Preoperative assessment
and preparation of
pediatric patient
Moderator Dr Anil Ohri
By –Dr Vishawjeet
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Psychological preparation
important aspect of preoperative care,
especially for younger children
Children aged 2-6 years are over five times
more likely to have significant preoperative
anxiety than older children and infants
Parental anxieties concerning surgery may be
profound and can be transmitted to child .
Efforts should be made to reduce parental
anxiety as well
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ANAESTHETIC ASSESSMENT
Full medical history
--previous history of illnesses and operations
--current medications
--allergies
--any unusual syndrome with anaesthetic implications
--parents should be asked whether infant child was born
at term or she breathed immediately at birth
--premature babies especially with apneic episodes are
likely to develop apnea following anaesthesia and should
not be accepted for day care procedure until they are 50
wks gestational age
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-- to know whether the child is malnourished or not
This may influence selection of anaesthetic equipments
eg size of endotracheal tube
History of URTI within 4 wks of operation or pts who have
symptoms of URTI preoperatively are at increased risk of
developing respiratory complications such as
laryngospasm, bronchospasm , atelectasis , hypoxemia
during or after anaesthesia
If the decision is made to proceed with surgery inspite of
URTI few days before surgery endotracheal tubes should
be used to prevent aspiration, risk of coughing or
laryngospasm
Postoperatively pt will require supplemental oxygen
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EXAMINATION
Head and neck should be examined to detect loose
decidual teeth
Signs for difficult intubation—
limited mouth opening
micrognathia
large tongye
noisy breathing
Presence of high temperature 38 deg c , cough ,malaise
and audible chest signs suggest LRTI .
elective anaesthesia should be postponed for atleast 4-6
wks to allow hyperactive airways to return to normal
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Diseases associated with difficult airway
---- mask and spontaneous ventillation
Preterm infant
Crouzon syndrome
Aperts syndrome
Choanal atresia
--MICROGNATHIA
pierre robin syndrome
First arch syndrome
Treacher collin syndrome
Goldenhar syndrome
Arthrogryposis
-----macroglossia
Beckwith-Wiedmann syndrome
Congenital hypothyroidism
Down syndrome
Congenital lingual tumor/ intraoral tumor
Cystic hygroma
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Intraoral pathology
Congenital temporomandibular joint
fusion /dysfunction
Laryngeal cyst , web
Laryngotracheal cleft
Microstomi
Cleft palate
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Preoperative investigations=
-- Routine Hb is indicated—
Neonates and ex premature infants under 1 yr
Children at risk for sickle cell ds
Children for whom intraoperative blood
transfusion may be necessary
Children with systemic ds
Preoperative Hb of less than 10 g/dl is
abnormal and needs to be investigated
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-- Routine biochemistry
It is indicated in children with metabolic ,
endocrine ,or renal ds
Children receiving iv fluids
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Child with murmur
Majority of pathological murmurs are diagnosed
perinatally and are already under care of pediatric
cardiologists. Antibiotic prophylaxis should be given
Previously unreported murmurs are commonly heard at
2-4 yrs of age . Majority are functional.
Pansystolic murmurs with normal heart sounds in a child
with normal oxygen saturation and no limitation in
exercise tolerance , can be assumed to be innocent and
no antibiotic prophylaxis is required.
If still in doubt a formal cardiac assessment should be
made
PREOPERATIVE FASTING
Fasting instructions are designed to minimize the
risk of regurgitation of gastric contents and
subsequent pulmonary aspiration
Prolonged fasting in infants can lead to
dehydration and hypovolemia
Clear fluids—2 hrs
Breast milk –4 hrs
Light meal , infant formula—6 hrs
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TOPICAL ANAESTHETICS
Topical anaesthetics reduce pain of
venepuncture and facilitate iv induction
Emla cream –eutectic mixture of 5% lidocaine
and 5% prilocaine in 1:1 ratio. Should be
avoided in children <1 yr of age becoz of the
risk of methemoglobinemia
Ametop –4% gel preparation of amethocaine .
It is licenced from 4 wks of age and has
vasodilating properties . Rapid onset of action
than E mla cream 30 min
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It is important to identify veins to be
anaesthetised and not blindly apply on
the dorsum of each hand.
Keep the area bandaged to prevent
removal or licking of cream
Ethyl chloride is cryoanalgesic . It is
used when topical creams are
contraindicated
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PREMEDICATIONS
Routine sedative premedication is
unnecessary
Children requiring premedication—
---Excessive upset child
---Children with previous unpleasant
experiences of surgery and anaesthesia
---Children with developmental delay
---Older children may request sedation
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_ Oral midazolam—0.5mg/kg
Ideal premedicant
Acts within 15-20 min, reduces anxiety
leading to more cooperative child.
Midazolam 0.2mg/kg can also be given
intranasally. Rapid action, poorly
tolerated, burning sensation in nasal
mucosa