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Pre - Anesthetic
pediatric assessment
Maria Matuszczak MD
Pediatric Anesthesia
University of Texas, Medical School
Children’s Memorial Hermann Hospital
Texas Medical Center Houston
no conflicts of interest or disclosures
Objectives!
Importance of the preoperative evaluation
The pre-anesthesia phone assessment
The anesthesia clinic
Steps of the assessment
Common preoperative problems
Importance of communication
Preoperative assessment
Fundamental concept of safe
anesthesia care and OR efficiency
Allows for better OR planning by avoiding
same day cancellations
Allows practitioner to know the patient:
medically, physically, emotionally
.
Preoperative assessment (cont.)
Allows parents / children to establish
contact with the anesthesia team
Allows to discuss anesthesia plan, regional
anesthesia, pain management,
Allows to explain special technics need to management the airway,
special protocols for metabolic diseases.
Allows to define and optimize pre-existing conditions if necessary
Pre anesthesia phone assessment
Ideally visit in anesthesia clinic
But volume would be too
important for most services
So all patients can first be
assessed via phone
ASA 1 and 2 can be cleared
via phone call
Pre anesthesia phone assessment (cont.)
Institutional commitment is important.
Trained nurses guided by a pediatric anesthesiologist
Allows to decide:
Need to come to clinic
Need for further evaluation
Need to postpone
Need for admission
61 children studies, 21 with URI
Randall Flick et al.
The records of 130 children identified as
having experienced laryngospasm under
general anesthesia were examined.
In our pediatric population, the risk of
laryngospasm was increased in children
with upper respiratory tract infection or
an airway anomaly.
This study provides evidence that the high risk for
perioperative respiratory adverse events is limited to
the first 2 weeks after an upper respiratory tract infection,
and thus rescheduling a patient 2 to 3 weeks after upper
respiratory tract infection would be a safe approach.
The incidence of upper respiratory tract infection in children
presenting for anesthesia is high, and the prevalence of
asthma is increasing in the pediatric population.
Thus, anesthetists have to manage increasing numbers of
children at high risk of perioperative respiratory
adverse events in everyday clinical practice
Pre anesthesia phone assessment (cont.)
If electronic anesthesia record is available
demographic patient data can be
completed early on:
Body weight, gender,
age ( post-conceptional age for premies)
Procedure, day of surgery, surgeons name
Anesthesia clinic visit
Guideline needed for nurse or residents to correctly assess
patient
Physical examination includes:
Auscultation,
Airway assessment,
Obesity
OSA
Psychological assessment
Anesthesia clinic visit ( cont.)
History:
any type of syndrome, malformation, disease should , previous
exams evaluating the syndrome / disease should be available.
Current medication:
all medication currently taken should be noted, are symptoms
treated with medication (seizures, asthma, reflux), for diabetic
children daily profile of blood sugar
Allergies:
medication, type of allergic reaction, or was it a side effect ,
(diarrhea after antibiotics; pruritus or nausea after morphine).
food allergy (egg allergy not a problem for propofol).
Anesthesia clinic visit ( cont.)
Birth history:
born at term or premature, post-conceptional week at birth, did
child need ventilator support, for how long; was child O2
dependent, for how long? If child is less than 6 month old
calculate post-conceptional age at time of surgery.
Previous anesthetics:
was it general anesthesia, was the child intubated, were there
any complications?
Anesthetic problems in the family:
only significant problems should be noted,
malignant hyperthermia, pseudocholinesterase deficiency,
hepatic porphyrias, muscular dystrophy disorders.
Anesthesia clinic visit ( cont.)
Discuss induction with parents and child
Premedication
Parents presence
Patient anxiety
Parent has chance to think it over before the day of surgery
more questions may arise
Regional anesthesia should be discussed with parents and
expectations about pain management
Anesthesia informed consent can be explained and signed
Examine children’s anxiety across the perioperative setting.
261 children ages 2–12. Anxiety was rated prior to surgery,
immediately after surgery, and for 2 weeks post-surgery at home
Low child sociability and high parent anxiety predicted
perioperative anxiety.
Perioperative anxiety was related to postoperative
pain and negative postoperative behavioral change.
Anesthesia clinic visit ( cont.)
These data can then be discussed with the
anesthesiologist who can complete
the chart by adding details about the procedure, positioning,
ETT or LMA, difficult intubation
what type of anesthesia is needed,
need for blood,,
postoperative pain management,
day surgery yes or no,
need for PICU bed
Frequent problems
Obstructive sleep apnea
Blood transfusion, erythropoietin
Hemophilia
Sickle Cell
Autism
Mitochondrial disorder
Common postoperative
airway complications
included airway
obstruction and respiratory arrest
of unclear etiology.
Deaths or neurologic injury
after tonsillectomy due to apparent apnea
in children suggest that at least 16 children
could have been rescued had respiratory
monitoring been continued throughout
first- and second-stage recovery, as well as on
the ward during the first postoperative night
Phone call the day before
Communication and coordination:
between the perioperative team is crucial
with parents about NPO times,
when to come, what waiting time to expect
Last change to catch infection or other problem
ASA NPO guidelines
Restriction of
clear fluids for 2 hours,
breast milk for 4 hours,
formula or cow's milk for 6 hours and
solid food for 8 hours before
induction of anesthesia in elective healthy patients.
The safety of the generic light meal in children the morning of
surgery (followed by 6 hours of fasting) as endorsed by the
ASA task force for adults has not been formally evaluated in
children.
Assessment the day of surgery
The least ideal situation,
Creates a lot of anxiety if problems are discovered last minute
Especially if no phone assessment has been performed
Time is limited for evaluation,
Frequently creates delays in the OR
Leads to Unsafe compromises
Cancellation is an efficiency disaster for the OR,
Frustrating for parents and for the perioperative team
Ideal organization of pre anesthesia assessment
Day of visit at surgeons office
Decision made to operate
patient visit anesthesia clinic right then and there
Anesthesia and surgery plan is established
Patient is followed by anesthesia from the start to the
recovery
including pain management postoperatively.
(perioperative surgical/anesthesia home)
Questions ?
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