prepare magnesium and heparin at some point

Below is a concise “set-up list” based on the previous plan and the notes.

***

## 1. Airway / Equipment

- ETT: 3.0 mm uncuffed (primary), 2.5 mm cuffed (backup), 3.5 mm uncuffed (backup).  
- Stylet, suction catheter, oral airway.  
- Laryngoscope: Miller 0 and Miller 1 blades.  
- Backup LMA: Size 1.  
- Arterial line: 24G kit (radial ± femoral).  
- Central line: equipment for PICC/CVC if new line needed.  
- NIRS sensors (cerebral + renal), TEE probe (neonate), temperature probes (naso + rectal/bladder).  
- CPB priming equipment per perfusion (neonatal circuit, prime with blood as per center).

***

## 2. Induction / Maintenance Medications (Draw Up)

**All doses for 3.9 kg (rounding acceptable).**

1. **Atropine**  
   - Dose: 0.02 mg/kg ≈ 0.08 mg IV.  
   - Prepare: 0.1 mg in labeled syringe.

2. **Fentanyl**  
   - Induction: 10–25 mcg/kg (40–100 mcg) IV.  
   - Prepare: 100 mcg total in one syringe (dilute to convenient volume).  
   - Continuous: Have infusion ready (e.g., 50 mcg/mL to run at 1–5 mcg/kg/hr).

3. **Midazolam**  
   - Induction: 0.05–0.1 mg/kg (0.2–0.4 mg) IV.  
   - Prepare: 1 mg syringe for titration.  
   - Infusion: optional, prepared but not mandatory.

4. **Rocuronium**  
   - Induction: 0.6–1 mg/kg (2.5–4 mg) IV.  
   - Prepare: 10 mg in syringe.  
   - Redosing or infusion available (same vial).

5. **Ketamine** (backup)  
   - Induction backup: 1–2 mg/kg (4–8 mg) IV.  
   - Prepare: 10 mg in syringe.

6. **Etomidate** (if used at your center)  
   - Induction: 0.2–0.3 mg/kg (0.8–1.2 mg) IV.  
   - Prepare: 2 mg in syringe.

***

## 3. Vasoactive / Inotrope Infusions (Pre-made)

Prepare infusions with your institutional standard concentrations; label clearly.

- **Epinephrine infusion**  
  - Start range: 0.02–0.05 mcg/kg/min (titrate up).  
  - Have ready and connected (carrier running).

- **Milrinone infusion**  
  - Start: 0.33–0.5 mcg/kg/min (NO loading dose).  
  - Prepare but do not start until post-CPB unless indicated.

- **Dopamine infusion** (backup)  
  - Range: 2–20 mcg/kg/min.

- **Dobutamine infusion** (backup)  
  - Range: 2–20 mcg/kg/min.

- **Norepinephrine infusion** (backup for vasoplegia)  
  - Range: 0.05–1 mcg/kg/min.

- **Vasopressin infusion** (backup)  
  - Range: 0.3–2 mU/kg/min.

- **Phenylephrine**  
  - Bolus: 5–10 mcg/kg IV.  
  - Prepare syringe (e.g., 100 mcg/mL) for bolus rescue.

***

## 4. Anticoagulation / Reversal

- **Heparin**  
  - Dose: 300–400 U/kg (≈1,200–1,600 U) IV before CPB, plus extra for ACT-guided dosing.  
  - Prepare: total required dose in syringe; have extra vial available.

- **Protamine**  
  - Dose guide: 1 mg per 100 U heparin total given.  
  - Prepare vial(s), calculate approximate required amount for handoff to end-of-bypass.

***

## 5. Fluids / Blood Products

- **Crystalloids**  
  - Two bags: NS and LR available, with buretrol.  
  - Maintenance: 4 mL/kg/hr ≈ 15–16 mL/hr.

- **Glucose-containing solution**  
  - D5 or D2.5 solution ready for infusion and glucose corrections.

- **Blood Products** (ensure availability)  
  - PRBCs: at least 10 mL/kg (~40 mL).  
  - FFP and platelets on standby per institutional cardiac protocol.  
  - Cryoprecipitate available if needed.

***

## 6. Emergency / Resuscitation Meds (Pre-drawn)

1. **Epinephrine 1:10,000 (0.1 mg/mL)**  
   - Arrest/bradycardia dose: 10 mcg/kg = 0.1 mL/kg.  
   - For 3.9 kg: ~40 mcg = 0.4 mL.  
   - Draw up 1–2 mL in syringe.

2. **Atropine** (same as induction syringe; can be used emergency)  
   - 0.02 mg/kg ≈ 0.08 mg.

3. **Adenosine**  
   - 0.1–0.3 mg/kg for SVT; have full vial ready.

4. **Calcium Chloride**  
   - 10–15 mg/kg central IV.  
   - Draw up appropriate volume based on concentration.

5. **Sodium Bicarbonate**  
   - 1–2 mEq/kg; prepare syringe.

6. **Magnesium Sulfate**  
   - 25–50 mg/kg; have vial for arrhythmias.

7. **Lipid Emulsion**  
   - Available in room (for LAST).

8. **Dantrolene**  
   - Ensure MH cart in room; know reconstitution protocol.

***

## 7. Post-CPB / Hemostasis

- **Tranexamic Acid or Aminocaproic Acid**  
  - Prepared according to your protocol for antifibrinolysis.

- **Albumin 5%**  
  - At least one bottle ready for volume support.

***

Right IJ CVC (3.9 kg neonate): central venous catheter

Size: 3 Fr or 4 Fr, single lumen (or 4 Fr double lumen if needed).

Length: 5–8 cm (short neonatal catheter).

----------


For this 8‑day‑old term neonate with critical AS under anesthesia, reasonable **intraoperative targets to accept/maintain** are:

- **Heart rate:**  
  - Aim: **120–150 bpm** (sinus).  
  - Avoid: HR <100 (↓CO) and significant tachycardia >170 (↓diastolic filling, ↓coronary perfusion).[1][2]

- **Blood pressure / MAP:**  
  - Term neonate normals around this age: SBP ~70–80, DBP ~45–50, MAP ~55–60 mmHg awake.[3][1]
  - Under anesthesia for cardiac surgery, accept **MAP ~35–50 mmHg**, but avoid sustained MAP <35, especially if lactate or NIRS worsen.[4][5]

- **Oxygenation and perfusion:**  
  - SpO₂: **>92%** (per CTICU plan).  
  - Cerebral (and renal) NIRS: aim **>65%** and stable trend.[5][6]
  - Lactate: keep **<3 mmol/L**, avoid rising trend as sign of inadequate systemic perfusion.[7][5]

- **Other bedside indicators:**  
  - Capillary refill ≤2–3 s, warm extremities, urine output ≥1 mL/kg/hr.[3][5]

Within those ranges, treat trends (falling MAP with rising lactate/NIRS drop or HR drifting out of range) rather than single numbers.

[1](https://www.nationwidechildrens.org/conditions/health-library/physical-exam-of-the-newborn)
[2](https://my.clevelandclinic.org/health/diagnostics/heart-rate)
[3](https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/neonatal/blood-pressure-disorders)
[4](https://onlinelibrary.wiley.com/doi/abs/10.1111/pan.12987)
[5](https://pmc.ncbi.nlm.nih.gov/articles/PMC7575728/)
[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC11979500/)
[7](https://www2.ccasociety.org/newsletters/2021summer/chip/predictors.html)
[8](https://link.springer.com/10.1007/s00467-023-05979-x)
[9](https://linkinghub.elsevier.com/retrieve/pii/S0146000503001289)
[10](http://archpedi.jamanetwork.com/article.aspx?doi=10.1001/archpedi.1955.02050110246012)
[11](https://www.cambridge.org/core/product/identifier/S0007114515000562/type/journal_article)
[12](https://www.semanticscholar.org/paper/56f69730de06a43b037bd8fe6fba0dbff989277c)
[13](https://www.physiology.org/doi/10.1152/japplphysiol.00970.2013)
[14](https://publications.aap.org/pediatrics/article/123/4/e646/71413/Repeat-Prenatal-Corticosteroid-Doses-Do-Not-Alter)
[15](https://www.semanticscholar.org/paper/612236badb608f19e6a3029bd8320d150509c1e0)
[16](https://academic.oup.com/ndt/article-lookup/doi/10.1093/ndt/gfv410)
[17](http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2011.1650)
[18](https://www.omicsonline.org/open-access/is-there-a-normal-blood-pressure-in-neonates-2167-1095-1000e112.pdf)
[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC3990926/)
[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC1272682/)
[21](https://pmc.ncbi.nlm.nih.gov/articles/PMC1029597/)
[22](https://ej-med.org/index.php/ejmed/article/download/1752/1041)
[23](https://pmc.ncbi.nlm.nih.gov/articles/PMC11061963/)
[24](https://pmc.ncbi.nlm.nih.gov/articles/PMC9112315/)
[25](https://pmc.ncbi.nlm.nih.gov/articles/PMC1626905/)
[26](https://www.childrensmercy.org/siteassets/media-documents-for-depts-section/documents-for-health-care-providers/evidence-based-practice/clinical-practice-guidelines--care-process-models/normal-blood-pressures-by-age.pdf)
[27](https://www.starship.org.nz/guidelines/blood-pressure-hypertension-in-neonates)
[28](https://www.bcm.edu/bodycomplab/BPappZjs/BPvAgeAPPz.html)
[29](https://www.ucsfbenioffchildrens.org/medical-tests/pulse)
[30](https://publications.aap.org/pediatrics/article/150/Supplement%202/e2022056415J/189882/Acute-Cardiac-Care-for-Neonatal-Heart-Disease)
[31](https://www.nccwebsite.org/content/documents/courses/Neonatal%20BP%20standards-1.pdf)
[32](https://pubmed.ncbi.nlm.nih.gov/7063425/)
[33](https://neopeds.academy/bp/)
[34](https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.740185/full)
[35](https://publications.aap.org/pediatricsinreview/article/41/6/307/35417/Neonatal-Hypertension)
[36](https://chemm.hhs.gov/pals.htm)
[37](https://pubmed.ncbi.nlm.nih.gov/36083106/)
[38](https://medlineplus.gov/ency/article/007329.htm)
[39](https://www.rch.org.au/clinicalguide/guideline_index/normal_ranges_for_physiological_variables/)
[40](https://www.nature.com/articles/s41390-024-03161-z)
[41](https://www.gosh.nhs.uk/documents/7745/Appendix_7_Normal_Blood_Pressures_R53BRgg.pdf)