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Purpose of Review: Clinical studies and new guidelines are frequently being published in the area of preoperative fasting. A growing population of patients with obstructive sleep apnea is being referred for outpatient procedures including adenotonsillectomy., Recent Findings: Recently published preoperative fasting guidelines for pediatric patients are covered along with studies comparing gastric volume following different fasting intervals. Pediatric obstructive sleep apnea is discussed. Clinical presentation, severity, perioperative risks, and controversies as whether outpatient procedures are suitable for these patients are presented. New data covering different perioperative aspects are presented., Summary: A more liberal preoperative intake is encouraged with fasting for 2 h for clear liquids, 4  h for breast milk, 6  h for formula and light meals, and 8  h for heavy meals is widely accepted. Interpersonal variation in residual gastric volume exists. Children with obstructive sleep apnea under 3 years of age and those with severe obstructive sleep apnea and comorbidities are not candidates for ambulatory surgery. Polysomnography has specific preoperative indications. Dexmedetomidine can decrease emergence agitation and has an opioid-sparing effect. Intravenous acetaminophen is presented as an opioid-sparing analgesic. Dexamethasone is effective in preventing postoperative nausea without increased risk of bleeding. Surgical techniques may affect postoperative pain.

Successful management of pediatric cardiac emergencies requires an accurate diagnosis to institute an appropriate plan of therapy. The diagnosis, however, is not always straightforward, as evidenced by the nonspecific clinical picture that can be presented by congenital heart defects. Entertaining the possibility of a cardiac problem in neonates with pulmonary symptoms unresponsive to standard therapies is crucial for successful management of patients with congenital heart disease. In addition to ventilatory support, prostaglandin E1 infusions or emergency interventional cardiac catheterization is often a life-saving initial measure in patients with acutely decompensated congenital cardiac lesions that require a patent ductus arteriosus for survival. Pericardial tamponade is associated with various acquired and iatrogenic causes. Emergent pericardiocentesis is mandatory when cardiovascular compromise occurs. The goal of anesthetic management is to maintain cardiac output. With the increasing use of central venous catheters in neonatal ICUs and the high mortality rate for central venous catheter-related cardiac tamponade, the diagnosis must be considered in any patient with a central venous catheter in situ who acutely develops unexplained hypotension, bradycardia, and diminished pulses. Arrhythmias also can cause hemodynamic instability in infants and children. Supraventricular tachycardia is by far the most common emergently presenting arrhythmia in the pediatric population. Unstable patients require immediate intravenous adenosine or synchronized cardioversion. Complete heart block is rare, but it can lead to congestive heart failure and occasionally to cardiovascular collapse and sudden death. Emergency treatment of complete heart block includes pharmacologic support and temporary or permanent pacemaker placement as indicated. In infants, congestive heart failure usually is related to congenital heart disease, whereas in older children, it tends to be secondary to an acquired cause. Supportive measures, fluid restriction, and inotropic support are the principles of initial treatment. Prompt recognition and initiation of appropriate therapy in pediatric cardiac emergencies are essential for favorable outcomes.

With estimates as high as 1 million patients in the United States, Parkinson's disease is a relatively common neurological disorder. It has long been thought that the primary biochemical disturbance in Parkinson's disease is dopamine related. Accordingly, many drugs have been developed that increase the supply of dopamine, affect the biochemical balance of dopamine, or act as a dopamine substitute. These drugs may have significant interactions with anesthetic agents. In addition, there are several disease and drug-induced physiological aberrancies that can have profound anesthetic implications in the patient with Parkinson's disease (e.g., aspiration pneumonitis, myocardial irritability, hypotension, hypertension, and respiratory impairment). Although surgical therapy for Parkinson's disease has a long history, with the advent of advanced neuroimaging techniques there has been a resurgence of these procedures (e.g., pallidotomy and thalamotomy) for advanced stages of Parkinson's disease. It is likely that these surgical procedures will become more commonplace, possibly prolonging the lifespan of patients with Parkinson's disease. Even though these cases are typically performed with local anesthesia, there are several important caveats to consider in the management of these patients (e.g., airway access with CNS changes, hypertension, and tremor). It's incumbent on anesthesiologists to become familiar with the special needs of patients with Parkinson's disease and alter the "days in hell" attitude among these patients toward surgery and anesthesia.