1556 SECTION XIV Pediatric Critical Care Anesthesia Principles in the Pediatric Intensive Care Unit the CO2 absorbent, and high concentrations of potassium or so dium hydroxides in the CO2 absorbent A[.]
1556 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit the CO2 absorbent, and high concentrations of potassium or sodium hydroxides in the CO2 absorbent Although of potential concern when studied in laboratory animals, there are no clinical data to suggest the nephrotoxic potential of compound A, suggesting that such concerns should not limit the use of sevoflurane even in patients with preexisting renal dysfunction Neuromuscular Blocking Agents See to Chapter 131 for a complete review of the use of NMBAs This section deals briefly with the aspects of NMBA administration that relate specifically to perioperative anesthetic care Intraoperatively, skeletal muscle relaxation may be required for the successful completion of a surgical procedure (exploratory laparotomy), may be required briefly for endotracheal intubation, or may be used to ensure patient immobility in situations in which inadvertent movement may be detrimental (craniotomy) Although frequently administered during the perioperative period, many surgical procedures can be performed without the administration of NMBAs NMBAs have no effect on the level of consciousness, provide neither amnesia nor analgesia, and not alter the dose of other medications required to induce and maintain general anesthesia When NMBAs are used, the patient requires an adequate level of general anesthesia and, in the ICU, an adequate level of sedation This is especially important because clinical signs of inadequate anesthesia (movement) are abolished It is also important to recognize that the airway must be controlled when NMBAs are used These agents are contraindicated if there is any concern regarding one’s ability to control ventilation and provide endotracheal intubation One additional caveat regarding the administration of NMBAs is that although problems are rare, NMBAs are high on the list of agents responsible for intraoperative anaphylactoid reactions (along with antibiotics and latex) Albeit rare, these anaphylactoid reactions are most common with succinylcholine and rocuronium Neuromuscular blockade may be used only to facilitate endotracheal intubation or may be continued throughout the surgical procedure to provide surgical relaxation When ongoing neuromuscular blockade is required, incremental doses, which are approximately one-fourth to one-fifth of the initial intubating dose, are administered based on the response obtained using neuromuscular blockade monitoring Alternatively, a continuous infusion of short- or intermediate-acting agents is occasionally used Given that repetitive doses or an infusion may result in excessive levels of neuromuscular blockade, monitoring of neuromuscular transmission is used to predict optimal conditions for endotracheal intubation, adequacy of surgical muscle relaxation, effectiveness of reversal of neuromuscular blockade, and to guide dosing of NMBAs during intraoperative care The goal of such monitoring is to allow incremental titration of NMBAs to maintain the desired level of blockade while maintaining sufficient neuromuscular function to allow reversal of a residual neuromuscular blockade at the completion of the surgical procedure To monitor a neuromuscular blockade, a supramaximal electrical stimulation from a peripheral nerve stimulator is delivered to electrodes placed over the distribution of the peripheral nerve This can be accomplished using the ulnar nerve at the wrist or elbow, the common peroneal nerve as it passes over the head of the fibula, or the facial nerve As any of these methods involve electrical stimulation, they are painful and should be performed only in an appropriately anesthetized patient Although various patterns of electrical stimulation of the peripheral nerve (single twitch, train-of-four [TOF], double burst suppression, tetanus, and posttetanic stimulation) have been advocated in the literature, TOF monitoring remains the technique used most commonly in clinical anesthesia practice Two electrical stimuli are delivered each second for seconds to give four twitches, or a train-of-four Despite its acceptance and use in everyday anesthesia practice, TOF monitoring is relatively nonspecific in that up to 70% to 80% of the acetylcholine receptors must be blocked in order to achieve any visible decrement in the TOF The goal of monitoring is to ensure that some residual neuromuscular function is present at the completion of the surgical procedure so that the effects can be reversed The goal of reversal is for the patient to sustain minute ventilation and maintain a patent airway to allow for tracheal extubation.139,140 In most clinical circumstances, one or two twitches of the TOF must be present to allow for effective pharmacologic reversal A TOF of 0.7 or greater, in which the fourth twitch is 70% or more of the height of the first twitch, is evidence of adequate reversal Other tests of adequacy of reversal include a sustained response to tetanus, a sustained head lift for to 10 seconds, and strong grip strength In infants, sustained hip flexion is a useful clinical sign Patients demonstrating profound blockade (no response to electrical stimulation) should not be reversed until some evidence of return of neuromuscular function has occurred Despite adequate reversal, recurrence of partial paralysis resulting in respiratory insufficiency or upper airway obstruction may occur during the postoperative period Reversal of residual neuromuscular blockade is accomplished by the administration of medications that inhibit acetylcholinesterase (edrophonium, neostigmine, or pyridostigmine) With the inhibition of acetylcholinesterase, acetylcholine accumulates at the nicotinic (neuromuscular junction) and muscarinic sites, increasing the competition between acetylcholine and the NMBA for the a subunits of the nicotinic cholinergic receptor As these medications also inhibit acetylcholinesterase at muscarinic sites, they must be coadministered with an anticholinergic agent such as atropine or glycopyrrolate to prevent bradycardia or asystole An inadequate response to the anticholinesterase medication with residual weakness may be secondary to excessive blockade at the time of reversal, allowing inadequate time since the administration of the reversal drug, an altered acid–base or electrolyte status, hypothermia, effects of other medications, or impaired clearance of NMBAs from the plasma secondary to renal or hepatic dysfunction The basic clinical practice as it pertains to the reversal of neuromuscular blockade has recently been changed by the novel pharmacologic agent, sugammadex (Bridion).141 Sugammadex received approval for clinical use in adults from the US Food and Drug Administration (FDA) in December 2015 Its unique mechanism of action differs completely from acetylcholinesterase inhibitors It encapsulates rocuronium or vecuronium, providing rapid and complete recovery even with profound or complete neuromuscular blockade, with limited residual neuromuscular function It is the first noncompetitive antagonist for the reversal of neuromuscular blockade Its unique chemical structure forms a one-to-one complex with rocuronium, encapsulating the drug in the plasma, reducing its effective concentration at the neuromuscular junction, thereby reversing neuromuscular blockade Although it has not yet received FDA approval for use in pediatric patients, prospective trials in children have demonstrated a more rapid onset and more effective reversal of rocuronium-induced neuromuscular blockade than neostigmine Reversal of neuromuscular blockade with sugammadex offers the advantage of a CHAPTER 129 Anesthesia Principles and Operating Room Anesthesia Regimens decreased incidence of residual neuromuscular blockade, and it may be advantageous in clinical situations in which reversal of neuromuscular blockade is problematic, including in patients with intense residual blockade, in the presence of hypothermia, and in those with myopathic conditions and increased sensitivity to NMBAs Sugammadex may be clinically advantageous in certain conditions in which acetylcholinesterase inhibitors are relatively contraindicated, including myotonic dystrophy and in cardiac transplantation patients In the adult population, reversal of either vecuronium- or rocuronium-induced neuromuscular blockade has been reported although the pediatric data is generally limited to reversal of rocuronium-induced neuromuscular blockade Intraoperative Anesthetic Care Maintenance Anesthesia This chapter has discussed the perioperative care of a surgical patient from the preoperative evaluation through premedication, monitoring, and the induction of general anesthesia Once the airway has been secured and ventilation/oxygenation established, maintenance anesthesia is provided for the duration of the surgical procedure Given the variety of inhalational anesthetic agents, intravenous anesthetic agents, opioids, and NMBAs available, several combinations of agents can be used to provide the prerequisites of general anesthesia The choice of agent varies widely and is determined by the personal preferences and experiences of the anesthesia provider; the patient’s comorbid features, such as the patient’s underlying CV function; the anticipated duration of the surgical procedure; the postoperative requirements (whether the patient’s trachea will be extubated at the completion of the procedure and whether ongoing postoperative analgesia is required); and the operative setting (whether rapid turnover of cases is desirable and whether rapid awakening and hospital discharge are needed) In most scenarios, the baseline level of anesthesia is provided by either a potent inhalational anesthetic agent or a propofol infusion and supplemented with intermittent dosing or a continuous infusion of an opioid If ongoing neuromuscular blockade is required, a continuous infusion of a short-acting agent or intermittent dosing of an intermediate- to long-acting agent can be used Although controlled ventilation is most commonly practiced, there are many surgical procedures for which spontaneous ventilation is acceptable The use of spontaneous ventilation is more common in the outpatient setting, in which endotracheal intubation is less common and general anesthesia is administered using a mask or a laryngeal mask airway In addition to the commonly monitored hemodynamic parameters, spontaneous ventilation supplies an effective means of evaluating the depth of anesthesia through the assessment respiratory rate and pattern, providing the optimal parameter for the titration of opioids When spontaneous ventilation is used, opioids can be dosed based on the patient’s respiratory rate to ensure that an appropriate amount is administered to provide postoperative analgesia while avoiding overdosing and postoperative respiratory depression Intraoperative Fluid Management In addition to monitoring hemodynamic and respiratory function, the anesthesiologist must also maintain fluid, electrolyte, and glucose homeostasis during anesthetic care Intraoperative 1557 fluid management uses isotonic crystalloid solutions such as lactated Ringer (LR), normal saline (NS), or Plasmalyte to provide ongoing maintenance fluids and replace preoperative deficits, intraoperative third-space losses, and blood losses when blood therapy is not necessary Third-space losses may be relatively trivial during superficial procedures (2–3 mL/kg per hour) or significant (10–15 mL/kg per hour) for intraabdominal procedures Although generally considered an isotonic fluid, LR has only 130 mEq of sodium per liter Therefore, it is relatively contraindicated in patients at risk for cerebral edema, such as the patient with a traumatic brain injury Large volumes of NS, although effective in supporting serum sodium, can result in a dilutional acidosis These issues have led to the consideration of using a combination of NS and LR or the use of a more balanced solution, such as Plasmalyte, which contains 140 mEq/L of sodium as well as physiologic amounts of chloride and gluconate/ acetate as buffers Given their distribution between the intravascular and extravascular space, if blood is not administered, blood loss is routinely replaced as mL of crystalloid for each mL of blood loss Alternatives to isotonic crystalloid solutions include synthetic and natural colloids, such as hydroxyethyl starch, albumin, or gelatins The latter are not currently available in the United States As with resuscitation in other areas, there are currently no studies demonstrating the superiority of any of these solutions over standard isotonic crystalloids, and it is likely that the crystalloid-colloid debate will continue for many years Potential drawbacks to the use of hydroxyethyl starch solutions include the potential for platelet dysfunction when amounts greater than 15 to 20 mL/kg are administered This reversible platelet dysfunction results from alterations in the efficacy of von Willebrand factor by the hydroxyethyl starch solutions Furthermore, studies in the adult population have demonstrated an increased incidence of acute kidney injury when these products are administered intraoperatively.142 During the postoperative period, especially in pediatric patients, given the potential for the development of postoperative hyponatremia, only isotonic fluids should be administered.143 Fluids with a lower tonicity are rarely if ever indicated For short surgical procedures when a Foley catheter is not inserted, aggressive fluid therapy with replacement of the preoperative deficit is not necessarily required because bladder distention during emergence from anesthesia may be uncomfortable for the patient Additionally, specific surgical procedures, such as intracranial neurosurgical and thoracic procedures, or patients with underlying CV dysfunction may mandate that the patient “be kept dry” to improve the intraoperative and postoperative course However, in many other surgical procedures—especially intraabdominal cases, burn debridement, or other cases with significant third-space losses—the administration of significant amounts of isotonic crystalloids may be required to maintain intravascular volume status Except for the neonatal population or patients chronically receiving parenteral nutrition fluids, dextrose-containing fluids are rarely administered In high-risk patients, those receiving glucosecontaining fluids, and patients with diabetes mellitus, intermittent monitoring of blood glucose may be indicated Such monitoring has been greatly facilitated by the ready availability of pointof-care testing for glucose Although a review of the perioperative care of the diabetic patient is beyond the scope of this chapter, evidence in the adult literature has suggested that the postoperative outcome for such patients may be improved by tight perioperative glucose control 1558 S E C T I O N X I V Pediatric Critical Care: Anesthesia Principles in the Pediatric Intensive Care Unit Postoperative Care Postoperative Analgesia Various factors may interfere with the delivery of effective postoperative analgesia Inadequate pain relief following surgery generally results from inappropriate methods of administration rather than ineffective analgesic agents Although frequently used in the past for the delivery of opioids in postoperative pain management, the intramuscular route should be abandoned as several factors result in inadequate analgesia, including variable absorption and unpredictable plasma opioid concentrations in addition to the child’s reluctance to ask for pain medication due to the pain associated with intramuscular injections.144 Fortunately, acute and postoperative analgesia has been an area of intense research, which has resulted in the development of new techniques and the refinement of treatment strategies Current modalities to provide better postoperative analgesia include intravenous patient-controlled analgesia (PCA), nurse-controlled analgesia (NCA), and the epidural or spinal application of local anesthetic agents or opioids.145 Although introduced first into the adult population, these techniques are now widely applied across all age ranges in pediatric patients PCA involves the self-administration of small doses of opioids to obtain and maintain analgesia Analgesia occurs when the plasma opioid concentration reaches the minimum effective analgesic concentration (MEAC) With PCA, patients are able to titrate the opioid to their own MEAC and can thereby maintain consistent analgesia.146–148 Numerous studies have demonstrated improved analgesia, fewer adverse effects, and decreased opioid consumption with the use of PCA Prior to the initiation of PCA, the patient receives a loading dose of the opioid administered either intraoperatively or postoperatively as multiple small doses of an opioid to achieve the MEAC Once this is accomplished, the PCA is started and a dose of opioid is self-administered at a specific interval or lockout period (generally 5–10 minutes) as needed by the patient Additionally, a continuous infusion can be added to the PCA regimen, although it has been suggested that this negates the safety feature of PCA in which no opioid is delivered if the patient is too sleepy to push the button An alternative to PCA is nurse-controlled analgesia With NCA, the same bolus and infusion are set, but the bedside nurse, instead of the patient, activates the device NCA may be used in children who are too young or lack the needed cognitive function to use PCA Although practices vary, continuous monitoring with pulse oximetry is generally recommended when PCA or NCA is used in the pediatric patient In addition to opioids, acetaminophen and nonsteroidal antiinflammatory agents (NSAIDs) play a significant role in the control of postoperative pain NSAIDs, acetaminophen, and salicylates act through the inhibition of the enzyme cyclooxygenase, blocking the synthesis of prostaglandins In distinction to opioids, these agents demonstrate a ceiling effect so that once a specific plasma concentration is achieved, no further analgesia is provided by increasing the dose These agents are classified according to their chemical structure as (1) para-aminophenol derivatives (acetaminophen), (2) NSAIDs (ibuprofen), and (3) salicylates (acetylsalicylic acid, choline magnesium trisalicylate).149 When considering the para-aminophenol derivatives, acetaminophen has a significant role in the management of acute pain, whereas phenacetin is no longer used given its potential toxicity profile (renal papillary necrosis) Although previously available only as an oral or rectal medication in the United States, acetaminophen is now also available for intravenous administration Commonly used NSAIDs include either ibuprofen for oral administration or ketorolac for intravenous administration An intravenous preparation of ibuprofen has received approval of the FDA for the treatment of pain and the control of fever in adults Regional anesthetic techniques, including either neuraxial blockade (epidural or spinal analgesia) or peripheral nerve blockade, can be continued into the postoperative period to provide effective analgesia while avoiding the potential adverse effects associated with parenteral opioid therapy Epidural and spinal local anesthetics provide profound analgesia; however, undesirable side effects of the use of high concentrations of local anesthetics include blockade of the sympathetic nervous system with hypotension, urinary retention, blockade of motor function, and risks of local anesthetic toxicity from systemic absorption Epidural and spinal opioids can provide intense, segmental, localized analgesia without sensory, motor, or sympathetic nervous system effects, although their adverse effects profile may include respiratory depression, nausea, pruritus, sedation, and urinary retention As a result, a combination of low-dose epidural local anesthetics and opioids is commonly used to take advantage of their synergistic effects and limit the side effects of each Fentanyl and morphine are commonly used opioids, and bupivacaine is the usual local anesthetic of choice The lipid solubility of the opioid predicts its clinical behavior Fentanyl is very lipid soluble, penetrating the dura and rapidly binding to spinal cord opioid receptors, producing a fast onset of action but a short duration of action Significant vascular absorption of fentanyl also occurs, decreasing its epidural effect and reducing its advantage over parenteral administration Morphine is lipid insoluble and has a slower onset of action but a much longer duration of action However, given its hydrophilic nature, morphine remains in the cerebrospinal fluid for a longer period of time with cephalad spread and the risks of delayed respiratory depression for up to 24 hours after neuraxial administration, mandating ongoing monitoring of respiratory function during this time Other methods of postoperative analgesia include the use of long-acting local anesthetic agents for either wound infiltration or peripheral nerve blockade Examples of peripheral nerve blockade include brachial plexus blocks for upper extremity pain, femoral nerve blocks for femur and knee surgeries, sciatic nerve blocks for analgesia below the knee, and intercostal nerve blocks for thoracic and abdominal surgeries Options include the placement of a catheter to allow for a continuous infusion during the postoperative period and to provide long-term analgesia for up to to days Conclusions The perioperative care of pediatric patients begins with the preparation of the operating room site as well as the preoperative evaluation of the patient The complexity of the latter varies tremendously based on the presence of comorbid conditions These coexisting conditions and the requirements of the surgical procedure influence the techniques used for intraoperative monitoring In its simplest form, general anesthesia includes amnesia, analgesia, muscle relaxation, and attenuation of the sympathetic nervous system’s response to surgical trauma The phases of general anesthesia include induction, maintenance, and emergence The induction of anesthesia can be carried out with the intravenous administration of an anesthetic agent or via the inhalation route with an inhalational anesthetic agent such as sevoflurane In pediatric patients, the inhalation induction of anesthesia is frequently chosen to avoid the need for obtaining intravenous access on an awake child Following CHAPTER 129 Anesthesia Principles and Operating Room Anesthesia Regimens anesthetic induction, one progresses into the maintenance phase of general anesthesia This may include the administration of intravenous agents, inhalational agents, or, most likely, a combination of the two Following the successful completion of the surgical procedure, a plan is determined for the postoperative delivery of analgesia, including some combination of intravenous opioids, agents to inhibit prostaglandin formation, or a regional anesthetic technique For complex surgical procedures, tracheal intubation and mechanical ventilation may be continued into the postoperative period, whereas a combination of tracheal extubation and the resumption of spontaneous ventilation is the general rule for the majority of surgical procedures Regardless of the type of anesthesia administered, close monitoring of hemodynamic and respiratory function is continued into the postoperative period either in the ICU or in a specialized postanesthesia care unit Key References American Society of Anesthesiologists Committee Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients 1559 undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters Anesthesiology 2017;26:376-393 Bhanaker SM, Ramamoorthy C, Geiduschek JM, et al Anesthesiarelated cardiac arrest in children: update from the pediatric perioperative cardiac arrest registry Anesth Analg 2007;105:344-350 Bryant J, Krishna SG, Tobias JD The difficult airway in pediatrics Advan Anesth 2013;31:31-60 Neil JM, Barrington MJ, Fettiplace MR, et al, The 3rd American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity Reg Anesth Pain Med 2018;43: 113-123 Tobias JD Preoperative anesthesia evaluation Semin Pediatr Surg 2018; 27:67-74 Tobias JD Caudal epidural block: test dosing and recognition of systemic injection Anesth Analg 2001;14:345-352 Tobias JD Inhalational anesthesia: basic pharmacology, end organ effects, and applications in status asthmaticus J Intensive Care Med 2009;24:361-371 Tobias JD Rapid sequence intubation: what does it mean? Does it really matter? Saudi J Anaesth 2014;8:153-154 The full reference list for this chapter is available at ExpertConsult.com e1 References Tobias JD Cervical plexus block in adolescents J Clin Anesth 1999;11:606-608 Tobias JD Brachial plexus anesthesia in children Paediatr Anaesth 2001;11:265-275 Tobias JD Regional anesthesia of the lower extremity in infants and children Paediatr Anaesth 2003;13:152-163 Fauteux-Lamarre E, Burstein B, Cheng A, Bretholz A Reduced length of stay and adverse events using bier block for forearm fracture reduction in the pediatric emergency department Pediatr Emerg Care 2019;35:58-62 Aarons CE, Fernandez MD, Willsey M, Peterson B, Key C, Fabregas J Bier block regional anesthesia and casting for forearm fractures: safety in the pediatric emergency department setting J Pediatr Orthop 2014;34:45-49 Tobias JD Caudal epidural block: test dosing and recognition of systemic injection Anesth Analg 2001;14:345-352 Tobias JD Spinal anesthesia in infants and children Paediatr Anaesth 2000;10:5-16 Whitaker E, Wiemann BZ, DaJusta DG, et al Spinal anesthesia for pediatric urological surgery: Reducing the theoretic neurotoxic effects of general anesthesia J Pediatr Urol 2017;13:396-400 Tobias JD, Ross AK Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use Anesth Analg 2010;110: 391-401 10 Bhanaker SM, Ramamoorthy C, Geiduschek JM, et al Anesthesiarelated cardiac arrest in children: update from the pediatric perioperative cardiac arrest registry Anesth Analg 2007;105:344-350 11 Bryant J, Krishna SG, Tobias JD The difficult airway in pediatrics Advan Anesth 2013;31:31-60 12 Tobias JD Preoperative anesthesia evaluation Semin Pediatr Surg 2018;27:67-74 13 Bock M, Fritsch G, Hepner DL Preoperative laboratory resting Anesthesiol Clin 2016;34:43-58 14 Edwards AF, Forest DJ Preoperative laboratory testing Anesthesiol Clin 2018;36:493-507 15 Burk CD, Miller L, Hander SD, Cohen AR Preoperative history and coagulation screening in children undergoing tonsillectomy Pediatrics 1992;89:691-695 16 Warner MA, Warner ME, Weber JG Clinical significance of pulmonary aspiration during the perioperative period Anesthesiology 1993;78:56-62 17 Kallar SK, Everett LL Potential risk and preventive measure for pulmonary aspiration: new concepts in preoperative fasting guidelines Anesth Analg 1993;77:171-182 18 Crawford M, Lerman J, Christensen S, et al Effects of duration of fasting on gastric fluid pH and volume in healthy children Anesth Analg 1990;71:400-403 19 Shevde K, Trivedi N Effects of clear liquids on gastric volume and pH in healthy volunteers Anesth Analg 1991;72:528-531 20 Phillips S, Hutchinson S, Davidson T Preoperative drinking does not affect gastric contents Br J Anaesth 1993;70:6-9 21 Read MS, Vaughn RS Allowing pre-operative patients to drink: effects on patients’ safety and comfort of unlimited oral water until hours before anaesthesia Acta Anaesthesiol Scand 1991;35:591-595 22 Goresky GV, Maltby JR Fasting guidelines for elective surgical patients Can J Anaesth 1990;37:493-495 23 Strunin L How long should patients fast before surgery? Time for new guidelines Br J Anaesth 1993;70:1-2 24 Green CR, Pandit SK, Schork MA Preoperative fasting time: is the traditional policy changing? Results of a national survey Anesth Analg 1996;83:123-128 25 Thomas M, Morrison C, Newton R, Schindler E Consensus statement on clear fluids fasting for elective pediatric general anesthesia Paediatr Anaesth 2018;28:411-414 26 American Society of Anesthesiologists Committee Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters Anesthesiology 2017;26:376-393 27 Jones CT, Raman VT, DeVries S, et al Optimizing anticonvulsant administration for children before anesthesia: a quality improvement project Pediatr Neurol 2014;51:632-640 28 Tobias JD Rapid sequence intubation: what does it mean? Does it really matter? Saudi J Anaesth 2014;8:153-154 29 Allen LG, Engelhardt T, Lendrum RA Do not know where to press? Cricoid pressure in the very young Eur J Anaesthesiol 2014;31: 333-334 30 Coté CJ, Cohen IT, Suresh S, et al A comparison of three doses of a commercially prepared oral midazolam syrup in children Anesth Analg 2002;94:37-43 31 Sheta SA, Al-Sarheed MA, Abdelhalim AA Intranasal dexmedetomidine vs midazolam for premedication in children undergoing complete dental rehabilitation: a double-blinded randomized controlled trial Paediatr Anaesth 2014;24:181-189 32 Kraemer FW, Stricker PA, Gurnaney HG, et al Bradycardia during induction of anesthesia with sevoflurane in children with Down syndrome Anesth Analg 2010;111:1259-1263 33 Walia H, Ruda J, Tobias JD Sevoflurane and bradycardia in infants with trisomy 21: a case report and review of the literature Inter J Pediatr Otorhinolaryngol 2016;80:5-7 34 Kozek-Langenecker SA, Marhofer P, Jonas K, et al Cardiovascular criteria for epidural test dosing in sevoflurane- and halothane-anesthetized children Anesth Analg 2000;90:579-583 35 Desparmet J, Mateo J, Ecoffey C, Mazoit X Efficacy of an epidural test dose in children anesthetized with halothane Anesthesiology 1990;72:249-251 36 Varghese E, Deepak KM, Chowdary KV Epinephrine test dose in children: is it interpretable on ECG monitor? Paediatr Anaesth 2009; 19:1090-1095 37 Sivarajan VB, Bohn D Monitoring of standard hemodynamic parameters: heart rate, systemic blood pressure, atrial pressure, pulse oximetry, and end-tidal CO2 Pediatr Crit Care Med 2011;12(suppl 4): S2-S11 38 Eichhorn V, Henzler D, Murphy MF Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room Curr Opin Anaesthesiol 2010;23:494-499 39 Tuman KJ, Roizen MF Outcome assessment and pulmonary artery catheterization: why does the debate continue? Anesth Analg 1997; 84:1-4 40 Connors AF, Speroff T, Dawson NV, et al The effectiveness of right heart catheterization in the initial care of critically ill patients JAMA 1996;276:889-897 41 American Society of Anesthesiologists Practice guidelines for pulmonary artery catheterization Anesthesiology 1993;78:380-392 42 American Society of Anesthesiologists Practice guidelines for preoperative transesophageal echocardiography Anesthesiology 1996;84: 986-1006 43 Ekman A, Lindholm ML, Lennmarken C, et al Reduction in the incidence of awareness using BIS monitoring Acta Anaesthesiol Scand 2004;48:20-26 44 Myles PS, Lelie K, McNeil J, et al Bispectral index monitoring to prevent awareness during anaesthesia: the B-aware randomized control trial Lancet 2004;363:1757-1763 45 Gan TJ, Glass PS, Windsor A, et al Bispectral index monitoring allows faster emergence and improved recovery from propofol, alfentanil and nitrous oxide anesthesia Anesthesiology 1997;87:808-815 46 Guignard B, Coste D, Menigaux C, et al Reduced isoflurane consumption with bispectral index monitoring Acta Anaeshtesiol Scand 2001;45:308-314 47 Courtman SP, Wardurgh A, Petros AJ Comparison of the bispectral index monitor with the COMFORT score in assessing level of sedation of critically ill children Intensive Care Med 2003;29: 2239-2246 ... maintenance fluids and replace preoperative deficits, intraoperative third-space losses, and blood losses when blood therapy is not necessary Third-space losses may be relatively trivial during superficial... rocuronium-induced neuromuscular blockade Intraoperative Anesthetic Care Maintenance Anesthesia This chapter has discussed the perioperative care of a surgical patient from the preoperative evaluation... patients with intense residual blockade, in the presence of hypothermia, and in those with myopathic conditions and increased sensitivity to NMBAs Sugammadex may be clinically advantageous in