PEDIATRICS: PART 2
PREOPERATIVE EVALUATION AND PROBLEM PATIENTS
From the 43rd Clinical Conference in Pediatric Anesthesiology, presented by the Pediatric Anesthesiology
Foundation,
Childrens Hospital Los Angeles
| PREOPERATIVE EVALUATION: WHO NEEDS IT ?—Jerrold Lerman, MD, Clinical Professor of Anesthesia, Women
and Children’s Hospital of Buffalo, State University of New York, Buffalo, School of Medicine and Biomedical Sciences,
and Strong Memorial Hospital, University of Rochester School of Medicine and Dentistry, Rochester, New York
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| Introduction: every child who comes to operating room (OR) should be evaluated preoperatively; necessary to know every
small issue that possibly could affect child, surgery, or anesthesia; failing to unearth necessary information before anesthesia
could result in problems; few circumstances where patient can go directly to OR (eg, resuscitation)
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| Ethical and legal issues: anesthesia provider becomes advocate for child in OR (responsible for child’s well-being after
leaving parents); moral obligation to obtain history, physical examination, and laboratory results, if appropriate; before
obtaining consent (may be verbal or written, depending on state, insurer, and circumstances), outline alternatives for anesthesia
(eg, postoperative pain control) and risks and benefits of anesthesia (unethical to proceed without exploring basic
risks expected with anesthesia; mention unlikely risks); legal ramifications for failing to evaluate patient before
arriving at OR; in New York state, considered professional misconduct not to identify yourself as provider of care when
care about to be provided; responsible physician must be present at all critical events (eg, induction emergence)
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| Purpose of preoperative evaluation: according to American Society of Anesthesiologists (ASA) Task Force, provider
must 1) discover and identify all diseases that may affect perianesthetic care before giving anesthetic, 2) verify and assess
known diseases and extent to which they have been affecting patient (including therapies administered and whether they
need to be optimized before anesthetic administered), and 3) develop plan for management of case; must be disclosed and
communicated not only to other staff involved in care but also to parents at appropriate time
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| Timing of preoperative evaluation: evaluation should be peformed before day of surgery then repeated on day of surgery,
in case patient’s condition changes; evaluation also may occur day before surgery (usually not repeated) or can take
place only on day of surgery
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| Performing preoperative evaluation: seriousness of disease and type of surgery greatest issues; regulations require
that evaluation take place in some privacy; speaker sits down in front of child and addresses child directly; gets as much
information as possible from child (this shows parents that clinician recognizes focus of care and identifies to child importance
speaker places on child); turn to parents when information from child ends or child loses interest
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| Crucial aspects of preoperative evaluation: preexisting medical conditions recognized, identified, and treated; nursing
admission list used to identify medical conditions, medical history, medication history, allergies (family history and
preanesthetic history), and issues with previous anesthetic; physical examination can be brief, but assess airway (90% of
assessment can be done by looking at profile of child’s head, asking child to open mouth, extend tongue, and extend neck
backwards); cardiorespiratory system self-evident; rhinorrhea common condition; clear rhinorrhea not contraindication
for surgery, but applying 2 drops of 0.25% oxymetazoline (Neo-Synephrine) in each nostril stops rhinorrhea from allergic
rhinitis (also reduces or eliminates secretions accumulating in back of throat during anesthetic); most important reasons
may be to assess child’s attitude toward having surgery, level of anxiety, whether he or she needs premedication,
and ease of intravenous access; most children do not require laboratory testing (obtain hemoglobin for child undergoing
blood transfusion, child with hemoglobinopathy or chronic illness); human chorionic gonadotropin (hCG) testing controversial;
patient may require referral for consultation (eg, thoracoscopic surgery in patient with congenital anomalies); important
to have close relationship with person giving consultation
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| Unique circumstance in preoperative evaluation
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 | Fasting: if patient has liquid 2 hr prior to 9 AM surgery, must be some latitude for disruption in OR schedule; keep child
npo after clear fluids for 3 hr before outpatient surgery and 4 hr prior to inpatient surgery; chewing gum controversial
(cancel case only if child swallows gum)
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| Specific testing: none necessary in healthy child; if child chronically ill, <6 mo of age, or scheduled for major surgery,
get basic blood work; no indication for preoperative cervical x-ray in child with Down syndrome; no evidence of increased
cervical disruption during laryngoscopy; test can be performed easily while watching child move around, asking
child to extend head and move it around, and asking about past or present numbness or tingling in hands or feet
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| Medications before surgery: do not stop most medications; all medications should continue until day of surgery (eg, inhalers,
clonidine, baclofen, valerian root) to avoid rebound complications; continue β-blockers and cardiac medications
until time of surgery; stop anticoagulants and many herbal preparations (Saint John’s wort affects metabolism of
many anesthetic drugs)
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| Psychologic preparation: multifactorial approach for bringing child to surgery important component of preoperative
evaluation; speaker’s institution offers tours, tutorial videos, and puppets; resource personnel necessary; also have psychopharmacologic
preparations available; OR tour, video, and coping strategies effective in reducing level of anxiety in
patients coming to OR, particularly in holding area and to lesser extent at separation; premedication key; child’s anxiety
not ameliorated by presence of parents; only one parent allowed; must follow instructions, otherwise chaos; never invite
parent into OR; explain risks, obligations, and responsibilities; parent must leave OR immediately when told to leave;
handicapped children do need parental presence (premedication ineffective)
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| Premedication: orogastric midazolam most common; speaker gives dose of 0.75 mg/kg in child up to 6 yr of age (≈0.3
mg/kg in child >6 yr of age); provides sedation in 100% of patients and facilitates separation within ≈10 min; other delivery
techniques unnecessary
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| Piercing: recognize extent of piercing and where involved in airway; may loosen and fall into airway during intubation attempt;
burns from electrocautery (bipolar preferred; grounding patch away from piercing), airway complications, and basic
tissue damage seen more commonly; remove piercing when in airway; keep holes in mouth open using epidural catheter or
suture
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| PROBLEM PARENTS AND PROBLEM CHILDREN —Linda J. Mason, MD, Professor of Anesthesiology and Pediatrics,
Loma Linda University School of Medicine, and Director, Pediatric Anesthesiology, Loma Linda University Medical
Center, Loma Linda, California
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| Perioperative period: stressful and anxiety provoking for both child and family; ability of child and family to cope depends
on family dynamics, cultural issues, and language skills; limited time to establish rapport in ambulatory setting;
important to interact with child
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| Identifying difficult child or parent: influenced by caretakers’ previous experiences and gut reactions when meeting
family; sometimes receive warning from surgeons or nursing staff based on previous encounters with family; child returning
for repeat surgery may cause biggest problems; important for caretaker to “step back, take a deep breath,” and realize importance
of helping child; understand child development and behavior (age-appropriate behavior in response to external situations);
know how to tailor appropriate therapy to child and parents
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| Age-specific anxieties: 0 to 6 mo—maximum stress for parents; infant not old enough to be frightened of strangers; 6
mo to 4 yr—benefit most from premedication; maximum fear of separation; may not understand processes and explanations;
significant postoperative emotional upset and behavior regression; begin to have magical thinking (may be able to
distract with stories); 4 to 8 yr—begin to understand processes and explanations; fear of separation remains; concerned
about body integrity; 8 yr to adolescence—tolerate separation well; understand processes and explanations; may interpret
everything literally; may fear awakening during surgery or not awakening at all; adolescent—independent; issues
of self-esteem and body image; fear of unknown
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| Developmental and behavioral disorders
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| Attention-deficit/hyperactivity disorder (ADHD): central deficit in processing incoming information and failure to inhibit
response until all information is considered; prevalence averages 5% of school-aged children; characterized by inattention,
hyperactivity, and impulsivity; 4 to 9 times more common in boys; usually presents before 7 yr of age; duration
longer than 6 mo; some children take stimulant drugs to enhance functioning of executive control; may be combination
of dextroamphetamine–methylphenidate (Ritalin), amphetamine/dextroamphetamine, and pemoline; if first case, usual
medication may be withheld and sedative premedication given; however, if scheduled later in day, allow child to take
medication to ensure more cooperative, attentive patient in waiting area
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| Pervasive developmental disorders (PDD): impairments in social interactions, communications, and imaginative activity;
autism most severe form and may present with mental retardation; may be genetic-associated diseases, including Rett,
Cornelia de Lange, Mobius, and Noonan; child may be taking serotonin reuptake inhibitors to suppress aggression or
naltrexone to decrease effects of hypersecretion of endorphins; continue to day of surgery; many children benefit from
sedative premedication; parent or familiar caregiver also may smooth course
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| Chronic illness: 12% of children <18 yr of age have chronic illness, and 10% have functional limitations that affect daily
lives
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| Family dynamics: determine who is in control, parent or child; family many times in state of stress, guilt ridden, or simply
exhausted; letting family talk and “vent” helps to establish rapport; well-organized, open, and communicative family
tends to be resourceful; disorganized and dysfunctional family tends to be angry and frustrated
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| Preanesthetic evaluation: may be delayed until immediately before surgery; goals of visit include reviewing illness,
previous experience, readiness for surgery, and assessing child’s interaction and bonding with parents or caregivers; assessment
of child’s behavior and interactions achieved through age-appropriate conversation; some children can be engaged
in imaginative play; also determine whether child has developmental disorder and how to proceed with anesthesia
care; important to know how child interacts with caregiver/parents (whether parents can set limits and follow through);
older child or teenager should be involved in decisions; some parents demand total control of situation; many have had
bad experiences or are frustrated by “the system”; important to be empathetic and understanding but to set limits and define
parents’ role clearly; if allowed to be present for induction of anesthesia, parents must be told they cannot stay for entire
procedure (avoids confrontation at crucial periods)
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| Premedication: Kain study indicates sedative premedication given in up to ≈50% of pediatric patients (oral midazolam
most commonly); parental presence during induction has increased, but more so in pediatric centers or with anesthesiologists
who are comfortable caring for children; midazolam most commonly used anxiolytic drug; only intervention
consistently proven to decrease undesirable outcomes (eg, feeding difficulties, apathy, separation anxiety, and difficult
induction; changes in behavior usually occur during first 2 wk after surgery); parental presence during induction may
increase or decrease child’s anxiety; decision to administer premedication should not be based on parental presence
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| Options: depends on age, type of surgery, length of surgery, family expectations, and previous experience; nasal route
achieves peak levels in 10 to 13 min, but sedation in 5 min; crying follows in most children; successful separation in
97%, and 81% adequately sedated for induction (in surgery for myringotomy and tubes); oral midazolam, 0.5 mg/kg to
maximum of 1 mg/kg, gives some antegrade amnesia and anxiolysis; delayed emergence in short cases; oral ketamine,
6 mg/kg, less effective than midazolam; delayed emergence; combination of oral midazolam, 0.5 mg/kg, and ketamine,
3 mg/kg, useful in difficult patient; separation can occur in 10 to 15 min (add drying agent if concerned about increasing
secretions); intramuscular ketamine effective for separation in uncooperative child
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| Parental presence: questions include, is parental presence beneficial to child? is this positive experience for parent? how
does anesthesia provider feel about parental presence during induction; children who benefit most from parental presence
are >4 yr of age, have low anxiety trait and low baseline level of activity or temperament; does not decrease anxiety more
than oral midazolam; parents more satisfied when allowed to be with child and felt they made difference, even if child received
premedication; many parents present for induction admitted being upset at some point, even if inapparent; parents’
preference for medication or parental presence at subsequent surgery influenced by child’s anxiety at initial surgery; arguments
against include distraction, impact on resident education, and legal implications; explain procedure to avoid surprises
for parents; must agree to leave immediately when requested by OR staff
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| Parents in postanesthesia care unit (PACU): reuniting as soon as possible important (less pain medication needed
and child able to be discharged earlier); sometimes helpful to debrief with parents in recovery room about feelings on
how to improve situation
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| Important issues: be attentive listener to spoken and unspoken messages of parents and child; empathy and support critical
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Educational Objectives
| The goal of this program is to educate the listener about preoperative anesthesia evaluations and problems in dealing with
the difficult parent or child. After hearing and assimilating this program, the participant will be better able to:
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| 1. Review the ethical and legal issues associated with preoperative evaluation.
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| 2. Describe the appropriate timing of a preoperative evaluation.
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| 3. Outline the crucial aspects of a preoperative evaluation.
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| 4. List the unique circumstances that occur during a preoperative evaluation.
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| 5. Identify and manage the difficult child or parent during pediatric anesthesia and surgery.
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Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [Tylenol, many others]
Amphetamine and dextroamphetamine [Adderall, Adderall XR]
Baclofen [Lioresal, Lioresal Intrathecal]
Clonidine HCl [Catapres, Duraclon]
Dextroamphetamine sulfate [Dexedrine, Dexedrine Spansules, DextroStat]
Ketamine HCl [Ketalar]
Methylphenidate HCl [Ritalin, others]
Midazolam HCl [Versed]
Naltrexone HCl [Depade, ReVia]
Oxymetazoline HCl [Neo-Synephrine, many others]
Pemoline [Cylert, PemADD, PemADD CT]
Saint John’s wort (Hypericum perforatum)
Valerian root (Valerina officinalis)
Suggested Reading
Bevan JC et al: Midazolam premedication delays recovery after propofol without modifying involuntary movements.
Anesth Analg 85:50, 1997; Bevan JC et al: Preoperative parental anxiety predicts behavioural and emotional responses
to induction of anaesthesia in children. Can J Anaesth 37:177, 1990; Caldwell-Andrews AA et al: Motivation and maternal
presence during induction of anesthesia. Anesthesiology 103:478, 2005; Crawford M et al: Effects of duration of
fasting on gastric fluid pH and volume in healthy children. Anesth Analg 71:400, 1990; Davis PJ et al: Preanesthetic
medication with intranasal midazolam for brief pediatric surgical procedures. Effect on recovery and hospital discharge
times. Anesthesiology 82:2, 1995; Ferrari LR: Preoperative evaluation of pediatric surgical patients with multisystem
considerations. Anesth Analg 99:1058, 2004; Kain ZN et al: Parental intervention choices for children undergoing repeated
surgeries. Anesth Analg 96:970, 2003; Kain ZN et al: Parental presence during induction of anesthesia versus
sedative premedication: which intervention is more effective? Anesthesiology 89:1147, 1998; Kain ZN et al: Parental
presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 84:1060, 1996; Kain ZN et al:
Parental presence during induction of anesthesia: physiological effects on parents. Anesthesiology 98:58, 2003; Kain ZN
et al: Preoperative preparation in children: a cross-sectional study. J Clin Anesth 8:508, 1996; Kain ZN et al: Preoperative
psychological preparation of the child for surgery: an update. Anesthesiol Clin North America 23:597, 2005; Kain
ZN et al: Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative
premedication in the United States, 1995-2002: results of a follow-up national survey. Anesth Analg 98:1252, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Lerman is a consultant/investigator for Baxter International Inc. and participated in a desflurane study in children
and is also a consultant with SkyePharma.
Drs. Lerman and Mason were recorded at the 43rd Clinical Conference in Pediatric Anesthesiology, presented January
28-30, 2005, by the Pediatric Anesthesiology Foundation, Childrens Hospital Los Angeles, and held in Hollywood, California.
The Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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