The preoperative evaluation of pediatric patients follows the same fundamental principles as in adults: review the chart, understand the medical history, and identify any red flags. While healthy children often present with straightforward histories, those with complex medical conditions or multiple prior anesthetics may have lengthy, repetitive records requiring careful review.

Although children generally have more physiologic reserve than adults, critically ill children, neonates, and ex-premature infants can be just as complex—or more so—than their adult counterparts. As a trainee, your goal should be to familiarize yourself with major pediatric surgical conditions. These include necrotizing enterocolitis, Hirschsprung’s disease, incarcerated hernia, gastroschisis, and abdominal wall defects.

Pediatric anesthesiologists play a crucial role in the emotional and physical safety of both child and parent. These preoperative conversations require careful word choice, calm presence, and trust-building. Watch experienced clinicians handle these interactions before attempting them yourself. Adult patients often tolerate a broad range of bedside communication styles. Parents of young children do not. Approach every interaction with empathy and professionalism.

The hallmark of a successful pediatric anesthetic is a well-prepared setup that allows the child to be induced quickly upon entering the OR. All drugs and monitors should be ready to deploy before the child crosses the threshold. This is not the time to untangle cords, do final equipment checks, or unlock drawers. The parents, patient, and OR team rely on a seamless transition.

Mask induction is a skill learned through practice. The absolute priority is that the child is breathing spontaneously and that the airway remains open. If breathing stops or the ETCO₂ trace disappears, do not wait for desaturation: perform a jaw thrust, use both hands, and ask for help obtaining IV access. Induction with parental presence can be challenging. If you haven’t done a pediatric mask induction before, it’s reasonable to observe one first or ask to rehearse the steps with your attending.

With airway obstruction or laryngospasm, even very healthy children will desaturate rapidly due to a combination of higher metabolic rate and lower functional residual capacity (FRC). Time is of the essence. Always have: oral airways, nasal trumpets, LMAs, endotracheal tubes, atropine, and succinylcholine immediately available.