What is the recommended anesthesia perioperative plan for a healthy 4-year-old girl (bilateral myringotomy and grommet insertion) undergoing elective surgery, including induction, airway management, and maintenance of anesthesia?

Anesthesia Perioperative Plan for Bilateral Myringotomy and Grommet Insertion

For this healthy 4-year-old undergoing bilateral myringotomy, use sevoflurane inhalational induction with spontaneous ventilation via facemask or laryngeal mask airway, maintain anesthesia with sevoflurane in oxygen/nitrous oxide, and ensure adequate analgesia with preoperative acetaminophen-codeine or ketorolac. 1

Preoperative Preparation

Equipment Setup

• Position with shoulder roll for optimal airway alignment and have appropriately sized oral/nasopharyngeal airways (size 2-3) immediately available 2
• Prepare supraglottic airway device (LMA size 2) as rescue device with maximum 3 insertion attempts if needed 3, 2
• Have suction immediately available and ensure standard monitoring (pulse oximetry, ECG, blood pressure, capnography) 2

Premedication and Analgesia

• Administer oral midazolam 0.5-0.7 mg/kg (approximately 7-10 mg for 14 kg) mixed with acetaminophen-codeine (acetaminophen 10 mg/kg + codeine 1 mg/kg) 30 minutes before induction 4, 5
• Alternative: oral ketorolac 1 mg/kg provides superior postoperative analgesia compared to acetaminophen alone 6
• The acetaminophen-codeine combination eliminates need for supplemental analgesics in most patients, whereas acetaminophen alone requires rescue analgesia in 48% of cases 4

Induction of Anesthesia

Inhalational Induction Technique

• Induce with sevoflurane 1-8% in oxygen 100% or oxygen/nitrous oxide 60:40 via facemask 1, 5
• Sevoflurane has nonpungent odor making it ideal for mask induction in pediatric patients 1
• Incrementally increase inspired sevoflurane concentration while closely monitoring heart rate, particularly given risk of bradycardia during induction 1
• Expected induction events: agitation 14%, cough 6%, breathholding 5%, laryngospasm 2% 1

Critical Monitoring During Induction

• Maintain continuous vigilance as younger children desaturate rapidly below 94% SpO₂ 2
• Have anticholinergic (atropine) and epinephrine immediately available 1

Airway Management

Primary Airway Strategy

• Maintain spontaneous ventilation throughout via facemask or LMA—avoid muscle relaxants for this brief procedure 2
• LMA reduces perioperative respiratory adverse events by 66% compared to tracheal intubation (relative risk 2.94 for intubation) 3
• LMA decreases risk of laryngospasm and bronchospasm 5-fold compared to endotracheal intubation 3

If Mask Ventilation Becomes Difficult

• Immediately optimize head position (neck flexion with head extension) and apply jaw thrust 2, 7
• Consider inserting oropharyngeal airway if ventilation remains inadequate 3, 2
• If ventilation still inadequate after airway maneuvers, insert supraglottic airway (maximum 3 attempts) 3, 2

Difficult Airway Algorithm

• If direct laryngoscopy required: maximum 2 attempts by senior practitioner 3
• Ensure oxygenation between attempts, maintain adequate depth of anesthesia 3
• Consider stylet, bougie, or videolaryngoscope if difficult visualization 3

Maintenance of Anesthesia

Anesthetic Maintenance

• Maintain with sevoflurane approximately 1.3 MAC (2.6% end-tidal) in oxygen/nitrous oxide 40:60 1, 5
• Use Mapleson D circuit with controlled or spontaneous ventilation 5
• Ensure adequate depth before surgical stimulation to prevent laryngospasm—monitor for signs of inadequate depth including movement, cough, or increased respiratory rate 2

Hemodynamic Expectations

• Expect 15-20% decrease in systolic blood pressure at 1 MAC sevoflurane 1
• Bradycardia (>20 beats/min below normal) occurs in 3% of pediatric patients with sevoflurane 1

Emergence and Recovery

Emergence Strategy

• Discontinue sevoflurane and nitrous oxide at end of surgery 5
• No recommendation exists for removing LMA deep versus awake—both techniques have equivalent serious complication rates 3
• If removing LMA under deep anesthesia, anticipate higher risk of upper airway obstruction and be prepared with jaw thrust or oropharyngeal airway insertion 3, 2
• If removing LMA awake, expect higher incidence of cough but lower risk of airway obstruction 3

Expected Recovery Times with Sevoflurane

• Time to eye opening: 11 minutes 5
• Time to respond to commands: 11-13 minutes 1
• Time to eligibility for discharge: 130-140 minutes 1, 5
• Recovery times similar to halothane but with 10% incidence of postoperative agitation versus 25% with halothane 5, 8

Management of Potential Complications

Laryngospasm Management

• Apply CPAP with 100% oxygen using reservoir bag and facemask while ensuring optimal head positioning and jaw thrust 7
• Apply Larson's maneuver: place middle finger in "laryngospasm notch" between posterior mandible and mastoid process, apply deep pressure while displacing mandible forward 7
• If laryngospasm persists, administer propofol 1-2 mg/kg IV 7
• For severe laryngospasm with total cord closure, administer suxamethonium 1 mg/kg IV immediately 7
• Monitor for bradycardia requiring atropine 7

Postoperative Analgesia

• Patients receiving preoperative acetaminophen-codeine require no supplemental analgesics versus 48% requiring rescue analgesia with acetaminophen alone 4
• Ketorolac provides superior postoperative pain control compared to acetaminophen or placebo 6

Critical Pitfalls to Avoid

• Do not perform multiple intubation attempts without maintaining oxygenation between attempts—use bag-valve-mask or supraglottic airway 3
• Do not ignore signs of inadequate depth before surgical stimulation—this precipitates laryngospasm 2, 7
• Complete laryngospasm presents with silent inspiration (no crowing sound) indicating total cord closure—if unrelieved, progresses to post-obstructive pulmonary edema and hypoxic cardiac arrest 7
• Acetaminophen alone provides inadequate analgesia—combine with codeine or use ketorolac 4, 6