A 2-year-old child with cerebral palsy and severe gastroesophageal reflux is scheduled to undergo iliopsoas release under general anesthesia. Which induction technique is most appropriate?

A 2-year-old child with cerebral palsy and severe gastroesophageal reflux is scheduled to undergo iliopsoas release under general anesthesia. Which induction technique is most appropriate?

• A. Inhalation induction with sevoflurane followed by mask anesthesia with cricoid pressure
• B. Inhalation induction with sevoflurane followed by tracheal intubation
• C. IV induction with propofol followed by laryngeal mask airway
• D. IV induction with propofol followed by tracheal intubation

Answer: (B)

In a toddler with cerebral palsy and severe gastroesophageal reflux, protecting the airway from aspiration is the top concern during anesthesia. Inducing with sevoflurane inhalation allows the child to fall asleep while continuing to breathe on their own, which is safer when the airway may be difficult and the risk of regurgitation is high. Sevoflurane is well tolerated in young children and helps avoid laryngospasm, providing a smooth transition. Once consciousness is established and spontaneous breathing is preserved, securing the airway with a tracheal tube gives definitive protection against aspiration and allows controlled ventilation throughout the procedure. In this scenario, the combination of inhalation induction with sevoflurane followed by tracheal intubation best balances maintaining ventilation, minimizing aspiration risk, and managing a potentially challenging pediatric airway. Using mask anesthesia with cricoid pressure doesn’t provide the same airway protection as a cuffed endotracheal tube, and a laryngeal mask airway offers less protection against aspiration in a patient with severe GERD. An IV induction with propofol followed by intubation can be rapid and controlled, but it removes the benefit of maintaining spontaneous ventilation during the induction and can increase aspiration risk if airway reflexes are lost before the airway is secured.

In a toddler with cerebral palsy and severe gastroesophageal reflux, protecting the airway from aspiration is the top concern during anesthesia. Inducing with sevoflurane inhalation allows the child to fall asleep while continuing to breathe on their own, which is safer when the airway may be difficult and the risk of regurgitation is high. Sevoflurane is well tolerated in young children and helps avoid laryngospasm, providing a smooth transition.

Once consciousness is established and spontaneous breathing is preserved, securing the airway with a tracheal tube gives definitive protection against aspiration and allows controlled ventilation throughout the procedure. In this scenario, the combination of inhalation induction with sevoflurane followed by tracheal intubation best balances maintaining ventilation, minimizing aspiration risk, and managing a potentially challenging pediatric airway.

Using mask anesthesia with cricoid pressure doesn’t provide the same airway protection as a cuffed endotracheal tube, and a laryngeal mask airway offers less protection against aspiration in a patient with severe GERD. An IV induction with propofol followed by intubation can be rapid and controlled, but it removes the benefit of maintaining spontaneous ventilation during the induction and can increase aspiration risk if airway reflexes are lost before the airway is secured.