Preoperative_Evaluation_in_General_Pediatrics by nuhman10

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									Preclinic Conference
March 31-April 4


               Preoperative Evaluation in General Pediatrics
Aims
   1. Review risks and risk stratification for anesthesia and procedures
   2. Review
   3. Use cases to discuss some specific medical concerns of preoperative evaluation

Competencies:
  1. Medical knowledge
  2. Interpersonal communication

General Approach:
What is the purpose of a preoperative evaluation?
   Provide a medical assessment of the level of risk associated with undergoing a
       procedure
   Provide medical recommendations for things that should be done prior to procedure
       to either better understand the risk (diagnostic testing) or lower the risk (therapy
       changes)

What determines the risk of these procedures?
   Risk of procedure (eg hypoplast repair vs. dental cleaning)
   Patient unique risk (hypotensive patient in PICU vs. well child for elective surgery)
   Skills of individuals and systems of care

What is the risk of anesthesia?
   Hard to determine, moving target of safety with constant improvements
   Variable reports in the literature
   Risk of anesthesia related cardiac arrest approximately 1 in 10,000 (reported in 2000)
   Risk of anesthesia related mortality approximately 1 in 40,000
   Risk of more minor complications due to anesthesia approximately 1 in 1000 for
       children 1-12 years old

Preoperative Evaluations in Clinic:
    Generally very low risk, elective procedures and relatively healthy children
    This makes our job relatively easy
    Almost all children (like >99%) we see will do great without our consultation, how do
      we find that 1%?

General Approach to Patients:
   General H and P focused on:
         o Family history of anesthesia problems, bleeding, neuromuscular problems,
            other unique problems
         o Medications and allergies
         o Past medical history focused on previous surgeries/anesthesia, chronic
            problems and state of control
         o ROS: including sleep disordered breathing, bleeding/bruising, acute illnesses


Some Specific Situations:


                                                                           Steiner, 4/18/2011
Preclinic Conference
March 31-April 4


Acute URI/LRI
      We usually leave final decision about cancelling surgery to anesthesia
      Increased risk laryngospasm, bronchospasm, atelectasis, and postextubation croup
      General rule, mild URI or in recovery, generally surgery OK, if ill with fever and LR
       signs postpone elective 4-6 weeks

Asthma
    Increased risk for bronchospasm and intra or postoperative problems
    AAP guidelines 1996, continue current therapy continue all medications up through
      surgery
    Other reviews, start standing dose albuterol a few days before procedure
    Don’t need spirometry for everyone, but can be used in some situations

Seizure Disorder
    Document baseline level of seizure control
    Continue medications through the day of surgery
    Make sure standard blood monitoring is up to date (CBC/LFTs for many
       anticonvulsants)
    Can consider anticonvulsant levels if seizures not well controlled

Other considerations:
Neuro and muscular diseases
Down Syndrome


Remember:

No one is “cleared”, even totally healthy kids having a low risk procedure can have
complications. We determine what their risk is (low, med, high) and whether there is
anything that needs to be done before procedure to lower or better understand that
risk. Lastly, alert anesthesia to anything you think may cause a problem.


AAP, Section on Anesthesiology. Evaluation and preparation of pediatric patients undergoing anesthesia.
        Pediatrics. 1996: 98 (3).
Maxwell LG. Age-associated issues in preoperative evaluation, testing and planning: pediatrics. Anesthesiology
        Clinics of North America. 2004: 22 (1).




                                                                                          Steiner, 4/18/2011

								
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