Mod V: Peds Pre-op Part 1 Flashcards
Perioperative Preparation
Why Perioperative Preparation so important?
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
Perioperative Preparation
Goals of Perioperative Preparation:
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
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:
Eleven P’s to Pediatric Perioperative Planning
Completing the Eleven P’s helps the anesthetist develop a comprehensive/individualized anesthetic plan
Perioperative Preparation
What are the Eleven P’s to Pediatric Perioperative
Planning?
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
Perioperative Preparation
What’s the main goal of Perioperative Preparation?
To minimize perioperative morbidity & mortality
Perioperative Evaluation
The main goal of Perioperative Preparation is to minimize perioperative morbidity & mortality. How could this be achieved?
Evaluate overall health status
Identify risks
Normal physiologic/anatomical challenges
Preexisting medical conditions
Determine optimization
Determine postoperative/discharge plan
Parents
Perioperative History
What should be assessed?
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
Preoperative Physical Exam
Cardiovascular pre-op evaluation must include:
HR/BP
Heart sounds
Murmur - CHD
Additional elements depending on pre-existing medical conditions of the child & nature of the surgery
Preoperative Physical Exam
Respiratory pre-op evaluation must include:
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
Preoperative Physical Exam - Respiratory
T/F: The pediatric pt is always considered to be difficult airway
True
Preoperative Physical Exam
Coexisting Diseases Requiring Special Considerations
Upper Respiratory Infection
(Recent or Current)
Asthma
Former Premature Infant
Heart Murmur
Sickle Cell Disease
Upper Respiratory Infection
Risk for perioperative respiratory event for pts with recent or current URI significantly increase your risk for which complications:
Laryngospasm
Bronchospasm
Hypoxemia
Postop croup
Upper Respiratory Infection
Risk of perioperative morbidity for pts with recent or current URI significantly increase especially when combined with which other conditions?
Asthma
Bronchopulmonary dysplasia
< 1 year of age (GREATEST)
Live in home with smoker
Sickle cell disease
Upper Respiratory Infection
Symptoms of Upper Respiratory Infection include:
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)
Upper Respiratory Infection Symptoms
Pts with Inflamed naso-oropharyngeal mucosa will complain of:
Sore throat
Nasal congestion
Upper Respiratory Infection Symptoms
What’s a characteristic of the cough a/w with Upper Respiratory infections
Non-productive cough
Upper Respiratory Infection
TO CANCEL OR NOT TO CANCEL…
Based on what would you make that determination?
Review each case individually
Risk-benefit ratio
Infectious vs. Allergies
Acute vs Chronic
Elective vs Emergent surgery
Upper Respiratory Infection
Proceed if:
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)
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?
2 wks
Upper Respiratory Infection
If S/S lower respiratory tract involvement, you should postpone for how long?
4-6 wks
Upper Respiratory Infection
BRONCHIAL HYPERACTIVITY leading to Bronchospasm MAY EXIST UP TO how long
7 WKS
Asthma
How do you Determine severity/control of disease?
Prior ER visit/hospitalization
Medications (prn vs. daily)
MUST BE OPTIMIZED prior to GA
Asthma
What should you do if Asthma a/w Active wheezing, or S/S of infection are present?
Postpone surgery
Asthma
T/F: If they have asthma, Continue meds up to & including DOS
True
Asthma
T/F: Ensure adequate hydration
True
Asthma
Why is Antianxiety premedication important?
Psychologic triggers could cause a asthma attack
Former Premature Infant
Definition of Former Premature Infant:
< 37 wks gestation at birth
< 2500 g at birth
Former Premature Infant
Under what condition could agitation/stimulation cause bronchospasm/cyanosis in Former Premature Infants?
Chronic neonatal respiratory disease
Wich could lead to Bronchopulmonary Dysplagia (BPD)
Former Premature Infant
Why is anti-anxiety/sedation required during exam in pts with Chronic neonatal respiratory disease or Bronchopulmonary Dysplagia (BPD)?
You could cause to have a Bronchospasm just by agitating them
Former Premature Infant
T/F: Prolonged mechanical ventilation at birth increases the risk of Laryngeal/tracheal stenosis and must be assessed
True
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%)
Apnea of Prematurity or Central Apnea
Bag-mask ventilation may be required
Former Premature Infant
What do As and Bs refer to in Premature Infants?
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
Former Premature Infant
What’s a major reason why Premature Infants are kept in the NICU for prolonged periods of time?
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
Former Premature Infant
What are risk factors for Apnea of prematurity or Central apnea post General Anesthesia?
Low gestational age
< 55 wks PCA
Anemia (Hgb <10)
Former Premature Infant
How could you prevent Apnea of prematurity or Central apnea post General Anesthesia?
Postpone elective surgery until > 55 wks PCA
Require postop respiratory monitoring for 24 hr admission
Heart Murmurs
Heart Murmurs are a common finding on exam for infants. The majority of these murmurs are:
Normal flow murmurs
< Grade II
Vibratory
Systolic over mitral & pulmonic valves
Heart Murmurs
Under which circumstances is a cardiology consult not required for heart murmur in infants?
Previously detected and documented
If they ‘ve had a Prior cardiac evaluation
Heart Murmurs
When would you Obtain cardiology consult?
Previously detected with cardiac evaluation order but
not completed
Previously undetected (new murmur)
Heart Murmur
What are possible clues to Previously undetected heart murmur?
Poor exercise tolerance/feeding intolerance
Hx CHD immediate family
Present in diastole
> Grade III
Abnormal peripheral pulses
Cyanosis/pallor/poor capillary refill
Sickle Cell Disease
All children of which racial group presenting for anesthesia not previously screened must be Evaluated/Screened for Sickle Cell Disease?
All black american children
Sickle Cell Disease
Evaluation of Sickle Cell Disease includes determining what?
Determine extent end-organ involvement
Preop transfusion requirements
Sickle Cell Disease
What’s the benchmark standard diagnostic test for Sickle Cell Disease?
Hgb electrophoresis
Sickle Cell Disease
T/F: Preop transfusion in Sickle Cell Disease is controversial
True
Sickle Cell Disease
What are pre-op hematological goals in Sickle Cell Disease peds?
Hct 35-40%
Normal (Hgb-A) = 50% of Total Hgb
Total Hgb = (Hgb-A + Hgb-S)
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)
Decreased blood viscosity
Increased O2 carrying capacity
Decreased sickling
Laboratory Evaluation
Why shouldn’t you expect to have routine labs available in the peds population?
Routine labs questionable in peds
Laboratory Evaluation
Although routine labs are questionable, results should be available for:
Specific labs for coexisting medical condition &
Specific labs required for surgical procedure
Laboratory Evaluation
Which labs are required from Healthy child scheduled for elective procedures?
None
Laboratory Evaluation
Hgb/Hct is routinely ordered pre-op for what age group? How is is collected?
< 6 mos
Usually collected with a finger stick
Laboratory Evaluation
Hgb/Hct is routine pre-op for < 6 mos. Which Hgb value is required to proceed with elective surgery?
Hgb > 10 gm/dl
Laboratory Evaluation
When would you consider coagulation studies for a Preterm?
Bleeding disorder
Potential large blood loss
Laboratory Evaluation
Which pre-op chemistry would you consider ordering for a premature infant?
Calcium
Glucose
Preoperative Fasting Guidelines
What’s the relationship between the length of fasting and Gastric volumes & pH in peds?
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!!!!
Preoperative Fasting Guidelines
Why should clear liquids be encouraged for up to 2 hours before surgery? What’s an exception to this?
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
CURRENT NPO GUIDELINES
Delay surgery for how long after SOLIDS?
6-8 HRS
CURRENT NPO GUIDELINES
Delay surgery for how long after FORMULA if <6 mos
4 HRS
CURRENT NPO GUIDELINES
Delay surgery for how long after FORMULA >6 mos
6 HRS
CURRENT NPO GUIDELINES
Delay surgery for how long after BREAST MILK?
4 HRS
CURRENT NPO GUIDELINES
Delay surgery for how long after CLEAR LIQUIDS?
2 HRS
Encourage apple/grape juice, flat cola, sugar water up to 2 hrs before surgery
Preoperative Fasting Guidelines
What are benefits of shorter fasting periods?
Inc. gastric pH
Dec. gastric volume
Dec. hypoglycemia
Dec. hypovolemia
Preoperative Fasting Guidelines
When is prolonged fasting recommended?
Disorders that affect digestion/gastric emptying require longer fasting periods
GERD
DM
Trauma
Pyloric stenosis
