A new series, and it starts where the difficulty actually is. The pharmacology of a
healthy three-year-old is forgiving. The twenty minutes before induction and the twenty after
emergence are not.
This is the age at which anaesthesia stops being a technical problem and becomes a behavioural
one. The child cannot be reasoned with, has no useful model of what is about to happen, and will
remember it. Almost everything below is about that.
Before the day
- Fasting, and the driftSix hours for solids, four for breast milk. Clear fluids have
moved to one hour in most Australian units — encourage drinking rather than forbid it, because
prolonged fasting makes a miserable, ketotic, hypotensive child and does not empty the stomach any
further. Check your own institution's current position; this one changed recently.
- The runny noseThe commonest cancellation and the commonest unnecessary one. A child
with clear rhinorrhoea, no fever and a clear chest can generally proceed. Fever, purulent
secretions, a wet cough or any lower respiratory signs are a different matter, and the airway stays
twitchy for weeks afterwards rather than days.
- Topical anaesthetic, timed properlyThe cream only works if it has been on long
enough, which means it is a ward job an hour ahead, not a holding-bay afterthought. Two sites, not
one, because the first cannula does not always go in.
- PremedicationWorth considering rather than reflexive. Oral midazolam works, tastes
unpleasant and can disinhibit; intranasal dexmedetomidine takes longer and is smoother. The evidence
favours premedication over parental presence for the genuinely frightened child, which is not the
answer most parents expect.
The parent question. Parental presence at induction is popular, humane, and does
not reliably reduce the child's anxiety in trials. It reduces the parent's, which is a legitimate
aim in itself, but a distressed parent at the head of the bed makes everything harder. Decide
deliberately, prepare them properly if they come, and have someone whose only job is to take them
out.
The induction
What actually works in the room
“We're going to blow up a balloon. You do the blowing, I'll hold it. Big breaths, as big as
you can — can you make it go all the way up?”
Give the child a task rather than an instruction to endure something. The mask arrives as part of
the game rather than as an event. Cup it above the face first and bring it down; clamping it on is
what produces the memory everyone is trying to avoid.
- Gas or cannulaInhalational induction remains the default at this age, and the child
who already has good topical anaesthetic and a visible vein may be better served intravenously.
Ask which they would prefer if they are old enough to have a view; four-year-olds often do.
- The excitement phaseExpect movement, breath-holding and rigidity partway through and
do not respond to it as though it were awareness. Keep the mask still, keep talking, and let the
parent go before this begins rather than during it.
- The airwayA supraglottic device covers most of this workload. When a tube is needed,
cuffed is standard now; check the pressure rather than trusting the leak. Look for loose teeth
before the blade, and document what you found.
Laryngospasm
The complication this age owns. It clusters around induction and emergence, in the
light plane at either end, and is commoner after a recent upper respiratory infection and around
secretions. Prevention is most of it: suction under adequate depth, do not instrument a light
patient, and choose the moment to remove the airway rather than letting it choose you.
When it happens: stop the stimulus, one hundred per cent oxygen, jaw thrust with firm pressure at
the laryngospasm notch behind the ear lobe, and gentle continuous positive pressure. If that fails,
deepen. If that fails, paralyse — and remember it works intramuscularly if there is no line,
which is exactly the situation in which you will need it.
Waking up
- Emergence deliriumPeaks in precisely this age group, more so after the volatile
agents, and is not pain, though it looks like it and is routinely treated as it. Inconsolable,
non-purposeful, not recognising the parent, settling over twenty minutes or so. Recognising it saves
the child an opioid they do not need.
- Reducing itA small dose of propofol at the end, or dexmedetomidine, or an adequate
regional block so they are not surfacing into pain. A quiet, dim recovery bay with the parent
already there does more than any of them.
- Analgesia planned, not rescuedParacetamol and an anti-inflammatory given early and
regularly, plus a block where the operation allows, means most of these children need nothing
stronger. The child who wakes in pain is very hard to catch up.
- NauseaCheap to prevent and grim to treat at this age, particularly for the operations
that carry the highest risk. Two agents from different classes for anyone with risk factors.
And the thing that lasts. A bad induction at three shapes every subsequent
encounter with a hospital — the dental visit, the immunisation, the anaesthetic at seven.
A play specialist, ten unhurried minutes and one attempt by the right person are not softness.
They are the intervention with the longest follow-up in this entire piece.
Over to you
What is your induction routine for a frightened three-year-old — the actual words,
the actual order?
This is the least written-down skill in the specialty and the most unevenly held. Some people have
a script they have used ten thousand times and have never told anyone. Send me yours and I will
collect them, with or without your name.
Send me your routine
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icuandyou@icloud.com instead.