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Preoperative Evaluation of the Pediatric Patient

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Title: Preoperative Evaluation of the Pediatric Patient


1
Preoperative Evaluation of the Pediatric Patient
  • Marvin S. Cohen MD.
  • UTMB

2
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Pharmacologyof the Newborn
  • TBW Neonate (80)gtInfant (70)gtAdult (60)
  • Hydrophillic durgs have greater vol of dist.
    (sux)
  • Redistribution is less effective (thiopental)
  • Delayed excretion
  • Decreased degradation
  • Less protein binding

4
Pharmacologyof the Newborn
  • Half life of drugs
  • Prolonged in neonate
  • Shortened in infants and children. (greater blood
    flow to liver and kidneys)
  • Becomes normalized in teens and adults

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Induction agents
  • Generally requires slightly elevated dose (STP
    5- 6 mg/kg) - larger vol. of dist.
  • Longer half life due to reduced clearance
  • May be more sensitive to resp depressant effects

7
Muscle relaxants
  • Non- depolarizers
  • More sensitive
  • Higher volume of distribution
  • Liver/kidney metabolism decreased
  • Succinylcholine
  • Less senstive
  • Higher volume of distribution - hydrophilic
  • Reserve for emergency (hyper K)
  • Beware bradycardia
  • No phase two block

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Inhalation Agents
  • Inhalation induction is faster in infants and
    neonates

10
Risk
  • Adultsltchildrenltinfantsltneonates
  • ASA1ltASA2ltASA3
  • Low birth weight
  • Incidence of cardiac arrest in children
    1.4/10,000 - POCA STUDY

11
Risk 2
  • Airway Management (68 )
  • Lanryngospasm
  • Bronchospam
  • Esophageal intubation
  • Aspiration
  • Cardiac Arrests (32 )
  • Halothane (two from sevoflurane)
  • Medications including caudal bupivicaine

12
Caudal Anesthesia
  • Good Technique
  • Catheter over needle
  • Aspirate frequently
  • Inject incrementally
  • Bupivicaine with 1200,000 epi
  • Tachycardia
  • T wave increase

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URI
  • See Dr. Abouleishs lecture 12/20

15
Asthma
  • Incidence in general population is growing
  • Anestheisa and Surgery increase risk of
    bronchospasm
  • Good history and physical
  • PFTs in children under 6 are not reliable.
  • Maximize preop preparation.

16
Asthma 2
17
Apnea
  • Infants born lt 37 weeks have increased risk of
    apneic spells (gt15 seconds)
  • All general anesthetics interfere with
    respiratory drive

18
Apnea 2Minimize risk
  • Delay surgery until 48 60 weeks
  • Use spinal/caudal anesthesia
  • Caffeine base 10mg/kg IV
  • Admit all patients at risk to ICU post op

19
Bronchopulmonary DysplasiaBPD
  • Oxygen dependence at 36 weeks PCA in Infants
    lt1500 gms
  • Increased risk of hypoxia
  • Brochospasm
  • V/Q mismatch
  • Cor pulmanale
  • Tracheomalacia
  • Pneumonia

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BPD 2Treatment
  • Bronchodilators
  • Antibiotics
  • Diuretics
  • Steroids

22
Epinephrine Your best friend
23
Murmurs
  • Functional murmurs
  • Normal S1 and S2
  • Normal exercise tolerance
  • Acyanotic
  • Growing well

24
Murmurs 2
  • Pathological (even asymptomatic)
  • Must be assessed by cardiology with at least ECG
    and a recent echocardiogram
  • Complete medical and surgical history must be
    available
  • Consider Chest Xray, hematicrit, O2 sat

25
SBE Prophylaxis
  • All children with congenital heart disease
    except
  • Ligated PDA
  • Primary closure of secundum ASD with out patch
  • All surgeries at risk of transient bacteremia
  • Dental, sinus, airway, GU, GI
  • Exception BMTs

26
SBE Prophylaxis 2
  • Respiratory and Esophageal Procedures
  • Ampicillin 50mg/kg IV
  • PCN allergy Cefazolin 25 mg/kg IV
  • GU and GI Procedures
  • Ampicilln 50 mg/kg and Gentamicin 1.5 mg/kg
  • PCN all Vancomycin 20 mg/kg and Gent.

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CNS
  • Hydrocephalus
  • Evaluate of ICP, shunt patency, meningitis
  • Latex precautions
  • Seizure History
  • If unstable get drug levels
  • Remember Post op administration

29
Sickle Cell Disease
  • Hemoglobin and hemoglobin S levels in major
    surgery.
  • Transfuse to Hgb of 10 g/dl and or Hemoglobin S lt
    30
  • Beware of
  • Cardiomyopathy
  • Nephropathy
  • Peripheral neuropathy
  • Respiratory dysfunction

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Retinopathy of Prematurity
  • Etiology is multifactorial
  • ?Low birth weight (lt1000 gms)
  • ?prolonged Oxygen exposure
  • Retina matures at 44 weeks PCA
  • Maintain SaO2 at 93 -95 if possible.

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Review of Systems Anesthetic Implications
34
Review of Systems Anesthetic Implications
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Review of Systems Anesthetic Implications
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DEVELOPMENTAL MILESTONES
37
DEVELOPMENTAL MILESTONES
38
DEVELOPMENTAL MILESTONES
39
DEVELOPMENTAL MILESTONES
40
Classic Stage Theories
41
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