What is the recommended anesthetic plan for a 4-year-old male weighing 13 kg with no mentioned significant medical history, undergoing tongue tie release?

Anesthetic Drug Chart for 4-Year-Old Male, 13 kg, Tongue Tie Release

For this brief oral procedure, use inhalational induction with sevoflurane and maintain anesthesia with a laryngeal mask airway (LMA) under spontaneous ventilation, avoiding endotracheal intubation and muscle relaxants entirely. 1

Preoperative Preparation

Equipment Setup

• Position patient with shoulder roll under shoulders to optimize airway alignment with neutral head positioning 1
• Have immediately available: Size 1.5 or 2 LMA, oral/nasopharyngeal airways, suction at bedside 1
• Confirm standard monitoring: pulse oximetry, ECG, blood pressure, capnography 1

Premedication (Optional)

• Consider antisialagogue (glycopyrrolate 0.01 mg/kg IV or 0.02 mg/kg IM, maximum 0.2 mg) to reduce salivation during airway manipulation 2
• Midazolam 0.5 mg/kg PO (maximum 20 mg) 20-30 minutes prior if anxious, though not mandatory for this brief procedure

Induction Phase

Primary Induction Agent

• Sevoflurane inhalational induction is the standard approach for this age and weight 1
• Start with 8% sevoflurane in 50% nitrous oxide/oxygen via face mask 3, 4
• Maintain continuous vigilance as children this age desaturate rapidly below 94% SpO₂ 1

Dosing for This Patient (13 kg)

Drug	Dose	Calculation	Route	Timing
Sevoflurane	8% initially, then 2-3% maintenance	Concentration-based	Inhalational	Start of induction
Fentanyl	13-26 mcg (1-2 mcg/kg)	1-2 mcg/kg	IV after induction	Before LMA insertion

Critical Induction Considerations

• If mask ventilation becomes difficult, immediately optimize head position with jaw thrust and consider oropharyngeal airway 1
• Avoid desflurane if any signs of upper respiratory infection, as it increases airway resistance compared to sevoflurane 5

Airway Management

LMA Insertion (Strongly Preferred)

• Use LMA rather than endotracheal intubation - this reduces perioperative respiratory adverse events by 66% and decreases laryngospasm/bronchospasm risk 5-fold 1
• Size 1.5 or 2 LMA appropriate for 13 kg patient 1
• Maximum 3 insertion attempts allowed 1
• Insert when adequate depth achieved (loss of eyelash reflex, jaw relaxation) - typically 1-3 minutes after sevoflurane induction 4, 6

Optional Adjuncts for LMA Insertion

• Lidocaine 13-26 mg IV (1-2 mg/kg) may be given 30 seconds to 5 minutes before LMA insertion to reduce laryngospasm risk, though evidence in healthy children is mixed 7
• Propofol 0.5-1 mg/kg IV can supplement if depth inadequate after sevoflurane induction 6

Avoid Intubation

• Do NOT use endotracheal intubation for this brief procedure - it increases respiratory complications 5-fold (relative risk 2.94) without providing necessary benefit 1
• Do NOT use muscle relaxants - maintain spontaneous ventilation throughout 1

Maintenance Phase

Anesthetic Maintenance

• Sevoflurane 2-3% in 50% oxygen/air mixture to maintain adequate depth 3, 8
• Maintain spontaneous ventilation - do not use controlled ventilation or muscle relaxants 1
• Monitor for adequate depth: absence of movement, stable respiratory rate, no cough 1

Intraoperative Monitoring

• Ensure adequate depth before surgical stimulation to prevent laryngospasm 1
• Watch for signs of light anesthesia: movement, cough, increased respiratory rate 1
• Maintain capnography waveform to confirm ventilation 1

Emergence and Recovery

LMA Removal Strategy

• No evidence favors either deep or awake removal - both have equivalent serious complication rates 1
• If removing deep: ensure effective spontaneous breathing (tidal volume ≥5 mL/kg = ≥65 mL for this patient, age-appropriate rate) 5
• If removing awake: wait for grimacing, cough with open mouth, or eye opening 5

Emergence Preparation

• Be prepared for upper airway obstruction during emergence 1
• Have jaw thrust and oropharyngeal airway ready to manage any obstruction 1
• Maintain optimal head positioning throughout emergence 1

Analgesic Plan

Intraoperative Analgesia

• Fentanyl 13-26 mcg (1-2 mcg/kg) IV given after induction 6
• Local anesthetic infiltration by surgeon at surgical site

Postoperative Analgesia

• Acetaminophen 15 mg/kg PO/PR (195 mg for 13 kg) every 6 hours, maximum 75 mg/kg/day
• Ibuprofen 10 mg/kg PO (130 mg for 13 kg) every 6-8 hours if needed, maximum 40 mg/kg/day

Critical Pitfalls to Avoid

• Never perform multiple airway attempts without maintaining oxygenation between attempts using bag-valve-mask 1
• Never ignore signs of inadequate depth before surgical stimulation - this precipitates laryngospasm 1
• Never choose endotracheal intubation for this brief procedure - it increases respiratory complications 5-fold 1
• Never use rapid IV bolus of propofol or ketamine without slow administration over 60 seconds, as this causes respiratory depression 2

Summary Drug Chart

Drug	Dose for 13 kg	Route	Timing
Sevoflurane	8% induction, 2-3% maintenance	Inhalational	Throughout
Fentanyl	13-26 mcg	IV	After induction
Lidocaine (optional)	13-26 mg	IV	Before LMA insertion
Acetaminophen	195 mg	PO/PR	Postoperative
Ibuprofen	130 mg	PO	Postoperative PRN