Paediatric anaesthesia
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Paediatric anaesthesia · Mar 2014
Review Meta AnalysisEffective postoperative pain management in children after ambulatory surgery, with a focus on tonsillectomy: barriers and possible solutions.
Pain following ambulatory surgery is often poorly managed at home. Certain procedures, such as tonsillectomy, cause high levels of pain for at least 1 week postoperatively. ⋯ A number of interventions have been suggested and trialled in an effort to address these barriers, which encompass educational strategies, improved information provision, improved medication regimens, and the provision of tools to aid parents in the pain management of their children. All in all, improvements in pain outcomes have been minor, and a more holistic approach, that appreciates the complex and multifaceted nature of pain management at home, is required.
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Reexpansion pulmonary edema (RPE) is an increased permeability pulmonary edema that usually occurs in the reexpanded lung after several days of lung collapse. This condition is recognized to occur more frequently in patients under the age of 40 years, but there has been no detailed analysis of reported pediatric cases of RPE to date. For this review, PubMed literature searches were performed using the following terms: 're(-)expansion pulmonary (o)edema' AND ('child' OR 'children' OR 'infant' OR 'boy' OR 'girl' OR 'adolescent'). ⋯ No specific treatment for RPE was identified, and treatment was administered according to the clinical features of each patient. Of the 22 reported cases, 10 occurred during the perioperative period, but were not related to any specific surgical procedures or anesthetic techniques, or to the duration of lung collapse. Pediatric anesthesiologists should be aware that pediatric RPE can occur after reexpansion of any collapsed lung and that some invasive therapies can be useful in severe cases.
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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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The physiology of the neonate is ideally suited to the transition to extrauterine life followed by a period of rapid growth and development. Intravenous fluids and electrolytes should be prescribed with care in the neonate. Sodium and water requirements in the first few days of life are low and should be increased after the postnatal diuresis. ⋯ More studies are required to guide fluid management in neonates, particularly in those with sepsis or undergoing surgery. A balanced salt solution such as Hartmann's or Plasmalyte should be used to replace losses during surgery (and blood or coagulation factors as indicated). Excessive fluid administration during surgery should be avoided.