bluuebunny/crossref_metadata_2025 huggingface dataset:
Neuromodulation and Spinal Cord Stimulators
Authors: Ngo Anh L. , Piszel Bruce A. , Jones Mark R. , Cases Hector J. , Kaye Alan D. , Boswell Mark V.
Published: October 2018

The Interventional Pain Management Ladder reflects a possible paradigm disruption in chronic pain management. For treatment of chronic pain after failure of pharmacotherapy, the standard of care should shift to less-invasive interventional pain management as the preferred second-line treatment prior to more tissue-disruptive spine surgery. Spinal cord stimulation with neuromodulation is an effective, reversible, and minimally invasive interventional therapy for many types of chronic and difficult-to-treat pain. This chapter presents a modern approach of least invasive therapies first prior to more tissue disruptive measures and aligns chronic pain care with treatment of other serious medical conditions, such as heart attack and stroke.
An Orientation to Implementation Science in Cancer
Authors: Chambers David A. , Norton Wynne E. , Vinson Cynthia A.
Published: October 2018

THE ROOTS of implementation science (IS) in cancer in some sense date back to the earliest days of uncovering cancer’s etiology, diagnosis, prevention, and treatment, although it was not called that. Indeed, unlocking the mysteries of cancer and determining effective ways to intervene began not in the lab but, rather, the clinic. As Mukherjee recounted in the seminal work, The Emperor of All Maladies, 1 cancer had been the subject of clinical examination for centuries, and the drive to optimize care began in those early days. As opposed to the largely separate worlds of research discovery and care delivery that exist today, scientific research and cancer treatment coexisted. In addition, epidemiologic observations of risk factors affecting oncogenesis developed targets for what types of prevention programs needed to be implemented. Naturally, the challenges of what exactly to implement and how best to implement have been with us throughout time.
Implementation Strategies
Authors: Powell Byron J. , Garcia Krystal G. , Fernandez Maria E.
Published: October 2018

Implementation strategies are methods or techniques that can be used to enhance the adoption, implementation, scale-up, and sustainment of evidence-based cancer control practices into routine care. This chapter defines implementation strategies, presents several taxonomies of implementation strategies that can be used to address multilevel implementation barriers, describes guidelines for reporting and specifying implementation strategies to ensure the efficient generation of knowledge and the replication of effective strategies in research and practice, briefly overviews the state of evidence for strategies, and suggests ways in which they can be carefully developed and applied to address the needs of specific contexts. The chapter concludes by presenting several research priorities related to implementation strategies.
Implementing Evidence-Based Media Engagement Practices to Address Cancer Disparities
Authors: Kohler Racquel E. , Ramanadhan Shoba , Viswanath K.
Published: October 2018

Public knowledge and understanding of health disparities is critical to generate support for programs and policies that address social determinants of health (SDH). Yet, public programs and policies are little informed by evidence or the link between SDH and health outcomes. This case study, using community-based participatory research principles, draws from the evidence of SDH and communication sciences. We describe Project IMPACT, an intervention to build capacity among community-based organizations (CBOs) to engage with media strategically, with the goal of influencing the information environment. The case offers an example of implementation science supporting an evidence-based approach, rather than a specific program or practice. We report how IMPACT leveraged the role community partners play in legitimizing issues so SDH and disparities are part of the public agenda. We assessed how strategic media engagement practices were implemented with the ultimate goal of changing public understanding of SDH and disparities to support SDH-related policies.
The FluFIT Program
Authors: Potter Michael B. , Kirkland Debbie , Walsh Judith M. E. , Somkin Carol P. , Gomez Vicky , Green Lawrence W.
Published: October 2018

The FluFIT program is an evidence-based intervention that leverages the time of annual influenza vaccination activities as an opportunity to offer colorectal cancer screening with fecal immunochemical testing to eligible adults between the ages of 50 and 75 years. Begun as a pilot program for a family medicine residency-based flu shot clinic in San Francisco in 2005, the FluFIT program has since been evaluated and implemented successfully in a wide variety of clinical settings throughout the United States. This case study describes the process of designing and testing a clinical intervention with the goal of implementation. Important steps included an initial needs assessment identifying the capabilities and opportunities for changing the behavior of clinical teams, as well as broadly conceived and continuously sustained stakeholder engagement at all stages of program design, evaluation, dissemination, and implementation.
Cancer Survivorship
Authors: Rowland Julia H.
Published: October 2018

The three case studies included in this chapter illustrate well the unique barriers to bridging the implementation gap in cancer survivorship science and also potential solutions to address these barriers. The studies also reflect the spectrum of implementation readiness seen in today’s interventions, from being “ready for prime time” to establishing metrics for success and identifying the right intervention for a known problem. An overarching theme across all three survivorship science case studies is the focus on cancer rehabilitation. Cancer has the potential to adversely affect all aspects of an individual’s life, from physical to financial. Finding and delivering interventions to reduce risk before treatment starts and planning for recovery when treatment ends are needed to reduce the burden of cancer on individuals, families, and society.
Using an Implementation Science Approach to Study and Improve Cancer Survivors’ Employment Outcomes
Authors: de Moor Janet S. , Alfano Catherine M. , Kent Erin E. , Padgett Lynne , Grimes Melvin
Published: October 2018

A cancer diagnosis and treatment can lead to a broad range of symptoms and side effects that interfere with a survivor’s ability to work. Multilevel and multidisciplinary strategies are needed to support individuals as they co-navigate cancer treatment and work. Cancer rehabilitation is an example of a multidisciplinary approach to care with potential to improve work outcomes among cancer survivors. As illustrated by this case study, a referral to cancer rehabilitation can improve the domains of functioning that are needed for work. However, implementation science is needed to overcome key challenges to integrating rehabilitation into cancer care, including testing different models of care delivery that support routine screening and assessment of cancer-related work limitations and referral for rehabilitation services.
The Challenge of Implementing Survivorship Care Plans
Authors: Birken Sarah A. , Hahn Erin E. , Yu Yan , Haines Emily , Mayer Deborah K. , Mittman Brian
Published: October 2018

This case study examines the challenge of implementing survivorship care plans (SCPs), which are intended to document cancer treatment, make recommendations for future care, and facilitate cancer survivors’ care transitions. It describes SCPs’ policy context and offers as a case study the SCP implementation experiences of a university-based hospital and an integrated delivery system. It recommends implementation science as a next step in developing more definitive evidence of SCPs’ effectiveness, which is determined in part by implementation. It also describes promising SCP implementation studies that take into account stakeholders’ perspectives on SCP implementation and plan to leverage findings for future studies in which implementation is examined as a determinant of SCP effectiveness. It recommends future research that uses stakeholder perspectives to develop systems for SCP implementation, adapts SCPs to fit cancer programs’ unique contexts, and investigates the implementation of survivorship care programs of which SCPs are just one component.
Cancer in the Global Health Context
Authors: Sivaram Sudha
Published: October 2018

Globally, a shift in the pattern of disease from infectious etiology to chronic conditions is leading to an increased focus on the prevention and control of non-communicable diseases. In this chapter, three cases are presented that illustrate the potential of implementation science in low- and middle-income countries. The first is a case from India that seeks to understand the context of care seeking and caregiving for cervical cancer in India. The second case presents more than a decade of work in El Salvador, a country with competing priorities in health. The third case describes how implementation science methods are being used in Vietnam to identify barriers to and facilitators for implementing a tobacco cessation intervention in community settings.
Adopting the PREVENTABLE Model
Authors: Maza Mauricio , Alfaro Karla , Gage Julia C. , Cremer Miriam
Published: October 2018

The Cervical Cancer Prevention in El Salvador (CAPE) program completed a series of human papillomavirus (HPV)-based screening demonstration projects that resulted in modification of screening guidelines and set the stage for national implementation of HPV primary screening. This chapter outlines the elements that contributed to the success of CAPE within a process of change model called PREVENTABLE. The model rests on two pillars, political will and evidence, which feed and complement one another. Recognizing political windows of opportunity and obtaining government commitment are crucial to support innovative programs and effect significant transformations. Simultaneously, convincing evidence motivates and channels political will. Thus, primary drivers of the model are research and evaluation of outcomes that reinforce the main pillars; secondary drivers are context dependent, including education, advocacy, negotiation, the legal framework, and budgetary constraints. The experiences from CAPE and PREVENTABLE provide possible blueprints to renovate existing paradigms of cancer control programs.
Implementing Evidence-Based Tobacco Use Treatment in Community Health Centers in Vietnam
Authors: Parascandola Mark , Shelley Donna
Published: October 2018

Although tobacco use has been declining in most high-income countries, it has remained constant or increased in other areas of the world, shifting to low- and middle-income countries (LMICs). The Framework Convention on Tobacco Control (FCTC) was adopted in 2003 to address the growing global epidemic of tobacco use. The 181 countries that are parties to the treaty are required to adopt a range of evidence-based tobacco control policies and programs, including access to tobacco use treatment. This case study provides an overview of the progress and gaps in implementing the FCTC and demonstrates the application of implementation science methods to identify and address barriers to implementing a cessation interventions in the context of a health system in an LMIC.
Assessing the Community Context When Implementing Cervical Cancer Screening Programs
Authors: Adsul Prajakta , Madhivanan Purnima
Published: October 2018

This case study demonstrates the use of qualitative, community-based, participatory research to understand the context in which cervical cancer screening programs are implemented in rural India, thereby enabling not just successful implementation but also future sustainability of the program in the community. A series of studies were undertaken to understand the cervical cancer screening program in its current state and provide information for the implementation of future programs. These studies included (1) qualitative interviews with physicians delivering cervical cancer care in the private and public sector, (2) focus group discussions with health workers in primary health care clinics, and (3) photovoice study with women residing in the communities. Study findings helped identify elements of the social and cultural context of rural communities, thereby providing a rich understanding of factors influencing of cervical cancer screening that can be integrated into pre-intervention capacity development in the future.
Overuse and De-Implementation of Inappropriate Cancer Screening, Diagnosis, and Treatment Practices
Authors: Doroudi Maryam , Kramer Barnett S. , Pinsky Paul F.
Published: October 2018

Overuse in cancer screening and diagnostic tests occurs when individuals undergo procedures that do not change the treatment success probability or when harms caused by the procedure may outweigh benefits. This chapter elucidates the issue of overuse in the cancer control continuum by highlighting the current literature and identifying areas ripe for future research on de-implementation. First, it presents examples of overuse in cancer screening and diagnostic tests and cancer treatment. Overuse is defined as the application of an intervention for which there is no reliable evidence of a meaningful benefit in important health outcomes compared to the previous standard of care. Overuse is often associated with opportunity costs—diverting resources that are better spent on more effective strategies to improve health. Next, factors promoting overuse are discussed, including those at the patient, provider, and systems levels. Finally, strategies to mitigate overuse are reviewed.
Future Directions in Implementation Science Across the Cancer Continuum
Authors: Norton Wynne E. , Vinson Cynthia A. , Chambers David A.
Published: October 2018

Implementation science in health has made considerable progress in the past decade, including in cancer control and prevention. As those in the field reflect on accomplishments and advancements, they must also consider emerging challenges and outstanding issues that have yet to be tackled. This chapter provides an overview of three issues in implementation science in health that warrant additional consideration and attention: minimum criteria for implementation, implementation strategies 2.0, and generalizability of implementation science. The goal of this chapter is to increase focus on these areas of inquiry and highlight some challenges that implementation science may encounter. The chapter takes a critical yet constructive approach to these issues and, in doing so, challenges the field to address these topics.
Acute Fluid Resuscitation for Intussusception
Authors: Williams Erin S.
Published: October 2018

Intussusception, or telescoping of bowel, is an abdominal emergency. It is typically seen in children younger than 3 years of age with the highest incidence occurring at ages 5 to 9 months. It is paramount that this diagnosis be made as early as possible, within a 24-hour window, in order to prevent significant morbidity and mortality. Presenting signs and symptoms include but are not limited to abdominal pain, vomiting, diarrhea, and a palpable sausage shaped mass on abdominal exam. Given the potential for gastrointestinal fluid losses dehydration is a significant risk; thus it is important to be able to adequately replace fluids in a patient at risk for hypovolemia.
Asthmatic for Adenotonsillectomy
Authors: Williams Erin S.
Published: October 2018

Asthma is a chronic reversible pulmonary condition. It is the most common respiratory disease as it affects 6 million to 9 million children in the United States. The patient with asthma can experience reversible bronchoconstriction, airway inflammation, airway hyperresponsivness, and increased mucus production. Inflammation is the fundamental abnormality. This dynamic process exists on a spectrum of mild, moderate, or severe. Patients may exhibit expiratory wheezing, obstruction to expiration, and/or inspiration, cough, and respiratory distress. Given the prevalence of asthma and its potential for significant morbidity and mortality, it is important that the anesthesiologist be able to determine the severity of disease and prevent and/or treat bronchospasm.
Egg and Soy Allergies and Propofol Use
Authors: Kibelbek Michael J. , Aronson Lori A. , Heyden Lisa D.
Published: October 2018

Anesthesiologists and sedationists often use propofol as the main anesthetic agent for brief procedures, such as esophagogastroduodenoscopy with biopsy for eosinophilic esophagitis (EoE). Pediatric patients presenting for endoscopy often have a history of reflux as well as drug and food allergies. Specifically, patients with EoE often have sensitivity to egg and soy, as well as milk and dairy products, tree nuts/peanuts, and seafood (fish/shellfish). Propofol use is often cited as a contraindication in patients with hypersensitivity to egg and soy. Current literature does not support avoiding propofol in egg- and soy-allergic patients. Most practitioners, however, continue to avoid propofol in patients with a history of egg anaphylaxis due to lack of evidence supporting its safe use in this population.
Obstructive Sleep Apnea
Authors: Ryan Laura , Hopkins Paul
Published: October 2018

Adenotonsillectomy is one of the most commonly performed surgeries in children and is the mainstay treatment for obstructive sleep apnea (OSA). Children with OSA have a higher risk of perioperative respiratory morbidity. Diagnosis of OSA is made by overnight polysomnography, but this resource is rare and expensive so children at risk for OSA must be identified based on parental history. Patients with risk factors for postoperative respiratory complications may need to be monitored in the hospital overnight. Anesthetic challenges associate with adenotonsillectomy include perioperative analgesia, prevention and treatment of postoperative nausea and vomiting, risk of airway fire, and management of airway obstruction.
Tonsillar Bleed
Authors: Aina Titilopemi A. O. , Redd Sharon
Published: October 2018

Post-tonsillectomy hemorrhage (PTH) is a very serious complication that can occur after a tonsillectomy. There are two broad categories of PTH, based on onset of bleeding: primary (less than 24 hours) or secondary (greater than 24 hours). Primary bleeding is often attributed to the surgical technique, and secondary bleeding is attributed to sloughing of healing surgical scar. Risk factors for PTH include male gender, age greater than 70 years (in adults), age greater than 5 years (in pediatrics), recurrent tonsillitis, use of nonsteroidal anti-inflammatory drugs (particularly ketorolac), among others. Rapid-sequence induction and intubation is advised to reduce the risk of aspiration for patients presenting with PTH.
Difficult Airway
Authors: Hopkins Paul , Ryan Laura
Published: October 2018

The management of the difficult airway is one of the most challenging situations an anesthesiologist may encounter. The pediatric patient provides unique challenges such as lack of cooperation, rapid desaturation while apneic, and the presence of syndromes with craniofacial manifestations not frequently encountered in adults. These craniofacial manifestations may include mandibular hypoplasia, facial asymmetry, and limited mouth opening, to name a few. This chapter presents a case of a 5-year-old boy with Klippel-Feil syndrome and discusses the different aspects involved when dealing with a difficult airway in a pediatric patient, including the use of fiberoptic devices, neuromuscular blockade, and sedative premedication.
Intraoperative Wheezing
Authors: Schackman Julie , Williams Erin S.
Published: October 2018

Intraoperative wheezing is a can occur for a number of reasons. The pediatric anesthesiologist must be facile with the various causes of wheezing in order to appropriately diagnose and subsequently treat the wheezing. The key tool that is paramount in the assessment of wheezing is the stethoscope. Without careful and vigilant auscultation, the cause of wheezing can be missed and or misinterpreted, which can potentially lead to increased morbidity. This chapter explains the causes of wheezing, explores the risk factors for perioperative bronchospasm, and discusses how to manage the child with intraoperative wheezing. A 3-year-old boy who presents to the ambulatory surgery center for bilateral ear tube insertion and adenoidectomy is used as a case example.
Cystic Fibrosis
Authors: Tinch Brian , Martin David , Wu Junzheng
Published: October 2018

Cystic fibrosis is an inherited disorder. The diagnosis should be suspected in an infant who has meconium ileus or infants presenting to the operating room with volvulus. Cystic fibrosis is characterized by frequent mucous plugging in the respiratory tract which may manifest as wheezing and frequent intermittent flare-ups of respiratory decompensation. Optimization of the affected child’s respiratory status prior to elective surgery is mandatory to prevent difficulty with intraoperative ventilation. While the laryngeal mask airway may be used for short procedures, the use of an endotracheal tube facilitates suctioning of the frequently inspissated secretions that accompany cystic fibrosis in order to optimize ventilation.
Management of Acutely Burned Children
Authors: McDougall Robert
Published: October 2018

The general approach for a child who has suffered burns, as for any injured child, should be assessment and management of airway, breathing, and circulation (ABC). A child status post-burn injury may require immediate intubation due to smoke inhalation and ensuing respiratory distress. The resuscitation of the child with burn injury poses a number of challenges to the anesthesiologist and requires an understanding of the pathophysiology of this type of injury. Appropriate vascular access and pain management are also of high priority in this scenario. This chapter discusses the approach to resuscitation of the child with acute burn injuries, reviews the key issues in developing a plan to secure the airway, and describes effective pain management in the setting of an acute burn.
Liver Transplant
Authors: Campos Carlos J. , Baijal Rahul
Published: October 2018

Orthotopic liver transplant is an established treatment for pediatric end-stage liver disease. There are many challenges in anesthetizing a child with pediatric end-stage liver failure. Adequate preparation and an exquisite understanding of the patient's pathophysiology are critical to anticipating all the potential complications for each stage of the transplant. Biliary atresia is the most common cause of neonatal cholestasis and is the most frequent indication for pediatric transplantation. The Kasai procedure is an important bridge until transplant. However, a previous Kasai procedure may make dissection of the native liver more difficult, secondary to scarring and adhesions. This chapter uses the case of a 1-year-old boy presenting for liver transplant as an example.
Kidney Transplantation
Authors: Aina Titilopemi A. O. , Prada Miguel
Published: October 2018

Patients with end-stage renal disease (ESRD) can be managed with kidney transplantation, hemodialysis, or peritoneal dialysis. The most common organ transplanted in the United States is the kidney. Kidney transplantation surgery can be divided into the following stages: incision/dissection of vessels, cross-clamping vessels, vascular anastomosis, unclamping of vessels, ureter anastomosis to bladder, and closing. The size of recipient and donor kidneys as well as the size of recipient blood vessels will determine the position of graft implantation—either intraperitoneal or extraperitoneal. At the conclusion of surgery, most of the patients are extubated. This chapter describes the key steps in the preoperative assessment, explains the features of intraoperative anesthetic management, reviews the risk factors for reintubation, and identifies the optimal plan for postoperative pain management.
Management of Children with Congenital Heart Disease for Noncardiac Surgery
Authors: Andropoulos Dean B.
Published: October 2018

Congenital heart disease (CHD) patients are increasingly presenting for noncardiac surgery, and the anesthesiologist must possess an understanding of the major classes of CHD and their pathophysiology, as well as surgical approaches for correction or palliation. A thorough preoperative evaluation and anesthetic plan, including invasive monitoring, inotropic support, blood transfusion, endocarditis prophylaxis, pacemaker/defibrillator functioning, and intensive care unit admission must be developed, and include a multidisciplinary team. Each patient has a unique pathophysiology and a systematic approach to understanding hemodynamic consequences, and developing hemodynamic goals for the anesthetic will improve the potential to minimize anesthetic complications and ensure the best possible outcomes.
Single-Ventricle Physiology
Authors: Gottlieb Erin A. , Vener David F.
Published: October 2018

Pediatric and adult patients with single ventricle physiology may present for elective and emergent procedures, and it is critical for pediatric anesthesiologists to be familiar with the stages of palliation. In addition, basic knowledge of how to manage each stage perioperatively is required to avoid morbidity and mortality. This chapter describes the anatomy and physiology of and ventilation and oxygenation strategies for each stage of single ventricle palliation. It also discusses the risks associated with anesthetizing the single-ventricle patient with a modified Blalock-Taussig shunt, the rationale for performing elective noncardiac surgery during the Glenn stage of the single ventricle pathway, and the effects of positive pressure ventilation on the patient with Fontan physiology. A perioperative plan for caring for single-ventricle patients undergoing noncardiac procedures is also covered.
Pulmonary Hypertension
Authors: Williams Erin S.
Published: October 2018

Pulmonary hypertension is one of the most challenging medical conditions for even the most experienced anesthesiologist to manage. The very dynamic nature of pulmonary vascular disease lends itself to potential catastrophic changes that can increase the perioperative morbidity and mortality. Given the potential for significant hemodynamic, oxygenation, and ventilation changes during perioperative care it is imperative that the pediatric anesthesiologist not only perform a history and physical exam in this high-risk patient population but also carefully evaluate the most recent cardiac studies such as echocardiograms and catheterizations. The anesthesiologist must ensure that the patient is not overdue for cardiology exams and studies. Finally, the pediatric anesthesiologist must also communicate with the surgeon and cardiologist regarding the risk and benefit of the procedure; along with the severity of the patient’s pulmonary hypertension, in order to formulate and ultimately execute an anesthetic plan that decreases the possibility for perioperative complications.
Open Globe Repair
Authors: Lin Michael , Williams Erin S.
Published: October 2018

Penetrating eye injury in the pediatric patient is an emergency that requires careful management by the anesthesiologist to prevent further eye damage by the potential extrusion of vitreous fluid. Additionally, since these injuries are due to trauma, the patients typically are not adequately fasted for surgery. Thus prevention of aspiration of gastric contents must also be considered during the perioperative management of the child with an open globe injury. Depending on the risk of aspiration, the anesthesiologist must determine whether to use succinylcholine, a nondepoloarizing muscle relaxant, or no muscle relaxant at all, prior to laryngoscopy. A delicate balance must exist to achieve a smooth induction of anesthesia, blunted response to airway stimulation during laryngoscopy and intubation, and prevention of aspiration. During the perioperative period, the pediatric anesthesiologist can employ a variety of methods to limit the potential for increased intraocular pressure in the patient with penetrating eye trauma.
Prone Positioning for Posterior Fossa Tumor Resection
Authors: König Matthias W. , Mahmoud Mohamed A. , McAuliffe III John J.
Published: October 2018

The prone position is employed for minor or major procedures on the dorsal aspect of the body. The more major procedures tend to be prolonged and may be associated with swelling of dependent areas, as well as prolonged pressure on certain pressure points. These possible complications must be adequately addressed with families during the preoperative visit in order to appropriately manage expectations when they see their loved ones in the immediate postoperative phase, especially after a long surgery. In order to prevent complications, proper padding and protection of dependent areas should be performed. This chapter considers the logistic challenges of turning a small patient into the prone position, explores potential complications unique to prone positioning, lists strategies to avoid position-related injuries, and discusses cardiopulmonary resuscitation in the prone position.
Anesthetic Considerations for Scoliosis Repair
Authors: Nguyen Kim-Phuong , Glover Chris D.
Published: October 2018

Scoliosis is an anatomical deformity caused by a lateral and rotational shift in the thoracolumbar spine. Surgical correction involves wide exposure of the spine for placement of stabilizing rods and can result in significant complications from excessive blood loss and neurologic impairments. These procedures require vigilance to acid-base status, hemodynamic fluctuations, coagulation, temperature maintenance, and neurologic monitoring from anesthesiologists. Other major anesthetic considerations discussed include maintaining the integrity of perfusion to the spinal cord, positioning concerns, optimal technique for neuromonitoring, and pain control in the perioperative period. This chapter presents a case study of a 14-year-old girl with adolescent idiopathic scoliosis who presents for posterior spinal instrumentation and fusion from T4-L4 with autologous bone graft.
Sickle Cell Disease
Authors: Ng Ann , Williams Erin S.
Published: October 2018

Sickle cell anemia (sickle cell disease) is a common hemoglobinopathy with anywhere from 90,000 to 100,000 Americans affected. This chronic condition has a predominance in populations of African descent, occurring in approximately 1 out of 365 African American births, compared to 1 out of 16,300 Hispanic births. The sickle cell trait can be detected in 1 of 13 African American births. One of the most common complications associated with sickle cell anemia, vaso-occlusive crises by sickled cells, results in severe pain. Other issues associated with this condition include acute chest syndrome, lung infections, end organ damage, and stroke. With improvements in the management and prevention of pain crises, infection, and other systemic involvement, these patients are living longer, thus increasing the potential for surgical needs. Whether it is for routine surgeries or surgeries that are due to the natural history of the disease; the pediatric anesthesiologist must be knowledgeable of the management of these patients in order to prevent morbidity and mortality.
The Oncology Patient
Authors: Ng Ann , Williams Erin S.
Published: October 2018

The pediatric oncology patient is one of the most challenging patients for the pediatric anesthesiologist not only due to the multiplicity of potential comorbidities that can occur due to the oncologic process and chemotherapy but also due to the myriad of anesthetic exposures that the patient must endure. Because this population of children are the most anesthetized group of patients, it is imperative that the anesthesiologist work with a multidisciplinary team to minimize the number of exposures to anesthesia and thereby decrease the number of times that the child is without food and decrease the potential for complications. Given the recent Food and Drug Administration’s warning regarding the potential for neurotoxicity and number of exposures to anesthetics, it is also important to limit the number of anesthetics; this can be accomplished using a multidisciplinary approach and combining procedures as much as possible.
The Opioid-Tolerant Patient
Authors: Zelisko Michael Blaine
Published: October 2018

Caring for the opioid-tolerant patient presents several challenges in the perioperative period, including a higher incidence of anxiety, pain, and unanticipated hospital admission. The goal of the anesthesiologist is to provide sufficient analgesia while preventing withdrawal symptoms. This chapter reviews multimodal analgesia techniques, and addresses opioid tolerance, opioid-induced hyperalgesia, opioid rotation, and the use of methadone during the perioperative period.
Neuroblastoma Resection
Authors: Sabato Stefano
Published: October 2018

Neuroblastoma is the most common extracranial solid tumor of childhood. Staging of neuroblastoma has both prognostic value and guides therapy and interventions. Surgical resection and chemotherapy remain the main modes of therapy, and chemotherapeutic agents have both immediate and long-term implications for the anesthetic management of these patients. Though less common, some patients may have catecholamine-induced hemodynamic instability. Thorough perioperative planning and adequate vascular access are required for these procedures. This chapter will prepare the reader to know how to assess and optimize a child with neuroblastoma for surgery, appreciate some of the difficulties of anesthesia for the child with cancer, and understand the principles of management of major blood loss during pediatric surgery.
The Diabetic Patient
Authors: Patino Mario , Varughese Anna M.
Published: October 2018

The perioperative management of diabetic patients is complex and requires knowledge of the patients’ pathophysiology, current regimen, and proposed surgical procedure. This chapter addresses perioperative risks, as well as the formulation of both goals of management and perioperative plan in the pediatric patient with diabetes. This chapter will enable the reader to differentiate appropriate preoperative metabolic control from nonoptimal control in a diabetic child, define the perioperative risks and complications for diabetic patients, describe perioperative goals in the management of children with diabetes and conceptualize a perioperative plan to meet these goals, and learn how to effectively manage life-threatening complications such as severe hypoglycemia.
Diabetic Ketoacidosis in a Child with Acute Surgical Abdomen
Authors: Baijal Rahul , Campos Carlos J.
Published: October 2018

Management of the pediatric surgical patient in diabetic ketoacidosis (DKA) is particularly challenging given the electrolyte and acid-base abnormalities, compounded with the risk of cerebral edema. This chapter highlights the risk factors, diagnosis, and treatment plan, for the pediatric surgical patient who presents in DKA. This chapter will help the reader identify children at risk for DKA, understand the clinical presentation and pathophysiology of DKA, identify children at risk for cerebral edema, manage cerebral edema in children with DKA, manage DKA in children, and understand the anesthetic implications in children with DKA.
Hypopituitarism
Authors: Sjoblom Matthew D. , Gordon Diane , Aronson Lori A.
Published: October 2018

Hypopituitarism is a decreased secretion of pituitary hormones. It is especially concerning during surgery and anesthesia if it results in adrenal insufficiency, hypothyroidism, or diabetes insipidus. Common causes in children include pituitary tumor and/or treatment, traumatic brain injury, and empty sella syndrome. Perioperative management includes recognition of clinical symptoms, such as hypotension, fatigue, polydipsia, and increased urine output. Unrecognized adrenal insufficiency may result in significant morbidity or mortality. Intraoperative treatment may involve stress-dose corticosteroids, careful fluid management, and desmopressin. This chapter uses the case study of a 9-year-old boy who presents for bilateral removal of tibial orthopedic hardware to illustrate the concepts.
Mitochondrial Disease and Anesthesia
Authors: Felberg Mary A.
Published: October 2018

Mitochondrial disease is a genetically, biochemically, and clinically heterogeneous group of disorders that arise from defects in cellular oxidative phosphorylation, most commonly within the electron transport chain. All mitochondrial diseases involve disruption in energy production; clinical symptoms usually manifest in tissues with high energy demands although all organs may be affected. The extent of disease depends not only on the mitochondrial defect but on the numbers of dysfunctional mitochondria present in each tissue. Despite in vitro evidence that almost every anesthetic agent studied has been shown to decrease mitochondrial function, all anesthetic agents have been used safely. Discussion of the implications of mitochondrial disease for anesthetic management includes preoperative preparation, volatile and intravenous anesthetic agents, avoidance of succinylcholine, risk of malignant hyperthermia, perioperative fluids, and postoperative management.
Exploratory Laparotomy for Necrotizing Enterocolitis
Authors: Wyatt Karla E. K. , Olutoye Olutoyin A.
Published: October 2018

Necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease that commonly affects premature infants. The pathogenesis is multifactorial and poorly understood, although certain risk factors have been identified. This disease, more commonly detected in premature infants with accompanying cardiac and pulmonary comorbid conditions, is associated with increased morbidity and mortality. Multiorgan system homeostasis becomes critical for the pediatric anesthesiologist when approaching medical and surgical interventions for affected patients. This chapter focuses on the population at risk for developing necrotizing enterocolitis, medical and surgical management, providing anesthesia care in the neonatal intensive care unit, as well as perioperative considerations and complications.
Tracheoesophageal Fistula Repair
Authors: Seipel Catherine P. , Aina Titilopemi A. O.
Published: October 2018

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a congenital malformation occurring in approximately 1:4,000 live births. TEF/EA is characterized by disrupted continuity of the esophagus. There are five distinct types, but the most common is EA with a distal TEF. Most cases are diagnosed postnatally after an inability to pass a nasogastric tube (NGT), with subsequent radiographic imaging finding the NGT coiled within the esophageal pouch. The anesthetic management of TEF/EA repair can be complicated by the presence of cardiac, renal, and vertebral anomalies. Additionally, ventilation can be challenging, and care must be taken to minimize insufflation of the stomach through the fistula. Postoperative analgesia should include consideration of intravenous opioids, nonopioid adjunct medications, and regional and neuraxial techniques.
Omphalocele/Gastroschisis
Authors: Wyatt Karla E. K. , Olutoye Olutoyin A.
Published: October 2018

Omphalocele and gastroschisis are the most common types of abdominal wall defects encountered in the neonatal population. Both conditions result in the herniation of abdominal viscera through a defect in the upper or lower abdominal wall. These neonates can present with herniated organs, intestinal obstruction, impaired blood supply to visceral organs, and major fluid deficits. The primary goal for a neonate with an abdominal wall defect is surgical closure. Prior to achieving this goal, maintenance of perfusion of the herniated viscera and minimization of evaporative fluid losses secondary to the exposed surface area are paramount. This chapter discusses the distinctly different etiologies of these conditions, comorbidities, and prognoses, as well as the surgical and anesthetic management strategies and commonly encountered perioperative complications.
Myelomeningocele Repair
Authors: Mavi Jagroop , Boat Anne C. , Sadhasivam Senthilkumar
Published: October 2018

Myelomeningocele (MMC) is a spinal birth defect associated with significant morbidity directly related to the exposure of meninges and neural structures. Further neurological dysfunction may occur secondary to Chiari II malformation and hydrocephalus. MMC repair is typically performed postnatally within the first 24 to 48 hours of life due to the concern for infection. Prenatal MMC correction is performed in select cases after studies showed improved neurological outcomes. Anesthesia for MMC repairs can be challenging, and appropriate screening should be performed preoperatively. During postnatal repair, care must be taken when positioning the infant to avoid any pressure on the MMC sac. Anesthesia can be maintained with a combination of inhalational agents and intravenous opioids. Prenatal MMC repairs must consider both fetal and maternal safety outcomes. They can be performed through both open and fetoscopic routes, with anesthesia focused on maintaining maternal blood pressure, optimizing uterine relaxation, and adequate pain control.
Neonatal Epidural
Authors: Moore David L. , Goldschneider Kenneth R.
Published: October 2018

Pain stemming from major surgery in neonates can be treated with epidural analgesia. The size of the infants strongly suggests alterations in technique from approaches used in adults. Furthermore, advances in technology have prompted use of ultrasound as a means of confirming catheter placement, though stimulation and fluoroscopic means can also be used. The three main approaches to placement of epidurals are at-level insertion, caudal catheter, and low lumbar (modified Taylor technique) placement. Each approach has pros and cons, which are reviewed below. Risks and technical aspects particular to neonates and young infants are presented as well as the use of various imaging techniques to assure ideal placement and maximal benefit.
Perioperative Management of the Child Following an Extremity Amputation
Authors: Sinton Jamie W.
Published: October 2018

Postamputation pain is multifactorial in nature. Pain often begins prior to the surgical amputation and can be related to trauma or malignancy. Types of pain experienced include nociceptive, neuropathic, phantom, and stump. Control of pain preoperatively and acutely in the postoperative phase, may prevent the conversion from acute to chronic pain. Each patient undergoing amputation experiences nociceptive pain due to surgery, and the overwhelming majority experience neuropathic and phantom limb pain as well. Goal-targeted pain therapies can reduce pain burden perioperatively. Multimodal analgesia begins preoperatively with antineuropathic agents; continues intraoperatively with regional anesthetics, anti-inflammatories, and opioid therapy; and continues for approximately 6 weeks postoperatively with nonpharmacologic and continued pharmacologic therapy.
Muscular Dystrophy
Authors: Kreeger Renee , Spaeth James P.
Published: October 2018

Duchenne muscular dystrophy (DMD) is a complex disease characterized by multiple physiologic perturbations, progressively leading to cardiomyopathy, respiratory failure, and, eventually, death. Patients with DMD create unique challenges for the anesthesia team, including management of a difficult airway, avoidance of volatile anesthetics and succinylcholine, the need for respiratory support, and discussion of advance directives. A thorough and multidisciplinary collaborative approach must be utilized in the care of these patients for the entire perioperative period. This chapter uses a case example of a 17-year-old boy with DMD who presents for preoperative anesthesia consultation in anticipation of percutaneous endoscopic gastrostomy tube placement.
Osteogenesis Imperfecta
Authors: Kakascik Aimee G.
Published: October 2018

Osteogenesis imperfecta (OI) is a genetic disorder that affects collagen formation and ultimately leads to increased bone fragility. The fragile nature of the bones leads to fractures, even from seemingly normal patient care. Affected patients are at the highest risk for unintentional fractures during perioperative care. There are several different types of OI. Type I is the most common. With the different types come varying degrees of severity. Types II and III are the more severe forms. The classic clinical triad seen in OI is blue sclerae, multiple fractures, and conductive hearing loss. The patient may have other systemic involvement beyond the fragile musculoskeletal system. It is imperative that the anesthesiologist be well-versed in the natural history and perioperative management of patients with OI in order to optimize care and minimize complications.
Accidental Awareness under General Anesthesia
Authors: Williams Erin S.
Published: October 2018

Accidental awareness, traditionally termed “awareness” while under general anesthesia, is perhaps the most feared complication of both patients and anesthesiologists alike. Awareness under anesthesia can result in severe physical and psychological pain and may predispose the patient to posttraumatic stress disorder. Reports of awareness, without recall of specific intraoperative events, has not been shown to have significant negative physical and/or psychological outcomes. However, it is the reports of actual awareness under very minimal anesthesia such as a patient who may have received muscle relaxants without accompanying inhalational anesthesia that are often associated with significant negative consequences. Such patients are able to provide specific details of the intraoperative and/or surgical period. The anesthesiologist must be careful to consistently assess and monitor the patient during surgery in order to avoid unintended awareness.
Acute Pain Management
Authors: Patel Nihar
Published: October 2018

Age-appropriate pain assessment and management is vital in the care of children with acute pain. Pain in children should be routinely and regularly assessed, documented, treated and reassessed with clear documentation. Poor pain management in the acute and postoperative setting can result in both short- and long-term consequences. The most effective analgesia plans are multimodal. This chapter focuses on the variety of treatment options for pain in the acute setting. Topics covered include age-appropriate pain assessment tools for children; the basics of age-appropriate pain management in children; as well as the role of opioids, nonsteroidal anti-inflammatory drugs, and patient-controlled analgesia in acute and postoperative pain management in children.
Postoperative Nausea and Vomiting in Patients with Prolonged QTc
Authors: Adler Adam C. , Watcha Mehernoor
Published: October 2018

Postoperative nausea and vomiting (PONV) is a very common complication after a general anesthetic. In some cases the feeling of nausea has been accredited to being worse than the actual pain. There are a number of medications that can be utilized to combat PONV. Of note, some of these agents can lead to cardiac arrhythmias. It is imperative to know which drugs may predispose patients to arrhythmias such as prolonged QT intervals as well as how to prevent or treat PONV in the patient with prolonged QT interval. This chapter discusses the basics of cardiac electrophysiology regarding the QT interval and the risks to the patient when it becomes prolonged, explains the potential effects of first- and second-generation 5-HT3 receptor antagonists on cardiac repolarization, and reviews currently used antiemetics and anticipated future developments in this field.