Smith’s Anesthesia for Infants and

Children
• In studies evaluating propofol requirements for
induction of anesthesia in children, Manschot et
al. (1992) noted that in children aged 3 to 15
years receiving 5 mcg/kg of alfentanil to reduce
the pain of propofol injection, age-related
differences in propofol requirements were
demonstrated.
• In children aged 10 to 15 years, 1.5 mg/kg of
propofol was sufficient to induce sleep, whereas
in children aged 3 to 9 years, a dose of 2.5 mg/kg
was needed.
• In a study by Hannallah et al. (1991) in which alfentanil was not
administered, the ED50 and ED95 for loss of eyelash reflex were 1.3
and 2 mg/kg, whereas the ED50 and ED95 for induction of
anesthesia were 1.5 and 2.3 mg/kg, respectively.
• Westrin (1991), in a study of infants aged 1 to 6 months and
children aged 10 to 16 years, noted that the ED50 of propofol was 3
mg/kg for infants and 2.4 mg/kg for the older children.
• In all three of these studies, propofol was administered over 10 to
30 seconds. However, as with most hypnotic agents, propofol also
demonstrates a rate- dependent induction. Stokes and Hutton
(1991) demonstrated that with the use of slower infusion rates,
induction time for anesthesia increases but smaller doses could be
used.
• In children, at a given depth of anesthesia (i.e., MAC), there are significant
nonlinear inverse correlations between BIS val- ues and age: BIS values are
higher in toddlers than in older chil- dren in all studies, including TIVA with
propofol. Furthermore, in addition to age-related variations in BIS values,
interindi- vidual variabilities in BIS index are much higher in infants and
children than in adults (Tirel et al.; 2006, Kern et al., 2007; Rigouzzo et al.,
2008).
• These characteristics of BIS in children may be associated with age-related
differences in brain maturation and synapse formation throughout
childhood (Watcha, 2001). The reliability of the BIS index is further
diminished in infants younger than 1 year (Tirel et al., 2006; Jeleazcov et
al., 2007; Kern et al., 2007; Rigouzzo et al., 2008).
• The clinical benefits of measuring BIS and maintaining appropriate levels
of anesthesia, such as reduced risk for intra- operative awareness and
improved recovery time, may still be valid in pediatric patients, with the
realization of certain char- acteristics of and differences in children.
• When transitioning a child from the preoperative area to the site of
induction, it is paramount that the well-sedated or asleep child is
minimally stimulated or disturbed and that the awake or lightly
sedated child is kept occupied and distracted by an anesthesiologist
or family member. One person, either the anesthesiologist or a
family member, should do all the talking, which should be
reassuring and continuous. Giving patients and families the choice
to have the child carried, walked, or wheeled to the induction
location is another way to encourage participation and give them a
sense of control. Perioperative staff need to remain quiet
immediately before and during the induction, or they should be
asked to step away. Regardless of location, age of the patient, or
intended procedure, induction of anesthesia should be completely
focused on the child and uninterrupted by other activities or last-
minute preparations.
• Parental presence during induction of anesthesia
(PPIA), induction rooms can help anesthesiologists
avoid some of these problems, but in both settings the
parents must be prepared for the changes that can
occur during induction, especially rapid loss of con-
sciousness, uncoordinated movements, increased
respiratory rate, and signs of upper airway obstruction.
The anesthesiol- ogist should be prepared to reassure
the parent and respond quickly, especially if something
goes wrong during induction. Parents need to be
escorted to the waiting room as soon as their child
loses consciousness.