THE PSYCHOLOGICAL STATE of a child and family as well as the clinical state of each child must be thoroughly understood before anesthesia and surgery or other intervention. Even if the medical issues are fully explored but the child is not treated in an age-appropriate manner, the entire perioperative experience will likely be suboptimal. Alternatively, if the psychological and emotional aspects of a child’s condition distract the anesthesia caregivers from the primary medical and surgical concerns, a thoroughly successful outcome may be compromised. It is therefore imperative that the anesthesiologist and, indeed, the entire health-care team strike the perfect balance between these two considerations.

PSYCHOLOGICAL PREPARATION

It is well recognized that significant preoperative anxiety is associated with a stormy and often prolonged anesthetic induction (1). Variables such as the temperament and age of the child as well as the situational distress of the parent and the outcome of previous medical encounters will affect the child’s anxiety. For many children, the immediate postoperative course is a mirror of the induction experience. Children who go to sleep without a struggle awaken peacefully and are known to have fewer difficulties in the postanesthetic care unit (PACU). It is therefore necessary to take the time to prepare the child for the anesthetic experience in an age-appropriate manner. In doing so, the child’s sense of control over the events will be enhanced and the negative long-term psychological effects may be reduced. There is consensus among anesthesiologists regarding the need for the treatment of a child’s anxiety before surgery (2). The development of coping skills is considered the most effective preoperative intervention, followed by modeling, play therapy, an OR tour, and printed material (3,4).

The level of maturity will affect each child’s understanding of and response to illness. Since reasoning skills have not yet matured in children, the understanding of and response to illness is affected. Communication skills are not highly developed either; therefore, the medical practitioner is required to anticipate the child’s needs and concerns and be able to interpret nonverbal expressions and actions. Infants fear separation from their primary caregivers and exhibit stranger anxiety; therefore, it is important that parental involvement in the perioperative experience be maintained. The toddler fears loss of control; so offering a child the opportunity to make choices, such as asking if the child would prefer the yellow or green hospital gown, will diminish preoperative anxiety by allowing him or her some control over his or her environment. Preschool-age children fear injury; they may fear that if blood is drawn, there would not be enough left (5). They think in a concrete manner and take statements quite literally; so caution is indicated when choosing the language used with this age group. The school-aged children fear that they may not be able to meet the expectations of adults. They may nod with understanding and listen intently despite the fact that they may not grasp what the adult is saying. They are reluctant to ask questions for fear that they should already know the answer. It is therefore incumbent on the anesthesiologist to clearly explain to the child what the expectations are. One might say “Once I hold the mask over your nose and mouth and you start to breathe the bubble gum air, I expect you not to pull it off. It won’t hurt you and if you feel sleepy, you can close your eyes.” Adolescent patients fear death and usually do not have much understanding of bodily functions. They are often panic stricken preoperatively, but do not wish to show any sign of weakness by revealing this; as a result, they might remain very quiet. It is the role of the anesthesiologist to anticipate this anxiety and reassure the adolescent without prompting. Comments such as “Although it may be hard for you to understand, you will be asleep throughout the entire operation and you will not wake up in the middle. We will wake you up at the end of the surgery and take you to the PACU” would help. A sigh of relief and perhaps even a smile may be noticed after this conversation.

RISKS OF ANESTHESIA

Most parents will express that they experience more anxiety about the administration of anesthesia to their child than the risks of surgery itself. They also frequently reveal that they are more concerned with the risks of anesthesia for their child than they would be for themselves. It has been demonstrated that parental anxiety surrounding anesthesia is highest when surgery is scheduled for infants <1 year of age and is the child’s first surgical experience (6). Comments such as “How do you know how much anesthesia to give, how can it be safe when my child is so small, etc.?” are not uncommon. Fear of anesthesia among parents originates largely from a lack of information regarding modern anesthetic practice rather than from a high probability of risk. It is often very effective for parents to engage in a discussion regarding the risks of an anesthetic for their child to help give them some perspective (7–9). Any medical comorbidities that exist which increase anesthetic risk should be described in detail, and the measures that the anesthesia team will take to safely care for patients with regard to these risks should be explained. An explanation of the monitoring equipment in place in each OR and the specific physiologic parameter that it measured is useful information to parents. In addition, a description of the number of personnel in the OR as well as those available in case of an emergency is a reassuring piece of information for parents. For a healthy child undergoing uncomplicated surgery, the risk of an adverse event is approximately 1 in 200,000 (10). The risk of death under anesthesia is the most feared complication. This risk is 1 in 10,000 for all patients of any age undergoing any surgical procedure (11–14). The incidence of anesthetic-related death is highest during the first year of life and is approximately 43:10,000. This decreases to 5:10,000 during the second year of life (15). Anesthetic risks increase by a factor of 6 during emergency procedures in all age groups. The specific risks of anesthesia are discussed in Chapter 4.

HISTORY AND REVIEW OF SYSTEMS

The medical history should begin with the prenatal course and neonatal period because events during pregnancy and delivery may influence the child’s current state of health (16). Any prior hospital admission, either for medical or surgical indications, should be noted. The objective of the history and physical examination is to determine the child’s current state of health as it compares to the usual state of health, realizing that the usual state of health may not be “normal” (17).

A complete review of systems should be included with emphasis placed on medical comorbidity, which might influence either the choice or outcome of the anesthetic (18). The presence of cough, asthma, or a recent upper respiratory infection (URI) might predispose the child to bronchospasm, atelectasis, or pneumonia. The new onset of a heart murmur, cyanosis, hypertension, exercise intolerance, or a history of rheumatic fever might suggest an evolving problem that could become exacerbated during the administration of an anesthetic or with a surgical procedure. Parents should be queried for the presence of vomiting, diarrhea, malabsorption, black stools, gastroesophageal reflux, or jaundice to reveal electrolyte imbalance, dehydration, hypoglycemia, anemia, or the need for a rapid sequence induction. The presence of seizures, head trauma, or swallowing problems may indicate a metabolic derangement, increased intracranial pressure, or sensitivity to muscle relaxants, and the anesthetic plan should be altered accordingly. The presence of a urinary tract abnormality should be sought in an attempt to evaluate the state of hydration and integrity of renal function. Abnormal development, alterations in serum glucose levels, or a history of chronic steroid use may indicate an endocrinopathy, diabetes mellitus, hypothyroidism, or adrenal insufficiency. Finally, a history of anemia, bruising, or excess bleeding may suggest a transfusion requirement or coagulopathy, which should be investigated before the time of surgery.

The child’s prior anesthetic experience should be explored during the preoperative visit, as reactions to previous anesthetics may guide the choice of techniques to use or avoid. If general anesthesia was previously induced with a mask, how well did that go? Was the parent present for induction? Was the induction stormy? Were there any sequelae after the hospital experience, such as nightmares, regression to earlier behavior, or new fears of odors? Will the child likely require premedication?

Family history should be explored for anesthesia-related events. A history of liver problems in family members after anesthesia should be actively sought. Malignant hyperthermia (MH) is always a concern in the pediatric age group, and high fevers or unusual events in the OR or in family members should be investigated. Although most pediatric anesthesiologists refrain from routinely using succinylcholine, questions about prolonged paralysis or mechanical ventilation after general anesthesia in family members should be asked. If there is a possible history of pseudocholinesterase deficiency, a simple blood test can be performed to determine if that child is at risk. Succinylcholine should be avoided in patients with specific enzyme deficiencies. Families should be asked if there is a history of unexpected death, sudden infant death syndrome (SIDS), genetic defects, or familial conditions such as muscular dystrophy, cystic fibrosis, sickle cell disease, bleeding tendencies, or human immunodeficiency virus (HIV) infection.

MEDICATIONS, ALLERGIES, ADJUNCT THERAPY, AND MORE

Many children have never been on medications; some have only been exposed to antibiotics for a simple illness; yet others may have received many medications for complex disease processes. It is essential to obtain a full medication history, including nonprescription medications administered for minor illness, because many over-the-counter cold remedies contain aspirin, nonsteroidal anti-inflammatory drugs, or other compounds that may interfere with coagulation and platelet function. The use of alternative therapies and herbal remedies should be documented because these may complicate the anesthetic management. There are reports of up to 30% of children receiving alternative or adjunctive therapies (19). The American Society of Anesthesiologists (ASAs) does not have a formal position on phytopharmaceutical or other forms of alternative therapy; however, taking “all natural” agents during the perioperative period may put a patient at risk for untoward events. Weight loss aids may augment sympathetic function, and agents designed to enhance muscle growth (e.g., creatine) may alter hepatic and renal function. It should be common practice during the preoperative interview to document the effects of specific herbal therapies and determine if an alteration in anesthetic technique is warranted (20). Similarly, the practice of body piercing is becoming increasingly more common in teenagers. Metal objects in the skin during surgery and anesthesia increase the risk of burn injury if there is an intraoperative electrocautery malfunction. Additionally, in the unconscious patient, metal objects may become caught on equipment in the OR, resulting in tearing of skin and subcutaneous tissue. Large metal objects pierced through the midline of the tongue may interfere with effective laryngoscopy and make securing the airway unnecessarily challenging. These objects may also tear costly nondisposable laryngeal mask airways. Patients (especially adolescents) should be counseled to remove all metal objects and disclose any body piercing that cannot be seen during the preoperative interview.

There is no direct evidence of any major interaction between immunization and commonly used anesthetic agents and techniques in children, but it is possible that immunosuppression caused by anesthesia and surgery may lead to decreased vaccine effectiveness. In addition, diagnostic difficulty may arise if a recently immunized child suffers from postoperative temperature elevation or malaise. From a risk management perspective, a review of the available evidence suggests that it would be prudent to adopt a cautious approach where the timing of elective surgery is discretionary. It is therefore recommend that elective surgery and anesthesia should be postponed for 1 week after inactive vaccination and 3 weeks after live attenuated vaccination in children (21,22).

Queries regarding known drug allergies should be made as seriously in children as they are in adult patients. Hopefully pediatric patients do not smoke cigarettes; however, inquiry regarding secondhand smoke exposure should be made because there is accumulating evidence to suggest that this causes an increase in perioperative airway complications (23). There is a strong association between passive inhalation of tobacco smoke and airway complications in children receiving general anesthesia. Significant physiologic effects may be documented as a result of passive tobacco smoke exposure. Cotinine is an alkaloid found in tobacco and is also a measurable metabolite of nicotine. The level of cotinine in the blood is proportionate to the amount of exposure to tobacco smoke; thus, it is a valuable indicator of tobacco smoke exposure, including secondary (passive) smoke. The presence of a smoking caregiver is a significant independent risk factor for URI during the first 3 years of life. Increased risk of lower respiratory infections of 2-fold or more occurs in infants and children from 4 months of age to 3 years. The risk of wheezing as a result of lower respiratory infections in the presence of a smoking caregiver was more than 3-fold in this age group of patients (24,25).

Several groups of pediatric patients are at increased risk for latex allergy, including children with spina bifida. Adverse reactions to bananas, latex balloons, other latex-containing toys, or the rubber dam used by a dentist should alert the practitioner to the possibility of latex allergy (26). Preoperative radioallergosorbent (RAST) testing should be performed, and if negative in children with a high index of suspicion, the more sensitive skin prick testing should be performed (27).

As in adult patients, all regular medications should be taken on the morning of surgery with a sip of water. Pediatric oral suspensions, although not clear fluids, should be administered. For children who cannot ingest oral medication without food, a spoonful of grape or apple jelly may be substituted as an acceptable alternative because it becomes a clear fluid when exposed to oral temperature.

PHYSICAL EXAMINATION

The general physical examination of young children must begin with simple observation from a distance because the infant or child may become frightened when approached directly. A great deal may be learned about relevant physical findings without touching the child. The color of the skin, including the presence of pallor, cyanosis, rash, jaundice, unusual markings, or prior surgical scars, may reveal the presence of organ system dysfunction. Because one congenital abnormality is often associated with others, abnormal facies should be an alert to additional anomalies.

The respiratory system should be evaluated by noting the rate and quality of respirations, the presence of noisy breathing, coughing, purulent nasal discharge, stridor, and wheezing. Signs of an acute URI should be evaluated. The ease of mouth opening and the presence of loose teeth should be determined.

If a heart murmur is detected on the cardiovascular examination, there are specific concerns that must be addressed. An innocent murmur may be due to turbulent blood flow during a growth spurt, whereas a pathological murmur is usually due to a structural abnormality; this distinction must be made. Lesions in which bacterial endocarditis prophylaxis or protection from paradoxical air embolism is required must be documented.

The patient’s neurologic evaluation should include the level of consciousness, presence of an intact gag reflex, and adequate cervical spine movement. General muscle tone and the presence of signs of an increase in intracranial pressure should also be noted.

DIAGNOSTIC TESTING

It is important to remember that phlebotomy is often traumatic for children and an event that they do not easily forget. For this reason, it is best to limit the number of invasive tests performed. The diagnostic studies should be selected based on the general medical health of the patient and the procedure being performed. In general, measurement of hematocrit in a healthy child undergoing elective surgery is unnecessary (28). A hematocrit should be measured if significant blood loss is anticipated or if the child is younger than 6 months or was born prematurely. Neither the routine measurement of the coagulation profile nor a history of “easy bruising” is reliable in predicting surgical bleeding (29). The presence of prior hematoma and bleeding from circumcision or large bruises should prompt an investigation; however, a negative history for bruising in an otherwise healthy child would require no further testing. Routine preoperative urinalysis is not indicated in children, and serum chemistries should only be performed when an abnormality is suspected. Children who are treated with anticonvulsants should have these medication levels checked, and an electrocardiogram or chest radiograph should only be ordered if the general medical condition warrants. Routine pregnancy testing is controversial, and the policy of the specific medical facility should be followed. There are differences in institutional policy regarding informing parents of the need to do pregnancy testing on postmenarchal females as well as informing parents of a positive result.

NPO GUIDELINES

It is no longer advisable or safe to restrict children to “NPO after midnight” (30). This severe restriction routinely increases each child’s chance of undergoing the induction of anesthesia when dehydrated, hypoglycemic, and cranky, all of which lead to a less than ideal situation. The risk of pulmonary aspiration of gastric contents in healthy children undergoing elective surgery is only 0.04% (31). The ASA has proposed practice guidelines that may be followed when determining the NPO restrictions in children (32). The ASA and others recommend fasting from clear fluids for 2 hours before anesthesia. Clear liquids consist of water, nonparticulate juices (apple, white grape, etc.), Pedialyte, and Popsicles. Fasting from breast milk for 4 hours and formula for 6 hours is recommended. The suggested fasting period for solid food is 6 hours for regular meals and 8 hours for fat-containing meals; however, a large survey of pediatric institutions recommends fasting from all solids for at least 8 hours in all children (33). It is best to check with each surgical facility for specific practice guidelines.

INDUCTION CHOICES

There are many different and effective ways to induce general anesthesia in pediatric patients, and these should be explored during the preoperative interview. Most children are afraid of needles; therefore, children younger than 8 years and older children with special circumstances are best induced with a volatile anesthetic agent administered by mask. The intravenous (IV) route for induction is usually acceptable to older children. The application of EMLA cream (eutectic mixture of local anesthetic) or Synera (lidocaine/tetracaine) is often used to achieve a painless IV insertion. It is essential that it be made clear that the choice of technique is the ultimate responsibility of the attending anesthesiologist and may be made with the input from the child and family members. The choices are based on the most appropriate method for each child and situation.

PARENT-PRESENT INDUCTION

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