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  1. Children of all ages continuously undergo numerous developmental changes affecting all aspects of anesthetic care, particularly in the neonatal period when caregiver knowledge of physiologic trajectories and patterns of malformation is essential.

  2. In the setting of acute upper respiratory infection, well-appearing afebrile children at their baseline activity level likely have minimally increased risk of perioperative respiratory complications and generally do not merit case cancelation.

  3. Antibiotic prophylaxis for endocarditis is recommended only for patients with prosthetic valve material, previous endocarditis, congenital heart disease in some settings, and heart transplant with valvulopathy; only invasive dental procedures, respiratory procedures with manipulation of mucosa, and procedures on infected tissues require prophylaxis.

  4. Succinylcholine may induce hyperkalemia in patients at risk for rhabdomyolysis who are not at risk for malignant hyperthermia and should be avoided in these settings but may generally be used safely in most other patients who are not hyperkalemic.

  5. Data increasingly suggest lack of harm and potential benefit from restrictive transfusion strategies, and transfusion should generally be withheld except for documented or reasonably suspected blood product deficiency with evidence of end-organ dysfunction.

  6. Preoperative fasting intervals for all patients before elective procedures requiring sedation or anesthesia are 2 hours for clear liquids; 4 hours for breast milk; 6 hours for light meals, including nonhuman milk and infant formula; and 8 hours for fried or fatty foods or meat.

  7. Preoperative pharmacologic premedication is more effective than nonpharmacologic intervention for prophylaxis of postoperative emergence delirium, which is associated with toddler age, male sex, certain agents and procedures, rapid emergence, and parental anxiety.

  8. Parental presence during induction of anesthesia does not significantly reduce patient anxiety in most settings unless anxious patients are accompanied by calm parents and may be counterproductive when calm children are accompanied by anxious parents.

  9. Developmental differences influence pharmacology in pediatric patients, in whom doses and regimens extrapolated from adult practice may not be accurate and venous access may not be readily available.

  10. Animal data demonstrate susceptibility of developing brain to anesthetic neurotoxicity under certain conditions; human data suggest modestly increased risk of adverse neurodevelopmental outcomes following multiple early exposures to anesthesia and surgery in children; the extent to which pediatric anesthetic exposure itself is neurotoxic remains unknown.


Preoperative assessment of newborns and children requires understanding of pediatric surgical procedures and appreciation of the unique physiology, psychology, and developmental trajectories of pediatric patients. In addition to more obvious differences in size, patterns of communication, and involvement of families and caregivers, children of all ages continuously undergo developmental changes that affect all aspects of anesthetic care. Understanding dynamic processes underlying these developmental changes allows meaningful preoperative assessment and formulation of appropriate anesthetic plans. Such an approach seeks not rigidly to apply paradigms of adult care to younger patients but to employ sensitivity, understanding, and flexibility in providing developmentally appropriate care to children of all ages.



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