paediatricpre-anaestheticevaluation-230805042821-1f8001ff.pptx

pre anesthesics

1. Pre- Anaesthetic Check up and PAC for pregnant, pediatric , geriatric patient Moderator - Dr. Priyanka Chourasia ( AP) Dr Diksha ( SR) Presentor - Dr.Chandresh ( pg2) Dr Akriti ( pg1)

2. OBJECTIVES OF PAE Evaluate the patient’s medical condition to ensure that it has been optimised Plan anaesthetic technique and peri -operative care. Develop a rapport with the patient to allay anxiety and facilitate conduct of anaesthesia Allow appropriate discussion with the patient and/or guardian regarding anaesthesia, peri -operative care and pain management Obtain informed consent for anaesthesia and related procedures.

3. COMPONENTS 1. HISTORY 2. PHYSICAL EXAMINATION 3. SYSTEMIC EXAMINATION 4. LABORATORY EVALUATION 5. ASA CLASSIFICATION 6. INFORMED CONSENT 7. PREOPERATIVE FASTING ORDERS 8. PREPARATION

4. HISTORY Social and Demographic Details: Name, Age, Sex, Guardian/Informant’s name, Educational Status of both child and Parents, the family’s SocioEconomic Status, Contact details. Chief Complaint History of Presenting Illness : elaboration of the presenting complaint History of any co-morbid conditions, congenital abnormalities

5. Respiratory System : -Recent history of URTI/LRTI -history suggestive of airway compromise OSA History of bronchial asthma

6. Cardiovascular System : Congenital or Rheumatic Heart Disease History of cyanotic or breath holding spells Consider possibility of cardiac lesion if child has any associated congenital conditions : tracheoesophageal fistula, esophageal atresia , Down Syndrome, VACTERL anomalies History of Failure to thrive - Medication history for CVS disease : Beta blockers, anticoagulants, antihypertensives , digoxin , antiplatelet drugs

7. CNS : - Seizure history, including h/o anticonvulsants - raised ICP features Progressive neurodevelopmental impairment Behavioural abnormalities Hepatic and Renal System History: Kernicterus , Jaundice Nephrotic or Nephritic symptoms Obstructive uropathy symptoms

8. Family History: - Consanguinous or Non- consanguinous marriage - Pedigree chart - h/o sudden intraoperative death, or hyperthermia after surgery : indicates risk of malignant hyperthermia Past History: Any previous surgeries requiring anaesthesia, blood transfusions History of mechanical ventilation Drug History Personal History: Appetite, Sleep, Bowel and Bladder habits Passive smoking Medical allergies

9. RESPIRATORY SYSTEM HISTORY

10. GASTROINTESTINAL SYSTEM HISTORY

11. RENAL SYSTEM HISTORY

12. GENERAL PHYSICAL EXAMINATION Anthropometry : General nutritional state, weight, height, mid arm circumference, head circumference Skin and mucosal colour : pallor, icterus , cyanosis Clubbing, Koilonychia Heart Rate, Blood Pressure, Capillary Filling Time, Oxygen Saturation. Respiratory Rate, Character of respiration Spine : spina bifida; whether hiatus well felt Potential sites for venepuncture – mark out for EMLA (Eutectic Mixture of Local Anaesthetic) application Presence or absence of nasal discharge

13. AIRWAY ASSESSMENT Inter Incisor Gap Dentition Modified Mallampatti Classification Upper Lip Bite Test Neck Circumference Thyromental Distance Sternomental Distance

14. Class I = visualize the soft palate, fauces , uvula, anterior and posterior pillars. Class II = visualize the soft palate, fauces and uvula. Class III = visualize the soft palate and the bas e of the uvula. Class IV = soft palate is not visible at all. Modified Mallampati Classification

15. LABORATORY INVESTIGATONS For minor procedure – In healthy children Hb %/Urine/ BT-CT For major procedure – Haematological profile/urine/X-ray-Chest/ S.Electrolytes /BUN/S. creatinine Random Blood Sugar – In adolescent patients 2D echo / Echocardiography – should be done if murmur is present or suspect CHD Other investigations like renal and hepatic function tests etc., should be done if systemic diseases are present

16. ASA CLASSIFICATION Class I: Healthy patient, no systemic disease Class II: Mild systemic disease with no functional limitations (mild chronic renal failure, iron deficiency anaemia, mild asthma) Class III: Severe systemic disease with functional limitations (hypertension, poorly controlled asthma or diabetes, congenital heart disease, cystic fibrosis) Class IV: Severe systemic disease that is a constant threat to life (critically and/or acutely ill patients with major systemic disease) Class V: Moribund patients not expected to survive 24 hr, with or without surgery add “E” for —emergency surgery

17. PREOPERATIVE FASTING Fasting Time (hr) * Age Milk and Solids Clear Liquids <6 months 4 2 6-36 months 6 3 >36 months 8 3

18. Systemic Examination Cardiovascular System : Features of cardiac murmurs Innocent Pathological Asymptomatic Symptomatic Soft Loud Early systolic Pan or late systolic, diastolic Continuous No thrill Thrill present Disappears with positioning May be a venous hum

19. Systemic Examination Respiratory System : Upper Respiratory Tract : congestion, discharge, hypertrophied turbinates , deviated nasal septum Lower Respiratory Tract :

20. INFORMED CONSENT Consent should be obtained from the parent or guardian for a paediatric patient, while explanation and discussion should involve the patient’s next-of-kin if the patient himself/herself is in no condition to provide consent for treatment.

21. Pediatric patient Birth History: -gestational age at birth -mode of delivery -birth weight -order of birth (whether firstborn) -baby cried immediately after birth - any NICU admission - when breastfeeding was started - h/o apnoeic spells- more likely to develop apnoea following anaesthesia and should not be accepted for day care procedures until they are atleast 50 wks gestation.

22. Antenatal History: - booked/not booked case - intake of Iron and Folic Acid tablets - any other drug intake - any infections/ febrile illness - GDM, PIH, other maternal comorbid conditions

23. Developmental History: - Gross Motor, Fine Motor, Social, Language Immunization History: - Appropriate to age as per IAP schedule. - Children may have received vaccines. Surgery should be planned in accordance with the vaccination programme .

24. Child with URTI Peri -operative problems include laryngospasm , bronchospasm , airway obstruction by secretion, intraoperative atelectasis and hypoxemia, post-extubation stridor . Incidence greater in infants <1 year old. Recommendations for anaesthesia in a child with RTI depends on its severity and the nature of the surgery (elective, emergency, minor or major) The child with mild RTI (no fever, clear nasal discharge, mild cough, child active, feeding well) can be anaesthetized for minor surgical procedure without tracheal intubation. Surgery for the child with active RTI (fever, recent onset of purulent nasal discharge, cough) should be postponed for at least 2 weeks, and ideally 4-6 weeks; LMA to be used if possible, to avoid airway manipulation.

25. Geriatric patient Physiology of the older person
Ageing refers to time-dependent post-maturity changes that take place at a cellular level. These changes may lead to a decline in physiological reserve and functional status.6

26. Cvs Over time, large- and medium-sized arterial vessels become less compliant, increasing systemic vascular resistance. Hypertension may cause left ventricular strain and hypertrophy. Increased collagen and fibrous tissue deposition can further impair diastolic filling. To maintain cardiac output, preload is increased. Whilst cardiac output is preserved initially, the heart now functions on a flatter part of the Frank–Starling curve with reduced physiological reserve.

27. This cause intraoperative fluctuations in blood pressure and cardiac output .Because of the ageing process, fat infiltration and fibrosis of the cardiac conducting pathways can lead to issues, such as heart block, atrial fibrillation, ectopic beats and arrhythmias.
Effects on cardiac structure-Progressive calcification of the cardiac valves is commonly seen in older people. This is most likely to affect the aortic valve, causing sclerotic disease and aortic stenosis.

28. Respiratory system Effects on lung mechanics and volumes-Structural changes to the lung parenchyma, spine and chest wall occur with age. These changes result in a reduction in airway elastase ,lung compliance and chest wall compliance. Total lung capacity, forced vital capacity, forced expiratory volume in 1 s and vital capacity all reduce with age; closing capacity (CC) increases with age. However, residual volume and hence functional residual capacity decrease.

29. This leads to an increased tendency of the alveoli and the terminal conducting airways to collapse. Gas exchange is impaired across the alveolar membrane. Smoking and the development of obstructive airways disease accelerate this process. There is a linear decrease in the arterial partial pressure of oxygen with age and an increase in the arterial partial pressure of carbon dioxide.

30. Renal system Reduction in renal function-Healthy adults lose 50% of their nephrons between the ages of 18 and 75 yrs , resulting in a reduction in renal cortical mass. Cortical blood flow and glomerular filtration rate are reduced because cardiac output is decreased. As there are fewer nephrons, the sodium load per nephron is greater. However, the ability to excrete sodium is reduced because of a deterioration of the countercurrent multiplier system in the loop of Henle.

31. There is also reduced activity along the renin–angiotensin–aldosterone axis, which further compromises the body’s ability to manage fluid and electrolyte balance. Older patients are therefore less able to tolerate hypo- or hypervolaemia in the perioperative setting. There are often other contributors to the progressive decline in renal function. These contributors include an increased burden of diseases, such as diabetes and hypertension, and the use of nephrotoxic drugs, such as angiotensin-converting enzyme inhibitors.

32. Neurological system The risk of cognitive dysfunction and dementia increases with age Visual impairment is more prevalent in older patients. This is largely attributable to age-related cataract formation, macular degeneration and glaucoma. Autonomic neuropathy is more prevalent with age and other conditions, particularly diabetes. Impaired baroreceptor responses can cause perioperative cardiovascular instability, and delayed gastric emptying is linked with an increased risk of aspiration.

33. Musculoskeletal system Muscle mass decreases with age. The reduction in subcutaneous fat also increases the rate of heat loss, and shivering is less effective because of the reduced muscle mass. Consequently, thermoregulation can be significantly impaired, and temperature monitoring should be routine intraoperatively .

34. Conclusions The care of older surgical patients frequently requires assessment and management of multiple medical conditions, geriatric syndromes Comprehensive geriatric assessment is an interdisciplinary, holistic, diagnostic and therapeutic process that facilitates the assessment and optimisation of the older surgical patient perioperatively .

35. In Pregnant patient CARDIOVASCULAR CONSIDERATIONS In pregnancy, cardiac output increases by 40% due to an increase in plasma volume (which also leads to dilutional anemia ), the basal heart rate increases by 10%, and vasodilation leads to a 10- to 20-mm Hg reduction in systemic blood pressure.9 These changes lead to an increased hypotensive response to both general and spinal anesthesia .

36. RESPIRATORY CONSIDERATIONS The growing uterus pushes up on the diaphragm, restricting the lungs and reducing functional residual capacity by about 20% when the patient is upright and 50% to 70% when recumbent. Minute volume and tidal volume increase during pregnancy by about 35%, predisposing patients to respiratory alkalosis.

37. RENAL CONSIDERATIONS Anatomic changes of a pregnant uterus cause some degree of urinary stasis and dilation of the pyelocaliceal system, increasing the propensity to develop urinary tract infections.

38. HEMATOLOGIC CONSIDERATIONS In pregnancy, the red blood cell mass volume increases, but the plasma volume increases more, leading to dilutional anemia . At the same time, pregnancy is associated with a 6-to 10-fold higher risk of deep vein thrombosis due to increased production of clotting factors I, II, V, VII, VIII, X, and XII and a reduction of factors of the fibrinolytic system.
Therefore, perioperative management should include prophylaxis against deep vein thrombosis30 with low-molecular-weight heparin (LMWH) in prophylactic doses.

39. GASTROINTESTINAL CONSIDERATIONS Gastroesophageal reflux is common in pregnant women owing to the growing uterus occupying more abdominal space, as well as progesterone contributing to slowing of gastric emptying time and reduced inferior esophageal sphincter tone.
Perioperative use of prokinetics , antacid medications, and reflux prevention strategies ( eg , elevating the head of the bed at least 15°, fasting 8 hours) are recommended.
Pregnant women should be considered to have full gastric content before surgery. If intubation is needed, a rapid sequence intubation protocol is indicated.

40. Avoid supine positioning
During the second and third trimesters of pregnancy, the uterus compresses the inferior vena cava when the patient lies flat, reducing venous return by about 30%, with a consequent decrease in cardiac output and placental perfusion.

41. Conclusion The perioperative assessment of the pregnant patient undergoing surgery is similar to that of the nonpregnant patient; however, the physiologic changes of pregnancy must be taken into consideration.

Diagnostic and therapeutic decisions should not neglect the mother and not withhold needed care for her with the purpose of protecting the fetus .

It is preferred to wait until the postpartum period for any elective surgery. However, if surgery is necessary, it can best be done during the second trimester. Emergency surgery should be pursued regardless of the gestational age. The preferred approach for abdominal surgery is by laparoscopy.

The preferred anesthetic approach is neuroaxial anesthesia if possible.

42. CONCLUSION Paediatric assessment and preparation is always a challenging subject and more with learning students. Hence considering all above mentioned points may help and also it’s now become a super speciality so that further study is always recommended.

43. THANK YOU