Paediatric anaesthesia
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Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. ⋯ Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.
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Paediatric anaesthesia · Jan 2014
ReviewWhere should we operate on the preterm neonate?: Moderator: Sulpicio G. Soriano.
The ideal venue for neonatal surgical procedures has been the subject of a contentious debate between the leading pediatric hospitals throughout the world. Bias toward the location of neonatal surgery tends to be based on institutional practices. The following opposing viewpoints from two leading pediatric institutions in the United Kingdom and the United States highlight the relevant issues.
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Paediatric anaesthesia · Jan 2014
ReviewAnesthetic considerations for neonates undergoing modified Blalock-Taussig shunt and variations.
The first Blalock-Taussig (BT) shunt was reported in 1944, and during the last 70 years, the procedure has evolved with the development of new materials and devices, and surgical approaches. It has, however, remained central to the palliation of neonates with complex congenital heart disease. The indications have expanded from the original aim of alleviating cyanosis and the pathophysiological results of chronic hypoxemia. ⋯ There is a significant incidence of periprocedural cardiac arrest, often related to myocardial ischemia. A clear understanding of the anatomy and physiology is important. Any discussion of BT shunt in the current era has to include consideration of hypoplastic left heart syndrome and 'single ventricle' physiology.
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Over the past decade, numerous preclinical and retrospective human studies have reported that the provision of anesthetic and sedative agents to infants and children may be associated with adverse neurodevelopmental outcomes. These data have gained widespread attention from professional and regulatory agencies, including the public at large. ⋯ To impart a framework from which anesthesiologists may address the apprehensions of parents who actively bring up this issue, we review the data supporting anesthetic neurotoxicity and discuss its strengths and limitations. As many parents are not yet aware and do not actively raise these concerns, we also discuss whether such a conversation should be undertaken as a part of the consent process.
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Neonatal anesthesia is fraught with potential risk for the patient and stress for the anesthesiologist. Where possible, recognition of these risks, avoidance of, and being able to manage them appropriately, must impact positively on perioperative outcomes in this vulnerable group of patients. Good communication with the parents, as well as with other healthcare providers, is crucial to safe and successful anesthetic care.