Chap 43: OB ANES:
Pain Pathways During Labor First Stage Latent phase T11-12 Active phase gradually involving T10 –L1 Visceral afferents travel sympathetic fibers thru uterine and cervical plexus, then thru hypogastric and aortic plexus before entering spinal cord w T10L1 nerve roots Second stage – perineal descent (pain)
Stretching and compression Pudendal nerve (S2-4) innervation
DON DANIELS COL MC
1
Chap 43: OB ANES:
Parenteral Agents
Cross the placenta Fetal Central nervous depresssion
Prolonged time to breath Respiratory acidosis Abnl neurobehavorial exam Loss of beat to beat variability Prematurity leads to increased sensitivity
DON DANIELS COL MC
2
Chap 43: OB ANES:
Parenteral agents
Meperidine – 10-25 mg IV or 25-50 mg IM Maternal and fetal resp depression occurs wn 10-20 min IV, 1-3 hrs IM Usually given early in labor
DON DANIELS COL MC
3
Chap 43: OB ANES:
Other Parenteral agents
Fentanyl – 50-100 mcg/hr Morphine – fetal causes greater respiratory depression Mixed agonist/antagonist offer no advantage in preventing fetal resp depression
DON DANIELS COL MC
4
Chap 43: OB ANES:
Other Parenteral Agents
Promethazine 25-50 mg IM & Hydroxyzine 50100 mg IM reduce anxiety, opioid requirements, incidence of nausea and do not add to neonatal depression Diazepam causes significant neonatal depression and causes amnesia in parturient Ketamine is a powerful analgesic at low doses 10-15 mg for 2-5 min. Can cause psychotomimetic effects
DON DANIELS COL MC 5
Chap 43: OB ANES:
INHALATION ANALGESIA
A practice of the past. Provided subanesthetic doses
Self administered via “Penthrane whistle” Better when given by trained anesthetist
Ideal, pt remains awake w intact reflexes
Limit to 50% N2O, 1% enflurane or 0.7% isoflurane
DON DANIELS COL MC 6
Chap 43: OB ANES:
PUDENDAL NERVE BLOCK
Second stage labor Used when perineal analgesia is not already present Iowa trumpet, 10 ml lido placed 1-1.5 cm behind sacrospinous ligament underneath ischial spine
DON DANIELS COL MC
7
Chap 43: OB ANES:
PARACERVICAL BLOCK
Analgesia for 1st stage only 33% chance of fetal bradycardia
Injection close to uterine artery is thought to result in uterine artery vasoconstriction and high fetal blood levels of local anesthetic
DON DANIELS COL MC
8
Chap 43: OB ANES:
NEURAXIAL OPIOIDS alone
Useful in pts who may not tolerate sympathectomy Hypovolemia, aortic stenosis, TOF, Eisenmenger’s or Pulm HTN Does not impair ability to push, but also does not provide perineal relaxation
DON DANIELS COL MC
9
Chap 43: OB ANES:
EPIDURAL OPIOIDS ALONE
Most effective during 1st stage
Morphine>7.5 mg, 30-60 min onset, up to 24 hrs duration, lots of side effects Meperidine 100 mg good but short (1-4 hr) analgesia Fentanyl 50-200 mcg 5-10 min peak, 1-2 hr duration Sufenta 10-50 mcg 5-10 min peak, 1-2 hr duration
DON DANIELS COL MC 10
Chap 43: OB ANES
Intrathecal Opioids Alone
Also best used during 1st stage
Morphine 0.5-1 mg slow onset, 6-8 hrs analgesia, lots of side effects Combo MSO4 0.25 mg +fentanyl 25 mcg or sufenta 5-10 mcg faster peak onset and shorter duration (4-5 hr) Intrathecal cath: meperidine 10 mg, fentanyl 5-10 mcg, or sufenta 5-10 mcg
DON DANIELS COL MC 11
Chap 43: OB ANES
LOCAL ANESTHETICS ALONE
Criteria for initiation of labor epidural
No fetal distress Good regular contractions Nullip 3-4 cm, multip 4-5 cm Fetal head engaged
Technique
Average depth 5 cm Place @ L3-4 or L4-5 for T10-S5 blockade
DON DANIELS COL MC 12
Chap 43: OB ANES
Local anesthetic choice
Lidocaine 1-1.5% Chloroprocaine 2-3%
Valuable for immediate onset of action Neurotoxity led to removal of bisulfite With EDTA backache may occur Decreases duration and effectiveness of duramorph
Bupivacaine 0.25-0.5%
Potential cardiotoxicity Long duration valuable for labor
DON DANIELS COL MC 13
Chap 43: OB ANES
Epidural for first stage of labor
500-1000 ml RL bolus
Avoid glucose solutions
3 ml local with 1:200,000 epi test Test dose neg after 5 min, give 4-8 ml local to get T10-L1 sensory level Monitor q 1-2 min NIBP x 20 min Reinject prn pain or 10 ml/hr 0.125% bupivacaine or 0.5% lidocaine
DON DANIELS COL MC 14
Chap 43: OB ANES
Epidural during 2nd stage
Goal is to include S2-4 dermatomes 1000-1500 ml LR bolus Place pt in sitting to place cath, semi upright position if cath present Give test dose After 5 min & neg test, give 10-15 ml local @ 5 ml q 30 sec Moniter NIBP q 1-2 min x 20 min
DON DANIELS COL MC 15
Chap 43: OB ANES
Prevention of Unintentional Intrathecal Injections
0.5-2.5% incidence of intrathecal injection Lidocaine 45-60 mg, chloroprocaine 100 mg or bupivacaine 12.5 mg will detect spinal injection wn 2-5 min
DON DANIELS COL MC
16
Chap 43: OB ANES
Prevention of Unintentional Intravascular Injections
5-15% incidence of vascular injecton OB Intravascular detection methods unreliable
Epi 15 mcg increases HR 20-30 beats wn 30-60 sec however, IV epi can reduce uterine blood flow causing fetal distress Alternative method include eliciting tinnutus, perioral numbness after 100 mg lidocaine, seeking chronotropic effects with isoproterenol 5 mcg, or injecting air while monitoring precordial doppler
DON DANIELS COL MC 17
Chap 43: OB ANES
Management of Hypotension
Left uterine displacement IV fluid bolus Ephedrine 5-15 mg Supplemental oxygen Head down position may cause decrease pulmonary gas exchange
DON DANIELS COL MC
18
Chap 43: OB ANES
Management of Unintentional IV injection
Early recognition Thiopental 50-100 mg for seizures Airway management and oxygenation Bupivacaine arrest is difficult to manage. Bretylium may reverse bupivacaine induced V. tach
DON DANIELS COL MC 19
Chap 43: OB ANES
Management of intrathecal injection
Attempt to aspirate local anesthetic Place pt supine w LUD Rx hypotension w IV fluids and ephedrine High spinal may require intubation and mechical ventilation w 100% oxygen
DON DANIELS COL MC
20
Chap 43: OB ANES
Management of PDPH
Oral analgesics Epidural saline injection 50-100 ml Caffeine sodium benzoate 500 mg IV for mild HA Epidural Blood patch (10-20 ml) moderate to severe HA
DON DANIELS COL MC
21
Chap 43: OB ANES
Caudal Anesthesia
Sacral canal placement more difficult than Lumbar placement, rectal exam necessary to exclude fetal injection Requires more local May interfere with normal rotation of fetal head due to early motor blockade of pelvic muscles Advantage: shorter onset of perineal analgesia 15-20 ml local for T10-S5 block
DON DANIELS COL MC 22
Chap 43: OB ANES
Spinal anesthesia or Saddle block
Profound anesthesia for vaginal delivery
Hyperbaric tetracaine 3-4 mg Bupivacaine 6-7 mg Lidocaine 20-40 mg Addition of fentanyl 10-25 mcg or sufentanil 5-10 mcg will intensify and prolong analgesia Inject between contractions to prevent cephalad spread
DON DANIELS COL MC
23
Chap 43: OB ANES
Local anesthetics w opioids: Epidural Analgesia
Combination results in less hypotension and drug toxicity Chloroprocaine interferes with opioid efficacy Initial bolus bupivacaine 0.0625–0.125% w fentanyl 50 mcg or sufentanil 5-20 mcg Maintenance w infusions of bupivacaine 0.0625-0.125% w 1-2 mcg/ml fentanyl or 0.20.3 mcg/ml sufentanil Weak solutions usually do not cause motor block
DON DANIELS COL MC 24
Chap 43: OB ANES
Continuous Spinal Analgesia
Unplanned wet tap w tuohy, just convert passing epidural catheter into intrathecal space Combined Epidural/Spinal Analgesia
Special designed Tuohy with a longer 25-27 gauge SA needle Intrathecal injection of sufentanil 5 mcg or fentanyl 25 mcg first then withdraw SA needle Thread epidural cath thru tuohy
DON DANIELS COL MC
25
Chap 43: OB ANES: General
Anesthesia for vaginal delivery
Indications
Fetal distress during 2nd stage Tetanic uterine contractions Breech extraction Version and extraction Manual removal of retained placenta Replacement of inverted uterus Uncontrollable psychiatric patients
Suggested GETA technique
LUD Preoxygenate while applying monitors RSI w cricoid using thiopental 4 mg/kg and sux 1.5 mg/kg when OB is ready and intubate with 67 mm OET. If hypotensive use ketamine 1 mg/kg. After intubation, use 1-2 MAC volatile agent in 100% O2 Once fetus delivered, Consider IV NTG 50-100 mcg reduce to ½ MAC if uterine relaxation Do not use mask GA even indicated if OB yells problem is DON DANIELS COL MC 26 solved
Chap 43: OB ANES
Anesthesia for Cesarean Section
Cesarean rates up to 25% Regional anesthesia preferred method
Decreased risk of maternal aspiration Mothers like to see baby at birth Fathers like to be present Post op analgesia via neuraxial opioids
General anesthesia
Always a backup Faster to achieve Potential less hypotension Control of airway Disadvantage of pulmonary aspiration Potential inability to intubate Possible fetal depression
DON DANIELS COL MC
27
Chap 43: OB ANES
Neuraxial anesthesia for C/S general principles
Requires T4 sensory level 1500-2000 ml bolus prior to blockade Left uterine displacement mandatory after block Supplemental O2 NIBP q 1-2 first 20 minutes
DON DANIELS COL MC 28
Chap 43: OB ANES
Spinal anesthesia for cesarean section
Hyperbaric Tetracaine 7-10 mg Hyperbaric Lidocaine 60-90 mg Hyperbaric Bupivacaine 12-15 mg Fentanyl 10-25 mcg enhances anesthesia and prolongs duration Sufentanil 5-10 mcg Duramorph 0.1-0.25 mg post op analgesia up to 24 hrs
DON DANIELS COL MC 29
Chap 43: OB ANES: Epidural Anesthesia for
cesarean section
15-25 ml local in 5 ml increments q 1 min for T4 2% lidocaine 3% chloroprocaine 0.5% bupivacaine Fentanyl 50-100 mcg Sufentanil 10-20 mcg Maybe add 1 meq/10 ml lidocaine or 0.1 meq/10 ml bupivacaine
Patchy blocks treated with 1020 mg ketamine or 30% N2O if pt wants to see baby Intolerable patchy blocks, begin GETA 5 ml duramorph for post op analgesia Remember 3.5-30% incidence of recurrent herpes simplex after duramorph Alternative analgesia by continuous infusion Butorphanol 2 mg for post op analgesia
30
DON DANIELS COL MC
Chap 43: OB ANES
General Anesthesia for Cesarean Section
Pulmonary Aspiration risk
1:500-400 in obstetric population 1:2000 in non obstetric population
Failed endotracheal intubation
1:300 in obstetric population 1:2000 in non obstetric population
Major causes of anesthesia related obstetric morbidity and mortality
DON DANIELS COL MC 31
Chap 43: OB ANES: General Anesthesia for
Cesarean Section
Predictors for
Aspiration Risk
Morbid obesity Active GERD symptoms Emergent surgical delivery Potentially difficult airway Less than 8 hrs fast
Predictors of
Difficult Airway
Abnormal dentition (buck teeth, absence upper incisors) Large breast Short neck, micrognathia obesity
32
DON DANIELS COL MC
Chap 43 OB ANES: General
Anesthesia for Cesarean Section Aspiration Prophylaxis
30 ml of 0.3 M sodium citrate 30-45 mins prior to induction Ranitidine 100-150 mg 1-2 hrs prior Metoclopramide 10 mg 1-2 hr prior Omeprazole 40 mg @ hs and am prior Robinul 0.2 mg for anticipated difficult airway
DON DANIELS COL MC
33
Chap 43: OB ANES: General Anesthesia for
Cesarean Section
Preparation of difficult airway
Exam neck, mandible, dentition, oropharynx & size of breast Have available short laryngoscope handle, @ least one extra styleted 6 OET, laryngeal mask or combitube Have a difficult airway plan
DON DANIELS COL MC
34
Chap 43 OB ANES: General Anesthesia for
Cesarean Section
Suggested technique
Position supine w LUD Pre oxygenate 100% O2 x 5 min Wait until prepped and draped When surgeons ready, RSI w cricoid 4mg/kg STP or 1 mg/kg ketamine, then sux 1.5 mg/kg Surgeon can go after confirm tube in trachea by auscultation and ETCO2
DON DANIELS COL MC 35
Chap 43 OB ANES: General Anesthesia for
Cesarean Section
Suggested technique
Avoid excessive hyperventilation 50% N2O w less than one MAC volatile agent. Can add muscle relaxant After neonate delivered, add 10-20 u oxytocin/liter of crystalloid If uterus fails to contract, add narcotic and dc volatile agent. Methergine 0.2 mg IM
DON DANIELS COL MC 36
Chap 43 OB ANES: Anesthesia for
Emergency Cesarean Section
Regional anesthesia contraindicated in hypovolemic or hypotensive patients. May not have time to increase level and density with existing epidural 4 breath preoxygenation then induce If surgeons take time to scrub, use 3% chloroprocaine w existing epidural
DON DANIELS COL MC
37
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Occiput Posterior
Fetal head does not rotate anterior Forceps more likely to assist rotation Epidural analgesia helps perineal and pelvic analgesia and relaxation to facilitate manual or forceps rotation and delivery
DON DANIELS COL MC
38
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Tranverse Lie
Leads to dysfunction labor Predisposes to cord prolapse Lately, epidural has been used to assist manual version Cesarean section indicated if membranes rupture with persistent transverse lie
DON DANIELS COL MC
39
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Breech presentation
Complicates 3-4% of deliveries Some Ob go to c/s to avoid trapping head or shoulders in vaginal delivery Epidural does not increase the need for breech extraction, may lesson the likelihood of trapped head due to perineal relaxation If trapped during regional , RSI GETA indicated, use of volatile agent or nitro 50-100 mcg IV
DON DANIELS COL MC
40
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Multiple gestations
Regional anesthesia for versions, extractions or cesarean section does not cause neonatal depressant effects as seen w GETA 2nd baby usually more depressed than the 1st Acid base status of twins better in epidural group than GETA group More prone to aortocaval compression
DON DANIELS COL MC 41
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Placenta Previa
Occurs more freq: prior C/S, prior myomectomy, multiparity, advanced maternal age, large placenta Complete previa covers os Partial previa partially covers os Low lying or marginal previa is close to internal os but does not extend beyond its edge Presents with painless bleeding Before 37 weeks, Rx with bedrest and observation After 37 weeks, delivery by cesarean section Low lyiers, may vag deliver if bleeding mild
DON DANIELS COL MC 42
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Placenta previa workup
Abdominal ultrasound Direct exam with vaginal speculum requires “Double setup”
Lithotomy Prepare for crash C/S Two large bore IV’s Blood immediately available Be prepared for emergency hysterectomy
DON DANIELS COL MC 43
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Abruptio Placentae
Risk factors are hypertension, trauma, short umbilical cord, multiparity, and abnormal uterus Diagnosis made by excluding placenta previa Most abruptio’s result in mild to mod bleeding, although bleeding may be concealed inside uterus Severe abruptio can cause coagulopathy DON DANIELS emergency 44 Severe abruptio is C/SCOL MC
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Uterine Rupture
Uncommon but may result from dehiscence of scar from old C/S, extensive myomectomy; forceps manipulations; spont rupture from prolonged labor; fetopelvic disproportion, or large thin weakened uterus Present as frank hemorrhage or as hypotension, and abrupt onset of continous abdominal pain even with epidural
DON DANIELS COL MC 45
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Chorioamnionitis
Use of regional anesthesia is controversial
theoretical risk of promoting meningitis or epidural abscess worsening hemodynamic instability of septic pt due to sympathectomy
In absence of overt signs of septicemia, thrombocytopenia or coagulopathy, most clinicians offer neuraxial anesthesia following antibiotic therapy
DON DANIELS COL MC 46
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Preterm labor
Tocolytics are used to inhibit labor (ritodrine, terbutaline, magnesium, Ca channel blockers & prostaglandin inhibitors) Labor epidural goal during labor is a slow controlled delivery with minimal pushing & complete pelvic relaxation Regional anesthesia preferred for C/S If GETA used, halothane, pcb, ketamine & ephedrine cautiously if beta agonist used to stop labor
DON DANIELS COL MC 47
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Pregnancy Induced Hypertension
Hypertension (SBP 140 or DBP 90, or consistent systolic increase 30 mm or diastolic 15 mm above baseline) Proteinuria (>500 mg/d) Edema
Primarily affects primigravidas related to placental ischemia
DON DANIELS COL MC 48
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy PIH treatment
Bed rest, sedation, antihypertensive drugs & magnesium Therapeutic magnesium 4-6 meq/L Esmolol has significant, potentially adverse fetal effects Ca channel blockers have tocolytic effects & potentiation of magnesium induced circulatory depression A line, central venous and pulmonary art monitoring may be indicated Definitive Rx is delivery of fetus and placenta
DON DANIELS COL MC
49
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
PIH: Anesthestic Management
Mild, use caution; Severe require Rx before anesthesia No coagulopathy, epidural anesthesia is best choice.
Decreases cathecholamines & improves uteroplacentall perfusion Judicious colloid bolus (250 ml) Epinephrine test dose controversial A line & Central monitoring in severe PIH Smaller doses vasopressor
Regional anesthesia is contraindicated if plt < 100,000 SNP, NTG, trimethaphan, labetalol for bp control w GETA Reduce nondepolarizer in pts on magnesium
DON DANIELS COL MC 50
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Cardiac Disease
Group 1: Mitral valve, Ao insufficiency or congenital left to right shunting
Benefit from epidural anesthesia: sympathectomy reduces preload and afterload, relieves pulm congestion and increases forward flow
Group 2: Ao stenosis, congenital right to left shunts or primary pulm HTN
Neuraxial anesthesia generally poorly tolerated Better managed with intraspinal opioids, systemic meds, pudendal NB or general anesthesia
DON DANIELS COL MC 51
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Amniotic Fluid Embolism
86% mortality Present w sudden tachypnea, cyanosis, shock, generalized bleeding. May see seizures & pulm edema. Acute LV dysfunction is common. Rx: aggressive cardiopulmonary resuscitation CPR & gravid uterus does not work, deliver it
DON DANIELS COL MC 52
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy
Postpartum Hemorrhage
Defined as over 500 ml
Involvement may be as little as securing IV access to full volume resuscitation under GETA GETA for bimanual uterine massage, manual extraction of retained placenta, reversion of inverted uterus, repair of major lac(s), or emergency hysterectomy
DON DANIELS COL MC 53
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Fetal heart rate monitoring Baseline heart rate 120-160 bpm
increased: prematurity, mild fetal hypoxia, chorioamnionitis, maternal fever, anticholinergics, beta agonist, or hyperthyroidism decreased: postterm pregnancy, fetal heart block, fetal asphyxia
DON DANIELS COL MC
Baseline variability - 3-6 beats/min
sustained decrease variability sign of fetal asphyxia CNS depressants, parasympatholytics also decrease variability Long term variability consist of periodic acclerations related to fetal movements & are 54 reassuring
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Fetal heart rate monitoring
Early Decelerations
10-40 bpm due to vagal response to head compression or neck stretch w contractions
Late Decelerations
may be as low as 5 bpm at or following the peak of uterine contractions due to decrease in PaO2 on chemoreceptors & assoc w fetal compromise
Variable Decelerations
often >30 bpm due to umbilical compression
DON DANIELS COL MC 55
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Fetal monitoring
Fetal blood sampling
pH >7.20 = vigorous neonate pH < 7.20 = depressed neonate Usually interpreted in conjunction w heart rate.
DON DANIELS COL MC
56
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Treatment of Asphyxiated Fetus
Treat causes of uteroplacental
compromise
Aortocaval compression maternal hypoxemia maternal hypotension excessive uterine activity
Treatment change maternal position supplemental oxygen intravenous ephedrine or fluid adjust oxytocin infusion persistent asphyxia requires immediate delivery
DON DANIELS COL MC
57
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Care of the Neonate
Apgar Scores
1 minute correlates with survival 2 minute correlates with neurologic outcome Assesses 5 areas with max 2 points
Heart rate Respiratory effort Muscle tone Reflex irritability Color
DON DANIELS COL MC 58
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/ Meconium staining
Thin watery meconium does not need suctioning Thick (pea soup)
needs suctioning with suction bulb as soon as head is out but before shoulders Tracheal suction before first breath, until no more meconium seen, max 3 times supplemental O2
DON DANIELS COL MC 59
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/Care of Depressed Neonate
Usually asphyxia, so goal is restore respiration Other contributing factor is hypovolemia Failure to respond to respiratory resuscitation, should move to securing vascular access and ABG Apgar 0-2 usually require intubation
DON DANIELS COL MC 60
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/Guidelines for ventilation of depressed neonate
Avoid excessive flexion or extension of the neck. Bag & mask @ 40-60 breaths FiO2 100% Initial peak pressures 40 cm H20, then reduce to <30 cm H2O 30 sec, reassess. If Hr <60, intubate & start chest compressions Intubate w Miller 0 or 1. OET 2.5 -3.5. Leak 20 cm, length tip to lip = 6 cm plus weight in kg
DON DANIELS COL MC
61
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/Guidelines for Chest Compressions
Indications are a HR < 60 & a HR 60-80 that is not rising after 30 secs of adequate ventilation w 100% oxygen Compressions should be 120/min compressing the sternum 1/2 to 3/4 in. Compression:Ventilation ratio 3:1 Stop compressions once HR > 80
DON DANIELS COL MC 62
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/Neonate vascular access
Cannulate umbilical vein w 3.5F or 5F umbilical catheter Tip should be below skin & allow backflow of blood. Further advancement may result in infusion into the liver Do not introduce air into artery or vein
DON DANIELS COL MC
63
Chap 43 OB ANES: Anesthesia for the
complicated pregnancy/Drug resuscitation for neonates
Epi: 0.01-0.03 mg/kg (0.1-0.3 ml/kg of a 1:10,000 solution) should be given for HR < 80. May be repeated 35 min. Naloxone: 0.01 mg/kg IV or 0.02 mg/kg IM to reverse respiratory depressant effect of opioids given to the mother in the last 4 hrs. NaHCO3: 2 meq/kg of a 0.5 meq/ml for severe metabolic acidosis Ca gluconate: 100 mg/kg or CaCl 30 mg/kg for documented hypocalcemia or suspected magnesium intoxication Glucose 200 mg/kg for documented hypoglycemia
DON DANIELS COL MC 64