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Atkins D, Eccles M, Flottorp S, et al: Systems for grading the quality of evidence and the strength of recommendations. In a flow cytometer, isotonic fluid is forced under pressure into a tube that delivers it to the flow cell, where a fluid column with laminar flow and a high flow rate is generated (socalled sheath fluid). The needle is then slightly withdrawn (to avoid subperiosteal injection) and the local anesthetic (1% or 2% lidocaine without epinephrine) is injected. Panel A (low power) shows bony spicules and marrow in section of bone marrow core biopsy. The distance at which the sciatic nerve is found can be correlated with patient age. Studies on the extracorporeal circulation and oxygenation of blood began many years ago. It has been shown that low temperature with a high hematocrit leads to a higher viscosity. Abdel-Rahman U, et al: Hypoxic reoxygenation during initial reperfusion attenuates cardiac dysfunction and limits ischemiareperfusion injury after cardioplegic arrest in a porcine model, J Thorac Cardiovasc Surg 137(4):978-982, 2009. This being said, it is imperative that the patient have enough blood and blood products (see also Chapter 61) available to perform surgery at any given time. The choice of a scientific explanation, similar to the choice of a statistical test, is always based on a prior understanding of the data and experimental situation. However, because Rmin,rs is the sum of airway resistances and includes the resistance in the ventilatory circuit and the endotracheal tube, a differential diagnosis of an increase in airway resistance should include endotracheal tube obstruction. Advances in prevention and treatment of O2 toxicity may allow more prolonged therapy than can currently be safely administered and hence a more aggressive approach to ischemic and infectious syndromes. Children whose platelet count has decreased because of idiopathic thrombocytopenic purpura or chemotherapy generally tolerate platelet counts as low as 15,000/ mm3 without a need for platelet transfusion. Jamali S, Monin S, Begon C, et al: Clonidine in pediatric caudal anesthesia, Anesth Analg 78:663-666, 1994. Ipratropium bromide, an inhaled anticholinergic, is sometimes paired with intermittent albuterol doses. Return-mail questionnaires can be used for patient follow-up after ambulatory surgery to help identify common sequelae that ambulatory patients should realistically expect to experience. Dorian P, Cass D, Schwartz B, et al: Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation, N Engl J Med 346:884-890, 2002. Booking times may be unrealistic, and scheduling anesthesiology time may be difficult. Commonly used anticonvulsants include lorazepam, phenobarbital, paraldehyde, and phenytoin. In this double-blind study, patients were randomized to receive room air or 100% facemask oxygen delivered at 10 L/min. If, for example, the anesthesiologist supports decreasing blood pressure but fails to tell the interventionalist, the proceduralist might continue under the assumption that all is well when in fact a search for retroperitoneal bleeding is more appropriate. Periodic breathing is also more common in infants, particularly preterm infants, and is probably due to inadequate development of the medullary respiratory centers. Panel B (high power) shows morphologic detail of hematopoietic tissue within the section. In every case involving the use of lasers, the risk of airway fire must be considered and appropriate precautions taken if any appreciable chance of ignition is present. Proposed changes include an increasing component of training in critical care medicine during anesthesia residency. Because of its rapid onset of neuromuscular blockade, succinylcholine is still the muscle relaxant of choice in this circumstance and should be administered at a dose of 1 to 2 mg/kg immediately after thiopental (5 to 6 mg/kg) or propofol (3 mg/kg). Most of the patients underwent thoracic, lumbar, or lumbar-sacral fusion procedures that were often repeat operations that mostly involved multilevel surgery. The drug spironolactone, which blocks the hormone aldosterone, is a weak diuretic but may prevent spare potassium loss. Lower extremity surgery with epidural anesthesia results in lower intraoperative catecholamine concentrations when compared with general anesthesia. The aspirate may later be filtered and submitted for histologic processing into a particle clot section.

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Arrhythmias in the early postoperative period are treated with amiodarone and -adrenergic blocker therapy. Intravenous opioid anesthesia did not blunt the stress response in the late postoperative period (>3 hours). Three to 6 months after birth, fetal hemoglobin has been replaced with adult hemoglobin. The gases are complexed only in the excited state (under pressure with electron discharge) and rapidly dissociate after emission, preserving population inversion. Future investigations using transcranial Doppler should address this mechanism of injury, as well. However, disasters can also originate in damaged or misused anesthesia equipment, including physiologic monitoring devices. In infants and neonates, owing to higher extracellular fluid content (Table 92-3), the distribution volume of all local anesthetics is greater than in adults, the consequences of which are (1) significant decrease in peak plasma concentration of all local anesthetics, thus decreasing the danger of systemic toxicity after a single dose, and (2) accumulation with reinjections, which increases drug plasma concentration and elimination half-life while concomitantly decreasing clearance. If the patient is awake, then unanticipated complaints of discomfort or restlessness and moving on the table may be important signs. The management of intracranial hemorrhage is generally medical and supportive, with control of arterial blood pressure to less than 180 mm Hg. Robotic surgery may require unprecedented, prolonged, one-lung ventilation, which may challenge the extent of our understanding of respiratory physiology. The patient usually Chapter 94: Anesthesia for Pediatric Cardiac Surgery 2849 myocardial contraction. Cryoablation of adrenal lesions can induce hypertensive crises as normal adrenal tissue responds to thawing. Preoperative, intraoperative, and postoperative therapy is similar to that for adults. Further investigation has shown that the superior survival rate seen in children is mostly attributable to a much better survival rate among infants and preschool-aged children compared with older children. The lack of a gravitational field makes it impossible to remove gas in the usual way. Mancebo J, Fernandez R, Blanch L, et al: A multicenter trial of prolonged prone ventilation in severe acute respiratory distress syndrome, Am J Respir Crit Care Med 173:1233-1239, 2006. Large nuclei, mitochondria, and surface membranes predominate within the myofibrils. Briegel J, Forst H, Haller M, et al: Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study, Crit Care Med 27:723-732, 1999. Avoiding hypoglycemia in this period after cardiac arrest seems equally important as treating hyperglycemia; hypoglycemia was also associated with increased mortality as well. During the development of guidelines by other organizations, this type of information is often overlooked, discounted, or given only brief consideration. The difference between arrhythmogenic and asphyxial arrests lies in the physiology. Bradyarrhythmias arise from either abnormal impulse generation or abnormal impulse propagation, which results in a slow rate. The eosin reacts with the basic cellular elements, imparting a reddish hue to cytoplasmic components and hemoglobin. The dominant neuroendocrine responses to pain involve hypothalamic-pituitary-adrenocortical and sympathoadrenal interactions. Energy settings for rectilinear biphasic waveforms should use 120 J for the initial shock. Southern blot is a labor-intensive technique which typically requires several days. Because it is difficult for the physician to localize the infection in an infant, repeated complete sepsis workups are often required. Platelet size distinguishes between inherited macrothrombocytopenias and immune thrombocytopenia. The posterior surface of the ear and the lower third of its anterior surface depend on the great auricular nerve and the lesser occipital nerve, two branches of the cervical plexus. Endovascular procedures performed by interventional neuroradiologists include the placement of procoagulant coils inside certain types of intracranial aneurysms. The logical evolution was to apply a peristaltic pump to the extracorporeal circuit. Practical countermeasures instituted for each type of bias are described in the following subsections.

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However, nociceptive stimulations transmitted to the dorsal horn by C fibers elicit long-lasting responses,5,6 probably as a result of extensive depolarization of surrounding neurons in response to the production of large amounts of substance P. Unless the inspired concentration is significantly reduced (usually to 3%), such assistance then increases the potential for anesthetic overdose while attempts are made to establish intravenous access. The presence of restrictive pulmonary conditions, such as preexisting chest wall deformity, postoperative abdominal binding, or abdominal distention, can also contribute to inadequate ventilation. Dementia is a syndrome that is due to disease of the brain, usually of a chronic or progressive nature, in which profound disturbance occurs in multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. In Smith I, McWhinnie D, Jackson I, editors: Oxford specialist handbook of day surgery, London, 2011, Oxford University Press, pp 41-50. The greatest metabolic responses are observed after a severe burn injury (>40% body surface area) with metabolic rates twice normal and catabolism that lasts for many months, leading to immunodepression, recurrent infections, and poor wound healing. Elevated catecholamines have been postulated to be among the reasons for the greater incidence of myocardial ischemia after vascular surgery in patients with hypothermia. In a remotely located mobile army surgical hospital unit or a recreational camping van, equipment may be grounded by connections to a spike that goes into the earth. Pittet D, Hugonnet S, Harbarth S, et al: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. A paramedian approach can be used instead in cases of spinous process anomaly or spine deformity. Coronary artery disease was present in 61%, hypertension in 27%, and diabetes mellitus in 24% of patients. Complications to anticipate include bleeding during thrombolysis, undesired embolization of nearby structures during embolization, and vessel disruption. The fluoroscopy table and fluoroscopy equipment are controlled by radiology technicians and cardiologists. Some complications are associated with placement of an epidural catheter, and several risks related to the use of indwelling epidural catheters. Dojat M, Brochard L, Lemaire F, Harf A: A knowledge-based system for assisted ventilation of patients in intensive care units, Int J Clin Monit Comput 9:239-250, 1992. Ficarra V, Cavalleri S, Novara G, Aragona M, Artibani W: Evidence from robot-assisted laparoscopic radical prostatectomy: a systematic review, Eur Urol 51(1):45-55, 2007. Local anesthetics with epinephrine Needle Fascia iliaca Fascia lata produce significantly lower plasma concentrations and should be preferred whenever possible. Prathep S, et al: Preliminary report on cardiac dysfunction after isolated traumatic brain injury*, Crit Care Med 42(1):142-147, 2014. This occurs because of the decreased density of helium as compared with nitrogen (approximately 1/7). This signal is used both to trigger the ventilator (neural trigger) and to deliver assistance in proportion to the instantaneous diaphragmatic electrical activity. This fluid is continued for the first several days of life until glucose values are stable. Contrast Material Contrast material is commonly administered during interventions guided by imaging. Basal opioid requirements can be administered systemically (typically intravenously) until the patient can tolerate an oral analgesic regimen. Ketamine can produce increased secretions; therefore, atropine should be considered. Prilocaine 20 mg combined with 20 g fentanyl was associated with a lower incidence of clinically significant hypotension compared with bupivacaine 7. The disease processes and the condition of pediatric patients can be extremely different as compared with adults. Similarly, glucose-containing solutions used as replacement solutions during hemofiltration can be a source of glucose calories, in one study providing 300 g/day of glucose. In general, children fare better than adults; in fact, children usually recover completely from a renal insult if the hypoxia or ischemia lasted only a short time and other organ systems are not involved. Porcine hepatocytes are preferentially used because human hepatocytes are difficult to grow in culture. Keita H, Diouf E, Tubach F, et al: Predictive factors of early postoperative urinary retention in the postanesthesia care unit, Anesth Analg 101(2):592-596, 2005.

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The problem with these statistical programs for personal computers is that the assumptions behind the statistics remain obscure. Gravenstein argues that this degree of vigilance is likely unrealistic, and the risk of adverse outcome to even a small number of patients is unwarranted. This is true for both inhaled and intravenous anesthesia in both inpatient and outpatient procedures. Tolerance refers to the pharmacologic property of an opioid in which an increasing amount is needed to maintain a given level of analgesia. More commonly, capacitive coupling becomes a problem during electrosurgery performed at higher frequencies, typically hundreds to thousands of kilocycles per second. After 3 days of bypass, the baby whom nurses named Esperanza, Spanish for hope, completely recovered. Unfortunately, a delay between the end of neural inspiratory effort and the end of ventilator assistance usually exists and may cause a severe disturbance of patient-ventilator interactions resulting in patient-ventilator asynchronies. Eccleston C: Role of psychology in pain management, Br J Anaesth 87:144-152, 2001. Several publications focusing only on the ilioinguinal and iliohypogastric nerves have appeared in the literature, especially with the development of ultrasound imaging. Lacroix J, et al: Transfusion strategies for patients in pediatric intensive care units, N Engl J Med 356(16):1609-1619, 2007. A randomised study of regional versus general anaesthesia in 438 elderly patients, Acta Anaesthesiol Scand 47:260-266, 2003. Rozner M: Pacemakers and implantable cardioverter defibrillators, Crit Care Med 32:1809-1812, 2004; author reply 1812. General considerations include presence of arrhythmias, hypoxemia, pulmonary hypertension, ventricular dysfunction, shunts, thrombosis, and need for antibiotic prophylaxis. Yet postoperative pain treatment may not provide major improvements in some outcomes because it is unlikely that a unimodal intervention can be effective in addressing a complex problem such as perioperative outcomes. Generally, a peripheral intravenous line and an indwelling arterial catheter, in the right upper extremity, are recommended for intraoperative and postoperative management. Hemoglobin F (Fetal-Maternal Hemorrhage and Sickle Cell Anemia) Fetal-maternal hemorrhage from a rhesus factor positive (Rh+) fetus to an Rh-mother may lead to immunization of the mother against fetal alloantigens. The search for specific toxins to be cleared, furthermore, has not been successful, despite years of research; urea and creatinine are generally used as reference solutes to measure renal replacement clearance for renal failure. Supplementation with any combination of intravenous propofol, smalldose remifentanil, or a muscle relaxant is usually required with sevoflurane. Ovesen T, Kamarauskas G, Dahl M, et al: Pain and bleeding are the main determinants of unscheduled contacts after outpatient tonsillectomy, Dan Med J 59(2):A4382, 2012. Accordingly, anesthesiologists may wish to consider requesting that the surgeon discuss the possible complication at an earlier, more relaxed preoperative visit. Patients need to be followed closely for the development of fluid overload or hypovolemia during the exchange. The tracheal tube is intentionally passed into the right main bronchus and then slowly withdrawn until breath sounds are heard on the left. The need for phosphate may be more theoretical than real, but in most situations, half the potassium is given as a phosphate salt. For example, infection or growth factor therapy often leads to increased prominence of the primary (azurophilic) granules in neutrophils, termed toxic granulation. Same orientation of epidural needles is appropriate whatever the spinal level before 6 mo of age; then adapt needle orientation to spinal flexures. It is not an absolute that the patient initiates every breath, because a back-up rate can be set. Putensen C, Muders T, Varelmann D, et al: the impact of spontaneous breathing during mechanical ventilation, Curr Opin Crit Care 12:13-18, 2006.

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The occurrence of complications does not seem to increase with the use of catheters. Between 12% and 15% of patients will die before hospitalization, and 25% will die within the first 48 hours, with initial hemorrhage the primary cause of death, followed by rebleeding. In the case of hematoma after thyroid or carotid surgery, an attempt can be made to decompress the airway by releasing the clips or sutures on the wound and evacuating the hematoma. Of prime importance, experience and careful attention to detail are required to deliver highquality rapid recovery with minimal side effects. Falsely low Clearly, the use of automated hematology analyzers has reduced laboratory costs and turnaround time coincident with improving the accuracy and reproducibility of blood counts. If the areas of the slide between cells are staining, it usually indicates inadequate washing of the slide, heparin anticoagulation, or possible paraproteinemia. In the following paragraphs, commonly used inotropic drugs are listed with brief comments regarding their use in pediatric intensive care (Table 95-1). In addition, bilateral radial artery catheters can be placed to monitor inadvertent innominate artery obstruction by the endoclamp catheter. Matsota P, Livanios S, Marinopoulou E: Intercostal nerve block with bupivacaine for post-thoracotomy pain relief in children, Eur J Pediatr Surg 11:21-22, 2001. If total support has to be achieved, then the blood flow through the artificial lung should be equivalent to the total cardiac output in both modes, requiring a system (cannulas, pump, circuit, artificial lung) that drains 60 to 100 mL/kg/min. It is these children who will benefit from heavy premedication, such as the combined oral midazolam, ketamine, and atropine (see earlier discussions). Neurologic Complications Exchange transfusion has a vital role in the treatment of neurologic complications from sickle cell disease. American Society of Anesthesiologists: Practice advisory for the prevention and management of operating room fires, Anesthesiology 108:786-801, 2008. In patients with complex defects requiring preoperative inotropic and mechanical ventilatory support, a carefully controlled hemodynamic induction and maintenance anesthetic with a potent opioid is generally chosen. In the United Kingdom, surgery should not be canceled solely on the basis of increased arterial blood pressure. Attention to recommended methods of protection will limit exposure to minimal levels. These substances can mediate undesirable effects such as myocardial damage (catecholamines), systemic and pulmonary hypertension (catecholamines, prostaglandins), pulmonary endothelial damage (complement, prostaglandins), and pulmonary vascular reactivity (thromboxane). In 1981 Harper and Saunders20 used a similar technique using tritiated (3H) nucleotides to label probes and autoradiographic methods to map human genes. In neonates, excessive bleeding and the escalating dilutional effects of selective component therapy on the remaining procoagulants make the treatment of bleeding difficult. This is most often due to the relatively large transfusions of citrate-rich and albumin-rich blood products, such as whole blood, fresh frozen plasma, platelets, and cryoprecipitate necessary for hemostasis, all of which bind calcium. The anesthetic regimen for this procedure comprises a high-dose opioid, muscle relaxant, antibiotic, and a continuation of any preoperative vasoactive infusions. It leads to protective reflexes such as autonomic reactions, muscle contraction, and rigidity. For the most part, these procedures require little or no sedation; however, obese patients who cannot lie flat need anesthesia support (see also Chapter 71). Special stains generally fall into two categories: cytochemical stains that use cellular enzymatic reactions to impart staining and immunocytochemical stains that identify cell-specific antigen epitopes. Parental presence should not be substituted for premedication if the child needs premedication. Several things are done to reduce the risk of aspiration of contaminated secretions. This type of technology will likely be the next advancement in improving safety for children under anesthesia by providing an early warning of developing cardiovascular dysfunction or the immediate assessment of response to vasoactive medications. Although the incidence of bradycardia is infrequent in older children, this author has observed one 13-year-old child in whom asystole developed for approximately 30 to 45 seconds after a single dose of succinylcholine administered with thiopental but not atropine; the asystole occurred before intubation and with 100% oxygen saturation and immediately responded to the administration of atropine and several chest compressions to circulate the atropine. In 1996, the 1-year prospective study of the French-Language Society of Pediatric Anesthesiologists evaluated 85,412 pediatric anesthetic procedures, including 24,409 involving regional anesthesia. The authors attributed the exaggerated response to a low dose of ketamine to a combination of hypoxemia and hemodynamic instability. A major criticism of the original van den Berghe study was that it was performed on relatively homogeneous surgical populations. The importance of maintaining gut integrity (the gut derives up to 70% of its nutrients from luminal food) is to reduce the translocation of bacteria from the gut.

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Being able to drink appropriate fluids is a more humane approach for both children and their parents without increasing the risk for pulmonary aspiration of gastric contents. Wrede C: Closed loop insulin therapy: the answer for all our questions on intensive insulin therapy in intensive care Contraction of the respiratory muscles provides the "power" required for ventilation. With the child lightly anesthetized and after infiltration of local anesthetic, an intravenous line is inserted. Preoperative or intraoperative angiography can result in ischemic injury, secondary to renal vasoconstriction and direct renal tubular injury. Vanhorebeek I, De Vos R, Mesotten D, et al: Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients, Lancet 365:53-59, 2005. However, in many cases a cause cannot be determined, and empiric treatment including scheduled administration of acetaminophen, application of cooling blankets, and, increasingly, more invasive methods of cooling are required. Provide detailed explanations concerning the scheduled anesthetic management, including beneficial as well as potentially detrimental effects, even in emergency situations. Many anesthesiologists do not undergo consistent or repetitive training in radiation safety. With a Mapleson D circuit, a high concentration of anesthetic can more easily be delivered because the anesthetic enters directly at the airway. The anesthesiologist must establish adequate intravenous access and invasive monitoring (rarely indicated) if appropriate; replace all fluid deficits, including loss from the defect (usually with normal saline); and ensure that crossmatched blood is available. Therefore events that can upset the child such as drawing of blood for analysis of gases, venipuncture for blood tests, and separation from parents, must be minimized. Methylprednisolone is commonly used because of its limited mineralocorticoid effects. Nonrandom primary changes are generally thought to be the cytogenetic changes that are consistently found in a cell population and are believed to be specific for a particular type or subtype of malignancy. Patel A, et al: Distraction with a hand-held video game reduces pediatric preoperative anxiety, Paediatr Anaesth 16(10):1019-1027, 2006. Nasoenteric tubes can be withdrawn into the stomach (in case of jejunal feeding) or the esophagus, increasing the risk for aspiration. The task force may then reevaluate all the assembled evidence before constructing a final recommendation. Intramuscular Induction of Anesthesia Many medications, such as methohexital (10 mg/kg), ketamine (2 to 10 mg/kg combined with atropine [0. The mathematical proofs and calculations that are behind statistical tables and computation programs make strict distinctions among the several types of data (Table 111-1). Leaving the operating room with a significant residual structural defect adversely affects survival and increases patient morbidity. Flying after diving and decompression sickness, Aviat Space Environ Med 64:801-807, 1993. Minimally interrupted and effectively performed chest compressions, ventilation, and prompt defibrillation are associated with improved resuscitation from cardiac arrest in children rather than medication administration. The authors point out this patient died with a second episode of sepsis 2 weeks later. Applicability of Gibbon-type pumpoxygenator to human intracardiac surgery: 40 cases, Ann Surg 144:2-8, 1956. Confounders, such as hypothermia, metabolic or endocrine compromise, and persistent sedative or neuromuscular drugs, should be avoided, corrected, or removed. In the randomized studies using neuropsychological testing after surgery, no clear picture emerges during the first postoperative week. The sciatic nerve runs in the midline of the posterior aspect of the thigh to the apex of the popliteal fossa. Controlled-release oxycodone did not improve pain scores or reduce opioid requirements within 24 hours of ambulatory gynecologic laparoscopic surgery. Constant vigilance, correction of electrolyte imbalance, maintenance of acid-base status, and appropriate heparinization will mitigate some of the morbidity. Stacked bar graph illustrates the total number and age distribution for heart transplantation in patients younger than 16 years of age.


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Either phenomenon will worsen the hypoxemia and eventually limit tissue oxygen (O2) delivery to the point of lactic acidosis. Cardiac sinus arrest may follow the first dose of succinylcholine but is more common after repeated bolus administrations; such arrest may occur in children of any age. Supplemental oxygen may be needed in flight, and low saturation may remain even with supplemental oxygen for patients with significant lung disease. Adenosine can be initially used in a dose of 6 mg, and, if necessary, a second dose of 12 mg can be administered in 1 to 2 minutes. Array-based genomic screening at diagnosis and during follow-up in chronic lymphocytic leukemia. Intracellular staining is performed after fixation and permeablization (reviewed in Ref. The optimal strategy to prevent neurologic injury during cardiac surgery remains controversial. Abnormalities in protein expression are commonly assessed using immunohistochemistry on fixed tissues, or blotting or immunoassays on fresh samples. Platelets are cytoplasmic fragments derived from marrow megakaryocytes that function in coagulation and hemostasis. Parolari A, Alamanni F, Cannata A, et al: Off-pump versus onpump coronary artery bypass: meta-analysis of currently available randomized trials, Ann Thorac Surg 76:37-40, 2003. Ambulatory surgery has expanded far beyond performing simple procedures on healthy patients. A range of values may be given such that it is determined with some likelihood (often at 95%) that the true values lay within that range. Decreasing certain consequences of the stress response, such as diminishing the degree of catabolism and lipolysis to reduce the loss of muscle and fat mass, offer other advantages. However, children with impaired hepatic blood flow-infants, patients undergoing liver transplantation, patients with trauma-may need exogenous calcium therapy. Each bed space should be standardized so that it can be used to provide any level of care. Lower doses may be effective when administered to older patients or when injected in the cervical or thoracic region. After caudal or lumbar epidural injection, Tmax is prolonged up to 2 hours in infants and Cmax is increased. Along with cyanosis, the presence of polycythemia in these patients increases their thrombovascular risk. Preventing the establishment of altered central processing by analgesic treatment may result in short-term. Depending on where the target vessels are, potential complications should be appropriately anticipated in terms of planning for physiologic sequelae and the need for blood products. However, the anabolic effects of insulin on protein metabolism were not observed in patients with trauma who were enterally fed. Hypertension is also occasionally observed, especially in teenagers, when the inspired concentration is rapidly increased or when the change from sevoflurane to isoflurane is sudden. Roos Y, Rinkel G, Vermeulen M, et al: Antifibrinolytic therapy for aneurysmal subarachnoid hemorrhage: a major update of a Cochrane review, Stroke 34:2308-2309, 2003. Kt/V is an established marker of adequacy of dialysis for small solutes correlating with medium-term (several years) survival in patients who are chronically ill and on hemodialysis. This device is also available with a stylet and slight bend to be used as an intubation bougie. On-board diagnostic tools are being developed, such as for remotely guided ultrasound examination. By using the nerve mapping technique the success rate of peripheral nerve blocks in children can be improved. Adatia I, Perry S, Landzberg M, et al: Inhaled nitric oxide and hemodynamic evaluation of patients with pulmonary hypertension before transplantation, J Am Coll Cardiol 25:1656-1664, 1995. The Child With a Full Stomach A child with a full stomach must be treated the same as an adult with a full stomach; that is, both should undergo rapid-sequence induction of anesthesia with the application of cricoid pressure (also see Chapters 34 and 55). Likely the best recommendation to be made regarding empiric antibiotic coverage is to meet with the infectious disease specialists and discuss the current hospital culture isolates and their antibiotic resistance. These indices reflect the frequency of occlusive and partially occlusive respiratory events per hour of sleep.