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Preoperative evaluation in infants and children: Recommendations of

the Italian Society of Pediatric and Neonatal Anesthesia and Intensive
Care (SARNePI)

Article  in  Minerva anestesiologica · October 2013

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REVIEW

Preoperative evaluation in infants and children:

recommendations of the
Italian Society of Pediatric and Neonatal Anesthesia
and Intensive Care (SARNePI)
G. SERAFINI 1, P. M. INGELMO 2, M. ASTUTO 3, S. BARONCINI 4, F. BORROMETI 5
L. BORTONE 6, C. CESCHIN 7, A. GENTILI 4, E. LAMPUGNANI 8, G. MANGIA 9
L. MENEGHINI 10, C. MINARDI 10, G. MONTOBBIO 8, F. PINZONI 11, B. ROSINA 11
C. ROSSI 7, E. SAHILLIOĞLU 12, M. SAMMARTINO 13, R. SONZOGNI 14
V. SONZOGNI 14, S. TESORO 15, C. TOGNON 10, N. ZADRA 10

1Dipartimento di Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico S. Matteo, Università di Pavia, Pavia,

Italy; 2McGill University Health Center. Montreal Children’s Hospital, Montreal, Canada; 3Dipartimento di Anestesia e
Rianimazione, Ospedale Universitario Policlinico, Catania, Italy; 4Dipartimento di Anestesia e Rianimazione Pediatrica,
Ospedale S. Orsola-Malpighi, Università di Bologna, Bologna, Italy; 5Servizio di Cure Palliative e Terapia del Dolore,
Ospedale SantobonoPausilipon, Napoli, Italy; 6Dipartimento di Anestesia e Rianimazione, Azienda Ospedaliera di
Parma, Parma, Italy; 7Servizio di Anestesia e Rianimazione, Dolo Hospital, Mirano, Italy; 8Dipartimento di Anestesia e
Rianimazione, IRCCS Ospedale dei Bambini G. Gaslini, Genova, Italy; 9Dipartimento di Anestesia, Ospedale S. Camillo,
Roma, Italy; 10Unità Operativa di Anestesia e Rianimazione Azienda Ospedaliera Padova, Padova, Italy; 11Dipartimento
di Anestesia Pediatrica, Ospedali Civili, Brescia, Italy; 12Department of Anaesthesia and Intensive Care, Anadolu Medical
Center, Kocaeli, Turkey; 13Dipartimento di Anestesia e Rianimazione, Ospedale Universitario A. Gemelli, Università
Cattolica del Sacro Cuore, Roma, Italy; 14Primo Servizio di Anestesia e Rianimazione, Ospedali Riuniti di Bergamo,
Bergamo, Italy; 15Sezione di Anestesia, Analgesia e Rianimazione, Dipartimento di Medicina Clinica e Sperimentale,
Università di Perugia, Perugia, Italy

ABSTRACT
Background. The preoperative assessment involves the process of evaluating the patient’s clinical condition, which
is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus
providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommenda-
tion was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing
elective surgery or diagnostic/therapeutic procedures.
Methods. We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the elec-
tronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed
by the Italian Center for Evaluation of the Effectiveness of Health Care’s scoring system for assessing the level of
evidence and strength of recommendations.
or other proprietary information of the Publisher.

Results. We produce a set of consensus guidelines on the preoperative assessment and on the request for preopera-
tive tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus,
emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio.
Conclusion. Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the
use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned,
and replaced by a selective and rational prescription, based on the patient history and clinical examination per-
formed during the preoperative evaluation. (Minerva Anestesiol 2014;80:461-9)
Key words: Child - Ambulatory care - Blood coagulation - Preoperative period - Anesthesia.

Vol. 80 - No. 4 MINERVA ANESTESIOLOGICA 461

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SERAFINI PREOPERATIVE EVALUATION GUIDELINES SARNEPI

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

T he preoperative assessment involves the

process of evaluating the patient’s clinical
condition, which is intended to define the physi-
cal status classification, eligibility for anesthesia
and the risks associated with it, thus providing
elements to select the most appropriate, indi-
vidualized anesthetic plan.
These recommendations were developed by
the Study Group on Preoperative Assessment of
the Italian Society of Pediatric and Neonatal An-
esthesia and Intensive Care (SARNePI) as a serv-
ice to SARNePI members and other healthcare
providers and/or their institutions. The primary
aim of these recommendations is to provide a
reference framework for the pediatric preopera-
tive evaluation assessment and to help a broad
spectrum of healthcare providers to enhance pa-
tient care.
This document should be applied on patients
without previous medical or surgical problems
(i.e. ASA I or II) undergoing elective surgery or
diagnostic/therapeutic procedures (Table I). The
decision whether or not to follow these recom-
mendations must be made by the responsible
physician on an individual basis, taking into ac-
count the condition of the patient and the avail-
able resources. The responsible physician is al-
lowed not to follow these recommendations if
there is a good justification to do so and it is
reported in the patient’s notes.
Methodology
Review of available literature
We obtained evidence concerning pediat-
ric preoperative evaluation from a systematic
search of the electronic databases MEDLINE
and Embase between January 1998 and Febru-
ary 2012. We used the format developed by the
Italian Center for Evaluation of the Effectiveness
of Health Care’s (CeVEAS) scoring system for
assessing the level of evidence and strength of
recommendations (Tables II, III). In reaching
consensus, emphasis was placed on the level of
evidence, clinical relevance and the risk/benefit
ratio.
These recommendations have undergone the

Table I.—ASA Classification.

ASA I Patient without organic physiological, biochemical or psychiatric changes
ASA II Moderate systemic disease
ASA III Severe systemic disease or disorder
ASA IV Severe systemic disease or disorder that is a constant potential threat to life
ASA V A patient is morbid and is at substantial risk of death within 24 hours
E Surgery should not be delayed and does not allow a full assessment of the patient: the letter E is added to the
corresponding ASA class

Table II.—Grading of recommendations: CeVEAS Scheme, Levels of evidence.

I Evidence obtained from multiple randomized controlled trials and/or systematic reviews of randomized trials
II Evidence from one randomized study with appropriate design
III Evidence obtained from non-randomized cohort studies with concurrent or historical controls or their meta-analysis
IV Evidence from retrospective case-control studies or their meta-analysis
V Evidence obtained from case studies (“case series”) without control groups
VI Evidence based on expert opinion or expert committees as indicated in guidelines or consensus conferences, or based
on opinions of the members of the working group responsible for these guidelines
or other proprietary information of the Publisher.

Table III.—Grading of recommendations: CeVEAS Scheme, Strength of recommendations.

A The execution of that particular procedure or diagnostic test is strongly recommended; it indicates a particular
recommendation supported by scientific evidence of good quality, although not necessarily of type I or II
B An expressed doubt that the particular procedure or intervention should always be recommended, but it is believed
that the execution should be carefully considered
C There is substantial uncertainty in favor of or against the recommendation to perform the procedure or intervention
D The execution of the procedure is not recommended
E The procedure is strongly unrecommended

462 MINERVA ANESTESIOLOGICA April 2014

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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
PREOPERATIVE EVALUATION GUIDELINES SARNEPI SERAFINI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
following review process. The final draft was re-
viewed by the members of the SARNePI study
group. It was posted to other relevant commit-
tees of the SARNePI not involved in the initial
preparation of these recommendations. It was
sent to three independent reviewers and com-
ments were collected by the Chair of the study
group and the recommendations amended as
appropriate. After that, a version in Italian was
published on the SARNePI website. The final
manuscript was approved by the SARNePI ex-
ecutive board and by the SARNePI general as-
sembly before submission for publication.
Preoperative evaluation
The joint document produced by the Italian
Society of Anesthesia, Analgesia and Intensive
Care (SIAARTI) and SARNePI stated that pr-
eoperative evaluation “must be performed in all
candidates that receive anesthesia. Only in un-
common circumstances, such as an emergency
condition may this rule be disregarded. In which
case, the reasons must be accurately defined and
reported in the medical record of the patient”.1, 2
SIAARTI and SARNePI stated in the same
document that the preoperative evaluation as-
sessment is an anesthesiologist’s responsability,
and only an anesthesiologist can decide which
patient is eligible to receive anesthesia. A preop-
erative assessment by other medical specialists
may provide additional information in deciding
the eligibility of a patient for anesthesia. The pre-
operative assessment should precede any request
of laboratory and instrumental tests to avoid un-
necessary testing.3
Timing
The timing of the preoperative evaluation
could be influenced by the demographic char-
or other proprietary information of the Publisher.
acteristics, the institutional organization, the
patient’s clinical condition or the surgical pro-
cedure. Hospitalization of healthy children for
a preoperative evaluation the day before surgery,
should be considered as improper in most mi-
nor elective surgical procedures. A day hospital
stay does not reduce cost nor does it save time
because the patient should be evaluated again
Vol. 80 - No. 4 MINERVA ANESTESIOLOGICA 463
on the day of surgery.4 This conditions may not
apply for children with complex medical condi-
tions and/or major surgery.
With the One-stop anesthesia method, the
anesthesiologist analyzes the data collected by
the surgeon at the time of the surgical visit and
decides which patient has a need for prospec-
tive pre-hospitalization and which may undergo
preoperative anesthesia evaluation on the same
day of surgery. This procedure allows for a single
access and a single anesthetic visit. The pedia-
trician provides patient information to the an-
esthesiologist and surgeon who in turn assess the
suitability for a same-day surgery admission.5-7
Medical history
During the medical history evaluation, par-
ticular attention should be provided to the fol-
lowing:
—— Medications: any information pertain-
ing to a recent intake of drugs (e.g.: Aspirin,
NSAIDs, natural medicines, etc) must be noted.
—— Allergies: any allergic reaction to food,
medications or other substances (e.g. latex) must
be noted.
—— Previous anesthesia: any possible prob-
lems or complications associated with previous
anesthesia, especially those related to airway
management or respiratory or cardiovascular
events should be noted.
—— Family history: information should be ob-
tained on whether there has been a family history
of malignant hyperthermia, cases of unexplained
deaths, bleeding disorders, passive smoking or
neuromuscular disease.
Physical examination
A thorough assessment of the airway, the car-
diovascular, respiratory and nervous system, and
the state of hydration should be performed be-
fore any procedure including anesthesia.
Request for preoperative tests
The ASA Task Force on Preanesthesia Evalu-
ation stated that preoperative tests should not
be required on a routine basis. Preoperative tests
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SERAFINI PREOPERATIVE EVALUATION GUIDELINES SARNEPI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
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should be requested on a selective basis in or-
der to guide or optimize preoperative conduct.
The indications for these investigations should
be documented and should be based on infor-
mation derived from previous medical records,
which could result in the type and invasiveness
of the proposed surgical procedure.3
The American Academy of Pediatrics stated
“preoperative tests should be ordered only when
they can provide added value, i.e. when there is a
reasonable certainty that they will reveal, or bet-
ter define the clinical conditions that are relevant
to the planned anesthesia and/or may affect the
anesthesia or surgical outcome. In these cases,
the correct definition of risk is essential, and it is
necessary to obtain a truly informed consent.”8
In 2000, SARNePI stated: “Apart from special
cases related to individual specialties (i.e. cardiac
surgery, neurosurgery, etc), the preoperative evalu-
ation of children older than 12 months, may not
necessarily require blood or other tests.”2
A preoperative test may be required to first,
highlight suspected conditions that may vary and
modify the operative risk evaluation (e.g. the pos-
sible presence of congenital heart disease). Sec-
ond, to highlight conditions in which a suspected
prior treatment can lead to a lower operative risk
(e.g. asthma). Third, to obtain a baseline assess-
ment that can be of assistance in making deci-
sions during and after surgery (e.g. hemoglobin).
A previous blood tests (within 6 months)
should only be repeated if the clinical conditions
indicate that there are changes that support a
new test.
Individual tests
Hemoglobin-hematocrit
The incidence of anemia in children is rare
and occurs more easily in infants younger than
or other proprietary information of the Publisher.
1 year. Moreover, the presence of a certain level
of anemia does not affect the decision to pro-
ceed with surgery. The incidence of anemia in
two studies including 2000 and 2500 children
undergoing day- surgery was less than 0.5%
and only in infants. The presence of moderate
anemia did not affect the decision to perform
the operation. 9, 10 The incidence of anemia de-
464 MINERVA ANESTESIOLOGICA April 2014
fined as Hb<9 g/dL was identified in 75 of 9500
(0.8%) children undergoing elective surgery.
None of those cases received preoperative treat-
ment for anemia. A transfusion of packed red
blood cells became necessary only in two cases,
both with values of Hb>9 g/dL. In all cases, the
decision was based on clinical factors and not on
the value of preoperative Hb (Table IV).11
Recommendation.—The determination of he-
moglobin levels is not justified and can be elimi-
nated as a complementary routine examination be-
fore minor surgery (D III) and should be restricted
to potentially bleeding surgical cases (B III).12
Glucose, creatinine, transaminase, elec-
trolytes.—Numerous studies have shown that
the risk of hypoglycemia is minimal in the child,
even after prolonged fasting. The determination
of blood glucose days before surgery is not able
to predict glycemia at the time of induction.13, 14
The dosage of plasma electrolytes is certainly not
justified in asymptomatic children. It should be
required only in the presence of digestive disor-
ders, alterations in acid-base or use of diuretics.14
Recommendation.—The determination of
plasma concentrations of glucose, creatinine,
transaminases, and electrolytes should be elimi-
nated as a routine test (D III).
Coagulation tests
The usefulness of routine coagulation tests, es-
pecially before ENT surgery or a central blocks,
remains one of the most controversial topics of
the preoperative evaluation. In the last decade,
most guidelines from international scientific so-
cieties have clearly expressed, the uselessness of
a coagulation screening in a non-selective man-
ner.15-18
Several studies documented the low sensitivity
and specificity, as well as on the low predictive
value of activated partial thromboplastin time
(aPTT), prothrombin time (PT) and platelet
counts.18 19 The aPTT test may be useful for an-
swering the question: “Why is this patient bleed-
ing?” but cannot answer the question “Will this
patient bleed?” in an unselected population.20 A
a long aPTT often makes clear disorders without
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PREOPERATIVE EVALUATION GUIDELINES SARNEPI SERAFINI

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Table IV.—Summary of recommendations.

Topic
Preoperative evaluation
Hematocrit and hemoglobin
Plasma glucose, creatinine,
transaminases, and electrolytes
Standardized questionnaires to
evaluate coagulation disorders
Coagulation tests
Pregnancy test
ECG in children
ECG in neonates and infants under 6 Recommended
months of age
Chest radiograph
Level of evidence and strength of
Recommendation recommendation
Must be performed in all candidates that receive anesthesia. A VI
Only in emergency condition this rule may be disregarded
Not recommended before minor surgery D III
Recommended in potentially bleeding cases B III
Not recommended D III
Recommended as key elements before any surgery or B III
invasive procedure
Not recommended in case of negative anamnesis D III
Recommended only in case of specific risk factors or in case C III
of a potentially bleeding surgery
Recommended in all female of childbearing age C VI
Not recommended in healthy children D III
Recommended in case of: B III
–– Heart murmur of uncertain interpretation
–– Suspicion of congenital heart disease
–– Obstructive sleep apnea syndrome
–– Severe scoliosis
–– Bronco Pulmonary Dysplasia
–– Neuromuscular disease
B III
Not recommended in healthy children D III
Recommended only in case of positive anamnesis or physical B III
exam or in case of:
–– Mediastinal mass
–– History of bronco-pulmonary dysplasia
–– Severe asthma
–– Neuromuscular disease

clinical significance, such as a deficiency of Fac-
tor XII, prekallikrein or a High MW kininogen.
A false positive aPTT prolongation is commonly
associate to nonspecific antiphospholipid anti-
bodies commonly present in children with ENT
infections or after vaccination.21-22
In contrast, a normal aPTT is present in 60%
of patients with von Willebrand disease (vWD)
or in children medium forms of hemophilia
(Factor VIII over the 30-50% range). aPTT is
unable to determine Factor XIII deficiency, or
congenital and acquired forms of thrombocy-
topenia and does not correlate entirely with the
or other proprietary information of the Publisher.
the adult. The liver immaturity is often respon-
sible for a defect in synthesis of factor IX. The
adult values are reached between six and twelve
months. There is no close parallelism between
the aPTT test results and the clinical hemosta-
sis in neonates and infants undergoing regional
anesthesia.23
An accurate medical history of the child and
his relatives (e.g. parents, siblings) associated
to a careful physical examination are the most
valuable tools in highlighting a coagulation dis-
order. Standardized questionnaires validated for
research are also useful for daily clinical practice

severity of coagulopathy.21, 22 in adults and children (Table V).24, 25 Standard-

The physiological characteristics of the new-
born and the infant increases the difficulty in in-
terpreting an aPTT. Factors II, VII and X, reach
the optimal values ten days after birth. Factors
I and V became normal in the third day of life.
The values of fibrinogen, factor VIII and the
von Willebrand factor are identical to those of
ized questionnaire has more sensitivity and nega-
tive predictive value than aPTT as coagulation
screening before surgery.22, 24, 26 Standardized
questionnaires has also limitations. Hemorrhagic
signs are rare in small children before they begin
to walk, even in the presence of an altered coagu-
lation. The impossibility of obtaining a family

Vol. 80 - No. 4 MINERVA ANESTESIOLOGICA 465

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Table V.—Watson-Williams Questionnaire (modified).26

Type A questions
–– Has the patient bled for more than 24 hours or has had need for a blood transfusion after surgery (circumcision, adenoidectomy?)
–– Has there been prolonged bleeding or recurrent bleeding 24 hours after the umbilical cord falls off, or after the fall of deciduous
teeth or after a tooth extraction?
–– Has there been a history of unexplained hematuria?
–– Has the patient been taking salicylates or non-steroidal anti-inflammatory drugs in the past two weeks?
–– Has the clinical examination showed any abnormal bruising, petechial, signs of malnutrition or mal-absorption or signs of liver
disease or blood disease?
Type B questions:
–– Have the previous episodes occurred in male relatives or in relatives from the maternal side?
–– Does bruising easily occur for no apparent reason?
–– Is there an epistasis tamponed that required surgery for secure hemostasis?
–– Does the site of the venipuncture bleed more than 15 minutes after the medication?
–– Has someone previously reported that the patient has an abnormal tendency to bleed?
A positive response to questions under the Type A category or two positive responses to the questions under the Type B category
show a positive history of a hemostasis disorder.

history of one or both parents’ may compromise
the reliability of the questionnaire.23, 27-30
Recommendation.—Accurate anamnesis of
the patient and her/his relatives with structured
questionnaires, as well as a careful physical ex-
amination are key elements before any surgery
or invasive procedure to anticipate bleeding dis-
orders (B III).
Routine use of coagulation tests is not recom-
mended (D II) unless there are specific risk fac-
tors in the history and physical examination or
in case of a potentially bleeding surgery (C III).
Pregnancy test
Although the pregnancy rate in presurgery
pediatric patients is low, the ethical and medico-
legal (potential teratogenicity, abortion) are con-
siderable. Even a careful history may not obtain
a response as a teenager may be reluctant to talk
about her sex life. The percentage of positive tests
varies from 0.3 to 2.5% of cases and in 100% of
cases affects the anesthetic management or refer-
ral to surgery.3 31
or other proprietary information of the Publisher.
percentage of changes in anesthesia (0-0.9%).32
The ability of ECG on predicting postoperative
complications is low, and there is no evidence to
support the value of the request for a baseline
ECG.8, 33-35 There is international consensus for
a selective oriented and non-routine ECG test
before surgery.1-3, 8, 36, 37
Recommendation.—Routine request of a pr-
eoperative ECG is not recommended in healthy
children (D III).
A preoperative ECG should be performed in
case of heart murmur of uncertain interpreta-
tion, suspicion of congenital heart disease, ob-
structive sleep apnea syndrome (OSAS), severe
scoliosis, broncopulmonary dysplasia (BPD)
and neuromuscular disease. This test could be
eventually followed by a cardiac ultrasound and/
or a pediatric cardiology evaluation (B III).
ECG in newborns and infants
Long QT Syndrome (LQTS) consists of an
ion channel malfunction caused by mutations
involving genes that encode ion currents (po-

Recommendation.—The execution of the preg-
nancy test is recommended in all female of child-
bearing age after proper information (C VI).
ECG in children
Several studies have shown that a great vari-
ability of abnormal ECG still led to a negligible
tassium and sodium) involved in the control of
ventricular repolarization (congenital LQTS)
or caused by metabolic alterations or drugs (ac-
quired LQTS). LQTS is characterized by the
onset of syncope due to ventricular tachycardia
like torsade de pointes (TdP) and a high risk of
sudden cardiac death in untreated patients.38
Symptomatic events may be triggered by

466 MINERVA ANESTESIOLOGICA April 2014

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PREOPERATIVE EVALUATION GUIDELINES SARNEPI SERAFINI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
physical activity and emotional stress. A number
of drugs (including anesthetic agents) can in-
terfere with cardiac repolarization, lengthening
the QT interval, and sometimes cause a drug-
induced TdP and sudden death. Sudden death
is the first manifestation of LQTS in about 12%
of patients. One third of those cases occurs dur-
ing the first year of life.38 In LQTS there is a
low penetrance, which means that carriers of the
mutated genes may not show the clinical phe-
notype and may have a normal QT interval.39
In addition, approximately 30% of cases are due
to ‘de novo’ mutations, which implies unaffected
parents and no family history.40
Long QT syndrome was recently related to
sudden infant death syndrome (SIDS). A pro-
spective study of 34,000 infants showed that QT
prolongation in the first week of life is the most
significant risk factor for SIDS.41 Molecular
studies, initially on anecdotal 42, 43 and recently
in two sets of 93 and 201 victims of SIDS,44, 45
have shown that 10% of SIDS cases may be due
to LQTS.
These elements and the low mortality of
LQTS after treatment (<2%) 46-48 have raised the
controversial proposal of neonatal ECG screen-
ing for early (from the 15th to the 25th day of
life) detection and treatment of patients with
LQTS.49, 59 The execution of an ECG in the first
month of life allowed for early identification of
still asymptomatic infants with LQTS and other
asymptomatic congenital heart diseases not de-
tected previously. This evaluation was also sig-
nificantly cost-effective.51
A second conduction abnormality that can
be highlighted by a neonatal ECG is the Wolff-
Parkinson-White syndrome (WPW). The preva-
lence of WPW syndrome was estimated to be
of 0.15-0.3%.52 The incidence of sudden death
in WPW during childhood was estimated to
be 0.5% and, cardiac arrest may be the initial
or other proprietary information of the Publisher.
presentation in children with pre-excitation.53 A
study performed on a series of 90 neonates and
infants with WPW syndrome and supraven-
tricular tachycardia (SVT) reported sudden
death in 2 patients with normal heart during
follow-up.54 A congenital heart disease is more
common in infants and children with pre-exci-
tation with prevalence of up to 45% for those
Vol. 80 - No. 4 MINERVA ANESTESIOLOGICA 467
infants with an ECG characterized by a right ac-
cessory connection. Consequently, in any young
patient with pre-excitation on the ECG, it is
recommended that a cardiac ultrasound evalu-
ation be performed in order to rule out cardiac
anomalies.40, 54
Symptoms of congenital heart disease presents
itself as severe in the first week of life or can be
detected before any clinical deterioration during
the first year of life.55 A recent study by Wren
reveals that more than 30% of newborns and
infants with congenital heart disease were dis-
charged after birth without diagnosis. 56 Routine
evaluation in search of a congenital heart disease
between the sixth and eighth week of life is rec-
ommended by national guidelines of Great Brit-
ain.57
Recommendation.—Investigate maternal fac-
tors and fetal factors associated to sudden infant
death (smoking, alcohol, socioeconomic status,
intrauterine hypoxia, prone position whilst asleep,
passive smoke). Request for an ECG in neonates
and infants under 6 months of age (B III).
Chest X-ray
All pediatric studies clearly indicate that a
chest radiograph does not provide more infor-
mation than those suggested by the patient’s his-
tory and/or clinical examination. In view of the
biological damage from ionizing radiation, the
systematic request of a chest radiograph before
surgery is not justified.3, 58-60
Recommendation.—The request for a routine
preoperative chest radiograph is not warranted
and should be abandoned (D III).
A chest radiograph may be necessary when
the clinical history (e.g. suspicion of mediasti-
nal mass) and physical examination suggests it,
in infants or children with a history of bronco-
pulmonary dysplasia (BPD), severe asthma and
neuromuscular disease (B III).
Conclusions
Preoperative evaluation should be mandatory
before any diagnostic or therapeutic procedure
that requires the use of anesthesia or sedation.
The ultimate goal of this manuscript is that a
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
SERAFINI PREOPERATIVE EVALUATION GUIDELINES SARNEPI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
broad spectrum of anesthesiologists and health-
care providers use these recommendations in
their daily practice. Based on the available lit-
erature (studies with levels of evidence III, and
VI) we can make recommendations with levels
of evidence B C and D.
Key messages:
—— The systematic prescription of com-
plementary tests in children should be
abandoned, and replaced by a selective and
rational prescription, based on the patient
history and clinical examination.
—— Blood test, ECG and chest radiograph
are not recommended in infants and chil-
dren with silent medical history and/or nega-
tive physical examination and scheduled for
minor surgery.
—— The execution of the pregnancy test is
recommended in all female of childbearing
age.
—— An ECG in neonates and infants un-
der 6 months of age is recommended.
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
PREOPERATIVE EVALUATION GUIDELINES SARNEPI SERAFINI
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on May 6, 2013. - Accepted for publication on September 3, 2013.
Corresponding author: P. M. Ingelmo, Department of Anesthesia, Montreal Children’s Hospital, 2300 rue Tupper #C1115, Montreal
(Quebec), Canada. E-mail: Pablo.ingelmo@muhc.mcgill.ca
or other proprietary information of the Publisher.
Vol. 80 - No. 4 MINERVA ANESTESIOLOGICA 469
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