An Overview of Pediatric Anesthesia

Abstract

Anesthesia in children is very safe. However, critical events do occur, with more than half of them involving the respiratory system and the airway. To maintain safety, surgery and anesthesia for children can only be performed in centers with the correct staff training, equipment and physical environment. Professional organizations have guidelines for these requirements. The law gives parents the right to decide about a child’s treatment, but consent and the right to refuse treatment becomes more complicated as the child’s age increases towards 16–18 years and the child is more likely to have Gillick competency. Although there is overlap between the anesthetic techniques used in adults and children, the techniques used in adults are not always appropriate in children—for example, IV induction is not always best, and the technique for adult rapid sequence induction requires modification to prevent complications in children. Children will not always keep their hand still for an IV insertion, and will not always simply accept a facemask. Techniques to assist with these common tasks are used in pediatric practice. After anesthesia, children are more likely than adults to wake unhappy and upset, and will not always suffer pain quietly. Emergence delirium is a common problem and can spoil an otherwise good anesthetic experience for the family. There are several effective strategies to prevent it.

Review Questions

• 1. A healthy but anxious 4 year old girl has anesthesia for myringotomy and tubes. She was given oral paracetamol as a premed. She had an inhalational induction, but did not willingly accept the mask at induction. After induction she was given sevoflurane 2% in nitrous oxide/oxygen for surgery and transferred to PACU. She woke soon after crying and thrashing. Why might she have woken like this? Could anesthesia have been different to prevent this outcome?

• 2. Justify your use of perioperative antiemetics in children.

• 3. A 2 year old child requires anesthesia for myringotomy and tube (ear grommets) insertion. What risks would you discuss with the parent?

• 4. A 12 year old girl is brought to theatre to have her broken arm treated. She is frightened, crying, and refuses to let you look at her hand to insert an IV for induction. What will you do?

• 5. A 15 year old has refused consent for open reduction of her forearm fracture. She was told there was a risk of nerve damage from the surgery, and is concerned this will stop her playing her much-loved musical instrument. Do you have to accept the child’s refusal? Can you seek consent from the parent instead? What would you discuss with the child?

• 6. An 18 month old boy has woken after anesthesia for laparotomy for intussusception and has a croupy cough and hoarse cry. What is the likely cause, and how will you decide if treatment is required? What are the treatment options?

• 7. You are asked to anaesthetize a 5 year old at a day surgery unit where you have not worked at before. How will you decide if is safe to anaesthetize the child there?

• 8. You are called to the day surgery ward to see a 2 year old who has a fever 1 h postop. She had a 2 h orthopedic procedure with an uneventful GA. The esophageal temperature at the end of anesthesia was 37.4°, and it was 37.7° when discharged from PACU. Why might this child have a fever and what will you do?