General anesthesia is usually induced by an intra-venous or inhalational technique. Induction with intramuscular ketamine (5–10 mg/kg) is reserved for specific situations, such as those involving combative, particularly mentally challenged, chil-dren and adults. Intravenous induction is usually preferred when the patient comes to the operating room with a functional intravenous catheter or will allow awake venous cannulation. Prior applica-tion of EMLA (eutectic mixture of local anesthetic) cream may render intravenous can-nulation less painful for the patient, and less stressful for the parent and anesthesiologist. EMLA cream is not a perfect solution. Some children become anx-ious at the sight of a needle, particularly those who have had multiple needle punctures in the past, with or without EMLA. Furthermore, it can be difficult to anticipate in which extremity intravenous cannula-tion will prove to be successful. Finally, to be effec-tive, EMLA cream must remain in contact with the skin for at least 30–60 min. Awake or sedated-awake intubation with topical anesthesia should be con-sidered for emergency procedures in neonates and small infants when they are critically ill or a poten-tial difficult airway is present.
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