PEDIATRIC ANESTHESIOLOGY Foreword Lee A. Fleisher xiii Preface Andrew T. Costarino, Jr and B. Randall Brenn xv Pediatric Anesthesia Historical Perspective 573 Andrew T. Costarino, Jr and John J. Downes This article examines how anesthesia evolved to serve the needs of children. Discussion includes milestones in technologic advancement related to pediatric anesthetic care and how collaboration among pediatric surgeons, neonatologists, and pediatric anesthesiologists has helped our specialty to progress. Conversely, the significant contributions of pediatric anesthesiology to pediatric critical care medicine, pain management, and pediatric public health care are also presented. Preoperative Psychological Preparation of the Child for Surgery: An Update 597 Zeev N. Kain and Alison A. Caldwell-Andrews Preoperative anxiety is associated with a number of poor postoperative outcomes and with significant parental and child distress before surgery. Preparing children for surgery can prevent many behavioral and physiologic manifestations of anxiety. Psychologic and behavioral interventions and pharmacologic interventions are available to treat preoperative anxiety in children. This article discusses the psychologic preparation of children for surgery. VOLUME 23 NUMBER 4 DECEMBER 2005 vii
The Genetics of Malignant Hyperthermia 615 Barbara W. Brandom The genetic evaluation of the ryanodine type one receptor (RYR1) gene is unlikely to be a useful screening test of malignant hyperthermia susceptibility. But when significant suspicion of malignant hyperthermia has been raised by well-documented clinical events or strong family history, the genetic evaluation of RYR1 could secure a diagnosis and indicate appropriate treatment for both the index patient and many relatives of all ages, including the youngest. Opioids in Pediatric Anesthesia 621 Denis H. Jablonka and Peter J. Davis Opioids are used widely in the practice of pediatric anesthesia and pediatric perioperative medicine. The benefits of opioids are well documented, and their pharmacology has been extensively studied. Nonetheless special care is important when using these agents in the pediatric population. This article addresses the developmental pharmacologic changes that occur with opioids as well as their most common clinical uses. Procedural Sedation in the Pediatric Patient 635 Venkat Shankar and Jayant K. Deshpande The demand for safe and effective procedural sedation for children is rapidly increasing because of the increased awareness about procedure-related anxiety even in young infants and children. The development of short-acting sedatives, improved monitoring, and new regulatory requirements have led to the evolution of new paradigms of safe, effective, and resource-efficient systems for providing procedural sedation outside the operating rooms by anesthesiologists and nonanesthesiologists. New Developments in Pediatric Cardiac Anesthesia 655 Laura K. Diaz and Dean B. Andropoulos As the practice of pediatric cardiac anesthesia continues to grow, anesthesiologists now routinely care for patients ranging in size from less than 2 kg to more than 100 kg. New clinical and laboratory research has enhanced our understanding of the effects of anesthetic drugs on the pediatric myocardium, and improvements in survival statistics for even the smallest and sickest infants have shifted the emphasis to evaluation of quality of life and neurological outcome in pediatric cardiac patients. The use of circulatory support in infants and children, both for rapid resuscitation and for more chronic indications such as bridge to transplantation, also continues to evolve, with the recent introduction of pulsatile and axial pumps for pediatric use. This article reviews anesthetic agents, bleeding and coagulation, neurological monitoring, and mechanical circulatory support in the treatment of infants and children. viii
Anesthesia Ventilators: Better Options for Children 677 Stephen Stayer and Olutoyin Olutoye Mechanical ventilation of pediatric patients in the operating room is challenging. Infants require significantly smaller tidal volumes than adults and changes in delivered volume that would be clinically insignificant for an adult patient, can produce unintended hyper- or hypoventilation in children. The consequences of these unintended ventilation changes can produce hypoxemia, hypercarbia, or barotrauma. This article discusses unique aspects of pediatric ventilation in the operating room, limitations of traditional anesthesia machine technology, the features of modern anesthesia ventilators that circumvent these limitations, and presents several comparison studies. Single-Lung Ventilation in Pediatric Anesthesia 693 Dinesh K. Choudhry Single-lung ventilation is requested for an increasing spectrum of surgical procedures in infants and children. A clear understanding of the physiology of single-lung ventilation, the techniques of lung separation, and the technical skill necessary to apply these techniques are essential for an anesthesiologist practicing thoracic anesthesia. This article focuses on various devices available for single-lung ventilation in the pediatric age group, the relevant respiratory physiology, and the strategies that optimize oxygenation during one-lung anesthesia. Anesthesia Considerations for Pediatric Thoracic Solid Organ Transplant 709 Glyn D. Williams and Chandra Ramamoorthy This article discusses the indications, perioperative management, postoperative complications, and patient outcome of pediatric heart transplantation and pediatric lung transplantation. Special emphasis is placed on the anesthetic considerations relevant for children who are undergoing or have received a solid thoracic organ transplant. Surgery and Anesthesia for Children Who Have Cerebral Palsy 733 Mary C. Theroux and Robert E. Akins Cerebral palsy is a spectrum of signs and symptoms resulting from an injury to the brain during its developmental stage. Children with cerebral palsy have disorders that impact their anesthetic management. In particular, abnormalities of the respiratory system, gastrointestinal system, and neuromuscular system must be considered. There is emerging evidence for abnormalities in their neuromuscular junction that potentially increase their anesthetic risk. In addition, there are recent data explaining possible reasons for increased bleeding in these children. ix
Anesthesia for Pediatric Obesity 745 B. Randall Brenn This article discusses the unique anesthetic implications of obesity, with an emphasis on children and adolescents. It also touches on the issues surrounding bariatric surgery in the morbidly obese adolescent population. Adolescent bariatric surgery is moving to the forefront as a treatment modality because weight-loss programs alone are not keeping pace with the growth of the problem. Bariatric surgery offers the potential to achieve the weight reductions necessary to reverse the debilitating and costly comorbidities of obesity. Anesthetic Management for Pediatric Spinal Fusion: Implications of Advances in Spinal Cord Monitoring 765 Sabina DiCindio and Daniel M. Schwartz Currently, the detection of emerging injury through intraoperative neurologic monitoring is the best way to prevent neurologic injury. This requires a team approach that includes the anesthesiologist, neurophysiologist, and surgeon. The monitoring modalities available for the patient must be considered in planning the anesthetic management. In addition, intraoperative care for the patient requires an ongoing attention to how the anesthetic drugs affect spinal cord monitoring. Pediatric Acute Pain Management 789 Robert P. Brislin and John B. Rose Children are benefiting from the advances made in developmental neurobiology and analgesic pharmacology over the past few decades. Heightened public awareness and increased political pressure from external regulatory agencies are helping to maintain the momentum in improving pediatric pain management. As a result, methods of assessing and managing children s pain are being refined, and new modalities of pain relief are being explored. This article summarizes selected current topics in pediatric acute pain management, with the major emphasis on acute postoperative pain management. Regional Anesthesia in Children 815 Maurice S. Zwass The future of regional anesthesia in children is to continue to use current techniques, but also to search for ways to make them easier to employ. The potential development of safe local anesthetic agents with much longer durations, will serve to facilitate improvements in the techniques and styles of practice. The advances in minimally invasive surgical techniques do not mean that regional techniques will not be necessary, but will result in an adaptation of techniques. Peripheral nerve blockade and local wound infiltration can still be used and in some instances, may be very appropriate. x
Palliative Care in Pediatrics 837 Bruce P. Himelstein Palliative care for children is not about dying; rather, it is about helping children and families to live to their fullest and to restore wholeness while facing complex medical conditions. Family centered pediatric palliative care is the art and science of improving quality of life and attending to suffering for children with lifethreatening conditions; the basic principles are presented and discussed in this article. Pediatric Anesthesiology: Thoughts on the Future 857 Andrew T. Costarino, Jr and Jayant K. Deshpande Pediatric anesthesiology has made a significant contribution to child health and will be necessary for progress in the health sciences and outcomes related to child health in the future. It is likely that the practice of pediatric anesthesiology will remain an interesting and rewarding but demanding profession for the next generations of physicians. Despite this favorable professional profile, stiff competition for resources will come from other segments of the health care community. This article outlines a multidimensional strategy for pediatric anesthesiology to sustain its progress as a profession and contribute to the health of our children. Cumulative Index 2005 863 xi