Chapter 64. Anesthesia for Children

Overall, pediatric anesthesia is extremely safe in the hands of experienced providers. Factors that may increase risk include age younger than 1 year and coexisting disease. Careful attention to maintenance of a patent airway is critical to the safe care of infants and children.

One of the challenges of pediatric anesthesia for trainees is selecting appropriately sized equipment and supplies. Endotracheal tubes are generally selected to yield a leak at 15 to 30 cm H2O. Cuffed tubes are gaining wider use in young children as well as those older than 8 years. Straight blades are most commonly used for intubation in infants, with the usual choices being Miller 0 for neonates and Miller 1 for infants. A Wis-Hipple 1.5 blade is often used in toddlers, with progression to Macintosh size 2 for children 3 years and older.

The physiologic and psychological contexts must be considered in planning an anesthetic for any child. Premedication and parental presence may be appropriate for children. Induction of anesthesia for elective surgery in young children frequently is accomplished by inhalation of a volatile anesthetic. Sevoflurane is the most common choice in modern practice based on the drug's rapid effect, low degree of airway irritation, and cardiovascular stability.

Succinylcholine is no longer used routinely in children because of the potential for hyperkalemia in undiagnosed myopathy. Succinylcholine may still be used when indicated for rapid-sequence induction or treatment of laryngospasm.

Regional anesthesia is a useful adjunct to general anesthesia in children for a variety of procedures. Surgery with a regional anesthetic alone is uncommon in young children; one exception is the use of spinal anesthesia in premature infants at risk for postoperative apnea. For common outpatient surgery such as hernia repair or orchidopexy, caudal blockade with a local anesthetic such as ropivacaine provides good intraoperative and postoperative analgesia. Epidural catheters also may be placed in children for more major procedures and generally are placed after induction of general anesthesia in children who are too young to cooperate.

Selection of an appropriate plan for postoperative analgesia is important for both inpatient and outpatient situations. Adequate doses of acetaminophen, nonsteroidal anti-inflammatory drugs when not contraindicated, and regional anesthesia may be appropriate in addition to or in place of opioid analgesia, depending on the procedure. Postoperative vomiting is common in children and may occur more frequently during certain procedures, such as strabismus surgery, and in patients with a history of motion sickness or postoperative vomiting. Prophylaxis frequently includes use of a 5-hydroxytryptamine3 (5-HT3) receptor antagonist or a steroid such as dexamethasone. Because of restrictions on the use of droperidol, 5-HT3 receptor antagonists are generally used as first-line treatment of postoperative nausea and vomiting in children.

Emergence agitation occurs in a significant number of toddlers and young children, particularly after use of a volatile anesthetic. Appropriate analgesia and possibly supplemental sedation may be helpful. The results in the literature are mixed with regard to links with specific agents (eg, sevoflurane); patient and parental ...