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Smith’s
Anesthesia for
Infants and Children
Volume1
Smith’s
Anesthesia for
Infants and Children

Tenth Edition
Peter J. Davis, MD
Professor
Department of Anesthesiology and Perioperative Medicine
Department of Pediatrics
Dr. Joseph H. Marcy Endowed Chair in Pediatric Anesthesia
University of Pittsburgh School of Medicine
Anesthesiologist-in-Chief
UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Franklyn P. Cladis, MD, FAAP

Professor
Department of Anesthesiology and Perioperative Medicine
UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Elsevier
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
SMITH’S ANESTHESIA FOR INFANTS AND CHILDREN, ISBN: 978-0-323-69825-2

TENTH EDITION

Copyright © 2022 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Chapter 30: Barry. D. Kussman retains copyright.
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
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Previous editions copyrighted 2017, 2011, 2006, 1996, 1990, 1980, 1968, 1963, and 1959
Library of Congress Control Number: 2021939106
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Content Development Specialist: Kristen Helm
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Printed in the US
Last digit is the print number: 9 8 7 6 5 4 3 2 1

DEDICATION
To our patients, who have allowed us the privilege of caring for them
and providing the opportunity of learning from them, and to our mentors, who
have shaped the way we care for patients and who have profoundly impacted the
specialty of pediatric anesthesiology.
CONTRIBUTORS
Phillip S. Adams, DO, FASA Benjamin B. Bruins, MD Ira Todd Cohen, MD, MEd, FAAP
Assistant Professor Assistant Professor Professor of Anesthesiology and Pediatrics
Department of Anesthesiology and Anesthesia and Critical Care Medicine Department of Anesthesiology and Pain
Perioperative Medicine Children’s Hospital of Philadelphia Medicine
Residency Program Director Philadelphia, PA Children’s National Medical Center
UPMC Children's Hospital of Pittsburgh Thomas M. Chalifoux, MD Ashley A. Colletti, MD
Pittsburgh, PA Assistant Professor Assistant Professor
Department of Anesthesiology and Department of Anesthesiology and Pain
Devon O. Aganga, MD Perioperative Medicine Medicine
Consultant University of Pittsburgh School of Medicine University of Washington
Department of Anesthesiology and UPMC Children's Hospital of Pittsburgh Seattle Children’s Hospital
Perioperative Medicine, Mayo Clinic UPMC Magee-Women's Hospital Seattle, WA
Assistant Professor in Anesthesiology Pittsburgh, PA
College of Medicine, Mayo Clinic Erin Conner, MD
Rochester, MN Mary Chapman Assistant Professor of Anesthesiology and
Pediatric Dentist Pediatrics
Sean S. Barnes, MD, MBA UPMC Children’s Hospital of Pittsburgh Oregon Health and Science University
Assistant Professor Pittsburgh, PA Portland, OR
Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Debnath Chatterjee, MD, FAAP Edward B. Cooper, MD
Medicine Associate Professor of Anesthesiology, Associate Professor
Baltimore, MD Children’s Hospital Colorado Departments of Anesthesiology and
Director of Fetal Anesthesia, Colorado Fetal Pediatrics
Bruno Bissonette, MD, FRCPC Care Center University of Cincinnati School of Medicine
Professor Emeritus of Anesthesia University of Colorado School of Medicine Cincinnati Children’s Hospital Medical
University of Toronto Aurora, CO Center
Founder and President Cincinnati, OH
Children of the World Anesthesia Rajeev Chaudhry, MD
Foundation Assistant Professor Joseph P. Cravero, MD
Rimouski, Quebec, Canada Department of Urology Anesthesiologist-in-Chief
University of Pittsburgh School of Medicine Boston Children’s Hospital
Brian Blasiole, MD, PhD UPMC Children’s Hospital of Pittsburgh Professor of Anaesthesia
Assistant Professor Pittsburgh, PA Harvard Medical School
Department of Anesthesiology and Boston, MA
Perioperative Medicine Sylvia Choi, MD, FAAP
University of Pittsburgh School of Medicine Associate Professor Jessica Cronin, MD, MBA
UPMC Children’s Hospital of Pittsburgh Department of Pediatrics Assistant Professor
Pittsburgh, PA University of Pittsburgh School of Medicine Division of Anesthesiology, Pain and
UPMC Children’s Hospital of Pittsburgh Perioperative Medicine
Adrian Bosenberg, MBChB FFA(SA) Pittsburgh, PA Children’s National Hospital
Professor Washington, DC
Department Anesthesiology and Pain Franklyn P. Cladis, MD
Management Professor Nicholas M. Dalesio, MD
University of Washington Department of Anesthesiology and Associate Professor
Pediatric Anesthesiologist Perioperative Medicine Anesthesiology and Critical Care Medicine
Seattle Children’s Hospital University of Pittsburgh School of Medicine Johns Hopkins School of Medicine
Seattle, WA UPMC Children's Hospital of Pittsburgh Baltimore, MD
Pittsburgh, PA
Claire M. Brett, MD, FAAP Jessica Davis, BA, JD, LLM
Emeritus Professor of Anesthesia and David E. Cohen, MD Troutman Pepper Hamilton Sanders, LLP
Perioperative Care and Pediatrics Associate Professor of Anesthesiology at Philadelphia, PA
Division of Pediatric Anesthesia The Children’s Hospital of Philadelphia
University of California Emeritus, Perelman School of Medicine
San Francisco, CA University of Pennsylvania
Anesthesiology and Critical Care Medicine
Children’s Hospital of Philadelphia
Philadelphia, PA
vi
CONTRIBUTORS vii
Peter J. Davis, MD Branden M. Engorn, MD Jessica A. George, MD, MEd

Professor Pediatric Anesthesiologist and Intensivist Assistant Professor
Department of Anesthesiology and Anesthesia Service Medical Group Medical Director for Pediatric Enhanced
Perioperative Medicine Rady Children’s Hospital San Diego Recovery After Surgery (ERAS) program
Dr. Joseph H. Marcy Endowed Chair in San Diego, CA Division of Pediatric Anesthesiology and
Pediatric Anesthesia Critical Care Medicine
University of Pittsburgh School of Medicine James J. Fehr, MD Johns Hopkins University School of
Anesthesiologist-in-chief Clinical Professor Medicine
UPMC Children’s Hospital of Pittsburgh Service Chief Anesthesia Baltimore, MD
Pittsburgh, PA Anesthesiology and Perioperative Pain
Stanford University School of Medicine Thierry Girard, MD
Karen A. Dean, MD Lucile Packard Children's Hospital Professor of Anesthesiology
Associate Professor of Anesthesiology, Palo Alto, CA Department of Anesthesiologie
Children’s Hospital Colorado University Hospital Basel
University of Colorado School of Medicine Jeffrey M. Feldman, MD, MSE University of Basel
Aurora, CO Attending Anesthesiologist Switzerland
Children’s Hospital of Philadelphia
Nina Deutsch, MD Professor of Clinical Anesthesiology Nancy L. Glass, MD, MBA, FAAP
Associate Professor Perelman School of Medicine Professor of Pediatrics and of Anesthesiology
Division of Anesthesiology, Pain and University of Pennsylvania Baylor College of Medicine and Texas
Perioperative Medicine Philadelphia, PA Children’s Hospital (Voluntary)
Children’s National Hospital Butterfly Team Physician, Houston Hospice
Washington, DC Marla B. Ferschl, MD Houston, TX
Professor of Anesthesia and Perioperative
James A. DiNardo, MD, FAAP Care Christine D. Greco, MD
Professor of Anaesthesia Division of Pediatric Anesthesia Section 2.01 Interim Chief, Division of Pain
Harvard Medical School University of California Medicine
Boston, MA San Francisco, CA Boston Children’s Hospital
Chief, Division of Cardiac Anesthesia Department of Anesthesiology, Critical Care
Francis X. McGowan Jr. MD Chair in Jonathan D. Finder, MD and Pain Medicine
Cardiac Anesthesia Director, Program for Technology Boston, MA
Boston Children’s Hospital Dependent Children
Boston, MA Professor, University of Tennessee Health Eliot Grigg, MD
Science Center Associate Professor
Laura A. Downey, MD Le Bonheur Children’s Hospital Department of Anesthesiology and Pain
Assistant Professor of Anesthesiology and Memphis, TN Medicine
Pediatrics University of Washington
Emory University School of Medicine Sean Flack, MBChB, DA, FCA Seattle Children’s Hospital
Children’s Healthcare of Atlanta Associate Professor, Anesthesiology and Pain Seattle, WA
Atlanta, GA Medicine
Director, Clinical Anesthesia Services Lorelei Grunwaldt, MD
John B. Eck, MD University of Washington Associate Professor of Plastic Surgery,
Associate Professor of Anesthesiology and Seattle Children’s Hospital Division of Pediatric Plastic Surgery
Pediatrics Seattle, WA Plastic Surgery
Duke University UPMC Children’s Hospital of Pittsburgh
Durham, NC Randall P. Flick, MD Pittsburgh, PA
Consultant
Peter Ehrlich, MD, MSC Department of Anesthesiology and Nina A. Guzzetta, MD, FAAP
Professor of Pediatric Surgery Perioperative Medicine, Mayo Clinic Professor of Anesthesiology and Pediatrics
Department of Surgery Assistant Professor in Anesthesiology Emory University School of Medicine
University of Michigan CS Mott Children’s College of Medicine, Mayo Clinic Children’s Healthcare of Atlanta
Hospital Rochester, MN Atlanta, GA
Ann Arbor, MI
Jeffrey L. Galinkin, MD Dawit T. Haile, MD
Demetrius Ellis, MD Anesthesiologist Consultant
Pediatrics US Anesthesia Partners Department of Anesthesiology and
University of Pittsburgh School of Medicine Greenwood Village, CO Perioperative Medicine, Mayo Clinic
UPMC Children's Hospital of Pittsburgh Assistant Professor in Anesthesiology
Pittsburgh, PA College of Medicine, Mayo Clinic
Rochester, MN
viii CONTRIBUTORS
Denise M. Hall-Burton, MD, FAAP Robert S. Holzman, MD, MA (Hon), FAAP Todd J. Kilbaugh
Assistant Professor Senior Associate in Perioperative Anesthesia Associate Professor of Anesthesiology,
Department of Anesthesiology and Boston Children’s Hospital Critical Care, and Pediatrics
Perioperative Medicine Professor of Anaesthesia Department of Anesthesiology and Critical
University of Pittsburgh School of Medicine Harvard Medical School Care Medicine
UPMC Children’s Hospital of Pittsburgh Department of Anesthesiology, Critical Perelman School of Medicine at the
Pittsburgh, PA Care and Pain Medicine University of Pennsylvania
Boston Children’s Hospital Children’s Hospital of Philadelphia
Gregory B. Hammer, MD Boston, MA Philadelphia, PA
Professor
Anesthesiology, Perioperative and Vincent C. Hsieh, MD, MS Anjali Koka, MD
Pain Medicine, and Pediatrics Associate Professor Department of Anesthesia
Stanford University School of Medicine Department of Anesthesiology and Pain Critical Care and Pain Medicine
Stanford, CA Medicine Boston Children’s Hospital
University of Washington Harvard Medical School
Jennifer L. Hamrick, MD Seattle Children’s Hospital Boston, MA
Senior Partner Seattle, WA
Anesthesia Service Medical Group Rahul Koka, MD, MPH
Pediatric Anesthesia Elizabeth A. Hunt, MPH, PhD, MD Section Chief, Pediatric General Anesthesia
Rady Children’s Hospital Drs. David S. and Marilyn M. Zamierowski Medical Director, Pediatric Operating
San Diego, CA Director Rooms
Johns Hopkins Medicine Simulation Center Assistant Professor
Justin T. Hamrick, MD Professor Anesthesia and Critical Care Medicine
Senior Partner Departments of Anesthesiology and Critical Johns Hopkins University School of
Anesthesia Service Medical Group Care Medicine, Pediatrics Medicine
Pediatric Anesthesia Health Informatics and Health Policy and Baltimore, MD
Pediatric Critical Care Medicine Management
Rady Children’s Hospital Johns Hopkins University School of Pete G. Kovatsis, MD, FAAP
San Diego, CA Medicine Senior Associate in Perioperative Anesthesia
Baltimore, MD Director of Anesthesia for Transplantation
Helen Harvey Co-Director, Anesthesia Advanced Airway
UCSD Pediatric Critical Care Fellowship James W. Ibinson, MD, PhD Management Service
Director Assistant Professor Department of Anesthesiology, Critical Care
Pediatric Critical Care Department of Anesthesiology and and Pain Medicine
University of California, San Diego, Rady Perioperative Medicine Boston Children’s Hospital
Children’s Hospital University of Pittsburgh School of Medicine Assistant Professor of Anaesthesia
San Diego, CA Chief of Anesthesiology Harvard Medical School
VA Pittsburgh Healthcare System Boston, MA
Andrew Herlich, DMD, MD, FAAP, FASA, Pittsburgh, PA
FAAOMS(H) Tatiana Kubacki, MD
Professor Emeritus Caleb Ing Assistant Professor
Department of Anesthesiology and Associate Professor Department of Anesthesiology
Perioperative Medicine Anesthesiology College of Physicians and Surgeons
University of Pittsburgh School of Medicine Columbia University Medical Center Columbia University
Clinical Professor, Department of Dental New York, NY New York, NY
Anesthesiology
University of Pittsburgh School of Dental Amanpreet Kalsi Barry D. Kussman, MBBCh, FFA (SA), FAAP
Medicine Clinical Assistant Professor Associate Professor of Anaesthesia
Pittsburgh, PA Division of Pediatric Anesthesiology Harvard Medical School
University of Michigan Boston, MA
Monica A. Hoagland, MD Ann Arbor, MI Senior Associate in Cardiac Anesthesia
Associate Professor of Anesthesiology, Boston Children’s Hospital
Children’s Hospital Colorado Evan Kharasch, MD, PhD Boston, MA
Associate Director of Obstetric and Fetal Merel H. Harmel Professor of Anesthesiology
Anesthesia, Colorado Fetal Care Center Vice-Chair for Innovation Kirk Lalwani, MD, FRCA, MCR, FASA
University of Colorado School of Medicine Department of Anesthesiology Professor of Anesthesiology and Pediatrics
Aurora, CO Duke University School of Medicine Vice Chair for Faculty Development
Durham, NC Department of Anesthesiology and
Perioperative Medicine
Oregon Health and Science University
Portland, OR
CONTRIBUTORS ix
Mary Landrigan-Ossar Ronald S. Litman, DO, ML* Lynn Martin, MD

Senior Associate in Perioperative Anesthesia Department of Anesthesiology and Critical Professor
Anesthesiology, Perioperative and Pain Medicine Care Department of Anesthesiology and Pain
Boston Children’s Hospital The Children’s Hospital of Philadelphia Medicine
Boston, MA Professor of Anesthesiology and Pediatrics University of Washington
Perelman School of Medicine at the Seattle Children’s Hospital
Robert Scott Lang, MD University of Pennsylvania Seattle, WA
Assistant Professor of Anesthesiology and Philadelphia, PA
Pediatrics, Director of Pain Management Francis X. McGowan Jr., MD, FAAP
Anesthesiology Justin L. Lockman, MD, MSEd, FAAP William J. Greeley Endowed Chair and Director,
Division of Surgical Anesthesiology, Associate Chair, Education Pediatric Anesthesiology Research
Department of Anesthesiology and Department of Anesthesiology and Critical Professor of Anesthesiology and Critical
Perioperative Medicine Care Medicine Care Medicine
A. I. duPont Hospital for Children/Sidney Children’s Hospital of Philadelphia Attending Cardiac Anesthesiologist
Kimmel Medical College at Thomas Associate Professor of Clinical Anesthesiology Children’s Hospital of Philadelphia
Jefferson University and Critical Care University of Pennsylvania Perelman School
Wilmington, DE Perelman School of Medicine of Medicine
University of Pennsylvania
Helen Victoria Lauro, MD, MPH, MSEd, Philadelphia, PA Gregory McHugh, MD
FAAP Clinical Assistant Professor
Clinical Associate Professor of Anesthesiology Joseph Losee, MD Department of Anesthesiology and
Department of Anesthesiology Ross H. Musgrave Professor of Pediatric Perioperative Medicine
State University of New York Downstate Plastic Surgery University of Pittsburgh School of Medicine
Health Sciences University Department of Plastic Surgery UPMC Children’s Hospital of Pittsburgh
Brooklyn, NY; University of Pittsburgh Medical Center Pittsburgh, PA
Site Director of Education Pittsburgh, PA
Department of Anesthesiology Carrie C. Menser, MD
State University of New York Downstate Igor Luginbuehl, MD Associate Professor of Anesthesiology
Health Sciences University Associate Professor Division of Pediatric Anesthesiology
University Hospital of Brooklyn Pediatric Anesthesiologist Monroe Carell Jr. Children’s Hospital at
Brooklyn, NY Department of Anesthesia and Pain Vanderbilt University Medical Center/
Medicine/Division of Cardiovascular Vanderbilt University School of Medicine
Elizabeth K. Laverriere, MD, MPH, FAAP Anesthesia Nashville, TN
Assistant Professor The Hospital for Sick Children
Department of Anesthesiology and Critical Toronto, Ontario, Canada Bruce E. Miller, MD
Care Medicine Associate Professor of Anesthesiology and
Children’s Hospital of Philadelphia Jennifer R. Marin, MD, MSc Pediatrics
Perelman School of Medicine at The Associate Professor of Pediatrics and Emory University School of Medicine
University of Pennsylvania Pediatric Emergency Medicine, Medical Children’s Healthcare of Atlanta
Philadelphia, PA Director Atlanta, GA
Point-of-Care Ultrasound
Susan Lei, MD UPMC Children’s Hospital of Pittsburgh Constance L. Monitto, MD
Assistant Professor and University of Pittsburgh School of Assistant Professor
Department of Anesthesiology Medicine Director, Pediatric Acute Pain Service
College of Physicians and Surgeons UPMC Children’s Hospital of Pittsburgh Division of Pediatric Anesthesiology and
Columbia University Pittsburgh, PA Critical Care Medicine
New York, NY Johns Hopkins University School of
Brian Martin, DMD, MHCDS Medicine
David Levin, MD, FRCPC, MSc, BESc (Mech) Vice President of Medical Affairs Baltimore, MD
Pediatric Anesthesiologist UPMC Children’s Hospital of Pittsburgh
Department of Anesthesia and Pain Medicine Clinical Assistant Professor Philip G. Morgan, MD
The Hospital for Sick Children (SickKids) University of Pittsburgh School of Dental Professor
Assistant Professor Medicine Anesthesiology and Pain Medicine
Department of Anesthesia Pittsburgh, PA University of Washington
The University of Toronto Seattle, WA
Toronto, Ontario Lizabeth Martin, MD
Assistant Professor Michael L. Moritz, MD
Richard Levy Department of Anesthesiology and Pain Professor
Professor Medicine Pediatrics
Anesthesiology University of Washington University of Pittsburgh Medical Center
Columbia University Medical Center Seattle Children’s Hospital UPMC Children’s Hospital of Pittsburgh
New York, NY Seattle, WA Pittsburgh, PA
x CONTRIBUTORS
Etsuro K. Motoyama, MD, FAAP Andrew Nowalk, MD, PhD Teeda Pinyavat, MD
Professor Emeritus Associate Professor and Clinical Director Assistant Professor of Anesthesiology
Anesthesiology and Pediatrics Division of Infectious Disease Department of Anesthesiology
University of Pittsburgh School of Medicine Department of Pediatrics Columbia University Medical Center
Pittsburgh, PA UPMC Children’s Hospital of Pittsburgh New York, NY
Advisory Dean
Rebecca Nause-Osthoff University of Pittsburgh School of Medicine George Demetrios Politis, MD, MPH
Clinical Assistant Professor Pediatric Residency Program Co-Director Associate Professor of Anesthesiology and
Division of Pediatric Anesthesiology Pediatric Scientist Development Program Pediatrics
University of Michigan (PedSDP) Co-Director University of Virginia Health System
Ann Arbor, MI UPMC Graduate Medical Education Charlottesville, VA
Pittsburgh, PA
Michael E. Nemergut, MD, PhD Andrew J. Powell, MD
Consultant Julie Nyquist, PhD Chief of the Division of Cardiac Imaging
Department of Anesthesiology and Director, Master of Academic Medicine Department of Cardiology
Perioperative Medicine, Mayo Clinic Program Boston Children’s Hospital
Assistant Professor in Anesthesiology Professor, Department of Medical Education Professor of Pediatrics
College of Medicine, Mayo Clinic Chair, 2021 Innovations in Medical Harvard Medical School
Rochester, MN Education Conference Boston, MA
Keck School of Medicine of the University of
Desiree Noel Wagner Neville, MD Southern California Alexander Praslick, MD
Assistant Professor of Pediatrics and Los Angeles, CA Clinical Assistant Professor
Pediatric Emergency Medicine Department of Anesthesiology and
Associate Director of Emergency Point-of- Shelley Ohliger, MD Perioperative Medicine
Care Ultrasound Assistant Professor University of Pittsburgh School of Medicine
UPMC Children’s Hospital of Pittsburgh Department of Anesthesiology UPMC Children's Hospital of Pittsburgh
and University of Pittsburgh School of Rainbow Babies and Children’s Hospital Pittsburgh, PA
Medicine Cleveland, OH
UPMC Children’s Hospital of Pittsburgh Srijaya K. Reddy, MD, MBA
Pittsburgh, PA Michale Sung-jin Ok, MD Associate Professor of Anesthesiology
Assistant Professor of Clinical Anesthesia Division of Pediatric Anesthesiology
Thanh Nguyen, MD and Pediatrics Monroe Carell Jr. Children’s Hospital at
Department of Anesthesiology University of Cincinnati College of Medicine Vanderbilt University Medical Center/
University of Colorado Anschutz Campus Cincinnati Children’s Hospital Medical Vanderbilt University School of Medicine
Children’s Hospital of Colorado Center Nashville, TN
Aurora, CO Cincinnati, OH
Paul Reynolds, MD, FAAP
Jonathan A. Niconchuk, MD Meghna D. Patel Professor
Assistant Professor of Anesthesiology Clinical Assistant Professor in Pediatric Chief of Pediatric Anesthesiology
Division of Pediatric Anesthesiology Cardiovascular ICU/Cardiology University of Michigan
Monroe Carell Jr. Children’s Hospital at Department of Pediatrics at Stanford Ann Arbor, MI
Vanderbilt University Medical Center/ University
Vanderbilt University School of Medicine Lucile Packard Children’s Hospital Karene Ricketts, MD
Nashville, TN Palo Alto, CA Associate Professor of Anesthesiology and
Pediatrics
Julie Niezgoda, MD James Peyton, MBChB MRCP FRCA Anesthesiology
Pediatric Anesthesiology Associate in Perioperative Anesthesia University of North Carolina
Cleveland Clinic Main Campus Department of Anesthesiology, Critical Care Chapel Hill, NC
Cleveland, OH and Pain Medicine
Boston Children’s Hospital Bobbie L. Riley, MD
Ken K. Nischal, MD, FAAP, FRCOphth Assistant Professor of Anaesthesia, Harvard Department of Anesthesia
Professor Medical School Critical Care and Pain Medicine
Department of Ophthalmology Boston, MA Boston Children's Hospital
University of Pittsburgh School of Medicine Harvard Medical School
Pediatric Ophthalmology Division Chief Phillip M.T. Pian, MD, PhD Boston, MA
UPMC Children’s Hospital of Pittsburgh Anesthesiologist
Pittsburgh, PA Anesthesiology Service
Veterans Affairs Eastern Colorado Health
Care System
Aurora, CO
CONTRIBUTORS xi
Mark A. Rockoff, MD Donald H. Shaffner, MD Deborah Studen-Pavlovich, DMD

Vice-Chairman Associate Professor Professor and Chair
Department of Anesthesiology, Perioperative Anesthesia and Critical Care Medicine Department of Pediatric Dentistry
and Pain Medicine Johns Hopkins University School of University of Pittsburgh School of Dental
Boston Children’s Hospital Medicine Medicine
Boston, MA Baltimore, MD Pittsburgh, PA
Thomas Romanelli, MD, FAAP Allan F. Simpao, MD, MBI Lena S. Sun, MD, FAAP, D.ABA
Assistant Professor of Anesthesiology Associate Professor of Anesthesiology and Emanuel M. Papper Professor of Pediatric
Division of Pediatric Anesthesiology Critical Care Anesthesiology
Monroe Carell Jr. Children’s Hospital at Children’s Hospital of Philadelphia Professor of Anesthesiology and Pediatrics
Vanderbilt University Medical Center/ University of Pennsylvania Perelman School Executive Vice Chairman, Department of
Vanderbilt University School of Medicine of Medicine Anesthesiology
Nashville, TN Philadelphia, PA Chief, Division of Pediatric Anesthesia
College of Physicians and Surgeons
Rachael S. Rzasa Lynn, MD Erica L. Sivak, MD Columbia University
Associate Professor Assistant Professor of Anesthesiology New York, NY
Department of Anesthesiology Department of Anesthesia and Pain Medicine
University of Colorado School of Medicine Nationwide Children’s Hospital Melissa Sutcliffe
University of Colorado Hospital Pain Columbus, OH Pediatric Neuropsychologist
Management Clinic Clinical Assistant Professor
Aurora, CO Sarah M. Smith, MD Division of Pediatric Rehabilitation
Assistant Professor Medicine
Nancy Bard Samol, MD Pediatric Cardiac Anesthesiology Children’s Hospital of Pittsburgh Inpatient
Associate Professor of Pediatric Center for Pediatric and Congenital Heart Rehabilitation Unit
Anesthesiology Disease Pittsburgh, PA
Cincinnati Children’s Hospital Medical Dell Children’s Medical Center
Center University of Texas at Austin Jonathan M. Tan, MD, MPH, MBI, FASA
Cincinnati, OH Austin, TX Assistant Professor of Anesthesiology and
Spatial Sciences
Paul J. Samuels, MD Jenna H. Sobey, MD Department of Anesthesiology Critical Care
Professor of Clinical Anesthesia and Pediatrics Assistant Professor of Anesthesiology Medicine
University of Cincinnati College of Medicine Division of Pediatric Anesthesiology Children’s Hospital Los Angeles
Cincinnati Children’s Hospital Medical Monroe Carell Jr. Children’s Hospital at Keck School of Medicine at the University of
Center Vanderbilt University Medical Center/ Southern California
Cincinnati, OH Vanderbilt University School of Medicine Spatial Sciences Institute at the University of
Nashville, TN Southern California
Jamie McElrath Schwartz, MD Los Angeles, CA
Division Chief, Pediatric Critical Care Kyle Soltys, MD
Medicine Associate Professor Jennifer M. Thomas, BSc, STD (Edu),
Co-Director, Blalock-Taussig-Thomas Thomas E. Starzl Transplant Institute MBChB, FFA
Pediatric and Congenital Heart Center University of Pittsburgh School of Medicine Emeritus Professor Paediatric Anaesthesia
Assistant Professor UPMC Children’s Hospital of Pittsburgh Red Cross War Memorial Children's Hospital
Anesthesia and Critical Care Medicine Pittsburgh, PA Department of Anaesthesia and Perioperative
Johns Hopkins University School of Medicine
Medicine Judy H. Squires, MD University of Cape Town
Baltimore, MD Associate Professor Rondebosch, Cape Town, South Africa
Chief of Ultrasound Imaging
Deborah A. Schwengel, MD Associate Program Director, Diagnostic Stevan P. Tofovic, MD, PhD, FAHA, FASN
Associate Professor Radiology Residency Associate Professor of Pharmacology and
Department of Anesthesiology and Critical Department of Radiology Chemical Biology and Medicine
Care Medicine University of Pittsburgh School of Medicine Department of Pharmacology and Chemical
Johns Hopkins University School of UPMC Children’s Hospital of Pittsburgh Biology
Medicine Pittsburgh, PA University of Pittsburgh School of Medicine
Baltimore, MD Pittsburgh, PA
Eric T. Stickles, MD
Victor L. Scott Assistant Professor of Anesthesiology and
Director Abdominal Transplant Pediatrics
Anesthesiology Alfred I. duPont Hospital for Children/
Avera Transplant Institute Sidney Kimmel Medical College at
Avera McKennan University Hospital Thomas Jefferson University
Sioux Falls, SD Wilmington, DE
xii CONTRIBUTORS
Lieu Tran, MD Keith M. Vogt, MD, PhD Eric P. Wittkugel, MD, FAAP
Assistant Professor Assisant Professor Associate Professor of Anesthesiology and
Department of Anesthesiology and Department of Anesthesiology and Pediatrics
Perioperative Medicine Perioperative Medicine Cincinnati Children’s Hospital Medical
University of Pittsburgh School of Medicine Bioengineering and Center for the Neural Center
UPMC Children’s Hospital of Pittsburgh Basis of Cognition Cincinnati, OH
Pittsburgh, PA University of Pittsburgh School of Medicine
Pittsburgh, PA Samuel Yanofsky, MD, MSEd
Premal M. Trivedi, MD Professor of Anesthesiology
Associate Professor of Anesthesiology Andrew Waberski, MD Vice Chair of Education
Department of Anesthesiology, Perioperative, Assistant Professor Department of Anesthesiology and Critical
and Pain Medicine, Division of Pediatric Division of Anesthesiology, Pain and Care Medicine
Cardiovascular Anesthesiology Perioperative Medicine Children’s Hospital Los Angeles
Texas Children’s Hospital, Baylor College of Children’s National Hospital
Medicine Washington, DC Myron Yaster, MD
Houston, TX Professor of Anesthesiology, Critical Care
Jeffrey R. Wahl, JD Medicine, and Pediatrics
Chinwe Unegbu, MD President and Co-Founder Johns Hopkins University School of Medicine
Assistant Professor MIDAS Healthcare Solutions, Inc. Retired
Division of Anesthesiology, Pain and Cleveland, OH Baltimore, MD
Perioperative Medicine
Children’s National Hospital Ari Y. Weintraub, MD Steven Zgleszewski, MD, FAAP
Washington, DC Assistant Professor of Clinical Anesthesiology Associate in Anesthesia
and Critical Care Anesthesiology, Perioperative and Pain
Samuel M. Vanderhoek Anesthesiology Medicine
Assistant Professor Perelman School of Medicine at the Boston Children’s Hospital
Department of Anesthesiology and Critical University of Pennsylvania Boston, MA
Care Medicine Children’s Hospital of Philadelphia
Johns Hopkins School of Medicine Philadelphia, PA Basil J. Zitelli, MD
Baltimore, MD Professor Emeritus
Timothy P. Welch, MD, MSPH Department of Pediatrics
Lisa Vecchione, DMD, MDS* Associate Professor of Anesthesiology and University of Pittsburgh School of Medicine
Director, Orthodontic Services Pediatrics UPMC Children’s Hospital of Pittsburgh
Cleft-Craniofacial Center Children’s Hospital and Medical Center Pittsburgh, PA
Children’s Hospital of Pittsburgh of UPMC University of Nebraska
Assistant Clinical Professor of Surgery College of Medicine Aaron L. Zuckerberg, MD
University of Pittsburgh School of Medicine Omaha, NE Children’s Diagnostic Center
Pittsburgh, PA North American Partners of Anesthesia
Emmett E. Whitaker, MD Sinai Hospital of Baltimore
Chido Vera, MD, MPH Associate Professor Baltimore, MD
Assistant Professor Departments of Anesthesiology, Neurological
Department of Radiology Sciences, & Pediatrics
VIDEO CONTRIBUTOR – SMITH
University of Vermont Larner College of
UPMC Children’s Hospital of Pittsburgh Medicine TALKS: A LECTURE-SEMINAR
Pittsburgh, PA Burlington, VT Peggy P. McNaull, MD
John Rowlingson Professor and Chair
Adriana M. Vieira, DDS, DMD, MS, PhD Robert K. Williams, MD Department of Anesthesiology
Professor and Chair University of Vermont Larner College of University of Virginia School of Medicine
Department of Pediatric Dentistry Medicine Charlottesville, VA, USA
University of Pittsburgh School of Dental Department of Anesthesiology
Medicine Burlington, VT
Pittsburgh, PA
*Deceased
P R E FA C E
Dr. Robert Smith, a distinguished pioneer in pediatric anesthesia and a great teacher and clinician, wrote the
first edition of this book in 1959, a book subsequently referred to as “the bible” of pediatric anesthesia. The
foreword to the first edition was written by the famous pediatric surgeon Robert E. Gross, the William E.
Ladd Professor of Children’s Surgery at the Harvard Medical School. Though his words in the foreword were
written over 60 years ago, at a time when the specialty of pediatric anesthesia and surgery was in its infant
stages, his words and ideas are still poignant and insightful today.
During the past decade surgery has made important strides in providing safer and improved methods for
handling various problems in infancy and childhood, indeed now making it possible to correct some condi-
tions that were previously thought to be entirely hopeless. Many factors have contributed to these dramatic
advances in pediatric surgery. Outstanding among them is the work of anesthesiologists who have focused
on the field and have provided well-standardized procedures for carrying small and critically ill patients
through operations on literally all portions and every system of the body. The surgeon realizes that the
chances for success or failure are determined in great measure by the capabilities of the person at the head
of the table who is administering the anesthetic.
In some medical circles, there seems to be an attitude that the surgical operator is managing the show; in
others, the anesthetist has an overly possessive feeling toward the patient. Neither approach is proper. It
is best for each to be cognizant of one’s own problems and also to know of the other’s difficulties; both must
work together for total care of the patient. Certainly, this is the most pleasant way to work, and surely it
is the most effective way to conduct a child through a surgical ordeal.
Since the initial printing of this textbook in 1959, the book has been markedly transformed in its content and
in its appearance. The book has gone from mainly a single- to a multi-author book and from a 400-page 70
by 100 book to a 1500-page 11.50 by 8.50 text with an online version. As learning styles have changed, so has
the format of this book. The book uses multimedia presentations to supplement, emphasize, and reinforce
concepts of pediatric anesthesia. However, even with the increases in page number, new information, and
media platforms, the basic tenets of anesthesia care and patient compassion, the legacy and tradition of the
nine previous editions have been retained.
The tenth edition has been prepared with the same considerations as the previous editions: to give anesthe-
siology care providers comprehensive coverage of physiology, pharmacology, and clinical anesthetic man-
agement of infants and children of all ages. The tenth edition has been reorganized into eight main sections.
Part I, Basic Principles and Physiology, contains updated chapters on behavioral development and respira-
tory, cardiovascular, renal, and thermal physiology.
Part II, Pharmacology, now has additional authors with specific chapters in developmental pharmacology,
intravenous anesthetic agents, inhaled anesthetic agents, opioids, local anesthetic agents, neuromuscular
blocking agents, and anesthetic adjuncts.
Part III, General Approach, addresses the basic concepts of caring for children and the principles involved in
the administration of anesthetics to children. The chapters have all been updated. Two new chapters have been
added to Part III: Normal and Difficult Airway Management and Point of Care Ultrasonography.
Part IV is a new section dedicated to Pain Management. It includes updated chapters on acute pain manage-
ment and regional anesthesia. The chapter on regional anesthesia has added some new authors with an
emphasis on ultrasound techniques. The reader will also be able to access video demonstrations of specific
regional anesthetic techniques in children. Part IV also has new chapters: Chronic Pain Management and
Palliative Pain Management.
Part V, Clinical Management of Specialized Surgical Problems, contains material written by new authors.
New authors for chapters on Anesthesia and Sedation for Out of OR Procedures, Pediatric Sedation, and
Medical Missions have been added. The chapter on Solid Organ Transplantation has been updated and also
contains new authors. The use of video has been maintained in a variety of chapters to further supplement
the clinical material. The chapter on Neonatology for Anesthesiologists has been revised into a comprehen-
sive work that updates the anesthesia provider with perinatal outcome data and serves as a primer for pedi-
atric anesthesiologists to better understand the pathophysiology of prematurity and the developmental
xiii
xiv PREFACE
physiology that occur with neonatal growth. This chapter also serves as a rich resource for the chapters on
Anesthesia for General Surgery in Neonates and Anesthesia for Fetal Surgery.
In view of the significant number of disorders that pediatric anesthesiologists are confronted with in the
everyday care of their patients, Part VI, Systemic Disorders and Associated Problems, was created to better
organize and provide information for both unusual patient diseases and to address everyday common peri-
operative anesthetic concerns. All of the chapters in this part have been updated. The chapter on Dermatol-
ogy for the Anesthesiologist has an extensive number of figures (both in the book and online) of lesions and
rashes that anesthesiologists frequently encounter. A new chapter on Infectious Diseases has been added to
this part.
Part VII, Critical Care in Pediatric Anesthesia, contains revised chapters on critical care medicine, cardiac
intensive care, and cardiopulmonary resuscitation. The Cardiopulmonary Resuscitation chapter contains
the latest (2020) recommendations from the American Heart Association.
Part VIII, Special Topics, includes updated chapters on Safety and Outcome in Pediatric Anesthesia, History
of Pediatric Anesthesia, Medicolegal and Ethical Aspects of Pediatric Anesthesia, and Statistics. A new chap-
ter on Education has been added. This chapter focuses on the role of education and provides guidance to
those who engage in teaching the specialty of pediatric anesthesiology as part of postgraduate training. The
education chapter is organized into six sections and uses “mind maps” (a graphic image of the key concepts)
to provide a quick overview of each of the chapter’s sections.
In keeping with advancements in technology, this edition is in color, and text material is further supple-
mented by a website. Videos of airway techniques, single-lung isolation, regional anesthesia, the use of
ultrasound, and anatomic dissections of congenital heart lesions are accessible with just a click of the mouse.
In addition, supplemental materials on organ transplantation, airway lesions, and pediatric syndromes
remain available.
The appendices, which can be found online at

ExpertConsult.com, include an updated list of
drugs and their dosages, normal growth curves,
normal values for pulmonary function tests in
children, and an expanded list of common and
uncommon syndromes of clinical importance for
pediatric anesthesiologists.
Finally, this edition, like the previous edition, also

includes online multiple-choice questions with an-
swers and explanations. As with any learning pro-
cess, it is important for the reader to have some
method to affirm that they understand the salient
features and to reinforce the learning process. Most
chapters have associated questions to aid the reader
in understanding the material.
In summary, considerable developments and prog-

ress in the practice of pediatric anesthesia are re-
flected in this new edition. The emphasis on the
safety and well-being of young patients during the
perianesthetic period remains unchanged—just as
Dr. Smith would have wanted.
Peter J. Davis, MD, FAAP

AC K N OW L E D G M E N T S
The project of revising a classic medical textbook presents many opportunities and challenges, and revising
this textbook during the SARS-CoV-2 (COVID-19) pandemic—when people were stressed, isolated, and
uncertain about their futures—proved to be particularly challenging. Nonetheless, the opportunity to review
and evaluate the new developments that have emerged in pediatric anesthesia since the publication of the last
edition of Smith’s Anesthesia for Infants and Children in 2017 has been rewarding. As always, we are deeply
indebted to the extraordinary work done and commitment made by Dr. Robert M. Smith in the first four
editions that made Anesthesia for Infants and Children a classic textbook in pediatric anesthesia.
Our ability to maintain this book’s standard of excellence is not just a reflection of the many gifted con-
tributors but also a result of the level of support that we have received at work and at home. We wish to thank
the staff members of the Department of Anesthesiology at UPMC Children’s Hospital of Pittsburgh for their
support and tolerance.
Our special thanks go to Joy Holden and Patty Klein, administrative assistants, of the Department of
Anesthesiology, UPMC Children’s Hospital of Pittsburgh, for their many hours of diligent work on the
book. We are also appreciative of Dr. Basil Zitelli, Professor Emeritus of Pediatrics, University of Pittsburgh
at UPMC Children’s Hospital of Pittsburgh, for his generosity in allowing us to use many of the photo-
graphs published in his own book, Atlas of Pediatric Physical Diagnosis.
Our special thanks also go to Elsevier’s Sarah Barth, Content Strategist; Kristen Helm, Content Develop-
ment Specialist; and Julie Taylor, Project Manager, for their editorial assistance.
As with the previous editions, we are deeply indebted to our family members Katie, Evan, Zara, Will,
Hunter, and Jake Davis; Julie, Andy, Elliott, Eila, and Mugsy Peet Potash; and Joseph Losee and Hudson
Cladis Losee for remaining loyal, for being understanding, and for providing moral support throughout the
lengthy and, at times, seemingly endless project. Finally, we are indebted to our patients, who grant us the
privilege to care and learn from them and who keep us humble.
Peter J. Davis, MD, FAAP

xv
CO
G NSTSEANRTYS
LO
Contributors, vi 22 Transfusion Medicine, 455

Preface, xii Michael E. Nemergut, Dawit T. Haile, Devon O. Aganga, and
Acknowledgments, xiv Randall P. Flick
PART I Basic Principles and Physiology PART IV Pain Management

1 Special Characteristics of Pediatric Anesthesia, 2 23 Acute Pain Management, 481
Peter J. Davis, Etsuro K. Motoyama, and Franklyn P. Cladis Constance L. Monitto, Jessica A. George, and Myron Yaster
2 Behavioral Development, 11 24 Regional Anesthesia, 519
Julie Niezgoda, Melissa Sutcliffe, Caleb H. Ing, and Richard J. Levy Robert Scott Lang, Denise Hall-Burton, Alexander Praslick,
3 Respiratory Physiology, 28 and Sean Flack
Etsuro K. Motoyama and Jonathan D. Finder 25 Chronic Pain Management, 578
4 Airway Physiology and Development, 78 Bobbie L. Riley, Anjali Koka, and Christine D. Greco
Robert S. Holzman 26 Pediatric Palliative Care and Hospice, 587
5 Cardiovascular Physiology, 90 Nancy L. Glass
Andrew Waberski, Chinwe Unegbu, and Nina Deutsch
6 Regulation of Fluids and Electrolytes, 119
Michael L. Moritz and Demetrius Ellis PART V C
linical Management of Specialized
7 Thermoregulation, 158 Surgical Problems
Branden Engorn, Helen Harvey, Peter J. Davis, Igor Luginbuehl,
and Bruno Bissonnette 27 Neonatology for Anesthesiologists, 596
Marla B. Ferschl and Claire M. Brett
28 Anesthesia for General Surgery in Neonates, 669
PART II Pharmacology Sean S. Barnes, Peter J. Davis, and Claire Brett
29 Anesthesia for Fetal Surgery, 709
8 Developmental Pharmacology, 179 Monica A. Hoagland, Karen A. Dean, and Debnath Chatterjee
Stevan P. Tofovic and Evan Kharasch 30 Anesthesia for Congenital Heart Disease, 732
9 Intravenous Anesthetics, 198 Barry D. Kussman, Francis X. McGowan Jr., Andrew J. Powell, and
Brian Blasiole and Peter J. Davis James A. DiNardo
10 Inhaled Anesthetics, 213 31 Anesthesia for Neurosurgery, 832
Susan Lei, Lena S. Sun and Tatiana Kubacki Jenna H. Sobey, Jonathan A. Niconchuk, Eric T. Stickles,
11 Local Anesthetics, 228 Carrie C. Menser, and Srijaya K. Reddy
Adrian T. Bösenberg 32 Anesthesia for Thoracic Surgery, 866
12 Opioids, 233 Gregory B. Hammer
Phillip M. T. Pian, Rachael S. Rzasa Lynn, Jeffrey L. Galinkin, and 33 Anesthesia for General Abdominal, Urologic Surgery, 885
Peter J. Davis Emmett E. Whitaker, Robert K. Williams, Helen Victoria Lauro, Rajeev
13 Neuromuscular Blocking Agents, 257 Chaudhry, and Peter J. Davis
John B. Eck 34 Anesthesia for Otorhinolaryngologic Surgery, 917
14 Anesthetic Adjuncts, 279 Samuel M. Vanderhoek, Nicholas M. Dalesio, and Deborah A. Schwengel
Erica L. Sivak and Denise M. Hall-Burton 35 Anesthesia for Plastic Surgery, 945
Franklyn P. Cladis, Lorelei Grunwaldt, and Joseph Losee
PART III General Approach 36 Anesthesia for Orthopedic Surgery, 969
Aaron L. Zuckerberg, Thanh Nguyen, and Myron Yaster
15 Psychological Aspects of Pediatric Anesthesia, 289 37 Anesthesia for Ophthalmic Surgery, 1001
Kirk Lalwani and Erin Conner Karene Ricketts and Ken Nischal
16 Preoperative Preparation, 302 38 Solid Organ Transplantation, 1024
Franklyn P. Cladis and Peter J. Davis Phillip S. Adams, Brian Blasiole, Peter J. Davis, Gregory McHugh,
17 Equipment, 328 Victor L. Scott, and Kyle Soltys
Allan Simpao, Jeffrey M. Feldman, and David E. Cohen 39 Anesthesia for Conjoined Twins, 1062
18 Monitoring, 358 Jennifer M. Thomas
Jonathan M. Tan and David E. Cohen 40 Anesthesia for Pediatric Trauma, 1083
19 Normal and Difficult Airway Management, 382 Rebecca Nause-Osthoff, Paul Reynolds, Aman Kalsi, Peter Ehrlich,
Pete G. Kovatsis, James Peyton, Edward B. Cooper, and Peter J. Davis Franklyn P. Cladis, and Peter J. Davis
20 Point-of-Care Ultrasonography, 405 41 Anesthesia for Burns, 1113
Desiree Noel Wagner Neville and Jennifer R. Marin Thomas Romanelli
21 Induction, Maintenance, and Recovery, 423
Shelley Ohliger, Jessica Cronin, and Nina Deutsch
xvi
CONTENTS xvii
42 Anesthesia for Dental Procedures, 1132 55 Dermatology for the Anesthesiologist, 1343
Andrew Herlich, Franklyn P. Cladis, Deborah Studen-Pavlovich, Thomas M. Chalifoux, Sylvia Choi, and Basil J. Zitelli
Adriana M. Vieira, Brian Martin, Mary Chapman, and Lisa Vecchione 56 Infectious Diseases, 1358
43 Anesthesia and Sedation for Out-of-Operating-Room Andrew Nowalk
Procedures, 1148
Lieu Tran, Judy Squires, Chido Vera, and Brian Blasiole
44 Pediatric Sedation, 1168 PART VII C
ritical Care in Pediatric
Mary Landrigan-Ossar and Joseph P. Cravero Anesthesia
45 Anesthesia for Surgical Missions, 1184
George Demetrios Politis 57 Cardiopulmonary Resuscitation, 1365
Jamie McElrath Schwartz, Rahul Koka, Justin T. Hamrick,
Jennifer L. Hamrick, Elizabeth A. Hunt, and Donald H. Shaffner
PART VI S
ystemic Disorders and Associated 58 Critical Care Medicine, 1413
Problems Elizabeth K. Laverriere, Benjamin Bruins, and Justin L. Lockman
59 Cardiac Critical Care Medicine, 1425
46 Endocrine Disorders, 1199 James Fehr, Meghna Patel, and Timothy Welch
Benjamin B. Bruins, Todd J. Kilbaugh, and Ari Y. Weintraub
47 Respiratory Disorders, 1214
Sarah M. Smith and Premal M. Trivedi
PART VIII Special Topics
48 Cardiovascular Disorders, 1238 60 Safety and Outcome in Pediatric Anesthesia, 1444
Phillip S. Adams Eliot Grigg, Lizabeth Martin, and Lynn Martin
49 Hematology and Coagulation Disorders, 1251 61 History of Pediatric Anesthesia, 1462
Nina A. Guzzetta, Laura A. Downey, and Bruce E. Miller David Levin and Mark A. Rockoff
50 Oncologic Disorders, 1282 62 Medicolegal and Ethical Aspects
Steven Zgleszewski, Franklyn P. Cladis, and Peter J. Davis of Pediatric Anesthesia, 1478
51 Genetic and Muscular Disorders, 1295 Jessica Davis and Jeffrey R. Wahl
Ashley A. Colletti, Philip G. Morgan, and Vincent C. Hsieh 63 Education, 1488
52 Malignant Hyperthermia, 1305 Samuel Yanofsky, Ira Todd Cohen, Franklyn P. Cladis, and Julie Nyquist
Teeda Pinyavat, Thierry Girard, and Ronald S. Litman 64 Statistics, 1499
53 Pediatric Obesity, 1319 James W. Ibinson and Keith M. Vogt
Paul J. Samuels and Michale Sung-jin Ok
54 Special Pediatric Disorders, 1330 Abbreviations, 1510
Eric P. Wittkugel and Nancy Bard Samol Index, 1516
*Deceased
PA R T I
Basic Principles and
Physiology
1. Special Characteristics of Pediatric 5. Cardiovascular Physiology, 90
Anesthesia, 2
6. Regulation of Fluids and Electrolytes, 119
2. Behavioral Development, 11
7. Thermoregulation, 158
3. Respiratory Physiology, 28
4. Airway Physiology and Development, 78
1
1
Special Characteristics of Pediatric Anesthesia
Peter J. Davis, Etsuro K. Motoyama, Franklyn P. Cladis
OUTLINE
Introduction, 2 Anatomic and Physiologic Differences, 7
Perioperative Monitoring, 2 Body Size, 7
Anesthetic Agents, 3 Relative Size or Proportion, 7
Airway Devices and Adjuncts, 4 Central and Autonomic Nervous Systems, 8
Intraoperative and Postoperative Analgesia in Neonates, 5 Respiratory System, 9
Point of Care Ultrasound, 5 Cardiovascular System, 9
Regional Analgesia in Infants and Children, 5 Fluid and Electrolyte Metabolism, 9
Fundamental Differences in Infants and Children, 6 Temperature Regulation, 9
Psychological Differences, 6 Summary, 10
Differences in Response to Pharmacologic Agents, 6
INTRODUCTION many anesthesiologists monitored only the heart rate in infants and
In the past few decades, new scientific knowledge of physiology and small children during anesthesia and surgery. Electrocardiographic
pharmacology in developing humans and technologic advancements and blood pressure measurements were either too difficult or too ex-
in equipment and monitoring have markedly changed the practice of travagant and were thought to provide little or no useful information.
pediatric anesthesia. In addition, further emphasis on patient safety Measurements of central venous pressure were thought to be inaccu-
(e.g., correct side-site surgery, correct patient identification, correct rate and too invasive, even in major surgical procedures. The insertion
procedure, appropriate prophylactic antibiotics) coupled with ad- of an indwelling urinary (Foley) catheter in infants was considered
vances in minimally invasive pediatric surgery have created a need invasive, and surgeons resisted its use.
for better pharmacologic approaches to infants and children and Smith also added an additional physiologic monitoring: soft, latex
improved skills in pediatric anesthetic management. blood pressure cuffs suitable for newborn and older infants, which
As a result of the advancements and emphasis on pediatric subspe- encouraged the use of blood pressure monitoring in children (Smith
cialty training and practice, the American Board of Anesthesiology has 1968). The Smith cuff (see Chapter 61: History of Pediatric Anesthesia;
now come to recognize the subspecialty of pediatric anesthesiology in Fig. 61.7) remained the standard monitoring device for infants and
its certification process, and the first subspecialty board examination children until the late 1970s, when automated blood pressure devices
was administered in 2013. began to replace them.
The introduction of pulse oximetry for routine clinical use in the early
1990s has been the single most important development in monitoring and
PERIOPERATIVE MONITORING patient safety, especially related to pediatric anesthesia, since the advent of
In the 1940s and 1950s, the techniques of pediatric anesthesia, and the the precordial stethoscope in the 1950s (Smith 1956) (see Chapter 17:
skills of those using and teaching them, evolved more as an art than Equipment; Chapter 18: Monitoring). Pulse oximetry is superior to clini-
as a science, as Dr. Robert Smith (now deceased) vividly and elo- cal observation and other means of monitoring, such as capnography,
quently recollected through his firsthand experiences in his chapter for the detection of intraoperative hypoxemia (Coté et al. 1988, 1991). In
on the history of pediatric anesthesia (see Chapter 61: History of Pe- addition, Spears and colleagues (1991) have indicated that experienced
diatric Anesthesia, updated by Mark A. Rockoff and David Neville pediatric anesthesiologists may not have an “educated hand” or a “feel”
Levine). The anesthetic agents and methods available were limited, as adequate to detect changes in pulmonary compliance in infants. Pulse
was the scientific knowledge of developmental differences in organ oximetry has revealed that postoperative hypoxemia occurs commonly
system function and anesthetic effect in infants and children. Moni- among otherwise healthy infants and children undergoing simple surgical
toring pediatric patients was limited to inspection of chest movement procedures, presumably as a result of significant reductions in functional
and occasional palpation of the pulse until the late 1940s, when Smith residual capacity (FRC) and resultant airway closure and atelectasis
introduced the first physiologic monitoring to pediatric anesthesia by (Motoyama and Glazener 1986). Consequently, the use of supplemental
using the precordial stethoscope for continuous auscultation of heart- oxygen in the postanesthesia care unit (PACU) has become a part of
beat and breath sounds (Smith 1953, 1968). Until the mid-1960s, routine postanesthetic care (see Chapter 3: Respiratory Physiology).
2
CHAPTER 1 Special Characteristics of Pediatric Anesthesia 3
Although pulse oximetry greatly improved patient monitoring,

there were some limitations, namely, motion artifact and inaccuracy in
ANESTHETIC AGENTS
low-flow states and in children with levels of low oxygen saturation More than a decade after the release of isoflurane for clinical use, two
(e.g., cyanotic congenital heart disease). Advances have been made in volatile anesthetics, desflurane and sevoflurane, became available in
the new generation of pulse oximetry, most notably through the use of the 1990s in most industrialized countries. Although these two agents
Masimo Signal Extraction Technology (SET). This device minimizes are dissimilar in many ways, they share common physiochemical and
the effect of motion artifact, improves accuracy, and has been shown pharmacologic characteristics: very low blood gas partition coeffi-
to have advantages over the existing system in low-flow states, mild cients (0.4 and 0.6, respectively), which are close to those of nitrous
hypothermia, and moving patients (Malviya et al. 2000; Hay et al. oxide and are only fractions of those of halothane and isoflurane; rapid
2002; Irita et al. 2003). induction of and emergence from surgical anesthesia; and hemody-
Trending of hemoglobin (Hgb) can also be performed with oxim- namic stability (See Chapter 10: Inhaled Anesthetic Agents; Chapter 21:
etry. Noninvasive pulse cooximetry (SpHb) has been used in both Induction, Maintenance, and Recovery). In animal models, the use of
children and neonates to measure SpHb. Pulse cooximetry uses pulse inhaled anesthetic agents has been shown to attenuate the adverse ef-
oximeter technology that involves sensors with light emitting diodes fects of ischemia in the brain, heart, and kidneys, whereas other studies
of many wavelengths. Patino and colleagues (2014) demonstrated in have raised concerns regarding the anesthetic agents causing neurotox-
children undergoing major surgical procedures with anticipated sub- icity in infants and children. (See Chapter 2: Behavioral Development.)
stantial blood loss that SpHb followed the trend in invasively measured Although these newer, less soluble inhaled agents allow for faster
Hgb with respect to bias and precision and that the trend accuracy was emergence from anesthesia, emergence excitation or delirium associ-
better than the absolute accuracy. In both term and preterm neonates ated with their use has become a major concern to pediatric anesthe-
who weighed less than 3000 g at birth, Nicholas and colleagues (2015) siologists (Davis et al. 1994; Sarner et al. 1995; Lerman et al. 1996;
noted a good agreement between the noninvasive SpHb and the inva- Welborn et al. 1996; Cravero et al. 2000; Kuratani and Oi 2008).
sive Hgb. In a study of adults and children, Park and colleagues (2018) Adjuncts, such as opioids, analgesics, serotonin antagonists, and
noted that the difference between lab-measured Hgb and SpHb was a1-adrenergic agonists, have been found to decrease the incidence of
less in children than in adults. emergence agitation (Aono et al. 1999; Davis et al. 1999a; Galinkin
Monitoring of cerebral function and blood flow, as well as infrared et al. 2000; Cohen et al. 2001; Ko et al. 2001; Kulka et al. 2001; Voepel-
brain oximetry, has advanced the anesthetic care and perioperative Lewis et al. 2003; Lankinen et al. 2006; Aouad et al. 2007; Tazeroualti
management of infants and children with congenital heart disease and et al. 2007; Bryan et al. 2009; Erdil et al. 2009; Kim et al. 2009; Hauber
traumatic brain injuries. Depth of anesthesia can be difficult to assess et al. 2015).
in children, and anesthetic overdose was a major cause of anesthesia- Propofol has increasingly been used in pediatric anesthesia as an
associated cardiac arrest and mortality. Depth-of-anesthesia monitors induction agent, for intravenous sedation, or as the primary agent of a
(bisectral index monitor [BIS], Patient State Index, Narcotrend) have total intravenous anesthetic technique (Martin et al. 1992). Propofol
been used in children and have been associated with the administra- has the advantage of aiding rapid emergence and causes less nausea
tion of less anesthetic agent and faster recovery from anesthesia. How- and vomiting during the postoperative period, particularly in children
ever, because these monitors use electroencephalography and a sophis- with a high risk for vomiting. When administered as a single dose
ticated algorithm to predict consciousness, the reliability of these (1 mg/kg) at the end of surgery, propofol has also been shown to de-
monitors in children younger than 1 year of age is limited. crease the incidence of sevoflurane-associated emergence agitation
More recently, interest has developed in the use of noninvasive (Aouad et al. 2007).
monitors to assess fluid responsiveness. Static variables (central venous Dexmedetomidine is an a1-adrenergic agonist approved for use as
pressure, pulmonary artery wedge pressure, and left ventricle area) are a sedation agent for adult ICU patients (Mason and Lerman 2011). In
not reliable predictors of fluid responsiveness. Dynamic indicators that pediatrics, off-label use of dexmedetomidine is common and has been
are based on cardiopulmonary interactions in mechanically ventilated used in the settings of procedural sedation and ICU sedation. It also
patients, such as aortic peak velocity, systolic blood pressure variation has been administered as an adjunct to general anesthesia in order to
(SPV), pulse pressure variation (PPV), and pleth variability index decrease both opioid and inhalational anesthetic requirements. It has
(PVI), have been shown to be predictive in adults. In children, the re- been used to treat supraventricular tachycardia and junctional ectopic
sults of studies involving dynamic variables have been mixed, but it tachycardia in pediatric cardiac patients and has been used successfully
appears that aortic peak velocity is a reliable indicator of fluid respon- for both prophylaxis and treatment of emergence agitation in postop-
siveness (Marik et al. 2009; Feldman et al. 2012; Byon et al. 2013; erative surgical patients (Erdil et al. 2009; Jooste et al. 2010; Gupta
Gan et al. 2013; Pinsky 2014; Nicholas et al. 2015). et al. 2013; Sun et al. 2014). In order to attenuate the biphasic hemo-
In addition to advances in monitors for individual patients, hospi- dynamic response of dexmedetomidine, the package insert recom-
tal, patient, and outside agency initiatives have focused on more global mends infusing the drug over 10 minutes. However, studies involving
issues. Issues of patient safety, side-site markings, time-outs, and rapid bolus administration (less than 3 seconds) of dexmedetomidine
proper patient identification, together with appropriate administra- in both healthy children and children who had received a heart trans-
tion of prophylactic antibiotics, have now become major priorities for plant demonstrated minimal clinical significance (Jooste et al. 2010;
healthcare systems. World Health Organization (WHO) checklists are Dawes et al. 2014; Hauber et al. 2015).
positive initiatives that have ensured that the correct procedure is per- Remifentanil, a µ-receptor agonist, is metabolized by nonspecific
formed on the correct patient and have fostered better communication plasma and tissue esterases. The organ-independent elimination of
among healthcare workers. In anesthesia, patient safety continues to be remifentanil, coupled with its clearance rate (highest in neonates and
a mantra for the specialty. Improved monitoring, better use of anes- infants compared with older children), makes its kinetic profile differ-
thetic agents, and the development of improved airway devices, cou- ent from that of any other opioid (Davis et al. 1999b; Ross et al. 2001).
pled with advancements in minimally invasive surgery, continue to In addition, its ability to provide hemodynamic stability, coupled with
advance the frontiers of pediatric anesthesia as a specialty medicine its kinetic profile of rapid elimination and nonaccumulation, makes
and improve patient outcomes and patient safety. it an attractive anesthetic option for infants and children. Numerous
4 PART 1 Basic Principles and Physiology
clinical studies have described its use for pediatric anesthesia (Wee Equipment; Chapter 19: Normal and Difficult Airway Management).
et al. 1999; Chiaretti et al. 2000; Davis et al. 2000, 2001; German et al. The importance of these advanced airway devices cannot be over-
2000; Dönmez et al. 2001; Galinkin et al. 2001; Keidan et al. 2001b; stated, as evidenced by their use in the algorithms for the difficult
Chambers et al. 2002; Friesen et al. 2003). When combined, intrave- pediatric airway (Park et al. 2017; Garcia-Marcinkiewicz et al. 2019;
nous hypnotic agents (remifentanil and propofol) have been shown to Fiadjoe and Nishisaki 2020).
be as effective and of similar duration as propofol and succinylcholine The variety of pediatric endotracheal tubes (ETTs) has focused on
for tracheal intubation. improved materials and designs. ETTs are sized according to the inter-
The development of more predictable, shorter-acting anesthetic nal diameter; however, the outer diameter (the parameter most likely
agents (see Part II: Pharmacology) has increased the opportunities for involved with airway complications) varies according to the manufac-
pediatric anesthesiologists to provide safe and stable anesthesia with turer (Table 1.1). Tube tips are both flat and beveled, and a Murphy eye
less dependence on the use of neuromuscular blocking agents. may or may not be present. The position of the cuff varies with the
Remimazolam is a new benzodiazepine that is metabolized by tissue manufacturer. The use of cuffed endotracheal tubes in pediatrics con-
carboxylesterases to an inactive metabolite. In adult volunteers it tinues to be controversial. In a multicenter, randomized prospective
is rapidly metabolized with fast onset and recovery times and has study of 2246 children from birth to 5 years of age undergoing general
moderate hemodynamic effect (Masui 2020; Schüttler et al. 2020). anesthesia, Weiss and colleagues (2009) noted that cuffed ETTs com-
pared with uncuffed ETTs did not increase the risk for postextubation
stridor (4.4% vs. 4.7%) but did reduce the need for ETT exchanges
AIRWAY DEVICES AND ADJUNCTS (2.1% vs. 30.8%), thereby reducing the possibility of additional trauma
Significant changes in pediatric airway management that have patient from multiple intubation attempts.
safety implications have emerged over the past few years. The laryngeal There has been a recent gradual but steady trend toward the routine
mask airway (LMA), in addition to other supraglottic airway devices and exclusive use of cuffed ETTs in pediatric anesthesia, including in
(e.g., the King LT-D, the Cobra pharyngeal airway), has become an infants (Dullenkopf et al. 2005; Weiss et al. 2009; Litman and Maxwell
integral part of pediatric airway management. Although the LMA is 2013; Tobias 2015). Murat (2001) was the first to propose the use of
not a substitute for the endotracheal tube, it can be safely used for cuffed ETTs exclusively for children of all ages with the record of no
routine anesthesia in both spontaneously ventilated patients and pa- complications without using uncuffed ETTs for a 3-year span in a
tients requiring pressure-controlled support (Keidan et al. 2001a). The major children’s hospital in Paris. The change in practice of not using
LMA can also be used in the patient with a difficult airway to aid in uncuffed ETT is due to the recognition that the shape of the glottic
ventilation and to act as a conduit to endotracheal intubation both opening at the cricoid ring, the narrowest fixed diameter in the upper
with and without a fiber optic bronchoscope. airways, is more elliptic in shape than circular, with a larger anteropos-
In addition to supraglottic devices, advances in technology for vi- terior (AP) diameter and a narrower transverse diameter (Dalal et al.
sualizing the airway have improved patient safety. Since the larynx 2009; Litman and Maxwell 2013). These findings mean that the most
could be visualized, at least 50 devices intended for laryngoscopy have appropriately sized uncuffed ETT (,20 cm H2O leak pressure) would
been invented. The newer airway visualization devices have combined compress the lateral wall mucosa of the cricoid, causing ischemia
better visualizations, video capabilities, and high resolution. even when there are enough anteroposterior spaces left for air leaks
The development and refinement of airway visualization equip- (Motoyama 2009). A recently developed thin-walled (with smaller
ment such as the McGrath, C-MAC, and Glidescope have added more outer diameter), cuffed endotracheal tube specifically designed for
options to the management of the pediatric airway and literally give pediatric anesthesia (Microcuff by Kimberly-Clark) has two major
the laryngoscopist the ability to see around corners (see Chapter 17: modifications: the cuff is made of ultrathin polyurethane, allowing a
TABLE 1.1 Measured Outer Diameters of Pediatric Cuffed Tracheal Tubes According
to the Internal Diameter of Tracheal Tubes Supplied by Different Manufacturers
ID Tracheal Tube Brand 2.5 3 3.5 4 4.5 5 5.5
OD (mm) Sheridan Tracheal Tube Cuffed Murphy NA 4.2 4.9 5.5 6.2 6.8 7.5
Sheridan Tracheal Tube Cuffed Magill NA 4.3 NA 5.5 NA 6.9 NA
Mallinckrodt TT High-Contour Murphy NA 4.4 4.9 5.7 6.3 7 7.6
Mallinckrodt TT High-Contour Murphy P-Series NA 4.3 5 5.7 6.4 6.7 7.7
Mallinckrodt TT Lo-Contour Magill NA 4.5 4.9 5.7 6.2 6.9 7.5
Mallinckrodt TT Lo-Contour Murphy NA 4.4 5 5.6 6.2 7 7.5
Mallinckrodt TT Hi-Lo Murphy NA NA NA NA NA 6.9 7.5
Mallinckrodt TT Safety Flex NA 5.2 5.5 6.2 6.7 7.2 7.9
Portex TT-Profile Soft Seal Cuff, Murphy NA NA NA NA NA 7 7.6
Rüsch Ruschelit Super Safety Clear Magill 4 5.1 5.3 5.9 6.2 6.7 7.2
Rüsch Ruschelit Super Safety Clear Murphy NA NA NA NA NA 6.7 7.3
Halyard Microcuff (formerly Kimberly-Clark Healthcare) NA 4.3 5.0 5.6 6.3 6.7 7.3
ID, Inner diameter; OD, outer diameter.

Modified from Weiss, M., Dullenkopf, A., Gysini, C., et al. (2004). Shortcomings of cuffed pediatric tracheal tubes. British Journal of Anaesthesia,
92, 78–88.
more effective tracheal seal at a much lower pressure than the pressure therapeutic applications in pediatric patients of all ages. In addition
known to cause tracheal mucosal necrosis, and the short cuff is located to its widely accepted role in regional anesthesia and vascular access,
more distally near the tip of the endotracheal tube shaft, allowing more ultrasonography can facilitate diagnostic procedures including airway
reliable placement of the cuff below the nondistensible cricoid ring management, pulmonary pathology like pneumothorax, fluid man-
and reducing the chance of endobronchial intubation (Dullenkopf agement, and nasogastric tube positioning. (See Chapter 20: Point of
et al. 2005; Litman and Maxwell 2013). Whether the new, more costly Care Ultrasonography.)
endotracheal tube actually reduces the incidence of intubation-related
airway injury is being investigated. REGIONAL ANALGESIA IN INFANTS
A main concern with cuffed endotracheal tubes relates to excessive
AND CHILDREN
pressure in the cuff. The exact pressure a cuff needs to exert against the
wall of the tracheal mucosae to induce ischemia is not known; recom- Although conduction analgesia has been used in infants and children
mendations range from 20 to 30 cm H2O. In an observational trial of since the beginning of the 20th century, the controversy about whether
200 pediatric patients, Tobias and colleagues (2012) noted that when anesthetic agents can be neurotoxic has caused a resurgence of interest
cuff pressures were measured, 23.5% of the patients had pressures in regional anesthesia (Abajian et al. 1984; Williams et al. 2006).
greater than 30. Various devices have been prepared to monitor intra- As newer local anesthetic agents with less systemic toxicity become
cuff pressure (Krishna et al. 2014; Ramesh et al. 2014; Kako et al. available, their role in the anesthetic/analgesic management of chil-
2015; Tobias 2015). Although the role of cuffed ETTs in neonates and dren is increasing. Studies of levobupivacaine and ropivacaine have
infants who require prolonged ventilation has yet to be determined demonstrated safety and efficacy in children that are greater than that
(Sathyamoorthy et al. 2015), it is clear that in neonates undergoing of bupivacaine, the standard regional anesthetic used in the 1990s
minimally invasive surgery, cuffed endotracheal tubes allow for more (Ivani et al. 1998, 2002, 2003; Hansen et al. 2000, 2001; Lönnqvist et al.
effective ventilation and more reliable end-tidal gas monitoring while 2000; McCann et al. 2001; Karmakar et al. 2002). A single dose of local
likely maintaining safety (de Wit et al. 2018; Thomas et al. 2018). anesthetics through the caudal and epidural spaces is most often used
for a variety of surgical procedures as part of general anesthesia and for
INTRAOPERATIVE AND POSTOPERATIVE postoperative analgesia. Insertion of an epidural catheter for continu-
ous or repeated bolus injections of local anesthetics (often with opi-
ANALGESIA IN NEONATES oids and other adjunct drugs) for postoperative analgesia has become
It has long been thought that newborn infants do not feel pain the way a common practice in pediatric anesthesia. The addition of adjunct
older children and adults do and therefore do not require anesthetic or medications, such as midazolam, neostigmine, tramadol, ketamine,
analgesic agents (Lippmann et al. 1976). Thus in the past, neonates and clonidine, to prolong the neuroaxial blockade from local anes-
undergoing surgery were often not afforded the benefits of anesthesia. thetic agents has become more popular, even though the safety of these
Later studies, however, indicated that pain experienced by neonates agents on the neuroaxis has not been determined (Ansermino et al.
can affect behavioral development (Dixon et al. 1984; Taddio et al. 2003; de Beer and Thomas 2003; Walker and Yaksh 2012) (see also
1995; Taddio and Katz 2005). Rats exposed to chronic pain without the Part IV: Pain Management).
benefit of anesthesia or analgesia showed varying degrees of neuro- In addition to neuroaxial blockade, specific nerve blocks that are
apoptosis (Anand et al. 2007). However, to add further controversy performed with or without ultrasound guidance have become an
to the issue of adequate anesthesia for infants, concerns have been integral part of pediatric anesthesia (see Chapter 24: Regional Anes-
raised regarding the neurotoxic effects of both intravenous and inha- thesia) (Boretsky et al. 2013; Hall-Burton and Boretsky 2014; Long
lational anesthetic agents (GABAergic and NMDA antagonists) (see et al. 2014; Visoiu et al. 2014; Suresh et al. 2015). The use of ultra-
Chapter 2: Behavioral Development). sound has allowed for the administration of smaller volumes of local
Although postoperative cognitive dysfunction (POCD) is an adult anesthetic and for more accurate placement of the local anesthetic
phenomenon, animal studies by multiple investigators have raised (Willschke et al. 2006; Gurnaney et al. 2007; Ganesh and Gurnaney
concerns about anesthetic agents being toxic to the developing brains 2009). The use of catheters in peripheral nerve blocks has also
of infants and small children (Jevtovic-Todorovic et al. 2003; Mellon changed the perioperative management for a number of pediatric
et al. 2007; Jevtovic and Olney 2008; Wang and Slikker 2008; Rappa- surgical patients. Continuous peripheral nerve catheters with infu-
port et al. 2015). Early work by Uemura and colleagues (1985) noted sions are being used by pediatric patients at home after they have been
that synaptic density was decreased in rats exposed to halothane in discharged from the hospital (Ganesh et al. 2007; Gurnaney et al.
utero. Further work with rodents, by multiple investigators, has shown 2014; Visoiu et al. 2014). The use of these at-home catheters has
evidence of apoptosis in multiple areas of the central nervous system allowed for shorter hospital stays.
during the rapid synaptogenesis period. This window of vulnerability As pediatric regional anesthesia becomes more prevalent, the abil-
appears to be a function of time, dose, and duration of anesthetic ex- ity to collect data, audit practice patterns, and report on complications
posure. In addition to the histochemical changes of apoptosis, the ex- in infants and children undergoing regional anesthesia becomes es-
posed animals also demonstrated learning and behavioral deficits later sential to improving care for children. In this context, the Pediatric
in life. The potential neurotoxic risk of anesthetic agents is less clear in Regional Anesthesia Network (PRAN) was formed (Polaner et al. 2012;
human pediatric patients. Studies performed on this population have Long et al. 2014; Taenzer et al. 2014; Suresh et al. 2015). Walker and
helped to clarify this risk, and it appears that a single short anesthetic colleagues (2018) reported on over 100,000 blocks in children from the
in early infancy has no adverse effects on IQ at 2 and 5 years of age. See PRAN registry and noted that there was no added risk of placing a
Chapter 2 (Behavioral Development) for a more in-depth discussion. block in the anesthetized child. The risk of transient neurologic deficit
was 2.4:10,000 patients and severe local anesthetic systemic toxicity
was 0.76:10,000 patients.
POINT OF CARE ULTRASOUND In addition to advances in anesthetic pharmacology and equip-
Ultrasound has advanced the care of many medical specialties, in- ment, advances in the area of pediatric minimally invasive surgery (MIS)
cluding pediatric anesthesiology. This technology has diagnostic and have improved patient morbidity, shortened the length of hospital
stays, and improved surgical outcomes (Fujimoto et al. 1999). Al- TABLE 1.2 Aspects of Developmental
though MIS imposes physiologic challenges in the neonate and small
Assessment and Common Developmental
infant, numerous neonatal surgical procedures can nevertheless be
successfully approached with such methods, even in infants with single-
Milestones
ventricle physiology (Georgeson 2003; Ponsky and Rothenberg 2008). Follows dangling object from midline through 1 month
The success of MIS has allowed for the evolution of robotic techniques, a range of 90 degrees
stealth surgery (scarless surgery), and Natural Orifice Transluminal Follows dangling object from midline through 3 months
Endoscopic Surgery (NOTES) (Dutta and Albanese 2008; Dutta et al. a range of 180 degrees
2008; Isaza et al. 2008). Consistent conjugate gaze (binocular vision) 4 months
Alerts or quiets to sound 0–2 months
FUNDAMENTAL DIFFERENCES IN INFANTS
Head up 45 degrees 2 months
AND CHILDREN Head up 90 degrees 3–4 months
Regardless of all the advances in equipment, monitoring, and patient Weight on forearms 3–5 months
safety initiatives, pediatric anesthesia still requires a special under- Weight on hands with arms extended 5–6 months
standing of anatomic, psychological, and physiologic development.
Complete head lag, back uniformly rounded Newborn
The reason for undertaking a special study of pediatric anesthesia is
that children, especially infants younger than a few months of age, Slight head lag 3 months
differ markedly from adolescents and adults. Many of the important Rolls front to back 4–5 months
differences, however, are not the most obvious. Although the most Rolls back to front 5–6 months
apparent difference is size, it is the physiologic differences related to Sits with no support 7 months
general metabolism and immature function of the various organ Hands predominantly closed 1 month
systems (including the heart, lungs, kidneys, liver, blood, muscles,
Hands predominantly open 3 months
and central nervous system) that are of major importance to the
anesthesiologist. Foot play 5 months
Transfers objects from hand to hand 6 months
Psychological Differences Index finger approach to small objects 10 months
For a child’s normal psychological development, continuous support and finger-thumb opposition
of a nurturing family is indispensable at all stages of development; Plays pat-a-cake 9–10 months
serious social and emotional deprivation (including separation from
Pulls to stand 9 months
parents during hospitalization), especially during the first 2 years of
Walks with one hand held 12 months
development, may cause temporary or even lasting damage to psycho-
social development (Forman et al. 1987). A young child who is hospi- Runs well 2 years
talized for surgery is forced to cope with separation from parents, to Social smile 1–2 months
adapt to a new environment and strange people, and to experience Smiles at image in mirror 5 months
the pain and discomfort associated with anesthesia and surgery Separation anxiety/stranger awareness 6–12 months
(see Chapter 2: Behavioral Development; Chapter 15: Psychological
Interactive games: peek-a-boo and pat-a-cake 9–12 months
Aspects of Pediatric Anesthesia).
The most intense fear in an infant or a young child is created Waves “bye-bye” 10 months
by separation from the parents, and it is often conceived as loss of Cooing 2–4 months
love or abandonment. The sequence of reactions observed is often Babbles with labial consonants (“ba,” “ma,” “ga”) 5–8 months
as follows: angry protest with panicky anxiety, depression, and de- Imitates sounds made by others 9–12 months
spair, and eventually apathy and detachment (Bowlby 1973). Older
First words (approximately four to six, including 9–12 months
children may be more concerned with painful procedures and the
“mama,” “dada”)
loss of self-control that is implicit with general anesthesia (Forman
Understands one-step command (with gesture) 15 months
et al. 1987). Repeated hospitalizations for anesthesia and surgery
may be associated with psychosocial disturbances in later childhood Ages are averages based primarily on data from Arnold Gesell.
(Dombro 1970). In children who are old enough to experience Modified from Illingworth, R. S. (1987). The development of the infant
fear and apprehension during anesthesia and surgery, the emotional and young child: normal and abnormal. New York: Churchill Livingstone.
factor may be of greater concern than the physical condition; in fact,
it may represent the greatest problem of the perioperative course
(see Chapter 15: Psychological Aspects of Pediatric Anesthesia) Differences in Response to Pharmacologic Agents
(Smith 1980). The extent of the differences among infants, children, and adults in
All of these responses can and should be reduced or abolished response to the administration of drugs is not just a size conversion.
through preventive measures to ease the child’s adaptation to the hos- During the first several months after birth, rapid development and
pitalization, anesthesia, and surgery. The anesthesiologist’s role in this growth of organ systems take place, altering the factors involved in
process, as well as having a basic understanding of neurobehavioral uptake, distribution, metabolism, and elimination of anesthetics and
development, is important (Table 1.2). Anesthesiologists must also related drugs. Interindividual variability of a response to a given drug
be open to new ideas regarding the role of family-centered care, spe- may be determined by a variety of genetic factors. Genetic influences
cifically in regard to pediatric patients with psychiatric diagnoses or in biotransformation, metabolism, transport, and receptor site all
special needs who may benefit from the presence of service animals. affect an individual’s response to a drug. These changes appear to
Ambardekar and colleagues (2013) reported on the use of a service be responsible for developmental differences in drug response and
animal to help with the induction of anesthesia. can be further modified by age-related and environmental factors.
The pharmacology of anesthetics and adjuvant drugs and their differ-

ent effects in neonates, infants, and children are discussed in detail in 30
65
Part II (Pharmacology). 60
55 25
0.8
Anatomic and Physiologic Differences 50
Body Size 95 0.7 45
3 90 20
As stated, the most striking difference between children and adults is 34 40
85 0.6
size, but the degree of difference and the variation even within the 32 35
80
pediatric age group are hard to appreciate. The contrast between an 30 15
75 0.5
infant weighing 1 kg and an overgrown and obese adolescent weighing 30
28 70
more than 100 kg who appear in succession in the same operating
26
Surface area in square meters

65 25
room is overwhelming. It makes considerable difference whether body 0.4
weight, height, or body surface area (BSA) is used as the basis for size 2 60 10
comparison. As pointed out by Harris (1957), a normal newborn in- 20
22 55
fant who weighs 3 kg is 1/3 the size of an adult in length, but 1/9 the
Height in centimeters
0.3
20
Weight in kilograms
adult BSA and 1/20 the adult weight (Fig. 1.1). Of these body measure- 50
Weight in pounds
15
Height in feet
ments, BSA is probably the most important, because it closely parallels
18 45
variations in basal metabolic rate measured in kilocalories per hour
per square meter. For this reason, BSA is believed to be a better crite- 5
16 40
rion than age or weight in judging basal fluid and nutritional require- 0.2
10
ments. For clinical use, however, BSA proves somewhat difficult to
14 35
determine, although a nomogram such as that of Talbot and associates
(1952) facilitates the procedure considerably (Fig. 1.2). For the anes-
thesiologist who carries a pocket calculator, the following formulas may 1 30
be useful to calculate BSA:
10
Formula of DuBois and DuBois (1916 ) 9 5
25 0.1
BSA (m2 ) 0.007184 Height 0.725 Weight 0.425 8
Formula of Gehan and George (1970 )

20
BSA (m 2
) = 0.0235 Height 0.42246
Weight 0.51456
.
Fig. 1.2 Body Surface Area Nomogram for Infants and Young Children.

(From Talbot, N. B., Sobel, E. H., McArthur, J. W., & Crawford, J. D. (1952).

Functional endocrinology from birth through adolescence. Cambridge, MA:

Harvard University Press.)
At full-term birth, BSA averages 0.2 m2, whereas in the adult it aver-
ages 1.75 m2. Table 1.3 shows the relation of age, height, and weight to
BSA. A simpler, crude estimate of BSA for children of average height
and weight is given in Table 1.4. The formula is also reasonably accu-
rate in children of normal physique weighing 21 to 40 kg (Vaughan
and Litt 1987):
BSA (m2 ) ( 0.02 kg) 0.40.
The caloric need in relation to BSA of a full-term infant is about

30 kcal/m2 per hour. It increases to about 50 kcal/m2 per hour by
2 years of age and then decreases gradually to the adult level of 35 to
40 kcal/m2 per hour.
Relative Size or Proportion

Weight Surface Length
1/21 area 1/3.3
Less obvious than the difference in overall size is the difference in rela-
1/9 tive size of body structure in infants and children. This is particularly
Fig. 1.1 Proportions of Newborn to Adult With Respect to Weight,

true with the head, which is large at birth (35 cm in circumference)—
Surface Area, and Length. (Data from Crawford, J. D., Terry, M. E., &

in fact, larger than chest circumference. Head circumference increases
Rourke, G. M. (1950). Simplification of drug dosage calculation by by 10 cm during the first year and an additional 2 to 3 cm during the
application of the surface area principle. Pediatrics, 5, 785.) second year, when it reaches three-fourths of the adult size (Box 1.1).
TABLE 1.3 Relation of Age, Height,

and Weight to Body Surface Area (BSA)*
Age (years) Height (cm) Weight (kg) BSA (m2)
Premature 40 1 0.1
Newborn 50 3 0.2
1 75 10 0.47
2 87 12 0.57
3 96 14 0.63
5 109 18 0.74
10 138 32 1.10
13 157 46 1.42
16 (Female) 163 50 1.59
16 (Male) 173 62 1.74
*Based on standard growth chart and the formula of DuBois and
DuBois (1916): BSA (m2) 5 0.007184 3 Height0.725 3 Weight0.425.
Fig. 1.3 A Normal Infant Has a Large Head, Narrow Shoulders and

Chest, and a Large Abdomen.

TABLE 1.4 Approximation of Body Surface
Area (BSA) Based on Weight
Weight (kg) Approximate BSA (m2) muscles. Furthermore, the rib cage is cartilaginous, and the thorax is
1–5 0.05 3 kg 1 0.05
too compliant to resist inward recoil of the lungs. In the awake state,
the chest wall is maintained relatively rigid with sustained inspiratory
6–10 0.04 3 kg 1 0.10
muscle tension, which maintains the end-expiratory lung volume
11–20 0.03 3 kg 1 0.20 (i.e., FRC). Under general anesthesia, however, the muscle tension is
21–40 0.02 3 kg 1 0.40 abolished and FRC collapses, resulting in airway closure, atelectasis,
and venous admixture unless continuous positive airway pressure
Modified from Vaughan, V. C., III, & Litt, I. F. (1987). Assessment of
growth and development. In R. E. Behrman & V. C. Vaughn III (Eds.),
(CPAP) or positive end-expiratory pressure (PEEP) is maintained. (See
Nelson’s textbook of pediatrics (13th ed.). Philadelphia: Saunders. Chapter 3: Respiratory Physiology.)
Central and Autonomic Nervous Systems

The brain of a neonate is relatively large, weighing about 1/10 of the
BOX 1.1 Typical Patterns of Physical Growth body weight compared with about 1/50 of the body weight in an adult.
Weight The brain grows rapidly; its weight doubles by 6 months of age and
Birth weight is regained by the 10th to 14th day. triples by 1 year of age. By the third week of gestation, the neural plate
Average weight gain per day: 0 to 6 months 5 20 g; 6 to 12 months 5 15 g. appears, and by 5 weeks’ gestation, the three main subdivisions of the
Birth weight doubles at 4 months, triples at 12 months, and quadruples at forebrain, midbrain, and hindbrain are evident. By the eighth week of
24 months. gestation, neurons migrate to form the cortical layers, and migration is
During the second year, average weight gain per month: 0.25 kg. complete by the sixth month. Cell differentiation continues as neu-
After 2 years of age, average annual weight gain until adolescence: 2.3 kg. rons, astrocytes, oligodendrocytes, and glial cells form. Axons and
synaptic connections continually form and remodel. Fig. 1.4 plots
Length/Height gestational brain growth as a percentage of brain weight at term
By the end of the first year, birth length increases by 50%. (Kinney 2006). At birth, about one-fourth of the neuronal cells are
Birth length doubles by 4 years of age and triples by 13 years of age. present. The development of cells in the cortex and brain stem is nearly
Average height gain during the second year: 12 cm. complete by 1 year of age. Myelinization and elaboration of dendritic
After 2 years of age, average annual growth until adolescence: 5 cm. processes continue well into the third year. Incomplete myelinization
is associated with primitive reflexes, such as the Moro and grasp re-
Head Circumference
flexes in the neonate; these are valuable in the assessment of neural
Average head growth per week: 0 to 2 months 5 0.5 cm; 2 to 6 months 5
development. (See Chapter 27: Neonatology for Anesthesiologists.)
0.25 cm.
At birth, the spinal cord extends to the third lumbar vertebra. By
Average total head growth: 0 to 3 months 5 5 cm; 3 to 6 months 5 4 cm;
the time the infant is 1 year of age, the cord has assumed its permanent
6 to 9 months 5  2 cm; 9 to 12 months 5 1 cm.
position, ending at the first lumbar vertebra (Gray 1973).
In contrast to the central nervous system, the autonomic nervous
system is relatively well developed in the newborn. The parasympa-
At full-term birth, the infant (Fig. 1.3) has a short neck and a chin thetic components of the cardiovascular system are fully functional at
that often meets the chest at the level of the second rib; these infants birth. The sympathetic components, however, are not fully developed
are prone to upper airway obstruction during sleep. In infants with until 4 to 6 months of age (Friedman 1973). Baroreflexes to maintain
tracheostomy, the orifice is often buried under the chin unless the head blood pressure and heart rate, which involve medullary vasomotor
is extended with a roll under the neck. The chest is relatively small in centers (pressor and depressor areas), are functional at birth in awake
relation to the abdomen, which is protuberant with weak abdominal newborn infants (Moss et al. 1968; Gootman 1983). In anesthetized
Cardiovascular System
HUMAN BRAIN GROWTH During the first minutes after birth, the newborn infant must change
100 his or her circulatory pattern dramatically from fetal to adult types of
90 circulation to survive in the extrauterine environment. Even for several
months after initial adaptation, the pulmonary vascular bed remains
80
% Full-term brain weight
exceptionally reactive to hypoxia and acidosis. The heart remains ex-

70 tremely sensitive to volatile anesthetics during early infancy, whereas
60 the central nervous system is relatively insensitive to these anesthetics.
50 Complicating factors involving the cardiovascular system are the
40 age-related changes and large variability in vital signs that occur with
age. This is especially pronounced in newly born term and premature
30
infants. As a result, defining hypotension in these infants becomes
20 challenging. Cardiovascular physiology in infants and children is dis-
10 cussed in Chapter 5 (Cardiovascular Physiology) and Chapter 27
0 (Neonatology for the Anesthesiologist).
18 20 22 24 26 28 30 32 34 36 38 40
Fluid and Electrolyte Metabolism
Gestational age (wks)
Like the lungs, the kidneys are not fully mature at birth, although the
Fig. 1.4 Normal Brain Growth From 20 to 40 Weeks’ Gestation.

formation of nephrons is complete by 36 weeks’ gestation. Maturation
Brain weight is expressed as a percentage of term brain weight. (From
continues for about 6 months after full-term birth. The glomerular fil-
Kinney, H. C. (2006). The near-term (late preterm) human brain and risk tration rate (GFR) is lower in the neonate because of the high renal
for periventricular leukomalacia: A review. Seminars in Perinatology, 30, vascular resistance associated with the relatively small surface area for
81–88. Data from Guihard-Costa, A. M., & Larroche, J. C. (1990). Dif- filtration. Despite a low GFR and limited tubular function, the full-term
ferential growth between the fetal brain and its infratentorial part. Early newborn can conserve sodium. Premature infants, however, experience
Human Development, 23(1), 27–40.) prolonged glomerulotubular imbalance, resulting in sodium wastage
and hyponatremia (Spitzer 1982). On the other hand, both full-term and
premature infants are limited in their ability to handle excessive sodium
newborn animals, however, both pressor and depressor reflexes are loads. Even after water deprivation, concentrating ability is limited at
diminished (Wear et al. 1982; Gallagher et al. 1987). birth, especially in premature infants. After several days, neonates can
The laryngeal reflex is activated by the stimulation of receptors produce diluted urine; however, diluting capacity does not mature fully
on the face, nose, and upper airways of the newborn. Reflex apnea, until after 3 to 5 weeks of life (Spitzer 1978). After water deprivation in
bradycardia, or laryngospasm may occur. Various mechanical and the term infant, the urine concentrating ability is only about 50% to 60%
chemical stimuli, including water, foreign bodies, and noxious gases, that of an adult. The premature infant is prone to hyponatremia when
can trigger this response. This protective response is so potent that it sodium supplementation is inadequate or with overhydration. Further-
can cause death in the newborn (see Chapter 3: Respiratory Physiology; more, dehydration is detrimental to the neonate regardless of gesta-
Chapter 5: Cardiovascular Physiology). tional age. The physiology of fluid and electrolyte balance is detailed in
Chapter 6 (Regulation of Fluids and Electrolytes).
Respiratory System
At full-term birth, the lungs are still in the stage of active development. Temperature Regulation
The formation of adult-type alveoli begins at 36 weeks postconception Temperature regulation is of particular interest and importance in
but represents only a fraction of the terminal air sacs with thick septa pediatric anesthesia. There is a better understanding of the physiology
at full-term birth. It takes more than several years for functional and of temperature regulation and the effect of anesthesia on the control
morphologic development to be completed, with a 10-fold increase in mechanisms. General anesthesia is associated with mild to moderate
the number of terminal air sacs to 400 to 500 million by 18 months of hypothermia, resulting from environmental exposure, anesthesia-
age, along with the development of rich capillary networks surround- induced central thermoregulatory inhibition, redistribution of body
ing the alveoli. Similarly, control of breathing during the first several heat, and up to 30% reduction in metabolic heat production (Bissonette
weeks of extrauterine life differs notably from control in older children 1991). Small infants have a disproportionately large BSA, and heat loss
and adults. Of particular importance is the fact that hypoxemia de- is exaggerated during anesthesia, particularly during the induction of
presses, rather than stimulates, respiration. Anatomic differences in the anesthesia, unless the heat loss is actively prevented. General anesthesia
airway occur with growth and development. Recently, the age-old decreases but does not completely abolish thermoregulatory threshold
concept of the child having a funnel-shaped larynx with the cricoid as temperature to hypothermia. Mild hypothermia can sometimes be
the narrowest portion of the airway has been challenged (Holzki et al. beneficial intraoperatively, and profound hypothermia is effectively
2018). Findings by Litman and colleagues (2003) using MRI and used during open heart surgery in infants to reduce oxygen consump-
video-bronchoscopic images by Dalal and colleagues (2009) both re- tion. Postoperative hypothermia, however, is detrimental because of
vealed that the shape of the infant larynx was more cylindrical (as for marked increases in oxygen consumption, oxygen debt (dysoxia), and
adults) than funnel shaped and did not change much with growth. resultant metabolic acidosis (Bissonette 1991). In the surgical neonate,
They also suggested for infants and children that the glottis, not the hypothermia in the perioperative period occurs frequently and has
cricoid, may be the narrowest portion in the paralyzed or cadaveric been associated with adverse events (Morehouse et al. 2014; Engorn
position (which can be gently widened with an ETT); the cricoid re- et al. 2017). The use of forced-air warming devices has become an
mains the solid narrowest segment of the upper airway system. The important component in the prevention of intraoperative hypother-
development of the respiratory system and its anatomy and physiology mia. Though concerns about its use and association with surgical
are detailed in Chapter 3 (Respiratory Physiology). site infection have been raised, clinical evidence for this is lacking.
Regulation of body temperature is discussed in detail in Chapter 7 use of preoperative sedation via the transmucosal route, the wide use of
(Thermoregulation). topical analgesia with a eutectic mixture of local anesthetic cream be-
fore intravenous catheterization, expanded use of regional anesthesia
with improved accuracy and safety by means of ultrasound devices, and
SUMMARY more general acceptance of parental presence during anesthetic induc-
Pediatric anesthesia as a subspecialty has evolved because the needs of tion and in the recovery room. Furthermore, a more diverse anesthetic
infants and young children are fundamentally different from those of approach has evolved through the combined use of regional analgesia,
adults. The pediatric anesthesiologist should be aware of the child’s together with the advent of newer and less soluble volatile anesthetics,
cardiovascular, respiratory, renal, neuromuscular, and central nervous intravenous anesthetics, sedatives, and shorter-acting synthetic opioids
system responses to various drugs, as well as to physical and chemical and muscle relaxants. Finally, the scope of pediatric anesthesia has sig-
stimuli, such as changes in blood oxygen and carbon dioxide tensions, nificantly expanded with the recent development of organized pain
pH, and body temperature. Their responses are different both qualita- services in most pediatric institutions. As a result, pediatric anesthesi-
tively and quantitatively from those of adults and among different ologists have assumed the leading role as pain management specialists,
pediatric age groups. More importantly, the pediatric anesthesiologist thus further extending anesthesia services and influence beyond the
should always consider the child’s emotional needs and create an envi- boundary of the operating room.
ronment that minimizes or abolishes fear and distress.
There have been many advances in the practice of anesthesia to
improve the comfort of young patients over the last decade. These ad-
REFERENCES
vances include a relaxation of preoperative fluid restriction, more fo- Complete references used in this text can be found online at Expert
cused attention to the child’s psychological needs with more extensive Consult.com.
Another random document with
no related content on Scribd:
Tiedät myös, että se tulppaani jäi seisomaan tuokkoseensa
pitkäksi aikaa sen jälkeen kun se oli kuihtunut. Se seisoi siinä vielä
keväälläkin muitten tulppaanien jo puhjettua puutarhassa. Sillä kaikki
aavistivat, ettei se ollut mikään tavallinen tulppaani, eikä kukaan
hennonut sitä heittää pois. Kirstikin katseli tuota sinertävää ja
rutistunutta kasvia hienotunteisella arkuudella, sillä hänkin tiesi, kuka
sen oli lähettänyt, ja että jos siihen kajosi, saattoi se koskea kipeästi
Yrjöön.
24.
Kevät tuli aikaisin sinä vuonna. Kottaraiset pesivät jo huhtikuussa.

Peipposet ja leivosetkin saapuivat samassa ja täyttivät ilman
liverryksillään. Noilla viljavilla aukeamilla oli kymmeniä ja satoja
yht'aikaa nousemassa korkeammalle ja korkeammalle kohti
loistavaa taivaan kupua ja kiitostaan laulamassa ylitsevuotavin
riemusävelin siitä että olivat olemassa. Siitä kiittivät myöskin helein
värein krokukset ja skillat puutarhassa ja siitä paisuivat koivujen
nuput. Mutta tuo ihme, joka yhtä vakaavana joka vuosi uudistuu, se
tapahtui lauantain ja sunnuntain välisenä yönä. Sunnuntaiaamuna
avatessamme ikkunat olivat koivut puhjenneet lehtiin ja voimakas
tuoksu lemusi vastaamme kostean lämpimässä aamutuoreudessa.
Viikkoa myöhemmin tulit ylioppilaaksi.
Isä ja minä kävelimme Aleksanterinkatua pitkin jutellen sinusta.

Puhuimme lapsuudestasi ja siitä pitkästä ulkomaanmatkasta, jolloin
ensi kertaa olimme sinusta erossa ja jolloin meillä lopulta molemmin
puolin oli niin ikävä, että laskimme päivät ja tunnit kotiin tuloomme.
Meidän sitten saapuessamme eräänä varhaisena aamuna kotiin,
nukkui koko talo, mutta äänemme olivat herättäneet sinut ja juosta
lippasit ulos paitasillasi portaille asti. Silloin sinä itkit ilosta.
Poissaolon aikana olit kasvanut kovasti ja näytit siinä pitkine paljaine
säärinesi kuin olisit kävellyt puujaloilla.
Mutta vielä enemmän puhuimme siitä onnesta, että sinulla oli

sellainen ystävä kuin Marja. Ja siitä että teidän suhteenne oli saanut
säilyä niin häiriintymättömänä molempien kodeissa ja niinikään
koulussa. Se oli ollut niin avoin ja raikas, että teidät oli jätetty
rauhaan.
Siitä iloitsimme lähestyessämme Senaatintoria. Jäisi ainiaaksi

kaunis muisto tästä ajasta teille molemmille, niin sinulle kuin
Marjallekin, vaikkei siitä kehittyisikään mitään sen enempää. Senpä
takia se tyttö ansaitsisi oikein kauniin ruusukimpun Yrjön
vanhemmilta.
Ja isä osti kukkia Yrjölle ja vielä muutamille heidän tovereilleen. Ja

hän antoi minulle toisen puolen heille jaettavaksi.
Senaatintori oli sitten täynnä odottavia, kuten tavallisesti tällaisissa

tilaisuuksissa. Siellä oli tietysti sukulaisia ja ystäviä — eikä vähimmin
ylioppilaita, jotka pari- kolmevuotisen arvonsa huipulta tahtoivat
tervehtiä nuoria keltanokkia. Seisottiin ja juteltiin — katsottiin tuon
tuostakin Nikolainkirkon tornia ja alettiin ikävystyä.
Silloin kuului huuto. Ja ensimmäinen joukko valkotakkisia juoksi

alas yliopiston portaita. Mutta sinä et ollut vielä heidän joukossaan.
Ihmiset saivat taas yrittää lyhentää odotusaikaansa kertomalla

toisilleen mitä tiesivät. Helsinkiläisillä oli kyllä hauskin vastaanotto,
arveltiin, koska heillä on eniten tuttuja ja he ovat joka vuosi
ensimmäiset. Nytkin istui jo ylioppilaita Kaivohuoneella odottamassa
uusia tovereitaan yhteiseen juhlaan.
Taas kuului huuto ja taas tulvi valkotakkisia leveitä portaita alas.

Pian oli pitkä poikamme raivautunut tungoksen läpi luoksemme ja
tervehti meitä ilosta sädehtien. Olit ehtinyt saada kukkia jo matkaltasi
— Henrik enolta — ja Etalta — ja Erikiltä — ja Anna tädiltä — ja
kaikki olivat tulleet varta vasten sinun takiasi! Ja nyt sinun piti pian
hankkia karjalaiset värit lakkiisi.
Sinä otit lakin päästäsi tarkastaaksesi lyyraa. Se ei ollut pienen

pieni eikä suuren suuri, vaan juuri sitä lajia kuin pitikin.
Ja koko elämä oli parhaimmillaan semmoisena kuin se oli juuri nyt.
Sitten sinä sait ruususi meiltä ja neilikan mummon ikkunalta ja

Kirstiltä kieloja, joita hän oli löytänyt metsästä. Niin tosiaankin, Kirsti!
Hän oli surumielisenä pistänyt kukkasensa äidin käteen, sillä eihän
hän saanut tulla kaupunkiin niin myöhään valvoakseen. Mutta sinä
kaipasit pientä liinapäätä sisartasi. Olisipa tuo ollut paras kaikesta,
jos hän olisi ollut mukana!
Mutta kun ei Marjaa näkynyt eikä kuulunut, vaikka häntä

odottelimme, saivat ympärillä seisovat toverit ensin oman osansa, ja
kun odotus tuntui olevan aivan tuloksetonta, vähitellen myöskin
Marjalle aiotut ruusut, niin että lopuksi seisoimme siinä tyhjin käsin.
Silloin hän tuli. Ilmestyi nauravana ja välkkyvin silmin ja kiersi

käsivartensa takaa päin kaulaani. Ja Marjan isä ojensi sinulle, Yrjö,
ruusun.
Silloin kävin niin murheelliseksi, että jalkani tuntuivat lyijyn
raskailta, ja ilta tuli harmaaksi ja värittömäksi. Ja pyysin sanattomasti
teiltä molemmilta anteeksi sitä, että olin ehkä nostattanut hattaran
teidän pilvettömälle taivaallenne.
Katsoin syrjäsilmällä sinuun ja olinkin huomaavinani pienen

pettymyksen ilmeen.
Mutta Marja ei tuntunut mitään odottaneen. Hän oli miltei

suunniltaan ihastuksesta:
— Voi miten äärettömän — käsittämättömän — kauhistuttavan

hauskaa!
Niin oli. Tietysti niin oli. Koetin salata pahaa mieltäni, mutta sanoin
itselleni, että siinä se nyt taas oli, se mitä eniten vihasin — tuo
elämän taitamattomuus — ah, juuri senlaatuinen paha, joka estää
hetken tulemasta niin rikkaaksi kuin se muuten voisi olla! — Siinä ne
aina niin äkkiarvaamatta ilmestyivät eteeni, nuo laiminlyöntisynnit —
pahimmat kaikista — joita pitäisi olla helppo välttää ja joita kuitenkin
jokaisella on omallatunnollaan hirvittävä liuta.
Mutta tehtyä ei voinut tehdä tekemättömäksi.
Ja heitin luotani mielenapeuteni. Mutta aavistin, että sinä tuossa

vieressäni kulkiessasi itseksesi haudoit, miten voisit Marjalle korvata
ne kukkaset, joita hän ei saanut isältä ja äidiltä. Pian kävit taas täysin
hilpeäksi ja sait minutkin siirtymään omaan tunnelmaasi.
Marja erosi meistä seuraten isäänsä, mutta tunnin perästä nuorten

piti tavata toisensa Kaivohuoneella, ja isä ja minä aioimme mennä
sinne mekin kerran katsomaan nuorten iloa.
Silloin oli tyyni ilta vaikka hiukan kolkko. Mutta eiväthän nuoret
siitä välittäneet. Kaivohuoneen salista kuului remuava melu ja
eteisessä juoksi ylioppilaita sisään ja ulos. Löysimme pienen pöydän
itsellemme ikkunan luona ja näimme sieltä, miten sinä seisoit portilla
Marjaa odottamassa. Napinlävessä sinulla oli ainoastaan pari kolme
kukkasta, muut kaikki, koko suuren kimpullisen ruusuja, pidit
kädessäsi. Toverit kulkivat toinen toisensa jälkeen ohitsesi päätä
nyökäyttäen, ikäänkuin olisi ollut päivän selvää, että siinä jotakin
odottelit.
Vihdoin Marja tulikin, valkoisiin puettuna, iloisena ja säteilevänä ja

pisti kätensä kainaloosi. Ja sinä, Yrjö — niin, Marja on sen minulle
perästäpäin kertonut — sinä otit takinkauluksesi alta pienen
orvokkikimpun, ojensit sen Marjalle ja sanoit:
— Tuon lähetti Henrik eno sinulle ja pyysi sanomaan terveiset.
— Hänkin! — Voi kuin tämä päivä on ihastuttava!
Mutta et itsekään muistanut, että Henrik eno, antaessaan sinulle

kukat, hienotunteisesti oli sanonut: Ja anna sitten nämä kukat sille
tovereistasi, josta eniten pidät. — Niin, sehän oli heti niin selvä asia.
Ja siinä astuessanne leveätä ja tuuheata lehmuskäytävää, nostit

koko kukkaisrunsautesi Marjan eteen, ojensit sen hänelle ja sanoit:
— Ja nämä saat sitten minulta!
— Yrjö — ei — miksi annat minulle kaikki kukkasesi?
Marja miltei säikähti.
— Sen takia vain, että annan.

— Miksikä niin — miksi annat kukkasesi pois? — Missä täti? —
missä setä? — missä he istuvat? — Tule! Niin paljon en ota sinulta!
Te löysitte meidät nurkastamme.
— Ajatelkaa! — mitä te siihen sanotte? — huudahti Marja. — Yrjö

antaa minulle kaikki kukkasensa! — Miksi pitää minun tänään saada
niin paljon? — miksi kaikki ihmiset ovat niin hyviä? — ja — kuinka
voin ottaa nämä vastaan sinulta, Yrjö?
— Ota sinä, minkä saat — sanoi isä vakavasti. — Sellaisia lahjoja

ei anneta eikä otetakaan kuin kerran elämässä, luulen ma.
Sitten katselimme teidän jälkeenne, kun te siinä käsi kädessä

kuljitte salin läpi omaa pöytäänne kohti, jossa toverit teitä odottivat.
Teihin kiinnitti moni muukin katseensa, yksi ja toinen kääntyi
tuolillaan teitä silmillään seuraamaan. Sillä teistä uhkui kevät ja
anteliaan luonnon kauneus, ja teitä yhdisti toisiinne se salaperäinen
voima, jota kaikki ihmiset tieten tai tietämättään eniten ihailevat ja
palvovat.
25.
Kylmä ja sumuinen viima kiersi Kaivopuiston rantoja. Se kiersi

katuja ja kulmauksia kuin hyljätty ja petetty; joka tahtoo kostaa
pettäjällensä.
Mutta kuka huomaa sellaista sinä päivänä, jolloin on lyyrynsä

saanut! Tällaisena aivan erikoisena, unohtumattomana iltana! Jos
meri olisi sinisenä siintänyt tai hopeaisena hohtanut Kaivopuiston
valleilta ja linnut pitäneet kevätlaulajaisiaan vanhoissa puissa, niin
tietysti se olisi ollut hurmaavaa ja olisi tullut siitäkin iloinneeksi. Mutta
kun sen sijaan miltei satoi räntää, ei tullut sitä ajatelleeksikaan, vaan
oli kuin se olisi asiaan kuulunut, ja kaikki oli siitä huolimatta niin
täydellistä, ettei mitään parempaa kaivannut.
Ja sinä tulit salin halki häntä kädestä pitäen, ja te astuitte hitain

askelin pöytien lomitse. Mutta toverisi näkivät heti, että kaikki
kukkasesi olivat tyttösi kädessä ja että hänen ilmeensä oli tullut
sisäisen hartaaksi ja lempeäksi.
Mutta kukaan ei siitä virkkanut mitään.
Sinä toit vettä korkeaan maljakkoon ja te istuuduitte muitten

seuraan.
Mutta vaikka katse oli teitä seurannutkin, vaikka muutkin asiat

tuokioksi kiinnittivät läsnäolijoitten mielen, missään ei viivytty, kaikki
yksityisseikat olivat kuin kuplia rientävän virran kalvossa. Elämän
riemu siinä virrassa lainehti. Nuoruuden hurmio siinä vaahtoili. Ja
virran mukana kulkijat näkivät maailman kuin lapsi näkee sen
unenpöpperöstä herätessään jouluaamuna, kun hän vielä kosteitten
silmäripsien lomitse tanssittaa aarrevarastoaan sikin sokin ja ylös
alaisin silmäinsä edessä.
Siinä tuli ovesta eräs sanomalehden toimittaja — pelätyimpiä

ivansa ja ankaran arvostelunsa vuoksi. Ja miten hän yhtäkkiä näytti
iäkkäältä! Pitkän pöydän päässä istui — sanoisinko — vanha
aviopari, tutun näköisiä ihmisiä. En olisi koskaan ennen sanonut
heitä iäkkäiksi, mutta nyt! Miltä mahdoimmekaan me itse näyttää?
Tämä ympäristö oli niin verevää nuoruutta täynnänsä, että kaikki
vähänkin pitemmälle elämän polulla ehtineet heti poikkeuksellisesti
pistivät silmään kuin oksattomat pökkelöt nuoressa viidakossa,
totiset ja harmaat.
Sanomalehdentoimittaja katsoi ympärilleen paikkaa etsien.

Hänestä oli kokonaan haihtunut tuo hänelle joskus ominainen yli-
ihmisen ilme ja hän näytti miltei vaatimattomalta. Tänä iltana hän
antoi vähäpätöisellekin anteeksi hänen vähäpätöisyytensä.
— Onko sinullakin jokin onnellinen täällä — kysyi hän ystävällisesti

tuttavaltaan ohitse kulkiessaan ja hipaistessaan hänen tuolinsa
selustinta.
— Poika on.
— Minulla on täällä kaksi yhtaikaa.
Ja hänen kasvoilleen välähti leveä hymy.
Siinä aaltoili nyt valkolakkisten meri ja pauhasi kuin vallattomat

hyrskyt kirkkaana kevätpäivänä. Ja pökkelöt salissa katselivat sitä
vaieten, nykyisyyttään unohtaen, nuoruuttaan muistaen, tapsiinsa
sulautuen. Mieli pehmeänä ja ehkä hiukan surunvoittoisena.
Arvoisa toimittaja löysi yksinäisen paikan toisessa nurkassa.

Kukaan ei häntä huomannut. Ylioppilaat melusivat ja huusivat — he
heiluttivat takkejansa ja laulaa jyrisivät. Hän katseli heitä ikäänkuin
he kaikki olisivat olleet hänen poikiansa — tahi ikäänkuin hänen
omat nuoruudenpäivänsä olisivat nousseet kuolleista. Ja hän tyytyi
täydelleen olemaan unohdettu ja syrjäytetty. Hänen herkkä ja hieno
minänsä, joka muuten peittyi kuorensa alle, otti hänet kokonaan
valtoihinsa.
Mutta äänten melske pauhasi taukoamatta. Mistään muusta ei
tiedetty, ei välitetty, kuin tämän hurmaavan illan taivasta
tavoittelevasta ilosta. Pois tieltä! Eläköön! — Ensi kertaa todella
vapaita! — Nyt vasta oikein täysi-ikäisiä! — Nimet
ylioppilasluettelossa! — Vanhempien ylioppilaiden juhlimia! —
Ylioppilas!— Ja koulu vihdoin jossain kaukaisessa menneisyydessä
— kirjat suolattuina ja opettajat kuin museossa! — Nyt ei ollut
kellään sanomista, vaikka olikin paperossi hampaissa, vaikka olisikin
lasia kallistanut! — Sai tehdä niin tai näin, olla maistamatta tai
maistaa, niinkuin kukin oli asian mielessään päättänyt. — Nyt oltiin
ylioppilaita! Ja pois tieltä vaan, tässä tuli vapaa mies!
Mutta maistoivatpa he tai ei, tarkastelivat he salaa jännittyneellä

uteliaisuudella niitä vanhempia tovereita, jotka olivat istuneet siellä
tuntikausia ja saaneet jo liikaa.
Ja voi tämän illan ystävyyttä ja veljeyttä! Siellä vaelsi poikia

käsikkäin tai kaulakkain tai kädet toistensa olkapäillä — sama
hyväntahtoisuus sulki heidät kaikki helmaansa. Pökkelöt
kummastelivat itseksensä, mistä mahtoi olla kotoisin tuo myöhempi
kinastelu ja puoluekiihko, joka aina pyrki kehittymään jokaisessa
ylioppilaspolvessa. Mistä sitten tullee, mutta ei siihen täällä tuntunut
alkuvihjaustakaan olevan.
Siinä oli pitkä poika, joka näytti tuntevan sellaista autuuden

ylenpalttisuutta, että hänen täytyi hypätä tasajaloin kaikkien lähellä
olevien pikkupöytien ääressä — hänen täytyi syleillä jokaista uutta
tuttavaa — hänen täytyi nousta tuolille heiluttamaan kättä niille
monille, joita hän ei voinut henkilökohtaisesti tavata. Hän oli istunut
siellä aikaisemmista iltapäivätunneista saakka, kuten samaan
seurueeseen kuuluva toverinsakin, joka piilotteli aarretta takkinsa
alle. Hän painoi sen hellästi povellensa, nosti joskus takin reunaa ja
tirkisti sen alle. Joillekuille hän sen näyttikin — pyhän vaitiolon
ehdolla — he räjähtivät nauramaan, löivät häntä olkapäälle ja
pyöräyttivät hänet ympäri. Silloin tällöin tempasi hän sen esille
aiheettomalla avomielisyydellä, pisti sen kainaloonsa, eikä ollut
tietävinäänkään. Silloin kävi ilmi, että se olikin vain ympyriäinen
tuolinistuin, jonka hän oli näperrellyt irti jostain tuolista.
Hän piti sitä yksityishuvituksenaan, joka sulostutti hänen iltansa.
Yrjö ja Marja istuivat kaukana salin toisessa päässä. He pitivät

iloansa ilman punssia ja liköörejä — siis myöskin ilman tuolinistuimia
ja tasajaloin hyppelehtimistä. Mutta heitäkin ja heitäpä varsinkin
hurmasi tuo yhteinen riemu, joka sulki koko maailman povellensa.
*****
Lähdimme aikaisin kotiin päin astumaan. Eteisessä tapasimme

Ennin, Yrjön ja Marjan toverin. Hän oli menossa kutsuihin, jotka
hänen vanhempansa olivat panneet toimeen hänen kunniaksensa.
Meri oli yhtenä ainoana sankkana pimeänä ja lyhtyjen valo oli

kelmeän kellertävä sumussa. Ei tihuuttanut kosteutta, mutta satoi
miltei lumiräntää.
Enni ei sitä näkynyt huomaavan.
— Jos ymmärtäisin — tarinoi hän meille herttaisella

avomielisyydellään — miksi kaikki on niin hauskaa, ei ainoastaan
tämä päivä, vaan muutenkin kaikki — mikään ei ole ikävää. Pidän
kaikista tovereista — tuskin koskaan voin heitä unhottaa — ja kun
sain lakin, luulin kuolevani ilosta. — Ja nyt saan mennä äidin kanssa
huvilallemme kylvämään puutarhaamme. Meillä on ikkunallamme
tomaatteja, tämän pituisia. Ja ensi talvena aion itse hoitaa
talouttamme — käyn torilla kysymässä kalanhintoja — leivon
pikkuleipiä ja teen kastikkeita — se on jännittävää ja hirveän
hauskaa! Pidän ihan kaikesta, myös siitä, mitä ennen en voinut
kärsiä — niinkuin yleisestä historiasta! Voisin vaikka hakea lisätietoja
kuninkaista ja piispoista, mikä ennen oli sietämätöntä. — Mutta
toistaiseksi on kaikkein hupaisinta mennä huomenna maalle lavaa
kylvämään.
Niinpä niin, Enni! Kaikki on kauhean hauskaa! Ainakin tänä

ihmeellisenä, sanomattoman autuaana toukokuun yönä, jolloin sataa
räntää ja pohjoinen puhaltaa ja kostea viima jäätää jäsenet
lämpimänkin vaipan alla.
26.
Aamulla hohtivat nurmikot valkoisina, ja lumi peitti allensa koivujen

lehdet. Isä jäi sanatonna seisomaan huoneensa avattuun akkunaan.
Lunta toukokuussa! Oliko talvi todellakin katunut aikaista
väistymistään, vai puhalteliko se kylmää vain pilan päiten? Nyt oli
maailma kuin loihdittuna tuon pehmeän vaipan alle, ei tiennyt oliko
kesä vai talvi, tuskin edes oliko päivä vai yö.
Mutta isä veti voimakkaasti sieraimiinsa mehevän rehevyyden

tuoksua, joka täytti kostean ilman.
Ja räystäistä valui vettä, oksista tippui raskaita vesikarpaloita

maahan. Ja ilma hohti harmahtavan hopeisen pilviverhon alla, jonka
takana päivä paistoi kuin himmeän lasin läpi.
Isä otti nahkasalkkunsa ja astui portaita alas eteiseen, veti

takkinsa ylleen, löysi hattunsa ja keppinsä tavallisilta paikoiltaan ja
oikaisi puutarhan läpi asemalle päin mennäkseen työhönsä
kaupunkiin.
Mutta korkeitten koivujen alle hän pysähtyi. Missä oli se tavallinen

piipatus ja vikinä puissa? Kottaraiset pysyivät niin hiljaa pesissään
kuin olisivat olleet kuolleet. Mutta sydän heillä varmaan tykytti
rauhattomuudesta ja neuvottomuudesta, siipi värisi ja pyöreät silmät
katsahtivat pesän reunan yli raskaitten lumipisaroitten tippuessa.
Sinä, Yrjö, olit nukkunut kauan sinä aamuna. Tuntui niin suloiselta
herätä ja muistaa ettei tarvinnut mihinkään kiirehtiä. Nousit
kumminkin lopuksi ja pukeuduit hitaasti ja vihellellen
kylpyhuoneessa. Käväisit suihkun alla tutisten ja päristen kylmässä
räiskeessä, ja puistit sitten vaatteesi kappale kappaleelta
parvekkeella, avaten oven selkoselälleen ja vetäen vaatteet yllesi
raikkaassa ulkoilmassa. Ketään ei näkynyt tiellä, kukaan ei astunut
veräjästä sisään. Naapurienkin puutarhat olivat tyhjät, eikä
hiiskaustakaan kuulunut mistään. Kaukana vihelsi juna — tullen —
mennen — yhtä kaikki.
Vihdoin olit pukeutunut ja sitonut kaulaliinasi. Muutamin harvoin

harppauksin laskeuduit tapasi mukaan portaita alas alakertaan,
samat vaaleanharmaat vaatteet ylläsi, kuin edellisenä päivänä
ollessasi lakkia saamassa.
Ruokahuoneessa odotti sinua aamiaispöytä, katettu yksin sinulle.

Pöydällä oli kukkia maljakossa ja toisia taitetun lautasliinan
kupeessa. Pehmeäksi keitettyjä munia oli kannen alla.
Kirsti hypähti jostain esille ja karkasi sinuun kiinni. Hän kiskoi
sinua kädestä ja istutti sinut kukkia ihailemaan. Ne hän oli näet itse
äsken puutarhasta poiminut, vaikka siinä jalat kastuivatkin. Nyt odotti
hän kiitosta ja sen hän sai. Sitten istuutui hän veljeään vastapäätä
pitääkseen hänelle seuraa.
Te puhuitte puoliääneen. Ikäänkuin salaliitossa keskenänne.

Joskus helähti Kirstin nauru ja hän huudahti jotakin äänekkäästi, ja
siitä syntyi väittely ja yhteinen ilon temmellys.
— En mene minnekään, kun saan kerran olla rauhassa kotona —

kuului vastaukseksi Kirstin kysymykseen.
— En minäkään sitten mene — en Eijan enkä Sirkankaan luo. —

Etkö lähde kaupunkiinkaan?
— Ai, se on totta, valokuvaajaan pitää mennä.
— Jaa! Katsopas nyt! — Etpä malttanut olla — etpä malttanut olla

— — jaa!
— Kyllä olisin malttanut — —
— Etpä olisi — etpä olisi, kyllä minä sen tiedän — etpä olisi
malttanut!
— Mitä sinä muka tiedät?
— En sano. Mutta tiedänpä mitä tiedän. Kaikkea ei sanotakaan —

eipä niinkään!
Sitten te taas vaivuitte hiljaiseen yhteisymmärrykseen.
*****
Mummo istui ikkunan ääressä poimuttaen pieluksen päällisten
nauhoja, ennenkuin järjesti puhtaat liinavaatteet kaappiin. Hänen
valkoista päätään peitti musta pitsimyssy ja hänen ruskeat silmänsä
hymyilivät. Hän katsahti silloin tällöin lapsiin, asetti valmiin päällisen
muitten valmiitten päälle ja otti käsiteltäväkseen uuden
suoranauhaisen viereltään, antaakseen sillekin saman pienen
hienostuksen leiman. Niitä ei millään muotoa sopinut järjestää
paikoilleen ilman näitä poimutettuja nauhoja, jotka osoittivat niiden
sivistyneisyyttä.
Ja mummo katsoi Yrjöön ja Kirstiin ja antoi tapansa mukaan

aatoksensa mennä omia menojaan.
— Tuossa ne nyt ovat — ajatteli hän — tuossa on Yrjö nyt

ylioppilaana — ja tuossa on Kirsti joka tuli miltei eilen. — Ja isä on
kaupungissa ja äiti missä lienee puutarhassa — ja he kuuluvat kaikki
toisillensa, vaikkeivät verisiteet sido heitä yhteen. Ja ehyempi on
tämä koti kuin moni muu, jossa on toisin. Ja minä tässä myöskin
olen ja askaroitsen ja kuulun minäkin tähän kokonaisuuteen, vaikka
minulla on monet muutkin lapset ja lastenlapset. Mutta kukapa ei
tuota Yrjöä rakastaisi omana lapsenaan — ja olen jo ennättänyt
Kirstinkin itselleni omistaa, niin ettei ole eroa mielessäni näitten ja
muitten lastenlasteni välillä. — Enhän aivan samalla lailla elä näissä
eteenpäin, kuin heissä. — Mutta onhan heihinkin vierasta tullut
paljonkin, ovat vain puoleksi tai neljänneksittäin omiani, eikä
niinkään paljon, jos oikein ajattelee. Mutta Jumalan kiitos — sitä ei
tule tuollaista niin miettineeksi — tulee vain heistä pitäneeksi
semmoisinaan — eikä tutkistele miksi. Onneksi ei olekaan tärkeätä
sitä tietää — tavallisesti rakastaa eniten silloin, kun ei mitään kysy.
Ja minä pidän heistä kaikista — se on pääasia.
Ja kun tulee vanhemmaksi — tuumi hän vielä lepuuttaen kättään
helmassaan — niin käyväthän lapset entistään rakkaammiksi, mutta
samalla rakastaa ehkä muitakin enemmän kuin ennen. Sillä siirtyy
itse ikäänkuin kaikesta loitommalle ja huomaa, että yhtähän he ovat
kaikki, omat ja vieraat — ja tänne ne jäävät kaikki, kun itse lähtee —
ja niinpä tekee mieli heitä kaikkia siunata mennessään.
*****
Sinä, Yrjö, olit lopettanut ruokailusi ja seurasit silmilläsi mummon

työtä. Seisoit siinä ja olit tyytyväisen näköinen. Mummo kysäisi, oliko
sinulla ollut hauska eilen.
Hauskako? Sinä nauroit ja vakuutit, että kyllä olit parastasi

koettanut. Ensin Kaivohuoneella. Mutta vasta sieltä lähdettyä olitte
oikein hullutelleet. Olit Jussin kanssa vaeltanut pitkin katuja ja nähnyt
jos mitä hullunkurista. Puistokadulla Henrik enon talon lähellä istua
kyykötti kaksi keltanokkaa matalalla puutarhamuurilla erästä ikkunaa
tähystellen. Sen takana tietysti asui jokin ihastus, jota he tahtoivat
palvoa salaa. Uudin oli alhaalla, mutta uutimen edessä istua mökötti
lurppakorva Musti, oikea mopsinaama. Tytön koira tietysti. Toisella
pojalla oli kova hattu kainalossa ja hän härnäsi sillä koiraa. Hän
vaihtoi ylioppilaslakin hattuun, keikautti sen kallelleen, oli olevinaan
päissään ja hoiperteli pitkin muuria jalat sisäänpäin käännettyinä.
Koira julmistui, nousi kahdelle jalalle, pullisti silmänsä ja oli vähällä
haukkua. Silloin oli mies muurilla selvä taasen, oikaisi jalkansa,
piilotti hatun kainaloon ja sai valkolakin päähänsä. Ja koira
rauhoittui. Silläpä koiralla oli kauneudenaistia — enemmän kuin
monella taidearvostelijalla. Mutta kun ei tyttöä näkynyt, eivätkä
ylioppilaat viitsineet enää mopsin kanssa ilvehtiä, valmistautuivat he
rauhassa nauttimaan olostansa, heittäytyivät muurille pitkälleen,
avasivat voileipäkäärönsä — ja olisit nähnyt, mummo, miten niissä
voileivissä oli kokoa! Ja noin paksulta kinkkua! Kyllä olivat
varustautuneet kauan odottamaan kaunottarensa heräämistä.
Ehkäpä istuvat siellä vieläkin.
Se huvitti sinua vielä perästäpäinkin. Ja kuitenkin sinusta tuntui,

kuin se kaikki olisi jo ollut jotakin kaukaista.
*****
Kuljit huoneitten läpi ja pysähdyit ikkunan eteen. Miten siellä

ulkona kaikki oli valkoista ja puhdasta! Saviset tietkin ja mustan
kiiltävät pellot. Ja miten kaikki oli hiljaista, kuin olisi luonnossa suuri
sunnuntairauha. Sinulla oli sunnuntaisi nyt kaikkien noitten vuosien
aherruksen jälkeen. Tuo valkeus ulkona oli kyllä vain hetken harhaa,
sillä räystäissä helisi sulavan lumen solina, ja puitten oksista satoi.
Pian olisivat nuo vainiot taas paljaat, ojissa lorisisi ruskea vesi, ja
teillä savi kuohuisi kuten keväällä aina. Mutta sekin oli tuttua ja
kotoista ja yhtä rakasta. Sillä siihen kuului leivosen liverrys ja
keväthuuhkajan yksitoikkoinen uukahdus valoisina kevätiltoina.
Kerrankin sait nauttia tästä kaikesta täysin rinnoin, kenenkään ja

minkään häiritsemättä. Sait vaipua omiin tunnelmiisi ja hommiisi ja
vihdoinkin olla rehellisesti oma itsesi omine harrastuksinesi.
Avasit ikkunan äidin huoneessa ja katselit ulos.
Kotirauhan ja kotiviihtymyksen tunne lämmitti sinua niin että

selkäpiitäsi suloisesti värähdytti. Kun oli paikka, josta ei tehnyt mieli
pois, vaan jonne mieli jäädä! Ja kuitenkin edessä avara maailma,
joka sekin aikanaan saisi osansa.
Tuossa oli kellertävä kotiaitaus ja sen takana pellot ruohoisine
ojineen. Peltojen keskellä oli lehtosaareke, josta puitten lomitse
kuulsi taittokattoinen herraskartanon pääty. Ja sivuitse siitä
alempana oli pieni keltainen pysäkkihuone ratavallilla ja sen alla yli
äyräittensä paisuvat tienristeykset. Aina niistä kuitenkin ylitse pääsi.
Ja kauempana oli metsäinen taivaanranta, josta paljaana paistoi

kivinen kukkula, venäläisten sotamiesten metsättömäksi tekemä.
Sinne oli monesti noustu katsomaan kaupunkia kaukaa kesäillan
valaistuksessa.
Ja pitkin teitä oli puhelinlankoja ja humisevia puhelinpylväitä ja

pieniä huviloita puutarhoineen toinen toisensa vieressä asemalle
asti. Siellä oli lautakäytävällä kiirehtiviä kulkijoita junien lähtöaikoina,
mutta väliajoin oli maassa rauha, kuten nyt — ja muu maailma
kaukana.
Täällä oli ihmisellä koti eikä vain asunto.
Siinä kulki Anna puutarhatietä pitkin kori käsivarrellaan nähtävästi

kauppapuotiin. Hän oli äsken sulkenut sähköpumpun, jonka ääni
kumisi talossa heti kun sähkönappula nostettiin keittiön seinällä.
Kuului silloin siltä kuin olisi tavaton ampiainen hyrräten surissut
huoneissa pääsemättä ulos. Aina kuulostelit tuota ääntä
päättääksesi, täyttyikö vesisäiliö tasaisesti vedellä ja oliko koneisto
kunnossa. Jos oli syytä epäilykseen, kiiruhdit heti vikaa korjaamaan.
Nyt seisoit ja katselit Annaa, joka oli sulkenut portin jälkeensä ja

loittoni tietä pitkin.
Hänkin oli sitä, mikä kuului tänne. Miten kauan hän jo oli täällä
liikkunut pitämässä huolta kellareista ja keittiöstä ja kaikesta muusta
talossa, sitä et muistanutkaan. Ja ennen kuin hän tänne tuli, oli hän
ollut mummon kodissa ja sitä ennen isän vanhempien kodissa, niin
että meille hän oli kuulunut nuoruudestaan asti. Hän puhui hiljaisella
äänellä ja hiukan yksitoikkoisesti, mutta eihän hänen elämässään
ollut niin kovin paljon vaihtelua ollutkaan.
Anna oli aarre, uskollinen ja tunnollinen. Kukaan ei siinä häntä

voittanut. Eikä hän vaivojaan säästänyt. Hän oli enemmän ystävä
talossa kuin perheen palvelija.
Mutta Kirsti oli kiertänyt puutarhat ja verannat, alakerrat ja

yläkerrat ja tuli veljensä luokse »Max und Moritz» kädessään,
valkoisiin korukansiin sidottuna ja nimi kannella hienoin mustin
kirjaimin. Sen olit saanut joskus jonkun ulkomaanmatkan tuomisina.
Kirstin mielestä olit nyt vieläkin joutilaamman näköinen kuin joskus
iltaisin läksyt luettuasi ja kirjoituspöytäsi laatikoista kaivettuasi esille
Husqvarnan tai muitten tehtaitten valmisteluetteloita, joita huviksesi
tutkistelit, tai autojen ja ilmalaivojen kuvasarjoja. Et nytkään estellyt,
vaan nostit hänet polvillesi ja näytit hänelle aina yhtä hauskan »Max
und Moritzin».
Istuit äidin keltaiseen nurkkasohvaan, tyttö sylissäsi, ja aloit:
Als die gute Witwe Bolte

sich von ihrem Schmerz erholte — — —
Kirsti tuijotti sinua silmiin, mitään ymmärtämättä ja kuitenkin

nauttien runon poljennasta ja vieraan kielen oudosta soinnusta.
Hetkisen perästä juoksi hän taasen tiehensä viedäkseen kirjan

takaisin paikoillensa.
Mutta sinä et voinut mihinkään tarttua. Olihan sitä tartuttukin
tarpeeksi ja liiaksikin, varsinkin viime aikoina, niin että nyt oli
hengähtämisen vuoro. Etkä tällä hetkellä toivonut mitään sen lisäksi
mitä oli. Siellä kaupungissa elämä pauhasi ja paloi, hurisi ja humisi
mukaansa tempoen tarkoituksettomastikin, usein ilman pontta ja
perää. Siellä kai toverit nytkin katuja kiertelivät, heillä kun ei ollut
kotia maalla.
Heittäydyit taasen sohvan nurkkaan, josta näit sekä salin että

ruokahuoneen ja katselit sieltä lattian kotikutoisia karvamattoja,
ruskean punamustine juovineen, jotka muistit siitä asti kun yleensä
aloit jotakin tajuta. Holmbergin metsämaisema oli myöskin aina
riippunut sohvaseinällä ja Thorvaldsenin friisi flyygelin yläpuolella.
Täällä pitäisi kaiken jäädä koskemattomaksi ikuisiksi ajoiksi. Juuri
tuossa piti olla nuottikaapin, ja ikkunoissa piti aina olla kukkivia
pelargooneja ja nupussa olevia ruusuja.
Tänne pitäisi saada tulla vastakin elämän tuoksinasta — ajattelit

sinä — kaukaakin ja pitkienkin aikojen perästä — ja tavata tämä
muuttumattomana ja alati samana.
Nousit, suljit ikkunan ja katsoit kelloasi. Voi ihmeitä! — Ihanhan

aika oli lentänyt — sinunhan piti joutua päiväjunalla kaupunkiin,
ennättääksesi sitten isän kanssa takaisin päivällisille.
— Äiti, missä olet? —Tulehan, katsohan — mitkä kukat sopisivat

napinläpeen, kun menen valokuvaajalle!
Harppailit ylös huoneeseesi ja osoitit lasia kirjoituspöydälläsi. Siinä

oli isän antama muutama ruusu ja mummon antama neilikka, Kirstin
kieloja ja yhtä ja toista sen lisäksi — ei paljon mitään valitsemisen
varaa.
— Tämän otan ainakin, sanoit nostaen lasista ruusun, neilikan ja
pari kieloa. Mutta jos otan tämän vielä, onko silloin liikaa? En voi
kärsiä liikaa kukittamista kuvissa.
Tunsin sen ruusun Marjan eilen antamaksi ja sanoin vain:
— Hyvä on. Juuri niinkuin pitää. Panen ne paperiin. — Kas tässä!
Otit paperitötterön ja juoksit alas portaita:
— Nuppineuloja, äiti!
— Pistin pari paperiin — katsohan tarkemmin!
27.
Seuraavana päivänä panit toimeen tanssiaiset tovereillesi.
Silloin tippui vielä vettä räystäistä ja ruohokentät olivat ohuen

lumen peitossa.
Mummo kasteli salissa kukkia ja asetti punaisen kaktuksen niin

päin, että sen puhjenneiden kukkien runsaus täytti ikkuna-aukon.
Toisessa ikkunassa rehoittivat ruusut, ja läntisellä seinällä korkealla
olevalta pitkältä ikkunalaudalta riippuivat kukkivat lobeliat.
Hän kääntyi Kirstiin, joka iltaa odottaessaan ei näkynyt malttavan

mihinkään ryhtyä.
— Tänään sinun täytyy auttaa äitiä! Ajattele, kuinka monta

voileipää hänen täytyy laittaa! Voit latoa ne tarjottimelle sitä myöten

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Children 10th Edition Peter J. Davis -

Smith’s Anesthesia for Infants and Children 9th Edition

(eBook PDF) Infants Children and Adolescents 8th

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(eBook PDF) Infants and Children Prenatal through

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Infants, Toddlers, and Caregivers 10th Edition (eBook

Critical Heart Disease in Infants and Children 3rd

Infants and Children

Infants and Children

Franklyn P. Cladis, MD, FAAP

SMITH’S ANESTHESIA FOR INFANTS AND CHILDREN, ISBN: 978-0-323-69825-2

Chapter 30: Barry. D. Kussman retains copyright.

Library of Congress Control Number: 2021939106

Content Strategist: Sarah Barth

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Peter J. Davis, MD Branden M. Engorn, MD Jessica A. George, MD, MEd

Mary Landrigan-Ossar Ronald S. Litman, DO, ML* Lynn Martin, MD

Mark A. Rockoff, MD Donald H. Shaffner, MD Deborah Studen-Pavlovich, DMD

The appendices, which can be found online at

Finally, this edition, like the previous edition, also

In summary, considerable developments and prog-

Peter J. Davis, MD, FAAP

Peter J. Davis, MD, FAAP

Contributors, vi 22 Transfusion Medicine, 455

PART I Basic Principles and Physiology PART IV Pain Management

4. Airway Physiology and Development, 78

Although pulse oximetry greatly improved patient monitoring,

ID, Inner diameter; OD, outer diameter.

The pharmacology of anesthetics and adjuvant drugs and their differ-

Surface area in square meters

Formula of Gehan and George (1970 )

Functional endocrinology from birth through adolescence. Cambridge, MA:

BSA (m2 )  ( 0.02  kg)  0.40.

The caloric need in relation to BSA of a full-term infant is about

Relative Size or Proportion

TABLE 1.3 Relation of Age, Height,

Chest, and a Large Abdomen.

Central and Autonomic Nervous Systems

exceptionally reactive to hypoxia and acidosis. The heart remains ex-

Kevät tuli aikaisin sinä vuonna. Kottaraiset pesivät jo huhtikuussa.

Viikkoa myöhemmin tulit ylioppilaaksi.

Isä ja minä kävelimme Aleksanterinkatua pitkin jutellen sinusta.

Mutta vielä enemmän puhuimme siitä onnesta, että sinulla oli

Siitä iloitsimme lähestyessämme Senaatintoria. Jäisi ainiaaksi

Ja isä osti kukkia Yrjölle ja vielä muutamille heidän tovereilleen. Ja

Senaatintori oli sitten täynnä odottavia, kuten tavallisesti tällaisissa

Silloin kuului huuto. Ja ensimmäinen joukko valkotakkisia juoksi

Ihmiset saivat taas yrittää lyhentää odotusaikaansa kertomalla

Taas kuului huuto ja taas tulvi valkotakkisia leveitä portaita alas.

Sinä otit lakin päästäsi tarkastaaksesi lyyraa. Se ei ollut pienen

Ja koko elämä oli parhaimmillaan semmoisena kuin se oli juuri nyt.

Sitten sinä sait ruususi meiltä ja neilikan mummon ikkunalta ja

Mutta kun ei Marjaa näkynyt eikä kuulunut, vaikka häntä

Silloin hän tuli. Ilmestyi nauravana ja välkkyvin silmin ja kiersi

Katsoin syrjäsilmällä sinuun ja olinkin huomaavinani pienen

Mutta Marja ei tuntunut mitään odottaneen. Hän oli miltei

— Voi miten äärettömän — käsittämättömän — kauhistuttavan

Mutta tehtyä ei voinut tehdä tekemättömäksi.

Ja heitin luotani mielenapeuteni. Mutta aavistin, että sinä tuossa

Marja erosi meistä seuraten isäänsä, mutta tunnin perästä nuorten

Vihdoin Marja tulikin, valkoisiin puettuna, iloisena ja säteilevänä ja

ebook download Smith's Anesthesia for Infants and Children 10th Edition Peter J. Davis - eBook PDF all chapter

ebook download Smith's Anesthesia for Infants and Children 10th Edition Peter J. Davis - eBook PDF all chapter

BSA (m2 ) ( 0.02 kg) 0.40.