Preoperative Visit to Pediatric Patients

1. Preoperative Visit to Pediatric Patients Marwa A. Khairy Lecturer of Anesthesia

2. 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

3. 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

4. Maternal History with Commonly Associated Neonatal Problems

5. Review of Systems: Anesthetic Implications

7. 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

8. Physical examination • Warm the stethoscope and your hands before examination • Fever , loose teeth , micrognathia , nasal speech • Heart murmurs • Edema • Signs of dehydration

9. 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

10. Special Situations

11. 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.

12. 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.

13. 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)

14. 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

15. 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?

16. 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

17. 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.

18. 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

19. 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

20. 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.

21. Prematurity

22. 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”.

23. 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.

26. 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)

29. 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?

30. 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.

31. Bronchopulmonary Dysplasia • Allow adequate time for expiration. • Avoid ETT if possible. • Awake spinal/caudal/penile block. • Postoperative apnea monitoring.

32. 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

34. 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

35. 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.

36. 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

37. 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

39. 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.

41. 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

46. Allaying anxiety of child/parent

47. 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.

48. 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.

49. Any Questions??