Principles of Pediatric Anesthesia
Angela Mordecai and Bailey Freeman, DNP, CRNA
Quick Facts
- Children are not small adults – Anatomical and physiological differences require specialized anesthetic care.
- Airway considerations – Pediatric airways are smaller, more anterior, and feature a proportionally larger tongue, increasing the risk of obstruction.
- Higher metabolic rate – Increased oxygen consumption and alveolar ventilation accelerate anesthetic uptake and emergence.
- Cardiovascular differences – Neonates and infants have a fixed stroke volume; cardiac output is primarily heart rate dependent.
- Thermoregulation – Infants are prone to hypothermia due to an increased surface area-to-body mass ratio and immature temperature regulation.
- Drug metabolism – Immature liver and renal function in neonates affect anesthetic drug metabolism and clearance.
Procedure
Indications
- Elective and emergency surgical procedures
- Diagnostic imaging requiring stillness (e.g., MRI, CT)
- Painful procedures (e.g., lumbar puncture, bone marrow aspiration)
- Sedation for non-invasive procedures in uncooperative children
Contraindications and Precautions
- Upper respiratory tract infection – Increases the risk of perioperative respiratory complications.
- Recent immunization (live vaccines) – May necessitate a delay in elective anesthesia due to immune interactions.
- Congenital anomalies – May complicate airway management, drug clearance, or physiological response to anesthesia.
- History of prematurity – Associated with increased sensitivity to anesthetics and risk of postoperative apnea.
Equipment and Preparation
- Age-appropriate masks, airways, laryngoscope blades, and endotracheal tubes
- ASA-standard monitors (ECG, SpO₂, NIBP, ETCO₂, temperature)
- Precordial stethoscope for infants
- Warming devices to prevent hypothermia
- Weight-based emergency medications and resuscitation equipment
Pharmacologic Considerations
- MAC: Age-dependent; infants may require higher values
- IV agents: Weight-based dosing with careful titration
- Muscle relaxants: Variable sensitivity—use neuromuscular monitoring if indicated
Confirmation Steps
- Verify fasting status and airway assessment
- Confirm appropriate equipment sizing
- Ensure warming methods are in place and functioning
- Check IV access, monitoring, and suction setup before induction
Documentation Requirements
- Preoperative assessment including fasting status and airway evaluation
- Guardian-informed consent
- Anesthetic plan and specific agents administered
- Intraoperative events and interventions
- Postoperative status and recovery progress
Scope Guide
Clinical Strategies
- Tailor care based on age-related physiological differences
- Maintain normothermia with proactive warming measures
- Communicate effectively with surgical team and caregivers
Troubleshooting
- Inadequate ventilation: Reassess positioning, use airway adjuncts
- Unexpected movement: Re-evaluate anesthetic depth and equipment
- Difficult IV access: Use distraction, topical anesthetics, or delay until after induction
Teaching Pearls
- Use developmentally appropriate communication with the child
- Monitor preterm infants for postoperative apnea
- Always double-check pediatric drug dosing calculations
Safety Priorities
- Confirm NPO status and airway risk
- Label all syringes clearly
- Keep emergency medications pre-calculated and drawn up
