The “10 P” Checklist
Cognitive aids, in the form of checklists, are techniques that ensure completeness with multistep processes and aid attention to detail. We devised the 10 P checklist to help anesthesia providers prepare for cases ( Table 13.1 ). This checklist is divided into preoperative, intraoperative, and postoperative considerations, and it will form the basis of the organization for this chapter.
| Patient | Discuss the patient’s history, physical exam, previous anesthetics, and implications of any comorbidities. |
| Procedure | Discuss the procedure and its considerations for anesthetic management. |
| Premedication | Discuss the premedication and dose to order. |
| Preoperative Fasting | Discuss the fasting orders. Healthy children should be encouraged to drink clear liquids up to 2 hours before the scheduled procedure time. |
| Preoperative labs | Appropriate tests are chosen depending on the medical condition of the patient and the nature of the surgery. |
| Perioperative monitoring | Additional monitors are obtained if dictated by the medical condition of the patient or the nature of the surgery. |
| Positioning | Preparations are made to enhance patient safety when using a position other than supine. |
| Plan | An anesthetic plan for induction, maintenance, and emergence from general anesthesia is formulated based on a combination of the above factors. |
| Pain control | Plans are formulated for intraoperative and postoperative analgesic requirements. This often includes a regional anesthesia technique. |
| Postoperative concerns | Considerations are given for possible postoperative concerns and complications on the medical condition of the patient and the nature of the surgery. Plans are made for possible ICU admission and ventilatory management if necessary. |
The Patient: History and Physical Exam
The preoperative history should focus on concurrent medical diseases and their treatment, currently administered medications, previous allergic reactions, previous problems with administration of anesthetics, and family history of problems with anesthesia. Anesthetic complications that tend to recur include airway obstruction, postoperative nausea and vomiting, and severity of postoperative pain. If a previous anesthesia record is accessible, it must be thoroughly reviewed. The history of anesthetic problems in the family is focused on detecting susceptibility to malignant hyperthermia or presence of pseudocholinesterase deficiency. Some concurrent medications may influence the anesthetic technique. For example, anticonvulsants tend to shorten the duration of action of the aminosteroidal neuromuscular blockers.
When anesthetizing a neonate, the preoperative history should also focus on the medical histories of the parents and the course of pregnancy and delivery. Some maternal medical conditions ( Table 13.2 ) and medications administered during pregnancy ( Table 13.3 ) may affect the health of the newborn.
| Maternal Condition Effect on Newborn | |
|---|---|
| Diabetes | Increased incidence of congenital anomalies, hypoglycemia, macrosomia, polycythemia, cardiomyopathy, hypocalcemia, immature lung disease, hypomagnesemia. hyperbilirubinemia |
| Oligohydramnios | Renal anomalies, fetal distress, growth retardation |
| Polyhydramnios | Tracheoesophageal fistula |
| Low alpha-fetaprotein levels | Trisomy 21 (Down syndrome) |
| Rh sensitization | Hydrops fetalis, or milder forms of hemolytic anemia |
| Antepartum bleeding | Anemia, hypovolemia |
| Premature membrane rupture | Neonatal infection, sepsis |
| Meconium-stained amniotic fluid | Interstitial pneumonitis |
| Systemic lupus erythematosus (SLE) | Congenital third-degree heart block |
| Myasthenia gravis | Neonatal myasthenia |
| Preeclampsia | Neutropenia and thrombocytopenia |
| Graves disease | Hypothyroidism or hyperthyroidism |
| Chorioamnionitis | Neonatal infection, sepsis |
| Aspirin and other NSAIDS | Hemorrhage. pulmonary artery hypertension |
| Opioids | Neonatal depression, or abstinence |
| Cephalosporins | Hyperbilirubinemia |
| Sulfonamides | Hyperbilirubinemia |
| Anticonvulsants | Congenital anomalies |
| Warfarin (Coumadin) | Congenital anomalies, developmental delay, seizures |
| Antithyroid medications | Hypothyroidism |
| Beta-blockers | Neonatal bradycardia, hypoglycemia |
| Cocaine | Congenital anomalies, placental abruption |
| Magnesium | Respiratory depression, hypotonia, sensitivity to neuromuscular blockers |
| Ritodrine | Hypoglycemia |
| Terbutaline | Hypoglycemia |
| Alcohol | Fetal alcohol syndrome: dysmorphic facies, growth retardation, developmental delay |
| Tobacco | Prematurity, IUGR placental abruption and previa |
| Lithium | Cardiac anomalies |
| Isotretinoin | Micrognathia, cardiac and CNS anomalies |
| ACE inhibitors | Hypotension, oliguria |
A history of an allergy to a medication is common in children presenting for surgery. All children who require insertion of tympanostomy tubes have been exposed to at least one type of antibiotic. Many of these children report development of a rash after administration of antibiotics with a penicillin, cephalosporin, or sulfa base and have not undergone further diagnostic testing to determine the cause of the rash. The anesthesia practitioner has no accurate way of determining the true allergic status of the child, other than by history, or report from the parent. Studies have consistently shown that history of a drug allergy does not accurately predict positive skin testing. In many cases, more detailed questioning of the parent reveals that the reaction was not allergic in nature. For example, a parent may report that their child is allergic to morphine because it caused the child to experience somnolence or itching.
The focus of the preoperative physical exam is on the cardiovascular system, respiratory system, neurologic function, and other indicators of normal function.
Examination of the cardiovascular system begins with a measurement of vital signs such as heart rate and blood pressure. Normal values for heart rate and blood pressure vary with age, gender, weight, and height. Active and irritable infants will not have accurate vital signs, which are irrelevant in otherwise healthy children. Likewise, auscultation of the heart in a healthy child is so low yield that one could argue that it is unnecessary and will inevitably lead to the presence of the “normal” murmur, inviting further discussion and possible evaluation.
If this occurs, the parents should be queried as to whether or not the murmur had been previously detected, and whether there was any previous cardiac evaluation. If the murmur has not been previously detected, the anesthesiologist must quickly decide whether or not to continue with the anesthetic or cancel the case pending cardiology consultation to determine the cause of the murmur. Nearly all murmurs in otherwise healthy children can be classified as normal flow murmurs. These are not louder than II/VI, are usually vibratory in nature, and occur in systole over the pulmonary or mitral areas of the chest wall ( Table 13.4 ). Cardiology consultation should be obtained if the characteristics of the murmur are different or if there are other findings relevant to the cardiovascular system on history or physical exam.
| Observation | Implications |
|---|---|
| General | |
| Hypotonia or hypertonia | Neurologic or metabolic disease |
| Cyanosis | Cardiac disease, sepsis |
| Pallor | Anemia, poor cardiac output |
| Cardiovascular | |
| Abnormal murmur | Congenital heart disease |
| Abnormal or absent pulses | Coarctation of the aorta, poor cardiac output |
| Respiratory | |
| Tachypnea, abnormal lung sounds (e.g, wheezing, rales, rhonchi), use of accessory muscles of respiration, grunting | All are nonspecific findings in a variety of respiratory or cardiac disorders |
| Head and Neck | |
| Abnormal craniofacial anatomy (e.g., micrognathia). limited mouth opening or jaw mobility, limited neck mobility | Indicators of possible difficulty with ventilation or intubation |
Important elements of the respiratory system include the upper and lower airways. Facial structure and mandibular mobility should be examined for clues to a possible difficult ventilation or difficult tracheal intubation. Loose teeth should be suspected in children between 5 and 10 years of age. The anesthesiologist should manually remove an extremely loose tooth after induction of anesthesia as a precaution against its unintentional dislodgement and passage into the bronchial tree. Lung auscultation in healthy children is probably not necessary; however, children with a history of reactive airway disease and those with a concurrent upper respiratory tract infection should be assessed for expiratory wheezing. Room air pulse oximetry should be performed; a value less than 96% should warrant an investigation of respiratory abnormalities. In general, respiratory rates greater than 44 breaths per minute are considered abnormal, except in otherwise healthy neonates and small infants, in whom normal breathing rates can occasionally reach 70 breaths per minute.
Additional elements of the physical exam will be largely dependent on the preexisting medical condition of the child and the nature of the surgery ( Table 13.5 ). For example, a focused neurologic exam is indicated before any neurologic or orthopedic surgery, and in children with neuromuscular diseases.
| History |
|
| Physical Exam |
|
Discussing Risks of Pediatric Anesthesia
During the preoperative informed consent process, it is helpful to know the modern-day risks for general anesthesia in children. A Mayo clinic study revealed an incidence of cardiac arrest in anesthetized children (for noncardiac surgery) of 2.9 per 10,000, although when attributed only to anesthetic causes, the incidence was 0.65 per 10,000 anesthetics. Very few of these patients were initially healthy before the procedure.
A controversial issue in pediatric anesthesia is the extent to which the anesthesiologist should reveal the risks for anesthesia to the parents. Will this discussion increase or decrease parental (or child) anxiety? Should the anesthesiologist discuss the risk for death? What risks are appropriate to reveal? The answers to these questions are not easily found and may partly depend on the informed consent laws of the state in which one practices. Studies universally demonstrate that anxiety is decreased with more information, even though that information may allude to more harmful risks. For example, in a questionnaire study, most parents whose anesthesiologist mentioned the risk for death indicated they were satisfied to hear about this rare risk. Many parents whose anesthesiologist did not specifically mention the risk for death indicated that it should have been mentioned.
This author’s practice is to allude to the potentially harmful, yet rare, risks of anesthesia without increasing anxiety by stressing the overall safety of the procedure. One such dialog to the parents of a healthy child for elective surgery is as follows: “I don’t expect any risks or complications. We can never say never, but the risk for a life-threatening complication is extremely rare. Overall the anesthesia is extremely safe, and one of us will always be there.” Of course, comorbidities and type of planned procedure increase any risk. For example, the overall risk for respiratory complications is increased in children with obesity. Therefore, the discussion should be appropriately tailored on a case-by-case basis.
Allowing Parents Into the Operating Room
The time of induction of anesthesia represents a frightening time for both patients and parents. Because many parents assert that they possess a right to be with their child during any and all phases of their child’s hospitalization, many centers have promoted a culture of parental presence during induction of anesthesia (PPIA). The benefits of this practice are obvious as the child may be less anxious if their parent is soothing them in an unfamiliar location surrounded by strangers.
However, studies have clearly shown that parental presence does not alter the behavioral distress of the child, nor does it alter outcomes such as negative postoperative behaviors. Parental presence is not superior to preoperative sedatives such as midazolam for preoperative anxiety and in certain patients may be associated with increased anxiety when the child is calm and the parent is anxious. Furthermore, many parents are terrified as they observe the placing of a mask over their child’s face, watching their child become limp as consciousness is lost, and the occasional episode of upper airway obstruction that may occur. Yet when queried, parents who have been with their child in the OR during induction universally feel that they have done the right thing for their child.
If a decision is made to allow a parent into the OR during induction, the anesthesiologist should fully explain the events that will occur during induction. Three major points should be addressed:
- 1.
There should be an explanation of the nature of the procedure and the possible effects on the child (excitation, limpness, airway obstruction, etc.).
- 2.
The parent must agree to leave immediately at any time when requested by an OR staff member.
- 3.
The parent must agree to leave immediately once the child has lost consciousness. One of the surgical team members or another OR staff member should accompany the parent from the OR to the parents’ waiting area.
Some institutions will ask a parent to sign a written agreement to these terms and a waiver of liability should the parent suffer an injury secondary to fainting or other calamity.
Procedure
An important aspect of the preoperative discussion is the procedure. Some procedures require nonroutine anesthetic management. For example, thyroid excision may require intraoperative and postoperative calcium measurements, which necessitates a large IV capable of blood draws. These decisions should be made preoperatively, ideally at the morning huddle with the surgeon.
Premedication
Why is it important to avoid a “Brutane” induction?
The most important outcomes related to preoperative distress in children are postoperative behavioral disorders. These include nightmarish sleep disturbances, feeding difficulties, apathy, withdrawal, increased level of separation anxiety, aggression toward authority, fear of subsequent medical procedures and hospital visits, and regressive behaviors such as bed wetting. Although these disturbances are primarily present within the first two postoperative weeks, in some children they may last longer. Much has been made of this issue in the recent literature, but the concept is not new. In 1953, Eckenhoff demonstrated that postoperative personality changes were associated with younger age and unsatisfactory inductions. However, that study was conducted in an era that we would not recognize.
Today, many different modalities are used in an attempt to decrease fear and anxiety in patients and their families. They include preoperative informational materials that consist of discussions, tours, written literature, videotapes, and even comic books. In some institutions, the Child Life department assumes an active role in development of these programs and coordinates their efforts with anesthesia personnel. In carefully performed and controlled studies, however, these aforementioned interventions do not fare much better than placebo in decreasing the incidence of postoperative behavioral disturbances. Although distraction techniques are often effective for allaying anxious behavior during induction of anesthesia ( Fig. 13.1 ), premedication with an anxiolytic drug such as midazolam is the only proven intervention to decrease these undesirable outcomes.
