Paediatric considerations

Why children are different (core concepts)

• Children are not “small adults”: physiology, anatomy, drug handling, and communication all differ.
• Smaller oxygen reserve + higher oxygen use means desaturation can happen quickly, especially in infants.
• Airway is smaller and more easily obstructed, small changes in swelling/secretions can significantly increase resistance.
• Temperature drops quickly (large surface area to weight ratio) → active warming is important from the start.
• Drug dosing is usually weight-based, always confirm weight and units (kg).
• Anxiety and separation distress are common, calm, structured communication reduces agitation and improves cooperation.

Pre-op essentials (new-starter checklist)

• Confirm: age, weight (kg), allergies, comorbidities, previous anaesthetics, recent infections, and current medications.
• Fasting: check local policy, ensure clear fluids allowed up to the appropriate time and avoid unnecessary prolonged fasting.
• Recent URTI (cough/coryza/fever/wheeze): assess severity and timing, discuss with senior early if symptomatic.
• Asthma/wheeze: check baseline control, recent bronchodilator use, and any hospital admissions, ensure inhalers available.
• Screen for obstructive sleep apnoea (OSA): snoring, witnessed apnoeas, daytime sleepiness, tonsillar hypertrophy, higher opioid sensitivity.
• Identify higher-risk groups: ex-premature infants, neonates, congenital heart disease, neuromuscular disease, difficult airway history.
• Plan analgesia and antiemetics early, consider multimodal approach and regional techniques with supervision.
• Consent: ensure parent/guardian consent, involve the child in an age-appropriate way (assent).

Airway and breathing (practical points)

• Pre-oxygenate as well as the child will tolerate, use distraction and a well-fitting mask.
• Expect rapid desaturation in infants/young children, have suction ready and be prepared to reposition quickly.
• Mask ventilation: use gentle pressures, consider an oral airway early if obstruction.
• Laryngospasm risk is higher (especially with URTI, secretions, airway surgery), aim for a smooth induction and emergence.
• Choose airway device with senior guidance: facemask, supraglottic airway (SGA), or tracheal tube depending on surgery and aspiration risk.
• Cuffed tubes are commonly used, ensure correct size and check leak/pressure as per local practice.
• Always have a clear backup plan (e.g., call for help early, SGA rescue, difficult airway equipment available).

Circulation and fluids

• IV access can be challenging, plan ahead (topical local anaesthetic cream, distraction, experienced help).
• If no IV initially, inhalational induction may be used, secure IV once asleep if appropriate.
• Fluid prescribing: use local paediatric guidance, avoid hypotonic maintenance fluids unless specifically indicated.
• Assess hydration and blood loss carefully, small absolute losses can be significant in small children.
• Use weight-based calculations for blood volume and allowable blood loss, ask a senior if unsure.
• Be cautious with vasodilation and bradycardia during induction, especially in infants, treat promptly and escalate early.

Drug dosing and prescribing safety

• Always dose in mg/kg (or micrograms/kg) and write the child’s weight clearly on the anaesthetic chart.
• Double-check concentration and volume drawn up, paediatric dosing errors are common and potentially serious.
• Use a paediatric drug calculator or local app, avoid mental arithmetic under pressure.
• Label syringes clearly, keep high-risk drugs separate and minimise distractions during preparation.
• Opioids: children with OSA or very young infants can be more sensitive—use the lowest effective dose and monitor closely.
• Local anaesthetic: calculate maximum safe dose (mg/kg) before injecting, consider total dose from all sources.

Temperature, glucose, and monitoring

• Prevent hypothermia: warm theatre, forced-air warming, warmed fluids, cover exposed areas, minimise wet prep time.
• Standard monitoring as per AAGBI/ASA: ECG, NIBP, SpO2, capnography, agent monitoring, consider temperature monitoring early.
• Neonates/infants are at higher risk of hypoglycaemia, follow local policy for glucose monitoring in at-risk children.
• Use appropriately sized cuffs, masks, airway devices, and probes to avoid inaccurate readings or injury.

Analgesia and PONV (common first-time scenarios)

• Use multimodal analgesia: paracetamol + NSAID (if not contraindicated) + local/regional techniques + small opioid doses if needed.
• Regional blocks can be very effective, perform only with appropriate training/supervision and full monitoring.
• PONV is common: consider prophylaxis (e.g., ondansetron +/- dexamethasone) based on local guidance and risk factors.
• Avoid over-sedation in recovery, ensure pain is treated but maintain airway safety and adequate ventilation.

Emergence and recovery

• Plan extubation strategy early (deep vs awake) with senior input, ensure suction and airway adjuncts ready.
• Laryngospasm/airway obstruction are common at emergence, treat early with jaw thrust, CPAP, and escalation if needed.
• Post-op monitoring: ensure appropriate observation for age, comorbidities (especially OSA), and opioid use.
• Discharge criteria: stable vitals, pain/nausea controlled, airway safe, hydration plan, and clear parent instructions.

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