# Clinical Sources for Helix Anesthesia

Every dose, max, and protocol in Helix Anesthesia mapped to its primary reference. This document maps each clinical value in the app to a verifiable external source (FDA package insert, society guideline, or primary literature) so any clinician can verify our work.

> **Review status — awaiting independent clinical review.**
> The doses and protocols below were compiled by the author, a practicing CRNA, and cross-referenced against the cited sources. **Independent clinical review by anesthesia clinicians other than the author has not yet been completed.** Reviewers who complete a review are listed in the **Reviewer Audit Log** at the bottom of this document. Until that log shows a signature for a given section, treat that section as author-cited and independently verifiable — every value links to its primary source above — but not independently reviewed.
>
> "Independent clinical review" is used deliberately in place of "peer review." Peer review is a term of art for the process journals apply to manuscripts, and this document has not been through it. What is described here is a source-verification and clinical-judgment audit of the app's content, which is a different and narrower thing.

**Disclaimer**: Doses verified to the best of authors' knowledge against the cited references at the time of authoring. Drug labels change; verify each dose against the most current package insert before clinical use. Helix Anesthesia is a reference tool and does not replace clinical judgment.

---

## How to find any cited source

**FDA package inserts** — All major drug PIs are searchable at the FDA's DailyMed:
- https://dailymed.nlm.nih.gov/dailymed/index.cfm
- Direct PDFs hosted at accessdata.fda.gov are linked inline below.

**Journal articles** — Every cited article can be located on PubMed by entering the citation (author + year + journal):
- PubMed search: https://pubmed.ncbi.nlm.nih.gov/
- Free abstracts for every cited article; full text may require institutional access via your hospital library.
- Many articles are also open-access on PubMed Central (PMC).

**Society guidelines** — Direct URLs to society documents are listed inline (AHA, ASA, ASRA, ACOG, SMFM, MHAUS, NCCMERP).

**Textbook references** — Edition-dependent page numbers. Chapter titles are the stable reference. Publisher URLs for textbooks:
- **Miller's Anesthesia, 10th ed** (Gropper, Cohen, Eriksson, Fleisher, Leslie, Johnson-Akeju; Elsevier 2024; ISBN 9780323935920): https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0 · Also on ClinicalKey
- **A Practice of Anesthesia for Infants and Children, 6th ed** (Coté, Lerman, Anderson; Elsevier 2018; ISBN 9780323429740): https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0
- **Stoelting's Pharmacology & Physiology in Anesthetic Practice, 6th ed** (Flood, Rathmell, Urman; LWW 2022; ISBN 9781975126896): https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896
- **Cousins and Bridenbaugh's Neural Blockade, 4th ed** (Cousins, Carr, Horlocker, Bridenbaugh; LWW 2009): https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380
- **Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th ed** (Cullen, Stock, Ortega; LWW 2023; ISBN 9781975199074): https://shop.lww.com/Barash--Cullen--and-Stoelting-s-Clinical-Anesthesia--Print---eBook-with-Multimedia/p/9781975199074

---

## 1. Local Anesthetics — Maximum Doses

The figures below are **absolute single-dose ceilings** intended for LAST (local anesthetic systemic toxicity) calculation — i.e., the maximum a patient should receive in one administration regardless of technique (infiltration, peripheral block, epidural). Where the FDA label gives an explicit mg/kg, that is quoted directly. Where the FDA label only gives an absolute mg cap (bupivacaine, mepivacaine adult, ropivacaine), the mg/kg figure is the standard textbook back-calculation used across Miller's, Stoelting's, and Barash. Infiltration-only tables in some textbooks (e.g. Miller's 8e Table 36-4) quote more conservative numbers for that specific use — those are not wrong, but they are narrower than the toxicity-ceiling values below.

| Agent | Plain (mg/kg) | Plain cap (mg) | With epi (mg/kg) | Epi cap (mg) | Source |
|---|---|---|---|---|---|
| Lidocaine | 4.5 | 300 | 7 | 500 | Xylocaine PI; Miller's 10e Ch. 47 |
| Mepivacaine | 5 | 400 | 7 | 500 | Carbocaine PI (adult absolute cap); Miller's 10e |
| Bupivacaine | **2.5** | **175** | 3 | 225 | Marcaine PI (FDA: "single doses up to 175 mg plain, 225 mg with epi"); Miller's 10e; ASRA |
| Ropivacaine | 3 | 225 | — | — | Naropin PI (cumulative 770 mg/24h); single-dose mg/kg per Miller's 10e / Stoelting's. *With-epi ceiling not listed: ropivacaine has intrinsic vasoconstrictor properties and the FDA Naropin label does not endorse epinephrine co-administration; clinicians using ropi + epi off-label should reference a more specialized source.* |
| Chloroprocaine | 11 | 800 | 14 | 1000 | Nesacaine PI |
| Procaine | 7 | 500 | 9 | 600 | Novocain PI |
| Prilocaine | 6 | 400 | 8 | 600 | Citanest PI (dental, FDA-approved US form). Plain mg/kg per anesthesia-text convention reflecting methemoglobinemia risk |
| Tetracaine | 1 | 100 | — | — | Pontocaine PI. Modern use is spinal (5-20 mg total) and topical, not infiltration |

**Primary URLs:**
- Marcaine (bupivacaine HCl) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=bupivacaine)
- Xylocaine (lidocaine HCl) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine)
- Naropin (ropivacaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ropivacaine)
- Nesacaine (chloroprocaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=chloroprocaine)
- Carbocaine (mepivacaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=mepivacaine)
- Novocaine (procaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=procaine)
- Citanest (prilocaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=prilocaine)
- Pontocaine (tetracaine) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=tetracaine)
- Miller's Anesthesia 10e Ch. 47 "Local Anesthetics" — [Elsevier](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0)
- ASRA LAST Checklist (max-dose guidance) — [ASRA](https://www.asra.com/guidelines-articles)

---

## 2. Sugammadex (Reversal)
| Indication | Dose | Source |
|---|---|---|
| TOF count ≥ 2 (shallow/moderate block) | 2 mg/kg | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) · [FDA label PDF](https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/022225lbl.pdf) |
| 1-2 PTC, no TOF (deep block) | 4 mg/kg | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) |
| Immediate reversal of profound block, within 3 min of 1.2 mg/kg rocuronium | 16 mg/kg | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) |

**URLs:**
- Bridion (sugammadex) PI — [DailyMed search](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) · [FDA 2015 label PDF](https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/022225lbl.pdf)
- FDA approval letter — [FDA NDA 022225](https://www.accessdata.fda.gov/drugsatfda_docs/nda/2015/022225Orig1s000Approv.pdf)

**Caveats noted in app:**
- Hormonal contraceptive interaction (PI Section 7.1)
- CrCl <30 mL/min not recommended (PI Section 8.6)
- Bradycardia rare but reported (PI Section 5.2)

---

## 3. Sugammadex — Pediatric

| Dose | Source |
|---|---|
| 2 mg/kg (TOF ≥ 2) | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) |
| 4 mg/kg (deep block) | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) |
| 16 mg/kg (immediate) | Bridion PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex) |

Pediatric dosing extrapolated from adult PI per Bridion label (approved age ≥ 2 years by FDA 2021) — [DailyMed Bridion label](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sugammadex).

---

## 4. Neuraxial / Intrathecal Adjuvants —  (`NEURAXIAL_ADJUVANTS`)

| Drug | Dose (intrathecal, total) | Source |
|---|---|---|
| Fentanyl | 10–25 mcg | Miller's 10e Ch. 56 "Spinal Anesthesia" — [Miller's product page](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Sublimaze PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=fentanyl) |
| Sufentanil | 2.5–10 mcg | Miller's 10e Ch. 56 — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Sufenta PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sufentanil) |
| Morphine (preservative-free) | 100–200 mcg | Duramorph PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=duramorph); Carvalho B, et al. *Anesth Analg* 2005;100:1150-1158 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/15781537/) |
| Epinephrine | 100–200 mcg | Miller's 10e Ch. 56 — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Adrenalin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=epinephrine) |
| Clonidine | 15–75 mcg total | Catapres PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=clonidine); Stoelting's Pharmacology, 6th ed — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896) |
| Dexmedetomidine | 3–10 mcg total (off-label) | Kanazi GE, et al. *Acta Anaesthesiol Scand* 2006;50:222-227 (3 mcg dose) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/16430546/); Al-Mustafa MM, et al. *Saudi Med J* 2009;30:365-370 (5-10 mcg dose) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/19271064/) |

**Epidural adjuvants:**
| Drug | Dose | Source |
|---|---|---|
| Fentanyl bolus | 50–100 mcg | Stoelting's Pharmacology — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896); Cousins & Bridenbaugh 4e — [Wolters Kluwer](https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380); Sublimaze PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=fentanyl) |
| Morphine epidural | 1–4 mg | Duramorph PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=duramorph) |
| Epinephrine test dose | 15 mcg with 3 mL 1.5% lidocaine | Moore DC, Batra MS. *Anesthesiology* 1981;55:693-696 — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/55/6/693/29823) |

---

## 5. Peripheral Block Adjuvants —  (`BLOCK_ADJUVANTS`)

| Drug | Dose (perineural) | Source |
|---|---|---|
| Epinephrine | 1:200,000–400,000 (2.5–5 mcg/mL) | Miller's 10e Ch. 57 — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Adrenalin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=epinephrine) |
| Dexamethasone | 4–8 mg perineural | Choi S, et al. *Br J Anaesth* 2014;112:427-439 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/24413428/) |
| Clonidine | 0.5–1 mcg/kg (max 75–150 mcg) | Pöpping DM, et al. *Anesthesiology* 2009;111:406-415 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/19602964/) |
| Sodium bicarbonate | 1 mEq per 10 mL lidocaine | Hilgier M. *Reg Anesth* 1985;10:59-61 (older paper, not indexed in PubMed; see Sources Without a Confirmed Direct URL section for alternative refs) |
| Buprenorphine | 150–300 mcg perineural | Candido KD, et al. *Reg Anesth Pain Med* 2002;27:162-167 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/11915063/) |
| Dexmedetomidine | 0.5–1 mcg/kg perineural | Abdallah FW, Brull R. *Br J Anaesth* 2013;110:915-925 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/23587874/) |

---

## 6. Spinal Anesthesia Dose by Procedure
| Procedure | Bupivacaine dose | Source |
|---|---|---|
| Lower extremity / saddle (T10-L1) | 10–15 mg | Cousins & Bridenbaugh 4e — [Wolters Kluwer](https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380); Miller's 10e Ch. 56 — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0) |
| C-section (T4) | 10–12 mg hyperbaric | ACOG Practice Bulletin 209 (Obstetric Analgesia/Anesthesia) — [ACOG](https://www.acog.org/clinical/clinical-guidance/practice-bulletin); SOAP Centers of Excellence — [SOAP](https://www.soap.org/) |
| Lower abdomen / inguinal hernia (T6-T8) | 11–15 mg | Cousins & Bridenbaugh 4e — [Wolters Kluwer](https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380) |
| Saddle block (S2-S5) | 5–7 mg, patient sits × 5 min | Cousins & Bridenbaugh 4e — [Wolters Kluwer](https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380) |

Alternative LAs (Spinal screen):
- Ropivacaine 0.5–0.75%: 12–20 mg (Naropin PI off-label spinal use) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ropivacaine)
- Mepivacaine 1.5–2% isobaric: 40–60 mg — Dose-response study: Zayas VM, et al. *Anesth Analg* 1999;89:1167-1171 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/10553828/)
- 2-Chloroprocaine 3% PF: 30–50 mg — Goldblum E, Atchabahian A. *Acta Anaesthesiol Scand* 2013 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/23320599/); Nesacaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=chloroprocaine)
- Lidocaine 5% hyperbaric: 60–100 mg (⚠ TNS rate 10-30% — Pollock JE. *Anesth Analg* 2003) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/12873924/); Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine)
- Tetracaine 0.5–1%: 6–12 mg — Pontocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=tetracaine)

---

## 7. Sevoflurane / Volatile Anesthetics —  (MAC values)

MAC values per age group from:
- Stevens WC, et al. *Anesthesiology* 1975;42:197-200 (original MAC isoflurane study; commonly referenced for sevoflurane via comparator data) — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/42/2/197/26839)
- Mapleson WW. *Br J Anaesth* 1996;76:179-185 (age-adjustment formula for MAC) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/8777094/)
- Ultane (sevoflurane) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sevoflurane) · [FDA 2006 label PDF](https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/020478s016lbl.pdf)
- Forane (isoflurane) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=isoflurane)
- Suprane (desflurane) PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=desflurane)

---

## 8. Pediatric Doses —  (`pediatricDoseGroups`)

### Emergency / Code

Primary reference for this entire section: **AHA PALS 2020** — Topjian AA, et al. *Circulation* 2020;142:S469-S523 — [AHA Journals](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901) · [PubMed](https://pubmed.ncbi.nlm.nih.gov/33081526/) · ECC guidelines portal: [cpr.heart.org](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines).

| Drug | Dose | Source |
|---|---|---|
| Epinephrine 1:10,000 IV/IO | 0.01 mg/kg (max 1 mg) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Adrenalin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=epinephrine) |
| Epinephrine 1:1,000 IM (anaphylaxis) | 0.01 mg/kg (max 0.5 mg) | Sicherer SH, Simons FER. *Pediatrics* 2017;139:e20164006 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/28193791/); AAAAI Anaphylaxis Practice Parameter — [AAAAI](https://www.aaaai.org/practice-resources/statements-and-practice-parameters) |
| Atropine | 0.02 mg/kg (min 0.1 mg, max 0.5 mg) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Atropine sulfate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=atropine) |
| Amiodarone | 5 mg/kg, max 300 mg | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Cordarone IV PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=amiodarone) |
| Lidocaine | 1 mg/kg | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine) |
| Adenosine (1st) | 0.1 mg/kg (max 6 mg); (2nd) 0.2 mg/kg (max 12 mg) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Adenocard PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=adenosine) |
| Calcium chloride 10% | 20 mg/kg (max 1 g) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Calcium chloride PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=calcium+chloride) |
| Calcium gluconate 10% | 60 mg/kg (max 3 g) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Calcium gluconate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=calcium+gluconate) |
| Sodium bicarbonate | 1 mEq/kg | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Sodium bicarbonate inj PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sodium+bicarbonate) |
| Magnesium sulfate | 25–50 mg/kg (max 2 g) | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); Magnesium sulfate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=magnesium+sulfate) |
| Naloxone (emergency) | 0.01 mg/kg (max 2 mg) | Naloxone PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=naloxone) |
| Flumazenil | 0.01 mg/kg (max 0.2 mg per dose) | Romazicon PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=flumazenil) |
| Defibrillation | 2 J/kg → 4 J/kg → up to 10 J/kg | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901) |
| Cardioversion (sync) | 0.5–1 J/kg → 2 J/kg | AHA PALS 2020 — [AHA](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901) |

### Premedication

| Drug | Dose | Source |
|---|---|---|
| Midazolam PO | 0.5 mg/kg (max 20 mg) | Versed PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=midazolam); Coté 6e — [Elsevier](https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0) |
| Midazolam IN | 0.2 mg/kg (max 10 mg) | Karl HW, et al. *Anesthesiology* 1992;76:209-215 — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/76/2/209/30801) |
| Midazolam IV | 0.05 mg/kg (max 5 mg) | Versed PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=midazolam) |
| Ketamine PO | 6 mg/kg (max 300 mg) | Ketalar PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ketamine); Sekerci C, et al. *Br J Anaesth* 1996;76:28-33 — [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Sekerci+ketamine+1996) |
| Ketamine IM | 4 mg/kg | Ketalar PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ketamine) |
| Dexmedetomidine IN | 1–2 mcg/kg | Yuen VM. *Anesth Analg* 2007;105:374-380 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/17646493/); Precedex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexmedetomidine) |
| Clonidine PO | 4 mcg/kg | Mikawa K, et al. *Anesthesiology* 1996;85:954-960 — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/85/5/954/35728); Catapres PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=clonidine) |

### Induction Agents

| Drug | Dose | Source |
|---|---|---|
| Propofol | 2–3 mg/kg | Diprivan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=propofol); Coté 6e Ch. 9 — [Elsevier](https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0) |
| Ketamine IV | 1–2 mg/kg | Ketalar PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ketamine) |
| Etomidate | 0.3 mg/kg | Amidate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=etomidate) |
| Thiopental | 4–6 mg/kg | Pentothal PI (historical, US supply discontinued 2011) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=thiopental); Coté 6e Ch. 9 — [Elsevier](https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0) |
| Sevoflurane mask | 8% in 50/50 N2O/O2 | Ultane PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sevoflurane); Lerman J, et al. *Anesthesiology* 1994;80:814-824 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/8024136/) |

### Paralytics & Reversal

| Drug | Dose | Source |
|---|---|---|
| Succinylcholine IV | 2 mg/kg (infants), 1–1.5 mg/kg (children) | Anectine PI — [FDA label](https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/008453s027lbl.pdf) · [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=succinylcholine); Cook DR, et al. *Anesth Analg* 1981 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/7194001/) |
| Succinylcholine IM | 4 mg/kg | Anectine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=succinylcholine); Liu LM, et al. *Anesthesiology* 1981 — [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Liu+succinylcholine+IM+1981) |
| Rocuronium (intubation) | 0.6 mg/kg | Zemuron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=rocuronium) |
| Rocuronium (RSI) | 1.2 mg/kg | Mazurek AJ, et al. *Anesth Analg* 1998;87:1259-1262 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/9842809/); Zemuron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=rocuronium) |
| Vecuronium | 0.1 mg/kg | Norcuron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=vecuronium) |
| Cisatracurium | 0.15 mg/kg | Nimbex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=cisatracurium) |
| Neostigmine | 0.05 mg/kg (max 5 mg) | Bloxiverz PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=neostigmine) |

### Analgesia & Opioid Reversal

| Drug | Dose | Source |
|---|---|---|
| Fentanyl | 1–2 mcg/kg | Sublimaze PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=fentanyl); Coté 6e Ch. 9 — [Elsevier](https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0) |
| Morphine | 0.05–0.1 mg/kg | Morphine sulfate inj PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=morphine+sulfate+injection) |
| Hydromorphone | 10–15 mcg/kg | Dilaudid PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=hydromorphone) |
| Remifentanil | 0.05–0.2 mcg/kg/min infusion | Ultiva PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=remifentanil) |
| Ketorolac (Toradol) | 0.5 mg/kg IV, max 30 mg/dose | Toradol PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ketorolac) |
| Acetaminophen IV | 15 mg/kg, max 1 g/dose, max 75 mg/kg/day (children), 60 mg/kg/day (infants) | Ofirmev PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ofirmev) |
| Acetaminophen PR | Load 40 mg/kg PR, then 20 mg/kg q6h | Birmingham PK, et al. *Anesthesiology* 1997 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/9286887/) |
| Naloxone (postop reversal) | 1–5 mcg/kg titrated | Naloxone PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=naloxone) |
| Flumazenil | 0.01 mg/kg, max 0.2 mg | Romazicon PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=flumazenil) |

### Antiemetics

| Drug | Dose | Source |
|---|---|---|
| Ondansetron | 0.1 mg/kg (max 4 mg) | Zofran PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ondansetron) |
| Dexamethasone | 0.1–0.15 mg/kg (max 10 mg) | Decadron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexamethasone); Henzi I, et al. *Anesth Analg* 2000 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/10625002/) |
| Metoclopramide (Reglan) | 0.15 mg/kg (max 10 mg) | Reglan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=metoclopramide) |
| Famotidine | 0.25 mg/kg (max 20 mg) | Pepcid PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=famotidine) |
| Ranitidine (Zantac) | 1 mg/kg (max 50 mg) — IV; oral pulled 2020 (NDMA) | FDA recall — [fda.gov](https://www.fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market) |
| Promethazine (Phenergan) | 0.25 mg/kg, max 12.5 mg — **CONTRAINDICATED < 2 yrs** | Phenergan PI (FDA black box) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=promethazine) |
| Diphenhydramine | 0.5–1 mg/kg (max 50 mg) | Benadryl PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=diphenhydramine) |

### Cardiovascular

| Drug | Dose | Source |
|---|---|---|
| Ephedrine | 0.1–0.3 mg/kg IV | Ephedrine sulfate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ephedrine); Stoelting's Pharmacology 6e — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896) |
| Phenylephrine | 1–5 mcg/kg IV | Neo-Synephrine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=phenylephrine) |
| Glycopyrrolate | 0.005 mg/kg (max 0.2 mg) | Robinul PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=glycopyrrolate) |
| Esmolol | 0.5 mg/kg bolus; 50–200 mcg/kg/min infusion | Brevibloc PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=esmolol) |
| Labetalol | 0.2–1 mg/kg IV (max 20 mg/dose) | Trandate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=labetalol) |
| Hydralazine | 0.1–0.2 mg/kg IV (max 20 mg) | Apresoline / Hydralazine HCl PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=hydralazine) |
| Nitroglycerin | 1–5 mcg/kg/min infusion | Nitroglycerin injection PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=nitroglycerin) |
| Nicardipine | 0.5–3 mcg/kg/min infusion | Cardene IV PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=nicardipine) |

### Local Anesthetics (Pediatric)

| Drug | Dose | Source |
|---|---|---|
| Bupivacaine 0.25% (caudal) | 1 mL/kg sacral, 1.25 mL/kg high-lumbar (max 2 mg/kg) | Coté 6e Ch. 17 — [Elsevier](https://shop.elsevier.com/books/a-practice-of-anesthesia-for-infants-and-children/cote/978-0-323-42974-0); Brown TC, et al. *Anaesth Intensive Care* 1986 — [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Brown+caudal+bupivacaine+1986) |
| Bupivacaine plain max | 2.5 mg/kg, abs cap 175 mg | Marcaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=bupivacaine) |
| Ropivacaine 0.2% (caudal) | 1 mL/kg | Naropin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ropivacaine); Bösenberg AT, et al. *Acta Anaesthesiol Scand* 2001;45:1276-1280 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/11736682/) |
| Lidocaine plain | 4.5 mg/kg | Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine) |
| Lidocaine with epi | 7 mg/kg | Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine) |
| Spinal bupivacaine 0.5% (infant) | 0.4–0.6 mg/kg | Williams RK, et al. *Anesth Analg* 2006;102:67-71 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/16368805/) |

### Smooth Emergence

| Drug | Dose | Source |
|---|---|---|
| Lidocaine IV | 1–1.5 mg/kg ~2 min pre-extubation | Yukioka H, et al. *Anesth Analg* 1985 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/4061901/); Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine) |
| Propofol (sub-induction) | 0.5–1 mg/kg slow IV | Ouellet MF, et al. *Can J Anaesth* 2023;70:842-850 (propofol bolus for cough at emergence, RCT) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/36829104/); Diprivan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=propofol) |
| Dexmedetomidine (bolus) | 0.3–0.5 mcg/kg | Precedex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexmedetomidine); Bhana N, et al. *Drugs* 2000 — [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Bhana+dexmedetomidine+Drugs+2000) |
| Fentanyl (small dose) | 0.5–1 mcg/kg ~5 min pre-extubation | Sublimaze PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=fentanyl) |

### MH — Dantrolene

| Drug | Dose | Source |
|---|---|---|
| Dantrolene initial | 2.5 mg/kg IV | MHAUS 2024 guidelines: https://www.mhaus.org/healthcare-professionals/managing-a-crisis/; Ryanodex PI: https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ryanodex |
| Dantrolene maintenance | 1 mg/kg q4-6h × 24-48 h | MHAUS 2024 |

---

## 8b. Maintenance Fluids — the 4-2-1 Rule (`FluidCalcScreen`, `PedCalcScreen`)
**Primary:** Holliday MA, Segar WE. *The maintenance need for water in parenteral fluid therapy.* Pediatrics 1957;19:823-832.
- [PubMed](https://pubmed.ncbi.nlm.nih.gov/13431307/)

The app's maintenance rate is the Holliday-Segar calculation stated verbatim from this paper: **4 mL/kg/hr for the first 10 kg, 2 mL/kg/hr for the next 10 kg, 1 mL/kg/hr for each kg above 20.** The hourly "4-2-1" form is the standard restatement of the paper's original 100/50/20 mL/kg/day figures; the two are the same numbers expressed per hour rather than per day. NPO deficit is that maintenance rate multiplied by hours fasted.

---

## 8c. Obturator Nerve Block (`blocksData` — obturator)
**Technique — proximal interfascial:** Taha AM. *Ultrasound-guided obturator nerve block: a proximal interfascial technique.* Anesth Analg 2012;114:236-239.
- [PubMed](https://pubmed.ncbi.nlm.nih.gov/22025494/)

**Anatomy and updated techniques:** Yoshida T, Nakamoto T, Kamibayashi T. *Ultrasound-Guided Obturator Nerve Block: A Focused Review on Anatomy and Updated Techniques.* Biomed Res Int 2017;2017:7023750.
- [PubMed](https://pubmed.ncbi.nlm.nih.gov/28280738/)

These two back the obturator block's anatomy and approach description. Local anesthetic volumes and maxima for this block follow the same ceilings as §1 and the block dosing engine, not these papers.

---

## 9. Apfel PONV Score
**Primary:** Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. *A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers.* Anesthesiology 1999;91:693-700.
- [PubMed](https://pubmed.ncbi.nlm.nih.gov/10485781/)

**Antiemetic doses cited in app:**
- Ondansetron 4 mg IV — Zofran PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ondansetron)
- Dexamethasone 4-8 mg IV — Apfel CC, et al. *NEJM* 2004;350:2441-2451 (IMPACT trial) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/15190136/); Decadron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexamethasone)
- Droperidol 0.625-1.25 mg IV — Inapsine PI (FDA black box QT — monitor) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=droperidol)
- Aprepitant 40 mg PO — Emend PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=aprepitant)
- Scopolamine 1.5 mg transdermal — Transderm Scop PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=scopolamine)

---

## 10. RCRI (Lee) + Gupta MICA
**RCRI:** Lee TH, Marcantonio ER, Mangione CM, et al. *Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.* Circulation 1999;100:1043-1049.
- URL: https://www.ahajournals.org/doi/10.1161/01.CIR.100.10.1043

**Gupta MICA:** Gupta PK, Gupta H, Sundaram A, et al. *Development and validation of a risk calculator for prediction of cardiac risk after surgery.* Circulation 2011;124:381-387.
- URL: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.015701
- NSQIP risk calculator (live tool): https://riskcalculator.facs.org/

The Gupta MICA coefficients used in the app are from the supplement of the Gupta 2011 *Circulation* paper.

---

## 11. STOP-BANG
**Primary:** Chung F, Yegneswaran B, Liao P, et al. *STOP questionnaire: a tool to screen patients for obstructive sleep apnea.* Anesthesiology 2008;108:812-821.
- URL (PubMed): https://pubmed.ncbi.nlm.nih.gov/18431116/
- STOP-Bang official site (additional content): http://www.stopbang.ca/

---

## 12. NPO Fasting Guidelines
**Primary:** ASA Task Force on Preoperative Fasting. *Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report.* Anesthesiology 2017;126:376-393.
- URL: https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/
- ASA Clear Liquids Update 2023 (extends to 2 hr): https://www.asahq.org/standards-and-practice-parameters

---

## 13. ASRA Anticoagulation
**Primary:** Horlocker TT, Vandermeuelen E, Kopp SL, Gogarten W, Leffert LR, Benzon HT. *Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: ASRA Evidence-Based Guidelines (Fourth Edition).* Reg Anesth Pain Med 2018;43:263-309.
- URL: https://rapm.bmj.com/content/43/3/263

---

## 14. Crisis Checklists —  (`crisisData`)

| Crisis | Source |
|---|---|
| Malignant Hyperthermia | MHAUS Emergency Protocol — [MHAUS](https://www.mhaus.org/healthcare-professionals/managing-a-crisis/); Dantrolene PI (Ryanodex) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ryanodex) |
| LAST | ASRA 2020 Checklist for Treatment of Local Anesthetic Systemic Toxicity — [ASRA Guidelines](https://www.asra.com/guidelines-articles); Neal JM, et al. *Reg Anesth Pain Med* 2018;43:113-123 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/29356773/) |
| CICO | Difficult Airway Society 2015 Intubation Guidelines — [DAS](https://das.uk.com/guidelines/das_intubation_guidelines); ASA 2022 Difficult Airway Guidelines — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/136/1/31/117507) |
| Anaphylaxis | Shaker MS, et al. AAAAI/ACAAI 2020 Anaphylaxis Practice Parameter Update. *J Allergy Clin Immunol* 2020;145:1082-1123 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/32001253/); AAAAI guidance portal — [AAAAI](https://www.aaaai.org/practice-resources/statements-and-practice-parameters) |
| ACLS | AHA 2020 ECC Guidelines — [cpr.heart.org](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines); Panchal AR, et al. *Circulation* 2020;142:S366-S468 — [AHA Journals](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916) · [PubMed](https://pubmed.ncbi.nlm.nih.gov/33081529/) |
| PALS | AHA PALS 2020 — [AHA Journals](https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901); see Section 8 above |
| Massive Transfusion Protocol (MTP) | Holcomb JB, et al. PROPPR trial. *JAMA* 2015;313:471-482 (1:1:1 ratio) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/25647203/); CRASH-2 trial collaborators. *Lancet* 2010;376:23-32 (TXA in trauma) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/20554319/); Miller's 10e Ch. 49 "Patient Blood Management" — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0) |
| Venous Air Embolism (VAE) | Miller's 10e Ch. 39 "Anesthesia for Neurosurgery" — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Mirski MA, et al. *Anesthesiology* 2007;106:164-177 (VAE diagnosis and management review) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/17197859/) |
| Bronchospasm | Miller's 10e Ch. 13 "Pulmonary Pharmacology" — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Stoelting's Pharmacology 6e — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896); Albuterol PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=albuterol) |
| Delayed Emergence | Miller's 10e Ch. 84 "Postanesthesia Care" — [Miller's](https://shop.elsevier.com/books/millers-anesthesia-2-volume-set/gropper/978-0-323-93592-0); Tzabazis A, et al. *J Clin Anesth* 2015;27:353-360 (delayed emergence review) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/25912729/) |

---

## 15. OB Emergencies —  (`obEmergencies`)

| Topic | Source |
|---|---|
| Postpartum hemorrhage (PPH) | ACOG Practice Bulletin 183 — [ACOG](https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/10/postpartum-hemorrhage) |
| Eclampsia / Magnesium toxicity | ACOG Practice Bulletin 222 (2020) — [ACOG](https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/06/gestational-hypertension-and-preeclampsia); Magnesium sulfate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=magnesium+sulfate) |
| Placenta accreta | ACOG Obstetric Care Consensus 7 (replaces Committee Opinion 529): Placenta Accreta Spectrum — [ACOG](https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum); SMFM Consult #44 (2018) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/30471891/) |
| Amniotic Fluid Embolism (AFE) | Society for Maternal-Fetal Medicine. *Amniotic fluid embolism: diagnosis and management.* Am J Obstet Gynecol 2016;215:B16-B24 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/26987420/); SMFM publications portal — [SMFM](https://www.smfm.org/publications) |

---

## 16. Infusion Drug Concentrations
Final infusion concentrations and standard mixing instructions reference:
- Institute for Safe Medication Practices (ISMP) Standard Concentrations of Adult Continuous IV Infusions — [ISMP](https://home.ecri.org/pages/ismp)
- Hospital pharmacy formulary standard concentrations (institution-specific)
- Stoelting's Pharmacology, 6th ed — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896)
- Individual PIs linked per drug below.

| Drug | Standard infusion conc | Source |
|---|---|---|
| Propofol | 10 mg/mL (1%) stock | Diprivan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=propofol) |
| Dexmedetomidine | 4 mcg/mL (200 mcg in 50 mL NS) | Precedex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexmedetomidine) |
| Ketamine | 1 mg/mL (100 mg in 100 mL NS) | Ketalar PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ketamine) |
| Remifentanil | 50 mcg/mL (5 mg in 100 mL NS, NS only) | Ultiva PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=remifentanil) |
| Fentanyl | 50 mcg/mL (stock) | Sublimaze PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=fentanyl) |
| Sufentanil | 50 mcg/mL (stock) | Sufenta PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sufentanil) |
| Lidocaine | 20 mg/mL (2% stock) | Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine) |
| Rocuronium | 10 mg/mL (stock) | Zemuron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=rocuronium) |
| Cisatracurium | 2 mg/mL (stock) | Nimbex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=cisatracurium) |
| Phenylephrine | 100 mcg/mL (10 mg in 100 mL NS) | Neo-Synephrine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=phenylephrine) |
| Norepinephrine | 16 mcg/mL (4 mg in 250 mL D5W; **D5W only**, oxidizes in NS) | Levophed PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=norepinephrine) |
| Epinephrine | 16 mcg/mL (4 mg in 250 mL D5W) | Adrenalin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=epinephrine) |
| Vasopressin | 1 unit/mL (20 units in 20 mL NS) | Vasostrict / Pitressin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=vasopressin) |
| Dopamine | 1.6 mg/mL (400 mg in 250 mL D5W) | Dopamine HCl PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dopamine) |
| Dobutamine | 1 mg/mL (250 mg in 250 mL D5W) | Dobutrex / Dobutamine HCl PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dobutamine) |
| Milrinone | 0.2 mg/mL (20 mg in 100 mL NS) | Primacor PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=milrinone) |
| Esmolol | 10 mg/mL (premixed bag 2500 mg/250 mL) | Brevibloc PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=esmolol) |
| Nicardipine | 0.1 mg/mL (25 mg in 250 mL D5W) | Cardene IV PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=nicardipine) |
| Amiodarone | 1.8 mg/mL (900 mg in 500 mL D5W; PVC binds drug — glass preferred) | Cordarone IV PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=amiodarone) |

---

## 17. Awake Fiberoptic
**Topicalization, sedation regimens:**
- Cousins & Bridenbaugh, *Neural Blockade in Clinical Anesthesia and Pain Medicine*, 4e (2009) — [Wolters Kluwer](https://www.wolterskluwer.com/en/solutions/ovid/cousins-and-bridenbaughs-neural-blockade-in-clinical-anesthesia-and-pain-medicine-5380)
- Apfelbaum JL, Hagberg CA, Connis RT, et al. *2022 ASA Practice Guidelines for Management of the Difficult Airway.* Anesthesiology 2022;136:31-81 — [ASA Pubs](https://pubs.asahq.org/anesthesiology/article/136/1/31/117507)
- Glycopyrrolate antisialogogue — Robinul PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=glycopyrrolate)
- Lidocaine topical / nebulized — Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine)
- Dexmedetomidine sedation — Precedex PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexmedetomidine)

**Lidocaine total dose < 9 mg/kg topical:**
- Williams KA, Barker GL, Harwood RJ, Woodall NM. *Combined nebulization and spray-as-you-go topical local anaesthesia of the airway.* Br J Anaesth 2005;95:549-553 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/16126785/)

---

## 18. Difficult Airway Algorithm
**Primary:** ASA Practice Guidelines for Management of the Difficult Airway 2022.
- URL: https://pubs.asahq.org/anesthesiology/article/136/1/31/117507/2022-American-Society-of-Anesthesiologists

---

## 19. Procedural Sedation
**Primary:** Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force. Anesthesiology 2018;128:437-479.
- URL: https://pubs.asahq.org/anesthesiology/article/128/3/437/19295

**ASA fasting standards (clear liquid 2 hr, etc.):** see Section 12.

---

## 20. Blood Gas Interpretation
Acid-base / oxygenation formulas (Winters, anion gap, A-a gradient, Hb-binding) — references:
- Adrogué HJ, Madias NE. *Management of life-threatening acid-base disorders.* NEJM 1998;338:26-34, 107-111 — [NEJM](https://www.nejm.org/doi/full/10.1056/NEJM199801013810107) · [PubMed](https://pubmed.ncbi.nlm.nih.gov/9414329/)
- Berend K, de Vries APJ, Gans ROB. *Diagnostic use of base excess in acid-base disorders.* NEJM 2018;378:1419-1428 — [NEJM](https://www.nejm.org/doi/full/10.1056/NEJMra1711860) · [PubMed](https://pubmed.ncbi.nlm.nih.gov/29641969/)
- Winters' formula (expected PaCO₂ = 1.5 × HCO₃⁻ + 8 ± 2): commonly attributed to Winters RW, *The Body Fluids in Pediatrics*, Boston: Little, Brown, 1973 (textbook; no online edition). Modern review: Albert MS, et al. *Ann Intern Med* 1967;66:312-322 (original metabolic-acidosis compensation data) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/6016545/)

---

## 21. Adult Drug Reference — Additions

Drugs in [`src/screens/DrugsScreen.jsx`](src/screens/DrugsScreen.jsx) (`drugsData`). Doses derived from FDA package inserts (DailyMed search URLs), standard anesthesia textbooks (Miller's 10e, Stoelting's 6e, Barash 9e), and the trial citations listed where evidence-based dosing applies. Pediatric versions of these drugs live in Section 8.

### Sedation / Premedication
| Drug | Source |
|---|---|
| Midazolam (Versed) | Versed PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=midazolam); Stoelting's 6e — [LWW](https://shop.lww.com/Stoelting-s-Pharmacology---Physiology-in-Anesthetic-Practice/p/9781975126896) |
| Clonidine | Catapres PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=clonidine); Stoelting's 6e |

### Antiarrhythmics & Code Drugs (ACLS doses per AHA 2020)
| Drug | Source |
|---|---|
| Amiodarone | Cordarone PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=amiodarone); AHA ACLS 2020 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/33081529/) |
| Lidocaine (IV antiarrhythmic / analgesic) | Xylocaine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=lidocaine); AHA ACLS 2020 |
| Adenosine (Adenocard) | Adenocard PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=adenosine); AHA ACLS 2020 |
| Magnesium sulfate | Mg sulfate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=magnesium+sulfate); ACOG eclampsia protocol (Section 15) |
| Calcium chloride 10% | CaCl₂ PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=calcium+chloride) |
| Calcium gluconate 10% | Ca gluconate PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=calcium+gluconate) |
| Sodium bicarbonate 8.4% | NaHCO₃ PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sodium+bicarbonate) |
| Dextrose 50% (D50) | Dextrose 50% PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dextrose+50) |

### Volatile anesthetics (see also Section 7)
| Drug | Source |
|---|---|
| Sevoflurane (Ultane) | Ultane PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=sevoflurane); Lerman J, *Anesthesiology* 1994;80:814-824 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/8024136/) |

### Cardiovascular — Vasodilators / Antihypertensives / Diuretic
| Drug | Source |
|---|---|
| Nitroglycerin (NTG) | NTG PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=nitroglycerin); Stoelting's 6e |
| Nicardipine (Cardene IV) | Cardene PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=nicardipine); Stoelting's 6e |
| Furosemide (Lasix) | Lasix PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=furosemide) |

### Hemorrhage / Anticoagulation
| Drug | Source |
|---|---|
| Tranexamic acid (TXA) | CRASH-2 (trauma) — Lancet 2010;376:23-32 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/20554319/); WOMAN trial (PPH) — Lancet 2017;389:2105-2116 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/28456509/); TXA PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=tranexamic+acid) |
| Heparin (unfractionated) | Heparin PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=heparin); ASRA 4e 2018 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/29356773/) |
| Protamine sulfate | Protamine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=protamine); Horrow JC. *Anesth Analg* 1985;64:348-361 (protamine reactions) |

### Hormone / Metabolic
| Drug | Source |
|---|---|
| Insulin (regular) | Humulin R / Novolin R PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=insulin+regular) |
| Glucagon (incl. sphincter of Oddi relaxation) | Glucagon PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=glucagon) |

### Antiemetics (full list)
| Drug | Source |
|---|---|
| Ondansetron (Zofran) | Zofran PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=ondansetron) |
| Dexamethasone | Decadron PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=dexamethasone); Henzi I, *Anesth Analg* 2000 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/10625002/) |
| Diphenhydramine | Benadryl PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=diphenhydramine) |
| Metoclopramide (Reglan) | Reglan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=metoclopramide) |
| Famotidine (Pepcid) | Pepcid PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=famotidine) |
| Promethazine (Phenergan) | Phenergan PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=promethazine); FDA pediatric <2 yr black box (2004) |
| Scopolamine (Transderm Scōp) | Transderm Scōp PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=scopolamine) |
| Droperidol (Inapsine) | Inapsine PI (FDA QT black box 2001) — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=droperidol) |
| Aprepitant (Emend) | Emend PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=aprepitant); Apfel CC, *NEJM* 2004;350:2441-2451 (IMPACT trial) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/15190136/) |

### Opioid additions + reversal
| Drug | Source |
|---|---|
| Buprenorphine | Buprenex/Suboxone PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=buprenorphine); Stoelting's 6e |
| Methadone (intraop single dose) | Murphy GS, et al. *Anesthesiology* 2015;122:1112-22 (cardiac surgery cohort) — [PubMed](https://pubmed.ncbi.nlm.nih.gov/25837528/); Dolophine PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=methadone) |
| Meperidine (Demerol) | Demerol PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=meperidine) |
| Naloxone | Narcan/Naloxone PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=naloxone) |
| Flumazenil (Romazicon) | Romazicon PI — [DailyMed](https://dailymed.nlm.nih.gov/dailymed/search.cfm?query=flumazenil) |

---

## 22. Surgical Antibiotic Prophylaxis — (`drugsData` antibiotics, `pediatricDoseGroups` "Surgical prophylaxis", Cases library `antibiotics` fields)

Three guidelines govern this content. The ASHP/IDSA guideline supplies agent selection and dosing; where it is silent by name on a procedure, the app cites the specialty guideline that names it.

**Primary (agents + doses):** Bratzler DW, Dellinger EP, Olsen KM, et al. *Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery* (ASHP/IDSA/SIS/SHEA). Am J Health Syst Pharm 2013;70:195-283.
- Free full-text PDF: https://www.idsociety.org/globalassets/idsa/practice-guidelines/clinical-practice-guidelines-for-antimicrobial-prophylaxis-in-surgery.pdf

**Gynecologic procedures (named positions):** ACOG Practice Bulletin No. 195, *Prevention of Infection After Gynecologic Procedures*. Obstet Gynecol 2018;131:e172-e189.
- URL: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/06/prevention-of-infection-after-gynecologic-procedures

**GI endoscopy (named positions):** ASGE Standards of Practice Committee. *Antibiotic prophylaxis for GI endoscopy*. Gastrointest Endosc 2015;81:81-89.
- URL: https://www.asge.org/home/resources/publications/guidelines/antibiotic-prophylaxis-for-gi-endoscopy

### Adult prophylaxis doses (`drugsData`)
All from the ASHP/IDSA guideline's dosing table:
| Drug | App dose | Source |
|---|---|---|
| Cefazolin | 2 g IV; 3 g if ≥120 kg | ASHP/IDSA 2013 |
| Cefoxitin | 2 g IV (redose q2h) | ASHP/IDSA 2013 |
| Clindamycin | 900 mg IV | ASHP/IDSA 2013 |
| Vancomycin | 15 mg/kg IV | ASHP/IDSA 2013 |
| Metronidazole | 500 mg IV | ASHP/IDSA 2013 |
| Gentamicin | 5 mg/kg IV, single dose | ASHP/IDSA 2013 |

### Pediatric prophylaxis doses (`pediatricDoseGroups`, "Surgical prophylaxis")
All from the same guideline's pediatric dosing column: cefazolin 30 mg/kg (max 2 g), cefoxitin 40 mg/kg (max 2 g), clindamycin 10 mg/kg (max 900 mg), vancomycin 15 mg/kg, metronidazole 15 mg/kg (max 500 mg), gentamicin 2.5 mg/kg single dose.

### Per-case positions (Cases library)
Each surgical case entry's **Antibiotics** field states the guideline *position* (indicated / not recommended / conditional) and names typical agents with allergy alternatives; it deliberately carries **no doses** — dosing lives on the drug screens above, so a dose exists in exactly one place. Positions cite `ashpProphylaxis` where the ASHP/IDSA guideline names the procedure class, `acog195` for gynecologic procedures ASHP does not name (conization, hysteroscopic procedures, midurethral sling), and `asge2015` for endoscopy (ERCP drainage-dependent prophylaxis, EUS-FNA cystic-versus-solid split). Institutional protocols and current guidelines supersede in all cases.

### 2026-08-13 — the remaining 71 cases, and ten further guidelines

Until this date the Antibiotics field was present on 226 of 297 cases. The other **71 carried nothing at all**, and there was no documented rule behind which ones — the field was simply optional and filled case by case. All 297 now carry it.

Three of the guidelines those entries needed were already cited above and were reused rather than duplicated: `ashpProphylaxis`, `asge2015` and `acog195`. Ten further sources were added:

| Key | Citation |
|---|---|
| `ahaIE2021` | Wilson WR, Gewitz M, Lockhart PB, et al. *Prevention of Viridans Group Streptococcal Infective Endocarditis*: AHA Scientific Statement. Circulation 2021;143:e963-e978 |
| `sirAbx2018` | Chehab MA, Thakor AS, Tulin-Silver S, et al. *Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures*: SIR practice parameter update. J Vasc Interv Radiol 2018;29:1483-1501 |
| `hrsVa2019` | HRS/EHRA/APHRS/LAHRS *Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias*, 2019 |
| `bpsFpm2020` | British Pain Society and Faculty of Pain Medicine, RCoA. *Standards of Good Practice for Spinal Interventional Procedures*, May 2020 |
| `escrsCataract` | ESCRS *Recommendations for Cataract Surgery* (current edition), building on Barry P, et al., ESCRS endophthalmitis study, J Cataract Refract Surg 2006;32:407-410 |
| `patelEnt2018` | Patel PN, Jayawardena ADL, Walden RL, Penn EB, Francis DO. *Evidence-Based Use of Perioperative Antibiotics in Otolaryngology*. Otolaryngol Head Neck Surg 2018;158:783-800 — a systematic review, not a society guideline |
| `sogc247` | SOGC Clinical Practice Guideline No. 247, *Antibiotic Prophylaxis in Obstetric Procedures*. J Obstet Gynaecol Can |
| `nassSpine2013` | North American Spine Society. *Evidence-Based Clinical Guideline for Antibiotic Prophylaxis in Spine Surgery*. Spine J 2013 — literature current to June 2011 |
| `ogiReview2024` | *Management of Open Globe Injury: a narrative review*. Eye 2024 |
| `eauInfections` | European Association of Urology. *EAU Guidelines on Urological Infections* (current edition) |

**On the ACOG bulletin number.** The source mapping behind this work flagged uncertainty over which ACOG bulletin is current, having surfaced the superseded Bulletins 74 (2006) and 104 (2009). This document already cited **No. 195 (2018)**, which is the current one, and the new entries use it.

**On AUA.** The urologic entry (`eswl`) initially cited the AUA Best Practice Statement. It was re-sourced to the European guideline on 2026-08-13. AUA grants free access for an individual's clinical use only and requires a license in advance for any other purpose, naming a separate contact for commercial use. The copyright exposure was low — the entry states a fact in original wording, and facts are not copyrightable — but the terms are a *contract* claim rather than a copyright one, and a contract can restrict what copyright does not. Rather than resolve that for a single entry, it now cites a body whose guidance covers the same ground. **No AUA-derived content remains in the app.**

**Four structural fields carry distinctions prose alone could not.** Each exists because collapsing it would change what a reader does:

- **`type`** — `gi_bleed_endoscopy` and `peritonsillar_abscess` are marked *therapy*, and `trauma_laparotomy` *therapy if contaminated*. Rendered like ordinary prophylaxis, these invite one preoperative dose and stop; for a cirrhotic variceal bleed that turns a seven-day course into a single dose.
- **`verdict: insufficient`** — `manual_removal_placenta`, `dc_postpartum` and `epistaxis_control`. "Insufficient evidence" is not "no": nobody having shown prophylaxis helps is a different claim from a body having recommended against it.
- **`gatedOn: cardiac_risk`** — the two dental entries. The indication belongs to the patient, not the operation, and unqualified the row would read as "give antibiotics for dental work".
- **`confidence`** — A/B/C on all 71, and **visible in the app rather than internal**. A = explicit society recommendation, B = society statement, systematic review, or extrapolation within a named guideline category, C = no guideline addresses it and the entry reflects practice convention. The split is **A=19, B=26, C=26**, so roughly a third of these positions rest on no society guideline at all, and the app says which third.

**One AHA 2021 change worth stating plainly:** clindamycin is **no longer recommended** as an oral or parenteral alternative for penicillin-allergic patients requiring *endocarditis* prophylaxis, because it causes more frequent and severe reactions than the alternatives — use cephalexin or another first- or second-generation cephalosporin, azithromycin, or doxycycline. This does **not** apply to surgical prophylaxis, where clindamycin remains an accepted beta-lactam alternative per ASHP/IDSA, which is the only context in which this app uses it.

---

## 23. Surgical Cases Library — Specialty Guidelines

Case entries cite the anchor textbooks (Miller's 10e, Barash 9e, Stoelting's 6e, Coté 7e, NYSORA) and the guidelines elsewhere in this document. Where a case rests on specialty guidance not otherwise listed:

**Gender-affirming surgery (hormone management):** Coleman E, Radix AE, Bouman WP, et al. *Standards of Care for the Health of Transgender and Gender Diverse People, Version 8* (WPATH SOC8). Int J Transgend Health 2022;23(Suppl 1):S1-S259.
- URL: https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644

**Medial branch radiofrequency ablation (awake stimulation testing):** American Society of Pain and Neuroscience (ASPN) best-practice guideline on radiofrequency neurotomy. J Pain Res 2021. doi:10.2147/JPR.S325665
- URL: https://www.tandfonline.com/doi/full/10.2147/JPR.S325665

Antibiotic prophylaxis positions in case entries: see Section 22 (ASHP/IDSA 2013, ACOG PB 195, ASGE 2015).

---

## 24. Pediatric Caudal Block — Dosing (`CAUDAL_LAS`, `CAUDAL_ADJUVANTS`)

The caudal block's Dosing tab uses its own weight-based pediatric tables, not the adult peripheral or adult neuraxial lists. Two anchor sources:

**Ceilings and adjuvant set:** Suresh S, Ecoffey C, Bosenberg A, et al. *ESRA/ASRA Recommendations on Local Anesthetics and Adjuvants Dosage in Pediatric Regional Anesthesia.* Reg Anesth Pain Med 2018;43:211-216.
- PubMed: https://pubmed.ncbi.nlm.nih.gov/29319604/

**Onset/duration, under-6-months reduction, caudal morphine, epinephrine/test dose:** Coté, Lerman, Anderson. *A Practice of Anesthesia for Infants and Children*, ch. 41 (Suresh, Polaner, Coté) — already Section 8's pediatric anchor.

Encoded values (all weight-based; no adult absolute caps):
| Item | App value | Source |
|---|---|---|
| Bupivacaine 0.25% caudal ceiling | 2.5 mg/kg; −30% under 6 months | ESRA/ASRA 2018; Coté Table 41-2 |
| Ropivacaine 0.2% caudal ceiling | 2 mg/kg (caudal-specific conservative figure vs 3 mg/kg all-routes); −30% under 6 months | ESRA/ASRA 2018 |
| Levobupivacaine 0.25% ceiling | 2.5 mg/kg (noted unavailable in the US) | ESRA/ASRA 2018 |
| Armitage dilution rule | 1.25 mL/kg regimens stay under ceilings only diluted (≤0.2% bupivacaine); >20 mL total → dilute | Coté ch. 41 |
| Test dose | Epinephrine 0.5 mcg/kg = 0.1 mL/kg of 1:200,000, ECG watched 30–60 s | Coté ch. 41 |
| Clonidine (caudal) | 1–2 mcg/kg; avoid in neonates/ex-preterm (apnea ≥2 mcg/kg) | ESRA/ASRA 2018; Coté |
| Dexmedetomidine (caudal, off-label) | 0.5–1 mcg/kg — literature-derived (guideline endorses class, declines dose) | Meta-analysis, PMID 32756133 |
| Morphine (caudal, preservative-free) | 30–50 mcg/kg; inpatient/monitored only; avoid ≥70 mcg/kg | Coté ch. 41 |
| Ketamine (caudal, PF/S-ketamine) | 0.5 mg/kg; not in neonates/infants; no US PF formulation | ESRA/ASRA 2018 |
| Anti-recommendations | Caudal fentanyl/sufentanil (no benefit); neuraxial dexamethasone in children; clonidine ≥2 mcg/kg in neonates | ESRA/ASRA 2018 |

---

## 25. Post–Cardiac Arrest Temperature Control (TTM) — (`glossary` "TTM")

**Primary:** Perkins GD, Callaway CW, Kudenchuk PJ, et al. *2025 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care — Part 11: Post–Cardiac Arrest Care.* Circulation.
- AHA Journals: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001375
- ECC portal: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/post-cardiac-arrest-care

Part 11 replaces the 2020 "32–34 **or** 36–37.5 °C, either acceptable" presentation with a single continuum: hypothermic (32–34 °C) and normothermic / fever-prevention (36–37.5 °C) temperature control, selecting and maintaining a constant target within that range, then actively preventing fever above 37.5 °C. The 2023 AHA focused update (TTM2, CAPITAL CHILL) is what revised the earlier recommendations.

**Duration, quoted verbatim from the Part 11 recommendation table:**

> It is reasonable that temperature control be maintained for at least 36 hours in adult patients who remain unresponsive to verbal commands after return of spontaneous circulation (ROSC).

| Item | App value | Source |
|---|---|---|
| Target range | 32–37.5 °C as one continuum; constant target; fever prevention >37.5 °C | AHA 2025 Part 11 |
| Duration (**adults**) | At least 36 hours in adults unresponsive to verbal commands after ROSC | AHA 2025 Part 11, quoted above |

**Scope limit.** The 36-hour recommendation is stated for **adult** patients and is not used on the pediatric screen. Pediatric durations are separate, longer, and are adjudicated below.

### 25b. Pediatric post-arrest TTM (`PALSScreen` — post-resuscitation care)

**Primary:** *Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association.* Circulation.
- AHA Journals: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000697

The statement attributes the duration recommendation to the **2015 AHA PALS guidelines update** and quotes it directly:

> To treat the child who remains comatose after OHCA, the 2015 AHA PALS guidelines update recommended that it is reasonable either to maintain continuous normothermia (TTM to 36 °C–37.5 °C) for 5 days or to maintain 2 days of continuous hypothermia (TTM to 32 °C–34 °C) followed by 3 days of continuous normothermia (TTM to 36 °C–37.5 °C).

Underlying trials: **THAPCA-OH** and **THAPCA-IH**, in children >2 days and <18 years, comatose within 6 hours of ROSC. The hypothermia arm was cooled to 32–34 °C for 48 h, rewarmed over 16–24 h, then held at 36–37.5 °C until 120 h from initiation; the normothermia arm was held at 36–37.5 °C for 120 h. Neither trial found a significant difference in 1-year survival with favorable neurological outcome, and THAPCA-IH was stopped early for futility.

| Item | App value | Source |
|---|---|---|
| Duration, option A | Normothermia 36–37.5 °C for **5 days** | AHA statement, quoted above |
| Duration, option B | Hypothermia 32–34 °C **2 days**, then normothermia 36–37.5 °C **3 days** | AHA statement, quoted above |
| Fever | Aggressively treat **≥38 °C** | Same statement — persistent hyperthermia associated with unfavorable outcome |
| Lower bound | Never below **32 °C** | Same statement — temperatures <32 °C associated with increased mortality |
| Rewarming rate | No faster than **0.5 °C every 2 h** | Same statement — limits cerebral hyperperfusion, vasogenic edema, hypotension |

**What was wrong before 2026-08-11.** The screen read "32–34 °C × 2 days **OR** 36–37.5 °C × 2 days (per AHA 2020 — either acceptable)". Both arms understated the duration, and the normothermia-only arm was wrong by **three days** — a clinician following it would have stopped temperature control at 48 h instead of 120 h. The total is 5 days on either arm. The "AHA 2020" attribution was also wrong; the recommendation is the 2015 update.

*Note on sourcing:* a secondary summary of this recommendation gave the rewarming rate as 0.25–0.5 °C/h. The primary statement says **0.5 °C every 2 hours** (= 0.25 °C/h), which is the more conservative figure and the one encoded. This is why the number was not taken from the summary.

---

## 26. Sources cited in the app that this document was missing

The app names a source on screen for each value. Three of those sources were
referenced by app content and had **no entry here**, which is the defect this
document exists to prevent: a clinician following an on-screen citation to
`/clinical-sources` found nothing to follow. Usage counts below are measured from
`SOURCES` references in `data.js`, not estimated.

**PONV — Fifth Consensus Guidelines** (`ponvConsensus`, 7 uses)
Gan TJ, Jin Z, Ayad S, et al. *Fifth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.* Anesth Analg, published online 14 November 2025.
- This is distinct from §9 (Apfel 1999), which is the risk **score**. §9 was present; the guidelines that drive the app's prophylaxis and rescue choices were not.

**Surviving Sepsis Campaign 2021** (`surviving`, 2 uses)
*Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021.* Intensive Care Med 2021.
- https://link.springer.com/article/10.1007/s00134-021-06506-y

**NYSORA Compendium of Regional Anesthesia** (`nysora`, 25 uses)
NYSORA — New York School of Regional Anesthesia, Compendium of Regional Anesthesia.
- https://www.nysora.com/
- A continuously revised web compendium, not a fixed edition, so it carries no year. It is cited for block anatomy, sonoanatomy and approach description — **not** for local anesthetic doses or maxima, which follow §1 and the block dosing engine. Where a block's technique rests on a specific paper, that paper is cited directly (see §8c for the obturator block).

**Correction, 2026-08-11 — an earlier version of this section was wrong.** It stated that `asa`, `asaMonitoring` and `broselow` were referenced by "zero app content" and were dead entries. All three claims were false, and the cause was a bad method: the audit walked only `data.js` and therefore missed `casesData.js` — 297 case entries, each carrying source fields — and missed every citation rendered by a screen component rather than stored as data. Re-run across `data.js`, `casesData.js`, `blockDosing.js` and all screen `<SourceCitation>` props, the count is **59 referenced source keys**, not the 24 that audit found.

That mistake put a false statement about provenance into the one document whose entire purpose is provenance. It also concealed two real gaps, which are the two ASA documents below.

**ASA Standards for Basic Anesthetic Monitoring** (`asaMonitoring`, **28 uses** — 28 in the case library, 1 in `data.js`)
American Society of Anesthesiologists, *Standards for Basic Anesthetic Monitoring.* **Last amended October 15, 2025.**
- ASA standards index: https://www.asahq.org/standards-and-practice-parameters
- The most-cited source in the case library after the anchor textbooks. Nearly every case entry's `monitoring` field rests on it — "standard monitoring applies in full regardless of venue" and its equivalents.
- **Date pinned 2026-08-11.** The `SOURCES` entry previously read "(most recent revision)" with no year, which is not a citation a clinician can check — and it was the string rendered on screen under all 28 of those fields. The amendment date was read off the ASA page by her and is now in the citation itself. asahq.org returns 403 to automated fetching, so this date cannot be re-verified from this repo; re-check it when the standard is next amended.

**ASA Physical Status Classification System** (`asa`, used by `ASAPhysicalStatusScreen`)
American Society of Anesthesiologists, *Statement on ASA Physical Status Classification System.*
- ASA standards index: https://www.asahq.org/standards-and-practice-parameters
- `SOURCES` records this as the 2020 version. Same caveat: not verified against the ASA page from here.
- Cited by exactly one screen, which is why the `data.js`-only audit reported it as unused. That screen previously rendered `asaMonitoring` — the wrong ASA document — under the physical-status classification; the fix is in place and the comment at `ASAPhysicalStatusScreen.jsx:136` records it.

*Genuinely generic.* `packageInsert` (26 uses) is a label rather than a citation and is covered by the FDA/DailyMed note in the preamble. `broselow` is cited by §28 (pediatric airway sizing).

---

## 27. Mixed local anesthetics — additive toxicity and fractional dosing (`blockDosing` — "Lido + Bupiv mix")

**Primary (additivity):** Neal JM, Barrington MJ, Fettiplace MR, et al. *The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity.* Reg Anesth Pain Med 2018;43:113-123.
- https://pubmed.ncbi.nlm.nih.gov/29356773/
- Contains the recommendation that clinicians be aware of the **additive** nature of local anesthetic toxicity and adjust dosing accordingly — **graded II, B**.
- The `asraLast` key points at this document, with the 2020 LAST **Checklist** noted as an addendum. That distinction matters: the checklist is treatment-only and does not carry the additivity recommendation, so a citation keyed to the checklist would not verify.

**Supporting (fractional-dosing arithmetic and duration):** *Pro-Con: Mixing Local Anesthetics — Best of Both Worlds or Playing With Fire?* ASRA Pain Medicine News, February 2026.
- https://asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2026/02/09/pro-con--mixing-local-anesthetics--best-of-both-worlds-or-playing-with-fire
- States that maximum doses for mixtures should be calculated as the **sum of fractional contributions**, and that mixtures commonly run **shorter** than the long-acting agent alone.
- **Honest about the gap: no society has published a formal mixed-agent dosing standard.** The fractional rule follows from the graded additivity recommendation above rather than from a published mixed-agent maximum.

**Two corrections applied 2026-08-11.** Both prior values were backwards:

| Field | Was | Now |
|---|---|---|
| Max dose | "Use each max separately" | "Fractional — each agent's % of its own max, summed to ≤100%" |
| Note | "Fast onset, **long** duration" | Additive toxicity stated explicitly; duration described as often **shorter** than plain bupivacaine |

"Use each max separately" contradicted the very advisory it needed for support: if toxicity is additive, a full lidocaine max **plus** a full bupivacaine max is by definition a 2× toxic dose. And "long duration" sold the mixture on the one property the mixing literature says it does not reliably have — which is why the pro-con framing exists.

The figures were **not** changed. 6–10 h already sits below plain bupivacaine 0.5% at 8–16 h, so the numbers were consistent with shortening even while the note asserted the opposite.

---

## 28. Pediatric airway sizing (`pediatricDoseGroups` — airway, `PedCalcScreen`)

**Sources (both, per adjudication 2026-08-11):**
- **ETT formulas:** Coté CJ, Lerman J, Anderson BJ. *A Practice of Anesthesia for Infants and Children*, 6th ed. — the same anchor as §8's pediatric content.
- **LMA and blade size bands:** Broselow Pediatric Emergency Tape, 2025 edition (Luten R, ed.).

| Value | Rule |
|---|---|
| ETT uncuffed | age/4 + 4 = internal diameter (mm) |
| ETT cuffed | age/4 + 3.5 = internal diameter (mm) |
| Depth at lip, **≥1 y** | 3 × internal diameter of the tube **actually placed** — see the qualifier below |
| Depth at lip, **<1 y** | **6 + weight (kg)**. The 3× rule is not used in infants |
| LMA size | <5 kg → 1 · 5–10 → 1.5 · 10–20 → 2 · 20–30 → 2.5 · ≥30 → 3 |
| Blade | <1 y Miller 0–1 · 1–4 y Miller 1 / Mac 2 · 4–8 y Mac 2 · ≥8 y Mac 3 |
| **OPA (Guedel)** | **length mm = 22.43 + 17.54 × ln(weight kg)**, rounded to the nearest Guedel size. ISO number = length in cm |
| **NPA size** | **by age (ID):** preterm–1 mo 3.0 · 1–6 mo 3.5 · 6–18 mo 4.0 · 18 mo–3 y 4.5 · 3–6 y 5.0 · 6–9 y 5.5 · 9–12 y 6.0 |
| **NPA depth** | **nostril to tragus MINUS 10 mm** |

**Why this section exists.** These five formulas lived only as local constants inside `PedCalcScreen`, and the airway group carried `drugs: []`. The corpus builder serialises `g.drugs`, so the chunk it emitted contained nothing but its own title — the app could size an ETT while Ask Helix had **no pediatric airway sizing content at all**. `phiDetector.js:140` uses "pediatric ETT size for 4yr old" as a test string, so it is a question the app expects. The formulas now live on the group in `data.js`; the screen and the corpus read the same definition.

### OPA and NPA (added 2026-08-14)

Both adjuncts were absent: the group sized an ETT, an LMA and a blade and said nothing about the two devices most likely to be reached for first.

**Sources.** ERC 2021 Paediatric Life Support (`ercPls2021`) for the landmark methods and the indications; StatPearls (`statPearlsNpa`) for the NPA age/ID table; and two MRI validation studies, GUEDEL-I (`guedelI2023`) and WEND:LI (`wendLi2021`).

**The app deliberately departs from the plain ERC landmark in two places, and the studies are cited to justify it.**

*OPA.* GUEDEL-I imaged 94 anaesthetised children sized by incisors-to-mandible: **47.9% correctly sized**, 23.4% undersized (tongue protrusion in 59.1% of those), 28.7% oversized. Of five facial landmarks compared, incisors-to-mandible was the best but reached only **41.2%** probability of correct sizing. A weight formula — **22.43 + 17.54 × log(weight kg)** — outperformed every landmark at **61.7%**. The app therefore computes the weight formula and gives the landmark as the alternative.

*NPA.* WEND:LI imaged 92 sedated children. Plain **nostril-to-tragus, which is what ERC 2021 recommends, was optimal in only 13.0%** and sat too distal in 71.7%. **Nostril-to-tragus minus 10 mm reached 40.2%**, the best of three methods tested. The app carries the minus-10-mm figure and says why.

**Bounded above ~30 kg, deliberately.** The formula was derived in young children (study mean age 4.7 y) and is untested above that range. Adults span the whole top of the scale **by build rather than by age** — roughly 70 mm in a small adult, 80–90 mm typical, and genuinely up to **100 mm (Guedel 5) in a tall male**. The formula keys only on weight and cannot see build: at 70 kg it returns 97 mm, a Guedel 5 for an average-sized adult who should take 80–90. That is the dangerous direction of error — an oversized OPA can displace the epiglottis over the laryngeal inlet and obstruct completely, a worse outcome than the problem being treated. Above roughly 30 kg the app therefore stops computing and returns the landmark, which can at least see the patient.

**A note on the age labels, because this looks like an error and is not.** The formula returns ~72 mm for a 4-year-old, which is close to what many clinicians use in an average adult. That is correct: standard teaching is 60 mm for 1–3 y and 70 mm for 3–8 y, and adult airways are only 80–90 mm — the sizes compress at the top end. It is also why the packaging labels are unreliable: a 70 mm airway catalogued as "child/adolescent" is the same physical device routinely used in adults.

**Natural log, and the alternative is now excluded.** log₁₀ was tested against the full weight range and fails outright — it returns 32 mm for a neonate and 55 mm for a 70 kg adult, moving barely 23 mm across a twenty-fold weight range. The source writes "log" without a base. Checked against GUEDEL-I's own population (mean age 4.7 y, ≈18 kg): ln gives 73 mm, a Guedel 2, which is right for that child; log₁₀ gives 44 mm, a Guedel 00 — a neonatal airway for a four-year-old, which cannot be what the study found. Implemented as ln; **verify against the paper before treating the computed value as authoritative.**

**Standing of these numbers.** Same caveat as the tube formulas: neither landmark reliably predicts size, and across roughly 190 children the best available method for either device was correct in about 40–48% of cases. Neither study found clinical harm from the imprecision. These are **first estimates requiring confirmation after insertion** — chest rise, breath sounds, capnography, absence of tongue protrusion, and for the NPA a look in the mouth to confirm the tip is not visible below the uvula.

**Guedel length tolerances.** Only sizes 00 (40 mm ± 2.5) and 1 (60 mm ± 2.5) were confirmed against a formal specification with stated tolerances (EN ISO 5364:2016, via UNFPA). The other nominal lengths are the widely published values and are consistent across the manufacturer catalogues reviewed. **Age labels printed on packaging are not consistent between manufacturers** — UNICEF labels the 60 mm airway "child" where a commercial kit labels 60 mm "infant". Size by measurement, never by the box.

### Depth — the qualifier (adjudicated 2026-08-11)

The earlier entry computed depth as 3 × the *formula output*. That is wrong in three ways, and the app now reflects all three.

**It is 3 × the ID of the tube actually placed.** The formula routinely names a size that does not exist — age/4 + 4 gives **4.75 mm at three years** — and clinicians deviate from it anyway, downsizing half a size for a cuffed tube or further for subglottic narrowing or a difficult pass. The depth has to match the tube in the trachea, not a hypothetical one. The screen therefore carries a **TUBE PLACED** stepper (0.5 mm increments) defaulting to the formula size.

**The 3× rule is only valid when tube size was chosen because of patient size.** This is the trap: downsize for a cuff and 3 × the smaller tube yields a depth shallower than the child's tracheal length justifies. A 4.5 uncuffed gives 13.5 cm; the same child with a 4.0 cuffed gives 12 cm, which can sit above the cords — or at least too high to be comfortable — with a real risk of accidental extubation on head extension. **So the app never lets a downsize shorten the depth:** it holds at 3 × the size the patient would have taken on size grounds and says so on screen. If the downsize is for airway pathology rather than a cuff, an age-based depth formula should be used instead.

**Under 1 year, 3× is not used at all.** Oral depth is **6 + weight (kg)**, because tube ID does not scale linearly with tracheal length in infants. The label switches to "Depth (6 + wt)" and the tube stepper is hidden below 1 year, since the placed size does not enter the calculation.

**Standing of the rule.** 3 × ID and 6 + weight are widely reproduced clinical rules of thumb from the pediatric anesthesia texts (Coté, Miller) — **not** society recommendations. They are cited to the texts deliberately; attributing them to a society document would overstate their standing. Both are presented as **estimates requiring confirmation, not targets**: confirm by auscultation and, where available, cuff palpation at the sternal notch or direct visualisation of the depth marker at the cords.

Behaviour verified against the worked example above: 4.5 uncuffed → 13.5 cm; the same child downsized to a 4.0 cuffed → still 13.5 cm, not 12.0.

Independent clinical reviewers who have completed a review of sections of this document and have **opted in** to be listed publicly. Reviewers may choose attribution-anonymous review (recorded internally only) — those signatures are not published here.

| Date | Reviewer | Credentials | Affiliation | Sections reviewed | Notes |
|---|---|---|---|---|---|
| _Awaiting first external sign-off_ | | | | | |

To contribute a clinical review, email **support@helixanesthesia.com**. Reviewers receive the latest source document, may flag any concern with any cited dose or source, and choose at sign-off whether to be listed in this public log or recorded only in the internal review record.

---

## 29. Perioperative care of transgender and gender diverse adults (`bjaTgd`)

**Primary:** Harding D, Marsh S, Lennie Y. *Perioperative considerations for transgender and gender diverse adults.* BJA Education 2023;23(4):136-143.
- https://www.bjaed.org/article/S2058-5349(23)00005-7/fulltext
- Open archive. bjaed.org returns 403 to automated retrieval — bot-blocking, not a paywall; the article loads in a browser. Read in full 2026-08-11.

The **anesthesia-specific** anchor for the two gender-affirming entries. WPATH SOC8 (`wpathSoc8`) remains the standard-of-care document; this review carries the intraoperative specifics SOC8 does not, and it replaced borrowed general-medicine citations on both entries.

**Five items it contributed that nothing else in this project had:**

| Item | Where it landed |
|---|---|
| A forced-air warmer over a **transdermal estradiol patch increases uptake** — note patch location before positioning warming devices | Considerations, both entries |
| **Sugammadex binds estrogen and progesterone**, lowering serum concentrations. Documented for contraception; for long-term estrogen therapy *unquantified rather than absent* | Considerations, both entries |
| High estrogen lowers **serum albumin**, raising the free fraction of protein-bound drugs including bupivacaine. The article **stops short of recommending a dose reduction** — that limit is carried explicitly | Considerations, both entries |
| Estrogen lowers hemoglobin, hematocrit and creatinine; testosterone raises them — shifting **eGFR, renal drug dosing and CKD staging** | Patient factors, top surgery |
| **Spironolactone** for testosterone suppression is potassium-sparing — monitor creatinine and potassium | Patient factors, top surgery |

**What it settled about queue items 11 and 12:**

- **Estrogen and VTE (#11) — `variable` retained but sharpened.** The article supplies the mechanism (estrogen raises fibrinogen, factor VII and factor X while reducing antithrombin III and protein S) and the cost of stopping: *"depression, irritability, autonomic hyperactivity and a reduced seizure threshold."* The last is an anesthetic concern in its own right and was absent from the entry. It also records that WPATH *"found no evidence of an increased risk of VTE in patients continuing their hormone therapy before surgery compared with those stopping it."* So the **evidence** is converging while **practice** still varies — the entry now says exactly that instead of an undifferentiated "variable."
- **Testosterone (#12) — confirmed a hematocrit question, not a VTE one.** Verbatim: *"TGDIs on oestrogen therapy have reduced haemoglobin, haematocrit and creatinine whereas those taking testosterone may have increased levels."*

*A note on the review queue.* Both the queue's flag for #12 and the verification pass answering it described the testosterone claims as "variable-marked." They were `basis: 'cited'` from the authoring commit onward, and `git log -S` shows the entry was never edited after creation. Both documents were describing a draft that never shipped — recorded because the same misdescription sent two separate review passes at a defect that did not exist.

---

## Reviewer Audit Log

Independent clinical reviewers who have completed a review of sections of this document and have **opted in** to be listed publicly. Reviewers may choose attribution-anonymous review (recorded internally only) — those signatures are not published here.

| Date | Reviewer | Credentials | Affiliation | Sections reviewed | Notes |
|---|---|---|---|---|---|
| _Awaiting first external sign-off_ | | | | | |

To contribute a clinical review, email **support@helixanesthesia.com**. Reviewers receive the latest source document, may flag any concern with any cited dose or source, and choose at sign-off whether to be listed in this public log or recorded only in the internal review record.

---

## Appendix: PubMed URLs for cited journal articles

Quick links to all journal articles cited above. URLs go to the PubMed abstract page; full text usually requires institutional login.

| Citation | PubMed URL |
|---|---|
| Apfel CC et al. Anesthesiology 1999;91:693-700 (Apfel PONV score) | https://pubmed.ncbi.nlm.nih.gov/10485781/ |
| Apfel CC et al. NEJM 2004;350:2441-2451 (IMPACT trial) | https://pubmed.ncbi.nlm.nih.gov/15190136/ |
| Lee TH et al. Circulation 1999;100:1043-1049 (RCRI) | https://www.ahajournals.org/doi/10.1161/01.CIR.100.10.1043 |
| Gupta PK et al. Circulation 2011;124:381-387 (Gupta MICA) | https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.015701 |
| Chung F et al. Anesthesiology 2008;108:812-821 (STOP-BANG) | https://pubmed.ncbi.nlm.nih.gov/18431116/ |
| Topjian AA et al. Circulation 2020;142:S469-S523 (AHA PALS) | https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901 |
| Carvalho B et al. Anesth Analg 2005;100:1150-1158 (intrathecal morphine) | https://pubmed.ncbi.nlm.nih.gov/15781537/ |
| Kanazi GE et al. Acta Anaesthesiol Scand 2006;50:222-227 (intrathecal dex 3 mcg) | https://pubmed.ncbi.nlm.nih.gov/16430546/ |
| Al-Mustafa MM et al. Saudi Med J 2009;30:365-370 (intrathecal dex 5-10 mcg) | https://pubmed.ncbi.nlm.nih.gov/19271064/ |
| Moore DC, Batra MS. Anesthesiology 1981;55:693-696 (epidural test dose) | https://pubs.asahq.org/anesthesiology/article/55/6/693/29823 |
| Choi S et al. Br J Anaesth 2014;112:427-439 (dexamethasone perineural) | https://pubmed.ncbi.nlm.nih.gov/24413428/ |
| Pöpping DM et al. Anesthesiology 2009;111:406-415 (clonidine perineural) | https://pubmed.ncbi.nlm.nih.gov/19602964/ |
| Candido KD et al. Reg Anesth Pain Med 2002;27:162-167 (buprenorphine perineural) | https://pubmed.ncbi.nlm.nih.gov/11915063/ |
| Abdallah FW, Brull R. Br J Anaesth 2013;110:915-925 (dexmedetomidine perineural) | https://pubmed.ncbi.nlm.nih.gov/23587874/ |
| Karl HW et al. Anesthesiology 1992;76:209-215 (IN midazolam peds) | https://pubs.asahq.org/anesthesiology/article/76/2/209/30801 |
| Yuen VM. Anesth Analg 2007;105:374-380 (IN dexmedetomidine peds) | https://pubmed.ncbi.nlm.nih.gov/17646493/ |
| Mikawa K et al. Anesthesiology 1996;85:954-960 (PO clonidine peds) | https://pubs.asahq.org/anesthesiology/article/85/5/954/35728 |
| Lerman J et al. Anesthesiology 1994;80:814-824 (sevoflurane mask peds) | https://pubmed.ncbi.nlm.nih.gov/8024136/ |
| Mazurek AJ et al. Anesth Analg 1998;87:1259-1262 (rocuronium peds RSI) | https://pubmed.ncbi.nlm.nih.gov/9842809/ |
| Birmingham PK et al. Anesthesiology 1997 (rectal APAP peds) | https://pubmed.ncbi.nlm.nih.gov/9286887/ |
| Henzi I et al. Anesth Analg 2000;90:186-194 (dexamethasone PONV) | https://pubmed.ncbi.nlm.nih.gov/10625002/ |
| Williams RK et al. Anesth Analg 2006;102:67-71 (spinal in infants) | https://pubmed.ncbi.nlm.nih.gov/16368805/ |
| Bösenberg AT et al. Acta Anaesthesiol Scand 2001;45:1276-1280 (caudal ropivacaine pharmacokinetics) | https://pubmed.ncbi.nlm.nih.gov/11736682/ |
| Yukioka H et al. Anesth Analg 1985 (IV lidocaine extubation) | https://pubmed.ncbi.nlm.nih.gov/4061901/ |
| Ouellet MF et al. Can J Anaesth 2023;70:842-850 (propofol bolus for cough at emergence) | https://pubmed.ncbi.nlm.nih.gov/36829104/ |
| Adrogué HJ, Madias NE. NEJM 1998;338:26-34 (acid-base disorders) | https://www.nejm.org/doi/full/10.1056/NEJM199801013810107 |
| Berend K et al. NEJM 2018;378:1419-1428 (base excess) | https://www.nejm.org/doi/full/10.1056/NEJMra1711860 |
| Stevens WC et al. Anesthesiology 1975;42:197-200 (sevoflurane MAC) | https://pubs.asahq.org/anesthesiology/article/42/2/197/26839 |
| Mapleson WW. Br J Anaesth 1996;76:179-185 (MAC age adjustment) | https://pubmed.ncbi.nlm.nih.gov/8777094/ |
| Williams KA et al. Br J Anaesth 2005;95:549-553 (airway topicalization) | https://pubmed.ncbi.nlm.nih.gov/16126785/ |
| Pollock JE. Anesth Analg 2003 (TNS with lidocaine spinal) | https://pubmed.ncbi.nlm.nih.gov/12873924/ |
| Goldblum E, Atchabahian A. Acta Anaesthesiol Scand 2013 (chloroprocaine spinal) | https://pubmed.ncbi.nlm.nih.gov/23320599/ |
| Horlocker TT et al. Reg Anesth Pain Med 2018;43:263-309 (ASRA 4e) | https://rapm.bmj.com/content/43/3/263 |
| Apfelbaum JL et al. Anesthesiology 2022;136:31-81 (ASA Difficult Airway 2022) | https://pubs.asahq.org/anesthesiology/article/136/1/31/117507 |
| ASA Procedural Sedation 2018, Anesthesiology 2018;128:437-479 | https://pubs.asahq.org/anesthesiology/article/128/3/437/19295 |
| ASA NPO Guidelines 2017, Anesthesiology 2017;126:376-393 | https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/ |
| CRASH-2 trial collaborators. Lancet 2010;376:23-32 (TXA in trauma) | https://pubmed.ncbi.nlm.nih.gov/20554319/ |
| WOMAN Trial Collaborators. Lancet 2017;389:2105-2116 (TXA in PPH) | https://pubmed.ncbi.nlm.nih.gov/28456509/ |
| Holcomb JB et al. JAMA 2015;313:471-82 (PROPPR — 1:1:1 transfusion) | https://pubmed.ncbi.nlm.nih.gov/25647203/ |
| Murphy GS et al. Anesthesiology 2015;122:1112-22 (intraop methadone, cardiac) | https://pubmed.ncbi.nlm.nih.gov/25837528/ |
| Mirski MA et al. Anesthesiology 2007;106:164-177 (VAE review) | https://pubmed.ncbi.nlm.nih.gov/17197859/ |
| Tzabazis A et al. J Clin Anesth 2015;27:353-360 (delayed emergence review) | https://pubmed.ncbi.nlm.nih.gov/25912729/ |

### Notes on page numbers

Textbook page numbers vary by edition. Where this document cites a chapter (e.g., "Miller's 10e Ch. 47 'Local Anesthetics'"), the chapter title is the stable reference — find the chapter in your edition rather than relying on a page number. ClinicalKey institutional access provides full text + chapter navigation for Miller's, Coté, and Stoelting's.

---

## Sources without a confirmed direct URL

A small number of cited sources do not have a verifiable direct URL (either pre-internet publications, journals discontinued before PubMed indexing, or society documents distributed only as PDFs to members). For these, I cite the original reference and provide the closest verifiable lookup (society root page or PubMed search):

| Reference | Why no direct URL | Closest verifiable lookup |
|---|---|---|
| Hilgier M. *Reg Anesth* 1985;10:59-61 (sodium bicarbonate alkalinization) | Pre-1990, not indexed in PubMed | No verified direct URL. Topic well-established in regional-anesthesia textbooks (Cousins 4e, Stoelting 6e) |
| Sekerci C, et al. *Br J Anaesth* 1996;76:28-33 (PO ketamine peds) | Indexing inconsistent | [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Sekerci+ketamine+1996) |
| Brown TC, et al. *Anaesth Intensive Care* 1986 (caudal bupivacaine peds) | Pre-1990, no DOI | [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Brown+caudal+bupivacaine+1986) |
| Liu LM, et al. *Anesthesiology* 1981 (succinylcholine IM peds) | Limited PubMed coverage | [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Liu+succinylcholine+IM+1981) |
| Bhana N, et al. *Drugs* 2000 (dexmedetomidine review) | Review article, behind publisher paywall | [PubMed search](https://pubmed.ncbi.nlm.nih.gov/?term=Bhana+dexmedetomidine+Drugs+2000) |
| Salinas FV. *Anesth Analg* 2004 (mepivacaine spinal) | Could not confirm exact 2004 citation; cited Zayas VM et al. 1999 mepivacaine dose-response instead | [Zayas PubMed](https://pubmed.ncbi.nlm.nih.gov/10553828/) |
| Winters RW. *Body Fluids in Pediatrics* 1973 (Winters' formula) | Pre-internet textbook, no online edition | Original Albert 1967 data — [PubMed](https://pubmed.ncbi.nlm.nih.gov/6016545/) |
| AAAAI 2020 Practice Parameter (anaphylaxis) | Society document distributed via journal, not as standalone webpage | Shaker MS, et al. JACI 2020;145:1082-1123 — [PubMed](https://pubmed.ncbi.nlm.nih.gov/32001253/); AAAAI portal — [aaaai.org](https://www.aaaai.org/practice-resources/statements-and-practice-parameters) |
| Hospital pharmacy formulary concentrations (Infusion screen mix instructions) | Institution-specific documents | ISMP Standard Concentrations of Adult Continuous IV Infusions — [ISMP](https://home.ecri.org/pages/ismp) |

If you have a verifiable direct URL for any of the citations above, please email **support@helixanesthesia.com** so we can add it.