Maria Matuszczak MDPediatric AnesthesiaUniversity of Texas, Medical SchoolChildren’s Memorial Hermann HospitalTexas Medical Center Houston

pediatric assessmentPre - Anesthetic

no conflicts of interest or disclosures

Objectives!

Importance of the preoperative evaluationThe pre-anesthesia phone assessmentThe anesthesia clinicSteps of the assessmentCommon preoperative problemsImportance of communication !

Preoperative assessment

Fundamental concept of safeanesthesia care and OR efficiency

Allows for better OR planning by avoiding same day cancellations

Allows practitioner to know the patient:medically, physically, emotionally

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Preoperative assessment (cont.)

Allows parents / children to establishcontact 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

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

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 evaluationNeed to postponeNeed for admission

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.

61 children studies, 21 with URI

Randall Flick et al.

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 respiratoryadverse events in everyday clinical practice

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

Anesthesia clinic visit

Guideline needed for nurse or residents to correctly assess patient

Physical examination includes:Auscultation, Airway assessment,ObesityOSAPsychological assessment

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).

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.

Anesthesia clinic visit ( cont.)

Discuss induction with parents and childPremedication Parents presencePatient anxietyParent has chance to think it over before the day of surgery more questions may ariseRegional anesthesia should be discussed with parents and expectations about pain management

Anesthesia informed consent can be explained and signed

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 predictedperioperative anxiety.

Perioperative anxiety was related to postoperativepain and negative postoperative behavioral change.

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 intubationwhat type of anesthesia is needed,need for blood,,postoperative pain management, day surgery yes or no, need for PICU bed

Frequent problems

Obstructive sleep apnea

Blood transfusion, erythropoietin

Hemophilia

Sickle Cell

Autism

Mitochondrial disorder

Common postoperativeairway complicationsincluded airwayobstruction and respiratory arrestof unclear etiology.

Deaths or neurologic injuryafter tonsillectomy due to apparent apneain 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

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

ASA NPO guidelines

Restriction ofclear fluids for 2 hours, breast milk for 4 hours, formula or cow's milk for 6 hours and solid food for 8 hours beforeinduction 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.

Assessment the day of surgery

The least ideal situation,

Creates a lot of anxiety if problems are discovered last minuteEspecially if no phone assessment has been performedTime 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

Ideal organization of pre anesthesia assessment

Day of visit at surgeons officeDecision made to operatepatient visit anesthesia clinic right then and thereAnesthesia and surgery plan is establishedPatient is followed by anesthesia from the start to the recovery including pain management postoperatively.(perioperative surgical/anesthesia home)

Questions ?

maria.matuszczak@uth.tmc.edu