Induction Techniques in Children

Pediatric Foundations - Tiny Patients, Big Care

• Anatomical & Physiological:
  • Airway: Large tongue, anterior larynx, omega epiglottis, cricoid narrowest. Infants: obligate nose breathers.
  • Respiratory: ↑$VO_2$, ↓$FRC$ → rapid desaturation.
  • Cardio: CO HR-dependent; bradycardia critical.
  • Thermo: ↑$BSA$ → hypothermia risk.
  • Pharm: Immature hepatic/renal function alters drugs.
• Psychological:
  • Separation anxiety (peak 6m-4y).
  • PPCI helpful. Distraction, premedication.
• Fasting (NPO): (📌 2-4-6-8 rule)
  • Clears: 2h
  • Breast milk: 4h
  • Formula/Light meal: 6h
  • Solids: 8h

⭐ Cricoid: narrowest part of airway in children <5 yrs (vs. glottis in adults).

Inhalational Induction - Gas Gurus Galore

• Most common pediatric induction: smooth, non-invasive, well-accepted.
• Key Agents:
  • Sevoflurane: Preferred. Sweet, non-pungent. MAC 2-2.5%. Rapid onset/offset. Minimal airway irritation.
  • Halothane: Historically used. Pleasant odor. MAC 0.75%. Risks: arrhythmias, halothane hepatitis. (Largely replaced)
• Techniques:
  • Standard Mask Induction: Gradual increase in inspired concentration.
  • Single Breath/Priming: Circuit primed with high concentration for rapid uptake.
  • Steal Induction: Agent introduced subtly to a seemingly asleep/distracted child.
• Potential Complications:
  • Airway: Laryngospasm, breath-holding, coughing, secretions.
  • Respiratory: Bronchospasm, desaturation.
  • 📌 Smooth Sevoflurane Soothes Small Sleepers.

⭐ Sevoflurane is associated with a higher incidence of emergence agitation/delirium compared to other volatile agents in children.

Intravenous Induction - Vein Victory Vials

• IV Access: Sites: hand dorsum, foot, antecubital fossa, infant scalp. Use topical anesthetic (e.g., EMLA).
• Key Agents:
  • Propofol: 2.5-3.5 mg/kg. Rapid onset/recovery. Cons: pain (mitigate with lidocaine), hypotension, apnea. ⚠️ PRIS risk (prolonged infusion).
  • Ketamine: 1-2 mg/kg IV. Analgesia, bronchodilation, sympathomimetic. Cons: ↑ secretions (consider antisialagogue), emergence reactions (minimize with benzodiazepines).
  • Thiopentone: 3-5 mg/kg. Ultra-short acting barbiturate. Cons: laryngospasm, bronchospasm, histamine release. ⚠️ Contraindicated: porphyria.
  • Etomidate: 0.2-0.3 mg/kg. Cardiovascular stability. Cons: injection pain, myoclonus, transient adrenal suppression.
• Principles: Always pre-oxygenate. Titrate dose to clinical effect. Co-induction (e.g., midazolam) may ↓ dose & side effects.

⭐ Ketamine (1-2 mg/kg IV) is often favored in hemodynamically unstable children or those with reactive airway disease due to its sympathomimetic and bronchodilatory properties.

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Advanced Techniques - Airway Alert Action

• Rapid Sequence Induction (RSI): For high aspiration risk (e.g., full stomach).
  • Preoxygenate: 3-5 min 100% $O_2$ / 4-8 Vital Capacity breaths.
  • Cricoid Pressure (Sellick): 10N (child awake), 30N (child asleep/induced).
  • Drugs (IV Push):
    • Induction: Propofol (2-3 mg/kg) / Ketamine (1-2 mg/kg).
    • Paralytic: Succinylcholine (1-2 mg/kg) / Rocuronium (0.9-1.2 mg/kg).
  • Intubate: No Bag-Mask Ventilation (BMV) prior.
• Difficult Airway Protocol (DAP):
  • Anticipate: Syndromes (Pierre Robin), prior history. Call experienced help early.
  • Strategy: Maintain Spontaneous Ventilation (SV) if possible.
  • Tools: Video Laryngoscope (VL), Supraglottic Airway Device (SAD), Fiberoptic Bronchoscope (FOB).

⭐ In anticipated difficult pediatric airway, consider inhalational induction maintaining spontaneous ventilation or awake fiberoptic intubation.

High‑Yield Points - ⚡ Biggest Takeaways

• Sevoflurane is the preferred inhalational agent for smooth induction in children.
• IV induction (e.g., Propofol) is faster with existing IV access or for Rapid Sequence Induction (RSI).
• RSI is indicated for full stomach or high aspiration risk; involves preoxygenation, cricoid pressure, and rapid-acting agents.
• Consider Atropine premedication to prevent bradycardia, especially in infants or with suxamethonium.
• Laryngospasm is a common pediatric airway emergency; manage with 100% O2, positive pressure, and deepening anesthesia.
• Always anticipate and prepare for a difficult airway with appropriate equipment and strategies.
• Parental Presence During Induction (PPDI) can reduce child anxiety but requires careful patient selection and team communication.