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Cardiac Physiology and Pharmacology

THE CARDIOVASCULAR SYSTEM plays a dominant role within the human body: a centrally located “powerhouse” provides oxygen and nutrients via an extensive network of vessels and capillaries throughout the body. All other organ systems depend on its normal development and function. At birth, and especially in the first few hours of life, the heart and the vascular system have to adapt to the extrauterine conditions. Prematurity,…

Anesthesia for Children Undergoing Heart Surgery

Preoperative Evaluation Congenital heart disease (CHD) accounts for nearly one-third of major congenital abnormalities, with an estimated worldwide birth prevalence of 9.1 cases per 1000 live births. In the United States, this represents the birth of 40,000 babies with CHD each year. Although CHD can occur in isolation, it is often associated with other cardiovascular and extracardiac malformations. The incidence of CHD is increased in the…

Essentials of Cardiology

Congenital Heart Disease Incidence Congenital heart disease (CHD) is the most common congenital anomaly, affecting approximately 1% of live births. Although CHD represents the leading cause of neonatal mortality, advances in medical and surgical management over the past several decades, including significant contributions related to anesthesia care, now allow for survival of most affected infants. A bicuspid aortic valve is the most common cardiac defect, occurring…

Anesthesia for Thoracic Surgery

General Perioperative Considerations A thorough preoperative evaluation is essential when caring for the child who is scheduled for thoracic surgery. Appropriate imaging and laboratory studies should be performed according to the lesion involved. Guidelines for fasting, choice of premedication, and preparation of the operating room (OR) are the same as for other infants and children scheduled for major surgery. After induction of anesthesia, placement of an…

The Pediatric Airway

The Differences Between The pediatric and adult airways are important determinants of the anesthetic technique. Knowledge of normal developmental anatomy and physiologic function is required to understand and manage both the normal and the pathologic airways of infants and children ( Video 14.1 ). Techniques and principles to assist in this management are reviewed in this chapter. Developmental Anatomy of the Airway The classic works by…

Essentials of Pulmonology

RESPIRATORY PROBLEMS ARE COMMON in children. The anesthesiologist often encounters pulmonary complications ranging from mild acute respiratory tract infections to chronic lung disease with end-stage respiratory failure during perioperative consultations, intraoperatively, or in the intensive care unit. This chapter discusses the basics of respiratory physiology, how to assess pulmonary function, and the practical anesthetic management of specific pulmonary problems. Airway and thoracic aspects pertinent to ventilation…

Strategies for Blood Product Management, Reducing Transfusions, and Massive Blood Transfusion

DESPITE ADVANCES IN PEDIATRIC SURGERY, infants and children may sustain major operative blood loss, but little information is available about when coagulation defects will begin to appear in children. Most studies of massive blood transfusions have involved adult patients, with little evidence from children to build a massive transfusion strategy. A rational blood transfusion strategy is imperative in children because there is limited blood available and…

Perioperative Management of the Oncology Patient

ALTHOUGH CHILDHOOD CANCER is not particularly common, it is the second most common cause of death in children younger than 15 years of age. The most common malignancies affecting children are different from those affecting adults. Leukemia, brain tumors, lymphomas, and sarcomas of tissue and bone are the most common pediatric cancers and account for over 50% of all pediatric malignancies ( Table 11.1 ). Embryonal…

Essentials of Hematology

HEMATOLOGIC DISORDERS IN CHILDHOOD may present to an anesthesiologist in many ways. They may be the primary cause for a surgical procedure, such as hereditary spherocytosis (HS) in a child requiring splenectomy, or a factor complicating a common surgical procedure, such as sickle cell disease in a child undergoing tonsillectomy. Questions about hematologic problems, such as anemia, thrombocytopenia, decreased or increased coagulation, childhood cancer, and hematopoietic…

Fluid Management

ELECTROLYTE DISTURBANCES ARE COMMON in children because of their small size, large ratio of surface area to volume, and immature homeostatic mechanisms. As a result, fluid management can be challenging. On the ward, in the operating room, or in the intensive care unit (ICU), additional difficulties may result when fluid management is not tailored to the individual or when therapeutic decisions are based on extrapolations from…

Total Intravenous Anesthesia and Target-Controlled Infusion

THE MOST COMMON INDICATIONS for total intravenous anesthesia (TIVA) techniques in children are as follows: those at risk for malignant hyperthermia (in whom inhalational agents are contraindicated); children with a high risk of postoperative nausea and vomiting, brief radiologic or painful procedures when rapid recovery is needed (e.g., magnetic resonance imaging, bone marrow aspiration, gastrointestinal endoscopy); frequent repeated anesthesia (e.g., radiation therapy); major surgery to control…

Pharmacokinetics and Pharmacology of Drugs Used in Children

THE PHARMACOKINETICS AND PHARMACODYNAMICS of most medications in children, especially neonates, differ from those in adults. Children exhibit different pharmacokinetics (PK) and pharmacodynamics (PD) from adults because of their immature renal and hepatic function, different body composition, altered protein binding, distinct disease spectrum, diverse behavior, and dissimilar receptor patterns. PK differences necessitate modification of the dose and the interval between doses to achieve the desired concentration…

Pharmacogenomics

U.S. PRESIDENT WILLIAM CLINTON, when announcing the relative completion of the Human Genome Project in July 2000, stated “With this profound new knowledge, humankind is on the verge of gaining immense new power to heal. Genome science will have a real impact on all of our lives—and even more, on the lives of our children. It will revolutionize the diagnosis, prevention, and treatment of most, if…

Ethical Issues in Pediatric Anesthesiology

CLINICIANS MUST TAKE SERIOUSLY “the experience, perspective, and power of children.” Clinicians should treat every child and family with the grace and consideration with which they would want their own child and family treated. Taking the experience of children seriously means involving interested children in developmentally appropriate decision making. Clinicians should not solicit a child's views without intending to consider them. Pro forma solicitations are harmful.…

Preoperative Evaluation, Premedication, and Induction of Anesthesia

Preparation of Children for Anesthesia Fasting Infants and children are fasted before sedation and anesthesia to minimize the risk of pulmonary aspiration of gastric contents. In a fasted child, only the basal secretions of gastric juice should be present in the stomach. In 1948, Digby Leigh recommended a 1-hour preoperative fast after clear fluids. Subsequently, Mendelson reported a number of maternal deaths that were attributed to…

Perioperative Behavioral Stress in Children

INTEREST IN CHILDREN'S PERIOPERATIVE behavior has increased dramatically over the past 20 years. Specifically, the recognition of the importance of developmental factors in perioperative research has created a dramatic growth of investigation in this area. In this chapter, we discuss developmental considerations that are relevant to the child's perioperative experience (cognitive development, attachment and separation, temperament). We then offer a review and synthesis of recent data…

Growth and Development

GROWTH IS A COMPLEX succession of phenomena that starts with the fusion of two cells and matures by 9 months into a complex organism known as a fetus. This phenomenally complex process not only produces a human being, it also traces the history of species with each and every fetus through embryology. Development is more than a simple increase in the number of cells; it includes…

The Practice of Pediatric Anesthesia

IN THIS CHAPTER, WE outline the basis of our collective practice of pediatric anesthesia. These basic principles of practice can be applied regardless of the circumstances; they provide the foundation for safe anesthesia. Preoperative Evaluation and Management Parents and Child Anesthesiologists must assume an active role in the preoperative assessment of children. Ideally, the same anesthesiologist who performs the preoperative evaluation will anesthetize the child. The…

Treatment Development: Directions and Areas in Need of Investigation

Introduction Over the past decades, numerous advances have been made in pain medicine. Despite these advances, there are many gaps in our knowledge of the treatments currently available. We describe potential areas for investigation, including perioperative pain management, pharmacologic, interventional, and non-interventional chronic pain management. Perioperative Pain Management Significant progress in the management of perioperative pain has been made over the past two decades. Increased awareness…

Ethical Issues in Pain Research

There are numerous ethical considerations when conducting pain research with humans. In this chapter, we will briefly review the genesis and growth of research ethics as a field, often in response to historical examples of research misconduct. We then discuss ethical issues specific to the study of pain, including (1) how pain can affect an individual’s ability to act autonomously, (2) unique risks of study participation…