Preoperative evaluation

and considerations in
children
PRESENTERS – DR. SANTOSH

DR. MEGHA

M O D E R AT O R – D R . R A K S H A
 Preoperative evaluation in pediatric
anaesthesia
Aims
To define the physical status of the child
To foresee the surgical and anesthetic risks
To prescribe preoperative tests and therapies or special preparation
To provide information regarding perioperative care
 For low risk patients undergoing low grading procedures –
same day of surgery

Timing of For high risk patients and/or scheduled for major surgery –
preoperative before the day of surgery
evaluation
ONE STOP ANAESTHESIA : Designed for day care procedures
Out Patient Out Patient
Department Department Pre – hospitalization

Clinical examination, Anaesthesia

Indications Questionnaire, Choosing timing Consultation Room
for Surgery delivery of information for anaesthesia
regarding procedure visit
One stop : pre-
anaesthesia assessment
done on day of surgery

Surgeon Surgeon - Nurse Anaesthesist Anaesthesist

 1. HISTORY
◦ Presenting condition – The procedure being performed, it’s
indication and urgency should be understood. Conditions having
other systemic effects should be sought out.

Components of
preanaesthetic ◦ Concurrent medical history – coexisting diseases must be identified
along with degree of severity, control, treatment given and
evaluation compliance to prescribed regimen, recent investigations related to
the disease.

◦ Birth history – history of prematurity, respiratory distress at birth,

whether child cried immediately after birth, history of hospitalization
and requirement of supplemental oxygen after birth
Developmental history – assess whether child is developmentally normal; if delay is present, assess which
spheres of development affected, and whether any associated conditions/syndromes present.

Family history – several hereditary conditions can influence anaesthetic management such as malignant
hyperthermia. They may have very little impact in daily life, hence history of immediate family members
suffering from problems with anesthetics must be looked for.

Anaesthetic history – document details of previous anaesthetic episodes, including any post operative sequelae
such as sore throat, headaches, PONV, unexpected ICU admission, need for prolonged intubation etc.

Drug history – all current medication must be documented, and their interaction with anaesthetic agents and
techniques should be considered. Also, advice regarding continuation or discontinuation of a medication prior
to surgery must be given at this time.
MEDICATION PREOPERATIVE MANAGEMENT IN PEDIATRIC POPULATION

1. Cardiac medications (e.g. beta blockers) Continue on day of surgery

2. Psychiatric medications (e.g. anxiolytics) Continue on day of surgery

3. Thyroid medications Continue on day of surgery

4. Eye drops Continue on day of surgery

5. Anticonvulsant medications Continue on day of surgery

6. Asthma medications Continue on day of surgery

7. Corticosteroids (oral and inhaled) Continue on day of surgery

8. insulin Discontinue short acting insulin (e.g. regular insulin), and for type 1 DM should take a small
amount (usually 1/3rd of usual morning long acting insulin dose on day of surgery.

9. Diuretics Discontinue on day of surgery

2. Examination : Features of clinical examination particularly relevant to the anesthetist are as follows –
◦ General – nutritional state, fluid balance, skin and mucous membranes (anemia, perfusion, jaundice),
temperature, features of syndromic child

◦ CVS – peripheral pulse (rate, rhythm, volume, radiofemoral delay), arterial blood pressure, heart sounds,
edema

◦ RS – central or peripheral cyanosis, oxygen saturation, respiratory rate and signs of respiratory distress
and laboured breathing to be looked for, auscultation of lung fields

◦ Airway - difficult airway should be noted on PAC sheet in bold letters.

◦ CNS – dysfunction of special senses, motor and sensory nerves (to be documented)
3. Investigations – avoid routine preoperative tests for patients younger than 16years and ASA1 scheduled for minor
day care surgeries (NICE guidelines)
◦ Tests should be ordered based on clinical history and examination e.g evaluation of hemoglobin in a surgery with
significant potential blood loss, cardiac ultrasound and 2D echo to rule out congenital cardiac anomalies

◦ Serum electrolytes should be ordered in patients with vomiting, diarrhea, use of diuretics, other conditions
associated with acid base abnormalities

◦ Coagulation tests should only be ordered for patients with known or suspected coagulopathies, or as a baseline
measure in procedures with high risk of significant bleeding.

◦ A Cxray is ordered when history and examination suggest lung disease, severe asthma, neuromuscular disease,
severe scoliosis etc.

◦ Institutional Guidelines : If report of a previous blood test within six months present, should only be repeated in
case of significant changes in the previous values.

◦ Investigations can be planned on case to case basis

 The ASA-PS classification system

Operating risk
Operating
Risk
Stratification

Note – an E after any class denotes emergency procedure

PREOPERATIVE
EVALUATION OF
CHILDREN WITH COMMON
COEXISTING CONDITIONS
 Allergies
Two main causes – muscle relaxants and latex
Can cause anaphylactic reaction or anaphylactoid
reaction
Atopy : Hereditary predisposition leading to synthesis
of IgE against various allergens. Clinical manifestations :
Asthma, allergic rhinitis, conjunctivitis, fever, eczema
History of cardiovascular collapse, bronchospasm, and
oedema during previous anesthesia – s/o allergic
reaction
Preoperative preparation –
1. Identification of patients at risk to latex allergy
. Special investigation : Allergy skin patch tests in –
2

Patients with documented allergy to an anaesthetic drug or latex

Patients with history of unexplained reactions during general anesthesia

Patients who belong to a group at high risk for latex allergy

3. Diphenhydramine, cimetidine, and steroids to be kept at hand in OT, in case requirement arises

4. In patients with previously documented reactions – ‘latex safe’ environment should be present in the perioperative
period, plan for anaesthesia should include regional anesthesia or general anaesthesia without neuromuscular
blocking drugs.

5. Known allergens should be marked with red pen on PAC sheet, so that they can be avoided in perioperative period.

6. Do not give any drugs to patient to which previous allergic reaction is documented.
 M/c/c of chronic lung disease in infants

Premature infants weighing ~1000g at birth that still need oxygen therapy
after 28days and after the 36th Gestational week

Triad : Airway obstruction, bronchial hyperreactivity, lung hyperinflation

Bronchopulmonary
dysplasia Clinical manifestations : Tachypnea, wheezing, coughing, frequent febrile
episodes, episodes of desaturation and bradycardia

At increased risk of laryngospasm, bronchospasm, desaturation, increased

secretions leading to occlusion of ETT (max during 1st year of life)

May become asymptomatic after 5-8 years, though bronchial

hyperreactivity persists
Preoperative optimization : Nutritional support, therapy with bronchodilators, antibiotics, diuretics,
corticosteroids

Preoperative investigations :

Echocardiography to assess cardiac contractility and rule out right ventricular dysfunction

Serum electrolytes in BPD patients on diuretic therapy

Arterial blood gas analysis

Patients with BPD may require monitoring and ventilation for 24-48 hours after surgery
Plan of anaesthesia should be decided in preoperative period, and general anaesthesia with supraglottic
airway devices or regional anaesthesia should be preferably used
Murmur Characteristics

•
•
Systolic or continuous
Increases and decreases
Heart Murmurs
• Mild or moderate ( <=2/6 )
Innocent Increased intensity from Common finding during childhood, but maximally
sitting to supine non pathological

• Diastolic, Pansystolic or late

systolic Look for – history of prematurity, presence of
• Generally intense ( >= 3/6 )
• Associated with tremors congenital malformations, respiratory symptoms
• Associated with signs or including repeated infections, cyanotic spells, chest
Pathological symptoms of heart disease
• Does not vary significantly pain, syncope, family history of sudden death
from sitting to supine position
Physical examination- auscultation of the heart in
both supine and sitting position, radio femoral delay
Special investigations –
1. ECG and Cxray have little diagnostic accuracy (can
be used as screening tools)
2. Gold standard – echocardiography. In presence of
murmur, 2D echo is recommended if –
Child less than 1 year old
Characteristics of pathological murmur are
present
Signs and symptoms of heart disease present
Evidence on ECG of left or right hypertrophy
Delay non urgent surgery in child with pathological
murmur, at least until report of echocardiography is
available.
Preoperative evaluation
Height and weight
Thorough examination of CVS and RS
Note any cyanosis/ clubbing/ cyanotic spells
Signs of Heart Failure : poor exercise tolerance, fatigue, tachypnea, signs Congenital
of respiratory distress, distended jugular veins, enlarged liver
Look for syndromic features heart disease
Evaluation –
Screening tools :
◦ Cardiac ultrasound
◦ Pulse oximetry
◦ ECG
◦ Chest Xray
Definitive diagnosis : 2D Echo
 Direction and degree of shunting
 Gradient of outflow tract obstruction
 1. PYLORIC STENOSIS
◦ Do blood gas analysis, and correct acid base imbalance
◦ Look for signs of dehydration (condition of mucous
membranes, skin pinch, capillary refill time, sunken eyes,
assess for thirst) and correct dehydration

Other important 2. SURGERIES WITH ANTICIPATED MAJOR BLOOD LOSS

co-existing ◦ Assess pre-operative hemoglobin, hematocrit, coagulation

conditions profile
◦ Arrange adequate blood and blood products
 Preoperative
fasting
guidelines
Preoperative fasting : Universally accepted
principle in elective cases to minimize the risk of
pulmonary aspiration of gastric contents posed by
combination of regurgitation and loss of
protective airway reflexes by anaesthetic agents.

ASA guidelines on preoperative fasting are given

in table
 Water

Non fizzy clear liquids

Tea/coffee without milk

What is meant Clear coconut water

by clear fluids?
ORS solution

Gatorade (and other carbohydrate drinks)

Apple juice

Pulp free juices e.g. orange juice without pulp

Prolonged fasting in children can result in detrimental metabolic and behavioral effects

Recent studies : Main risk period for an aspiration event is during induction, may also occur during
maintenance or emergence.

Patient factors associated with aspiration of gastric contents : Full stomach, bowel obstruction,
abdominal pain, diabetes, or associated trauma with reduced gastric emptying

Anesthetic factors associated with aspiration of gastric contents : Drug related issues (eg opioids),
patient positioning, choice of airway management, light plane or inadequate anaesthesia
Small children have higher metabolic rate, reduced glycogen stores as compared to adults – 28%
incidence of hypoglycemia found in toddlers fasting for at least 6 hours, as compared to those who had a
drink of milk 4 hours prior to surgery.

Prolonged fasting in already starving child is associated with ketoacidosis , more so in children less than
36months of age

Prolonged fasting more common than inadequate fasting in most centres in pediatric population

Prolonged fasting may also increase the need for perioperative analgesia, and increase the incidence of
perioperative nausea and vomiting

Other side effects of prolonged fasting – metabolic acidosis, dehydration, cardiovascular instability,
discomfort, hunger, thirst, and grumpiness
Strategies to decrease incidence of prolonged fasting in children –

1. Reduce real fasting times to follow ASA guidelines exactly

2. Decreasing the fasting limit for small amounts of clear fluids from 2 hours to 1 hour – not found
to increase incidence of pulmonary aspiration, widely followed in various centres now.

3. Offering a drink of water to children fasting for more than 4 hours

In children where delayed gastric emptying is suspected or where incompetence of LES is present i.e.
Achalasia cardia, adequate fasting (8 hours) must be ensured.