This chapter describes the principles and practice of anaesthesia for craniofacial surgery. A comprehensive account of the assessment, planning and conduct of anaesthesia is given. Commonly performed craniofacial procedures will be considered in detail, along with specific anaesthetic considerations.

Ophthalmic surgery takes place in children of all ages, from premature neonates to teenagers, the majority of whom are ASA 1 or 2. In some cases, the ocular pathology may be part of a wider congenital or metabolic abnormality and anaesthesia is not so straightforward. Nearly all will require general anaesthesia. Anxiety can be common in children returning for repeated procedures, and premedication may be necessary. Surgery can be extraocular or intraocular. Simple day-case procedures can usually be managed with an inhalational spontaneous breathing technique and supraglottic airway device (SAD). Certain more complex cases necessitate a completely still eye, and muscle relaxation is therefore usually required. Special anaesthetic considerations are management of the oculocardiac reflex (OCR), commonly elicited by traction on the recti muscles and prevention of postoperative nausea and vomiting (PONV); strabismus surgery is particularly emetogenic. The majority of ophthalmic surgery is not particularly painful, and simple analgesia with paracetamol and NSAIDs is sufficient. Regional ophthalmic blocks, such as sub-Tenons, can supplement or offer an alternative to opiates when additional analgesia is required. This has the added advantage of producing akinesis of the globe and a beneficial reduction in PONV and the OCR.

Cleft lip and palate is a relatively common congenital condition presenting for surgical correction. Anaesthetic management has some specific considerations involving airway surgery in infants and young children who may have other associated anomalies. Surgical care pathway and approaches are discussed as relevant to anaesthesiologists. Perioperative management, including preassessment of the child, optimisation prior to surgery, intraoperative and postoperative care, is presented. The importance of a multidisciplinary approach, good communication, shared airway management and adequate multimodal analgesia with the avoidance of respiratory depression are highlighted. Anaesthesia for secondary speech surgery is also presented.

The majority of paediatric surgery carried out is for minor procedures in fit and healthy children and can be performed as day-case procedures. A large quantity of this work is performed in non-specialist hospitals. Children and families need to be able to access high-quality services close to home, and delivering care locally, where possible to do so safely, can add to the patient and parent experience. A non-specialist centre should have arrangements and local guidance for treating and managing simple surgical emergencies in the paediatric population, along with the ability to resuscitate and stabilise critically ill children of all ages before transfer to a tertiary specialist centre for either paediatric critical care or surgery. Continual education and training within regional networks are vital in maintaining skills and confidence of staff in non-specialist centres, and standardisation along with protocols is helpful in the anaesthetic management, analgesic plan, preassessment and critical transfers of children in a non-specialist centre.

As antenatal diagnosis improves and surgical techniques are developed, the paediatric cardiac anaesthetist has an increasing role in the multidisciplinary team looking after the child undergoing cardiac surgery. Successful major operations in the neonatal period require balancing circulation and managing inotropy, coagulation and technical challenges. The anaesthetist must understand the entire perioperative period. This chapter covers the essentials of cardiac-stable anaesthesia, management of cardiopulmonary bypass and the physiological changes that can occur during children’s surgery for heart disease. Common cardiac lesions and their anaesthetic management are described in addition to the potential decompensation pathways and strategies to mitigate them. Right-to-left and left-to-right shunts, complex anatomical arrangements and anaesthesia for poor ventricular function are all covered.

Congenital heart disease (CHD) is the commonest birth defect, and children may present at all ages with variably corrected lesions for both elective and emergency surgery. No single anaesthetic approach can be recommended in this heterogeneous group of children, so a general strategy is presented based on applied physiology and the available evidence. Pathophysiological patterns are presented along with the common physiological consequences of cardiac disease in children: cardiac failure, cyanosis, pulmonary hypertension and arrhythmias. Children with congenital heart disease presenting for non-cardiac surgery are at increased perioperative risk compared to their unaffected peers. Risk factors are identified, and a scoring system to predict in-hospital mortality is presented. Preoperative assessment encompasses consideration of the optimal location for surgery as well as specific considerations, including echocardiography, infectious endocarditis prophylaxis and pacemaker/ defibrillators. In general, a balanced anaesthetic technique including controlled ventilation and opioids to reduce volatile exposure is preferred. However, with appropriate understanding of the underlying physiology, most anaesthetic techniques can be used safely and successfully in children with CHD.

Intravenous fluids are routinely given to children when the enteral route is not sufficient or it’s not an option, such as during surgery and anaesthesia. Lack of understanding of the composition of fluids and the appropriate rate to administer them has been associated with serious morbidity and mortality in children. Recent evidence has shown that giving children isotonic fluids with a sodium concentration similar to plasma decreases the risk of hyponatraemia without an increase in adverse effects. This has led to a change in guidelines, which now recommend that isotonic fluids are used in children along with regular monitoring of fluid balance and electrolytes. Current evidence supported by several anaesthesia societies across the world recommend that children are allowed and should be encouraged to drink clear fluids up to one hour before elective surgery. Evidence is starting to emerge from enhanced recovery programmes in children of improved outcomes from individualised perioperative fluid therapy and avoidance of prolonged preoperative fasting. Strategies to reduce blood transfusion in children having surgery include treatment of preoperative iron deficiency, acceptance of low transfusion thresholds, cell salvage and tranexamic acid administration.

Neonates presenting for specialist neonatal and paediatric surgery range in age and complexity from the extremely premature infant undergoing laparotomy for necrotising enterocolitis to the healthy term neonate undergoing hernia repair. Many patients presenting for repair of congenital abnormalities are born prematurely and/or have congenital cardiac defects, which leads to additional challenges. The most common general surgical conditions presenting in the newborn period are oesophageal atresia (OA) with or without trachea-oesophageal fistula (TOF), congenital diaphragmatic hernia (CDH), intestinal atresias, meconium ileus, malrotation and volvulus, Hirschsprung’s disease, imperforate anus, exomphalos, gastroschisis and necrotising enterocolitis (NEC). Anaesthetic techniques should be tailored to the relevant surgical condition, but most of the key principles of management are similar and require an in-depth knowledge of the anatomical, physiological and pharmacological differences particular to this vulnerable group of patients. In this chapter, we discuss the general considerations for anaesthesia in neonatal surgery and then each specific neonatal condition in relation to their anaesthetic and surgical management.

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 will be considered in detail, together with the management of dentofacial infection and maxillofacial trauma in children.

This chapter provides an outline of the areas of paediatric intensive care relevant to an anaesthetist. The chapter examines current epidemiology in critical care and the characteristics of children requiring transfer from local hospitals to specialist centres. It reviews differences between adult and paediatric respiratory physiology, outlines an approach to medications used in intubation and discusses respiratory support for critically unwell children. The chapter provides key basic guidance on the use of high-frequency oscillatory ventilation (HFOV) in children. Maintenance fluid and inotrope selection are also reviewed. The chapter also reviews presentations commonly encountered on paediatric intensive care units (PICU) across respiratory, cardiovascular, gastrointestinal, renal, neurological, metabolic and infectious conditions. Neuroprotection criteria are provided, with key relevance to anaesthetists who may need to undertake time-critical transfers from their usual place of work to neurosurgical centres. Organ donation and non-accidental injury are also discussed.

Paediatric orthopaedic surgery is wide-ranging in scope and complexity. Many patients have coexisting conditions, including cerebral palsy and neuromuscular diseases. Cerebral palsy presents a wide spectrum of motor dysfunction. Preoperative assessment must be guided by associated comorbidities and particularly evaluate respiratory function and any associated cardiac disease. Patients with muscular dystrophy presenting for major orthopaedic or spinal surgery have a high risk of morbidity and mortality, which must be discussed preoperatively; inhalational agents must be avoided due to the risk of rhabdomyolysis. Patients with conditions including osteogenesis imperfecta and arthrogryposis must be carefully managed and meticulously positioned for surgery. Major orthopaedic and spinal surgery can be accompanied by a significant risk of bleeding. Multimodal analgesic strategies, including the use of local anaesthetic blocks, should be used. Scoliosis may be congenital, acquired or idiopathic. Adolescent children with idiopathic scoliosis are often otherwise fit and healthy. In contrast, patients with acquired neuromuscular scoliosis often have significant comorbidities, particularly poor cardiorespiratory function, epilepsy and poor nutrition. Elective postoperative ventilation is frequently required. Intraoperative neuromonitoring is employed to detect and prevent potential spinal cord injury. Total intravenous anaesthesia is required for robust neuromonitoring of motor pathways, and muscle relaxation must be avoided intraoperatively.

This chapter describes the principles and practice of anaesthesia for oncology treatments 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.

This chapter covers principles of anaesthesia for children with congenital and inherited disease, with specific consideration of some conditions of particular relevance to paediatric anaesthetists, including the muscular dystrophies, malignant hyperthermia and the mucopolysaccharidoses.

Burns are a common injury throughout the world and are mostly preventable. A moment of inattention by a guardian or an older child playing with fire can lead to a lifetime of burn care. Children have a higher incidence of burns than adults, although most burns are small. Burns over 10% require formal fluid resuscitation to mitigate the effects of systemic oedema and burn shock. Definitive treatment involves non-operative techniques, such as application of dressings, or for larger or deeper injuries, operations to debride the wound and apply skin grafts. Each burn generates background, breakthrough and procedural pain that must be managed effectively. Small burns may be complicated by infection, larger burns by multiple organ failure. The outcomes are generally good, and children can survive and thrive even after very large injuries. Anaesthetists are involved in all aspects of burn care once a child reaches hospital, and they are an essential part of the multidisciplinary burn care team. The aim of this team is to deliver faster healing and better pain control, and to prevent complications. This chapter describes current burns care for children in the United Kingdom.