The safe administration of drugs is a key area in anaesthesia and intensive care. Ensuring patients receive the correct dose of the correct drug requires great care during the drawing up process (with any dilution required) and appropriate drug labelling. The anaesthetist must always remain vigilant for adverse drug reactions including anaphylaxis. Some of the drugs classes encountered maybe familiar to novices (such as opioids and some sedatives, antibiotics) but others will be less familiar (especially intravenous and volatile anaesthetic agents, both depolarising and non-depolarising neuromuscular blocking drugs, and nitrous oxide). Anaesthetists are often required to administer other drugs such as antibiotics, drugs affecting coagulation and drugs to assist imaging.

New areas are discussed, such as the transition away from nitrous oxide, desflurane and suxamethonium and the widespread use of sugammadex to reverse rocuronium, as well as the choice of total intravenous anaesthesia (TIVA) or volatile-based anaesthesia.

The story is told through the experience of the patient, Paul, as well as through his partner and carer during that time, Sally. Their accounts feature next to each other, to provide a contrast for the different experiences of the patient and his wife. Following the decision to take early retirement from a high-powered job in business, Paul suffered a severe mental breakdown, which gradually led him into a world of fear, paranoia, catastrophic thinking and a desire to take his own life. For his own safety he was sectioned and spent four months in a psychiatric hospital. After various antidepressants and antipsychotics had no effect, Paul was persuaded to undergo ECT and, after only six sessions of treatment, had what his partner describes as ‘a complete and miraculous cure’. Four years after the event he is still fit and well and has had no relapses. This story explores the thoughts and feelings of someone who is suffering with acute anxiety/depression, as well as presenting the fears and desperation experienced by his partner.

Trauma is the leading cause of mortality and morbidity in children in developed countries. Traumatic brain injury is responsible for the largest proportion of deaths. Preventable death due to major haemorrhage occurs early in the first 24 hours. Mechanisms vary with age. Blunt injury represents over 80% of cases. Falls and road traffic collisions (RTCs) are the most common mechanisms across all ages, except for non-accidental injury (NAI) in < 1 year olds. There has been a substantial rise in penetrating trauma due to gun and knife crime in the adolescent population. The centralisation of trauma services in the United Kingdom with the creation of regional networks has changed how paediatric trauma is managed. Severely injured children are triaged at scene and taken directly to major trauma centres (MTCs). Outcomes have improved, and there is better standardisation between treating institutions. Initial trauma management involves stabilisation, resuscitation, identification and treatment of life-threatening injuries in the primary survey. Some patients will need damage control surgery to control haemorrhage. This is followed by definitive care and rehabilitation. Anaesthetists are an integral part of the trauma team involved throughout the patient journey. Dedicated anaesthetic roles are airway management and ongoing resuscitation during surgery.

Paediatric anaesthesia employs a range of equipment to ensure safe and effective achievement of anaesthetic goals. Variation in size and physiology in this age group has implications for clinicians using these technologies. Applied aspects and practical tips of this phenomenon are discussed in this chapter. Areas covered include equipment used to manage airway, vascular access, drug and fluid delivery, monitoring of various physiologic parameters, etc. While it is imperative to stay abreast with increasingly sophisticated drug delivery and monitoring systems, no monitor is a substitute for the presence and vigilance of the well-trained anaesthetist.

Children presenting for general paediatric surgery range in both age and complexity from neonates undergoing hernia repair to older children undergoing appendicectomy or excision of extensive neuroblastoma. In this chapter, we provide an overview of general surgery for infants and children beyond the neonatal period. We discuss the anaesthetic management of major and minor cases highlighting the variety of general and regional anaesthetic techniques available to anaesthetists. Children presenting for major surgery or multiple procedures or those with significant additional comorbidities warrant additional attention. Here, close communication with the surgeon and wider multidisciplinary team is necessary to establish risks, develop plans to mitigate risk and communicate risk to children and parents effectively.

Ophthalmic surgery takes place in children of all ages, from premature neonates to teenagers, the majority of whom are ASA 1 or 2. In some cases, the ocular pathology may be part of a wider congenital or metabolic abnormality and anaesthesia is not so straightforward. Nearly all will require general anaesthesia. Anxiety can be common in children returning for repeated procedures, and premedication may be necessary. Surgery can be extraocular or intraocular. Simple day-case procedures can usually be managed with an inhalational spontaneous breathing technique and supraglottic airway device (SAD). Certain more complex cases necessitate a completely still eye, and muscle relaxation is therefore usually required. Special anaesthetic considerations are management of the oculocardiac reflex (OCR), commonly elicited by traction on the recti muscles and prevention of postoperative nausea and vomiting (PONV); strabismus surgery is particularly emetogenic. The majority of ophthalmic surgery is not particularly painful, and simple analgesia with paracetamol and NSAIDs is sufficient. Regional ophthalmic blocks, such as sub-Tenons, can supplement or offer an alternative to opiates when additional analgesia is required. This has the added advantage of producing akinesis of the globe and a beneficial reduction in PONV and the OCR.

Cleft lip and palate is a relatively common congenital condition presenting for surgical correction. Anaesthetic management has some specific considerations involving airway surgery in infants and young children who may have other associated anomalies. Surgical care pathway and approaches are discussed as relevant to anaesthesiologists. Perioperative management, including preassessment of the child, optimisation prior to surgery, intraoperative and postoperative care, is presented. The importance of a multidisciplinary approach, good communication, shared airway management and adequate multimodal analgesia with the avoidance of respiratory depression are highlighted. Anaesthesia for secondary speech surgery is also presented.

This chapter covers principles of anaesthesia for children with congenital and inherited disease, with specific consideration of some conditions of particular relevance to paediatric anaesthetists, including the muscular dystrophies, malignant hyperthermia and the mucopolysaccharidoses.

The majority of children undergoing elective surgery can be discharged home on the same day. This has significant benefits for the child, improves productivity and reduces cost. A paediatric day-case service needs an infrastructure based on the guidelines set up by the Department of Health and professional bodies. The anaesthetist plays a vital role in this service and must be trained to use techniques that minimise perioperative pain and postoperative nausea and vomiting. There are clear published guidelines for the process of selecting appropriate patients and cases. In the past, performing tonsillectomies in children with obstructive sleep apnoea (OSA) as a day-case procedure was controversial. With improving surgical and anaesthetic techniques, most of these cases can now be done as day cases. A consensus statement was released in 2018 with recommendations of which patients should be excluded from this group. Good planning by the ward nurses, play therapists, theatre staff, surgeons and anaesthetists is essential to ensure the smooth running of a unit. Anaesthesia techniques require planning and attention to detail. A multimodal to approach to pain relief including local/regional anaesthesia is essential. Knowledge of risk factors and appropriate prevention of postoperative nausea and vomiting (PONV) is also vital. Regular patient satisfaction surveys and audit of quality and safety of care should be conducted using published standards.

Anaesthesia for paediatric urology may be for minor to major complex surgery. In this chapter, we discuss the anaesthetic management of a subspecialty that allows for a variety of general and regional anaesthetic techniques to be applied. Minor procedures include cystoscopy, resection of posterior urethral valves, circumcision, insertion of suprapubic (SP) lines, hypospadias repair and orchidopexy. We discuss techniques for major surgery, including pyeloplasty, ureteric re-implantation, nephrectomy, resection of Wilms tumour (nephroblastoma), bladder exstrophy and epispadias repair, bladder augmentation (ileocystoplasty) and formation of Mitrofanoff, as well as renal transplantation. Preoperatively, children undergoing cystoscopy and major urological and reconstructive surgery require a urine culture to guide antibiotic prophylaxis. Local ‘maximum surgical blood ordering schedules’ should be followed for guidance regarding cross-matching of blood for major procedures. Close communication with the surgeon and wider multidisciplinary team is necessary to identify the extent of surgery, positioning and appropriate vascular access for complex surgery and renal transplantation.

The vivisection debates are an undervalued nexus for nineteenth-century beliefs about pain. Close readings of the Report of the 1876 Royal Commission on Vivisection reveal how conceptualisations of animal physiology, anaesthetic action, reflex responses, and pithing undermined direct correspondences between injury, pain, and expressions of suffering. The chapter then examines representations of graphic registration and recording technologies in laboratory handbooks. These devices seemed to offer a new, universal, wordless language, yet frequently conjured precisely those images of inscription, symbolism, and transliteration that many scientists were anxious to avoid. The chapter then presents animalographies and antivivisection poetry ‘spoken’ by animals. By purporting to access a more complete and individual non-human consciousness, these texts presented themselves as rivals to mechanical laboratory devices. Nevertheless, despite efforts to ‘listen’ to animals, antivivisectionists and experimental scientists encountered the same vexatious problem: Language, like pain, seemed equally troubled by the distance between signifier and signified.

In anesthesiology and critical care medicine, specific arterial blood pressure targets should be attained, depending on the setting. For instance, a growing body of evidence indicates that perioperative blood pressure should not markedly deviate from its usual level. This underscores the importance of blood pressure measurement, ideally non-invasively, and has therefore spurred intense research efforts . Recent advances in non-invasive blood pressure monitoring are noteworthy. They involve not only innovative technologies such as the automatic finger cuff but also the widely used automatic upper arm cuff. The present chapter aims at providing a state of the art of non-invasive blood pressure monitoring in adult patients in acute care settings with emphasis on recent advances. This chapter addresses several key issues such as “are non-invasive measurements of blood pressure true and accurate?”, “can non-invasive monitoring detect changes in blood pressure? ” and “what if the patient is obese and / or has cardiac arrhythmia?”