Summary The anaesthetic risk is much more important in small children than in adult surgical patients. The age of the patient and the experience of the anaesthesiologist are main predictors of complications, and poor experience of the anaesthetist combined with suboptimal equipment and time pressure enhance a fatal course. Insufficient airway management is the predominant risk factor. Complications, such as coughing, desaturation and laryngospasm, are more common in children with upper respiratory infection; however, the experienced practitioner will be able to anticipate or recognize and successfully treat most of these complications. A modified rapid sequence induction is used to prevent the occurrence of pulmonary aspiration, whereas the classic rapid sequence induction with apnoea is obsolete in paediatric anaesthesia. Cardiac co-morbidity increases the risk of perioperative complications; especially the relevance of cardiomyopathy and pulmonary hypertension is often underestimated. Although blood pressure is only a surrogate for adequate organ perfusion, it should be measured from the beginning of the case and kept within safe limits. Hyponatraemia is a continuous threat in paediatric acute care; only balanced crystalloid solutions (e.g. Ringer acetate) should be used in the perioperative field. An anaesthetic overdose is a common cause of cardiac arrest. Opioids can cause postoperative oversedation and respiratory depression. A focus on apoptosis and neurotoxicity detracts from the real, existing problems, such as the often lacking experience of the responsible anaesthesiologist and the suboptimal management of the case. Optimal preparation and check lists are helpful to reduce the risk. Experience, foresight and carefulness are of paramount importance.