Paediatric Anaesthesia Formulas

Fluid requirements

Fasting Guidelines for Pediatric Patients

TYPE Fasting Time (hr)

Clear liquids* 2
Breast milk 4
TYPE Fasting Time (hr)
Infant formula 6†
Solid (fatty or fried) foods 8
*Includes only fluids without pulp; clear tea or coffee without milk products.
†The American Society of Anesthesiologists guideline allows a “light breakfast” (tea and plain toast) 6 hours before
anesthesia; however, determining what a “light breakfast” means for a child is difficult.

Maintenance Requirements in Children

Weight (kg) Maintenance Requirements in Children

(mL/hour)

0-10 4 (mL/kg)
11-20 40 + 2 (mL/kg)
> 20 kg 60 + 1 (mL/kg)

Replacement of Losses

Procedure Insesnsible losses

Non-invasive (inguinal hernia, clubfoot) 0-2 cc/kg/hr
Mildly invasive (uteteral reimplantation) 2-4 cc/kg/hr
Moderately invasive (bowel reanastamosis) 4-8 cc/kg/hr
Significantly invasive (NEC) > 10 cc/kg/hr

Intraoperative Glucose

Infants: 4 mg/kg/min = 240 mg/kg/hr maintenance requirements D5 = 50 mg/mL Delivery of D5 @

> 4 mL/kg/hr may lead to hyperglycemia

Catheter sizes and their flow rates

MEAN FLOW RATE RANGE (mL/min)

Catheter Size Length Crystalloid Crystalloid Blood
(gauge) (inches) (gravity) (pressure) (pressure)
24 0.75 14 to 15 42 to 47 20 to 30
22 1 24 to 26 65 to 77 44 to 50
20 1.25 to 2 38 to 42 103 to 126 69 to 81
18 1.25 to 2 55 to 62 164 to 214 150 to 164
16 2 75 to 81 248 to 280 216 to 286
 MEAN FLOW RATE RANGE (mL/min)
Catheter Size Length Crystalloid Crystalloid Blood
(gauge) (inches) (gravity) (pressure) (pressure)
14 2 92 to 93 301 to 319 334 to 410
20 8 5 16 3
18 8 13 51 22
16 8 31 97 35
Data summarized from Hodge D III, Fleisher G: Pediatric catheter flow rates. Am J Emerg Med
3:403, 1985.

Paediatric Airway Equipments

Pediatric Endotracheal Tube Size

Age Internal Depth (cm)

Diameter (mm)
Preterm 2.5 6-8
Term 3.0 9 - 10
6 months 3-3.5 10
1 - 2 years 4.0 10 - 11
3 - 4 years 4.5 12 - 13
5 - 6 years 5.0 14 - 15
10 years 6.0 16 - 17

Pediatric Endotracheal Tube Depth

 For preemies and neonates (cm) = weight (in kg) + 6 For 1 year or older (cm) = age + 10 cm

Pediatric Airway Equipment

Age Miller Blade

< 32 weeks 00
Term 0 (< 3 kg)
3-18 mo. 1 (3-10 kg)
> 18 mo 2 (> 12 kg)

Pediatric LMA Size

 LMA sizes ~ weight (kg) / 20 + 1 (round to nearest 0.5)

Laryngeal mask airway size characteristics

Laryngeal Mask Airway Size Approximate Weight (kg) Cuff Volume (mL)
1 <5 2 to 5
1.5 5 to 10 3 to 8
2 10 to 20 5 to 10
2.5 20 to 30 10 to 15
3 30 to 50 15 to 20
4 50 to 70 ≤30
5 70 to 100 ≤40
6 >100 ≤50

Pediatric-sized laryngeal mask airways and compatible endotracheal tubes[*]

Laryngeal Maximum Lubricated Maximum Lubricated Cuffed Maximum Flexible

Mask Airway Uncuffed Standard Standard Endotracheal Tube Bronchoscope
Size Endotracheal Tube Inner Inner Diameter (mm) Size[†]
Diameter (mm)

1 3.5 3.0 2.7

1.5 4.0 4.0 3.0
2 5.0 4.5 3.5
2.5 6.0[‡] 5.0 4.0
3 — 6.0 5.0
4 — 6.0 5.0
[†]
5 — 7.0 5.0
[†]
6 — 7.0 5.0
Litman RS: The difficult pediatric airway. In Litman RS, editor: Pediatric anesthesia: The
requisites, St. Louis, 2004, Mosby.
*Based o e peri e ts perfor ed the author, As per LMA North A eri a, Largest availa le u uffed
endotracheal tube available at The Children's Hospital of Philadelphia.
Laryngoscope blade types and sizes

BLADE TYPE AND SIZE

Age Miller Wis-Hippel Macintosh
Premature neonate 0 — —
Term neonate 0 to 1 — —
1 to 12 mo 1 1 —
1 to 2 yr 1 1.5 2
2 to 6 yr 2 — 2
6 to 12 yr 2 — 3

Endotracheal tube size[*]

Age Weight ID (mm) Length (OT) Length (NT) Suction Catheter

(kg) (cm) (cm) (F)
Premie 0.7 to 1.0 2.5 7 to 8 9 5
Premie 1.0 to 2.5 3.0 8 to 9 9 to 10 5
Newborn 2.5 to 3.5 3.5 9 to 10 11 to 12 6
3 mo 3.5 to 5.0 3.5 10 to 11 12 6
3 to 9 mo 5.0 to 8.0 3.5 to 4.0 11 to 12 13 to 14 6
9 to 18 mo 8.0 to 11.0 4.0 to 4.5 12 to 13 14 to 15 8
1.5 to 3 yr 11.0 to 4.5 to 5.0 12 to 14 16 to 17 8
15.0
4 to 5 yr 15.0 to 5.0 to 5.5 14 to 16 18 to 19 10
18.0
6 to 7 yr 19.0 to 5.5 to 6.0 16 to 18 19 to 20 10
23.0
8 to 10 yr 24.0 to 6.0 to 6.5 20 to 22 21 to 23 10
30.0
10 to 11 30.0 to 6.0 to 20 to 22 22 to 24 12
yr 35.0 6.5[†]
12 to 13 35.0 to 6.5 to 20 to 22 23 to 25 12
yr 40.0 7.0[*]
14 to 16 45.0 to 7.0 to 20 to 22 24 to 25 12
yr 55.0 7.5[*]
Data modified from Smith RM: Anesthesia for infants and children. CV Mosby, 1980, St. Louis;
Davenport HT: Paediatric anaesthesia. Year Book Medical Publishers, 1973, Chicago.
ID, inner diameter; OT, orotracheal tube; NT, nasotracheal tube; F, French size (number is
approximately equal to ID × 4).
* The endotracheal tube should fit so as to allow full normal expansion of both lungs with positive airway
pressure ut to per it a gas leak a out the tu e at 20 to 25 H2O. Cuffed tu e.

Recommended nasotracheal tube dimensions

TUBE LENGTH (L) (cm)

Age (yr) Tube Size (S) (ID, mm) Yates et al. (1987) Rees (1966) Steward (1979)
0 to 3 mo 2.5 to 3.0 9.5 to 11.0 11.8 13.5
4 to 7 mo 3.5 to 4.0 12.5 to 14.0 13.6
1 4.0 14.0 14.5 15.0
2 4.5 15.5 15.2 16.0
3 4.5 to 5.0 15.5 to 17.0 15.6
4 5.0 17.0 16.5 17.0
5 5.0 to 5.5 17.0 to 18.5 16.8
6 5.5 18.5 17.1 19.0
7 5.5 to 6.0 18.5 to 20.0 17.8
8 6.0 20.0 18.3 21.0
9 6.0 to 6.5 20.0 to 21.5 18.8
10 6.5 21.0 19.1 22.0
11 6.5 to 7.0 21.5 to 23.0 19.1
12 7.0 23.0 22.0

Medications for Children

Preoperative Medication in Children

PO Nasal IV IM
Midazolam 0.5 - 1.0 mg/kg 0.05 - 0.10 mg/kg
Fentanyl 1 - 3 ucg/kg
Morphine 0.05 - 0.10 mg/kg
Sufentanil 0.25 - 0.5 ucg/kg
Ketamine 2-4 mg/kg 4-6 mg/kg

Resuscitation Medication in Children

  Epinephrine = 10-100 ucg/kg for arrest (100 ucg/kg in ETT), 1-4 ucg/kg for hypotension
 Atropine = 0.01 - 0.02 mg/kg (0.3 mg/kg in ETT) - actual dose 0.1 - 1 mg
 Adenosine = 0.1 mg/kg (max dose 6 mg)
 Lidocaine = 1-1.5 mg/kg
 SCh = 2-3 mg/kg
 Rocuronium 1 mg/kg
 Calcium chloride = 10-20 mg/kg (dilute to 10 mg/cc or else veins will sclerose, try to give
centrally if possible)
 Bicarbonate = 1 mEq/kg (dilute to 1 mEq/cc or else veins will sclerose)
 Naloxone = 0.1 mg/kg
 DEFIBRILLATION = 2 J/kg (can increase up to 4 J/kg)

Preoperative Medication in Children

 Midazolam 0.05-0.1 mg/kg IV (0.5-1 mg/kg PO, 15 mg max)

 Methohexital 1-2 mg/kg IV (25-30 mg/kg PR, 500 mg max)
 Ketamine 1-2 mg/kg IV, 10 mg/kg IM, 5-8 mg/kg PO
 Sodium Pentothal 1-2 mg/kg IV (separation), 4-6 mg/kg IV (induction)
 Propofol 0.1-1 mg/kg IV (separation), 2-4 mg/kg IV (induction)
 Etomidate 0.2-0.3 mg/kg IV

Antibiotic Doses in Children

 Cefazolin 25 mg/kg q6-8h up to 1-2 grams

 Cefotaxime 20-30 mg/kg q6h
 Ampicillin 50-100 mg/kg q6h up to 3 grams
 Gentamicin 2-2.5 mg/kg q8h (must monitor serum levels, longer interval in renal
impairment)
 Clindamycin 5-10 mg/kg q6-8h up to 900mg
 Mezlocillinn 50-100 mg/kg q6h up to 2g
 Vancomycin 10 mg/kg q6h up to 1g

Other Useful Medication in Children

 Glycopyrrolate 0.01 mg/kg IV, IM, ETT (max 0.4 mg)

 Morphine 0.05 - 0.1 mg/kg IV (max 0.4 mg/kg)
 Fentanyl 1-5 ucg/kg IV
 Ketorolac 0.5 mg/kg IV
 Tylenol 20 mg/kg PO, 40 mg/kg PR
 Zofran 0.05-0.15 mg/kg
 Droperidol 20-25 ucg/kg
 Dexamethasone 0.1-0.5 mg/kg for pain, N/V prophylaxis
 Neostigmine 0.07 mg/kg
 Dexamethasone 0.5-1 mg/kg for tracheal edema
 Solumedrol 1 mg/kg IV
Characteristics of volatile anesthetics

MAC (%)
Infant (1 to 6 mo) Child (3 to 10 yr) Adult
Halothane 1.1 0.9 0.7
Enflurane –– –– 1.6
Isoflurane 1.7 1.6 1.2
Desflurane 9.4 8.0 6.0
Sevoflurane 3.3 2.5 2.0
Adapted in part from Jones RM: Desflurane and sevoflurane; inhalation anesthetics for this
decade? Br J Anaesth 65:527, 1990. Copyright © The Board of Management and Trustees of the
British Journal of Anaesthesia. Reproduced by permission of Oxford University Press/British
Journal of Anaesthesia.

Intravenous dosage of opioids in children

Drug As Major Anesthetic As Adjunct As Postoperative

Analgesic

Morphine 2 to 3 mg/kg 0.05 to 0.1 mg/kg per hr 0.05 to 0.1 mg/kg

Fentanyl 50 to 100 mcg/kg 1 to 3 mcg/kg per hr 1 to 2 mcg/kg
Sufentanil 10 to 15 mcg/kg 0.1 to 0.3 mcg/kg per hr —
Alfentanil 150 to 200 mcg/kg 1 to 3 mcg/kg per min —
Remifentanil 0.2 to 1.0 mcg/kg per 0.1 to 0.4 mcg/kg per —
min min

Hydromorphone 5 to 10 mcg/kg 3 to 5 mcg/kg per hr 3 to 5 mcg/kg

Intravenous doses of muscle relaxants in children

MAINTENANCE ED95 (mg/kg)

Drug Intubation Bolus Continuous Infusion Infants Children
(mg/kg) (mg/kg) (mcg/kg/m)

Mivacurium 0.2 to 0.3 0.1 10 to 20 0.1 0.1

Cisatracurium 0.15 0.1 1 to 5 0.05 0.05
Vecuronium 0.05 to 0.1 0.025 1 0.024 0.026
Rocuronium 0.8 to 1.0 0.3 to 0.5 15 0.2 0.3
Pancuronium 0.1 0.5 — 0.05 0.05
Pipecuronium 0.1 — — 0.035 0.05

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Drug Age Group Dose (mg/kg) Interval

Acetaminophen Preterm Term Load: 20; 15(PO), 20 (PR) q12h
>3 mo Load: 20 to 30; 20 (PO) q8h
Load: 20 (PO); 15 (PO) q4h
40 (PR), 20 (PR) q6h
Diclofenac >1 yr 1 (PO) q8h
Ibuprofen >6 mo 10 to 15 (PO) q6h
Ketorolac >6 mo 0.25 to 0.5 (IM, IV) q6h
Naproxen >6 mo 5 to 10 (PO) q8–12h
Celecoxib >1 yr 1.5 to 3 (PO) q12h

Regional Anaesthesia

I. DOSES OF EPIDURAL ANALGESICS

Usual Doses and Infusion Regimens for Epidural Anesthesia in Pediatric Patients

Continuous Infusion (Max.

Agent Initial Dose Repeat Injections
Doses)
Bupivacaine, Solution: 0.25% with <4 mo: 0.2 mg/kg/hr 0.1 to 0.3 mL/kg
levobupivacaine 5 µg/mL (1/200,000) (0.15 mL/kg/hr of a 0.125% every 6-12 hr of a
 Continuous Infusion (Max.
Agent Initial Dose Repeat Injections
Doses)
epinephrine solution or 0.3 mL/kg/hr of 0.25% or 0.125%
Dose: a 0.0625% solution) solution (according to
<20 kg: 0.75 mL/kg 4-18 mo: 0.25 mg/kg/hr pain scores)
20-40 kg: 8-10 mL (or (0.2 mL/kg/hr of a 0.125%
0.1 mL/year/number of solution or 0.4 mL/kg/hr of
metameres) a 0.0625% solution)
>40 kg: same as for adults >18 mo: 0.3-0.375 mg/kg/hr
(0.3 mL/kg/hr of a 0.125%
solution or 0.6 mL/kg/hr of
a 0.0625% solution
Same age-related infusion
rates in mg/kg/hr as for
0.1 to 0.3 mL/kg
Solution: 0.2% bupivacaine (usual
every 6-12 hr of a
Dose: same regimen in concentration of
Ropivacaine 0.15% or 0.2%
mL/kg as for bupivacaine ropivacaine: 0.1%, 0.15%,
solution (according to
(see above) or 0.2%)
pain scores)
Do not infuse for more than
36 hr in infants < 3 mo
Select only one additive:
Fentanyl: 1-2 µg/mL
Avoid in infants < 6 mo
Sufentanil: 0.25-0.5 µg/mL Morphine (without
Fentanyl (1-2 µg/kg) or
Adjuvants Morphine: 10 µg/mL preservatives): 25-
sufentanil (0.1-0.6 µg/kg)
Hydromorphone: 1-3 µg/mL 30 µg/kg every 8 hr
or clonidine (1-2 µg/kg)
Clonidine 0.3 at 1 µg/mL of
solution

Recommendations for dosing caudal and epidural blocks.

Concentration Dose Possible Additives

Single-dose caudal
Continuous caudal or lumbar
epidural catheters
Continuous thoracic epidural
0.175% to 0.75 to 1.25 mL/kg not Epinephrine 2.5 to 5
0.5% to exceed 3 mng/kg mcg/mL
Clonidine 1 to 2 mcg/kg
Morphine 30 to 70
mcg/kg
0.1% to 0.25% 0.4 mL/kg per hr or 0.2 Fentanyl 2 to 5 mcg/mL
to 0.4 mg/kg per hr Hydromorphone 5 to 10
mcg/mL
0.1% to 0.25% 0.3 mL/kg per hr or 0.1 Fentanyl 2 to 5 mcg/mL
to 0.2 mg/kg per hr Hydromorphone 5 to 10
 mcg/mL
Bupivacaine, levobupivacaine, or ropivacaine may be used. Greater concentrations and larger doses
should be reserved for levobupivacaine or ropivacaine. Doses and concentrations should be reduced
in infants. Children less than 2 years of age who receive morphine centrally require 24-hour
monitoring after its delivery.

II. SPINAL ANAESTHESIA DOSES

Volumes of local anesthetic solutions for peripheral nerve blocks and regional anesthesia in
children

Block Volume (mL/kg)

Axillary 0.2 to 0.5
Interscalene 0.33
Sciatic 0.15 to 0.2
Femoral 0.5
Intravenous 0.5 to 10
Caudal 0.5 to 1.0
Intrapleural (infusion) 0.5 (per hr)

Usual Doses of Local Anesthetics for Spinal Anesthesia in Neonates and Former Preterm
Neonates Younger than 60 Weeks of Preconceptual Age (up to a Weight of 5 kg)

Local Anesthetic Dose (mg/kg) Volume (mL/kg) Duration (min)

Tetracaine 1% 0.4-1.0 0.04-0.1 60-75
Tetracaine 1% with epinephrine 0.4-1.0 0.04-0.1 90-120
Bupivacaine 0.5% isobaric or hyperbaric 0.5-1.0 0.1-0.2 65-75
Levobupivacaine 0.5% 1.0 0.2 75-88
Ropivacaine 0.5% 1.08 0.22 51-68

Usual Doses of Local Anesthetics for Spinal Anesthesia in Children and Adolescents

Local Anesthetic Usual Dose(s)

0.5% Isobaric or hyperbaric bupivacaine
0.5% Isobaric or hyperbaric tetracaine
0.5% Isobaric levobupivacaine
5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)
>15 kg: 0.3 mg/kg (0.06 mL/kg)
5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)
>15 kg: 0.3 mg/kg (0.06 mL/kg)
5 to 15 kg: 0.4 mg/kg (0.08 mL/kg)
Local Anesthetic Usual Dose(s)
15-40 kg: 0.3 mg/kg (0.06 mL/kg)
>40 kg: 0.25 mg/kg (0.05 mL/kg)
0.5% Isobaric ropivacaine 0.5 mg/kg (max 20 mg)

III. RECOMMENDATIONS FOR DOSING OF PERIPHERAL NERVE BLOCKS

Recommended Volumes of Local Anesthetic for Single-Shot Upper Limb Blocks with
Neurostimulation by Patient Weight

Patient Weight
Conduction Block ≤10 kg 11-30 kg 31-60 kg >60 kg
Brachial plexus above 10 mL + 0.5 mL/kg 20 mL + 0.25 mL/kg
1 mL/kg 30 mL
clavicle above 10 kg above 30 kg
Brachial plexus below 5 mL + 0.25 mL/kg 10 mL + 0.15 mL/kg
0.5 mL/kg 15 mL
clavicle above 10 kg above 30 kg
Any nerve trunk at
0.2 mL/kg 0.15 mL/kg 0.15 mL 10 mL
elbow
Any nerve trunk at 3-
0.05 mL/kg 0.05 mL/kg 0.05 mL/kg
wrist 5 mL

Recommended Volumes of Local Anesthetic for Single-Shot Lower Limb Blocks with
Neurostimulation

Conduction Block ≤10 kg 11-30 kg 31-60 kg >60 kg

Lumbar plexus (psoas 10 mL + 0.5 mL/kg
1 mL/kg 20 mL 20 mL
compartment) above 10 kg
5 mL + 0.35 mL/kg 12 mL + 0.3 mL/kg
Femoral 0.5 mL/kg 25 mL
above 10 kg above 30 kg
10 mL + 0.5 mL/kg 20 mL + 0.25 mL/kg
Fascia iliaca 1 mL/kg 30 mL
above 10 kg above 30 kg
10 mL + 0.5 mL/kg 20 mL + 0.3 mL/kg
Proximal sciatic 1 mL/kg 30 mL
above 10 kg above 30 kg
3 mL + 0.2 mL/kg
Sciatic in popliteal fossa 0.3 mL/kg 6 mL + 0.15 mL/kg 12.5 mL
above 10 kg
Usual Local Anesthetic Infusion Rates with or without Bolus Doses of Either Ropivacaine
0.2%, Bupivacaine 0.125%, or Levobupivacaine 0.15% to 0.2% for Continuous Peripheral
Nerve Blocks

Plexus and Proximal Conduction Nerve Axillary and Popliteal

Techniques
Blocks * Blocks
0.1 mL/kg/hr up to
Infusion rate 0.2 mL/kg/hr up to 10 mL/hr
5 mL/hr
0.1 mL/kg/hr up to
Bolus doses 0.2 mL/kg up to 5 mL
3 mL/hr
Maximum bolus doses per
3 3
hour

Regional Technique Bolus Dose Continuous Infusion (mLμ/kg per

(mLμ/kg)[*] hr)
Axillary Parascalene 0.2 to 0.5 0.2 to 0.4 0.1 to 0.2 0.1 to 0.2
Femoral or lateral femoral 0.3 to 1 0.15 to 0.3
cutaneous
Fascia iliaca 0.5 to 1 0.15 to 0.3
Lumbar plexus 0.5 to 1 0.15 to 0.3
Sciatic 0.3 to 1 0.15 to 0.3
Ilioinguinal/iliohypogastric 0.25 NA
Penile block 0.1 NA
Paravertebral 0.5 0.2 to 0.25
NA, not applicable.

Bupivacaine, levobupivacaine, or ropivacaine may be used. For bolus dosing, lower concentrations
such as 0.2% to 0.25% should be used in infants and young children, whereas concentrations of
0.375% to 0.5% should be used in children >5 to 8 years of age. For continuous infusions, lower
concentrations such as 0.1% to 0.2% of all agents are acceptable

Ref:

1. SMITH'S Anesthesia for Infants and Children, Seventh Edition.

2. Miller's Anesthesia - 8th ed.