Pediatric Preoperative Evaluation

Document Sample
Pediatric Preoperative Evaluation Powered By Docstoc
					Pediatric Preoperative Evaluation
                     Preoperative URI
 Risk is 9 – 11 times greater up to 2 weeks following URI
        Decreased O2 Diffusion Capacity
        Decreased Compliance
        Increased Resistance
        Decreased Closing Volumes
        Increased Shunting (V/Q Mismatch)
        Increased Hypoxemia
        Increased Airway Reactivity
   Intubation increases the risk of these adverse effects
                 Preoperative URI
Increased Risk of
      Laryngospasm
      Bronchospasm
      Postintubation Croup
      Atelectasis
      Pneumonia
      Intraoperative Desaturation

   Intubation increases the risk of these adverse effects
   Evaluation of the URI Patient
 Age
 Lung Sounds
 Nasal Secretions (quantity & quality)
 Spontaneous Cough
 Fever
 General Appearance
 Frequency of Illness / URI
Asthma Evaluation of Patient
Intraoperative Considerations
    of the Pediatric Airway
              Pediatric Airway
Obligate Nose Breathers with Narrow Airways
          Easy Obstruction with Secretions
Large Tongue
          May Obstruct Airway while increasing
          difficulty of Laryngoscopy & Intubation
Large Occiput
          Place Roll under shoulders

                                              Glottis Location
                                                        C3 premature infants
                                                        C3-C4 Infants
                                                        C5 Adults
                                                        Larynx More Anterior
                                                        Crocoid Pressure Helpful
                                              Larynx & trachea Funnel Shaped
                                                        Narrowest @ Cricoid
                                                        ETT leak @ 30 cm H20
                                              Vocal Cords Slant Anteriorly
       Pediatric Airway Considerations
• More anterior than the adult
    – less head tilt to open the airway

• Smaller diameter of airway than the adult
    – easily blocked by secretions or blood

• Large tongue in relation to jaw size
    – likely to cause obstruction when child is
      unconscious



9
              Breathing Considerations

      Small children are dependent on
      contraction of the diaphragm to breathe.

     A child’s primary response to respiratory
      distress is to increase the rate and effort of
      breathing.



10
  Pediatric Pulmonary Differences
Decreased # & Smaller Aveoli
    13 X increase in alveoli between birth and 6 years of age
    3 X increase in size of alveoli

Decreased Compliance & Elastin
    Atelectasis

Smaller Airways & Increased Resistance
    Increased Work of Breathing
    Atelectasis is significant

Less type – 1 / High Oxidative Muscle
    Fatigue Sooner

Less FRC & TLC
    More Rapid Desaturation

Higher Closing Volumes
    Lower Dead Space Ventilation
     A child may have pronounced retractions of
      the chest wall because the chest wall is less
        muscular and has more flexible bones.


12
                  Breathing Considerations
                            Pediatric Respiratory Rates

                   Age                    Rate (breaths per minute)

          Infant (birth–1 year)                      30–60

          Toddler (1–3 years)                        24–40

          Preschooler (3–6 years)                    22–34

          School-age (6–12 years)                    18–30
          Adolescent (12–18 years)                   12–16


     A silent chest is an ominous sign of low blood
              oxygen in the pediatric patient.

13
     Oxygenation Considerations

 Children compensate efficiently in hypoxemia
  by increasing heart rate and vasoconstriction
  but then decompensate rapidly.




14
                            Pediatric Pulse Rates
                   Age                         Low     High
 Infant (birth–1 year)                   100                  160
 Toddler (1–3 years)                     90                   150

 Preschooler (3–6 years)                 80                   140
 School-age (6–12 years)                 70                   120

 Adolescent (12–18 years)                60                   100


          Bradycardia is a late sign of low blood oxygen
                    in the pediatric patient


15
                  Low-Normal Pediatric Systolic Blood Pressure

                       Age*                          Low Normal

       Infant (birth–1 year)                greater than 60*

       Toddler (1–3 years)                  greater than 70*

       Preschooler (3–6 years)              greater than 75

       School-age (6–12 years)              greater than 80

       Adolescent (12–18 years)             greater than 90

     *Note: In infants and children aged three years or younger,
     the presence of a strong central pulse should be substituted
                    for a blood pressure reading.


16
         Pediatric Cardiac Differences
 Cannot Increase Contractility
      Increase CO by Increasing HR only
 Immature Baroreceptor Reflex
      Limited Ability to Compensate for Hypotension by increasing HR
      Susceptible to Cardiac Depressants (volatile anesthestics)
 Increased Vagal Tone
      Prone to Bradycardia
 Major Causes of Bradycardia
        Hypoxia
        Vagal Stimulation (laryngoscopy, occulocardiac reflex)
        Volatile Anesthetics
        Multiple Doses of Succinylcholine
17
         Anesthetic Management
• Generally have higher drug requirements
  (mg/kg) because they have a greater volume
  of distribution
     – More Fat
     – More Body Water
• Children less than age 1 have increased
  sensitivity to respiratory depressant effects of
  opiods

18
          Normal Vital Signs by Age
 Age            HR       Resp. Rate    Systolic   Diastolic

  <1         120 – 160    30 - 60      60 - 95    35 - 69


 1–3         90 – 140     24 – 40     95 – 105    50 - 65


 3–5         75 – 110     18 – 30     95 – 110     50 -65


8 – 12       75 – 100     18 – 30     90 – 110    57 – 71


12 – 16       60 – 90     12 – 16     112 – 130   60 - 80
                Intubation
• Picture showing layout of equipment
      Complications of Intubation
• Malposition                • Physiologic
  – Esophageal                 - Hypertension
  – Endobronchial
                               -   Tachycardia
• Trauma
                               -   Laryngospasm
  – Tooth/Teeth
  – Lip/Tongue/Mucosa          -   Intracranial HTN
  – Sore Throat                -   Intraocular HTN
  – Retropharyngeal          • Post Intubation Croup
    Dissection
  – Bleeding (airway prep)
                               - Cuff (Age & Size)
  – Nasal                      - Size of Tube
   Choosing the Correct ETT Size

Size (Diameter)
  16 + Patient Age   Roughly the size of patient’s pinky finger
         4
Length

12 + Patient Age     3 X the internal diameter of ETT
          2
          Airway Complications
• Laryngospasm
  – Positive Pressure O2
  – Deepen Anesthesia
  – Succinylcholine
• Bronchospasm
  – Inhaler (partial)
  – Epinephrine (full)
        Advanced Airway Devices
• ETT Insertion w/ Macintosh Blade
   – http://www.medicalgeek.com/animations/7886-intubation-
     animation.html

• ETT Insertion w/ Miller Blade
   – http://www.doereport.com/generateexhibit.php?ID=12137&Ex
     hibitKeywordsRaw=&TL=&A

• Laryngeal Mask Airway (LMA)

   – http://www.doereport.com/generateexhibit.php?ID=12141
• Combitube
   – http://www.youtube.com/watch?v=MhRj6MLEVoE
                   Fluid Management
• Estimated blood Volume
  Neonate                  90 ml / kg
  Infant ( < 1 )           80 ml / kg
  Child                    70 ml / kg
  Adult                    65 ml / kg

• Fluid Management
                                    Replacement
  – “4-2-1” Rule                        1st Hour: ½ deficit + maint.
      • 0 – 10 kg: 4 ml/kg/hr           2nd Hour: ¼ deficit + maint.
      • 10 – 20 kg: 2 ml/kg/hr          3rd Hour: ¼ deficit + maint.
                                        4th Hour plus: maint. only
      • > 20 kg: 1 ml/kg/hr
                        PONV
• Patient Factors
  –   Age > 6 years
  –   Hx of PONV
  –   Hx of Motion Sickness
  –   Preoperative Nausea
  –   Extreme Preoperative Anxiety
• Surgery / Anesthesia Factors
  – Surgery > 20 minutes
  – Opiod Use
  – Nitrous Oxide ??
    Postoperative Complications
 Fever
   Usually related to dehydration
 Treatment
    hydration
   Acetaminophen or ibuprofen
    Active Cooling Measures
PONV
Dehydration
Pain

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:8/10/2012
language:English
pages:27