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Approach to Any Condition

Manual Infusions (TIVA)

Anaesthesia

Drug	Loading Dose (microgram/kg)	Maintenance Infusion (microgram/kg/min)	Maintenance Infusion (microgram/kg/h)
Alfentanil	50-150	0.5-3	30-90
Fentanyl	5-15	0.03-0.1	1.8-6.0
Sufentanil	0.5-5	0.01-0.05	0.6-3.0
Remifentanil	0.5-1.0	0.1-0.4	6-24
Ketamine	1500-2500	25-75	1500-4500
Propofol	1000-2000	50-150	3-9
Midazolam	50-150	0.25-1.5	15-90

Sedation or Analgesia

Drug	Loading Dose (microgram/kg)	Maintenance Infusion (microgram/kg/min)	Maintenance Infusion (microgram/kg/h)
Alfentanil	10-25	0.25-1	15-60
Fentanyl	1-3	0.01-0.03	0.6-1.8
Sufentanil	0.1-0.5	0.005-0.01	0.3-0.6
Remifentanil	†	0.025-0.1	1.5-6
Ketamine	500-1000	10-20	600-1200
Propofol	250-1000	10-50	600-3000
Midazolam	25-100	0.25-1	15-60

Practical Protocol for TCI Using Different Models

General Principles

• Remifentanil TCI targets:
  • Minto ≈ Eleveld (reduce in elderly).
  • Eleveld targets are lower than Marsh → Lower than Schnider for propofol during the first 10 min.
• Key point: Titrate to individual patient/procedure

Sedation

• Propofol TCI range: 0.5–2.0 µg/mL.
• Painful parts:
  • Occasional pain:
    • Alfentanil: 0.25-0.75 mg.
    • Remifentanil: 0.2-0.5 µg/kg bolus.
  • Continuous or frequent pain:
    • Remifentanil infusion: TCI 0.5–2.0 ng/mL.
• Key point: Always titrate for free airway–adequate spontaneous ventilation!

General Anaesthesia

1. Start with:
   • Propofol sedation and/or remifentanil for sensitivity testing.
2. Propofol Induction Targets (TCI):
   • Eleveld: 3.0 µg/mL.
   • Schnider: 6.0* µg/mL.
   • Marsh: 4-5* µg/mL.
   • *(For March and Schnider reduce to 3-4 µg/mL after unconsciousness, i.e., after a few minutes.).
3. Remifentanil Targets:
   • Laryngeal Mask Airway (LMA): 6 ng/mL.
   • Endotracheal Tube (ETT): 10 ng/mL.
4. Maintenance:
   • Propofol 2.5-4 µg/mL.
   • Remifentanil as needed (2-15 ng/mL).

Children TIVA Recipe

• Propofol 10mg/ml
  • Bolus 3-5mg/kg over 3 min
  • Start at 15-10mg/kg/hour for 30 min then 8-10mg/kg/hour 
  • This is equivalent to 3ug/ml effect site concentration. 
• Remifentanil: Draw up solution to 1ug/kg/ml
  • Bolus 1-5ug/kg 
  • Run at 6 ml/hour = 0.1ug/kg/min
• Precedex 4ug/ml 
• Bolus: 0.51ug/kg bolus over 10 min 
  • • 0.5ug/kg bolus has been shown to lead to faster recovery Use for short cases
• Target 0.5ug-1ug/kg/hour 

Red Cross Hospital Sedation Protocol for MRI or Radiotherapy (Children)

• Dexmedetomidine
  • IVI: 1-2ug/kg bolus over 5 min (lasts between 30-45min)
    • Top up: 0.5-1ug/kg
  • Nasal: 3-4ug/kg
• Propofol
  • 1-2mg/kg can be added or used as top up sedation
  • Or TCI targeting CET 1.8-3.0 (Paedfuser or Eleveld)
• Clonidine (for older children who can actually lie still)
  • Used as 5ug/kg oral 1 hour pre-op
• Always enquire if contrast will be required
  • IV line will then be required
  • Paradoxical reaction about 5 minutes after injection of contrast (unknown aetiology)
    • Top up bolus (Dexmed 1ug/kg or propofol 1mg/kg) is usually administered at this time
• Monitoring
  • C02 with 20G Jelco at nose, S02 and HR

Fibre Optic Protocol

Awake Fibre Optic Intubation Mix

• Lignocaine Recipe:
  • Goal: 4% lignocaine with 20 µg/ml adrenaline
  • Components:
    • 10% lignocaine
    • 1 mg/ml adrenaline (1:1000) diluted to 100 µg/ml
    • 2 x 10 ml normal saline ampoules
• Preparation:
  • Add 4 ml of 10% lignocaine to a 10 ml syringe
  • Add 2 ml of adrenaline mix (100 µg/ml, i.e., 200 µg)
  • Fill with saline to a total volume of 10 ml
  • Result: 4% lignocaine with 20 µg/ml adrenaline
• Administration:
  • Nebulize 5 ml
  • Split remaining 5 ml into two 10 ml syringes for spray
• Plan:
  • Nebulize in pre-op area
  • IVI with clave, give glycopyrrolate
  • Consider dexmedetomidine 1ug/kg over 10 min in preop area
  • Consider airway blocks (Glossopharyngeal, RLN, superior laryngeal nerve)
  • Oxymetazoline drops in each nostril
  • Remicaine-covered pus swabs into nasopharynx while setting up/monitoring
  • Start sedation ASAP
    • Combination of remifentanil 0.05-0.15ug/kg/min (use TIVA not TCI to avoid bolus with TCI) with loading dose of Dexmedetomidine
    • Hand Bolus of propofol if required
  • If tolerates Remicaine-covered NPA in nostril, proceed with fibre optic intubation

Ketamine/Magnesium Sulphate/Lidocaine (KLM) Loading and Infusion

Option 1

Loading Dose

• Ketamine: 0.2-0.5 mg/kg
• Lidocaine: 1-1.5 mg/kg
• Magnesium Sulfate (MgSO4): 30-50 mg/kg

Maintenance

• In a 50 ml syringe, run at 10 ml/h:
  • Lidocaine: 1-1.5 mg/kg
  • Ketamine: 0.15 mg/kg
  • MgSO4: 15 mg/kg

Example for a 70 kg Man in a 50 ml Syringe for Maintenance @ 10 ml/h:

• Lidocaine: 350 mg (7 mg/ml) 70 ml/hour
• Ketamine: 50 mg (1 mg/ml) 10 mg/hour
• MgSO4: 5 g (100 mg/ml) 1 g/hour

Option 02

• Components in a 20 ml Syringe:

  • Ketamine: 2 mg/ml
  • Magnesium: 100 mg/ml
  • Lidocaine: 10 mg/ml

• Doses:

  • 2 g Mg
  • 40 mg Ketamine
  • 200-300 mg Lidocaine

• Administration:

  • Bolus: 0.1 ml/kg over 1 minute
  • Infusion: 0.1 ml/kg/h (For every 10 kg, 1 ml/hour)

Calculated Doses

• Lidocaine: 1-1.5 mg/kg
• Ketamine: 0.15 mg/kg
• MgSO4: 15 mg/kg

Procedural Sedation

• Fentanyl Bolus:
  • 0.5-1.5 µg/kg
  • Typical dose: 50-100 µg (1-2 ml)

Ketafol 10:10 (Almost)

• 20 ml Syringe:
  • 18 ml 10 mg/ml propofol (180 mg)
  • 2 ml 100 mg/ml ketamine (200 mg)
• 10 ml Syringe:
  • 9 ml 10 mg/ml propofol (90 mg)
  • 1 ml 100 mg/ml ketamine (100 mg)
• Sedation Dose for 10:10 Ketafol:
  • 0.25-0.5 mg/kg
  • Example: For 70 kg: 1.5-3.5 ml boluses

ICU Sedation or Transfer Sedation

• Ketafol 10:10 Solution:
  • 50 ml Syringe:
    • 40 ml 10 mg/ml propofol (400 mg)
    • 8 ml 50 mg/ml ketamine (400 mg)
    • 2 ml saline
  • Total: 8 mg/ml propofol and ketamine
  • Initial Bolus for 70 kg: 4-5 ml (500 µg/kg)
  • Maintenance Rate for 70 kg: 4-6 ml/hour (10 µg/kg/min)

Ketamine Alone

• Sedation Dose:

  • 4 mg/kg/hour (280 mg/hour)
  • Mixture: 200 mg ketamine in a 50 ml syringe with normal saline, run at the patient’s weight
  • For 70 kg: 70 ml/hour

• Double Dose Method:

  • Mixture for 8 mg/ml of ketamine
    50 ml Syringe with 400 mg ketamine (8 mg/ml)
    • Run at half the patient’s body weight (35 ml/hour for 70 kg)

Ketamine/Midazolam TIVA

• Components:
  • Ketamine: 10 mg/ml
  • Midazolam: 0.1 mg/kg
  • Run at 30-50 ml/hour

Epidural Protocols

Matt O’Neil Recipe

• Components:

  • 10 ml 0.5% Bupivacaine
  • 7 ml 2% Lidocaine
  • 2 ml Fentanyl

• Administration:

  • Load: 3 ml
  • Bolus: 5 ml
  • Total volume: 12-15 ml for T10 from L4 epidural

Cary Paediatric Epidural

• Loading Dose:
  • 0.25% Bupivacaine 0.2 ml/kg up to 0.8 ml/kg

Labour Epidurals

• Position: Left lateral
• Test Dose:
  • 2.5 ml of 2% lignocaine, wait 5 minutes
• Bolus Dose:
  • Mix: 5 ml of 0.5% bupivacaine, 4 ml saline, and 50 µg fentanyl (10 ml of 0.25% bupivacaine; 5 µg/ml fentanyl)
  • Administer two 4 ml boluses 3 minutes apart
  • Measure BP every 5 minutes and test level in 20 minutes (aim T8-T10)
• Infusion:
  • Remove 24 ml from a 100 ml saline bag and add 20 ml of 0.5% bupivacaine and 200 µg fentanyl (0.1% Bupivacaine; 2 µg/ml fentanyl)
  • Rate: 8-14 ml/hour (start when block is no higher than T8)
• Breakthrough Pain:
  • 1.5 ml per segment of 0.25% bupivacaine, divided doses, or 5-10 ml of 0.1% solution with fentanyl 25 µg if near full dilatation
• Top Up for C/S:
  • 17 ml 2% lignocaine, 50 µg fentanyl, 1 ml 8.4% sodium bicarbonate, 1 ml 1/10000 adrenaline (diluted to 1 ml)
  • Administer 5 ml boluses after test dose
  • Total volume: 16-22 ml for effective block to T4

Requirements for Epidural

• 16G or 18G Braun Soft Tip Epidural Kit
• Sterile gown
• Bupivacaine 0.5%
• 100 ml saline
• Fentanyl (from labour ward drug cupboard)
• Saline ampoules
• 10 ml syringe
• 5 ml syringe
• 2 ml syringe
• Lignocaine 2% x 2 (one for test dose, one for skin infiltration)
• Needles: green, pink, and black
• Epidural sterile pack (with gauze, kidney dish, etc.)
• Sterile gloves
• Chlorhexidine bottle
• Tegaderms (large)
• Micropore for strapping

Cardiac Combined Spinal-Epidural (CSE) Recipe

• Intrathecal Injection:
  • Hyperbaric bupivacaine: 2.5-5 mg
  • Fentanyl: 15-25 µg
• Epidural Boluses:
  • Plain 0.5% bupivacaine or 2% lidocaine, 2-3 ml over 15-30 minutes after intrathecal injection

Laryngospasm Mix

• Mixture:
  • Lignocaine 2% 1 ml
  • Adrenaline 50 µg (0.5 ml)
  • Normal Saline 0.5 ml
• Dosage:
  • <1 year: 1 ml

  • 1 year: 2 ml

PCA Pump Recipes

• Morphine + Droperidol:

  • Morphine: 1 mg/ml (50 mg in 50 ml)
  • Droperidol: 25 µg/ml (1.25 mg in 50 ml)

• Fentanyl + Droperidol:

  • Fentanyl: 20 µg/ml (1000 µg in 50 ml)
  • Droperidol: 25 µg/ml (1.25 mg in 50 ml)

• Fentanyl/Ketamine + Droperidol:

  • Fentanyl: 20 µg/ml (1000 µg in 50 ml)
  • Ketamine: 1 mg/ml (50 mg in 50 ml)
  • Droperidol: 25 µg/ml (1.25 mg in 50 ml)

• Morphine/Ketamine + Droperidol:

  • Morphine: 1 mg/ml (50 mg in 50 ml)
  • Ketamine: 1 mg/ml (50 mg in 50 ml)
  • Droperidol: 25 µg/ml (1.25 mg in 50 ml)

Wound Infusion Catheters at GSH

• Rate: Present on device
• Solution:
  • For 0.2% bupivacaine:
    • 11 amps of 50 mg in 10 ml in 275 ml

Helpful Doses and Infusions

Total Intravenous Anaesthesia (TIVA)

• Remifentanil:
  • Induction: 0.4 µg/kg/min
  • Maintenance: 0.2 µg/kg/min
• Propofol:
  • Induction: 2 mg/kg (full bolus) and then 10 mg/kg/hr (1 ml/kg/hr)
  • Maintenance: 5 mg/kg/hour (0.5 ml/kg/hour)

Malignant Hyperthermia (MH)

• Dantrolene:
  • 3 mg/kg, repeat 1 mg every 5 minutes, total 10 mg/kg

Intralipid 20%

• Dosage:
  • 1.5 ml/kg (up to 3 doses)
  • 15 ml/kg/hr, can increase to 30 ml/kg/hr

Noradrenaline

• Solution:
  • 1 mg ampoule
  • 4 x ampoules into 200 ml 5% dextrose (20 µg/ml)

Adrenaline

• Solution:
  • 60 µg/kg in 50 ml
  • 1 ml/hr = 0.02 µg/kg/min

Milrinone

• Solution:
  • 1.5 mg/kg into 50 ml
  • 1 ml/hr = 0.5 µg/kg/min

Clysis

• Solution:
  • 1 amp Plain Marcaine
  • 1 amp adrenaline
  • 4.4 ml of mix into 200 ml bag
  • Max dose: 20 ml/kg

Sufentanil

• Solution:
  • 5 µg/ml (250 µg in 50 ml)
• Doses:
  • Induction and intubation: 0.2-0.3 ng/ml
  • Spontaneous Ventilation (SV): 0.1 ng/ml
  • Stop 20 minutes before end
  • Decent dose: 1 µg/kg (do not exceed 20 µg in an hour)

Dexmedetomidine

• Solution:
  • 200 µg into 50 ml (4 µg/ml)
• Doses:
  • 0.2-0.8 µg/kg/hr (spines/awake crani)
  • 0.7-1.0 µg/kg/hr (AFOI)
  • 0.2-1.4 µg/kg/hr (sedation ICU)
• Model:
  • Hannivort: 0.4-0.6 ng/ml
  • Normal: 0.1 µg/kg – 1.0 bolus 15 mins

Porrill Infusion (KLM)

• Solution:
  • Ketamine: 2 mg/ml (0.4 ml of 100:1)
  • Lidocaine: 10 mg/ml (2 ml of 10%)
  • MgSO4: 100 mg/ml (2 amps)
• Total:
  • 20 ml solution
  • Per ml: Lidocaine 10 mg, Ketamine 2 mg, MgSO4 100 mg
  • Run at 0.1 ml/kg/hr

Post-op Infusion

• Solution:
  • Lidocaine 10 mg/ml
  • Ketamine 1 mg/ml
• Doses:
  • Initial bolus: Lidocaine 1.5 mg/kg, MgSO4 30 mg/kg, Ketamine 0.2 mg/kg
  • Maintenance: Half the rate, stop MgSO4

Lidocaine Infusion

• Solution:
  • Bolus: 1.5 mg/kg
  • Infusion: 1 mg/kg/hr

Tranexamic Acid (TXA)

• Adults:
  • Bolus: 1 g
  • Infusion: 1 mg/kg/hr
  • Mix: 500 mg in 25 ml total volume (20 mg/ml)
• Paediatrics:
  • 500 mg into 50 ml (10 mg/ml)
  • Weight/hour: 10 mg/hr
  • Bolus dose: 10-30 mg/kg
  • Infusion: 10 mg/kg/hr

Neb/Topical Mix

• Solution:
  • 2 x 10 ml syringes
  • 2 x needles to draw up
  • 1 amp 10% lignocaine (5 ml)
  • 1 amp adrenaline (1 mg)
  • Saline to top up
  • Syringe labels
• Preparation:
  • Dilute 1 mg adrenaline into 10 ml in one syringe (100 µg/ml)
  • Draw up 2 ml of dilute adrenaline and 4 ml lignocaine (400 mg) into another syringe
  • Top up with saline to 10 ml (4% lignocaine with 20 µg/ml adrenaline)
  • Use 5 ml for nebulization and the rest for spray as you go

Spray for Down Peadiatric ETT (Bronchospasm mix)

• Solution:
  • 1 ml 2% lignocaine
  • 50 µg adrenaline
  • Saline up to 2 ml
• Dosage:

  • 1 year: 2 ml

  • <1 year: 1 ml

Valeron (Tilidine)

• Dosage:
  • 1 drop every 2.5 kg (4 drops every 10 kg)
  • Frequency: 4-6 hourly
  • 1 mg/kg

Blood Products

• Platelets:
  • 1 ml/kg increases platelets by 5
• Cryoprecipitate:
  • 1 unit (15 ml) per 5 kg or 3 ml/kg increases fibrinogen by 1
• Red Blood Cells:
  • 4 ml/kg increases Hb by 1 g/dl

Calcium Gluconate

• Dosage:
  • 0.5 ml/kg

Ketamine – Burns (TIVA)

• Dosage:
  • Loading: 2 mg/kg
  • Infusion: 200 mg in 50 ml (4:1)
    • 12 mg/kg/hour for 20 minutes (ml/h = x3 bodyweight)
    • 8 mg/kg/hour for 20 minutes (ml/h = x2 bodyweight)
    • 4 mg/kg/hour for remainder (ml/h = bodyweight)

Laparoscopic Surgery for Neonates

• Cisatracurium Infusion:
  • Loading: 150 µg/kg
  • Infusion: 100 µg/kg/hr

Hypoglycemia

• Solution:
  • 2.5 ml/kg 10% dextrose slowly

Mannitol

• Dosage:
  • 0.25-1 g/kg

Hypertonic Saline

• Dosage:
  • 3%: 3-5 ml/kg
  • 250 ml over 1/2 hour

Asthma Management

• Nebulizations:
  • Salbutamol: 2.5-5 mg every 20-30 minutes
  • Fenoterol: 0.5-1 mg
• MDI:
  • 2 puffs every 2 minutes up to 10 puffs
• Ipratropium Bromide:
  • 250 µg every 20-30 minutes
• Steroids:
  • Prednisone/Prednisolone: 1-2 mg/kg PO
    • 2-5 years: 20 mg
    • More than 5 years: 30-40 mg
  • Methylprednisolone: 2 mg/kg 8 hourly IVI
  • Dexamethasone: 0.6 mg/kg IVI daily
• IVI Salbutamol:
  • 15 µg/kg once over 10 minutes
  • Infusion: Loading dose then rate
• IVI Aminophylline:
  • Loading dose and infusion with ECG
• MgSO4:
  • 30-40 mg/kg
• Ketamine Infusion:
• Leukotriene Receptor Agonists:
  • Not used acutely

Epidural for C/S

• Solution:
  • 2 ml 8.4% sodium bicarbonate
  • 50 µg adrenaline
  • 17 ml 2% lignocaine

Transfer Checklist

1. Airway: Secure + backup equipment
2. Breathing: Method of ventilation/oxygen
3. Circulation: IV line
4. Disability: Adequate sedation/analgesia, additional drugs you might need
5. Exposure: Dignity, warmth, care with adjuncts (e.g., drains)
6. Firmly Package: Care with pressure points
7. Good Documentation
8. Handover
9. Team: Porter/sister/anaesthetist
10. Monitoring

Opioid-Free Analgesia (OFA)

1. Premedication:
   • 0.25 µg/kg Dexmedetomidine (max 20 µg) when monitors are applied.
2. OFA Mix:
   • Dexmedetomidine 50 µg + Ketamine 50 mg + Lidocaine 500 mg diluted to 50 ml with normal saline
3. Induction:
   • OFA mix 0.1 ml/kg ABW + Propofol to effect + Rocuronium
   • Dexamethasone 10 mg
   • MgSO4 40 mg/kg ABW
4. Maintenance:
   • OFA mix 0.1 ml/kg ABW/hr infusion + Propofol infusion or volatile
   • Repeat induction bolus if patient remains tachycardic before skin incision
   • Additional 25 mg Ketamine before skin incision if needed
5. Pre-End of Surgery:
   • Decrease OFA mix to 0.05 ml/kg ABW/hr 15 minutes before end
6. Post-op:
   • Continue OFA mix at 0.05 ml/kg ABW/hr
   • Paracetamol and NSAID

Alternative Option:

• Fentanyl 200 µg
• Infusion of Ketamine: 0.2 mg/kg ABW loading dose and 0.1 mg/kg ABW/hr
• Lidocaine: 1.5 mg loading dose and 1 mg/kg ABW/hr
• Remifentanil: 0.1-0.15 µg/kg ABW/min
• Paracetamol: 2 g
• Parecoxib: 40 mg (when not contraindicated)
• Dexamethasone: 8 mg
• Skin infiltration with Bupivacaine prior to port placement
• MgSO4 can be used when sugammadex is available to reverse rocuronium

Conversion Factors

• mmHg to cmH2O:
  • 1 cmH2O = 0.74 mmHg
  • 1 mmHg = 1.36 cmH2O

Weight Calculation

Total Body Weight (TBW)

The actual weight of the individual.

Lean Body Weight (LBW)

Fat-free mass, used for dosing in certain medical contexts. In the obese, it exceeds Ideal Body Weight and plateaus at:

• Approximately 100 kg for men
• Approximately 70 kg for women

Ideal Body Weight (IBW)

Devine Formula

• Male: 50 kg + 2.3 kg x (height in inches – 60)
• Female: 45 kg + 2.3 kg x (height in inches – 60)

Note: 1 cm = 0.4 inches

Broca Formula

• Men: Height in cm minus 100
• Women: Height in cm minus 105

Adjusted Body Weight (ABW)

Used when TBW is more than 30% above IBW:

• Formula: IBW + 0.4 (TBW – IBW)

Naloxone Infusion Protocol

Naloxone Dosing and Administration

Adult Dose

• IV Bolus: 400-2000 micrograms given by slow IV injection (over 3-5 minutes), repeated at intervals of 2 to 3 minutes, up to 10mg. If a total of 10mg is given with no satisfactory response, then the diagnosis should be questioned.

IV Infusion (Unlicensed Concentration)

• The initial hourly rate for infusion (second column) is set at 60% of the bolus needed to obtain a response and may be adjusted according to clinical response.

Initial Bolus Dose Giving Response	Initial Hourly Rate of Infusion	Volume per Hour (of 200 micrograms/mL solution)
400 micrograms	240 micrograms/hour	1.2 mL/hour
600 micrograms	360 micrograms/hour	1.8 mL/hour
800 micrograms	480 micrograms/hour	2.4 mL/hour
1000 micrograms	600 micrograms/hour	3.0 mL/hour
1200 micrograms	720 micrograms/hour	3.6 mL/hour
1400 micrograms	840 micrograms/hour	4.2 mL/hour
1600 micrograms	960 micrograms/hour	4.8 mL/hour
1800 micrograms	1080 micrograms/hour	5.4 mL/hour
2000 micrograms	1200 micrograms/hour	6.0 mL/hour

Presentation: Naloxone is stocked at RBCH in 400 micrograms/mL injections and 800 micrograms/2mL Min-I-jets.

Links

• Sedation
• Anaesthesia Formulas

Summaries:

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