HALLAZGOS COMO RESULTADO DE LOS PROYECTOS SOBRE LENGUAJE CLARO 1) DUDAS Y OBSERVACIONES:

Anesthesia and Chronic Pain Management

Patients. with. CP. frequently. present. for. surgery. for. a. variety. of. reasons.. Common. surgical. conditions. include. lower. and. upper. limb. orthopaedic. surgery,. spinal. surgery,. dental. procedures,.surgery.to.control.gastroesophageal.reflux.(reflux),. gastrostomies.and.surgical.procedures.to.control.spasticity.such. as. selective. dorsal. rhizotomy. and. intrathecal. baclofen. pump. implantation.[A]..The.patient.with.CP.presents.a.real.challenge. for. anesthesiologists. because. of. the. associated. multiple. disabilities.and.systemic.problems..A.pediatric.anesthesiologist. who.has.experience.with.children.with.neuromuscular.disorders. is.an.asset.to.the.treatment.team.. Preoperative assessment Children.with.CP.require.special.consideration.because.of.their. various.disabilities.[B]..Medical,.communication,.general.care. problems.and.social.issues.often.complicate.the.preoperative. assessment.of.patients.with.CP..

Be. aware. of. the. visual. and. hearing. deficits,. behavioural. and. communication.problems.that.the.child.has..

Behavioural problems

Children.are.sensitive.and.need.enough.time.to.communicate. their. feelings. and. problems.. The. parental. attitudes. must. be. accepted. and. respected.. Make. every. effort. to. increase. communication.with.the.child.and.the.parents..Be.understanding. of.the.aggressive,.overprotective.or.negative.behaviours.they. show,. recognize. that. these. are. manifestations. of. stress,. fear,. anger.and.frustration..

Gastroesophageal problems

Evaluate. all. systems. extensively. to. ensure. an. uneventful. perioperative.course..Esophageal.dysmotility,.abnormal.lower. esophageal.sphincter.function,.and.spinal.deformity.can.cause. reflux. and. pulmonary. aspiration.. Cisapride,. commonly. used. for.treatment.of.reflux,.can.cause.prolonged.QT.interval.and. ventricular. dysrhythmias.. Drooling. can. be. a. problem. during. induction.and.emergence.from.anesthesia..

Nutritional problems

Electrolyte. imbalance. and. anemia. from. malnutrition. require. preoperative.nutritional.support.in.a.small.group.of.patients.with. feeding.problems..Consider.preoperative.feeding.gastrostomy. to.improve.nutrition,.decrease.postoperative.infection.risk,.and. enhance.wound.healing.

Common surgical procedures Lower and upper limb orthopaedic surgery Spine surgery

Dental procedures Anti-reflux surgery Gastrostomy

Selective dorsal rhizotomy

Intrathecal baclofen pump implantation

Special considerations in preoperative assessment Behavioural problems Gastroesophageal problems Nutrition Pulmonary

Dental and mouth hygiene Convulsions Latex allergy Spasticity Pulmonary problems Start.preoperative.physiotherapy,.bronchodilators.or.antibiotics. as.required.to.optimize.the.perioperative.care.of.patients.with. recurrent. respiratory. infections. and. possibility. of. pulmonary. aspiration.from.reflux.and.chronic.lung.disease..

Dental and mouth hygiene

Note. the. presence. of. loose. teeth,. dental. caries. and. temporomandibular. joint. dysfunction. preoperatively. because. these. frequently. cause. difficulty. with. laryngoscopy. during. endotracheal.intubation..

Epilepsy

Children.who.receive.regular.anticonvulsant.medication.should. continue. their. medicine. during. the. perioperative. period. for. symptom.stability..Keep.in.mind.the.side.effects.of.these.agents,. such.as.bleeding.tendency.with.valproate.sodium.. Latex allergy Patients.with.CP.are.at.increased.risk.of.developing.latex.allergy. because.of.multiple.surgical.procedures.and.exposure.to.latex. allergens.from.an.early.age..Ask.the.parents.about.respiratory. symptoms.such.as.wheezing.or.allergic.rhinitis.and.cutaneous. manifestations. such. as. rush,. itch,. oedema. when. exposed. to. products.containing.latex.

Spasticity

Remember. that. antispastic. medications. such. as. baclofen,. benzodiazepines. and. botulinum. toxin. have. side. effects. that. interfere.with.anesthesia..Oral.baclofen.may.delay.emergence.from. anesthesia.and.cause.bradycardia-hypotension.during.anesthesia.. Premedication and preoperative management

Forbid.the.intake.of.solid.foods.4.hours.before.surgery.in.infants. and.8.hours.before.surgery.in.older.children..Allow.clear.fluids. and.water.until.3.hours.before.surgery.. The.child.with.CP.may.be.anxious.because.of.the.past.multiple. hospital.admissions..He.is.frightened.and.does.not.understand. what.is.expected..Show.empathy.and.patience.during.induction.. Consider.sedatives.to.reduce.anxiety.and.spasm..The.response. to.such.medication.may.be.unpredictable..Psychological.delay. and.behavioural.disturbance.result.in.serious.separation.anxiety.. Allow.the.parents.to.remain.with.the.child.during.the.induction. and.recovery.periods.to.minimize.this.anxiety.[C].. Increased.tone.may.prevent.the.insertion.of.an.intravenous. line.in.the.spastic.or.dystonic.child.considering.that.stress.and. fear.increases.muscle.tone.even.more..Apply.creams.containing. lidocaine.or.prilocaine.to.the.venepuncture.site.at.least.1.hour. before.insertion.to.lessen.trauma.and.ease.induction.

Allow the mother into the operating theatre to minimize the child’s anxiety.

70 Anesthesia & Chronic Pain Management

Cover the young child in cotton to mini- mise heat loss during surgery.

Anesthetic management

Anesthesia. is. difficult. because. of. lack. of. communication. and. cooperation. with. the. patient.. Intravenous. access. may. be. a.problem.caused.by.spasticity,.dystonia.or.refusal..Consider. rapid. sequence. induction. especially. in. patients. with. reflux.. Inhalational.induction.of.anesthesia.may.be.messy.and.risky.in. patients.severely.affected.by.drooling..All.common.agents.for. intravenous. induction. of. anesthesia. are. suitable. but. propofol. seems.to.be.more.painful.for.these.patients.

Secure. the. airway. with. a. laryngeal. mask. when. clinically. appropriate..Perform.tracheal.intubation.if.reflux.and.drooling. are.present..A.nasogastric.suction.catheter.may.be.beneficial.for. longer.operations.

Studies. of. muscle. relaxants. indicate. slight. sensitivity. to. succinylcholine.and.resistance.to.vecuronium.in.patients.with. CP.. The. possible. mechanisms. include. drug. interaction. with. anticonvulsant.medication.and.chronic.immobilization..

Minimum. alveolar. concentration. for. anesthesia. may. be. decreased. for. volatile. anesthetics.. Most. anesthetics. have. anticonvulsant. properties.. Avoid. enflurane,. ketamine. and. etomidate.in.patients.with.epilepsy..

Perioperative. heat. loss. is. a. common. significant. problem. causing.systemic.problems.and.delaying.emergence..Minimize. hypothermia.by.humidifying.gases,.using.warmed.intravenous. fluids,.using.forced.air.warming.blankets.and.avoiding.a.cold. operating.room.[A].

Perioperative.epidural.anesthesia.decreases.the.requirement. of. general. anesthetics. and. the. incidence. of. delayed. arousal. from.anesthesia.[B].

Proper. patient. positioning. may. be. difficult. because. of. contractures.[C]..Consider.taking.precautions.for.prevention.of. pressure.sores.and.nerve.damage.[D].

Insert.a.urinary.catheter.for.long.operations.with.significant. blood.loss.and.fluid.shifts.to.monitor.urine.output.and.decrease. the. risk. of. renal. failure. that. is. caused. by. inappropriate. fluid. administration.

Postoperative management

Emergence. from. anesthesia. may. be. delayed. because. of. hypothermia.and.residual.volatile.anesthetic.agents..Frequent. suctioning. is. required. in. patients. who. had. been. drooling. preoperatively.. Protect. the. airway. from. excessive. secretions,. regurgitation.and.vomiting.

Patients. will. be. irritable. [E]. during. emergence. from. anesthesia.in.unfamiliar.surroundings,.especially.if.they.have. intellectual.disability,.pain,.visual.defects,.hearing.deficits.or. urinary.retention.

Positioning for surgery may be difficult due to contractures, bilateral tourniquets and multiple cath- eters.

Depending on the extent of surgery caudal or epidural analgesia will provide effective pain relief.

Contractures prevent appropriate positioning and cause increased pressure over the bony prominences. Skin ulcers occur especially if

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