BJA Education, 23(6): 238e244 (2023)

doi: 10.1016/j.bjae.2023.01.009
Advance Access Publication Date: 21 March 2023

Matrix codes: 1I05;

2A03; 3D00

Paediatric preoperative assessment

H. Lewis1,* and A. Norrington2
1
The Royal London Hospital, London, UK and 2South Tees NHS Trust, Middlesbrough, UK
*Corresponding author. h.lewis4@nhs.net

Keywords: anaesthesia; paediatrics; preoperative assessment

Key points
Learning objectives
By reading this article, you should be able to:
Preoperative assessment is the opportunity to
prepare and optimise a patient before surgery.

Outline how paediatric preoperative assessment

Preoperative assessment can be virtual or face to
services can be organised in line with the new
face depending on the individual needs of the
Association of Paediatric Anaesthetists of Great
child.
Britain and Ireland Best Practice Guidance.

Most children attending preoperative assessment

Explain the role of preoperative assessment for
are of ASA Grade 1 or 2 having ambulatory
common chronic conditions, including asthma
surgery.
and diabetes mellitus.

Increasing numbers of children with complex

Discuss the perioperative management of anti-
comorbidities are presenting for elective surgery.
coagulation therapy for children.

Health screening for conditions, such as obesity,
should occur at preoperative assessment.

Anaesthetic preoperative assessment of adult patients is a

argument. However, the last few decades have seen signifi-
well-established part of perioperative practice, supported by
cant reductions in neonatal mortality without corresponding
an increasing body of evidence.1 Preoperative assessment for
reductions in morbidity or preterm birth.2 Diagnosis and
children and young people lags behind adult services, occur-
management of disease in childhood have evolved, and sur-
ring more sporadically and with no formalised standards of
gical presentations are now more complex. The argument for
care until recently. This situation probably stems from the
high-quality, consistent preoperative assessment services,
view that children are at ‘lower risk’ and do not require pre-
described in the recent Association of Paediatric Anaesthetists
operative interventions, which historically was a valid
of Great Britain and Ireland (APAGBI) Best Practice Guidance,
is therefore an easy one to make.3
Preoperative assessment encompasses many elements,
Hannah Lewis MSc FRCA is a consultant paediatric anaesthetist at which facilitate improved service delivery and satisfaction
The Royal London Hospital. She is joint chair of the national Paedi- from patients and carers. It is an opportunity for detailed
atric Anaesthesia Trainee Research Network (PATRN). Her areas of anaesthetic assessment and allows for multidisciplinary
specialist interest are preoperative assessment, quality improvement planning, shared decision-making, optimisation of chronic
and anxiety management in children. conditions and provision of information before surgery. It
allows early identification and management of anxiety and
Amy Norrington BSc Hons, DCH PGCertMedEd FRCA is a consultant
reduces potential long-term negative psychological effects
paediatric anaesthetist and lead for paediatric anaesthesia and
from perioperative experiences. Finally, preoperative
preoperative assessment at South Tees NHS Trust. She was a
assessment is a ‘teachable moment’ for opportunistic health
contributing author for the recent Association of Paediatric Anaes-
screening and intervention, bringing together objectives
thetists of Great Britain and Ireland Best Practice Guidance for
from the NHS Long Term Plan and the campaign ‘Making
paediatric preoperative assessment services. Her areas of interest
Every Contact Count’.3
include preoperative assessment and management of perioperative
anxiety in children.

Accepted: 27 January 2023

Crown Copyright © 2023 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: permissions@elsevier.com

238

Delivering paediatric preoperative
assessment
All children having procedures under anaesthesia should have
preoperative assessment before the day of surgery, specifically
tailored to their needs in an area designed for them.
The key organisational elements of paediatric preoperative
assessment include3,4
(i) Triage: children and young people should pass through
an electronic or paper-based triage system to individu-
alise their care. This system aims to establish the type of
assessment needed and any additional requirements.
Suggested criteria for face-to-face assessment are shown
in Box 1.
(ii) Nurse-led preoperative assessment: the central part of
the service is nurse-delivered preoperative assessment,
which can be face-to-face or virtual.
(iii) Consultant anaesthetist review: children with complex
medical or behavioural comorbidities or children un-
dergoing complex procedures should be reviewed by a
consultant anaesthetist.
The timing of preoperative assessment varies depending
on the complexity of the case and the scheduled procedure. It
should occur at least 2 weeks before admission to hospital.
With more complex cases, referral may occur before surgery is
scheduled. This is to allow sufficient time for information
gathering, investigations, optimisation and preparation.
Perioperative plans should be created for all children using a
collaborative multidisciplinary approach. Shared decision-
making should be used throughout.3,4
Preoperative assessment also has broader roles within
healthcare. It is an important part of efficient service delivery,
ensuring conditions are managed at the most appropriate
hospital for the patients’ needs. Cooperation between preop-
erative assessment and operational delivery networks also
potentially allows for a wider regional collaborative approach
to reducing waiting lists.3
Established preoperative assessment clinics can provide a
central contact point for patients and families, improving
consistency of perioperative advice. One of the most common
reasons for day-of-surgery cancellation is upper respiratory
Box 1
Criteria for face-to-face preoperative assessment2
Criteria requiring face-to-face assessment
Preterm infants less than 60 weeks post-conceptual age
Potential difficult airway
Poorly controlled chronic illness (e.g. asthma)
Kidney or liver disease
Cardiac disease (including a new heart murmur)
Genetic disorder
Diabetes mellitus or metabolic disease
Learning difficulties or autism
Haemoglobinopathy, anaemia or clotting problem
Hypertension requiring treatment
Safeguarding concerns or children requiring consent by
social services
Previous history or family history of problem with
anaesthesia
Complex physical disability
Requires any investigations (e.g. blood tests and swabs)
Request from the patient or carer
Preoperative assessment in children
tract infections. A central contact number with nurse-
delivered flowcharts creates an opportunity for earlier post-
ponement of children who are unwell and optimisation of
valuable operating theatre time.4
History and examination
A standardised history should be taken recording birth his-
tory, immunisation status, chronic or congenital conditions,
prior anaesthetic experiences, anxiety or behavioural con-
cerns, medications and allergies. Patients with conditions
affecting the conduct of anaesthesia, for example neuro-
muscular disease, previous anaphylaxis or reactions to
anaesthesia (malignant hyperthermia or suxamethonium
apnoea), should be reviewed and an individualised plan for
anaesthesia made. Children receiving non-invasive ventila-
tion, home oxygen or with a tracheostomy may also need
more detailed planning.
Anxiety occurs in up to 80% of children presenting for
surgery. Early identification allows for planning and prepa-
ration, including the use of play therapists, psychologists,
premedication and virtual or actual hospital tours. A detailed
discussion of the management of anxiety is beyond the scope
of this article but should be considered by all.
Every child should have their height, weight and appropriate
observations (heart rate, oxygen saturations, temperature and
blood pressure in children 3 yrs old) measured. Children who
are suitable for telephone preoperative assessment can have
these measurements taken on the day of surgery. Airway
assessment is essential, including loose deciduous teeth, pre-
vious upper airway problems and suspected airway challenges.
Examination should also include potential i.v. access sites and
auscultation of the chest, which is important even in children
who are well, to detect undiagnosed heart murmurs.
It is important to establish specific communication needs of
both patients and carer. For some patients, early involvement
of the hospital’s learning disability team is appropriate.3,4
Investigations
Well children undergoing ambulatory surgery do not routinely
require investigations. A full blood count (FBC) and group and
save should be performed before surgery, where there is a
possibility of significant blood loss, or in children at risk of
anaemia. Other investigations are only necessary for children
with more complex medical problems (Table 1).3,4
Outcomes from preoperative assessment
At completion of the preoperative assessment visit, each child
should have an individualised plan and enough information
to prepare them and their carers for the perioperative journey.
This plan should include.
(i) Suitability for day-case surgery and type of inpatient
bed required
(ii) Referral of children to a more specialist centre if services
required before or after surgery are not available locally
(iii) Specific logistics relating to anaesthesia, for example
remote site
(iv) Anaesthetic and analgesic plans should be discussed
with children and their carers, including pre-
medications, preferred induction strategy and
advanced analgesic techniques.
BJA Education - Volume 23, Number 6, 2023 239
Preoperative assessment in children

(v) Decisions concerning the perioperative management of
medications for children with chronic conditions
should be taken with the parent medical team. A writ-
ten plan should be provided for patients and carers to
help with the management of any changes.
(vi) Verbal and written information on local fasting policy
should be provided.
(vii) Risks of anaesthesia should be communicated in line
with General Medical Council (GMC) guidance.
(viii) Families should be counselled about key events on the
day of surgery, including pregnancy tests and viral swabs.
(ix) Information and preparation resources should be pro-
vided. These may include virtual resources or apps,
sequencing cards, leaflets or online links. Some chil-
dren may benefit from targeted play specialist input.
(x) The results of health screening should be described
capturing the surgical motivator for positive behavioural
change.
Patients’ and clinicians’ satisfaction with the preoperative
assessment service should be audited at all stages.3,4
Health screening
Preoperative assessment provides the ideal opportunity to
address health and lifestyle changes. Obesity, smoking, mental
health, chronic pain and dental care can all be assessed.3
Oral health
Twenty-five percent of children aged 5 yrs have dental
decay. Children identified with poor oral health should be
referred to NHS dental services. It may be worth considering
dental interventions at the time of their surgery. Parents can
be directed to the Health Education England resource ‘Mini
Mouth Care Matters’ for further information.3
Obesity
All children attending preoperative assessment should have
their BMI calculated. Almost a quarter of paediatric patients
undergoing surgery are overweight (>91st centile), have
obesity (>98th centile) or have severe obesity (>99.6th centile).
Children with obesity are more challenging to anaesthetise
and prone to perioperative complications.5
The psychological impact of weight should be explored and
lifestyle advice offered. Local pathways should be in place to
identify children who would benefit from further in-
terventions, which may include.
(i) Detailed assessment of the airway
(ii) Investigations to screen for comorbidities (fasting
glucose, HbA1c, liver function, thyroid function, lipids
and vitamin D, sleep study, ECG, ECHO and spirometry)
(iii) Referral to community weight management pro-
grammes or paediatric specialists
(iv) Review of any safeguarding concerns
All preoperative assessment units should have their own
pathways for children with obesity taking into account na-
tional guidance.3,5
Tobacco smoking
Environmental exposure to tobacco smoke increases the inci-
dence of adverse perioperative events. Children living in
households with smokers are more likely to develop chronic
conditions, such as asthma, and are at higher risk for acute ill-
nesses, such as middle ear infections and bacterial meningitis.
Screening for parental smoking should be incorporated in
the preoperative assessment health questionnaire. All
smokers should be offered smoking cessation advice. A model
for such intervention is ‘very brief advice’, which comprises
three main domains.
(i) Ask about exposure.
(ii) Advise on risk to the child’s general and perioperative
health.
(iii) Act to refer for smoking cessation support.
Parents who smoke are more likely to stop in these cir-
cumstances, and this ‘teachable moment’ should be exploited
throughout the perioperative process.3,6
Specific conditions
Respiratory
Asthma
Children with asthma are at increased risk of perioperative res-
piratoryadverseevents(PRAEs).Keymarkersofincreasedriskare.
(i) Respiratory tract infection within 4 weeks
(ii) Previous exacerbation under anaesthesia
(iii) Moderate or severe asthma
(iv) Previous artificial ventilation for acute asthma
(v) Children 5 yrs old7

Table 1 Investigations at preoperative assessment2

Investigation ASA 1 ASA 2 ASA 3e5

Full blood count Minor surgery: not routinely
Major surgery: yes
Urea and electrolytes Minor surgery: not routinely
Major surgery: yes
Coagulation screen Minor surgery: not routinely
Major surgery: not routinely
ECG Minor surgery: not routinely
Major surgery: not routinely
Minor surgery: not routinely
Major surgery: yes
Minor surgery: not routinely
Major surgery: yes
Minor surgery: not routinely
Major surgery: not routinely
Minor surgery: not routinely
Major surgery: not routinely
Minor surgery: not routinely
Major surgery: yes
Minor surgery: If at risk of acute kidney
injury
Major surgery: yes
Minor surgery: not routinely
Major surgery: discuss with consultant
anaesthetist
Minor surgery: discuss with consultant
anaesthetist
Major surgery: discuss with aconsultant
anaesthetist

240 BJA Education - Volume 23, Number 6, 2023


The latest respiratory clinic letter and the child’s asthma
management plan should be reviewed. Completion of the
‘asthma control test’ is useful with referral back to the asthma
team or general practitioner, where indicated.3 If control is poor,
deferral of elective surgery should be considered. Severe cases
should be seen by the parent medical team and reviewed by a
consultant anaesthetist. Additional investigations are not usu-
ally necessary.
Asthma medications should be given as usual before sur-
gery to reduce the chance of exacerbations. In some instances,
short courses of oral corticosteroids may be helpful. Children
with recurrent infections may benefit from preoperative an-
tibiotics. Smoking cessation advice should be given to any
smoker within the household.3,7,8
Sleep-disordered breathing
Sleep-disordered breathing is a spectrum of disorders ranging
from simple snoring to obstructive sleep apnoea (OSA).
Obstructive sleep apnoea is classified as mild (apnoea hypo-
pnoea index [AHI] of <5 h1), moderate (AHI 5e10 h1) or se-
vere (AHI >10 h1) on polysomnography. The most common
cause is adenotonsillar hypertrophy, with diagnosis peaking
aged 2e6 yrs. Other causes include chromosomal abnormal-
ities, craniofacial syndromes, cerebral palsy, neuromuscular
disorders and obesity. Adenotonsillectomy is the mainstay of
treatment for moderate-to-severe OSA.9,10
Diagnosis is primarily clinical, with a history of snoring three
or more times per week, audible or witnessed apnoea three or
more nights per week and behavioural symptoms. All children
presenting to preoperative assessment should be asked about
these symptoms. The gold-standard diagnostic investigation is
polysomnography, but this test is reserved for cases where
diagnostic uncertainty exists. Overnight pulse oximetry is less
expensive but not as diagnostically reliable and is a poor pre-
dictor of PRAEs. An echocardiogram should be considered for
patients where there are signs of right ventricular dysfunction
or severe desaturation (<70%) on polysomnography.9,10
Obstructive sleep apnoea is an independent risk factor for
PRAEs. Risk stratification is important for perioperative plan-
ning. Risk factors to consider are.
(i) Age (3 yrs old)
(ii) Weight (above 99.6 BMI centile or below 0.4 BMI centile)
(iii) Severe OSA
(iv) Comorbidities (cardiac complications, craniofacial ab-
normalities, cerebral palsy, neuromuscular disorders,
mucopolysaccharidosis, achondroplasia and other sig-
nificant comorbidity)9,10
In the UK, secondary centres can treat children 2 yrs old
and 12 kg without additional risk factors. Patients <3 yrs old
should generally be admitted overnight. Children who have
additional risk factors or who are <2 yrs old should be
managed at centres with appropriate critical care facilities.
Perioperative risk stratification is not straightforward and
may require multidisciplinary planning.9,10
Cystic fibrosis
Perioperative management of cystic fibrosis (CF) in children
is complex and should always involve the parent CF team.
Preoperative assessment should ascertain disease severity,
functional status, glycaemic control and additional organ
involvement. Frequency of exacerbations and sputum vol-
ume in younger children are good indicators of severity.
Recent imaging should be reviewed. Patients may be
Preoperative assessment in children
admitted to hospital before surgery for physiotherapy,
bronchodilators and mucolytics, and in some cases anti-
biotic therapy. Preoperative planning is important to enable
timely physiotherapy, allocation of side rooms, list sched-
uling and involvement of the CF team. The need and timing
of i.v. access should be considered, as it may affect the
planning of anaesthesia.11
Tracheostomy
Children with a tracheostomy have a greater perioperative risk.
The indication for the tracheostomy, type and size, usual care
regimen, details of previous upper airway management and
any home ventilation protocols should be recorded.
Postoperative care depends on the individual needs of the
child. Some children can be discharged the same day, whereas
others may require critical care input. Not all tracheostomy
tubes are compatible with MRI, and these should be changed
before scanning. Multidisciplinary involvement, including the
respiratory team, is paramount.12
Endocrine
Diabetes mellitus
Diabetes mellitus (DM) is the most common endocrine disor-
der in childhood. Glucose control is disrupted in the periop-
erative period, and multidisciplinary planning with input
from the child’s endocrine team is essential. The child should
be reviewed by a consultant anaesthetist and an individual
management plan created. This will depend on the child’s
current treatment regimen, type and timing of surgery and
expected starvation period.13
Modification of the child’s usual insulin regimen is
adequate for minor surgery. Children on a basal bolus regime
can continue long-acting insulin and halve or omit
immediate-acting insulin with the missed meal. A variable-
rate insulin infusion may be needed for children having ma-
jor surgery, where oral intake is unlikely to resume immedi-
ately. Type 2 DM in children receiving insulin can be managed
in the same way. Oral hypoglycaemics can be given up until
the day of surgery, except for metformin.13
A recent HbA1c (within 3 months), serum electrolytes,
current blood glucose and blood or urinary ketones should be
recorded. Any previous episodes of hypoglycaemia and cor-
responding symptoms should be noted. Elective surgery
should be postponed if diabetes is not well controlled (HbA1c
>8.5%/69 mmol mol1), and the child should be referred for
optimisation. Patients should be scheduled early on the
operating list to minimise the duration of fasting.13
Children with other more complex endocrine conditions,
such as thyroid disease, diabetes insipidus or phaeochromo-
cytoma, should be reviewed by a consultant anaesthetist and
a multidisciplinary plan developed with paediatric endocrine
teams well in advance of surgery.
Metabolic disorders
Children with metabolic disorders are at high risk for acute
decompensation in the perioperative period. Infection, fasting
and the stress response to surgery can all trigger decompen-
sation. Metabolic disorders in children should be managed in
centres with appropriate critical care facilities and in collab-
oration with the paediatric metabolic team. Supplemental co-
factors and special diets should be continued. Fasting times
should be minimised with patients scheduled early on the list,
and where there is risk of hypoglycaemia, i.v. solutions
BJA Education - Volume 23, Number 6, 2023 241
Preoperative assessment in children
containing dextrose 10% started. A preoperative FBC, urea and
electrolytes, blood gas, ammonia concentration and capillary
blood glucose are recommended. Patients should be reviewed
by a consultant anaesthetist for individualised planning.14
Renal disease
Multidisciplinary care is essential for children with renal
disease. History should include the cause, duration and
severity of impairment and involvement of other systems.
Daily urine output, fluid restriction, blood pressure, mode of
dialysis and medication should be ascertained. Recent blood
tests and ECG should be reviewed. Surgery should be timed
with preoperative dialysis.15
Anaemia
Anaemia increases the need for perioperative blood trans-
fusion and mortality after surgery. All children undergoing
major surgery or with risk factors for anaemia should have a
preoperative FBC. In children with a new diagnosis of
anaemia, haematinics (folate, B12 and ferritin concentrations)
and iron studies should be measured, and the general prac-
titioner informed. Iron deficiency remains the most common
cause of anaemia and should be treated with preoperative oral
iron and response checked. I.V. iron should be considered if
there is no response. If the child is anaemic and haematinics
and iron studies are normal, clinical review and haematology
referral are recommended. Children with a known inherited
anaemia should be reviewed by a consultant anaesthetist and
a plan made in collaboration with the haematology team.3,16
Sickle cell anaemia
Sickle cell anaemia in children requires careful multidisci-
plinary management with the haematology team involved.
Day-case surgery is usually not advised. Recommended in-
vestigations include FBC, cross match, haemoglobin electro-
phoresis and urea and electrolytes. Additional investigations
depend on whether chronic complications are present. The
fasting period should be minimised with children scheduled
early on the operating list, and i.v. fluids considered once
fasting commences. The acute pain team should be made
aware of children undergoing major surgery, especially chil-
dren with a history of chronic pain. Preoperative transfusion
should optimise haemoglobin concentrations to 10 g dl1.
Children having high-risk surgery may also require an ex-
change transfusion, so the haemoglobin S level is <30%. Se-
vere cases may need review by a consultant anaesthetist.
Children with sickle cell trait rarely have any clinical symp-
toms and usually cope well with surgery. They should be
identified at preoperative assessment so that any necessary
adjustments to their perioperative journey can be made.17
Cardiac disease
Children with cardiac disease having non-cardiac surgery
have a higher 30-day mortality and an increased incidence of
perioperative cardiac arrest. Risk stratification is important to
determine where these children should be managed in the
perioperative period and whether surgery is appropriate.
Complex and decompensated disease; pulmonary hyperten-
sion, cardiac failure, arrhythmias or cyanosis, should be
managed in a specialist cardiac centre. Highest-risk lesions for
adverse events are cardiomyopathy, aortic stenosis and
single-ventricle circulations. Children having major surgery
242 BJA Education - Volume 23, Number 6, 2023
and children <2 yrs old should be referred to a specialist
centre. Cardiac disease in low-risk patients (e.g. physiologi-
cally normal, or well compensated disease, in an older child
having minor surgery) can be managed locally, although dis-
cussion with their specialist team is recommended.18,19
Preoperative assessment should include a discussion with
the child’s cardiology team and most recent cardiac in-
vestigations. Difficult venous access should be anticipated in
the child who has undergone multiple procedures and
intensive care admissions.
Most cardiac medications should be continued, but this
approach should be reviewed on an individual basis.
Antithrombotic therapy may need to be altered or stopped in the
perioperative period. Decisions should be made in conjunction
with the cardiology, haematology and surgical teams. In gen-
eral, aspirin should be continued, especially in children with
shunts, to prevent thrombosis. Angiotensin-converting enzyme
inhibitors are omitted routinely in adult practice; the evidence in
children is less clear and is done on a case-by-case basis.18,19
Neurological
Epilepsy
Epilepsy is one of the most common neurological pre-
sentations in children. Seizure history, including type, fre-
quency and control, should be ascertained. Anti-epileptic
drugs should be continued and a rescue plan for seizures
documented. The most recent epilepsy review should be ob-
tained, including blood tests and drug concentrations. Addi-
tional investigations depend on specific patient factors (e.g.
cardiac involvement in patients with tuberous sclerosis). A
consultant anaesthetist should review children with epilepsy
syndromes or poorly controlled disease.20
Cerebral palsy
Cerebral palsy is a non-progressive brain injury that occurs in
the neonatal period. Severity varies greatly, making every
patient unique. Common associations include problems with
muscle tone and movement, joint contractures and scoliosis.
Patients may also present with epilepsy, visual and hearing
problems, communication and behavioural challenges and
gastrointestinal issues. It is important to establish precise
patient needs in preoperative assessment. This affects list
organisation, surgical positioning, airway management,
venous access, pain assessment and postoperative care. The
multidisciplinary team should be involved throughout.21
Neuromuscular disease
Patients with neuromuscular disease require specific plan-
ning, related to respiratory and cardiac function and the
impact of underlying disease on anaesthetic technique. Con-
siderations include.
(i) Degree of respiratory and cardiac impairment and
requirement for postoperative critical care
(ii) Rhabdomyolysis: the risk is highest in younger children
(<8 yrs old). Known triggers (volatile agents and sux-
amethonium) should be avoided.
(iii) Malignant hyperthermia (MH): known triggers (volatile
agents and suxamethonium) should be avoided in chil-
dren with a confirmed diagnosis, significant family his-
tory or specific predisposing condition (central core
disease, KingeDenborough syndrome and Evans
myopathy).22
 Preoperative assessment in children

Table 2 Management of anticoagulant therapy for children.23 LMWH, low-molecular-weight heparin; VTE, venous thromboembolism

Anticoagulant Minor thrombosis risk (e.g. long- Intermediate thrombosis risk Major thrombosis risk (e.g. VTE
term secondary prevention) (e.g. VTE last 6e12 weeks or within 6 weeks or metallic heart
stroke last 3 months) valve)

Oral anticoagulant Minor surgery: stop >24 h; stop
(e.g. rivaroxaban) >48 h if impaired renal function
Major surgery: stop >48 h
After surgery: restart after 6e8 h if
no risk of bleeding; give
prophylactic LMWH 6e12 h after
if risk of bleeding
LMWH Before surgery: stop 1 day before
After surgery: give prophylactic
LMWH after 6e12 h
Warfarin Preoperative: stop 4 days before
After surgery: give prophylactic
LMWH after 6e12 h
Minor surgery: stop >24 h; stop
>48 h if impaired renal function
Major surgery: stop >48 h
After surgery: restart after 6e8 h if
no risk of bleeding; give
prophylactic LMWH 6e12 h after
if risk of bleeding
Before surgery: stop 1 day before
After surgery: give prophylactic
LMWH after 6e12 h
Preoperative: stop 4 days before;
give prophylactic LMWH 3 days
before surgery
After surgery: give prophylactic
LMWH after 6e12 h
Minor surgery: stop >24 h; stop
>48 h if impaired renal function
Major surgery: stop >48 h
After surgery: restart after 6e8 h if
no risk of bleeding; give
prophylactic LMWH 6e12 h after
if risk of bleeding or consider
heparin infusion
Before surgery: stop 1 day before;
consider substituting with
prophylactic LMWH or a heparin
infusion if >24 h until surgery
After surgery: give therapeutic
LMWH after 6e12 h
Preoperative: stop 4 days before;
give therapeutic LMWH 3 days
before surgery or consider
heparin infusion
After surgery: give therapeutic
LMWH after 6e12 h

Antithrombotic therapy satisfaction and reduces the risk of day-of-surgery cancella-

tion. In stretched healthcare systems with long waiting times
Management of anticoagulant therapy for children is a bal-
and social demand for timely care close to home, preoperative
ance between the bleeding risk from surgery and the risk of
assessment allows children and young people to be assessed
perioperative thrombosis. A written plan should be put in
and undergo surgery safely and efficiently at the right time,
place for both stopping and restarting medications. Therapy
right place and with the right team.
can be continued when the procedure is a low risk for
bleeding, for example dental treatment. When risk of throm-
bosis is low, therapy can usually be stopped temporarily. Declaration of interests
Children at high risks of both bleeding and thrombosis may
The authors declare that they have no conflicts of interest.
require bridging with a heparin infusion (Table 2).23

Implantable devices
Children with implantable devices, such as cardiac pace-
makers, programmable shunts, vagal nerve stimulators and
deep brain stimulators, require special precautions and input
from the consultant anaesthetist. Plans may include decisions
about positioning, use of diathermy and MRI compatibility of
the device. Not all devices are compatible with MRI imaging,
and discussions with manufacturers are vital if there is doubt.
The surgeons should be informed, as medical devices may
have implications for surgical technique.
Some devices require cardiac or neurophysiologists to
reprogramme them. This process may affect the organisation
of the operating list. If there is a chance of any electromag-
netic interference during surgery, implantable cardiac de-
fibrillators should be switched off and external pads applied.
Children with pacing dependency should have the device
reprogrammed to an asynchronous mode during surgery.24
Conclusions
Formalised preoperative assessment in paediatrics is a
desirable development, bringing the care of children in line
with that of adults. It allows for individualised care, shared
decision making and informed consent. It improves
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
References
1. The Faculty of Intensive Care Medicine, Intensive Care
Society, Association of Anaesthetists, Royal College of
Anaesthetists. Preoperative assessment and optimisation
for adult surgery including consideration of Covid-19 and
its implications 2021. Available from https://static1.
squarespace.com/static/5e6613a1dc75b87df82b78e1/t/
6178045dc738d662e3bb14b5/1635255456609/
Preoperativeþassessmentþandþoptimisationþguidance_
format1.pdf (accessed 3 November 2022).
2. UNICEF. Neonatal mortality 2023. Available from https://
data.unicef.org/topic/child-survival/neonatal-mortality/
(accessed 3 November 2022).
3. S. Courtman, Best practice guidance. Preassessment ser-
vices for children undergoing surgery or procedures, 2022.
Available from https://www.apagbi.org.uk/sites/default/
files/2022-05/Best%20Practice_Preassessment%
20standards%20in%20Children%20%202022%20-%
20Published.pdf (accessed 3 November 2022).

BJA Education - Volume 23, Number 6, 2023 243

Preoperative assessment in children
4. Norrington A. Paediatric preassessment guidelines, 2022
April. Available from https://www.apagbi.org.uk/file/
paediatric-pre-assessment-guidelines (accessed 5 August
2022).
5. Z. Burton, K. Russell, F. Saddington and M. AbouDaya,
Anaesthesia for children living with obesity, 2022. Avail-
able from https://www.apagbi.org.uk/news/soba-
anaesthesia-children-living-obesity. (accessed 3 16. Centre for Perioperative Care. Guideline for the manage-
November 2022)
6. Riley C, Ladak N. Reducing pediatric exposure to envi-
ronmental tobacco smoke: the effects of pediatric expo-
sure to environmental tobacco smoke and the role of
pediatric perioperative care. Paediatr Anaesth 2020; 30:
1199e203
7. Bali S, Seglani S, Challands J. Perioperative management
of the child with asthma. BJA Educ 2022; 22: 402e10
8. Lauer R, Vadi M, Mason L. Anaesthetic management of
the child with co-existing pulmonary disease. Br J Anaesth
2012; 109: 147e59
9. Zalan J, Vaccani J, Murto K. Paediatric adenotonsillec-
tomy, part 2: considerations for anaesthesia. BJA Educ
2020; 20: 193e200
10. ENT UK, Royal College of Anaesthetists British Associ-
ation for Paediatric Otolaryngology. Association of pae-
diatric anaesthetists of Great Britain and Ireland. Safe
Delivery of paediatric ENT Surgery in the UK: a national
strategy, 1e32. London: Report of a combined working
party; 2019
11. Williamson D, Sharma A. Cystic fibrosis in children: a
pediatric anestheiologist’s perspective. Paediatr Anaesth
2021; 32: 167e73
12. Okonkwo I, Cochrane L, Fernandez E. Perioperative
management of a child with a tracheostomy. BJA Educ
2020; 20: 18e25
244 BJA Education - Volume 23, Number 6, 2023
13. Lewis H, Naik M, Willemsen R. Perioperative management
of infants and children with diabetes. Paediatr Anaesth
2019; 402: 1e10
14. Grant S, Ahmad N. Perioperative care of children
with inherited metabolic disorders. BJA Educ 2011; 11: 62e8
15. Guruswamy V, Barbour R. Anaesthesia for children with
renal disease. BJA Educ 2015; 15: 294e329
ment of anaemia in the perioperative pathway 2022.
Available from https://www.cpoc.org.uk/sites/cpoc/files/
documents/2022-09/1.%20CPOC_
GuidelinefortheManagementofAnaemia_September2022.
pdf (accessed 14 September 2022).
17. Akrimi S, Simiyu V. Anaesthetic management of children
with sickle cell disease. BJA Educ 2018; 18: 331e6
18. White M, Peyton J. Anaesthetic management of children
with congenital heart disease for non-cardiac surgery. BJA
Educ 2012; 12: 17e22
19. Raviraj D, Flannery K. Anaesthesia in children with
congenital heart disease for non-cardiac surgery. Paediatr
Anaesth 2022; 467: 1e9
20. Ahmed B, Mallory S. Anaesthesia and childhood epilepsy.
BJA Educ 2011; 11: 93e8
21. Hayakawa H, Pincott ES, Uli A. Anaesthesia and cerebral
palsy. BJA Educ 2022; 22: 26e32
22. Ragoonanan V, Russell W. Anaesthesia for children with
neuromuscular disease. Cont Educ Anaesth Crit Care Pain
2010; 10: 143e7
23. Doyle A, Crowley M, Hunt B. Perioperative management
of anti-thrombotic treatment in children. Paediatr Anaesth
2019; 29: 405e13
24. Bryant H, Roberts P, Diprose P. Perioperative management
of patients with cardiac implantable electronic devices.
BJA Educ 2016; 16: 388e96