Masui. The Japanese journal of anesthesiology
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Procedural sedation and analgesia comprise an integral part of high quality tertiary care in pediatrics. All patients undergoing procedural sedation should be evaluated as extensively as in patients receiving general anesthesia, and an appropriate fasting time should also be considered. Since cardio-respiratory side effects are inevitably associated with sedative medications, (1) only medical personnel with an expertise in the use of these medications should manage procedural sedation, and (2) additionally, the choice of medication should be decided on a case-by-case basis as no single sedation recipe has proven superior to others. ⋯ Following the procedure, medical staff should also monitor patients until full recovery is achieved. Pediatric anesthesiologists should be involved in the sedation procedure for patients with complicated medical histories. Finally, care should be taken to avoid ferrous equipment when performing sedation in an MRI suite.
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The practice of pediatric pain management has made a great progress in the last decade with the development and validation of pain assessment tools specific to pediatric patients. Adequate pediatric pain management has not been advanced as that of adult analgesia due to a lack of clinical knowledge, insufficient pediatric research and the fear of opioid side effects and addiction. Even pediatric anesthesiologists have believed the myths that neonates and infants do not feel severe pain compared to adults because of immatured development of nervous system. ⋯ Accurate assessment of pain in different age groups and the effective treatment of postoperative pain are constantly being refined. Systemic opioids in patient-controlled analgesia, nonsteroidal antiinflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined in a multimodal approach to treat acute pain in perioperative pediatric patients.
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Case Reports
[A case of a patient with Forestier's disease--intubation by Airway Scope and bronchofiberscope].
Forestier's disease accompanies difficult airway management with the ossification of the anterior longitudinal ligament of the spine. The abnormalities include limited cervical mobility, constrained epiglottic elevation, exclusion of the part of aryepiglottic, recurrent nerve paralysis and thinning of respiratory tract mucosa. ⋯ We could intubate an enforced tube (internal diameter 7.5 mm) with the bronchofiberscope guidance without any complications. This procedure seems to be safe for intubation in a Forestier's disease patient.
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Most drugs used in practical pediatric anesthesia are off-label. Pediatric anesthesiologists and non-pediatric anesthesiologists who rarely encounter pediatric patients need to be aware of the clinical usage of these drugs based on pediatric pharmacokinetics and pharmacodynamics to ensure that children are not exposed to unnecessary risks. Clinical guidelines on anesthetic drugs have been made available on the Japanese Society of Anesthesiologists website, and anesthesiologists are encouraged to access this site at least once. ⋯ Rocuronium and sugammadex have been used safely in pediatric patients so far, and may change the induction methods used in difficult airway patients and the management of airway emergencies. Desflurane is novel in Japan and has not been commonly used in pediatric anesthesia. Desflurane may cause very high irritability in the airway and may be used for the maintenance of anesthesia in limited situations.
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Regional anesthesia has been widely applied as an excellent method for perioperative analgesia. Recent studies suggested that regional anesthesia is a promising approach to minimize the risk of surgical site infection and postoperative cancer recurrence, subsequently providing the benefits to the long-term outcome. ⋯ Besides, during the perioperative periods, tumor immunity is significantly depressed due to surgical pain, activation of sympathetic nervous system, inflammatory responses, and others. In this review article, we discuss the tumor immunity during the perioperative period, with focus on the alterations of tumor immunity and regional anesthesia.