Preoperative assessment and preparation of pediatric patient

1. Preoperative assessment and preparation of pediatric patient Moderator Dr Anil Ohri By –Dr Vishawjeet

2. Psychological preparation • important aspect of preoperative care, especially for younger children • Children aged 2-6 years are over five times more likely to have significant preoperative anxiety than older children and infants • Parental anxieties concerning surgery may be profound and can be transmitted to child . Efforts should be made to reduce parental anxiety as well

3. ANAESTHETIC ASSESSMENT • Full medical history • --previous history of illnesses and operations • --current medications • --allergies • --any unusual syndrome with anaesthetic implications • --parents should be asked whether infant child was born at term or she breathed immediately at birth • --premature babies especially with apneic episodes are likely to develop apnea following anaesthesia and should not be accepted for day care procedure until they are 50 wks gestational age

4. -- to know whether the child is malnourished or not • This may influence selection of anaesthetic equipments eg size of endotracheal tube • History of URTI within 4 wks of operation or pts who have symptoms of URTI preoperatively are at increased risk of developing respiratory complications such as laryngospasm, bronchospasm , atelectasis , hypoxemia during or after anaesthesia • If the decision is made to proceed with surgery inspite of URTI few days before surgery endotracheal tubes should be used to prevent aspiration, risk of coughing or laryngospasm • Postoperatively pt will require supplemental oxygen

5. EXAMINATION • Head and neck should be examined to detect loose decidual teeth • Signs for difficult intubation— • limited mouth opening • micrognathia • large tongye • noisy breathing • Presence of high temperature 38 deg c , cough ,malaise and audible chest signs suggest LRTI . • elective anaesthesia should be postponed for atleast 4-6 wks to allow hyperactive airways to return to normal

6. Diseases associated with difficult airway • ---- mask and spontaneous ventillation • Preterm infant • Crouzon syndrome • Aperts syndrome • Choanal atresia • --MICROGNATHIA • pierre robin syndrome • First arch syndrome • Treacher collin syndrome • Goldenhar syndrome • Arthrogryposis • -----macroglossia • Beckwith-Wiedmann syndrome • Congenital hypothyroidism • Down syndrome • Congenital lingual tumor/ intraoral tumor • Cystic hygroma

7. Intraoral pathology • Congenital temporomandibular joint fusion /dysfunction • Laryngeal cyst , web • Laryngotracheal cleft • Microstomi • Cleft palate

8. Preoperative investigations= • -- Routine Hb is indicated— • Neonates and ex premature infants under 1 yr • Children at risk for sickle cell ds • Children for whom intraoperative blood transfusion may be necessary • Children with systemic ds • Preoperative Hb of less than 10 g/dl is abnormal and needs to be investigated

9. -- Routine biochemistry • It is indicated in children with metabolic , endocrine ,or renal ds • Children receiving iv fluids

10. Child with murmur • Majority of pathological murmurs are diagnosed perinatally and are already under care of pediatric cardiologists. Antibiotic prophylaxis should be given • Previously unreported murmurs are commonly heard at 2-4 yrs of age . Majority are functional. • Pansystolic murmurs with normal heart sounds in a child with normal oxygen saturation and no limitation in exercise tolerance , can be assumed to be innocent and no antibiotic prophylaxis is required. • If still in doubt a formal cardiac assessment should be made

11. PREOPERATIVE FASTING Fasting instructions are designed to minimize the risk of regurgitation of gastric contents and subsequent pulmonary aspiration Prolonged fasting in infants can lead to dehydration and hypovolemia Clear fluids—2 hrs Breast milk –4 hrs Light meal , infant formula—6 hrs

12. TOPICAL ANAESTHETICS • Topical anaesthetics reduce pain of venepuncture and facilitate iv induction • Emla cream –eutectic mixture of 5% lidocaine and 5% prilocaine in 1:1 ratio. Should be avoided in children <1 yr of age becoz of the risk of methemoglobinemia • Ametop –4% gel preparation of amethocaine . It is licenced from 4 wks of age and has vasodilating properties . Rapid onset of action than E mla cream 30 min

13. It is important to identify veins to be anaesthetised and not blindly apply on the dorsum of each hand. • Keep the area bandaged to prevent removal or licking of cream • Ethyl chloride is cryoanalgesic . It is used when topical creams are contraindicated

14. PREMEDICATIONS • Routine sedative premedication is unnecessary • Children requiring premedication— • ---Excessive upset child • ---Children with previous unpleasant experiences of surgery and anaesthesia • ---Children with developmental delay • ---Older children may request sedation

15. _ Oral midazolam—0.5mg/kg • Ideal premedicant • Acts within 15-20 min, reduces anxiety leading to more cooperative child. • Midazolam 0.2mg/kg can also be given intranasally. Rapid action, poorly tolerated, burning sensation in nasal mucosa