Be just as confident managing children as adults! This book will give students and clinicians the knowledge and practical information you need to get the most out of your precious paediatric training time. The first Australian text on the subject of paediatric anaesthesia, this book is written in a readable and practical style and provides practitioners and students with the practical clinical skills and techniques to care for children. More info: http://www.mcgraw-hill.com.au/html/9780071000222.html

1. YOUR GUIDE TO
PAEDIATRIC
ANAESTHESIA
CRAIG SIMS & CHRIS JOHNSON
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2. YOUR GUIDE TO
PAEDIATRIC
ANAESTHESIA
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3. DEDICATION
To those who have taught us so well
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4. YOUR GUIDE TO
PAEDIATRIC
ANAESTHESIA
CRAIG SIMS & CHRIS JOHNSON
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5. Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are
required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is
complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes
in medical sciences, neither the editors, nor the publisher, nor any other party who has been involved in the preparation or publication of this work war-
rants that the information contained herein is in every respect accurate or complete. Readers are encouraged to confirm the information contained herein
with other sources. For example, and in particular, readers are advised to check the product information sheet included in the package of each drug they
plan to administer to be certain that the information contained in this book is accurate and that changes have not been made in the recommended dose
or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.
Copyright © 2011 McGraw-Hill Australia Pty Limited
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National Library of Australia Cataloguing-in-Publication Data
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Title: Your guide to paediatric anaesthesia / Craig Sims, Chris
Johnson, editors.
ISBN: 9780071000222 (pbk.)
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Subjects: Pediatric anesthesia—Handbooks, manuals, etc
Children—Surgery—Care—Handbooks, manuals, etc.
Pediatric anesthesia—Examinations—Study guides.
Other Authors/Contributors: Sims, Craig. Johnson, Chris.
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Dewey Number: 617.96
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McGraw-Hill Australia Pty Ltd
Level 2, 82 Waterloo Road, North Ryde NSW 2113
Acquisitions editor: Fiona Richardson
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Cover and internal design: Alicia Freile
Production editor: Laura Carmody, Jess Ní Chuinn
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Copyeditor: Laura Davies
Illustrations: Laserwords
Proofreader: Jill Pope
Indexer: Glenda Browne
Typeset in Minion Pro Regular 10/14 pt by Laserwords, India
Printed in China on 80gsm matt art by CTPS

6. v
C O NTE NTS
Contributors vii
Preface viii
Twelve current issues ix
Useful formulae for paediatric anaesthesia xi
Abbreviations used in the text xiii
1 An overview of paediatric anaesthesia 1
2 Pharmacology of anaesthetic agents in children 20
3 Behavioural management of children 40
4 Airway management 55
5 Fluid management 83
6 Equipment and monitoring 97
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7 Resuscitation and emergency drugs 114
8 Acute pain management
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Regional anaesthesia 150
10 Respiratory illnesses and their influence on anaesthesia 165
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11 Chronic diseases of childhood 179
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Congenital syndromes & conditions 195
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Neonatal anaesthesia 201
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14 Anaesthesia for paediatric general surgery 224

7. vi YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
15 Anaesthesia for ENT surgery 238
16 Bronchoscopy & removal of foreign bodies from the trachea 250
17 Anaesthesia for dental procedures 260
18 Orthopaedic surgery 265
19 Congenital heart disease 271
20 Anaesthesia for thoracic surgery 284
21 Anaesthesia for plastic surgery 290
22 Paediatric neuroanaesthesia 296
23 Anaesthesia for ophthalmic surgery 303
24 Anaesthesia for urological surgery 307
25 Trauma and burns 313
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26 Malignancy and treatment of malignancies 326
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Procedural sedation: anaesthesia & sedation of children away from the OR 334
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28 Vascular access 342
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29 The child at risk—child protection and the anaesthetist 350
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30 Paediatric intensive care 354
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31 Glossary of syndromes and diseases 364
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Short-answer questions from past FANZCA and FRCA examinations 369
Index 375
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8. E D I TO R S A N D C O N T R I B U TO R S vii
E D ITO R S
Dr Craig Sims MBBS, FANZCA
Paediatric Anaesthetist
Princess Margaret Hospital for Children
Perth, Western Australia
Dr Chris Johnson MBBS, FANZCA
Director, Surgical Services
Paediatric Anaesthetist
Princess Margaret Hospital for Children
Perth, Western Australia
C O NTR I B UTO R S
From the Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children. Perth,
Western Australia:
Dr Ric Bergesio* MBBS, FANZCA
Dr Alison Carlyle* MBChB, FRCA, FANZCA
Dr Neil Chambers* MBBS, FRCA, FANZCA
Dr Elaine Christiansen* MBBS, FANZCA
Dr Tanya Farrell* MBBS, FANZCA, MBA
Dr Ian Forsyth* BSc (Hons), MBChB, FANZCA
Dr Mairead Heaney* MB BCh Dch FCARCSI FCICM FANZCA
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Dr Mary Hegarty* BSc, MBBS, FRCA, FANZCA
Dr Bruce Hullett* MBBS, FANZCA
Dr Charlotte Jorgensen* MBBS, FANZCA
Dr Serge Kaplanian* MBBS, FRACGP, FANZCA
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Dr Lisa Khoo* MBBS, FANZCA
Dr Soo Im Lim* MBBS, FANZCA
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Dr Tessa Meyer* MBBS, FRCA, FANZCA
Prof Britta von Ungern-Sternberg** MD, PhD, DEAA, FANZCA
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Dr Claudia Rebmann* MD, FRCA, FANZCA
Dr Phil Russell* MBBS(Hons), FANZCA
Dr Prani Shrivastava* MBBS, FANZCA
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Dr Priya Thalayasingam* AM, MBBS, FANZCA
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Dr John Thompson* MBBS, FANZCA
From the Paediatric Intensive Care Unit, Princess Margaret Hospital for Children. Perth, Western Australia:
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Dr Daniel Alexander*** MBBS, FRACP, FJFICM
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* Paediatric Anaesthetist
** Chair of Paediatric Anaesthesia, The University of Western Australia and Princess Margaret Hospital for
Children, Perth, Western Australia
*** Paediatric Intensivist

9. v iii YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
P R E FA C E
Why are so many anaesthetists nervous at the thought of looking after children? Two reasons: firstly, it is the
management of the child’s small airway—everyone knows that children go blue very fast! Secondly, it is the
management of childhood behaviour and anxiety, often transmitted from parents. Children let everyone know if
they’re scared or in pain.
The key to paediatric anaesthesia is to learn the skills to be confident about managing a child’s airway. Once
you have mastered this you can relax into anaesthetising children, start to enjoy working with them and their
parents and learn the art of managing anxiety in parents and their children.
This book will give you the knowledge and practical information you need to get the most out of your precious
paediatric training time so that you can become as confident managing children as you are with adults. This is
the one book that gives both all the information you need to prepare for specialist exams, and the knowledge of
contemporary paediatric anaesthesia that will stand you in good stead as a consultant anaesthetist. This book
assumes prior knowledge about anaesthesia in adults and concentrates on fully explaining what is different about
children.
The editors and chief authors are both clinical, full-time paediatric anaesthetists in the public and private
health systems, anaesthetising about 2000 children each year between them. The authors are all experienced,
clinical paediatric anaesthetists. Some may see it as a limitation that they are all from one hospital. Your authors,
however, are all well-studied and trained, and give you the experience gained in 17 leading paediatric institutions
in eight countries across the UK, Europe, North America and South Africa as well as Australia and New Zealand.
Many ‘multinational, multi-author’ texts only give you the views of one author from one institution in each
chapter. We have been careful that our work reflects contemporary Western practice and is not merely the
approach from a single institution. Although we have discussed a range of approaches for each clinical problem,
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we have been careful to highlight a safe and pragmatic approach for the reader based on the authors’ extensive
clinical experience.
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We hope that you enjoy reading this book and learn much from it. We would encourage reader feedback
on ideas for future topics, and most of all, hope that it aids you to become more relaxed and comfortable
anaesthetising children.
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Craig Sims and Chris Johnson
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10. T W E LV E C U R R E N T I S S U E S I N PA E D I AT R I C A N A E S T H E S I A ix
T W E LV E C U R R E N T I S S U E S I N PA E D I ATR I C A N A E STH E S I A,
AN D W H E R E TO FI N D TH E M
1. Emergence delirium
Young children sometimes wake from anaesthesia crying and unhappy. There are many reasons for this, although
sevoflurane dysphoria is commonly blamed. See Chapter 1, ‘An overview of paediatric anaesthesia’, page 12.
2. Dextrose in IV fluids for children
Hypotonic, dextrose-containing solutions have been traditionally used for IV fluids in children. The risk of
hyponatraemia from these fluids is so high that salt-rich fluids are recommended nowadays. See Chapter 5, ‘Fluid
management’, page 88.
3. The uncooperative child
Many do not like anaesthetising children because of difficulty with the child’s behaviour at induction. See
Chapter 3, ‘Behavioural management of children’.
4. The airway
Many anaesthetists do not like caring for children because of difficulty managing their airway. See Chapter 4,
‘Airway management’, for many practical tips.
5. Cuffed endotracheal tubes
Uncuffed endotracheal tubes have traditionally been used in children. It is now realised that cuffed ETTs offer
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many advantages. See Chapter 4, ‘Airway management’, page 69.
6. Neurotoxicity of anaesthetic agents on
There is laboratory evidence that many anaesthetic agents, including volatiles, affect the developing brain of
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7. Intubation without relaxants
Muscle relaxants are being used less and less in children as it is realised that satisfactory intubating conditions can
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be achieved without them. See Chapter 4, ‘Airway management’, page 72.
8. Dexamethasone in tonsillectomy
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Dexamethasone is commonly used in tonsillectomy to reduce pain and vomiting and to shorten the time to
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oral intake. There is some evidence that high-dose dexamethasone increases bleeding after tonsillectomy. See
Chapter 15, ‘Anaesthesia for ENT surgery’, page 244.
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9. Child abuse
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More and more legislatures are passing laws that make it mandatory for all involved in the care of children to
report any suspicion of child abuse. See Chapter 29, ‘The child at risk: child protection and the anaesthetist’.

11. x YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
10. Reducing pain and distress during procedures
Holding a child down to perform a procedure is becoming less and less acceptable. Many techniques and drugs
are now used to make procedures more comfortable and less distressing for the child, parents and staff. See
Chapter 27, ‘Procedural sedation: anaesthesia and sedation of children away from the operating room’.
11. Managing the critically ill child before transfer to a paediatric centre
There are several recurrent issues that may require attention when a child is transferred from a peripheral hospital.
See Chapter 30, ‘Paediatric intensive care’, page 356.
12. Laparoscopic surgery
More and more laparoscopic surgery is being performed in neonates and infants. See Chapter 14, ‘Anaesthesia for
paediatric general surgery’, page 226.
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12. USE FU L FOR M U LAE xi
U S E F U L F O R M U L A E F O R PA E D I ATR I C A N A E STH E S I A
Weight
Body weight for infants 5 (age in months 1 9) / 2
Body weight for children 1–10 y 5 (age 1 4) 3 2
Body weight for children older than 10 y 5 age 3 3 (large variation in normal adolescent weight, however)
Blood pressure
Expected systolic blood pressure for children older than 1 y 5 80 1 (age in years 3 2) mmHg
Fluids
Maintenance fluid rate in mL/h: (4:2:1 rule)
4 mL/kg first 10 kg weight 1 2 mL/kg next 10 kg weight 1 1 mL/kg for rest of weight
(e.g. for 19 kg child: (10 3 4) 1 (9 3 2 ) 5 58 mL/h)
Minimum 10% dextrose infusion for neonate day one (4 mg/kg/min) in mL/h 5 2.5 3 weight in kg
(e.g. 3 kg neonate needs at least 7.5 mL/h 10% dextrose)
Blood transfusion
Blood volume of child 5 (70 3 weight in kg) mL
Blood volume of infant 5 (80 3 weight in kg) mL
10 mL/kg of packed cells increases the Hb by 3 g/dL; or 4 mL/kg of packed cells increases the Hb by 1 g/dL
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initial Hb 2 final Hb
Allowable blood loss 5 __________________ 3 blood volume
intial Hb
ETT size
Uncuffed ETT size for child over 2 y: (Age / 4) 1 4 5 ETT size (inside diameter, mm)
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Cuffed ETT size for child over 2 y: (Age / 4) 1 3.5 5 ETT size (ID, mm)
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ETT length
Position at vocal cords 5 ID size of ETT (e.g. 4.5 ETT should be 4.5 cm at vocal cords)
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Oral ETT length (at lips in cm) 5 (Age / 2) 1 12
Nasal ETT length (at nostril in cm) 5 (Age / 2) 1 15 (and diameter of correct-size nasal ETT same as oral ETT
for children)
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Neonates: oral ETT length (at lips in cm) 5 weight (kg) 1 6
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Neonates: nasal ETT length (at nares in cm) 5 (weight (kg) 3 1.5) 1 7
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13. xii YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
Suction catheter for ETT
Size of suction catheter for ETT (in French Gauge) 5 2 3 size of ETT (ID)
Urinary catheter
Urinary catheter size (FG) 5 2 3 size of ETT (ID)
CVC
Depth for CVC placement in right IJV 5 10% of height
(e.g. 8 cm in an 80 cm child)
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14. A B B R E V I AT I O N S xiii
A B B R E V I AT I O N S U S E D I N TH E TE X T
Abbreviation Meaning Abbreviation Meaning
ABG arterial blood gas ETT endotracheal tube
ADH anti-diuretic hormone EUA examination under anaesthesia
ALL acute lymphoblastic leukaemia EVD external-ventricular drain
APL adjustable pressure limiting FANZCA Fellowship of the Australian and New
APS acute pain service Zealand College of Anaesthetists
ARDS acute respiratory distress syndrome FEV forced expiratory volume
ASD atrial septal defect FRC functional residual capacity
AVSD atrioventricular septal defect FRCA Fellowship of the Royal College of
AXR abdominal X-ray Anaesthetists
BAL broncho-alveolar lavage GCS Glasgow Coma Score
BHR bronchial hyperreactivity GFR glomerular filtration rate
BMI body mass index GIT gastrointestinal system
BMR basal metabolic rate HbA adult haemoglobin
BP blood pressure HbF foetal haemoglobin
bpm beats per minute HDU high dependency unit
BSA body surface area HDU/ICU high dependency unit/intensive care
BSL blood sugar level unit
CBF cerebral blood flow HFOV high frequency oscillatory ventilation
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CDH congenital diaphragmatic hernia HLHS hypoplastic left heart syndrome
CNS central nervous system HMD hyaline membrane disease
CPP
CPR
cerebral perfusion pressure
cardiopulmonary resuscitation
IAP
ICF
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intra-abdominal pressure
intracellular fluid volume
CSF cerebrospinal fluid ICU intensive care unit
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CVC central venous catheter IJV internal jugular vein
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CVP central venous pressure IOP intraocular pressure
CXR chest X-ray IPPV intermittent positive pressure
DIC disseminated intravascular ventilation
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coagulation IVC inferior vena cava
DLT double-lumen tube LMA laryngeal mask airway
DORV double-outlet right ventricle LTA laryngeal tube airway
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DRG dorsal root ganglion LV left ventricle
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DVT deep vein thrombosis MAC minimum alveolar concentration
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ECF extracellular fluid volume MAP mean arterial pressure
ECG electrocardiogram MDI metered dose inhaler
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ECMO extracorporeal membrane MPS mucopolysaccharidoses
oxygenation MV minute ventilation
EEG electroencephalogram NAI non-accidental injury
ENT ear nose and throat NEC necrotising enterocolitis

15. xiv YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
NGT nasogastric tube RDI respiratory disturbance index
NMBD neuromuscular blocking drugs RDS respiratory distress syndrome
NRS numerical rating scale ROP retinopathy of prematurity
OLV one-lung ventilation RR respiratory rate
OME otitis media with effusion RSV respiratory syncytial virus
OR operating room RV right ventricle
OSA obstructive sleep apnoea SVC superior vena cava
OSD obstructive sleep disorder SVR systemic vascular resistance
PACU post-anaesthesia care unit TBI traumatic brain injury
PAT pain assessment tool TBW total body water
PCA postconceptual age TCI targe controlled infusion
PDA patent ductus arteriosus TENS transcutaneous electrical nerve
PEA pulseless electrical activity stimulator
PEEP positive end expiratory pressure TOF tracheo-oesophageal fistula/tetralogy
PICC peripherally inserted central venous of Fallot
catheter VAS visual analogue scale
PICU paediatric intensive care unit VFT ventilatory function test
PVR pulmonary vascular resistance VSD ventricular septal defect
RBC red blood cell
A note on the text
Terms from the ‘Glossary of syndromes and diseases’ (page 364) appear in bold when first used in the
chapter text.
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16. C HA P T E R 1
AN OVERVIEW OF
P A E D I ATR I C A N A E S T H E S I A
Craig Sims and Tanya Farrell
T he terms ‘paediatric’ and ‘child’ apply to someone aged less than 18 years. The
American Academy of Pediatrics defines ‘pediatric’ as less than 21 years, while
some centres use 16 years. An ‘infant’ is a child aged between one and 12 months;
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‘neonate’ applies to the first four weeks after birth.
Children make up a quarter of the population in most Western countries on
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and a higher proportion in developing countries. Paediatric anaesthesia is very
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common—5.5% of children have an anaesthetic each year. The commonest indication
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for anaesthesia is ENT surgery, but children often need anaesthesia for procedures
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such as scans and dental treatment that an adult would tolerate without anaesthesia.
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Safety of paediatric anaesthesia
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Anaesthesia for children has become very safe. Parents can be reassured that the profession has taken many steps
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over the years to reduce risk. These steps include analysing past incidents (anaesthesia was the first specialty to
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perform incident monitoring), embracing new monitoring technologies, improving specialist training and taking
advantage of safer drugs. The overall mortality from anaesthesia alone in a healthy child is approximately 1 in
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17. 2 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
Morbidity is common with anaesthesia in children. The incidence is higher at young ages—children aged
3 years and younger have a higher risk than older children. Infants are particularly at risk, with critical incidents
four times more likely in this age group compared to older children. Young children are at greater risk due to
their small airway diameter, predisposition to develop apnoea or airway obstruction from airway irritation, and
predisposition to rapid desaturation.
The risk of morbidity is lower if the anaesthetist is experienced and has a large paediatric case load. Although
there are no formal requirements for anaesthetists caring for children, it is generally agreed that practitioners
anaesthetising children aged 3 years and younger should regularly anaesthetise this age group, and anaesthetists
caring for children aged less than 1 year should regularly anaesthetise infants. Neonatal anaesthesia should be
performed by those who have a fellowship in paediatric anaesthesia.
KEY POINT
Children aged less than 3 years, and especially aged less than 1 year, are at a higher
risk from anaesthesia than older children.
Organisation of services
If you are anaesthetising a child in a non-paediatric hospital, it is important to ensure that it is safe to do so.
The professional colleges and societies issue guidelines for anaesthetists caring for children. These outline the
staffing requirements and the types of equipment and facilities needed. In addition, there are guidelines from the
professional bodies responsible for nurses, surgeons, medical specialties and hospitals that are directed at their
fellows and members.
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Several factors determine if a child can be safely cared for at a particular facility. Broadly, there are factors
relating to the patient and the type of surgery planned (see Table 1.1), and factors relating to the hospital, such as the
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level of staffing, equipment and facilities (see Table 1.2). An older child undergoing day surgery has different health
facility requirements to an infant with coexisting medical problems requiring overnight admission after surgery.
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The Australian and New Zealand College (ANZCA) guideline PS29 (2008) and the United Kingdom College
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(RCOA) guidelines discuss staffing for the care of children in non-paediatric hospitals. These policies particularly
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Table 1.1 Patient factors to consider in determining level of staff and facilities needed to safely care for
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children
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Patient factor
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Age of child, especially if , 12 months
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Type of surgery
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ASA status/general health of child
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Overnight admission
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Emergency procedure
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18. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 3
Table 1.2 Summary of requirements to safely anaesthetise children
Organisation of services
Staff Experience and case load to maintain competency in relevant ages and case mix of:
Anaesthetist
Assistant
Recovery
Ward nurses
Equipment In addition to equipment and facilities needed to safely anaesthetise adult patients:
Size-appropriate breathing circuit, airway equipment and monitoring
Anaesthetic machine and ventilator suitable for ages of children being anaesthetised
Suitable fluid administration devices (may include burette)
Resuscitation drugs and equipment (including defibrillator and pads suitable for children)
Ability to control temperature of OR
Beds and cots suitable to contain child and prevent falls
Facilities Ability for parents to accompany child to theatre and be present in recovery
Separated areas from adults—wards, OR, PACU
Accommodation for parents if overnight admission
Links to tertiary paediatric centres for advice and transfer of patients if postoperative
problems
Pharmacy knowledgeable in paediatric doses
Acute pain service, HDU/ICU if relevant to case mix
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Adapted from ANZCA PS29 and RCOA guidelines.
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apply to infants and neonates because of their greater risk. Anaesthetists looking after children should have
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training in the relevant age group, and should not anaesthetise children if they are not comfortable to do so
from either lack of recent experience or inadequate case load. Having a second anaesthetist to help should be
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considered for infants and children ASA3 status or higher, and the anaesthetic assistant and perioperative staff
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should have training in the care of children. Finally, it should be possible to obtain advice from an established
specialist paediatric facility should it be required. The more detailed UK guidelines recommend a lead consultant
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to oversee provision of paediatric anaesthetic services.
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Preoperative assessment
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Just as with adults, assessment of children before anaesthesia includes a history and examination that aim to
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assess previous anaesthetic problems and the severity of co-existing diseases. It is also an opportunity to establish
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rapport with the child and parents, assess the child’s behaviour and reassure the parents with your manner and
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professionalism. Most children are healthy and active, although there is always the possibility of an unrecognised
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abnormality or syndrome. Some children have dysmorphic features suggesting an underlying syndrome (see
Table 1.3 overleaf). If a child has one congenital malformation it is more likely that there will be another. Common
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19. 4 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
conditions to specifically ask about include preterm delivery, recent upper respiratory tract infection and
obstructive sleep disorder.
Examination needs to take into consideration the modesty of the child, particularly with school-aged children
and adolescents. Weight, temperature, heart rate and oxygen saturation are routinely measured. Examination
may occasionally reveal a previously unrecognised heart murmur (see Chapter 19), signs of asthma or URTI
(see Chapter 10) or loose teeth. The most important aspect of airway assessment is mandibular size (see
Chapter 4). Investigations such as haemoglobin, chest X-ray (CXR) and urinalysis are not routinely performed
in healthy children undergoing minor surgery. Haemoglobin is not tested because significant anaemia is rare
in children and mild anaemia does not affect the decision to proceed with anaesthesia. Some centres use the
Sickledex test in patients at risk of sickle cell anaemia.
Table 1.3 Facial dysmorphic features that may indicate a congenital syndrome
Dysmorphic feature
Widely spaced eyes (hypertelorism)
Beaked or other nose abnormality
Low hairline on forehead
Low-slung or malformed ears
Craniosynostosis
Microcephaly
Pre-anaesthetic clinics are not always used for healthy children. Clinics are unlikely to reveal significant
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medical problems, are inconvenient for the family, and the most likely reason for cancellation of surgery is a viral
illness just before surgery. Assessment is commonly made by a telephone interview before admission and review
by the anaesthetist on the day of surgery. on
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Loose teeth
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Children lose deciduous teeth from 5 years of age. A very loose tooth may dislodge and be aspirated during
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anaesthesia and is sometimes removed (with parental permission) after induction. The tooth needs to be very
loose before trying this, and usually has no visible root (it is resorbed). If the tooth is not very loose it can be
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surprisingly difficult and unpleasant to remove, and the gum may bleed. A tooth that is not on the verge of falling
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out can be watched carefully during airway manipulation to avoid dislodgement and checked at the end of the
case to make sure it has not been dislodged.
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Consent
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The legal age for consent is usually between 16 and 18 years, depending on the jurisdiction. Consent for children
is therefore obtained from the parent or legal guardian. There is growing recognition, however, of the rights of
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20. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 5
older school-aged children, even though they may not be able to give legal consent. Further complicating this area
is the increasing recognition by courts of children’s ability to make their own decisions about treatment. Some
health areas have policies in place that allow children as young as 14 years to consent to treatment. However, these
policies are not a replacement for laws and it is still usual to obtain parental consent when the child is younger
than 16–18 years.
The Gillick competency test establishes the legal principles to decide a child’s ability to make healthcare
decisions. The Gillick test forms part of common law in Australia, and it arose from a case about whether
or not a parent’s permission was required for prescription of the oral contraceptive to a 16-year-old girl. The
findings of this case have been used to determine consent issues in general. For a child to be deemed competent
to decide about their health care, they must have the ability to understand the factual, moral and emotional
consequences of their decision. Competence is not reliant on a fixed age, and competence for one situation does
not imply competence for all. The child’s age is still considered—the younger the child, the less likely the child can
understand the implications of their decision.
KEY POINT
Although some adolescents are mature enough to consent to anaesthesia and surgery,
it is wise to obtain a parent’s consent.
In certain life-threatening circumstances, society allows the wishes of a child or the parents to be overridden.
This is firstly because a child is unlikely to competently rationalise life and death decisions, especially when
they are so easily influenced by authority figures. Secondly, society is unwilling to allow any person to make life
and death decisions for someone else, including one’s own child. Hence laws make it possible in an emergency
to override the wishes of a person aged less than 18 years. The exact legal mechanisms for this vary between
jurisdictions, and the involvement of the hospital’s medical administrator is usual. These emergency provisions
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only apply if the procedure is critical and life saving—a blood transfusion in severe hypovolaemic shock may
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be permitted, but not force-feeding an anorexic child who is not critically ill. As a practical matter, it is best to
negotiate a compromise before proceeding to the courts for permission. Consent to treatment is more likely to be
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given when the child’s and parents’ wishes and concerns are considered.
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Fortunately for paediatric anaesthetists, consent issues are usually resolved by the time a child presents for
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surgery. However, consent issues for anaesthetists may arise at the time of induction—is it reasonable to proceed
when the child withdraws their hand from the IV cannula, or pushes away the face mask? Children older than
about 8–10 years who are developmentally normal probably should not be restrained. Fear is often a large part of
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the child’s refusal, and this can be allayed with discussion, parental involvement, involvement of play therapists
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in children having many anaesthetics, and pharmacological premedication if agreed. Younger children are
probably not able to understand the importance of their treatment and it may be reasonable to restrain the child
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and proceed if other strategies fail. Supervising the parent to help restrain a younger child can help parents to
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accept this course of action. Although restraining a 2 or 3-year-old child is straightforward and not uncommon,
restraining a young school-aged child is unpleasant for the child, parent and staff, and should be avoided as
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much as possible by paying attention to the behavioural management aspects of the child. The age beyond which
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restraint is not reasonable depends on many surgical, patient, practical, societal and reality factors. A great deal
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of judgement is involved from case to case. Sometimes during induction a decision must be made quickly to take
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one path or another before the child’s cooperation deteriorates further.
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21. 6 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
Blood transfusion in a Jehovah’s Witness child
A blood transfusion critical to survival of the child (usually as determined by more than one doctor) can be
given legally without the consent of the parents. In fact, doctors have a legal obligation not to allow a child to
die by withholding treatment. In the elective situation, children older than 14–16 years may be able to refuse a
transfusion themselves, but the legality of this would need to be determined before proceeding with surgery.
When the child’s parents refuse permission for a blood transfusion, they are usually only trying to do what is
best for their child. Indeed, anaesthetists should be trying to minimise blood transfusion in every child—there are
many risks of transfusion, and children have a long life ahead for these risks to become apparent.
Confrontation over this issue can be minimised by listening to the parents, telling them all the things that you
will do to try to avoid blood products, and telling them that you are legally obliged not to let their child die. There
is no need to force parents to explicitly agree with this plan and thus refute their own beliefs. There is also little to
be gained from a confrontation with parents who are under stress about their child’s anaesthesia and surgery when
the likelihood of transfusion is extremely low. As medical providers, the legal obligation is straightforward and
most parents are aware of these legal obligations. Ongoing argument serves only to put parents and sometimes
the child under further stress.
Intravenous access
A short 24G or 22G cannula in the dorsum of the hand is the commonest method of securing IV access in
children. The finer 24G cannula may be more difficult to insert, but it is less likely to be felt by the child. The lack
of feeling may allow a second attempt to insert the IV if the first attempt failed. The 24G cannula is the usual size
for neonates and small infants, but in older children it tends to kink when the child moves post op.
Positioning for IV access
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Tapes and equipment should be prepared before inserting the cannula to facilitate quick fixation, as the child may
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move and dislodge the cannula. If the child lies on the bed, blankets can be placed to hide their hand and restrict
movement. Younger children can also sit across a parent’s lap, with their arm brought under the parent’s arm (see
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Figure 1.1). This position hides the hand from the view of the child and parent and helps to keep it still by placing
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the child at a mechanical disadvantage.
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Assistance
A good assistant is vital to maximise the chances of successful venepuncture. Just using a tourniquet for a young
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child is unlikely to work. It is important that the assistant holds the child’s hand and arm correctly, aiming to distend
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the veins and prevent withdrawal of the child’s hand. The assistant needs to hold the forearm tight enough to act as a
tourniquet, but not so tight that the hand turns white from arterial compression. The assistant also gently retracts the
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child’s skin up the limb which helps to fix the vein. The assistant’s other hand can be placed across the child’s elbow
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joint, which helps prevent sudden limb movement if the child feels the needle (see Figure 1.2, p. 8). The anaesthetist
can stabilise their own arm by resting their elbow on something to compensate for sudden movements by the child.
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Tips for venepuncture
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If no veins are visible, using the index finger to very gently feel the dorsum of the hand may detect the faint
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bulge of an underlying vein. It is best to try this before using antiseptic, as this leaves the skin very slightly sticky,
making it much harder to feel subtle variations. Sometimes a faint blue tinge can be seen as an indication of a
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22. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 7
All equipment, including tape, is prepared beforehand. The child sits sideways across the seated parent’s lap and is
distracted with stickers or a toy. The parent’s arm hugs the child’s back and the child’s arm is brought under the parent’s
arm. An assistant stabilises the child’s arm and squeezes it as a tourniquet. The anaesthetist holds the child’s hand and
stabilises it for insertion of the cannula.
Seated parent, back to
anaesthetist and with
child sideways on lap.
Child’s arm brought
under parent’s arm and
behind parent’s back
Assistant stabilising
child’s arm and acting
as a tourniquet
Anaesthetist holding
child’s hand for cannula
insertion
F I G U R E 1. 1 Po s i t i on i ng t h e c l i n g y o r u n c o o p e r at i ve t o d d l e r f o r i n s e r t i o n o f a n I V
vein. The child’s feet can also be used for induction; IV insertion in the foot, however, is more painful than in the
hand. An IV can be left in the foot for postop use depending on the child’s age, length of stay and postoperative
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ambulation.
Some veins are constant in position and can be accessed on the basis of landmarks only. These sites are:
1. the long saphenous vein just in front of the medial malleolus—feel for the groove in the malleolus that
contains the vein
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2. between the fourth and fifth metacarpal bones on the dorsum of the hand
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3. the cephalic vein on the lateral aspect of the forearm, which tends to be in line with the skin crease between
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the thumb and index finger, 1–3 cm proximal to the wrist.
Injection of air bubbles is always avoided in children as they may have undiagnosed congenital heart disease
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or a patent foramen ovale allowing bubbles to cross into the arterial circulation. Care to remove air bubbles is
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required every time a venous line is used.
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Induction
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Inhalational or intravenous induction is the usual choice, although rectal induction is also used in some European
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countries. There are several advantages and disadvantages to each induction type (see Table 1.4 overleaf) and
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there is often an institutional preference for a particular type. IV induction became more popular after the
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introduction of topical anaesthetic creams. However, an IV can still be sited using nitrous oxide/oxygen and
distraction. Possibly the greatest advantage of the IV induction is that IV access is present from the outset. Some
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23. 8 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
The assistant’s hand encircles the child’s forearm. It acts as a tourniquet, retracts the skin on the dorsum of the hand and
prevents the child pulling away.
Assistant
gently retracts
child’s skin
Assistant’s hand
encircling and stabilising
child’s arm, and acting
as tourniquet
Anaesthetist
stabilising child’s
hand while
inserting IV
cannula
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F I G U R E 1. 2 Te c hn i qu e f o r I V c an nu l at i o n i n s m a l l c h i l d r e n
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Table 1.4 Advantages and disadvantages of IV and inhalational induction
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IV induction Inhalational induction
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IV access present No needle
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Less cooperation from child required Gradual loss of airway
Less excitatory movement No pain from propofol
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No smelly gas Faster wake up than after IV induction
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Less pollution Parent can see what is happening to child
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children still hate needles even though they may be old enough to understand that the anaesthetic cream will
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work. Inhalational induction requires skill in distraction and behavioural management to enable the child to
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keep the mask on long enough for the volatile agent to work. Parental presence at induction is standard in most
paediatric hospitals and is discussed in Chapter 3.
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24. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 9
For all paediatric inductions there is a limited window of opportunity to distract the child, after which stress
and fear can make the induction increasingly difficult. It is important to be organised with an induction plan, to
brief your assistant before starting and to make sure that all equipment is ready to use.
Inhalational induction
Sevoflurane is the only available inhalational agent suitable for induction. A routine induction includes 66%
nitrous oxide in oxygen for 20–40 seconds, followed by 8% sevoflurane. If the T-piece is used for induction, it is
useful to give the child a few breaths at 0.5% before going to 8% sevoflurane. (The fresh gas flow enters the T-piece
very close to the face mask, and the sudden smell of 8% sevoflurane may be noticed by the child.)
There is no need to incrementally increase the sevoflurane during induction as this slows induction and
increases excitatory phenomena The timing of nitrous administration is critical, as too short a time means that
the child is more likely to reject the mask when sevoflurane is started, and too long a time makes it more likely the
child will either lose interest and cooperation or become dysphoric from the nitrous oxide. Induction is possible
without nitrous, but it is more likely that the mask will be rejected.
KEY POINT
There is no need to incrementally increase sevoflurane concentration during gas
induction—this slows induction and increases the incidence of excitatory phenomena.
The incremental technique is a hangover from the technique of halothane induction.
Some airway obstruction is common after consciousness is lost, due partly to excitatory phenomena that
occur with sevoflurane (see Chapter 2), and partly due to loss of upper airway tone. Continuous positive
airway pressure (CPAP) and gentle jaw thrust are used to overcome this. Nitrous oxide can be eliminated at
this stage if desired and sevoflurane given in 100% oxygen. An oral airway should not be inserted at this stage.
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It is important to maintain the sevoflurane at 8% until a deeper level of anaesthesia is reached and this partly
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obstructed, excitatory stage has ended. Listening to the heart rate and observing tidal volume will also give a
guide to depth and the need to reduce the sevoflurane concentration. Cardiovascular depression occurs with high
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concentrations of sevoflurane, but in these early stages of inhalational induction it is the airway that will cause
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problems, not hypotension.
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Intravenous induction
IV access is obtained and anaesthesia is induced, most commonly with propofol. Co-induction techniques using
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benzodiazepines and opioids are uncommonly used in children because it is less important in children to blunt
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the haemodynamic responses to induction and intubation, and the priority is often to induce an upset child as
quickly as possible. Preoxygenation and application of monitors before induction are omitted in many centres to
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reduce stress to the child.
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Rapid sequence induction
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Induction for the child at risk of aspiration follows the same principles as in adults—injection of a precalculated
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dose of induction agent followed immediately by a rapidly acting muscle relaxant and cricoid pressure. The
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most important difference is that gentle mask ventilation is always given during cricoid pressure. It is difficult
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to preoxygenate children and they desaturate quickly if left apnoeic before intubation. This results in a hurried
‘crash’ intubation with the risk of morbidity. Cricoid pressure protects the stomach from insufflation during
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25. 10 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
mask ventilation. If mask ventilation cannot be achieved during cricoid pressure, the pressure is reduced or
removed completely if ventilation is still difficult.
KEY POINT
Rapid sequence induction in children includes gentle mask ventilation before intubation.
The second major difference from treating adults in rapid sequence induction is that cricoid pressure is often
omitted in neonates and infants. Cricoid pressure compresses and obstructs the soft, compliant trachea and
distorts the upper airway anatomy. It may not be performed correctly by the assistant if they are not routinely
involved in anaesthesia for children. Gastro-oesophageal sphincter tone and minimising the time between
induction and intubation are relied on instead of cricoid pressure.
The force required for cricoid pressure in adults is about 44 N. Lower pressures (30–40 N, equivalent to
3–4 kg) are applied in children and neonates because of their compliant tracheal cartilages. It is well known that
anaesthetic assistants are less skilled at applying cricoid pressure in children.
Although suxamethonium is commonly used for rapid sequence induction in children, non-depolarising
relaxants are also commonly used. This is because they have a fast onset in infants and children and their effect
is markedly enhanced by volatile anaesthetic agents given during ventilation before intubation. It is safe to
overpressure the volatile agent dose in most children during induction.
Finally, use of a rapid sequence induction does not mandate a cuffed endotracheal tube (ETT). Either a cuffed
or uncuffed ETT may be chosen for children with full stomachs—uncuffed ETTs have a long history of safe use
in children in this situation. If suxamethonium has been used to facilitate intubation with an uncuffed ETT that
then needs to be changed because of excessive leak, consider giving a long-acting relaxant before the tube change.
Many would re-apply the cricoid pressure during the tube change.
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Maintenance on
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The choice of technique during maintenance follows the same principles as with adults. The choice of airway
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management and type of ventilation depends on a variety of patient, procedure and anaesthetic factors. Neonates
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and small infants are commonly intubated and ventilated for all but the briefest case. Otherwise great care must
be taken with the issues of rebreathing, respiratory muscle fatigue and loss of a clear airway. Furthermore, as
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the patient is so small, the surgical field is close to the airway and it is difficult to instrument the airway during
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surgery if problems arise.
Another important difference between children (especially preschool-aged) and adults is that more care is
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required during maintenance to ensure calm and safe emergence. Pain and dysphoria are two important reasons
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for children waking upset and distressed, and these can be minimised during maintenance. Unlike adults who
may suffer in silence from inadequate analgesia, children will let everyone know if they are uncomfortable or
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distressed.
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Hypothermia
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Hypothermia during anaesthesia is common in both children and adults. Children, however, are more at risk: they
have a large surface area relative to body weight, so heat production is relatively low compared to environmental
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26. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 11
Relative body proportions of infant and adult. Note the relatively large head of the infant, making up 20% of the surface area.
Infant Adult
F I G U R E 1. 3 Ch an ge s i n b od y p r op o r t i o n s
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losses. Infants and neonates also have reduced ability to generate heat because of absent or reduced shivering. A
child’s head is large in proportion to the rest of the body (see Figure 1.3), so it is a site of significant heat loss if it
is not covered.
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Most heat is lost through the skin via radiation and convection. Losses are minimised by keeping the child
covered, warming the OR (typically to about 21 °C for children, higher for neonates) and using a forced air
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warmer.
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Conductive heat loss may be large if gel pads are placed under the child to prevent pressure injuries. These gel
pads are made of dense visco-elastic polymer with a large thermal mass and will draw heat from the child. They
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should either not be used, or prewarmed with a forced air warmer. Only about 10% of heat loss is through the
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airway, and passive humidification is adequate in paediatric anaesthesia.
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Recovery
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The facilities required for paediatric recovery are the same as for adults and are covered in professional and College
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guidelines. Staff should have experience in paediatric recovery and receive ongoing training in resuscitation.
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Staffing numbers in paediatric recovery need to be higher as even an awake child needs to be watched closely; for
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example, a child may try to climb out of their cot or bed. As in theatre, paediatric recovery requires the full size
range of airway and resuscitation equipment.
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27. 12 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
Many centres allow parents into recovery. This requires having enough space to accommodate parents, enough
staff to escort the parent into recovery and a method to ensure privacy for other patients. Most centres wait until
the child is awake and not at risk of airway problems before allowing the parent in.
Common recovery problems
Emergence agitation and delirium
Children will soon let everyone know if they wake up sore or unhappy. Anaesthetists looking after children are
careful to ensure good analgesia on awakening. Children can be agitated when they wake up for many different
reasons; however, it is important to exclude pain before considering other causes (see Table 1.5). Agitated children
cry and are unhappy but are consolable, recognise their parent and can usually communicate.
Table 1.5 Causes of a child waking agitated and crying after anaesthesia
Cause of agitation at awakening
Pain
Full bladder
Disorientation
Bad taste
Bad feeling
Parental separation
Hypoxia
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Delirium
Difficult induction
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Emergence delirium is a drug-induced disorientation. The child cries or screams, may be hallucinating, is
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uncooperative and inconsolable, and thrashes around. The child often does not appear to recognise their parent.
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It is common in preschool-aged children after anaesthesia with sevoflurane and desflurane. The reported
incidence varies enormously because of variations in definition. Rapid awakening seems to contribute, and
propofol maintenance reduces the incidence. Midazolam and other sedatives can paradoxically cause delirium if
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given as a premed before short cases where the child wakes before the effect has worn off. Delirium begins as the
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child awakens and usually lasts less than 30 minutes, although it can last longer.
Treatment begins with eliminating other causes including hypoxia (although it can be difficult to get accurate
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oximeter readings on a thrashing child) and pain. Reassure the parents, who are usually very distressed at seeing
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their child behaving like this, and ensure that the child avoids injury. Most children just need observation
and time to settle, but others benefit from pharmacological intervention. Consider small doses of propofol
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0.5–2 mg/kg (ensuring equipment is available in case of apnoea), IV clonidine (0.5–1 microgram/kg), or fentanyl
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0.5–1 microgram/kg. Ketamine or dexmedetomidine may also be effective, but midazolam is not effective. Some
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cases only improve if the child can be made to sleep for 10 or 15 minutes and re-awaken gradually. Sedation
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calms the child and gives the recovery staff and parents time to regroup from what can be a very harrowing
experience.
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28. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 13
Oxygen dependence
A proportion of children require oxygen to maintain their oxygen saturation at 96% or above. Oxygen is given
by face mask or with a mask nearby (‘blow-by’ oxygen). Most children won’t tolerate nasal prongs. Small infants
can be given oxygen using a nasopharyngeal catheter and flow rates of 1 litre/min or less. Prolonged oxygen
dependence after anaesthesia is abnormal and a cause needs to be determined. The commonest reason is
a resolving URTI where the child simply needs time to wake up, cough, clear secretions and re-expand their
lungs. However, causes such as aspiration and other pulmonary events need to be borne in mind and excluded if
appropriate. A CXR will help if the child looks unwell or if oxygen is still required for more than an hour or two.
Routine chest X-rays are not taken because of concerns about radiation exposure.
Discharge from recovery
This is usually based on criteria or a scoring system rather than time. Scoring systems such as the modified
Aldrete or Steward scores are commonly used. These measure several parameters to give a score, and discharge
occurs when a certain score is reached. In general, the score ensures the child is conscious, maintaining their
airway, has acceptable oxygen saturation, good pain control, and is not agitated.
Complications
This section deals with some of the causes of morbidity after anaesthesia in children.
Postoperative nausea and vomiting (PONV)
Children under 2 years of age are at low risk of PONV and are not usually given prophylactic antiemetic therapy.
PONV is a common problem after this age, however. The incidence is the same in boys and girls until puberty,
after which it is higher in girls. There are several procedures with a particularly high incidence of PONV. These
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include strabismus repair (up to 70% PONV incidence if no antiemetic given), umbilical hernia repair, prominent
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ear correction, middle ear surgery and open orthopaedic procedures. An important reason for PONV in all types
of surgery is too much opioid relative to the amount of pain.
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Antiemetic drugs are discussed in Chapter 2. Ondansetron and the other 5HT3 antagonists are effective and
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widely used, although cost limits their use in some centres.
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Post extubation stridor
A croupy cough or inspiratory stridor is uncommon if care is taken with ETT size selection. However, these
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symptoms occasionally occur and are due to oedema at the cricoid ring, which narrows the airway and causes
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turbulent or obstructed airflow. It is more likely in small children (who already have a small diameter airway),
children with a recent URTI (where there may already be some inflammation and oedema of the upper airway),
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or if an ETT was used that was too large (i.e. no leak at 20 cm H2O pressure or cuff too large to gently pass
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through cricoid ring). Observation alone may be appropriate if there is no significant obstruction. Otherwise
IV dexamethasone is given if there is concern that obstruction may worsen, or nebulised adrenaline given if
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obstruction is significant (see Table 1.6 overleaf). Racemic adrenaline was incorrectly believed to cause less
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arrhythmias and is no longer used; 1% adrenaline solution for nebulisers is now more commonly used. If this
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is not available, the 1:1000 (0.1%) IV form of adrenaline can be used. If treatment with adrenaline is required,
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overnight admission for observation should be considered. Heliox (> 60% helium in oxygen) may be helpful, but
many children won’t tolerate the close-fitting mask that its use requires.
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29. 14 YO U R G U I D E T O PA E D I AT R I C A N A E S T H E S I A
Table 1.6 Treatment of post extubation croup in recovery
Treatment for post extubation croup
Dexamethasone IV 0.5–0.6 mg/kg
Nebulised adrenaline—2 types available:
i) L-isomer adrenaline 1% nebuliser solution 0.05 mL/kg diluted with normal saline to 4 mL
Or
ii) Adrenaline 1:1000 (IV preparation) 0.5 mL/kg (maximum 5 mL), use undiluted in nebuliser bowl
Deep vein thrombosis (DVT)
Deep vein thrombosis (DVT) is rare in children, possibly due to high levels in children of the thrombin inhibitor
alpha-2 macroglobulin, which only reduce to adult levels during adolescence. Seventy per cent of DVTs occur in
infants and teenagers. Sick neonates in ICU who have a CVC (central venous catheter) are at high risk for venous
thromboembolism, but also for complications from thromboprophylaxis. Teenage patients presenting for surgery
are at high risk if they have malignancy, are undergoing major surgery of the pelvis or lower limbs, or have a
past history of venous thromboembolism. Factor V Leiden and deficiencies of the regulatory proteins C, S, or
Antithrombin III do not appear to be important until puberty.
Anti-embolic and compression stockings are used for DVT prevention in children who are at risk and large
enough for them to fit. Low molecular weight heparin (enoxaparin) 0.75 mg/kg (maximum 20 mg) twice a day is
given to children older than 6 months by vertical subcutaneous injection in the lower abdomen. This is preferably
given two hours before surgery, but otherwise after induction. The adult dose of 40 mg once a day can be used
in children heavier than 40 kg. Factor Xa levels and platelet count are checked on day one if heparin is continued
postop. One per cent of children develop heparin-induced thrombocytopenia.
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Aspiration
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Aspiration is rare but slightly more common in children than adults. The incidence in children is about 1 in
2–3000. Children have less sequelae after aspiration than adults. Even in the presence of CXR changes, they
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usually improve very quickly without specific therapy. Reflux symptoms are common in infants and young
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children, but are not necessarily an indication for a rapid sequence induction. Medications to reduce the risk of
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aspiration are not usually used in children because of the rarity of aspiration and sequelae. A child who aspirates a
small amount is usually oxygen dependent for a period after anaesthesia and is admitted for observation.
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Awareness
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Awareness in children (0.5–1.0%) is quite different to adults (0.1–0.2%). It is more common, may occur in non-
paralysed children without signs of inadequate anaesthesia, and does not seem to cause distress or post-traumatic
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stress disorder. The reason for the high incidence of awareness in children is not known. There is concern that it may
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reflect problems in the questionnaire methodology used in studies of awareness—children may be more suggestible
and more likely to report memories on repeated questioning. They may also have a diminished ability to encode and
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consolidate memory, making it difficult to differentiate true memories from imagined events and dreams.
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Laryngospasm
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Laryngospasm most commonly occurs at induction and emergence, but occasionally in recovery. All paediatric
recovery areas should have the equipment, training and procedures to deal with this. It can be prevented by
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30. CHAPTE R 1 A N O V E R V I E W O F PA E D I AT R I C A N A E S T H E S I A 15
having all children awake on arrival in recovery. However, the rapid awakening required to achieve this may
not always be practicable and may increase the likelihood of emergence agitation. Laryngospasm is discussed
in detail in Chapter 4.
N OTE
Always remember to let the child’s parent know about any intraoperative problems. It is
unprofessional and unfair for the parent to find out later from nursing staff and increases
the likelihood of a complaint.
Day surgery
At least half of all procedures in children are performed as day cases, although the proportion at any given centre
varies with its case mix.
Suitability for day surgery
As with adults, suitability for day surgery depends on the type of procedure and the requirements for
postoperative observation, care and pain control, underlying medical conditions, age of child, ability of the
parent to care for the child and the location of the child’s home relative to the hospital. Not all infants are suitable
for day surgery: former preterm infants whose post conceptual age (PCA) is less than 52 weeks and term infants
who are less than 44 weeks PCA are at risk of apnoea after anaesthesia and must be admitted for observation (see
Chapter 13). Children at risk of malignant hyperthermia (MH) who have been given a trigger-free anaesthetic
are suitable for day surgery.
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Discharge criteria
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Discharge occurs when a set of criteria are met. The exact criteria vary between centres, but all aim to allow time
to detect any complications that may cause problems at home after discharge (see Table 1.7).
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Table 1.7 Discharge criteria after anaesthesia
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Criteria
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Awake, not dizzy
Observations, including oxygen saturations, satisfactory
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Pain controlled, with no intravenous analgesics recently (usually within last 60–90 min)
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No nausea and vomiting; tolerating (or likely to tolerate) oral fluids
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No croup or upper airway obstruction
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Parent or carer willing to take child home, preferably by car or taxi
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Instructions (preferably written and procedure specific) about postoperative care
(surgical and anaesthetic) including who to contact if problems occur
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