Anesthesia for adolescents

INTRODUCTION — Approximately 2 million surgical procedures are performed annually for adolescents, defined as children ages 12 to 17. During adolescence, children undergo unique anatomic, physiologic, cognitive, and behavioral changes. This topic will discuss the changes of adolescence that affect anesthetic care, preoperative evaluation, and anesthetic management, with a specific focus on those issues that are different between adolescents, adults, and younger children.

Anesthesia for infants and young children is discussed separately. (See "General anesthesia in neonates and children: Agents and techniques".)

Various aspects of anesthetic management in adults are discussed in multiple other topic reviews.

PHYSIOLOGIC CHANGES DURING ADOLESCENCE — During puberty there are significant changes in body size and composition, as well as developmental changes in the brain that appear to be correlated with maturing executive and emotional function. These changes are of significance to the anesthesiologist caring for adolescents.

●Growth and metabolism – There is a growth spurt during puberty (early to mid-adolescence) under the influence of overlapping effects of multiple hormones. (See "Normal puberty", section on 'Growth spurt'.)

This growth spurt is accompanied by increases in muscle mass and strength, which may play a role in development of negative pressure pulmonary edema, discussed below. (See 'Negative pressure pulmonary edema' below.)

There are significant metabolic changes associated with this increase in body mass, which can influence anesthetic management in very specific ways.

•High oxygen consumption – Maximal oxygen consumption (VO_2max) increases from about 8 years until about 16 years in males and 13 years in females, then plateaus in all adolescents. On average, both values are greater in boys than in girls [1]. Elevated basal oxygen consumption (VO₂) results in a linear increase in basal minute CO₂ production, which requires increased minute ventilation to maintain normocarbia during anesthesia. (See 'Ventilation' below.)

CO₂ levels and the need for ventilation may increase even more during procedures that involve CO₂ insufflation (eg, laparoscopy) or in patients who are febrile. Preoperative anxiety can also increase VO₂ and CO₂ production in fit adolescents because of the increase in endogenous catecholamines, which can explain a high end tidal CO₂ at the start of anesthesia.

•Changing systemic vascular resistance – Unlike infants and young children (<5 years of age), adolescents are more likely to become hypotensive from sympathectomy associated with neuraxial block, similar to adults. [2-4]. The reasons for this difference are not well understood. (See 'Regional anesthesia' below.)

•High cardiac output – Increased VO₂ is associated with increased cardiac output and pulmonary blood flow, which slow induction of anesthesia with inhaled anesthetics. These changes increase uptake of anesthetic agent from the alveoli, delaying establishment of equilibrium between agent concentrations in alveoli and pulmonary capillary blood, thereby slowing inhalation induction. (See "Inhalation anesthetic agents: Properties and delivery", section on 'Cardiovascular factors' and 'Intravenous versus inhalation induction' below.)

●Muscle mass – During adolescent development, the fit teenager has more cardiorespiratory reserve than at any other time in life. Muscle mass and activity level peak at about 12 to 14 years of age, and then decline during adolescence. This increase in muscle mass is associated with concomitant decrease in fat mass in physically active adolescents. This change in body composition is one factor that shifts the volume of distribution of many medications used in anesthesia from that of younger children towards that of adults.

Physical working capacity (ie, the ability to perform maximal work) triples in males and doubles in females linearly between 7 and 17 years of age. (See "Exercise testing in children and adolescents: Principles and clinical application", section on 'Normal capacity'.)

●Brain development – Structural and functional changes in the brain occur in parallel during adolescence. Neural connections and myelination develop in various parts of the brain throughout childhood and adolescence and continue until approximately 25 years of age [5]. Thus, there are developmentally based differences between the brains of adolescents and adults, reflected in the way they behave in emotional situations. Adolescents’ emotional experiences are wired for greater intensity, while they are, at the same time, making progress to the mature executive function more characteristic of adults. They may become excessively dramatic when upset. The physical growth spurt is accompanied by enhanced abstract thought and an emerging perspective on “bigger pictures” and empathy, which happens over the course of adolescence. These changes are frequently accompanied by the tensions of forming a self-identity (as in, separation from parents) yet also fighting with parents and other adults.

Adolescents may need guidance in how to think about anesthesia options presented to them and navigate the boundary between parental desires, concerns, and their own ability to listen to and participate in the decision-making. Straightforward and honest conversation is best; their fears and fantasies about the possibilities are often far worse than the facts clinicians can present to them, and the importance of hope, especially for major operations, is crucial.

●Pharmacology – Unlike small children, the pharmacodynamics and pharmacokinetics of intravenous drugs are similar in adolescents and in adults. The pharmacodynamic effects related to hormonal changes, and pharmacogenetic and neurodevelopmental differences are not well understood. Nonetheless, in healthy adolescents, the volume of distribution and end organ maturation do not significantly differ from adults, such that adolescents generally handle anesthetics like adults.

PREOPERATIVE EVALUATION

Medical evaluation — Most adolescents are healthy and fit, and preanesthesia evaluation is like other healthy patients. The extent of preoperative evaluation should be determined by physical findings, any comorbidities, and the planned surgery. (See "Preoperative evaluation for anesthesia for noncardiac surgery" and "Preoperative medical evaluation of the healthy adult patient".)

However, the preoperative history and physical examination may require modification due to adolescent psychological and body image issues. As an example, adolescent females may be reluctant to allow auscultation of the chest without appropriate draping, perhaps with a parent or caregiver present or behind a curtain. Considerations for patient modesty and privacy are crucial for adolescents, especially related to gender and culture, and are important even in the exigency of preoperative evaluation.

In the typically brief preoperative visit, anesthesiologists are challenged with establishing rapport (not only with the adolescent but also with the parents or caregivers), obtaining a complete and truthful history, and finding out about substance use, which can have significant implications for anesthetic planning, emergence, and perioperative recovery.

Medical conditions and issues that are of particular concern in evaluating adolescents include the following:

●Eating disorders – Eating disorders are important concerns in adolescents. A 2011 study found that the lifetime prevalence of anorexia in adolescents was 0.3 percent in both males and females. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis", section on 'Epidemiology'.)

Anorexia is associated with multiple medical complications that may affect anesthetic care, including atrioventricular (AV) block; QT prolongation; supra- and ventricular tachycardias; electrolyte abnormalities (eg, hypokalemia and contraction alkalosis with hypochloremia; hypomagnesemia); impaired thermoregulation; and osteoporosis. If arrhythmias occur in patients with anorexia, it is important to consider electrolyte abnormalities. Furthermore, the risk of aspiration should be considered, due to gastroparesis either from electrolyte abnormalities or as a constitutional response to the decrease in metabolism resulting from chronic starvation [6]. (See "Anorexia nervosa in adults and adolescents: Medical complications and their management".)

The preoperative interview with patients with anorexia and their families or caregivers may be challenging and stressful for the anesthesia clinician. It may be difficult to acquire information. Patients may be defensive and angry when questioned, and denial is common. In this setting, clinicians may unconsciously avoid some in-depth medical questions because patients with anorexia are often composed, poised, and appear fit and healthy. It is important to realize that these patients can become sick and deteriorate quickly.

●Obesity – Childhood and adolescent obesity has increased dramatically over time in the United States… Based on data from 2020 to 20212023, 1:3 adolescents were overweight or obese, higher for Latino (43 percent) and Black (40 percent) youth compared to White (27 percent) and Asian/Pacific Islander (25 percent) adolescents [7]. (See "Definition, epidemiology, and etiology of obesity in children and adolescents".)

Similar to adults, obesity is an important predisposing factor for difficult mask ventilation, obstructive sleep apnea, obesity hypoventilation syndrome, hypertension, type II diabetes and gastroesophageal reflux disease (GERD), all of which may affect anesthetic care. Children with obesity have a higher incidence of difficult mask ventilation, airway obstruction, major oxygen desaturation, and overall critical respiratory adverse events [8]. (See "Overview of the health consequences of obesity in children and adolescents" and "Preanesthesia medical evaluation of the patient with obesity" and "Anesthesia for the patient with obesity".)

Anesthetic considerations for patients with obesity and/or OSA are discussed in detail separately. (See "Anesthesia for the patient with obesity" and "Intraoperative management of adults with obstructive sleep apnea".)

●Substance use – Substance use is a common risk-taking behavior among adolescents. During preoperative evaluation, it is important to elicit information about this highly charged topic (eg, cigarette smoking; vaping; substance use, including alcohol or psychoactive drugs; and other risky behaviors). Such discussions may be difficult, particularly with adolescents who are not willing to answer honestly in front of parents or caregivers. In a study that compared the results of questionnaires on illicit substance use completed confidentially by adolescent patients with the same questionnaire completed by parents, patient reported use of substances was much higher than parental reports [9]. Clinicians should be skeptical about preoperative questionnaires, especially those filled out in the presence of parents, by parents, or over the internet.

The prevalence of substance use in adolescents was reported in a long-term study of substance use and related behaviors in individuals in the United States from 1975 to 2018 [10]. In 2018, up to 27 percent of adolescents had used an illicit drug (most commonly marijuana) in the previous year. Annual use of illicit drugs other than marijuana (eg, cocaine, opioids, methamphetamine, inhalants, club drugs) was approximately 9 percent among adolescents and varied widely with the individual drug. (See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis".)

Cigarette smoking has been decreasing in adolescents, whereas the use of e-cigarettes (vaping) is increasing. In 2019, 12 percent of high schoolers reported use of a combustible tobacco product (eg, cigarettes, cigars, pipe tobacco, hookah) in the past 30 days [11]; approximately 20 percent of high school students reported current use of e-cigarettes in 2020 [12]. Epidemiology of smoking among adolescents and anesthetic implications are discussed separately. (See "Prevention of smoking and vaping initiation in children and adolescents", section on 'Epidemiology' and "Smoking or vaping: Perioperative management".)

Anesthetic implications of other types of substance use/misuse are discussed separately. (See "Anesthesia for adult trauma patients", section on 'Substance use disorder or acute intoxication'.)

●Attention deficit hyperactivity disorder (ADHD) – ADHD is one of the most common disorders in childhood, and is associated with depression, oppositional defiant disorder, anxiety disorders, and learning disabilities. (See "Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis", section on 'Epidemiology'.)

While there is a very broad range of behaviors associated with ADHD, some of which can be challenging in the perioperative environment (eg, anger, opposition, and aggression), many adolescents with ADHD can also be cognitively adept, engaging, and funny. Nevertheless, patients with ADHD may have problems following and absorbing the anesthesia preoperative discussion and may exhibit perioperative maladaptive behaviors [13], which may require support and reassurance from parents or caregivers and also sedation in the preoperative care unit. In our experience, most adolescents with ADHD engage well with electronic devices and often a cellphone or tablet is all that is needed to accompany the patient to the operating room. Patients who are chronically treated with methylphenidate have been found via neuroimaging studies to have a significant increase of synaptic and extracellular dopamine [14], which may increase the anesthetic dose requirement.

●Depression – The lifetime prevalence of major depression in adolescents is as high as 11 percent, with a two to one ratio in females compared with males. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Epidemiology'.)

Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is commonly used to treat depression in adolescents. SSRIs generally do not require modification of the choice of drugs for anesthesia. However, fluoxetine and some other SSRIs are potent inhibitors of the cytochrome PY2D6 enzyme, which is required to convert hydrocodone, codeine, and tramadol into active forms. Thus, for patients who require opioids for postoperative analgesia, opioids that are not dependent on CYP2D6 metabolism (eg, fentanyl, morphine, oxycodone) should be used for effective analgesia (see "Selective serotonin reuptake inhibitors: Pharmacology, administration, and side effects", section on 'Drug-drug interactions'). Unless there is a clinical history of bleeding abnormality while taking SSRIs, we do not avoid coadministering nonsteroidal anti-inflammatory drugs such as ketorolac to patients on SSRIs.

For patients who take serotonin norepinephrine reuptake inhibitors or tricyclic antidepressants, the possible adverse end organ effects of chronically elevated catecholamines may include decreases in immune competence, splanchnic perfusion, gastrointestinal motility, and increased insulin resistance [15]. Evaluation should be determined by a suspicious history as well as physical findings.

Preoperative testing — Similar to adults, preoperative testing for adolescents should be performed selectively, based on the patient's medical status, the planned procedure, and the likelihood that test results will help with risk assessment or change management. Apart from pregnancy testing, healthy adolescents do not usually require preoperative laboratory testing for routine procedures with minimal blood loss. (See "Preoperative evaluation for anesthesia for noncardiac surgery", section on 'Selective testing'.)

Pregnancy testing — Most children’s hospitals (including the author’s institution) routinely perform preoperative pregnancy testing in postmenstrual females; reported rates of positive preoperative pregnancy tests are approximately 1 percent [16,17]. At the author’s institution, the average number of HCG tests is 2800 per year, about 150 of which are serum tests due to an inability to void. As of 2022, there has been one false negative result in 25 years and less than five false positive results. There has not been a positive HCG result in over five years, which may be the result of declining risk in adolescent females.

The American Society of Anesthesiologists states that there is an ethical obligation to offer pregnancy testing, though such pregnancy testing can be refused [18]. (See 'Confidentiality and informed consent' below and "Pregnancy in adolescents", section on 'Pretest counseling'.)

Adults can be offered the choice of pregnancy testing [19] with the reassurance that, as yet, there is no evidence of teratogenicity with the administration of anesthetic medications. Adolescents cannot be counseled the same way. Sexually active adolescents may have difficulty recognizing or accepting the possibility of pregnancy and may be reluctant to discuss or disclose their sexual history, especially in the presence of parents or caregivers. Furthermore, vaginal bleeding in early pregnancy may be mistaken for a menstrual period.

Routine pregnancy testing as an institutional policy in children's hospitals and relieves all parties of the burden of ambiguity. If a positive test occurs, elective surgery is canceled, and notification of the parents or caregivers is up to the patient, with support services provided if needed. Institutional policies for adolescent pregnancy testing should include the following:

●A preanesthetic educational and informational program for adolescent females and their parents or caregivers as a basis for the informed consent/assent discussion [20].

●A consent/assent process for pregnancy testing.

●A specification for honoring confidentiality when feasible.

●A plan for managing a positive pregnancy test that provides the adolescent with access to obstetric and psychosocial evaluations and counseling, including availability of social workers, child-life workers, and teen-pregnancy advisors. Elective surgery should be canceled and rescheduled as appropriate.

●A plan for follow-up to protect against potential physical and/or psychological retribution and to empower the adolescent to make further pregnancy-related decisions in a noncoercive, nonmanipulative, and nonthreatening milieu. The anesthesiologist's ethical obligations include managing the test results and championing the adolescent's wellbeing [18].

Medication management — The decision to continue or stop any usual medications is similar to such a decision for adults, which is discussed separately. (See "Perioperative medication management", section on 'Principles of medication management'.)

However, behavioral or psychiatric medications are sometimes not disclosed because of the fear of stigma and embarrassment, notwithstanding legitimate medical indications for their use. Psychotropic medications are used by more than 6 percent of adolescents, with antidepressants and ADHD medications used in equal amounts [21].

●For patients who take medication for ADHD, we generally continue the medication until the morning of surgery, recognizing that anesthetic requirements may be increased.

●For patients who take antidepressants, we usually continue the medication until surgery to avoid antidepressant discontinuation syndrome.

●For patients who take lithium, we discuss preoperative discontinuation with the patient, parents or caregivers, and the patient’s psychiatrist. We balance the risk of psychiatric implications of discontinuing the drug versus the risk of perioperative lithium toxicity, particularly for patients who undergo major procedures with potential for volume depletion and kidney dysfunction. Lithium potentiates neuromuscular blockade with depolarizing and nondepolarizing agents and can also prolong anesthesia. These risks can be mitigated by discontinuing lithium for the 24 hours preceding anesthesia, as one-half of an oral dose is excreted within 12 hours of administration. Lithium is also associated with multiple drug-drug interactions, which can be determined using the drug interactions program included in UpToDate. (See "Perioperative medication management", section on 'Psychotropic agents' and "Bipolar disorder in adults and lithium: Pharmacology, administration, and management of adverse effects", section on 'Lithium toxicity'.)

All patients should be asked about herbal medicines and supplements, which are commonly used by adolescents. In a US National Health and Nutrition Examination Survey for 2017-2018, approximately one third of adolescents used some form of dietary supplement (eg, vitamins and minerals, probiotics, fiber, melatonin, botanicals, nutrition supplements) [22]. We stop herbal supplements a week before surgery. Because many adolescents are day surgery patients, it is important to share this guidance with surgeons and other proceduralists who will be evaluating these patients prior to the day of surgery. Scripts for telephone screeners and templates for preoperative history forms should be modified accordingly.

Commonly used herbals and their potential clinical significance include the following [23]:

●Ephedra – tachycardia and hypertension

●Garlic, ginkgo, ginseng, vitamin E – bleeding

●Kava, St. John’s Wort, valerian – delayed emergence from anesthesia.

Patient and parental anxiety — When discussing anesthesia plans during the preoperative interview, it is important to emphasize patient comfort, safety, and the goals of the anesthetic and procedure, while reassuring the patient and the family or caregiver and leaving them with a feeling of confidence. Many adolescents have concerns and fears like those of adults (uncertainty of the procedure, the diagnosis, recovery, and restoration of function) with the additional burden of a self-image that is still forming and the possible perceived threat of alteration of body appearance or function. In many cases, adolescents hide their fears and anxieties better than adults, especially in front of parents and medical professionals.

A particular challenge is addressing the adolescent’s developing sense of self control in the context of being “put to sleep” and therefore relinquishing that control. The author finds that the most straightforward approach is to explain that this uncertainty is common, that everyone feels it to some extent, and it is an understandably strange feeling to give up consciousness and autonomy and leave them in the care of a perfect stranger. We explain that anesthesia is not magic or witchcraft, and that the various anesthetic medications work in combination to produce this pharmacological effect.

Confidentiality and informed consent — The concepts of informed consent and confidentiality are complex when the patient is an adolescent, particularly when the wishes of the adolescent conflict with those of the parents or caregivers. The laws governing consent and confidentiality in adolescent health care vary from country to country, and within the United States from state to state. The circumstances in which adolescents may consent for their own care and in which confidentiality is protected depend upon the adolescent's status as a minor or adult and other factors. Clinicians should be aware of the specific provisions in the consent and confidentiality laws in their own state and in federal law. These issues are discussed in separate topic reviews, which include resources for determining state laws and other regulations. (See "Consent in adolescent health care" and "Confidentiality in adolescent health care".)

ANESTHETIC MANAGEMENT

Premedication — We individualize the use of premedication based on the patient’s desire to avoid loss of control versus their desire to be “knocked out” and to not remember anything, subject to potential support from parents or caregivers when present. However, not all adolescents welcome the loss of self-control associated with premedication, and this should be assessed by asking them directly and listening to their answer carefully as well as watching how they answer.

Intravenous midazolam is the most frequently used anxiolytic for adolescents in our practice. When an IV is present, doses are easily titrated to produce the desired level of sedation. Paradoxical reactions seen in younger children, especially toddlers, are rare in adolescents. For patients in pain, it may make more sense to premedicate with analgesics such as hydromorphone, morphine, or fentanyl. For behaviorally challenged patients who require a mask induction, heavier premedication or pre-induction medications should be considered. In our institution this commonly consists of adding ketamine to an oral or intramuscular dose of midazolam to achieve unconsciousness but preserve spontaneous breathing in the preoperative holding area. For patients with poorly controlled impulse disorders such as aggression, it is important to have a clear strategy for preinduction medications as well as the cooperation of parents or caregivers and a sufficient number of assisting personnel (eg, nursing aides, nurses, and/or hospital security personnel). A brief huddle prior to medication administration is crucial so that everyone knows their roles following medication administration. Parents or caregivers are typically the strongest allies in this plan.

General anesthesia

Intravenous versus inhalation induction — Most adolescents readily accept placement of an intravenous catheter with some local anesthetic delivered by a skin wheal or needleless injection device (J-Tip) and typically find this a more pleasant induction technique. Nevertheless, there is a subgroup who asks for a mask induction, who are often veterans of the operating room or teens with various reasons for coping difficulties and needle phobias. For adolescents who request a mask induction, it should be carefully explained that this may ultimately be less pleasant than an IV induction, as they may feel somewhat out of control as they go through a more prolonged progression to unconsciousness.

Inhaled induction of general anesthesia may take 5 to 10 minutes, significantly longer than it does in younger children, due to the differences in uptake and distribution of inhaled anesthetics in adolescents (see 'Physiologic changes during adolescence' above). Induction time can be shortened by starting an IV once the patient is deep enough to allow it and completing the induction with intravenous agents.

Inhalation induction is discussed more fully separately. (See "Induction of general anesthesia: Overview", section on 'Inhalation anesthetic induction'.)

Maintenance of anesthesia — Various aspects of the maintenance of anesthesia are discussed in a number of other topics (eg, selection of intravenous and inhalation anesthetics, use of neuromuscular blocking agents, prophylaxis for postoperative nausea and vomiting). Issues specific to adolescents are discussed here.

Medications

●Neuromuscular blockade – In muscular adolescents, neuromuscular blockade may be required to facilitate surgical exposure and bony manipulation for orthopedic procedures, despite an ability to forego muscle relaxants for similar procedures in children or older adults (see "Clinical use of neuromuscular blocking agents in anesthesia"). Surgeons will often comment that muscular tension in the surgical field interferes with optimal exposure.

For reversal of rocuronium or vecuronium, sugammadex is increasingly replacing the routine use of neostigmine. Of note, sugammadex binds and inhibits oral contraceptives. Patients should be counseled to use alternative contraceptive techniques for seven days after exposure to sugammadex. Reversal of neuromuscular blockade is discussed in detail separately. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of neuromuscular block'.)

●Prophylaxis for postoperative nausea and vomiting (PONV) – It remains unclear whether adolescents should be guided by the pediatric or the adult recommendations for PONV prophylaxis. We typically follow adult recommendations for risk assessment and prophylaxis. Healthy adolescent females undergoing gynecologic or abdominal procedures are at high risk for PONV. Risk assessment, prophylaxis, and treatment for PONV are discussed separately. (See "Postoperative nausea and vomiting".)

Fluid management — Intravenous fluid requirement in adolescents is similar to such requirements in adults, though with a slight increase in free water requirement due to their increased oxygen consumption. For most procedures in healthy patients, this minor difference is not clinically relevant, especially when the patients approach the body mass and age of an adult. However, volume resuscitation (eg, during sepsis, burns) in adolescents may require more aggressive fluid therapy than in adults due to the increased basal requirements.

For maintenance IV fluid, we typically follow the 4-2-1 rule for fluid administration because it is based on daily free water requirements in accordance with the nonlinear scaling appropriate to oxygen consumption [24]. The 4-2-1 formula consists of administering 4 mL/kg/hr for the first 10 kg of weight, 2 mL/kg/hr for the next 10 kg, and 1 mL/kg/hr for each kilogram thereafter.

We typically administer Lactated Ringer's or Plasmalyte solutions as in adults. Intraoperative fluid administration is discussed in detail separately. (See "Intraoperative fluid management".)

Ventilation — Healthy adolescents usually have very high lung compliance as lung elastance increases through childhood and adolescence [25]. Requirements for minute ventilation are higher than adults, in keeping with the elevated oxygen consumption characteristic of the teenage years [26-29]. While nonanesthetized patients increase their minute ventilation to maintain normocarbia, we typically ventilate the anesthetized adolescent with an increase of 10 to 20 percent above middle-aged adult sex-matched patients. Thus, minute ventilation requirements are typically approximately 85 to 100 mL/kg/minute, compared with adult levels of about 70 mL/kg/minute [26,27,30]. Oxygen consumption is higher in males than females because of the influence of androgenic hormones throughout adolescence [28,29]. Procedures utilizing insufflation of carbon dioxide such as laparoscopy or thoracoscopy will further increase the minute CO₂ burden and therefore the minute ventilation required for normocarbia.

The high lung compliance during adolescence affects the optimal mode of ventilation. Lung-protective strategies for mechanical ventilation (eg, tidal volume 6 mL/kg, low peak inspiratory pressures, use of positive end expiratory pressure [PEEP]) are often used for mechanical ventilation during anesthesia. In healthy anesthetized adolescents in the supine position, generating a tidal volume/compliance curve can facilitate setting the optimal tidal volume and best PEEP. (See "Mechanical ventilation during anesthesia in adults", section on 'Individualized PEEP'.)

Maintaining normothermia — Maintenance of normothermia is a priority for all patients who undergo anesthesia. Because the body mass of adolescents is larger than that of infants and children, larger patients are more difficult to warm if they are allowed to cool. Therefore, prevention of heat loss is key, particularly if an extensive skin prep occurs before covering the patient. (See "Perioperative temperature management".)

Emergence from anesthesia — A brief period of agitation is common during emergence from anesthesia. Emergence delirium is one cause of emergence agitation (table 1); emergence delirium occurs in up to 9 percent of adolescents [31]. Emergence delirium is typically brief, resolving over approximately 20 minutes. However, emergence agitation and delirium are of particular concern in adolescents because of their size and the potential for self or staff injury, wound disruption, and/or pulling out catheters or drains. We do not typically change the anesthetic to try to prevent emergence delirium, but we are vigilant and ready to call on additional personnel to help restrain a thrashing adolescent and keep the patient and staff safe. Emergence delirium and agitation in children and adults is discussed separately. (See "Emergence delirium and agitation in children" and "Delayed emergence and emergence delirium in adults".)

Extubation — Extubation strategies are similar in adolescents and adults and are discussed in detail separately. Issues of particular concern for adolescents are discussed here. (See "Extubation following anesthesia".)

Deep versus awake removal of the airway device

●Deep extubation – Deep extubation may rarely be performed to reduce emergence phenomenon such as bronchospasm, coughing, straining, and hemodynamic stress. Deep extubation may be beneficial for patients with reactive airway disease, asthma, and patients with surgical indications (eg, patients who have had body wall reconstruction or open globe repair). However, after deep extubation the patient will transition through the excitement phase of emergence without a protected airway, while at risk for laryngospasm and aspiration. Moreover, adolescents who develop laryngospasm are at risk for negative pressure pulmonary edema. (See "Extubation following anesthesia" and 'Negative pressure pulmonary edema' below.)

●Deep removal of a supraglottic airway – It is perhaps even more common to remove a supraglottic airway while the patient is still deeply anesthetized. The decision to remove an SGA deep or awake should be based on patient factors and clinician preference, and data to support either choice are inconclusive. In a meta-analysis of 15 randomized trials in adults (five trials) and children (11 trials), laryngospasm was similar with deep versus awake removal, but airway obstruction was more common after deep removal (15.6 versus 4.6 percent) [32]. Overall quality of the data for most outcomes was low or very low.

Should airway obstruction occur after SGA removal, adolescents may be at increased risk of negative pressure pulmonary edema. Nevertheless, many SGAs are removed safely while the patient is deeply anesthetized, even in adolescents.

Laryngospasm — Laryngospasm is not a rare occurrence in pediatric anesthesia, and although more common in infants and small children, it can certainly occur in adolescents [33]. Anxiety is often thought by clinicians to predispose to laryngospasm, although there is no published evidence for this. Laryngospasm is more common in patients with a recent or current upper respiratory infection or asthma [34]. (See "Anesthesia for the child with a recent upper respiratory infection" and "Anesthesia for adults with upper respiratory infection" and "Anesthesia for the child with asthma or recurrent wheezing".)

Laryngospasm should be treated quickly, as it can result in hypoxemia, negative pressure pulmonary edema, and cardiac arrest. Laryngospasm is discussed separately. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Emergence laryngospasm'.)

Negative pressure pulmonary edema — Large negative interpleural pressures can be generated by inspiration against a closed glottis or obstructed upper airway (up to -140 mmHg [35,36]). These high negative pressures can result in pulmonary edema, though the mechanism by which this happens is unclear. It has been our experience, particularly with adolescents, that negative pressure pulmonary edema is more common when airway obstruction occurs after extubation than at other times during anesthesia, and this is regardless of the airway device used.

Signs of negative pressure pulmonary edema in patients who have had upper airway obstruction or laryngospasm, particularly after extubation, include oxygen desaturation despite administration of supplemental oxygen and rales, which may indicate an increase in lung water and elevated pulmonary vascular resistance.

Treatment includes relief of airway obstruction and administration of supplemental oxygen via a nonrebreathing mask. Oxygen is the most potent pulmonary vasodilator. However, oxygen provided by nasal cannula or simple face mask is often insufficient to adequately oxygenate in this setting. Some patients will require diuretics and continuous positive airway pressure (CPAP). Noninvasive continuous positive airway pressure and rarely, tracheal intubation with mechanical ventilation and positive end expiratory pressure (PEEP) will be necessary [37,38].

Regional anesthesia — While almost all regional blocks can be performed with local anesthesia and mild to moderate sedation in cooperative adults, many adolescents resist having needles placed, even when they are assured they will be comfortable, sedated, and likely amnestic. Routine use of ultrasound guidance for regional anesthesia allows safe performance of regional anesthesia techniques with the patient under general anesthesia, and the majority of our peripheral nerve blocks and some neuraxial blocks are performed this way. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Awake versus asleep block or catheter placement'.)

Even precisely placed regional blocks may not meet the anesthetic needs of an adolescent because of underlying patient anxiety or simply the duration of the procedure, even if the surgical field is completely numb. Considerations include not only the blocking of pain but also the blocking of touch and all other ancillary components of a surgical anesthetic, such as immobility and comfort in nonblocked areas.

In patients who have both general and regional anesthesia with a completely numb surgical field, it is easy to become complacent about the stability of the anesthetic without considering the possibility of accidental awareness. The use of a processed electroencephalographic (EEG) monitor (eg, BIS, Sedline) may be warranted to assess the depth of unconsciousness (see "Accidental awareness during general anesthesia", section on 'Monitoring'). This may be particularly important for patients taking medications that alter levels of neurotransmitters, such as selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs) for depression or methylphenidate for attention-deficit/hyperactivity disorder.

Pediatric anesthesiologists rarely see significant changes in blood pressure with the onset of neuraxial blockade in infants and young children up to about five to eight years of age because of their already low systemic vascular resistance, due to their higher basal metabolism and arteriolar dilation. This begins to change between five and eight years of age and by the time of adolescence, neuraxial blockade, unlike in younger children, will result in sympatholysis and decreases in blood pressure, similar to adults. In our experience, adolescents often require additional IV fluid boluses and/or small doses of vasopressors to prevent hypotension following neuraxial block [39].

PLAN FOR POSTOPERATIVE PAIN CONTROL — Perioperative pain management is a major concern for adolescents. They are often suspicious of superficial answers about what to expect postoperatively, so a thorough discussion is warranted. Adolescents are often less concerned about intraoperative management, as they know that they will be asleep.

The degree of postoperative pain for a given procedure will be influenced by the patient’s prior experience with surgery, coping abilities, and anxiety regarding pain. For surgery amenable to regional anesthesia techniques, patients can be presented options. For example, patients may be asked whether they would accept having a numb body part as a result of regional anesthesia, with the benefit of remaining very alert and allowing eating, talking to friends, or gaming, versus an opioid based analgesic regimen with potentially less adequate pain control and some attendant sedation. Regional analgesia and associated sensory changes may be particularly problematic for late maturing adolescents with a fragile body image, and they may need to be reminded that their body part is numb because of the medication administered and that it will wear off (like at the dentist). They should understand these sensory effects as part of shared decision making regarding regional analgesia techniques.

The pharmacology of analgesic medications is similar in adolescents and adults, but the level of emotional development and maturity of the adolescent are critical factors in successful pain management. Even mature adolescents may regress due to perioperative dependence on family members, caregivers, or nursing staff, and may need help with self-care and pain management. Patient requirements for pain management can vary from those who require heavy sedation, to those who decline adequate pain relief in an attempt to appear tough.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pediatric anesthesia".)

SUMMARY AND RECOMMENDATIONS

●Physiologic changes during adolescence – Adolescents undergo significant changes in body size and composition, associated increases in oxygen consumption, systemic vascular resistance, and cardiac output, and maturing thought processes and emotional control, all of which affect anesthetic management. (See 'Physiologic changes during adolescence' above.)

The pharmacodynamics and pharmacokinetics of intravenous drugs are similar in adolescents and in adults.

●Preoperative evaluation

•The preoperative evaluation and preoperative medication management for healthy adolescents is similar to healthy adults. Conditions that are relatively common in adolescents include eating disorders, obesity, substance use, attention deficit hyperactivity disorder (ADHD), and depression. (See 'Medical evaluation' above and 'Medication management' above.)

•Pregnancy testing should be offered to all menstrual females and is routine institutional policy in most children’s hospitals. (See 'Pregnancy testing' above.)

●General anesthesia

•Induction – Most adolescents will accept IV catheter placement for IV induction of anesthesia. If inhalation induction is chosen, it will likely take longer than in small children due to the increased cardiac output in adolescents. (See 'Intravenous versus inhalation induction' above.)

•Maintenance – Most aspects of maintenance of anesthesia for adolescents are similar to adults. (See 'Maintenance of anesthesia' above.)

•Emergence and extubation

-Deep versus awake extubation – The decision to remove an airway device (endotracheal tube or supraglottic airway) when the patient remains deeply anesthetized (ie, deep extubation) versus awake should be based on patient factors and clinician preference, recognizing that deep extubation leaves the patient at increased risk of post-extubation airway obstruction. (See 'Deep versus awake removal of the airway device' above.)

-Negative pressure pulmonary edema – Large negative airway pressures can be generated by inspiration against a closed glottis or obstructive airway, and can result in negative pressure pulmonary edema. The risk of negative pressure pulmonary edema may be increased in muscular adolescents, who are able to generate high inspiratory pressures. Immediate treatment includes relief of airway obstruction and administration of supplemental oxygen via a nonrebreathing mask. (See 'Negative pressure pulmonary edema' above.)

●Regional anesthesia – For adolescents who resist awake placement of regional blocks, peripheral nerve blocks or neuraxial anesthesia procedures can be safely performed with the patient anesthetized, similar to small children. Expectations regarding numb body parts during and after surgery should be explained to the patient. (See 'Regional anesthesia' above.)

Unlike small children (<5 to 8 years of age), adolescents are at risk for hypotension with neuraxial block. Fluid boluses and/or vasopressors may be necessary to prevent hypotension.