This chapter will focus on the role of education and provide guidance to those who engage in teaching the specialty of pediatric anesthesiology as part of postgraduate training. It is organized into six sections. Sections 2 to 5 begin with a “mind map” (a graphic image of the key concepts) to provide a quick overview. The sections are (1) Historical Background; (2) Roles of the Clinical…
Introduction Physicians are confronted with a variety of unique legal issues on a daily basis. It would be nearly impossible to cover all of them—even in broad strokes—in a single chapter. Accordingly, this chapter focuses on two issues that may be of specific importance to pediatric physicians: informed consent and related medical malpractice actions. It is important to note at the outset that this chapter is…
Introduction The pediatric anesthesiologist does not generally diagnose or cure patients but rather guides and supports each young patient through a surgical or diagnostic procedure with the least possible mental and physical stress. The history of pediatric anesthesia is best told by tracing the steps others have taken, steps toward increased precision in regulation and control of neurologic, respiratory, cardiovascular, and other body systems to serve…
Introduction Patients engage the healthcare system seeking help—help managing pain, help regaining function, and help restoring some level of homeostasis in their lives. Unfortunately, for many patients, the system designed to help instead introduces new risks, new ailments, and new disabilities. The ability of the healthcare system to both heal and harm is one of the central conflicts for providers, patients, and policy makers alike. Patients…
Background and historical context Pediatric critical care began with the pediatric intensive care unit (PICU) created by Dr. Jack Downes in 1967 at Children’s Hospital of Philadelphia, many years after the initial attempts to palliate or repair congenital cardiac anomalies ( ; ). The development of the dedicated PICU offered hope to critically ill children suffering from respiratory failure, sepsis, and trauma. For many years, there…
Introduction: Critical care medicine Critical care medicine is a requisite aspect of the perioperative course for a significant portion of children presenting for surgery and other procedures necessitating anesthesia. Accordingly, the pediatric anesthesiologist’s understanding of the tenets of critical care medicine is exceedingly important. Critical care facilitates the optimization of critically ill patients before presentation for some patients, and postoperative care is routinely completed in the…
Cardiac arrest during anesthesia Incidence of cardiac arrest during anesthesia This chapter provides an overview of incidence, etiologies and outcomes of pediatric perioperative cardiac arrest, the physiology of cardiopulmonary resuscitation, current therapeutic recommendations as well as physiologic and scientific underpinnings of those recommendations. The 2020 American Heart Association updates are presented thoughout the chapter and summarized in Box 57.1 . A perioperative cardiac arrest is an…
Introduction: The challenge of healthcare-associated infection In the landmark 1999 report “To Err is Human,” the Institute of Medicine identified safety in healthcare as a significant contributor to avoidable morbidity and mortality ( ). Among the preventable categories of safety events, healthcare-associated infections (HAI) remain prominent. A 2018 report of data from government surveillance in the United States noted that on an average day, 1 in…
Introduction Pediatric cutaneous disorders are of significant importance to the anesthesiologist. Many dermatologic signs may signal potential anesthesia pitfalls or complications. Infectious disorders must be recognized to protect not only the patient but also the physicians and the staff caring for the patient. We present a variety of cutaneous signs associated with multiple conditions with potential anesthesia implications. The clinical condition is described with attending photographs…
Autism spectrum disorder Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder characterized by impairments in two major domains: (1) deficits in social communication and social interaction in multiple settings and (2) restricted repetitive patterns of behavior, interests, and activities. ASD includes disorders previously known as autism, childhood disintegrative disorder, pervasive developmental disorder, and Asperger syndrome. The diagnosis of ASD is made clinically, based on…
Introduction The dramatic rise in pediatric obesity has made it a common consideration for the pediatric anesthesiologist and surgeon. For the first time in human history, obesity now rivals malnutrition as the most life threatening global disorder among children ( ). According to a 2016 estimate from the World Health Organization (WHO), worldwide obesity has tripled since 1975. Nearly 41 million children under the age of…
History 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, specifically the potent halogenated inhaled volatile anesthetics and the nondepolarizing neuromuscular blocker succinylcholine. The reaction was first alluded to in a textbook published in 1952 by Arthur E. Guedel and more clearly delineated in 1960…
Genetic work during the past several years has led to a clearer understanding of the molecular causes of genetic-based muscle diseases. In most cases, the identification of the proteins altered in the disease states has added to our understanding of the development of muscle and the neuromuscular junction. The anesthetic management suggested for these diseases and syndromes can be better planned as a result of this…
Introduction Cancer during childhood remains one of the leading causes of disease-related mortality among pediatric patients. With advancements in the treatment of pediatric oncologic disorders and improved survival rates, the pediatric anesthesiologist will encounter these patients in the operating room, radiology suites, radiation therapy, inpatient floors for pain management, and oncology clinic settings. This chapter will review the three most common pediatric oncologic disorders that involve…
Introduction Managing the coagulation system is an integral part of pediatric anesthesiology and surgery. Pediatric anesthesiologists must have a fundamental understanding of normal and abnormal hemostasis in children as complex surgical procedures on neonates, infants, and children have become common. We must also be knowledgeable of potential abnormalities of hemostasis imposed on children, whether congenital or acquired. Although meticulous surgical technique is a cornerstone for blood…
Introduction Cardiovascular disease in children, while at times sharing some similarities, is quite different from that of adults. Common adult cardiovascular disease is typically the culmination of years of hypertension, atherosclerosis from hypercholesterolemia, valvulopathy and vasculopathy from progressive calcification, and adverse effects from tobacco abuse and obesity. These events and more predispose to coronary artery disease and heart failure. Cardiovascular disease in the pediatric patient is…
Asthma Asthma is a chronic inflammatory disease of the airways characterized by variable degrees of airflow obstruction and bronchial hyperreactivity ( ). Different clinical presentations are common, with patients varying greatly in their symptom onset and duration, triggers, severity, and response to treatment, reflecting the complex and multifactorial etiology of this disease. Tenets of anesthetic management include preoperative assessment of asthma severity and control and the…
Diabetes mellitus Background 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 pathophysiologic process, mediated by autoantibodies, including anti-GAD (glutamic acid decarboxylase) and insulinoma-associated antibody. Insulin deficiency results in abnormalities of glucose…
Introduction Individuals in high-resource nations have provided surgical service and training in low-resource countries (LRCs) as early as the 1940s, if not earlier. Those early efforts were typically self-arranged. Organized efforts appeared in the late 1950s and early 1960s, leading to numerous short-term volunteer opportunities. The Plastic Surgery Education Foundation (PSEF) in partnership with the Medical International Cooperation Organization and Children’s Medical Relief International were among…
Introduction Sedation of children for tests and procedures inside and outside the operating room remains a critical part of the role anesthesiologists play in providing compassionate and effective care for children. Unlike other areas of anesthesia practice, in pediatric procedural sedation medical specialists (other than anesthesiologists) also provide sedation to children. This is driven largely by the workforce reality that more children will require sedation for…