of preference for blood products
Type-specific (or type-compatible) crossmatched unit
Type-specific (or type-compatible) but not crossmatched unit (e.g., patient has been screened, but there is not enough time to complete crossmatching)
Uncrossmatched, type-O, Rh-negative unit (O-neg RBCs)
If patient has received > 1 blood volume of emergency release blood products (O-neg RBCs), keep transfusing O-neg RBCs. Testing for antibodies must be completed prior to switching back to patient’s type-specific blood
Transfuse blood and blood products through fluid warmer to avoid hypothermia
Washed PRBCs, platelets, FFP, and cryoprecipitate are usually at room temperature but also need to be warmed
Coagulopathy during massive transfusion is primarily due to dilution of clotting factors and/or platelets but may be due to fibrinolysis or DIC
Blood and blood product administration
Platelets
Monitor for thrombocytopenia and consider transfusion of platelets after 1 to 1.5 blood volumes have been lost
Replacement should be 10 to 15 mL/kg of platelets for each blood volume replaced
Hypothermia causes platelet dysfunction even with normal platelet counts
Factors
Initiate transfusion of FFP after 1 blood volume of RBCs has been transfused
Transfusion of RBCs and FFP should be at a ratio of 2:1 (RBC:FFP)
Monitor labs and hemodynamics to guide therapy
Hematocrit
Platelets
PT/aPTT
Ca 2+
K +
ECG tracing for evidence of electrolyte abnormalities
HR and BP
CVP
TEE/TTE
Complications
Arrhythmias
Coagulopathy/DIC
Acidosis
Alkalosis
Hypocalcemia
Hyperglycemia
Hyperkalemia
Hypernatremia
Hypothermia
Transfusion-related infection
Transfusion reaction/ABO incompatibility
Transfusion-associated graft-versus-host disease
ARDS/TRALI
Volume overload and hypertension
Cardiac arrest
Suggested Reading
Anaphylaxis in the Pediatric Patient
Definition
Anaphylaxis in the pediatric patient is an IgE-mediated response that is caused by exposure to an antigenic substance in a sensitized pediatric patient.
Etiology
Administration of, or exposure to, an agent that the patient has been previously sensitized to, with production of antigen-specific IgE
Typical Situations
In patients with a known allergy or sensitivity to a specific agent or a history of atopy or allergy to nondrug allergens
After exposure to substances that can trigger anaphylaxis
Neuromuscular blocking drugs
Latex
Antibiotics
Opioids
Protamine
Amino-ester local anesthetic agents
Blood and blood products
Iodinated contrast material
Chlorhexidine preparation solutions
Sedative-hypnotics
Colloid administration (e.g., dextrans, hydroxyethyl starch)
Patients with frequent latex exposure
Patients requiring multiple reconstructive surgical procedures (e.g., myelomeningocele repair for spina bifida, patients with congenital genitourinary abnormalities)
Prevention
Avoid agents to which the patient has a documented allergy
Minimize the use of latex products in health care
If there is a history of latex allergy, establish a latex-free environment
Avoid contact with, or manipulation, of latex devices
Use nonlatex surgical gloves
Use syringe/stopcock methods or unidirectional valves for injecting medications
Do not insert a needle through any multiple-dose vial with a natural rubber stopper
Take the top of the vial completely off
Use the same medication from a glass ampule, if available
Use glass syringes as an alternative to plastic syringes with natural rubber seal on plunger (plastic syringes may use nonlatex seals—check manufacturer’s information for syringe materials)
Obtain a careful history of previous allergic reactions, atopy, asthma, or significant latex exposure
Avoid transfusion of blood or blood products whenever possible
If a specific drug must be administered to a patient known to be at risk of an allergic reaction, administer prophylaxis
Corticosteroids, H 1 antagonists
Administer test dose of drug
Obtain consultation from an allergist if a critical allergy must be defined
Manifestations
Anaphylaxis has the potential for acute onset with catastrophic consequences. Severe hypotension, increased peak airway pressure, and hypoxemia are the most common initial signs but need not be present simultaneously.
Cardiovascular
Severe hypotension
Tachycardia
Bradycardia may be initial sign
Arrythmias
Cardiac arrest
Respiratory
Hypoxemia
Decreased lung compliance
Severe bronchospasm
Cutaneous—may be obscured by surgical drapes
Flushing, hives, urticaria, pruritus
Swelling of mucosal membranes, angioedema, head and neck swelling
Similar Events
Medication causing direct histamine release (e.g., morphine)
Anesthetic overdose or medication error (see Event 72, Volatile Anesthetic Overdose , and Event 63, Drug Administration Error )
Cutaneous allergy (rapid urticarial reactions)
Bronchospasm (see Event 29, Bronchospasm )
Hypotension from other causes (see Event 9, Hypotension )
Pulmonary edema from other causes (see Event 20, Pulmonary Edema )
Cutaneous manifestations of mastocytosis, carcinoid syndrome, hereditary angioedema
Transfusion reaction (see Event 50, Transfusion Reaction )
Cardiac tamponade (see Event 18, Cardiac Tamponade )
Stridor (see Event 97, Laryngospasm )
PE (see Event 21, Pulmonary Embolism )
Vasovagal reaction
Septic shock (see Event 13, The Septic Patient )
Aspiration of gastric contents (see Event 28, Aspiration of Gastric Contents )
Pneumothorax (see Event 35, Pneumothorax )
Esophageal intubation
Management
Stop administration of any possible antigen (e.g., discontinue antibiotics)
Retain blood products for analysis
Identify all latex products and remove from contact with the patient
Inform the surgeons and call for help
Check to see whether they have injected or instilled a substance into a body cavity
Consider aborting surgical procedure if severe or there is no response to initial treatment
Anaphylaxis can be biphasic and can recur after successful initial treatment
Ensure adequate oxygenation and ventilation
Administer 100% O 2
Intubate the trachea if not already intubated
The airway can rapidly become edematous, making intubation more difficult or impossible
Anaphylaxis is treated with epinephrine (the drug of CHOICE in anaphylaxis) and IV fluid
Epinephrine dosing and route—drug calculations are CRITICAL
For patients with profound hypotension or shock and a KNOWN working IV/IO line, administer epinephrine 0.5 to 1 μg/kg and increase rapidly up to 10 μg/kg as needed; maximum dose 1000 μg
For patients in early phase without profound hypotension, shock or cardiac arrest, or for those patients in which IV/IO access HAS NOT BEEN OBTAINED, administer epinephrine IM, 10 μg/kg q5-15m; maximum 300 μg per dose
Given difficulty in obtaining IV access in children, the IM dose is preferred by some anesthesia professionals and clinicians who deal with pediatric emergencies
For cardiovascular collapse or cardiac arrest, give epinephrine IV, 10 μg/kg (see Event 94, Cardiac Arrest in the Pediatric Patient )
Consider epinephrine infusion (20-200 ng/kg/min) with increasing dose to maintain BP
Rapidly expand the circulating blood volume
Administer 10-30 mL/kg NS or LR
Immediate fluid needs may be massive
Decrease or stop the administration of anesthetic agents if hypotension is severe
If bronchospasm is present
Administer bronchodilator
Inhaled β-agonist (e.g., albuterol MDI)
Volatile anesthetic agents may be administered for bronchodilation if the patient is normotensive
Administer H 1 and H 2 histamine antagonists
Diphenhydramine IV, 1 mg/kg up to maximum of 50 mg
Famotidine IV, 0.25 mg/kg, or ranitidine IV, 1 mg/kg IV
Administer corticosteroids
Methylprednisolone IV, 1 to 2 mg/kg, or dexamethasone IV, 0.2 mg/kg
In the absence of any other cause, consider latex allergy
Ensure all latex products in contact with the patient have been removed from the surgical field
Consider placement of an arterial line and urinary catheter to help guide vasopressor and fluid management
Obtain blood sample for mast cell tryptase levels within 2 hours to confirm the diagnosis of anaphylaxis
Arrange admission to ICU for continued postoperative management
Consider referring patient to an allergist on discharge from the hospital
Complications
Hypoxemia
Inability to intubate, ventilate, or oxygenate
Hypertension and tachycardia from vasopressors
ARDS
Renal failure
Cardiac arrest
DIC
Death
Suggested Reading
Aspiration of a Foreign Body
Definition
Aspiration of a foreign body into the respiratory tract
Etiology
Child placing a foreign body into the mouth
Tooth dislodged into the airway
Material left in the airway after a surgical procedure
Typical Situations
Occurs in children between 7 months and 4 years of age with peak incidence at 1 to 2 years
Foreign body aspiration is a leading cause of death in children < 1 year of age
Food is the most common foreign body in the infant/toddler age groups
Incomplete dentition and immature swallowing coordination increase susceptibility
Nonorganic material, such as disc batteries, beads, pins, tacks, coins, and parts of toys are common in older children
After a surgical procedure
Prevention
Encourage home-safety programs to keep food and small objects out of the reach of unsupervised toddlers
Perform laryngoscopy carefully
Consider extracting loose teeth prior to laryngoscopy
Double check that all materials placed in the airway are removed before extubation
Manifestations
Cough
Dyspnea
Cyanosis
Decreased breath sounds
Tachypnea
Stridor
Wheezing
Hemoptysis
Hoarseness
Fever
Aphonia
Recurrent pneumonia
Physical examination may be normal
Radiographic visualization of the foreign body or of air trapping, infiltrates, or atelectasis
The right mainstem bronchus is the most common site for a foreign body to lodge
Organic material may be poorly visualized on CXR
High-resolution spiral CT scan can characterize disease severity distal to the foreign body
Similar Events
Recurrent pneumonia not related to aspiration of a foreign body
Foreign body in the esophagus
Laryngospasm (see Event 97, Laryngospasm )
Croup
Anaphylaxis (see Event 16, Anaphylactic and Anaphylactoid Reactions )
Management
Obtain history of onset of symptoms from witnesses
Check the O 2 saturation
Ensure adequate oxygenation and ventilation
This may not be possible until foreign body is removed emergently
Confirm the diagnosis of foreign body aspiration
Perform a physical examination of the airway and chest
Examine upper airway anatomy
Check for uniformity and symmetry of breath sounds and adventitious sounds (e.g., bronchospasm)
Obtain a CXR looking for the presence and location of a foreign body
Air trapping
Atelectasis
Pneumonia
Postobstructive airway collapse
Overexpansion
Anesthetic Induction for the Patient with a Foreign Body Aspiration
Discuss the surgical approach and method of ventilation with the team in advance
In addition to an ENT surgeon, consider consultation with a cardiothoracic or general surgeon depending on location and severity of foreign body obstruction
Obtain IV access
Cardiovascular collapse may occur in response to movement of the foreign body causing severe hypoxemia
Consider the potential need for ECMO or CPB
Plan for this early as it takes time to set up
Preoxygenate the lungs prior to induction of anesthesia
Complete airway obstruction may occur at any time, and rigid bronchoscopy must be performed immediately to remove the obstruction or dislodge it to another site that permits ventilation
Perform an inhalation induction with sevoflurane and 100% O 2
Controlled or spontaneous ventilation may be appropriate, depending on the location of the obstruction and the surgical approach
IV induction may be an acceptable alternative, depending on the clinical scenario
Following induction of anesthesia, the bronchoscopist should intubate the trachea with a ventilating bronchoscope in order to remove the foreign body
There may be increased resistance to ventilation when a telescopic lens is inserted through the bronchoscope
Ventilation may need to be alternated with attempts to locate and remove the foreign body
Facilitate passage of the foreign body through the laryngeal inlet
Maintain an adequate depth of anesthesia to prevent patient movement or coughing
Total IV anesthesia will maintain a consistent level of anesthesia during frequent circuit interruptions
Consider administering a small dose of a short-acting muscle relaxant just prior to removing the foreign body
If the foreign body cannot be removed through the bronchoscope and ventilation is inadequate, an emergency thoracotomy and bronchotomy may be necessary
Examine the tracheobronchial tree after removal of the foreign body
Following endoscopic examination, intubate the trachea with an ETT or allow the patient to awaken with a natural airway
The usual criteria for awake extubation should be applied
Allow the child with a natural airway to completely emerge prior to movement to the PACU
Complications
Hypoxemia
Hypercarbia
Laryngospasm
Pneumonia
Chemical pneumonitis
Bacterial infection
Hypotension
Massive hemoptysis
Severe bronchospasm
Pneumothorax
Airway rupture
Pneumomediastinum
Suggested Reading
Bradycardia in the Pediatric Patient
Definition
Bradycardia in the pediatric patient is a HR slower than the age-appropriate normal level.
Etiology
Hypoxemia is a common cause of bradycardia/cardiac arrest in pediatric patients
Decreased automaticity of sinus node
Increased vagal tone
Drug related
Succinylcholine
Digoxin
Opioids
Cholinesterase inhibitors
Anesthetic agents
Hypothermia
Reflex response to hypertension
Treatment with phenylephrine
CNS mass
CNS conditions (e.g., autonomic dysreflexia)
Complication from congenital heart surgery or cardiac catheterization
Caused by injury of the sinus node or the conduction pathway
Acquired heart disease
Cardiomyopathies (e.g., dilated or hypertrophic)
Inflammatory (e.g., rheumatic fever or post viral)
Ischemic (e.g., Kawasaki disease)
Right atrial thrombi or tumors
Congenital heart disease
Certain forms of congenital heart disease (e.g., heterotaxy syndromes) are associated with bradycardia
Typical Situations
Acute severe bradycardia from any etiology can be an indication of impending cardiac arrest in children. The most common cause of bradycardia is respiratory distress or failure.
Preoperative finding
Isolated finding in asymptomatic patient
Symptom of underlying medical condition
Pacemaker malfunction
Congenital or acquired heart disease
OSA
Side effect of medication
Prematurity
Increased ICP
Intraoperative finding
Medications that can cause bradycardia
Succinylcholine
Volatile anesthetics
Opioids (e.g., remifentanil)
α 2 -Agonists (e.g., clonidine, dexmedetomidine)
Cholinesterase inhibitors (e.g., neostigmine)
Cardiovascular agents (e.g., esmolol or phenylephrine)
Increased vagal stimulation
Mechanical/iatrogenic
Laryngoscopy
ETT too deep or pushing on carina
Nasopharyngeal or oropharyngeal suctioning or tube placement
Raised intraocular pressure or traction on eyeball
Tracheal suctioning
Traction on peritoneum
Bladder catheterization
Increased intrathoracic pressure or Valsalva maneuver
Normal physiologic response
Sleeping
Breath holding
Coughing
Gagging or vomiting
Pathophysiologic
Gastroesophageal reflux disease (GERD)
Increased ICP
Severe OSA
Apnea and bradycardia of prematurity
Interruption of ongoing inotropic infusions (e.g., line disconnect or kinking)
Prevention
Maintain adequate oxygenation and ventilation
Ensure appropriate position of ETT
Premedicate children at risk of bradycardia with an anticholinergic agent
Glycopyrrolate IV or IM, 10 to 20 μg/kg
Atropine IV or IM, 10 to 20 μg/kg
Treat bradycardia early
Avoid excess vagal simulation
External ocular pressure, traction on peritoneum, prolonged attempt at laryngoscopy
Manifestations
Slow HR
ECG
Pulse oximeter
Arterial line
Peripheral pulses
Junctional or ventricular escape beats
Hypotension
In the awake, nonanesthetized patient
Dizziness
Syncope
Altered mental status
Fatigue/lethargy
Nausea/vomiting
Infants and nonverbal children
Altered mental status
Irritability
Poor feeding
Similar Events
Monitor artifact
ECG lead disconnection or failure
Failure of monitor to count QRS or pulse
Oximeter probe misplaced or failure
Heart block
Second degree with intermittent dropped beats
Third-degree complete heart block with ventricular escape beats
Pacemaker malfunction or failure
Lead fracture
Lead disconnection
Inappropriate settings (e.g., output too low, sensitivity too high)
AF or flutter with poor perfusion
Management
Verify bradycardia and assess patient’s hemodynamic status
ECG, pulse oximeter, arterial line
Check peripheral pulse
Check BP
Check ET CO 2 waveform for evidence of adequate CO
Ensure adequate oxygenation and ventilation
Bradycardia is a common sign of hypoxemia in small infants
Deliver 100% O 2 (except in certain forms of congenital heart disease)
Check position of ETT
Consider decreasing level of anesthesia
Decrease or turn off volatile anesthetics, propofol, and other infusions
Check surgical field for operative causes
Alert surgeon to stop the precipitating stimulus
Rule out intracranial hypertension as a possible treatable etiology
If bradycardia is mild-moderate but stable (e.g., HR is low but not dropping or is associated with mild-moderate symptoms such as modest decrease in BP and no change in ET CO 2 )
Ensure adequate IV/IO access
Atropine IV, IO, or endotracheal
IV or IO dose: 20 μg/kg, NO minimum dose, maximum dose 0.5 mg
Endotracheal dose: 40 to 60 μg/kg
Glycopyrrolate IV, 10 to 20 μg/kg, maximum dose 0.4 mg
Ephedrine IV, 0.1 to 0.3 mg/kg
Not routinely used in young children
Consider isoproterenol IV infusion, 0.1 to 1 μg/kg/min
May result in vasodilation with inadequate coronary and cerebral perfusion
Anticipate and plan for deterioration in patient status
Consider obtaining crash cart and placing pediatric defibrillator/pacing pads
Continuously reassess for change in ECG or hemodynamic status
Be prepared to start CPR
Consider aborting procedure if problem persists
If bradycardia is unstable (e.g., dropping HR or associated with severe symptoms such as hypotension, loss of consciousness, or drop in ET CO 2 ) ( see Event 94, Cardiac Arrest in the Pediatric Patient )
Administer epinephrine IV, IO, or endotracheal (SC/IM dosing is not appropriate treatment of bradycardia)
IV/IO dose: 10 μg/kg, maximum dose 1 mg
Endotracheal dose: 100 μg/kg, maximum dose 2.5 mg
Call for more help and notify surgeon
Start CPR
Call an OR or hospital code
Call for crash cart and defibrillator if not already done
Place pediatric defibrillator/pacing pads on patient
Consider pacing the patient
Transcutaneous pacemaker
In situ pacer wires will be present in some postoperative patients
Search for and treat possible causes
Consider ECMO
Complications
Junctional or ventricular escape beats
Tachyarrhythmias or hypertension secondary to pharmacologic treatment of bradycardia
Inappropriate pacemaker firing
Pneumothorax from chest compression
Intracranial hemorrhage in premature infants
Secondary to boluses of epinephrine or from acute hypertension
Cardiac arrest
Suggested Reading
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