Professional Documents
Culture Documents
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Disclosure Statement
• The author has no relevant financial
interest or other relationship with the
manufacturer(s) of any commercial
product(s) and/or provider(s) of
commercial services that are discussed
in this educational activity.
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Outline
• Goals of pre-operative assessment
• Anesthesia associated risk
• General pre-operative management
• Pulmonary issues
• Cardiac issues
• Brief review of cardiac risk assessment and management in non-
cardiac surgery – adult guidelines
• Morbid obesity
• Neurologic issues and Epilepsy
• Musculoskeletal and craniofacial issues
• SCD
• Perioperative Management of Diabetes
• Perioperative VTE Prophylaxis
• Psychological preparation for surgery
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Goal of preoperative assessment
• Detection of unrecognized conditions that
increase the risk of surgery.
• Optimize the patient’s current medical
problems and anticipate potential
complications.
– Anticipate pulmonary edema post-T/A
– OSA
– Monitor for atlantoaxial instability (Down’s)
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Model of Plane Flight
PATIENT
Surgeon = Pilot Anesthesia = Co-Pilot
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General perioperative concerns in
Pediatrics.
• Congenital heart disease
– Hypoxia, arrhythmias, and cardiovascular instability paradoxical
air emboli
• Prematurity
– Postoperative apnea
• Gastrointestinal reflux
– Aspiration pneumonia
• URI
– Laryngospasm, bronchospasm, hypoxia, and pneumonia
• Craniofacial abnormality
– Difficult airway
Perioperative risk
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Michota F, Frost S; Med Clin N Am 2002. 9
Role of the surgeon
• Surgeons are typically consulted for
evaluation and treatment of:
– healthy child who is undergoing elective
surgery
– the chronically ill child who requires surgery
– the acutely ill on injured child who requires
emergent surgery.
Pediatrics 1996;98;502-508.
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Role of the anesthesiologist
• Anesthesia may begin outside the OR with
the administration of preoperative
medication.
• Patient follow up until D/C from the PACU
– Except if regional analgesia or spinal block
are used
Pediatrics 1996;98;502-508.
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Anesthesia-associated risk
• Risk for adverse events continues to be higher in
infants and young children
• Overall mortality rate was 0.9/10,000 anesthetics
• Incidence of cardiac arrest of 1.7/10,000
– Adult (1.4/10,000).
– Children < 12 y/o (4.7/10,000) – 3x
– Complications of airway management (laryngospasm,
difficult intubation, and pulmonary aspiration of gastric
contents)
– Halothane (hypotension, arrhythmia, or both).
Pediatrics 1996;98;502-508.
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Pre-operative evaluation
• Family history
– Anesthetic-related complications
• malignant hyperthermia
• prolonged paralysis after anesthesia
(pseudocholinesterase deficiency)
– Bleeding disorders
– Muscular dystrophy
– Drug use (aminoglycosides)
Pediatrics 1996;98;502-508.
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Pre-operative evaluation
• Last meal intake
• Physical examination
– Hydration status
Pediatrics 1996;98;502-508.
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Ancillary testing
• Hb - when significant anemia (<9 g/L) is
suspected
– (eg, infants, growing premature infants, and
patients with chronic illnesses)
– to establish a reference point in anticipation to
significant blood loss (Orthopedic surgery).
• Pregnancy testing
Pediatrics 1996;98;502-508.
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Ancillary testing
• Coagulation profile
– history or medical condition suggests a possible hemostatic defect:
• large bruises and hematomas
• simultaneous bruising on several parts of the body
• Hematochezia
• frequent and prolonged epistaxis
• Hemarthrosis
• unusual bleeding after minor trauma (including dental extraction)
– Recent ingestion of aspirin or NSAIDS.
– Cardiopulmonary bypass – induction of hemostatic disorder by platelet
activation and consumption
– Tonsillectomy; airway surgery
– Neurosurgical patients (craniotomy)
Pediatrics 1996;98;502-508.
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Fasting guidelines
• 8-6-4-2
• 8 hours solids
• 6 hours formula
• 4 hours breast milk
• 2 hours clear liquids
Anesthesiology. 1999;90(3):896-905
Acta Anaesthesiol Scand 2005;49:1041-1047.
Best Practice & Research Clinical Anaesthesiology. 2006; 20(3):471-
10/15/09 81. 21
Pulmonary issues
• URI – defer surgery until symptoms resolve
– Increased risk of bronchospasm
– Decreased 50% with use of Laryngeal Mask Airway
• Asthma – should be optimally controlled
– Continue bronchodilators and oral meds in AM of
surgery
– Delay surgery 6 wk after asthma attack (FEV1
remains low x 6 wk).
– Prednisone 1 mg/kg 24-48 h pre-operatively and in
the AM of surgery.
Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
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Pediatrics 1996;98;502-508.
Pulmonary issues
• FEV1/FVC -useful predictors of the need for
postoperative mechanical ventilation among
patients at risk (eg, cystic fibrosis, severe
scoliosis, or kyphoscoliosis).
• Adults - increased incidence of need for
postoperative mechanical ventilation:
– FEV1/FVC < 50%
– FEV1 < 35% predicted
– Absolute FVC < 25 mL/kg
10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 23
Pulmonary issues
• Cystic fibrosis – continue pulmonary
toilet, optimize nutritional status, continue
home meds (inhaled and systemic
antibiotics, dornase alpha, acetylcysteine,
bronchodilators).
Pediatrics 1996;98;502-508.
Current Opinion in Anaesthesiology 2007, 20:216–220
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Hypoplastic Left Heart Syndrome
and Non-cardiac surgery
Circulation. 2008;118:887-896.
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Antibiotic dose for BE prophylaxis
SINGLE DOSE 30-60 MIN BEFORE
• Amoxicillin p.o. 50 mg/kg
• Ampicillin 50 mg/kg IM/IV or Cefazolin or
ceftriaxone 50 mg/kg IM/IV
• Allergic to penicillins:
– Cephalexin p.o. 50 mg/kg
– Clindamycin 20 mg/kg
– Azithromycin or clarithromycin 15 mg/kg
– Cefazolin or ceftriaxone - 50 mg/kg IM/IV
– Clindamycin 20 mg/kg IM or IV
Circulation. 2008;118:887-896.
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Morbid Obese patient
• Overweight: BMI > 85%le
• Obesity: BMI of more than 95%le
• Superobesity: BMI > 99 %le
• Adolescent/Adult: BMI > 40 kg/m2
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Morbid obesity: medical etiology
• Prader–Willi syndrome
• Laurence–Moon–Biedl syndrome
• Hypercaloric diet (glycogen storage
diseases)
• Steroid induced (Hem-Onc, nephrotic
syndrome)
• Poor mobility (late stage Duchenne’s)
Current Opinion in Anaesthesiology 2008;21:308–312.
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Prader Willi Syndrome
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Morbid obesity: Pediatric
perioperative considerations
• Slipped capital femoral epiphysis
• Blount’s disease
• Cholelithiasis
• Polycystic ovary syndrome
• Idiopathic intracranial hypertension
(pseudotumour cerebri)
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Morbid obesity: Pre-operative
examination in children
• History:
– symptoms of sleep apnea
– tolerance to exercise: breathlessness, asthma;
– recent weight loss or gain
– medications, including OTC herbs or special mixtures taken to
lose weight which can interfere with anaesthesia or
haemostasis.
• e.g. garlic, ginger, etc.
• Document BMI in percentile chart.
• Pulse-oximetry (SpO2) on room air / Nocturnal SpO2
• Fasting blood glucose
• Echocardiography (Hypertensive patient)
• Preoperative fasting – similar rules as the nonobese population.
• GERD: usual anti-reflux therapy should be administered.
Current Opinion in Anaesthesiology 2008;21:308–312.
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Elective surgery in morbid obesity:
2009 AHA guidelines
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Circulation. 2009;120:86-95.
Neural tube defects
• Assessment for coexistent congenital anomalies
• 90% require CSF diversion
• Subsequent surgeries:
– Infection
– Malfunction
– Outgrowing the shunt hardware
• Associated urogenital and musculoskeletal dysfunction
– UTI/VUR/hydronephrosis renal function evaluation
– Scoliosis respiratory function evaluation
– Lower-extremity abnormalities
• Latex allergy
Pediatrics 1996;98;502-508.
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Neuromuscular disorders
• Inhalational agents: cerebral vasodilation increase ICP
• Ensure patency and proper functioning of CSF shunt
• Immediate postop period Impaired airway reflexes
– Document pre-operatively any evidence of brainstem dysfunction
(eg, vocal cord paralysis, swallowing dysfunction, or aspiration)
• Increased risk for postoperative weakness postoperative
respiratory care and prolonged mechanical ventilation / PP.
• Succinylcholine Hyperkalemia; malignant hyperthermia
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Paediatric Anaesthesia 2000;10:121–128 56
Cervical spine instability
• Mucopolysaccharidoses (Hurler’s and Monquio’s
syndromes): odontoid hypoplasia
• Rheumatoid arthritis: atlantoaxial instability,
subaxial instability, and superior migration of the
odontoid process.
• Down syndrome: 15% asymptomatic atlantoaxial
instability
• Document pre-operative screening flexion-
extension Cervical spine Roentgenograms
• Consider fiberoptic intubation.
Pediatrics 1996;98;502-508.
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Craniosynostosis
• Multidisciplinary evaluation by a craniofacial team
• Monitor for signs of increased intracranial pressure
• Nonsyndromic craniosynostosis are usually otherwise
healthy.
• Syndromic craniosynostosis can have associated
anomalies:
– Crouzon’s or Apert’s syndrome can have very abnormal airway
anatomy fiberoptic intubation.
• Identifying a history of OSA
• Apert’s syndrome congenital cardiac defects.
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Regional anesthesia and SCD
• Redistribution of blood flow may lead to an increase in
capillary and venous oxygen tension in the blocked
region
• Compensatory vasoconstriction in nonblocked areas
leads to a fall in the SvO2.
• Lack of control of ventilation, regional hypoperfusion and
venous stasis.
• Cooperative Study of Sickle Cell Disease (N=3765)
– 10 y.
– 1079 surgeries (N= 717)
– Post-op SCD-related complications (painful crisis, ACS, and
CVA) were more frequent in patients who received regional
anaesthesia (P=0.058).
Conclusions.
“Minor or low-risk elective surgical procedures
in children with Hb SS may not routinely
require pre-operative transfusion”
No
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Rhodes ET. Anesth Analg 2005;101:986 –99
Lantus insulin regime
No
Yes
No
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Rhodes ET. Anesth Analg 2005;101:986 –99
Insulin pump – for surgery < 2h
No
No
No
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Rhodes ET. Anesth Analg 2005;101:986 –99
Post-operative DM management
No
Yes
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