Guidelines for safe paediatric anaesthesia

of the Committee on Quality and Safety

in Anaesthesia, Polish Society of
Anaesthesiology and Intensive Therapy
*Andrzej Piotrowski

Fig. 1. Algorithm of anaesthesia maintenance with sevoflurane after volatile or

intravenous induction in children

Table 1. Assessment of post-anaesthesia recovery according to Steward

classification

The safety of procedures has always been a priority in anaesthesiology.

Relevance of this issue is emphasized in the document announced recently during the
latest congress of the European Society of Anaesthesiology called Helsinki Declaration
on Patient Safety in Anaesthesiology [1]. For paediatric anaesthesia the fundamental
question is whether it can be safely performed in general hospitals or rather in specialist
paediatric hospitals. The answer is simple – each anaesthesia and surgery in a child
under 16 years of age should be administered in paediatric centres, with recovery and
postoperative surveillance rooms, optimally with ITUs. Unfortunately, such
requirements are not feasible to be met and many children >10 years of age, even >6
years are anaesthetized in general hospitals. The Act issued by the Minister of Health on
November 10, 2006 (law gazette no 06.213.1568, later changed into 08.30.187), states
that children should always stay in separate wards (those <3 years separated from older
children) and in rooms with suitable equipment. In many cases, these are small wards of
multi-profile hospitals; therefore, it is essential that all anaesthesiologists have
appropriate trainings in anaesthesia for developmental age patients. According to the
Federation of European Societies of Paediatric Anaesthesia (FEAPA), currently the
European Society for Paediatric Anaesthesia (ESPA), such trainings, lasting about 3
months, should be carried out in a multi-profile paediatric hospital [2]. During the
trainings, anaesthesiologists should anaesthetize unaided at least 10 infants <1 year, 20
aged 1-3 years and 60 aged 3-10 years. Poland still lacks such requirements although
the training in paediatric anaesthesia, compulsory to specialize, is to be lengthened.
Moreover, supplementary trainings in paediatric anaesthesia, every several years
(preferably every 5 years) are considered.

In the majority of cases, surgical procedures in children are performed under general
anaesthesia. The preparation for anaesthesia and surgery includes first contacts of a
child and parents with an anaesthesiologist, whose role at this stage is extremely
important and goes well beyond assessing the physical status, checking test results or
prescribing premedication.

PREPARATIONS FOR ANAESTHESIA

Hospital stay is associated with great stress and can adversely affect the development of
a child regressing it even by several “steps”. The essential factors reducing this stress
include shortening the stay to a minimum, parental presence, mental and
pharmacological preparation before anaesthesia as well as postoperative pain
management. Furthermore, to humanize the hospital stay, the plans regarding the child
should not be concealed from him/her, and anaesthesia induced in the presence of
parents [3], who should also be present as soon as possible after surgery; additionally,
toys ought to be available. The advances in this field are associated with the
introduction of “one-day surgery” (80% of procedures in children in the United States),
the EMLA cream before catheterization of vessels, a limited number of laboratory tests,
and exclusively oral premedication. In children in good general status aged >6 months,
with negative medical history, laboratory tests can be completely abandoned [4].

The current indications for preoperative haemoglobin determinations are as follows:

 surgery with anticipated high or medium blood loss,

 history of blood neoplasm, chemotherapy or radiation therapy,

 symptoms suggestive of anaemia (dyspnoea, easy fatigue, tachycardia),

 history of anaemia or polycytheamia,

 kidney diseases, hypertension, liver failure, malnutrition.

If haemoglobin or haemotocrit was determined within the last 3 months and the general
state of a child has not changed, blood re-sampling is not necessary. Moreover,
compared to the recommendations of the late 20th century, lower safe values of
haemoglobin are permissible, i.e. 5.58 mmol L-1, which is related to physiological
anaemia in children and better monitoring during anaesthesia.

The anaesthesia-related risk of death in children was not completely eliminated; its
incidence for scheduled procedures is 1:20 000 – 1:40 000 of anaesthesias [5]. Children
often sustain critical events during relatively simple procedures; such events are usually
associated with insufficient blood saturation resulting from improper lung ventilation.
The anaesthesia risk increases in cases of additional conditions and in emergent
procedures. The degree of risk is mainly assessed according to the ASA classification of
physical status.
In order not to miss any important existing disease or risk, the anaesthetic visit is
necessary before anaesthesia, preferably in the ambulatory setting at the clinic of
anaesthesiology. Its relevant element is the conversation with parents to obtain
information concerning past diseases, procedures or intraoperative deaths in the family
(possible cause –malignant hyperthermia). For this purpose, the “anaesthetic
questionnaire” is useful. During the visit, the child is mainly inspected; the majority of
information can be obtained without palpation. The basic activities include getting to
know the body structure, state of nutrition, behaviour and physical efficiency, searching
for symptoms such as fatigue, cough, cyanosis, dyspnoea, etc. Additional data are
provided by the inspection of the throat, auscultation of the heart and lungs. The
information gathered and knowledge about the type of surgery justify ordering
additional tests, if necessary. Parents, once informed about the type of anaesthesia and
its typical course, have the chance to ask questions and then are obliged to sign their
written consent for anaesthesia. Patients above 16 years of age additionally sign such
consents.

FASTING TIME

An important element of safe anaesthesia is the appropriately long fasting period.

Before anaesthesia, the volume of gastric fluid should not exceed 0.4 mL kg-1;
according to more recent studies, 0.8 mL kg-1 [6].

The time from the latest meal should correspond to the time of gastric emptying. For
solid foods, this time is 6-8 h, for liquids (including milk) – 6 h (4 h for breast milk).
For clear liquids, such as glucose or tea, the interval from drinking (50 mL) to the
procedure should be 2 h. The regularity of feeding is also considered – e.g. if an infant
receives natural food regularly, every 3 h, the interval from the latest feeding to the
procedure can be that long [6]. On the other hand, anxiety, pain or severe general state
of a child can markedly and unpredictably delay gastric emptying. Chewing gum and its
effects on gastric emptying have not been fully elucidated yet it is generally known that
this habit can increase the volume of residual gastric fluid and increase pH [7].

PREMEDICATION

Some children seem to be brave during the preoperative visit yet are extremely anxious
on the day of surgery. This anxiety should be prevented by administering drugs, which
also decreases the requirements for anaesthetics [8, 9] and incidence of complications
after anaesthesia [10]. Premedication is administered orally and includes mainly
benzodiazepines – midazolam 0.5 mg kg-1 used 30 min before wheeling to the
operating room. Diazepam, characterized by longer action, can also be used 0.25-0.4 mg
kg-1 (which is not beneficial in cases of early discharge). Diazepam is available in
tablets and as a suspension; midazolam is administered in tablets or as a liquid directly
from an ampoule or mixed with juice or syrup. Extremely anxious and uncooperative
children may receive midazolam sublingually 0.2-0.4 mg kg-1 [11]. Nasal supply is also
possible although less pleasant [9]. This route can also be used for ketamine.
Additionally, in premedication for children <1 year, oral atropine is needed 0.02-0.05
mg kg-1. This drug should also be used in children <4 years of age undergoing volatile
induction of anaesthesia and when muscle relaxation is provided with suxamethonium.
Midazolam or diazepam can be supplemented with oral morphine 0.3 mg kg-1 or
ketamine 3 mg kg-1 [12, 13], yet this is associated with higher incidences of dizziness,
nausea and vomiting.

Postoperative vomiting occurs in about 20% of all anaesthetized children. To reduce the
incidence of these unpleasant incidents, antiemetic drugs are recommended in
premedication, e.g. ondansetron, 60 min before surgery [14]. 

SPECIAL SITUATIONS

Children with asthma should receive routine oral and volatile drugs in the morning
before the procedure; in steroid hormone therapy, hydrocortisone 1 mg kg-1 is
administered on induction of anaesthesia and every 6 h until drugs can be taken orally
[15].

Surgeries in diabetic children should be performed first in a series of scheduled

procedures, preferably as “one-day surgeries”, if their extent permits. In such cases, the
morning dose of insulin is omitted and during anaesthesia, neutral fluids, e.g. 0.9%
NaCl, are administered. The blood glucose level ought to be checked. Children
(similarly to adults) react to operative stress with hyperglycaemia. After surgery, a
typical protocol of insulin therapy and oral food supply should be returned to. During
extensive procedures in children with unstable diabetes, the infusion of glucose and
short-acting insulin should be started simultaneously with the induction of anaesthesia
and continued monitoring the level of glucose, acid-base balance and electrolytes in
blood.

In children with upper respiratory tract infections, even up to 4 weeks after the disease,
the incidence of anaesthesia-related complications, such as laryngospasm,
bronchospasm or apnoea with decreased blood saturation, is higher. On the other hand,
children suffering from a common cold without fever >38o C, without auscultatory
changes over the lung fields and in good general state should not be disqualified,
especially when surgery is performed urgently or emergently; it is advised to postpone
scheduled procedures for about 7 days [15].

In the period of 3-7 days after vaccination, anaesthesias and scheduled procedures
should be withheld due to possible post-vaccination reactions.

MONITORING

The basic monitoring includes:

 Pulse oximetry and concentration of oxygen supplied (oximetry),

 ECG and the respiration curve,

 capnometry,

 body temperature,

 non–invasive arterial blood pressure,

  a precordial stethoscope.

Except for capnometry, the remaining elements of monitoring are necessary in the
immediate postoperative period. During total volatile anaesthesia, monitoring can be
limited to ECG and pulse oximetry, if the child’s spontaneous breathing is preserved.
However, determinations of the level of volatile anaesthetics in the inhaled and exhaled
air are strongly recommended.

In paediatric anaesthesia, an efficient pulse oximeter with the plethysmographic curve is

essential. The device provides reliable readings of saturation even in fidgety children.

INDUCTION OF ANAESTHESIA

A. Volatile induction. Such an induction and maintenance of anaesthesia belong to the

oldest anaesthetic methods. For this purpose, semi-closed systems with absorbers and
transparent facial masks are currently used. At body weight <20 kg, the circle breathing
system should be replaced with the paediatric one.

A relevant element of safety of this management is to preserve the child’s spontaneous

breathing during induction without imposing control ventilation. Thanks to that, the risk
of undetected circulatory depression is avoided, depression which is always preceded by
markedly shallow breathing followed by apnoea.

During induction and maintenance of inhalation anaesthesia, various respiratory

disturbances are likely to develop – cough, shallow respiration (decreased tidal volume)
or even apnoea. This last phenomenon is associated not only with depression of the
respiratory centre but also with relaxation of pharyngeal and laryngeal muscles
(obstructive apnoea). Therefore, the child’s breathing should be meticulously observed,
and sounds warning about the development of airway obstruction listened to (snoring,
whizzes). The complications discussed are relatively common in infants. After the loss
of ciliary reflex, airway patency disorders can be easily eliminated by the placement of
the oropharyngeal tube.

Two techniques of volatile induction are used – slowly increasing the concentration of
an anaesthetic – every 2 breaths by 1% or rapid-sequence induction using high
concentrations and only a few breaths (even one). Gradual induction is safer; if possible,
the concentration of sevoflurane should not exceed 6% and it should be administered in
the respiratory gas mixture of the flow: O2 – 2 L min-1 and N2O – 4 L min-1, or O2 – 3
L min-1 and air – 3 L min-1. In younger children the flow of fresh gases ought to be
suitably lower. Inhalation induction cannot be performed with desflurane and isoflurane
due to their irritating smell causing cough and choking.

Inhalation induction, if performed by an experienced anaesthesiologist, is a relatively

simple and convenient method, which may be additionally facilitated by:

 leaving the child dressed (for many small children undressing is extremely
stressful),

 parental presence during induction (holding a child on his/her lap, if patents are
calm),
  using transparent masks, or abandoning their use in favour of free gas flow over
the child’s face or using a hand as a funnel,

 making the mask smelling nice by applying a suitable oil or cooking essence
(e.g. strawberry- or lemon-scented). Inhalation induction of general anaesthesia
may also be carried out before the intravenous access has been prepared.

B. Intravenous induction. Intravenous induction in children is safe and convenient. It

may be additionally facilitated when the EMLA cream is applied 45-60 min before the
procedure over one or two most likely places of intravenous access. Thiopentone is
most useful for such an induction (in the average dose of 5 mg kg-1, in infants – 7 mg
kg-1), in children aged >3 years, propofol is used. Propofol is a short acting anaesthetic
used in the dose of 2.5 – 3.5 mg kg-1, in children below 10 years of age and 1.5 – 2 mg
kg-1 in older children. To relieve the pain during administration, lidocaine should be
added. Propofol-Lipuro, the agent containing medium-chain triglyceryde (MCT) failed
in reducing injection-related pain [16]. Propofol, like thiopentone, reduces the blood
pressure and slows down the heart rate. Unlike barbiturates, however, it prevents sudden
pressure increases during intubation and enables smooth placement of the laryngeal
mask. Moreover, it has some antiemetic properties. Since the solution does not contain
the bacteriostatic agent and microorganisms are likely to develop in the lipid
environment, maximum sterility has to be provided and the open ampoule should be
used within the period <6 h.

In paediatric anaesthesia, ketamine is also extremely useful, not only due to its lack of
depressive circulatory effects but also possible intramuscular, oral or rectal
administration, and obviously because of minimal depression of breathing (unless
administered too quickly). The routine intravenous dose is 2 mg kg-1; due to increased
saliva secretion, it is recommended to precede it with atropine. Ketamine is particularly
useful in children in severe conditions (shock, respiratory failure) and for short
procedures, e.g. changes of dressings in patients with burns, bone marrow biopsy or
abscess incision. Moreover, it is an excellent agent preparing for regional anaesthesia,
for postoperative pain management, also in infusions [17]. Ketamine acts about 15-30
min, yet its action can be substantially prolonged by administering opioids or
barbiturates. However, overlapping of action of several agents in the immediate
postoperative period may be dangerous. Thus, the use of this anaesthetic does not
ensure 100% safety!

The combination of ketamine and propofol (0.5-1 mg kg-1 and 1-2 mg kg-1,
respectively) seems beneficial, e.g. for short intravenous anaesthesias in otolaryngology,
cardiology and paediatric orthopaedic surgery.

ENDOTRACHEAL INTUBATION

Endotracheal intubation is particularly recommended in children <1 year of age due to

higher risks of upper airway obstruction. It is also beneficial in procedures lasting >1 h,
those in lateral recumbent and prone positions as well as in neck and nasopharyngeal
procedures, oeosophagoscopy or gastroscopy. In other cases, the laryngeal mask may be
sufficient (lower risk of laryngeal oedema and stridor). Compared to the intubation tube,
the laryngeal mask may also be placed at light anaesthesia.
Volatile agents alone – mainly sevoflurane at the concentration of at least 2.7%, may be
used for endotracheal intubation [18]. In general, the procedure is performed after the
administration of a muscle relaxant. For short procedures, mivacurium is most useful,
0.25 mg kg-1 (its action starts after 90 sec.), the relaxing effect maintains for 10-14 min.
This agent is broken down by plasma cholinesterase; in patients with normal function of
this enzyme, neostigmine to reverse the block is not required. Mivacurium releases
histamine similarly to atracurium, which is likely to manifest as skin redness and
reduced arterial pressure.

For longer procedures (30-60 min), vecuronium, atracurium, cis-atracurium or

rocuronium are more useful for muscle relaxation. Rocuronium administered in the dose
of 0.6 mg kg-1 produces neuromuscular blockage for about 40 min, providing good
conditions for intubation already after 50 sec in infants and 60 sec in children. The dose
of 1.2 mg kg-1 enables intubation within 40 sec since the injection of the agent [19].
The block induced with rocuronium or vecuronium may be reversed using sugammadex
4 – 16 mg kg-1  depending on the interval from the administration of a relaxant.

In neonates, when difficult intubation is anticipated, and in those with full stomach,
suxamethonium is successfully used – 2 mg kg-1 for children <2 years and 1-1.5 mg kg-
1 for older children. Complete muscle relaxation is achieved most quickly – already
after 40 sec; moreover, spontaneous breathing returns quickly – after 4 min. Due to the
risk of bradycardia, atropine premedication is important. The use of suxamethonium is
associated with the risk of cluster seizures with subsequent muscle pains (not occurring
in children <6 years of age), malignant hyperthermia and hyperkalemia.
Suxamethonium should not be administered to patients with neuromuscular diseases
(dystrophies), those bedridden for a long time, after burns, and with crushing
syndromes.

Endotracheal intubation in children can also be performed with propofol 3-4 mg kg-1 in
combination with remifentanil 3 µg kg-1 [20, 21]. Remifentanil in children is safe if
administered in infusions (e.g. 0.2 µg kg-1 min-1) and not in a single dose, which may
induce bradycardia and thoracic rigidity [20]. The supply of opioids before intubation
should be generally limited due to frequent difficulties in artificial lung ventilation
caused by the thoracic rigidity mentioned.

Prior to endotracheal intubation, the patient should be suitably oxygenated to reach the
blood saturation of at least 96-98%. In children, decreased saturation develops much
quickly than in adults.

For children >6 years of age or younger and for oropharyngeal procedures, intubation
tubes with sealing cuffs should be used. The intubation tube diameter is tailored
according to the formula: (mm) = (age in years/4) + 4 mm. The depth of intubation
through the mouth is usually: (cm) = tube diameter (mm) x 3.

LARYNGEAL MASKS

In children with ASA I and II physical status, laryngeal masks are safe and easy to
apply devices securing patent airways during some surgeries and diagnostic procedures,
except for those within the thorax, abdomen, cranial or oral cavity. They are particularly
recommended for procedures <1 h. However, they do not fully protect against aspiration
of gastric contents to the lungs. Muscle relaxants are not required; their placement is
possible under light (compared to intubation) anaesthesia. The ProSeal mask provides
better tightness of airways compared to classical masks. Furthermore, laryngeal masks
are the basic devices during unanticipated difficult intubation and can be used for
cardio-pulmonary resuscitation, especially by physicians with short-term experience in
intubation. After the mask placement, it is recommended to provide control/assist
ventilation of the lungs and to avoid leaving the spontaneously breathing patients.

MAINTENANCE OF ANAESTHESIA

General anaesthesia can be successfully maintained with halogenated volatile agents:

isoflurane (1-2%), sevoflurane (2-3%) or desflurane (5-9%). They offer good control of
anaesthesia as their brain concentration can be quickly increased or decreased, which is
associated with low values of blood-gas solubility coefficients. This is particularly
relevant when the procedure duration is difficult to anticipate. The use of volatile
anaesthetics is also connected with lower risk of postoperative respiratory depression
compared to opioids, at the expense of analgesic effects. Good local analgesia should be
provided or early, optimally pre-emptive one. The addition of N2O in the concentration
of 50-70% facilitates anaesthesia and ensures smoother recovery.

During the procedure, control mode of ventilation is carried out with the frequency
according to the child’s age and tidal volume of about 6 mL kg-1 (or higher; due to
compliance of the respiratory system and dead space, capnographic monitoring is
necessary).

The use of desflurane, isoflurane and sevoflurane is associated with higher incidences of
agitation in the postoperative period compared to already historic halothane. Agitation
may be partially prevented by providing effective analgesia by the end of the procedure
and in the postoperative period (e.g. block analgesia or supply of opioids) and by
avoiding the sevoflurane concentrations >6 %. The symptoms of agitation can be treated
with iv midazolam or ketamine [22, 23].

Opioids are indispensible elements of anaesthesia for painful procedures. In most cases,
fentanyl 1-5 µg kg-1 or sufentanil 1 µg kg-1 is used. For shorter procedures, alfentanil
in the initial dose of 7-20 µg kg-1 or remifentanil in infusion 0.03-0.5 µg kg-1 min-1
should be applied. Generally, the supply of opioids does not exclude the use of a
volatile agent, rather permits to limit its concentration.

After the completion of procedure, the commonly met problem is the return of efficient
breathing of the patient. To avoid such a situation, volatile agents should be early
withdrawn, fentanyl should not be administered within the final 30 min of anaesthesia
and aminophylline or theophylline (5 mg kg-1) ought to be used to stimulate the
respiratory centre [24]. Naloxone should be given to children whose breathing does not
return, despite the mentioned activities and subsidence of relaxant effects.

In the majority of cases, neuromuscular blockage subsides spontaneously by the end of

anaesthesia; if not, neostigmine is routine management. The block should be reversed
using atropine 0.015 mg kg-1 and neostigmine 0.06 mg kg-1.

BLOCK ANAESTHESIA
This kind of analgesia is increasingly common in children, also under ambulatory
conditions.

The most widely used blocks include:

 block of the ilioinguinal and iliohypogastric nerve using 0.5% bupivacaine 2 mg

kg-1, administered medially from the anterior superior iliac spine – particularly
useful for inguinal hernia repairs or retained testis procedures;

 block of the dorsal nerve of the penis – e.g. by circular injections of the penis
base (circular block) using 0.25% bupivacaine, especially recommended for
phimosis procedures (adrenaline should be avoided due to the risk of ischaemia
and necrosis);

 subarachnoid block, especially that reduced arterial pressure and headaches are
less common in children than in adults. This method is recommended in infants
with bronchopulmonary dysplasia to avoid intubation. The typical dose of 0.5%
bupivacaine for urological procedures is 0.4-0.5 mg kg-1. Another dosage
formula is 0.1 mL kg-1 + 0.1 mL (dead space of the needle);

 epidural block from the sacral access using 0.25% bupivacaine 1 mL kg-1, ideal
for anaesthesia for all procedures performed in the region innervated by the
branches originating from Th10 – S5.

Ilioinguinal and iliohypogastric blocks can be performed by the surgeon before wound
suturing during hernia repairs and retained testis surgeries. Injections of the wound with
0.25% bupivacaine in the dose ≤0.5 – 1 mg kg-1 by the end of the procedure is also an
effective way to provide postoperative analgesia. 

FLUID SUPPLY

In procedures lasting >30 min and those in children at risk of high blood loss or
postoperative vomiting (retained testis surgery, strabotomy, tonsillectomy), fluids must
be transfused. Fluids should not contain glucose to avoid the risk of hyperglycaemia,
which is likely to cause higher number of intra- and postoperative complications. The
optimal fluid is the preparation containing sodium ions in the concentration of at least
130 mmol L-1, e.g. 0.9% NaCl solution, Ringer’s solution or Ringer’s lactate.

Fluids should be transfused according to the following principle:

 during the first hour of procedure – supplementation of fluids in the amount of

25 mL kg-1 in children ≤3 years and 15 mL kg-1 in children >4 years;

 during next hours – 6 mL kg-1 h-1 for minor, 8 mL kg-1 h-1  for moderate and
10 mL kg-1 h-1  for major surgical trauma.

POSTOPERATIVE CARE

In the postoperative period, the range of monitoring of vital functions must be the same
as during anaesthesia. The child should be continuously observed, heart rate, respiration
and saturation monitored. Vital parameters should be recorded every 15 min. During
this period, apnoea, vomiting, bleeding from the wound and pain are likely to develop.
The anaesthesiologist should be within reach (the recovery room must be adjacent to the
operative theatre or ITU). 

Pain after less extensive procedures is usually managed with paracetamol 20 mg kg-1,
tramadol 2 mg kg-1 (beware of vomiting !), and in children >3 years of age – metamizol
4 mg kg-1. Morphine 0.1-0.2 mg kg-1 at 2-4 h intervals is recommended for surgeries
that are more painful.

DISCHARGE FROM A RECOVERY ROOM

The relevant factors, which should be considered while taking the decision about
discharge to the setting where monitoring is not accessible include:

 return of consciousness and stabilization of basic vital functions;

 efficient breathing of the frequency typical of a given age, SpO2 >95% without
oxygen therapy.

The physician should decide about discharge personally after inspecting the patient.

After ambulatory procedures, the child may be discharged once the following is
fulfilled:

 stability and full normalization of basic vital parameters;

 consciousness and contact in the range similar to that before anaesthesia;

 ability to move suitably to the age;

 no nausea and vomiting.

The general status of the patient after anaesthesia is assessed according to the Steward
classification; children scored 6 are candidates for hospital discharge.

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