Pediatric preoperative evaluation, set-up, and anesthetic induction techniques Flashcards
________ have the highest rate of adverse events (even more so than adults)
infants <1 month old
bradycardia, respiratory complications, cardiac arrest, medication related, equipment related
Bradycardia is secondary to
hypoxia & high inhalation anesthetic concentration
Describe psychological preparation.
preoperative prep is very important
some centers may have a child-life specialist, videos, hospital tours, etc.
basic objective is to explain to the child & parents in respectful simple, understandable, and reassuring terms
bond with the child- key for decreasing parental anxiety too
Psychological aspects for age 0-6 months include
not usually upset by separation from parents; prolong separation may impair parent-child bonding
Psychological aspects for ages 6 months to 4 years include
separation anxiety, fear of hospitalization. may show regressive behavior
Psychological aspects for school-age children include
less upset by separation from parents, asks questions, involved, wants choices, more concerned with surgical procedure and its possible affects on body image
Psychological aspects for adolescents include
fear the process of narcosis, the loss of control, waking up during surgery, and pain of surgery; value modesty; HcG testing in females
Psychological aspects for parents include
provide explanation of what to expect
Describe important considerations for adolescents
transitioning from childhood illness to adulthood
mental health
confidentiality
assent vs. consent- blood transfusion, epidural for childbirth, abortion, gender affirmation
HcG testing- aprepitant & sugammadex considerations
experimentation with alcohol, marijuana, amphetamines, narcotics, vaping
Parental presence at induction is based upon
the age of the child & if it provides added benefit
is important to prepare the parent of what to expcet
Parental presence may not be appropriate in certain circumstances including:
adequate preoperative sedation
the parent’s level of anxiety
language barrier
emergency/RSI cases
anticipated difficult airway or an unstable patient
pregnant mother (due to nitrous oxide exposure)
The interview and physical exam should include
sources of information include the EMR, parents, and the child NPO status current weight auscultation of lungs and heart evaluation of the airway, inquire about loose teeth PMH/previous anesthetics/MH recent URI's or fevers cigarette exposure in the home possibility of pregnancy allergies & current medications
NPO guidelines include
clear liquids: 2 hours
breast milk: 4 hours
formula, non-human milk, light meal: 6 hours
fatty foods: 8 hours
Review of the child’s history for age should include
gestational, conceptional, birth history, maternal pregnancy history
Review of the child’s history for CNS should include
seizures, hydrocephalus, neuromuscular disorders, head trauma, autism
Review of the child’s CV history includes
murmur, cyanosis, dyspnea, sweating, hypertension, exercise tolerance, congenital heart defects, indications for subacute bacterial endocarditis
Review of the child’s respiratory history includes
prematurity, respiratory distress syndrome, apnea, recent upper respiratory infection (URI), cough, croup, asthma, cystic fibrosis, need for preop-oxygen therapy
Review of the child’s gastrointestinal history includes
NPO status
reflux, vomiting, diarrhea, liver
Review of the child’s GU system includes
renal failure, bladder surgery
Review of the child’s endocrine system includes
DM, thyroid, pituitary, adrenal, steroid therapy
Review of the child’s hematology system includes
anemia, bruising, bleeding, sickle cell
Review of the child’s immunology system includes
allergies, immunocompromised
Preop lab considerations:
often unnecessary for most healthy children
consider if labs are needed while awake or could wait until the patient is under GA
consider glucose in prolonged fasting & metabolic disorders
consider pregnancy testing in females
Consider a hemoglobin on
neonates, premature infants, cardiopulmonary disease, known hematologic dysfunction, and anticipated major blood loss during the surgical procedure
For the child with an URI, it may be
a simple common viral infection or may be a symptom of a much more serious illness
Irritable airways are at increased risk for
laryngospasms, bronchospasm, post-intubation croup, atelectasis, pneumonia, and desaturations
For the child with an URI, consider
LMA over ETT if appropriate; tricky b/c not a secure airway
For patients with URI, consider
rescheduling elective surgery 2-4 weeks for URIs, and 6-8 weeks for LRI
Some reasons to postpone surgery include
elective, febrile, elevated WBC, productive/purulent sputum, getting worse, acutely ill, malaise, tachypnea, wheezing
Anesthesia with an URI, present an increased risk of complications with GA including
need for ETT
asthma, reactive airway, etc.
tracheal mucociliary flow & pulmonary bactericidal activity is decreased by general anesthesia
PPV may help spread the infection from upper to lower airways
Management of anesthesia with an URI includes
adequate hydration, & oxygenation
reduce secretions, limit airway manipulation
bronchodilators (beta 2 agonists) for wheezing
anticholinergics (inhibits cholinegic-mediated bronchospasm)
muscle relaxants for laryngospasm
Children ages 2-6 commonly have a functional
systolic “Still’s” murmur
a heart murmur is detected in up to 50% of pediatric patients
innocent or pathologic
A cardiologist may need to evaluate previously undiagnosed murmurs prior to induction of anesthesia such as in patients with:
difficulty feeding, SOB
poor exercise tolerance, can’t match peers
family history of CHD
cyanotic episodes
abnormal peripheral pulses
unequal blood pressures in upper vs. lower extremities (coarctation)
Infants younger than <6-12 months
usually separate from parents without the need for premedication
Oral premedication may
prolong time to discharge
Midazolam is most commonly used premed & dose is
0.5 mg/kg PO (usual max is 20 mg)*** 15 to 30 min prior to induction
Special considerations with oral premedication include
careful sedating a child with congenital heart disease, increased ICP, OSA, sepsis, trauma, or suspected difficult airway
Nasal premedications & dosages include
midazolam 0.2 mg/kg nasal
ketamine 3 mg/kg nasal
dexmedetomidine 1-2 mcg/kg nasal
Set up & monitoring should include
blood pressure (appropriate size cuff)
ECG- often 3 lead (5 lead for cardiac patients)
pulse oximetry (weight-based probe): purple <3 kg or >40 kg; orange 3-20 kgs
capnography
temperature
neuromuscular function
shoulder roll
Describe normal vital signs for a premature baby.
HR 120-170
BP 55-75/35-45
MAP 40-55
Describe normal vital signs for 0-3 months old.
HR 100-150
BP 65-85/45-55
MAP 52-65
Describe normal vital signs for 3-6 months old.
HR 90-120
BP 70-90/50-65
MAP 57-73
Describe normal vital signs for 6-12 months.
80-120
BP 80-100/55-65
MAP 63-77
Describe normal vital signs for 1-3 yrs.
HR 70-110
BP 90-105/55-70
MAP 67-82
Preparation for induction of anesthesia includes.
warm the operating room & ensure warming devices are functioning
pre-induction checklist of equipment, suction, emergency airway devices, ventilator default, and monitoring settings, etc.
consider a chair or stool if the parent is present to help avoid fainting epsiodes
ensure a quiet, calm OR
A variety of induction techniques exist and should be based upon
past medical & surgical history
child’s developmental level
ability to cooperate
previous experiences
LMA size 1 is appropriate for
neonates/infants up to 5 kg
LMA size 1.5 is appropriate for
infants 5-10 kg
LMA size 2 is appropriate for
infants/children 10-20 kg
LMA size 2.5 is appropriate for
Children 20-30 kg
LMA size 3 is appropriate for
30-50 kg
Laryngoscopy includes use of straight blade in
children <1 year
Describe considerations for laryngoscopy.
ensure head is correctly positioned and supported- shoulder roll, caution in patients with potential unstable cervical spine (e.g., down syndrome, trauma)
examine for loose teeth- if they are removed, should return to parents
Describe the approximate depth calculation of peds ETT tubes
<3 kg: 1-2-3 kg or 7-8-9 cm at lips
>3 kg: ID x 3
Emergency medication set up of atropine includes
0.4 mg/mL
<10 kgs- place in 1 mL syringe
>10 kgs- place in 3 mLs syringe
Emergency medication set up of succinylcholine includes
3 mL syringe
20 mg/mL
IM needle (22 ga)
Caution with using flush syringes as these may result in
syringe swaps & inadvertent administrations***
Pediatric breathing circuits are needed because
small enough for sensitivity to small tidal volume
big enough to give a vital capacity breath
neonatal- ask anesthesia tech for neonate circuit
peds circuit 1L bag <30 kgs
In children <2 years old, may not administer ______ for nasal intubations to avoid______
afrin; hypertension
The most common method of inducing anesthesia in children is
inhalation induction with sevoflurane being the age of choice
Additional considerations for inhalation induction include
pacifiers are okay to leave in, may need a larger mask
okay to have the child lay down, sit up, or sit in someone’s lap
may use N2O & O2 for 1-2 minutes and then use sevoflurane at 6-8%
after GA is induced, the sevoflurane should be reduce to around 4-5% to prevent overdose & assisted ventilation may be necessary
IV is placed following stage 2 and prior to instrumentation of the airway
Mask induction aids & distraction techniques include
scented masks bubbles playing video games or watching a movie use of the elbow without a mask and tenting with the hand music jokes steal induction in an asleep child single-breath inhalation
IV induction of anesthesia is the
most reliable & rapid
necessary when inhalation induction is contraindicated (i.e. difficult airway, full stomach, cardiac instability)
The main disadvantage of IV induction of anesthesia is that
starting an IV can be painful and threatening to a child and therefore is usually reserved for older children (>8)
may place IV under N2O in older children
topical anesthetics (EMLA, ethyl-chloride spray)
Ideally all children should be ________ before intravenous induction, but this is not always possible
pre-oxygenated with 100% oxygen
IV access should be obtained if
the patient is at risk for aspiration requiring a RSI
anticipated difficult airway
potential cardiac instability
When obtaining IV access in pediatric patients for induction,
consider use of a topical anesthetic cream
keep the equipment from the child’s view if especially fearful
be deliberate in insertion, flash may be slower than expected
be cautious of all potential air bubbles
It is preferable to avoid _____ injections in children
IM
IM induction may be indicated in
uncooperative children who refuse other routes of sedation
-commonly utilized is concentrated IM ketamine where large volume will necessitate multiple injections
development of laryngospasm during inhalation induction
-if IV access is not present, succinylcholine & atropine can be given IM or sublingually
With mask anesthesia, avoid
applying pressure over the soft tissue of the chin & neck during mask anesthesia
precordial stethoscope can be helpful to monitor breath sounds
Sites for peripheral IVs include
back of hands feet-including top, sides, & saphenous inside wrist avoid AC Iv's if possible b/c difficult to tell if it gets infiltrated EJ/scalp veins
By far the two most commonly accessed veins are:
superficial dorsal hand veins
saphenous vein
Describe IV size for neonates, infants, & children.
neonates: 24 gauge
infants 24-22 gauge
children 22-20 gauge
Bolus for pediatrics is
10-20 mL/kg
Use of ________ for IV fluid administration in peds <30 kg
metered chamber buretol
***** close roller-clamp between IV bag & chamber
expel any air
Describe the use of arterial lines for children
may use an IV catheter rather a premade arterial line device
22g >2 years old
24g for <2 years old
Wires for Seldinger’s technique include
“Baby wire” is 0.012 in & often used with 24 g. IVs
Describe benefits of caudal anesthesia
intraoperative & postoperative analgesia
reduction in systemic opioid requirements & side effects
reduction in anesthesia requirements
Procedures in which caudal anesthesia may be used include
circumcision, inguinal herniorrhaphy, hypospadias, anal surgery, clubfoot repair, other sub-umiblical procedures
Contraindications to caudal anesthesia include
infection around the site
coagulopathy
anatomic abnormalities like sacral dimple
parental refusal
Caudal landmarks include
sacral hiatus
2 PSIS
Describe caudal dosing for genital & anal surgery:
0.5-0.75 mL/kg
Describe caudal dosing for lower abdomen, extremity:
1 mL/kg
Describe caudal dosing for abdominal incision
1-1.25 mL/kg
Using clonidine in caudal anesthesia may lead to
increase in duration of 2-3 hours
increased sedation scores, potential for hypotension & respiratory depression in some infants (avoid dexmedetomidine if clonidine is placed in the caudal)
Traveling post anesthesia considerations include:
appropriately sized ambu bag
oxygen source: blow=by vs. facemask vs. nasal cannula
monitoring (pulse ox only, vs. ECG and/or BP)
emergency meds (atropine, succinylcholine, epinephrine)
pain medications
treatment for emergence delirium (e.g. dexmedetomidine, propofol, fentanyl)
lateral position
Handover report for PACU should include
name, age, weight, & allergies
PMH, operation/procedure
airway, IVs, medications, fluids
