Marwa A. KhairyLecturer of Anesthesia

Preoperative Visit to Pediatric Patients

GOALS

Baseline information Detection of co-morbid conditions and

optimization of these if any, e.g. URI, anemia

Assessment of risk and obtaining informed consent

Allaying anxiety of child/parent

Baseline information

Maternal History Birth History:- Full term or preterm baby Determine post conceptual age Hospitalization, immunization, illnesses,

medications prolonged intubation Records, previous anesthesia and surgery

Maternal History with Commonly Associated Neonatal Problems

Problems with neonates Maternal history

Hemolytic anemia , hyperbillirubinemia, kernicterus

Rh - ABO incompatibility

SGA Toxemia - hypertension

Sepsis , thrombocytopenia Infection

Hypoglycemia , birth trauma , LGA, SGA

Diabetes

TEF, anencephaly, multiple anomalies Polyhydramnions

Renal hypoplasia , pulmonary hypoplasia

Oligohydramnions

Review of Systems: Anesthetic Implications

Anesthetic implications Questions to ask System

Irritable airway , bronchospasm ,medications , atelectasisSubglottic narrowingPostoperative apnea

Cough, asthma, recent cold

CroupApnea / bradycardia

Respiratory

Septal defect , airbubbles Right to left shuntTetrology of FallotCoarctation, renal diseaseValvular heart diseaseCHF, cyanosis

Murmur CyanosisSquattingHypertensionRheumatic feverExercise intolerance

Cardiovascular

MedicationsIntracranial hypertensionAspiration, ER , HHRelaxant sensitivity , MH

SeizuresHead traumaSwallowing incoordinationNeuromuscular disease

Neurologic

Electrolyte imbalance, dehydration , full stomachAnemiaAnemia , hypovolemiaFull stomachDrug metabolism / hypoglycemia

Vomiting , diarrhea

MalabsorptionBlack stoolsRefluxjaundice

Gastrointestinal / Hepatic

UTI , diabetes , hypercalcemiaState of hydrationEvaluate RF

FrequencyLast urinationFrequent UTI

Genitourinary

Hypothyroidism , DMHypoglycemia , adrenal insuff.

Abnormal developmentHypoglycemia , steroid

Endocrine / metabolic

Transfusion Coagulopathy Hydration, transfusion

Anemia Bruising SCD

Hematologic

Drug interaction Medications Allergic

Teeth aspiration, SBE prophylaxis

Loose teeth Dental

Family History

Prolonged paralysis with anesthesia (pseudocholinesterase deficiency)

Unexpected death (sudden infant death syndrome, MH)

Genetic defects Muscle dystrophy, cystic fibrosis, SCD, hemophilia,

von Willebrand disease (familial) Allergic reactions

Physical examination

Warm the stethoscope and your hands before examination

Fever , loose teeth , micrognathia , nasal speech Heart murmurs Edema Signs of dehydration

Laboratory Data

That healthy children elective minor surgery (no need)

significant blood loss may be expected, a Hb10 g · dl–1 older than 3 months or age.

Routine chest x-rays and urinary analysis is unnecessary

coagulation should only be considered in selected situations

Special Situations

Full Stomach

The most common problem in pediatric anesthesia 4 positions suctioning for fluids Prepare 2 laryngoscopes, 2 suctions IV access Atropine 0.02 mg/kg, preoxygenation, STP 5-6 mg/kg

or propofol 3 mg/kg or ketamine 1-2 mg/kg (hypovolemia), succinyl choline 1-2 mg/kg.

Sellick maneuver? Consider fasting hours only till time of injury.

Anemia

Chronic anemia? HCT? 25? Risks of blood transfusion to raise it to

30 is unjustified. Minor surgery? Elective with significant anticipated blood loss? Anemic former premature needs postoperative apnea

monitoring.

Sickle Cell Disease

Start IV fluids the night before with 1.5 times maintenance fluid volume

Keep warm, well oxygenated

Hematologic consultation (usually HCT 30 is targeted)

Upper Respiratory Tract Infection

Allergic rhinitis or URTI? (seasonal, clear discharge, no fever, not a contraindication for surgery)

Accept: clear nasal discharge, mild cough, no wheezes or crepitus, no fever, active and happy child, clear rhinorrhea, clear lungs, older child

Upper Respiratory Tract Infection

Postpone: fever 380, malaise, cough, poor appetite, just developed symptoms last night, lethargic, ill-appearing, wheezes, purulent nasal discharge, lower airway affection, leucocytosis, child <1 year, ex-premie, history of reactive airway disease, major operation, endotracheal tube required

Keep: albuterol, succinyl choline, inhalation agent in oxygen

If postoned: how long?

Asthma & Reactive Airway Disease

Wheezing, ER visit, medications Continue all medications till morning of surgery Theophylline level 10-20 microgram/ml Short term oral steroid therapy Minimal airway intervention ETT adaptors for metered dose inhalers better than simple

spraying through ETT PaCO2 > 45 (incipient respiratory failure) Emergency: oxygen-hydration-SC epinephrine-aminophylline-

ventolin-steroids-antibiotics

Anesthesia and Vaccination

Vaccine-driven adverse events (fever, pain, irritability) might occur but should not be confused with postoperative complications.

Appropriate delays for the type of vaccine between immunization and anesthesia are recommended to avoid misinterpretation of vaccine-associated adverse events as postoperative complications. Likewise, it seems reasonable to delay vaccination after surgery until the child is fully recovered.

Fever

0.5-1 degree is without symptoms is not a contraindication to GA

Symptoms: rhinitis- pharyngitis - otitis media – dehydration or any other symptoms of impending illness

Emergency: paracetamol

Cognitively Impaired Children

Extensive medical and surgical histories should be taken with great patience

Gastrointestinal reflux is common (anticholinergics)

Continue medications

Sedation: oral midazolam

Family member presence

If markedly scared: IM ketamine 3-4mg/kg, atropine 0.02mg/kg, midazolam 0.05-0.1mg/kg

Seizure Disorders

Medication-schedule-possible interaction with anesthetic drugs.

Stress may reduce seizure threshold.

Continue all medications.

Emergency with missing 1-2 doses: no problem but if longer periods consider IV therapy.

Blood levels: seizure free with sub-therapeutic levels for one year.

Methohexital exacerbate temporal lobe epilepsy.

Prematurity

Former Premature

“Neonates and especially ex-premature infants have a tendency toward periodic breathing that is accentuated

by anesthetics, increasing the risk of postoperative apnea until approximately 55-60 weeks post-

conceptual age and require continuous monitoring of blood oxygen saturation and

heart rate until 12-hours of apnea free period”.

Former Premature

Apnea (1) central apnea, due to immaturity or depression of the respiratory drive; (2) obstructive apnea, due to an infant's inability to maintain a patent airway; and (3) mixed apnea, a combination of both central and obstructive apnea.

Apnea (cont’d)

Susceptibility to Central apnea is exacerbated by hypothermia, hypoglycemia, and hypocalcemia, anemia, opioids .

Treatment: xanthines (caffeine & theophylline)

▲ Hct

▲ FiO2

Never give caffeine & send the neonate home as being “safe now”. Even patients treated with naloxone require continuous monitoring of

blood oxygen saturation and heart rate until 12-hours of apnea free period.

Obstructive apnea is treated by changing the head position, inserting an oral or nasal airway, placing the infant in a prone position or by applying continuous positive airway pressure (CPAP)

Retinopathy of Prematurity

Sick-low birth weight septic infants <1000 g with long oxygen therapy

No correlation with specific PaO2

Appear in infants with cyanotic heart disease who never received oxygen

Avoid hyperoxia under anesthesia?

Bronchopulmonary Dysplasia

Chronic lung disease associated prolonged mechanical ventilation (barotrauma) & oxygen toxicity in a premature neonate with hyaline membrane disease.

Chronic hypoxemia-hypercarbia-abnormal functional airway growth-tracheomalacia-bronchomalacia-reactive airway disease-propensity toward atelectasis and pneumonia-increased pulmonary vascular resistance + IVH.

Commonly on diuretic/steroid therapy. May need oxygen on transport to OR.

Bronchopulmonary Dysplasia

Allow adequate time for expiration. Avoid ETT if possible. Awake spinal/caudal/penile block. Postoperative apnea monitoring.

Diabetic Children

the most common endocrine problem

Is the child metabolic control acceptable? No ketonuria Normal serum electrolytes HbA1c <7.5

Choose protocol according to : Split-mixed insulin regimen (50%) Basal-bolus insulin therapy (Levemir 75%, Lantus 100%)

once daily Insulin pump Oral agent + insulin for type 2 DM

PREOPERATIVE PROTOCOL FOR ALL PATIENTS

Hold oral hypoglycemics and morning doses of insulin

Omit breakfast Child should arrive in the early morning First case of the day Labs needed: RBS , electrolytes ,K.BUN Keep RBS <250mg/dl using SC rapidly acting

insulin using correction method

correction factor

The calculation for insulin correction factor :   1.    Divide 1500 by child's total daily dose

(TDD).   2.    Example: if TDD = 50 units, then insulin

correction factor is 1 unit regular insulin to lower blood glucose by 30 mg/dL.

A.BASAL BOLUS INSULIN

A-FOR BASAL BOLUS INSULIN THERAPY

(LANTUS)-(LEVEMIR) OR SPLIT MIXED DOSAGES• If night dose was not given: give 75% of (levemir) or

100% of(lantus), 50% of (NPH) or (lantus) in split-mixed insulin regimen

• If given: • Check RBS/h, if<250 start D5%/1/2 NS maintenance,

if>250 give SC insulin using correction factor

A.BASAL BOLUS INSULIN

A-FOR BASAL BOLUS INSULIN THERAPY

(LANTUS)-(LEVEMIR) OR SPLIT MIXED DOSAGES• If night dose was not given: give 75% of (levemir) or

100% of(lantus), 50% of (NPH) or (lantus) in split-mixed insulin regimen

• If given: • Check RBS/h, if<250 start D5%/1/2 NS maintenance,

if>250 give SC insulin using correction factor

In procedures<2hrs continue SC pump at its usual rate with administration of additional SC units if needed

In procedures >2hrs keep infusion regimen as follows –

maint. Fluid (D10% + 1/2N.S)with Ins. inf.(1unit/ml) <12kg-1unit/5gm dex. >12kg-3gm dex.

B- INSULIN SC PUMP

C-TYPE II D.M

STOP oral hypoglycemics 24 hrs befog procedure

Give 50% of NPH or lantus if used Control RBS intraoperative by SC regimen as

usual

Allaying anxiety of child/parent

Fear pain, threat of needles, parental separation, no experience to place.

“The greater understanding and amount of information available to the parents, the less anxiety and the better attitude reflected in the child”.

“Anesthesia is a type of deep sleep in which you feel no pain from surgery and from which you’ll definitely awaken”.

Smiling, eye contact, holding the child’s hand.

Psychological Preparation of Children for Surgery

“A blood pressure cuff will check your blood pressure”

“ECG will watch your heart beats”. “A stethoscope will continuously listen to the heart

sounds”. “A pulse oximeter will measure the oxygen in the your

blood”. “A carbon dioxide analyzer will monitor the

breathing”. Discuss anesthetic risks in clear terms.

Psychological Preparation of Children for Surgery

Any Questions??