Gregory J. Latham

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia.

One of the prices paid for chemo‐ and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three‐part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems‐based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Anesthetic considerations for the pediatric oncology patient - Part 3: Pain, cognitive dysfunction, and preoperative evaluation

In part three of this three‐part review, we continue with discussion of the effects of tumor and its therapy as they impact neurocognitive functioning, psychosocial issues of the patient and family, and the mechanisms and experience of pain in the child with cancer. A discussion of preanesthetic testing and evaluation in this patient population is next presented for the reader, focusing on the factors which pose the commonest and greatest risks to the child undergoing surgery. Lastly, an algorithmic approach to evaluating and managing key components of the medical history of pediatric patients is presented.

High‐frequency micro‐ultrasound for vascular access in young children – a feasibility study by the High‐frequency UltraSound in Kids studY (HUSKY) group

Cannulation of small arteries and veins in young children can be challenging. Although anesthesiologists frequently use ultrasound for placement of central venous lines and nerve blocks, its use for cannulation of small, peripheral vessels is less helpful. Ultrasound systems (7‐15 MHz) currently used in clinical practice focus poorly at the sub‐10‐mm space and thus lack the resolution to allow accurate ultrasound‐guided cannulation of small vessels. High‐frequency micro‐ultrasound (HFMU) is a new technology that allows higher resolution (15–50 MHz) compared with conventional ultrasound. Limited human studies have been performed thus far with HFMU, and none have been performed in young children or for vascular access.

Anesthetic considerations for the pediatric oncology patient – part 1: a review of antitumor therapy

The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should possess a basic understanding of cancer treatment. While this is an ever‐changing field, a basic knowledge of chemotherapeutic drugs, radiation therapy, and the toxicities of each is necessary to prepare a safe anesthetic plan. Such an understanding also assists the anesthesiologist as the perioperative specialist for these children in consultation with the surgeon and oncologist. This article, which is the first of a three‐part review series, will review current principles of cancer therapy and the general mechanisms of toxicity to the child. Although this article is not intended to comprehensively review the fundamentals of chemotherapy and radiation therapy, the consequences of anticancer therapy that impact perioperative care and decision making are presented for the anesthesiologist.

Anesthesia for the Child with Cancer

Children with cancer undergo a host of surgeries and procedures that require anesthesia during the various phases of the disease. A safe anesthetic plan includes consideration of the direct effects of tumor, toxic effects of chemotherapy and radiation therapy, the specifics of the surgical procedure, drug-drug interactions with chemotherapy agents, pain syndromes, and psychological status of the child. This article provides a comprehensive overview of the anesthetic management of the child with cancer, focuses on a systems-based approach to the impact from both tumor and its treatment in children, and presents a discussion of the relevant anesthetic considerations.

Oxymetazoline and hypertensive crisis in a child: can we prevent it?

Oxymetazoline nasal spray is not FDA approved for use in children less than 6 years; however, its safety and efficacy are widely accepted, and it is in widespread use in children prior to procedures that may lead to epistaxis. We report a case of intraoperative oxymetazoline toxicity in a 4‐year‐old boy that led to a hypertensive crisis. While examining the possible causes for this problem, we became aware that the method of drug delivery led to an unanticipated overdose. The position in which the bottle is held causes pronounced variation in the quantity of oxymetazoline dispensed.

Perioperative morbidity in children with elastin arteriopathy.

Children with elastin arteriopathy (EA), the majority of whom have Williams–Beuren syndrome, are at high risk for sudden death. Case reports suggest that the risk of perioperative cardiac arrest and death is high, but none have reported the frequency or risk factors for morbidity and mortality in an entire cohort of children with EA undergoing anesthesia.

Thrombotic complications in children from short-term percutaneous central venous catheters: what can we do?

The reported incidence of venous thromboembolism (VTE) in children has increased dramatically over the past decade, and the primary risk factor for VTE in neonates and infants is the presence of a central venous catheter (CVC). Although the associated morbidity and mortality are significant, very few trials have been conducted in children to guide clinicians in the prophylaxis, diagnosis, and treatment of CVC‐related VTE. Furthermore, pediatric guidelines for prophylaxis and management of VTE are largely extrapolated from adult data. How then should the anesthesiologist approach central access in children of different ages to lessen the risk of CVC‐related VTE or in children with prior thrombosis and vessel occlusion? A comprehensive review of the pediatric and adult literature is presented with the goal of assisting anesthesiologists with point‐of‐care decision‐making regarding the risk factors, diagnosis, and treatment of CVC‐related VTE. Illustrative cases are also provided to highlight decision‐making in varying situations. The only risk factor strongly associated with CVC‐related VTE formation in children is the duration of the indwelling CVC. Several other factors show a trend toward altering the incidence of CVC‐related VTE formation and may be under the control of the anesthesiologist placing and managing the catheter. In particular, because children with VTE may live decades with its sequelae and chronic vein thrombosis, careful consideration of lessening the risk of VTE is warranted in every child. Further studies are needed to form a clearer understanding of the risk factors, prophylaxis, and management of CVC‐related VTE in children and to guide the anesthesiologist in lessening the risk of VTE.

Outcomes of a Failure Mode and Effects Analysis for medication errors in pediatric anesthesia.

The Institute of Medicine has called for development of strategies to prevent medication errors, which are one important cause of preventable harm. Although the field of anesthesiology is considered a leader in patient safety, recent data suggest high medication error rates in anesthesia practice. Unfortunately, few error prevention strategies for anesthesia providers have been implemented. Using Toyota Production System quality improvement methodology, a multidisciplinary team observed 133 h of medication practice in the operating room at a tertiary care freestanding childrens hospital. A failure mode and effects analysis was conducted to systematically deconstruct and evaluate each medication handling process step and score possible failure modes to quantify areas of risk. A bundle of five targeted countermeasures were identified and implemented over 12 months. Improvements in syringe labeling (73 to 96%), standardization of medication organization in the anesthesia workspace (0 to 100%), and two‐provider infusion checks (23 to 59%) were observed. Medication error reporting improved during the project and was subsequently maintained. After intervention, the median medication error rate decreased from 1.56 to 0.95 per 1000 anesthetics. The frequency of medication error harm events reaching the patient also decreased. Systematic evaluation and standardization of medication handling processes by anesthesia providers in the operating room can decrease medication errors and improve patient safety.

Anesthetic Considerations and Management of Transposition of the Great Arteries

Transposition of the great arteries was once an almost uniformly fatal disease in infancy. Six decades of advances in surgical techniques, intraoperative care, and perioperative management have led to at least 90% of patients reaching adulthood, most with a good quality of life. This review summarizes medical and surgical decision making during the neonatal perioperative period, with a special emphasis on factors pertinent to the anesthetic evaluation and care during primary surgical repair of transposition of the great arteries. A review is also provided of anesthetic considerations for noncardiac surgery later in childhood or adulthood, for those survivors of the arterial switch operation, Rastelli procedure, Nikaidoh procedure, and the réparation á l’étage ventriculaire procedure.