Transcript Preoperative Visit to Pediatric Patientsx

Hany El-Zahaby, MD
 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.
 “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.
Maternal history
Problems with neonates
Rh - ABO incompatibility
Hemolytic anemia ,
hyperbillirubinemia, kernicterus
Toxemia - hypertension
SGA
Infection
Sepsis , thrombocytopenia
Diabetes
Hypoglycemia , birth trauma , LGA,
SGA
Hemorrhage
Anemia , shock
Polyhydramnions
TEF, anencephaly, multiple anomalies
Oligohydramnions
Renal hypoplasia , pulmonary
hypoplasia
Cephalopelvic disproportion
Pelvic trauma
Alcoholism
Hypoglycemia, congenital
malformation, SGA
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 trama
Swallowing incoordination
Neuromuscular disease
Medications
Intracranial hypertension
Aspiration, ER , HH
Relaxant sensitivity , MH
Gastrointestinal /
Hepatic
Vomiting , diarrhea
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
 Hospitalization, immunization, illnesses, medications
 Prematurity, apnea, bradycardia
 Croup, prolonged intubation
 Records, previous anesthesia and surgery
 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
 Drug addiction (drug withdrawal, HIV)
 Children interaction with parents and health care givers
 Pallor , cyanosis , sweating , jaundice , apprehension , pain,
signs of previous operations
 Signs of URTI
 Signs of respiratory difficulty: Nasal flaring grunting,
stridor ,retractions, wheezing
 abdominal distension.
 Congenital abnormalities.
 Warm the stethoscope and your hands before examination
 Fever , loose teeth , micrognathia , nasal speech
 Heart murmurs
 Edema
 Signs of dehydration
 CBC: <6M, hemoglobinopathy, former premature.
 Bleeding profile: reconstructive surgery
 Electrolytes, RFT, ABG,ECG, echo, LFT, anticonvulsants
levels, digoxin level, PFT when appropriate
 Hypoglycemia is unlikely in healthy pediatric patients, only
in debilitated, poorly nourished child with metabolic
dysfunction.
 Clear fluids:2h
 Breast milk: 4h
 Milk formula & solid food:6h
 High risk patients: GERD, previous esophageal surgery,
difficult airway, morbid obesity (Cimetidine 7mg/kg,
metoclopramide 0.1 mg/kg, clear antacid 30 ml)
 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.
 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.
 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
 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?
 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.
 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
 SCT, SCD by hemoglobin electrophoresis?
 SCD, Frequent sickler, morphine addiction?
 Start IV fluids the night before with 1.5 times maintenance
fluid volume
 Keep warm, well oxygenated
 Hematologic consultation (usually HCT 30 is targeted)
 Extensive medical and surgical histories should be taken
with great patience
 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
 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?
 “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”.
 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.
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 12hours 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)
 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 diseasepropensity toward atelectasis and pneumonia-increased
pulmonary vascular resistance + IVH.
 Commonly on diuretic/steroid therapy.
 May need oxygen on transport to OR.
 Allow adequate time for expiration.
 Avoid ETT if possible.
 Awake spinal/caudal/penile block.
 Postoperative apnea monitoring.
 With expansion of the lungs during the first breath, pulmonary
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vascular resistance decreases and blood flow to the lungs increases.
Neonatal hypoxia, hypercarbia, or acidosis increase PVR & may result
in a return to the fetal-type circulatory pattern with right-to-left shunt
via the PFO or PDA (PA to AO).
Persistent PDA after declining of pulmonary vascular resistance causes
left to right shunt with pulmonary hypertension and increased
ventilatory support.
PDA is diagnosed by bounding peripheral pulses, a harsh systolic
ejection murmur at the left sternal border and a large pulse-pressure,
Echo.
PDA is treated by indomethacin, coiling or surgical ligation.
 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.
 Avoid contaminating the line
 Avoid sudden stoppage
 Use infusion pump & decrease the rate by 33-50% (lower
metabolic rate)
 Monitor glucose, potassium, sodium, calcium, acid-base
 Check proper IV line placement
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-ventolinsteroids-antibiotics
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
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.
PREOPERATIVE PROTOCOL FOR ALL PATIENTS:
 Hold oral hypoglycemics and morning doses of
insulin
 Omit breackfast
 Child should arrive in the early morning
 First case of the day
 Labs needed: RBS , electrolytes ,K.B
 Keep RBS <250mg/dl using SC rapidly acting
insulin using correction method
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
In procedures<2hrs continue SC pump at its usual rate
with adminstration 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 И D.M
• STOP oral hypoglycemics 24 hrs befor procedure
• Give 50% of NPH or lantus if used
• Control RBS intraoperative by SC regimen as usual