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Ophthalmologic Surgery

This chapter covers general considerations for ophthalmologic procedures in children, specific anesthetic considerations for the more commonly performed pediatric ophthalmologic procedures, and several unique anesthetic complications that occur in pediatric ophthalmologic procedures. Although the vast majority of children presenting for surgery on the eye are healthy, some ophthalmologic conditions are accompanied by coexisting morbidities. The majority of infants presenting for cataract surgery in the newborn period…

Neurosurgery

Pediatric neurosurgical patients present a unique set of anesthetic challenges that include treatment of increased intracranial pressure (ICP), the frequent use of lateral and prone positions, and the anesthetic implications of neurophysiologic monitoring. These and other considerations for the neurosurgical patient are addressed in the first part of this chapter, followed by a discussion of anesthetic techniques for common pediatric neurosurgical procedures. Pathophysiology and Treatment of…

Orthopedic Surgery

Musculoskeletal Trauma General Considerations Whether via monkey bar falls or trampoline accidents, children often find a way into the operating room for the treatment of musculoskeletal injuries. Approximately 40% of boys and 25% of girls will have at least one fracture before the age of 16. Upper extremity fractures account for two-thirds of fractures in children with the radius being the most commonly involved . Surgical…

Thoracic Surgery

Anesthetic care for pediatric thoracic surgery covers a wide range of ages, concomitant disease processes, and surgical pathology. The clinical scenario ranges from an elective, outpatient procedure on an otherwise healthy patient to an emergent procedure in a neonate with a severe underlying illness or associated congenital heart disease. The surgical pathology may have limited physiologic impact on the patient; or, as in the case of…

General Surgery

In this chapter, we review principles of anesthetic management of some common and unique surgical procedures that are within the purview of the general pediatric surgeon. The first section contains a discussion of concerns for intraabdominal procedures, especially in neonates and small infants. The second section reviews the unique aspects of some common surgical conditions of the abdomen that are of interest to pediatric anesthesiologists and…

ENT Surgery

Anesthesia for ENT surgery is one of the most challenging because of the frequency of airway obstruction in infants and small children and requisite sharing of the airway that is often at a distance from the anesthesiologist. The trainee must learn a variety of airway management techniques that are appropriate for each type of procedure and the different types of airway instruments used by otolaryngologists. Ear…

Malignant Hyperthermia

Malignant hyperthermia (MH) is a serious and possibly fatal syndrome of skeletal muscle hypermetabolism and calcium dysregulation that occurs when genetically susceptible individuals are exposed to certain anesthetic “triggering” agents- the potent halogenated inhaled volatile anesthetics and the nondepolarizing neuromuscular blocker succinylcholine. MH susceptibility is conferred by the inherited or spontaneous (de novo) acquisition of a variant in genetic loci that encode for proteins that are…

Regional Anesthesia

Nearly all regional anesthetic blocks in children are performed while they are anesthetized because conscious or sedated children will not cooperate sufficiently to ensure their safety. The main disadvantage of this approach is the theoretical injury of a nerve that would have otherwise been detected in a conscious patient by an immediate reaction of extreme pain or a motor response. However, the worldwide experience of regional…

Management of General Anesthesia

There are many features of the administration of general anesthesia that differ between children and adults. In this chapter, we discuss those differences, with an emphasis on anesthetic medications and ventilation strategies. We also review the importance of racial disparities in pediatric anesthesia, surgical site infection prophylaxis, and the possibility of neurotoxicity of anesthetics to the developing brain. In the United States, most children that require…

The Difficult Pediatric Airway

In this chapter we review principles of pediatric difficult airway management, with a focus on those entities that cause anatomic or functional airway obstruction above the level of the glottis. We consider causes and treatments of anticipated and unanticipated difficult intubation and difficult ventilation. Finally, we will touch upon updated equipment and techniques for difficult airway management. The most important aspect of anesthetic management of the…

Routine Airway Management

General anesthesiologists that occasionally anesthetize children should be intimately familiar with the anatomy of the pediatric upper airway. In this chapter, the pertinent features of the pediatric airway and the correct ways to manage the pediatric airway are detailed. Several common and serious complications related to airway management are reviewed. These include laryngospasm, pulmonary aspiration, and negative-pressure (postobstructive) pulmonary edema. Anatomy of the Pediatric Upper Airway…

Temperature Regulation

This chapter reviews the importance of thermoregulation and temperature monitoring in anesthetized children. It addresses the significance of keeping children normothermic and will help the trainee understand why pediatric anesthesiologists become apoplectic when faced with the possibility that the small infant they are caring for may become hypothermic. Important updates in this revision include new information and references regarding temperature control in neonates, and early detection…

Monitoring

Four monitors are used for virtually every pediatric anesthesia case: pulse oximetry, capnography, electrocardiogram (ECG), and blood pressure measurement. These monitors are components of the Basic Monitoring Standards of the American Society of Anesthesiologists. Temperature monitoring is also performed except in relatively short cases (i.e., <30 minutes duration) where hypothermia or hyperthermia is unlikely, and fluid and blood loss is minimal (e.g., myringotomy and tube insertion).…

Fluid and Blood Administration

A variety of intravenous fluid and blood products are administered to children in the perioperative period. Indications include preoperative deficit replacement, ongoing maintenance requirements, fluid loss replacement, and treatment of anemia and hypovolemia. This chapter describes the use of these fluid and blood products in pediatric patients in the perioperative period. Normal Fluid Requirements Water Requirements Water maintenance rates in children are based on studies that…

Preanesthetic Preparation of the Pediatric Patient

The “10 P” Checklist Cognitive aids, in the form of checklists, are techniques that ensure completeness with multistep processes and aid attention to detail. We devised the 10 P checklist to help anesthesia providers prepare for cases ( Table 13.1 ). This checklist is divided into preoperative, intraoperative, and postoperative considerations, and it will form the basis of the organization for this chapter. Table 13.1 The…

The Formerly Premature Infant

With the advent of antenatal steroids, surfactant therapy, and the overall improvement in care of extremely premature infants, mortality from medical problems of prematurity has decreased. However, as survival rates of premature infants increase, the incidence of chronic medical conditions related to prematurity has also increased. As a consequence, anesthesia providers are exposed to a growing number of infants and children who were born prematurely and…

The Premature Infant

In the last several decades, the incidence of prematurity in the United States has risen to 11.5%. Maternal risk factors for prematurity include absence of prenatal care, low socioeconomic status, tobacco abuse, poor nutrition and genitourinary tract infections, to name only a few. Despite a relative increase in prematurity, perinatal mortality rates have decreased to approximately 6 in every 1000 live births. Late-preterm births, defined as…

Endocrine Diseases

Diabetes Mellitus The endocrine condition most frequently encountered in the perioperative period in children is diabetes mellitus. Diabetes mellitus is the result of an absolute or functional deficiency of insulin production by the pancreas. In type 1 diabetes, this deficiency is caused by an autoimmune process, mediated by autoantibodies including anti-GAD (glutamic acid decarboxylase) and insulinoma-associated antibody. Insulin deficiency results in abnormalities of glucose transport and…

Genetic and Inherited Diseases

Trisomy 21 (Down Syndrome) With an incidence of approximately1 in 700 live births , trisomy 21 is the most common chromosomal abnormality and the most common cause of intellectual disability associated with genetic disease. These children are characterized by their distinctive facial appearance ( Fig. 9.1 ) and a variety of possible disorders. Surgical intervention is required for a number of disease entities that occur in…

Oncologic Diseases

Common Oncologic Disorders Leukemia The leukemias, which result from malignant transformation of early hematopoietic stem cells, are some of the most common malignancies of childhood ( Table 8.1 ). Acute lymphoblastic leukemia (ALL) accounts for 75% of all childhood acute leukemia, acute myelogenous leukemia (AML) accounts for 20%, and chronic myelogenous leukemias (CML) accounts for the other 5% of childhood leukemias. Table 8.1 Incidence of Childhood…