This document provides guidance on pre-anaesthetic evaluation for paediatric patients. It discusses the importance of a thorough history, physical exam, and assessment to plan safe anaesthesia and post-operative care. The key components of evaluation are outlined, including assessing medical history, performing a physical exam, reviewing investigations, determining ASA classification, obtaining consent, and preparing the patient. Factors like temperature control, fluid management, and psychological preparation are also addressed to optimize patient safety and outcomes.

1. D R . S H R I N I V A S K U L K A R N I
P R O F E S S O R & H O D
D E P T O F E M E R G E N C Y M E D I C I N E
A V M V & H P O N D I C H E R R Y
Paediatric Pre-Anaesthetic
Evaluation

2. INTRODUCTION
 Careful preoperative assessment is the cornerstone
of safe anaesthetic practice.
 Allows for careful planning of the child’s surgical and
post-anaesthetic care.
 Evaluation of the child’s present health, past medical
and anaesthetic history, and review of relevant
investigations.
 These factors then integrated with the anticipated
effects of surgery to allow planning of appropriate
anesthetic goals.

3. OBJECTIVES OF PAE
 Evaluate the patient’s medical condition to ensure that it
has been optimised
 Plan anaesthetic technique and peri-operative care.
 Develop a rapport with the patient to allay anxiety and
facilitate conduct of anaesthesia
 Allow appropriate discussion with the patient and/or
guardian regarding anaesthesia, peri-operative care and
pain management
 Obtain informed consent for anaesthesia and related
procedures.

4. COMPONENTS
1. HISTORY
2. PHYSICAL EXAMINATION
3. SYSTEMIC EXAMINATION
4. LABORATORY EVALUATION
5. ASA CLASSIFICATION
6. INFORMED CONSENT
7. PREOPERATIVE FASTING ORDERS
8. PREPARATION

5. HISTORY
 Social and Demographic Details: Name, Age, Sex,
Guardian/Informant’s name, Educational Status of
both child and Parents, the family’s SocioEconomic
Status, Contact details.
 Chief Complaint
 History of Presenting Illness : elaboration of the
presenting complaint
 History of any co-morbid conditions, congenital
abnormalities

6.  Respiratory System :
-Recent history of URTI/LRTI
-history suggestive of airway compromise
- OSA
- History of bronchial asthma

7. RESPIRATORY SYSTEM HISTORY

8. Child with URTI
 Peri-operative problems include laryngospasm,
bronchospasm, airway obstruction by secretion,
intraoperative atelectasis and hypoxemia, post-extubation
stridor.
 Incidence greater in infants <1 year old.
 Recommendations for anaesthesia in a child with RTI
depends on its severity and the nature of the surgery (elective,
emergency, minor or major)
 The child with mild RTI (no fever, clear nasal discharge, mild
cough, child active, feeding well) can be anaesthetized for
minor surgical procedure without tracheal intubation.
 Surgery for the child with active RTI (fever, recent onset of
purulent nasal discharge, cough) should be postponed for at
least 2 weeks, and ideally 4-6 weeks; LMA to be used if
possible, to avoid airway manipulation.

9.  Cardiovascular System :
- Congenital or Rheumatic Heart Disease
- History of cyanotic or breath holding spells
- Consider possibility of cardiac lesion if child has any
associated congenital conditions : tracheoesophageal
fistula, esophageal atresia, Down Syndrome,
VACTERL anomalies
- History of Failure to thrive
- Medication history for CVS disease : Beta blockers,
anticoagulants, antihypertensives, digoxin,
antiplatelet drugs

10.  CNS :
- Seizure history, including h/o anticonvulsants
- raised ICP features
- Progressive neurodevelopmental impairment
- Behavioural abnormalities
 Hepatic and Renal System History:
- Kernicterus, Jaundice
- Nephrotic or Nephritic symptoms
- Obstructive uropathy symptoms

11. GASTROINTESTINAL SYSTEM HISTORY

12. RENAL SYSTEM HISTORY

13.  Antenatal History:
- booked/not booked case
- intake of Iron and Folic Acid tablets
- any other drug intake
- any infections/ febrile illness
- GDM, PIH, other maternal comorbid conditions

14.  Birth History:
-gestational age at birth
-mode of delivery
-birth weight
-order of birth (whether firstborn)
-baby cried immediately after birth
- any NICU admission
- when breastfeeding was started
- h/o apnoeic spells- more likely to develop apnoea
following anaesthesia and should not be accepted for
day care procedures until they are atleast 50 wks
gestation.

15.  Developmental History:
- Gross Motor, Fine Motor, Social, Language
 Immunization History:
- Appropriate to age as per IAP schedule.
- Children may have received vaccines. Surgery should
be planned in accordance with the vaccination
programme.

16.  Family History:
- Consanguinous or Non-consanguinous marriage
- Pedigree chart
- h/o sudden intraoperative death, or hyperthermia after
surgery : indicates risk of malignant hyperthermia
 Past History:
- Any previous surgeries requiring anaesthesia, blood
transfusions
- History of mechanical ventilation
- Drug History
 Personal History:
- Appetite, Sleep, Bowel and Bladder habits
- Passive smoking
- Medical allergies

17. GENERAL PHYSICAL EXAMINATION
 Anthropometry : General nutritional state, weight,
height, mid arm circumference, head circumference
 Skin and mucosal colour : pallor, icterus, cyanosis
 Clubbing, Koilonychia
 Heart Rate, Blood Pressure, Capillary Filling Time,
Oxygen Saturation.
 Respiratory Rate, Character of respiration
 Spine : spina bifida; whether hiatus well felt
 Potential sites for venepuncture – mark out for EMLA
(Eutectic Mixture of Local Anaesthetic) application
 Presence or absence of nasal discharge

18. AIRWAY ASSESSMENT
 Inter Incisor Gap
 Dentition
 Modified Mallampatti Classification
 Upper Lip Bite Test
 Neck Circumference
 Thyromental Distance
 Sternomental Distance

19. Class I = visualize the soft palate, fauces, uvula, anterior
and posterior pillars.
Class II = visualize the soft palate, fauces and uvula.
Class III = visualize the soft palate and the base
of the uvula.
Class IV = soft palate is not visible at all.
Modified Mallampati Classification

20. Equipment Category Recommended Equipment
Airways
Oral and nasopharyngeal (trumpet) airways in all
sizes for preterm infants to adults
Endotracheal tubes
Cuffed and uncuffed endotracheal tubes of
various size (uncuffed down to size 2.0 mm ID)
Stylets Stylets in several sizes
Laryngoscopy
Laryngoscope blades in multiple sizes and
configurations
Several handles, extra batteries
Oxyscope (Heine Optotechnik, D-82211
Herrsching)
Laryngeal mask airways
All sizes 1.0 to 6.0
ProSeal LMAs for patients with a full stomach or
those who require higher peak inflation pressure
for successful ventilation
Large-volume syringes for the larger masks
Fiberoptic intubation
Fiberoptic scopes—several sizes, including one
that will fit through a 2.5-mm ID endotracheal
tube
Light source
Teeth protectors
Oral airways designed for fiberoptic intubation
Silicon lubricant

21. Systemic Examination
 Cardiovascular System :
 Features of cardiac murmurs
Innocent Pathological
o Asymptomatic Symptomatic
o Soft Loud
o Early systolic Pan or late systolic, diastolic
Continuous
o No thrill Thrill present
o Disappears with positioning
o May be a venous hum

22.  Clinical Features of Congestive Cardiac Failure :
 Tachypnea, Sweating, Hepatomegaly

23. Systemic Examination
 Respiratory System :
 Upper Respiratory Tract : congestion, discharge,
hypertrophied turbinates, deviated nasal septum
 Lower Respiratory Tract :

24.  Central Nervous System
 Per Abdomen Examination

25. LABORATORY INVESTIGATONS
 For minor procedure – In healthy children
Hb%/Urine/ BT-CT
 For major procedure – Haematological
profile/urine/X-ray-Chest/S.Electrolytes/BUN/S.
creatinine
 Random Blood Sugar – In adolescent patients
 2D echo / Echocardiography – should be done if
murmur is present or suspect CHD
 Other investigations like renal and hepatic function
tests etc., should be done if systemic diseases are
present

26. ASA CLASSIFICATION
 Class I: Healthy patient, no systemic disease
 Class II: Mild systemic disease with no functional
limitations (mild chronic renal failure, iron deficiency
anaemia, mild asthma)
 Class III: Severe systemic disease with functional
limitations (hypertension, poorly controlled asthma or
diabetes, congenital heart disease, cystic fibrosis)
 Class IV: Severe systemic disease that is a constant threat
to life (critically and/or acutely ill patients with major
systemic disease)
 Class V: Moribund patients not expected to survive 24 hr,
with or without surgery
 add “E” for —emergency surgery

27. INFORMED CONSENT
 Consent should be obtained from the parent or
guardian for a paediatric patient, while explanation
and discussion should involve the patient’s next-of-
kin if the patient himself/herself is in no condition to
provide consent for treatment.

28. PREOPERATIVE FASTING
Fasting Time (hr) *
Age Milk and Solids Clear Liquids
<6 months 4 2
6-36 months 6 3
>36 months 8 3

30. PREPARATION
 Paediatric Sedation :
Psychological preparation and premedication are
much needed in paediatric patients. Infants more
than 6 months do resent separation from parents
and it is advisable to either have the parent hold the
child for “stealing with inhalational induction”.

32.  Venous access should be secured under topical local
anaesthetic cover.
 The commonly used drugs to avoid separation
anxiety are Midazolam and Ketamine. An attractive
alternative is transmucosal Fentanyl and oral
Clonidine. Routine use of atropine as a premedicant
is not recommended nowadays.
Atropine/Glycopyrrolate has only specific
indications like tonsillectomy, cleft lip and palate,
difficult intubation or when secretogogues like
ketamine are used.

33. 10 – 12 months—separation anxiety

34. Oral Midazolam 0.5
mg/kg
Ketamine 4 mg/kg
Atropine 20 mic/kg
This oral premed can
prevent crying for
separation
 1 – 4 yrs ---premed very
useful

37. TEMPERATURE CONTROL

38. PREPARARTION
 TEMPERATURE CONTROL:
 Due to their small size with increased body surface area to
body weight ratio and increased thermal conductance, infants
and young children are at significant risk for thermal
instability.
 The minimal ability to shiver during the first 3 months of life
makes cellular thermogenesis (metabolism of brown fat) the
principal method of heat production.
 Important to address all aspects of possible heat loss during
anesthesia, as well as during transport to and from the
operating room.
 Placing the baby on a warming mattress and warming the
operating room (80°F or warmer) reduce heat lost by
conduction.

39.  Keeping the infant in an incubator, covered with blankets,
minimizes heat lost through convection. The head should also
be covered.
 Heat lost from radiation is decreased with the use of a double-
shelled Isolette during transport. Heat lost through
evaporation is lessened by humidification of inspired gases,
the use of plastic wrap to decrease water loss through the skin,
and warming of skin disinfectant solutions.
 Hot air blankets are the most effective means of warming
children.
 Anesthetic agents can alter many thermoregulatory
mechanisms, particularly nonshivering thermogenesis in
neonates.

40.  Risk is higher for premature infants and infants who
are small for gestational age.
 Although awake infants are able to maintain
normothermia, they can do so only within a narrow
range of ambient temperatures and only for a limited
amount of time.
 Exposure to the operating room with its normally
low ambient temperature combined with the high
airflow from the air-conditioning system during
anaesthesia and surgery, and the use of cold
infusions and dry anaesthetic gases can easily
overwhelm the thermal homeostatic mechanisms
and result in potentially serious complications.

41.  Hypothermia-related complications include increased
morbidity, surgical wound infections, coagulopathies,
increased allogenic transfusions, negative nitrogen
balance, delayed wound healing, delayed postoperative
anaesthetic recovery, prolonged hospitalization,
shivering, and patient discomfort.
 Prevention of Hypothermia is crucial. Operating room
temperatures of 27° and 29° C are recommended for full
term and premature newborns, respectively.
 Other measures of preventing hypothermia include use
of radiant heaters, reflecting blankets, skin surface
warming blankets, warming matresses, humidified and
heated gases and warming of intravenous fluids.

42. FLUID MANAGEMENT

43. PREPARATION

44. 5% 10% 15%

45. Careful assessment of dehydration and accordingly
correction should be done with:
 50ml/kg IV Fluids for mild dehydration
 100ml/kg for moderate
 150ml/kg IV fluids for severe dehydration.

46. CONCLUSION
 Paediatric assessment and preparation is always a
challenging subject and more with learning students.
Hence considering all above mentioned points may
help and also it’s now become a super speciality so
that further study is always recommended.

47. THANK YOU