Pediatric pre op evaluation Dr. Peters

Medical Evaluation & Preparation of the Pediatric Patient David C. Peters, M.D. MAJ, MC Pre-Operative Goals • • • • • Identify potential problems Optimize medical condition Discuss expectations Develop plan Relieve concerns Normal Fears of the Child: • • • • • Separation anxiety (>6mos) Pain Unknown Acceptable behavior- possible retribution Loss of control Pediatrics 56:187,1975. Medical Evaluation • Identify Disease Processes – acute – chronic • Subspecialist PRN • Procedure/Indications PMHx: • Pregnancy – term vs. premature – problems • Neonatal period • Hospitalizations Why premie’s are different: Respiratory Problems – Surfactant = 32wks+ – Alveoli = 36wks – Decreased CO2 response – Hering-Breuer reflex – V-Q mismatch Cardiac Problems – PDA – PPHN Post-Operative ApneaWhat to do: • Identify patients at risk • Admit for monitoring • Tailor anesthetic Anes. 66:483-88,1987. Post-op Apnea in Pre-term Infants: Anes. 66:483-488,1987. BAMC Guidelines: • No patients (full term or premature) less than 1 month old. • Premature infants must be 50 wks PCA. • ASA 1 & 2 only. • Same day surgery only. Past Surgical Hx: • • • • Indications/Procedure Anesthetic type Anesthetic complications Post-op complications Family Hx: • Syndromes • Bleeding d/o’s • MH Review of Systems: • Similar to that of adult with the addition of a couple of sub-headings– growth – development Growth Chart: • 9-10 kg at 1 yr • +2 kg/yr after 1 y.o. ROS: Cardiovascular• • • • History of murmur Cyanotic episodes HTN Exercise tolerance ROS: CV (cont.)• Murmur: – ASD- potential paradoxical VAE – antibiotic prophylaxis? ROS: CV (cont)• Cyanosis: – R to L shunt – paradoxical VAE – endocarditis prophylaxis ROS: CV (cont)• HTN: – coarctation – pheochromocytoma – renal disease ROS: Pulmonary• • • • • CF BPD RAD OSA URI ROS: Pulmonary• BPD – chronic O2 dependence – hyper-reactive airways (peripherally) – tachypnea – failure to thrive (chronic hypoxemia) ROS: Pulmonary• RAD – – – – ED visits admissions intubations treatment regimen ROS: PulmonaryURI: • Risks (?) – – – – bronchospasm intra-op hypoxemia A-a gradient post-op hypoxemia Anes 68:276-9,1988. ROS: Pulmonary- URI: Why the big deal? Anes Anal 72:282-8,1991. ROS: Pulmonary- URI: Why the big deal? Anes Anal 72:282-8,1991. ROS: PulmonaryLRI: • Fever > 38 C • Productive cough • Wheezing/rales/rhonchi Ped Clin North Am 41:121,1994. ROS: CNS• • • • • Seizure disorder Developmental delay Down’s ADD Muscular dystrophy, myotonia ROS: Gastrointestinal• Primary concern is to assess GE sphincter integrity – frequent ‘spitting up’ – frequent LRI – wheezing • Liver dz ROS: Hematologic• Sickle cell disease or trait • Excessive bleeding NPO Guidelines: • Solids/Milk- 4-6 hr • Clears- 2hrs • Patients at risk: – bicitra – reglan (0.1mg/kg) – zantac (2.5mg/kg) Anes 72:589,1990 Anes 72:593,1990 Anes 90:978,1999