Preoperative Examination in Children

Aka: Preoperative Examination in Children, Pediatric Perioperative Evaluation, ADVANCE Family Centered Interventions for Surgery

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II. Epidemiology

  1. Incidence of surgery in children and teens in U.S.: 3.9 Million per year
  2. Most common surgical procedures
    1. Orthopedic Surgery
    2. Tonsillectomy and Adenoidectomy

III. History: Surgery-specific clearance questions for Children

  1. Growth and development problems
  2. Nerve or Muscle disorders
  3. Exercise tolerance
  4. Intubation history
  5. Dyspnea on exertion
  6. Cyanosis (e.g. at lips)
  7. Wheezing
  8. Snoring
  9. Upper respiratory symptoms in the last 4 weeks
  10. Bleeding Disorders (personal or Family History)
    1. See HEMSTOP Preoperative Hemostatic Assessment Questionnaire
  11. Blood thinner use (e.g. Aspirin, NSAIDS, Warfarin)
  12. Anemia History (or took Iron Supplementation)
  13. Anesthesia problems, especially cardiopulmonary (personal or Family History)
  14. Pregnancy risk

IV. History: Documentation Components

  1. Surgery Indication
  2. Medication Allergies
  3. Birth History
  4. Problem List
  5. Prior Surgeries or Trauma
  6. Tobacco use, Nicotine use (e.g. Vaping), Alcohol use, Marijuana use and other Ilicit Drug use
  7. Medications (including Herbals, over-the-counter medications and supplements)
    1. See Preoperative Guidelines for Medications Prior to Surgery
    2. See Perioperative Corticosteroid (Stress Dose Steroid in Adrenal Insufficiency)
    3. Identify which medications should be held (and how far in advance of surgery)
    4. Identify which medications should be taken on the day of surgery (and if dose modified)

V. Precautions

  1. Catch-up preventive care should be performed at a separate visit (not combined with preoperative evaluation)

VI. Exam

  1. Vital Signs
    1. Blood Pressure, Heart Rate and Respiratory Rate
    2. Weight, height an Body Mass Index
  2. Head and Neck Exam
    1. Airway abnormalities (see LEMON Mnemonic)
  3. Cardiopulmonary Exam
    1. Heart Exam
    2. Lung Exam
    3. Fluid Status
  4. Focus areas
    1. Evaluate any positive answers to surgery-specific clearance questions
    2. Evaluate comorbid condition specific examination

VII. Evaluation

  1. See ASA Physical Status Classification System
  2. Perioperative Risk Assessment
    1. https://riskcalculator.facs.org/peds/
  3. Diagnostic Testing
    1. Routine labs, imaging, EKG are not routinely ordered unless comorbid conditions or procedure dictates
    2. Routine infection screening during epidemics (e.g. COVID-19) are per local guidelines
    3. Consider Pregnancy Testing in all menstruating females (esp. 15 years and older)

VIII. Management: General

  1. See Preoperative Fasting Recommendation
  2. ADVANCE Family Centered Interventions for Surgery
    1. ADVANCE Mnemonic reflects goals of protocol
      1. Anxiety Reduction
      2. Distraction
      3. Video modeling and education
      4. Adding parents
      5. No excessive reassurance
      6. Coaching
      7. Exposure (shaping)
    2. Protocol (in addition to other surgery preparation)
      1. Day 5-7 before surgery (Preoperative Preparation Visit, Video and pamphlets given)
        1. What to expect on the day of surgery
        2. How parents can manage their anxiety and that of their child
        3. Distraction techniques
        4. Anesthesia mask practice kit (with instructions)
      2. Day 2 before surgery
        1. Confirm Caregiver received and reviewed information
        2. Confirm the Caregiver has a plan to distract their child
      3. Day of surgery (preoperative holding area)
        1. Age appropriate toys given to child
        2. Surprise box given to child that may not be opened until time of Anesthesia induction
      4. Day of surgery (Anesthesia induction)
        1. Caregiver follows plan for distracting child
        2. Caregiver accompanies child to the operating room
        3. Anesthesia mask is introduced to child and child is allowed to open the surprise box
  3. References
    1. Kain (2007) Anesthesiology 106(1): 65-74 [PubMed]

IX. Management: Respiratory Disorders - Perioperative

  1. Airway Abnormality
    1. See Advanced Airway in Children
    2. See Advanced Airway (includes LEMON Mnemonic, MOANS Mnemonic)
    3. Consult ENT regarding severe craniofacial abnormalities in the perioperative period
      1. In some cases, Tracheostomy may be considered before surgery
    4. Consult Anesthesia prior to surgery regarding airway concerns
    5. Disorders affecting airway
      1. Congenital: Down Syndrome, Pierre Robin Syndrome, Goldenhar Syndrome, Turner Syndrome
      2. History of orofacial surgery, neck surgery or neck radiation
      3. Neck lesions (Cystic Hygroma, Neck Hemangioma) may also interfere with airway management
  2. Obstructive Sleep Apnea and other sleep disordered breathing
    1. Evaluate for comorbid airway disorders (see above), neuromuscular disorders and cardiopulmonary disorders
    2. Manage Childhood Obesity well before surgery
    3. If child is on CPAP, bring the machine on the day of surgery
    4. Consider ENT consult if concerns for Tonsillar or adenoid hypertrophy
    5. Consider Sleep Study or Pulmonology Consult if suspected but undiagnosed Obstructive Sleep Apnea
    6. Consult Anesthesia regarding perioperative concerns and possible postoperative admission
  3. Asthma
    1. See Asthma Management
    2. Define Asthma severity (consider Pulmonary Function Tests if disorder not well defined or atypical)
      1. Intermittent Asthma
      2. Mild Persistent Asthma
      3. Moderate Persistent Asthma
      4. Severe Persistent Asthma
    3. Identify recent exacerbations and risks for Status Asthmaticus
      1. Recent Corticosteroids
      2. Recent emergency department visits or hospitalizations
      3. Recent increased beta Agonist use
      4. History of Endotracheal Intubation
    4. Optimize Asthma Management prior to surgery
      1. Stay on maintenance medications including on the day of surgery
      2. Consider prophylactic Albuterol in the hours before surgery
      3. Consider Perioperative Corticosteroids in Severe Asthma
      4. Defer non-urgent surgery until Asthma is stable
      5. Consult pulmonology or Asthma specialist for perioperative concerns (esp. Severe Asthma)
  4. Cystic Fibrosis
    1. Consult patient's pulmonologist and Anesthesia prior to surgery
    2. Optimize pulmonary function, airway secretions and nutrition in the perioperative period
    3. Consider perioperative Vitamin K Supplementation if impaired hepatic function (decrease bleeding risk)
  5. Perioperative Respiratory Infections
    1. Catch up on Immunizations well before surgery
    2. Screen for important respiratory infections during epidemics (e.g. Covid19)
    3. Evaluate for fever, lower respiratory tract infection and reactive airway disease findings
    4. Defer non-urgent surgery until improved
    5. Consult Anesthesia for perioperative respiratory infection concerns

X. Management: Cardiovascular Disorders - Perioperative

  1. Congenital Heart Disease
    1. Evaluate for Pediatric Congestive Heart Failure
    2. Consult with pediatric cardiology and Anesthesia in the perioperative period
      1. SBE Prophylaxis indications
      2. Preoperative cardiac evaluation (e.g. EKG, Echocardiogram, Chest XRay)
      3. Optimize cardiovascular status management (medications)
      4. Perioperative Anticoagulation
      5. Pacemakers and other cardiac rhythm management devices
      6. Minimize NPO period prior to surgery
  2. Heart Murmur
    1. See Heart Murmur in Children
    2. Evaluate for Pediatric Congestive Heart Failure
    3. Review prior Echocardiogram
    4. Consult pediatric cardiology if concerns for pathologic murmur and related testing (e.g. echo, ekg)

XI. Management: Hematology and Oncology Disorders - Perioperative

  1. Bleeding Disorders
    1. See HEMSTOP Preoperative Hemostatic Assessment Questionnaire
    2. Obtain preoperative coagulation studies preoperatively (Platelet Count, INR, PTT)
    3. Consult pediatric hematology if undiagnosed Bleeding Disorder identified in preoperative evaluation
  2. Hypercoagulability
    1. Ask about Family History and personal history of Venous Thromboembolism
    2. Consider Hypercoagulable evaluation if significant risks are identified
    3. See DVT Prevention in Perioperative Period
    4. Encourage preoperative hydration
  3. Cancer
    1. Consult pediatric hematology oncology regarding perioperative management
    2. Identify risks associated with treatment (e.g. neck Radiotherapy, Immunocompromised state, cardiovascular effects)
  4. Sickle Cell Anemia
    1. Consult hematology for perioperative management
    2. Maximize hydration prior to surgery
    3. Consider transfusion prior to surgery
    4. Labs should include Renal Function

XII. Management: Endocrine Disorders - Perioperative

  1. Diabetes Mellitus (Type 1 Diabetes Mellitus or Type 2 Diabetes Mellitus in Children)
    1. See Perioperative Diabetes Management (includes perioperative Insulin management)
    2. Consult pediatric endocrinology as needed prior to surgery
      1. Poorly controlled diabetes
      2. Insulin Pump management
    3. Consult pediatric nephrology for significant Chronic Kidney Disease
  2. Childhood Obesity
    1. Screen for Obstructive Sleep Apnea and Diabetes Mellitus
    2. Optimize lifestyle management

XIII. Management: Neurologic Disorders - Perioperative

  1. Developmental Delay
    1. Consider perioperative behavioral and mood management
    2. Follow ADVANCE Family Centered Interventions for Surgery protocol (see above)
  2. Seizure Disorder
    1. Consult neurology for recent uncontrolled Seizures
      1. Increased Seizure frequency
      2. Seizure-related hospitalizations
      3. Status Epilepticus history
    2. Continue antiepileptic medications on the day of surgery

XIV. Management: Genetic Disorders - Perioperative

  1. Malignant Hyperthermia Family History or Personal History
    1. Consider Genetic Testing or caffeine Halothane contracture test (CHCT)
    2. Alert Anesthesia to the use of non-triggering Anesthetic
  2. Pseudocholinesterase Deficiency
    1. Acquired (plasmapharesis history) or inherited
    2. Results in prolonged Depolarizing Neuromuscular Blocking Agent activity (e.g. Succinylcholine)
      1. Prolonged respiratory paralysis following Succinylcholine and delayed Extubation
    3. Anesthesia will typically use a Non-depolarizing Neuromuscular Blocking Agent (e.g. Rocuronium)
  3. Trisomy 21 (Down Syndrome)
    1. Airway risks include large Tongue, small mouth, propensity for laryngospasm, and Atlantoaxial Instability
    2. Consult pediatric cardiology for known cardiac defect or prior cardiac surgery

XV. Management: Miscellaneous Disorders - Perioperative

  1. Jehovah's Witness
    1. Understand family wishes and stipulations regarding human Blood Products in the perioperative period
    2. Anesthesia and surgery should review with family options for blood conservation
    3. Consider hematology consult regarding possible Iron Supplementation or Erythropoietin
    4. Discuss ethical and legal concerns in witholding Blood Products for life threatening Hemorrhage in a minor child
  2. Preterm Birth
    1. Consider preterm birth complications and consult specialty care as indicated
      1. Bronchopulmonary Dysplasia
      2. Low weigh and feeding difficulties
      3. Cardiac or neurologic deficits
    2. Management
      1. Consider postoperative hospital stay
      2. Alert Anesthesia to the risk of perioperative apnea and Bradycardia
      3. Optimize preoperative nutritional status

XVI. References

  1. (2014) Pediatrics 134(3): 634-41 [PubMed]
  2. Basel (2018) Anesthesiol Clin 36(4): 689-700 [PubMed]
  3. Fletke (2022) Am Fam Physician 105(6): 640-9 [PubMed]

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