Parents Demand and Teenager Refuses Epidural Anesthesia.

A 15-year-old girl is scheduled to undergo an upper lobectomy to debulk metastatic Ewing sarcoma. The anesthesiologist recommended placement of a thoracic epidural catheter to provide postoperative analgesia. The patient did not want a needle to be placed near her spine. She was terrified that the procedure would be painful and that it might paralyze her. Although the anesthesiologist reassured her that sedation and local anesthesia would make the procedure comfortable, she remained vehemently opposed to the epidural procedure. The parents spoke privately to the anesthesiologist and asked for placement of the epidural after she was asleep. They firmly believed that this would provide optimal postoperative analgesia and thus would be in her best interest. Experts discuss the pros and cons of siding with the patient or parents.

Where should we operate on the preterm neonate?

The ideal venue for neonatal surgical procedures has been the subject of a contentious debate between the leading pediatric hospitals throughout the world. Bias toward the location of neonatal surgery tends to be based on institutional practices. The following opposing viewpoints from two leading pediatric institutions in the United Kingdom and the United States highlight the relevant issues.

Premedication for nonemergency endotracheal intubation in the neonate.

Endotracheal intubation is a common procedure in newborn care. The purpose of this clinical report is to review currently available evidence on use of premedication for intubation, identify gaps in knowledge, and provide guidance for making decisions about the use of premedication.

Ethical concerns in the management of pain in the neonate.

The debate about the management of pain in the neonate has continued to evolve over the past 30 years. This controversy can be understood as evolving through now three eras of thought about the effect of pain and its management in newborns and infants. The first generation was characterized by a widespread belief that newborns lacked the complete development of the neuroanatomical and neuroendocrine components necessary to perceive pain. During this period, newborns often received inadequate anesthesia and analgesia for painful procedures, if not no treatment at all. The second generation was heralded by research that demonstrated that newborns did demonstrate similar or even exaggerated physiological and hormonal responses to pain compared with those observed in older children and adults and that exposure to prolonged or severe pain may increase neonatal morbidity. Controversy in this generation focused around the dosage of analgesia to newborns as well as the risks and benefits of pain management techniques. We are now in a third generation of thought about pain in the neonate, defined by intense debate over the significance of a growing number of studies in immature animal models that demonstrate degenerative effects of several anesthetics on neuronal structure. The challenge of this era is to integrate the advances in diagnosis and treatment achieved in previous generations with ongoing adaptation of clinical practice as dictated by research advances in the field. In this review, we examine the evolution of medical thought and ethical concerns regarding pain treatment in the neonate.

Successful and safe delivery of anesthesia and perioperative care for children with complex special health care needs.

STUDY OBJECTIVE: To determine the utilization of anesthesia resources by children with complex special health care needs. DESIGN: Observational, inception cohort study of medical records. SETTING: Urban, pediatric, tertiary-care hospital. MEASUREMENTS: All general anesthetic cases were screened for preexisting complex special health care needs. Medical records were reviewed for demographic, clinical, and outcome data. MAIN RESULTS: 435 children with complex special health care needs accounted for 479 delivered general anesthetic cases. This figure represented 14% of the total 3,437 cases presenting during the study period. It also represented 22% (49 of 224) of all cancellations. Down syndrome was the most identifiable developmental disorder (n = 43, 9%). Another 143 (30%) cases showed preexisting technology dependence. Scheduled surgical procedures (n = 425, 89%) comprised the majority of cases. Intraoperative and recovery room complications occurred in 6 (1%) and 133 (28%) cases, respectively. Eleven (2.3%) cases required unplanned post-anesthetic hospital ward or pediatric intensive care unit admission. Documentation of health care proxy or resuscitation status was not identified in any child under 18 years, and in only 4 of 33 children older than 18 years. CONCLUSIONS: Children with complex special health care needs represented one out of 7 of all pediatric general anesthetic cases at a tertiary-care, academic center.