Ying T. Sia, MD, MSc, FRCRC

• Associate Professor
• Department of Medicine
• University of Montreal
• Attending
• Department of Medicine, Service of Cardiology
• Centre Hospitalier de l?niversity of Montreal
• Montreal, Quebec, Canada

An evaluation of a single dose of magnesium to supplement analgesia after ambulatory surgery: randomized controlled trial purchase 75 mg pregabalin with mastercard. Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery discount pregabalin amex. Preoperative dexamethasone enhances quality of recovery after laparoscopic cholecystectomy: effect on in-hospital and postdischarge recovery outcomes buy pregabalin 150 mg on-line. Etomidate and fatal outcome - even a single bolus dose may be detrimental for some patients (letter) purchase pregabalin. Lidocaine is more efficient than the choice of propofol formulations to reduce incidence of pain on induction order pregabalin 75 mg with mastercard. Haemodynamic changes and heart rate variability during midazolam-propofol co-induction cheap 75 mg pregabalin with visa. The effect of co-induction with midazolam upon recovery from propofol infusion anaesthesia. Omitting fentanyl reduces nausea and vomiting, without increasing pain, after sevoflurane for day surgery. Ibuprofen provides longer lasting analgesia than fentanyl after laparoscopic surgery. Recovery after propofol with and without intraoperative fentanyl in patients undergoing ambulatory gynecologic laparoscopy. A comparison of midazolam co-induction with propofol predosing for induction of anaesthesia. Propofol auto-co-induction as an alternative to midazolam co-induction for ambulatory surgery. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Comparative evaluation of the effects of propofol and sevoflurane on cognitive function and memory in patients undergoing laparoscopic cholecystectomy: a randomised prospective study. Effect of propofol, sevoflurane, and isoflurane on postoperative cognitive dysfunction following laparoscopic cholecystectomy in elderly patients: a randomized controlled trial. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systemic review of randomized controlled studies. A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. Total intravenous anaesthesia versus single-drug pharmacological antiemetic prophylaxis in adults. A comparison of total intravenous anaesthesia using propofol with sevoflurane or desflurane in ambulatory surgery: systematic review and meta-analysis. Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults. Pharmacokinetic models for propofol - defining and illuminating the devil in the detail. Airway irritation produced by volatile anaesthetics during brief inhalation: comparison of halothane, enflurane, isoflurane and sevoflurane. Rapid increase in desflurane concentration is associated with greater transient cardiovascular stimulation than with rapid increase in isoflurane concentration in humans. Comparison of vital capacity induction with sevoflurane to intravenous induction with propofol for adult ambulatory anesthesia. Induction of anesthesia in the elderly ambulatory patient: a double-blind comparison of propofol and sevoflurane. Meta-analysis of trials comparing postoperative recovery after anesthesia with sevoflurane or desflurane. A comparison of recovery after sevoflurane or desflurane in ambulatory anesthesia. Comparison of desflurane with isoflurane or propofol in spontaneously breathing ambulatory patients. Effect of increased body mass index and anaesthetic duration on recovery of protective airway reflexes after sevoflurane vs desflurane. Postoperative results after desflurane or sevoflurane combined with remifentanil in morbidly obese patients. Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative awareness and postoperative emesis in randomized controlled trials. Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and metaanalysis. The use of esmolol as an alternative to remifentanil during fast-track outpatient gynecologic laparoscopic surgery. Day surgery postoperative nausea and vomiting at home related to peroperative fentanyl. A comparison of anaesthesia using remifentanil combined with either isoflurane, enflurane or propofol in patients undergoing gynaecological laparoscopy, varicose vein or arthroscopic surgery. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. Intraoperative use of remifentanil and opioid induced hyperalgesia/acute opioid tolerance: systematic review. Nitrous oxide (N2O) reduces postoperative opioid-induced hyperalgesia after remifentanil-propofol anaesthesia in humans. Efficacy and tolerability of ready-to-use intravenous paracetamol solution as monotherapy or as an adjunct analgesic therapy for postoperative pain in patients undergoing elective ambulatory surgery: open, prospective study. The efficacy of intravenous paracetamol versus tramadol for postoperative analgesia after adenotonsillectomy in children. Efficacy of esmolol versus alfentanil as a supplement to propofol-nitrous oxide anesthesia. The effect of intraoperative use of esmolol and nicardipine on recovery after ambulatory surgery. Intraoperative esmolol infusion in the absence of opioids spares postoperative fentanyl in patients undergoing ambulatory laparoscopic cholecystectomy. The sparing effect of low-dose esmolol on sevoflurane during laparoscopic gynaecological surgery. The effect of a continuous infusion of low-dose esmolol on the requirement for remifentanil during laparoscopic gynecologic surgery. A comparison of esmolol and labetalol for the treatment of perioperative hypertension in geriatric ambulatory surgical patients. Determination of endtidal sevoflurane concentration for tracheal intubation and minimum alveolar anesthetic concentration in adults. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Adverse laryngeal effects following short-term general anesthesia: a systematic review. Brief review: airway rescue with insertion of laryngeal mask airway devices with patients in the prone position. Analysis of 1000 consecutive uses of the ProSeal laryngeal mask airway by one anaesthetist at a district general hospital. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Postoperative nausea, vomiting, airway morbidity, and analgesic requirements are lower for the ProSeal laryngeal mask airway than the tracheal tube in females undergoing breast and gynaecological surgery. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. A systematic review and meta-analysis of the i-gel vs laryngeal mask airway in adults. Postdural puncture headache after spinal anaesthesia in young orthopaedic outpatients using 27-g needles. Transient neurologic symptoms after spinal anesthesia with lidocaine versus other local anesthetics: a systematic review of randomized, controlled trials. Factors associated with delayed postsurgical voiding interval in ambulatory spinal anesthesia patients: a prospective cohort study in 3 types of surgery. Anaesthesia and post-operative morbidity after elective groin hernia repair: a nation-wide study. Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial. Prilocaine spinal anesthesia for ambulatory surgery: a review of the available studies. A comparison of spinal, epidural, and general anesthesia for outpatient knee arthroscopy. Hospital discharge after ambulatory knee arthroscopy: a comparison of epidural 2-chloroprocaine versus lidocaine. Caudal epidural block versus other methods of postoperative pain relief for circumcision in boys. Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review. Effect of dexmedetomidine on the characteristics of bupivacaine in a caudal block in pediatrics. Disposition of lignocaine for intravenous regional anaesthesia during day-case surgery. Pharmacoeconomics of intravenous regional anaesthesia vs general anaesthesia for outpatient hand surgery. A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis. A systematic review of adjuncts for intravenous regional anesthesia for surgical procedures. The analgesic effect of lornoxicam when added to lidocaine for intravenous regional anaesthesia. Does dexamethasone improve the quality of intravenous regional anesthesia and analgesia The addition of sufentanil, tramadol or clonidine to lignocaine for intravenous regional anaesthesia. Ultrasound-guided regional anesthesia and patient safety: update of an evidence-based analysis. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery (Review). Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty. Bupivacaine in microcapsules prolongs analgesia after subcutaneous infiltration in humans: a dose-finding study. A phase 3, randomized, placebo-controlled trial of DepoFoam bupivacaine (extended-release bupivacaine local analgesic) in bunionectomy. The efficacy and safety of DepoFoam bupivacaine in patients undergoing bilateral, cosmetic, submuscular augmentation mammaplasty: a randomized, double-blind, active-control study. A two-year observational study assessing the safety of DepoFoam bupivacaine after augmentation mammaplasty. Liposomal bupivacaine versus interscalene nerve block for pain control after total shoulder arthroplasty: a systematic review and meta-analysis. The efficacy of liposomal bupivacaine using periarticular injection in total knee arthroplasty: a systematic review and meta-analysis. Role of periarticular liposomal bupivacaine infiltration in patients undergoing total knee arthroplasty-a meta-analysis of comparative trials. Comparison of neosaxitoxin versus bupivacaine via port infiltration for postoperative analgesia following laparoscopic cholecystectomy: a randomized, double-blind trial. A phase 1, dose-escalation, double-blind, block-randomized, controlled trial of safety and efficacy of neosaxitoxin alone and in combination with 0. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia; 2014. Wide variation in patient response to midazolam sedation for outpatient oral surgery. Propofol infusion during regional anesthesia: sedative, amnestic and anxiolytic properties. Royal College of Anaesthetists and British Society of Gastroenterology joint working party. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Remifentanil provides better analgesia than alfentanil during breast biopsy surgery under monitored anesthesia care. An evaluation of conscious sedation using propofol and remifentanil for tension-free vaginal tape insertion. Remifentanil-propofol versus fentanyl-propofol for monitored anesthesia care during hysteroscopy. Remifentanil administration during monitored anesthesia care: are intermittent boluses an effective alternative to a continuous infusion

Umbilical arterial catheters are useful for measuring arterial blood pressure and withdrawing blood for blood gas analysis and pHa generic pregabalin 75 mg mastercard. Arterial oxygen saturation (SaO2) can be measured immediately after birth by attaching a pulse oximeter to a hand or foot discount 150mg pregabalin free shipping. Importantly safe pregabalin 75mg, pediatric in-hospital arrests are less commonly caused by arrhythmias (10% of pediatric arrests vs discount generic pregabalin uk. Further investigations have shown that the superior survival rate seen in children is mostly attributable to a much better survival rate among infants and preschool age children compared with older children proven pregabalin 150 mg. Pediatric patients who suffer an in-hospital cardiac arrest often have changes in their physiological status in the hours leading up to their arrest event purchase cheap pregabalin line. Early recognition plays a key role in identifying a prearrest state in children, who unlike adults may be able to mount a prolonged physiologic response to a worsening clinical picture. The caveat is that prearrest states must be identified to initiate monitoring and interventions that may inhibit the progression to an arrest. While a significant amount of research dollars and resources are spent on the other phases of cardiac arrest, particular focus on the prearrest state may yield the greatest improvement in survival and neurologic outcomes. With that said, the pediatric provider must consider the predominance of asphyxia and hypoxemia as precursors to cardiac arrest. In order to improve outcomes from pediatric cardiac arrest, it is imperative to shorten the no-flow phase of untreated cardiac arrest. To that end, it is important to monitor high-risk patients to allow early recognition of the cardiac arrest and prompt initiation of basic and advanced life support. Important tenets of basic life support are push hard, push fast, allow full chest recoil between compressions, and minimize interruptions of chest compression. The myocardium receives blood flow from the aortic root, mainly during diastole, via the coronary arteries. When the heart arrests and no blood flows through the aorta, coronary blood flow ceases. Therefore, full elastic recoil (release) is critical to create a pressure difference between the aortic root and the right atrium. The immediate post-resuscitation stage is a high-risk period for ventricular arrhythmias and other reperfusion injuries. Goals of interventions implemented during the immediate post-resuscitation stage and the next few days include adequate tissue oxygen delivery, treatment of postresuscitation myocardial dysfunction, and minimizing post-resuscitation tissue injury. This postarrest/resuscitation phase may have the greatest potential for innovative advances in the understanding of cell injury (excitotoxicity, oxidative stress, metabolic stress) and cell death (apoptosis and necrosis), ultimately leading to novel molecular-targeted interventions. The rehabilitation stage concentrates on salvage of injured cells, and support for reengineering of reflex and voluntary communications of these cell and organ systems to improve long-term functional outcome. Interventions that improve outcome during one phase may be deleterious during another. The same intense vasoconstriction during the post-resuscitation phase increases left ventricular afterload and may worsen myocardial strain and dysfunction. Current understanding of the physiology of cardiac arrest and recovery allows us to only crudely manipulate blood pressure, oxygen delivery and consumption, body temperature, and other physiologic parameters in our attempts to optimize outcome. Future strategies likely will take advantage of increasing knowledge of cellular injury, thrombosis, reperfusion, mediator cascades, cellular markers of injury and recovery, and transplantation technology, including stem cells. The difference between arrhythmogenic and asphyxial arrests lies in the physiology. In this circumstance, rescue breathing with controlled ventilation can be a life-saving maneuver. In short, the resuscitation technique should be titrated to the physiology of the patient to optimize patient outcome. To allow good venous return in the decompression phase of external cardiac massage, it is also important to allow full chest recoil and to avoid overventilation (preventing adequate venous return because of increased intrathoracic pressure). By actively pulling during the decompression phase, blood is drawn back into the heart by the negative pressure. However, survival in both groups was 0%, indicating that the population may have been too severely injured or too late in the process to benefit from this aggressive therapy. A variety of medications are used during pediatric resuscitation attempts, including vasopressors (epinephrine and vasopressin), antiarrhythmics (amiodarone and lidocaine), and other drugs such as calcium chloride and sodium bicarbonate. Vasopressin is a long-acting endogenous hormone that acts at specific receptors to mediate systemic vasoconstriction (V1 receptor) and reabsorption of water in the renal tubule (V2 receptor). Vasoconstrictive properties are most intense in the skeletal muscle and skin vascular beds. In experimental models of cardiac arrest, vasopressin increases blood flow to the heart and brain and improves long-term survival compared with epinephrine. Therefore, it is unlikely that vasopressin will replace epinephrine as a first-line agent in pediatric cardiac arrest. However, the available data suggest that its use in conjunction with epinephrine may deserve further investigation, especially in prolonged arrest unresponsive to initial epinephrine resuscitation. Calcium is used frequently in cases of pediatric cardiac arrest, despite the lack of evidence for efficacy. There are no randomized controlled studies in children examining the use of sodium bicarbonate for management of pediatric cardiac arrest. Two randomized controlled studies have examined the value of sodium bicarbonate in the management of adult cardiac arrest189 and in neonates with respiratory arrest in the delivery room. In fact, one multicenter retrospective in-hospital pediatric study found that sodium bicarbonate administered during cardiac arrest was associated with decreased survival, even after controlling for age, gender and first documented cardiac rhythm. Clinical trials involving critically ill adults with severe metabolic acidosis do not demonstrate a beneficial effect of sodium bicarbonate on hemodynamics despite correction of acidosis. Pediatric patients with implanted cardiac pacemakers may have an increased threshold for myocardial electrical stimulation when acidotic195; therefore, administration of bicarbonate or another buffer is appropriate for management of severe documented acidosis in these children. Administration of sodium bicarbonate also is indicated in the patient with a tricyclic antidepressant overdose, hyperkalemia, hypermagnesemia, or sodium channel blocker poisoning. The buffering action of bicarbonate occurs when a hydrogen cation and a bicarbonate anion combine to form carbon dioxide and water. Carbon dioxide must be cleared through adequate minute ventilation; thus, if ventilation is impaired during sodium bicarbonate administration, carbon dioxide buildup may negate the buffering effect of bicarbonate. Because carbon dioxide readily penetrates cell membranes, intracellular acidosis may paradoxically increase after sodium bicarbonate administration without adequate ventilation. In a patient with impaired minute ventilation, tromethamine may be preferable when buffering is necessary to mitigate severe acidosis. Tromethamine undergoes renal elimination, and renal insufficiency may be a relative contraindication to its use. Carbicarb, an equimolar combination of sodium bicarbonate and sodium carbonate, is another buffering solution that generates less carbon dioxide than sodium bicarbonate. However, at the end of the 6-hour study period, all resuscitated animals were in a deep coma, so no inferences regarding meaningful survival can be drawn. Using an approach of "therapeutic normothermia" with scheduled administration of antipyretic medications and the use of external cooling devices, while monitoring core temperature, may be necessary to prevent hyperthermia in this population. Many children become hyperthermic post-arrest despite the intent to prevent hypothermia. Postarrest/resuscitation myocardial dysfunction is very common and is often associated with hypotension (discussed later). However, in animal models, brief induced hypertension following resuscitation results in improved neurologic outcome compared with normotensive reperfusion. Therefore, a practical approach to blood pressure management following cardiac arrest is to attempt to minimize blood pressure variability in this highrisk period following resuscitation. Post-resuscitation Myocardial Dysfunction Postarrest myocardial stunning and arterial hypotension occur commonly after successful resuscitation in both animals and humans. General critical care principles suggest that appropriate therapeutic goals are adequate blood pressures and adequate oxygen delivery. Reasonable interventions for vasodilatory shock with low central venous pressure include fluid resuscitation and vasoactive infusions. Appropriate considerations for left ventricular myocardial dysfunction include euvolemia, inotropic infusions, and afterload reduction. Although the optimal SpO2 is not known, we recommend titration of FiO2 to the lowest amount necessary to assure SpO2 >94%. Oxidative injury may be greatest in the early phases of post-resuscitation therapy following cardiac arrest. There may be an underlying advantage for these patients as well, stemming from predominantly single-organ failure compared with patients with noncardiac etiologies of cardiac arrest, allowing for a greater chance of full recovery after resuscitation. In general, the mortality rate increases by 7% to 10% per minute of delay to defibrillation. The recommended defibrillation dose is 2 J/ kg, but the data supporting this recommendation are not optimal and are based on old monophasic defibrillators. In the mid-1970s, authoritative sources recommended starting doses of 60 to 200 J for all children. Because of concerns for myocardial damage and animal data suggesting that shock doses ranging from 0. More recent data demonstrate that an initial shock dose of 2 J/kg terminates fibrillation in less than 60% of children, suggesting that a higher dose may be needed. Despite 5 decades of clinical experience with pediatric defibrillation, the optimal dose remains unknown. However, after an unsuccessful attempt at electrical defibrillation, medications to increase the effectiveness of defibrillation should be considered. If epinephrine and a subsequent repeat attempt to defibrillate are unsuccessful, lidocaine or amiodarone should be considered. When airway development is complete, the terminal airways remodel and multiply to form a cluster of large saccules, or alveolar precursors, that can support gas exchange. True alveoli appear before and after birth, and the respiratory saccules are thin and septate during postnatal growth. At birth, children have approximately 24 million alveoli; by 8 years of age, the number has increased to 300 million (Table 79. After that, further lung growth is primarily the result of increased alveolar size. There is less elastic tissue in the neonatal lung than in the lungs of adults, and the elastin extends only to the alveolar duct. Lung compliance is integrally related to the amount of elastin; hence, compliance peaks in adolescence. Several factors determine the likelihood of survival after cardiac arrest including the mechanism of the arrest. These factors should all be considered before deciding to terminate resuscitative efforts. During fetal life, additional arteries develop to accompany the respiratory airways and saccules. By 19 weeks, the elastic tissue extends to the seventh generation of arterial branching, and muscularization extends distally. In the fetus, muscularization of the arteries ends at a more proximal level than in children and adults. The muscularized arteries have thicker walls than arteries of similar size in adults. The pulmonary arteries are actively constricted until the latter part of gestation. The pulmonary arteries continue to develop after birth; new artery formation follows airway branching up to about 19 months of age, and supernumerary arteries continue to grow until 8 years of age. As alveolar size increases, the acinar branching pattern becomes more extensive and complex. The arterial structure also changes as preexisting arteries increase in size; the thickness of the muscular arteries decreases to adult levels during the first year of life. Biochemical Development By 24 weeks of gestation, the alveolar cuboidal epithelium flattens, and type I pneumocytes become the lining and supporting cells for the alveoli. However, several important circulatory and mechanical changes must occur immediately after birth for pulmonary gas exchange to be adequate. Initially, there is right-to-left intrapulmonary shunting through atelectatic areas of the lung, as well as left-to-right shunting through the ductus arteriosus and some right-to-left shunting through the foramen ovale. The resultant PaO2 of 50 to 70 mm Hg indicates a right-to-left shunt that is three times that of normal adults. Postnatally, the pulmonary vascular bed remains constricted if it is exposed to acidosis, cold, or hypoxia. If pulmonary artery constriction occurs, right-toleft shunting of desaturated blood through the foramen ovale and ductus arteriosus increases and consequently reduces pulmonary blood flow. Maintenance of this active pulmonary vasoconstriction is called persistent pulmonary hypertension of the newborn or persistent fetal circulation. Changes in these opposing forces during postnatal development affect lung volume, the pattern of respiration, and the work of breathing. Lung Compliance Versus Age Lung compliance changes with age because of the changing alveolar structure, amount of elastin, and amount of surfactant. At birth, compliance is low because alveolar precursors have thick walls and decreased amounts of elastin. The improved lung compliance occurring over the first years of life is the result of continued development of alveoli and elastin. Chest Wall the chest wall of infants is very compliant because their ribs are cartilaginous.

A qualitative and quantitative systematic review of preemptive analgesia for postoperative pain relief: the role of timing of analgesia purchase pregabalin toronto. Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques purchase pregabalin line. Review of the enhanced recovery pathway for children: perioperative anesthetic considerations trusted pregabalin 75 mg. Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center discount 75mg pregabalin overnight delivery. A report by the American Society of Anesthesiologists Task Force on Pain Management purchase pregabalin paypal, Acute Pain Section generic 75mg pregabalin fast delivery. Postoperative analgesic effects of three demand-dose sizes of fentanyl administered by patient-controlled analgesia. 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Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Effects of nonsteroidal antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized controlled trials. High-dose ketorolac affects adult spinal fusion: a meta-analysis of the effect of perioperative nonsteroidal anti-inflammatory drugs on spinal fusion. Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function. Management options for patients with aspirin and nonsteroidal antiinflammatory drug sensitivity. Effects of celecoxib, a novel cyclooxygenase-2 inhibitor, on platelet function in healthy adults: a randomized, controlled trial. 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The newborn goes through a transitional circulation and it takes some days for the pulmonary circulation to adjust quality pregabalin 75 mg. Hypoxia or acidosis in the newborn can lead to significant pulmonary vasoconstriction and resultant pulmonary hypertension order pregabalin 150mg with amex. This may lead to right to left shunting order pregabalin 150 mg with amex, exacerbating arterial hypoxia and thus leading to a vicious cycle of worsening pulmonary hypertension buy 150mg pregabalin otc, acidosis best buy pregabalin, hypoxia pregabalin 150 mg, and eventual cardiovascular collapse. The neonatal lung is fragile and particularly prone to injury from excessive tidal volumes. In contrast, careful attention to ventilation is required to maintain functional residual capacity and avoid atelectasis. Even brief disconnection of the airway circuit or mechanical ventilator can lead to significant alveolar collapse and should thus be avoided if possible. In the operating room neonates should only be anesthetized with ventilators that are designed to include neonatal use, and it is optimal to have monitoring equipment that can accurately measure tidal volumes in a neonate. It is also increasingly recognized that intubated neonates should be transferred to and from the operating room with appropriate neonatal transport ventilator equipment rather than simply a bag and t-piece. Traditionally an acceptable mean arterial pressure in mm Hg was judged to be roughly the same as the postmenstrual age of the child in weeks; however there is little if any evidence to support this. Recent studies have suggested that the neonatal brain may be particularly susceptible to hypotension. The differentiation between conscious and unconscious can also be problematic in neonates. However, what exactly constitutes a state of adequate anesthesia in the neonate is unclear. Propofol and inhaled anesthetics can result in profound cardiovascular depression in the neonate. Anesthesiologists must be particularly cautious about opioid-induced bradycardia and its consequences on cardiac output. Low concentrations of potent inhaled anesthetics can be used with opioids to provide a means of controlling hemodynamic responses without significantly depressing the myocardium. The relative merits of one anesthetic technique over another are not well defined. Caudal and spinal anesthesia are relatively straightforward; however the safe placement of a lumbar or thoracic epidural block requires considerable skill. Epidural local anesthetic infusions can result in systemic toxicity due to immature metabolism. The following should be considered in addition to the usual concerns for the management of neonates: (1) special positioning for tracheal intubation. The anesthesiologist must establish adequate intravenous access to replace all fluid deficits, including loss from the defect (usually with normal saline), and ensure that cross-matched blood is available (especially if rotational skin flaps are planned). Latex allergy precautions should be used with these children for their first and all subsequent anesthetics. These children must have an adequate preoperative work-up that includes an echocardiogram to assess both anatomy and myocardial function. Postoperative ventilation is usually required for these A patients as a result of a tight abdominal wall closure. Infants with omphalocele or gastroschisis require careful management preoperatively to minimize the likelihood of infection or compromise of bowel function. For all children, adequate fluid resuscitation should be provided and electrolyte imbalances corrected prior to surgery. Invasive monitoring is occasionally necessary, particularly if the child has an associated cardiac defect. The liberal use of muscle relaxants provides optimal surgical conditions for closure of the defect. Hypotension during closure may occur due to tension on the liver or caval compression. Similarly raised abdominal pressure during closure may impede adequate ventilation. Postoperative ventilation may be necessary until the abdominal wall has had time to stretch to accommodate the viscera. It should be noted that increased abdominal pressure after a tight closure (abdominal compartment syndrome) may compromise hepatic and renal function and significantly alter drug metabolism. Staged closure with a premade spring-loaded silastic silo is being used with increasing frequency, thus minimizing repeat trips to the operating room. A small percentage of children with omphalocele will also have Beckwith-Wiedemann syndrome, a condition characterized by profound hypoglycemia, hyperviscosity syndrome, congenital heart disease, and associated visceromegaly. Tracheoesophageal Fistula A tracheoesophageal fistula can have five or more configurations, most of which are diagnosed after an inability to swallow because of an associated esophageal atresia (the esophagus ends in a blind pouch). In these cases the characteristic diagnostic test is an inability to pass a suction catheter into the stomach. Neonates may have aspiration pneumonitis from a distal fistula connecting the stomach to the trachea through the esophagus or from a proximal connection of the esophagus with the trachea. Neonates with the rarer H-type fistulae have a fistula between esophagus and trachea; however the esophagus is patent with no atresia. These children present later, typically with respiratory distress and chest infections. Any child with a tracheoesophageal fistula or esophageal atresia should be suspected of having the other anomalies. An echocardiogram to examine for a right-sided aortic arch and the presence of congenital heart disease should be performed before anesthesia. A major aim of anesthesia is to ensure adequate ventilation despite the presence of the fistula. Since positive pressure ventilation may inflate the stomach through the fistula and cause distension of the stomach, it should be avoided until an endotracheal tube is placed distal to the fistula and/or the fistula is occluded or ligated. The risk of abdominal distension and hypoventilation is greatest when the fistula is large or the lung compliance is poor. The distended stomach will further compromise ventilation of the lungs, exacerbating the situation. Coordination with the surgeon is critical to defining the optimal way to ensure adequate ventilation until the fistula is occluded. Bronchoscopy is usually performed after induction to assess the size and location of the fistula. At bronchoscopy a Fogarty catheter or similar device may be placed directly in the fistula to occlude it. The endotracheal tube is ideally placed in the trachea distal to the origin of the fistula. This may be done blindly by advancing the tube into a main bronchus and then carefully pulling it back until equal air entry is heard. The endotracheal tube may be inadvertently placed into the fistula resulting in rapid gastric distension and arterial oxygen desaturation. Urgent transcutaneous gastric decompression may be needed or intraabdominal clamping of the distal esophagus through an abdominal incision. Invasive blood pressure monitoring is recommended since intraoperative arterial desaturation or hypotension may occur with manipulation of mediastinal structures. A preductal and postductal pulse oximeter can be useful in diagnosing an intracardiac shunting. Some surgeons prefer that the infant remain intubated postoperatively, whereas others prefer an attempt at extubation of the trachea. Postoperative pain may be managed with a local anesthetic infusion, or intermittent bolus, via a caudal catheter threaded up to the thoracic level, or with a paravertebral catheter placed by the surgeon. Many of the abdominal viscera, including the liver and spleen, may be above the diaphragm. The primary concern with respect to anesthesia management is pulmonary hypoplasia and associated pulmonary hypertension. It is important to note that surgery does not directly correct the pulmonary hypertension and respiratory status may acutely deteriorate postsurgery. Thus surgery should not be rushed, but planned for when the child is in optimal condition. Anesthetic management of children with a diaphragmatic hernia includes the following: (1) preventing any exacerbation of pulmonary hypertension through avoiding hypoxemia and excessive hypercapnia, and blunting the stress response. The child may be severely dehydrated with a profound hypochloremic, hypokalemic, metabolic alkalosis. Children should be carefully evaluated, and any dehydration or metabolic imbalance should be corrected before surgery. The metabolic imbalance and dehydration can be corrected slowly, provided there is no cardiovascular instability and hypovolemic shock. Nasogastric tubes are not always used preoperatively as they may worsen the electrolyte imbalance. Even if the child arrives with a nasogastric tube in place the stomach should still be immediately suctioned with a widebore vented catheter in the supine and the right and left lateral positions immediately before induction of anesthesia. Awake-intubation has been frequently used; however this approach is becoming less common. One study demonstrated fewer attempts and one half the time for successful intubation of the trachea when a muscle relaxant was used. If it is applied and there is no clear view of the larynx then the pressure should be relaxed. Infants rapidly desaturate with apnea so it is often necessary to gently ventilate the child with 100% oxygen prior to laryngoscopy to avoid hypoxemia and bradycardia. A variety of different intravenous anesthetic agents and neuromuscular blocking agents have been described in this situation. Postoperative analgesia is generally provided by local infiltration of the skin incision and acetaminophen. Rectus sheaf and transversus abdominis plane blocks have also been described in this setting. The major anesthesia concern around infant inguinal hernia repair is the risk of postoperative apnea. Apnea still occurs even with sevoflurane or desflurane anesthesia; therefore the newer volatile anesthetics have not eliminated this concern. Infant Inguinal Hernia Repair Inguinal hernia repair is one of the most common surgeries performed in infants. Inguinal hernia is often bilateral and is more common in males and in ex-premature infants. Waiting until the child is older may reduce anesthesia risk; however, an unrepaired asymptomatic hernia is still at risk of incarceration, which may be a life-threatening complication. Awake-caudal anesthesia has been described but usually requires substantial additional sedation. The spinal anesthetic usually provides 60 to 90 minutes of anesthesia and thus may not be appropriate for hernia repair that is anticipated to be complex. A caudal local anesthetic block, ilioinguinal block, or local infiltration of local anesthetic by the surgeon can all provide adequate analgesia and obviate the need for opioids. Cleft Lip and Palate Cleft lip and palate are relatively common congenital malformations. Approximately one third are associated with a wide range of other syndromes so careful and thorough preoperative assessment is required. Cleft lip is usually repaired at 3 to 6 months of age whereas the palate is repaired at 9 to 12 months of age. In children with large or bilateral clefts, the tongue may impinge in the cleft obstructing the airway, or the laryngoscope blade may fall into the cleft. Postoperative analgesia is based on regular acetaminophen and the judicious use of opioids. This may be asymptomatic or result in dyspnea, orthopnea, pain, cough, or superior vena cava syndrome. These children frequently present for a biopsy of the lesion or other lymph node which, for accurate diagnosis and appropriate management, must be obtained prior to any chemotherapy or radiotherapy. The major anesthesia concern is profound cardiorespiratory collapse and death on induction of anesthesia. The exact etiology of this collapse is uncertain, but probably relates to increasing compression of major vessels, heart, and/or the airway. As a result, some pediatric anesthesiologists advocate avoiding neuromuscular blocking agents and maintaining spontaneous respiration. Echocardiography can be helpful to determine if positioning might have any impact on compression of vessels and cardiac function. In severe cases, every effort should be made to obtain the biopsy without general anesthesia so that further management options can be determined. Inhaled Foreign Body Inhalation of foreign bodies is a major source of morbidity and mortally in young children, occurring most frequently in children ages 1 to 2 years. The airway obstruction may be acute, causing significant respiratory distress and require urgent management; however, often the diagnosis is delayed. The acute choking episode may not have been witnessed and the child may present late with signs of pneumonia. The urgency of removal depends on the degree of respiratory symptoms and the likely location of the obstruction. Clear, effective, and ongoing communication with the surgeon before and throughout the procedure is paramount. Often anticholinergic agents are given prior to induction to reduce secretions and steroids given to reduce airway swelling.