What is the recommended anesthetic plan, including drugs and technique, for a 1-year-old child weighing 16kg undergoing general anesthesia (GA) via a mask technique?

Anesthetic Plan for Pure Mask GA in a 16kg, 1-Year-Old Child

For a 1-year-old child weighing 16kg undergoing pure mask general anesthesia, use sevoflurane 8% in oxygen for induction via facemask, then maintain with 2-3% sevoflurane in oxygen/nitrous oxide mixture (50:50) at 1-2 L/min fresh gas flow, with spontaneous ventilation throughout the procedure. 1, 2

Induction Technique

Pre-Induction Setup

• Position the child with a shoulder roll for optimal airway alignment (flexion of neck and extension of head) given age <2 years 3
• Have appropriately sized oral/nasopharyngeal airways immediately available 3
• Ensure supraglottic airway device (size 1.5 or 2) is readily accessible as rescue device 3

Induction Protocol

• Apply facemask gently and deliver 8% sevoflurane in 100% oxygen at 6 L/min fresh gas flow 1, 4
• Expected induction time is approximately 40-95 seconds to loss of eyelash reflex 5, 4
• This high-concentration primed-circuit technique is faster than incremental induction without increasing complications 4
• Monitor for common induction events: cough (6%), breathholding (5%), laryngospasm (2%), agitation (14%) 1, 2

Critical Airway Management Points

• Younger children desaturate rapidly below 94% SpO2 - maintain continuous vigilance 3
• If mask ventilation becomes difficult, immediately optimize head position with jaw thrust and consider oropharyngeal airway 3
• If ventilation remains inadequate after airway maneuvers, insert supraglottic airway (maximum 3 attempts) 3

Maintenance of Anesthesia

Standard Maintenance

• Reduce sevoflurane to 2-3% once adequate depth achieved 1, 2
• Add nitrous oxide 50-60% in oxygen mixture to reduce sevoflurane requirements 1, 4
• Reduce fresh gas flow to 1-2 L/min for maintenance 6
• Maintain spontaneous ventilation throughout - avoid muscle relaxants for pure mask technique 3

Depth Monitoring

• Ensure adequate depth before surgical stimulation to prevent laryngospasm 3
• Signs of inadequate depth include movement, cough, or increased respiratory rate 3
• At 1 MAC sevoflurane, expect 15-20% decrease in systolic blood pressure without clinically significant hypotension 1

Emergence and Recovery

Emergence Strategy

• Discontinue sevoflurane at procedure completion while maintaining oxygen flow 1, 2
• Expected time to eye opening: 8-11 minutes 1, 5
• Expected time to respond to commands: 9-13 minutes 1
• Sevoflurane provides faster emergence than halothane (12 vs 19 minutes) 1, 2

Airway Management During Emergence

• Risk of upper airway obstruction is higher when emerging under deep anesthesia 3
• Anticipate need for jaw thrust or oropharyngeal airway insertion 3
• Maintain optimal head positioning throughout emergence 3
• Consider gastric decompression if significant gastric inflation occurred 3

Common Pitfalls and Complications

Induction Complications

• Bradycardia requiring intervention occurs in 3% of pediatric cases 1
• Have anticholinergic (atropine 0.02 mg/kg) immediately available 1
• Laryngospasm occurs in approximately 2% - treat with positive pressure, jaw thrust, and deepening anesthesia 1, 2

Emergence Agitation

• Postoperative agitation occurs in 14% of children with sevoflurane 1, 2
• This is similar to halothane rates (10-11%) and not consistently different between agents 1, 2
• Early pain may be more intense with rapid emergence - have analgesia ready 2

Respiratory Complications

• Cough is less common with sevoflurane than halothane during emergence 3
• Postoperative nausea/vomiting may be less with sevoflurane compared to halothane 2, 7
• Monitor for at least 30 minutes in recovery until cardiovascular and respiratory stability assured 3, 5

Contraindications and Warnings

• Do not use in patients with known/suspected malignant hyperthermia susceptibility 1
• Avoid in patients with known neuromuscular disease (risk of hyperkalemia) 1
• Use caution and incremental increases in patients with Down syndrome due to bradycardia risk 1

Equipment Requirements

• Appropriately sized facemask for 1-year-old 3
• Oral airways (sizes 40-50mm) and nasopharyngeal airways 3
• Supraglottic airway device size 1.5 or 2 as backup 3
• Suction immediately available 3
• Standard monitoring: pulse oximetry, ECG, blood pressure, capnography 3