If a general anesthetic is planned, what are the induction options?
Either an inhalation or intravenous induction is appro-priate. There are several factors to consider when making this decision. Does the patient have an intravenous catheter in place? Is there an increased risk of pulmonary aspira-tion? Are there any underlying medical conditions that make one technique preferable over another? IV access may be difficult to achieve in the patient with a long and complicated neonatal course. If there is no increased risk of pulmonary aspiration, IV access may be easier to achieve after an inhalation induction. However, be prepared for a rapid induction and the possibility of myocardial depression and bradycardia. Some anesthesiologists may opt to pre-medicate these patients with intramuscular atropine prior to an inhalation induction. Obviously, if IV access is already present, an IV induction would be appropriate.
The airway may be secured either with an ETT or laryn-geal mask airway (LMA). Common practice is to secure the airway with an ETT. Normally, the ETT size is based on age. But if there is a history of prolonged intubation, there may be subglottic narrowing and the need for a smaller ETT. Attention to the “fit” of the ETT, by checking for an adequate air leak (<30 cm H2O), is key to the prevention of postoper-ative edema and airway obstruction. An LMA may be used if there are no contraindications, such as gastroesophageal reflux. LMA size #1 is appropriate for patients weighing <5 kg. Assisted ventilation is required when using an LMA.