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8361 Exam 2 > Mod V: Peds Pre-op Part 1 > Flashcards

Mod V: Peds Pre-op Part 1 Flashcards

1
Q

Perioperative Preparation

Why Perioperative Preparation so important?

A

The number one error in pediatric anesthesia is inadequate preparation

Absence of adequate pre-anesthetic assessment is one of the top three causes of lawsuits against anesthetist

Recovery occurs more quickly when the anesthetist allays patient concerns regarding what is to come and plans postoperative pain management with the patient

Planning prevents problems

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2
Q

Perioperative Preparation

Goals of Perioperative Preparation:

A

Educate child/family

Anesthesia - Perioperative care - Pain management

Obtain pertinent information

Medical Hx - Physical & mental condition

Determine/decide

Consultations - Tests

Anesthetic plan

Guided by risk factors & pt choice

Obtain informed consent

Ultimate Goal => reduce morbidity

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3
Q

Perioperative Preparation

A structured/comprehensive method to reviewing anesthetic considerations for a child’s medical condition & surgical procedure; including Preoperative, Intraoperative, and Postoperative periods is also known as:

A

Eleven P’s to Pediatric Perioperative Planning

Completing the Eleven P’s helps the anesthetist develop a comprehensive/individualized anesthetic plan

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4
Q

Perioperative Preparation

What are the Eleven P’s to Pediatric Perioperative
Planning?

A

Patient

(H & P - Medical conditions requiring special consideration)

Procedure

Premedication

Preoperative fasting

Perioperative labs

Perioperative monitoring

Perioperative fluid

Positioning

Plan

(Induction - Maintenance - Emergence)

Pain

(Intra- & postop concerns)

Postoperative

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5
Q

Perioperative Preparation

What’s the main goal of Perioperative Preparation?

A

To minimize perioperative morbidity & mortality

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6
Q

Perioperative Evaluation

The main goal of Perioperative Preparation is to minimize perioperative morbidity & mortality. How could this be achieved?

A

Evaluate overall health status

Identify risks

Normal physiologic/anatomical challenges

Preexisting medical conditions

Determine optimization

Determine postoperative/discharge plan

Parents

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7
Q

Perioperative History

What should be assessed?

A

Parents medical history

Maternal history

Birth/neonate history

Medications

Concurrent medical conditions

Allergies

Prior anesthetics

Airway difficulty - PONV

Family history of anesthetic complications

MH - Pseudocholinesterase deficiency

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8
Q

Preoperative Physical Exam

Cardiovascular pre-op evaluation must include:

A

HR/BP

Heart sounds

Murmur - CHD

Additional elements depending on pre-existing medical conditions of the child & nature of the surgery

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9
Q

Preoperative Physical Exam

Respiratory pre-op evaluation must include:

A

Airway

MP 5 (!!!)

The pediatric pt is always considered to be difficult airway

Concurrent URI

Asthma

Additional elements depending on pre-existing medical conditions of the child & nature of the surgery

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10
Q

Preoperative Physical Exam - Respiratory

T/F: The pediatric pt is always considered to be difficult airway

A

True

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11
Q

Preoperative Physical Exam

Coexisting Diseases Requiring Special Considerations

A

ŸUpper Respiratory Infection

(Recent or Current)

ŸAsthma

ŸFormer Premature Infant

ŸHeart Murmur

ŸSickle Cell Disease

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12
Q

Upper Respiratory Infection

Risk for perioperative respiratory event for pts with recent or current URI significantly increase your risk for which complications:

A

Laryngospasm

Bronchospasm

Hypoxemia

Postop croup

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13
Q

Upper Respiratory Infection

Risk of perioperative morbidity for pts with recent or current URI significantly increase especially when combined with which other conditions?

A

Asthma

Bronchopulmonary dysplasia

< 1 year of age (GREATEST)

Live in home with smoker

Sickle cell disease

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14
Q

Upper Respiratory Infection

Symptoms of Upper Respiratory Infection include:

A

Expiratory wheezing

Inflamed naso-oropharyngeal mucosa

Sore throat - Nasal congestion

Rhinorrhea/mucopurulent drainage

Malaise

Non-productive cough

Because this is an upper, not lower respiratory infection

Low grade fever (37.5°C – 38.5°C)

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15
Q

Upper Respiratory Infection Symptoms

Pts with Inflamed naso-oropharyngeal mucosa will complain of:

A

Sore throat

Nasal congestion

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16
Q

Upper Respiratory Infection Symptoms

What’s a characteristic of the cough a/w with Upper Respiratory infections

A

Non-productive cough

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17
Q

Upper Respiratory Infection

TO CANCEL OR NOT TO CANCEL…

Based on what would you make that determination?

A

Review each case individually

Risk-benefit ratio

Infectious vs. Allergies

Acute vs Chronic

Elective vs Emergent surgery

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18
Q

Upper Respiratory Infection

Proceed if:

A

Short elective procedures, and they have…

Chronic cold

Clear runny nose,

Optimized

ETT not required, and they are…

> 1 year of age

URI resolving (Bacterial URI, and they have been on Abx and it is going away)

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19
Q

Upper Respiratory Infection

If they have any of the followings:

Productive cough - Croup - Upper respiratory stridor - High fever - Purulent nasal drainage - Infectious nasopharyngitis you should postopone the procedure for how long?

A

2 wks

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20
Q

Upper Respiratory Infection

If S/S lower respiratory tract involvement, you should postpone for how long?

A

4-6 wks

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21
Q

Upper Respiratory Infection

BRONCHIAL HYPERACTIVITY leading to Bronchospasm MAY EXIST UP TO how long

A

7 WKS

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22
Q

Asthma

How do you Determine severity/control of disease?

A

Prior ER visit/hospitalization

Medications (prn vs. daily)

MUST BE OPTIMIZED prior to GA

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23
Q

Asthma

What should you do if Asthma a/w Active wheezing, or S/S of infection are present?

A

Postpone surgery

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24
Q

Asthma

T/F: If they have asthma, Continue meds up to & including DOS

A

True

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25
Q

Asthma

T/F: Ensure adequate hydration

A

True

26
Q

Asthma

Why is Antianxiety premedication important?

A

Psychologic triggers could cause a asthma attack

27
Q

Former Premature Infant

Definition of Former Premature Infant:

A

< 37 wks gestation at birth

< 2500 g at birth

28
Q

Former Premature Infant

Under what condition could agitation/stimulation cause bronchospasm/cyanosis in Former Premature Infants?

A

Chronic neonatal respiratory disease

Wich could lead to Bronchopulmonary Dysplagia (BPD)

29
Q

Former Premature Infant

Why is anti-anxiety/sedation required during exam in pts with Chronic neonatal respiratory disease or Bronchopulmonary Dysplagia (BPD)?

A

You could cause to have a Bronchospasm just by agitating them

30
Q

Former Premature Infant

T/F: Prolonged mechanical ventilation at birth increases the risk of Laryngeal/tracheal stenosis and must be assessed

A

True

31
Q

Former Premature Infant

Central apnea post GA which manifest as Cessation breathing > 15secs, and is a/w Bradycardia (30 bpm below baseline), and Hypoxia (SaO2 < 90%)

A

Apnea of Prematurity or Central Apnea

Bag-mask ventilation may be required

32
Q

Former Premature Infant

What do As and Bs refer to in Premature Infants?

A

Apneas and Bradycardias

where infant will hold breath, then become bradycardic.

They will usually rebound on their own.

This is watched carefully in the NICU. If no quick recovery, they will be bag masked

33
Q

Former Premature Infant

What’s a major reason why Premature Infants are kept in the NICU for prolonged periods of time?

A

Apnea of prematurity

They will go home on apnea monitor so that parents could be alarmed if they become apneic while not under direct suppervison such as at night when sleeping

34
Q

Former Premature Infant

What are risk factors for Apnea of prematurity or Central apnea post General Anesthesia?

A

Low gestational age

< 55 wks PCA

Anemia (Hgb <10)

35
Q

Former Premature Infant

How could you prevent Apnea of prematurity or Central apnea post General Anesthesia?

A

Postpone elective surgery until > 55 wks PCA

Require postop respiratory monitoring for 24 hr admission

36
Q

Heart Murmurs

Heart Murmurs are a common finding on exam for infants. The majority of these murmurs are:

A

Normal flow murmurs

< Grade II

Vibratory

Systolic over mitral & pulmonic valves

37
Q

Heart Murmurs

Under which circumstances is a cardiology consult not required for heart murmur in infants?

A

Previously detected and documented

If they ‘ve had a Prior cardiac evaluation

38
Q

Heart Murmurs

When would you Obtain cardiology consult?

A

Previously detected with cardiac evaluation order but

not completed

Previously undetected (new murmur)

39
Q

Heart Murmur

What are possible clues to Previously undetected heart murmur?

A

Poor exercise tolerance/feeding intolerance

Hx CHD immediate family

Present in diastole

> Grade III

Abnormal peripheral pulses

Cyanosis/pallor/poor capillary refill

40
Q

Sickle Cell Disease

All children of which racial group presenting for anesthesia not previously screened must be Evaluated/Screened for Sickle Cell Disease?

A

All black american children

41
Q

Sickle Cell Disease

Evaluation of Sickle Cell Disease includes determining what?

A

Determine extent end-organ involvement

Preop transfusion requirements

42
Q

Sickle Cell Disease

What’s the benchmark standard diagnostic test for Sickle Cell Disease?

A

Hgb electrophoresis

43
Q

Sickle Cell Disease

T/F: Preop transfusion in Sickle Cell Disease is controversial

A

True

44
Q

Sickle Cell Disease

What are pre-op hematological goals in Sickle Cell Disease peds?

A

Hct 35-40%

Normal (Hgb-A) = 50% of Total Hgb

Total Hgb = (Hgb-A + Hgb-S)

45
Q

Sickle Cell Disease

What’s the benefit of ensuring that Hct 35-40% with concentration of normal Hgb (Hgb-A) as close as possible to 50% of the total Hgb (Hgb-A + Hgb-S)

A

Decreased blood viscosity

Increased O2 carrying capacity

Decreased sickling

46
Q

Laboratory Evaluation

Why shouldn’t you expect to have routine labs available in the peds population?

A

Routine labs questionable in peds

47
Q

Laboratory Evaluation

Although routine labs are questionable, results should be available for:

A

Specific labs for coexisting medical condition &

Specific labs required for surgical procedure

48
Q

Laboratory Evaluation

Which labs are required from Healthy child scheduled for elective procedures?

A

None

49
Q

Laboratory Evaluation

Hgb/Hct is routinely ordered pre-op for what age group? How is is collected?

A

< 6 mos

Usually collected with a finger stick

50
Q

Laboratory Evaluation

Hgb/Hct is routine pre-op for < 6 mos. Which Hgb value is required to proceed with elective surgery?

A

Hgb > 10 gm/dl

51
Q

Laboratory Evaluation

When would you consider coagulation studies for a Preterm?

A

Bleeding disorder

Potential large blood loss

52
Q

Laboratory Evaluation

Which pre-op chemistry would you consider ordering for a premature infant?

A

Calcium

Glucose

53
Q

Preoperative Fasting Guidelines

What’s the relationship between the length of fasting and Gastric volumes & pH in peds?

A

Gastric volumes & pH are similar with shorter periods of fasting compared to longer

Shorter periods of fasting periods are no less safe than longer

Encourage clear liquids up to 2 hours before surgery!!!!

54
Q

Preoperative Fasting Guidelines

Why should clear liquids be encouraged for up to 2 hours before surgery? What’s an exception to this?

A

Clear liquids up to 2 hours before surgery decreases gastric residual volume

Exception to this includes presence of co-existing disease such as gastric paresis that prevents the emptying of the stomach

55
Q

CURRENT NPO GUIDELINES

Delay surgery for how long after SOLIDS?

A

6-8 HRS

56
Q

CURRENT NPO GUIDELINES

Delay surgery for how long after FORMULA if <6 mos

A

4 HRS

57
Q

CURRENT NPO GUIDELINES

Delay surgery for how long after FORMULA >6 mos

A

6 HRS

58
Q

CURRENT NPO GUIDELINES

Delay surgery for how long after BREAST MILK?

A

4 HRS

59
Q

CURRENT NPO GUIDELINES

Delay surgery for how long after CLEAR LIQUIDS?

A

2 HRS

Encourage apple/grape juice, flat cola, sugar water up to 2 hrs before surgery

60
Q

Preoperative Fasting Guidelines

What are benefits of shorter fasting periods?

A

Inc. gastric pH

Dec. gastric volume

Dec. hypoglycemia

Dec. hypovolemia

61
Q

Preoperative Fasting Guidelines

When is prolonged fasting recommended?

A

Disorders that affect digestion/gastric emptying require longer fasting periods

GERD

DM

Trauma

Pyloric stenosis

8361 Exam 2 (20 decks)

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