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Fetal Intervention and the EXIT Procedure

the advent of fetal intervention introduced the concept of surgically correcting or ameliorating known congenital defects in utero. With improvements in prenatal imaging and surgical techniques, fetal interventions have grown to include diagnoses associated with intrauterine demise and significant postnatal morbidity. The goal of fetal intervention is to improve the probability that the fetus will develop normally with minimal postnatal morbidity. Increasingly, advances have changed some…

The Extremely Premature Infant (Micropremie) and Common Neonatal Emergencies

THE PREMATURE INFANT IS DEFINED as birth before 37 weeks gestation. Premature births can be classified as low-birth-weight (LBW) infants (<2500 g), very low-birth-weight (VLBW) infants (<1500 g), and extremely low-birth-weight (ELBW) infants (<1000 g). Alternatively, they may be classified as moderate to late prematurity (32 to <37 weeks), very premature (28 to <32 weeks), and extremely premature (<28 weeks). A neonate is an infant in the first 28…

Burn Injuries

MILLIONS OF PEOPLE ARE TREATED FOR BURNS every year in the United States: hundreds of thousands of those who are hospitalized have a significant mortality rate. The National Burn Repository Report for 2014 reviewed its 10-year experience (2003–2013) ; overall mortality from 191,848 records in both males (3.4%–2.7%) and females (4.6%–3.3%) was reduced compared with the previous epoch. Children younger than 5 years of age accounted…

Plastic and Reconstructive Surgery

pediatric plastic surgery is performed in children of all ages, even in utero. However, the majority of children who undergo plastic surgical and reconstructive procedures are between 2 and 9 years of age, with a median age of 5 years. A wide spectrum of associated craniofacial abnormalities, underlying medical conditions, and surgical procedures characterizes this pediatric population. Consequently, a thorough preoperative assessment, consultation with medical and…

Ophthalmology

THE INFANT OR CHILD who presents for elective ophthalmic surgery requires careful preanesthesia assessment. In addition to ophthalmologic issues, the infant or child may have associated or unassociated systemic disorders. In this chapter, we review the essential issues that should be addressed preoperatively and difficulties that may be anticipated in the perioperative period. Many ophthalmologic diagnoses can be confirmed only by examining a cooperative infant or…

Otorhinolaryngologic Procedures

Otorhinolaryngologic Procedures Represent a large segment of elective surgery in infants and children. Anesthetic management is provided by both pediatric and general anesthesiologists, commonly in ambulatory surgery centers and office practices. Additionally, anesthesiologists are often consulted to help manage potentially life-threatening pediatric otolaryngologic emergencies. These include airway obstruction caused by croup, foreign body aspiration, airway trauma, bacterial tracheitis, and, rarely, acute epiglottitis. In both the elective…

Orthopedic and Spine Surgery

ANESTHESIA FOR ORTHOPEDIC AND SPINAL SURGERY provides a multitude of challenges. Children often present with concomitant diseases that affect cardiovascular and respiratory function. The ability to maintain a clear airway during anesthesia is not straightforward for some children, such as those with arthrogryposis multiplex congenita. Operating times can be protracted. Significant blood loss can occur that requires strategies for blood product management and transfusion reduction (see…

Organ Transplantation

Liver Transplantation The first successful pediatric liver transplant was performed by Tom Starzl and colleagues in 1967, but the history of liver transplantation actually began in 1955 with Stuart Welch in Albany and Jack Cannon at UCLA. Welch was the first to describe auxiliary liver transplantation in the dog and Cannon was the first to attempt orthotopic liver transplantation (OLT) in dogs. Unfortunately, none of the…

Essentials of Hepatology

Anatomy THE LIVER AND BILIARY TREE are derived from the endoderm of the dorsal foregut during the late third to the early fourth week of gestation. By the sixth week, the fetal liver primarily serves as a hematopoietic organ, while critical biologic functions such as glycolysis, bile acid synthesis, and metabolic waste processing are managed by the maternal liver through fetoplacental circulation. Oxygenated blood is shunted…

General Abdominal and Urologic Surgery

ABDOMINAL SURGERY AND UROLOGIC interventions make up a large fraction of anesthetic practice for the pediatric anesthesiologist. The field is rapidly evolving, with increased use of laparoscopic surgery, including robot-assisted procedures. This chapter focuses on the specific issues related to abdominal and urologic surgery, particularly in young children. The management of infants for pyloromyotomy and other neonatal abdominal procedures is discussed in Chapter 37 . General…

Essentials of Nephrology

THE ANESTHESIA PRACTITIONER IS OFTEN FACED with a child who has acute kidney injury (AKI) or renal failure. Renal disease requires the practitioner to be vigilant about fluid homeostasis, acid-base balance, electrolyte management, choice of anesthetics, and potential complications. This requires a thorough understanding of the excretory and fluid homeostatic functions of the kidney, particularly in the neonate and younger child. If not managed assiduously, perioperative…

Essentials of Endocrinology

Diabetes Mellitus * * Adapted and updated from Rhodes ET, Ferrari LR, Wolfsdorf JI. Perioperative management of pediatric surgical patients with diabetes mellitus. Anesth Analg. 2005;101:986–999. The incidence of type 1 diabetes mellitus in children is increasing worldwide, and while type 2 diabetes in children remains a less common disorder, its prevalence is also increasing. The use of insulin pumps and various multicomponent insulin regimens has…

Pediatric Neurosurgical Anesthesia

children who require neurosurgical procedures present unique challenges to pediatric anesthesiologists. In addition to addressing problems common to general pediatric anesthesia practice, anesthesiologists must consider the effects of anesthesia on the developing central nervous system (CNS) of children with neurologic disease. This chapter reviews the age-dependent physiology of the CNS of children undergoing neurosurgical procedures requiring anesthesia and addresses some of the unique situations that anesthesiologists…

Surgery, Anesthesia, and the Immature Brain

MILLIONS OF CHILDREN UNDERGO SURGERY with anesthesia every year. During the perioperative period they are exposed to a multitude of stressors capable of interfering with normal brain development. Pain, stress, inflammation, hypoxia, and ischemia have all been shown to adversely affect the immature central nervous system (CNS). However, recent findings from animal studies have indicated that sedatives and anesthetics—the very drugs used to reduce pain and…

Essentials of Neurology and Neuromuscular Disorders

DISORDERS OF THE NERVOUS SYSTEM are common in childhood, and their diverse manifestations and complications may lead to diagnostic and surgical interventions that require anesthesia. Children with these disorders are subject to the same acute illnesses, such as acute appendicitis, as other children. Many neurologic disorders exert profound effects on other body systems that function under complex autonomic control. For example, dysfunction of bulbar musculature may…

Anesthesia for Noncardiac Surgery in Children With Congenital Heart Disease

THE NATURAL HISTORY OF CONGENITAL HEART DISEASE (CHD) has been favorably altered over the past several decades by remarkable advances in medical and surgical care. These refinements have resulted in decreased morbidity and improvement in long-term outcomes in affected children. As survival rates further improve and life expectancy continues to increase, an escalating number of children with CHD will present for noncardiac surgery or other procedures…

Interventional Cardiology

THE USE OF CATHETERIZATION in the care of children with congenital heart disease (CHD) was first described by Dexter and colleagues in 1947 with the first interventional procedure, balloon atrial septostomy, subsequently described by Rashkind and Miller in 1966. Over the intervening decades the discipline of pediatric interventional cardiology has vastly expanded within the field of pediatric cardiovascular medicine. Technologic advances have increased the scope of…

Mechanical Circulatory Support

THE NUMBER OF INFANTS and children who are hospitalized each year with cardiorespiratory collapse that requires artificial support is substantive. Despite maximal medical therapy, failure of the cardiac and/or respiratory systems to provide adequate end-organ perfusion and oxygenation often results in the need for mechanical support of the circulation, either as an adjunct to cardiopulmonary resuscitation (CPR) or as a bridge to recovery or transplantation. The…

Medications for Hemostasis

BLEEDING IS AN INEVITABLE CONSEQUENCE of surgery and trauma. Provided the coagulation processes are normal, a meticulous hemostatic surgical technique is usually adequate to achieve hemostasis for most surgical procedures. However, if the degree of injury is more extensive, major blood loss can occur, particularly if there is a coexistent deficiency of the normal coagulation process. Since the early part of the 20th century, it has…

Cardiopulmonary Bypass and Management

THIS CHAPTER REVIEWS THE equipment and strategies for cardiopulmonary bypass (CPB) in infants and children, focusing on how they differ compared with CPB in adults. We review the effects of CPB on the key organ systems and discuss specific management issues that occur in daily practice. Basic Aspects of Cardiopulmonary Bypass The basic principles of CPB remain unchanged from when they were first introduced in the…