Pro–con debate: intravenous vs inhalation induction of anesthesia in children

Abstract

IntroductionInduction of anesthesia in a child can often be arelaxed event, but this is not always the case. Theselection of approach and technique has some basisin scientific evidence and published data, but in real-ity the procedure is more complex. Induction ofanesthesia is not simply a technical exercise. Itinvolves a variety of rapid individual evaluations andjudgements relating to both child and parent, the sit-uation and to some extent the experience and prefer-ences of the individual anesthetic team on aparticular day.It is clear from the outset that one mode of induc-tion may be indicated over the other in particular clini-cal situations, but that in more general terms, it is nota case of one or the other. Most pediatric anesthetistsuse both induction methods at different times but usu-ally have a preference. The articles below thereforereflect the personal opinions of two experienced pediat-ric anesthetists who have kindly agreed to put a casefor each method. They have addressed the sciencewhere possible but also have given personalizedaccounts which will stimulate individual reflection onpractice and rationale.In support of intravenous induction of anesthesiaDr Marzena ZielinskaFor many children, the induction of anesthesia can behighly stressful and current estimations, indicate thatmore than 60% of children suffer anxiety in the pre-operative period (1). The reasons of this are complex:first, children are afraid of being separated from theirparents and home environment and this is com-pounded by unfamiliar routines, new strange people,frightening equipment such as anesthetic machine andsurgical instruments which all contribute to the processof building high levels of anxiety.Not surprisingly then, the method of induction canplay a crucial role in generation of perioperative anxi-ety. Pediatric anesthesiologists make a choice betweentwo recommended methods: inhalational or intra-venous. Traditionally, the inhalational method ofinduction of anesthesia is thought to be less harmfulfor children (2–4). In many textbooks of pediatricanesthesia, the potential fear of a needle among pediat-ric patients is stressed. But it is clear to experiencedanesthesiologists working with children that childrenare not only afraid of a needle but also a mask. Usu-ally, children struggle to accept the presence of anyforeign body on their face and they start to expresstheir dissatisfaction immediately after placing the maskclose to their face. This then becomes even less accept-able if the mask is then kept against their face despitetheir protests. Volatile agents have an unfamiliar andoften pungent smell causing even the most well-pre-pared child to lose composure when the concentrationof anesthetic gas is increased.