Trauma is the leading cause of mortality and morbidity in children in developed countries. Traumatic brain injury is responsible for the largest proportion of deaths. Preventable death due to major haemorrhage occurs early in the first 24 hours. Mechanisms vary with age. Blunt injury represents over 80% of cases. Falls and road traffic collisions (RTCs) are the most common mechanisms across all ages, except for non-accidental injury (NAI) in < 1 year olds. There has been a substantial rise in penetrating trauma due to gun and knife crime in the adolescent population. The centralisation of trauma services in the United Kingdom with the creation of regional networks has changed how paediatric trauma is managed. Severely injured children are triaged at scene and taken directly to major trauma centres (MTCs). Outcomes have improved, and there is better standardisation between treating institutions. Initial trauma management involves stabilisation, resuscitation, identification and treatment of life-threatening injuries in the primary survey. Some patients will need damage control surgery to control haemorrhage. This is followed by definitive care and rehabilitation. Anaesthetists are an integral part of the trauma team involved throughout the patient journey. Dedicated anaesthetic roles are airway management and ongoing resuscitation during surgery.

The demand for procedural sedation is increasing in children of all ages who due to anxiety, medical need or the requirements of the intervention or investigation need a periprocedural plan consisting non-pharmacological and pharmacological approaches. While paediatric procedural sedation is practised by many medical and nursing specialists, for varied indications and in differing hospital locations it remains the responsibility of anaesthetists to have a comprehensive understanding of this discipline in order to advance this field and maintain safety standards. In the past decade, guidelines have been developed to ensure that children who undergo sedation are managed by clinicians who can competently assess their needs, take informed consent and plan and deliver a safe and effective sedation strategy in multiple scenarios, such as for painless imaging, painful procedures, dentistry and endoscopy. Recent updated fasting guidelines which are less restrictive means that children will be hydrated, less irritable and more stable when sedated. The drug dexmedetomidine and its extremely favourable respiratory profile and low rate of airway and respiratory complications have changed the face of sedation for painless imaging and are allowing a greater range of children to have these procedures without the need for general anaesthesia. The field of procedural sedation for children is rapidly growing in popularity amongst both clinicians and patients, and it is therefore vital for paediatric anaesthetists to stay up to date and aware of guidelines and advances.

Centralisation of specialist services, such as paediatric critical care, major trauma, cardiac surgery or neurosurgery, improves outcomes. For the critically ill child, accessing specialist critical care services may require transfer, either primarily by a ‘front line’ ambulance (bypassing non-specialist centres) or secondarily by hospital teams after initial resuscitation and stabilisation in a non-specialist centre.

This chapter describes the principles and practice of stabilisation and transport of the critically ill child between centres.

Total intravenous anaesthesia (TIVA) in children has for many years been seen as a niche method of anaesthetising children, reserved for enthusiasts and specific cases. The increased availability of programmable pumps and recognition of the value of TIVA in preventing postoperative nausea and vomiting (PONV), malignant hyperpyrexia (MH) and its excellent track record in minimising airway complication has led to a resurgence in interest in this technique. This chapter explains in detail the pharmacology of TIVA and the use of target-controlled infusions (TCI), focusing on propofol as the main agent used in TIVA, and elaborates on the development of newer pharmacokinetic models for delivering a consistency in concentration to children across the age spectrum. The chapter also looks remifentanil and its unique place in paediatric anaesthesia. We discuss the practicalities of using TCI in everyday cases as well as describe some specific benefits of the technique, especially in airway surgery, where TIVA and high-flow nasal oxygen are becoming an increasingly popular technique for airway examination and surgery. Finally, the chapter discusses areas in which TIVA use is challenging – neonates, teenagers and obesity – where extremes of weight and maturity make pharmacokinetic modelling difficult.

The impact of premature birth can be lifelong, and although the risk of acute complications reduces throughout infancy and early childhood, long-term morbidity remains high. Low gestational age at birth is an independent risk factor for increased mortality from respiratory, cardiovascular, endocrine and congenital disorders in childhood and early adulthood. This chapter describes the definitions and risk factors of prematurity and the clinical manifestations unique to the premature infant, including thermoregulatory instability, respiratory distress syndrome and bronchopulmonary dysplasia, apnoea of prematurity, patent ductus arteriosus, necrotising enterocolitis, intraventricular haemorrhage and retinopathy of prematurity. The preoperative, intraoperative and postoperative considerations for management of these vulnerable infants will be discussed. Finally, the conduct of anaesthesia in the ex-premature infant will be described and key points highlighted.

Centralisation of specialist services, such as paediatric critical care, major trauma, cardiac surgery or neurosurgery, improves outcomes. For the critically ill child, accessing specialist critical care services may require transfer, either primarily by a ‘front-line’ ambulance (bypassing non-specialist centres) or secondarily by hospital teams after initial resuscitation and stabilisation in a non-specialist centre.

Paediatric anaesthesia employs a range of equipment to ensure safe and effective achievement of anaesthetic goals. Variation in size and physiology in this age group has implications for clinicians using these technologies. Applied aspects and practical tips of this phenomenon are discussed in this chapter. Areas covered include equipment used to manage airway, vascular access, drug and fluid delivery, monitoring of various physiologic parameters, etc. While it is imperative to stay abreast with increasingly sophisticated drug delivery and monitoring systems, no monitor is a substitute for the presence and vigilance of the well-trained anaesthetist.

Pain following surgery continues to be a common experience in children, despite advances in acute pain management. The effective and safe management of pain in children of all ages requires significant knowledge of the biopsychosocial experience of pain and strategies available for its management. Numerous factors can influence the success of analgesic treatment: Developmental age has a profound effect on both the processing of nociceptive information and the response to analgesia; the pharmacology of all drugs is age and size dependent, requiring appropriate dosage adjustments; and communication with the very young or those with developmental delay can influence the ability to assess pain and monitor the response to treatment.

Anaesthetists working in paediatric settings may care for patients ranging in age from preterm neonates to teenagers, some of whom will be undergoing relatively simple procedures for isolated conditions whereas others will have extremely complex needs and will be undergoing complicated, high-risk procedures. What all of these patients will have in common, however, is the need for developmentally appropriate communication from and with the professionals caring for them. Alongside an understanding and knowledge of the anatomical, physiological and pharmacological issues relevant to the care of the paediatric patient, anaesthetists also need an understanding of the developmental, communication, emotional and behavioural issues relevant to their paediatric patient. This chapter summarises some of the key theories of cognitive and psychosocial development, including beliefs about illness, and how these are relevant to the child undergoing anaesthesia. Effective communication with children and their families is central to the delivery of high-quality care, and this is discussed alongside the role of preparation and behavioural and psychological techniques in optimising experiences and outcomes for the child, family and anaesthetist.

Anaesthesia for ENT surgery in children is varied, interesting and challenging. It ranges from grommet insertion and adenotonsillectomy, some of the most commonly conducted procedures in children, to the rare and evolving fields of airway reconstruction and EXIT procedures. Excellent teamwork and situational awareness are crucial to be safe and effective. This is particularly important in airway surgery given the small size of the paediatric airway, which is shared and often crowded with instruments, the sensitive physiology of small children and their frequent and complex comorbidities. Multidisciplinary team meetings and shared decision-making is increasingly important for these complex procedures and also on occasion for commonly conducted ENT procedures where there is a paucity of data around central issues such as postoperative admission criteria in children with obstructed sleep apnoea (OSA) and analgesia after tonsillectomy. Ultimately agreed local guidance should be followed as further investigations continue. An area of particular interest is the development of more effective modes of oxygenation such as high-flow oxygen delivery.

This chapter explains principles of safeguarding, the relevant law and statutory framework, the role of the anaesthetist in safeguarding, specific forms of abuse, the safeguarding process for children when concerns arise and the investigation process when a child dies.

Paediatric patients differ significantly from adults in the way that drugs affect them, for a number of reasons, including differences in their size, physiology and comorbidities. Developmental changes affecting the absorption, distribution, metabolism and excretion of many anaesthetic drugs, particularly during the first few months of life, profoundly affect both their pharmacokinetics and pharmacodynamics. Drugs discussed are the intravenous induction agents propofol, thiopental and ketamine; the sedatives dexmetetomidine and midazolam; and the opioids morphine, fentanyl and remifentanil, as well as muscle relaxants such as suxamethonium and non-depolarising relaxants. Inhalational anaesthetics are assessed for their usefulness in paediatric practice. Appropriate drug dosages are included and important differences from adult values emphasised.

This chapter describes the principles and practice of anaesthesia for radiological imaging and interventional procedures. A comprehensive account of the assessment, planning and conduct of anaesthesia for these patients is given. Commonly performed interventional radiology procedures and their associated conditions are considered in detail. Consideration of the challenges of providing anaesthesia in ‘remote sites’, such as the imaging suite, is offered.

Children presenting for general paediatric surgery range in both age and complexity from neonates undergoing hernia repair to older children undergoing appendicectomy or excision of extensive neuroblastoma. In this chapter, we provide an overview of general surgery for infants and children beyond the neonatal period. We discuss the anaesthetic management of major and minor cases highlighting the variety of general and regional anaesthetic techniques available to anaesthetists. Children presenting for major surgery or multiple procedures or those with significant additional comorbidities warrant additional attention. Here, close communication with the surgeon and wider multidisciplinary team is necessary to establish risks, develop plans to mitigate risk and communicate risk to children and parents effectively.

Patient safety is the avoidance of unintended or unexpected harm to people during the provision of health care. Anaesthetists have been leaders in patient safety for decades. In the United Kingdom, wholesale reform of children’s surgical delivery was undertaken after review of paediatric surgical outcomes in the 1990s, and in cardiac surgery, after an anaesthetist noted poor patient outcomes in children undergoing the arterial switch operation (see Kennedy 1996 in ‘Further Reading’).

The provision of safe, appropriate and effective vascular access for children is complex and can be very challenging. This chapter will outline the routes available for vascular access, the factors influencing the choice of catheters and devices used and their associated complications. Choosing the most appropriate site and type of vascular access must be specific to each child and to their treatment requirements. The use of care bundles as part of an evidence-based package of care is also discussed.

This chapter describes the principles and practice of anaesthesia for dental surgery. A comprehensive account of the assessment, planning and conduct of anaesthesia is given. Commonly performed dental procedures are considered in detail, together with the management of dentofacial infection and maxillofacial trauma in children.

The safe and effective delivery of neuroanaesthesia in children requires knowledge of normal development and neurophysiology. Preoperative assessment must pay particular attention to the symptoms and signs of raised intracranial pressure. The conduct of anaesthesia is influenced by the underlying pathology, the procedure being performed and the need for intraoperative neuromonitoring. Extreme vigilance is required in circumstances where venous air embolus (VAE) is a risk, and the provision of appropriate facilities is essential.

The neonatal period marks the transition from prenatal to postnatal life. This transition is characterised by rapid physiological change and neurodevelopmental plasticity. Anaesthesia, surgery and perioperative events have the potential to trigger long-lasting adverse outcomes. Understanding the changes that occur in the neonatal period is the key to delivering safe and effective care. In this chapter, we consider the development of major organ systems in utero, the transition from intrauterine to extrauterine life and aspects of newborn physiology relevant to the paediatric anaesthetist. We will also address the continuing debate regarding the potential for anaesthesia exposure in infancy to lead to persistent neurocognitive impairment.

This chapter describes the principles and practice of anaesthesia for oncology and other medical procedures. A comprehensive account of the assessment, planning and conduct of anaesthesia for these patients is given. Common paediatric cancers and their relevance to anaesthesia are discussed.