This chapter discusses the diagnosis, evaluation and management of solid organ abdominal trauma. It presents special circumstances which make diagnosis and management of solid organ abdominal trauma difficult in pediatric patients. The primary survey for solid organ abdominal trauma should be aimed at determining which patients need immediate laparotomy versus those that are stable for further diagnostic workup. Vital signs provide a key to hemodynamic stability. Unstable patients with blunt or penetrating trauma to the abdomen require immediate laparotomy. All patients after significant trauma, both blunt and penetrating, should receive screening AP chest radiography. Given small anteroposterior diameter and developing abdominal musculature, children are more vulnerable to blunt forces. The most likely reason for sudden deterioration in a trauma patient with solid organ injury is hemorrhagic shock; therefore more aggressive resuscitation has to be considered and the process to get patient to the OR for laparotomy is facilitated.

This chapter talks about the management of post-cardiac arrest care. It discusses the special circumstances in which adequate hemodynamic stability cannot be achieved during post-cardiac arrest care. An immediate assessment of a patient after the return of spontaneous circulation should include a focused history (usually obtained from bystanders or emergency medical services personnel), physical examination, diagnostic testing, and imaging studies. The physical examination should follow the ABCs, checking the airway for appropriate endotracheal tube (ETT) placement, the presence of bilateral breath sounds, circulatory status and blood pressure, heart rate and rhythm, disability with neurological response and Glasgow coma scale, and exposure to fully expose the patient and complete the examination. The extent of brain injury and cardiovascular instability are the major determinants of mortality after cardiac arrest. Brain injury is responsible for mortality in 68% of out-of-hospital arrests and 23% of in-hospital arrests.

In the immediate postoperative period, close attention must be paid to hemodynamic stability by focusing on preventing right ventricular failure and maintaining chronotropic competence. Preoperative support of the recipient circulation by mechanical assist devices appears to significantly increase the risk of post-transplantation primary graft failure. Primary cardiac allograft failure accounts for 40 percentage of mortality within 30 days of heart transplantation (HT). Following HT, the use of intraoperative and peri-operative corticosteroids remains the mainstay of early therapy. Monitoring of therapeutic drug levels is important but there is some controversy in how best to monitor the target levels of calcineurin inhibitors (CNIs). Early after transplantation, particularly in the first 3 months when the risk of rejection is highest, invasive biopsies are recommended at decreasing intervals. Close vigilance for re-emergence of circulating antibodies is needed, and newer approaches using complement inhibitors or intensive B-cell modulating drugs such as bortezomib are being studied.

This chapter presents a case study of a 3-month-old male who had an uncomplicated term delivery presented for repair of craniosynostosis. Premedication was avoided and a peripheral intravenous catheter was started because of the young age, presence of mid-facial hypoplasia, and concern regarding potential problems with ventilation and intubation. Probably the most challenging part of the anesthetic management of craniosynostosis repair is the significant blood loss and frequent rate of blood product transfusion. Craniosynostosis repair presents a number of challenges to the anesthesiologist: (1) small size of the patients; (2) significant and often unavoidable blood loss; (3) need for intraoperative transfusion of blood products; and (4) associated anomalies including airway problems and obstructive sleep apnea. All of these potential complications call for careful preoperative and intraoperative planning, meticulous attention to intravascular volume status and hemodynamic stability as well as maintenance of normothermia.

This chapter presents a case study of a 58-year-old female with multiple intact unsecured aneurysms, who presented for clipping of one paraclinoid aneurysm. Dexmedetomidine and nitrous oxide are commonly used as adjuvants to volatile agents or other intravenous anestheticsm. The case describes these agents in combination with each other for anesthetic maintenance of a cerebral aneurysm clipping. Hemodynamic stability was achieved both intraoperatively and postoperatively, preserving cerebral perfusion pressure and avoiding hypertension. Dexmedetomidine is unique in its ability to produce sedation, anxiolysis and analgesia with little respiratory depression. The hemodynamic stability associated with dexmedetomidine may also be cardioprotective. It becomes especially important when discussing an anesthetic agent in neurosurgery to examine its neurophysiologic profile. The combination of nitrous oxide and dexmedetomidine provided a complete anesthetic while maintaining hemodynamic stability, enabling neurophysiologic monitoring, and facilitating a prompt emergence in a patient with a history of delayed recovery from general anesthesia.

Developments in ventricular assist devices (VADs) and the limited supply of donor hearts for transplantation have made the former an important method of treatment for patients with end-stage heart failure. This chapter presents the case of a patient who underwent two surgical procedures for subdural hematoma evacuation while on left VAD (LVAD) support. Anesthetic management and potential problems such as coagulation status and hemodynamic stability in patients with an LVAD are presented and discussed. The chapter presents a case study of a 72-year-old male who presented for an emergent subdural hematoma decompression. As the number of patients chronically supported with long-term implantable devices grows, general surgical problems that are commonly seen in other hospitalized patients are becoming more common and will eventually lead to an increase in the number of patients with LVADs coming in for noncardiac elective or emergency surgery.