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BackgroundBlood pressure measurement is a standard of monitoring during general anesthesia. Invasive measurement is considered the gold standard but is less commonly used than non‐invasive. Automated oscillometric blood pressure devices measure the mean arterial pressure (MAP) and use an algorithm to determine the systolic and diastolic pressures. Few devices have been validated in children, particularly during anesthesia. Few studies have assessed the agreement between invasive and non‐invasive blood pressure measurements in children.MethodsThis was a multi‐center prospective observational study of children under 16 years undergoing cardiac catheterization with general anesthesia. Paired invasive and non‐invasive blood pressure measurements were recorded for each patient during stable periods of the procedure. Correlation within and between sites was assessed with Pearson's correlation coefficient, and agreement was examined using Bland–Altman methodology to determine bias. Agreement during episodes of hypotension and for age and weight was also determined. Bias greater than 5 mmHg and standard deviation greater than 8 mmHg was considered clinically significant. The primary end point was agreement of MAP measurements.ResultsA total of 683 paired blood pressure values were collected from 254 children in three pediatric hospitals. Median [IQR] age and weight were 3 [1–7] years and 13.9 [8–23] Kg. The overall bias (SD) for mean arterial pressure values was 7.2 (11.4) mmHg. During hypotension (190 readings), the bias (SD) was 15 (11.0) mmHg. The non‐invasive MAP was frequently higher than invasive MAP during infancy, and lower in older children.ConclusionAutomated oscillometric blood pressure measurement is unreliable in anesthetized children during cardiac catheterization. Invasive pressure measurement should be considered for high‐risk cases.