This chapter explains the law surrounding consent for the medical treatment of children, when children can give consent themselves, who can give consent of their behalf and when a refusal of consent should be respected. It also considers guidelines relevant for the practice of restraint in paediatric anaesthesia. Finally, it discusses the unique features of the ethics of research involving children, including the levels of risk that are deemed acceptable.

Anaesthetic preoperative assessment is an essential part of the child’s admission. Standards of care dictate that this needs to be done in advance of the day of admission to ensure the patient is medically optimised and prepared for their anaesthetic. A detailed discussion about the side effects and risk of anaesthesia is essential, and families should be given written or electronic information as part of this process. All anaesthetists who are involved in the care of children should have a sound knowledge of common medical conditions in childhood. They should understand how these conditions can be affected by anaesthesia and surgery and what preoperative investigations and planning are required to deliver a safe anaesthetic. Those medical specialties that are regularly involved in the care of the child should be contacted to help guide the perioperative management and ensure a collaborative approach to the care of the child.

The majority of children undergoing elective surgery can be discharged home on the same day. This has significant benefits for the child, improves productivity and reduces cost. A paediatric day-case service needs an infrastructure based on the guidelines set up by the Department of Health and professional bodies. The anaesthetist plays a vital role in this service and must be trained to use techniques that minimise perioperative pain and postoperative nausea and vomiting. There are clear published guidelines for the process of selecting appropriate patients and cases. In the past, performing tonsillectomies in children with obstructive sleep apnoea (OSA) as a day-case procedure was controversial. With improving surgical and anaesthetic techniques, most of these cases can now be done as day cases. A consensus statement was released in 2018 with recommendations of which patients should be excluded from this group. Good planning by the ward nurses, play therapists, theatre staff, surgeons and anaesthetists is essential to ensure the smooth running of a unit. Anaesthesia techniques require planning and attention to detail. A multimodal to approach to pain relief including local/regional anaesthesia is essential. Knowledge of risk factors and appropriate prevention of postoperative nausea and vomiting (PONV) is also vital. Regular patient satisfaction surveys and audit of quality and safety of care should be conducted using published standards.

This chapter describes the principles and practice of anaesthesia for paediatric hepatobiliary surgery, including transplantation. Hepatobiliary physiology, the pathophysiology of paediatric liver disease and its sequelae are discussed. A comprehensive account of the assessment, planning and conduct of anaesthesia for these patients is given. Commonly performed hepatobiliary surgical procedures and their associated conditions are considered in detail. Particular focus on liver transplantation in children is given.

The catheterisation laboratory (cath lab) continues to advance with updated technology and novel devices, allowing catheter-based interventions on more complex cases of congenital and acquired heart disease with the added benefit of reduced radiation exposure. Today, a wider range of catheter-based interventions exist, replacing or postponing the need for a surgical approach. Even extremely preterm infants (some less than 800 g) can now be offered interventional procedures in the cardiac catheter laboratory. Conversely, there is a reduced need for cardiac catheterisation as a purely diagnostic tool, as non-invasive imaging modalities such as cardiac CT and MRI continue to increase in their application and sophistication. The anaesthetist will find themselves undertaking high-risk anaesthetics, with challenges inherent to the cath lab, with riskier and more complex children, in a location which may be remote from the theatre suite. Anaesthetists managing children with complex congenital cardiac disease have to understand the pathophysiology of these patients and, importantly, the effects that anaesthesia and any intervention will have on their underlying physiology.

This chapter describes the principles and practice of regional anaesthesia and analgesia in children. The anatomy, imaging, pharmacology and clinical principles of the most commonly used blocks are described.

Anaesthesia for paediatric urology may be for minor to major complex surgery. In this chapter, we discuss the anaesthetic management of a subspecialty that allows for a variety of general and regional anaesthetic techniques to be applied. Minor procedures include cystoscopy, resection of posterior urethral valves, circumcision, insertion of suprapubic (SP) lines, hypospadias repair and orchidopexy. We discuss techniques for major surgery, including pyeloplasty, ureteric re-implantation, nephrectomy, resection of Wilms tumour (nephroblastoma), bladder exstrophy and epispadias repair, bladder augmentation (ileocystoplasty) and formation of Mitrofanoff, as well as renal transplantation. Preoperatively, children undergoing cystoscopy and major urological and reconstructive surgery require a urine culture to guide antibiotic prophylaxis. Local ‘maximum surgical blood ordering schedules’ should be followed for guidance regarding cross-matching of blood for major procedures. Close communication with the surgeon and wider multidisciplinary team is necessary to identify the extent of surgery, positioning and appropriate vascular access for complex surgery and renal transplantation.

Anaesthesia for thoracic surgery in children poses a variety of challenges for the paediatric anaesthetist, who will encounter problems different from those faced in adult practice. It is a low-volume surgical speciality, thus predominantly confined to specialist paediatric centres with anaesthesia required for a heterogenous range of conditions. One-lung ventilation may often be required, and knowledge of the techniques used for the varying size of the paediatric airway is essential. The impact of patient positioning, surgical retraction of the lung and the underlying disease process poses further challenges to the paediatric anaesthetist. This chapter covers management of the most common paediatric specific disease processes, including congenital and acquired lung abnormalities, intrathoracic masses, intrapleural collections and pectus surgery with an emphasis on lung isolation techniques and perioperative analgesia, including regional anaesthesia.

Which of the following is U.S. Food and Drug Administration (FDA)-approved for the treatment of schizophrenia in adolescents?

Which of the following represents an evidence-based intervention for a child with SSRI-related activation?

In addition to D2 antagonism, clozapine’s effect at which of the following receptors may contribute to its antipsychotic efficacy?

When discontinuing an SSRI in an adolescent with major depressive disorder following 12 months of treatment, the highest risk of relapse occurs: