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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
and using any information, methods, compounds or experiments described herein. Because of rapid
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contained in the material herein.
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.
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This day was close at hand. Christmas means little, however, as a
festival, in time of war. Angela contrived to fill the stockings of the
negro children with apples and walnuts and molasses candy made in
the kitchen by Mummy Tulip, but otherwise there was no attempt at
festivity.
Some of the neighbors and friends had already lost brothers and
sons in the bloody battles of the summer, and the rest were too
much concerned for the fate of their best beloved to attempt any
merrymaking.
Mrs. Charteris, whose heart was as good as her tongue was active,
had taken in a family of refugees which included five children, and as
she assumed the duties of doctor, nurse, and governess, her hands
were full, and she scarcely had time even to revile Mr. Brand, who
showed no signs of taking up arms for his country.
The weather, which up to that time had been singularly mild and
beautiful, suddenly grew gray and stormy and bitterly cold. No guest
had passed the doors of Harrowby since Colonel Tremaine left. It
was now the day before Christmas, and all day long Angela had
anxiously watched for Colonel Tremaine’s arrival.
About five o’clock, when it was already dark, and earth and sky and
river were all an icy and forbidding gray, Angela stood by the hall fire
with Lyddon, who had just come in from his afternoon tramp.
“I do so hope,” Angela said, “that Uncle Tremaine will get here before
it snows. Mammy Tulip says that she feels it in her bones that snow
will fall deep and everything will be frozen up. She thinks so because
she hears the owls hooting at night or something of the sort.”
“I think so,” replied Lyddon, “because the wind is from the northwest
and the clouds have hung heavy all day.”
“How different it is,” cried Angela, “from last year!”
She came close to Lyddon and, as she often did in her earnestness,
laid her hand upon his arm and looked with dark and bewildered
eyes into his face.
“Last year,” she continued, “all was peace; this year all is war. Not
only everywhere, but here in my heart. It seems to me as if I were at
war with everyone in this house except you.”
“Poor child!” was all Lyddon could reply.
Angela drew back on the other side of the hearth and said: “But I
want to be at peace. I would like to be at peace with Uncle Tremaine
and Aunt Sophia—I love them so much. Even Archie is changed
toward me, and that little insignificant George Charteris looks at me
with contempt when he takes off his hat to me. And do you
remember how pleased I was at the idea of Madame Isabey and
Madame Le Noir coming here? Well, Madame Le Noir is at war with
me.”
“Life is all a battle and a march,” was Lyddon’s answer.
He glanced at the dim and worn painting of Penelope and the suitors
over the fireplace. Here, indeed, was a Penelope, and Lyddon
considered she had narrowly missed having an unconscious suitor in
the person of Philip Isabey. Luckily he had gone away before the
impression made upon him by Angela had deepened and changed
the current of his being.
Lyddon looked critically at Angela. She was certainly growing very
pretty, with a kind of beauty captivating as it was irregular. She would
never be classed as a beauty, but was as charming as Adrienne Le
Noir was seductive.
While these thoughts flashed through Lyddon’s mind he glanced
toward the western window and saw in the gloom of the wintry
evening the Harrowby carriage coming down the cedar lane.
“There’s Colonel Tremaine,” he said.
Angela’s thoughts were suddenly diverted into practical channels. “I
must have Uncle Tremaine’s fire lighted at once!” she cried, and,
stepping out upon the back porch, she rang the bell five times, which
was supposed to summon Tasso, but, after ringing in turn for
Mirandy and Jim Henry, finally succeeded in getting both of them,
who proceeded to hunt the place for Tasso instead of lighting the fire
themselves.
Meanwhile the carriage was at the door, and Angela, snatching up
her crimson mantle and throwing it over her fair head, ran down the
steps and herself opened the carriage door.
Out stepped Colonel Tremaine and kissed her affectionately. But
there was another person within the carriage—a man, pale and worn
and haggard, with a leg and an arm bound up. It was Philip Isabey.
The shock of seeing him was shown in Angela’s expressive face.
Instead of the warm and ready greeting which a guest usually
receives, she stood at the carriage door, her mantle dropping off her
shoulders, looking at Isabey with eyes which had in them something
both of fear and of delight. She felt more emotion at this sudden
apparition of him than she had ever felt at seeing anyone in her life
before. And with it an instinctive dread of being thrown with him
again instantly sprang into life.
Isabey, himself, had the disadvantage of being a close observer. He
had looked forward to this meeting not with fear but with pure delight,
and was prepared to watch how Angela greeted him; she was so
guileless that she was easily read by an experienced eye.
He held out his hand feebly and said in his old, pleasant, musical
voice: “How glad I am to see you again!”
Then Colonel Tremaine began explaining sonorously: “My dear
Angela, I had the extreme good fortune to come across Captain
Isabey when he most needed a friend. He had been severely
wounded and, though out of danger, was quite helpless, and lying on
the floor in a miserable shanty. I, of course, picked him up, bag and
baggage, and, instead of leaving him in the hospital at Richmond,
brought him back to Harrowby. You must do for him what my dearest
Sophie is doing for our beloved Richard—be nurse, amanuensis,
reader, and companion for him.”
“I will do all I can,” answered Angela, as if in a dream. And then
Lyddon appearing, he and Colonel Tremaine assisted Isabey up the
steps and into the hall.
It was not until he was seated in a great chair before the hall fire and
in the full glare of the blazing lightwood knots, that Angela saw the
havoc made in him by wounds and illness. He was very thin, and his
gray uniform was shabby and too large for his shrunken figure. His
dark complexion had grown pale, and there was a painful thinness
about his eyes and temples. His voice, however, had the same
cheerful, musical ring.
Isabey, in truth, was filled with rapture. By the hand of fate he had
been brought out of the direst misery into the companionship,
without seeking it, of this girl whose image he had been unable to
drive from his mind. His imagination had already been at work. He
knew perfectly well the conditions which prevailed at Harrowby. No
one would be there except Colonel Tremaine, Lyddon, Angela, and
himself. He would see Angela every day and all day long. She would
minister to him, and he might ask services of her inexpressibly sweet
to receive from her. And he would have long hours when he could
talk to her unheard by others. He had pictured to himself the
welcome which would shine in her face when she saw him, and the
divine pity with which she would listen to the story of his sufferings.
He did not fail to remind himself that Angela was not for him; she
was the wife of another man. But it is not in masculine nature to
refrain from inhaling the odor of a delicious flower which belongs to
another man or of breathing the air of heaven, although it may be in
the garden of another.
Any thought of betraying himself to Angela, or acquiring any
ascendency over her, was very far from Isabey’s mind, but when at
last they had met he had seen enough of agitation in her to know
that the meeting meant something to her as well as to him. And
being a very human man, he was penetrated with secret joy.
He saw still more plainly when she stood looking at him by the
firelight that she was reckoning up with a sympathy dangerously
near to tenderness all of his wounds, his pains, his fevers, all the
miseries which he had suffered. It seemed to Isabey then as if they
were but a small price to pay for a month in Angela’s society or even
for that one hour of peace and warmth and rest with Angela looking
down upon him with eyes of sweetest pity.
Colonel Tremaine, in response to Lyddon’s inquiries, began to tell
about Richard, and Angela, forcing herself to look away from Isabey,
listened to the story:
“We found our son recovering from the measles, a most grotesque
complaint for a soldier to have, but he had not taken proper care of
himself during the illness and was in a very low state when we
arrived. If he had been in fit condition to travel like our friend Captain
Isabey, we should have at once brought him to Harrowby, but the
snow is four feet deep in the upper country, and it is impossible to
think of moving Richard at this inclement season. His mother,
therefore, remains with him and Archibald also to minister to them
both. I felt it my duty to return to Harrowby. Your Aunt Sophia, my
dear, has sent you a letter, so has your brother Archibald, and
Richard sent you his best love and says you are to write to him as
well as to your Aunt Sophia.” And Colonel Tremaine handed two
letters to Angela.
“Our son had heard that Captain Isabey had been badly wounded,
and was somewhere in the neighborhood of Winchester. I at once
caused inquiries to be made and found that he was easily accessible
——”
“I beg your pardon,” interrupted Isabey with a wan smile, “coming to
fetch me meant traveling twenty-five miles over mountain roads in
December after a fortnight of snow.”
“At all events,” cried Colonel Tremaine expansively, “I was able to
find Captain Isabey, and, unlike our son, he was in a condition to be
moved, and the surgeon said if he could be made comfortable and
have rest and proper treatment for a couple of months, his right arm
and right leg would be as good as his left arm and left leg. So I and
my boy, Hector, wrapped him up in blankets, bundled him in the
carriage——”
“And drove most of the way himself,” said Isabey in a voice of
gratitude.
“And here he is, and I think, my dear Angela, if you could get him
some of your aunt’s excellent blackberry wine——”
Angela disappeared as soon as the word blackberry wine was
mentioned. In a few minutes she returned with a glass of it, piping
hot with spices in it. By that time she had recovered her composure
and was the Angela of old.
“This,” she said, smiling as she handed the glass to Isabey, “is an
Elizabethan drink—one of what Mr. Lyddon calls his formulas. In the
Elizabethan days, you know, people made wine out of everything.”
“And very good wine, too,” responded Isabey. “Better, no doubt, than
the doctored stuff of the post-Elizabethan days.”
He took the glass from Angela’s hand and drank the mulled wine,
warm and comforting. The wine and the fire brought the color into his
pale face and warmth into his chilled body. Angela, leaning her
elbow upon the mantle, said meditatively and with the air of the
chatelaine of Harrowby: “What would be the best room for Captain
Isabey?”
“Richard’s room,” suggested Lyddon. “It’s on the same level with the
study.”
“Capital!” exclaimed Colonel Tremaine.
“I think so,” said Angela, “and I shall go now and have it prepared.”
She went out, and in half an hour Mammy Tulip came into the hall
and delivered this message to Isabey:
“Miss Angela, she sent her bes’ ’spects an’ say Marse Richard’s
room is ready fur you, an’ I’se gwine ondress you an’ put you to
baid.”
Colonel Tremaine looked much shocked. “That, Tulip,” he said
severely, “will be Tasso’s duty, who in the absence of Peter in
attendance upon his young master has charge of that room.”
Mammy Tulip received this emendation with undisguised contempt.
“Tasso, he good ’nuff fur well folks, but Cap’n Isabey, he’s wounded
and distrusted an’ I ain’t gwine let dat fool nigger ondress a sick
man.” And then to Isabey, “Come ’long, honey, an’ le’ me do fur you
jes’ what I do fur dem boys.”
Lyddon had seen this cool defiance of master and mistress every
day of the twelve years he had spent at Harrowby, but was still
surprised at it.
However, Isabey with the weakness of illness felt a placid pleasure in
yielding himself to Mammy Tulip’s motherly care, and willingly
allowed her to “hyst” him up as she expressed it, and leaning upon
her stout arm with Lyddon on the other side, Colonel Tremaine
walking behind, and Tasso, Jim Henry, Mirandy, and several of their
coadjutors bringing up the rear, the procession moved toward
Richard’s room.
One charm no room at Harrowby could ever lack—a roaring wood
fire. It had already taken the chill off the unused room, and to Isabey
the glow, the warmth, the great soft feather bed with its snowy linen,
was a little glimpse of paradise. And Angela moving softly about and
concerned for his comfort was the sweetest part of the dream.
A round table was drawn up to an armchair in front of the fireplace,
and on it were quilled pens, cut by Lyddon, and red ink made from
the sumac berries, and the coarse writing paper which was the best
to be had in the Confederacy; and there were also some books. One
rapid glance showed Isabey that they were the books he liked;
Angela remembered all his tastes.
“Here,” she said, “you will have your supper, and then,” she added
with perfect simplicity, “Mammy Tulip will put you to bed.”
“And,” continued Mammy Tulip as she settled Isabey comfortably in
the chair with pillows, “I gwine to hab a big washtub brought in heah
an’ a kittle of b’iling water an’ I gwine gib you a nice hot bath wid
plenty ob soap an’ towels.” At which Isabey laughed faintly and
Lyddon grinned, much to the amazement of Angela and Colonel
Tremaine, who were accustomed to Mammy Tulip’s ministrations.
Isabey did not see Angela any more that night, and did not in truth
feel able to stand further excitement.
Mummy Tulip was as good as her word, and took entire charge of
him, and when she had given him his supper and had bathed him in
the big washtub as she had threatened, and had covered him up in
the great soft bed, Isabey felt that most exquisite of all bodily
sensations, release from pain. He had not slept an unbroken night
through since his leg and arm had been torn by a shell, but by the
time he realized his delicious well-being, sleep came upon him. Nor
did he open his eyes again until next morning. The fire was again
dancing in the chimney and Mammy Tulip was standing by his
bedside and holding a cup of something hot.
“It sutney is Gord’s mercy,” she said to him, “dat you an’ ole Marse
git heah lars’ night. De snow begin fallin’ a’ter sundown an’ ain’ stop
one single minit sence. De boys had to shovel a path in de snow so
ter git f’om de kitchen to de house, an’ dey had to breck de ice in de
waterin’ troughs fur de ho’ses an’ cows an’ sich.”
Isabey felt if anything an increase in his ease of body and mind at
what Mammy Tulip told him. There was something ineffably
seductive in the thought that he was, as it were, shut in from the
whole world by the rampart of snow and ice. That he could lie in the
soft bed and rise when he chose, and be washed and dressed like
an infant, and take that short and easy journey into the study where
he would find the companionship of books and Lyddon’s strong talk
and Colonel Tremaine’s warm courtesy and best of all—Angela.
For many months he had marched and fought and starved by day
and night. In summer heats, in autumn’s drenching rains and chilling
nights he had ridden and tramped through mud and latterly through
snow, and had known hunger and sleeplessness and, with all,
incessant fighting. Then had come a day of battle when almost the
last shot that was fired had nearly torn him to pieces. Following had
come a time of fearful suffering in a wretched shanty, where all that
could be done for him was an occasional hurried dressing of his
wounds by a surgeon who had learned to do without food or sleep.
Around Isabey had been others suffering as miserably as himself,
and his mind was distracted from his own tortures by watching with
pity others more tortured than himself.
Now, however, all this seemed a painful dream, and here he was in
warmth and peace and ease and paradise for a little time, and when
these should have done their work he would be ready once more for
hard campaigning.
CHAPTER XIV
SNOWBOUND
ISABEY remembered that it was Christmas morning. Snow had been

falling all the night through and lay white and deathlike over the land.
The Christmas was unlike any Christmas which Harrowby had ever
known. There were neither wreaths nor decorations nor any
Christmas cheer. After breakfast, the negro children came into the
hall, where Angela distributed their Christmas stockings with such
homely sweets as she could provide, and the children went away
quietly.
The shadow of the war was upon them, too, and they understood
dimly in their childish way the vague unrest, the fears, the agitating
hopes of their elders, to whom the universe was changing daily and
who knew that things would never be as they had once been.
Angela was glad of the excuse of Isabey’s illness to keep the house
quiet. Colonel Tremaine retired to his library; the day to him was one
of bitter introspection. Lyddon, whom no weather could daunt, went
for a tramp in the snow. Angela busied herself with her household
affairs and then wrote a letter to Neville and afterwards to Mrs.
Tremaine, Richard, and Archie. It was the first time in her short life
she had been separated from them all on Christmas day.
It was twelve o’clock before Isabey was dressed and helped into the
study. There he found Angela sitting in a low chair reading. With
Mammy Tulip’s help, she made him comfortable on the old leather
sofa drawn close to the glowing fire. Hector, having cheerfully
permitted Mammy Tulip to perform all the services which Isabey’s
disability required, was on the spot to assume the direction of things
and to compare the campaign of Joshua round the walls of Jericho
with General Scott’s entrance into the City of Mexico.
He was, however, rudely cut short by Mammy Tulip hustling him out
of the way while she brought Isabey the inevitable “something hot.”
Hector retired with Mammy Tulip to have it out on the back porch,
and Angela and Isabey were left alone together.
“Mr. Lyddon will have George Charteris in the dining room every
morning after this,” she said. “This is to be your sitting room and you
are to send everybody out of it when you feel like it; Uncle Tremaine,
Mr. Lyddon, and me.”
“I shan’t send you away,” said Isabey in a low voice and quite
involuntarily. Angela blushed deeply.
She rose and went to the window through which was seen a world all
white under a menacing leaden sky. Even the river was covered with
snow and its voice was frozen.
“I never mind being snowbound,” she said, coming back to the fire.
“It always seems to me as if I could think and read better in winter
than in summer.”
“And in summer you enjoy and feel. Is it not like that?” asked Isabey.
“Yes,” replied Angela, smiling. “When I was a little girl and Mr.
Lyddon would talk to me about Nature, I thought Nature was a great
goddess and was smiling in the summer when the sun shone and
the birds chirped, and in the autumn, when everything was dull and
gray and quiet, that the goddess was in the sulks. Then in winter
when the snow and ice came I thought Nature was in a bad humor
and had quarreled with her lover, the sun. What strange notions
children have!”
“And what a strange, poetic little child you must have been!”
“All real children are strange and poetic, I think; but, you see, not
many small girls are taught by a man like Mr. Lyddon. Now tell me
what happened to you when you were wounded.”
Isabey sighed. “When I’m stronger,” he said. “But now I want to put it
all away from me for a little while. I mean to give myself a whole
month of peace.”
“The doctors said two months.”
“The doctors always say two months when one month will do. Then I
shall be ready to go again. A soldier’s life is not all hardship. War is
the game of the gods.” After a moment he added in a perfectly
conventional tone: “I hope you hear good news from Captain
Tremaine?”
“It’s good news that he’s well,” replied Angela. “I hear from him
irregularly. I should have been with him long ago if he could have
had me, but he’s out in the far West, where there are no railroads or
stages or anything. I believe,” she added, the flush, which had died
from her face, returning quickly, “the very people for whom Neville
sacrificed everything don’t trust him. It’s because they don’t know
him. They only know that he is a Southern man in the Northern
Army. I feel so sorry for Neville and so indignant for him that I could
weep with grief and anger.”
“It’s also very hard for you,” said Isabey, gently.
“Yes, very, but what I endure is only a trifle compared with what
Neville has to suffer. You know he had great ambitions and he’s a
fine officer, everyone says that, and now all is forgotten and he has
no chance. But I ought not to inflict all of my burdens and vexations
upon you. Shall I read to you a little?”
“With pleasure,” answered Isabey.
Angela went to the bookcase and brought back several volumes.
“These,” she said with authority, “aren’t the books which you
particularly like, but the books which Mr. Lyddon says are soothing.
They’re all poetry books. Poetry, you know, calms and makes one
forget this workaday world.”
Isabey picked up a volume of “Childe Harold.” “I should like you to
read this to me. One likes the old familiar things when he is as weak
as I am. When I was in Europe I always carried ‘Childe Harold’ in my
pocket and read it among the very scenes which Byron describes.
You see, I was very young.”
“Youth may be wise. That’s just what I should do if I had seen Rome
and Venice and the Rhine.”
“Some day you will.”
Angela shook her head. “Neville isn’t fond of travel, and besides we
shall be poor because his father and mother will never give him
anything after this. He was to have had Harrowby, and we should
have settled down here as quietly as Uncle Tremaine and Aunt
Sophia. Richard, you know, meant to enter public life, and so the
place wasn’t so much to him, and he would have got, like Archie,
other property instead of Harrowby. Uncle Tremaine and Aunt
Sophia used to talk about it before them, but now all is changed.
Neville will have nothing, not an acre, not a stick, not a stone to call
his own.”
“But he will have you,” replied Isabey, in a low voice and really
thinking aloud.
“And I shall have him,” responded Angela, quickly, and looking
steadily into Isabey’s eyes. She had uttered no word of reproach, but
Isabey after a moment said quietly:
“You must not be offended with me now for anything I say. I’m so
weak in body that it affects my will. I often found myself when I was
lying on the floor of that wretched hut asking the doctor for things
which I knew in advance he could not have supplied to save his life.
Be patient with a man who doesn’t know very well how to bear pain
of any sort.”
What woman could resist that? Angela said nothing, but her eyes
spoke forgiveness.
“He lay watching Angela with her quick-changing
expression.”
Then she opened the book and began to read. Her reading was
good and her understanding of the lines perfect. Isabey knew them
well, and their far-off, half-forgotten music fell softly upon his spirit.
He lay watching Angela with her quick-changing expression, her
easy and graceful attitude. It was all so sweetly, divinely peaceful,
and then before he knew it his eyes closed and he slept.
Angela read on, the music of her voice filling the low, small room.
She did not put down the book until Isabey slept soundly. Then she
watched him with her heart in her eyes.
If he had returned well and strong and full of the charm, the grace,
the captivations, the splendid accomplishments which had so
dazzled her at their first meeting, she would have been on her guard.
But who need be on her guard, she asked herself, with a wounded
soldier, a man as helpless as a child, and who was entitled to have
all things made soft and easy for him? And how ashy white he
looked, the whiter from the blackness of his hair!
In his sleep he moved his right arm and groaned without waking.
Angela rose and, changing the position of his arm a little, Isabey
moaned no more. The silence in the room was broken only by his
light breathing and the occasional dropping of a coal upon the ashes.
Without was that deep and dreamlike silence of overwhelming snow.
It seemed to Angela as if not only the face of the world but all the
people in it had changed within the year.
The Christmas before she had never seen Isabey, but her mind
working on the problem as women’s minds work, it seemed to her us
if she had really known him ever since those days when as a little girl
she saw the pictures of him taken with Richard. Her childish
imagination had seized upon Isabey’s image with a sort of
foreknowledge; she had been in love with him before she ever saw
him.
When this thought occurred to her, she reasoned with herself coolly.
To be in love with a name, with a fanciful image even of a real man
was not love. She had been in love with Lara, with Childe Harold,
even some of those old Greek and Roman heroes whose names she
had spelled out painfully when she was a child at Lyddon’s knee.
However, one of these heroes—Isabey—had taken shape and had
come bodily before her, and deep down in her heart, this airy
romance, this thing of dreams had become something real and
menacing to her happiness.
As she sat before the fire thinking these thoughts, Isabey waked
without stirring. He had been dreaming of Angela and to find her
close to him, her delicate profile outlined against the dark, book-
covered walls, to hear the occasional rustle of her gown, and to
watch her dark, narrow-lidded eyes in the gleam from the firelight,
seemed to him a continuation of his soft and witching dream. He
observed that her air and expression had matured singularly since
he had first seen her, when the syringas bloomed, the lilacs were in
their glory, and the blue iris hid shyly under its polished leaves, but
outwardly Angela was not yet a woman any more than the little rose
bushes of last year’s planting were rose trees now.
The silence, the warmth, the sweetness seemed to enwrap Isabey,
and without was that white and frozen world which made each
homestead a solitude. He lay thus for half an hour furtively watching
Angela. Then she turned toward him and met his dark eyes.
“I thought you were asleep,” she said, stepping toward him.
“I was asleep,” he replied, smiling, “and dreamed.”
“Do you remember it is Christmas day?” she asked, arranging his
pillows for him.
“I believe I knew it, but I have not exerted myself to think since I have
been under this roof. Everything is too deliciously sweet.”
“It is the strangest Christmas,” said Angela, returning to her low
chair. “Everything as quiet as death, not a sound in the house. I filled
the stockings of all the little negro children with apples and nuts and
molasses candy and gave them out early this morning. But I made
them keep quiet for fear of waking you. They were quiet enough;
something odd seems to have come over the negroes.”
“I should think so. With their ignorance of events and inability to read
and knowing neither geography nor history, don’t you suppose they
must be secret excited and bewildered by this war, in which they
have so huge a stake?”
“So Mr. Lyddon says. Every one of them is different, it seems to me,
since the war broke out, even Mammy Tulip and Uncle Hector. I don’t
mean that they are not just as faithful, but they listen to us when we
talk, and watch us, and I think repeat to each other what we say. I
wonder how I shall feel when I go North to Neville and shan’t have
any black people to wait upon me.”
“You will feel very queer, I dare say. I never grew accustomed to
being waited upon by white men all the time I was abroad. It is true
that I had my own boy with me, but I often felt a yearning for the
kindly negro faces, and longed to hear them laugh when they were
spoken to.”
While Angela and Isabey were talking, Colonel Tremaine came in.
He had taken advantage of Mrs. Tremaine’s absence to array
himself in a suit of before-the-war clothes, and was feeling much
more at ease in them than in homespun, and so expressed himself.
“Mrs. Tremaine’s wishes, my dear Captain Isabey, are paramount in
this house, and especially with me, and have been from the day that
I determined to ask her to become mine. She makes it somewhat a
point of conscience that I shall wear a suit of homespun, woven and
spun on the estate, and made by Mrs. Tremaine herself with the
assistance of her woman, Tulip. But I frankly confess that I feel more
comfortable in the clothes made by my Baltimore tailor. In other
respects, I submit cheerfully to the privations of the war. I have no
longer any objection to tallow candles, or to blackberry wine, or to
potato coffee sweetened with honey, or even to being shaved with
soft soap made by Tulip and of the color and consistency of mud and
molasses and presented by Hector in a gourd. And I can offer you
some apple brandy manufactured last summer in the Harrowby
kitchen. It is better than the alleged French brandy which I bought
from Captain Ross, the blockade-runner. I accused him of having
watered it. This he strenuously denied, but it appears he had diluted
it on the voyage and had inadvertently used salt water, and if you will
believe me, the scoundrel swore to my face that he had not mixed
any ingredients with the brandy, although it was as salt as Lot’s wife.
Running the blockade appears to make great liars of all connected
with the trade.”
Isabey duly sympathized with Colonel Tremaine’s grievances over
the salt-watered brandy, and the Colonel continued:
“In many ways we still enjoy the comforts to which we are
accustomed. The land brings forth fruitfully. The hens, ducks, and
turkeys seem to vie with each other in producing a multitude of eggs.
The fish still run in the river, and the oysters have not so far
concerned themselves with States’ rights, so at least we shall not
starve while you are with us.”
Isabey replied with truth that in lowland Virginia one might live like a
lord as long as the sun rose and the rivers ran.
At three o’clock the Christmas dinner was served, and around the
great mahogany table gathered a group smaller than it had ever held
before—Colonel Tremaine, Lyddon, Angela, and Isabey for a part of
the time. The dinner was rich in oysters, fishes, meats, and
vegetables, but deficient in sweets. When, according to the old
custom, the cloth was removed and the decanters on coasters were
sent around the table, Colonel Tremaine proposed the Christmas
toast to “our absent ones—the lady who reigns over this mansion
and also over the heart of its master, to its sons—” here he paused.
Angela said in a quick, tremulous voice, “Neville, Richard, and
Archie.”
Colonel Tremaine’s face darkened. The mention of his traitor son, as
he regarded Neville, was always painful to him, but he did not refuse
to drink the toast.
When the dinner was over the short wintry afternoon was closing in.
Snow was again falling heavily in a world already wrapped in
whiteness and silence. There were no sounds of merrymaking from
the negro quarters. All seemed to share the mood of tenseness and
somber expectation.
Colonel Tremaine was visibly depressed. It was the first Christmas
he had spent in forty years apart from Mrs. Tremaine and he felt it
deeply.
As the twilight closed in, Angela, wrapped in her red mantle, with the
hood over her head, went out into a misty world of snow and faint
moonshine, which penetrated a break in the overhanging clouds. A
pathway had been cut through the snow to the garden gate and
thence down the main walk to the old brick wall at the end. Angela
began to pace up and down her favorite walk. Her sense of
aloneness and aloofness was complete. The swirling white eddies
shut everything from her except the bare shrubs in the garden
standing like ghosts in the faint spectral glare of the moon on a
snowy night.
She began to question herself. Would she, if she were entirely free
to act, go at once to Neville? She answered her own question and
satisfactorily. Certainly she would. Did she love Neville? Yes, just as
she had always done, from the time she was a little girl and never
felt so safe with anyone as when her tiny hand lay in Neville’s boyish
palm. Was she in love with him? Ah, no! And would she ever be? To
that, too, her heart gave no doubtful answer, but a strong negative.
She was never to have a dream of love, any of those soft illusions
which make a young girl’s heart tremble.
Then relentlessly she asked herself if she was in love with Isabey.
She stopped in her walk and looked about her with scared eyes, as if
love were a specter to affright her. She was enveloped in the misty
veil of the falling snow which eddied about her and which was lighted
by that ghostly and silvery sheen of the hobgoblin moon.
Did she not feel the color come to her face whenever she caught
Isabey’s eyes fixed upon her? Did not her heart beat at his footsteps,
and did not his mere presence electrify the atmosphere?
Then another question forced itself into her mind, like a dagger into
an open wound. Was Isabey in love with her?
She had never thought or even suspected such a thing until he had
returned, the pitiful wreck of his former self. But Angela being, like all
the rest of her sex, learned in the secrets of the heart, had found out
what Isabey in truth was too ill, too weak, to conceal—that she was
dear to him.
Had they met one week earlier!
“But then,” she replied to herself, “it would have made no difference;
I could not have refused to stand by Neville when all the world was
arrayed against him.”
Whatever she or Isabey might suffer, Neville’s heart should be at
peace. She would be to him so tender, so affectionate, so watchful to
please him, that he would never suspect she had not given him her
whole treasure. And, feeling this, she had an expansion of the soul
which seemed to raise her in her own esteem.
Why need she be on her guard against Isabey? He had suffered so
much. He was the object which most appeals to a woman’s heart—a
wounded soldier. He was so weak, so worn, that no woman on earth
could refuse him her pity. And of his integrity, his delicacy, she had
not the smallest doubt. It seemed to her then so easy to be loyal
both to the real and to the ideal.
She resumed her walk in the swirling snow. At the same moment
Isabey, lying on the couch in the study watching the pallid twilight of
the snowstorm without and the rosy glow of the fire within, was
asking himself some of the same questions which Angela put to
herself in the storm-swept garden.
Was he in love with this girl? Yes. And more, he loved her with all his
heart. She was already the wife of a man whom he admired and
honored; she was born among different surroundings from his own:
bred differently from any girl he had ever known; of different blood
and religion and customs to his own, and yet an unbreakable chain
had been forged between them.
The first circumstance of this was strange to him—Angela’s suddenly
putting her hand in his that summer day, now six months past. He
was accustomed to the French method of training girls, and here
was Angela, who enjoyed even greater freedom than was usually
accorded to those girls of colder climes than Louisiana. This wife of

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Smith's Anesthesia for Infants and

Children 10th Edition Peter J. Davis

Smith’s Anesthesia for Infants and Children 9th Edition

Infants and Children: Prenatal Through Middle Childhood

Wongu2019s Nursing Care of Infants and Children 11th

Critical Heart Disease in Infants and Children 3rd

Infants and Children: Prenatal Through Middle

Nurse Anesthesia 6th Edition Edition John J. Nagelhout

Marine Biology 10th Edition Peter Castro

The Summoning J. P. Smith

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-

ISABEY remembered that it was Christmas morning. Snow had been

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Full download Smith's Anesthesia for Infants and Children 10th Edition Peter J. Davis file pdf all chapter on 2024

Full download Smith's Anesthesia for Infants and Children 10th Edition Peter J. Davis file pdf all chapter on 2024

Full download Smith's Anesthesia for Infants and Children 10th Edition Peter J. Davis file pdf all chapter on 2024

BSA (m2 ) ( 0.02 kg) 0.40.