Seminars in pediatric surgery
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Semin. Pediatr. Surg. · Aug 2004
ReviewPostoperative neuraxial pain relief in the pediatric patient.
Pain serves as a useful warning function of potential tissue damage. The systemic response to pain is characterized by activation of the sympathetic nervous system. ⋯ When effective neuraxial anesthesia and analgesic techniques are employed, the surgical patient may benefit from decreases in morbidity, mortality, and prevention of subsequent development of chronic pain. The use of intrathecal and epidural techniques in the pediatric population is well established and allows these patients to benefit from superior pain relief and improved surgical outcomes.
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The physiology of the preterm and term neonate is characterized by a high metabolic rate, limited pulmonary, cardiac and thermoregulatory reserve, and decreased renal function. Multisystem immaturity creates important developmental differences in drug handling and response when compared to the older child or adult. Neonatal anesthetic management requires an understanding of the pharmacophysiologic limitations of the neonate as well as the pathophysiology of coexisting surgical disease. This review addresses the pertinent aspects of neonatal physiology and pharmacology, general considerations in the anesthetic care of surgical neonates, and concludes with a brief review of the anesthetic management of neonates with necrotizing enterocolitis, diaphragmatic hernia, and tracheoesophageal fistula.
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Good airway management technique is an essential skill for physicians in most specialties. This article begins with a review of basic airway anatomy and the physiology of the uninstrumented airway. This subject is of particular importance given the increasing use of procedural sedation and the increased recognition of sleep-disordered breathing in infants and children. ⋯ The fetus with the prenatal diagnosis of a lesion that predicts a difficult airway presents a particular challenge. The utilization of an ex-utero intrapartum treatment method is presented as an important approach for the delivery and airway management of these infants. This section closes with a discussion of the prehospital airway management of the pediatric patient.
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Pediatric surgical patients can present with a number of challenging common respiratory problems. This article reviews potential perioperative implications and anesthetic management of asthma, upper respiratory tract infections, bronchopulmonary dysplasia, and the effects of passive environmental smoke on children presenting for surgery.
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Penetrating injuries account for 10% to 20% of all pediatric trauma admissions at most centers. Gunshot wounds are responsible for the overwhelming majority of penetrating traumatic injuries and have a significantly higher mortality rate than do blunt injury mechanisms. ⋯ Management approaches have been adopted in large part from the more robust adult experience. However, application of these strategies to similar life-threatening injuries in the pediatric population appears appropriate.