Subspecialty

Pediatric Anesthesia

Tiny patients, vast physiology.

Children are not small adults. Pediatric anesthesia requires familiarity with weight-based dosing, age-related airway anatomy (large occiput, anterior larynx, narrowest at cricoid in <8 yo), brisk vagal tone, rapid desaturation, and developmental considerations.

Key concepts

ETT sizing

Cuffed: (age/4) + 3.5. Uncuffed: (age/4) + 4. Depth (cm): age/2 + 12, or 3× ETT size.

Maintenance fluids — 4-2-1 rule

4 mL/kg/h for first 10 kg, 2 mL/kg/h for next 10 kg, 1 mL/kg/h thereafter.

Inhalational induction

Sevoflurane is agent of choice — sweet, fast, hemodynamically stable. Watch for emergence delirium (mitigate with low-dose propofol or fentanyl).

Emergence delirium

Most common in preschoolers post-sevoflurane. Premedicate with midazolam, use IV adjuncts (propofol, fentanyl, dexmedetomidine).

Fasting

ASA: clear liquids 2 h, breast milk 4 h, formula/light meal 6 h, fatty meal 8 h.

Monitoring

Precordial stethoscope
Pulse oximetry
Capnography
Temperature (active warming)

Common drugs

SevofluranePropofolFentanylRocuroniumAcetaminophenDexmedetomidineAtropine 0.02 mg/kg

Clinical pearls

1Pre-treat with atropine before succinylcholine in infants to prevent bradycardia.

2Avoid succinylcholine in undiagnosed myopathies — hyperkalemic cardiac arrest reported.

3Always have a clear weight in kg — most pediatric errors are dosing errors.

References & Further Reading

1
GuidelineOpen source
American Society of Anesthesiologists. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393.
2
Textbook
Gropper MA, Miller RD, Cohen NH, et al., eds. Miller's Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.
3
Textbook
Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC, Ortega R, Sharar SR, Holt NF. Clinical Anesthesia. 8th ed. Philadelphia: Wolters Kluwer; 2017.
4
Textbook
Butterworth JF IV, Mackey DC, Wasnick JD. Morgan & Mikhail's Clinical Anesthesiology. 6th ed. New York: McGraw-Hill; 2018.

Citations are provided to direct further study. Always check the most current edition of guidelines and society recommendations — the information in this chapter is a teaching summary, not primary source material.