Update Hx

The following is a list of updates to the Anesthesia & Critical Care Reference Sheet. I take all requests for changes and corrections seriously and integrate them in a timely fashion. I document the version number of the sheet in red text at the bottom of the back page.


March 22, 2021 (v21.1)
- All changes made were in the Adult ACLS area using new 2020 AHA handbook.

- Atropine dose changed to 1 mg so it is the same for asystole and bradycardia PEA. Atropine 0.5 mg dose is no longer recommended for bradycardia. Dose now reads “1 mg IV/IO q 3-5 min for asystole/bradycardia/bradycardic PEA, 3 mg (0.04 mg/kg) max.”

- Changed PSVT to SVT in adenosine (Adenocard) dose since that is what is is called now in 2020 AHA handbook.

- Calcium (CaCl2) dose changed from 2-4 mg/kg q10 min prn to 500-1000 mg prn which is what is now listed in AHA handbook.

- Vasopressin (Pitressin®dose, and indication changed to “0.02-0.04 U/min for Vasodilatory shock.” Vasopressin is no longer indicated for cardiac arrest.

January 1, 2021 (v21.0)
- Changed titles "Pediatric Code" to Pediatric Code (PALS) and "Adult ACLS to Adult Code (ACLS)" for clarity.

- Removed year on title header and changed sheet version to reflect this as well, meaning new version is 21.0, old version would have been 2021.0.

August 4, 2020
- Brand new website using the latest online store technology. This upgrade is easier to use (especially on mobile devices) and has expanded options for payment. It will eventually allow tracking for all orders. It provides better customer feedback and shipping notification. Same pricing as before and invoicing for large orders available.

December 15, 2019 (v2020.0)
- Updated wording for sugammadex (Bridion®) to more clearly define seperate dose for rapid reversal after high dose rocuronium (Zemuron®) induction.

January 23, 2019 (v2019.0)
- Added aprepitant (Emend®) to Antiemetics. It is a Neurokinin1 antagonist used as an antiemetic in chemothearpy that was approved for prevention of postoperative nausea and vomiting (PONV) in adults. Despite it being an oral medication, it is very effective at controling PONV in combination thearpy and is becoming more popular clinically.

- Changed “Neuromuscular Blockers” title to “Neuromuscular Blockade.”

- Removed d-tubocurarine (curare) from Neuromuscular Blockade because it is no longer used clinically and is no longer available.

- Clarified succinylcholine laryngospasm dose, 10 -20 mg IV and added 3-4 mg/kg IM/IL dose and added atropine to dose to protect from bradycardia/asystole in children.

January 1, 2018 (v2018.0)
- Updated title logo with a new look. No new drugs to add.

January 28, 2016 (v2016.1)
- Finally after years of testing the FDA approved sugammadex (Bridion®), so it was therefore added to my sheet. If all goes well, it will be a revolutionary new drug!

- Removed thiopental (Pentothal®) and fospropofol (Lusendra®) because they were both discontinued and no longer available.

- Added q6h to acetominophen (Ofirmev®) dosing.

- Updated NPO Practice Guidelines to include "Women in Labor: Clear Liquids allowed". The ASA did not come out and recommend light meals. See ASA Report for more information.

December 30, 2015 (v2016.0)
- Reviewed and updated Pediatric Code and Adult ACLS for new fall 2015 guidelines. I left vasopressin dosing on the sheet although it is no longer included. Will remove at a later date.

December 24, 2014 (v2015.1)
- Added Lipid Rescue lipid emulsion dosing to Local Anesthetics for local anesthetic (bupivicaine) toxicity and referenced lipidrescue.org.

- Added ibuprofen IV (Caldolor®) to Analgesics.

- Added q6h to acetaminophen IV (Ofirmev®) dosing.

- Combined the sections "Reversal of Neuromuscular Blockade" and "Postoperative Medications (Analgesics, Antiemetics, Reversal) into a single section now called "Reversal Agents, Analgesics, Antimetics." This change adds space for new medications and simplifies the table.

December 8, 2014 (v2015.0)
- Darkened colors for better readability. Now they look more like the colors prior to sheet rewrite in 2012.0 version.

December 24, 2013 (v2014.0)
- Added IV doses for acetaminophen (Ofirmev®). It was previously on the sheet but I made room for the actual word "Ofirmev®."

- Using thicker paper for mini sheet which makes for more accurate printing and less bleed through.

November 8, 2012 (v2013.0)
- Improved mini sheet lamination process and size. Sheet now 5 1/4" x 7 1/4" from 5 1/2" x 7 1/4" so it's a little narrower to better fit in pockets. Rounded corners on all corners now.

December 12, 2011 (v2012.0)
- Complete rewrite of entire sheet (although visually it's the same). Sheet was imported into a new program so that it can be edited on current computers. Many small formatting changes to increase readability, especially in the formulas area.

October 10, 2011 (v2011.3)
- Defined "N/R = Not Recommended" under intravenous Anesthetics because I had the space. Began rewrite of sheet for 2012.

June 12, 2011 (v2011.2)
- Added IV doses for acetaminophen (Ofirmev®) which was recently approved.

- Changed adenosine dose so it's 6 mg first dose then 12 mg second dose. Previously there were two 12 mg doses after the 6 mg dose.

- Updated amiodarone in ACLS section to more clearly seperate cardiac arrest dosing from wide complex tachycardia dosing.

- Fixed typo for fospropofol.

January 17, 2011 (v2011.1)
- Added fospropofol (Lusedra®) bolus and infusion doses to Intravenous Agents. I used information from a guest lecture (Dr. Joe Answine) from the Eisai company and recent studies for information about unadvertised doses for induction and infusions.

- Decreased order delivery time to from 2-3 to 1-2 weeks. I'm going to try to stay ahead this year and get orders out once a week.

-Started a Facebook page so everyone who's interested can keep up to date on what's happening with Anesthesia Reference Sheets.

December 26, 2010 (v2011.0)
- Changed pancuronium (Pavulon®) infusion dose from 1 - 15 mcg/kg/min to 0.5 - 1.5 mcg/kg/min. Very difficult dose to find and infrequently used for infusions, but my prior reference (Omoigui) was obviously incorrect. Thanks go to Ben Moor at Tufts Medical Center for bringing this to my attention.

- Changed MHAUS international number to 011-315-464-7079. The extra zero at the beginning is no longer necessary.

June 27, 2010 (v2010.2)
- Updated atropine dosing in the Adult ACLS section. Bradycardia dose is 0.5 mg which is different from the 1 mg dose for asystole and bradycardic PEA.

- Added IO (intraosseous) dosing to atropine, amiodarone, epinephrine, and lidocaine. Minimal formatting changes to main title of sheet (slowly working to add more space to add a new drug).

- Updated website with a new order process with pop ups to select quantity and size. Prior order page available for greater quantity discounts.

March 11, 2010 (v2010.1)
- At the request of Hospira Worldwide, Inc. I changed dexmedetomidine (Precedex®) Consious Sedation bolus of 1 mcg/kg from 10-20 minutes to just 10 minutes and the infusion from 0.2-0.7 mcg/kg/min to 0.2-1.0 mcg/kg/min in the Intravenous Anesthetics section. The FDA granted indications for dexmedetomidine (Precedex®) for Consious Sedation and the recommended doses slightly changed as noted in their package insert.

- Diazepam (Valium®) was removed from footer of the Adult ACLS section as part of the NAVEL pneumonic for code drugs that can be given via ETT (Endotracheal Tube). Because diazepam (Valium®) is fat soluble it is NOT supposed to be given via ETT according to new ACLS protocol. The NAVEL pneumonic is still valid because vasopressin can be given via ETT and this has been verified in the latest ACLS guidelines.

- In the Adult ACLS section I changed the atropine max dose from 0.04 mg/kg to 3 mg as stated in the latest ACLS protocol.

January 4, 2010 (v2010.0)
- Updated website with a new order process with pop ups to select quantity and size. Unfortunately it does not provide the same flexibility with mixed orders or high quantity (greater than 15) orders than the old process but it will work for the majority of customers and simplifies things. For now it is available as an option.

August 08, 2009 (v2009.1)
- Corrected IM dose of midazolam (Versed®) for Peds Sedation Coctail in Pediatric Preoperative/Sedative Medications. Prior dose of 15 mcg/kg was underdose by a factor of 10 and was changed to 0.15 mg/kg (Thanks Michael Hammer). New Mini sheet printing process and printer. Trimming cuts are more accurate, colors better, text sharper.

January 01, 2009 (v2009.0)
- Small formating changes made to sheet (too bad sugammadex wasn't approved but the dose is 4 mg/kg anyway!). I'm using a new Ricoh Color Laser Printer for the standard size sheet which gives the best results yet. Mini sheet is again available for purchase.

January 01, 2008 (v2008.0)
- Updated Pediatric Code section to latest recommendations. Doses did not change but fine tuned drug administration and formating. For epinepherine I removed the note about increasing the 2nd dose since it is no longer recommended.

September 15, 2007
- The Mini (half size) sheet is no longer available due to ordering and production complexities. Mini sheets were often shipped much later than regular sheets. Both the ordering and production process for mini sheets need to be streamlined and improved before it is reintroduced. I'm very sorry about this and I will work hard to get the Mini sheet back, hopefully by mid 2008.

April 07, 2007 (v2007.2)
- Corrected labetalol (Normodyne®) IV infusion units to 2 - 8 mg/min (not mcg/min). Loading dose remains correct. Thank you Thomas Burnakis, Pharm. D. at Baptist Medical Center.

March 19, 2007 (v2007.1)
- Changed rocuronium (Zemuron®) IV intubating dose from 0.45 - 1.0 mg/kg to 0.45 - 1.2 mg/kg at the request of an Organon district manager to reflect current manufactures recommendations. Rapid Sequence Intubating (RSI) dose remains the same at 0.6 - 1.2 mg/kg.

January 12, 2007 (v2007.0)
- Standard size sheet is a little smaller due to slightly smaller lamination (1/4" less top and side). Changed from 9" x 11-1/2" to 8-3/4" x 11-1/4".

- Pricing was increased to better reflect current costs and work involved. The price had been the same for over 6 years so an increase was due. Despite higher beginning price, you will get deeper percent discounts for higher quantities. 1st tier is discount is 20% where prior discount was 10%. All other tiers add another 10% discount per tier. 100+ quantity tier was added. The increased price also helped me justify still producing the mini sheet for now.

August 22, 2006 (v2006.2)
- Added dexmedetomidine (Precedex®) bolus and infusion doses to Intravenous Agents. Although it is not an induction agent it can be used as a primary anesthetic for balanced anesthesia along with sedation and analgesia.

- Deleted morphine from Intravenous Agents because it is no longer used clinically as an induction or balanced anesthesia agent. Morphine remains in the Pediatric and Adult Preoperative Meds.

- Added vasopressin (Pitressin®) to Autonomic / Cardivascular Drugs since it is now being use intraoperatively and in the ICU via infusion along with its continued use in ACLS protocol.

- Deleted bretylium (Bretylol®) from Autonomic / Cardivascular Drugs since it is no longer being manufactured or used clinically. It was removed from ACLS protocol in 2000.

- Reviewed the 2006 ACLS guidelines but no changes were needed on my sheet since drug doses did not change. Only the algorithms changed, specifically timing of CPR and defibrillation.

- Created a Limited Liability Corporation called Anesthesia Reference Sheets LLC and added it the Copyright section. All business transactions will go through this corporation.

May 1, 2006 (v2006.1)
- Added the year back to the title on front page.

- Updated LMA sizes to include the 1 1/2 size for pediatrics.

- Changed "NPO Orders" to "NPO Practice Guidelines" and adopted new age independent recommendations from the ASA.

January 1, 2006 (v2006.0)
- Removed the year in the title on front page. Version of sheet can be found on the back page, copyright info at the bottom.

May 20, 2005 (v2005.1)
- Clarified dose of vasopressin via Endotracheal Tube to be the same as IV.

- Added dexamethasone (Decadron®) 8 mg IV adult (0.25 mg/kg IV child) to Antiemetics.

January 6 , 2005 (v2005.0)
- ACCRS is now laser printed at 1200 dpi. Text appears sharper and the difference is even more noticible on the Mini sheet. As a side note printing is faster and more accurate so orders will be filled faster.

March 2, 2004 (v2004.1)
- Added Fat:Blood Partition Coefficients to Inhalational Anesthetics at the request of the Pharmaceutical Sales Trainer from Baxter Pharmaceuticals. Updated other Partition Coefficients using new references.

- Added the new Mini sheet as an ordering option. Discontinued the Bill Me option for ordering from my website. This will greatly increase the speed in which orders are filled.

December 15 , 2003 (v2004.0)
- Added granisetron (Kytril®) to antiemetics.

- Deleted metaraminol (Aramine®) from Autonomic / Cardiovascular drugs. It was taken off the market by Merck and is no longer available.

- Increased size of sideways text for better readability on Mini sheet.

September 4 , 2003 (v2003.3)
- Changed dark yellow text of Non-Opiod Anesthetics to black text with yellow background for better readability.

July 20 , 2003 (v2003.2)
- esmolol (Brevibloc®) loading dose changed from 0.25 - 1 to 0.5 - 1 (2003 PDR).

- Added mg/kg dose for promethazine (Phenergan®) (from Cote's A Practice of Anesthesia for Infants and Children).

- Added mg/kg dose for morphine on pre-op medication area.

- Fixed tab mistake on labetalol (Normodyne®).

- Changed MH Protocol by adding "Continue IV dantrolene for at least 24 hours after control of the episode (approximately 1 mg/kg q6h)" since it is mentioned twice in the latest acute protocol. Removed sentence about mixing dantrolene with water. At bottom of MH protocol, took off info by fax number and replaced with MHAUS website address and international phone number. The info by fax is no longer available and was replaced by the website.

December 23 , 2002 (v2003.1)
- Changed sheet name to 2003 to include all updates of 2002. To increase clarity and minimize errors, instituted new numbering and unit changes as recommended to improve prescription writing. All units of µg are changed to mcg. Zeros are added in front of all decimal points and no trailing zeros are added after decimal points i.e. 0.1 mcg not .1µg and 3 mcg not 3.0 µg.

August 17 , 2002 (v2002.5)
- Changed the phrase in the Malignant Hyperthermia Protocol for dantroline (Dantrium®) dosing from Max dose = 10 mg/kg but sometimes more is needed to sometimes up to 30 mg/kg if necessary.

- In Hemodynamic Formulas area corrected units for SVR, SVRI, PVR and PVRI from dynes-cm-sec -5 to dynes-sec-cm -5. My prior reference was Barash's Clinical Anesthesia 2nd ed and it was incorrect in that text! Thanks to Dr. Richard H. Savel for pointing this out.

July 20 , 2002 (v2002.4)
- Changed the maintenance infusion dose of cisatracurium (Nimbex®) from 1-2 to 1-3 mcg/kg/min after doing anesthesia for a kidney transplant and discovering that 2 mcg/kg/min wasn't enough. 1-3 mcg/kg/min was listed for ICU infusion in the PDR.

- Added mg/kg dosing of 0.6 mg/kg to hydroxyzine (Vistaril®, Atarax®) in addition to the standard adult dose of 25-100 mg PO/IM.

June 17 , 2002
- Pricing and ordering changes instituted. Price increased to better reflect the amount of work necessary to process orders along with increased materials and shipping costs. PayPal transactions simplified with the addition of a "Shopping Cart". Even more important is that my website now calculates the correct amount to charge given the quantity ordered. You must have javascript enabled for this to work.

May 20 , 2002 (v2002.3)
- In Local Anesthetics, changed toxic dose of bupivicaine (Marcaine®) to not exceed from 200 mg to 175 mg without and 225 mg with epinephrine. Changed mg/kg dose from 2.0 without epinephrine and 2.0-3.0 with epi to 2.5 without and 3 mg/kg with epinephrine. This is after the dose was questioned and I did some research. Especially helpful was the Regional Anesthesia in Infants, Children, and Adolescents text by Bernard Dalens. I also added a visual aid to all doses and durations of local anesthetics using epinephrine by making the number purple to reflect the epinephrine.

March 28 , 2002 (v2002.2)
- Added phenylephrine (Neosynephrine®) 2-5 mg intrathecal dose to Local Anesthetics. Added light grey line background to Fluid Management section for better readability. Added brand names to Autonomic / Cardiovascular Drugs where applicable after creatively squeezing the data. Increased printing resolution from 720 dpi to 2880 dpi for improved text sharpness and smoothness of colors (takes 3 times as long to print).

January 12 , 2002 (v2002.1)
- Instituted version numbering system to better track updates and for copyright issues. Version will be located after copyright area on second page. Cleaned up some minor spacing, abbreviation and font issues. Changed sheet name to 2002.

October 30 , 2001
- Changed heading for "Third Space Losses" to Third-Space or Incensible Losses" because some medical students did not realize they were the same.

- Corrected loading dose for diltiazem (Cardizem®) from 75 - 150 mcg/kg to 0.25 / 0.35 mg/kg for first and second dose (Thanks to Cleve Waterman at LSU).

August 8, 2001
- Added pediatric induction dose of propofol (Dipravan®) 2.5-3.5 mg/kg.

- Reformated document with more readable condensed font, Adobe Myriad Pro Condensed to replace Futura Condensed. Changed e-mail address to accrs@cusick.com. Changed website address from http://www.cusick.com/ars/ to new domain http://www.accrs.com/ for easier recall and more professional look.

April 5, 2001
- rapacuronium (Raplon) was withdrawn from the market (and from my drug sheet) due to rare but lethal bronchospasm. It therefore freed up some space to add amiodarone (Cordanone®) to the cardiovascular drugs.

January 20, 2001
- Corrected loading dose of milirinone (Primacor®) from 20 mcg/kg to 50 mcg/kg.

December 10, 2000
- American Heart Association ACLS and PALS Guidelines 2000 Update included with the following changes

  • amiodarone (Cordanone®) added to Adult ACLS and Pediatric Code tables. Can be given IO in children.
  • bretylium removed from code areas as it is no longer a recommended therapy.
  • Vasopressin added to Adult ACLS table as it is now a first line therapy (not recommended for responsive patents with coronary artery disease). Endotracheal dose same as IV and IO (40 U IV push x 1). Vasopressin also added to the "NAVEL" mnemonic for drugs that can be given via Endotracheal Tube (Naloxone, Atropine, Vasopressin/Valium, Epinephrine, Lidocaine)
  • High dose epinephrine dose for adults removed as not proved effective. Note added to epinephrine dose for Pediatric code that second and subsequent doses may be increased. Changed units from 10 mcg/kg to 0.01 mg/kg to conform with how it is being taught. Adult dose is now 1 mg q3-5 min, changed from 0.5 - 1 mg.
  • Isoproterenol dose changed from 2-20 mcg/min to 2-10 mcg/min for Adult ACLS. Note added to titrate to adequate heart rate.
  • magnesium doses added to Pediatric Code.
  • Note added to Pediatric Code Defibrillation dose to repeat after each medication.
  • Note added to adenosine on Adult ACLS table that it does not convert atrial fib/flutter or Ventricular Tachycardia.
  • New increased procainamide dose (100 mg IV push q5 min) for refractory VF/VT added.
  • Lidocaine initial dose now 1.0 - 1.5 mg/kg from 1.5 mg/kg. Additional dose (0.5 - 0.75 mg/kg), maintenance infusion (30 - 50 mcg/kg/min) and maximum total dose (3 mg/kg) added.

- Amrinone (Inocor®) name changed to inamrinone as mandated by US Pharmacopeia (it sounded to much like amiodarone). Labetalol infusion dosage changed to 2 - 8 mcg/min from 2.0.

September 28, 2000
- PayPal Online Ordering Now Available. Larger, thicker (5 mil) lamination should increase durability. Prices increased to defray extra cost of thicker laminate, shipping, tax, handling, online ordering, website design/maintainence and advertising. Ordering process kept simple by not having to quote separate shipping and handling charges because they are included in the price.

July 30, 2000
- dolasetron (Anzemet®) added to antiemetics.

- physostigmine (Antilirium®) removed from reversal agents as it is no longer used to reverse benzodiazepines.

- Verified Malignant Hyperthermia Protocol current to latest 2000 recommendations.

May 25, 2000
- sevoflurane (Ultane) MAC % changed to reflect new package insert. Adult and >60 yr ranges changed. Fluid Management: Infant Urine Output added (2.0 ml/kg/hr).

October 10, 1999
- Major updates to include...

  • LMA sizes updated to include new #5 size.
  • rapacuronium (Raplon®) added. A new nondepolarizing muscle relaxant approved by the FDA Aug 15, 1999. Fast onset with short duration.
  • Added RSI (Rapid Sequence Intubation) doses for appropriate neuromuscular blockers.
  • Revamped neuromuscular blocker doses, now with a single "quick look" dose to choose from.
  • Malignant Hyperthermia Protocol updated to latest MHAUS 1999 recommendations.
  • New printing process with use of double sided coated paper allows best quality printing yet!

February 5, 1999
- The Anesthesia & Critical Care Reference Sheet is now laminated!

1992 - 1998
- Anesthesia Reference Sheet developed. Updated almost daily during my anesthesiology residency at Wilford Hall Medical Center. Peer reviewed during that time. Photocopied version in sheet protector was freely distributed to all Anesthesiology and CRNA residents with yearly updates.