well as the pediatric anesthesia and neurodevelopmental assessment (PANDA) study concluded that single exposure to general anesthesia under 3 hours was not associated with altered neurodevelopmental outcomes (5,6). Some human studies, but not all, have shown later-learning difficulties, but it is impossible to isolate the effects of anesthesia from those of surgery or the child’s underlying illness. The risks of general anesthesia and the potential for adverse outcomes if surgery is delayed should be discussed with parents during the preoperative assessment.
TABLE 15.1 Developmental Considerations During Preoperative Preparation
What was the child’s reaction to previous anesthetics?
Which techniques were successful or which should be avoided?
Was anesthesia induced with a mask?
Was the parent present during induction?
Was the induction difficult?
Were any sequelae noted after the hospital experience, such as nightmares, bad dreams, regression to earlier behavior, or new fears of odors?
Will the child probably require premedication?
Family history regarding anesthesia-related events is explored.
Is there a history of hepatitis or liver problems after anesthesia in a family member?
Is there a history of malignant hyperthermia in a family member?
Is there a history of prolonged paralysis or mechanical ventilation after general anesthesia in family members indicating a possibility of pseudocholinesterase deficiency? Simple blood tests can measure plasma cholinesterase levels and dibucaine number to determine if that child is at risk.
Is there a family history of unexpected death, sudden infant death syndrome, genetic defects, or familial conditions such as muscular dystrophy, CF, sickle cell disease, bleeding tendencies, or human immunodeficiency virus infection?
Nonprescription cold remedies, which contain aspirin or aspirin-like compounds that interfere with platelet function and coagulation.
NSAIDs, which are discontinued 1 to 5 days before surgery.
In children who have been treated for a malignancy, specific chemotherapeutic regimens are identified and cumulative doses noted. Preoperative assessment of cardiopulmonary function is considered if toxic agents have been administered. Areas of radiation therapy are noted.
TABLE 15.2 Focused Perioperative Screening
Focus of Questions
Possible Anesthetic Concerns
Cough, asthma, recent cold
Irritable airway, bronchospasm, atelectasis, pneumonia
Murmur, cyanosis, history of squatting, hypertension, rheumatic fever, exercise intolerance
Avoidance of air bubbles in intravenous line, right-to-left shunt, tetralogy of Fallot, coarctation, renal disease, heart failure, cyanosis
Seizures, head trauma, swallowing problems
Medication interactions, metabolic derangement, increased intracranial pressure, aspiration, sensitivity to neuromuscular blocking agents, hyperpyrexia
Vomiting, diarrhea, malabsorption, black stool, gastroesophageal reflux, jaundice
Electrolyte imbalance, dehydration, full stomach considerations for induction of anesthesia, anemia, hypovolemia, hypoglycemia
Frequency, time of last urination, frequency of urinary tract infections
Infection, hypercalcemia, hydration status, adequacy of renal function
Abnormal development, hypoglycemia, steroid use
Endocrinopathy, hypothyroidism, diabetes mellitus, hypoglycemia, adrenal insufficiency
Anemia, excess bleeding
Transfusion requirement, coagulopathy, thrombocytopenia, hydration status, possible exchange transfusion
Loose teeth, carious teeth
Aspiration of loose teeth, infective endocarditis prophylaxis
Adjunct therapies and herbal remedies are documented. The use of products such as St. John’s wort and weight-loss agents such as fenfluramine hydrochloride, phentermine hydrochloride, and dexfenfluramine hydrochloride can alter physiology, which may complicate the course of a general anesthetic.
Latex allergy is detected by asking about sensitivity to bananas, the rubber dam used by dentists and oral surgeons, or latex balloons (7).
Exposure to tobacco smoke needs to be investigated and documented during the preoperative interview. Children with long-term exposure to tobacco smoke may experience airway complications under general anesthesia (8).
The color of the skin and the presence of pallor, cyanosis, rash, jaundice, unusual markings, birthmarks, and scars from previous operations are noted.
Abnormal facies might be an indication of a syndrome or constellation of congenital abnormalities (Table 15.3). One congenital anomaly often is associated with others.
The rate, depth, and quality of respirations are evaluated.
Nasal or upper respiratory obstruction is indicated by noisy or labored breathing.
The color, viscosity, and quantity of nasal discharge are documented.
The origin of a cough (upper vs. lower airway) and the quality (dry or wet) can be evaluated even before auscultation of the lungs.
Is wheezing or stridor audible or are retractions visible?
The airway is evaluated for ease of intubation. A manual estimation of the hyomental distance should be made. Children with micrognathia, as in Pierre Robin syndrome or Goldenhar syndrome, may be especially difficult to intubate.
The presence of loose teeth is documented.
Is the murmur innocent or pathologic?
Is hemodynamic compromise apparent?
Innocent or nonpathologic heart murmurs can be identified by four characteristics: the murmur is early systolic to midsystolic; it is softer than grade III of VI; the pitch is low to medium; and the sound has a musical, not harsh, quality.
Is the child at risk for paradoxical air embolus?
Is prophylaxis for infective endocarditis required?
Associated congenital syndromes, neurologic deficits, metabolic disorders, or seizure disorders are noted.
TABLE 15.3 Craniofacial Deformities and Associated Conditions
Craniosynostosis, hypoplastic midface
Polysyndactyly, possible mental compromise
Difficult intravenous access
Craniosynostosis, hypoplastic maxilla, hypertelorism, exophthalmos
Conductive hearing loss, possible mental compromise
Possible upper airway obstruction
Unilateral mandibular hypoplasia, cleft palate, micrognathia
Possible difficult intubation
Unilateral ear anomalies, unilateral mandibular hypoplasia
Possible difficult intubation
Micrognathia, limited mandibular mobility
Possible cranial nerve VI and VII palsy, ptosis, limited tongue movement
Brachycephaly, hypoplastic maxilla
Broad thumbs and toes, syndactyly, possible mental compromise
Pierre Robin syndrome
Mandibular hypoplasia, micrognathia, glossoptosis, cleft palate
Treacher Collins syndrome
Mandibular hypoplasia, zygomatic arch, hypoplasia, ear malformations
Adapted with permission from Badgwell JM, ed. Clinical Pediatric Anesthesia. Philadelphia, PA: Lippincott-Raven Publishers; 1997.
Nausea, vomiting, difficulty concentrating, headaches, gait disorders, hypotonia, altered mental status, and inability to protect the airway may result from increases in intracranial pressure.
Neurologic impairment may manifest as an increase in head circumference, hypotonia, spasticity, or flaccidity.
The physical examination includes an evaluation of the level of consciousness, ability to swallow, intactness of the gag reflex, an adequate cervical spine range of motion, hypotonia, spasticity, or flaccidity.
Hemoglobin determination is indicated for premature infants and infants younger than 6 months and when significant surgical blood loss is anticipated.
Coagulation screening may be indicated in children who have a history of abnormal bleeding or are scheduled for surgery in which abnormal coagulation might be induced (cardiopulmonary bypass) or procedures in which adequate hemostasis is essential (tonsillectomy, neurosurgical procedures).
A urinalysis is not needed before surgery for most children.
Serum chemistry measurements are indicated only to confirm a suspected abnormality.
Serum medication levels are measured when specifically indicated.
Chest radiographs, electrocardiograms, and echocardiograms are indicated only when abnormalities are suspected.
Pregnancy testing has caused a great deal of controversy. A confidential interview with a postmenarchal female discloses current sexual activity, the use of birth control, or the possibility of pregnancy. Often parents refuse pregnancy testing for their child because it assumes that the child either is sexually active or is not truthful about her sexual activities. The legality of such testing is not clear and practice is dictated by hospital policy.
clear breath sounds during quiet respirations. Crackles are best detected during coughing and crying.