RESUMEN
PURPOSE OF REVIEW: This article reviews the development of simulation-based training strategies to educate sedation providers. RECENT FINDINGS: Medical simulation has been utilized to train and evaluate providers in numerous domains related to sedation. Sedation providers come to the patient with a wide range of clinical training and experience and simulation can serve as a platform for achieving a baseline skill level and for periodic retraining. Although widely accepted by participants in simulation training, data demonstrating simulation's efficacy in improving sedation-related clinical outcomes are lacking. SUMMARY: Simulation provides an opportunity for sedation providers to develop deliberative practice, to consider rare or challenging clinical conditions, and to benefit from directed feedback, in a manner that does not put patients in harm's way.
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Simulación por Computador , Sedación Consciente , Educación Médica/métodos , Niño , Competencia Clínica , Humanos , Guías de Práctica Clínica como AsuntoAsunto(s)
Dolor Agudo , Procedimientos Quirúrgicos Cardíacos , Bloqueo Nervioso , Cirugía Torácica , Adulto , Analgésicos Opioides , Niño , HumanosAsunto(s)
Anestesiología/educación , Internado y Residencia , Pediatría/educación , Competencia Clínica , Becas , HumanosRESUMEN
BACKGROUND: Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications in children, including pulmonary hypertensive crisis and cardiac arrest. Uncertainty remains about the safety of ketamine anesthesia in this patient population. AIM: Retrospectively review the medical records of children with PAH to ascertain the nature and frequency of peri-procedural complications and to determine whether ketamine administration was associated with peri-procedural complications. METHODS: Children with PAH (mean pulmonary artery pressure > or =25 mmHg and pulmonary vascular resistance index > or =3 Wood units) who underwent general anesthesia for procedures during a 6-year period (2002-2008) were enrolled. Details about the patient, PAH, procedure, anesthetic and postprocedural course were noted, including adverse events during or within 48 h of the procedure. Complication rates were reported per procedure. Association between ketamine and peri-procedural complications was tested. RESULTS: Sixty-eight children (median age 7.3 year, median weight 22 kg) underwent 192 procedures. Severity of PAH was mild (23%), moderate (37%), and severe (40%). Procedures undertaken were major surgery (n = 20), minor surgery (n = 27), cardiac catheterization (n = 128) and nonsurgical procedures (n = 17). Ketamine was administered during 149 procedures. Twenty minor and nine major complications were noted. Incidence of cardiac arrest was 0.78% for cardiac catheterization procedures, 10% for major surgical procedures and 1.6% for all procedures. There was no procedure-related mortality. Ketamine administration was not associated with increased complications. CONCLUSIONS: Ketamine appears to be a safe anesthetic option for children with PAH. We report rates for cardiopulmonary resuscitation and mortality that are more favorable than those previously reported.
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Anestesia General/efectos adversos , Anestésicos Disociativos/efectos adversos , Hipertensión Pulmonar/fisiopatología , Complicaciones Intraoperatorias/fisiopatología , Ketamina/efectos adversos , Adolescente , Presión Sanguínea/fisiología , Procedimientos Quirúrgicos Cardíacos , Reanimación Cardiopulmonar , Niño , Preescolar , Femenino , Paro Cardíaco/complicaciones , Humanos , Hipertensión/complicaciones , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/mortalidad , Hipoxia/complicaciones , Lactante , Recién Nacido , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/mortalidad , Enfermedades Pulmonares/complicaciones , Masculino , Monitoreo Intraoperatorio , Arteria Pulmonar/fisiología , Estudios Retrospectivos , Disfunción Ventricular Izquierda/complicacionesRESUMEN
Perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults. At particular risk are neonates born prematurely, neonates with major or severe congenital heart disease, and neonates with pulmonary hypertension. Presently no consensus exists regarding the safest anesthetic regimen for neonates. Regional anesthesia appears to be safe, but does not reduce the overall risk of postoperative apnea. Former preterm infants require postoperative observation for apnea. The anesthesiologist caring for the neonate for major surgery should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout.
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Anestesia/métodos , Procedimientos Quirúrgicos Operativos/métodos , Anestesia/efectos adversos , Paro Cardíaco/etiología , Humanos , Hipertensión Pulmonar/complicaciones , Recién Nacido/fisiología , Recien Nacido Prematuro , Pulmón/anatomía & histología , Complicaciones Posoperatorias/etiología , Respiración Artificial , Procedimientos Quirúrgicos Operativos/efectos adversosRESUMEN
Tetralogy of Fallot with pulmonary atresia and major aortopulmonary collaterals (TOF/PA/MAPCAs) is a heterogeneous disease with varying degrees of severity, requiring complex anesthetic management. Our institution has adopted the approach of early complete repair with incorporation of all lung segments, extensive lobar and branch segmental pulmonary artery reconstruction, and ventricular septal defect closure. While the surgical management of TOF/PA/MAPCAs has been extensively described and varies depending on the institution, there is a paucity of literature on the anesthetic management for such procedures. Herein, we describe our anesthetic management based on our own institution's surgical approach at Lucile Packard Children's Hospital/Stanford University.
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Anomalías Múltiples/cirugía , Anestesia/métodos , Circulación Colateral , Defectos de los Tabiques Cardíacos/cirugía , Atresia Pulmonar/cirugía , Tetralogía de Fallot/cirugía , Puente Cardiopulmonar/métodos , Humanos , Atención Perioperativa/métodos , Estudios RetrospectivosRESUMEN
BACKGROUND: Many factors contribute to prolonged length of stay (LOS) for pediatric patients in the postanesthesia care unit (PACU). We designed this prospective study to identify the pre- and postoperative factors that prolong LOS. METHODS: We studied 166 children, aged 1-18 yr, who underwent tonsillectomy and adenoidectomy or tonsillectomy and adenoidectomy, and bilateral myringotomy with tube insertion under general anesthesia. The primary outcome measure was the time spent in the PACU until predetermined discharge criteria were met. RESULTS: The number of episodes of postoperative nausea and vomiting, patient age, and number of oxygen desaturations contributed significantly (P < 0.05) to prolonged LOS. Each episode of postoperative nausea and vomiting (P < 0.05) or oxygen desaturation to <95% (P < 0.05) increased the patient's LOS by 0.5 h. History of upper respiratory tract infection, emergence agitation, and parental anxiety did not significantly predict increased LOS. CONCLUSION: This investigation is the first composite view of LOS in pediatric patients. The significance of identifying patients at risk of prolonged LOS prior to anesthesia is of use not only in allocating PACU resource and staffing needs, but also for improving quality of care and ensuring a minimally traumatic anesthetic experience for our pediatric patients and their families.
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Adenoidectomía , Procedimientos Quirúrgicos Ambulatorios , Periodo de Recuperación de la Anestesia , Anestesia General/estadística & datos numéricos , Tonsilectomía , Adenoidectomía/estadística & datos numéricos , Adolescente , Factores de Edad , Procedimientos Quirúrgicos Ambulatorios/estadística & datos numéricos , California/epidemiología , Niño , Preescolar , Estudios de Cohortes , Análisis Factorial , Hospitales Pediátricos/estadística & datos numéricos , Humanos , Lactante , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Oportunidad Relativa , Oxígeno/sangre , Náusea y Vómito Posoperatorios/epidemiología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sala de Recuperación/estadística & datos numéricos , Medición de Riesgo , Factores de Riesgo , Tonsilectomía/estadística & datos numéricos , Membrana Timpánica/cirugíaRESUMEN
BACKGROUND: Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals (PA/VSD/MAPCAs) is a complex form of congenital heart defect. There are limited data regarding late hemodynamics of patients after repair of PA/VSD/MAPCAs. This study evaluated the hemodynamics of patients who underwent complete repair of PA/VSD/MAPCSs and subsequently returned for a conduit change. METHODS: This was a retrospective review of 80 children undergoing a right ventricle (RV)-to-pulmonary artery conduit replacement after complete repair of PA/VSD/MAPCAs. All patients underwent preoperative cardiac catheterization to define the cardiac physiology. Patients were an average age of 6.5±1.2 years, and the average interval between complete repair and conduit change was 4.5±1.1 years. RESULTS: The preoperative cardiac catheterization demonstrated an average RV right peak systolic pressure of 70±22 mm Hg and pulmonary artery pressure of 38±14 mm Hg. This pressure gradient of 32 mm Hg reflects the presence of conduit obstruction. After conduit change, the intraoperative RV systolic pressure was 34±8 mm Hg, similar to 36±9 mm Hg at the conclusion of the previous complete repair. The corresponding RV/aortic pressure ratios were 0.36±0.07 and 0.39±0.09, respectively. CONCLUSIONS: The data demonstrate that patients who underwent complete repair of PA/VSD/MAPCAs had nearly identical pulmonary artery pressures when they returned for conduit change some 4.5 years later. This finding indicates that the growth and development of the unifocalized pulmonary vascular bed is commensurate with visceral growth. We would hypothesize that complete repair, along with low RV pressures, will confer a long-term survival advantage.