Seminars in anesthesia最新文献

Rendering anesthetic care to the expremature patient, particularly those born severely premature (<30 weeks’ gestation), poses unique challenges. These patients often suffer life-long sequelae of their prematurity, the severity of which depends on the type and extent of their morbidities of prematurity. Chronic lung disease (CLD), persistent apnea, and neurodevelopmental disabilities complicate the care of these patients. The expremature patient most commonly requires anesthesia for inguinal hernia repair, magnetic resonance imaging, stoma closure after surgery for necrotizing enterocolitis (NEC), vitrectomy for retinopathy of prematurity (ROP), and musculoskeletal procedures due to cerebral palsy (CP). The anesthesiologist must be aware of the propensity for reactive airway disease, vulnerability to upper respiratory infections (URI), and apnea and bradycardia following general anesthesia in those less than 60 weeks’ postconceptual age (PCA).

In 2006, we have further defined the optimal types of pediatric patients and procedures for ambulatory management in major medical centers and free-standing surgery centers. This review presents a summary of our experience with ambulatory surgical patients at The Children’s Hospital of Philadelphia. Preoperative, intraoperative, and postoperative concerns are addressed. In addition, criteria for ambulatory management, on the basis of patient health status, are reviewed in detail.

Claims of medical malpractice are widespread and will likely affect every physician during the course of their professional careers. The causes of these claims and the most effective means defending them should, therefore, be of great interest to the provider. This article deals with some of the more common causes for lawsuits and the ways physicians can attempt to minimize the risks of a lawsuit both before and after it has been filed.

Emergence delirium (ED), also referred to in the literature as emergence agitation (EA) or post-anesthetic excitement, is a well-documented phenomenon occurring in children and adults in the immediate postoperative period and lasting 5-15 minutes. Emergence delirium is a clinical condition in which patients are “awake” but experience alterations in disorientation and other mental status changes that range from confusion and lethargy to violent and harmful behavior. First addressed on a large scale in the 1960s, ED continues to gain recognition among anesthesiologists who have begun to document the potential pharmacological association and other pre-morbid predictors that increase the risk of developing ED. Investigators have attempted to define ED, validate appropriate assessment tools, distinguish potential risk factors, and identify acute management. The current paper reviews ED and explores theoretical subtypes of ED with and without pain/agitation for clinical assessment.

Sleep disordered breathing is a continuum of breathing abnormalities that affects children and adults. In children, the diagnosis of the most severe form, obstructive sleep apnea (OSA), is difficult. Polysomnography is not widely used, rather the diagnosis is based on clinical history and physical exam. These children may suffer from cardiorespiratory and neurobehavioral effects from the OSA. Treatment for children is primarily tonsillectomy and adenoidectomy surgery. Children who desaturate intermittently during sleep appear to be more sensitive to the respiratory depressant effects of opioids. Careful postoperative care for those at risk for complications is warranted.

Health care in the United States is tragically complicated by medical error. This article focuses on understanding how we learn, how we err, and how the features of human cognition interact to produce errors in medical care. In terms of lives affected adversely and dollars lost to the economy, the magnitude of this problem is staggering. Federal and state governments are now involved in moving forward with private groups, third party-payors, and health care providers to bring the successes of other industries, such as commercial nuclear power and aviation, to the bedside. Anesthesiology has taken a first position in this effort with organizations like the Anesthesia Patient Safety Foundation (http://www.apsf.org) and tools such as the Crisis Management Manual from the Australian Patient Safety Foundation (http://www.apsf.net.au).

Childhood obesity has reached epidemic proportions around the world. However, there is limited information for the pediatric anesthesiologist. We review the current literature for pediatrics and make extrapolations from management of obese adult patients. This paper covers current definitions and some epidemiology of childhood obesity. We discuss potential co-morbidities for both children and adults. We detail what is known regarding pharmacology for obese patients. We provide details to assist with the preoperative evaluation, and make recommendations for intraoperative and postoperative management. Management of these patients can be challenging and complex; and we hope to provide tools to make it safer.

Pediatric pain management for children undergoing surgical care presents unique and significant challenges for clinicians. Effective and thoughtful pain management begins prior to the child’s arrival in the facility’s preanesthesia holding room, lasts throughout the entire perioperative process, and well into the postoperative period. The nature of pain, particularly in children, is complex and results from the interplay of biological, psychological, social, and spiritual factors influencing not only the child, but also the child’s family. We now know that adequate pediatric pain management may improve both short- and long-term health outcomes for many years following surgical intervention. This manuscript reviews the current state-of-the-art trends in neonatal and pediatric pain assessment and management. Topics included in this review are pain assessment, neonatal pain, opioids, regional anesthesia, and psychological and physical strategies for reducing acute pediatric pain.

Awareness that occurs under general anesthesia is an infrequent event that may have serious, long-term sequelae. Associated recall of intra-operative events may cause adverse psychologic consequences, including signs and symptoms of post-traumatic stress disorder (PTSD). Awareness under anesthesia may be especially difficult to diagnose in children, and its incidence in this population is likely to be under-appreciated. This review will include predisposing factors, methods of diagnosis, and principles of prevention of awareness in children undergoing general anesthesia.