Steal Induction Using A Modified Transparent Hood For Mask-free Induction of Anaesthesia In Uncooperative Paediatric Patients: A Case Report

Steal Induction Using A Modified Transparent Hood For Mask-free Induction of Anaesthesia In Uncooperative Paediatric Patients: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Steal Induction Using A Modified Transparent Hood For Mask-free Induction of Anaesthesia In Uncooperative Paediatric Patients: A Case Report Zheng Ning KOH, Jing Xiao QUEK, Lorraine Wai Mun HO, Chung Wei NAH, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8755832/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Inhalational induction with volatile agents is widely used in paediatric anaesthesia, however not always tolerated well by children who refuse the mask. Steal induction without requiring placement of a mask might be more acceptable to this patient population. Case presentation: We report the case of a 6-year-old boy with a right hydrocele undergoing an elective right inguinal herniotomy and circumcision with two previous cancellations and known mask refusal. After premedication, the child was brought into the operating room and a make-shift hood using a transparent drape placed over the child’s head and shoulders. A breathing circuit without a mask was introduced below this hood and the child was induced successfully with Sevoflurane, Nitrous oxide and Oxygen. Conclusions Steal induction using a transparent hood can be an alternative method for inducing general anaesthesia in children who refuse conventional inhalational induction techniques. Inhalational induction paediatric anaesthesia uncooperative steal induction oxygen hood Figures Figure 1 Background Inhalational induction with volatile agents is a widely used technique in the paediatric population 1 . Benefits include a painless induction of anaesthesia 2 prior to obtaining intravenous access, especially in uncooperative, needle-phobic children 2 . However, some children refuse inhalational induction due to the strong smell of the mask and gas 3 , 4 , and the perception of intrusion into their personal space 3 , Techniques employed to smoothen the experience include using scented masks 4 , parental presence during induction 5 , distraction techniques with cartoons 6 , 8 or video games 7 , 8 , and sedative premedication 9 . Despite these measures, some children still refuse the mask. Steal induction is a technique first described by Meyers et al. in 1977, where the child arrives in the operating room (OR) already asleep, undergoing anaesthesia induction without being awoken 10 . Oxygen hoods have been used to deliver oxygen to paediatric patients. With adequate seal of the device around the patient's head, this may theoretically deliver an FIO2 of up to 1.0 and enable adequate CO2 clearance with adequate gas flow rate 11 . In addition, the use of hoods has been described in the context of non-invasive ventilation provision 12 or scavenging in paediatric patients intubated with uncuffed endotracheal tubes 13 . We describe a mask-free technique of steal induction using a transparent hood in a fretful child who previously failed inhalational induction despite pre-medication and use of a scented mask. To the best of our knowledge, this technique has not yet been described in the current literature for use in paediatric inhalational induction. Written informed consent was obtained from the child’s father for this case report. Case Description A 6-year-old, 17kg, 114cm tall boy with a right hydrocele re-presented for an elective right inguinal herniotomy and circumcision after 2 previous procedure cancellations. He had a background history of childhood asthma, strabismus, and was followed up with the Child Development Unit as he was deemed at risk of attention deficit hyperactivity disorder (ADHD). He underwent general anaesthesia for oral rehabilitation when he was 4 years old, where an inhalational induction was done without sedative pre-medication. He first presented with a hydrocele 8 months prior to our encounter, but the procedure was postponed due to an active upper respiratory tract infection. A second attempt at the procedure a month later was postponed due to persistent refusal of the mask for inhalational induction. During that encounter, 2 attempts were made at induction of anaesthesia. The first attempt was done without sedative pre-medication as the child was engaging well during the pre-operative review. However, he became fretful on arrival in the OR and adamantly refused the mask. 50mcg of buccal Dexmedetomidine was administered and a second attempt at induction was made 30 minutes after with the child asleep. This was unsuccessful as the child again became fretful and refused the mask. The decision was made to postpone the elective procedure to avoid traumatizing the child. He re-presented for the procedure 7 months later. The primary anaesthetist discussed pre-medication and induction options considering his previous induction experience and obtained consent from his father for intranasal premedication and the steal induction technique using a hood. EMLA cream was applied to bilateral hand dorsums, and 20mcg of atomized intranasal Dexmedetomidine administered. He was soundly asleep in the lateral position 30 minutes after and was transferred to the OR in his bed. The pulse oximeter was gently applied on his toe before induction. A make-shift hood was created using a transparent drape placed over his head and shoulders (Fig. 1 ). The posterior margin was taped to the bed using the in-built adhesive strip. The caudal margin was tucked gently under his blanket, and the cephalic and anterior margins naturally draped over his head and rested on the pillow. The breathing circuit without the mask was introduced just under the anterior margin and hidden by the pillow, avoiding detection by the child. Directing gas flow in a non-dependent direction accounted for Sevoflurane being more dense than atmospheric air. Sevoflurane was administered at 8% concentration, with 10L/min of Oxygen (FiO2 50%) and Nitrous Oxide (FiN20 50%) as the carrier gas. After waiting for about 2 minutes, a mask was connected to the breathing circuit and gently placed under the drape on the child’s face. Respiratory rate was regular, and he tolerated a gentle jaw thrust without stirring. The drape was removed at this point and the child turned supine. An intravenous cannula was placed and a laryngeal mask airway (LMA) inserted after. He was then transferred to the operating table where an ilio-inguinal and penile block were done. The procedure was completed uneventfully, and the LMA was removed under deep anaesthesia. The child was transferred to the recovery room with an oral airway and awoke calmly without any pain. He was discharged on the same day. Discussion The induction of general anaesthesia has the potential to be psychologically traumatizing for a child. Studies have shown that anxiety in children is contributed by previous negative hospital/ theatre experiences 14 , increases significantly prior to surgery, and peaks at mask introduction 15 . Children who were anxious prior to surgery are also more likely to develop emergence delirium, sleep disturbances, and experience more pain during the recovery period 16 . Options present if a child refuses the mask or IV setting despite reasoning and pre-medication include postponement of elective surgery, proceeding with inhalational induction under restraint for time-sensitive surgery, or intramuscular injection of sedatives. Though a consensus has yet to be reached on acceptable practice regarding the use of physical restraint 17 , 18 , the loss of control experienced by the child can lead to a loss of safety and security, and impact personality or emotional development 19 . We recommend the use of this transparent hood technique as an alternative method that can be considered by anaesthetists when faced with uncooperative children who exhibit mask refusal preoperatively. The use of a hood minimizes leakage and dilution of anaesthetic agents by surrounding air, allowing for a sufficiently high concentration of anaesthetic agent to be delivered. This can be achieved without the need to hold a mask directly against the child’s face – an act which can worsen a child’s anxiety and discomfort. A transparent drape was intentionally chosen to facilitate continued monitoring of the child during the induction process. If used in an awake child, the transparent drape also allows for continued visualization of the caregiver’s face, which is a crucial factor in providing psychological reassurance to the child. The child can also continue watching videos through the drape while anaesthetic gases are delivered within the hood. Though not done in this case, better tolerance of the hood as compared to the mask can optimize pre-oxygenation, which is often truncated to facilitate a speedy induction in a fretful child. Induction using 100% Oxygen as a carrier gas, though slower as compared to if Nitrous Oxide was used due to the loss of concentration 20 and second gas effect 21 , would also be more feasible since the hood is better tolerated. This would provide a greater margin of safety against hypoxia in the event of airway crises and provide added benefit for patients with cardiorespiratory comorbidities who are less tolerant of hypoxia. Having the transparent drape taped down on one side also allows for rapid undraping for emergent management of the airway or resuscitation. Lastly, this transparent drape is readily available as part of the underbody warming blanket set deployed for all paediatric cases in our institution, but often unused and discarded. Institutions who do not have these pre-formed drapes can easily improvise with a large clear transparent sheet and tape. Limitations to this technique include the need for high flow of inhalational agents to fill the hood, and the resultant potential larger carbon footprint 22 . As hypoxia during induction may occur due to airway obstruction and use of nitrous oxide 23 , continuous SpO2 monitoring is mandatory prior to induction to ensure safe application of this technique. Placement of the SpO2 probe may still upset a fretful child though this can be mitigated with application of probe by the patient’s parent in the absence of healthcare providers. Exposure to large amounts of volatile gases when the hood is removed also places healthcare workers at increased risks of health hazards 24 , 25 . Conclusions We recommend that this technique of steal induction with a transparent hood be used in the anxious child or children with behavioural disorders, as an alternative after establishing that the child is not amenable to conventional mask inhalational induction techniques. This smoothens the induction process after sedative pre-medication is administered. Further research can explore the application of this technique in other contexts and quantify its carbon footprint. Abbreviations OR Operating Room ADHD Attention Deficit Hyperactivity Disorder LMA Laryngeal Mask Airway Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Written informed consent was obtained from the patient’s parents for publication of clinical details. Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests: The authors declare no competing interests. Funding: None. Author’s contributions: Conceptualizing the presented idea: Rui Chun Sean LIM. Performing of case and data collection: Zheng Ning KOH and Lorraine Wai Mun HO. Drafting the manuscript: Zheng Ning KOH. Compilation of pictures and revising manuscript: Jing Xiao QUEK, Chung Wei NAH and Rui Chun Sean LIM. All authors read and approved the final manuscript. Acknowledgements: Not applicable. References Jöhr M. Paediatric anaesthesia: inhaled or intravenous technique? Anaesthesiol Reanim. 2004;29(3):64–8. Sellers C, Woodman N. Inhalational Induction in Paediatric Anaesthesia. BJA Educ. 2022;23(1). Sommerfield D, von Ungern-Sternberg BS. The mask or the needle? Which induction should we go for? Curr Opin Anaesthesiol. 2019;32(3):377–83. Gupta A, Mathew PJ, Bhardwaj N. Flavored Anesthetic Masks for Inhalational Induction in Children. Indian J Pediatr. 2017;84(10):739–44. Sadeghi A, Khaleghnejad Tabari A, Mahdavi A, Salarian S, Razavi SS. Impact of parental presence during induction of anesthesia on anxiety level among pediatric patients and their parents: a randomized clinical trial. Neuropsychiatr Dis Treat. 2017;12:3237–41. Wang X, Zhang J, Xin H, Tan W, Liu Y, Wan J. Effectiveness of two distraction strategies in reducing preoperative anxiety in children in China: A randomized controlled trial. J Pediatr Nurs. 2022 Nov. PATEL A, SCHIEBLE T, DAVIDSON M, TRAN MCJ, SCHOENBERG C. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Pediatr Anesth. 2006;16(10):1019–27. Manyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Reviews. 2015 Jul 14. Dave NM. Premedication and induction of anaesthesia in paediatric patients. Indian J Anaesth. 2019;63(9):713. MEYERS EF MURAVCHICKS. Anesthesia Induction Technics in Pediatric Patients. Anesth Analgesia. 1977;56(4):538–42. Napolitano N, Berlinski A, Walsh BK, Ginier E, Strickland SL. AARC Clinical Practice Guideline Management of Pediatric Patients with Oxygen in the Acute Care Setting. Respir Care. 2021;66(7):1214–23. Ronan C, Turton C, Vaidya M, Rajan TS. 1345 The Use of Hood Cpap to Improve Compliance with Non-Invasive Ventilation (NIV): A Single Centre Experience. Pediatr Res. 2010;68:666. Panni MK, Corn SB. The Use of a Uniquely Designed Anesthetic Scavenging Hood to Reduce Operating Room Anesthetic Gas Contamination During General Anesthesia. Anesth Analgesia. 2002;95(3):656–60. Tan L, Meakin GH. Anaesthesia for the uncooperative child. Continuing Educ Anaesth Crit Care Pain. 2010;10(2):48–52. FORTIER MA, DEL ROSARIO AM, MARTIN SR, KAIN ZN. Perioperative anxiety in children. Pediatr Anesth. 2010;20(4):318–22. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery. Pediatrics. 2006;118(2):651–8. HOMER S JR. Physically restraining children for induction of general anesthesia: survey of consultant pediatric anesthetists. Pediatr Anesth. 2010;20(7):638–46. LEWIS I, BURKE C, VOEPEL-LEWIS T, TAIT AR. Children who refuse anesthesia or sedation: a survey of anesthesiologists. Pediatr Anesth. 2007;17(12):1134–42. Lerwick JL. Minimizing pediatric healthcare-induced anxiety and trauma. World J Clin Pediatr. 2016;5(2):143. Korman B, Mapleson WW. Concentration and second gas effects: can the accepted explanation be improved? Br J Anaesth. 1997;78(5):618–25. Zafirova Z, Sheehan C, Hosseinian L. Update on nitrous oxide and its use in anesthesia practice. Best Pract Res Clin Anaesthesiol. 2018;32(2):113–23. Narayanan H, Raistrick C, Tom Pierce JM, Shelton C. Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study. Br J Anaesth. 2022;129(2). Becker DE, Rosenberg M. Nitrous Oxide and the Inhalation Anesthetics. Anesth Prog. 2008;55(4):124–31. Varughese S, Ahmed R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg. 2021;133(4). Lucio LMC, Braz MG, Nascimento Junior P do, Braz JRC, Braz LG. Occupational hazards, DNA damage, and oxidative stress on exposure to waste anesthetic gases. Brazilian Journal of Anesthesiology (English Edition). 2018;68(1):33–41. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers invited by journal 05 Mar, 2026 Editor invited by journal 06 Feb, 2026 Editor assigned by journal 03 Feb, 2026 Submission checks completed at journal 03 Feb, 2026 First submitted to journal 01 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8755832","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":602508210,"identity":"0fd57512-23c5-4b7c-8acf-aefe673331dc","order_by":0,"name":"Zheng Ning KOH","email":"","orcid":"","institution":"National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zheng","middleName":"Ning","lastName":"KOH","suffix":""},{"id":602508211,"identity":"61580f4b-145e-4036-9ff7-4697be4f6fdd","order_by":1,"name":"Jing Xiao QUEK","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACxmYQaQDlNFQA2RKkaTlDhBZU/Y1tRGhhbuc9/JqnwE6OgT3H8OHMedvkzKUbGD98zGGwl3fA5TC+NMsZBsnGDDxvjA03brttbDnnALPkzG0MiRsP4NLCY2bwwYA5sUEix0zy4bbbiRtuJLAx825jSDBswKMlwaAepMX858M5CC32eLQYP/hgcBhsC+PGBoQWxvk4vA+yhXGGwXFjNp5nxZIzjt02NriR2Az0i0TiBhxaDPvPGH/m+VMtx8+evPFjT81tOYMbyQc/fNxmYy+Pw2FAB7OBI4KNIQFuM0itBIPBAexa5IFR8wHCTECXwmHLKBgFo2AUjDgAACd3WXyOzYPWAAAAAElFTkSuQmCC","orcid":"","institution":"National University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jing","middleName":"Xiao","lastName":"QUEK","suffix":""},{"id":602508212,"identity":"4ea4d23b-4a13-45a1-82c1-fb5322be0ac9","order_by":2,"name":"Lorraine Wai Mun HO","email":"","orcid":"","institution":"National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lorraine","middleName":"Wai Mun","lastName":"HO","suffix":""},{"id":602508215,"identity":"28d50896-eeb3-46fb-a542-7286560c754d","order_by":3,"name":"Chung Wei NAH","email":"","orcid":"","institution":"National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chung","middleName":"Wei","lastName":"NAH","suffix":""},{"id":602508221,"identity":"c98eb9c7-aae1-4a14-ac1b-cddcfc9a6b1b","order_by":4,"name":"Rui Chun Sean LIM","email":"","orcid":"","institution":"National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"Chun Sean","lastName":"LIM","suffix":""}],"badges":[],"createdAt":"2026-02-01 11:40:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8755832/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8755832/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104343629,"identity":"199175cd-1970-44e2-8f30-79467ba766da","added_by":"auto","created_at":"2026-03-10 17:13:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":641080,"visible":true,"origin":"","legend":"\u003cp\u003eSetup showing position of hood and patient during induction\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8755832/v1/e5ae05f0a70b03c510ebc4b5.png"},{"id":104343643,"identity":"df45e81f-0be1-4a7f-8f9d-ec51947e15ef","added_by":"auto","created_at":"2026-03-10 17:14:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1327684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8755832/v1/a98b9dd0-36d8-46b2-81dd-ba75230e5e6d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Steal Induction Using A Modified Transparent Hood For Mask-free Induction of Anaesthesia In Uncooperative Paediatric Patients: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eInhalational induction with volatile agents is a widely used technique in the paediatric population\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Benefits include a painless induction of anaesthesia\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e prior to obtaining intravenous access, especially in uncooperative, needle-phobic children\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. However, some children refuse inhalational induction due to the strong smell of the mask and gas\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, and the perception of intrusion into their personal space\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, Techniques employed to smoothen the experience include using scented masks\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, parental presence during induction\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, distraction techniques with cartoons\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e or video games\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, and sedative premedication\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Despite these measures, some children still refuse the mask. Steal induction is a technique first described by Meyers et al. in 1977, where the child arrives in the operating room (OR) already asleep, undergoing anaesthesia induction without being awoken\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOxygen hoods have been used to deliver oxygen to paediatric patients. With adequate seal of the device around the patient's head, this may theoretically deliver an FIO2 of up to 1.0 and enable adequate CO2 clearance with adequate gas flow rate\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In addition, the use of hoods has been described in the context of non-invasive ventilation provision\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e or scavenging in paediatric patients intubated with uncuffed endotracheal tubes\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. We describe a mask-free technique of steal induction using a transparent hood in a fretful child who previously failed inhalational induction despite pre-medication and use of a scented mask. To the best of our knowledge, this technique has not yet been described in the current literature for use in paediatric inhalational induction. Written informed consent was obtained from the child\u0026rsquo;s father for this case report.\u003c/p\u003e"},{"header":"Case Description","content":"\u003cp\u003eA 6-year-old, 17kg, 114cm tall boy with a right hydrocele re-presented for an elective right inguinal herniotomy and circumcision after 2 previous procedure cancellations. He had a background history of childhood asthma, strabismus, and was followed up with the Child Development Unit as he was deemed at risk of attention deficit hyperactivity disorder (ADHD). He underwent general anaesthesia for oral rehabilitation when he was 4 years old, where an inhalational induction was done without sedative pre-medication.\u003c/p\u003e \u003cp\u003eHe first presented with a hydrocele 8 months prior to our encounter, but the procedure was postponed due to an active upper respiratory tract infection. A second attempt at the procedure a month later was postponed due to persistent refusal of the mask for inhalational induction. During that encounter, 2 attempts were made at induction of anaesthesia. The first attempt was done without sedative pre-medication as the child was engaging well during the pre-operative review. However, he became fretful on arrival in the OR and adamantly refused the mask. 50mcg of buccal Dexmedetomidine was administered and a second attempt at induction was made 30 minutes after with the child asleep. This was unsuccessful as the child again became fretful and refused the mask. The decision was made to postpone the elective procedure to avoid traumatizing the child.\u003c/p\u003e \u003cp\u003eHe re-presented for the procedure 7 months later. The primary anaesthetist discussed pre-medication and induction options considering his previous induction experience and obtained consent from his father for intranasal premedication and the steal induction technique using a hood. EMLA cream was applied to bilateral hand dorsums, and 20mcg of atomized intranasal Dexmedetomidine administered. He was soundly asleep in the lateral position 30 minutes after and was transferred to the OR in his bed. The pulse oximeter was gently applied on his toe before induction. A make-shift hood was created using a transparent drape placed over his head and shoulders (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The posterior margin was taped to the bed using the in-built adhesive strip. The caudal margin was tucked gently under his blanket, and the cephalic and anterior margins naturally draped over his head and rested on the pillow. The breathing circuit without the mask was introduced just under the anterior margin and hidden by the pillow, avoiding detection by the child. Directing gas flow in a non-dependent direction accounted for Sevoflurane being more dense than atmospheric air. Sevoflurane was administered at 8% concentration, with 10L/min of Oxygen (FiO2 50%) and Nitrous Oxide (FiN20 50%) as the carrier gas.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter waiting for about 2 minutes, a mask was connected to the breathing circuit and gently placed under the drape on the child\u0026rsquo;s face. Respiratory rate was regular, and he tolerated a gentle jaw thrust without stirring. The drape was removed at this point and the child turned supine. An intravenous cannula was placed and a laryngeal mask airway (LMA) inserted after. He was then transferred to the operating table where an ilio-inguinal and penile block were done.\u003c/p\u003e \u003cp\u003eThe procedure was completed uneventfully, and the LMA was removed under deep anaesthesia. The child was transferred to the recovery room with an oral airway and awoke calmly without any pain. He was discharged on the same day.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe induction of general anaesthesia has the potential to be psychologically traumatizing for a child. Studies have shown that anxiety in children is contributed by previous negative hospital/ theatre experiences\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, increases significantly prior to surgery, and peaks at mask introduction\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Children who were anxious prior to surgery are also more likely to develop emergence delirium, sleep disturbances, and experience more pain during the recovery period\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Options present if a child refuses the mask or IV setting despite reasoning and pre-medication include postponement of elective surgery, proceeding with inhalational induction under restraint for time-sensitive surgery, or intramuscular injection of sedatives. Though a consensus has yet to be reached on acceptable practice regarding the use of physical restraint\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, the loss of control experienced by the child can lead to a loss of safety and security, and impact personality or emotional development\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe recommend the use of this transparent hood technique as an alternative method that can be considered by anaesthetists when faced with uncooperative children who exhibit mask refusal preoperatively. The use of a hood minimizes leakage and dilution of anaesthetic agents by surrounding air, allowing for a sufficiently high concentration of anaesthetic agent to be delivered. This can be achieved without the need to hold a mask directly against the child\u0026rsquo;s face \u0026ndash; an act which can worsen a child\u0026rsquo;s anxiety and discomfort. A transparent drape was intentionally chosen to facilitate continued monitoring of the child during the induction process. If used in an awake child, the transparent drape also allows for continued visualization of the caregiver\u0026rsquo;s face, which is a crucial factor in providing psychological reassurance to the child. The child can also continue watching videos through the drape while anaesthetic gases are delivered within the hood.\u003c/p\u003e \u003cp\u003eThough not done in this case, better tolerance of the hood as compared to the mask can optimize pre-oxygenation, which is often truncated to facilitate a speedy induction in a fretful child. Induction using 100% Oxygen as a carrier gas, though slower as compared to if Nitrous Oxide was used due to the loss of concentration\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e and second gas effect\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, would also be more feasible since the hood is better tolerated. This would provide a greater margin of safety against hypoxia in the event of airway crises and provide added benefit for patients with cardiorespiratory comorbidities who are less tolerant of hypoxia.\u003c/p\u003e \u003cp\u003eHaving the transparent drape taped down on one side also allows for rapid undraping for emergent management of the airway or resuscitation. Lastly, this transparent drape is readily available as part of the underbody warming blanket set deployed for all paediatric cases in our institution, but often unused and discarded. Institutions who do not have these pre-formed drapes can easily improvise with a large clear transparent sheet and tape.\u003c/p\u003e \u003cp\u003eLimitations to this technique include the need for high flow of inhalational agents to fill the hood, and the resultant potential larger carbon footprint\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. As hypoxia during induction may occur due to airway obstruction and use of nitrous oxide\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e, continuous SpO2 monitoring is mandatory prior to induction to ensure safe application of this technique. Placement of the SpO2 probe may still upset a fretful child though this can be mitigated with application of probe by the patient\u0026rsquo;s parent in the absence of healthcare providers. Exposure to large amounts of volatile gases when the hood is removed also places healthcare workers at increased risks of health hazards\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe recommend that this technique of steal induction with a transparent hood be used in the anxious child or children with behavioural disorders, as an alternative after establishing that the child is not amenable to conventional mask inhalational induction techniques. This smoothens the induction process after sedative pre-medication is administered. Further research can explore the application of this technique in other contexts and quantify its carbon footprint.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOR \u0026nbsp;Operating Room\u003c/p\u003e\n\u003cp\u003eADHD\u0026nbsp;Attention Deficit Hyperactivity Disorder\u003c/p\u003e\n\u003cp\u003eLMA \u0026nbsp; Laryngeal Mask Airway\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s parents for publication of clinical details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualizing the presented idea: Rui Chun Sean LIM. Performing of case and data collection: Zheng Ning KOH and Lorraine Wai Mun HO. Drafting the manuscript: Zheng Ning KOH. Compilation of pictures and revising manuscript: Jing Xiao QUEK, Chung Wei NAH and Rui Chun Sean LIM. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJ\u0026ouml;hr M. Paediatric anaesthesia: inhaled or intravenous technique? Anaesthesiol Reanim. 2004;29(3):64\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSellers C, Woodman N. Inhalational Induction in Paediatric Anaesthesia. BJA Educ. 2022;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSommerfield D, von Ungern-Sternberg BS. The mask or the needle? Which induction should we go for? Curr Opin Anaesthesiol. 2019;32(3):377\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta A, Mathew PJ, Bhardwaj N. Flavored Anesthetic Masks for Inhalational Induction in Children. Indian J Pediatr. 2017;84(10):739\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi A, Khaleghnejad Tabari A, Mahdavi A, Salarian S, Razavi SS. Impact of parental presence during induction of anesthesia on anxiety level among pediatric patients and their parents: a randomized clinical trial. Neuropsychiatr Dis Treat. 2017;12:3237\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Zhang J, Xin H, Tan W, Liu Y, Wan J. Effectiveness of two distraction strategies in reducing preoperative anxiety in children in China: A randomized controlled trial. J Pediatr Nurs. 2022 Nov.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePATEL A, SCHIEBLE T, DAVIDSON M, TRAN MCJ, SCHOENBERG C. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Pediatr Anesth. 2006;16(10):1019\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManyande A, Cyna AM, Yip P, Chooi C, Middleton P. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Reviews. 2015 Jul 14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDave NM. Premedication and induction of anaesthesia in paediatric patients. Indian J Anaesth. 2019;63(9):713.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMEYERS EF MURAVCHICKS. Anesthesia Induction Technics in Pediatric Patients. Anesth Analgesia. 1977;56(4):538\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNapolitano N, Berlinski A, Walsh BK, Ginier E, Strickland SL. AARC Clinical Practice Guideline Management of Pediatric Patients with Oxygen in the Acute Care Setting. Respir Care. 2021;66(7):1214\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRonan C, Turton C, Vaidya M, Rajan TS. 1345 The Use of Hood Cpap to Improve Compliance with Non-Invasive Ventilation (NIV): A Single Centre Experience. Pediatr Res. 2010;68:666.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanni MK, Corn SB. The Use of a Uniquely Designed Anesthetic Scavenging Hood to Reduce Operating Room Anesthetic Gas Contamination During General Anesthesia. Anesth Analgesia. 2002;95(3):656\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan L, Meakin GH. Anaesthesia for the uncooperative child. Continuing Educ Anaesth Crit Care Pain. 2010;10(2):48\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFORTIER MA, DEL ROSARIO AM, MARTIN SR, KAIN ZN. Perioperative anxiety in children. Pediatr Anesth. 2010;20(4):318\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery. Pediatrics. 2006;118(2):651\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHOMER S JR. Physically restraining children for induction of general anesthesia: survey of consultant pediatric anesthetists. Pediatr Anesth. 2010;20(7):638\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLEWIS I, BURKE C, VOEPEL-LEWIS T, TAIT AR. Children who refuse anesthesia or sedation: a survey of anesthesiologists. Pediatr Anesth. 2007;17(12):1134\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLerwick JL. Minimizing pediatric healthcare-induced anxiety and trauma. World J Clin Pediatr. 2016;5(2):143.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorman B, Mapleson WW. Concentration and second gas effects: can the accepted explanation be improved? Br J Anaesth. 1997;78(5):618\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZafirova Z, Sheehan C, Hosseinian L. Update on nitrous oxide and its use in anesthesia practice. Best Pract Res Clin Anaesthesiol. 2018;32(2):113\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan H, Raistrick C, Tom Pierce JM, Shelton C. Carbon footprint of inhalational and total intravenous anaesthesia for paediatric anaesthesia: a modelling study. Br J Anaesth. 2022;129(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker DE, Rosenberg M. Nitrous Oxide and the Inhalation Anesthetics. Anesth Prog. 2008;55(4):124\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVarughese S, Ahmed R. Environmental and Occupational Considerations of Anesthesia: A Narrative Review and Update. Anesth Analg. 2021;133(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucio LMC, Braz MG, Nascimento Junior P do, Braz JRC, Braz LG. Occupational hazards, DNA damage, and oxidative stress on exposure to waste anesthetic gases. Brazilian Journal of Anesthesiology (English Edition). 2018;68(1):33\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Inhalational induction, paediatric anaesthesia, uncooperative, steal induction, oxygen hood","lastPublishedDoi":"10.21203/rs.3.rs-8755832/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8755832/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInhalational induction with volatile agents is widely used in paediatric anaesthesia, however not always tolerated well by children who refuse the mask. Steal induction without requiring placement of a mask might be more acceptable to this patient population.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe report the case of a 6-year-old boy with a right hydrocele undergoing an elective right inguinal herniotomy and circumcision with two previous cancellations and known mask refusal. After premedication, the child was brought into the operating room and a make-shift hood using a transparent drape placed over the child\u0026rsquo;s head and shoulders. A breathing circuit without a mask was introduced below this hood and the child was induced successfully with Sevoflurane, Nitrous oxide and Oxygen.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSteal induction using a transparent hood can be an alternative method for inducing general anaesthesia in children who refuse conventional inhalational induction techniques.\u003c/p\u003e","manuscriptTitle":"Steal Induction Using A Modified Transparent Hood For Mask-free Induction of Anaesthesia In Uncooperative Paediatric Patients: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 17:13:52","doi":"10.21203/rs.3.rs-8755832/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-26T14:35:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113482661958404622771875221300065833666","date":"2026-03-08T05:42:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-05T10:47:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-06T11:21:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-03T09:46:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-03T09:45:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-02-01T11:25:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eff5dc14-446d-49e8-bdd7-552d1b95e599","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-10T17:13:52+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 17:13:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8755832","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8755832","identity":"rs-8755832","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}