Anesthesia, Intensive Care and Pain in Neonates and Children Series Editors:A. Gullo, Catania University Hospital, Catania, Italy M. Astuto, Catania University Hospital, Catania, Italy I. Salvo, “V. Buzzi” Hospital, Milan, Italy Marinella Astuto Editor Basics In cooperation with Luigi Marchiori Silvia Pachera Luca Bortolasi Riccardo Manfredi Paola Capelli 1 3 Marinella Astuto,MD Department of Anesthesia and Intensive Care Pediatric Anesthesia and Intensive Care Section Catania University Hospital Catania,Italy Library of Congress Control Number:2008936497 ISBN 978-88-470-0654-6 Springer Milan Berlin Heidelberg New York e-ISBN 978-88-470-0655-3 Springer is a part of Springer Science+Business Media springer.com ©Springer-Verlag Italia 2009 This work is subject to copyright. 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In every individual case the user must check such infor- mation by consulting the relevant literature. Cover design:Simona Colombo,Milan,Italy Typesetting:Graphostudio,Milan,Italy Printing and binding:Grafiche Porpora,Segrate (MI),Italy Printed in Italy Springer-Verlag Italia S.r.l. – Via Decembrio 28 – I-20137 Milan To my father, who would have been the first and most interested reader of this book, and to Maria, my teacher, both of anesthesia and of life Foreword In March 2006 I took up my new position as Chairman of the Department of Anes- thesia and Intensive Care and Director of the School at the University of Catania,a position that represents an ideal continuity with 30 years of professional teaching at the bed-side involving several hundred students and anesthesiologists in training at Trieste Medical School. In Catania the excellent working group of anesthesiologists established a coop- erative program with the prestigious Children’s Hospital of McGill University in Mon- treal,Canada. Giuliana Rizzo,MD,during 2 years of fellowship in Montreal was interested in taking part actively in a dynamic process of development in clinical anesthesia,in- tensive care and pain management in neonates and children. The excellent background of Giuliana Rizzo gained at the University of Catania in this field favored her appoint- ment to the staff of the Children’s Hospital with autonomy and decision making abil- ity in routine procedures and also in the management of difficult and life-threaten- ing critical care conditions. In September 2007 a special task force coordinated by Marinella Astuto,MD,as clinical leader of the Catania team in pediatric anesthesia,in collaboration with the Montreal group directed by Prof. Ronald Gottsman,organized a 3-day masterclass in pediatric anesthesia,intensive care and pain in which 45 experts from several re- gions of Italy participated. During 2008 the two groups worked actively to finalize the 19 chapters which are collected in the present volume. My hope is that residents and practicing anesthesi- ologists find the contents of this book a useful guide to good clinical practice. Catania,27 September 2008 Prof. Antonino Gullo Director,Department and School of Anesthesia and Intensive Care,Catania School of Medicine,Catania,Italy Council World Federation Societies of Intensive and Critical Care Medicine (WFSICCM) Preface The success of the fellowship program developed by the School of Medicine of Catania in collaboration with McGill University of Montreal led to the organization of the first masterclass in anesthesia,intensive care and pain in neonates and chil- dren,held in September 2007 in Catania with a selected group of participants. An additional remarkable outcome of this cooperation is the present book pub- lished by Springer-Verlag Italia and based on the content of the masterclass includ- ing formal lectures,interactive sessions,case presentation,and problem solving. It is my opinion that anyone who anesthetizes infants and children, who takes care of children in the ICU or who manages pain in children must understand the differences in physiology and clinical pharmacology that exist between children and adults. For many years it has been considered that infants and children are small adults, but in the majority of situations this is no true. The anesthesiologist who fails to understand these differences will have a hard time when facing unex- pected events,and the result could be dangerous for the patient. My goal was to produce a book that provides a basic approach to anesthesia, perioperative medicine, intensive care and pain management in pediatric patients (from the neonate to the child). To reach this goal,I convinced a group of pediatri- cians,experts on infectious diseases,and anesthesiologists to contribute with their talent to pass on their expertise to all allied professionals interested in the field. I thank Prof. Gullo for his enthusiasm and strong support for an exciting and successful initiative. Finally,I am grateful to the residents; I have learned as much from them as they have heard from me. Their curiosity and their interest in improv- ing their knowledge and professional skill shows to all that the mission to achieve excellence may be possible. Catania,27 September 2008 Marinella Astuto,MD Table of Contents List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XIII List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .XVII Part I: Highlights 1 Anatomy and Physiology in Neonates and Children . . . . . . . . . . . . . . . . 3 M. Astuto,A.L. Paratore,A. Gullo 2 Strategy to Manage Pediatric Patients:the Family and the Child . . . . 11 G. Rosano,M. Antoci,M. Astuto 3 Off-Label Drugs in Pediatric Perioperative Medicine . . . . . . . . . . . . . . . 19 M. Astuto,M. Antoci,A. Gullo Part II: Guidelines and Standardization of Procedures 4 The Pediatric Difficult Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 T. Valois 5 Central Venous Cannulation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 N. Disma,M. Astuto 6 Prevention of Bloodstream Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 H.K.F. van Saene,K. Thorburn,A.J. Petros Part III: Perioperative Medicine, Intensive Care, Pain 7 Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 I. Salvo,A. Camporesi XII Table of Contents 8 Anesthesia Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 M. Astuto,D. Lauretta 9 Monitoring the Level of Anesthesia and Sedation in Children: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 N. Disma,A.J. Davidson,M. Astuto 10 Locoregional Anesthesia in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 M. Astuto 11 Perioperative Fluid Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .135 D.E. Withington 12 Adrenal Insufficiency in Pediatric Critical Illness . . . . . . . . . . . . . . . . . . .151 G. Rizzo,K. Menon 13 Perioperative Care in Pediatric Cardiac Surgery . . . . . . . . . . . . . . . . . . .161 J. Lavoie 14 Acute Pain Service:Clinical Assessment and Standard of Care . . . . . .173 J. Desparmet 15 Anesthesia Outside the Operating Room . . . . . . . . . . . . . . . . . . . . . . . . . . .185 T. Valois 16 Tracheotomy in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 G. Rizzo,P. Murabito,F. Rubulotta,C. Cutuli,M. Sorbello,M. Astuto 17 Infection Control in Neonates and Children . . . . . . . . . . . . . . . . . . . . . . . .215 R.E. Sarginson,H.K.F. van Saene,A. Gullo 18 Pediatric Palliative Care in the Intensive Care Unit . . . . . . . . . . . . . . . . .231 S. Liben 19 Chronic Pain Management:Organization, Techniques and Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 J. Desparmet Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .255 List of Contributors Manuela Antoci Department of Anesthesia and Intensive Care,Postgraduate School of Anesthesia and Intensive Care,Catania University Hospital,Catania,Italy Marinella Astuto Department of Anesthesia and Intensive Care,Pediatric Anesthesia and Intensive Care Section,Catania University Hospital,Catania,Italy Anna Camporesi Department of Pediatric Anesthesia and Intensive Care,“V. Buzzi”Hospital, Milan,Italy Carmela Cutuli Department of Anesthesia and Intensive Care,Postgraduate School of Anesthesia and Intensive Care,Catania University Hospital,Catania,Italy Andrew J. Davidson Department of Anesthesia and Pain Management,Royal Children’s Hospital, Melburne,Australia Joëlle Desparmet Acute and Chronic Pain Service (Pediatric),Montreal Children’s Hospital, Montreal,Canada Nicola Disma Department of Anesthesia,Pediatric and Neonatal Intensive Care,“G. Gaslini” Children’s Hospital,Genoa,Italy Antonino Gullo Department of Anesthesia and Intensive Care,Postgraduate School of Anesthesia and Intensive Care,Catania University Hospital,Catania,Italy