Masui. The Japanese journal of anesthesiology
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Case Reports
[Helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury].
We report helicopter transportation of a sedated, mechanically ventilated patient with cervical cord injury. A 20-year-old male sustained traumatic injury to the cervical spinal cord during extracurricular activities in a college. On arrival at the hospital, a halo vest was placed on the patient and tracheostomy was performed. ⋯ In consideration for patient's psychological stress, he was sedated with propofol. RSS (Ramsay sedation scale) scores were recorded to evaluate whether the patient was adequately sedated during helicopter transportation. Prior to transport, we rehearsed the sedation using bispectral index monitoring (BIS) in the hospital to further ensure the patient's safety during the transport.
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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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Preoperative fasting is principally intended to minimize the risk of pulmonary aspiration of gastric contents and facilitate the safe and efficient conduct of anesthesia. Liberalization of fasting guidelines has been implemented in most countries. In general, clear fluids are allowed up to 2h before anesthesia, and light meals up to 6h. ⋯ These guidelines apply to healthy children only. Exclusion criteria included obesity, diabetes, gastroesophageal reflux, ileus, bowel obstruction and emergency care. In particular, trauma and other emergency cases are at higher risk for aspiration regardless of fasting interval and should be managed appropriately.
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Fever and upper respiratory tract infections (URI) are frequently-encountered preoperative comorbidities. Whether or not to proceed with anesthesia for a child with common cold is still a continuing dilemma for anesthesiologists. We, anesthesiologists often feel uncomfortable in making a decision whether or not to proceed because URI is associated with perioperative respiratory adverse events (PRAEs) and there are no definite rules to proceed with or postpone a case. ⋯ Moreover, because children per se are vulnerable to PRAEs, we cannot reduce the risk to zero even without a URI. Therefore, we should be familiarized with how to cope with PRAEs. In making a decision to proceed with or postpone the case, it is important to take various factors together into account, and the decision ultimately depends on whether or not we feel "Yes, we can".
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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.