Down syndrome (Trisomy 21)

Top concerns

1. 1.Atlantoaxial instability (~15%): avoid forceful neck flexion/extension during laryngoscopy and positioning; ask about neuro symptoms preop
2. 2.Congenital heart disease in ~40–50% (AV septal defects most characteristic) — know the anatomy and repair status before induction
3. 3.Subglottic stenosis is common — expect to downsize the ETT by 0.5–1.0 from age-predicted
4. 4.OSA is near-universal; heightened sensitivity to sedatives and postoperative airway obstruction
5. 5.Bradycardia with sevoflurane induction is well described — have atropine drawn up
6. 6.Hypotonia + large tongue → airway obstruction on induction and in PACU

Drug do's and don'ts

• CAUTIONSevoflurane mask induction— Watch for bradycardia — reported even without hypoxia; treat promptly.
• CAUTIONSedative premedication— OSA + hypotonia amplify obstruction; use reduced doses with monitoring.
• PREFERAnticholinergic (atropine) availability— For vagal-predominant responses; mydriatic sensitivity historically overstated at clinical doses.

Airway & positioning

• Neutral head position; manual in-line-style care with any neck manipulation if instability not excluded
• Smaller ETT than predicted; anticipate easy-to-obstruct mask airway (large tongue, midface hypoplasia)
• Extubate awake with airway adjuncts ready; PACU obstruction is common

Pearls

• The heart, the neck, and the tube size — clear all three before you start.
• A 'routine' URI-season Down syndrome case has stacked risks: reactive airway + subglottic narrowing + OSA.

Suggested reading

• Coté: A Practice of Anesthesia for Infants and Children, 6e
• Miller's Anesthesia, 9e

Educational quick-reference only — defer to clinical judgment, institutional protocols, and the primary texts above.