Essential Components of Preoperative Screening Presented by Danyel Dorn RN, MSN, CPN- Clinical Nurse Educator-Pediatric Service Line

Purpose Comprehensive preoperative screening will provide the information for developing a pediatric individualized plan of care for both the patient and the family.

Competency Statement The perianesthesia registered nurse will be able to perform a comprehensive screening of the pediatric patient.

Preoperative Screening Health History Review of patient’s medical record Including: prenatal history, gestational age, previous surgical procedures, previous anesthesia history – including if MH is in the family history

Preoperative Screening Current medications including dose, route and frequency Allergies and sensitivities Developmental delays, syndromes and learning disorders Chronic respiratory illness requiring treatment (i.e., asthma, reactive airway disease, bronchopulmonary dysplasia, obstructive or central sleep apnea, sleep disordered breathing)

Scenario During a preoperative screening you asked the patient’s mother if she has been sick recently. She states no but her older sibling is sick with the flu. Is this important information to call the anesthesia provider with?

Preoperative Screening Continued Use of inhalers, nebulizer treatments and the last administration Home use of respiratory support – oxygen, ventilator, CPAP, trach Remember if any patient has a trach, emergency back-up supplies should come with the patient. Cardiovascular history Congenital syndromes or diseases Diabetes, obesity, other endocrine disorders

Preoperative Screening Continued Reproductive assessments – if aged appropriate- menarche, LMP and initiate pregnancy testing if appropriate (according to CRMC Policy). Presence of external or implanted medical devices Renal disease

Scenario A 12 year-old scheduled to have surgery shows up at preadmission testing with her parents. According to policy, a HCG was performed and is positive. What do you do?

Preoperative Screening Continued Musculoskeletal disorders affecting movement (muscular dystrophy and cerebral palsy) History of neurological disorders (Seizures, if so ask about the type, frequency, date of most recent seizure activity

Preoperative Screening Continued History of multiple drug resistant organisms Recent exposure to contagious illness Current dermatologic conditions Immunizations Developmentally appropriate pain assessment Psychological or behavioral issues

Scenario You are interviewing the parent of a 9 year old boy and she states that her son is autistic. What are some other questions you can ask the parent that will directly impact his care during the surgical process? What suggestions can you advise for his mom to do to make the procedure day less stressful? What services/resources can you offer him on his day of arrival to the hospital to make it less stressful?

Preoperative Screening Continued Barriers to communication Assess need for interpreter services Psychosocial- Determine the responsible individual Assess legal issues affecting consent for surgery (court orders, custody issues, foster care) Identify family concerns regarding the procedure

Testing/Referrals Determine the need for preanesthesia testing visit Consult anesthesia provider regarding recent illness Instruct responsible individuals to comply with any recommended referrals to subspecialty providers

NPO Guidelines Per American Society of Anesthesiologists • NPO Guidelines per American Society of Anesthesiologists (ASA)4 Ingested Material Minimum Fasting Period Clear liquids 2 hours Breast milk 4 hours Infant formula 6 hours Nonhuman milk 6 hours Light meal 6 hours *May be changed per provider discretion

NPO Continued Making a child NPO does not guarantee complete gastric emptying. The NPO instructions may change, by case, by the Surgeon or Anesthesiologist’s specific practice. ASA has studied various studies that show small amounts of clear liquids 2-3 hours prior to receiving anesthesia are acceptable for normal, healthy children and do not increase the risk of aspiration.

Question What are examples of clear liquids? What is a example of a light meal? Why do we tell parents, no fried or fatty foods pre or post general anesthesia?

Answers Clears are water, sprite, apple juice, clear grape juice, over-the-counter electrolyte drinks and popsicles. Orange juice is not allowed because of the pulp. Light meal = toast, clear liquids, cereal w/milk Fried or fatty foods may prolong gastric emptying time.

At Risk for Aspiration Kids that are morbidly obese, renal failure, hepatic dysfunction, ascites, neurological dysfunction, diabetes mellitus, delayed gastric emptying, and uncoordinated swallowing.

Psychosocial Considerations Withholding food from children is very distressing to family members, especially mothers of young infants. They require extensive education and patience. Often times mothers of young infants require education regarding the risks to their infants if they do not comply with the NPO instructions.

NPO & Medications Prescribed medications should be clarified with anesthesia. Also review the hospital policy regarding gum or mints as it can increase gastric secretions.

CRMC Policy # 23967

Questions

Reference ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting.

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