The main aim of a perioperative fluid therapy is to maintain or normalize the patient’s homeostasis. Small children have higher fluid volumes, metabolic rates and fluid needs than adults. Therefore, short perioperative fasting periods (formula milk 4 hours, breast milk 3 hours, clear fluids 1 hour) are important to avoid iatrogenic dehydration, hypotension, ketoacidosis and uncooperative behavior. Balanced electrolyte solutions with 1–2.5% glucose are favored for intraoperative maintenance infusion. Glucose- free balanced electrolyte solutions should then be added as needed to replace intraoperative fluid deficits or minor blood loss. Gelatin solutions or hydroxyethyl starch are useful in hemodynamically unstable patients or those with major blood loss, especially when crystalloids alone are not effective and blood products are not indicated. The monitoring should focus on the maintenance or restoration of a stable tissue perfusion.In nonsurgical or postoperative children, balanced electrolyte solutions should be used instead of hypotonic solutions, both with 5% glucose, as recent clinical studies and reviews showed a lower incidence of hyponatremia.

A common care location for seizure and epilepsy patients is the emergency department and inpatient setting. A thorough history to discern a specific diagnosis and localization guides testing and treatment decisions. These decisions include the need for additional imaging/laboratory testing and whether to start an antiseizure medicine (ASM). Electroencephalograms (EEGs) are often required with time length depending on clinical question. If an epilepsy diagnosis is certain without clear localization, one hour of testing is preferred. If the question (or diagnosis) is status epilepticus, 24-hour EEG is indicated. For patients with known epilepsy, ASM alteration can occur for seizures with appropriate compliance. If there is noncompliance, an ASM increase may not be required. The perioperative period requires ASM continuation, although the administration route may change. Patients with renal or hepatic impairment often necessitate dose adjustment. Specific situations like alcohol withdrawal seizures have accepted paradigms to follow and are discussed. Lastly, patients in epilepsy monitoring units (EMUs) are hospitalized for diagnostic reasons with management needs different than other epilepsy patients.

This chapter explores some of the new roles that have been introduced into perioperative care over the last couple of decades. These are the surgical first assistant, surgical care practitioner, and anaesthetic associate. It highlights the history, educational pathways, role boundaries, scope of practice, and the professional and legal implications of each of the extended or advanced roles.

This chapter focuses on the perioperative care of the paediatric patient and aims to undermine the common misconception that children are just little adults. Providing safe and effective care for children requires a clear underpinning knowledge of their unique needs. Conscious consideration of age-dependent characteristics such as anatomical, physiological, psychological, and behavioural are essential in the delivery of paediatric patient care. The rationale for adaptations to the delivery of care is to ensure children receive anaesthesia and surgery in a safe and appropriate environment.

The primary purpose of the anaesthetic machine is to deliver anaesthetic gases and volatile agents safely to the patient - helping to maintain a suitable level of consciousness and analgesia for surgery. It is vital that any clinician checking and using an anaesthetic machine is familiar with the type of machine they are intending to use and possess a detailed knowledge of how it operates. Machines must be rigorously checked and tested by a suitably trained person before use and a breathing circuit check should take place between each patient. This chapter is an introduction to the anaesthetic machine, highlighting the main components and features that are essential to maintaining user and patient safety.

Key Learning Points

1. 1. Cardiac output (CO) quantification is used clinically as a surrogate for tissue oxygenation in peri-operative and critical care patient management, and may be used to avoid injudicious fluid administration.

2. 2. Devices estimate and monitor CO using the Fick principle, Doppler frequency shift and pulse pressure analysis.

3. 3. Devices differ by invasiveness, provision of other indices and clinical information, required expertise and limitations and potential complications. Pulmonary artery catheters still remain the gold standard, but evidence supports the accuracy of other less invasive devices.

4. 4. Selection of device is determined by the clinical setting, patient factors and clinician expertise.

5. 5. Because CO is estimated, rather than measured directly, trends and response to interventions are more clinically meaningful than absolute values.

Key Learning Points

1. 1. High-risk surgery is associated with significant inpatient mortality, and post-operative morbidity is associated with increases in long-term morbidity and mortality.

2. 2. Perioperative care should be a team effort and proactive, rather than reactive.

3. 3. Adequate risk assessment and ICU care triage are key to effective perioperative care.

4. 4. Care bundles may reduce risk across a variety of surgeries and medical conditions through the aggregation of marginal gains.

5. 5. Clear handover in the ICU can reduce medical error and improve patient safety.

Key Learning Points

1. 1. The same principles of evidenced-based intensive care should be applied to cardiac surgical patients.

2. 2. There is particular focus on invasive haemodynamic monitoring and immediate access to echocardiography.

3. 3. Many elective patients can be managed aiming for early extubation and rapid discharge.

4. 4. Inotropes and vasopressors are titrated according to assessment of left and right heart function and vascular resistance.

5. 5. Complications include bleeding, tamponade, low cardiac output syndrome and arrhythmias.

Managing diabetes during surgery is complex. Adverse outcomes associated with poor preoperative diabetes management includes higher morbidity and mortality, higher risk of diabetic ketoacidosis and hypoglycaemia, prolonged inpatient stay, and higher systemic and surgical complications. The author provides a detailed description of pre- and postoperative management of insulin- and noninsulin-dependent diabetic patients.

Two issues relate to prescribing for the surgical patient: managing their previous medication during the metabolically stressful and starved perioperative period, and prescribing drugs required as a consequence of surgery. The author considers both issues, with particular attention paid to perioperative anticoagulation, fluids and analgesia, and prophylaxis.

The risk of perioperative neurologic injury has decreased over the years, yet it remains a significant clinical problem that may result in severe debilitation and death. Noninvasive intraoperative monitoring of regional cerebral oxygen saturation (rScO2) by near infrared spectroscopy (NIRS) is used in this vein to ensure an adequate balance between cerebral oxygen supply and demand. NIRS technology, already employed in cardiac surgical patients, is increasingly used in orthopedic, vascular, and neurosurgical procedures. Furthermore, NIRS usage in other clinical settings – including trauma, critical care, and cardiopulmonary resuscitation – is also being investigated. This chapter reviews the basic principles and interpretation of cerebral oximetry, research studies that examine its efficacy, and novel uses of this technology.