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Monitoring

Basic monitoring Anesthetic morbidity remains an important consideration in pediatric anesthesia practice, with risk increasing as the age of the patient decreases. This is despite the development of newer anesthetics and techniques. In addition, advances in medical and surgical care have led to increasing complexity of patients because of increased survival. Serious adverse events in pediatrics occur in 1.4 per 1000 anesthetics. Among these serious events,…

Equipment

Introduction Pediatric anesthesiologists care for a diverse patient population. Anesthetizing a 500-g neonate can be followed immediately by care for a 100-kg adolescent. This broad range of patient ages and sizes requires a diverse array of anesthesia equipment. This chapter discusses the types of pediatric anesthesia equipment and highlights the unique adaptations for their use in children. Humidifiers During normal breathing, the nasal mucosa and upper…

Preoperative preparation

Anesthesiology has evolved into an incredibly safe medical specialty. In large part, this is due to improvements in monitoring and medications, and the preoperative evaluation and preparation by the anesthesiologist are also important components of this safety. There are multiple goals for the preoperative evaluation. One goal is to identify issues that increase the risks to patient safety and to intervene to reduce these risks. The…

Psychological aspects of pediatric anesthesia

“ Remember me and smile, for it’s better to forget than to remember me and cry. ” —Theodor Seuss Geisel (Dr. Seuss), 1904–1991 Introduction Millions of children undergo surgery ever year in the United States, and a significant proportion of them will experience preoperative anxiety, fear, postoperative psychological distress, and maladaptive behaviors. It is apparent to most of us that these phenomena are not new; what…

Anesthetic adjuncts

Introduction Anesthetic adjuncts are increasingly important supplemental medications. Their actions range from bronchodilation, vagolysis, and secretion reduction to pain modulation and the prevention and treatment of postoperative nausea and vomiting (PONV). The use of these medications is becoming increasingly common throughout the pediatric anesthesia practice. Anticholinergic agents In pediatric anesthesia, anticholinergic agents are frequently administered as premedicants, antisialagogues, bronchodilators, and prophylactic agents for nausea and oculocardiac…

Neuromuscular blocking agents

Introduction Neuromuscular blockade is used extensively in pediatric anesthesia and intensive care settings to optimize conditions for endotracheal intubation, ventilation, and surgical and diagnostic procedures. A thorough understanding of the maturational changes in neuromuscular anatomy and physiology, along with an understanding of age-related responses to neuromuscular blocking agents (NMBAs), is fundamental to the safe and effective use of these agents in children. Developmental anatomy and physiology…

Opioids

Introduction To avoid the major adverse hemodynamic effects caused by potent inhalation anesthetic agents, the use of narcotic anesthesia has reemerged. Relative potencies of the various narcotics are listed in Table 12.1 . Initially, meperidine (0.5 to 1 mg/kg) and morphine (0.05 to 0.1 mg/kg) were used to reinforce nitrous oxide anesthesia in the neonate. However, concerns regarding the toxicity and increased sensitivity of neonates to…

Local anesthetics

Local anesthetics are nondiscriminating compounds that have a low affinity for all seven isoforms of voltage-gated sodium channels in tissues (e.g., myocardium, skeletal muscle, brain, spinal cord, and nerves). There is minimal variation in local anesthetic affinity among these isoforms, and there is no specific local anesthetic antagonist as a consequence ( ). All local anesthetic agents in clinical use consist essentially of three parts: a…

Inhaled anesthetics

Introduction History of inhaled anesthetics The discovery of inhalational agents played a critical role in anesthesia history. The search for the perfect agent capable of rapid induction of anesthesia, one with a high safety profile and minimal side effects, has led research efforts for over a hundred years and still continues. The early reports of the use of nitrous oxide, ether, and chloroform as inhalation anesthetics…

Intravenous anesthetics

Introduction Sedative hypnotic agents are an essential element in the care of pediatric patients. These drugs are used as premedicants, induction agents, and adjuvants for the maintenance of anesthesia or sedation. They are administered either as sole agents or in combination with other drugs. The multiple indications and routes of administration of these agents require an understanding of the effect of age on the pharmacokinetics and…

Developmental pharmacology

Introduction Developmental changes profoundly affect the clinical response to medicines. Dr. Abraham Jacobi, a founder of American pediatrics, recognized more than a century ago that children are not “miniature men and women, with reduced doses and the same class of disease in smaller bodies,” that pediatrics “has its own independent range and horizon,” and that age-appropriate pharmacotherapy was important ( ). More recently, as the immaturity…

Thermoregulation

Introduction Because of a sophisticated and efficient thermoregulatory system, humans are able to maintain their core body temperature constant within ±0.2°C of its normal value of 37.0°C despite changing ambient temperatures. This characteristic defines a homeothermic organism in contrast to a poikilothermic organism, where body temperature approximates ambient temperature (e.g., reptiles). The German physician Karl R. A. Wunderlich (1815–1877) should be regarded as one of the…

Regulation of fluids and electrolytes

Introduction Concentrations of minerals and electrolytes in extracellular fluid (ECF) are maintained nearly constant, despite large day-to-day variations in the dietary intake of salt and water. Such homeostasis is governed primarily by the kidneys through an array of intricate processes that may be influenced by intrarenal and extrarenal vasoactive substances and hormones. Although the basic tenets governing nephron function and homeostasis of body fluid composition have…

Cardiovascular physiology

Introduction The cardiovascular system consists of a complex interaction between the heart and lungs, evolving along a continuum from fetal circulation to adolescence in order to meet the changing needs of an individual’s body as he or she grows and matures. The subcellular makeup of cardiac myocytes produces the heart’s unique structure, which allows for both mechanical and electrical function. In utero, the fetal circulation allows…

Airway physiology and development

Developmental anatomy The upper airway Formation of the cranial vault and base The skull is a critical factor in the development of the face and upper airway. The skull develops from a membranous and cartilaginous neurocranium ( Fig. 4.1 ). The membranous neurocranium gives rise to the flat bones of the cranial vault and the cartilaginous neurocranium (chondrocranium) forms the skull base. The flat bones of…

Respiratory physiology

Among many physiologic adaptations for the survival of humans at birth, cardiorespiratory adaptation is by far the most crucial. The respiratory and circulatory systems must be developed sufficiently in utero for the newborn infant to withstand drastic changes at birth—from the fetal circulatory pattern with liquid-filled lungs to air breathing with transitional circulatory adaptation in a matter of a few minutes. The newborn infant must exercise…

Behavioral development

Introduction Assessment of growth and development of infants and children typically falls under the domain of the pediatrician or pediatric subspecialist. Delays or deviations from normal often dictate the need to conduct extensive diagnostic evaluations and management strategies. Familiarity with developmental stages may also benefit the pediatric anesthesiologist, allowing the practitioner to recognize the different coping mechanisms children use to respond to the anxiety and stresses…

Special characteristics of pediatric anesthesia

Introduction In the past few decades, new scientific knowledge of physiology and pharmacology in developing humans and technologic advancements in equipment and monitoring have markedly changed the practice of pediatric anesthesia. In addition, further emphasis on patient safety (e.g., correct side-site surgery, correct patient identification, correct procedure, appropriate prophylactic antibiotics) coupled with advances in minimally invasive pediatric surgery have created a need for better pharmacologic approaches…

The intensive care unit

This chapter provides an overview of general adult intensive care, the key components of which are resuscitation and stabilisation; physiological optimisation to prevent deterioration and organ failure; support of failing organ systems; and management and communication with patients and family of likely treatment outcomes, including potential failure. Levels of care have been described from level 0 (ward-based care) to level 3 (patients requiring advanced respiratory support…

Anaesthesia and organ transplantation

Improvements in surgical and perioperative technique, immunosuppression regimens and organ preservation over the last century have meant that organ transplantation is now considered the primary treatment for organ failure. Solid organ transplants (kidney, liver, heart, lung and pancreas) make up the majority of procedures ( Fig. 47.1 ), although the range of organs and tissues available for transplantation is continually expanding. Open full size image Fig.…