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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Perioperative Evaluation and Treatment In Pediatrics
- 1. Perioperative Management of the Pediatric Patient Moises Auron MD, FAAP FACP Assistant Professor of Medicine Hospital Medicine
- 5. Model of Plane Flight P A T I E N T Surgeon = Pilot Anesthesia = Co-Pilot Michota F. Jaffer A. CCJM. 2006
- 9. Patient related risk Procedure related risk Anesthetic-related risk Provider-related risk Perioperative risk Michota F, Frost S; Med Clin N Am 2002.
- 15. ASA Classification in Pediatrics Pediatric Anesthesia 2007 17: 216–222.
- 29. Post-operative atelectasis Anesthesiology 2005; 102:838–54 Curr Opin Anaesthesiol. 2007;20:37–42.
- 32. Chest 1995; 107:81-84 N = 100 postop cardiac surgery patients
- 35. Hypoplastic Left Heart Syndrome and Non-cardiac surgery J Pediatr Surg. 2002;37:1399-1403.
- 47. Prader Willi Syndrome Pediatric Anesthesia 2006 16: 712–722
- 51. Elective surgery in morbid obesity: 2009 AHA guidelines Circulation . 2009;120:86-95.
- 60. Systemic manifestations of SCD Fu T. Pediatr Blood Cancer 2005;45:43–47. Marchant WA. Paediatric Anaesthesia 2003;13:473–489
- 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
- 71. Insulin half life Rhodes ET. Anesth Analg 2005;101:986 –99
- 72. Insulin correction factor Rhodes ET. Anesth Analg 2005;101:986 –99
- 73. Mixed insulin regime (NPH/Lente) + No Rhodes ET. Anesth Analg 2005;101:986 –99
- 74. Lantus insulin regime No Yes No Rhodes ET. Anesth Analg 2005;101:986 –99
- 75. Insulin pump – for surgery < 2h No Rhodes ET. Anesth Analg 2005;101:986 –99
- 76. Insulin pump Surgery > 2h No Rhodes ET. Anesth Analg 2005;101:986 –99
- 78. Post-operative DM management No Yes Rhodes ET. Anesth Analg 2005;101:986 –99
- 79. Pediatric Anesthesia 2008 18: 478–487
- 80. Perioperative VTE prophylaxis Pediatric Anesthesia 2008 18: 478–487
- 81. Perioperative VTE prophylaxis Pediatric Anesthesia 2008 18: 478–487
- 82. VTE risk of Surgery Pediatric Anesthesia 2008 18: 478–487
- 83. VTE Risk in the ICU Pediatric Anesthesia 2008 18: 478–487
- 86. Thank you!
Editor's Notes
- 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