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Preparation for induction of anesthesia includes:

- warming the OR
- ensure warming devices work
-preinduction checklist (variety of sizes of masks, airways, blades, etc
-anesthesia machine and monitoring equipment are prepared
-precordial stethoscope
-ensure a quite and calm OR environment


inhalation induction in children

-what is the optimal induction sequence in toddlers?
what are some ways to do this?

-avoid making them feel vulnerable
-have them pick out a lip balm flavor for their mask
-allow them to sit in the lap of a parent
-distract them by having them "blow up the balloon"


what should be at hand to help position and hold the child when needed.



do we let children bring their favorite toy or security blanket into the OR



how do we distract older children

allow them play electronic handheld games or to watch a movie on a portable electronic device


how is the tradition mask induction of anesthesia accomplished

nitrous oxide to 02 - 2:1


offering children the choice of a scented mask

bubble gum or strawberry flavor, applied to the inside of the face mask may disguise the odor of the plastic.

let them play with the mask ahead of time.


what can be seen with induction

Sevoflurane is then introduced and can be rapidly increased to 8% in a single stepwise increase, without significant bradycardia or hypotension in otherwise healthy children.


.The reason for maintaining delivery of a high concentration of sevoflurane is to minimize the risk of

awareness during the early period of the induction sequence.


IV induction is usually reserved for who?
What should the child be doing prior to iv induction?

reserved for : older kids, those who request it, those with a previously established IV , potential CV instability, and those who need RSI

ideally, child should be breathing 100% O2 before induction


iv induction dose of Thiopental



iv induction dose of Methohexital

1-2.5 mg/kg


iv induction dose of propofol

2.5-3.5 mg/kg


iv induction dose of etomidate

0.2-0.3 mg/kg


iv induction dose of ketamine

1-2 mg/kg


airway obstruction during anesthesia or loss of consciousness appears to be most frequently related to loss of muscle tone in the pharyngeal and laryngeal structures rather than

apposition of the tongue to the posterior pharyngeal wall.


the progressive loss of tone with deepening anesthesia results in progressive airway obstruction primarily at the level of the

soft palate and the epiglottis

*in children, the pharyngeal airway space decreases in a dose dependent manner w/ increasing concentrations of both sevo and propofol anesthesia.


extension of the head at the atlantooccipital joint with anterior displacement of the c.spine (sniffing position) improves hypopharngeal airway patency but does not necessarily change

the position of the tongue


compared with chin lift and CPAP, the jaw thrust maneuver is the most effect means to do what?

improve airway patency and ventilation in children undergoing adenotonsillectomy


Laryngospasm is defined as the reflex closure of the

false and true vocal cords


complete laryngospasm is defined as closure of the false vocal cords and apposition of the laryngeal surface of the

epiglottis and interarytenoids

**net effect is complete cessation of air movement and noisy respiration, absence of movement of the reservoir bag, and an absent capnogram.


Review slide 33 - laryngospasm algorithm



IV fluid administration sets should be prepared before

the child arrives in the OR.


Appropriate size bag of LR and equipment for:
- young children
- infants < 1 yr old

young children: 500mL bag of LR with a graduated buretrol is appropriate

infants < 1 yr: 250mL bag with buretrol is preferable

**always use a buretrol


the use of a buretrol and IV fluid bag are intended to limit the risk of

adverse events should the entire bag inadvertently be infused in the child.


Initial blood loss may be replaced with balanced salt solution at a rate of

3mL of solution for every 1mL of blood loss.



For thrid space losses, replacement is based on teh severity of the losses:

minor: 1-2ml/kg
moderate: 2-5 ml/kg
major: 6-10 ml /kg


the smallest IV cannula through which blood can be infused rapidly:

22 g


Fluid management 4-2-1 rule

1st 10kg = 4 ml/kg
2nd 10kg = 2 ml/kg
each kg >20kg = 1 ml/kg

total ml/kg/ HOUR


deficit estimation:

hourly requirement x NPO hours

-give 50% in hour 1
-remainder in hours 2 and 3