Age-associated issues in preoperative evaluation, testing, and planning: pediatrics

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Preoperative Evaluation of the Pediatric Patient

The article reviews frequently encountered preoperative concerns with a goal of minimizing complications during administration of pediatric anesthesia. It is written with general anesthesiologists in mind and provides a helpful overview of concerns for pediatric patient preparation for routine and nonemergent procedures or interventions. It covers unique topics for the pediatric population, including gestational age, respiratory and cardiovascular concerns, fasting guidelines, and management of preoperative anxiety, as well as the current hot topic of the potential neurotoxic effects of anesthetics on the developing brain.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Anesthesia complications of pediatric radiation therapy

PURPOSE

Complications of anesthesia for pediatric radiation therapy are imperative for both radiation oncologists and anesthesiologists to clinically assess and manage. We performed the first systematic review to date addressing this important issue.

METHODS

A systematic search of PubMed and EMBASE was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches were not restricted based on publication date. Nine original investigations were identified, analyzed, and collated for this report.

RESULTS

General anesthesia has proven superior to conscious sedation with regard to maintaining satisfactory procedural sedation while maintaining low respiratory and cardiovascular complication rates. Although agents such as ketamine (complication rates approaching 23%-24%) have been used in the past, other agents such as propofol and volatile anesthetics have lower complication rates because of improved drug side effect profiles (0.01%-3.5%). Most common complications are respiratory-based (eg, airway obstruction, broncho/laryngospasm, desaturation, apnea), followed by those that are cardiovascular-based (eg, tachy/bradycardia, arrhythmias, hypotension) and nausea/vomiting. Though procedure duration and anesthetic dose can be associated with higher complication risks, prior or concurrent chemotherapy does not confer added risks other than neutropenia-related sepsis. Other potential complications include those with vascular access devices, observed in up to 20% to 25%, with peripherally inserted central catheters having the highest rates of vascular complications and port catheters the lowest.

CONCLUSIONS

Rates of anesthetic complications encountered in pediatric radiation therapy are similar, if not lower, than rates reported in controlled operating room settings, implying that anesthesia for pediatric radiation therapy is safe, with low complication rates periprocedurally. Propofol infusion and oxygen delivery via nasal cannula offer the lowest immediate anesthetic complication rates and are hence most recommended for use. Though the long-term neurocognitive consequences of multiple anesthetics in pediatric patients have yet to be clearly defined, health care providers should be cognizant of the potentially serious implications.

Pediatric fasting times before surgical and radiologic procedures: benchmarking institutional practices against national standards

Prolonged preoperative fasting can be associated with adverse outcomes, particularly in children. Our aims were to assess the time pediatric patients fasted prior to surgical or radiologic procedures and evaluate whether fasting (NPO) orders complied with national guidelines. We measured NPO start time, time of last intake, and time test or surgery was scheduled, took place, or was cancelled in 219 pediatric patients. Findings demonstrate that pediatric patients experienced prolonged fasting before procedures and that the majority of NPO orders were non-compliant with national guidelines. We have developed strategies to reduce fasting times and ensure compliance with recommended national fasting standards.

Respiratory complications in the pediatric postanesthesia care unit

This article focuses on common respiratory complications in the postanesthesia care unit (PACU). Approximately 1 in 10 children present with respiratory complications in the PACU. The article highlights risk factors and at-risk populations. The physiologic and pathophysiologic background and causes for respiratory complications in the PACU are explained and suggestions given for an optimization of the anesthesia management in the perioperative period. Furthermore, the recognition, prevention, and treatment of these complications in the PACU are discussed.

Variations in pre-operative management of adolescents undergoing elective surgery

OBJECTIVE

To understand whether preoperative care of adolescent patients differs according to two different pediatric subspecialties with respect to patient pregnancy status, drug use, and patient assent. To understand how preoperative care of adolescent patients varies with length of practice and practice setting.

METHODS

A cross-sectional study surveyed 51 American Society of Pediatric Otolaryngology (ASPO) members and 108 American Pediatric Surgical Association (APSA) members. Outcomes included how often ('always', 'sometimes', 'never') participants ask adolescents (ages 12-18 years) about substance use, pregnancy, and assent for surgery. Differences according to physicians' practice duration and setting were also examined. Fisher's exact tests and Cochran-Armitage tests were applied for statistical analysis.

RESULTS

Although ASPO and APSA members did not differ significantly in how often they ask adolescent patients about pregnancy, ASPO members were more likely to 'always' cancel elective surgery in a pregnant patient (p<0.007). ASPO members were also more likely to 'always' ask about substance use, although this difference was not significant (p<0.06). APSA members were more likely to proceed with surgery despite an adolescent's refusal (p<0.007). Physicians in both specialties with <5 years in practice were most likely to 'always' ask about pregnancy, and physicians with fewer adolescent patients in their practice were more likely to 'always' ask about substance use. Physicians in differing practice settings varied in their responses about proceeding with elective surgery in a pregnant patient (p<0.03).

CONCLUSION

ASPO and APSA members differ in their preoperative management of adolescent patients. Newer physicians and those with fewer adolescent patients also differ from physicians with more extensive experience with adolescents.

Innovative use of perianesthesia nurses in imaging services: meeting the needs of children with disabilities

A new imaging center was established within a children's specialty hospital that provides services for children and adults with childhood-onset disabilities. New services in this advanced imaging center include computed tomography, magnetic resonance imaging, fluoroscopy, and ultrasound. Individuals with disabilities are particularly at risk for complications during procedures requiring sedation and anesthesia. The perianesthesia nurses' role was developed to support the sedation needs of this population during imaging services. Perianesthesia nurses developed an advanced imaging screening process to prepare patients for sedation during imaging services. With these processes, the new Advanced Imaging Center is providing timelier and better coordinated imaging services.

Cardiac medications are not associated with clinically important preoperative electrolyte disturbances in children presenting for cardiac surgery

BACKGROUND

Preoperative laboratory examination of patients undergoing elective surgical procedures has been routinely performed for decades. Although there is a large body of literature concerning the appropriate preoperative assessment of adult patients, corresponding literature for the pediatric population is not as well defined. Children and young adults with cardiac disease are a particularly vulnerable subset of patients who often undergo an extensive battery of preoperative laboratory testing. We examined the serum chemistry profiles for children with cardiac disease presenting for outpatient surgery. The investigation aims to define the effectiveness of preoperative electrolyte determination in this population of children and young adults.

METHODS

A retrospective chart review of all children presenting as outpatients to a tertiary care, freestanding children's hospital for elective cardiac surgery between January 1, 2000 and January 31, 2003 was performed. All patient charts in which the admission date matched the cardiac surgical date were examined. Patients were excluded if the preoperative laboratory evaluation was performed outside of our facility, preoperative laboratory investigation was not performed, or the patient was transported by medical transport to our hospital. Patients were grouped according to three methods: the number of cardiac medications (none to four), and cardiac medications, noncardiac medications, and no medications. The presence of electrolyte abnormalities was also examined in the context of cardiac medications with various pharmacologic effects. The primary outcome measure was the incidence of abnormal laboratory values for children taking various cardiac medications.

RESULTS

Of the 933 initial entries found, 774 met the investigational criteria and were included in the analysis. Although statistically significant differences in preoperative electrolytes were associated with the use of cardiac and noncardiac medication, there was no clinical value to this correlation. The data demonstrate a very low incidence of hypokalemia and hypomagnesemia in the entire study population.

CONCLUSION

Preoperative electrolyte disturbances in children and young adults presenting for cardiac surgery are uncommon. The concern of hypokalemia or hypomagnesemia important in the adult population taking cardiac medications was not identified in the pediatric population. These data do not support the need for routine preoperative electrolyte evaluation in children taking cardiac medications.

Evidence-based preoperative evaluation

Preoperative assessment is a complex and multidisciplinary task. It encompasses surgical and anaesthesia assessment, preoperative testing, preparation of patients for surgery, and obtaining consent to the surgery. The scope of this chapter is to review the available evidence on anaesthesia preoperative evaluation (who, when and how to conduct it) and its relevance to clinical practice, and to indicate areas for future research.