Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Ethical Aspects of Anesthesia Care

Key Points ▪ Deontologic (“rules-based”) ethical theory and utilitarian (outcome-based) theory clash in clinical scenarios in which the interests of individual patients are pitted against the interests of larger populations. ▪ In the United States, the predominant medical ethical principle is that of respect for the patient’s autonomy, and its expression is in the informed consent of patients for medical therapy. ▪ Competent and autonomous individuals…

Patient Simulation

Key Points ▪ Led by the discipline of anesthesiology, simulators and the use of simulation have become integral parts of many health care domains for various uses including training of novices, advanced residents, and experienced professionals; research about and with simulation; system probing; and performance assessment. Patient simulation can be part of an organization’s patient safety strategy and supports building a culture of safety (see Chapter…

Avoiding Patient Harm in Anesthesia: Human Performance and Patient Safety

Key Points ▪ Excellent clinical performance is not achieved by the use of sound medical knowledge alone, as clinicians have to face multifaceted challenges not just medical issues. There is an increased awareness that human factors—both on the individual and the team level—as well as organizational factors in the health care system play major roles in providing excellent medical care. Therefore, for anesthesia professionals (1) the…

Quality Improvement in Anesthesia Practice and Patient Safety

Key Points ▪ Quality needs to be an integral characteristic of the system in which care is delivered. Improving the quality of care often requires reorganization of the way we work. A challenge to the anesthesia team is to combine efficiency in perioperative care (especially the operating room) with safety and the best quality possible. ▪ The growing demand from patients, clinicians, insurers, regulators, accreditors, and…

Informatics in Perioperative Medicine

Key Points ▪ Individual computers are connected via networks to share information across many users. ▪ Information security is about ensuring that the correct information is available only to the correct users at the correct time. ▪ Healthcare information storage and exchange is regulated to protect patient privacy. ▪ Information regarding the provision of anesthesia care is highly structured and organized compared to most healthcare specialties.…

Perioperative Medicine

Key Points ▪ The practice of anesthesiology continues to evolve with health care for patients undergoing new and, in many cases, more complicated procedures in the operating room as well as minimally invasive or interventional procedures performed in other nonoperating room settings. With the rapid growth of nonoperating room anesthesia, traditional operating room anesthesia care no longer dominates most anesthesia practices. ▪ The number of anesthesia…

Anesthesia and Analgesia in the Global Context

Key Points ▪ More than 5 of the world’s 7 billion people lack access to safe anesthesia and surgical services. Surgical disease accounts for 30% of global disease burden, yet less than 1% of development assistance for health supports delivery of anesthesia and surgical care. Lack of access to safe, timely, and affordable anesthesia and surgery kills more than 4 times as many as acquired immunodeficiency…

The Scope of Modern Anesthetic Practice

Key Points ▪ The scope of modern anesthesia practice includes preoperative evaluation and preparation; intraprocedural care; postoperative care including acute pain management; critical care, resuscitation, and retrieval; chronic pain management; and palliative care. Anesthesia plays a key role in health service delivery and has a significant impact on population health and the burden of disease. ▪ Global and national forces for change include changing patient populations,…

The Critically Ill Child

Because critically ill children may occasionally present for emergency surgery, all anesthesiologists should have a working knowledge of the most common critical illnesses and their therapies. In this chapter, we review the clinical features of these illnesses, and also describe the most current Pediatric Advanced Life Support (PALS) guidelines and the use of inotropic medications and methods of providing invasive access in children. Pediatric Advanced Life…

Trauma and Burn Management

With approximately 15,000 deaths per year, trauma is the leading cause of death in children over 1 year of age in the United States. Anesthesiologists and anesthetists in nearly every type of hospital setting will eventually be exposed to the multiply injured child. In this chapter, we review in detail the anesthetic considerations for trauma and burn management in the pediatric population. The most common causes…

Chronic Pain

Pain is considered chronic when it is constant or recurrent and lasts for more than 3 months. It may persist because of ongoing tissue inflammation, as seen in children with inflammatory bowel disease or juvenile rheumatoid arthritis. It may also occur without tissue inflammation when peripheral or central nervous system neurons become abnormally modified by disease or lesion, or neuropathic pain. Neuropathic pain syndromes are an…

Acute Pain Management

“Acute pain” in the pediatric setting is generally nociceptive pain arising from tissue injury, inflammation, or infection. It is typically most pronounced immediately after the insult and gradually improves as the tissues repair. This type of pain usually responds to regional techniques, opioid medications, nonsteroidal antiinflammatory drugs (NSAIDs) and nonpharmacologic interventions, such as cognitive behavioral therapy and acupuncture; it rarely progresses to chronic pain. Nociception involves…

Local Anesthetics and Adjuvant Analgesics

Local anesthetics are synthetic derivatives of cocaine, a plant alkaloid obtained from the leaves of the South American coca plant, and the first local anesthetic to be discovered. Cocaine is a benzoic acid derivative coupled to a tertiary amine compound by an ester linkage. It is a weak base that is poorly soluble in water. Similarly, all local anesthetics contain a lipophilic benzoic acid derivative linked…

Analgesic Medications

Insufficient knowledge about the pharmacology of analgesic medications in the pediatric age group has led to inadequate treatment of pediatric pain partly related to the fluctuating pharmacokinetic and pharmacodynamics properties of analgesics during development. Although all analgesic medications have undergone thorough pharmacologic investigation in adults, similar studies have not always been performed in children. Only since 2001 has the Food and Drug Administration (FDA) required studies…

Pediatric Pain Assessment

The next several chapters are dedicated to teaching trainees about pediatric pain and the various options for pain management in children. In this first of five chapters, we introduce the topic of pediatric pain assessment. Because expression of pain is related to age and development, practitioners must use specially developed and validated tools for assessing and measuring pain in different age groups. You cannot manage what…

Postoperative Considerations

The pediatric postanesthesia care unit (PACU) is a noisy and chaotic environment. Nurses are attempting to calm crying toddlers, parents are being educated, physicians are being summoned for discharge orders, and the phones ring continuously with reports of available inpatient beds. Monitor alarms are artifactually ringing, and entire families gather in their child’s room to watch the latest reality television show. But lying beneath the din,…

Remote Anesthetizing Locations

More and more pediatric anesthesia cases are scheduled in non operating room (OR) locations. These locations are often far from the main surgical area, and some anesthesiologists feel out of place in these environments because they may not have easy access to anesthesia equipment and helpful personnel. This chapter will review the implications for anesthetizing children in the most common non-OR areas so that you will…

Urologic Surgery

Most urologic procedures are simple surgical repairs in healthy children and are performed on an outpatient basis. Some children require complex repairs, and it helps to understand the repair to tailor the anesthetic technique. Circumcision Children beyond the newborn period may present for circumcision under general anesthesia as an elective procedure for cosmetic reasons, or as a treatment for recurrent phimosis. Preoperative assessment should include assessment…

Plastic Surgery

In this chapter we review plastic surgery procedures that pose a wide range of perioperative challenges for the anesthesiologist, including difficult airway management, significant intraoperative blood loss, and comorbidities secondary to an underlying genetic syndrome. We also review considerations for subcutaneous administration of epinephrine. Craniofacial Anomalies The Committee on Nomenclature and Classification of Craniofacial Anomalies of the American Cleft Palate Association has organized facial anomalies into…