Perioperative Evaluation and Treatment In Pediatrics

Perioperative Management of the Pediatric Patient Moises Auron MD, FAAP FACP Assistant Professor of Medicine Hospital Medicine

Disclosure Statement
The author has no relevant financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services that are discussed in this educational activity.

Outline
Goals of pre-operative assessment
Anesthesia associated risk
General pre-operative management
Pulmonary issues
Cardiac issues
Brief review of cardiac risk assessment and management in non-cardiac surgery – adult guidelines
Morbid obesity
Neurologic issues and Epilepsy
Musculoskeletal and craniofacial issues
SCD
Perioperative Management of Diabetes
Perioperative VTE Prophylaxis
Psychological preparation for surgery

Goal of preoperative assessment
Detection of unrecognized conditions that increase the risk of surgery.
Optimize the patient’s current medical problems and anticipate potential complications.
Anticipate pulmonary edema post-T/A
OSA
Monitor for atlantoaxial instability (Down’s)

Model of Plane Flight P A T I E N T Surgeon = Pilot Anesthesia = Co-Pilot Michota F. Jaffer A. CCJM. 2006

Anesth Analg 2004;99:1058-69.

What is different in Pediatrics
Age - > 70 y/o – robust indicator for post-operative pulmonary morbidity
Exercise capacity – unclear in infants and toddlers
Climb 1 flight of stairs = 4 mets = low CV risk
Medication use
Risk for venous thromboembolism

General perioperative concerns in Pediatrics.
Congenital heart disease
Hypoxia, arrhythmias, and cardiovascular instability paradoxical air emboli
Prematurity
Postoperative apnea
Gastrointestinal reflux
Aspiration pneumonia
URI
Laryngospasm, bronchospasm, hypoxia, and pneumonia
Craniofacial abnormality
Difficult airway
Childs Nerv Syst (2006) 22:834–843

Patient related risk Procedure related risk Anesthetic-related risk Provider-related risk Perioperative risk Michota F, Frost S; Med Clin N Am 2002.

Role of the surgeon
Surgeons are typically consulted for evaluation and treatment of:
healthy child who is undergoing elective surgery
the chronically ill child who requires surgery
the acutely ill on injured child who requires emergent surgery.
Pediatrics 1996;98;502-508.

Role of the anesthesiologist
Anesthesia may begin outside the OR with the administration of preoperative medication.
Patient follow up until D/C from the PACU
Except if regional analgesia or spinal block are used
Pediatrics 1996;98;502-508.

Anesthesia-associated risk
Risk for adverse events continues to be higher in infants and young children
Overall mortality rate was 0.9/10,000 anesthetics
Incidence of cardiac arrest of 1.7/10,000
Adult (1.4/10,000).
Children < 12 y/o (4.7/10,000) – 3x
Complications of airway management (laryngospasm, difficult intubation, and pulmonary aspiration of gastric contents)
Halothane (hypotension, arrhythmia, or both).
Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43.

Anesthesia-associated risk
Greater risk occurs in infants < 4 wk old.
More likely to be having major surgery (intrathoracic or intraabdominal)
Have more serious underlying disease
Increased percentage are (ASA) physical status 3–5.
Reduction in respiratory-related events compared with previous studies was believed to be because of improved detection of impending respiratory events caused by oximetry and capnography.
Associated with emergency surgery, halothane or sevoflurane, caudal injection of bupivacaine/epinephrine
Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43

ASA Classification
Class 1 A normally healthy patient
Class 2 A patient with mild systemic disease
Class 3 A patient with severe systemic disease that is not incapacitating
Class 4 A patient with an incapacitating systemic disease that is a constant threat to life
Class 5 A moribund patient who is not expected to survive for 24 h with or without operation
Anesthesiology 1963; 24: 111. Pediatric Anesthesia 2007 17: 216–222.

ASA Classification in Pediatrics Pediatric Anesthesia 2007 17: 216–222.

Preoperative Evaluation
HPI
PMH
Croup
OSA
Cervical instability (Down’s)
Medications – NSAID’s
Allergies – Latex (spina bifida)
Pediatrics 1996;98;502-508.

Pre-operative evaluation
Family history
Anesthetic-related complications
malignant hyperthermia
prolonged paralysis after anesthesia (pseudocholinesterase deficiency)
Bleeding disorders
Muscular dystrophy
Drug use (aminoglycosides)
Pediatrics 1996;98;502-508.

Pre-operative evaluation
Last meal intake
Physical examination
Hydration status
Pediatrics 1996;98;502-508.

Ancillary testing
Hb - when significant anemia (<9 g/L) is suspected
(eg, infants, growing premature infants, and patients with chronic illnesses)
to establish a reference point in anticipation to significant blood loss (Orthopedic surgery).
Pregnancy testing
Pediatrics 1996;98;502-508.

Ancillary testing
Coagulation profile
history or medical condition suggests a possible hemostatic defect:
large bruises and hematomas
simultaneous bruising on several parts of the body
Hematochezia
frequent and prolonged epistaxis
Hemarthrosis
unusual bleeding after minor trauma (including dental extraction)
Recent ingestion of aspirin or NSAIDS.
Cardiopulmonary bypass – induction of hemostatic disorder by platelet activation and consumption
Tonsillectomy; airway surgery
Neurosurgical patients (craniotomy)
Minor surgery and a negative history: no tests are suggested.
Pediatrics 1996;98;502-508.

Fasting guidelines
8-6-4-2
8 hours solids
6 hours formula
4 hours breast milk
2 hours clear liquids
Anesthesiology. 1999;90(3):896-905 Acta Anaesthesiol Scand 2005;49:1041-1047. Best Practice & Research Clinical Anaesthesiology. 2006; 20(3):471-81.

Pulmonary issues
URI – defer surgery until symptoms resolve
Increased risk of bronchospasm
Decreased 50% with use of Laryngeal Mask Airway
Asthma – should be optimally controlled
Continue bronchodilators and oral meds in AM of surgery
Delay surgery 6 wk after asthma attack (FEV1 remains low x 6 wk).
Prednisone 1 mg/kg 24-48 h pre-operatively and in the AM of surgery.
Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 Pediatrics 1996;98;502-508.

Pulmonary issues
FEV1/FVC -useful predictors of the need for postoperative mechanical ventilation among patients at risk (eg, cystic fibrosis, severe scoliosis, or kyphoscoliosis).
Adults - increased incidence of need for postoperative mechanical ventilation:
FEV1/FVC < 50%
FEV1 < 35% predicted
Absolute FVC < 25 mL/kg

Pulmonary issues
Cystic fibrosis – continue pulmonary toilet, optimize nutritional status, continue home meds (inhaled and systemic antibiotics, dornase alpha, acetylcysteine, bronchodilators).

Pulmonary issues
Obstructive Sleep apnea
Adenotonsillar hyperthrophy, obesity, Prader Willi, Down’s
Pulmonary HTN and Cor Pulmonale
Greatest risk of post-op upper airway obstruction
Tissue edema
Secretions
Sedation (narcotics)
Pulmonary edema
Best practice: 24 h observation in PICU

Pulmonary issues
Prematurity and apnea
Decreased risk with spinal anesthesia
Preoperative use of caffeine
Admit and monitor with SpO2.

Former Preterm  Risk for Postoperative apnea
Bronchopulmonary dysplasia
Chronic hypoxemia and hypercarbia
Tracheomalacia; bronchomalacia
Pulmonary hypertension; Cor pulmonale
Risk factors:
Anemia (Hct <30%)
Apnea at home
Gestational age (<30 wk)
LBW (< 1.5 kg)
Lower weight at time of surgery
Complicated NICU course
Murphy JJ. J Pediatr Surg. 2008. May;43(5):865-8

Post-operative atelectasis
Impaired surfactant
Increased gas reabsorption
Extrinsic compression
Favored by:
General anesthesia
Recumbent position – decrease FRC 0.5 – 1.0 L
High FiO 2
Surgery close to the diaphragm
Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.

Post-operative atelectasis Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.

Age and atelectasis
Children age 1–3 years  atelectasis develop more readily than in adults.
Increased thoracic rib cage compliance  less outward recoil of the chest wall  less distending force on the lung.
High closing volume (the lung volume at which small airways begin to close)

Physiologic consequences of atelectasis
Decreased compliance
Hypoxemia
Increased pulmonary vascular resistance
Lung injury (repetitive opening and closure of small airways).

Chest 1995; 107:81-84 N = 100 postop cardiac surgery patients

Tonsillectomy: special considerations
Risk for post-operative obstructive apnea
Risk for post-obstructive pulmonary edema
Increased risk of bleeding – use of post-operative NSAIDS is controversial as it is associated with increased re-operation.
Anesth Analg 2003;96:68 –77.

Child with cardiac murmur
Innocent murmur
Pathologic murmur
New Endocarditis prophylaxis guidelines
Cardiology evaluation and f/u for a child with complex congenital heart disease.
Pediatrics 1996;98;502-508. Current Opinion in Anaesthesiology 2007, 20:216–220

Hypoplastic Left Heart Syndrome and Non-cardiac surgery J Pediatr Surg. 2002;37:1399-1403.

Prophylaxis against bacterial endocarditis
CLASS IIa
Prophylaxis against infective endocarditis is reasonable for the following patients at highest risk for adverse outcomes from infective endocarditis who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa:
Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair. (Level of Evidence: B)
Patients with previous infective endocarditis. (Level of Evidence: B)
Patients with CHD. (Level of Evidence: B)
Circulation. 2008;118:887-896.

Prophylaxis against bacterial endocarditis
CLASS IIa
Unrepaired cyanotic CHD, including palliative shunts and conduits. (Level of Evidence: B)
Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure. (Level of Evidence: B)
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or
prosthetic device (both of which inhibit endothelialization). (Level of Evidence: B)
Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve. (Level of Evidence: C)
Circulation. 2008;118:887-896.

CLASS III
Prophylaxis against infective endocarditis is not recommended for nondental procedures:
transesophageal echocardiogram, EGD, or colonoscopy) in the absence of active infection. (Level of Evidence: B)
Prophylaxis against bacterial endocarditis Circulation. 2008;118:887-896.

Antibiotic dose for BE prophylaxis
SINGLE DOSE 30-60 MIN BEFORE
Amoxicillin p.o. 50 mg/kg
Ampicillin 50 mg/kg IM/IV or Cefazolin or ceftriaxone 50 mg/kg IM/IV
Allergic to penicillins:
Cephalexin p.o. 50 mg/kg
Clindamycin 20 mg/kg
Azithromycin or clarithromycin 15 mg/kg
Cefazolin or ceftriaxone - 50 mg/kg IM/IV
Clindamycin 20 mg/kg IM or IV
Circulation. 2008;118:887-896.

Morbid Obese patient
Overweight: BMI > 85%le
Obesity: BMI of more than 95%le
Superobesity: BMI > 99 %le
Adolescent/Adult: BMI > 40 kg/m 2
Current Opinion in Anaesthesiology 2008;21:308–312.

Morbid obesity: medical etiology
Prader–Willi syndrome
Laurence–Moon–Biedl syndrome
Hypercaloric diet (glycogen storage diseases)
Steroid induced (Hem-Onc, nephrotic syndrome)
Poor mobility (late stage Duchenne’s)

Prader Willi Syndrome Pediatric Anesthesia 2006 16: 712–722

Morbid obesity: perioperative considerations
Hypertension and LVH
Obstructive sleep apnea / hypoventilation
Diabetes / insulin resistance
GERD
NAFLD / NASH

Slipped capital femoral epiphysis
Blount’s disease
Cholelithiasis
Polycystic ovary syndrome
Idiopathic intracranial hypertension (pseudotumour cerebri)
Morbid obesity: Pediatric perioperative considerations Current Opinion in Anaesthesiology 2008;21:308–312.

Morbid obesity: Pre-operative examination in children
History:
symptoms of sleep apnea
tolerance to exercise: breathlessness, asthma;
recent weight loss or gain
medications, including OTC herbs or special mixtures taken to lose weight which can interfere with anaesthesia or haemostasis.
e.g. garlic, ginger, etc.
Document BMI in percentile chart.
Pulse-oximetry (SpO 2 ) on room air / Nocturnal SpO 2
Fasting blood glucose
Echocardiography (Hypertensive patient)
Preoperative fasting – similar rules as the nonobese population.
GERD: usual anti-reflux therapy should be administered.

Elective surgery in morbid obesity: 2009 AHA guidelines Circulation . 2009;120:86-95.

Neural tube defects
Assessment for coexistent congenital anomalies
90% require CSF diversion
Subsequent surgeries:
Infection
Malfunction
Outgrowing the shunt hardware
Associated urogenital and musculoskeletal dysfunction
UTI/VUR/hydronephrosis  renal function evaluation
Scoliosis  respiratory function evaluation
Lower-extremity abnormalities
Latex allergy
Pediatrics 1996;98;502-508.

Neuromuscular disorders
Inhalational agents: cerebral vasodilation  increase ICP
Ensure patency and proper functioning of CSF shunt
Immediate postop period  Impaired airway reflexes
Document pre-operatively any evidence of brainstem dysfunction (eg, vocal cord paralysis, swallowing dysfunction, or aspiration)
Increased risk for postoperative weakness  postoperative respiratory care and prolonged mechanical ventilation / PP.
Succinylcholine  Hyperkalemia; malignant hyperthermia

Epilepsy
Record type and frequency of seizures
Continue antiepileptic medications on the AM of surgery
Uncontrolled seizures  Neurology evaluation.
Check serum levels of anticonvulsant
Most anticonvulsants have long half-lives, and the omission of one dose does not decrease the blood level significantly.
No need to determine anticonvulsant levels if:
seizure-free for 2 years
no adjustment of their anticonvulsant dose
Pediatrics 1996;98;502-508. Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43

Epilepsy: perioperative considerations
Tuberous sclerosis
cardiac rhabodomyomas: obstruction, dysrhythmias
Renal lesions  HTN, CKD
Traditional antiepileptics: P-450 inducers
Topiramate  NAG metabolic acidosis
Sodium valproate  platelet abnormalities, bleeding
Sodium valproate and Felbamate  liver failure
Ketogenic diet  avoid lactated Ringers solution
Sevoflurane  Epileptogenic potential
Childs Nerv Syst. 2006;22:834–843. J Anesth. 2006;20:135–137. Paediatric Anaesthesia 2002;12:700–704.

Phakomatoses: extra-CNS findings
Linear nevus sebaceous of Jadassohn
Aortic coarctation, PDA, VSD
Neurofibromatosis
Pheochromocytoma – 5%
Kyphoscoliosis (type 1)
Sturge Weber
Aortic coarctation
Von Hippel Lindau
Pheocromocytoma – 10%
RCC – 25%
Paediatric Anaesthesia 2000;10:121–128

Cervical spine instability
Mucopolysaccharidoses (Hurler’s and Monquio’s syndromes): odontoid hypoplasia
Rheumatoid arthritis : atlantoaxial instability, subaxial instability, and superior migration of the odontoid process.
Down syndrome : 15% asymptomatic atlantoaxial instability
Document pre-operative screening flexion-extension Cervical spine Roentgenograms
Consider fiberoptic intubation.
Pediatrics 1996;98;502-508.

Craniosynostosis
Multidisciplinary evaluation by a craniofacial team
Monitor for signs of increased intracranial pressure
Nonsyndromic craniosynostosis are usually otherwise healthy.
Syndromic craniosynostosis can have associated anomalies:
Crouzon’s or Apert’s syndrome can have very abnormal airway anatomy  fiberoptic intubation.
Identifying a history of OSA
Apert’s syndrome  congenital cardiac defects.
Am J Med Gen. 2005; 45(6):758 - 760. Anesthesiology Clin. 2007;25:465–481

Sickle cell patients
Heterozygous sickle cell trait  generally asymptomatic
Active sickling conditions (SS, SC, S-  thalassemia)
reduce risk of complications by preoperative transfusions to reduce the total HbS level < 40%.
Coordination among the pediatrician, hematologist, anesthesiologist, and surgeon is essential.
Fu T. Pediatr Blood Cancer 2005;45:43–47. Marchant WA. Paediatric Anaesthesia 2003;13:473–489

Systemic manifestations of SCD Fu T. Pediatr Blood Cancer 2005;45:43–47. Marchant WA. Paediatric Anaesthesia 2003;13:473–489

Perioperative management of SCD
Avoid dehydration – impaired renal concentrating ability.
Deoxygenation – incentive spirometry; SpO2 monitoring
Vascular stasis – maintaining a normal C.O., a normal blood volume, and BP.
Hypothermia – keeping the patient warm
Acidosis – good hydration, warm
Infection – prophylactic antibiotics
Adequate analgesia, to enable effective physiotherapy and early ambulation must be emphasized.

Regional anesthesia and SCD
Redistribution of blood flow may lead to an increase in capillary and venous oxygen tension in the blocked region
Compensatory vasoconstriction in nonblocked areas leads to a fall in the SvO2.
Lack of control of ventilation, regional hypoperfusion and venous stasis.
Cooperative Study of Sickle Cell Disease (N=3765)
10 y.
1079 surgeries (N= 717)
Post-op SCD-related complications (painful crisis, ACS, and CVA) were more frequent in patients who received regional anaesthesia (P=0.058).
Koshy M, et al. Blood 1995; 86: 3676–3684. Marchant WA. Paediatric Anaesthesia 2003;13:473–489

Transfusion in SCD with General Anesthesia Conclusions. “ Minor or low-risk elective surgical procedures in children with Hb SS may not routinely require pre-operative transfusion” Fu T. Pediatr Blood Cancer 2005;45:43–47

Adenotonsillectomy and SCD
Postop. pain, hypoventilation, atelectasis, hypoxia.
Aggressive pulmonary toilet, NIPPV, bronchodilators and incentive spirometry
HbS < 40%.
Preoperative Transfusion in Sickle Cell Disease Study Group (N=118)  no advantage in aggressive transfusion regimen vs. conservative regime.
Marchant WA. Paediatric Anaesthesia 2003;13:473–489 Waldron P. J Ped Hematol Onc 1999; 21:129–135.

Cholecystectomy and SCD
Laparoscopic approach is preferred
Avoid emergency surgery
high morbidity
Conservative pre-operative transfusion
National Preoperative Transfusion Study (N=364)
Aggressive: preop Hb 10 g/dL and HbS < 30%
Conservative: Hb 10 g/dL independent of HbS.
No difference between groups.
Marchant WA. Paediatric Anaesthesia. 2003;13:473–489. Haberkern CM. Blood. 1997;89(5):1533-1542.

Orthopedic Surgery and SCD
Aseptic necrosis of the hip occurs in up to 50% of patients.
Conservative preoperative transfusion – Hb (9-11 g/dL).
Careful use of tourniquet - stasis, hypoxia and acidosis beneath and distal to the tourniquet cuff  favors red cell sickling.
Marchant WA. Paediatric Anaesthesia. 2003;13:473–489

Neurosurgery and SCD
Keep Hct > 30 and HbS < 30%
Minimize risk of stroke
Careful use of hypertonic agents
Urea – preferred
Old contrast media
Careful use of Epsilon-Aminocaproic Acid
Generally used in spinal surgery
Can predispose to vaso-occlusive crises
Avoid hypothermia

Cardiac Surgery and SCD
Open-heart surgery with hypothermic cardiopulmonary bypass precipitate sickling.
Preoperative correction of anemia
Pre-operative exchange transfusion
Increase in 2,3-DPG  increase DO 2
Avoidance of hypoxia and acidosis
Avoidance of aortic cross-clamping, hypothermia, cardioplegia and topical cooling

Patients on chronic steroids
Perioperative stress dose of steroids
Prednisone p.o. 2.5–5 mg/m2 BSA the night before
Hydrocortisone 50 mg/m2 before anesthetic induction

Diabetes mellitus
Acceptable metabolic control:
No ketonuria
Normal serum electrolytes
HbA1c within target range for age:
< 5 years: 7 – 9%
5 – 13 years: 6 – 8.5%
> 13 years: 6 – 8%
Rhodes ET. Anesth Analg 2005;101:986 –99

Insulin half life Rhodes ET. Anesth Analg 2005;101:986 –99

Insulin correction factor Rhodes ET. Anesth Analg 2005;101:986 –99

Mixed insulin regime (NPH/Lente) + No Rhodes ET. Anesth Analg 2005;101:986 –99

Lantus insulin regime No Yes No Rhodes ET. Anesth Analg 2005;101:986 –99

Insulin pump – for surgery < 2h No Rhodes ET. Anesth Analg 2005;101:986 –99

Insulin pump  Surgery > 2h No Rhodes ET. Anesth Analg 2005;101:986 –99

Oral hypoglycemic agents
Hold on the morning of surgery
No Rhodes ET. Anesth Analg 2005;101:986 –99

Post-operative DM management No Yes Rhodes ET. Anesth Analg 2005;101:986 –99

Pediatric Anesthesia 2008 18: 478–487

Perioperative VTE prophylaxis Pediatric Anesthesia 2008 18: 478–487

VTE risk of Surgery Pediatric Anesthesia 2008 18: 478–487

VTE Risk in the ICU Pediatric Anesthesia 2008 18: 478–487

Child 1–2 months – 750 ug/kg s.q. bid.
Child 2 months–18 years – 500 ug/kg s.q. bid.
Maximum dose 20 mg s.q. bid.
Adolescents of >40 kg weight
Adult dosing of 40 mg qday
Pediatric Anesthesia 2008;18: 478–487

Psychological preparation of the children for surgery
50-75% of patients develop significant anxiety
Anesthesiology Clin N Am. 2005;23: 597- 614

Thank you!

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Perioperative Evaluation and Treatment In Pediatrics

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Perioperative Evaluation and Treatment In Pediatrics — Presentation Transcript