a) Patient blood pressure and heart rate are monitored for the assessment of the cardiovascular system.
b) Pulse oximetry and capnography are used for the assessment of the adequacy of oxygenation and ventilation, a temperature probe for intermittent or continuous assessment of core body temperature, and a neuromuscular function monitor for the evaluation of the child’s response to the administration of neuromuscular blocking drugs.
c) A precordial or esophageal stethoscope should be used for the continuous assessment of heart rate during anesthetic induction and throughout the perioperative period.
d) Some circumstances require the application of arterial and central venous pressure monitoring. Small multilumen catheters are available for pediatric patients. These catheters are advantageous when large blood losses are expected (e.g., during burn débridement and skin grafting). However, these catheters have long, thin lumens that may severely limit the rate at which IV fluid or blood may be administered.
8. Anesthetic induction
a) Mask induction is the most popular and is easily accomplished in infants younger than 8 months of age, as well as in children.
b) The essential monitoring modalities for inhalation induction include a precordial stethoscope and a pulse oximeter.
c) Anesthetic induction is begun with a 70:30 mixture of nitrous oxide and oxygen via mask or a “cupped hand” that is placed on the child’s chin with the anesthetic mixture directed toward the mouth and nose.
d) A pacifier may quiet the infant during the induction, or the infant may suck on the end of the anesthesia provider’s gloved finger. Sevoflurane is added to the nitrous oxide–oxygen mixture beginning with a 2% concentration, with a rapid increase to 8%.
e) The mask may then be introduced as the inspired concentration is increased. The anesthesia provider should await the return of respiration and avoid the temptation to administer a breath because this may produce coughing and laryngospasm.
f) Unconsciousness is produced with inspired sevoflurane concentrations 6% to 8%. After the loss of consciousness, nitrous oxide is discontinued, and sevoflurane is administered in 100% oxygen. Because of the low blood gas solubility coefficient and rapid uptake, the choice to use nitrous oxide is provider specific.
g) At this time, the anesthesia provider should begin to assist respiration and promptly decrease the inspired anesthetic concentration of sevoflurane to 2% to 2.5%. Controlled ventilation with high-inspired concentrations of inhalation agent aggravates myocardial depression, precipitating the development of sudden cardiac arrest.