PRE ANAESTHETIC

EVALUATION AND
PREPARATION OF
CHILDREN FOR SURGERY
 AIM
• Understand current status

• Nature of current surgery

• Potential need for stabilization

• Formulate anaesthetic management

• Communicate with the child and the parents , understand their

psychological make up , inform about the plan and help sooth
their concerns
• ON FIRST MEETING
• Build rapport

• Introduce oneself , say hello to the child and try to engage him
in a social conversation

• If child is old enough explain about anesthesia in simple terms

( like going to sleep at night )
• Begin with medical record review

• ATTENTION TO
• Previous anesthetic record
• Drug allergies
• h/o airway or cardiopulmonary anomalies
 HISTORY
NEONATES
• Course of IU growth , labour , immediate post partum

• Any maternal factor affecting fetal growth

• h/o feeding and hydration

• h/o need for ventilatory support

• h/o seizures or Intra ventricular hemorrhage

• Estimation of gestational status ?premature / IUGR

• Greater the prematurity , greater physiological abnormality ,
variable response to anesthetics and fluids
• 35-37weeks – feeding difficulties
hyper bilirubinemia

• 30-34 weeks – feeding abnormality

lung immaturity –RDS
persistent PDA
apneic response to stress
temperature instability
• Very low birth weight < 1500g
• Complications inversely proportional to weight

• Respiratory Distress Syndrome

• Intraventricular Hemorrhage
• Necrotizing enterocolitis
• Bronchopulmonary dysplasia
Other abnormalities in preterm include
• Hypotension & bradycardia
• Pulmonary hypertension
• Kernicterus
• Hypoglycemia
• Hypocalcemia
• Hypothermia
• Anemia
• Vit k deficiency
• Retinopathy of prematurity
System History Anesthetic implication
CNS & neuromuscular Seizure Drug interaction ; drug
induced hepatotoxicity ;
inadequate therapy
Head trauma Elevated ICP ; Anemia
Hydrocephalus Elevated ICP
CNS tumor Elevated ICP ;
chemotherapy
Developmental delay Bulbar dysfunction ; risk
of aspiration
Muscle disease Risk of malignant
hyperthermia ,
rhabdomyolysis , ARF
CVS Heart murmur R – L air embolism ;
SBE prophylaxis
Cyanotic HD R – L shunt
h/o squatting TOF
Diaphoresis with Congestive heart failure
feeding or crying
Hypertension Coarctation of
aorta ;renal disease ;
pheochromocytoma
RESPIRATORY Prematurity Post op apnea
BPDysplasia Lower airway
obstruction ; reactive
airway ; subglottic
stenosis ; pulmonary
hypertension
Resp infection / cough Reactive airways ,
bronchospasm
 Snoring OSA ; subglottic
stenosis or anomaly ;
peri op airway obstrctn

Asthma B agonist , steroid

therapy , reactive airway
GIT Vomiting , diarrhoea Electrolyte imbalance ,
dehydration , risk of
aspiration

Growth failure Low glycogen reserves

GERD Risk of aspiration ,
reactive airways
Jaundice Hypoglycemia ,
coagulopathy , altered
metabolism

Liver transplant recipient Altered drug metabolism

, immunosuppression ,
coagulopathy
RENAL Frequency ,nocturia Occult DM ,electrolyte
disturbances , UTI
sepsis
Renal failure , dialysis Electrolyte
disturbance ,hyper/
hypovolemia, anemia
Renal transplant Immunosupression ,
recipient hypertension , poor
toleration of hypotension
ENDOCRINE Diabetes Insulin requirement ,
intra op
hyper/hypoglycemia
Steroid therapy Adrenocortical axis
suppression
HEMATOLOGICAL Anemia Transfusion
requirement , occult
hemoglobinopathy
Bruising , h/o bleeding Coagulopathy
Sickle cell disease Anemia , adequate
hydration , avoid
tourniquet
Dental Loose primary teeth Risk of aspiration
 Child with runny nose
• Lack of clarity in literature

• Definition of URI varies from study to study

• Definite increase in respiratory complications

• Hyper reactive airway – 6 to 8 weeks to normalize

• Risk of laryngospasm , bronchospasm , post intubation croup ,

atelectasis , pneumonia and rapid desaturation episodes
• Same incidence of complications in active as well as
recovering URI

• No hard and fast rules regarding cancellation or posting a case

• Acute disease with fever , cough and chest signs – better to

postpone. OR

• Child with only a running nose but sick looking and obviously
worsening – better to postpone
• Children for ENT procedures like adenotonsillectomy have frequent
URIs – in this context postponement may not be practical

• If the child is active and has no fever or chest signs and normal
chest xrays –

• Benefit of doubt and judicious anesthesia may be given to such

patients who have clear rhinitis or dry cough or are recovering from
it.
• Expect and be Ready to tackle the complications if they arise.
• Parents should be well informed about it.
• Last minute cancellations should be avoided
 Difficult airway
• Treacher collins syndrome , pierre Robin’s , midface
hypoplasias , TM ankylosis , Aperts syndrome , Beckwith
wiedmann syndrome , mucopolysaccharidoses , hemangiomas
and lymphangiomas of the neck etc present with difficult
airway scenarios

• Previous surgical records may provide clues

• Skeletal & soft tissue abnormalities grow with the child

• So a child with uneventful anaesthetic may prove to be
presently difficult to intubate
• Assess mandibular space – distance between mandible and
hyoid - 2-3 adult finger breadth

• Represents the space occupied by soft tissues when

compressed by laryngoscope

• In syndromes with retrognathia this space is reduced

• In mucopolysaccharidoses and lymphangiomas and

hemangiomas of neck there is increase in soft tissue content
• In mucopolysaccharidoses – regional mostly fail because of
abnormal chemical deposits in nervous system

• X ray soft tissue neck lateral view – delineate air shadow from
mouth oropharynx down to the trachea

• Different types of laryngoscopes, LMAs, fibreoptic

laryngoscope, airway devices for retrograde intubation, tube
changers, airway cricothyrotomy and tracheostomy should be
planned and to be kept ready in such cases
 Cardiovascular problems
• Require meticulous planning and optimization of general
condition , electrolytes and cardiovascular drugs

• History of breathlessness on exertion

• inability to run and play in older children and
• inability to feed without breathlessness in infants and
reduction of general activity point to a compromise.
• Residual pulmonary hypertension may persist after corrective
surgeries

• Soft systolic murmurs without symptoms are usually benign

• Loud constant transmitted murmurs , diastolic murmur
generally have structural defects

• Cardiology consultation 2D echo – significance of murmur ,

need for prophylactic antibiotics , plan of management
• Periop analgesia – extremely important to avoid stress –
pulmonary hypertension

• Good rapport and gentle handling – psychological baggage

from previous surgery
 Ex premature baby
• Post op apnea , retinopathy of prematurity , bronchopulmonary
dysplasia etc

• Risk of apnea inversely proportional to gestational age during

delivery and post conception age

• Preterm infants <56wks post conception age are at increased

risk of apnea

• Sedative supplementation especially ketamine markedly

increase apnea
 Fasting guidelines
• Framed by ASA in 2006
Fasting time (hrs)
Age Milk and solids Clear liquids
<6months 4 2
6-36months 6 3
>36months 8 3

• NPO for breast milk – 4hrs

• Clear fluids may be allowed upto 3hrs prior to surgery
• Examples of clear fluids
• Water
• Real / artificial fruit juice without pulp
• Clear tea / black coffee without creamer or milk
• Infant electrolyte solutions

• Recommended volumes
• no more than two ounces for patients up to 5 years of age
• no more than four ounces for patients 5 through 13 years of age
• no more than eight ounces (1 regular-sized cup) for patients
over 13 years of age.
• Liberalized in children because of higher metabolic rate and
increased body surface to mass ratio – rapid dehydration

• When surgery is to be delayed beyond the anticipated time -

small infants younger than 18 months old, are offered clear
fluids or given intravenous fluids to prevent dehydration or
hypovolemia
Children at increased risk of aspiration
• Not fasted the requisite amount of time
• Oesophageal dysmotility
• GERD
• Paralytic ileus , vomiting and electrolyte disorders
• Diabetic ketoacidocis – delayed gastric emptying

• NPA 0.5ml/kg , metocloperamide 0.1mg/kg , rantidine

2.5mg/kg
• Guidelines same for obese / overweight children

• Chewing gum – increases gastric fluid volume & acidity

 Vaccination and
anesthesia
• 1) immunomodulatory effects of anesthesia and surgery may
affect the efficacy of vaccine(returned to pre op values within
2 days)

• 2) inflammatory response to vaccines may alter post operative

course

• Vaccine driven adverse events (fever , pain , irritability ) can

be confused with post op complications
• Adverse events to inactivated vaccines appear by 2 days and
live vaccines from 7 – 21 days

• Appropriate delays are recommended to avoid

misinterpretation

• Vaccines may be delayed after surgery till full recovery

 Premedication
• Need for premedication must be individualized
• Should be administered under close monitoring , tools for
resuscitation readily available
Depends on
• Underlying medical condition
• Length of surgery
• Desired induction of anesthesia
• Psychological make up of child and family

• Not normally necessary for <6mo old child

• But warranted for older children afraid of separation
• orally, intramuscularly, intravenously, rectally, sublingually, or
nasally

• Oral easy to administer but slower onset , drug taste , depend on

child co operation

• i.m rapid onset , but painful , can lead to abscess

• Iv rapid onset but painful to the child

• Intranasal has rapid absorption but could be irritating and somewhat

difficult to administer
BENZODIAZEPINES
• Midazolam most common
• Short onset and offset of action
• Standard syrup preparation – open(lower pH)and closed
chain(higher pH)
• Open structure – lipophilic & physiologically active
• Combination of diluents to make it more palatable could alter
pH and therefore bioavailability
• 0.25-0.75mg / kg oral
• Satisfactory sedation and anxiolysis by 10 – 20mins
• 0.2mg/ kg intranasal – rapid ; peak at 10mins
• burning sensation
• Bitter taste after oral/nasal
• Use preservative free

• In children with functioning iv line

• 0.025 – 0.1mg iv – time to peak is 5 minutes
• Preferable to wait this time before administering another dose
• Anterograde amnesia within 10mins after oral
Adverse effects
• Causes respiratory depression
• Paradoxical agitation and behavioral changes
 KETAMINE
• Phencyclidine derivative

• Dissociation of cortex and limbic system

• Sedation and analgesia while preserving respiratory drive and upper

airway muscular tone

• causes increased oral secretions , nystagmus , post operative emesis ,

hallucinations nightmares and delirium
• Asso with larger doses & repeated doses
• Attenuated by midazolam
• Anticholinergics to reduce the secretions

• IV , IM , Oral , nasal , transmucosal & rectal

• IM ketamine 2mg/kg effective in sedating combative children

with developmental delay or those refusing oral medications

• Oral ketamine 5-8mg/kg – sedation sufficient for IV access

within 12mins
Not associated with emergence delirium
• Oral lytic cocktail of ketamine(3mg/kg) &
midazolam(0.5mg/kg) – effective for children with h/o
inadequate sedation in the past with either agents alone

• Nasal ketamine 6mg / kg ; use preservative free

OPIOIDS
• Resp depression in neonates – rarely used

• Fentanyl – parenteral ,transdermal ,oral ,nasal

• OTFC - oral transmucosal fentanyl citrate – ‘lollipop’
delivery system
• Readily absorbed (50% BA)
• Dose10 – 15 ug / kg
• Primary indicated in treatment of breakthrough cancer patients
• Sufentanyl 1-1.5 mcg / kg intranasal is very effective but
reduced chest wall compliance reported.

• Opioids in combination with bzd cause severe respiratory

depression

• Dose of each drug should be adjusted

• nausea and vomiting

ά2 agonists
• Clonidine and dexmedetomedine
• Provide sedation , as well as anxiolysis
• No respiratory depression
• Decreases neuro endocrine stress response
• Post operative analgesia
• Side effect – bradycardia and hypotension

• Oral clonidine – 4mcg / kg administered 60-120 mins prior to

induction
• Dexmedetomedine 8 times more specific at ά2
IV , intranasal , oral
• Intranasal dose 1-2mcg/kg , onset time 45mins and peaks by
90-150mins
• Oral dose is 3 – 4 mcg / kg but bioavailability is only 16%
• Buccal preparation has 82% bioavailability
• ANTIHISTAMINES like hydroxyzine and diphenhydramine
were used in the past but are uncommon now
ANTICHOLINERGICS
Routinely used in the past to
• Prevent bradycardia associated with anesthetics ( halothane , scoline )
• Decrease secretions
• Minimize autonomic vagal reflexes

• Now not used routinely

• Atropine 0.02mg / kg I.V

• Glycopyrollate 0.01mg / kg I.V

• Very useful as adjuvants to ketamine anesthesia

TOPICAL ANESTHETICS
• EMLA cream ( eutectic mixture of 2.5% lignocaine and 2.5%
prilocaine )

• One hr application
• Vasoconstriction and blanching
• Methemoglobinemia in neonates

• AMETOP (4% tetracaine ) – onset 30-40mins

• No venoconstriction ; no methemoglobinemia
• ELA Max – 4% lignocaine
• S caine patch – eutectic mixture of lidocaine and tetracaine ;
uses controlled heating system to accelerate delivery
THANK YOU