This chapter focuses on the perioperative care of the paediatric patient and aims to undermine the common misconception that children are just little adults. Providing safe and effective care for children requires a clear underpinning knowledge of their unique needs. Conscious consideration of age-dependent characteristics such as anatomical, physiological, psychological, and behavioural are essential in the delivery of paediatric patient care. The rationale for adaptations to the delivery of care is to ensure children receive anaesthesia and surgery in a safe and appropriate environment.

The nature and origin of hypoxia is multifaceted. The prevention and treatment include optimisation of pre- and peroxygenation and the wise choice and use of neuromuscular blocking agents. Upper airway reflexes are important to anaesthetists as a clear airway allows safe ventilation of the lungs and oxygenation of the patient. Anaesthetic agents produce changes in the sensitivity of upper airway reflexes, with propofol being associated with depression of upper airway reflexes. This means that airway manipulation, and insertion of airways, including laryngeal mask airways, are more easily tolerated following induction of anaesthesia with propofol compared with other induction agents. Ageing leads to a gradual reduction in the sensitivity of upper airway reflexes. Cigarette smoking increases the sensitivity of upper airway reflexes, a change which persists for up to 2 weeks following cessation of smoking.

Extubation and emergence are high-risk phases of anaesthesia which accounted for 28% of the anaesthesia cases reported to the Fourth National Audit Project of the Difficult Airway Society and the Royal College of Anaesthetists. Problems generally relate to the patient’s anatomy, physiology or to the context in which extubation is carried out. Minor issues such as coughing and breath-holding are common, more serious complications such as aspiration, laryngospasm, post-obstructive pulmonary oedema and hypoxic brain injury are often preventable with proper planning. In this chapter we discuss how to formulate an extubation strategy including risk stratification, planning, awake and deep extubation and modifications aimed at reducing the risk of complications. An awake extubation is suitable for most patients but special techniques such as supraglottic airway exchange, remifentanil infusion or the use of an airway exchange catheter may be helpful in high-risk situations. Post-operative care does not end when the tracheal tube has been removed, handover and documentation are essential components of the extubation plan.

Patients undergoing ear nose and throat (ENT, otorhinolaryngeal) surgery probably present more airway management challenges than any other branch of surgery. ENT procedures encompass a range of operations varying in duration, severity and complexity from simple short cases such as myringotomy, through to complex resection and reconstructive surgeries for head and neck cancer. In all cases the surgical team operates close to the airway and in many within the airway, which is therefore shared with the anaesthetist. In this chapter, the authors discuss in some depth these challenges and how to address them, airway management and ventilation options and strategies including but not limited to awake intubation, different subtypes of jet ventilation, and high flow nasal oxygenation as well recent advances in the field. They further discuss extubation strategies and controversies as well as a plan to manage commonly encountered complications such as bleeding in the airway. For a successful outcome, these ‘shared airway’ procedures require close communication and cooperation between anaesthetist and surgeon, an understanding of each other’s challenges, knowledge of specialist equipment, and a thorough preoperative evaluation to identify potential risk factors for poor perioperative outcomes.

This chapter presents the most common pediatric surgery, myringotomy and ear tube placement. The author reviews in the indications for eat tubes in the setting of a child with upper respiratory tract infection. The perioperative considerations for upper respiratory tract infection are considered with relation to case postponement.