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Principles and Practice of Pediatric Anesthesia
Snehalata H Dhayagude, Nandini M Dave
SECTION 1: BASIC PRINCIPLES
CHAPTER 1:
Anatomy, Growth and Development
INTRODUCTION
ANTHROPOMETRY
Weight
Length or Height
Head Circumference
Chest Circumference
Midarm Circumference
Body Mass Index
Body Surface Area
FACE
TEETH
FONTANELLES
NEONATAL REFLEXES
Primitive Reflexes
UPPER AIRWAY
Head
Nares
Tongue
Pharynx
Epiglottis
Larynx
LOWER AIRWAY
SMALL AIRWAYS, LARGE CONTROVERSIES
CHEST WALL
CENTRAL NERVOUS SYSTEM
THE SPINAL CORD
THE EPIDURAL SPACE
THE CAUDAL CANAL
HEART
MUSCULOSKELETAL SYSTEM
NEUROMUSCULAR JUNCTION
ABDOMEN
GASTROINTESTINAL SYSTEM
CHAPTER 2:
Physiological Characteristics and Anesthetic Implications
INTRODUCTION
PREMATURITY
GENERAL GROWTH AND DEVELOPMENT PATTERNS
Weight
Height
Head Circumference (HC)
Chest Circumference (CC)
Eruption of Teeth
Body Surface Area (BSA), Basal Metabolic Rate and Caloric Requirement
DEVELOPMENTAL PHYSIOLOGY
Cardiovascular System
Renal System
Hepatic System
Gastrointestinal Tract
Neurological Development
RESPIRATORY PHYSIOLOGY
Control of Breathing
Response to Hypoxemia
Response to Carbon Dioxide Levels
Upper Airway Receptors
Types of Breathing10,11
Effects of Anesthesia on Control of Breathing
Physiological Aspects of Development of Chest Wall Mechanics and Lung Volumes
Closing Volume and Closing Capacity
Airway Resistance
Ventilation and Pulmonary Gas Exchange
Surfactant
Oxygen Transport
CARDIOVASCULAR PHYSIOLOGY
Fetal Circulation (Fig. 2)
Circulatory Changes at Birth (Fig. 3)
Transitional Circulation
Persistent Fetal Circulation
Pulmonary Vascular Resistance
Cardiac Output and the Myocardium
Myocardial Performance
Autonomic Nervous System
PHYSIOLOGY OF CENTRAL NERVOUS SYSTEM
Blood-brain Barrier
Physiology of Cerebrospinal Fluid
Cerebral Blood Flow
Autoregulation of Cerebral Blood Flow
Effects of Blood Pressure
Effects of Oxygen
Effects of Carbon Dioxide
Development of Pain Pathways
Spinal Cord and Dura Matter
Implications
RENAL PHYSIOLOGY
Renal Blood Flow
Glomerular Filtration
Serum Creatinine
Tubular Function
Sodium
Glucose
Implications
HEPATIC PHYSIOLOGY
Functional Development
Carbohydrate Metabolism
Protein Synthesis
Synthesis of Clotting Factors
Principles of Hepatic Drug Metabolism
Phase I Reactions
Phase II Reactions
Physiological Jaundice
Implications
GASTROINTESTINAL SYSTEM
HEMOPOEITIC SYSTEM
Blood Volume in Relation to Age
Implications
Fetal Hemoglobin
Characteristics of HbF
Implication
White Blood Cells
Platelets
CHAPTER 3:
Essentials of Pharmacology in Neonates, Infants and Children
INTRODUCTION
PHARMACOKINETIC DIFFERENCES OF DRUGS IN CHILDREN
PHARMACODYNAMICS OF DRUGS IN CHILDREN
COMMONLY USED PHARMACOLOGIC AGENTS IN PEDIATRIC ANESTHESIA
Inhalational Agents
Pharmacokinetics
Pharmacodynamics
Individual Inhalational Agents
Nitrous Oxide
Halothane
Isoflurane
Sevoflurane
Desflurane
Intravenous Anesthetic Agents
Propofol
Thiopentone
Ketamine
Etomidate
Sedatives
Midazolam
Clonidine
Dexmedetomidine
Opioids
Morphine
Fentanyl
Remifentanil
Tramadol
Buprenorphine
Non-Opioid Analgesics
Ketorolac
Acetaminophen (Paracetamol)
Diclofenac
Neuromuscular Blocking Agents
Succinylcholine
Atracurium
Cisatracurium
Vecuronium
Rocuronium
Mivacurium
REVERSAL OF NEUROMUSCULAR BLOCKADE
Neostigmine
Sugammadex
ANTIEMETICS
Ondansetron
Dexamethasone
Metoclopramide
ANTICHOLINERGICS
Atropine
Glycopyrrolate
LOCAL ANESTHETICS
ADJUVANTS
Clonidine
Ketamine
Opioids
CHAPTER 4:
Understanding the Pediatric Chest Radiograph
INTRODUCTION
IMAGING A CHILD
READING A CHEST RADIOGRAPH
NORMAL CHEST RADIOGRAPH
Structures Seen in a Normal Chest Radiograph
SIGNS IN A CHEST RADIOGRAPH
The Silhouette Sign
Cervicothoracic Sign
Thoracoabdominal Sign
Spine Sign
ABNORMAL CHEST RADIOGRAPH
Congenital Lung Anomalies
Congenital Lobar Emphysema
Pulmonary Agenesis, Aplasia, and Hypoplasia
Hypogenetic Lung Syndrome
Congenital Emphysematous Bulla
Bronchogenic Cyst
Congenital Pulmonary Airway Malformation
Congenital Heart Diseases
Situs
Diagnosis
OTHER CONGENITAL LESIONS ON A PEDIATRIC CHEST RADIOGRAPH
Congenital Diaphragmatic Hernia
Classification
Congenital Chest Anomalies
Kartagener Syndrome
INFECTIVE LUNG DISEASES
Bacterial Pneumonias
COMPLICATIONS OF PNEUMONIA
Lung Abscess (Figs 34 to 39)
Bronchiectasis
Viral Pneumonia
Pulmonary Tuberculosis
Differential Diagnosis of Hilar Lymphadenopathy (Fig. 43)
Traumatic
Pneumothorax
TENSION PNEUMOTHORAX
Characterized by
PNEUMOMEDIASTINUM
Miscellaneous
Foreign Body
Hyaline Membrane Disease
Lipoid Pneumonia
Normal Position of Endotracheal Tube
Normal Position of Central Venous Pressure (CVP) Line
Thalassemia Major
CHAPTER 5:
Interpretation of Pediatric Electrocardiogram
INTRODUCTION
INDICATIONS
ECG Recording and Interpretation
Steps to read Pediatric Electrocardiograms
Step I: Heart Rate Calculation
Step II: Determining the Rhythm
Step III: P Wave Analysis
Step IV: Axis Detection
Step V: Intervals
Step VI: QRS Wave Analysis
Step VII: T Wave and ST Changes
SOME DISEASE SPECIFIC ECG CHANGES7
ARRHYTHMIAS IN CHILDREN
SUMMARY
SECTION 2: ANESTHETIC MANAGEMENT
CHAPTER 6:
Preoperative Evaluation and Premedication
INTRODUCTION
ROLE OF SURGEON
ROLE OF ANESTHESIOLOGIST
ROLE OF PEDIATRICIAN
THE PREANESTHESIA CONSULTATION2
General Considerations
Special Preoperative Considerations and Implications in Pediatric Patients
Respiratory System
Cardiovascular System
PREOPERATIVE INVESTIGATIONS
PREMEDICATION
Advantages
Disadvantages
Conditions where One has to be Cautious in Prescribing Premedication
PREOPERATIVE FASTING
PSYCHOLOGICAL PREPARATION OF THE CHILD
Nonpharmacological Measures to Reduce Anxiety
Pharmacological Measures
Benzodiazepines
Ketamine
Opioids
Nonbarbiturate Sedatives
Anticholinergic Drugs
α2 Agonists
Antihistaminics
Topical Anesthetics
CHAPTER 7:
Induction, Maintenance and Emergence
INTRODUCTION
PREPARATION
INDUCTION OF ANESTHESIA
Choice of Induction Technique
Inhalational Induction
Intravenous Induction
Intravenous Cannulation
Intravenous Drugs
Modified Rapid Sequence Induction and Intubation
AIRWAY EQUIPMENT AND TECHNIQUES
Suction
Face Masks
Oropharyngeal and Nasopharyngeal Airways
Supraglottic Devices
Tracheal Tubes
Drugs Used for Tracheal Intubation
Technique of Tracheal Intubation
Laryngoscopes
Breathing Systems
MONITORING AND DOCUMENTATION
MAINTENANCE OF ANESTHESIA
Inhalational Anesthetics
Intravenous Anesthetics
Analgesia
Opioids
Nonopioid Analgesics
Regional Anesthetic Techniques
Neuromuscular Blocking Drugs (NMBD)
Temperature Maintenance
EMERGENCE FROM ANESTHESIA
INTRAOPERATIVE COMPLICATIONS
Arterial Oxygen Desaturation
Laryngospasm
Bronchospasm
Airway Obstruction
Bradycardia
Emergence Agitation
ACKNOWLEDGMENT
CHAPTER 8:
Monitoring in Pediatric Anesthesia
INTRODUCTION
PHYSICAL SIGNS
PRECORDIAL/ESOPHAGEAL STETHOSCOPE
ELECTROCARDIOGRAPHY
Electrocardiography Features in Children
Danger Signals on ECG
PULSE OXIMETRY (SpO2)
Physiological Limitations
Technical Limitations
Points to Remember
Possible Complication
PLETH VARIABILITY INDEX (PVI)
SIGNAL EXTRACTION TECHNOLOGY (SET)
CUTANEOUS OXYGEN TENSION PsO2
Disadvantages of PsO2 Monitor
NONINVASIVE BLOOD PRESSURE MONITORING (NIBP)
INVASIVE OR DIRECT BLOOD PRESSURE MEASUREMENT
Indications (IBP)
CENTRAL VENOUS PRESSURE MONITORING (CVP)
Indications for CV Cannulation
NONINVASIVE RESPIRATORY GAS MONITORING
Endtidal Carbon Dioxide (ETCO2)
Uses of Capnography
Features of Mainstream Capnography
Features of Side Stream Capnography
Factors Influencing Measurement of ETCO2 in Children
Interpretation of Capnogram (Figs 3A to C)
CUTANEOUS CARBON DIOXIDE TENSION (PsCO2)
MEASUREMENT OF OTHER RESPIRATORY GASES
Advantages of Multigas Analysis
BISPECTRAL INDEX MONITOR (BIS)
NEAR INFRARED SPECTROSCOPY (NIRS)
PULSE OXIMETRY-BASED HEMOGLOBIN DETERMINATION
Indications for Use
TEMPERATURE MONITORING
NEUROMUSCULAR BLOCK (NMB) MONITORING
Nerve Muscle Unit Used for Assessment of NMB (Figs 7A to D)
Modes of Stimulation and Evaluation
Measurement of Response
URINE OUTPUT
Indications
BLOOD CHEMISTRY
OTHER MONITORING AIDS
CONCLUSION
CHAPTER 9:
Perioperative Fluid and Electrolyte Therapy
INTRODUCTION
NEONATAL PHYSIOLOGY
Developmental Changes in Body Composition and Fluid Compartments
Blood Volume
Changes in Capillary Permeability
Maturation of the Skin
Renal Function
Maturation of End-organ Responsiveness to Hormones Involved in the Regulation of Fluid and Electrolyte Balance
Heart
Central Nervous System
Glucose Metabolism
Metabolism
REQUIREMENTS OF NEONATES
Water
Glucose
Sodium
Potassium
Calcium
Bicarbonate
Precautions
Preoperative Evaluation of the Neonate should include
INTRAOPERATIVE FLUID MANAGEMENT IN NEONATES
THREE COMPONENTS OF INTRAVENOUS FLUID THERAPY
Maintenance Fluid Requirement in Children
Identification and Correction of Fluid Deficit in Children
Fluid Deficit because of Nil Per Os Orders
Replacement of Preexisting Deficit
Ongoing Losses and Third Spacing
Composition of Replacement Fluid
Intraoperative Fluid Glucose Composition
Indications for Vigorous Glucose Monitoring and Need for Higher Glucose Supplementation
INTRAOPERATIVE COLLOIDS
POSTOPERATIVE HYPONATREMIA
Incidence and Evidence
Causes
Reasons for Children being more Susceptible than Adults to the Effects of Hyponatremia76
Symptomatology and Outcome
Investigations
Solution
POSTOPERATIVE FLUID MANAGEMENT
Type of Fluid
Type of Isotonic Fluid
Postoperative Pulmonary Edema
Postoperative Fluid Rate
CORRECTION OF WATER AND ELECTROLYTE ABNORMALITIES IN PERIOPERATIVE PERIOD
Deficit Replacement Strategy
Phase I
Phase II
DISTURBANCES OF POTASSIUM METABOLISM
Hypokalemia
Hyperkalemia
DISTURBANCES OF CALCIUM METABOLISM
Hypocalcemia
Treatment of Hypocalcemia
CHAPTER 10:
Assessment and Management of the Difficult Pediatric Airway
INTRODUCTION
Pediatric Airway: Unique Anatomical and Physiological Features and their Implications
ASSESSMENT
History
Clinical Examination
ILLUSTRATIVE PICTURES OF DIFFICULT AIRWAY IN CHILDREN
PLANNING AND PREPARATION
TECHNIQUES OF DIFFICULT AIRWAY MANAGEMENT
Mask Ventilation
Endotracheal Intubation
Techniques for Endotracheal Intubation Include
CHOICE OF ANESTHESIA
Techniques of Airway Anesthesia
Supraglottic Airway Devices
EQUIPMENT FOR MANAGEMENT OF DIFFICULT AIRWAY MANAGEMENT
Specialized Masks
Alternate Laryngoscopes and Blades for Direct Laryngoscopy
Video Laryngoscopes
Intubation Aids (Fig. 12)
Optical Stylets or Lighted Stylets (Fig. 13)
Rescue Devices
TECHNIQUES OF ENDOTRACHEAL INTUBATION IN DIFFICULT AIRWAY
Techniques with Direct Laryngoscopy
Video laryngoscopy
Fiberoptic Guided Intubation Techniques
Preparation of the Equipment and Patient
Fiberoptic Guided Nasotracheal Intubation (NTI )
Fiberoptic Guided Orotracheal Intubation (OTI)
Fiberoptic Assisted Retrograde Intubation
Intubation through SAD
Confirmation of Endotracheal Intubation
Trouble Shooting During Endotracheal Intubation
Exit Strategies
Rescue Procedures
Role of Supraglottic Airway Devices
Advantages of SAD
Extubation of a Difficult Airway
Management of Post-extubation Complications
Post-extubation Complications
Difficult Airway Algorithms
Approach to Unanticipated Difficulty in Intubation25-27
Controversies in Difficult Airway Management
Recent Advances
Changing Trends in Practice
CHAPTER 11:
Pediatric Pain Assessment and Management
INTRODUCTION
PAIN ASSESSMENT4-6
NEUROPHYSIOLOGY OF PAIN7
PATHOPHYSIOLOGY OF PAIN
Physiological Response9
Hormonal Response
Metabolic response
Psychological Response
PAIN MANAGEMENT
Applied Anatomy,10 Physiology10 and Pharmacology11
PEDIATRIC PAIN MANAGEMENT STRATEGIES
Preemptive, Preventive and Multimodal Analgesia7,12
Pharmacological Approaches
Patient-Controlled Analgesia14,15,16
Regional Analgesia5,7,13,16-19
CHRONIC PAIN IN CHILDREN
FUTURE OF PEDIATRIC PAIN MANAGEMENT
SUMMARY
CHAPTER 12:
Ventilatory Strategies in the Operating Room
INTRODUCTION
RESPIRATORY PHYSIOLOGY
Resistance and Airflow
Compliance
Functional Residual Capacity and Closing Capacity
Dead Space
EQUIPMENT
Laryngeal Mask Airway
Endotracheal Tube
Advantages of Cuffed Tubes
Filter
BREATHING CIRCUITS
T Piece System (JR Circuit)(Fig. 1)
Advantages
Disadvantages
Circle System (Figs 2 and 3)
Advantages of Circle System
Disadvantages of Circle System
MODES OF VENTILATION
CONTROLLED MODES
Pressure Controlled Ventilation
Advantages
Disadvantages
Initial Settings
Volume Controlled Ventilation
Advantages
Disadvantages
Pressure Support Ventilation
COMBINED MODES OF VENTILATION
Synchronized Intermittent Mandatory Ventilation
Volume Targeted Ventilation
SPECIAL SITUATIONS
Laparoscopy
Thoracoscopy
Neonates
Magnetic Resonance Imaging
Air Trapping
ACKNOWLEDGMENT
CHAPTER 13:
Regional Anesthesia in Infants and Children
INTRODUCTION
REGIONAL ANESTHESIA—BENEFITS3
REGIONAL ANESTHESIA IN CHILDREN—AWAKE OR ANESTHETIZED?
FACTORS INFLUENCING THE CHOICE OF TECHNIQUE
CONTRAINDICATIONS TO REGIONAL ANESTHESIA
COMPLICATIONS OF REGIONAL BLOCKS
Complications of Central Blocks9
Complications of Peripheral Blocks
ADJUVANTS TO LOCAL ANESTHETICS
Epinephrine
Opioids
Clonidine
Ketamine
OTHER ADDITIVES
Midazolam
Tramadol
INDIVIDUAL BLOCKS
CAUDAL BLOCK
Anatomy
Technique
Equipment
Methods to Confirm Localization of Caudal Space
Drug Dosing—Volume of LA
Complications
LUMBAR EPIDURAL BLOCK
Indications
Anatomy
Sites of Action of LA
Equipment
Technique
Test Dose
Approach to the Epidural Space
Drug Dosing
Complications
SPINAL BLOCK
Indications61,62
Technique
Drug Dosing
Possible Complications
ABDOMINAL WALL BLOCKS
ILIOINGUINAL /ILIOHYPOGASTRIC NERVE BLOCK
Indications
Technique
Complications
RECTUS SHEATH BLOCK
Indications
Technique
Complications
TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK
Technique
Complications
OTHER NERVE BLOCKS
Penile Nerve Block
Indications
Technique
PARAVERTEBRAL BLOCK
Technique
Some Useful Formulae
Complications
INFRAORBITAL NERVE BLOCK
Indications
Technique
Intraoral Approach
Extraoral Approach
Complications
GREATER PALATINE NERVE BLOCK
Technique85
Complications
SAFETY RULES FOR PERFORMING REGIONAL ANESTHESIA
Skin Preparation
ROLE OF ULTRASOUND
Ultrasound Imaging and Central Neuraxial Blocks
Ultrasound Imaging and Peripheral Nerve Blocks
ROLE OF NEUROSTIMULATION
REFERENCES
INTRODUCTION
FACTORS INFLUENCING TOXICITY OF LOCAL ANESTHESIA
TOXIC PLASMA LEVELS OF LOCAL ANESTHETICS
CLINICAL PICTURE OF TOXICITY
Local Anesthetic Systemic Toxicity (LAST)
LEARNING POINTS TO REDUCE RISK OF TOXICITY
TREATMENT FOR LAST
Emergency Treatment of Seizures
Emergency Treatment of Cardiac Complications
CONCLUSION
REFERENCES
CHAPTER 14:
Transfusion Therapy and Bleeding Disorders
INTRODUCTION
TRANSFUSION THERAPY
BLOOD AND BLOOD COMPONENTS
Red Cells
Transfusion Trigger
Platelets
Platelet Trigger
Contraindications
Fresh Frozen Plasma
Indications
Contraindications
Dose and Response
Cryoprecipitate
Indications
Plasma Derivatives
Purified Factor VIII Products
Prothrombin Complex Concentrate (PCCs)
Topical Agents
Recombinant Products
PHARMACEUTICAL PREPARATIONS
Tranexamic Acid
DDAVP
Indications
AVAILABLE MODIFICATIONS OF BLOOD COMPONENTS
Open System vs Closed System
Fresh Blood
Plasma Reduction
Removal of Additive Solution
Leukoreduction
Random Donor Platelets vs Single Donor Platelets
Irradiation
Limited Donor Exposures
Directed Donation
Warming
TRANSFUSION PROCEDURE
Collection and Labeling of Blood Sample
Types of Blood Release
Rate of Transfusion
INVESTIGATIONS
BLEEDING DISORDERS AND TRANSFUSION THERAPY
Von Willebrand Disease
Hemophilia
Other Congenital Deficiencies
Acquired Coagulation Factor Inhibitors
Acquired Platelet Disorders
Vitamin K Deficiency
Disseminated Intravascular Coagulation (DIC)
Dilutional Coagulopathy
Liver Diseases and Warfarin Effect
Uremia
ADVERSE TRANSFUSION REACTIONS
Allergic Reactions
Hemolytic Transfusion Reactions (HTRs)
Hypocalcemia
Hyperkalemia
Alloimmunization
Post-transfusion Purpura
Transfusion Associated GvHD
Transfusion-related Acute Lung Injury (TRALI)
SECTION 3: SUBSPECIALTY ANESTHESIA
CHAPTER 15:
Anesthesia for Surgery in the Neonate
INTRODUCTION
NEONATAL PHYSIOLOGY AND THE SURGICAL NEONATE
Respiratory System
Postoperative Apnea
Cardiovascular System
Temperature Regulation
Fluid and Electrolyte Management
Glucose Homeostasis
Calcium Homeostasis
Neurologic Development
Monitoring
NEONATAL PHARMACOLOGY AND CONSIDERATIONS FOR ANESTHESIA
Intravenous Anesthetics and Analgesics
Inhaled Anesthetic Agents
Muscle Relaxants
Local Anesthetics
SPECIFIC NEONATAL SURGICAL LESIONS
Gastrointestinal Problems
Obstructive Lesions
Lesions with Compromise in Intestinal Blood Supply
Abdominal Wall Defects–Omphalocele and Gastroschisis
Initial Management Goals
Preoperative Management
Surgical Procedure
Anesthesia Technique
Postoperative Care
Complications
Intestinal Obstruction
Surgical Conditions Causing Obstruction
Anesthesia Technique
Anorectal Malformations
Surgical Procedure
Anesthesia Considerations
Postoperative Care
Necrotizing Enterocolitis
Clinical Presentation
Laboratory Investigations
Initial Management
Anesthesia Technique
Postoperative Care
Pyloric Stenosis
Clinical Presentation
Pathophysiology
Diagnosis
Management
Surgical Procedure
Anesthesia Goals
Anesthesia Technique
Tracheoesophageal Fistula and Esophageal Atresia
Anatomy of TEF34
Clinical Presentation and Diagnosis
Preoperative Management
Surgical Procedure
Anesthesia Concerns
Anesthesia Technique
Monitoring
Postoperative Care
Complications
Congenital Diaphragmatic Hernia
Association with Other Anomalies
Pathophysiology
Prenatal Diagnosis and Treatment
Postnatal Diagnosis and Management
Preoperative Stabilization and Timing of Surgery
Surgical Procedure
Anesthesia Technique
Complications
Inguinal Hernia
Surgical Procedure
Anesthesia Technique
Sacrococcygeal Teratoma
Pathophysiology
Anesthesia Technique
Complications
MYELOMENINGOCELE
Pathophysiology
Surgical Procedure
Anesthesia Technique
Complications
CHAPTER 16:
Anesthesia for Ear, Nose and Throat Procedures in Children
INTRODUCTION
ANESTHESIA FOR EAR SURGERY
Myringotomy
Anesthesia Concerns
Myringoplasty, Tympanoplasty and Mastoidectomy
Anesthesia Considerations
Cochlear Implantation
Preanesthetic Concerns
ANESTHESIA FOR RHINOLOGIC PROCEDURES
Preoperative
Intraoperative
Postoperative Concerns
REDUCTION OF NASAL BONE FRACTURE
NASAL POLYPECTOMY
Special Anesthetic Considerations
ENDOSCOPIC SINUS SURGERY
CHOANAL ATRESIA
Anesthesia Considerations
ANESTHESIA FOR THROAT PROCEDURES
Tonsil Adenoid Resection
Preanesthetic Evaluation
Intraoperative Considerations
Postoperative Pain Management
Postoperative Considerations
Postoperative Complications
Post-tonsillectomy Bleeding
Anesthetic Management
PERITONSILLAR ABSCESS
Anesthesia Concerns
SUPRAGLOTTITIS
Signs and Symptoms
Anesthetic Management
STRIDOR
Anesthetic Considerations
ENDOSCOPY OF AIRWAY
Preoperative Examination Aims to Assess
Anesthesia Concerns
Direct Laryngoscopy
RIGID BRONCHOSCOPY
SURGERY FOR LARYNGEAL STENOSIS
MICROLARYNGEAL SURGERY
Preoperative Concerns
Considerations and Precautions During Microlaryngeal Laser Surgery
ANESTHESIA FOR MICROLARYNGOSCOPY
SURGICAL TRACHEOSTOMY
Anesthetic Considerations
BRONCHOSCOPY FOR FOREIGN BODY REMOVAL
Anesthesia Plan
ESOPHAGEAL FOREIGN BODY (EFB) EXTRACTION
Anesthesia Considerations
CHAPTER 17:
Anesthesia for Plastic and Reconstructive Surgery
INTRODUCTION
CLEFT LIP AND PALATE
Preoperative Assessment
Investigations
ANESTHESIA MANAGEMENT
CRANIOFACIAL SURGERY
PREOPERATIVE ASSESSMENT
Investigations
ANESTHESIA MANAGEMENT
Intraoperative Problems
Monitoring
TEMPOROMANDIBULAR JOINT ANKYLOSIS
PRESENTATION
OTHER PLASTIC SURGICAL PROCEDURES
CONCLUSION
CHAPTER 18:
Anesthesia for Pediatric Dentistry
INTRODUCTION
CLINICAL PRESENTATION
PEDIATRIC DENTAL PROCEDURES3
THE DENTAL CHAIR
LOCAL ANESTHETICS
LOCAL ANESTHETIC ALLERGY
PROCEDURAL SEDATION
Sedation Techniques7
Nitrous Oxide Sedation
Technique
SEDATIVE DRUGS COMMONLY USED
Midazolam
Chloral Hydrate and Trichlofos
Promethazine (Phenergan)
Alpha-2 Adrenergic Agonists
Ketamine
Opioids
Propofol
REVERSAL DRUGS
GENERAL ANESTHESIA
Indications for GA
PREOPERATIVE EVALUATION AND OPTIMIZATION
Antibiotic Prophylaxis for Bacterial Endocarditis24,25
ANESTHESIA MANAGEMENT
Recovery
Postoperative Analgesia
COMPLICATIONS
Discharge Criteria
Solving Common Problems
Cerebral Palsy
CONGENITAL BLEEDING DISORDERS
ACKNOWLEDGMENT
CHAPTER 19:
Anesthesia for Ophthalmic Procedures
INTRODUCTION
PATHOPHYSIOLOGY
Intraocular Pressure
Oculocardiac Reflex
Oculorespiratory Reflex
Oculoemetic Reflex
ANESTHETIC IMPLICATIONS OF DRUGS USED IN OPHTHALMOLOGY: TOPICAL AND SYSTEMIC (TABLE 2)
ANESTHESIA GOALS
ANESTHESIA TECHNIQUE
Premedication
Induction
Induction Agents
Inhalational Agents
Airway Management
Neuromuscular Blockers
Maintenance
Analgesia
Opioids
Topical Ophthalmic Anesthesia
Regional Block
Extubation
CLINICAL PRESENTATION, SURGICAL PROCEDURE AND ANESTHESIA MANAGEMENT
Oculoplastic Disorders
Vitreoretinal Disorders
Corneal Surface Disorders
Keratoplasty
Examination Under Anesthesia
Emergency Eye Surgery
MONITORING
POSTOPERATIVE CARE
Postoperative Nausea and Vomiting
POSSIBLE COMPLICATIONS
CHAPTER 20:
Anesthesia for Major Burns and its Consequences
INTRODUCTION
UNDERSTANDING BURN INJURY
BURN INJURY—LOCAL EFFECTS
CLASSIFICATION OF BURNS
BURN SEVERITY GRADING
PATHOPHYSIOLOGY OF BURN INJURY
Burn Injury Shock
Hypermetabolic Phase
Inhalational Injury
Chemical Injury
Electrical Injury
MANAGEMENT OF BURNS
RESUSCITATION DURING BURN SHOCK PHASE
Airway
Breathing
Circulation
Fluid Therapy Between 24 and 48 Hours
Fluid Therapy After 48 Hours
Early Enteral Feeding
Antibiotics
ANALGESIA AND ANXIOLYSIS
Pharmacological Treatment
Opioids
Ketamine
Nonsteroidal Anti-inflammatory Drugs
Nitrous Oxide
Antidepressants and Anticonvulsants
Alpha-2 Agonists
Nonpharmacological Treatment
EARLY EXCISION AND GRAFTING SURGERY
ANESTHESIA CONCERNS IN EARLY EXCISION
Anesthetic Technique
Blood Loss
ANESTHESIA CONCERNS FOR DELAYED EXCISION
ANESTHESIA CONCERNS FOR CONTRACTURE RELEASE
CHAPTER 21:
Anesthesia for Pediatric Neurosurgical Procedures
INTRODUCTION
PATHOPHYSIOLOGY
Intracranial Pressure (ICP)
Cerebral Blood Flow (CBF)
Cerebral Metabolism
Effects of Anesthetic Agents
CLINICAL PRESENTATION
ANESTHESIA GOALS
ANESTHETIC MANAGEMENT
Premedication
Monitoring
Induction of Anesthesia
Airway Management
Maintenance of Anesthesia
Positioning
Intravenous Fluids and Blood Administration
Temperature Management
Emergence
Postoperative Management
POSSIBLE ISSUES AND COMPLICATIONS
ANESTHESIA CONSIDERATIONS FOR SPECIFIC SURGICAL PROCEDURES
CSF Diversion Surgeries
Intracranial Tumor Excision
Supratentorial Tumors
Infratentorial Tumors
Pediatric Head Injuries
Craniofacial Surgeries
Encephalocele Excision
Surgeries for Vascular malformations
Arteriovenous Malformations
Moyamoya Disease
Epilepsy Surgery
Anesthesia for Surgeries involving Neurophysiological Monitoring
CHAPTER 22:
Anesthesia and Pediatric Liver Diseases
INTRODUCTION
Children with Liver Disease for Anesthesia
GENERAL PRINCIPLES OF PEDIATRIC ANESTHESIA IN LIVER DISEASES
Functions of the Liver
Anesthetics and Liver Functions
Fluid Management
Liver Function Tests and Interpretation
Physiological Jaundice in the Neonate
Biliary Atresia
Anesthetic Concerns
Disorders of Bilirubin Metabolism
Alpha1antitrypsin Deficiency
Viral Hepatitis
Wilson's Disease
Non-alcoholic Steatohepatitis (NASH) and Obesity syndromes in children
Familial Hypercholesterolemia
Choledochal Cyst and Cholelithiasis
Cholelithiasis
Neoplasms
Liver Diseases Presenting for Transplant
ACKNOWLEDGMENT
CHAPTER 23:
Anesthesia for Pediatric Urologic Procedures
INTRODUCTION
RENAL PHYSIOLOGY AND ANESTHESIA1,2
RENAL FUNCTION IN THE NEWBORN4
PREOPERATIVE ASSESSMENT
POSITIONING FOR UROLOGICAL PROCEDURES7
Points to Remember while Positioning the Child in Lithotomy (Fig. 1)
Lateral Position7 (Fig. 2)
Trendelenburg Position7
ANESTHETIC MANAGEMENT FOR INDIVIDUAL PROCEDURES
Posterior Urethral Valves
Presentation/Diagnosis
Management
Cystoscopy for other Pathology:Anesthetic Management
Exstrophy Epispadias Complex (Fig. 3)
Presentation, Diagnosis
Surgery/Anesthetic Management
Pyeloplasty
Presentation/Diagnosis
Surgical Aspects/Anesthetic Management
Vesicoureteric Reflux
Diagnosis/Surgical Treatment
Anesthetic Management
Hypospadias (Figs 4 and 5)
Surgical Aspects
Anesthetic Management
Cryptorchidism
Surgical Aspects
Anesthetic Management
Torsion Testis
Signs and Symptoms
Anesthetic Management
Intersex Disorders
Cloaca
Wilms’ Tumor14
Laparoscopy and Robotic Surgery
Urolithiasis16
RENAL TRANSPLANTATION IN CHILDREN
Epidemiology17
Pathophysiology of Renal Failure
Indications for Renal Transplantaion19
Contraindications for Renal Transplantation
Surgical Technique
Anesthesia Concerns
Anesthetic Technique
Postoperative Complications
CONCLUSION
ACKNOWLEDGMENTS
CHAPTER 24:
Anesthesia for Pediatric Laparoscopic Surgeries
INTRODUCTION
INDICATIONS FOR LAPAROSCOPIC PROCEDURES
Diagnostic
Therapeutic
CONTRAINDICATIONS
ANESTHETIC CHALLENGES
Physiological Effects of CO2 Pneumoperitoneum and Raised Intra-abdominal Pressure (IAP)
Effects on Cardiovascular System
Effects on Respiratory System
Effects on Renal System
Neurological Effects
Effects on Gastrointestinal System
PATIENT POSITIONING
HYPOTHERMIA
ANESTHETIC MANAGEMENT
Premedication and Induction
Maintenance
Management of the Airway
Mechanical Ventilation during Laparoscopy
Intraoperative Monitoring
Analgesia
Postoperative Care
Postoperative Nausea and Vomiting
COMPLICATIONS OF LAPAROSCOPY
Hypoxia and Hypercapnea
Pneumothorax and Pneumomediastinum
CO2 Embolism
Surgery-related Complications
ADVANCES IN LAPAROSCOPY
CONCLUSION
CHAPTER 25:
Anesthesia for Pediatric Thoracic Surgery
INTRODUCTION
PHYSIOLOGY OF SINGLE LUNG VENTILATION (SLV) IN CHILDREN
Ventilation-Perfusion in Lateral Decubitus (Figs 1A and B)
PREOPERATIVE EVALUATION
PREOPERATIVE PREPARATION
ESSENTIAL MONITORING DURING SLV
PERIOPERATIVE MANAGEMENT
VIDEO-ASSISTED THORACOSCOPIC SURGERY (VATS)
MEASURES TO MANAGE DESATURATION DURING SLV
METHODS OF SINGLE-LUNG VENTILATION IN PEDIATRIC PATIENTS (Fig. 2)
POSTOPERATIVE MANAGEMENT
POSTOPERATIVE COMPLICATIONS
POSTOPERATIVE PAIN CONTROL
SALIENT FEATURES IN MANAGING PEDIATRIC THORACIC LESIONS
Pulmonary Sequestrations
Congenital Cystic Lesions
Congenital Lobar Emphysema
Congenital Diaphragmatic Hernia
Tracheoesophageal Fistula
Mediastinal Mass
Pectus Excavatum
Empyema
CONCLUSION
CHAPTER 26:
Anesthesia at Remote Locations
INTRODUCTION
GOALS1
PROBLEMS
PRE-PROCEDURE PLANNING
Guidelines for Anesthetic Care Delivered Outside the Operating Room: American Society of Anesthesiologists (Asa) 1994 Guidelines for Non–operating Room Anesthetizing Locations1
Patient Evaluation
Preprocedural Fasting Guidelines
MEDICATIONS
Inhalational Agents
DOCUMENTATION
ANESTHESIA TECHNIQUE
MONITORING
RECOVERY AND DISCHARGE PLANNING5,6
INDIVIDUAL SCENARIOS
MRI Anesthesia
Magnetic Field
Patient
Auditory Damage
Duration
Postprocedure Recovery
Anesthesia Considerations
Equipment for MRI
CT Scan
Anesthetic Considerations
Interventional Radiology
Indications
Anesthetic Considerations
Goals of Anesthesia
Special Requirements
Cardiac Catheterization3
Indications
Anesthesia Considerations
Ultrasound Procedures
Anesthesia Considerations
Nuclear Medicine (PET/SPECT)
Indications
Anesthesia Considerations
Scopy
Indications
Anesthesia Considerations
Radiation Oncology
Anesthesia Considerations
Gamma Knife (Fig. 4)
Indications
Dental Procedures
Burn Dressings
CHAPTER 27:
Ambulatory Anesthesia in Children
INTRODUCTION
ADVANTAGES
LIMITATIONS
GUIDELINES
Selection of the Procedure
Selection of Patient
Special Risk Factors
Exclusion Criteria for Outpatient Surgery
Preoperative Preparation
Premedication
General Anesthesia
Airway Management
Regional Anesthesia
Monitored Anesthesia Care
Discharge Criteria
Post-discharge Instructions
Complications and Hospitalization
Evaluation of Patient and Family Satisfaction
GUIDELINES FOR A GOOD AMBULATORY SURGICAL FACILITY
CHAPTER 28:
Anesthesia for Pediatric Orthopedic Surgery
INTRODUCTION
ANESTHESIA ISSUES
PREOPERATIVE EVALUATION AND PREMEDICATION
TOURNIQUETS
CONGENITAL DEFORMITIES—LOWER LIMB
Clubfoot [Congenital Talipes Equino Varus (CTEV)]
Overview
Pathophysiology
Clinical Presentation
Nonsurgical Procedures
Anesthesia Concerns
Anesthesia for Surgical Treatment
Congenital Dislocation of Hip
Overview
Pathophysiology
Clinical Presentation
Anesthesia Concerns
Surgical Procedures and Anesthesia
CONGENITAL DEFORMITIES—UPPER LIMB
Radial Club Hand
Overview
Clinical Features
Treatment
Anesthesia
NEUROLOGICAL CONDITIONS
Cerebral Palsy
Overview
Pathophysiology
Clinical Features
Swedish Classification for CP
Anesthetic Issues
Anesthetic Management
MUSCULAR DYSTROPHIES
GROWTH DISORDER
Achondroplasia
Overview
Clinical Presentation (Figs 5A and B)
Surgical Procedures
Anesthesia Issues
INFECTIONS
Osteomyelitis
Overview
Clinical Features
Surgical Treatment
Anesthesia
METABOLIC DISORDERS
Mucopolysaccharidosis
Pathophysiology
Clinical Presentation and Anesthetic Challenges (Figs 6A and B)
Surgical Procedures
Renal Osteodystrophy
Pathophysiology
Clinical Presentation
Anesthesia Concerns
Rickets
Overview
Pathophysiology
Clinical Presentation
Anesthetic Concerns
OTHER CONDITIONS
Arthrogryposis Multiplex Congenita (AMC)
Overview
Pathophysiology
Clinical Presentation (Fig. 8)
Nonsurgical Care
Surgical Procedures
Anesthesia Issues
Osteogenesis Imperfecta (OI)
Overview
Pathophysiology
Clinical Presentation (Figs 9A and B)
Treatment
Surgical Procedures
Anesthetic Considerations30-32
SCOLIOSIS
Classification38,39
Pathophysiology
Respiratory System
Cardiovascular
Measurement of Curve Magnitude
Clinical Manifestations
Preoperative Assessment and Preparation
Respiratory Function
Cardiovascular System
Neurological System
Anesthetic Management
Neurologic Injury During Surgery
Methods of Spinal Cord Monitoring
Wake-up Test
Clonus Test
Somatosensory Evoked Potential (SSEP) Monitoring
Motor Evoked Potential (MEP) Monitoring
Other Complications
Postoperative Pain Management
BONE CYSTS AND TUMORS
TRAUMA
COMMONLY USED REGIONAL BLOCKS FOR ORTHOPEDIC PROCEDURES
Central Neuraxial Blocks
Caudal Epidural Block
Lumbar Epidural Block
Spinal Block
LOWER EXTREMITY BLOCKS
Femoral Nerve Block
Indications
Technique (Fig. 16)
Dosage
Complications
Fascia Iliaca Block (Alternative to Femoral Nerve Block)
Indication
Technique
Dosage
Complications
Sciatic Nerve Block
Indications
Contraindication
Technique
Drug Dosage
Popliteal Nerve Block
Indications
Contraindication
Technique
Ankle Block
Indications
Technique
UPPER EXTREMITY BLOCKS: BRACHIAL PLEXUS BLOCK (Fig. 20)
Supraclavicular Approach
Indications
Technique
Axillary Approach
Indications
Technique
Infraclavicular Approach
Indications
Technique
Dosage
Interscalene Block
Indications
Technique
Wrist Block
Intravenous Regional Anesthesia (IVRA) Bier's Block
Indication
Technique
ACKNOWLEDGMENT
CHAPTER 29:
Anesthesia for Pediatric Trauma
INTRODUCTION
ROLE OF ANESTHESIOLOGIST IN TRAUMA CARE
TYPES AND PATTERNS OF PEDIATRIC TRAUMA
INITIAL ASSESSMENT: PEDIATRIC ADVANCED TRAUMA LIFE SUPPORT PRINCIPLES
PRIMARY SURVEY AND RESUSCITATION
SECONDARY SURVEY
MONITORING
ANESTHETIC CONSIDERATIONS FOR SPECIFIC TRAUMA
Anesthesia for Head Injury
ANESTHESIA FOR CHEST/AIRWAY INJURY
ANESTHESIA FOR ABDOMINAL INJURY
ANESTHESIA FOR UROLOGICAL/PELVIC INJURY
ANESTHESIA FOR ORTHOPEDIC INJURY; DAMAGE CONTROL RESUSCITATION
ANESTHESIA FOR REIMPLANTATION
ANESTHESIA FOR SPINAL INJURIES
ANESTHESIA FOR OPHTHALMIC INJURIES
ANESTHESIA FOR FACIOMAXILLARY INJURIES
FLUID MANAGEMENT
PAIN MANAGEMENT
CHILD ABUSE
TRANSFER AND TRANSPORT OF PEDIATRIC TRAUMA PATIENT
PEDIATRIC INTENSIVE CARE AFTER TRAUMA SURGERY
BRAIN DEATH AND ORGAN DONATION
CHAPTER 30:
Anesthesia for Pediatric Cardiac Surgery
INTRODUCTION
UNDERSTANDING THE CARDIO-PULMONARY PHYSIOLOGY IN CHILDREN
Restoration of Fetal to Normal Systemic Circulation
Alterations in Pulmonary Circulation
Myocardial Reserve
Ventricular Mass
Poor Calcium Reserves
PATHOPHYSIOLOGY
CLASSIFICATION
PREOPERATIVE EVALUATION
PREOPERATIVE PREPARATION
Premedication
Fasting Guidelines
Infective Endocarditis Prophylaxis
MONITORING
CHOICE OF ANESTHETIC DRUGS AND GENERAL PRECAUTIONS
INDUCTION AGENTS
Opioids
Propofol
Thiopental
Etomidate
Ketamine
Dexmedetomidine
Inhalational Agents
Nitrous Oxide
Benzodiazepines and Muscle Relaxants
CENTRAL LINES AND ARTERIAL LINES
ANESTHETIC CONSIDERATIONS DURING CARDIOPULMONARY BYPASS
DIFFICULTY IN WEANING CPB
ANESTHETIC CONSIDERATIONS FOR COMMON LESIONS
Factors that Increase PVR
Factors/ Drugs that Decrease PVR
Factors/ Drugs that Increase SVR
Drugs that Decrease SVR?
Managing Cyanotic/ Hypercyanotic/Tet Spell
Clinical Profile
Postulated Mechanisms
Acute Treatment
POSTOPERATIVE CARE IN PEDIATRIC CARDIAC PATIENT
Bleeding
Arrhythmias
Junctional Ectopic Tachycardia
Supraventricular Tachycardia
Complete Heart Block
Low Cardiac Output Syndrome
Pulmonary Hypertension Crisis
ANESTHESIA FOR CLOSED HEART PROCEDURES
ANESTHESIA FOR CARDIAC CATHETERIZATION
Diagnostic Procedures
Therapeutic Procedures
Electrophysiological (EP) Studies and Ablation Techniques
ANESTHESIA FOR CARDIAC RADIOLOGY PROCEDURES
FAST-TRACKING AND REGIONAL ANESTHESIA
CHAPTER 31:
Anesthetic Management of Children with Congenital Heart Disease for Noncardiac Surgery
INTRODUCTION
THE NEONATE
CLASSIFICATION
1. Based on Presence/Absence of Cyanosis: Acyanotic or Cyanotic
Acyanotic Heart Disease
Cyanotic Heart Disease
2. Classification on the Basis of Pulmonary and Systemic Flow
Excessive Pulmonary Blood Flow
Inadequate Pulmonary Blood Flow
Inadequate or Obstruction to Systemic Blood Flow
Abnormal mixing
PREOPERATIVE CONSIDERATIONS
RISK STRATIFICATION
Physiological Status
Cardiac Failure
Pulmonary Hypertension
Arrhythmias
Cyanosis
Complexity of Heart Disease
Parallel or ‘Balanced’ Circulation
Single-ventricle Circulation
Cardiomyopathy
Aortic Stenosis
Type of Surgery and Age
Monitoring
Anesthetic Technique
CONCLUSION
SECTION 4: SPECIAL PROBLEMS AND SITUATIONS
CHAPTER 32:
Common Pediatric Medical Conditions: Anesthetic Considerations
INTRODUCTION
PATHOGENESIS3
PREOPERATIVE OPTIMIZATION
INTRAOPERATIVE MANAGEMENT
Reducing Secretions4
Prevention of Airway Stimulation3,4
INTRODUCTION
PREOPERATIVE EVALUATION
PERIOPERATIVE MANAGEMENT1,3,5
MANAGEMENT OF INTRAOPERATIVE WHEEZING/BRONCHOSPASM
EXTUBATION3
POSTOPERATIVE MANAGEMENT5
MANAGEMENT IN SPECIAL CIRCUMSTANCES5
Emergency Surgery
Asthmatics with Increased Intracranial Pressure
INTRODUCTION
ETIOLOGY7,9
CLINICAL FEATURES8,10
PRESURGICAL AND INTRAOPERATIVE OPTIMIZATION11
INDICATIONS OF BLOOD TRANSFUSIONS11
INTRODUCTION
EVALUATION OF EOSINOPHILIA
PREOPERATIVE OPTIMIZATION
INTRAOPERATIVE MANAGEMENT
POSTOPERATIVE MANAGEMENT17
INTRODUCTION
MANAGEMENT OPTIONS FOR DIABETES MELLITUS IN CHILDREN18
RISKS ASSOCIATED WITH DIABETES MELLITUS20
PREOPERATIVE ASSESSMENT20-22
PREOPERATIVE MANAGEMENT OF A CHILD POSTED FOR A MAJOR SURGERY22
PREOPERATIVE MANAGEMENT OF A CHILD POSTED FOR MINOR SURGERY (TABLE 5)23
EMERGENCY PROCEDURE22
TYPE 2 DIABETES22
POSTOPERATIVE MANAGEMENT20
INTRODUCTION
ANESTHETIC IMPLICATIONS OF HYPOTHYROIDISM3,24
PREOPERATIVE EVALUATION3,24
INTRAOPERATIVE ANESTHETIC MANAGEMENT3,24
POSTOPERATIVE CARE3
INTRODUCTION
PHYSIOLOGICAL AND PHARMACOKINETIC CONSIDERATIONS26
PREANESTHETIC EVALUATION
Management of Status Epilepticus28,29
Epilepsy Surgery26,27
Non-epilepsy Surgery27,30
Postoperative Management26,27
INTRODUCTION
ANESTHETIC CONSIDERATIONS32,33
PREOPERATIVE MANAGEMENT32
INTRAOPERATIVE MANAGEMENT34
POST-OPERATIVE MANAGEMENT31
INTRODUCTION
ETIOLOGY36
PREANESTHETIC EVALUATION35
ANESTHETIC CONCERNS35
Systemic Abnormalities
Malignant Hyperthermia
Difficult Airway
Difficult Intravenous Access
Patient Anxiety/Poor Cooperation
CHAPTER 33:
Anesthesia Management in Special Conditions
INTRODUCTION
PATHOPHYSIOLOGY
Pathogenic Risk Factors for CP4-9
Congenital CP (80%)
Acquired CP (20%)—Develops during the First 2 Years of Life
CLASSIFICATION
CLINICAL PRESENTATION
Neurological Disorders
Respiratory System
Gastrointestinal System
Musculoskeletal and Skin
Urological Disorders
SURGICAL PROCEDURE
ANESTHESIA TECHNIQUE
Preoperative Management
Intraoperative Management
Postoperative Management
SPECIFIC PROBLEMS (PREOPERATIVE)
INTRODUCTION
PATHOPHYSIOLOGY3
MUSCULAR DYSTROPHY
Duchenne Muscular Dystrophy (DMD)
Preoperative Assessments
Anesthetic Considerations
Becker's Muscular Dystrophy (BMD)
Anesthetic Considerations
MYOTONIAS
Myotonic Dystrophy (Steinert`s Disease)
Preoperative Assessment
Anesthetic Considerations2
CONGENITAL MYOPATHIES
Central Core Disease
MITOCHONDRIAL AND METABOLIC MYOPATHIES
Anesthetic Considerations
Choice of Anesthetic Technique in Mitochondrial Disorders
CHANNELOPATHIES
Familial Periodic Paralysis
Hyperkalemic
Hypokalemic
Ligand-Gated Calcium Channelopathy
Malignant Hyperthermia
Complications
Rhabdomyolysis
Autonomic Dysfunction
Myotonias
Cardiorespiratory Complications
INTRODUCTION
DESCRIPTION: CHILDHOOD OBESITY
PREVALENCE
PATHOPHYSIOLOGY, CLINICAL PRESENTATION, ANESTHETIC ISSUES AND PHARMACOKINETICS OF ANESTHETIC AGENTS
ANESTHESIA TECHNIQUE
Postoperative Care
POSSIBLE RISKS AND COMPLICATIONS (PERIOPERATIVE)
INTRODUCTION
ETIOLOGY OF SLEEP DISORDERED BREATHING IN CHILDREN
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
DIAGNOSIS
OSA SEVERITY SCORING14
SURGICAL PROCEDURE
ANESTHETIC CONSIDERATIONS
Preoperative Assessment
Intraoperative Management
POSTOPERATIVE COMPLICATIONS
POSTOPERATIVE PAIN RELIEF
INTRODUCTION
PATHOPHYSIOLOGY
Biosynthesis and Metabolism of Catecholamines7
CLINICAL PRESENTATION
PREOPERATIVE WORKUP
Preoperative Medical Management
SURGICAL RESECTION OF THE TUMOR
Surgical Procedures20-23
ANESTHESIA GOALS
ANESTHESIA TECHNIQUE
POSSIBLE COMPLICATIONS
INTRODUCTION
PATHOPHYSIOLOGY
CLASSIFICATION
The International Society for the Study of Vascular Anomalies Classification2
Vascular Tumors
Vascular Malformations
CLINICAL PRESENTATION
Venous Malformation
Arteriovenous Malformation
Lymphatic Malformation
Capillary Malformation
Complex Combined Vascular Malformations
TREATMENT
Sclerotherapy/Embolization Procedures
Anesthesia Goals
Anesthesia Technique
ANESTHETIC CONCERNS AND COMPLICATIONS
CHAPTER 34:
Cardiopulmonary Resuscitation in Neonates and Children
INTRODUCTION
PRIMARY CAUSES OF PEDIATRIC CARDIAC ARREST (TABLE 1)
STRATEGIES AND GUIDELINES TO IMPROVE SURVIVAL
Chain of Survival
Prevention
Early Detection and Treatment of Life Threatening Illness in Child
Early Cardiopulmonary Resuscitation (CPR)
Early Access to EMS
GUIDELINES REGARDING USE OF AED IN CHILDREN
Early Advanced Life Support
Postresuscitation Care9
SPECIAL SITUATIONS
Arrest Under Anesthesia
Causes
Prevention
Treatment
Neonatal Resuscitation7,10
Drowning22
Foreign Body Airway Obstruction (FBAO)(Flowchart 3)22
Anaphylaxis22
Poisoning11,22
Trauma in Children8,23
Electrical injuries22
Manifestations
Treatment
Periarrest Arrhythmias
Tachyarrhythmias
Bradyarrhythmias
RECENT AHA UPDATE 2015
CONCLUSION
CHAPTER 35:
Acute Complications During Anesthesia
INTRODUCTION
CAUSES OF ACUTE PROBLEMS DURING ANESTHESIA IN CHILDREN
Cardiovascular
Respiratory
Medication Related
Equipment and Monitoring
Miscellaneous
ACUTE CARDIOVASCULAR PROBLEMS10,11
Bradycardia12,13
Causes
Management
Tachycardia
Management
Acute Hypotension
Causes
Management
Acute Hypertension14-16
Causes
Management
Massive Hemorrhage and Transfusion17
Management
Hyperkalemia11
Causes?
Diagnosis
Management
Air Embolism11
Diagnosis
Management
Sudden Intraoperative Decrease in Electrocardiogram Amplitude
Management
ACUTE RESPIRATORY PROBLEMS
Hypoxemia (Desaturation and/or loss of ETCO2 trace)19
Initial Response
Determine Cause
Management
Hypercarbia
Elevated Airway Pressures
Laryngospasm20,21
Diagnosis
Management
Severe Bronchospasm22-24
Causes
Clinical Suspicion and Diagnosis
Causes of Wheezing Under Anesthesia
Causes of Increased Peak Airway Pressure During IPPV
Management
Aspiration25,26
Causes
Management
Airway Leak Around the ETT following Change in Position, e.g. Prone Position
Management
Difficulty in Extubation
Cause
Management
Airway Fires
Cause
Management
LOCAL ANESTHETIC TOXICITY11
Clinical Diagnosis
Management
GENERALIZED SEIZURES
Differential Diagnosis
Management
ANAPHYLAXIS27,28
Clinical Diagnosis
Common Causative Agents
Management
MALIGNANT HYPERTHERMIA11
Clinical Diagnosis
Management
TRANSFUSION REACTIONS11
Management
Management of Hemolytic Reaction
Anaphylactic Reaction
MEDICATION RELATED PROBLEMS29
SECTION 5: ANESTHETIC TECHNIQUES
CHAPTER 36:
Vascular Access in Infants and Children
INTRODUCTION
PERIPHERAL VEIN CANNULATION
ULTRASOUND-GUIDED VASCULAR ACCESS
PERIPHERALLY INSERTED CENTRAL CATHETER INSERTION
EXTERNAL JUGULAR VEIN CANNULATION
CENTRAL VENOUS CATHETERIzATION
Internal Jugular Vein Cannulation
Anterior Approach
Central Approach (Called as Anterior Approach by Many in the Literature)
Posterior Approach
Subclavian Vein Cannulation
Femoral Vein Cannulation
TUNNELED CENTRAL VENOUS CATHETERIZATION
PORT IMPLANTATION
INTRAOSSEOUS NEEDLE PLACEMENT
ARTERIAL CANNULATION
UMBILICAL VEIN CATHETERIZATION
UMBILICAL ARTERY CATHETERIZATION
RECENT DEVELOPMENTS
CHAPTER 37:
Ultrasound-guided Regional Blocks
INTRODUCTION
ADVANTAGES OF ULTRASOUND IMAGING IN REGIONAL BLOCKS
STEPS IN PERFORMING ULTRASOUND- GUIDED NERVE BLOCKS
The author follows the following protocol.
UPPER LIMB BLOCKS
Brachial Plexus Block
Interscalene Approach
Supraclavicular Approach
Infraclavicular Approach
Axillary Approach
LOWER LIMB BLOCKS
Lumbar Plexus Block
Technique
The Lumbar Paravertebral Ultrasound
Technique
End-point
Outcome
Femoral Nerve Block
Indications
Technique
Neurostimulation
Volume of local anesthetic
Sciatic Nerve Block
Indications
Technique
Popliteal Sciatic Nerve Block
Thoracic Paravertebral Block
Indications
Contraindications
Technique
Approaches
Out-of-plane Technique
Volume
Complications
In-plane Thoracic Paravertebral Block
Transversus Abdominis Plane (TAP) Block
Indications
Anatomy
Technique
Complications
SONOANATOMY OF THE SPINE
SINGLE-SHOT CAUDAL BLOCK
Indications
ULTRASOUND-GUIDED CATHETERS
EQUIPMENT
ACKNOWLEDGMENTS
SECTION 6: NOTES ON ALLIED TOPICS
CHAPTER 38:
Safety and Quality in Pediatric Anesthesia
INTRODUCTION
HIGH QUALITY ANESTHESIA CARE HAS SIX ATTRIBUTES
ASSESSMENT OF QUALITY OF ANESTHESIA CARE
IMPLEMENTATION OF QUALITY IMPROVEMENT
COMMON CAUSES OF UNDESIRABLE EVENTS DURING ANESTHESIA
ANESTHETIC TRAINING SHOULD INCORPORATE
SPECIALTY PROFESSIONAL TRAINING HAS EVOLVED INTO MULTIDISCIPLINARY EDUCATION (MDE) INVOLVING MANY STEPS
CONCLUSION
CHAPTER 39:
Ethical Issues in Pediatric Anesthesia
INTRODUCTION
INFORMED CONSENT
ASSENT
MATURE MINOR
The Emancipated Minor
SPECIAL SITUATIONS
Children of Jehovah's Witnesses
Battered Baby Syndrome
Do-not-Resuscitate Orders/Do not Intubate/Life Sustaining Medical Therapy
RESEARCH IN PEDIATRIC PATIENTS
OBLIGATIONS OF PEDIATRIC ANESTHESIOLOGISTS
CONCLUSION
CHAPTER 40:
Simulation in Pediatric Anesthesia
INTRODUCTION
WHAT IS SIMULATION?
TYPES OF SIMULATION (BOX 2)
Simulated Environments
Integrated Simulators
CONCEPTUAL ISSUES ABOUT PATIENT SIMULATION
SETTING OF THE SIMULATION EXERCISE
Setting Introduction
Simulator Briefing or Familiarization
Theory Input
Case Briefing
Simulation Scenario
Debriefing
Ending
RESOURCE MANAGEMENT IS A CRUCIAL SKILL FOR ANESTHESIA PROFESSIONALS
SIMULATION IN PEDIATRIC ANESTHESIA
PEDIATRIC SIMULATORS
APPLICATIONS OF SIMULATION IN PEDIATRIC ANESTHESIA
Clinical Skills
Team Training
Soft Skills/ Non Technical Skills
Competency Testing
Retraining and Certification
IN SITU PEDIATRIC SIMULATION
APPENDICES:
APPENDIX 1:
Index of Syndromes and Anesthetic Implications
APPENDIX 2:
Pediatric Drug Index
ANTIBIOTICS
ANTICONVULSANTS
ANTIEMETICS
ANTIPRURITICS
BRONCHODILATORS
ANTIHYPERTENSIVES
CARDIAC DRUGS
RESUSCITATION DRUGS
ANALGESICS
OPIOIDS
SEDATIVES/ANESTHETICS
MUSCLE RELAXANTS
REVERSAL AGENTS
MISCELLANEOUS
STEROIDS
APPENDIX 3:
Quick Reference Tables and Formulae
NORMAL RESPIRATORY VALUES
RELATION OF AGE, WEIGHT AND BODY SURFACE AREA
BLOOD PRESSURE DURING 1ST YEAR OF LIFE
TOTAL BODY WATER AND ITS DISTRIBUTION IN PERCENTAGE OF WEIGHT- ACCORDING TO AGE
ENDOTRACHEAL EPINEPHRINE DOSES DURING CARDIAC ARREST
AGE RELATED K+ (POTASSIUM) LEVELS IN PLASMA
AGE AND WEIGHT-BASED SIZING CHART
TEMPERATURE REGULATION IN NEWBORNS AND INFANTS
FLUID REQUIREMENTS IN PREMATURE BABIES
PAIN ASSESSMENT SCALES
CONGENITAL MALFORMATIONS DUE TO DEVELOPMENTAL PATHOLOGY AND RELATIVE TIMING
PHOTO GALLERY
INDEX
TOC
Index
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