bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of Changing Global Patterns of Atherosclerosis on Stress Testing
Authors: Samtani Sonia R. , Thomas Gregory S.
Published: January 2019

The Impact of Changing Global Atherosclerosis Patterns on Stress Testing chapter reviews changes in cardiovascular death (CVD) mortality in developed and developing countries and its impact on exercise testing. Age-adjusted CVD mortality in the United States decreased by 75% between 1950 and 2014. Similar decreases have occurred in other developed countries. The causes of this decrease represent decreases in risk factor burden and improvement in medical and surgical care. With a decreasing burden of CVD in many countries patients are presenting for exercise testing with less severe coronary artery disease. CVD mortality in developing countries, however, including in India and China, is increasing. The wide availability and cost-effectiveness of exercise testing makes it an ideal first test for most patients being evaluated for CVD in both developed and developing countries. .
Punctate Calcification Group
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter discusses punctate calcification group and related disorders and includes discussion on Greenberg dysplasia, chondrodysplasia punctata Conradi-Hünermann type, CHILD (congenital hemidysplasia with ichthyosiform erythroderma and limb defects) syndrome, chondrodysplasia punctata (rhizomelic type), chondrodysplasia punctata (brachytelephalangic type), chondrodysplasia punctata (autosomal dominant type), chondrodysplasia punctata (tibia-metacarpal type), and Keutel syndrome. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Rhizo-Mesomelic Dysplasias
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter discusses rhizo-mesomelic dysplasias and related disorders and includes discussion on omodysplasia (autosomal recessive), Robinow syndrome, dyschondrosteosis, mesomelic dysplasia (Langer type), mesomelic dysplasia (Kantaputra type), mesomelic dysplasia (Werner type), mesomelic dysplasia (Reardon-Kozlowski type), mesomelic dysplasia (Nievergelt-Savarirayan type), and mesomelic dysplasia with acral synostoses. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Acromesomelic and Acromelic Dysplasias/Dysostoses
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter discusses acromesomelic and acromelic dysplasias/dysostoses and related disorders and includes discussion on acromesomelic dysplasias (Maroteaux type), Grebe dysplasia, brachydactyly A1, brachydactyly B, brachydactyly C, brachydactyly D, brachydactyly E, brachydactyly (Christian type), tricho-rhino-phalangeal dysplasia (type 1), tricho-rhino-phalangeal dysplasia (type 2), acrocapitofemoral dysplasia, Albright hereditary osteodystrophy, acrodysostosis, geleophysic dysplasia, acromicric dysplasia, Myhre syndrome, and SOFT syndrome. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Dense Bone Dysplasias with Meta-Diaphyseal Modeling Defects
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter discusses dense bone dysplasias with meta-diaphyseal modeling defects and includes discussion on Blomstrand chondrodysplasia, infantile cortical hyperostosis, dysplastic cortical hyperostosis type Kozlowski-Tsuruta, three conditions presenting in the pre- or perinatal period, osteoectasia with hyperphosphatasia, endosteal hyperostosis (Van Buchem type), Camurati-Engelmann disease, Ghosal hematodiaphyseal dysplasia, Lenz-Majewski hyperostotic dysplasia, hypertrophic osteoarthropathy (autosomal recessive), pachydermoperiostosis (autosomal dominant), sclerosteo-cerebellar syndrome, craniodiaphyseal dysplasia, craniometaphyseal dysplasia, craniometadiaphyseal dysplasia wormian bone type, Pyle disease, metaphyseal dysplasia (Braun-Tinschert type), oculodentoosseo dysplasia, tricho-dento-osseous dysplasia, and diaphyseal medullary stenosis with bone malignancy. Each discussion includes major radiographic features, major clinical findings, genetics, discussions on the course of the disorder, appropriate investigations and potential treatment, major differential diagnoses, and a bibliography.
Osteolyses
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter further discusses bone dysplasias, and includes discussion on familial expansile osteolysis, hyaline fibromatosis, mandibuloacral dysplasia, progeria, Winchester-Torg syndrome, Hajdu-Cheney osteolysis, and multicentric carpal-tarsal osteolysis. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Polytopic Dysostoses
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter further discusses bone dysplasias and includes discussion on campomelic dysplasia, cousin dysplasia, spondylo-megaepiphyseal-metaphyseal dysplasia, cleidocranial dysplasia, Yunis-Varon syndrome, CDAGS, nail-patella syndrome, ischio-pubic-patellar dysplasia, ischiospinal dysostosis, and cerebro-costo-mandibular syndrome. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Overgrowth/Accelerated Skeletal Maturation Syndromes (Selected)
Authors: Spranger Jürgen W. , Brill Paula W. , Hall Christine , Nishimura Gen , Superti-Furga Andrea , Unger Sheila
Published: January 2019

This chapter discusses overgrowth/accelerated skeletal maturation syndromes and includes discussion on Marshall-Smith syndrome, Moreno-Nishimura-Schmidt overgrowth syndrome, Weaver syndrome, and CNP-overexpression overgrowth syndrome. Each discussion includes major radiographic features, major clinical findings, genetics, major differential diagnoses, and a bibliography.
Georges Gilles de la Tourette
Authors: Walusinski Olivier
Published: January 2019

An exhaustive biography of French neuropsychiatrist Georges Gilles de la Tourette (1857–1904) has never been undertaken. Gilles de la Tourette worked closely with the nineteenth-century founder of neurology in Paris, Jean-Martin Charcot. His name is universally known because of the eponymous, disabling syndrome that affects 0.9% of children/adolescents. Unpublished family archives, as well as Gilles de la Tourette’s correspondence with the Parisian journalist Georges Montorgueil, conserved at the national Archives in Paris, were examined together with press and police archives to portray Georges Gilles de la Tourette’s family and professional life in an original light. These archives have never before been studied or made available to the public. How the eponymous syndrome was isolated, the errors initially made in its description, the hidden role of Jean-Martin Charcot, and the disputes with other authors are covered in detail based on multiple sources, original or already published. An in-depth analysis of the genesis of Gilles de la Tourette’s prolific neurological and psychiatric works within their historical context rounds out this biography. Major figures of neurology of the time are also featured—including Freud, Charcot and his son, Brissaud, and Babiński. Interwoven with Gilles de la Tourette’s life and times are discussions of politics, theater, literature, the 1900 Paris World’s Fair, and numerous letters exchanged with Jules Claretie of the Académie Française to highlight his significant involvement in each of these domains. The book concludes with a complete bibliography of all works written by Gilles de la Tourette, compiled for the first time.
Georges Gilles de la Tourette (1857–1904)
Authors: Walusinski Olivier
Published: January 2019

This chapter clarifies the toponymic origin of Georges Gilles de la Tourette’s family name, describes the family environment in which he grew up, details his married life, and also introduces his children. It presents also the key events in Gilles de la Tourette’s personal and family life together, giving some idea of how the provincial bourgeoisie lived in France during the nineteenth century. All of the new information in the chapter is based on family archives that were found in a museum in the village of Loudun, in western France. These archives have never before been used for historical study.
The Assassination Attempt
Authors: Walusinski Olivier
Published: January 2019

Although 1893 began with a promising start as Gilles de la Tourette finished the second part of his treatise on hysteria, Hystérie pathologique. Later, in June, he was pronounced “Chevalier de la Légion d’honneur” on behalf of the French Ministry of the Interior for the decisive role he had played in the erection of a statue to honor Théophraste Renaudot. However, five weeks after the death of his son from meningitis in July 1893, Gilles de la Tourette’s teacher Charcot died. Then, in December of the same year, Rose Kamper, a former patient at La Salpêtrière, attempted to assassinate Gilles de la Tourette in his office. The author examines this murder attempt in the context of unpublished documents and newspaper articles.
Chief Physician for the 1900 World’s Fair in Paris
Authors: Walusinski Olivier
Published: January 2019

In 1896, Gilles de la Tourette was appointed head of the medical department for the 1900 World’s Fair in Paris. His nomination inevitably made him the object of intense envy and several venomous attacks by the press. He responded in the best way possible, by devoting himself to his duties. The fair’s medical department was perfectly organized and fulfilled all of its missions throughout the five years the event lasted, including its set-up and dismantling. The initial criticism was forgotten once Gilles de la Tourette set to work, leaving no room for further censure. This chapter examines his record and the malicious gossip aimed at discrediting him, while revealing a few well-kept secrets.
Vibratory Medicine and Therapeutic Suspension Techniques
Authors: Walusinski Olivier
Published: January 2019

Although the framework of neurological nosography was established during the second half of the nineteenth century, with Jean-Martin Charcot and his Salpêtrière School playing a major role, therapies for the recently identified diseases remained relatively ineffective. Since many Parkinson’s patients reported an improvement in their condition after being violently shaken during travel in mail carriages, Charcot recycled an old treatment method based on a vibratory armchair, assigning the preliminary study to Gilles de la Tourette, who tried to extend the technique to other pathologies by using a vibratory helmet. Another technique recommended by Charcot for treating tabes patients was “suspension,” thought to elongate the spinal cord. The related therapeutic tests in France and Europe are discussed in detail. Gilles de la Tourette made significant use of suspension at the time. The author compares his reports with the scientific challenges to his techniques and examines the resulting discussions.
Sœur Jeanne des Anges, supérieure des Ursulines de Loudun
Authors: Walusinski Olivier
Published: January 2019

Gilles de la Tourette, Charcot, Bourneville, and Axenfeld all belonged to the group of atheist or free-thinking physicians who sought, during the second half of the nineteenth century, to fit possession, ecstasy, visions, and miraculous healings into the framework of mental pathology. This meant frontal opposition to the Church and to Catholic physicians. The book by Gilles de la Tourette and Gabriel Legué, Sœur Jeanne des anges, Supérieure des Ursulines de Loudun, published in 1886 in the “Bibliothèque diabolique” collection directed by Bourneville, was their contribution to this medical-political cause. The genesis of the work, its bibliographic sources, and society’s view of hysteria at the time are discussed with relation to the historical, political, and literary aims of Gilles de la Tourette and Legué.
Correspondence Between Octave Lebesgue, Known as Georges Montorgueil, and Gilles de la Tourette
Authors: Walusinski Olivier
Published: January 2019

Octave Lebesgue (1857–1933), better known by the pen name Georges Montorgeuil, was a contemporary of Georges Gilles de la Tourette. They were brought together by their anticlerical, progressive political ideas and by friends in common, and both made significant advances in their professional careers during the last decade of the nineteenth century. Their epistolary exchange is conserved in the French National Archives in Paris, but has been neglected until now. Beyond their close friendship, it reveals the mutual favors exchanged between them. Well-connected in the political world of the Third Republic, Montorgueil helped build Gilles de la Tourette’s reputation. The detriments of this media coverage came at a time when Gilles de la Tourette’s illness began to disrupt his behavior and weaken his judgment. Decline marked the final years of this neuropsychiatrist, whose fame had been in part due to the support of his journalist friend.
The Impacts of Procedural Stress
Authors: Chorney Jill , Howlett Melissa
Published: January 2019

Children often experience stress around medical procedures. High procedural stress can interfere with the quality or outcome of a procedure and the ease with which it is accomplished. High, unmanaged procedural stress is also associated with more pain, longer recovery times, behavioral disturbances, and increased procedural stress and fear about future medical procedures. Both malleable and nonmalleable factors are predictive of children’s procedural stress, as well as their use of coping behaviors. While nonmalleable factors cannot be changed at the time of the procedure, the presence of such factors can alert healthcare providers to children in need of support. Many well-researched strategies are available to target malleable predictors and thereby mitigate procedural stress, such as adequate preparation for both children and parents, and effective use of coping behaviors. Implementation of such strategies can facilitate optimal procedure completion and foster a positive medical experience for children, thereby giving them greater confidence for future medical encounters.
Sedation Effects
Authors: Linzer Jeffrey
Published: January 2019

While respiratory concerns tend to be the first consideration with sedation medications, many can have important effects on the cardiovascular system that need to be managed. Changes in heart rate, blood pressure, and cardiac work have to be considered. While most of these medications will affect arterial blood pressure in one way or another, some will have no effect on heart rate. While one agent may work well in majority of patients, that same medication could have potentially devastating effects because of a patient’s underlying condition. Additionally, simply changing the rate of drug administration can potentially reduce or increase the cardiovascular effects.
Fasting and Aspiration Risk in Procedural Sedation
Authors: Bhatt Maala , Roback Mark G.
Published: January 2019

There is a documented increase in the risk of aspiration of stomach contents during airway management for general anesthesia. This risk of a serious complication has resulted in strict regulatory recommendations concerning preprocedural fasting even for moderate and deep sedation. The physiology and evidence for fasting recommendations before procedural sedation care in children are discussed here.
Discharge Considerations
Authors: Rhoads Michelle M. , Campbell Tracy
Published: January 2019

Preparation for discharge should begin well before the patient arrives in the recovery room. To ensure a safe and timely discharge, goals must be established for each patient. Elements of a successful discharge include collaboration of team members, use of evidence-based policies and procedures, and adequate patient preparation. Readiness for discharge can be determined by using objective and measureable discharge criteria, taking into consideration the needs of the patient and family. Assessment for discharge readiness should include use of validated discharge criteria or sedation score, postoperative nausea and vomiting evaluation, management of pain, postprocedural/sedation care education, and an understanding of follow-up needs. Adherence to these essential criteria will not only help to ensure a timely and safe discharge but will also improve patient and family satisfaction.
Definition and Incidence of Adverse Events
Authors: Fagin David
Published: January 2019

To perform effective and safe procedural sedation, one must be knowledgeable about the adverse events that can occur with the administration of various sedatives and analgesics. Adverse events (sometimes thought of as complications of care) are often predictable if the sedationist properly assesses the patient’s physiologic and psychological conditions and understands the side effects of the medications administered and the procedural conditions that may exacerbate risk. With such preparation, the sedationist can monitor for the event and can either prevent it or provide supportive care in a timely manner. The American Academy of Pediatrics and other national organizations have developed guidelines for caring for patients requiring procedural sedation with the intent of informing sedationists of the risks involved in sedation care and the skills and equipment needed to ameliorate or prevent patient harm. Adverse events can be classified as minor, moderate, and major.
Moderate Adverse Events
Authors: Chumpitazi Corrie E.
Published: January 2019

The incidence of sedation-related adverse events depends on (1) the medications used; (2) the type, duration, invasiveness, and location of the procedure; and (3) patient factors (e.g., age, medical condition, psychological factors). For the purposes of this chapter, moderate adverse sedation-related events represent physiologic change that is extremely likely to lead to significant patient harm if unnoticed or responded to ineffectively by the sedationist. Apnea, airway obstruction, and laryngospasm are examples. The relative likelihood of events of this type (1 of every 400 sedation episodes) provides significant impetus for effective preparation and training so that sedationists can effectively respond to these adverse events or preempt them. Even though they are categorized as “moderate” and may not be associated with harm in and of themselves, these events may certainly progress to produce significant harm.
Major Adverse Events
Authors: Chumpitazi Corrie E.
Published: January 2019

The incidence of sedation-related adverse events depends on medication characteristics, procedure conditions, and preexisting patient physiologic and psychological conditions. Major adverse sedation-related events represent extreme physiologic change causing significant patient harm that may be long-lasting or permanent, particularly if responded to ineffectively by the sedationist. Large safety studies of pediatric sedation events suggest that events of this type occur very rarely when well-organized, equipped, and trained sedation teams are present. However, sporadic reports of death during pediatric sedation continue to surface, providing significant impetus for effective preparation and training for sedationists. Major adverse sedation-related events discussed here are aspiration, cardiovascular collapse, respiratory failure, and death.
Methods of Rescue/Response
Authors: Rees Chris A. , Chumpitazi Corrie E.
Published: January 2019

Sedation in pediatric patients can lead to decreased muscle tone and subsequent tissue relaxation and airway narrowing. Thus, sedated children are at risk of respiratory depression, laryngospasm, airway obstruction, apnea, and loss of airway reflexes. Hypotension and cardiopulmonary arrest may also occur, although these complications usually result from failure to recognize and correct respiratory compromise. Despite careful presedation assessment, appropriate medication and dose selection, and appropriate cardiovascular monitoring during the procedure, the risks associated with sedation cannot be eliminated entirely. As it is common for children to pass from the intended level of sedation to deeper levels of sedation, providers should be capable of providing appropriate rescue interventions from one level of sedation deeper than what is intended. Algorithms for response to monitored changes in ventilation and oxygenation are presented that can aid the sedationist in responding effectively to an event, preventing the spiral to a condition producing lasting harm to the patient.
The Obese Child
Authors: Hertzog James H.
Published: January 2019

Given that the incidence of obesity is increasing worldwide for both adults and children, sedationists will encounter obese children in their practice. Understanding the obesity-related risks of pediatric procedural sedation will assist the sedationist in managing and mitigating these risks. Obesity is associated with an increase in airway-related adverse events and the need for airway interventions during sedation. Obese patients also need modifications in the dosing of sedative and analgesic agents. Obstructive sleep apnea is commonly associated with obesity and should be identified during the presedation evaluation. With proper screening and preparation, obese patients may be safely and successful sedated for diagnostic and therapeutic interventions.
Voiding Cystourethrography
Authors: Scherrer Patricia , Bredbenner Laura
Published: January 2019

The voiding cystourethrogram (VCUG), which involves bladder catheterization and then fluoroscopic imaging of bladder filling and voiding, is the “gold standard” procedure for the diagnosis of vesicoureteral reflux in children. However, it can be associated with significant distress and discomfort for children. Child Life Specialists are essential to preprocedure preparation and coping strategies for all children, but some patients may also require procedural sedation. Oral or intranasal midazolam and nitrous oxide are the two most commonly used agents, each with its own advantages. Some children may benefit from even deeper levels of sedation, including dissociative sedation/analgesia with oral or intravenous ketamine, deep sedation with intravenous propofol, or even general anesthesia with inhaled anesthetics such as sevoflurane. The choice of regimen should be a joint decision among the multidisciplinary team members to best meet the needs of the child.
Endoscopy
Authors: Dilos Barbara , Gooden Cheryl K.
Published: January 2019

Esophagogastroduodenoscopy (EGD) and colonoscopy are two gastrointestinal procedures that are commonly performed in the pediatric population. For the most part, they can be performed with sedation; generally deeper levels are required for the younger, less cooperative child. However, in some clinical scenarios these procedures will require general anesthesia and artificial airway maintenance. Sedating a child for EGD and/or colonoscopy can present challenges because of the necessity for a cooperative, immobile child who maintains spontaneous breathing. While sedation care is usually associated with lower costs and resource utilization compared with general anesthesia, the sedationist has the responsibility to balance safety, efficiency, and cost-saving measures.
Pulmonary
Authors: Smith Paul G.
Published: January 2019

Sedation is used for virtually all children undergoing fiberoptic airway endoscopy. Because the sedating and procedural physicians “share the airway,” overlapping responsibilities necessitate coordination between them. This section describes the components of a directed preprocedural assessment, emphasizes the need for communication with the bronchoscopist, gives an overview of sedation options, and outlines anticipated complications. Procedural considerations for common FAE indications are highlighted, along with how they influence the choice of setting and sedation agents and methods. Use of short-acting and ultrashort-acting agents will be stressed, as they are ideal sedatives to allow rapid return of normal respiratory drive. Adjuvant medications to facilitate the procedure will also be reviewed.
Cutaneous
Authors: Barber Judson , Cooper Jacinta
Published: January 2019

Lacerations, abscesses, and burns are common presenting complaints evaluated in outpatient settings, urgent care centers, and emergency departments. These conditions are often painful, and the treatment procedures may cause additional pain or anxiety. The location and severity of the wound and the chronologic and developmental age of the patient influence the need for local anesthesia or systemic medications to make procedures tolerable for the patient. This section discusses the safe administration of medications to facilitate laceration repair, incision and drainage of abscesses, and burn debridement. General principles of the types of analgesia or sedation that are useful for these procedures are discussed.
Botox Injections for Spasticity and Sialorrhea
Authors: Mannix Christina
Published: January 2019

In patients with cerebral palsy, injections of botulinum toxin type A (Botox) into muscle groups to reduce spasticity may decrease spasmodic pain and improve movement by increasing range of motion, thereby facilitating care and potentially lessening contracture development. This procedure requires little time but is painful, and repeated treatments are necessary. The level of sedation used for this procedure varies among institutions and from patient to patient, ranging from no sedation at all to general anesthesia. Minimal to moderate sedation with nitrous oxide is an effective method of sedation for this procedure. The sedationist must be prepared to handle complications such as emesis and aspiration. Injection of the submandibular and parotid glands for sialorrhea is a growing indication for Botox injection; deeper levels of sedation are required for sialorrhea than for spasticity to allow localization of the gland and precise delivery of the treatment.
Sedation in the Pediatric Dental Practice
Authors: Unkel John H.
Published: January 2019

A contemporary dental practice offers a variety of sedation medications and routes of administration. Most dental sedation is delivered to children by inhalational and oral routes, although the nasal route is gaining acceptance. Minimal and moderate sedation are the levels that the dentist, acting as both the sedationist and the proceduralist, will wish to achieve in the dental office. Combinations of medications offer the ability to achieve ideal moderate sedation. Nitrous oxide, benzodiazepines, antihistamines, and other agents are discussed. Dental procedures are invasive and unique in that they occur in the oral airway. To achieve a successful outcome, sedationists and proceduralists must take into account instrumentation, loud noises, treatment duration, delivery of local anesthetics, and oropharyngeal protective barriers. Local anesthetic administration can be painful when delivered in the oral cavity. As this is the initial invasive step the child will encounter during the dental experience, providing sedation care may be of value in addition to topical anesthetic.
Intranasal Medications
Authors: Tsze Daniel S. , Reynolds Jason
Published: January 2019

The intranasal route is an effective means of administering sedatives and analgesics. It is a needle-free alternative to intravenous or intramuscular routes, it is not subject to first-pass metabolism, and its efficacy approaches that of intravenous administration. There is absorption through the highly vascular nasal mucosa, as well as utilization of the nose–brain pathway that bypasses systemic circulation and the blood–brain barrier and transports medications directly to the brain. Intranasal administration of sedative and analgesic medications has been shown to be safe and effective for children in a variety of settings. It provides an opportunity to avoid intravenous line placement in many situations, which may reduce the pain and anxiety associated with many diagnostic and therapeutic procedures in children. More studies are needed to compare important sedation outcomes between intranasal sedation regimens and the more common intravenous sedation regimens in order to guide best practice.
Oral Medications
Authors: Burger Rebecca K. , Jain Shobhit
Published: January 2019

Midazolam, the most commonly used oral sedative in children, is used primarily as a premedication but can also be beneficial in brief, minimally invasive procedures, with few side effects. Ketamine can be used for brief, painful procedures but can cause vomiting. Dexmedetomidine can be used as a premedication but has not been extensively studied. Chloral hydrate is useful for imaging studies and noninvasive procedures but is limited by its prolonged sedative effects. Melatonin can be used for sedation and anxiolysis for imaging and noninvasive testing, but there is conflicting literature about its analgesic effects. There are limited studies on the use of meperidine and hydroxyzine for dental procedures. Ketamine and dexmedetomidine intravenous preparations have been administered enterally. Melatonin and clonidine are enteral medications that may prove useful in pediatric procedural sedation. In general, enteral administration is associated with preprocedural anxiolysis, uneven bioavailability, and unpredictable onset of action and recovery times.
Topical and Local Anesthetics
Authors: Vinson Amy E. , Houck Constance S.
Published: January 2019

Local anesthesia is an important part of pediatric procedural sedation. Not only does it allow for pain reduction during intravenous catheter placement, but it can also reduce the total amount of sedation that is required during painful procedures and minimize the need for postoperative analgesia. This chapter outlines the historical aspects of topical local anesthetic use in children. The benefits and risks of topical and subcutaneous local anesthetics during procedural sedation are reviewed. While the topical use of local anesthetics is generally safe, careful titration of dosage based on the patient’s age and weight and the drug’s side-effect profile is important to prevent toxicity. Current recommendations for the treatment of local anesthetic systemic toxicity are provided.
Nursing Perspective
Authors: Rhoads Michelle M. , Briening Eileen , Crego Nancy , Paula-Santos Kimberly , Huster Lauren
Published: January 2019

The nursing process can be used in the safe and effective delivery of pediatric sedation care. Nurses contribute to the direct care of sedated patients by developing competency and expanding knowledge and expertise within their specialty. While the provision of care to patients and families is of paramount importance, ensuring an environment conducive to delivery of safe, quality care by the healthcare team is another fundamental aspect of nursing. Management of sedation, analgesia, and anxiety in pediatric procedural sedation is an intrinsically multidisciplinary process that involves nursing, physicians, child life specialists, and other healthcare providers. In general, pediatric procedural sedation is a relatively new specialty with limited data on the role of the pediatric nurse in this multiprofessional team. It is an opportunity for nursing to collaborate with other healthcare professionals to establish guidelines and protocols to facilitate optimal patient care and efficiency as well as to share and expand their knowledge base and clinical skill set. Specialty certification and credentialing, team concept values, and the evolving role of the sedation nurse are all elements to consider within pediatric procedural sedation from the nursing perspective.
Society Guidelines
Authors: Tirodker Urmila
Published: January 2019

In the past several decades the practice of procedural sedation and analgesia has evolved into a distinct skill set and a service that has rapidly grown in terms of indications, need, practitioner types, and practice settings. The scope of non-anesthesiology sedation providers includes but is not limited to intensivists, emergency medicine physicians, hospitalists, dentists, gastroenterologists, pulmonologists, cardiologists, advanced practice providers, and nursing. Several subspecialty societies and regulatory institutions have published and revised guidelines and standards to enhance patient safety by standardizing various aspects related to patient evaluation, personnel, monitoring, and management of procedural sedation and analgesia and its recovery. The American Academy of Pediatrics, American Society of Anesthesiologists, and the American College of Emergency Physicians are the groups that have published the most widely disseminated, comprehensive guidelines. This chapter gives an overview of these societies’ guidelines.
Hospital and Professional Reimbursement
Authors: Banks David , Werner David
Published: January 2019

The sustainability of a sedation service depends on its ability to generate revenue, both for the providers and for the facility/institution. A complete understanding of the process of coding and billing to achieve maximum reimbursement is necessary for planning a new sedation service, as well as maintaining and expanding an existing one. This section discusses CPT coding and billing for deep sedation, moderate sedation, provider consulting, and facility fees. Coding and billing for deep sedation involves using CPT codes for anesthesia services. Coding and billing for moderate sedation involves the use of the moderate sedation CPT codes that were updated for 2017. Coding and billing for hospital services associated with providing deep sedation involves the use of facility revenue codes.
Quality Improvement in Pediatric Sedation
Authors: Krishna Ashwin , Landers Cheri
Published: January 2019

Pediatric sedation programs benefit from tracking quality metrics and implementing processes to improve the sedation experience. Quality, safe pediatric sedation care involves well-organized, educated teams that track outcomes and constantly review events and situations that need improvement. This requires a multidisciplinary approach, an effort to decrease waste in terms of time and human resources, a focus on equitable care for all patients, and efforts to tailor care to the specific needs of the individual. Tracking appropriate metrics and making changes to pediatric sedation practice and process in order to maintain benchmarks and improve current practice can help institutions improve the quality of the sedation experience for patients, families, and providers. Pediatric sedation programs, regardless of resources, provider type, or institutional constraints, will benefit from using data to create processes that correctly identify and address obstacles to high-quality sedation care.
Hip Dislocation in a Patient with Scleroderma
Authors: Wofford Lisa Mouzi , Deng Yi
Published: January 2019

Scleroderma is a complex, autoimmune connective tissue disease that results in fibrosis and vasculopathy throughout the body. Advanced disease can manifest with significant musculoskeletal, cardiac, pulmonary, gastrointestinal, and renal abnormalities that can make anesthesia management very challenging. Scleroderma has a higher morbidity and mortality than any other rheumatic disease. The anesthesiologist should have a thorough understanding of the pathophysiology of this disease to mitigate potential complications, such as heart failure, prolonged ventilatory support, aspiration, vasospastic ischemia, and difficult airway management. Topics covered in this chapter include Raynaud’s phenomenon, vasculitis, pulmonary hypertension, interstitial lung disease, and microstomia, among other concepts related to scleroderma.
The LVAD Patient Presenting for Noncardiac Surgery
Authors: Tanaka Christopher Y. , Vue Elizabeth M.
Published: January 2019

As the number of end-stage heart failure patients steadily grows, more patients are implanted with long-term left ventricular assist devices (LVAD). Increasingly, noncardiac-trained anesthesiologists are caring for LVAD patients presenting for noncardiac surgery. While continuous-flow LVAD physiology creates unique physiologic and management challenges, patients can be safely anesthetized with appropriate education and training. A multidisciplinary team approach is recommended to review potential perioperative issues for each LVAD patient, including cardiovascular status, LVAD function, anticoagulation, and antibiotic prophylaxis. The anesthesiology team should be comfortable managing hemodynamic instability, arrhythmias, and cardiac arrest in LVAD patients. This chapter uses a case study of an LVAD patient presenting for noncardiac surgery as an example.
TEVAR—Thoracic Endovascular Surgery—Cerebral Spinal Fluid Drainage Catheters
Authors: Kreme Oran , Vivek Kumar
Published: January 2019

Thoracic aortic aneurysms (TAA) are potentially life-threatening conditions that must be monitored closely. Aortic aneurysms can arise at all levels of the aorta and are associated with several medical conditions and congenital syndromes. Aneurysms can progress to acute dissections and/or rupture, requiring emergent intervention. Classically, TAAs were repaired with large thoracotomies, but new techniques and technologies allow these aneurysms to be repaired by endovascular technique. Even though these techniques are minimally invasive, they still carry significant morbidity and mortality, including devastating neurologic injury from spinal cord ischemia. Lumbar spinal drains and other techniques are being used to prevent neurologic injury and improve the outcomes of TAA repairs.
Robotic Prostatectomy
Authors: Chambers Terry Ann
Published: January 2019

Robotic surgery has become more regularly sought after as an advanced surgical technique that can achieve greater operator control. This technology was developed as the next phase in advancing the capabilities of minimally invasive surgery and overcoming the limitations of laparascopy. They eliminate the need to twist and turn in awkward positions, allow increased degrees of freedom of movement of the instruments and can compensate for the surgeon’s tremor. In these ways, they are valuable in areas inaccessible to conventional laparascopy. Of these, the most frequently performed is the robotic assisted laparascopic prostatectomy (RALP). This chapter uses a case study of a 63-year-old man with prostate cancer who presents for RALP. Topics covered include risk factors and diagnosis of prostate cancer and anesthetic considerations for the patient in the case study. The procedure for RALP is also described. The chapter ends with summary points and review questions that cover the material in the chapter.
End-Stage Renal Disease—Patient for Kidney Transplant
Authors: Gyulai Ferenc
Published: January 2019

Attempts at organ transplantation have been made since the 19th century. Renal transplantation is the preferred treatment for end stage renal disease. Renal transplant anesthesia requires a thorough understanding of the metabolic and systemic abnormalities in end-stage renal disease, familiarity with transplant medicine, and expertise in managing and optimizing these patients for the best possible outcome. Also, the associated comorbid conditions increase the complexity of anesthesia, pain management, and perioperative morbidity and mortality. Hence a good perioperative management of these patients includes a multidisciplinary collaboration with well-planned anesthetic strategies. This chapter uses a case study of a 69-year-old man who presents for preoperative evaluation prior to consideration of renal transplantation.
Update on Blood Management in Liver Transplant
Authors: Arora Lovkesh , Kim Sung , Sharma Surangama
Published: January 2019

Hemostasis in patients presenting for liver transplantation is characterized by a reduction in both pro- and anticoagulant factors. Blood loss is due to multiple factors but usually a consequence of pre-existing abnormalities of the hemostatic system, portal hypertension with multiple collateral vessels, portal vein thrombosis, previous abdominal surgery, splenomegaly, and poor functional recovery of the new liver. The intrinsic coagulopathic features of end-stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge, and, despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss, the requirements for blood or blood products remains high. The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of post-transplant outcome.
Anesthetic Considerations in a Liver Transplant Recipient Presenting for Nontransplant Surgery
Authors: Sreedharan Roshni , Khanna Sandeep
Published: January 2019

Liver transplantation is the definitive treatment for end-stage liver disease. The United Network for Organ Sharing reports that there were about150,000 liver transplants done between 1988 and 2016. With increasing number of liver transplantations and improved patient survival, more of these patients will present for further surgical interventions, which may or may not be related to the initial organ transplant. These patients present with unique medical challenges associated with the transplanted organ and medications used for conferring immunosuppression. This chapter uses the case study of a 65-year-old male who had a past liver transplant who presents for nontransplant-related surgery to explore anesthetic considerations in a liver transplant recipient presenting for nontransplant surgery.
Pregnancy Management in a Parturient with Tetralogy of Fallot
Authors: Deng Yi , Murugan Shobana
Published: January 2019

Tetralogy of Fallot (ToF) is the most prevalent cyanotic congenital heart disease (CHD) at birth and is also the most common repaired cyanotic CHD encountered as an adult. Over the past several decades surgical improvement has made great strides in lowering morbidity/mortality and extending life expectancy of these patients, and most will reach adulthood and achieve pregnancy. Management of a parturient with either repaired or unrepaired ToF must be individualized and requires thorough workup and participation from multiple disciplines, but overall outcomes can be excellent with lower risk to mother and fetus compared to other types of cyanotic CHD. Because many parturients with repaired ToF have clinically silent disease until late, it is imperative for anesthesiologists to familiarize themselves with potential complications and pitfalls regarding cardiovascular changes during pregnancy and how they affect peripartum CHD management.
Diabetic Ketoacidosis Management
Authors: Delva Guensley , Straker Tracey
Published: January 2019

Diabetic ketoacidosis (DKA) is an acute complication of diabetes that most often affects patients with type 1 diabetes mellitus. DKA is a form of elevated anion gap metabolic acidosis that results in hyperosmolar diuresis, fatty acid breakdown as a source of alternate energy, and electrolyte changes. Vigilant replacement of intravascular water deficits, glycemic control, and electrolyte replacement is at the centerpiece of effective DKA management. This chapter uses a case study of a 24-year-old female with a past medical history significant for diabetes type 1 and alcohol abuse history who is in the postanesthesia care unit after undergoing surgery for a fractured right arm and is complaining of right quadrant abdominal pain.
Patient with a Large Goiter Presenting for Thyroid Surgery
Authors: Gooden Cheryl K. , Ralph Walter
Published: January 2019

Graves’ disease is an autoimmune disorder that affects all age groups, with a peak incidence in middle-aged individuals. The gender that is most commonly affected by Graves’ disease is female. Its presentation is often characterized by hyperthyroidism, goiter, and eye involvement. At times, however, one or more of these features may not be observed. The diagnosis and treatment of Graves’ disease should not be delayed as this can negatively impact several different organ systems. Although the history and physical examination will reveal pertinent information linked to the disorder, laboratory and imaging studies are necessary for a definitive diagnosis of Graves’ disease. Treatment options exist with their associated risks and benefits.
Sickle Cell Disease and Cholecystectomy
Authors: Powell Thomas , Deng Yi
Published: January 2019

Sickle cell disease (SCD) is a hereditary hemoglobinopathy in which the normal β‎-globin structure is mutated, producing hemoglobin S. The pathophysiologic changes induced by this mutation are complex and produce a clinical picture of chronic hemolytic anemia, intermittent painful crises due to the sickling of erythrocytes, chronic vascular endothelial inflammation and damage, progressive multiorgan damage and failure, and early death. Due to chronic hemolysis and accelerated bilirubin turnover, cholelithiasis is extremely common in this patient population; in fact, cholecystectomy is the most commonly performed surgical procedure in patients with SCD. Although outcomes have improved over the past several decades, the perioperative period remains a time of high risk for the development of SCD-related morbidity and mortality. Because of this, it is crucial for the anesthesiologist to understand these complications, as well as strategies to prevent them or treat them should they occur.
Tracheal Stenosis
Authors: Broderick Nichelle , Straker Tracey
Published: January 2019

Tracheal stenosis is a narrowing or constriction of the airway which results in abnormal airflow. Patients will normally present with complaints of dyspnea. There can be congenital or acquired pathology leading to tracheal stenosis, but the most common cause is iatrogenic. A through history is important to obtain in order to make the correct diagnosis. A computed tomography scan is useful in evaluating the degree of stenosis, level of stenosis in the airway, and the actual length of the stenotic region. Bronchoscopy is often the gold standard for airway evaluation in this patient population because it permits direct visualization of the tracheal lumen. Often, surgical intervention is needed to improve a patient’s symptoms by relieving the narrowing of the tracheal lumen. For the anesthesiologist, managing the airway of a patient with tracheal stenosis can be challenging and calls for sharing the airway with the surgical team, extensive communication between the anesthesiologist and surgical team, and detailed planning.
Anesthetic Management of the Patient with Retropharyngeal Abscess with Emphasis on Perioperative and Airway Management
Authors: Maktabi Mazen A.
Published: January 2019

Retropharyngeal abscess is a surgical emergency as well as an airway emergency. Patients with this condition must have their airway secured as soon as possible in the operating rooms where safe and efficient help is available. Calling for assistance from experienced anesthesiologists and technicians is critical for the successful conduct of the fiber-optic intubation. Ensuring that operating rooms and airway equipment are promptly prepared and having a surgeon who is ready to insert a surgical airway are also essential steps in the process. The most experienced anesthesiologist should perform the intubation under American Society of Anesthesiologists monitoring and after institution of effective topical airway anesthesia and conscious sedation if time and the condition of the patient allow. Effective collaboration between nursing, surgery, and anesthesia services are important for the effective and safe conduct of securing the airway.