Preoperative Evaluation of the Pediatric Patient

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Preoperative Evaluation of the Pediatric Patient

• Marvin S. Cohen MD.
• UTMB

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Pharmacologyof the Newborn

• TBW Neonate (80)gtInfant (70)gtAdult (60)
• Hydrophillic durgs have greater vol of dist.
  (sux)
• Redistribution is less effective (thiopental)
• Delayed excretion
• Decreased degradation
• Less protein binding

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Pharmacologyof the Newborn

• Half life of drugs
• Prolonged in neonate
• Shortened in infants and children. (greater blood
  flow to liver and kidneys)
• Becomes normalized in teens and adults

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Induction agents

• Generally requires slightly elevated dose (STP
  5- 6 mg/kg) - larger vol. of dist.
• Longer half life due to reduced clearance
• May be more sensitive to resp depressant effects

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Muscle relaxants

• Non- depolarizers
• More sensitive
• Higher volume of distribution
• Liver/kidney metabolism decreased
• Succinylcholine
• Less senstive
• Higher volume of distribution - hydrophilic
• Reserve for emergency (hyper K)
• Beware bradycardia
• No phase two block

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Inhalation Agents

• Inhalation induction is faster in infants and
  neonates

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Risk

• Adultsltchildrenltinfantsltneonates
• ASA1ltASA2ltASA3
• Low birth weight
• Incidence of cardiac arrest in children
  1.4/10,000 - POCA STUDY

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Risk 2

• Airway Management (68 )
• Lanryngospasm
• Bronchospam
• Esophageal intubation
• Aspiration
• Cardiac Arrests (32 )
• Halothane (two from sevoflurane)
• Medications including caudal bupivicaine

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Caudal Anesthesia

• Good Technique
• Catheter over needle
• Aspirate frequently
• Inject incrementally
• Bupivicaine with 1200,000 epi
• Tachycardia
• T wave increase

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URI

• See Dr. Abouleishs lecture 12/20

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Asthma

• Incidence in general population is growing
• Anestheisa and Surgery increase risk of
  bronchospasm
• Good history and physical
• PFTs in children under 6 are not reliable.
• Maximize preop preparation.

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Asthma 2
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Apnea

• Infants born lt 37 weeks have increased risk of
  apneic spells (gt15 seconds)
• All general anesthetics interfere with
  respiratory drive

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Apnea 2Minimize risk

• Delay surgery until 48 60 weeks
• Use spinal/caudal anesthesia
• Caffeine base 10mg/kg IV
• Admit all patients at risk to ICU post op

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Bronchopulmonary DysplasiaBPD

• Oxygen dependence at 36 weeks PCA in Infants
  lt1500 gms
• Increased risk of hypoxia
• Brochospasm
• V/Q mismatch
• Cor pulmanale
• Tracheomalacia
• Pneumonia

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BPD 2Treatment

• Bronchodilators
• Antibiotics
• Diuretics
• Steroids

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Epinephrine Your best friend
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Murmurs

• Functional murmurs
• Normal S1 and S2
• Normal exercise tolerance
• Acyanotic
• Growing well

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Murmurs 2

• Pathological (even asymptomatic)
• Must be assessed by cardiology with at least ECG
  and a recent echocardiogram
• Complete medical and surgical history must be
  available
• Consider Chest Xray, hematicrit, O2 sat

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SBE Prophylaxis

• All children with congenital heart disease
  except
• Ligated PDA
• Primary closure of secundum ASD with out patch
• All surgeries at risk of transient bacteremia
• Dental, sinus, airway, GU, GI
• Exception BMTs

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SBE Prophylaxis 2

• Respiratory and Esophageal Procedures
• Ampicillin 50mg/kg IV
• PCN allergy Cefazolin 25 mg/kg IV
• GU and GI Procedures
• Ampicilln 50 mg/kg and Gentamicin 1.5 mg/kg
• PCN all Vancomycin 20 mg/kg and Gent.

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CNS

• Hydrocephalus
• Evaluate of ICP, shunt patency, meningitis
• Latex precautions
• Seizure History
• If unstable get drug levels
• Remember Post op administration

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Sickle Cell Disease

• Hemoglobin and hemoglobin S levels in major
  surgery.
• Transfuse to Hgb of 10 g/dl and or Hemoglobin S lt
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• Beware of
• Cardiomyopathy
• Nephropathy
• Peripheral neuropathy
• Respiratory dysfunction

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Retinopathy of Prematurity

• Etiology is multifactorial
• ?Low birth weight (lt1000 gms)
• ?prolonged Oxygen exposure
• Retina matures at 44 weeks PCA
• Maintain SaO2 at 93 -95 if possible.

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Review of Systems Anesthetic Implications
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Review of Systems Anesthetic Implications
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Review of Systems Anesthetic Implications
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DEVELOPMENTAL MILESTONES
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DEVELOPMENTAL MILESTONES
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DEVELOPMENTAL MILESTONES
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DEVELOPMENTAL MILESTONES
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Classic Stage Theories
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