Pediatric clinics of North America
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There has been a tremendous amount of progress in the perioperative approach to the child since Levy wrote "Psychic trauma of operations in children and a note on combat neurosis" nearly 50 years ago. Recognition of prolonged behavioral derangements following the anesthetic-surgical-hospital experience and the prominent role that the parent and physician play in modifying these have dramatically changed the contemporary pediatric perioperative care. Of paramount importance is the psychological preparation of family and child. With increasing outpatient or same-day admission surgery and free-standing surgical centers, preoperative preparation will, of necessity, increasingly become the responsibility of the pediatrician.
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Preoperative evaluation and preparation are directed toward minimizing the intrinsic risks of anesthesia and surgery by having the child in the healthiest possible condition prior to surgery. The pediatrician can contribute to this goal by understanding the effects of general anesthesia on the physiology of children. ⋯ The preoperative evaluation is designed to ensure that the child's preoperative needs may be met by providing the anesthesiologist both qualitative and quantitative information regarding the child's state of health and disease. The relationship between the child, parents, and pediatrician places the pediatrician in an ideal position to prepare families for their children's surgical experience.
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Neuromuscular blocking drugs are valuable adjuncts to the practice of pediatrics. Monitoring of drug effects is technically more difficult in the younger patient. Nevertheless, careful observation of drug effects will improve the usefulness of NMB and safeguard the patient from prolonged weakness. ⋯ The advantages of these long-acting drugs are minimal cardiovascular side effects (i.e., tachycardia or hypotension from histamine release) and longer dosing interval. In all children, the dosing interval should be adjusted to the needs of the individual. In children with renal insufficiency or in those receiving drugs which impair neuromuscular function (e.g., aminoglycosides), the interval at which supplemental doses are required is longer than normal.
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This article reviews specific considerations for greater anesthetic mortality in the first year of life as well as significant differences in pediatric anesthetic morbidity associated with routine anesthetic management. Clinical conditions such as upper respiratory tract infection, congenital heart disease, and muscle disease are addressed. Loss experience suggests a different profile for pediatric anesthesia.