Mod V: Peds Pre-op Part 1

Question 1

_{Perioperative Preparation}

Why Perioperative Preparation so important?

Answer 1

The number one error in pediatric anesthesia is inadequate preparation

Absence of adequate pre-anesthetic assessment is one of the top three causes of lawsuits against anesthetist

Recovery occurs more quickly when the anesthetist allays patient concerns regarding what is to come and plans postoperative pain management with the patient

Planning prevents problems

Question 2

_{Perioperative Preparation}

Goals of Perioperative Preparation:

Answer 2

Educate child/family

Anesthesia - Perioperative care - Pain management

Obtain pertinent information

Medical Hx - Physical & mental condition

Determine/decide

Consultations - Tests

Anesthetic plan

^{Guided by risk factors & pt choice}

Obtain informed consent

Ultimate Goal => reduce morbidity

Question 3

_{Perioperative Preparation}

A structured/comprehensive method to reviewing anesthetic considerations for a child’s medical condition & surgical procedure; including Preoperative, Intraoperative, and Postoperative periods is also known as:

Answer 3

Eleven P’s to Pediatric Perioperative Planning

Completing the Eleven P’s helps the anesthetist develop a comprehensive/individualized anesthetic plan

Question 4

_{Perioperative Preparation}

What are the Eleven P’s to Pediatric Perioperative
Planning?

Answer 4

Patient

^{(H & P - Medical conditions requiring special consideration)}

Procedure

Premedication

Preoperative fasting

Perioperative labs

Perioperative monitoring

Perioperative fluid

Positioning

Plan

^{(Induction - Maintenance - Emergence)}

Pain

^{(Intra- & postop concerns)}

Postoperative

Question 5

_{Perioperative Preparation}

What’s the main goal of Perioperative Preparation?

Answer 5

To minimize perioperative morbidity & mortality

Question 6

_{Perioperative Evaluation}

The main goal of Perioperative Preparation is to minimize perioperative morbidity & mortality. How could this be achieved?

Answer 6

Evaluate overall health status

Identify risks

^{Normal physiologic/anatomical challenges}

^{Preexisting medical conditions}

Determine optimization

Determine postoperative/discharge plan

Parents

Question 7

_{Perioperative History}

What should be assessed?

Answer 7

Parents medical history

Maternal history

Birth/neonate history

Medications

Concurrent medical conditions

Allergies

Prior anesthetics

^{Airway difficulty - PONV}

Family history of anesthetic complications

^{MH - Pseudocholinesterase deficiency}

Question 8

_{Preoperative Physical Exam}

Cardiovascular pre-op evaluation must include:

Answer 8

HR/BP

Heart sounds

^{Murmur - CHD}

Additional elements depending on pre-existing medical conditions of the child & nature of the surgery

Question 9

_{Preoperative Physical Exam}

Respiratory pre-op evaluation must include:

Answer 9

Airway

^{MP 5 (!!!)}

^{The pediatric pt is always considered to be difficult airway}

Concurrent URI

Asthma

_{Additional elements depending on pre-existing medical conditions of the child & nature of the surgery}

Question 10

_{Preoperative Physical Exam - Respiratory}

T/F: The pediatric pt is always considered to be difficult airway

Answer 10

True

Question 11

_{Preoperative Physical Exam}

Coexisting Diseases Requiring Special Considerations

Answer 11

ŸUpper Respiratory Infection

^{(Recent or Current)}

ŸAsthma

ŸFormer Premature Infant

ŸHeart Murmur

ŸSickle Cell Disease

Question 12

_{Upper Respiratory Infection}

Risk for perioperative respiratory event for pts with recent or current URI significantly increase your risk for which complications:

Answer 12

Laryngospasm

Bronchospasm

Hypoxemia

Postop croup

Question 13

_{Upper Respiratory Infection}

Risk of perioperative morbidity for pts with recent or current URI significantly increase especially when combined with which other conditions?

Answer 13

Asthma

Bronchopulmonary dysplasia

< 1 year of age (GREATEST)

Live in home with smoker

Sickle cell disease

Question 14

_{Upper Respiratory Infection}

Symptoms of Upper Respiratory Infection include:

Answer 14

Expiratory wheezing

Inflamed naso-oropharyngeal mucosa

^{Sore throat - Nasal congestion}

Rhinorrhea/mucopurulent drainage

Malaise

Non-productive cough

^{Because this is an upper, not lower respiratory infection}

Low grade fever (37.5°C – 38.5°C)

Question 15

_{Upper Respiratory Infection Symptoms}

Pts with Inflamed naso-oropharyngeal mucosa will complain of:

Answer 15

Sore throat

Nasal congestion

Question 16

_{Upper Respiratory Infection Symptoms}

What’s a characteristic of the cough a/w with Upper Respiratory infections

Answer 16

Non-productive cough

Question 17

_{Upper Respiratory Infection}

TO CANCEL OR NOT TO CANCEL…

Based on what would you make that determination?

Answer 17

Review each case individually

Risk-benefit ratio

Infectious vs. Allergies

Acute vs Chronic

Elective vs Emergent surgery

Question 18

_{Upper Respiratory Infection}

Proceed if:

Answer 18

Short elective procedures, and they have…

^{Chronic cold}

^{Clear runny nose,}

^Optimized

ETT not required, and they are…

^{> 1 year of age}

^{URI resolving (Bacterial URI, and they have been on Abx and it is going away)}

Question 19

_{Upper Respiratory Infection}

If they have any of the followings:

^{Productive cough - Croup - Upper respiratory stridor - High fever - Purulent nasal drainage - Infectious nasopharyngitis} you should postopone the procedure for how long?

Answer 19

2 wks

Question 20

_{Upper Respiratory Infection}

If S/S lower respiratory tract involvement, you should postpone for how long?

Answer 20

4-6 wks

Question 21

_{Upper Respiratory Infection}

BRONCHIAL HYPERACTIVITY leading to Bronchospasm MAY EXIST UP TO how long

Answer 21

7 WKS

Question 22

_Asthma

How do you Determine severity/control of disease?

Answer 22

Prior ER visit/hospitalization

Medications (prn vs. daily)

MUST BE OPTIMIZED prior to GA

Question 23

_Asthma

What should you do if Asthma a/w Active wheezing, or S/S of infection are present?

Answer 23

Postpone surgery

Question 24

_Asthma

T/F: If they have asthma, Continue meds up to & including DOS

Answer 24

True

Question 25

Asthma T/F: Ensure adequate hydration

Answer 25

True

Question 26

Asthma Why is Antianxiety premedication important?

Answer 26

Psychologic triggers could cause a asthma attack

Question 27

_{Former Premature Infant} Definition of Former Premature Infant:

Answer 27

**\< 37 wks** gestation at birth **\< 2500 g** at birth

Question 28

_{Former Premature Infant} Under what condition could agitation/stimulation cause bronchospasm/cyanosis in Former Premature Infants?

Answer 28

**Chronic neonatal respiratory disease** Wich could lead to _Bronchopulmonary Dysplagia_ (**BPD**)

Question 29

Former Premature Infant Why is anti-anxiety/sedation required during exam in pts with Chronic neonatal respiratory disease or Bronchopulmonary Dysplagia (BPD)?

Answer 29

You could cause to have a Bronchospasm just by agitating them

Question 30

_{Former Premature Infant} T/F: Prolonged mechanical ventilation at birth increases the risk of Laryngeal/tracheal stenosis and must be assessed

Answer 30

True

Question 31

_{Former Premature Infant} Central apnea post GA which manifest as Cessation breathing \> 15secs, and is a/w Bradycardia (30 bpm below baseline), and Hypoxia (SaO2 \< 90%)

Answer 31

**Apnea of Prematurity** or **Central Apnea** Bag-mask ventilation may be required

Question 32

_{Former Premature Infant} What do As and Bs refer to in Premature Infants?

Answer 32

**Apneas** and **Bradycardias** where infant will hold breath, then become bradycardic. They will usually rebound on their own. This is watched carefully in the NICU. If no quick recovery, they will be bag masked

Question 33

_{Former Premature Infant} What's a major reason why Premature Infants are kept in the NICU for prolonged periods of time?

Answer 33

**Apnea of prematurity** They will go home on apnea monitor so that parents could be alarmed if they become apneic while not under direct suppervison such as at night when sleeping

Question 34

_{Former Premature Infant} What are risk factors for Apnea of prematurity or Central apnea post General Anesthesia?

Answer 34

Low gestational **age** ^{< 55 wks PCA} **Anemia** (Hgb \<10)

Question 35

_{Former Premature Infant} How could you prevent Apnea of prematurity or Central apnea post General Anesthesia?

Answer 35

**Postpone** elective surgery until \> 55 wks PCA Require postop respiratory **monitoring** for 24 hr admission

Question 36

_{Heart Murmurs} Heart Murmurs are a common finding on exam for infants. The majority of these murmurs are:

Answer 36

**Normal** flow murmurs **\< Grade II** **Vibratory** **Systolic** over mitral & pulmonic valves

Question 37

_{Heart Murmurs} Under which circumstances is a cardiology consult not required for heart murmur in infants?

Answer 37

**Previously** _detected_ and _documented_ If they 've had a Prior cardiac evaluation

Question 38

_{Heart Murmurs} When would you Obtain cardiology consult?

Answer 38

Previously detected with cardiac evaluation order but **not completed** Previously **undetected** (new murmur)

Question 39

_{Heart Murmur} What are possible clues to Previously undetected heart murmur?

Answer 39

Poor **exercise** tolerance/**feeding** intolerance **Hx CHD** immediate family Present in **diastole** **\> Grade III** Abnormal peripheral **pulses** **Cyanosis/**pallor/poor capillary refill

Question 40

_{Sickle Cell Disease} All children of which racial group presenting for anesthesia not previously screened must be Evaluated/Screened for Sickle Cell Disease?

Answer 40

All **black** american children

Question 41

_{Sickle Cell Disease} Evaluation of Sickle Cell Disease includes determining what?

Answer 41

Determine extent **end-organ** involvement Preop **transfusion** requirements

Question 42

_{Sickle Cell Disease} What's the benchmark standard diagnostic test for Sickle Cell Disease?

Answer 42

Hgb **electrophoresis**

Question 43

_{Sickle Cell Disease} T/F: Preop transfusion in Sickle Cell Disease is controversial

Answer 43

True

Question 44

_{Sickle Cell Disease} What are pre-op hematological goals in Sickle Cell Disease peds?

Answer 44

**Hct 35-40%** Normal (Hgb-A) = 50% of Total Hgb Total Hgb = (Hgb-A + Hgb-S)

Question 45

_{Sickle Cell Disease} What's the benefit of ensuring that Hct 35-40% with concentration of normal Hgb (Hgb-A) as close as possible to 50% of the total Hgb (Hgb-A + Hgb-S)

Answer 45

Decreased **blood viscosity** Increased **O2 carrying capacity** Decreased **sickling**

Question 46

_{Laboratory Evaluation} Why shouldn't you expect to have routine labs available in the peds population?

Answer 46

Routine labs **questionable** in peds

Question 47

_{Laboratory Evaluation} Although routine labs are questionable, results should be available for:

Answer 47

_Specific labs_ for **coexisting medical condition** & _Specific labs_ required for **surgical procedure**

Question 48

_{Laboratory Evaluation} Which labs are required from Healthy child scheduled for elective procedures?

Answer 48

None

Question 49

_{Laboratory Evaluation} Hgb/Hct is routinely ordered pre-op for what age group? How is is collected?

Answer 49

**\< 6 mos** Usually collected with a **finger stick**

Question 50

_{Laboratory Evaluation} Hgb/Hct is routine pre-op for \< 6 mos. Which Hgb value is required to proceed with elective surgery?

Answer 50

**Hgb \> 10 gm/dl**

Question 51

_{Laboratory Evaluation} When would you consider coagulation studies for a Preterm?

Answer 51

**Bleeding disorder** Potential l**arge blood loss**

Question 52

_{Laboratory Evaluation} Which pre-op chemistry would you consider ordering for a **premature** infant?

Answer 52

**Calcium** **Glucose**

Question 53

_{Preoperative Fasting Guidelines} What's the relationship between the length of fasting and Gastric volumes & pH in peds?

Answer 53

_Gastric volumes_ & _pH_ are **similar** with shorter periods of fasting compared to longer Shorter periods of fasting periods are _no less safe_ than longer _**Encourage clear liquids** up to 2 hours before surgery!!!!_

Question 54

_{Preoperative Fasting Guidelines} Why should clear liquids be encouraged for up to 2 hours before surgery? What's an exception to this?

Answer 54

Clear liquids up to 2 hours before surgery d**ecreases gastric residual volume** Exception to this includes presence of co-existing disease such as **gastric paresis** that prevents the emptying of the stomach

Question 55

_{CURRENT NPO GUIDELINES} Delay surgery for how long after SOLIDS?

Answer 55

**6-8 HRS**

Question 56

_{CURRENT NPO GUIDELINES} Delay surgery for how long after FORMULA if \<6 mos

Answer 56

**4 HRS**

Question 57

_{CURRENT NPO GUIDELINES} Delay surgery for how long after FORMULA \>6 mos

Answer 57

**6 HRS**

Question 58

_{CURRENT NPO GUIDELINES} Delay surgery for how long after BREAST MILK?

Answer 58

**4 HRS**

Question 59

_{CURRENT NPO GUIDELINES} Delay surgery for how long after CLEAR LIQUIDS?

Answer 59

**2 HRS** Encourage apple/grape juice, flat cola, sugar water up to 2 hrs before surgery

Question 60

_{Preoperative Fasting Guidelines} What are benefits of shorter fasting periods?

Answer 60

Inc. gastric pH Dec. gastric volume Dec. hypoglycemia Dec. hypovolemia

Question 61

_{Preoperative Fasting Guidelines} When is prolonged fasting recommended?

Answer 61

Disorders that affect digestion/gastric emptying require longer fasting periods **GERD** **DM** **Trauma** **Pyloric stenosis**