Transcript Preoperative Visit to Pediatric Patients

Preoperative Visit to Pediatric
Patients
Marwa A. Khairy
Lecturer of Anesthesia
GOALS
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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
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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
Problems with neonates
Rh - ABO incompatibility
Hemolytic anemia ,
hyperbillirubinemia, kernicterus
Toxemia - hypertension
SGA
Infection
Sepsis , thrombocytopenia
Diabetes
Hypoglycemia , birth trauma , LGA,
SGA
Polyhydramnions
TEF, anencephaly, multiple anomalies
Oligohydramnions
Renal hypoplasia , pulmonary
hypoplasia
Review of Systems: Anesthetic
Implications
System
Questions to ask
Anesthetic implications
Respiratory
Cough, asthma, recent cold
Croup
Apnea / bradycardia
Irritable airway , bronchospasm,
medications , atelectasis
Subglottic narrowing
Postoperative apnea
Cardiovascular
Murmur
Cyanosis
Squatting
Hypertension
Rheumatic fever
Exercise intolerance
Septal defect , airbubbles
Right to left shunt
Tetrology of Fallot
Coarctation, renal disease
Valvular heart disease
CHF, cyanosis
Neurologic
Seizures
Head trauma
Swallowing incoordination
Neuromuscular disease
Medications
Intracranial hypertension
Aspiration, ER , HH
Relaxant sensitivity , MH
Gastrointestinal / Vomiting , diarrhea
Hepatic
Malabsorption
Black stools
Reflux
jaundice
Electrolyte imbalance,
dehydration , full stomach
Anemia
Anemia , hypovolemia
Full stomach
Drug metabolism /
hypoglycemia
Genitourinary
Frequency
Last urination
Frequent UTI
UTI , diabetes , hypercalcemia
State of hydration
Evaluate RF
Endocrine /
metabolic
Abnormal development
Hypoglycemia , steroid
Hypothyroidism , DM
Hypoglycemia , adrenal insuff.
Hematologic
Anemia
Bruising
SCD
Transfusion
Coagulopathy
Hydration, transfusion
Allergic
Medications
Drug interaction
Dental
Loose teeth
Teeth aspiration, SBE
prophylaxis
Family History
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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
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Warm the stethoscope and your hands before
examination
Fever , loose teeth , micrognathia , nasal speech
Heart murmurs
Edema
Signs of dehydration
Laboratory Data
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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
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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
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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
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Start IV fluids the night before with 1.5 times
maintenance fluid volume
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Keep warm, well oxygenated
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Hematologic consultation (usually HCT 30 is targeted)
Upper Respiratory Tract Infection
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Allergic rhinitis or URTI? (seasonal, clear
discharge, no fever, not a contraindication for
surgery)
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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
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Postpone: fever 380, malaise, cough, poor appetite,
just developed symptoms last night, lethargic, illappearing, 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
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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-aminophyllineventolin-steroids-antibiotics
Anesthesia and Vaccination
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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
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0.5-1 degree is without symptoms is not a
contraindication to GA
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Symptoms: rhinitis- pharyngitis - otitis media –
dehydration or any other symptoms of impending
illness
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Emergency: paracetamol
Cognitively Impaired Children
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Extensive medical and surgical histories should be taken with great
patience
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Gastrointestinal reflux is common (anticholinergics)
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Continue medications
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Sedation: oral midazolam
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Family member presence
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If markedly scared: IM ketamine 3-4mg/kg, atropine 0.02mg/kg,
midazolam 0.05-0.1mg/kg
Seizure Disorders
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Medication-schedule-possible interaction with anesthetic drugs.
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Stress may reduce seizure threshold.
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Continue all medications.
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Emergency with missing 1-2 doses: no problem but if longer
periods consider IV therapy.
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Blood levels: seizure free with sub-therapeutic levels for one year.
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Methohexital exacerbate temporal lobe epilepsy.
Prematurity
Former Premature
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“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 postconceptual age and require continuous
monitoring of blood oxygen saturation and
heart rate until 12-hours of apnea free period”.
Former Premature
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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
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Sick-low birth weight septic infants <1000 g
with long oxygen therapy
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No correlation with specific PaO2
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Appear in infants with cyanotic heart
disease who never received oxygen
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Avoid hyperoxia under anesthesia?
Bronchopulmonary Dysplasia
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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
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Allow adequate time for expiration.
Avoid ETT if possible.
Awake spinal/caudal/penile block.
Postoperative apnea monitoring.
Diabetic Children
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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
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PREOPERATIVE PROTOCOL FOR
ALL PATIENTS
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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 splitmixed 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 splitmixed 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
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.
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C-TYPE II D.M
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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
Psychological Preparation of Children for
Surgery
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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
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“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??