Perioperative Evaluation and Treatment In Pediatrics

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Presentation on the preoperative assessment and perioperative management of the pediatric patient with emphasis on the medically complex children.

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  • Good day. It’s my pleasure meeting you, and that you enjoying your day? Can you allowed me to introduce my self to you. My name is Kine Gaye . I will like to get acquainted with you. please I'll be glad if you write to me or send your email address direct at my private email address (kinegaye00@hotmail.com) because i have some important thing i will like to discuss with you privately. Hope to hear from you soon. Kine.
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  • Excellent presentation. I found it tough to find good info on VTE prophyaxis. This is great. Thanks.
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  • good and informative slides
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  • PCP play a leading role in the medical evaluation and psychological preparation of children before surgery or other procedures requiring anesthesia. Ensure that the child’s medical issues are clearly defined and that the physiologic impact and limitations imposed by each condition are well delineated. The primary care provider’s knowledge of the patient’s PMH and an appropriate physical and/or laboratory evaluation provide valuable information to both the anesthesiologist and the surgeon in making the determination as to whether the procedure should take place.
  • A thorough preoperative organ system-based evaluation of the pediatric patient is essential to minimize perioperative morbidity. Infants are at higher risk for perioperative morbidity and mortality than any other age group [11, 39, 40]. Respiratory and cardiac related events account for a majority of these complications. A complete airway examination is essential because some craniofacial anomalies may require specialized techniques to secure the airway [41]. Congenital heart disease may not be apparent immediately after birth and a pediatric cardiologist should evaluate patients with suspected problems to help optimize cardiac function prior to surgery. Furthermore, the massive blood loss, swings in blood pressure and aggressive fluid, and blood administration may lead to derangements in myocardial contractility and acute myocardial failure.
  • The preoperative consultative evaluation by the surgeon will include a history of the current surgical problem, H/P, and, if indicated, scheduling of preoperative laboratory and/or diagnostic studies. The surgeon will explain the surgical procedure to the parent and child and will include discussion of potential complications, postoperative cane, anticipated outcome, and follow-up. The family should also be informed that surgery will likely be cancelled if a concurrent illness develops that would compromise the procedure, anesthesia, on postoperative recovery. The need for blood transfusion, as well as options for donation, should be discussed. The surgeon should communicate with the primary provider regarding the consultation. Adequate planning between PCP, surgeon, anesthesiologist, and medical specialists is essential.
  • The goal of preoperative assessment and preparation is to identify factors that may increase the risk for adverse perioperative events to appropriately inform parents (and the rest of the surgical t am) of potential risks and to allow for management strategies that will minimize known risks.
  • The ASA PS has become widely used to describe preoperative physical status. It is also used as a predictor of perioperative risk despite the fact that it was never designed for this purpose
  • Initially, glucose-loaded fluids empty a little slower, but after 90 min this difference is negligible In contrast, the gastric emptying curve for solids is linear (20, 21) (Fig. 2). Gastric emptying of solid food starts approximately 1 h after a meal. Within 2 h, approximately 50% of the solid food ingested is passed to the duodenum. The gastric emptying of solids is independent of the amount of food ingested but dependent on the caloric density of the meal. Gastric emptying is slower in females than in males and slower in the elderly.
  • The current definition of BPD is: oxygen dependence at 36 weeks post-conceptual age (with a total duration of oxygen therapy of less than 28 days) in infants born at birthweights between 500 and 1500 g. It is essential that the pulmonary status of these children be optimized before surgery and anesthesia. Bronchodilators, antibiotics, diuretics, and corticosteroid therapy may all be of benefit. Respiratory infections or bronchospasm in children who have BPD must be managed intensively before elective surgery. Monitor electrolytes given use of diuretics in BPD patients. Apnea occurred in 49% of premature infants undergoing anesthesia for inguinal hernia repair. Recent study by BC Children’s (Vancouver) – 5% (change in anesthetics and increased monitoring).
  • Generally, the child who has a murmur— but who has a normal S1 and S2, normal exercise tolerance, is acyanotic, and is growing well—tolerates a general anesthetic without complication. Appropriate preoperative evaluation reasonably includes a thorough physical examination and an ECG. If there is any question of a significant structural cardiac abnormality, preoperative echocardiography and evaluation by a pediatric cardiologist are mandatory. The presence of an abnormal murmur, cyanosis, decreased exercise tolerance, poor weight gain, sweating, decreased femoral pulses, or a precordial heave necessitates a more complete preoperative evaluation (hematocrit, ECG, chest radiograph, oxygen saturation, and cardiology consultation). If a child who has known congenital heart disease presents for preoperative evaluation, the anesthesiologist should become familiar with the precise details of any previous surgery, current intracardiac anatomy, cardiac conduction defects, and myocardial function, cardiac medications being taken, and the relative stability or lability of the patient’s clinical condition
  • Methods: A retrospective review of hospital discharge data for 2,457 children less than 2 years of age with HLHS for 1988 through 1997 was performed. The authors examined the outcomes of HLHS children undergoing only noncardiac surgical procedures during their hospital stay. Differences in hospital mortality rates between 1988 through 1992 versus 1993 through 1997 were assessed using the X2 square statistic. Results: Nineteen percent of the 147 children with HLHS undergoing noncardiac, surgical procedures died (95% CI,13% to 25%). Comparing the 2 study periods, there was no significant change in outcome among HLHS children undergoing noncardiac, surgical procedures (78% v. 83%; P > .1). There was no significant difference in the percentage of hospital discharges with noncardiac, surgical procedures performed per year. Conclusions: Although children with HLHS were not undergoing an increase in the number of noncardiac surgical procedures performed annually, even minor surgical procedures were associated with considerable mortality. Outcomes after noncardiac surgery in high-risk children with congenital heart disease warrant further investigation.
  • Not class I anymore Not considering HOCM or MVP
  • Will just show a brief review of how do we perform the perioperative CV evaluation in the adult patient – to introduce concepts as “metabolic equivalents”, etc. Functional capacity can be expressed as metabolic equivalents (METs); the resting or basal oxygen consumption (VO2) of a 70-kg, 40-year-old man in a resting state is 3.5 mL per kg per min, or 1 MET. For this purpose, functional capacity has been classified as excellent (greater than 10 METs), good (7 to 10 METs), moderate (4 to 6 METs), poor (less than 4 METs), or unknown.
  • Should obtain an EKG and echo in all children with TS Topiramate  inhibits carbonic anhidrase
  • Monitor for signs of increased intracranial pressure, such as visual difficulties, nausea and vomiting, somnolence, or headaches. These findings are unusual in infants presenting with craniosynostosis, but may be seen in older children or in cases with fusion of multiple sutures [3].
  • General anesthesia may be safer
  • ‘ Congenital heart disease’ implies patients who have previously undergone heart surgery but are now considered to be corrected. Children who have ongoing cardiac disease, such as prosthetic valves or cardiomyopathy are a separate population and will usually be having their elective surgery at specialist centers. ‘ Preexisting thrombophilic conditions’ are the following: Antiphospholipid antibodies, Antithrombin deficiency, Factor II (G20210A) (=prothrombin), Factor V Leiden, Hyperhomocysteinemia, Increased factor VIII (>1500 IUÆL)1 unrelated to acute phase reaction), Increased lipoprotein, Protein C deficiency, Protein S deficiency, Sickle cell anemia Polycythemia, ‘ Certain metabolic diseases’ include carbohydrate deficient glycoprotein, syndrome (CDG), ‘ Certain malformations’ includes anal atresia, porencephaly, and the Kasabach–Merritt association (Kaposi hemangioendothelioma and thrombocytopenia) Preexisting medical problems are: ‘ Inflammatory diseases’ are Kawasaki’s disease, Ulcerative colitis, Crohn’s disease, Nephrotic syndrome, etc. ‘Connective tissue diseases’ are SLE, RA etc. ‘Previous thrombosis at any site’ includes previous DVT, portal vein thrombosis, Purpura fulminans
  • Perioperative Evaluation and Treatment In Pediatrics

    1. 1. Perioperative Management of the Pediatric Patient Moises Auron MD, FAAP FACP Assistant Professor of Medicine Hospital Medicine
    2. 2. Disclosure Statement <ul><li>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. </li></ul>
    3. 3. Outline <ul><li>Goals of pre-operative assessment </li></ul><ul><li>Anesthesia associated risk </li></ul><ul><li>General pre-operative management </li></ul><ul><li>Pulmonary issues </li></ul><ul><li>Cardiac issues </li></ul><ul><li>Brief review of cardiac risk assessment and management in non-cardiac surgery – adult guidelines </li></ul><ul><li>Morbid obesity </li></ul><ul><li>Neurologic issues and Epilepsy </li></ul><ul><li>Musculoskeletal and craniofacial issues </li></ul><ul><li>SCD </li></ul><ul><li>Perioperative Management of Diabetes </li></ul><ul><li>Perioperative VTE Prophylaxis </li></ul><ul><li>Psychological preparation for surgery </li></ul>
    4. 4. Goal of preoperative assessment <ul><li>Detection of unrecognized conditions that increase the risk of surgery. </li></ul><ul><li>Optimize the patient’s current medical problems and anticipate potential complications. </li></ul><ul><ul><li>Anticipate pulmonary edema post-T/A </li></ul></ul><ul><ul><li>OSA </li></ul></ul><ul><ul><li>Monitor for atlantoaxial instability (Down’s) </li></ul></ul>
    5. 5. Model of Plane Flight P A T I E N T Surgeon = Pilot Anesthesia = Co-Pilot Michota F. Jaffer A. CCJM. 2006
    6. 6. Anesth Analg 2004;99:1058-69.
    7. 7. What is different in Pediatrics <ul><li>Age - > 70 y/o – robust indicator for post-operative pulmonary morbidity </li></ul><ul><li>Exercise capacity – unclear in infants and toddlers </li></ul><ul><ul><li>Climb 1 flight of stairs = 4 mets = low CV risk </li></ul></ul><ul><li>Medication use </li></ul><ul><li>Risk for venous thromboembolism </li></ul>
    8. 8. General perioperative concerns in Pediatrics. <ul><li>Congenital heart disease </li></ul><ul><ul><li>Hypoxia, arrhythmias, and cardiovascular instability paradoxical air emboli </li></ul></ul><ul><li>Prematurity </li></ul><ul><ul><li>Postoperative apnea </li></ul></ul><ul><li>Gastrointestinal reflux </li></ul><ul><ul><li>Aspiration pneumonia </li></ul></ul><ul><li>URI </li></ul><ul><ul><li>Laryngospasm, bronchospasm, hypoxia, and pneumonia </li></ul></ul><ul><li>Craniofacial abnormality </li></ul><ul><ul><li>Difficult airway </li></ul></ul>Childs Nerv Syst (2006) 22:834–843
    9. 9. Patient related risk Procedure related risk Anesthetic-related risk Provider-related risk Perioperative risk Michota F, Frost S; Med Clin N Am 2002.
    10. 10. Role of the surgeon <ul><li>Surgeons are typically consulted for evaluation and treatment of: </li></ul><ul><ul><li>healthy child who is undergoing elective surgery </li></ul></ul><ul><ul><li>the chronically ill child who requires surgery </li></ul></ul><ul><ul><li>the acutely ill on injured child who requires emergent surgery. </li></ul></ul>Pediatrics 1996;98;502-508.
    11. 11. Role of the anesthesiologist <ul><li>Anesthesia may begin outside the OR with the administration of preoperative medication. </li></ul><ul><li>Patient follow up until D/C from the PACU </li></ul><ul><ul><li>Except if regional analgesia or spinal block are used </li></ul></ul>Pediatrics 1996;98;502-508.
    12. 12. Anesthesia-associated risk <ul><li>Risk for adverse events continues to be higher in infants and young children </li></ul><ul><li>Overall mortality rate was 0.9/10,000 anesthetics </li></ul><ul><li>Incidence of cardiac arrest of 1.7/10,000 </li></ul><ul><ul><li>Adult (1.4/10,000). </li></ul></ul><ul><ul><li>Children < 12 y/o (4.7/10,000) – 3x </li></ul></ul><ul><ul><li>Complications of airway management (laryngospasm, difficult intubation, and pulmonary aspiration of gastric contents) </li></ul></ul><ul><ul><li>Halothane (hypotension, arrhythmia, or both). </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43.
    13. 13. Anesthesia-associated risk <ul><li>Greater risk occurs in infants < 4 wk old. </li></ul><ul><ul><li>More likely to be having major surgery (intrathoracic or intraabdominal) </li></ul></ul><ul><ul><li>Have more serious underlying disease </li></ul></ul><ul><ul><li>Increased percentage are (ASA) physical status 3–5. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Associated with emergency surgery, halothane or sevoflurane, caudal injection of bupivacaine/epinephrine </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    14. 14. ASA Classification <ul><li>Class 1 A normally healthy patient </li></ul><ul><li>Class 2 A patient with mild systemic disease </li></ul><ul><li>Class 3 A patient with severe systemic disease that is not incapacitating </li></ul><ul><li>Class 4 A patient with an incapacitating systemic disease that is a constant threat to life </li></ul><ul><li>Class 5 A moribund patient who is not expected to survive for 24 h with or without operation </li></ul>Anesthesiology 1963; 24: 111. Pediatric Anesthesia 2007 17: 216–222.
    15. 15. ASA Classification in Pediatrics Pediatric Anesthesia 2007 17: 216–222.
    16. 16. Preoperative Evaluation <ul><li>HPI </li></ul><ul><li>PMH </li></ul><ul><ul><li>Croup </li></ul></ul><ul><ul><li>OSA </li></ul></ul><ul><ul><li>Cervical instability (Down’s) </li></ul></ul><ul><li>Medications – NSAID’s </li></ul><ul><li>Allergies – Latex (spina bifida) </li></ul>Pediatrics 1996;98;502-508.
    17. 17. Pre-operative evaluation <ul><li>Family history </li></ul><ul><ul><li>Anesthetic-related complications </li></ul></ul><ul><ul><ul><li>malignant hyperthermia </li></ul></ul></ul><ul><ul><ul><li>prolonged paralysis after anesthesia (pseudocholinesterase deficiency) </li></ul></ul></ul><ul><ul><li>Bleeding disorders </li></ul></ul><ul><ul><li>Muscular dystrophy </li></ul></ul><ul><ul><li>Drug use (aminoglycosides) </li></ul></ul>Pediatrics 1996;98;502-508.
    18. 18. Pre-operative evaluation <ul><li>Last meal intake </li></ul><ul><li>Physical examination </li></ul><ul><ul><li>Hydration status </li></ul></ul>Pediatrics 1996;98;502-508.
    19. 19. Ancillary testing <ul><li>Hb - when significant anemia (<9 g/L) is suspected </li></ul><ul><ul><li>(eg, infants, growing premature infants, and patients with chronic illnesses) </li></ul></ul><ul><ul><li>to establish a reference point in anticipation to significant blood loss (Orthopedic surgery). </li></ul></ul><ul><li>Pregnancy testing </li></ul>Pediatrics 1996;98;502-508.
    20. 20. Ancillary testing <ul><li>Coagulation profile </li></ul><ul><ul><li>history or medical condition suggests a possible hemostatic defect: </li></ul></ul><ul><ul><ul><li>large bruises and hematomas </li></ul></ul></ul><ul><ul><ul><li>simultaneous bruising on several parts of the body </li></ul></ul></ul><ul><ul><ul><li>Hematochezia </li></ul></ul></ul><ul><ul><ul><li>frequent and prolonged epistaxis </li></ul></ul></ul><ul><ul><ul><li>Hemarthrosis </li></ul></ul></ul><ul><ul><ul><li>unusual bleeding after minor trauma (including dental extraction) </li></ul></ul></ul><ul><ul><li>Recent ingestion of aspirin or NSAIDS. </li></ul></ul><ul><ul><li>Cardiopulmonary bypass – induction of hemostatic disorder by platelet activation and consumption </li></ul></ul><ul><ul><li>Tonsillectomy; airway surgery </li></ul></ul><ul><ul><li>Neurosurgical patients (craniotomy) </li></ul></ul><ul><li>Minor surgery and a negative history: no tests are suggested. </li></ul>Pediatrics 1996;98;502-508.
    21. 21. Fasting guidelines <ul><li>8-6-4-2 </li></ul><ul><li>8 hours solids </li></ul><ul><li>6 hours formula </li></ul><ul><li>4 hours breast milk </li></ul><ul><li>2 hours clear liquids </li></ul>Anesthesiology. 1999;90(3):896-905 Acta Anaesthesiol Scand 2005;49:1041-1047. Best Practice & Research Clinical Anaesthesiology. 2006; 20(3):471-81.
    22. 22. Pulmonary issues <ul><li>URI – defer surgery until symptoms resolve </li></ul><ul><ul><li>Increased risk of bronchospasm </li></ul></ul><ul><ul><li>Decreased 50% with use of Laryngeal Mask Airway </li></ul></ul><ul><li>Asthma – should be optimally controlled </li></ul><ul><ul><li>Continue bronchodilators and oral meds in AM of surgery </li></ul></ul><ul><ul><li>Delay surgery 6 wk after asthma attack (FEV1 remains low x 6 wk). </li></ul></ul><ul><ul><li>Prednisone 1 mg/kg 24-48 h pre-operatively and in the AM of surgery. </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 Pediatrics 1996;98;502-508.
    23. 23. Pulmonary issues <ul><li>FEV1/FVC -useful predictors of the need for postoperative mechanical ventilation among patients at risk (eg, cystic fibrosis, severe scoliosis, or kyphoscoliosis). </li></ul><ul><li>Adults - increased incidence of need for postoperative mechanical ventilation: </li></ul><ul><ul><li>FEV1/FVC < 50% </li></ul></ul><ul><ul><li>FEV1 < 35% predicted </li></ul></ul><ul><ul><li>Absolute FVC < 25 mL/kg </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    24. 24. Pulmonary issues <ul><li>Cystic fibrosis – continue pulmonary toilet, optimize nutritional status, continue home meds (inhaled and systemic antibiotics, dornase alpha, acetylcysteine, bronchodilators). </li></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    25. 25. Pulmonary issues <ul><li>Obstructive Sleep apnea </li></ul><ul><ul><li>Adenotonsillar hyperthrophy, obesity, Prader Willi, Down’s </li></ul></ul><ul><ul><li>Pulmonary HTN and Cor Pulmonale </li></ul></ul><ul><ul><li>Greatest risk of post-op upper airway obstruction </li></ul></ul><ul><ul><ul><li>Tissue edema </li></ul></ul></ul><ul><ul><ul><li>Secretions </li></ul></ul></ul><ul><ul><ul><li>Sedation (narcotics) </li></ul></ul></ul><ul><ul><ul><li>Pulmonary edema </li></ul></ul></ul><ul><ul><li>Best practice: 24 h observation in PICU </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    26. 26. Pulmonary issues <ul><li>Prematurity and apnea </li></ul><ul><ul><li>Decreased risk with spinal anesthesia </li></ul></ul><ul><ul><li>Preoperative use of caffeine </li></ul></ul><ul><ul><li>Admit and monitor with SpO2. </li></ul></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    27. 27. Former Preterm  Risk for Postoperative apnea <ul><li>Bronchopulmonary dysplasia </li></ul><ul><li>Chronic hypoxemia and hypercarbia </li></ul><ul><li>Tracheomalacia; bronchomalacia </li></ul><ul><li>Pulmonary hypertension; Cor pulmonale </li></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Anemia (Hct <30%) </li></ul></ul><ul><ul><li>Apnea at home </li></ul></ul><ul><ul><li>Gestational age (<30 wk) </li></ul></ul><ul><ul><li>LBW (< 1.5 kg) </li></ul></ul><ul><ul><li>Lower weight at time of surgery </li></ul></ul><ul><ul><li>Complicated NICU course </li></ul></ul>Murphy JJ. J Pediatr Surg. 2008. May;43(5):865-8
    28. 28. Post-operative atelectasis <ul><li>Impaired surfactant </li></ul><ul><li>Increased gas reabsorption </li></ul><ul><li>Extrinsic compression </li></ul><ul><li>Favored by: </li></ul><ul><ul><ul><li>General anesthesia </li></ul></ul></ul><ul><ul><ul><li>Recumbent position – decrease FRC 0.5 – 1.0 L </li></ul></ul></ul><ul><ul><ul><li>High FiO 2 </li></ul></ul></ul><ul><ul><ul><li>Surgery close to the diaphragm </li></ul></ul></ul>Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.
    29. 29. Post-operative atelectasis Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.
    30. 30. Age and atelectasis <ul><li>Children age 1–3 years  atelectasis develop more readily than in adults. </li></ul><ul><li>Increased thoracic rib cage compliance  less outward recoil of the chest wall  less distending force on the lung. </li></ul><ul><li>High closing volume (the lung volume at which small airways begin to close) </li></ul>Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.
    31. 31. Physiologic consequences of atelectasis <ul><li>Decreased compliance </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Increased pulmonary vascular resistance </li></ul><ul><li>Lung injury (repetitive opening and closure of small airways). </li></ul>Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.
    32. 32. Chest 1995; 107:81-84 N = 100 postop cardiac surgery patients
    33. 33. Tonsillectomy: special considerations <ul><li>Risk for post-operative obstructive apnea </li></ul><ul><li>Risk for post-obstructive pulmonary edema </li></ul><ul><li>Increased risk of bleeding – use of post-operative NSAIDS is controversial as it is associated with increased re-operation. </li></ul>Anesth Analg 2003;96:68 –77.
    34. 34. Child with cardiac murmur <ul><li>Innocent murmur </li></ul><ul><li>Pathologic murmur </li></ul><ul><li>New Endocarditis prophylaxis guidelines </li></ul><ul><li>Cardiology evaluation and f/u for a child with complex congenital heart disease. </li></ul>Pediatrics 1996;98;502-508. Current Opinion in Anaesthesiology 2007, 20:216–220
    35. 35. Hypoplastic Left Heart Syndrome and Non-cardiac surgery J Pediatr Surg. 2002;37:1399-1403.
    36. 36. Prophylaxis against bacterial endocarditis <ul><li>CLASS IIa </li></ul><ul><li>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: </li></ul><ul><li>Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair. (Level of Evidence: B) </li></ul><ul><li>Patients with previous infective endocarditis. (Level of Evidence: B) </li></ul><ul><li>Patients with CHD. (Level of Evidence: B) </li></ul>Circulation. 2008;118:887-896.
    37. 37. Prophylaxis against bacterial endocarditis <ul><li>CLASS IIa </li></ul><ul><li>Unrepaired cyanotic CHD, including palliative shunts and conduits. (Level of Evidence: B) </li></ul><ul><li>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) </li></ul><ul><li>Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or </li></ul><ul><li>prosthetic device (both of which inhibit endothelialization). (Level of Evidence: B) </li></ul><ul><li>Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve. (Level of Evidence: C) </li></ul>Circulation. 2008;118:887-896.
    38. 38. <ul><li>CLASS III </li></ul><ul><li>Prophylaxis against infective endocarditis is not recommended for nondental procedures: </li></ul><ul><ul><li>transesophageal echocardiogram, EGD, or colonoscopy) in the absence of active infection. (Level of Evidence: B) </li></ul></ul>Prophylaxis against bacterial endocarditis Circulation. 2008;118:887-896.
    39. 39. Antibiotic dose for BE prophylaxis <ul><li>SINGLE DOSE 30-60 MIN BEFORE </li></ul><ul><li>Amoxicillin p.o. 50 mg/kg </li></ul><ul><li>Ampicillin 50 mg/kg IM/IV or Cefazolin or ceftriaxone 50 mg/kg IM/IV </li></ul><ul><li>Allergic to penicillins: </li></ul><ul><ul><li>Cephalexin p.o. 50 mg/kg </li></ul></ul><ul><ul><li>Clindamycin 20 mg/kg </li></ul></ul><ul><ul><li>Azithromycin or clarithromycin 15 mg/kg </li></ul></ul><ul><ul><li>Cefazolin or ceftriaxone - 50 mg/kg IM/IV </li></ul></ul><ul><ul><li>Clindamycin 20 mg/kg IM or IV </li></ul></ul>Circulation. 2008;118:887-896.
    40. 45. Morbid Obese patient <ul><li>Overweight: BMI > 85%le </li></ul><ul><li>Obesity: BMI of more than 95%le </li></ul><ul><li>Superobesity: BMI > 99 %le </li></ul><ul><li>Adolescent/Adult: BMI > 40 kg/m 2 </li></ul>Current Opinion in Anaesthesiology 2008;21:308–312.
    41. 46. Morbid obesity: medical etiology <ul><li>Prader–Willi syndrome </li></ul><ul><li>Laurence–Moon–Biedl syndrome </li></ul><ul><li>Hypercaloric diet (glycogen storage diseases) </li></ul><ul><li>Steroid induced (Hem-Onc, nephrotic syndrome) </li></ul><ul><li>Poor mobility (late stage Duchenne’s) </li></ul>Current Opinion in Anaesthesiology 2008;21:308–312.
    42. 47. Prader Willi Syndrome Pediatric Anesthesia 2006 16: 712–722
    43. 48. Morbid obesity: perioperative considerations <ul><li>Hypertension and LVH </li></ul><ul><li>Obstructive sleep apnea / hypoventilation </li></ul><ul><li>Diabetes / insulin resistance </li></ul><ul><li>GERD </li></ul><ul><li>NAFLD / NASH </li></ul>Current Opinion in Anaesthesiology 2008;21:308–312.
    44. 49. <ul><li>Slipped capital femoral epiphysis </li></ul><ul><li>Blount’s disease </li></ul><ul><li>Cholelithiasis </li></ul><ul><li>Polycystic ovary syndrome </li></ul><ul><li>Idiopathic intracranial hypertension (pseudotumour cerebri) </li></ul>Morbid obesity: Pediatric perioperative considerations Current Opinion in Anaesthesiology 2008;21:308–312.
    45. 50. Morbid obesity: Pre-operative examination in children <ul><li>History: </li></ul><ul><ul><li>symptoms of sleep apnea </li></ul></ul><ul><ul><li>tolerance to exercise: breathlessness, asthma; </li></ul></ul><ul><ul><li>recent weight loss or gain </li></ul></ul><ul><ul><li>medications, including OTC herbs or special mixtures taken to lose weight which can interfere with anaesthesia or haemostasis. </li></ul></ul><ul><ul><ul><li>e.g. garlic, ginger, etc. </li></ul></ul></ul><ul><li>Document BMI in percentile chart. </li></ul><ul><li>Pulse-oximetry (SpO 2 ) on room air / Nocturnal SpO 2 </li></ul><ul><li>Fasting blood glucose </li></ul><ul><li>Echocardiography (Hypertensive patient) </li></ul><ul><li>Preoperative fasting – similar rules as the nonobese population. </li></ul><ul><li>GERD: usual anti-reflux therapy should be administered. </li></ul>Current Opinion in Anaesthesiology 2008;21:308–312.
    46. 51. Elective surgery in morbid obesity: 2009 AHA guidelines Circulation . 2009;120:86-95.
    47. 52. Neural tube defects <ul><li>Assessment for coexistent congenital anomalies </li></ul><ul><li>90% require CSF diversion </li></ul><ul><li>Subsequent surgeries: </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Malfunction </li></ul></ul><ul><ul><li>Outgrowing the shunt hardware </li></ul></ul><ul><li>Associated urogenital and musculoskeletal dysfunction </li></ul><ul><ul><li>UTI/VUR/hydronephrosis  renal function evaluation </li></ul></ul><ul><ul><li>Scoliosis  respiratory function evaluation </li></ul></ul><ul><ul><li>Lower-extremity abnormalities </li></ul></ul><ul><li>Latex allergy </li></ul>Pediatrics 1996;98;502-508.
    48. 53. Neuromuscular disorders <ul><li>Inhalational agents: cerebral vasodilation  increase ICP </li></ul><ul><li>Ensure patency and proper functioning of CSF shunt </li></ul><ul><li>Immediate postop period  Impaired airway reflexes </li></ul><ul><ul><li>Document pre-operatively any evidence of brainstem dysfunction (eg, vocal cord paralysis, swallowing dysfunction, or aspiration) </li></ul></ul><ul><li>Increased risk for postoperative weakness  postoperative respiratory care and prolonged mechanical ventilation / PP. </li></ul><ul><li>Succinylcholine  Hyperkalemia; malignant hyperthermia </li></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    49. 54. Epilepsy <ul><li>Record type and frequency of seizures </li></ul><ul><li>Continue antiepileptic medications on the AM of surgery </li></ul><ul><li>Uncontrolled seizures  Neurology evaluation. </li></ul><ul><li>Check serum levels of anticonvulsant </li></ul><ul><li>Most anticonvulsants have long half-lives, and the omission of one dose does not decrease the blood level significantly. </li></ul><ul><li>No need to determine anticonvulsant levels if: </li></ul><ul><ul><li>seizure-free for 2 years </li></ul></ul><ul><ul><li>no adjustment of their anticonvulsant dose </li></ul></ul>Pediatrics 1996;98;502-508. Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    50. 55. Epilepsy: perioperative considerations <ul><li>Tuberous sclerosis </li></ul><ul><ul><li>cardiac rhabodomyomas: obstruction, dysrhythmias </li></ul></ul><ul><ul><li>Renal lesions  HTN, CKD </li></ul></ul><ul><li>Traditional antiepileptics: P-450 inducers </li></ul><ul><li>Topiramate  NAG metabolic acidosis </li></ul><ul><li>Sodium valproate  platelet abnormalities, bleeding </li></ul><ul><li>Sodium valproate and Felbamate  liver failure </li></ul><ul><li>Ketogenic diet  avoid lactated Ringers solution </li></ul><ul><li>Sevoflurane  Epileptogenic potential </li></ul>Childs Nerv Syst. 2006;22:834–843. J Anesth. 2006;20:135–137. Paediatric Anaesthesia 2002;12:700–704.
    51. 56. Phakomatoses: extra-CNS findings <ul><li>Linear nevus sebaceous of Jadassohn </li></ul><ul><ul><li>Aortic coarctation, PDA, VSD </li></ul></ul><ul><li>Neurofibromatosis </li></ul><ul><ul><li>Pheochromocytoma – 5% </li></ul></ul><ul><ul><li>Kyphoscoliosis (type 1) </li></ul></ul><ul><li>Sturge Weber </li></ul><ul><ul><li>Aortic coarctation </li></ul></ul><ul><li>Von Hippel Lindau </li></ul><ul><ul><li>Pheocromocytoma – 10% </li></ul></ul><ul><ul><li>RCC – 25% </li></ul></ul>Paediatric Anaesthesia 2000;10:121–128
    52. 57. Cervical spine instability <ul><li>Mucopolysaccharidoses (Hurler’s and Monquio’s syndromes): odontoid hypoplasia </li></ul><ul><li>Rheumatoid arthritis : atlantoaxial instability, subaxial instability, and superior migration of the odontoid process. </li></ul><ul><li>Down syndrome : 15% asymptomatic atlantoaxial instability </li></ul><ul><li>Document pre-operative screening flexion-extension Cervical spine Roentgenograms </li></ul><ul><li>Consider fiberoptic intubation. </li></ul>Pediatrics 1996;98;502-508.
    53. 58. Craniosynostosis <ul><li>Multidisciplinary evaluation by a craniofacial team </li></ul><ul><li>Monitor for signs of increased intracranial pressure </li></ul><ul><li>Nonsyndromic craniosynostosis are usually otherwise healthy. </li></ul><ul><li>Syndromic craniosynostosis can have associated anomalies: </li></ul><ul><ul><li>Crouzon’s or Apert’s syndrome can have very abnormal airway anatomy  fiberoptic intubation. </li></ul></ul><ul><li>Identifying a history of OSA </li></ul><ul><li>Apert’s syndrome  congenital cardiac defects. </li></ul>Am J Med Gen. 2005; 45(6):758 - 760. Anesthesiology Clin. 2007;25:465–481
    54. 59. Sickle cell patients <ul><li>Heterozygous sickle cell trait  generally asymptomatic </li></ul><ul><li>Active sickling conditions (SS, SC, S-  thalassemia) </li></ul><ul><ul><li>reduce risk of complications by preoperative transfusions to reduce the total HbS level < 40%. </li></ul></ul><ul><li>Coordination among the pediatrician, hematologist, anesthesiologist, and surgeon is essential. </li></ul>Fu T. Pediatr Blood Cancer 2005;45:43–47. Marchant WA. Paediatric Anaesthesia 2003;13:473–489
    55. 60. Systemic manifestations of SCD Fu T. Pediatr Blood Cancer 2005;45:43–47. Marchant WA. Paediatric Anaesthesia 2003;13:473–489
    56. 61. Perioperative management of SCD <ul><li>Avoid dehydration – impaired renal concentrating ability. </li></ul><ul><li>Deoxygenation – incentive spirometry; SpO2 monitoring </li></ul><ul><li>Vascular stasis – maintaining a normal C.O., a normal blood volume, and BP. </li></ul><ul><li>Hypothermia – keeping the patient warm </li></ul><ul><li>Acidosis – good hydration, warm </li></ul><ul><li>Infection – prophylactic antibiotics </li></ul><ul><li>Adequate analgesia, to enable effective physiotherapy and early ambulation must be emphasized. </li></ul>
    57. 62. Regional anesthesia and SCD <ul><li>Redistribution of blood flow may lead to an increase in capillary and venous oxygen tension in the blocked region </li></ul><ul><li>Compensatory vasoconstriction in nonblocked areas leads to a fall in the SvO2. </li></ul><ul><li>Lack of control of ventilation, regional hypoperfusion and venous stasis. </li></ul><ul><li>Cooperative Study of Sickle Cell Disease (N=3765) </li></ul><ul><ul><li>10 y. </li></ul></ul><ul><ul><li>1079 surgeries (N= 717) </li></ul></ul><ul><ul><li>Post-op SCD-related complications (painful crisis, ACS, and CVA) were more frequent in patients who received regional anaesthesia (P=0.058). </li></ul></ul>Koshy M, et al. Blood 1995; 86: 3676–3684. Marchant WA. Paediatric Anaesthesia 2003;13:473–489
    58. 63. 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
    59. 64. Adenotonsillectomy and SCD <ul><li>Postop. pain, hypoventilation, atelectasis, hypoxia. </li></ul><ul><ul><li>Aggressive pulmonary toilet, NIPPV, bronchodilators and incentive spirometry </li></ul></ul><ul><ul><li>HbS < 40%. </li></ul></ul><ul><ul><li>Preoperative Transfusion in Sickle Cell Disease Study Group (N=118)  no advantage in aggressive transfusion regimen vs. conservative regime. </li></ul></ul>Marchant WA. Paediatric Anaesthesia 2003;13:473–489 Waldron P. J Ped Hematol Onc 1999; 21:129–135.
    60. 65. Cholecystectomy and SCD <ul><li>Laparoscopic approach is preferred </li></ul><ul><li>Avoid emergency surgery </li></ul><ul><ul><li>high morbidity </li></ul></ul><ul><li>Conservative pre-operative transfusion </li></ul><ul><ul><li>National Preoperative Transfusion Study (N=364) </li></ul></ul><ul><ul><li>Aggressive: preop Hb 10 g/dL and HbS < 30% </li></ul></ul><ul><ul><li>Conservative: Hb 10 g/dL independent of HbS. </li></ul></ul><ul><ul><ul><li>No difference between groups. </li></ul></ul></ul>Marchant WA. Paediatric Anaesthesia. 2003;13:473–489. Haberkern CM. Blood. 1997;89(5):1533-1542.
    61. 66. Orthopedic Surgery and SCD <ul><li>Aseptic necrosis of the hip occurs in up to 50% of patients. </li></ul><ul><li>Conservative preoperative transfusion – Hb (9-11 g/dL). </li></ul><ul><li>Careful use of tourniquet - stasis, hypoxia and acidosis beneath and distal to the tourniquet cuff  favors red cell sickling. </li></ul>Marchant WA. Paediatric Anaesthesia. 2003;13:473–489
    62. 67. Neurosurgery and SCD <ul><li>Keep Hct > 30 and HbS < 30% </li></ul><ul><ul><li>Minimize risk of stroke </li></ul></ul><ul><li>Careful use of hypertonic agents </li></ul><ul><ul><li>Urea – preferred </li></ul></ul><ul><ul><li>Old contrast media </li></ul></ul><ul><li>Careful use of Epsilon-Aminocaproic Acid </li></ul><ul><ul><li>Generally used in spinal surgery </li></ul></ul><ul><ul><li>Can predispose to vaso-occlusive crises </li></ul></ul><ul><li>Avoid hypothermia </li></ul>Marchant WA. Paediatric Anaesthesia. 2003;13:473–489
    63. 68. Cardiac Surgery and SCD <ul><li>Open-heart surgery with hypothermic cardiopulmonary bypass precipitate sickling. </li></ul><ul><li>Preoperative correction of anemia </li></ul><ul><li>Pre-operative exchange transfusion </li></ul><ul><ul><li>Increase in 2,3-DPG  increase DO 2 </li></ul></ul><ul><li>Avoidance of hypoxia and acidosis </li></ul><ul><li>Avoidance of aortic cross-clamping, hypothermia, cardioplegia and topical cooling </li></ul>Marchant WA. Paediatric Anaesthesia. 2003;13:473–489
    64. 69. Patients on chronic steroids <ul><li>Perioperative stress dose of steroids </li></ul><ul><li>Prednisone p.o. 2.5–5 mg/m2 BSA the night before </li></ul><ul><li>Hydrocortisone 50 mg/m2 before anesthetic induction </li></ul>Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
    65. 70. Diabetes mellitus <ul><li>Acceptable metabolic control: </li></ul><ul><ul><li>No ketonuria </li></ul></ul><ul><ul><li>Normal serum electrolytes </li></ul></ul><ul><ul><li>HbA1c within target range for age: </li></ul></ul><ul><ul><ul><li>< 5 years: 7 – 9% </li></ul></ul></ul><ul><ul><ul><li>5 – 13 years: 6 – 8.5% </li></ul></ul></ul><ul><ul><ul><li>> 13 years: 6 – 8% </li></ul></ul></ul>Rhodes ET. Anesth Analg 2005;101:986 –99
    66. 71. Insulin half life Rhodes ET. Anesth Analg 2005;101:986 –99
    67. 72. Insulin correction factor Rhodes ET. Anesth Analg 2005;101:986 –99
    68. 73. Mixed insulin regime (NPH/Lente) + No Rhodes ET. Anesth Analg 2005;101:986 –99
    69. 74. Lantus insulin regime No Yes No Rhodes ET. Anesth Analg 2005;101:986 –99
    70. 75. Insulin pump – for surgery < 2h No Rhodes ET. Anesth Analg 2005;101:986 –99
    71. 76. Insulin pump  Surgery > 2h No Rhodes ET. Anesth Analg 2005;101:986 –99
    72. 77. Oral hypoglycemic agents <ul><li>Hold on the morning of surgery </li></ul>No Rhodes ET. Anesth Analg 2005;101:986 –99
    73. 78. Post-operative DM management No Yes Rhodes ET. Anesth Analg 2005;101:986 –99
    74. 79. Pediatric Anesthesia 2008 18: 478–487
    75. 80. Perioperative VTE prophylaxis Pediatric Anesthesia 2008 18: 478–487
    76. 81. Perioperative VTE prophylaxis Pediatric Anesthesia 2008 18: 478–487
    77. 82. VTE risk of Surgery Pediatric Anesthesia 2008 18: 478–487
    78. 83. VTE Risk in the ICU Pediatric Anesthesia 2008 18: 478–487
    79. 84. <ul><li>Child 1–2 months – 750 ug/kg s.q. bid. </li></ul><ul><li>Child 2 months–18 years – 500 ug/kg s.q. bid. </li></ul><ul><ul><li>Maximum dose 20 mg s.q. bid. </li></ul></ul><ul><li>Adolescents of >40 kg weight </li></ul><ul><ul><li>Adult dosing of 40 mg qday </li></ul></ul>Pediatric Anesthesia 2008;18: 478–487
    80. 85. Psychological preparation of the children for surgery <ul><li>50-75% of patients develop significant anxiety </li></ul>Anesthesiology Clin N Am. 2005;23: 597- 614
    81. 86. Thank you!

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