Pediatrics — the quick physiologic reset

Top concerns

1. 1.Desaturation is fast: O₂ consumption 6–8 mL/kg/min (≈2× adult) with a small FRC
2. 2.Bradycardia in a child is hypoxia until proven otherwise — oxygenate first, then atropine/epi per algorithm
3. 3.Laryngospasm risk, especially with recent URI, secretions, light planes at extubation
4. 4.Airway anatomy: prominent occiput, relatively large tongue, cephalad larynx — shoulder roll beats head lift in infants
5. 5.Temperature lability — warm room, warm fluids, cover the head
6. 6.Fluids by 4-2-1; dextrose-containing maintenance only when indicated (neonates, prolonged fasting)

Drug do's and don'ts

• PREFERCuffed ETTs (modern low-pressure)— Contemporary practice accepts cuffed tubes in infants/children; monitor cuff pressure.
• AVOIDSuccinylcholine (routine elective use)— FDA boxed warning — risk of hyperkalemic arrest with undiagnosed myopathy; reserve for emergency airway/laryngospasm.
• PREFERAtropine drawn up / immediately available— Vagal-predominant physiology; pre-induction availability is the norm.

Airway & positioning

• Infants: neutral position or shoulder roll; avoid overextension (obstructs)
• ETT size (cuffed) ≈ age/4 + 3.5; depth ≈ 3× tube size — confirm clinically
• Uncuffed leak check historically 20–25 cmH₂O when uncuffed tubes are used

Pearls

• Fix hypoxia before treating the bradycardia it caused.
• A crying child pre-induction beats an obstructed one post-premedication — titrate premeds to the child, not the schedule.

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.