Pre-Op Preparation and Assessment of Pediatric Patients

7/28/2019 Pre-Op Preparation and Assessment of Pediatric Patients

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Pre-operative Preparation& Assessment of

Paediatric Patients

Dr. Felicia LimConsultant Paediatric Anaesthesiologist

Jabatan Anestesiologi & Rawatan Intensif

Pusat Perubatan Universiti Kebangsaan Malaysia


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Paediatric Anaesthesia

Very challenging

Requires knowledge of paediatric / neonatalphysiology & pharmacology

Covers a wide range of patient size and age Newborns

Pretermneonates

Ex-preterminfants

Full termneonates Infants

Children

Adolescent


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Pre-operative Preparation &

Assessment Aims

Risks of Anaesthesia

Preoperative Assessment Child with URTI

Preterm and former preterm infants

Child with asthma, congenital heart disease

Preoperative optimization of patient

When to book PICU/NICU or HDU beds

Psychological Preparation


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The preparation of a child who is about to undergo surgeryor anaesthesia involves

Child & his/her family,

Surgeon

Anaesthesiologist,

Other specialists- paediatrician, cardiologist, oncologist

Communication among the individuals caring for thepatient is important.

Established lines of communication permit the efficient andmeaningful transfer of patient information.


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Aims of Preoperative Preparation

& Assessment

Evaluate childs health status

Detection of unrecognized conditions that

increase the risk of surgery.

Optimize the patients current medical problemsand anticipate potential complications.

Information & instruction for patient/parent Psychological preparation


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Risk of Anaesthesia in Children five-year study (between J uly 1, 2003 and August 30,

2008) of children(< 18 years) undergoing anaesthesia atRoyal Childrens Hospital Melbourne

incidence of anaesthesia-related death - one in 10,188

anaesthetics (or 0.98 cases per 10,000)

10 anaesthesia-related deaths out of 101,885 anaesthetics

In all 10 cases, pre-existing medical conditions were identified asbeing a significant factor in the patients death, and five of theseinvolved children with pulmonary hypertension, or abnormally highblood pressure in the arteries of the lungs.

Healthy child risk is very very low


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Pre-operative Preparation

Medical

Psychological


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Anaesthestic Preparation

Pre-operative visit & assessment

To meet patient and parent and toestablish rapport and gain confidence

To assess for fitness for anaesthesia andrisk

To explain re anaesthetic technique, pre-

op fasting, post-op pain management etcTo take consent for anaesthesia, regional

anaesthesia, blood transfusion


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Anaesthetic Assessment

History

Birth- term, premature, problems,postconceptual age, developmental milestones

Previous surgery

Other medical problems eg asthma, CHD

Medications

Allergies Recent URTI

Family history


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Anaesthetic Assessment

Clinical Examination

General Condition,

Respiratory URTI. asthma Cardiovascular murmur

Neurological


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Airway any problem with airwaymanagement

Dysmorphic featuresCongenital abnormalies eg

Pierre Robin

Treacher collins

Downs syndrome

obesity


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Potential Difficult Airway

Goldenhar Syndrome


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Potential Difficult Airway

Child with no neckPierre Robin Syndrome


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Presence of a congenital malformation

or disease Presence of one malformation should lead to

investigation for other associated malformation

Eg: TOF VACTERLVertebraAnal

Cardiac

Trachea

Esophagus

Radial , RenalLimb

Downs syndrome cardiac lesions


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Laboratory Investigations

should be considered according to thephysical condition of the child and the natureof the surgery

value of routine tests in healthypatient isquestionable when the surgical procedureswill not involve significant blood loss

Should be performed only if their resultscould influence anaesthetic management.


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Laboratory Investigations Hb

Not necessary for healthy child for minorprocedures

Necessary ifchild is anaemic clinically,

premature infants,

patient with chronic diseases

As a baseline in anticipation of significant surgicalloss

Blood Chemistry

Only where there are specific indications


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Preoperative Fasting

previous prolonged fasting periodinappropriate

Drinking clear fluid up to 2 hours beforesurgery does not residual gastric volume oralter pH of gastric content

Clear fluid a liquid that you can see printthrough eg water, fruit juice without pulp


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Preoperative FastingMore liberal use of clear fluid in theimmediate preoperative period may decrease the incidence of preoperative

dehydration and possible hypotension duringinduction.

prevent hypoglycaemia

result in less agitated child and a happierparent


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Fasting Guidelines for Children(hours of fasting)

Clear fluid 2 hours

Breast milk 4 hours

Infant formula/cow's milk 6 hours

Solid 6-8 hours


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A Child with Upper Respiratory

Tract Infection (URTI)Preschool children average 6 URTI per year

both upper and lower airways affected

95% viral aetiology, self-limit ing

viral infections damage respiratory

epithelium

airway hyperreactivity persist for6-12 weeks


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Upper Respiratory Tract Infection

Problems of anaesthetizing a child with URTI laryngospasm,

bronchospasm,

stridor,

breath holding,

airway obstruction by secretion

Desaturation

Bacterial pneumoniaCan occur during anaesthesia and in the postoperativeperiod


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Risks Under GA

Studies by Cohen & Cameron showedanaesthesia in the presence of URTI

Presence of URTI (cf no URTI)

2-7 times greater incidence ofrespiratory complications

11 times if the trachea had been

intubated

incidence infants < 1 year old


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Risk factors

Age

Intubation

Co-morbid conditions Airway management

Surgery


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Risk Factors

Age: the younger the greater the risk

infants


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Risk Factors

Co-morbid conditions

Asthma

Congenital heart diseases

Airway ManagementETT > LMA > face mask

SurgeryAirway surgery

Upper abdominal surgery


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Guidelines

There is no consensus regarding the best

management of children with URTI

Main worry - potential for complications

easy to cancel if child is overtly sick dilemma in grey area

consider case by case


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Guidelines Elective or emergency

Minor or major surgery

Mild or severe URTI

No of times canceled


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Guidelines For URTI in Children

Elective surgery

Mild URTI no fever, clear nasal discharge,

mild cough, child active

can be anaesthetized for minorsurgical

procedure without intubation


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Guidelines For URTI in Children

Active infection

fever,

recentonsetof purulentnasal discharge

cough

may represent a prodrome of a more serious orinfectious illness like chicken pox or measles.

Should be postponed


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When to reschedule surgery?

no optimum time to wait before surgery rescheduled

most reports say 3-4 weeks or at least 2 weeks afterpeak symptoms

longer time not practical (2

nd

episode may occur) uncomplicated nasopharyngitis 1-2 weeks delay

acceptable (Berry 1984)

balance between need to proceed and time

required for resolution of symptoms + reduced risk General consensus to postpone for 2-4 weeks


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Child with URTI symptoms

Surgery Urgent?

Proceed Infectious Etiology?

Severe

Symptoms?

Proceed

Postpone 2-4 wks General Anaesthesia?

Risk Factors?Hx of asthma, Use of an ETT

Copious secretions

Nasal congestion

Parental smoking

Surgery of airway

Hx of prematurity

Other Factors?

Need for expedience

Parents traveled far

Surgery canceled previously

Comfort anesthetizing child with URI

Proceed

Benefit/Risk?

Proceed

Postpone 2 - 4 wks

Management

Avoi d ETT, Cons ider LMA,

Pulse Oximetry, Hydration,

Humidification? ,

Ant icholinergics?

Yes

Yes No

NoYes

YesNo

GoodPoor

No


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PRETERM OR FORMER

PRETERM INFANTS


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Ex-preterm Infant forherniotomy

Expretermfor Elective Surgery

EUA for ROPEUA for ROP


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Preterm baby for

Emergency Surgery


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Surgery in OT or NICU?Surgery in OT or NICU?

Sick, septic infant

Ventilatory support eg Highfrequency Oscillatory Ventilation

Inotropic support

Syringe pumps


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Avoid problems of transporting sick andunstable patient.

Need to transport under similar conditions to those in

NICU maintaining the same ventilatoryand inotropicsupport.

incubator, ventilator, batteries, oxygen and air cylindersand many volumetric syringe pumps

Difficulty in maintaining similar ventilatory

support during surgery in OT eg HFOV

Advantage of performing the

surgery in NICU:


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Surgery in NICU


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Main Concern in Preterm Infant

Post-operative Apnoea Definition

cessation of respiratory movements of >20 secor


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Post-operative Apnoea Risk

Risk is inversely related to postconceptual age(PCA) PCA = gestational age + postnatal age

eg born at 28 wks, 1 month oldPCA=28+4 = 32 weeks

risk higher in lower PCA babies

PCA


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Guidelines

If PCA < 48 weeks , arrange for bed in ICU orHDU for post-operative observation

Should be monitored for at least 24 hourspostoperatively.

Apnoea monitoring should be continued untilthe infant is apnoea-free for 12 hours.


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Child with Asthma

Should be optimized before anaesthesia

All medications continue up to andincluding day of surgery

Oral medications taken with sips of waterup to 1-2 hr before surgery

Inhaled bronchodilators administer just

before coming to OT No elective surgery on wheezing patient

or recent asthmatic attack


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Child with Cardiac Lesion

Murmur innocent or pathological?

Symptomatic or asymptomatic?

Degree of compromise

Cardiac consult

Complex congenital heart

Subacute bacterial endocarditisprophylaxis new AHA guidelines


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Preoperative Preparation

Optimise Medical Condition Before Surgery

Hypovolaemia

Dehydration

Metabolic derangement


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CONGENITAL PYLORIC STENOSIS

Medical emergency notSurgical emergency

correct dehydration &metabolic derangement

first before surgery


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Vomiting Dehydration Metabolic

derangement

Congenital Pyloric Stenosis


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Dehydration

Assessment

General appearance

Mucous membrane, skin turgor

Anterior fontanell

Capillary refill

BP, pulse

Urine output

Degree of dehydration Mild (5%)

Moderate (10%)

Severe (>10%)


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Symptoms & Signs Mild

(5%)

Moderate

(10%)

Severe

(>10%)

General appearance Alert , restless,

thirsty

Thirsty, restless,

lethargic

Drowsy to comatous

Sweaty, cold

Pulse

rate & Volume

Normal , weak Rapid, feeble

Anterior fontanelNormal Sunken Markedly depressed

Skin turgor Normal Eye Normal Sunken, dry Markedly sunken very

dry

Mucous membrane Normal Dry Very dry

Capillary refill Normal < 2sec > 3 sec

BP Normal Normal or low Low or unrecordable

Resp Normal Deep Deep or rapid

Urine output Adequate decrease Oliguria or anuria


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Metabolic Derangement

hyponatraemia, hypokalaemia,hypochloraemia, metabolic

alkalosis

Na+ 127mEq/l,

Cl- 84mEq/l,

K+ 2.8mEq/l,

bicarbonate 35mmol/l , base deficit: +12, pH 7.65


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Correct Dehydration

Pt with >10% dehydration

pt in impending shock

rapid infusion of 10-20ml/kg of N/S

once circulation restored & U/Oreplace deficit over 24-48 hrs.

Fluids

normal saline

Add K+ when U/O established

Maintenance fluid should be given


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Dehydration

5-10% dehydration

Fluid Deficit

% dehydration X body wt (gm)

eg 10% dehydration in 4kg body wt infant

(10% X 4000) ml = 400ml

replace deficit over 24 hrs

over 1st 8 hr, next 8, next 8


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Correct Metabolic Derangement

Correct by itself once dehydration is

corrected


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When to proceed for surgery?

Haemodynamic Well hydrated

Good urine output

Biochemical end point pH 130mmol/l

Cl > 90 mmol/l

K > 3.0mmol/l

HCO3 < 28mmol/l


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Preoperative Preparation

When to book ICU/NICU/HDU beds?

Sick, septic patient

Preterm babies


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About 65% of children experienceintense anxiety throughout

perioperative period, especially in thepreoperative holding area and duringinduction of anaesthesia

Kain et al, Anesthesiology 2009


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Experience can be traumatic enough as toinduce life long aversion to hospital, fear ofdoctors

Children who had multiple surgeries, longhospital stay may suffer lasting psychologicaleffects

Reducing preoperative anxiety decreases

incidence of postoperative negative behaviours(nightmares, fear of separation)


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Important to allay anxiety parent & patient

Provide adequate information re surgery& anaesthesia

Explanation

Flyers, pamphlets etc

Video of OR Visit to OR


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Reduce fears and anxieties

Parent accompanies child to OT

Favorite toy

Play area in OT

DVD favorite cartoons


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Summary

The preparation of a child who is about toundergo surgery involves the child, hisfamily, surgeon, anaesthetist and other

specialists

Communication is important

Besides medical preparation of patient,

psychological preparation is important toally anxieties and fears

Documents

Pre-Op Preparation and Assessment of Pediatric Patients