Preoperative visit to pediatric patients
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Preoperative Visit to Pediatric Patients. Marwa A. Khairy Lecturer of Anesthesia. 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.

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Preoperative Visit to Pediatric Patients

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Preoperative visit to pediatric patients

Preoperative Visit to Pediatric Patients

Marwa A. Khairy

Lecturer of Anesthesia


Goals

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

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

Maternal History with Commonly Associated Neonatal Problems


Review of systems anesthetic implications

Review of Systems: Anesthetic Implications


Family history

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

Physical examination

  • Warm the stethoscope and your hands before examination

  • Fever , loose teeth , micrognathia , nasal speech

  • Heart murmurs

  • Edema

  • Signs of dehydration


Laboratory data

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

Special Situations


Full stomach

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), succinylcholine 1-2 mg/kg.

  • Sellick maneuver?

  • Consider fasting hours only till time of injury.


Anemia

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

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

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 infection1

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, succinylcholine, inhalation agent in oxygen

  • If postoned: how long?


Asthma reactive airway disease

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

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

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

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

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

Prematurity


Former premature

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 premature1

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

Apnea (cont’d)

SusceptibilitytoCentral 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

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

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 dysplasia1

Bronchopulmonary Dysplasia

  • Allow adequate time for expiration.

  • Avoid ETT if possible.

  • Awake spinal/caudal/penile block.

  • Postoperative apnea monitoring.


Diabetic children

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

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

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.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 insulin1

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


B insulin sc pump

B- INSULIN SC PUMP

  • 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.


C type ii d m

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

Allaying anxiety of child/parent


Psychological preparation of children for surgery

Psychological Preparation of Children for Surgery

  • 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 surgery1

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.


Any questions

Any Questions??


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