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Anesthesiology:
doi: 10.1097/ALN.0000000000000184
Reviews of Educational Material

Current Issues and Controversies in Pediatric Anesthesiology, International Anesthesiology Clinics 50 (4), Fall 2012.

Mukherji, Isabella I. M.D.

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Advances in pediatric anesthesiology are making significant inroads into the current practice of this subspecialty. The cutting-edge information and controversies provided in Current Issues and Controversies in Pediatric Anesthesiology are easy reading and are highly likely to influence the practitioner in his or her clinical decision-making process. The book is a compilation of various topics designed to provide interesting and useful snippets of information that will afford the anesthesiologist involved in care of pediatric patients a basis for more rational, evidence-based management.
The purpose of this book, as the preface explains, is to espouse the “undeveloped, unsettled areas of pediatric anesthesiology, some of which will succeed and become established practice, whereas others will fail and never materialize.” The book succeeds in this goal by presenting multiple topics not covered in anesthesiology texts.
In the chapter on pediatric congenital heart disease, the authors touch upon new technologic advances, such as pediatric ventricular assist device. Because organ transplantation rates have remained stable, the application of pediatric ventricular assist device in children with burgeoning heart failure from congenital heart disease is rapidly expanding, with newer indications for its use. Perioperative genomics is also a new and exciting field, with an emergent role in unveiling new facets of congenital heart disease. It is hoped that genetic testing will help assess and stratify risk and help explain differences in outcomes.
Esoteric topics such as fetal anesthesia for the ex utero intrapartum treatment are likely to captivate readers as hypothetical concepts are translated into practice with unimaginable possibilities. The notion of fetal surgery to palliate or correct congenital fetal anomalies before delivery with intact fetal circulation and uteroplacental support could pose multiple risks and challenges to the anesthesiologist who has to optimize both maternal and fetal circulations. The anesthetic management, in contrast to that of cesarean delivery, is intended to provide uterine relaxation and maintain uteroplacental flow to facilitate fetal surgery.
Among the potpourri of topics is one on the future of pediatric anesthesiology, training, education, and professionalism, which would be of interest to academicians. The authors provide a fresh perspective that highlights key concerns in furthering the goals of the subspecialty. The ubiquity of workplace computers and mobile devices offers anesthesiologists a growing variety of educational content, through textbooks, online journals, clinical forums, and social networking.
The chapter on anesthetic concerns in obstructive sleep apnea syndrome in children is a reminder of the hazards of perioperative management of common procedures, such as adenotonsillectomy. The pathophysiology, perioperative care, and monitoring aspects are reviewed in detail. Interestingly, managing children with severe obstructive sleep apnea who are undergoing magnetic resonance imaging sleep studies poses a challenge as using airway adjuvants are not an option. Dexmedetomidine infusion remains an attractive agent for procedural sedation in these children.
Pediatric liver transplantation is another frontier which is progressively evolving. As with solid-organ failure, finding a bridge to transplant in children with liver failure has remained elusive. Although anesthesiologists are not directly involved in screening recipients for transplant, it is important to review the screening algorithms to identify high-risk patients. Challenges inherent to transplant still remain, including coagulopathy, graft size mismatch, small-for-size syndrome. Post-transplant challenges to management include unstable hemodynamics, technical aspects related to hepatic venous obstruction, biliary tract complications, and graft failure. The pediatric transplant anesthesiologist needs to be familiar with split liver and living-donor liver transplants, because these offer different surgical and anesthetic considerations related to size, preservation techniques, and ischemia time
The existing analgesia protocols and their limitations are reviewed in the chapter on Pediatric Acute and Surgical Pain Management. Understanding of the role of pharmacogenetics in drug response is rapidly evolving. Although pharmacogenetics may account for a significant percentage of drug response variability, the challenge of validating genotype–phenotype associations and incorporating them into decision-making process remains. The authors also clarify that the objectives of establishing standards for meaningful pain control is not to eliminate pain but rather to facilitate rapid return to normal activity and prevent transition of postoperative pain to chronic pain and hyperalgesia. The potential neurotoxicity of opioids suggests the harmful effect of morphine on neurogenesis in newborn babies, but the authors make no firm recommendations regarding its use.
Pediatric palliative care is an emerging field of medicine that focuses on quality of life for children with serious or terminal illness. The authors describe the field as interdisciplinary, with the care model defined by the child’s needs. The authors provide a lot of useful information regarding the criteria for acceptance into pediatric palliative care, which also includes children with complex health care needs. The pediatric palliative care covers a host of topics dealing with end-of-life care issues as well as management of common ailments.
Overall, this book makes interesting reading for the novice and the practiced physician seeking to enhance their knowledge and become familiar with current controversies. The issues and controversies in frontier areas of fetal surgery, cardiac surgery, pain medicine, palliative care, and liver transplant have been appropriately addressed. Although the book is not intended to be used as an essential resource, the readers will quickly appreciate the succinct narrative of the thought-provoking articles that delve into the frontiers of this subspecialty.
Isabella I. Mukherji, M.D.
, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois. imukherji@luriechildrens.org

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