Pediatric Patients

15.1 The Pediatric Patient

Lynne R. Ferrari

The objective of the preoperative evaluation of the pediatric surgical patient is to gather medical information and alleviate the fear and anxiety of the child and family. The preoperative visit is an opportunity for the anesthesiologist to evaluate the child’s psychological status and family interactions.

PSYCHOLOGICAL PREPARATION

Diseases carry with them different psychosocial aspects for children than in adults. For many healthy children who undergo elective surgery, the emotional disruption may surpass the medical issues. Children respond to the prospect of surgery in a varied and age-dependent manner, and the anesthesiologist must consider this during the preoperative interview since the understanding of and response to illness is affected by a child’s maturity (1). The developmental considerations for specific age groups are noted in Table 15.1.

RISKS OF ANESTHESIA

Parents may ask about the risks of anesthesia for their child, and this must be considered on an individual basis, considering the child’s age, type of surgery, comorbidities, and other confounding factors. Most deaths in children due entirely to anesthesia occur in the first week of life. However, patients under 1 year of age and those with significant associated comorbidities are at increased risk for both major and minor complications. Of closed claims reviewed between 1990 and 2000, 53% involved children between the ages of 1 and 3 years of age. Death is most frequent in ASA-PS 3 to 5 patients under 2 years of age, with 50% of those under 1 year of age (2). The most common causes of all complications are cardiovascular and respiratory in origin. Hemorrhage, especially in cases involving craniofacial and spinal intervention, is a reported source of major complications in children (3). Careful optimization of comorbidities and planning for risk mitigation of intraoperative events are critical.

The potential for long-term neurotoxic effects of drugs used to administer general anesthesia and sedation in children under the age of 3 years has been a subject of recent concern (4). The general anesthesia versus spinal anesthesia (GAS) study as

well as the pediatric anesthesia and neurodevelopmental assessment (PANDA) study concluded that single exposure to general anesthesia under 3 hours was not associated with altered neurodevelopmental outcomes (5,6). Some human studies, but not all, have shown later-learning difficulties, but it is impossible to isolate the effects of anesthesia from those of surgery or the child’s underlying illness. The risks of general anesthesia and the potential for adverse outcomes if surgery is delayed should be discussed with parents during the preoperative assessment.

TABLE 15.1 Developmental Considerations During Preoperative Preparation

Characteristics	Strategy for Preparation
1-4 year olds
Magical thinking Ability to understand but perhaps not able to verbalize thoughts Egocentric Preoccupied with guilt and blame Trust in primary caregiver	Due to limited sense of time, offer preparation no more than 2 days in advance Use of real objects helps build mastery of the situation Repetition of key ideas and words is essential Reinforcement of good behavior is necessary Keep parent with child at all times if possible
4-10 year olds
Beginning to think logically and understand that there is an inside to the body Communicates verbally with ease Mastery of skills Seeks control of decisions Enthusiastic learner	Preparation can be offered 1-2 weeks in advance Offer time for questions Use simplistic, but somewhat medical, terms Use concrete teaching materials and equipment, such as diagrams and pictures Offer reassurance that although one part of the body is sick, the whole body is not sick
10 year olds and older
Thought is technical Need for independence Search for privacy May oppose or disagree with parents Peer pressure Angry at illness May fight authority but seeks reassurance and approval	Preparation as soon as the diagnosis Involve teen in decision making Respect privacy issues Respect body image and fear of being seen nude Offer explanations in clear, technical terms Support need for control and independence Encourage confidentiality (even the exclusion of parents from certain information) Allow control within limits

HISTORY AND REVIEW OF SYSTEMS

The medical history for pediatric patients begins with a description of the prenatal period since events during pregnancy and delivery may influence the current state of health in children up to 1 year of age. Prior surgical experiences or medical admissions to the hospital are noted. A complete review of systems is completed, with particular attention to the items listed in Table 15.2.

The child’s prior anesthetic experience is explored during the preoperative visit.

What was the child’s reaction to previous anesthetics?
Which techniques were successful or which should be avoided?
Was anesthesia induced with a mask?
Was the parent present during induction?
Was the induction difficult?
Were any sequelae noted after the hospital experience, such as nightmares, bad dreams, regression to earlier behavior, or new fears of odors?
Will the child probably require premedication?
Family history regarding anesthesia-related events is explored.
Is there a history of hepatitis or liver problems after anesthesia in a family member?
Is there a history of malignant hyperthermia in a family member?
Is there a history of prolonged paralysis or mechanical ventilation after general anesthesia in family members indicating a possibility of pseudocholinesterase deficiency? Simple blood tests can measure plasma cholinesterase levels and dibucaine number to determine if that child is at risk.
Is there a family history of unexpected death, sudden infant death syndrome, genetic defects, or familial conditions such as muscular dystrophy, CF, sickle cell disease, bleeding tendencies, or human immunodeficiency virus infection?

MEDICATIONS AND ALLERGIES

Currently prescribed and previously ingested medications can have significant effects on the outcome of general anesthesia, especially the following:

Nonprescription cold remedies, which contain aspirin or aspirin-like compounds that interfere with platelet function and coagulation.
NSAIDs, which are discontinued 1 to 5 days before surgery.

In children who have been treated for a malignancy, specific chemotherapeutic regimens are identified and cumulative doses noted. Preoperative assessment of cardiopulmonary function is considered if toxic agents have been administered. Areas of radiation therapy are noted.

TABLE 15.2 Focused Perioperative Screening

System	Focus of Questions	Possible Anesthetic Concerns
Respiratory	Cough, asthma, recent cold	Irritable airway, bronchospasm, atelectasis, pneumonia
Cardiovascular	Murmur, cyanosis, history of squatting, hypertension, rheumatic fever, exercise intolerance	Avoidance of air bubbles in intravenous line, right-to-left shunt, tetralogy of Fallot, coarctation, renal disease, heart failure, cyanosis
Neurologic	Seizures, head trauma, swallowing problems	Medication interactions, metabolic derangement, increased intracranial pressure, aspiration, sensitivity to neuromuscular blocking agents, hyperpyrexia
Gastrointestinal/hepatic	Vomiting, diarrhea, malabsorption, black stool, gastroesophageal reflux, jaundice	Electrolyte imbalance, dehydration, full stomach considerations for induction of anesthesia, anemia, hypovolemia, hypoglycemia
Genitourinary	Frequency, time of last urination, frequency of urinary tract infections	Infection, hypercalcemia, hydration status, adequacy of renal function
Endocrine/metabolic	Abnormal development, hypoglycemia, steroid use	Endocrinopathy, hypothyroidism, diabetes mellitus, hypoglycemia, adrenal insufficiency
Hematologic	Anemia, excess bleeding	Transfusion requirement, coagulopathy, thrombocytopenia, hydration status, possible exchange transfusion
Allergy	Medications	Drug interactions
Dental	Loose teeth, carious teeth	Aspiration of loose teeth, infective endocarditis prophylaxis

Adjunct therapies and herbal remedies are documented. The use of products such as St. John’s wort and weight-loss agents such as fenfluramine hydrochloride, phentermine hydrochloride, and dexfenfluramine hydrochloride can alter physiology, which may complicate the course of a general anesthetic.
Latex allergy is detected by asking about sensitivity to bananas, the rubber dam used by dentists and oral surgeons, or latex balloons (7).
Exposure to tobacco smoke needs to be investigated and documented during the preoperative interview. Children with long-term exposure to tobacco smoke may experience airway complications under general anesthesia (8).

PHYSICAL EXAMINATION

A key feature of examining children is simple observation because approaching the child may cause inconsolable crying.

The color of the skin and the presence of pallor, cyanosis, rash, jaundice, unusual markings, birthmarks, and scars from previous operations are noted.
Abnormal facies might be an indication of a syndrome or constellation of congenital abnormalities (Table 15.3). One congenital anomaly often is associated with others.
The rate, depth, and quality of respirations are evaluated.
Nasal or upper respiratory obstruction is indicated by noisy or labored breathing.
The color, viscosity, and quantity of nasal discharge are documented.
The origin of a cough (upper vs. lower airway) and the quality (dry or wet) can be evaluated even before auscultation of the lungs.
Is wheezing or stridor audible or are retractions visible?
The airway is evaluated for ease of intubation. A manual estimation of the hyomental distance should be made. Children with micrognathia, as in Pierre Robin syndrome or Goldenhar syndrome, may be especially difficult to intubate.
The presence of loose teeth is documented.

The child with a heart murmur or a history of a murmur warrants special consideration.

Is the murmur innocent or pathologic?
Is hemodynamic compromise apparent?
Innocent or nonpathologic heart murmurs can be identified by four characteristics: the murmur is early systolic to midsystolic; it is softer than grade III of VI; the pitch is low to medium; and the sound has a musical, not harsh, quality.
Is the child at risk for paradoxical air embolus?
Is prophylaxis for infective endocarditis required?

The child with significant or active cardiac disease might require an evaluation by a cardiologist before general anesthesia. Information from specialized cardiac testing (e.g., catheterization, echocardiography) and endocarditis prophylaxis recommendations are included in the preoperative evaluation.

Neurologic status is assessed by the following:

Associated congenital syndromes, neurologic deficits, metabolic disorders, or seizure disorders are noted.

TABLE 15.3 Craniofacial Deformities and Associated Conditions

Name	Deformity	Associated Conditions	Anesthetic Implications
Apert syndrome	Craniosynostosis, hypoplastic midface	Polysyndactyly, possible mental compromise	Difficult intravenous access
Crouzon disease	Craniosynostosis, hypoplastic maxilla, hypertelorism, exophthalmos	Conductive hearing loss, possible mental compromise	Possible upper airway obstruction
Goldenhar syndrome	Unilateral mandibular hypoplasia, cleft palate, micrognathia	Vertebral anomalies	Possible difficult intubation
Hemifacial microsomia	Unilateral ear anomalies, unilateral mandibular hypoplasia	None	Possible difficult intubation
Möbius syndrome	Micrognathia, limited mandibular mobility	Possible cranial nerve VI and VII palsy, ptosis, limited tongue movement	Difficult intubation
Pfeiffer syndrome	Brachycephaly, hypoplastic maxilla	Broad thumbs and toes, syndactyly, possible mental compromise	Difficult intubation
Pierre Robin syndrome	Mandibular hypoplasia, micrognathia, glossoptosis, cleft palate	None	Difficult intubation
Treacher Collins syndrome	Mandibular hypoplasia, zygomatic arch, hypoplasia, ear malformations	Compromised hearing	Difficult intubation
Adapted with permission from Badgwell JM, ed. Clinical Pediatric Anesthesia. Philadelphia, PA: Lippincott-Raven Publishers; 1997.

Nausea, vomiting, difficulty concentrating, headaches, gait disorders, hypotonia, altered mental status, and inability to protect the airway may result from increases in intracranial pressure.
Neurologic impairment may manifest as an increase in head circumference, hypotonia, spasticity, or flaccidity.
The physical examination includes an evaluation of the level of consciousness, ability to swallow, intactness of the gag reflex, an adequate cervical spine range of motion, hypotonia, spasticity, or flaccidity.

DIAGNOSTIC TESTING

Few, if any, diagnostic laboratory tests are routinely necessary in the pediatric population. Diagnostic studies are individualized to the patient’s medical condition and the surgical procedure being performed. Determination of hemoglobin level before elective surgery is unnecessary for most healthy children. Mild abnormalities in white blood cell and platelet counts have no significant impact on the perioperative outcome in healthy children. The routine measurement of coagulation parameters is controversial, and a history of “excess bruising” is subjective. A history of abnormal coagulation, prolonged epistaxis, bleeding from circumcision or a tooth extraction, and the presence of hematomas and large bruises are better predictors of abnormal coagulation. If an otherwise healthy child has a negative history for bruising, no further testing is required because commonly used screening tests such as bleeding time, aPTT, PT, and platelet count do not reliably predict surgical bleeding.

Hemoglobin determination is indicated for premature infants and infants younger than 6 months and when significant surgical blood loss is anticipated.
Coagulation screening may be indicated in children who have a history of abnormal bleeding or are scheduled for surgery in which abnormal coagulation might be induced (cardiopulmonary bypass) or procedures in which adequate hemostasis is essential (tonsillectomy, neurosurgical procedures).
A urinalysis is not needed before surgery for most children.
Serum chemistry measurements are indicated only to confirm a suspected abnormality.
Serum medication levels are measured when specifically indicated.
Chest radiographs, electrocardiograms, and echocardiograms are indicated only when abnormalities are suspected.
Pregnancy testing has caused a great deal of controversy. A confidential interview with a postmenarchal female discloses current sexual activity, the use of birth control, or the possibility of pregnancy. Often parents refuse pregnancy testing for their child because it assumes that the child either is sexually active or is not truthful about her sexual activities. The legality of such testing is not clear and practice is dictated by hospital policy.

In summary, because blood draws are painful and distressing to children, an attempt is made to minimize psychological and physical pain. A child who has become upset in the preoperative period may show problematic behavior during the anesthetic induction.

SPECIAL CIRCUMSTANCES

Immunization

Frequently, children present for general anesthesia shortly after an immunization. Postimmunization effects include fever, pain at the injection site, malaise, and irritability. These clinical symptoms must not be confused with perioperative complications. The effect of anesthesia on the immune response during elective surgery is minor and usually persists for 48 hours, and there is no contraindication to the immunization of healthy children scheduled for elective surgery. However, when feasible, delaying exposure to general anesthesia for 2 days after the administration of inactivated vaccines such as diphtheria-pertussis-tetanus (DPT) or 14 to 21 days for live, attenuated vaccines such as measles-mumps-rubella (MMR) immunization may be prudent (9). Having a time interval between immunizations and procedures may be important in preventing misinterpretation of vaccine-driven adverse events as postprocedure complications. This includes, but is not limited to, routine scheduled vaccines as well as seasonal and flu vaccine. When a vaccine is administered within 7 days of a procedure, the anesthesiologist and surgeon should be informed. Cases are not automatically cancelled but left to the discretion of the anesthesiologist and surgeon.

Concussion

Sport or recreation-related concussion may occur in the setting of trauma requiring surgical intervention under general anesthesia. The effect of surgery and general anesthesia on brain recovery, either favorable or unfavorable, in this population is unknown. There is no evidence-based clinical pathway describing the optimal timing of surgery and anesthesia for semi-elective procedures following a concussion. The decision to proceed in patients with known concussion is based on individual clinician’s judgment. Elective surgery is often delayed in patients with known concussion until the patient is cleared to “return to play” or “free of symptoms.” Rest and avoidance of second or recurrent collisions are essential to the patient’s recovery. However, there is no clear clinical definition of “rest” or how much time is needed for full recovery (10).

Upper Respiratory Infection

Children can have up to six URIs each year, and there are no consensus on timing of surgery and anesthesia with this common problem. The child who has an active cold or is recovering from a recent one is at risk for atelectasis, oxygen desaturation, bronchospasm, croup, and laryngospasm (11). Most children with URIs may be anesthetized for short procedures. The decision to perform a lengthy or invasive procedure is made with caution. Decisions to cancel or postpone surgery are made in conjunction with the surgeon based on the procedure, its urgency, and the child’s overall medical condition. Because bronchial hyperreactivity may exist for up to 7 weeks after the resolution of URI symptoms, delaying surgery for this length of time is often impractical. Most practitioners would agree that surgery can proceed no sooner than 2 weeks after the initial evaluation and after the acute symptoms have resolved. The presence of secretions and their color are noted. Clear secretions usually indicate a viral illness, whereas green or yellow secretions suggest a bacterial infection. Cough is a sign of lower respiratory involvement and should be evaluated for origin (upper airway or bronchial) and quality (wet or dry). Most children have
clear breath sounds during quiet respirations. Crackles are best detected during coughing and crying.

Cervical Spine Instability

Several groups of pediatric patients are at risk for cervical spine instability due to atlantoaxial instability and superior migration of the odontoid process. Many children with mucopolysaccharidosis and 15% of children with Down syndrome may be affected. Routine radiographic examination of the cervical spine in a child without symptoms is no longer recommended. Symptomatic patients should undergo flexion-extension and odontoid view radiographs of the cervical spine, as well as neurologic consultation. If cervical abnormalities are noted, intubation in a neutral head position or somatosensory evoked potential monitoring of the upper extremities may be required. Children with limited mobility of the cervical spine (i.e., juvenile rheumatoid arthritis, arthrogryposis) may be at risk for restricted neck extension and difficulty with direct laryngoscopy and endotracheal intubation.

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