These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect.

Children undergoing single event multilevel surgery present specific difficulties. Locating the source of pain can be even more difficult, often involving a process of elimination of common causes (Patients are often attending many different specialists because of their multiple pathologies. Anesthetic challenges for consideration include increased sensitivity to non-depolarizing muscle relaxants, malignant hyperthermia with succinylcholine and volatile anesthetics, pituitary adrenal axis suppression, skeletal deformity with restricted mobility of temporomandibular joint and cervical spine, and impaired temperature regulation [6].

Postoperative analgesia is an essential part of the management.

Peri‐operative management. In this phase, succinylcholine typically is not given. Cognitive, communication and behavioural problems will influence the management plan as much as associated medical conditions and drug therapy. Parents and carers are best suited to allaying their fear and anxiety in addition to being their strongest advocate.

Another drug given during this phase is a muscle relaxant to obtain optimal intubating conditions, assuming an endotracheal tube is to be placed. In the more severely developmentally delayed, fear may make separation from carers difficult. If epidural analgesia is used for postoperative pain management, prolonged pressure over bony prominences may lead to troublesome skin breakdown, especially in malnourished children. BoNT/A produces reversible muscle denervation and results in a temporary reduction in muscle tone.BoNT/A was first used therapeutically in humans in 1980 for the treatment of strabismus and blepharospasm, and has since been used for dystonia and spasticity disorders [It is taken up at the presynaptic nerve terminal and prevents the release of acetylcholine at the neuromuscular junction.

Knowledge of pathology associated with different types of CP, related clinical conditions and their drug treatment will enable the anaesthetist to predict likely problems which might impinge on anaesthesia and the peri‐operative period.

One catheter is placed at the level corresponding to the dermatomes where the cephalad incision is made (usually LSurgery for correction of scoliosis may be performed in patients with CP in whom pre‐operative pulmonary function testing is impossible.

It is likely that the involuntary movements seen with propofol are myoclonic rather than epileptiform in origin.

Epidural and intrathecal morphine have been used [Children are expected to experience pain postoperatively. Priority can then be given to certain interventions, and surgical procedures can be appropriately spaced or even coordinated to occur on the same day.

Intellectual disability and epilepsy are often associated findings. It is more important to maintain anticonvulsant cover for children with a history of generalised convulsions than for those with partial seizures. Muscle fibres within 2–3 cm of the injection site are denervated. Sodium valproate, carbamazepine and diazepam may be administered rectally, although absorption is variable by this route.

Clinical manifestations relate to the area affected.

It is valuable to have the child's confidence.

A thorough understanding of the preoperative neurological deficits is important. A list of medications should be provided to the anesthesiologist for consideration in the anesthetic plan.Numerous factors have been known to contribute to MS relapses including infection, emotional stress, physical trauma, and the perioperative and peripartum periods. Feeding difficulties may be severe, requiring nasogastric feeding or a gastrostomy. Tracheal intubation should be performed if this is a concern or if there is a history of gastro‐oesophageal reflux. Children can use pain to manipulate situations in their favour. Minimising the number of anaesthetists involved in the child's care may be beneficial.Common drug groups encountered in children with CP are anticonvulsants, antispasmodics, anticholinergics, antireflux agents, antacids, laxatives and antidepressants.

Theoretical concerns over stimulation of antibodies requires injections to be spaced at least 3 months apart. Meticulous pressure care, vigilant observation, splitting of plaster casts and leg elevation reduce the risk of this complication.Children with CP are prone to constipation because of reduced mobility, reduced fluid intake and undiagnosed gut motility problems.

Attempts have been made to construct a pain scale based on behavioural indicators. Attention to normal bowel habits for that child and the prescription of laxatives, supplemented by enemas, may be necessary.Pain assessment in children with CP may be very difficult because of conceptual problems associated with intellectual disability or poor verbal communication skills. Intellectual disability and epilepsy are common in the latter group. Many of these children may be anxious because of poor understanding or difficulty communicating. Autonomic … (1990).

Induction of anaesthesia.