Preoperative Evaluation of Pediatric Patients

Preoperative Evaluation of Pediatric Patients - Tiny Humans, Key Rules

• Unique Physiology: Higher metabolic rate & surface area/volume. Distinct airway, CV, respiratory, renal, hepatic functions.
• Crucial History:
  • Prior anesthesia/family Hx (Malignant Hyperthermia).
  • Recent URI: ↑ risk (laryngo/bronchospasm). Postpone elective if febrile/productive cough.
  • NPO: Clear liquids 2h, breast milk 4h, formula/solids 6h. 📌 2-4-6 rule.
• Focused Examination:
  • Airway: Large occiput/tongue, anterior larynx, cricoid narrowest (infants).
  • Loose teeth check.
• Investigations: Selective (e.g., Hb for major surgery/anemia).

⭐ Neonates are obligate nose breathers until approximately 3-5 months of age, making nasal patency crucial.

Preoperative Evaluation of Pediatric Patients - Clues, Cues & Check-ups

• History is Key:
  • Birth Hx: Prematurity, congenital anomalies.
  • Anesthetic Hx: Self/Family (e.g., MH).
  • Allergies, Meds.
  • Recent Illness: Esp. URI.
  • Fasting: NPO guidelines critical.
  • Immunizations.
• Physical Exam Focus:
  • General: Activity, hydration.
  • Airway: Pediatric features (large tongue, anterior larynx). Loose teeth!
  • CVS & Resp: Murmurs, wheezes.
• NPO Guidelines (📌 NPO-246):
  • Clear liquids: 2h
  • Breast milk: 4h
  • Formula/Light meal: 6h
• Syndromic Child: Anticipate difficulties (e.g., Down's, Pierre Robin).
• Investigations: Selective, not routine.

⭐ A child with a recent Upper Respiratory Infection (URI) has a 2-7 fold increased risk of respiratory adverse events during anesthesia, peaking in the first 2 weeks.

Preoperative Evaluation of Pediatric Patients - Tummy Empty, Calm Ready

• Fasting (NPO) Guidelines: 📌 NPO: 2-4-6-8 rule (Clear-Breast-Formula-Solid).
  • Clear liquids: 2 hrs.
  • Breast milk: 4 hrs.
  • Formula (infant), non-human milk, light meal: 6 hrs.
  • Solids (heavy, fatty/fried/meat): 8 hrs.
• Anxiolysis & Premedication: Aim: calm child, smooth induction.

  ⭐ Oral midazolam 0.25-0.5 mg/kg (max 15-20 mg) is a common anxiolytic premedication in children, given 20-30 minutes before induction.

  • Alternatives: Ketamine (PO/IM), Dexmedetomidine (IN).
  • Non-pharmacological: Parental presence, distraction techniques.
• Final Readiness Check:
  • Consent verified, allergies noted.
  • Equipment: age/weight appropriate.
  • Difficult airway strategy prepared.

Preoperative Evaluation of Pediatric Patients - Alerts & Special Kiddos

• Alerts & Key Considerations:

  • Recent URI: ↑ risk laryngospasm, desaturation, bronchospasm.
    • Clear rhinorrhea, afebrile, clear lungs: Proceed cautiously.
    • Fever, purulent sputum, wheeze: Postpone elective surgery 4-6 wks.
  • Anemia: Hb < 10 g/dL (infants), < 7 g/dL (children) often a concern.
  • Asthma/Reactive Airway Disease: Optimize preoperatively; consider premedication.

• Special Kiddos & Specific Risks:

  • Ex-premature:

    ⭐ Ex-premature infants born <37 weeks gestation are at increased risk of post-operative apnea if less than 52-60 weeks post-conceptual age (PCA).

  • Down Syndrome (Trisomy 21): Difficult airway (large tongue, small mouth), atlantoaxial instability (AAI), congenital heart disease (CHD).
  • Cerebral Palsy (CP): Gastroesophageal reflux disease (GERD) risk, seizures, variable muscle relaxant response.
  • Malignant Hyperthermia (MH) Susceptibility: Family Hx, specific myopathies (e.g., Duchenne).
  • Obstructive Sleep Apnea (OSA): High risk post-op respiratory compromise; plan for appropriate monitoring.

High‑Yield Points - ⚡ Biggest Takeaways

• NPO guidelines are critical: 2 hrs for clear fluids, 4 hrs for breast milk, 6 hrs for formula/light meal.
• Recent URTI (<4-6 wks): ↑ risk of laryngospasm/bronchospasm; postpone elective surgery if symptomatic.
• Congenital Heart Disease (CHD): Detailed assessment vital; SBE prophylaxis per current guidelines.
• Pediatric Airway: Characterized by a large tongue, anterior larynx, and narrowest point at the cricoid cartilage (relevant for uncuffed ETTs).
• Key labs: Preoperative Hb/Hct for major surgery or anticipated significant blood loss; others guided by clinical indication.
• Anxiety reduction is paramount; consider parental presence during induction to alleviate distress ancooperationd improve cooperation.