029 Reddy PDF

PREOPERATIVE EVALUATION
OF THE PEDIATRIC PATIENT

Aru Reddy, M.B.,B.S
Assistant Professor
Department of
Anesthesiology
University of Kentucky
THE OBJECTIVES
Discuss Preoperative Evaluation of the

Pediatric Surgical Patient
Discuss the Complications of Anesthesia in
children with Upper Respiratory Infections
Discuss the Safety of anesthetic agents in
the pediatric population
Is This Necessary?
Helps streamline the day of surgery

Helps eliminate the preventable causes for
cancellation of surgery
Helps to optimize medical management
Helps familiarize child and parent to the hospital
Reduce the percentage of cancellations and OR
delays
Enhance the utilization of OR time
Preoperative Evaluation
Objectives
Obtaining a medical history

Performing a physical examination
Review of systems
Family history
NPO status
Appropriate laboratory tests
Maternal Health and Children
Maternal
Health
Implications to Children
Diabetes
Mellitus
Neonatal hypoglycemia, macrosomia,

respiratory distress, cardiac anomalies,
vertebral anomalies
Pre eclampsia
IUGR, preterm delivery, high incidence of

meconium at birth
Alcohol Abuse
Mental retardation, congenital heart disease,

cleft palate, skeletal anomalies
An Outline
Birth History:- Full term or pre term baby

Determine post conceptual age
History of previous hospitalizations and
surgical procedures
Concurrent medical illnesses
History of recent upper respiratory
infection
Allergies
Birth History
The Former Preterm Infant
Problems
Pulmonary:- lung immaturity,

bronchopulmonary dysplasia, elevated
pulmonary vascular resistance
Airway:- tracheomalacia, subglottic
stenosis
Multiple medications
Apnea and bradycardia
Postoperative Apnea and

Bradycardia
Factors affecting include: Prematurity
Post conceptual age less than 60 weeks
Anemia
History of Apnea and bradycardia, on
home apnea and bradycardia monitor
Preoperative evaluation
Physical Examination
Here, importance is given to the evaluation
of: Airway
Dentition
Heart murmurs
Neurological status and deficits
Physical Examination
Here, importance is given to the evaluation
of: Airway
Dentition
Heart murmurs
Neurological status and deficits
Miscellaneous workups
Laboratory studies
Radiographs
CT scans/MRI
Cardiac/pulmonary/hematology consults
where necessary
Family History
Aspects of Family History with increased
anesthetic risks include
Unusual reactions to surgery or anesthesia
Malignant Hyperthermia
Sickle cell disease
Thalassemia
Atypical Pseudo cholinesterase
Neuromuscular disorders
NPO Guidelines
Clear liquids
Breast milk
Infant formula
Nonhuman Milk
Solids
2
4
6
6
8
hours
hours
hours
hours
hours
My Child Has A Running Nose

URIs and Anesthesia
Upper Respiratory Infections
URIs affect the apparatus of the upper airways

Frequently occurring URIs include:
The Common Cold
Pharyngitis
Laryngitis
Croup
Epiglottitis
Sinusitis

URIs and Anesthesia
URI
Causative Agents
Common
Rhino, Corona , RSV, Para influenza,
Cold
Influenza , Adenoviruses
Pharyngitis Viral:- cold Virus, Coxsackie, Herpes
simples, E-B virus.
Bacterial:- Streptococcus
Laryngitis Viral:-Influenza, Para influenza, Rhino,
Adeno, RSV
Bacterial:-Streptococcus
Fungal:-Candida Albicans

URIs and Anesthesia
URI
Causative Agents
Croup
Para influenza viruses

type1,2,3;, Influenza and RSV
Epiglottitis
H. Influenza type B
Sinusitis
S.pneumonia, H influenza,
S.aureus, S.pyogenes, fungal
infections
Symptoms and signs of URI

Rhinorrhea, nasal congestion
Cough with or without expectoration
Sneezing
Malaise and decreased activity
Sore Throat
Head ache
Fever
URIs and Anesthesia
One URI can progress to another type

Signs and symptoms are similar
Difficult to distinguish these infections
from one another
Most children develop 6-10 colds a year
Less frequent after age 6
URIs and Anesthesia

Differential diagnosis of URI: Vasomotor rhinitis
Allergic rhinitis
Risk factors for Perioperative

Complications
Copious secretions
ETT in children <3yrs
History of prematurity
Nasal congestion
Parental smoking
History of Reactive airway disease
Surgery involving the airway
Productive Sputum
Tait et al, Anesthesiology, V 95,

No 2, Aug 2000.
URI and Pulmonary Function

Pulmonary Function following URI: Reduced FEV1
Decreased mucociliary clearance
Increased airway reactivity
Increased closing volumes
Compromised diffusion capacity
Increased intrapulmonary shunting and worsening
ventilation perfusion mismatch
Causes for airway hyper-reactivity
Respiratory epithelial cell damage

Activation of the sub epithelial receptors
Release of Mast cells, substance P
Bronchial smooth muscle stimulation
URI:-Perioperative adverse events
Laryngospasm
Airway obstruction
Croup
Hypoxemia
Bronchospasm
Stridor
Breath holding
Laryngospasm and URI
Schreiner, Anesthesiology vol. 85(3), Sept. 96
Laryngospasm is 2 times more common

More likely to be in the younger age group
More likely to be scheduled for airway
surgery
Anesthesia supervised by a less
experienced anesthesiologist
Cardiac surgery and URI

Malviya et al (Anesthesiology 98, March 03)
Intraoperatively: Increased airway complications
Postoperatively an increased incidence of : Respiratory complications
Bacterial infections
Atelectasis
Extended stay in the ICU
My Child has a LITTLE cough

Should surgery be
cancelled?
Figure 1. Suggested algorithm for the assessment and anesthetic management of the child
with an upper respiratory infection.
Tait A R , Malviya S Anesth Analg 2005;100:59-65
2004 by Lippincott Williams & Wilkins
Child with symptoms

of URI
Child with symptoms

of URI
Proceed
Yes
Surgery Urgent
No
Child with symptoms

of URI
Proceed
Yes
Surgery Urgent
No
No
Severe Symptoms
Ye
Cancel
surgery
Child with symptoms

of URI
Proceed
Yes
Surgery Urgent
No
Yes
GA
No
Severe Symptoms
No
Proceed
Ye
Cancel
surgery
Child with symptoms

of URI
Proceed
Surgery Urgent
Yes
No
GA
Yes
Risk Factors?
Other Factors
No
Severe Symptoms
No
Proceed
Ye
Cancel
surgery
Child with symptoms

of URI
Proceed
Surgery Urgent
Yes
No
Severe Symptoms
No
Risk Factors?
Proceed
Other Factors
Good
Proceed with
care
Risk Benefit ?
Poor
Cancel
surgery
No
GA
Yes
Ye
Postpone
Surgery
In Conclusion--Upper respiratory infection and

anesthesia
What seems like a little cough to me may
not mean the same to my colleagues.
And, when this cough is associated with
other signs of infection like fever, sputum
which is greenish-yellow, wheezes,
lethargy, ------ it most definitely is not a
Little Cough.
Is it safe for my baby to have

anesthesia ?
Pain And Its Effects In The Human Neonate And

Fetus
Anand KJ, Hickey PR, N Engl J Med. 1987
Randomised Trial Of Fentanyl Anaesthesia In Preterm Babies

Undergoing Surgery
Anand, Sippell and Aynsley-Green Lancet 1987
Premature neonates for ligation of PDA

Randomized
Nitrous oxide and curare with fentanyl (10 g/kg)

Nitrous oxide and curare
No fentanyl group
Metabolic acidosis
Hyperglycemia
Post operative
Ventilator requirements
Bradycardia
Intraventricular hemorrhages
hypotension
What We Think That We Know

Now
Based on Anands early work, Infants have

a profound physiological response to
surgical trauma
This response has an impact on outcome
Poor outcomes can be reduced by the
judicious use of anesthetics
Bottom line: Infants have pain
Commonly used Anesthetic

Agents
Blockade of NMDA Receptors

and Apoptotic
Neurodegeneration in the
Developing Brain
Chrysanthy Ikonomidou,* Friederike Bosch, Michael Miksa,
Petra Bittigau, Jessica Vckler, Krikor Dikranian,
Tanya I. Tenkova, Vanya Stefovska, Lechoslaw Turski,
John W. Olney
Programmed cell death occurs during normal development
Blockade of NMDA glutamate receptors produce widespread apoptotic
neurodegeneration in developing rat brain

Suggested that glutamate acting at NMDA receptors controls neuronal
survival
Question: Does this have relevance to human
neurodevelopmental disorders?
Early Exposure to Common Anesthetic Agents Causes

Widespread Neurodegeneration in the Developing Rat Brain
and Persistent Learning Deficits
Jevtovic-Todorovic et al, J Neurosci, 2003
Triple cocktail (P7 rat

pups)
Midazolam
Isoflurane
Nitrous oxide
Histological changes
neurodegeneration
Functional changes
Memory impairments
Learning impairments
Human Babies are not Large Rat

Pups!!
Problems with Rodent Experimental Paradigm
Duration of exposure to drugs

7 rat days 27 human months
6 hour 1 month

Pups!!

Lack of precise physiological monitoring
Physiological Monitoring

Pups!!

End-organ perfusion
Varying anesthetic depth
MAC values
Target-controlled infusions

Pups!!

Interspecies variation

Pups!!

Interspecies variation
Dose-response
Drug metabolism
Peak susceptibility
Early exposure to Anesthesia and

Learning Disabilities
Population based birth cohort study

Children born between 01/1976 - 2/1982
Risk factor was exposure to general anesthesia <4yrs of
age (total of 593)
Tested for learning disabilities
Higher incidence of LD
1. in those exposed to 2 or more anesthetics
2. in those receiving anesthesia >120mins.
Initiatives by the Pediatric Anesthesia

Community
Neonatal Drug Development Initiative Workshops

Society for Pediatric Anesthesia
American Society of Anesthesiology
Awareness-educational programs
Registry and complications database
Increased awareness
Funding investigators
Multi-center Randomized Control Trial
GAS Study
Multi-national, multi-center collaborative group
Andrew Davidson, Melbourne, Australia

Mary Ellen McCann, Boston, USA
Neil Morton, Glasgow, Scotland
Randomized controlled equivalence trial
Inguinal hernia in infants
Spinal (bupivacaine) versus general (sevoflurane) anesthesia

Neurodevelopmental assessments at 2 and 5 years
Timeline
2007
2008
2009
Recruit
Yr 2
assessme
nt
Yr 5
assessme
nt
2010
2011
2012
2013
2014

anesthesia?
For now:
Drug induced apoptosis is a valid concern
Much needed area of research
Does it affect just preterms or neonates or are adults
vulnerable too?
Is the plasticity of human brain able to overcome these
insults
Until we have more convincing data on this subject it is
prudent that we continue with our current level of care

anesthesia ?
Remember:
1.Majority have been animal studies
2. Questionable intraop monitoring
3. Limited data in primates

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PREOPERATIVE EVALUATION

OF THE PEDIATRIC PATIENT

Discuss Preoperative Evaluation of the

Helps streamline the day of surgery

Obtaining a medical history

Neonatal hypoglycemia, macrosomia,

IUGR, preterm delivery, high incidence of

Mental retardation, congenital heart disease,

Birth History:- Full term or pre term baby

Pulmonary:- lung immaturity,

Postoperative Apnea and

My Child Has A Running Nose

Upper Respiratory Infections

URIs affect the apparatus of the upper airways

My Child Has A Running Nose

My Child Has A Running Nose

Para influenza viruses

Symptoms and signs of URI

URIs and Anesthesia

One URI can progress to another type

URIs and Anesthesia

Risk factors for Perioperative

Tait et al, Anesthesiology, V 95,

URI and Pulmonary Function

Causes for airway hyper-reactivity

Respiratory epithelial cell damage

URI:-Perioperative adverse events

Laryngospasm and URI

Schreiner, Anesthesiology vol. 85(3), Sept. 96

Laryngospasm is 2 times more common

Cardiac surgery and URI

My Child has a LITTLE cough

Tait A R , Malviya S Anesth Analg 2005;100:59-65

2004 by Lippincott Williams & Wilkins

Child with symptoms

Child with symptoms

Child with symptoms

Child with symptoms

Child with symptoms

Child with symptoms

In Conclusion--Upper respiratory infection and

Is it safe for my baby to have

Pain And Its Effects In The Human Neonate And

Randomised Trial Of Fentanyl Anaesthesia In Preterm Babies

Premature neonates for ligation of PDA

Nitrous oxide and curare with fentanyl (10 g/kg)

What We Think That We Know

Based on Anands early work, Infants have

Commonly used Anesthetic

Blockade of NMDA Receptors

neurodegeneration in developing rat brain

Early Exposure to Common Anesthetic Agents Causes

Jevtovic-Todorovic et al, J Neurosci, 2003

Triple cocktail (P7 rat

Human Babies are not Large Rat

Duration of exposure to drugs

Human Babies are not Large Rat

Duration of exposure to drugs

Human Babies are not Large Rat