Infants and children are fasted before sedation and anesthesia to minimize the risk of pulmonary aspiration of gastric contents. In a fasted child, only the basal secretions of gastric juice should be present in the stomach. In 1948, Digby Leigh recommended a 1-hour preoperative fast after clear fluids. Subsequently, Mendelson reported a number of maternal deaths that were attributed to aspiration at induction of anesthesia.¹ During the intervening 20 years, the fasting interval before elective surgery increased to 8 hours after all solids and fluids. In the late 1980s and early 1990s, an evidence-based approach to the effects of fasting intervals on gastric fluid pH and volume concluded that fasting more than 2 hours after clear fluids neither increased nor decreased the risk of pneumonitis should aspiration occur.²^–¹⁰ In the past, the risk for pneumonitis was reported to be based on two parameters: gastric fluid volume greater than 0.4 mL/kg and pH less than 2.5; however, these data were never published in a peer-reviewed journal.^1,¹¹ In a monkey, 0.4 mL/kg of acid instilled endobronchially, equivalent to 0.8 mL/kg aspirated tracheally, resulted in pneumonitis.¹² Using these corrected criteria for acute pneumonitis (gastric residual fluid volume greater than 0.8 mL/kg and pH less than 2.5), studies in children demonstrated no additional risk for pneumonitis when children were fasted for only 2 hours after clear fluids.²^–⁹

The incidence of pulmonary aspiration in modern routine elective pediatric or adult cases without known risk factors is small.¹³^–¹⁶ This small risk is the result of a number of factors including the preoperative fasting schedule. The half-life to empty clear fluids from the stomach is approximately 15 minutes (Fig. 4-1); as a result, 98% of clear fluids exit the stomach in children by 1 hour. Clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. Although fasting for 2 hours after clear fluids ensures nearly complete emptying of the residual volume, extending the fasting interval to 3 hours introduces flexibility in the operative schedule. The potential benefits of a 2-hour fasting interval after clear fluids include a reduced risk of hypoglycemia, which is a real possibility in children who are debilitated, have chronic disease, are poorly nourished, have metabolic dysfunction, or are preterm or formerly preterm infants.¹⁷^–²⁰ Additional benefits include decreased thirst, decreased hunger (and thus reduced temptation that the fasting child will “steal” another child’s food), decreased risk for hypotension during induction, and improved child cooperation.^2,^11,²¹

FIGURE 4-1 Clear liquids are rapidly absorbed from the stomach with a half-life of approximately 15 minutes. In this figure, for example, 200 mL of apple juice would be reduced to 12.5 mL after 60 minutes.

(Data abstracted from Hunt JN, MacDonald M. The influence of volume on gastric emptying. J Physiol 1954;126:459-74.)

A scheduled operation on a preterm infant or neonate may occasionally be delayed, thus extending the period of fasting to a point that could be potentially dangerous (i.e., from hypoglycemia or hypovolemia). In this circumstance, the infants should be given glucose-containing intravenous maintenance fluids before induction of anesthesia. Alternatively, if the period may be protracted, the infant should be offered clear fluids orally until 2 hours before induction.

Breast milk, which can cause significant pulmonary injury if aspirated,²² has a very high and variable fat content (determined by maternal diet), which will delay gastric emptying.²¹ Breast milk should not be considered a clear liquid.²³ Two studies estimated the gastric emptying times after clear fluids, breast milk, or formula in full-term and preterm neonates.^24,²⁵ The emptying times for breast milk in both age groups were substantively greater than for clear fluids, and the gastric emptying times for formula were even greater than those for breast milk. With half-life emptying times for breast milk of 50 minutes and for formula of 75 minutes, fasting intervals of at least 3.3 hours for breast milk and 5 hours for formula are required. More importantly, perhaps, was the large (15%) variability in gastric emptying times for breast milk and formula in full-term infants (E-Fig. 4-1). Based in part on these data, the Task Force on Fasting of the American Society of Anesthesiologists (ASA) issued the following guidelines: for breast milk, 4 hours; and for formula, 6 hours (Table 4-1).¹⁰

TABLE 4-1 Preoperative Fasting Recommendations in Infants and Children

Clear liquids*	2 hours
Breast milk	4 hours
Infant formula	6 hours^†
Solids (fatty or fried foods)	8 hours

^*Include only fluids without pulp, clear tea, or coffee without milk products.

^†Some centers allow plain toast (no dairy products) up to 6 hours prior to induction.

From Warner MA, Caplan RA, Epstein B. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures. A report by the American Society of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology 1999;90:896-905.

E-FIGURE 4-1 Percentage of gastric feeding remaining in the stomach after water, breast milk, or formula versus time after ingestion by infants. Data are expressed as mean ± standard deviation. The time to 50% gastric emptying of water was 15 minutes, of breast milk 50 minutes, and of formula 80 minutes. On the basis of these data, about 95% emptying (i.e., four half-lives) of gastric feedings should occur in about 1 hour after water, about 3.5 hours after breast milk, and about 5.5 hours after infant formula. However, note the wide standard deviations for the emptying times for breast milk and formula.

(From Cavell B. Gastric emptying in preterm infants. Acta Paediatr Scand 1979;68:725-30; Cavell B. Gastric emptying in infants fed human milk or infant formula. Acta Paediatr Scand 1981;70:639-41.)

Children who have been chewing gum must dispose of the gum by expectorating it, not swallowing it. Chewing gum increases both gastric fluid volume and gastric pH in children, leaving no clear evidence that it affects the risk of pneumonitis should aspiration occur.²⁶ Consequently, we recommend that if the gum is discarded, then elective anesthesia can proceed without additional delay. If, however, the child swallows the gum, then surgery should be cancelled, because aspirated gum at body temperature may be very difficult to extract from a bronchus or trachea.

Children can never be trusted to fast. Therefore, anesthesiologists must always be suspicious and question children just before induction as to whether they have eaten or drunk anything (although the veracity of the answer may always be questioned as well). It is not unusual to find bubble gum, candy, or other food in a child’s mouth. This is another reason to ask children to open their mouth fully and stick out their tongue during the preoperative examination of the airway.

When the anesthesiologist suspects that the child has a full stomach, induction of anesthesia should be adjusted appropriately. The incidence of pulmonary aspiration of gastric contents during elective surgery in children ranges from 1 : 1163 to 1 : 10,000, depending on the study.¹³^–¹⁵ ²⁷ In contrast, the frequency of pulmonary aspiration in children undergoing emergency procedures is several times greater, 1 : 373 to 1 : 4544.²⁷ Risk factors for perianesthetic aspiration included neurologic or esophagogastric abnormality, emergency surgery (especially at night), ASA physical status 3 to 5, intestinal obstruction, increased intracranial pressure, increased abdominal pressure, obesity, and the skill and experience of the anesthesiologist.¹⁴

The majority of aspirations in children occur during induction of anesthesia, with only 13% occurring during emergence and extubation. In contrast, 30% of the aspirations in adults occur during emergence. Bowel obstruction or ileus was present in the majority of infants and children who aspirated during the perioperative period in one study, with the risk increasing in children younger than 3 years of age.²⁷ A combination of factors predispose the infant and young child to regurgitation and aspiration, including decreased competence of the lower esophageal sphincter, excessive air swallowing while crying during the preinduction period, strenuous diaphragmatic breathing, and a shorter esophagus. In one study, almost all cases of pulmonary aspiration occurred either when the child gagged or coughed during airway manipulation or during induction of anesthesia when neuromuscular blocking drugs were not provided or before the child was completely paralyzed.²⁷

When children do aspirate, the morbidity and mortality are exceedingly small for elective surgical procedures and generally reflect their ASA physical status. In general, most ASA 1 or 2 patients who aspirate clear gastric contents have minimal to no sequelae.^13,²⁷ If clinical signs of sequelae from an aspiration in a child are going to occur, they will be apparent within 2 hours after the regurgitation.²⁷ The mortality rate from aspiration in children is exceedingly low, between zero and 1 : 50,000.^13,^14,²⁷

Piercings

Body piercing is common practice in adolescents and young adults. Single or multiple piercings may appear anywhere on the body. To minimize the liability and risk of complications from metal piercings, they must be removed before surgery. Complications that may occur if they are left in situ during anesthesia are listed in E-Table 4-1.²⁸^–³⁰

E-TABLE 4-1 Complications from Metal Piercings

Electrocautery Burns

All tissues adjacent to metal piercings are at risk; to avoid burns, use bipolar cautery or an harmonic knife; the cautery grounding pad should be remote from the piercing.

Airway Difficulty with Intubation

Laryngospasm and hypoxia

Pulmonary aspiration

Tissue Damage

Necrosis

Bleeding

Modified from Rosenberg AD, Young M, Bernstein RL, Albert DB. Tongue rings: just say no. Anesthesiology 1998;89:1279-80; Wise H. Hypoxia caused by body piercing. Anaesthesia 1999;54:1129.

Primary and Secondary Smoking

Primary Smoking

Unfortunately, cigarette smoking is not only limited to adults. Each day, about 6000 American adolescents smoke their first cigarette. Of these, 50% will become regular smokers. Even though two thirds of these adolescents will regret taking up the habit and will want to quit, three quarters of them will not succeed because they are addicted to the nicotine. Sadly, about one third of those who cannot quit will die prematurely due to smoking.³¹ Even though the rate of new smokers in North America has waned in the past 2 decades, this has been offset by the increasing rate of new smokers in other continents. Media, peer influence, and secondhand smoke exposure play a significant role in influencing initiation of smokers in this age group.³²

Smoking is known to increase blood carboxyhemoglobin concentrations, decrease ciliary function, decrease functional vital capacity (FVC) and the forced expiratory flow in midphase (FEF_25%-75%), and increase sputum production. There is extensive evidence that smokers undergoing surgery are more likely to develop wound infections and postoperative respiratory complications.³³ Although stopping smoking for 2 days decreases carboxyhemoglobin levels and shifts the oxyhemoglobin dissociation curve to the right, stopping for at least 6 to 8 weeks is necessary to reduce the rate of postoperative pulmonary complications.^34,³⁵

We seldom interview our patients 8 weeks before surgery, but because the perioperative period is the ideal time to abandon the smoking habit permanently, anesthesiologists can perhaps play a more active role in facilitating this process. Physician communication with adolescents regarding smoking cessation has been shown to positively impact their attitudes, knowledge, intentions to smoke, and quitting behaviors.³⁶ In summary, during the preoperative visit with adolescents, anesthesiologists should inquire about cigarette smoking and emphasize the need to stop the habit by offering measures to ameliorate the withdrawal (e.g., nictoine patch).

Secondary Smoking

The World Health Organization has estimated that approximately 700 million children, or almost half of the children in the world, are exposed to environmental tobacco smoke (ETS).³⁷ Children exposed to ETS are more likely to have asthma, otitis media,³⁸ atopic eczema, hay fever,³⁹ and dental caries.⁴⁰ There is also an increased rate of lower respiratory tract illness in infants with ETS exposure.^41,⁴²

Several authors have demonstrated that ETS results in increased perioperative airway complications in children. In one study ⁴³ of children receiving general anesthesia, urinary cotinine, the major metabolite of nicotine, was used as a surrogate of ETS. A strong association was found between passive inhalation of tobacco smoke and airway complications on induction and emergence from anesthesia. Other investigators confirmed that ETS exposure was associated with an increased frequency of respiratory complications during emergence and recovery from anesthesia.⁴⁴

The evidence against ETS is clearly overwhelming. During the preoperative visit, the anesthesiologist must question the child’s exposure to ETS by asking parents or guardians about smoking within the household. This is an opportune time to educate parents and guardians about the dangers of ETS for their children.

Psychological Preparation of Children for Surgery

The perioperative period is stressful and anxiety-provoking for the child and family; many parents express more concern about the risks of anesthesia than those of the surgery. The factors that influence the ability of the child and family to cope with the stress of surgery include family dynamics, the child’s developmental and behavioral status and cultural biases, and our ability to explain away misperceptions and misinformation. Because of logistics and today’s practice constraints, there is limited time to evaluate family dynamics and establish rapport. It is therefore vital for the anesthesiologist to interact directly with the child in a manner that is consistent with the child’s level of development. A specific child-oriented approach by the anesthesiologist, surgeon, nurses, and hospital staff is required. Preoperative evaluation is usually simplified once the basic concepts of how to evaluate a child are understood.

Although the preoperative evaluation and preparation of children are similar to those of adults from a physiologic standpoint, the psychological preparation of infants and children is very different (see also Chapter 3). Many hospitals have an open house or a brochure to describe the preoperative programs available to parents before the day of admission.⁴⁵ However, printed material should not replace verbal communication with nursing and medical staff.⁴⁶ Anesthesiologists are encouraged to participate in the design of these programs so that they accurately reflect the anesthetic practice of the institution. The preoperative anesthetic experience begins at the time parents are first informed that the child is to have surgery or a procedure that requires general anesthesia. Parental satisfaction correlates with the comfort of the environment and the trust established between the anesthesiologist, the child, and the parents.⁴⁷ If parental presence during induction is deemed to be in the child’s best interest, a parental educational program that describes what the parent can expect to happen if he or she accompanies the child to the operating room can significantly decrease parents’ anxiety and increase their satisfaction.⁴⁸ The greater the understanding and amount of information the parents have, the less anxious they will be, and this attitude, in turn, will be reflected in the child.^49,⁵⁰

Informed consent should include a detailed description of what the family can anticipate and our role to protect the welfare of the child. Before surgery, the anesthetic risks should be discussed in clear terms but in a reassuring manner by describing the measures that will be taken to carefully and closely monitor the safety of the child. Mentioning specific details and the purpose of the various monitoring devices may help diminish the parents’ anxiety by demonstrating to them that the child will be anesthetized with the utmost safety and care. A blood pressure cuff will “check the blood pressure,” an electrocardiographic monitor will “watch the heartbeat,” a stethoscope will help us “to continuously listen to the heart sounds,” a pulse oximeter will “measure the oxygen in the bloodstream,” a carbon dioxide analyzer will “monitor the breathing,” an anesthetic agent monitor will “accurately measure the level of anesthesia,” and an intravenous catheter will be placed “to administer fluid and medications as needed.” Children who are capable and their parents should be given ample opportunity to ask questions preoperatively. Finally, they should be assured that our “anesthetic prescription” will be designed specifically for their child’s needs, taking into account the child’s underlying medical conditions and the needs of surgery to ensure optimal conditions for surgery, the safety of the child, and analgesia.

It has been shown that parents desire comprehensive perioperative information, and that discussion of highly detailed anesthetic risk information does not increase parent’s anxiety level.⁵¹ Inadequate preparation of children and their families may lead to a traumatic anesthetic induction and difficulty for both the child and the anesthesiologist, with the possibility of postoperative psychological disturbances.⁵² Numerous preoperative educational programs for children and adults have evolved to alleviate some of these fears and anxiety. They include preoperative tours of the operating rooms, educational videos, play therapy, magical distractions, puppet shows, anesthesia consultations, and child life preparation.⁵³ The timing of the preoperative preparation has been found to be an important determinant of whether the intervention will be effective. For example, children older than 6 years of age who participated in a preparation program more than 5 to 7 days before surgery were least anxious during separation from their parents, those who participated in no preoperative preparation were moderately anxious, and those who received the information 1 day before surgery were the most anxious. The predictors of anxiety correlated also with the child’s baseline temperament and history of previous hospitalizations.⁵⁴ Children of different ages vary in their response to the anesthetic experience (see also Chapter 3).⁵⁵ Even more important may be the child’s trait anxiety when confronted with a stressful medical procedure.⁵⁶

Child Development and Behavior

Understanding age-appropriate behavior in response to external situations is essential (E-Table 4-2). Infants younger than 10 months of age tolerate short periods of separation from their parents. Many do not object to an inhalation induction and frequently respond to the smell of the inhalation agents by sucking or licking the mask. These infants usually do not need a sedative premedication.

E-TABLE 4-2 Age-Specific Anxieties of Pediatric Patients

Age	Specific Type of Perioperative Anxiety
0-6 months	• Maximum stress for parent • Minimum stress for infants—not old enough to be frightened of strangers
6 months-4 years	• Maximum fear of separation • Not able to understand processes and explanations • Significant postoperative emotional upset and behavior regression • Begins to have magical thinking • Cognitive development and increased temper tantrums
4-8 years	• Begins to understand processes and explanations • Fear of separation remains • Concerned about body integrity
8 years-Adolescence	• Tolerates separation well • Understands processes and explanations • May interpret everything literally • May fear waking up during surgery or not waking up at all
Adolescence	• Independent • Issues regarding self-esteem and body image • Developing sexual characteristics and fear loss of dignity • Fear of unknown

Modified with permission from Cruickshank BM, Cooper LJ. Common behavioral problems. In: Greydanus DE, Wolraich ML, editors: Behavioral pediatrics. New York: Springer; 1992.

Children between 11 months and 6 years of age frequently cling to their parents. In an unfamiliar environment such as a hospital, preschool children tend to become very anxious, especially if the situation appears threatening. Their anxiety may be exacerbated if they sense that their parents are anxious. Efforts to educate the parents to allay their anxiety can also reduce the child’s anxiety.^45,^57,⁵⁸ A heightened anxiety response may lead to immediate postoperative maladaptive behavior, such as nightmares, eating disturbances, and new-onset enuresis. Compared with other patients, children 2 to 6 years of age are more likely to exhibit problematic behavior when separated from their parents (see also Chapter 3).⁵⁵ Children who display one or more of the predictive risk factors would probably benefit from a sedative premedication.⁵⁹^–⁶² They are generally more content if their parents accompany them during induction or if they are sedated in the presence of their parents in a nonthreatening environment before entering the operating room (see later discussion).

Children older than 6 years of age and those who attend preschool or kindergarten are more willing to accept brief periods of separation from their parents. They tend to be more independent because of their school experience. They are better able to communicate and have a greater understanding of their environment. Their sense of curiosity and interest in new things and their trust of adults can be used to elicit their cooperation for a mask induction of anesthesia without the need for premedication.

Children ages 4 to 10 years may exhibit psychological factors that are predictive of postoperative behavior (e.g., abnormal sleep patterns, parental anxiety, aggressive behavior).^63,⁶⁴ In addition, children who have pain on the day of the operation have behavioral problems that continue well after the pain has been relieved.⁶⁵ Therefore, preventing postoperative pain decreases and limits the duration of postoperative behavioral problems.

Special aspects of a child’s perception of anesthesia should be anticipated; children often have the same fears as adults but are unable to articulate them. The reason and need for a surgical procedure should also be carefully explained to the child. It is important to reassure children that anesthesia is not the same as the usual nightly sleep but rather a special sleep caused by the medicines we give during which they cannot be awakened and no matter what the surgeon does, they cannot feel pain. Many children fear the possibility that they will wake up in the middle of the anesthetic and during surgery. They should be reassured that they will awaken only after the surgery is completed.

The words the anesthesiologist uses to describe to the child what can be anticipated must be carefully chosen, because children think concretely and tend to interpret the facts literally. Examples of this are presented by the following anecdotes:

Example 1: A 4-year-old child was informed that in the morning she would receive a “shot” that would “put her to sleep.” That night, a frantic call was received from the mother, describing a very upset child; the child thought she was going to be “put to sleep” like the veterinarian had permanently “put to sleep” her sick pet.

Example 2: A 5-year-old child admitted for elective inguinal herniorrhaphy received a heavy premedication and was deeply sedated on arrival in the operating room. After discharge, the parents frequently discovered him wandering about the house at night. On questioning, the child stated that he was “protecting” his family. He stated: “I don’t want anyone sneaking up on you and operating while you are sleeping.”

In the first example, the child’s concrete thought processes misunderstood the anesthesiologist’s choice of words. The second case represents a problem of communication: the child was never told he would have an operation.

The importance of proper psychological preparation for surgery should not be underestimated. Often, little has been explained to both patient and parents before the day of surgery. Anesthesiologists have a key role in defusing fear of the unknown if they understand a child’s age-related perception of anesthesia and surgery (see Chapter 3). They can convey their understanding by presenting a calm and friendly face (smiling, looking at the child and making eye contact), offering a warm introduction, touching the patient in a reassuring manner (holding a child’s or parent’s hand), and being completely honest. Children respond positively to an honest description of exactly what they can anticipate. This includes informing them of the slight discomfort of starting an intravenous line or giving an intramuscular premedication, the possible bitter taste of an oral premedication, or breathing our magic laughing gas through the flavored mask.

The postoperative process, from the operating room to the recovery room, and the onset of postoperative pain should be described. Encourage the child and family to ask questions. Strategies to maintain analgesia should be discussed, including the use of long-acting local anesthetics; nerve blocks; neuraxial blocks; patient-controlled, nurse-controlled, or parent-controlled analgesia or epidural analgesia; or intermittent opioids (see also Chapters 41, 42, and 43).

As children age, they become more aware of their bodies and may develop a fear of mutilation. Adolescents frequently appear quite independent and self-confident, but as a group, they have unique problems. In a moment their mood can change from an intelligent, mature adult to a very immature child who needs support and reassurance. Coping with a disability or illness is often very difficult for adolescents. Because they are often comparing their physical appearance with that of their peers, they may become especially anxious when they have a physical problem. In general, they want to know exactly what will transpire during the course of anesthesia. Adolescents are usually cooperative, preferring to be in control and unpremedicated preoperatively. The occasional overly anxious or rambunctious adolescent, however, may benefit from preanesthetic medication.

Monitoring the attitude and behavior of a child is very useful. A child who clings to the parents, avoids eye contact, and will not speak is very anxious. A self-assured, cocky child who “knows it all” may also be apprehensive or frightened. This know-it-all behavior may mask the child’s true emotions, and he or she may decompensate just when cooperation is most needed. In some cases, nonpharmacologic supportive measures may be effective. In the extremely anxious child, supportive measures alone may be insufficient to reduce anxiety, and premedication is indicated.

Identifying a difficult parent or child preoperatively is not always easy, especially if the anesthesiologist first meets the child or family on the day of surgery and has limited time to assess the situation. Occasionally, we receive a warning regarding a difficult parent or child from the surgeon or nursing staff, based on their encounters with the family. With experience, some anesthesiologists are able to identify difficult parents and children during the short preoperative assessment and make appropriate adjustments to the anesthetic management plan.

The “veterans” or “frequent flyers” of anesthesia can also be difficult in the perioperative period. They have played the anesthesia and surgical game before and are not interested in participating again, especially if their previous experiences were negative. These children may benefit the most from a relatively heavy premedication; reviewing previous responses to premedication will aid in the adjustment of the current planned premedication (e.g., adding ketamine and atropine to oral midazolam so as to achieve a greater depth of sedation).

It is important to observe the family dynamics to better understand the child and determine who is in control, the parent or the child. Families many times are in a state of stress, particularly if the child has a chronic illness; these parents are often angry, guilt ridden, or simply exhausted. Ultimately, the manner in which a family copes with an illness largely determines how the child will cope.⁶⁶ The well-organized, open, and communicative family tends to be supportive and resourceful, whereas the disorganized, noncommunicative, and dysfunctional family tends to be angry and frustrated. Dealing with a family and child from the latter category can be challenging. There is the occasional parent who is overbearing and demands total control of the situation. It is important to be empathetic and understanding but to set limits and clearly define the parent’s role. He or she must be told that the anesthesiologist determines when the parent must leave the operating room; this is particularly true if an unexpected development occurs during the induction.

Parental Presence during Induction

One controversial area in pediatric anesthesia is parental presence during induction. Some anesthesiologists encourage parents to be present at induction, whereas others are uncomfortable with the process and do not allow parents to be present. Inviting a parent to accompany the child to the operating room has been interpreted by some courts as an implicit contract on the part of the caregiver who invited the parent to participate in the child’s care; in one case, the institution was found to have assumed responsibility for a mother who suffered an injury when she fainted.⁶⁷ Each child and family must be evaluated individually; what is good for one child and family may not be good for the next.⁶⁸^–⁷¹ (See Chapter 3 for a full discussion of this and other anxiolytic strategies in children.)

If the practice of having parents present at induction is to work well, then the anesthesiologist must be comfortable with such an arrangement. No parent should ever be forced to be present for the induction of anesthesia, nor should any anesthesiologist be forced into a situation that compromises the quality of care he or she affords a child in need.

Parents must be informed about what to anticipate in terms of the operating room itself (e.g., equipment, surgical devices), in terms of what they may observe during induction (e.g., eyes rolling back, laryngeal noises, anesthetic monitor alarms, excitation), and when they will be asked to leave. They must also be instructed regarding their ability to assist during the induction process, such as by comforting the child, encouraging the child to trust the anesthesiologist, distracting the child, and consoling the child (Video 4-1). Personnel should be immediately available to escort parents back to the waiting area at the appropriate time. Someone should also be available to care for a parent who wishes to leave the induction area or who becomes lightheaded or faints. An anesthesiologist’s anxiety about parents’ presence during induction decreases significantly with experience.⁷²

Explaining what parents might see or hear is essential. We generally tell parents the following:

As you see your child fall asleep today, there are several things you might observe that you are not used to seeing. First, when anyone falls asleep, the eyes roll up, but since we are sleeping we do not generally see it. You may see your child do that today, and I do not want you to be frightened by that—it is expected and normal. The second thing is that as children go to sleep from the anesthesia medications, the tone of the structures in the neck decreases, so that some children will begin to snore or make vibrating noises. Again, I do not want you to be frightened or think that something is wrong. We expect this, and it is normal. The third thing you might see is what we call “excitement.” As the brain begins to go to sleep, it can actually get excited first. About 30 to 60 seconds after breathing the anesthesia medications, your child might suddenly look around or suddenly move his or her arms and legs. To you it appears that he is awakening from anesthesia or that he or she is upset. In reality, this is a good sign, because it indicates to us that your child is falling asleep and that 15 to 30 seconds later he or she will be completely anesthetized. Also you should know that even though your child appears to be awake to you, in reality he or she will not remember any of that. As soon as your child loses consciousness, we will ask you to give your child a kiss and step out of the operating room.

This kind of careful preparation provides to the parents the confidence that the anesthesiologist really knows what he or she is talking about, and it avoids frightening the parents. In general, the more information provided, the lower the parental anxiety levels.

Occasionally, the best efforts to relieve a child’s anxiety by parental presence or administration of a sedative premedication (or both) are not successful, and an anticipated smooth induction may not go as planned. There are three options that may be used depending on the age of the child: (1) renegotiate (which is seldom successful), (2) hold the mask farther away from the child’s face, or (3) suggest an intravenous or intramuscular induction. Sedation can be considered if it was not already used and may be intramuscular, oral, inhalational (nitrous oxide), or given by another route). If an intramuscular shot or intravenous induction is proposed, the child will usually choose the mask. If the situation is totally out of control, either elective surgery can be rescheduled or intramuscular ketamine can be used if the parents choose to proceed. These situations are particularly difficult for the parents and the caregivers but must be handled on an individual basis.

History of Present Illness

The medical history of a child obtained during the preanesthetic visit allows the anesthesiologist to determine whether the child is optimized for the planned surgery, to anticipate potential problems due to coexisting disease, to determine whether appropriate laboratory or other tests are available or needed, to select optimal premedication, to formulate the appropriate anesthetic plan including perioperative monitoring, and to anticipate postoperative concerns including pain management and postoperative ventilatory needs. The history of the present illness is described to the physicians by the parents and verified by the referring or consultant surgeon’s notes. If the child is old enough, it is helpful to obtain the child’s input. The history should focus on the following aspects:

A review of all organ systems (Table 4-2) with special emphasis on the organ system involved in the surgery

Medications (over-the-counter and prescribed) related to and taken before the present illness, including herbals and vitamins, and when the last dose was taken

Medication allergies with specific details of the nature of the allergy and whether immunologic testing was performed

Previous surgical and hospital experiences, including those related to the current problem

Timing of the last oral intake, last urination (wet diaper), and vomiting and diarrhea. It is essential to recognize that decreased gastrointestinal motility often occurs with an illness or injury.

TABLE 4-2 Review of Systems: Anesthetic Implications

System	Factors to Assess	Possible Anesthetic Implications
Respiratory	Cough, asthma, recent cold Croup Apnea/bradycardia	Irritable airway, bronchospasm, medication history, atelectasis, infiltrate Subglottic narrowing Postoperative apnea/bradycardia
Cardiovascular	Murmur Cyanosis History of squatting Hypertension Rheumatic fever Exercise intolerance	Septal defect, avoid air bubbles in intravenous line Right-to-left shunt Tetralogy of Fallot Coarctation, renal disease Valvular heart disease Congestive heart failure, cyanosis
Neurologic	Seizures Head trauma Swallowing incoordination Neuromuscular disease	Medications, metabolic derangement Intracranial hypertension Aspiration, esophageal reflux, hiatus hernia Neuromuscular relaxant drug sensitivity, malignant hyperpyrexia
Gastrointestinal/hepatic	Vomiting, diarrhea Malabsorption Black stools Reflux Jaundice	Electrolyte imbalance, dehydration, full stomach Anemia Anemia, hypovolemia Possible need for full-stomach precautions Drug metabolism/hypoglycemia
Genitourinary	Frequency Time of last urination Frequent urinary tract infections	Urinary tract infection, diabetes, hypercalcemia State of hydration Evaluate renal function
Endocrine/metabolic	Abnormal development Hypoglycemia, steroid therapy	Endocrinopathy, hypothyroid, diabetes Hypoglycemia, adrenal insufficiency
Hematologic	Anemia Bruising, excessive bleeding Sickle cell disease	Need for transfusion Coagulopathy, thrombocytopenia, thrombocytopathy Hydration, possible transfusion
Allergies	Medications	Possible drug interaction
Dental	Loose or carious teeth	Aspiration of loose teeth, bacterial endocarditis prophylaxis

In the case of a neonate, problems that may have been present during gestation and birth may still be relevant in the neonatal period and beyond (E-Table 4-3). The maternal medical and pharmacologic history (both therapeutic and drug abuse) may also provide valuable information for the management of a neonate requiring surgery.

E-TABLE 4-3 Maternal History with Commonly Associated Neonatal Problems

Maternal History	Commonly Expected Problems with Neonate
Rh-ABO incompatibility	• Hemolytic anemia, hyperbilirubinemia, kernicterus
Toxemia	• SGA and its associated problems,* muscle relaxant interaction with magnesium therapy
Hypertension	• SGA and its associated problems *
Drug addiction	• Withdrawal, SGA
Infection	• Sepsis, thrombocytopenia, viral infection
Hemorrhage	• Anemia, shock
Diabetes	• Hypoglycemia, birth trauma, LGA, SGA, and associated problems *
Polyhydramnios	• Tracheoesophageal fistula, anencephaly, multiple anomalies
Oligohydramnios	• Renal hypoplasia, pulmonary hypoplasia
Cephalopelvic disproportion	• Birth trauma, hyperbilirubinemia, fractures
Alcoholism	• Hypoglycemia, congenital malformation, fetal alcohol syndrome, SGA, and associated problems *

SGA, Small for gestational age; LGA, large for gestational age.

^*See Table 2-2.

Past/Other Medical History

The past medical history should include a history of all past medical illnesses with a review of organ systems, previous hospitalizations (medical or surgical), childhood syndromes with associated anomalies, medication list, herbal remedies, and any allergies, especially to antibiotics and latex. Whether the child was full-term or preterm at birth should be discerned; if preterm, any associated problems should be noted, including admission to a neonatal intensive care unit, duration of tracheal intubation, history of apnea or bradycardia (including oxygen treatment, home apnea monitor, intraventricular hemorrhage), and congenital defects.

Examination of previous surgical and anesthesia records greatly assists in planning the anesthesia. Particular attention should be paid to any difficulties encountered with airway management, venous access, or emergence. The response to or need for premedication and the route of administration utilized should be noted.

Herbal Remedies

Increasing numbers of children are ingesting herbal medicine products. During the preoperative interview, anesthesiologists should include specific inquiries regarding the use of these medications because of their potential adverse effects and drug interactions. Hospital surveys suggest that the use of herbal remedies ranges from 17% to 32%⁷³^–⁷⁵ of presurgical patients, and 70% of these patients do not inform their anesthesiologist of such use.

In Hong Kong, 80% of patients undergoing major elective surgery use prepacked over-the-counter traditional Chinese herbal medicines, and 8% use medicines prescribed by traditional Chinese medicine practitioners.⁷⁶ The prescription users of traditional Chinese medicines experienced a greater incidence of adverse perioperative events. In particular, this group was twice as likely to have hypokalemia or impaired hemostasis (i.e., prolonged international normalized prothrombin ratio [INR] and activated partial thromboplastin time [aPTT]) than nonusers, although there was no significant difference in the incidence of perioperative events between self-prescribed users and nonusers. To further complicate this subject, there is an important difference between Chinese and Western herbs. Traditional Chinese herbal medicines consist of multiple herbs that are combined for their effects, whereas Western herbs are usually ingested as a single substance.⁷⁷

Herbal medicines are associated with cardiovascular instability, coagulation disturbances, prolongation of anesthesia, and immunosuppression.⁷⁸ The most commonly used herbal medications reported are garlic, ginseng, Ginkgo biloba, St. John’s wort, and echinacea.⁷⁹ The three “g” herbals, together with feverfew (Tanacetum parthenium), potentially increase the risk of bleeding during surgery. The amount of active ingredient in each preparation may vary, the dose taken by a child may also vary, and detection of a change in platelet function and other subtle coagulation disturbances may be difficult. St. John’s wort is the herb that most commonly interacts with anesthetics and other medications, usually via a change in drug metabolism, because it is a potent induction of the cytochrome P-450 enzymes (e.g., CYP3A4) and P-glycoprotein. A potentially fatal interaction between cyclosporine and St. John’s wort has been well documented.⁸⁰^–⁸³ Heart, kidney, or liver transplant recipients who were stabilized on a dose of cyclosporine experienced decreased plasma concentrations of cyclosporine and, in some cases, acute rejection episodes after taking St. John’s wort. A summary of the most commonly used herbal remedies and their potential perioperative complications is shown in E-Table 4-4.

E-TABLE 4-4 Pharmacologic Effects and Potential Perioperative Complications of Eight Commonly Used Herbal Remedies

To avoid potential perioperative complications, the ASA has encouraged the discontinuation of all herbal medicines 2 weeks before surgery,⁸⁴ although this recommendation is not evidence based. Indeed, some herbs such as valerian, a treatment for insomnia (Valeriana officinalis), should not be discontinued abruptly but tapered; otherwise, abrupt discontinuation may result in a paradoxical and severe reaction.⁸⁵ Each herb should be carefully evaluated using standard resource texts, and a decision should be made regarding the timing of or need for discontinuation as determined on a case-by-case basis.⁸⁶