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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

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
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
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.
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
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.
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