Masui. The Japanese journal of anesthesiology
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Recent advances in pediatric airway management contribute to a significant decrease in morbidity and mortality in pediatric anesthesia. This article reviews the current concept of routine and difficult pediatric airway with special emphasis on preoperative pediatric airway assessment. ⋯ Based on the pediatric protocol recently published by the Difficult Airway Society (DAS), we discuss structured algorithms for unanticipated difficult pediatric airway. Simulation technology will aid acquisition and retention of pediatric airway management skills.
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Perioperative fluid therapy aims to provide water, electrolytes and calorie to maintain metabolic homeostasis. The landmark article in which Holliday and Segar proposed the rate and composition of parenteral maintenance fluids for hospitalized children is used to the fluid management for the pediatric surgical patient. ⋯ Routine intraoperative dextrose administration is no longer necessary. We should ultimately change our approach according to major intraoperative fluid shifts by rational, monitored, goal-directed combination of both crystalloid and colloid therapy, similar to that occurring in adult surgical patients.
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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.