1. Pre - Anesthetic pediatric assessment Maria Matuszczak MD
Pediatric Anesthesia
University of Texas, Medical School
Children’s Memorial Hermann Hospital
Texas Medical Center Houston

2. no conflicts of interest or disclosures

3. ! Objectives! Importance of the preoperative evaluation
The pre-anesthesia phone assessment
The anesthesia clinic
Steps of the assessment
Common preoperative problems
Importance of communication

4. . Preoperative assessment Fundamental concept of safe
anesthesia care and OR efficiency
Allows for better OR planning by avoiding
same day cancellations
Allows practitioner to know the patient:
medically, physically, emotionally .

5. Preoperative assessment (cont.)
Allows parents / children to establish
contact with the anesthesia team
Allows to discuss anesthesia plan, regional
anesthesia, pain management,
Allows to explain special technics need to management the airway, special protocols for metabolic diseases.
Allows to define and optimize pre-existing conditions if necessary

7. Pre anesthesia phone assessment
Ideally visit in anesthesia clinic
But volume would be too
important for most services
So all patients can first be
assessed via phone
ASA 1 and 2 can be cleared
via phone call
The use of pre-hospital video tours and pamphlets are very helpful

8. Pre anesthesia phone assessment (cont.)
Institutional commitment is important.
Trained nurses guided by a pediatric anesthesiologist
Allows to decide:
Need to come to clinic
Need for further evaluation
Need to postpone
Need for admission
Need for further evaluation by other specialists ( neurologist, cardiologist, hematologist)

9. 61 children studies, 21 with URI
The records of 130 children identified as having experienced laryngospasm under general anesthesia were examined.
In our pediatric population, the risk of laryngospasm was increased in children with upper respiratory tract infection or an airway anomaly.
Randall Flick et al.

10. adverse events in everyday clinical practice
This study provides evidence that the high risk for perioperative respiratory adverse events is limited to
the first 2 weeks after an upper respiratory tract infection, and thus rescheduling a patient 2 to 3 weeks after upper respiratory tract infection would be a safe approach.
The incidence of upper respiratory tract infection in children presenting for anesthesia is high, and the prevalence of asthma is increasing in the pediatric population.
Thus, anesthetists have to manage increasing numbers of children at high risk of perioperative respiratory
adverse events in everyday clinical practice
Children at high risk for perioperative respiratory adverse events might benefit from anesthesia management, including a specialist pediatric anesthetist, intravenous induction and maintenance with propofol, and avoidance of tracheal tube for airway management when possible
The investigators analyzed 9297 such questionnaires. Risk factors associated with an increased risk for anesthesia-related complications were bronchospasm (relative risk [RR] 8.46; 95% confidence interval [CI], 6.18  ; P < .0001), laryngospasm (RR, 4.13; 95% CI, 3.37 - 5.08; P < .0001), and perioperative cough, desaturation, or airway obstruction (RR, 3.05; 95% CI, 2.76 - 3.37; P < .0001).
Of note, the study confirmed previous findings suggesting that current or recent upper respiratory tract infection increased the risk for perioperative respiratory adverse events. If symptoms were present at the time of surgery, RR was 2.05 (95% CI, 1.82 - 2.31; P < .0001); if symptoms were present less than 2 weeks before the procedure, RR was 2.34 (95% CI, 2.07 - 2.66; P < .0001).
a third of all perioperative cardiac arrests and more than three quarters of all critical incidents in pediatric anesthesia are caused by respiratory adverse events. In this study, we aimed to identify associations between the child's history, family history, anesthesia management, and occurrence of respiratory adverse events. This allowed us to pinpoint specific risk factors for respiratory complications, as well as some indications for prevention strategies regarding anesthesia management.
Children who have been identified to be at a particularly high risk for respiratory complications can benefit from a preoperative optimization of lung function by the primary care physician, if indicated and time allows, and targeted anesthesia management, which should include a specialist pediatric anesthetist, intravenous induction of anesthesia, maintenance of anesthesia with propofol, and avoidance of invasive airway management, if possible

11. The best evidence based data is found in Cote’s48 combined analysis of 255 preterm infants
undergoing inguinal herniorrhaphy under general anesthesia. Apnea was defined as >15 seconds without
bradycardia or <15 seconds when accompanied by bradycardia. Apnea was strongly and inversely related to both
gestational age and post conceptual age, continuing apnea at home and anemia (<10 gm/dl). In the nonanemic child
with a gestational age of 32 weeks and a post conceptual age of 56 weeks the probability of apnea was less than 1%.
With a gestational age of 35 weeks and a post conceptual age of 54 weeks the probability of apnea was less than 1%
also.
Caffeine has been shown to decrease the risk of apnea in preterm infants undergoing general anesthesia. In
32 preterm infants (37-44 weeks post-conceptual age) who received caffeine 10 mg/kg or placebo – the caffeine
group had no postoperative bradycardia, prolonged apnea, periodic breathing or postoperative oxygen saturation
<90% while 81% of the patients in the control group had prolonged apnea at 4-6 hours postoperatively.49 A
systematic review supported the evidence that caffeine reduces apnea risk.50

12. Pre anesthesia phone assessment (cont.)
If electronic anesthesia record is available
demographic patient data can be
completed early on:
Body weight, gender,
age ( post-conceptional age for premies)
Procedure, day of surgery, surgeons name

13. Anesthesia clinic visit
Guideline needed for nurse or residents to correctly assess patient
Physical examination includes:
Auscultation,
Airway assessment,
Obesity
OSA
Psychological assessment

14. Anesthesia clinic visit ( cont.)
History:
any type of syndrome, malformation, disease should , previous exams evaluating the syndrome / disease should be available. Current medication:
all medication currently taken should be noted, are symptoms treated with medication (seizures, asthma, reflux), for diabetic children daily profile of blood sugar
Allergies:
medication, type of allergic reaction, or was it a side effect , (diarrhea after antibiotics; pruritus or nausea after morphine). food allergy (egg allergy not a problem for propofol).

15. Anesthesia clinic visit ( cont.) Birth history:
born at term or premature, post-conceptional week at birth, did child need ventilator support, for how long; was child O2 dependent, for how long? If child is less than 6 month old calculate post-conceptional age at time of surgery.
Previous anesthetics:
was it general anesthesia, was the child intubated, were there any complications?
Anesthetic problems in the family:
only significant problems should be noted,
malignant hyperthermia, pseudocholinesterase deficiency,
hepatic porphyrias, muscular dystrophy disorders.
For DSU cases every child born before the 36th week of pregnancy must be 55 weeks PCA or older at the time of procedure, if younger than 55 weeks PCA child needs to be admitted over night because of increased risk of post anesthesia apnea spells.

16. Anesthesia clinic visit ( cont.)
Discuss induction with parents and child
Premedication
Parents presence
Patient anxiety
Parent has chance to think it over before the day of surgery
more questions may arise
Regional anesthesia should be discussed with parents and expectations about pain management
Anesthesia informed consent can be explained and signed

17. Examine children’s anxiety across the perioperative setting.
261 children ages 2–12. Anxiety was rated prior to surgery, immediately after surgery, and for 2 weeks post-surgery at home
Low child sociability and high parent anxiety predicted
perioperative anxiety.
Perioperative anxiety was related to postoperative
pain and negative postoperative behavioral change.

18. Anesthesia clinic visit ( cont.)
These data can then be discussed with the
anesthesiologist who can complete
the chart by adding details about the procedure, positioning, ETT or LMA, difficult intubation
what type of anesthesia is needed,
need for blood,,
postoperative pain management,
day surgery yes or no,
need for PICU bed

19. Obstructive sleep apnea Blood transfusion, erythropoietin Hemophilia
Frequent problems
Obstructive sleep apnea
Blood transfusion, erythropoietin
Hemophilia
Sickle Cell
Autism
Mitochondrial disorder
However, in children
with severe obstructive sleep apnea (AHI >16.4 events/hr, SaO2 <85%) obstructive events occurred more frequently
on the first night after adenotonsillectomy suggesting overnight monitoring with pulse oximetry is indicated
OSAS patients with preoperative nocturnal oximetry oxygen saturation of 80% or less had an increase from
20% of postoperative respiratory complications to 50%

20. obstruction and respiratory arrest of unclear etiology.
Common postoperative
airway complications
included airway
obstruction and respiratory arrest
of unclear etiology.
Deaths or neurologic injury
after tonsillectomy due to apparent apnea
in children suggest that at least 16 children could have been rescued had respiratory monitoring been continued throughout
first- and second-stage recovery, as well as on the ward during the first postoperative night
A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, postanesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA.
Outcome, risk, and error and the child with obstructive sleep apnea
ambulatory T&As were performed in children (under 15 years) in American ambulatory programs including hospitals and freestanding ambulatory surgery centers (2005)
An estimate of mortality following T&A is 0.6 per (12). Although lethal hemorrhage following T&A occurs, less than one-third of tonsillectomy mortality is attributed to bleeding
The Medical Liability Mutual Insurance Company in New York State reported 36 court trials for malpractice claims of death/major brain injury following T&A, between 1985 and 2007
postoperative airway events accounted for the majority (60%) of death/major brain injury in children.

21. A total of 111 cases were included in the final analysis
A total of 111 cases were included in the final analysis. Death and permanent neurologic injury occurred in 86 (77%) cases and were reported in the operating room, post-anesthesia care unit, on the ward, and at home. Sixty-three (57%) children fulfilled American Society of Anesthesiologists criteria to be at risk for OSA.
Stop bang questionnaire

22. Phone call the day before Communication and coordination:
between the perioperative team is crucial
with parents about NPO times,
when to come, what waiting time to expect
Last change to catch infection or other problem
nothing is more disappointing for parents
if they are told they are first case and then have to wait for many hours
Sixty-four percent of institutions allowed clear liquids up to 2 hours prior to
general anesthesia in children younger than 6 months and 48% allowed the same in children 6 months and older.
There was less agreement on breast milk. Most institutions (77%) consider at least a 4 hour fast for breast
milk to be sufficient but 23% allowed it to be ingested less than 4 hours prior to induction.
For formula, institutions were equally divided between 4 or 6 hour fast for formula (39% each) in
children less than 6 months. But in children greater than 6 months of age, a 6 hour fast for formula was considered
appropriate in 50% of institutions.
For solid food, respondents were divided between a 6 hour fast and fasting after midnight in the 6-36 month
old population. But greater than 36 months half of all institutions restricted solid foods after midnight

23. formula or cow's milk for 6 hours and solid food for 8 hours before
ASA NPO guidelines
Restriction of
clear fluids for 2 hours,
breast milk for 4 hours,
formula or cow's milk for 6 hours and
solid food for 8 hours before
induction of anesthesia in elective healthy patients.
The safety of the generic light meal in children the morning of surgery (followed by 6 hours of fasting) as endorsed by the ASA task force for adults has not been formally evaluated in children.
nothing is more disappointing for parents
if they are told they are first case and then have to wait for many hours
Sixty-four percent of institutions allowed clear liquids up to 2 hours prior to
general anesthesia in children younger than 6 months and 48% allowed the same in children 6 months and older.
There was less agreement on breast milk. Most institutions (77%) consider at least a 4 hour fast for breast
milk to be sufficient but 23% allowed it to be ingested less than 4 hours prior to induction.
For formula, institutions were equally divided between 4 or 6 hour fast for formula (39% each) in
children less than 6 months. But in children greater than 6 months of age, a 6 hour fast for formula was considered
appropriate in 50% of institutions.
For solid food, respondents were divided between a 6 hour fast and fasting after midnight in the 6-36 month
old population. But greater than 36 months half of all institutions restricted solid foods after midnight
Shorter fasting times decrease patient irritability, increase patient satisfaction and decrease the risk of
severe hypotension during anesthetic induction secondary to hypovolemia and also the possibility of hypoglycemia.

24. Assessment the day of surgery The least ideal situation,
Creates a lot of anxiety if problems are discovered last minute
Especially if no phone assessment has been performed
Time is limited for evaluation,
Frequently creates delays in the OR
Leads to Unsafe compromises
Cancellation is an efficiency disaster for the OR,
Frustrating for parents and for the perioperative team
tell story about my case.

25. Ideal organization of pre anesthesia assessment
Day of visit at surgeons office
Decision made to operate
patient visit anesthesia clinic right then and there
Anesthesia and surgery plan is established
Patient is followed by anesthesia from the start to the recovery
including pain management postoperatively.
(perioperative surgical/anesthesia home)
tell story about my case.

26. Questions ?