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Chest Pain in a Patient With Coronary Artery Disease – I

Case Study A rapid response event was initiated by the bedside nurse for acute onset hypotension. On prompt arrival of the rapid response team, it was noted that the patient was a 66-year-old female with a known history of ST-elevation myocardial infarction (STEMI) status post coronary artery bypass grafting a year ago, hypertension, and type 2 diabetes. She initially presented to the hospital for right flank…

Simulation in Pediatric Anesthesia

THE FIELD OF PEDIATRIC anesthesia has become increasingly subspecialized, with unique challenges that demand high-quality teaching and training. Pediatric anesthesia is focused in detail, diverse in surgical and technical complexity, and tolerates an exceedingly small margin for error. With the advancement of technology in radiology, the rise of procedural sedation and pediatric intensive care unit (ICU) requirements for bedside surgery, there is an increased challenge to…

Pediatric Equipment

Heating and Cooling Systems Consider for a moment the design of the surgical gown. It is designed to be a sterile barrier to protect the patient, yet it also must be a barrier to body fluids to protect the wearer. Because it is waterproof, it exchanges air poorly and in turn prevents dissipation of body heat. The surgeon wants to turn down the temperature in the…

Pediatric Anesthesia in Developing Countries

THE POPULATION IN THE DEVELOPING WORLD CONTINUES TO GROW while world demographics trend toward an aging population in an urbanized, developed world. Children, many orphaned by the ravages of war, human immunodeficiency virus (HIV) infection, and famine, constitute more than one-half of the population in many of these countries. Eighty-five percent will require surgery before their 15th birthday. The burden of surgical disease requires safe anesthesia,…

Infectious Disease Considerations for the Operating Room

THE RABBIT HOLE THAT IS THE PERIOPERATIVE ENVIRONMENT is not well understood by the majority of our general pediatric colleagues. Similarly, the rabbit hole of the primary care clinic or the pediatric inpatient ward is not well understood by the majority of our anesthesiology colleagues. A pediatric patient may repeatedly enter the rabbit hole over the course of a hospital admission, a journey fraught with dangers…

Procedures for Vascular Access

VASCULAR CANNULATION IS AN IMPORTANT PROCEDURE in the anesthetic and perioperative management of children. Its routine use was introduced in the 1950s. The indications are to provide routes to administer fluids, drugs, and blood products, monitor cardiopulmonary function, and access blood for laboratory testing. Although establishing vascular access may be extremely difficult at times, especially in the very young or small child, no child should be…

Sedation for Diagnostic and Therapeutic Procedures Outside the Operating Room

The Evolution of Pediatric Sedation and the Anesthesiologist's Role Perhaps more than ever, the care of children in the hospital setting requires the provision of sedation in a timely and effective manner. Many children who require an imaging procedure or invasive test before surgery will not tolerate the procedures without sedation. In addition, children with neurologic, gastroenterologic, or oncologic (medical) illness require repeated tests and procedures…

The Postanesthesia Care Unit and Beyond

EMERGENCE FROM ANESTHESIA IN CHILDREN differs substantially compared with adults. The process is multifaceted, dependent on the nature of the surgery, patient characteristics, and the type of anesthesia administered. In young children, emergence from inhalational agents can be quite rapid as a result of increased minute ventilation, increased blood flow to the vessel-rich group (see Chapter 7 ), and decreased total body muscle and fat stores,…

Anesthesia Outside the Operating Room

the approach to providing anesthesia outside the operating room (OR) for children (also known as “non–operating room anesthesia” [NORA] or “Off-site Anesthesia”) varies greatly among health care organizations and even from one anesthesia provider to another. Because of its very nature, NORA practice is neither as standardized as anesthesia delivered in the OR nor is it as well studied or reported. As such, it is a…

Chronic Pain

THE PRACTICING PEDIATRIC ANESTHESIOLOGIST is involved in chronic pain in one of three main venues: a child who is scheduled for a procedure, in consultation, or during acute pain management rounds. In this chapter, we focus on the essential approaches to children with chronic pain and provide guidelines to help the children and colleagues who request anesthesiology assistance. Chronic Pain in Children Chronic pain affects a…

Acute Pain

the practice of pain management in children continues to advance. Since the early 1980s, clinicians have recognized that neonates and infants experience pain and process those learning experiences. Research has demonstrated long-term adverse consequences of unrelieved pain, including harmful neuroendocrine responses, disrupted eating and sleep cycles, and increased pain perception during subsequent painful experiences. Adequate pain control is second only to correct diagnosis when parents are…

Ultrasound-Guided Regional Anesthesia

peripheral nerve blocks are frequently performed in children to provide anesthesia or analgesia during the perioperative period. Success depends on the ability to accurately place the needle—and thereby the local anesthetic—close to the target nerve without causing injury to the nerve or adjacent structures. Peripheral nerve blocks are not without risk and can pose a serious challenge even to the experienced anesthesiologist because they are usually…

Regional Anesthesia

THE USE OF REGIONAL anesthesia techniques in children has increased dramatically in the past two decades. Regional anesthesia is most commonly used in conjunction with general anesthesia in children, although in certain circumstances regional anesthesia may be the sole technique. In addition to central neuraxial blocks, peripheral nerve blocks are used with increasing frequency; the introduction of high-resolution portable ultrasound imaging has opened up new vistas…

Malignant Hyperthermia

MALIGNANT HYPERTHERMIA (MH) is a pharmacogenetic disease of skeletal muscle that may precipitate a potentially fatal sequence of metabolic responses in the presence of triggering anesthetics. The primary triggers for MH—inhalational anesthetics and succinylcholine—induce an uncontrollable release of intramyoplasmic calcium (Ca 2+ ) that results in sustained muscle contractures, which produce a hypermetabolic response. The hypermetabolic response manifests with hypercarbia, hyperpnea, tachycardia, and if not treated…

Cardiopulmonary Resuscitation

THE PEDIATRIC ANESTHESIOLOGIST must be prepared to resuscitate a child who suffers a cardiac arrest in the course of a routine elective anesthetic, during a high-risk surgery, or outside the operating room (OR) during the delivery of an anesthetic or as a vital part of the “code team.” The goal of this chapter is to provide pediatric anesthesiologists with an in-depth understanding of cardiopulmonary-cerebral resuscitation physiology…

Trauma

ANESTHESIOLOGISTS COMMONLY PROVIDE CARE TO CHILDREN who have suffered traumatic injuries of varying complexity. They range from the healthy, older child with an isolated elbow fracture to the infant with a life-threatening epidural hematoma. The anesthesiologist should view the management of children with traumatic injuries as a continuum of care that may originate in the prehospital setting with emergency medical services (EMS), progress to the emergency…