Parents in the Operating Room

It is very common for parents to request to be present during anesthetic induction. I welcome their participation in this process (limited to one, not both parents) because on some occasions, the security of having a parent present and avoiding separation allows us to omit premedication whereas in other situations, parental presence reduces anxiety sufficiently so that light premedication is adequate. Parental presence must, however, take into consideration the developmental level of the child and the reason for their presence. It serves no purpose to have a parent present during induction of anesthesia in a newborn or a 6-month-old who is completely trusting of strangers. Likewise, it is unlikely to benefit a child who has been heavily premedicated.^{[259] [260]} Certainly, they must not be present for rapid induction. Parents are present for the benefit of their child, and if the child does not benefit or if it makes the physicians uncomfortable, a parent should not be present.^[261] The safety and care of the child are top priority. I sometimes even explain that their participation in this process is a privilege, but not a right. Each physician and each institution must determine what works and what does not work for them. If I make a decision to allow a parent to be present, it is vital to explain to them what they might see so that there are no surprises. I explain that when anyone goes to sleep, the eyes roll upward. This response is normal, and they might see their child do this a few times. I assure them that they should expect this and not to worry that something is wrong. I next warn them that as people fall asleep, they often make noises from their throat (e.g., snoring) and that this is also normal and they might hear noises from their child's throat as their child falls asleep (I do not explain that this noise might be airway obstruction or developing laryngospasm). Third, I point out that the "brain often gets excited before it goes to sleep"; thus, after their child breathes the anesthesia medicine for 15 to 30 seconds, it is not unusual for the child to suddenly become restless and move the arms and legs. This response is expected, and shortly afterward their child will be completely anesthetized. I further explain that despite appearing to be awake, they do not remember this at all. Thus, the eye rolling, possible airway obstruction, and excitement are all explained and the parent is not frightened. I also make sure that the parent is sitting in a chair and explain that as soon as we ask them to leave, they must do so because at that point we must completely focus on the care of their child. For smaller children, I like to anesthetize them on the parent's lap. I have the child facing straight forward with the parent's arms wrapped around the child and helping to hold the arms near the child's side to reduce the potential for them to reach up and grab the mask. I explain to the parent that they are going to be able to hug their child as they go to sleep. I also explain that the child will become limp and could fall unless they hold on tight. I further state that as their child loses consciousness, we will pick their child up and place the child on the operating room table. They can then kiss their child and then proceed to the family waiting area. If there is a language barrier, I will ask a translator to help explain this process and allow the translator in the operating room to help the communication that is needed to perform a nontraumatic mask induction.

Rectal Induction of Anesthesia

A number of medications may be administered rectally for induction/premedication of anesthesia (methohexital, thiopental, ketamine, midazolam). The main advantage of this approach is that the child falls asleep in the parent's arms or, as is the case with midazolam, separates atraumatically from the parents.^{[130] [163] [262]} This technique is no more intimidating than taking a rectal temperature, but it is generally reserved for children still in diapers. Care must be taken to not allow the child to see the rectal catheter or syringe, which would appear very large to the child. Rectal administration of 10% methohexital reliably induces anesthesia within 8 to 10 minutes in 85% of young children and toddlers.^[130] Oxygen desaturation is not usually a problem unless the child's head is allowed

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Intramuscular Induction of Anesthesia

Many medications, such as methohexital (10 mg/kg), ketamine (2 to 10 mg/kg combined with atropine and midazolam), or midazolam alone (0.15 to 0.2 mg/kg), are administered intramuscularly for premedication or induction of anesthesia. The main advantage of this route of administration is its reliability; the main disadvantage is that it is painful.

Intravenous Induction of Anesthesia

Intravenous induction of anesthesia is the most reliable and rapid technique. The main disadvantage is that starting an intravenous line can be painful and threatening for the child. Intravenous induction may be preferable when induction by mask is contraindicated (e.g., in the presence of a full stomach). A two-needle technique using a butterfly-type catheter with a 25-gauge needle is suitable for induction of anesthesia, followed by placement of an intravenous catheter once anesthesia is safely induced. Older children will often allow insertion of an intravenous catheter after administration of 50% nitrous oxide and local anesthetic. It is important to emphasize to the child that this procedure will not be excessively painful. Occasionally, children will cry with local anesthetic infiltration and become hysterical when they see the intravenous catheter. Two maneuvers help minimize this response: (1) do not allow the patient to see the catheter; (2) puncture the anesthetized area with a needle, ask the child to look at the needle, and then ask if there is any sensation. Often, the child is astounded at the lack of pain and stops crying. The use of a eutectic mixture of local anesthetic (EMLA) cream, if time permits, may also provide analgesia without the need for a painful injection.^[263]