Anesthesia for Special Situations

SPECIAL SITUATIONS

Patients with elevated intracranial pressure and those at risk of its development should have intra-cranial pressure (ICP) monitoring in place, if pos-sible, to enable the appropriate management of cerebral perfusion pressure. The cerebral perfu-sion pressure should be maintained >50 mm Hg by adequate mean arterial pressure and a 20–25° head-up position. Mild hypothermia should be considered.

The management of patients who are at risk of or have elevated ICP should include the following:

·        ICP < 20 mm Hg

·        CPP > 50 mm Hg

·        Mean arterial pressure >60 mm Hg

·        Proper bed position (elevate the head of the bed by 20–25°)

·        Controlled airway and ventilation

·        Controlled sedation (eg, propofol)

·        Vasopressor support (eg, vasopressin, norepinephrine) when necessary

·        Controlled hypothermia (32–33 ^oC)

·        Glycemic control

·        Aggressive treatment of metabolic acidosis and coagulopathy

·        CVVHD

Pediatric Liver Transplantation

Selected pediatric centers report survival rates of 90% at one year. The use of reduced-size and living donor grafts has increased the organ availability in this patient population.

Living Donor Transplantation

The use of living donors has increased the pool of organs available for transplantation. However, this procedure does expose healthy individuals to mor-bidity and mortality risks. Informed consent from the donor must be obtained with the understanding that there is often a great deal of emotional pressure on family members to donate, and that consent must be freely given without coercion.

In most donor anesthesia protocols, main-tenance of a CVP <5 cm H₂O is utilized to reduce intraoperative blood loss. Good postoperative anal-gesia is required so that comfortable donor patients may be extubated at the end of the procedure. Complications of this surgery for the donor patient include transient hepatic dysfunction, wound infec-tion, postoperative bleeding, portal vein thrombosis, and biliary leaks. An increased incidence of periop-erative nerve injury to the brachial plexus has been reported in donor patients