Pre-operative Preparation & Assessment of Paediatric Patients

Dr. Felicia Lim

Consultant Paediatric Anaesthesiologist Jabatan Anestesiologi & Rawatan Intensif Pusat Perubatan Universiti Kebangsaan Malaysia

Paediatric Anaesthesia
Very challenging Requires knowledge of paediatric / neonatal physiology & pharmacology Covers a wide range of patient size and age
Newborns Preterm neonates Ex-preterm infants Full term neonates Infants Children Adolescent

Pre-operative Preparation & Assessment

Aims Risks of Anaesthesia Preoperative Assessment Child with URTI Preterm and former preterm infants Child with asthma, congenital heart disease Preoperative optimization of patient When to book PICU/NICU or HDU beds Psychological Preparation

The preparation of a child who is about to undergo surgery or anaesthesia involves Child & his/her family, Surgeon Anaesthesiologist, Other specialists- paediatrician, cardiologist, oncologist Communication among the individuals caring for the patient is important. Established lines of communication permit the efficient and meaningful transfer of patient information.

Aims of Preoperative Preparation & Assessment

Evaluate childs health status Detection of unrecognized conditions that increase the risk of surgery. Optimize the patients current medical problems and anticipate potential complications. Information & instruction for patient/parent Psychological preparation

Risk of Anaesthesia in Children

five-year study (between July 1, 2003 and August 30, 2008) of children(< 18 years) undergoing anaesthesia at Royal Childrens Hospital Melbourne
incidence of anaesthesia-related death - one in 10,188 anaesthetics (or 0.98 cases per 10,000) 10 anaesthesia-related deaths out of 101,885 anaesthetics In all 10 cases, pre-existing medical conditions were identified as being a significant factor in the patients death, and five of these involved children with pulmonary hypertension, or abnormally high blood pressure in the arteries of the lungs.

Healthy child risk is very very low

Pre-operative Preparation
Medical Psychological

Anaesthestic Preparation
Pre-operative visit & assessment To meet patient and parent and to establish rapport and gain confidence To assess for fitness for anaesthesia and risk To explain re anaesthetic technique, preop fasting, post-op pain management etc To take consent for anaesthesia, regional anaesthesia, blood transfusion

Anaesthetic Assessment
History
Birth- term, premature, problems, postconceptual age, developmental milestones Previous surgery Other medical problems eg asthma, CHD Medications Allergies Recent URTI Family history

Anaesthetic Assessment
Clinical Examination
General Condition, Respiratory URTI. asthma Cardiovascular murmur Neurological

 Airway any problem with airway management

Dysmorphic features Congenital abnormalies eg Pierre Robin Treacher collins Downs syndrome obesity

Potential Difficult Airway

Goldenhar Syndrome

Potential Difficult Airway

Pierre Robin Syndrome Child with no neck

Presence of a congenital malformation or disease

Presence of one malformation should lead to investigation for other associated malformation Eg: TOF VACTERL
Vertebra Anal Cardiac Trachea Esophagus Radial , Renal Limb

Downs syndrome cardiac lesions

Laboratory Investigations
should be considered according to the physical condition of the child and the nature of the surgery value of routine tests in healthy patient is questionable when the surgical procedures will not involve significant blood loss Should be performed only if their results could influence anaesthetic management.

Laboratory Investigations
Hb Not necessary for healthy child for minor procedures Necessary if
child is anaemic clinically, premature infants, patient with chronic diseases As a baseline in anticipation of significant surgical loss

Blood Chemistry
Only where there are specific indications

Preoperative Fasting
previous prolonged fasting period inappropriate
Drinking clear fluid up to 2 hours before surgery does not residual gastric volume or alter pH of gastric content Clear fluid a liquid that you can see print through eg water, fruit juice without pulp

Preoperative Fasting
More liberal use of clear fluid in the immediate preoperative period may
decrease the incidence of preoperative dehydration and possible hypotension during induction. prevent hypoglycaemia result in less agitated child and a happier parent

Fasting Guidelines for Children (hours of fasting)

Clear fluid 2 hours Breast milk 4 hours Infant formula/cow's milk 6 hours Solid 6-8 hours

A Child with Upper Respiratory Tract Infection (URTI)

Preschool children average 6 URTI per year both upper and lower airways affected 95% viral aetiology, self-limiting viral infections damage respiratory epithelium airway hyperreactivity persist for 6-12 weeks

Upper Respiratory Tract Infection

Problems of anaesthetizing a child with URTI
laryngospasm, bronchospasm, stridor, breath holding, airway obstruction by secretion Desaturation Bacterial pneumonia

Can occur during anaesthesia and in the postoperative period

Risks Under GA
Studies by Cohen & Cameron showed anaesthesia in the presence of URTI Presence of URTI (cf no URTI) 2-7 times greater incidence of respiratory complications 11 times if the trachea had been intubated incidence infants < 1 year old

Risk factors
Age Intubation Co-morbid conditions Airway management Surgery

Risk Factors
Age:
the younger the greater the risk infants <6 months higher risk of bronchospasm children <2 years higher risk for oxygen desaturation (Tait 2001)

Intubation
associated with adverse complications in URTI those nonintubated, URTI 9X risk than without URTI those intubated, URTI 11X risk than without URTI (Cohen 1991)

Risk Factors
Co-morbid conditions
Asthma Congenital heart diseases

Airway Management
ETT > LMA > face mask

Surgery
Airway surgery Upper abdominal surgery

Guidelines
There is no consensus regarding the best management of children with URTI Main worry - potential for complications easy to cancel if child is overtly sick dilemma in grey area consider case by case

Guidelines
Elective or emergency Minor or major surgery Mild or severe URTI No of times canceled

Guidelines For URTI in Children

Elective surgery
Mild URTI no fever, clear nasal discharge, mild cough, child active can be anaesthetized for minor surgical procedure without intubation

Guidelines For URTI in Children

Active infection fever, recent onset of purulent nasal discharge cough may represent a prodrome of a more serious or infectious illness like chicken pox or measles. Should be postponed

When to reschedule surgery?

no optimum time to wait before surgery rescheduled most reports say 3-4 weeks or at least 2 weeks after peak symptoms longer time not practical (2nd episode may occur) uncomplicated nasopharyngitis 1-2 weeks delay acceptable (Berry 1984) balance between need to proceed and time required for resolution of symptoms + reduced risk General consensus to postpone for 2-4 weeks

Child with URTI symptoms

Surgery Urgent?
Yes No

Proceed
Yes

Infectious Etiology?
No

Proceed

Postpone 2-4 wks

Yes

Severe Symptoms?

No

General Anaesthesia?
No

Yes

Risk Factors?
Hx of asthma, Use of an ETT Copious secretions Nasal congestion Parental smoking Surgery of airway Hx of prematurity

Proceed Other Factors?

Need for expedience Parents traveled far Surgery canceled previously Comfort anesthetizing child with URI

Management
Avoid ETT, Consider LMA, Pulse Oximetry, Hydration, Humidification? , Anticholinergics?

Benefit/Risk? Proceed
Poor Good

Postpone 2 - 4 wks

PRETERM OR FORMER PRETERM INFANTS

Expreterm for Elective Surgery

Ex-preterm Infant for herniotomy

EUA for ROP

Preterm baby for Emergency Surgery

Surgery in OT or NICU?
Sick, septic infant Ventilatory support eg High frequency Oscillatory Ventilation Inotropic support Syringe pumps

Advantage of performing the surgery in NICU:

Avoid problems of transporting sick and unstable patient.
Need to transport under similar conditions to those in NICU maintaining the same ventilatory and inotropic support. incubator, ventilator, batteries, oxygen and air cylinders and many volumetric syringe pumps

Difficulty in maintaining similar ventilatory support during surgery in OT eg HFOV

Surgery in NICU

Main Concern in Preterm Infant

Post-operative Apnoea
Definition cessation of respiratory movements of >20 sec or <20 sec +desaturation (Spo2 <90%) or bradycardia (heart rate 100/min). Observed during recovery from GA Other factors: hypothermia, hypoglycaemia hypocalcaemia

Post-operative Apnoea Risk

Risk is inversely related to postconceptual age (PCA) PCA = gestational age + postnatal age eg born at 28 wks, 1 month old PCA=28+4 = 32 weeks risk higher in lower PCA babies

PCA <44 weeks, incidence 26%

rare in babies older than 48 weeks in the absence of neurological disease Risk increased with history of neonatal apnoea, ventilation, bronchopulmonary dysplasia, anaemia

Guidelines
If PCA < 48 weeks , arrange for bed in ICU or

HDU for post-operative observation Should be monitored for at least 24 hours postoperatively. Apnoea monitoring should be continued until the infant is apnoea-free for 12 hours.

Child with Asthma

Should be optimized before anaesthesia All medications continue up to and including day of surgery Oral medications taken with sips of water up to 1-2 hr before surgery Inhaled bronchodilators administer just before coming to OT No elective surgery on wheezing patient or recent asthmatic attack

Child with Cardiac Lesion

Murmur innocent or pathological? Symptomatic or asymptomatic? Degree of compromise Cardiac consult Complex congenital heart Subacute bacterial endocarditis prophylaxis new AHA guidelines

Preoperative Preparation
Optimise Medical Condition Before Surgery Hypovolaemia Dehydration Metabolic derangement

CONGENITAL PYLORIC STENOSIS

Medical emergency not Surgical emergency correct dehydration & metabolic derangement first before surgery

Congenital Pyloric Stenosis Vomiting Dehydration Metabolic derangement

Dehydration
Assessment
General appearance Mucous membrane, skin turgor Anterior fontanell Capillary refill BP, pulse Urine output

Degree of dehydration
Mild (5%) Moderate (10%) Severe (>10%)

Symptoms & Signs

Mild (5%) Alert, restless, thirsty Normal

Moderate (10%) Thirsty, restless, lethargic , weak

Severe (>10%) Drowsy to comatous Sweaty, cold Rapid, feeble

General appearance

Pulse rate & Volume Anterior fontanel Skin turgor Eye Mucous membrane Capillary refill BP Resp Urine output

Normal Normal Normal Normal Normal Normal Normal Adequate

Sunken Sunken, dry Dry < 2sec Normal or low Deep decrease

Markedly depressed Markedly sunken very dry Very dry > 3 sec Low or unrecordable Deep or rapid Oliguria or anuria

Metabolic Derangement
hyponatraemia, hypokalaemia, hypochloraemia, metabolic alkalosis
Na+ 127mEq/l, Cl- 84mEq/l, K+ 2.8mEq/l, bicarbonate 35mmol/l , base deficit: +12, pH 7.65

Correct Dehydration
Pt with >10% dehydration pt in impending shock rapid infusion of 10-20ml/kg of N/S once circulation restored & U/O replace deficit over 24-48 hrs. Fluids normal saline Add K+ when U/O established Maintenance fluid should be given

Dehydration
5-10% dehydration
Fluid Deficit
% dehydration X body wt (gm) eg 10% dehydration in 4kg body wt infant (10% X 4000) ml = 400ml

replace deficit over 24 hrs over 1st 8 hr, next 8, next 8

Correct Metabolic Derangement Correct by itself once dehydration is corrected

When to proceed for surgery?

Haemodynamic Well hydrated Good urine output Biochemical end point
pH <7.5 Na >130mmol/l Cl > 90 mmol/l K > 3.0mmol/l HCO3 < 28mmol/l

Preoperative Preparation
When to book ICU/NICU/HDU beds?
Sick, septic patient Preterm babies <48 weeks PCA Expect intraoperative events
bleeding, fluid shift difficult airway

Prolong surgery

Psychological Preparation
About 65% of children experience intense anxiety throughout perioperative period, especially in the preoperative holding area and during induction of anaesthesia
Kain et al, Anesthesiology 2009

Psychological Preparation
Experience can be traumatic enough as to induce life long aversion to hospital, fear of doctors Children who had multiple surgeries, long hospital stay may suffer lasting psychological effects Reducing preoperative anxiety decreases incidence of postoperative negative behaviours (nightmares, fear of separation)

Important to allay anxiety parent & patient

Provide adequate information re surgery & anaesthesia
Explanation Flyers, pamphlets etc Video of OR Visit to OR

Reduce fears and anxieties

Parent accompanies child to OT Favorite toy Play area in OT DVD favorite cartoons

Summary
The preparation of a child who is about to undergo surgery involves the child, his family, surgeon, anaesthetist and other specialists Communication is important Besides medical preparation of patient, psychological preparation is important to ally anxieties and fears