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General anesthesia in neonates and children: Agents and techniques

Authors
Stephanie A Black, MD, EdM
Lynne G Maxwell, MD, FAAP
Section Editor
Lena S Sun, MD
Deputy Editor
Marianna Crowley, MD

INTRODUCTION

Pediatric anesthesia differs in important ways from anesthesia for adults. This topic will discuss general principles of preanesthesia preparation, induction and maintenance of general anesthesia, and emergence from anesthesia for the healthy child undergoing routine surgery.

Induction and maintenance of general anesthesia for adults are discussed separately. (See "General anesthesia: Induction" and "General anesthesia: Maintenance and emergence".)

PREOPERATIVE EVALUATION

History and physical examination — All children should be evaluated with a preanesthesia medical history, review of systems, and an anesthesia directed physical examination. The preanesthesia evaluation is similar to that of an adult, with modifications appropriate for the child’s stage of development, pediatric physiology, and family history. Important components of the preoperative history and physical examination for a child are shown in tables (table 1 and table 2).

A preanesthesia airway evaluation, including assessment of predictors of difficulty with airway management, should be performed in children, as it would be for adults, with particular attention to findings which may be associated with difficult intubation, such as reduced thyromental distance (micrognathia), decreased mouth opening, reduced neck mobility, or large tongue. The components of the airway examination for children are shown in a table (table 2). (See "Airway management for induction of general anesthesia", section on 'Airway assessment' and "Airway management for induction of general anesthesia", section on 'Prediction of the difficult airway'.)

Laboratory assessment — Preoperative laboratory testing should be individualized, based on patient factors and institutional norms. Routine laboratory studies are usually not required in healthy children.  

                                   

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Literature review current through: May 2017. | This topic last updated: Jun 19, 2017.
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References
Top
  1. Hackmann T, Steward DJ, Sheps SB. Anemia in pediatric day-surgery patients: prevalence and detection. Anesthesiology 1991; 75:27.
  2. Azzam FJ, Padda GS, DeBoard JW, et al. Preoperative pregnancy testing in adolescents. Anesth Analg 1996; 82:4.
  3. Wheeler M, Coté CJ. Preoperative pregnancy testing in a tertiary care children's hospital: a medico-legal conundrum. J Clin Anesth 1999; 11:56.
  4. Hennrikus WL, Shaw BA, Gerardi JA. Prevalence of positive preoperative pregnancy testing in teenagers scheduled for orthopedic surgery. J Pediatr Orthop 2001; 21:677.
  5. Larcher V. Developing guidance for checking pregnancy status in adolescent girls before surgical, radiological or other procedures. Arch Dis Child 2012; 97:857.
  6. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 474: nonobstetric surgery during pregnancy. Obstet Gynecol 2011; 117:420.
  7. Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116:522.
  8. Patel RI, DeWitt L, Hannallah RS. Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice. J Clin Anesth 1997; 9:569.
  9. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 144:S1.
  10. Thongyam A, Marcus CL, Lockman JL, et al. Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study. Otolaryngol Head Neck Surg 2014; 151:1046.
  11. Coté CJ, Kelly DH. Postoperative apnea in a full-term infant with a demonstrable respiratory pattern abnormality. Anesthesiology 1990; 72:559.
  12. Fortier MA, Bunzli E, Walthall J, et al. Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): formative evaluation and randomized controlled trial. Anesth Analg 2015; 120:915.
  13. Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007; 106:65.
  14. Manyande A, Cyna AM, Yip P, et al. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev 2015; :CD006447.
  15. http://www.fda.gov/Drugs/DrugSafety/ucm532356.htm.
  16. Tiret L, Nivoche Y, Hatton F, et al. Complications related to anaesthesia in infants and children. A prospective survey of 40240 anaesthetics. Br J Anaesth 1988; 61:263.
  17. Flick RP, Sprung J, Harrison TE, et al. Perioperative cardiac arrests in children between 1988 and 2005 at a tertiary referral center: a study of 92,881 patients. Anesthesiology 2007; 106:226.
  18. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg 2007; 105:344.
  19. DeFronzo R, Fleming GA, Chen K, Bicsak TA. Metformin-associated lactic acidosis: Current perspectives on causes and risk. Metabolism 2016; 65:20.
  20. Kain ZN, Wang SM, Mayes LC, et al. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg 1999; 88:1042.
  21. Kain ZN, Mayes LC, Wang SM, Hofstadter MB. Postoperative behavioral outcomes in children: effects of sedative premedication. Anesthesiology 1999; 90:758.
  22. Kain ZN, Mayes LC, Wang SM, et al. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology 1998; 89:1147.
  23. Coté CJ, Cohen IT, Suresh S, et al. A comparison of three doses of a commercially prepared oral midazolam syrup in children. Anesth Analg 2002; 94:37.
  24. Kain ZN, Caldwell-Andrews AA, Krivutza DM, et al. Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow-up national survey. Anesth Analg 2004; 98:1252.
  25. Karl HW, Rosenberger JL, Larach MG, Ruffle JM. Transmucosal administration of midazolam for premedication of pediatric patients. Comparison of the nasal and sublingual routes. Anesthesiology 1993; 78:885.
  26. Chiaretti A, Barone G, Rigante D, et al. Intranasal lidocaine and midazolam for procedural sedation in children. Arch Dis Child 2011; 96:160.
  27. Funk W, Jakob W, Riedl T, Taeger K. Oral preanaesthetic medication for children: double-blind randomized study of a combination of midazolam and ketamine vs midazolam or ketamine alone. Br J Anaesth 2000; 84:335.
  28. Lin Y, Chen Y, Huang J, et al. Efficacy of premedication with intranasal dexmedetomidine on inhalational induction and postoperative emergence agitation in pediatric undergoing cataract surgery with sevoflurane. J Clin Anesth 2016; 33:289.
  29. Peng K, Wu SR, Ji FH, Li J. Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis. Clinics (Sao Paulo) 2014; 69:777.
  30. Jannu V, Mane RS, Dhorigol MG, Sanikop CS. A comparison of oral midazolam and oral dexmedetomidine as premedication in pediatric anesthesia. Saudi J Anaesth 2016; 10:390.
  31. Kain ZN, Caldwell-Andrews AA, Maranets I, et al. Predicting which child-parent pair will benefit from parental presence during induction of anesthesia: a decision-making approach. Anesth Analg 2006; 102:81.
  32. Kain ZN, Maclaren J, Weinberg M, et al. How many parents should we let into the operating room? Paediatr Anaesth 2009; 19:244.
  33. Miller KA, Balakrishnan G, Eichbauer G, Betley K. 1% lidocaine injection, EMLA cream, or "numby stuff" for topical analgesia associated with peripheral intravenous cannulation. AANA J 2001; 69:185.
  34. Nafiu OO, Prasad Y, Chimbira WT. Association of childhood high body mass index and sleep disordered breathing with perioperative laryngospasm. Int J Pediatr Otorhinolaryngol 2013; 77:2044.
  35. Nafiu OO, Burke CC, Gupta R, et al. Association of neck circumference with perioperative adverse respiratory events in children. Pediatrics 2011; 127:e1198.
  36. Bricker SR, McLuckie A, Nightingale DA. Gastric aspirates after trauma in children. Anaesthesia 1989; 44:721.
  37. Olsson GL, Hallen B. Laryngospasm during anaesthesia. A computer-aided incidence study in 136,929 patients. Acta Anaesthesiol Scand 1984; 28:567.
  38. Smiley RM. An overview of induction and emergence characteristics of desflurane in pediatric, adult, and geriatric patients. Anesth Analg 1992; 75:S38.
  39. Lerman J, Houle TT, Matthews BT, et al. Propofol for tracheal intubation in children anesthetized with sevoflurane: a dose-response study. Paediatr Anaesth 2009; 19:218.
  40. Kim SH, Hong JY, Suk EH, et al. Optimum bolus dose of propofol for tracheal intubation during sevoflurane induction without neuromuscular blockade in children. Anaesth Intensive Care 2011; 39:899.
  41. Politis GD, Stemland CJ, Balireddy RK, et al. Propofol for pediatric tracheal intubation with deep anesthesia during sevoflurane induction: dosing according to elapsed time for two age groups. J Clin Anesth 2014; 26:25.
  42. Jones RD, Chan K, Andrew LJ. Pharmacokinetics of propofol in children. Br J Anaesth 1990; 65:661.
  43. Bartkowska-Śniatkowska A, Bienert A, Wiczling P, et al. Pharmacokinetics and pharmacodynamics of propofol in children undergoing different types of surgeries. Pharmacol Rep 2014; 66:821.
  44. Westrin P. The induction dose of propofol in infants 1-6 months of age and in children 10-16 years of age. Anesthesiology 1991; 74:455.
  45. Manschot HJ, Meursing AE, Axt P, et al. Propofol requirements for induction of anesthesia in children of different age groups. Anesth Analg 1992; 75:876.
  46. Short SM, Aun CS. Haemodynamic effects of propofol in children. Anaesthesia 1991; 46:783.
  47. Shah PS, Shah VS. Propofol for procedural sedation/anaesthesia in neonates. Cochrane Database Syst Rev 2011; :CD007248.
  48. https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019627s046lbl.pdf.
  49. Fahnenstich H, Steffan J, Kau N, Bartmann P. Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants. Crit Care Med 2000; 28:836.
  50. Segura LG, Lorenz JD, Weingarten TN, et al. Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures. Paediatr Anaesth 2013; 23:855.
  51. www.accessdata.fda.gov/drugsatfda_docs/label/2010/008845s065lbl.pdf.
  52. Drake-Brockman TF, Ramgolam A, Zhang G, et al. The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial. Lancet 2017; 389:701.
  53. Tait AR, Pandit UA, Voepel-Lewis T, et al. Use of the laryngeal mask airway in children with upper respiratory tract infections: a comparison with endotracheal intubation. Anesth Analg 1998; 86:706.
  54. Parnis SJ, Barker DS, Van Der Walt JH. Clinical predictors of anaesthetic complications in children with respiratory tract infections. Paediatr Anaesth 2001; 11:29.
  55. Sinha A, Sharma B, Sood J. ProSeal as an alternative to endotracheal intubation in pediatric laparoscopy. Paediatr Anaesth 2007; 17:327.
  56. Weiss M, Dullenkopf A, Fischer JE, et al. Prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in small children. Br J Anaesth 2009; 103:867.
  57. Burgoyne LL, Anghelescu DL. Intervention steps for treating laryngospasm in pediatric patients. Paediatr Anaesth 2008; 18:297.
  58. Cravero JP, Beach ML, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108:795.
  59. Flick RP, Wilder RT, Pieper SF, et al. Risk factors for laryngospasm in children during general anesthesia. Paediatr Anaesth 2008; 18:289.
  60. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet 2010; 376:773.
  61. Lakshmipathy N, Bokesch PM, Cowen DE, et al. Environmental tobacco smoke: a risk factor for pediatric laryngospasm. Anesth Analg 1996; 82:724.
  62. Mamie C, Habre W, Delhumeau C, et al. Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth 2004; 14:218.
  63. Orliaguet GA, Gall O, Savoldelli GL, Couloigner V. Case scenario: perianesthetic management of laryngospasm in children. Anesthesiology 2012; 116:458.
  64. Gregory GA, Eger EI 2nd, Munson ES. The relationship between age and halothane requirement in man. Anesthesiology 1969; 30:488.
  65. Cameron CB, Robinson S, Gregory GA. The minimum anesthetic concentration of isoflurane in children. Anesth Analg 1984; 63:418.
  66. Taylor RH, Lerman J. Minimum alveolar concentration of desflurane and hemodynamic responses in neonates, infants, and children. Anesthesiology 1991; 75:975.
  67. Lerman J, Sikich N, Kleinman S, Yentis S. The pharmacology of sevoflurane in infants and children. Anesthesiology 1994; 80:814.
  68. McFarlan CS, Anderson BJ, Short TG. The use of propofol infusions in paediatric anaesthesia: a practical guide. Paediatr Anaesth 1999; 9:209.
  69. Mani V, Morton NS. Overview of total intravenous anesthesia in children. Paediatr Anaesth 2010; 20:211.
  70. Browne BL, Prys-Roberts C, Wolf AR. Propofol and alfentanil in children: infusion technique and dose requirement for total i.v. anaesthesia. Br J Anaesth 1992; 69:570.
  71. Auten RL, Davis JM. Oxygen toxicity and reactive oxygen species: the devil is in the details. Pediatr Res 2009; 66:121.
  72. Shah RD, Suresh S. Applications of regional anaesthesia in paediatrics. Br J Anaesth 2013; 111 Suppl 1:i114.
  73. Polaner DM, Taenzer AH, Walker BJ, et al. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesth Analg 2012; 115:1353.
  74. Patel RI, Hannallah RS, Norden J, et al. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients. Anesth Analg 1991; 73:266.
  75. Mathew PJ, Mathew JL. Early versus late removal of the laryngeal mask airway (LMA) for general anaesthesia. Cochrane Database Syst Rev 2015; :CD007082.
  76. Sanikop C, Bhat S. Efficacy of intravenous lidocaine in prevention of post extubation laryngospasm in children undergoing cleft palate surgeries. Indian J Anaesth 2010; 54:132.
  77. Mihara T, Uchimoto K, Morita S, Goto T. The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis. Anaesthesia 2014; 69:1388.
  78. Qi X, Lai Z, Li S, et al. The Efficacy of Lidocaine in Laryngospasm Prevention in Pediatric Surgery: a Network Meta-analysis. Sci Rep 2016; 6:32308.
  79. Nawfal M, Baraka A. Propofol for relief of extubation laryngospasm. Anaesthesia 2002; 57:1036.
  80. Afshan G, Chohan U, Qamar-Ul-Hoda M, Kamal RS. Is there a role of a small dose of propofol in the treatment of laryngeal spasm? Paediatr Anaesth 2002; 12:625.
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