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Pediatric Anesthesia Practice

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Overview

Cambridge Pocket Clinician / Pediatric Anesthesia is designed to be a vital point-of-care guide to aid the clinician in the care of children in the perianesthetic period. It is a condensed and practical approach to the patient management, showcasing consistent standards that have been tested at the leading children's hospitals world-wide. It is divided into three main sections: surgical procedures, co-existing diseases, and regional anesthesia.

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Editorial Reviews

Doody's Review Service
Reviewer: Tariq M. Malik, MD (University of Chicago Pritzker School of Medicine)
Description: This quick guide for administering pediatric anesthesia provides a complete anesthetic plan for quite a few procedures in a concise fashion.
Purpose: The book is meant for anesthesiologists who do not take care of children on a regular basis.
Audience: The audience of nonpediatric anesthesiologists includes anesthesia residents and general anesthesiologists. The 61 contributors are from a variety of institutions.
Features: The first section deals with common diseases that occur in children and infants. Each disease is covered as a separate entity and its anesthetic and surgical implications are discussed in a way to provide practical and concise information that can be reviewed in five minutes. This section's 31 chapters encompass all common pediatric diseases, but not rare syndromes. The second section has 103 chapters that cover 103 surgical procedures. No chapter in this section is more than three pages of bulleted information. Each chapter covers pre-, intra- and postanesthetic considerations. The book is amazing in the way it provides such complete information about such a vast field and yet can easily be carried around in a pocket. It does, however, lack a chapter on pharmacology and dosage of drugs. A chapter on infant physiology, namely fluid requirement, maturation or liver, kidney function would have added great value. Similarly, a chapter on airways, especially hints on tube size selection, would have helped stressed anesthesiologists who have not done a pediatrics case in a while. The absence of these topics takes nothing away from the book, however. Surprisingly, no references are provided, which may make this book a little less attractive to residents who may want to expand their horizons.
Assessment: This book lives up to its promise as a pocket guide to pediatric anesthesia practice. No other book on the market provides this information in such a convenient format. It will not tax a tired mind in the middle of the night when a quick refresher course in pediatric anesthesia is needed.
From the Publisher
"No other book on the market provides this information in such a convenient format."
—Doody's Book Review Service
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Product Details

  • ISBN-13: 9780521709378
  • Publisher: Cambridge University Press
  • Publication date: 7/31/2007
  • Series: Cambridge Pocket Clinicians Series
  • Pages: 228
  • Product dimensions: 5.98 (w) x 8.98 (h) x 0.39 (d)

Read an Excerpt


Cambridge University Press
978-0-521-70937-8 - Pediatric Anesthesia Practice - Edited by Ronald S. Litman, DO. and FAAP
Excerpt



PART ONE

Coexisting Diseases





ANTERIOR MEDIASTINAL MASS

PAUL STRICKER, MD

BACKGROUND

■  Most common cause: lymphoma

■  Suspect in pts presenting for cervical mass biopsy.

■  Other dxs: neuroblastoma, teratoma, germ cell tumor, bronchogenic cyst, foregut cyst, lymphangioma, mesenchymal tumor

■  Symptoms due to compression of anatomic structures

■  Symptoms worse when supine

■  Symptoms may be relieved by lateral or upright position.

■  Clinical: cough, hoarseness, dyspnea, wheezing, orthopnea, stridor, chest pain, syncope, SVC syndrome, tracheal deviation, retractions

■  Asymptomatic or nonspecific: fever, fatigue, weight loss


PREOPERATIVE ASSESSMENT

■  Preoperative radiation tx may interfere with accuratehistologic dx & optimal tx regimens.

■  Physical exam: orthopnea, tracheal deviation, jugular venous distention, wheezing, retractions, unilateral decreased breath sounds

■  CXR: tracheal deviation, tracheal compression, abnormal cardiothymic silhouette

■  Echo: direct compression of cardiac chambers and/or great vessels, pericardial effusion

■  CT: assess severity & location of tracheal compression

■  Preop sedation: avoid or give in monitored setting

■  Antisialagogue (e.g., glycopyrrolate) useful

■  Obtain Ⅳ access prior to OR, ideally in lower extremity.

■  Correct preexisting dehydration or hypovolemia.


INTRAOPERATIVE MANAGEMENT

■  Potential catastrophic airway or cardiovascular collapse during induction of anesthesia

■  Monitors: std; A-line for great vessel or cardiac compression

■  All sized endotracheal tubes and rigid bronch immed avail in OR

■  For severe cases, ECMO or CPB stand-by

■  Liberal fluid administration if great vessel/cardiac compression

■  Position: semi-recumbent, sitting, or lateral

■  Local anesthesia without sedation is safest strategy, but not feasible for small children.

■  Most important to avoid airway/CV collapse: MAINTAIN SPONTANEOUS VENTILATION

■  Mask or LMA OK

■  Ketamine allows spontaneous ventilation & provides sympathetic stimulation.

■  Sevoflurane or Ⅳ agents OK if titrated to avoid apnea

■  Paralysis & controlled ventilation OK for mild cases, but no way to predict safety

■  Tx of airway obstruction: positive pressure, change position to lateral, sitting or prone if CV arrest

■  Rigid bronch may bypass airway obstruction.

■  ECMO or CPB as lifesaving measure


POSTOPERATIVE CONCERNS

■  Airway obstruction may occur postop during recovery.

■  Recover in lateral or semi-recumbent position.

■  Titrate opioids: avoid apnea.


ASTHMA

SANJAY M. BHANANKER, MD, FRCA

BACKGROUND

■  Incidence: 7–19%

■  Cause: chronic inflammation & mucus hypersecretion of lower airways

■  Symptoms: airway hyperreactivity with variable degrees of airflow obstruction

■  Strong association with atopy and allergy


PREOPERATIVE ASSESSMENT

■  Note severity and frequency of acute exacerbations, precipitating factors.

■  Elicit history of drug therapy, especially systemic steroids, to gauge severity.

■  If acute exacerbation or URI within 6 wks, consider postponing elective surgery.

■  Premed: inhaled beta-2 agonist, steroids (daily meds)

■  Anxiolysis with oral midazolam; fear, stress, excitement, or hyperventilation can provoke acute attack


INTRAOPERATIVE MANAGEMENT

■  Mask induction with sevoflurane or IV induction with propofol or ketamine

■  Minimize airway manipulation.

■  Face mask or LMA preferred

■  Avoid histamine-releasing drugs: thiopental, morphine, mivacurium, succinylcholine.

■  All volatile anesthetic drugs, propofol and ketamine are bronchodilators.

■  Administer stress dose of Ⅳ hydrocortisone if pt on oral prednisone.

■  If intraoperative wheezing occurs:

   i. Rule out kinked ET tube or bronchial intubation

   ii. Give 100% oxygen, deepen anesthesia with propofol, ketamine, or volatile agents

   iii. IV lidocaine 0.5–1 mg/kg bolus

   iv. Use low respiratory rate and long expiratory time to avoid intrinsic PEEP

   v. Nebulized beta-2 agonist such as albuterol via ET tube or LMA


POSTOPERATIVE CONCERNS

■  Deep extubation for pts with uncomplicated airway avoids risk of bronchospasm during emergence.

■  If awake extubation planned, nebulized prophylactic beta-2 agonist, IV lidocaine

■  Humidify supplemental oxygen, ensure adequate systemic hydration: dry anesthetic gases and O2 are potential triggers for asthma.


ATRIAL SEPTAL DEFECT (ASD)

LUIS M. ZABALA, MD

DISEASE CHARACTERISTICS

■  Definition: opening in the atrial septum except patent foramen ovale (PFO)

■  7–10% of all CHD

■  Incidence of PFO in adults: 25%

■  Pathophys: extra load on right side of the heart (L to R shunt)

■  Magnitude of shunt relates to size of defect, ventricular compliance, & pulmonary artery pressures.

■  L to R shunt: RA & RV enlargement

■  Pulmonary vascular changes develop from long-standing volume overload.

■  Majority of pts are asymptomatic during childhood.

■  In adulthood, extra load on RV leads to CHF, failure to thrive, recurrent respiratory infections, & symptomatic supraventricular dysrhythmias.

■  Pulm htn in up to 13% of nonoperated pts


PREOPERATIVE ASSESSMENT

■  CXR: RA & RV enlargement.

■  ECG: right or left axis deviation possible; incomplete RBBB from stretch in right bundle of His

■  Echo: secundum or primum defect; mitral regurg from anterior leaflet cleft.

■  Ventricular dysfunction possible from long-standing volume overload

■  Cardiology consultation for symptomatic pts

■  Premed: PO midazolam (0.5 mg/kg) or PO pentobarbital (4 mg/kg)

■  Caution with oversedation & hypoventilation: can worsen PVR & RV fn


INTRAOPERATIVE MANAGEMENT

■  Std monitors during noncardiac surgery or transcatheter closure of ASD

■  Symptomatic or complicated pts may require additional monitoring.

■  Intracardiac surgical repair requires extracorporeal circulation and arterial invasive monitoring.

■  Central venous monitoring at discretion of anesthesiologist

■  Transesophageal echo helpful to assess de-airing of left heart & adequacy of surgical repair

■  Inhalation induction generally safe

■  Inhalation agents, narcotics, muscle relaxants, and/or re-gional anesthesia usually well tolerated

■  De-bubble all Ⅳ lines.

■  Atrial dysrhythmias common in adult unrepaired pt


POSTOPERATIVE CONCERNS

■  Immediate or early tracheal extubation possible following uncomplicated surgical repair of ASD

■  Pts with good ventricular function prior to repair do not require inotropic support.

■  Dopamine 3–5 mcg/kg/min usually sufficient for ventricular dysfunction

■  Pulm htn may occur in older pts after ASD repair; use aggressive ventilation & milrinone.

■  Pts with unrepaired ASD undergoing noncardiac surgery should be monitored closely for CHF due to volume overload or atrial dysrhythmias.

■  Titrate analgesia to pain control without vent depression.


CEREBRAL PALSY

NATHALIA JIMENEZ, MD, MPH

BACKGROUND

■  Definition: static motor encephalopathy

■  Secondary to perinatal or early childhood (<2 yr) CNS injury

■  Incidence 2.4 per 1,000 live births

■  4 categories: spastic (quadriplegia, diplegia, hemiplegia), dyskinetic (dystonia, athetosis, chorea), ataxic (tremor, loss of balance, speech involvement), mixed

■  Assoc with developmental delay, visual & cognitive abnormalities, & motor problems possible with normal cognitive function

■  Require multiple surgeries: mainly orthopedic (spinal fusion and release of limb contractures)

■  Bulbar motor dysfunction predisposes to GE reflux, swallowing disorders & loss of airway protective mechanisms leading to chronic aspiration, recurrent pneumonia, hyperactive airways

■  Seizures in 30%: continue anticonvulsant on day of surgery & reinstitute early in postop period

■  Baclofen used for muscle spasms, can cause urinary retention & leg weakness

■  Abrupt baclofen withdrawal may cause seizures; overdose assoc with decreased consciousness & hypotension


PREOPERATIVE ASSESSMENT

■  Premedication tolerated in most pts; reduce dose or avoid if hypotonic

■  Anticholinergic will decrease secretions in pts with bulbar dysfunction.


INTRAOPERATIVE MANAGEMENT

■  Contractures make positioning and Ⅳ access difficult.

■  Impaired temp regulation due to hypothalamic dysfunction

■  Monitor temperature and use warming measures.

■  Inhalation induction safe unless severe reflux

■  Increased sensitivity of succinylcholine: use only in emergency situations

■  Decreased sensitivity to non-depolarizing muscle relaxants: requires higher doses

■  Increased sensitivity to inhaled anesthetics and opioids: use lower doses

■  Awake extubation in OR


POSTOPERATIVE CONCERNS

■  Pain assessment difficult due to inability to communicate: use modified behavioral pain scales

■  Regional techniques for postop analgesia recommended

■  Low-dose benzodiazepines (diazepam) to prevent/treat muscle spasms


COARCTATION OF THE AORTA

SCOTT D. MARKOWITZ, MD

BACKGROUND

■  Prevalence: 8% of pts with CHD

■  Coexisting bicuspid aortic valve, arch hypoplasia, other heart defects

■  Hypertension is usually present pre-repair and may persist postop.

■  May be repaired with balloon dilation or surgical correction end-to-end anastomosis or subclavian flap arterioplasty

■  Residual or recurrent coarct may occur early or late: eval by right arm vs. leg BP & Doppler echo.


PREOPERATIVE ASSESSMENT

■  ECG & echo: ventricular hypertrophy/dysfunction, valve dysfunction, residual coarct

■  BP measurements in all extremities, identification of previous recurrent laryngeal nerve injury

■  Antihypertensive regimen assessed and instructions for day of surgery medication administration given


INTRAOPERATIVE MANAGEMENT

■  SBE prophylaxis even after repair

■  If pre-repair: BP monitoring on pre-coarct artery (usually right arm except in cases of aberrant subclavian artery)

■  If post-repair: monitors accurate in any extremity, except if residual coarct

■  Left arm BP unreliable after subclavian flap repair

■  Caution with intercostal blocks if intercostal arteries dilated


POSTOPERATIVE CONSIDERATIONS

■  Std pain management: opioids & NSAIDs

■  Monitor for arrhythmias; resume antihypertensive therapy as appropriate.


CRANIOFACIAL SYNDROMES

SALLY E. RAMPERSAD, MB FRCA

BACKGROUND

■  Premature fusion of one or more skull sutures

■  Major component of several congenital syndromes: Crouzon, Saethe-Chotzen, Pfeiffer, Carpenter, Aperts


PREOPERATIVE ASSESSMENT

■  Previous anesthetic records: airway issues & management

■  Examine for obstructing mass (cystic hygroma, large tongue in Beckwith-Wiedemann syndrome; micrognathia/retrognathia in Pierre Robin); limited mouth opening, limited neck mobility, facial asymmetry (Goldenhars).

■  Abnl ear form & position indicate other facial anomalies.

■  Inform family of potential airway complications.

■  Snoring, daytime somnolence, or hx of stridor may indicate significant airway obstruction.

■  Cleft lip/palate are part of other syndromes (eg, CHARGE, trisomy 18, velocardiofacial syndrome).

■  Associated anomalies: ear, renal, CV

■  Avoid pre-op sedation in pts with potential airway obstruction, or administer with anesthesiologist present.

■  PO or Ⅳ atropine (0.02 mg/kg) as antisialagogue/vagolytic

■  Prepare different sizes of facemasks (air-filled cushion for asymmetric face), LMAs, oral & naso-pharyngeal airways, endotracheal tubes, fiberoptic bronchoscopes, stylets.





© Cambridge University Press
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Table of Contents

Part I. Co-Existing Diseases: Preface; 1. Anterior mediastinal mass; 2. Asthma; 3. Atrial septal defect (ASD); 4. Cerebral palsy; 5. Coarctation of the aorta; 6. Craniofacial syndromes; 7. Cystic fibrosis; 8. Emergence agitation; 9. Endocardial cushion defects: atrioventricular septal defects (AVSD) Ex-premature infant; 10. Hemophilia; 11. Mitochondrial myopathy; 12. Mucopolysaccharidoses; 13. Muscular dystrophy; 14. Neurofibromatosis; 15. Obstructive sleep apnea; 16. Oncological disease; 17. Patent ductus arteriosus; 18. Post operative nausea and vomiting (PONV) postoperative apnea; 19. Premature infant; 20. Seizure disorders; 21. Sickle cell disease; 22. Single ventricle physiology; 23. Tetralogy of fallot; 24. Thalassemia; 25. Transposition of great arteries (d-TGA); 26. Trisomy 21 (Down Syndrome); 27. Ventricular Septal Defect (VSD); 28. von Willebrand disease; Part II. Surgical Procedures: 29. Anterior spinal fusion; 30. Arterial switch procedure for transposition of the great arteries; 31. Atrial septal defect repair; 32. Awake craniotomy for seizures; 33. Bidirectional Glenn or Hemi-Fontan procedure; 34. Brachial cleft cyst excision; 35. Burn debridement; 36. Cardiac catheterization; 37. Cervical node biopsy/excision; 38. Choledochal cyst excision; 39. Circumcision; 40. Cleft lip repair; 41. Cleft palate repair; 42. Cloacal extrophy repair; 43. Club foot repair; 44. CNS tumor excision; 45. Coarctation of the aorta repair; 46. Colonoscopy; 47. Congenital cystic adenomatoid malformation (CCAM) excision; 48. Congenital diaphragmatic hernia repair (CDH); 49. Congenital lobar emphysema; 50. Craniosynostosis repair; 51. Craniotomy for head trauma; 52. CT Scans; 53. Cystic hygroma (Lymphatic Malformation) excision; 54. Dental extractions and rehabilitation; 55. Dorsal rhizotomy; 56. Endoscopy - EGD (Esophagogastroduodenoscopy); 57. Epiglottitis; 58. Esophageal dilatation; 59. Exploratory laparotomy for abdominal trauma; 60. Fontan procedure; 61. Foreign body in the trachea or bronchus; 62. Gastroschisis repair; 63. Gastrostomy tube placement; 64. Heel cord lengthening; 65. Hypospadias repair; 66. Imperforate anus repair (pena procedure or posterior sagittal anorectoplasty); 67. Inguinal hernia repair; 68. Intussusception repair; 69. Kasai procedure for biliary atresia; 70. Kidney transplant; 71. Lacrimal duct probing and irrigation; 72. Laparoscopy; 73. Laser removal of port wine stain; 74. Liver transplant; 75. Lower extremity fracture; 76. Mediastinoscopy; 77. MRI; 78. Myelomeningocele repair; 79. Myringotomy and tubes insertion; 80. Norwood stage 1 procedure; 81. Omphalocele repair; 82. Open globe injury repair; 83. Orchidopexy (undescended testicle repair); 84. Otoplasty; 85. Patent ductus arteriosus (PDA) ligation; 86. Pectus carinatum repair; 87. Pectus excavatum repair; 88. Pelvic osteotomy; 89. Posterior spinal fusion; 90. Posterior urethral valve repair; 91. Pull-throughs for hirschsprung's; 92. Pulmonary sequestration; 93. Pyloromyotomy; 94. Radiotherapy; 95. Retropharyngeal abscess; 96. Slipped capital femoral epiphysis (SCFE) repair; 97. Splenectomy; 98. Strabismus repair; 99. Syndactyly repair; 100. Testicular torsion repair; 101. Tetralogy of fallot repair; 102. Thyroglossal duct cyst; 103. Total anomalous pulmonary venous return (TAPVR) repair; 104. Tracheoesophageal fistula and esophageal atresia repair; 105. Tracheostomy; 106. Umbilical hernia repair; 107. Ureteral reimplant; 108. Vascular ring repair; 109. Ventricular septal defect repair; 110. Video-assisted thoracoscopic surgery (VATS); 111. Volvulus (malrotation); 112. Wilms' tumor excision; Part III. Regional Anesthesia: 113. Epidural analgesia; 114. Spinal anesthesia.

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