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Marwa A. Khairy Lecturer of Anesthesia Preoperative Visit to Pediatric Patients.

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Presentation on theme: "Marwa A. Khairy Lecturer of Anesthesia Preoperative Visit to Pediatric Patients."— Presentation transcript:

1 Marwa A. Khairy Lecturer of Anesthesia Preoperative Visit to Pediatric Patients

2 GOALS Baseline information Detection of co-morbid conditions and optimization of these if any, e.g. URI, anemia Assessment of risk and obtaining informed consent Allaying anxiety of child/parent

3 Baseline information Maternal History Birth History:- Full term or preterm baby Determine post conceptual age Hospitalization, immunization, illnesses, medications prolonged intubation Records, previous anesthesia and surgery

4 Maternal History with Commonly Associated Neonatal Problems Problems with neonatesMaternal history Hemolytic anemia, hyperbillirubinemia, kernicterus Rh - ABO incompatibility SGAToxemia - hypertension Sepsis, thrombocytopeniaInfection Hypoglycemia, birth trauma, LGA, SGA Diabetes TEF, anencephaly, multiple anomaliesPolyhydramnions Renal hypoplasia, pulmonary hypoplasia Oligohydramnions

5 Review of Systems: Anesthetic Implications

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7 Family History Prolonged paralysis with anesthesia (pseudocholinesterase deficiency) Unexpected death (sudden infant death syndrome, MH) Genetic defects Muscle dystrophy, cystic fibrosis, SCD, hemophilia, von Willebrand disease (familial) Allergic reactions

8 Physical examination Warm the stethoscope and your hands before examination Fever, loose teeth, micrognathia, nasal speech Heart murmurs Edema Signs of dehydration

9 Laboratory Data (no need) That healthy children elective minor surgery (no need) significant blood loss may be expected, a Hb10 g · dl–1 older than 3 months or age. Routine chest x-rays and urinary analysis is unnecessary coagulation should only be considered in selected situations

10 Special Situations

11 Full Stomach The most common problem in pediatric anesthesia 4 positions suctioning for fluids Prepare 2 laryngoscopes, 2 suctions IV access Atropine 0.02 mg/kg, preoxygenation, STP 5-6 mg/kg or propofol 3 mg/kg or ketamine 1-2 mg/kg (hypovolemia), succinyl choline 1-2 mg/kg. Sellick maneuver? Consider fasting hours only till time of injury.

12 Anemia  Chronic anemia?  HCT? 25? Risks of blood transfusion to raise it to 30 is unjustified.  Minor surgery?  Elective with significant anticipated blood loss?  Anemic former premature needs postoperative apnea monitoring.

13 Sickle Cell Disease  Start IV fluids the night before with 1.5 times maintenance fluid volume  Keep warm, well oxygenated  Hematologic consultation (usually HCT 30 is targeted)

14 Upper Respiratory Tract Infection  Allergic rhinitis or URTI? (seasonal, clear discharge, no fever, not a contraindication for surgery)  Accept: clear nasal discharge, mild cough, no wheezes or crepitus, no fever, active and happy child, clear rhinorrhea, clear lungs, older child

15 Upper Respiratory Tract Infection  Postpone: fever 38 0, malaise, cough, poor appetite, just developed symptoms last night, lethargic, ill- appearing, wheezes, purulent nasal discharge, lower airway affection, leucocytosis, child <1 year, ex-premie, history of reactive airway disease, major operation, endotracheal tube required  Keep: albuterol, succinyl choline, inhalation agent in oxygen  If postoned: how long?

16 Asthma & Reactive Airway Disease Wheezing, ER visit, medications Continue all medications till morning of surgery Theophylline level microgram/ml Short term oral steroid therapy Minimal airway intervention ETT adaptors for metered dose inhalers better than simple spraying through ETT PaCO2 > 45 (incipient respiratory failure) Emergency: oxygen-hydration-SC epinephrine-aminophylline- ventolin-steroids-antibiotics

17 Anesthesia and Vaccination Vaccine-driven adverse events (fever, pain, irritability) might occur but should not be confused with postoperative complications. Appropriate delays for the type of vaccine between immunization and anesthesia are recommended to avoid misinterpretation of vaccine-associated adverse events as postoperative complications. Likewise, it seems reasonable to delay vaccination after surgery until the child is fully recovered.

18 Fever  degree is without symptoms is not a contraindication to GA  Symptoms: rhinitis- pharyngitis - otitis media – dehydration or any other symptoms of impending illness  Emergency: paracetamol

19 Cognitively Impaired Children  Extensive medical and surgical histories should be taken with great patience  Gastrointestinal reflux is common (anticholinergics)  Continue medications  Sedation: oral midazolam  Family member presence  If markedly scared: IM ketamine 3-4mg/kg, atropine 0.02mg/kg, midazolam mg/kg

20 Seizure Disorders  Medication-schedule-possible interaction with anesthetic drugs.  Stress may reduce seizure threshold.  Continue all medications.  Emergency with missing 1-2 doses: no problem but if longer periods consider IV therapy.  Blood levels: seizure free with sub-therapeutic levels for one year.  Methohexital exacerbate temporal lobe epilepsy.

21 Prematurity

22 Former Premature  “Neonates and especially ex-premature infants have a tendency toward periodic breathing that is accentuated by anesthetics, increasing the risk of postoperative apnea until approximately weeks post- conceptual age and require continuous monitoring of blood oxygen saturation and heart rate until 12-hours of apnea free period”.

23 Former Premature  Apnea  Apnea (1) central apnea, due to immaturity or depression of the respiratory drive; (2) obstructive apnea, due to an infant's inability to maintain a patent airway; and (3) mixed apnea, a combination of both central and obstructive apnea.

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26 Apnea (cont’d) Susceptibility to Central apnea is exacerbated by hypothermia, hypoglycemia, and hypocalcemia, anemia, opioids. Treatment: xanthines (caffeine & theophylline) ▲ Hct ▲ FiO 2 Never give caffeine & send the neonate home as being “safe now”. Even patients treated with naloxone require continuous monitoring of blood oxygen saturation and heart rate until 12-hours of apnea free period. Obstructive apnea is treated by changing the head position, inserting an oral or nasal airway, placing the infant in a prone position or by applying continuous positive airway pressure (CPAP)

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29 Retinopathy of Prematurity  Sick-low birth weight septic infants <1000 g with long oxygen therapy  No correlation with specific PaO2  Appear in infants with cyanotic heart disease who never received oxygen  Avoid hyperoxia under anesthesia?

30 Bronchopulmonary Dysplasia  Chronic lung disease associated prolonged mechanical ventilation (barotrauma) & oxygen toxicity in a premature neonate with hyaline membrane disease.  Chronic hypoxemia-hypercarbia-abnormal functional airway growth-tracheomalacia-bronchomalacia-reactive airway disease-propensity toward atelectasis and pneumonia-increased pulmonary vascular resistance + IVH.  Commonly on diuretic/steroid therapy.  May need oxygen on transport to OR.

31 Bronchopulmonary Dysplasia  Allow adequate time for expiration.  Avoid ETT if possible.  Awake spinal/caudal/penile block.  Postoperative apnea monitoring.

32 Diabetic Children the most common endocrine problem Is the child metabolic control acceptable? No ketonuria Normal serum electrolytes HbA1c <7.5 Choose protocol according to : Split-mixed insulin regimen (50%) Basal-bolus insulin therapy (Levemir 75%, Lantus 100%) once daily Insulin pump Oral agent + insulin for type 2 DM

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34 PREOPERATIVE PROTOCOL FOR ALL PATIENTS Hold oral hypoglycemics and morning doses of insulin Omit breakfast Child should arrive in the early morning First case of the day Labs needed: RBS, electrolytes,K.BUN Keep RBS <250mg/dl using SC rapidly acting insulin using correction method

35 correction factor The calculation for insulin correction factor : 1. Divide 1500 by child's total daily dose (TDD). 2. Example: if TDD = 50 units, then insulin correction factor is 1 unit regular insulin to lower blood glucose by 30 mg/dL.

36 A.BASAL BOLUS INSULIN A-FOR BASAL BOLUS INSULIN THERAPY (LANTUS)-(LEVEMIR) OR SPLIT MIXED DOSAGES If night dose was not given: give 75% of (levemir) or 100% of(lantus), 50% of (NPH) or (lantus) in split- mixed insulin regimen If given: Check RBS/h, if 250 give SC insulin using correction factor

37 A.BASAL BOLUS INSULIN A-FOR BASAL BOLUS INSULIN THERAPY (LANTUS)-(LEVEMIR) OR SPLIT MIXED DOSAGES If night dose was not given: give 75% of (levemir) or 100% of(lantus), 50% of (NPH) or (lantus) in split- mixed insulin regimen If given: Check RBS/h, if 250 give SC insulin using correction factor

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39 In procedures<2hrs continue SC pump at its usual rate with administration of additional SC units if needed In procedures >2hrs keep infusion regimen as follows – maint. Fluid (D10% + 1/2N.S)with Ins. inf.(1unit/ml)  <12kg-1unit/5gm dex.  >12kg-3gm dex. B- INSULIN SC PUMP

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41 C-TYPE II D.M STOP oral hypoglycemics 24 hrs befog procedure Give 50% of NPH or lantus if used Control RBS intraoperative by SC regimen as usual

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46 Allaying anxiety of child/parent

47  Fear pain, threat of needles, parental separation, no experience to place.  “The greater understanding and amount of information available to the parents, the less anxiety and the better attitude reflected in the child”.  “Anesthesia is a type of deep sleep in which you feel no pain from surgery and from which you’ll definitely awaken”.  Smiling, eye contact, holding the child’s hand. Psychological Preparation of Children for Surgery

48  “A blood pressure cuff will check your blood pressure”  “ECG will watch your heart beats”.  “A stethoscope will continuously listen to the heart sounds”.  “A pulse oximeter will measure the oxygen in the your blood”.  “A carbon dioxide analyzer will monitor the breathing”.  Discuss anesthetic risks in clear terms. Psychological Preparation of Children for Surgery

49 Any Questions??


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