What are the recommended medications and dosages for pediatric induction of anesthesia?

Pediatric Induction Medications in Anesthesia with Dosage

For pediatric anesthesia induction, succinylcholine is recommended as the first-line muscle relaxant for rapid sequence induction, with age-appropriate dosing: <1 month: 1.8 mg/kg, 1 month to 1 year: 2.0 mg/kg, 1-10 years: 1.2 mg/kg, >10 years: 1.0 mg/kg. 1

Muscle Relaxants for Induction

Rapid Sequence Induction

• Use of a rapid-onset muscle relaxant is strongly recommended for rapid sequence induction in children 1
• Succinylcholine remains the expert choice for rapid sequence induction with age-appropriate dosing 1
• When succinylcholine is contraindicated, rocuronium at doses >0.9 mg/kg is recommended as an alternative 1
• The choice between succinylcholine and rocuronium should consider the desired duration of muscle relaxation, risk of difficult intubation, and presence of neuromuscular disease 1

Contraindications for Succinylcholine

• Succinylcholine is contraindicated in cases of primary muscle damage (myopathies) or up-regulation of nicotinic acetylcholine receptors at the motor end plate (chronic motor deficit) 1
• In patients with specific muscle disorders (myopathy, myotonia), succinylcholine can induce generalized contraction with rhabdomyolysis 1
• Avoid succinylcholine in patients with impaired nicotinic acetylcholine receptors due to risk of life-threatening hyperkalemia 1

Intravenous Induction Agents

Propofol

• For children aged 3-15 years, propofol 2.5 mg/kg is an appropriate induction dose when preceded by 5 μg/kg alfentanil 2
• For unpremedicated children 3-12 years old, the effective dose (ED95) for successful induction is 2.3 mg/kg 3
• A dose of 2.5-3.0 mg/kg is recommended to ensure smooth transition to inhalational maintenance technique 3
• Use of antecubital veins is associated with lower incidence of pain on injection 3
• Propofol dosage should be individualized according to the patient's condition, with reduced doses in patients who have received large doses of narcotics 4

Sevoflurane

• For inhalational induction, sevoflurane is commonly used at 8% in oxygen/nitrous oxide mixture 5, 6
• Sevoflurane is associated with less intraoperative body movement compared to propofol maintenance in pediatric surgeries lasting less than 1 hour 6
• Low-flow technique (reducing fresh gas flow to 1 L/min after applying facemask) can significantly reduce sevoflurane consumption without compromising induction time or conditions 7

Combination Approaches

• During inhalational induction, the use of muscle relaxants may be beneficial, especially in infants, improving intubation conditions and reducing adverse respiratory events 1
• The combination of sevoflurane with propofol (1 mg/kg bolus at the end of surgery) may optimize recovery 6
• When using propofol for induction, a dose of 2.5 mg/kg preceded by alfentanil (5 μg/kg) provides appropriate conditions 2

Special Considerations

• Monitoring of neuromuscular blockade is warranted in pediatric anesthesia, as residual neuromuscular blockade is estimated at 28% in children receiving muscle relaxants 1
• The duration of apnea without hypoxemia is shorter in younger children, necessitating rapid airway protection after loss of consciousness 1
• For reversal of neuromuscular blockade, the recommended dose is 0.2 mg glycopyrrolate for each 1.0 mg of neostigmine or 5.0 mg of pyridostigmine 8
• In children with upper respiratory infections, preoperative inhaled salbutamol (2.5 mg for <20 kg, 5 mg for >20 kg) may reduce perioperative respiratory adverse events 1

Common Pitfalls and Caveats

• Doses of opioid or hypnotics that allow tracheal intubation without a muscle relaxant are high and have significant hemodynamic effects 1
• Apnea occurs more frequently in older children and with larger propofol doses 2
• Blood pressure may decrease by more than 20% from baseline when halothane is used after propofol bolus 3
• Sugammadex is useful for reversing rocuronium effects but may not be approved for use in children in all regions 1
• The risk of anaphylaxis with muscle relaxants should be considered, though it is generally low 1

1, 9, 8, 4, 2, 5, 6, 3, 7