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Preanesthesia Considerations for the Nurse Practitioner
Original Article
Preanesthesia Considerations for the Nurse Practitioner Jamie Reddinger, RN, MSN, CPNP, Kathleen Oft, RN, MSN, CRNP-BC, & Katrina Geier, RN, MSN, CPNP
ABSTRACT With increases in pediatric ambulatory surgery, primary health care providers such as nurse practitioners are being called upon to provide input about patients preoperatively or prior to other procedures requiring anesthesia. Because the anesthesia team may not meet the patient and family until the day of surgery; a thorough evaluation done by the primary care provider can supply the anesthesia team with the information required for optimal care. Such information includes a detailed history, including the patient’s birth history, medical diagnoses, medications, allergies, recent laboratory test values, and the results of a recent physical examination. The purpose of this article is to provide primary care nurse practitioners with guidelines and information to consider when seeing their patient for a preprocedural visit. J Pediatr Health Care. (2005) 19, 374-379.
Jamie Reddinger is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Kathleen Oft is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Katrina Geier is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Reprint requests: Kathy Oft, Children’s Hospital of Pittsburgh, Same Day Surgery, 3705 Fifth Ave, Pittsburgh, PA 15213; e-mail: [email protected]. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2005.07.009
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www.jpedhc.org
Primary care nurse practitioners play a pivotal role in the medical evaluation and psychological preparation of a child before anesthesia. While the surgical service has the opportunity to assess the patient before a surgical procedure, operating room availability may cause a delay in scheduling, so the surgical assessment may not be current. Many hospitals and surgical units do not have a preoperative anesthesia evaluation clinic in which the patient can be seen prior to the day of surgery (Pasternak, 2002). Therefore, the anesthesia team may not have a chance to evaluate the patient until the day of surgery. Preoperative evaluation clinics help prepare patients for surgery in a way that minimizes cost and optimizes outcomes (Pollard, 2002). Consequently, it benefits the patient to have a primary care provider who is familiar with his or her medical history to provide a preoperative assessment. It is the ultimate responsibility of the anesthesiologist to clear patients for anesthesia; however, this decision is often dependent upon information provided by the primary health care provider (Pasternak, 2002). The issues to be addressed are the medical problems of the patient and how they are being managed. The patient should be in as optimal condition as possible before undergoing anesthesia. The child’s presurgical health status should be compared with his or her usual state of health. The stress of surgery and anesthesia may strain the physiologic reserves of a patient who has a chronic illness even if the patient is stable at the time of surgery (Ferrari, 1997). The child must be thoroughly evaluated and all medical issues addressed, including any new or chronic conditions. The issue of the timing of the preanesthesia evaluation and the appropriate staff by whom it Journal of Pediatric Health Care
should be done has yet to be critically evaluated (Pasternak, 2002). Evidence has not supported the notion that all patients need to have a preanesthesia visit by an anesthesiologist prior to the day of surgery. The convenience of having this type of evaluation is affected by issues such as the practice environment, geography, and patient population. In some instances, an anesthesia consultation prior to surgery is most helpful in directing the care of complex patients. However, healthy patients scheduled to have procedures of minor or intermediate complexity or stable patients with significant medical issues but with procedures of low risk or complexity may have their evaluation on the day of surgery. Appropriate information must be available for the anesthesia staff to review (Pasternak, 2002), and this information can be provided in the form of a history and physical examination from the patient’s primary health care provider. According to the Practice Advisory in the Journal of Anesthesiology (Pasternak et al., 2002), the preanesthesia evaluation is defined as the “process of clinical assessment that precedes the delivery of anesthesia for surgery and for nonsurgical procedures” (p. 485). One goal of the preoperative medical evaluation is to decrease perioperative morbidity, recognizing that preoperative medical conditions often predict postoperative problems. Preanesthetic evaluation includes the review of previous medical records, interview with the parents and the patient, and a physical examination. Subsequently, further medical testing and laboratory testing may be deemed necessary. Preoperative testing may be indicated for the following: discovery of a disease or disorder that may affect anesthetic care, verification of a disease that may already be present, or determining the status of a known disease. This preanesthesia evaluJournal of Pediatric Health Care
ation will be used for developing a plan of care before, during, and after surgery. Postoperative pain management should also be included in the plan. The nurse practitioner must obtain a complete and detailed history from the parents and/or the patient. Birth history, other medical conditions, and previous surgeries, as well as reactions to the anesthetics, must be included. Specifically, it is helpful to be aware of any adverse reaction to anesthesia, such as postoperative nausea and vomiting, drug reactions, cardiac or respiratory problems, changes in temperature, or prolonged paralysis. For infants, pertinent birth history such as prematurity and ventilation are important factors because the most serious risk in a
though this history is always elicited by the anesthesia staff, if this information is known ahead of time, it will facilitate planning the anesthetic management of the patient. Malignant hyperthermia is a rare, inherited disease that most often manifests in childhood. It occurs in susceptible individuals who receive inhalation anesthetics with or without succinylcholine. It is characterized by cardiac arrhythmias, increased body metabolism, muscle rigidity, and high fever, which is a late sign. The patient may develop a spasm of the masseter muscle, making it impossible to open the mouth for tracheal intubation (Stoelting & Miller, 2000). Pseudocholinesterase deficiency is also an inherited disorder that results in abnormally slow degrada-
Preanesthetic evaluation includes the review of previous medical records, interview with the parents and the patient, and a physical examination. former premature infant is postanesthetic apnea, especially before 44 weeks postconceptual age (Malviya, Swartz, & Lerman, 1993). Additional risk factors of prematurity are a history of apnea and bradycardia, multisystem medical conditions, respiratory distress, intubation, mechanical ventilation, or a hematocrit of less than 30%, according to Welborn, Hannallah, Luban, and Ruttimann (as cited in Cote et al., 1995). Concurrent medical conditions such as gastroesophageal reflux, asthma, cancer, cardiac conditions, and seizure disorders should be included. A family history of anesthesiarelated complications such as malignant hyperthermia or pseudocholinesterase deficiency must be documented and investigated. Al-
tion of exogenous choline ester drugs such as succinylcholine. This condition is recognized when respiratory paralysis persists for a longer period of time than expected. Treatment of respiratory insufficiency due to pseudocholinesterase deficiency is mechanical ventilation until diffusion of succinylcholine permits the return of neuromuscular function (Alexander, 2002). The names of any medications the child is taking, their doses and frequency of administration, and any significant previous medications the child had been taking recently should be documented. Herbal supplementation must be included in the list of the patient’s medications; these agents may be contraindicated for anesthesia and November/December 2005 375
Herbal supplementation must be included in the list of the patient’s medications; these agents may be contraindicated for anesthesia and surgery. surgery. For example, increased bleeding has been associated with the use of gingko and garlic, hypertension with ginseng, and excess sedation with St. John’s Wort. Valerian and St. John’s Wort may prolong the action of anesthetics (Crowe & Lyons, 2004). Ang-Lee, Moss, and Yuan (2001) suggest that patients stop taking kava and ephedra 24 hours before surgery, ginko 36 hours before surgery, garlic and ginseng 1 week before surgery, and St. John’s Wort at least 5 days before surgery. These suggestions are based on the pharmacokinetics of the herbal medications. Children taking anticonvulsants should be encouraged to take their doses as per their home schedule as long as it allows them to adhere to the fasting guidelines. Use of any asthma medications, especially bronchodilators, should be encouraged prior to anesthesia. Children with a history of reactive airway disease are at a slightly increased risk for bronchospasm with the administration of anesthesia and instrumentation of the airway (Maslow et al., 2000). Based on current data, the anesthesia staff may recommend a prophylactic dose of the patient’s bronchodilator prior to the administration of anesthesia to minimize this risk of airway reactivity (American Academy of Pediatrics [AAP], 1996; Ferrari, 1997; & Maslow et al.). In children with chronic conditions, it is advisable to continue all medications up to the time of surgery. Note any drug and food allergies and the type of reaction. Because sedatives can cause a paradoxical reaction in some children and narcotics may cause a myriad of 376 Volume 19 • Number 6
adverse effects, it is important to note the child’s prior experience with them. Food and environmental allergies also must be listed. An allergy to eggs and soybean oil may be a contraindication to administration of Diprivan (propofol), a commonly used anesthetic agent, because it contains egg lecithin and soybean oil (Hofer, McCarthy, Buck, & Hendrick, 2003).
gery. However, recent literature suggests that because of variable and unpredictable rates of gastric emptying, fears of aspiration may be unfounded (Stoelting & Miller, 2000). In some cases, prolonged periods of fasting may create potentially harmful situations because cardiac function and blood pressure are less well maintained when intravascular volume is depleted (Ferrari, 1997). For this reason, ingestion of clear fluids should be encouraged up until the cutoff time given by the surgical institution. A comparison study by Flick, Schears, and Warner (2002) postulates that based on the available data, aspiration remains more common in children than in adults; however, morbidity associated
The emphasis of the physical examination for anesthesia is focused on upper airway, respiratory, cardiovascular, and neurologic systems and the body system that is the focus of the particular surgical procedure. Concerning adolescents, questions regarding tobacco, alcohol use, and recreational drugs including marijuana, heroin, cocaine, and ecstasy must be asked privately to optimize honesty in disclosure. It is helpful for health care providers to reinforce the importance of following the preoperative fasting guidelines. Fasting guidelines are given to patients and their families before surgery or other procedures requiring general anesthesia. The purpose of preoperative fasting is to allow sufficient time for gastric emptying, because aspiration of ingested food or liquid into the lungs can cause aspiration pneumonia. These instructions must be clearly and repeatedly given to the parents prior to sur-
with aspiration is rare across all age groups. Consequently, because data regarding this issue remain somewhat contradictory, it is essential to advise parents to strictly follow the instructions given by the institution regarding fasting times to prevent cancellation of surgery. In general, there is no uniform fasting practice for children before elective surgery in the United States. However, it is generally agreed that ingestion of clear liquids 2 to 3 hours prior to anesthesia is acceptable (Ferrari, Rooney, & Rockoff, 1999). The emphasis of the physical examination for anesthesia is focused on upper airway, respiratory, cardiovascular, and neurologic systems and the body system Journal of Pediatric Health Care
TABLE 1. ASA Physical Status Classification System I II III IV V VI E (emergency operation)
A normal healthy patient A patient with systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive with or without the operation A declared brain-dead patient whose organs are being removed for donor purposes Any patient in whom an emergency operation is required
American Society of Anesthesiologists (1963). Reprinted with permission of the American Society of Anesthesiologists, 520N Northwest Highway, Park Ridge, IL 60068-2573.
that is the focus of the particular surgical procedure. Preoperative evaluation of the patient’s airway helps to determine the route and method for tracheal intubation. The size of the tongue in relation to the size of the oral cavity can help determine the degree of difficulty involved in intubation (Stoelting & Miller, 2000). Facial structure and mandibular mobility should be examined for clues for difficult intubation. Several congenital syndromes such as Goldenhar, Pierre Robin, and TreacherCollins often are associated with airways that are difficult to manage as a result of craniofacial abnormalities. Children should be questioned about and examined for loose teeth. After induction of anesthetic, the anesthesiologist may opt to remove loose teeth to avoid accidental dislodgement into the bronchial tree. An important element of the respiratory system includes auscultation of the upper and lower airway. Good respiratory effort is critical in the respiratory examination. Breath sounds should be clear and equal bilaterally without adventitious lung sounds. Examination of the cardiovascular system begins with vital signs including heart rate and blood pressure. Auscultation of the heart is performed to determine normal heart sounds and any abnormal murmurs. If a murmur is found, the parents should be asked if the murmur was previously detected. Murmurs in healthy children are usually flow murmurs. They typically are not louder than II/VI and Journal of Pediatric Health Care
occur in systole over the pulmonic or mitral areas of the chest wall. A new murmur should be evaluated by a cardiologist. Subacute bacterial endocarditis prophylaxis may be required in patients with significant heart disease. In addition, some anesthetic agents are myocardial depressants, and a child with heart disease may be at in-
(URI) merits careful evaluation. Anesthetizing a child with an active URI involves risks such as atelectasis, oxygen desaturation, bronchospasm, laryngospasm, postintubation croup, and pneumonia. Compared with other children, those with acute URIs have a twofold to seven-fold increase in respiratory-related events during and
Anesthetizing a child with an active URI involves risks such as atelectasis, oxygen desaturation, bronchospasm, laryngospasm, postintubation croup, and pneumonia. creased risk for complications. A complete neurologic evaluation is not necessary for a healthy child. Much information can be gained by observation of the child’s behavior. An interactive, playful child is unlikely to have a severe neurologic problem. However, a basic neurologic assessment, including an observation of the cranial nerves, motor and sensory function, reflexes, and cognitive function, should be performed. Any history of cervical spine instability also should be documented because precautions will need to be taken when intubating the patient, particularly in children with Down syndrome (Ferrari, 1997). A child who has had a recent upper respiratory tract infection
after surgery (Cohen & Cameron, 1991). If the child has an active or recent upper respiratory infection, he or she is at greater risk for adverse respiratory events such as oxygen desaturation, breath holding, and severe coughing. These risks are further increased if the patient requires intubation (Tait et al., 2001). Although most studies concur that children with active or recent URIs are at increased risk for perioperative complications, these events are mostly manageable and without long-term sequelae. However, most anesthesiologists would agree that any child with severe URI symptoms should have surgery postponed for at least 4 weeks (Tait & Malviya, 2005). Because uniform guidelines for preoperative laboratory testing do November/December 2005 377
not exist, the patient’s history and physical examination, as well as the judgment of the health care provider, are most commonly used as the basis for testing (Meneghini, Zadra, Zanette, Baiocchi, & Giusti, 1998, & Pasternak, 2002). Preanesthesia testing should be based on the relevance the results may have on the anesthetic plan. For example, surgeries that may result in a large amount of blood loss and fluid shifts may require a preoperative hemoglobin and hematocrit, coagulation screening, and an order for banked blood. A child with congenital heart disease or other cardiac problem may benefit from a cardiology consult and/or echocardiogram prior to surgery. Urinalysis is not routinely indicated preoperatively. However, depending on hospital policy, mandatory pregnancy screening may be required for female adolescents. In general, healthy patients having minor procedures usually do not require preoperative laboratory testing. A myriad of issues may occur in the hours, days, and weeks after surgery, and the patient’s primary health care provider usually will be the first contact. Children with a history of recurrent croup or with a recent history of cold symptoms are at an increased risk for the development of postoperative croup (Ferrari, 1997). The incidence of croup is highest in the hours after intubation; however, parents should be educated about the signs and symptoms of stridor as well as the appropriate intervention (ie, cool mist, humidified air, and emergency department referral if necessary). Once the patient has returned home, the primary care nurse practitioner should be available for questions concerning pain management. Another issue that should be closely monitored in the hours after surgery is the child’s hydration status. It is not uncommon, particularly after procedures involving the upper airway (ie, adenotonsillectomy) for patients to 378 Volume 19 • Number 6
have decreased oral intake. Intake should be monitored by the caregivers and information regarding dehydration should be provided. Research has shown that children may exhibit behavioral disturbances in the days and even weeks following hospitalization (Keaney, Diviney, Hare, & Lyons, 2004). Such changes may include anxiety, bedwetting, night terrors, or regression. The study done by Keaney et al. compared the behavioral responses of children who had received one of two different inhaled anesthetic agents and evaluated whether the use of these agents translated into prolonged behavioral changes well after their administration. It was found that
sent, but the primary care nurse practitioner may introduce the notion that there are always risks with the use of general anesthesia and precautions should be taken to minimize these risks. In general, the safety of pediatric anesthesia has greatly improved over recent years, with decreases in anesthesia-related mortality (Motoyoma, in press). The American Society of Anesthesiologists (ASA) (1963) developed the physical status categories, shown in Table 1, to make an overall assessment of the degree of illness or physical state prior to administering anesthesia. This information can be used to estimate a patient’s fitness for the surgery and for anesthetic technique; however,
A detailed history that focuses on significant previous anesthetic experiences, birth history, medical diagnoses and their management, as well as a recent physical examination, is necessary for the anesthesia team to customize the anesthetic plan to the patient’s particular needs. 65% of patients exhibited some negative behavioral changes in the month following surgery, and these changes occurred more frequently with decreasing age. Furthermore, it was concluded by Kain, Wang, Mayes, Caramico, and Hofstadter (1999) that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. Parents may ask the anesthesia team whether their child would be an appropriate candidate for premedication with sedating agents. The anesthesia staff will review the risks and benefits of anesthesia prior to obtaining informed con-
it is not intended to represent an estimate of anesthesia risk. According to Morray et al. (2000), patients who experienced anesthesia-related cardiac arrests were most strongly associated with ASA PS categories 3 to 5 and emergency surgery. The highest incidence of anesthesia-related deaths is in children younger than 1 year of age and in patients with severe underlying disease (Morray et al.). Parents often want to know the risks associated with anesthesia. Serious risks include laryngospasm, bronchospasm, dental trauma, major drug reactions, aspiration, pneumonia, hypoxemia, arrhythmia, and coma. However, most of these risks are usually not life-threatenJournal of Pediatric Health Care
ing. Minor temporary complications include sore throat, nausea and vomiting, postintubation croup, coughing, hoarseness, and oral trauma (Ferrari, 1997). It is important to reassure parents that modern anesthetic medications and practice are very safe and the equipment utilized to monitor patients is sophisticated. The overall risk of anesthesia-related mortality is very low. In summary, when performing a preanesthesia assessment, thoroughly assess the patient and document all medical issues. A detailed history that focuses on significant previous anesthetic experiences, birth history, medical diagnoses and their management, as well as a recent physical examination, is necessary for the anesthesia team to customize the anesthetic plan to the patient’s particular needs. In addition, a preanesthesia consult either via phone or in person with an anesthesia team member may be warranted in children with severe underlying disease, those known or suspected to have an airway that is difficult to manage, or those with a family history of malignant hyperthermia or pseudocholinesterase deficiency. Communication between the anesthesia staff and the primary health care provider is central to ensuring a safe perioperative course. Special thanks to James A. Greenberg, MD, Clinical Associate Professor of Anesthesiology, University of Pittsburgh School of Medicine. REFERENCES Alexander, D. R. (2002). Pseudocholinesterase deficiency. eMedicine. Retrieved June 3, 2003, from http://www. emedicine.com/med/topic1935.htm
Journal of Pediatric Health Care
American Academy of Pediatrics. (1996). Evaluation and preparation of pediatric patients undergoing anesthesia. Pediatrics, 98, 502-508. American Society of Anesthesiologists. (1963). New classification of physical status. Anesthesiology, 24, 111. Ang-Lee, M. K., Moss, J., & Yuan, C. (2001). Herbal medicines and perioperative care. JAMA, 286, 208-216. Cohen, M. M., & Cameron, C. B. (1991). Should you cancel the operation when a child has an upper respiratory tract infection? Anesthesia & Analgesia, 72, 282-288. Cote, C. J., Zaslavsky, A., Downes, J. J., Kurth, C. D., Welborn, L. G., Warner, L.O., et al. (1995). Postoperative apnea in former preterm infants after inguinal herniorrhaphy: A combined analysis. Anesthesiology, 82, 809-822. Crowe, S., & Lyons, B. (2004). Herbal medicine use by children presenting for ambulatory anesthesia and surgery. Paediatric Anaesthesia, 14, 916-919. Ferrari, L. R. (1997). Cleared for anesthesia: What it means, how to do it. Contemporary Pediatrics Archive. Retrieved August 27, 2004, from http://www. contemporarypediatrics.com Ferrari, L. R., Rooney, F. M., & Rockoff, M. A. (1999). Preoperative fasting practices in pediatrics. Anesthesiology, 90, 978-980. Flick, R. P., Schears, G. J., & Warner, M. A. (2002). Aspiration in pediatric anesthesia: Is there a higher incidence compared with adults? Current Opinion in Anaesthesiology, 15, 323-327. Hofer, K. N., McCarthy, M. W., Buck, M. L., & Hendrick, A. E. (2003). Possible anaphylaxis after propofol in a child with food allergy. Annals of Pharmacotherapy, 37, 398-401. Kain, Z. N., Wang, S., Mayes, L. C., Caramico, L. A., & Hofstadter, M. B. (1999). Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesthesia & Analgesia, 88, 1042-1047. Keaney, A., Diviney, D., Hare, S., & Lyons, B. (2004). Postoperative behavioral changes following anesthesia with sevoflurane. Pediatric Anesthesia, 14, 866-870. Malviya, S., Swartz, J., & Lerman, J. (1993). Are all preterm infants younger than 60 weeks postconceptual age at risk for
postanesthetic apnea? Anesthesiology, 78, 1076-1081. Maslow, A. D., Regan, M. M., Israel, E., Darvish, A., Mehrez, M., Boughton, R., et al. (2000). Inhaled albuterol, but not intravenous lidocaine, protects against intubation-induced bronchoconstriction in asthma. Anesthesiology, 93, 1198-1204. Meneghini, L., Zadra, N., Zanette, G., Baiocchi, M., & Giusti, F. (1998). The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children. Paediatric Anaesthesia, 8, 11-15. Morray, J. P., Geiduschek, J. M., Ramamoorthy, C., Haberkern, C. M., Hackel Caplan, R. A., Domino, K. B., et al. (2000). Anesthesia-related cardiac arrest in children: Initial findings of the Pediatric Perioperative Cardiac Arrest (PCOA) Registry. Anesthesiology, 93, 6-14. Motoyama, E. K. (in press). Safety and outcome in pediatric anesthesia. In Motoyama E. K., & Davis, P. J. (Eds.), Smith’s anesthesia for infants and children (7th ed). St. Louis: Mosby. Pasternak, L. R. (2002). ASA practice guidelines for preanesthetic assessment. International Anesthesiology Clinics, 40, 31-46. Pasternak, L. R., Arens, J. F., Caplan, R. A., Connis, R. T., Fleisher, L. A., Flowerdew, R., et al. (2002). Practice advisory for preanesthesia evaluation: A report by the American Society of Anesthesiologists task force on preanesthesia evaluation. Anesthesiology, 96, 485-496. Pollard, J. B. (2002). Economic aspects of an anesthesia preoperative evaluation clinic. Current Opinion in Anaesthesiology, 15, 257-261. Stoelting, R. K., & Miller, R. D. (2000). Basics of anesthesia, 4th ed. Philadelphia: Churchill Livingstone. Tait, A. R., & Malviya, S. (2005). Anesthesia for the child with an upper respiratory tract infection: Still a dilemma? Anesthesia & Analgesia, 100, 59-65. Tait, A. R., Malviya, S., Voepel-Lewis, T., Munro, H. M., Siewert, M., & Pandit, U. A. (2001). Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology, 95, 299-306.
November/December 2005 379
Preanesthesia Considerations for the Nurse Practitioner Jamie Reddinger, RN, MSN, CPNP, Kathleen Oft, RN, MSN, CRNP-BC, & Katrina Geier, RN, MSN, CPNP
ABSTRACT With increases in pediatric ambulatory surgery, primary health care providers such as nurse practitioners are being called upon to provide input about patients preoperatively or prior to other procedures requiring anesthesia. Because the anesthesia team may not meet the patient and family until the day of surgery; a thorough evaluation done by the primary care provider can supply the anesthesia team with the information required for optimal care. Such information includes a detailed history, including the patient’s birth history, medical diagnoses, medications, allergies, recent laboratory test values, and the results of a recent physical examination. The purpose of this article is to provide primary care nurse practitioners with guidelines and information to consider when seeing their patient for a preprocedural visit. J Pediatr Health Care. (2005) 19, 374-379.
Jamie Reddinger is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Kathleen Oft is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Katrina Geier is Certified Registered Nurse Practioner, Children’s Hospital of Pittsburgh, Same Day Surgery/Department of Anesthesiology, Pittsburgh, Pa. Reprint requests: Kathy Oft, Children’s Hospital of Pittsburgh, Same Day Surgery, 3705 Fifth Ave, Pittsburgh, PA 15213; e-mail: [email protected]. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2005.07.009
374
Volume 19 • Number 6
www.jpedhc.org
Primary care nurse practitioners play a pivotal role in the medical evaluation and psychological preparation of a child before anesthesia. While the surgical service has the opportunity to assess the patient before a surgical procedure, operating room availability may cause a delay in scheduling, so the surgical assessment may not be current. Many hospitals and surgical units do not have a preoperative anesthesia evaluation clinic in which the patient can be seen prior to the day of surgery (Pasternak, 2002). Therefore, the anesthesia team may not have a chance to evaluate the patient until the day of surgery. Preoperative evaluation clinics help prepare patients for surgery in a way that minimizes cost and optimizes outcomes (Pollard, 2002). Consequently, it benefits the patient to have a primary care provider who is familiar with his or her medical history to provide a preoperative assessment. It is the ultimate responsibility of the anesthesiologist to clear patients for anesthesia; however, this decision is often dependent upon information provided by the primary health care provider (Pasternak, 2002). The issues to be addressed are the medical problems of the patient and how they are being managed. The patient should be in as optimal condition as possible before undergoing anesthesia. The child’s presurgical health status should be compared with his or her usual state of health. The stress of surgery and anesthesia may strain the physiologic reserves of a patient who has a chronic illness even if the patient is stable at the time of surgery (Ferrari, 1997). The child must be thoroughly evaluated and all medical issues addressed, including any new or chronic conditions. The issue of the timing of the preanesthesia evaluation and the appropriate staff by whom it Journal of Pediatric Health Care
should be done has yet to be critically evaluated (Pasternak, 2002). Evidence has not supported the notion that all patients need to have a preanesthesia visit by an anesthesiologist prior to the day of surgery. The convenience of having this type of evaluation is affected by issues such as the practice environment, geography, and patient population. In some instances, an anesthesia consultation prior to surgery is most helpful in directing the care of complex patients. However, healthy patients scheduled to have procedures of minor or intermediate complexity or stable patients with significant medical issues but with procedures of low risk or complexity may have their evaluation on the day of surgery. Appropriate information must be available for the anesthesia staff to review (Pasternak, 2002), and this information can be provided in the form of a history and physical examination from the patient’s primary health care provider. According to the Practice Advisory in the Journal of Anesthesiology (Pasternak et al., 2002), the preanesthesia evaluation is defined as the “process of clinical assessment that precedes the delivery of anesthesia for surgery and for nonsurgical procedures” (p. 485). One goal of the preoperative medical evaluation is to decrease perioperative morbidity, recognizing that preoperative medical conditions often predict postoperative problems. Preanesthetic evaluation includes the review of previous medical records, interview with the parents and the patient, and a physical examination. Subsequently, further medical testing and laboratory testing may be deemed necessary. Preoperative testing may be indicated for the following: discovery of a disease or disorder that may affect anesthetic care, verification of a disease that may already be present, or determining the status of a known disease. This preanesthesia evaluJournal of Pediatric Health Care
ation will be used for developing a plan of care before, during, and after surgery. Postoperative pain management should also be included in the plan. The nurse practitioner must obtain a complete and detailed history from the parents and/or the patient. Birth history, other medical conditions, and previous surgeries, as well as reactions to the anesthetics, must be included. Specifically, it is helpful to be aware of any adverse reaction to anesthesia, such as postoperative nausea and vomiting, drug reactions, cardiac or respiratory problems, changes in temperature, or prolonged paralysis. For infants, pertinent birth history such as prematurity and ventilation are important factors because the most serious risk in a
though this history is always elicited by the anesthesia staff, if this information is known ahead of time, it will facilitate planning the anesthetic management of the patient. Malignant hyperthermia is a rare, inherited disease that most often manifests in childhood. It occurs in susceptible individuals who receive inhalation anesthetics with or without succinylcholine. It is characterized by cardiac arrhythmias, increased body metabolism, muscle rigidity, and high fever, which is a late sign. The patient may develop a spasm of the masseter muscle, making it impossible to open the mouth for tracheal intubation (Stoelting & Miller, 2000). Pseudocholinesterase deficiency is also an inherited disorder that results in abnormally slow degrada-
Preanesthetic evaluation includes the review of previous medical records, interview with the parents and the patient, and a physical examination. former premature infant is postanesthetic apnea, especially before 44 weeks postconceptual age (Malviya, Swartz, & Lerman, 1993). Additional risk factors of prematurity are a history of apnea and bradycardia, multisystem medical conditions, respiratory distress, intubation, mechanical ventilation, or a hematocrit of less than 30%, according to Welborn, Hannallah, Luban, and Ruttimann (as cited in Cote et al., 1995). Concurrent medical conditions such as gastroesophageal reflux, asthma, cancer, cardiac conditions, and seizure disorders should be included. A family history of anesthesiarelated complications such as malignant hyperthermia or pseudocholinesterase deficiency must be documented and investigated. Al-
tion of exogenous choline ester drugs such as succinylcholine. This condition is recognized when respiratory paralysis persists for a longer period of time than expected. Treatment of respiratory insufficiency due to pseudocholinesterase deficiency is mechanical ventilation until diffusion of succinylcholine permits the return of neuromuscular function (Alexander, 2002). The names of any medications the child is taking, their doses and frequency of administration, and any significant previous medications the child had been taking recently should be documented. Herbal supplementation must be included in the list of the patient’s medications; these agents may be contraindicated for anesthesia and November/December 2005 375
Herbal supplementation must be included in the list of the patient’s medications; these agents may be contraindicated for anesthesia and surgery. surgery. For example, increased bleeding has been associated with the use of gingko and garlic, hypertension with ginseng, and excess sedation with St. John’s Wort. Valerian and St. John’s Wort may prolong the action of anesthetics (Crowe & Lyons, 2004). Ang-Lee, Moss, and Yuan (2001) suggest that patients stop taking kava and ephedra 24 hours before surgery, ginko 36 hours before surgery, garlic and ginseng 1 week before surgery, and St. John’s Wort at least 5 days before surgery. These suggestions are based on the pharmacokinetics of the herbal medications. Children taking anticonvulsants should be encouraged to take their doses as per their home schedule as long as it allows them to adhere to the fasting guidelines. Use of any asthma medications, especially bronchodilators, should be encouraged prior to anesthesia. Children with a history of reactive airway disease are at a slightly increased risk for bronchospasm with the administration of anesthesia and instrumentation of the airway (Maslow et al., 2000). Based on current data, the anesthesia staff may recommend a prophylactic dose of the patient’s bronchodilator prior to the administration of anesthesia to minimize this risk of airway reactivity (American Academy of Pediatrics [AAP], 1996; Ferrari, 1997; & Maslow et al.). In children with chronic conditions, it is advisable to continue all medications up to the time of surgery. Note any drug and food allergies and the type of reaction. Because sedatives can cause a paradoxical reaction in some children and narcotics may cause a myriad of 376 Volume 19 • Number 6
adverse effects, it is important to note the child’s prior experience with them. Food and environmental allergies also must be listed. An allergy to eggs and soybean oil may be a contraindication to administration of Diprivan (propofol), a commonly used anesthetic agent, because it contains egg lecithin and soybean oil (Hofer, McCarthy, Buck, & Hendrick, 2003).
gery. However, recent literature suggests that because of variable and unpredictable rates of gastric emptying, fears of aspiration may be unfounded (Stoelting & Miller, 2000). In some cases, prolonged periods of fasting may create potentially harmful situations because cardiac function and blood pressure are less well maintained when intravascular volume is depleted (Ferrari, 1997). For this reason, ingestion of clear fluids should be encouraged up until the cutoff time given by the surgical institution. A comparison study by Flick, Schears, and Warner (2002) postulates that based on the available data, aspiration remains more common in children than in adults; however, morbidity associated
The emphasis of the physical examination for anesthesia is focused on upper airway, respiratory, cardiovascular, and neurologic systems and the body system that is the focus of the particular surgical procedure. Concerning adolescents, questions regarding tobacco, alcohol use, and recreational drugs including marijuana, heroin, cocaine, and ecstasy must be asked privately to optimize honesty in disclosure. It is helpful for health care providers to reinforce the importance of following the preoperative fasting guidelines. Fasting guidelines are given to patients and their families before surgery or other procedures requiring general anesthesia. The purpose of preoperative fasting is to allow sufficient time for gastric emptying, because aspiration of ingested food or liquid into the lungs can cause aspiration pneumonia. These instructions must be clearly and repeatedly given to the parents prior to sur-
with aspiration is rare across all age groups. Consequently, because data regarding this issue remain somewhat contradictory, it is essential to advise parents to strictly follow the instructions given by the institution regarding fasting times to prevent cancellation of surgery. In general, there is no uniform fasting practice for children before elective surgery in the United States. However, it is generally agreed that ingestion of clear liquids 2 to 3 hours prior to anesthesia is acceptable (Ferrari, Rooney, & Rockoff, 1999). The emphasis of the physical examination for anesthesia is focused on upper airway, respiratory, cardiovascular, and neurologic systems and the body system Journal of Pediatric Health Care
TABLE 1. ASA Physical Status Classification System I II III IV V VI E (emergency operation)
A normal healthy patient A patient with systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive with or without the operation A declared brain-dead patient whose organs are being removed for donor purposes Any patient in whom an emergency operation is required
American Society of Anesthesiologists (1963). Reprinted with permission of the American Society of Anesthesiologists, 520N Northwest Highway, Park Ridge, IL 60068-2573.
that is the focus of the particular surgical procedure. Preoperative evaluation of the patient’s airway helps to determine the route and method for tracheal intubation. The size of the tongue in relation to the size of the oral cavity can help determine the degree of difficulty involved in intubation (Stoelting & Miller, 2000). Facial structure and mandibular mobility should be examined for clues for difficult intubation. Several congenital syndromes such as Goldenhar, Pierre Robin, and TreacherCollins often are associated with airways that are difficult to manage as a result of craniofacial abnormalities. Children should be questioned about and examined for loose teeth. After induction of anesthetic, the anesthesiologist may opt to remove loose teeth to avoid accidental dislodgement into the bronchial tree. An important element of the respiratory system includes auscultation of the upper and lower airway. Good respiratory effort is critical in the respiratory examination. Breath sounds should be clear and equal bilaterally without adventitious lung sounds. Examination of the cardiovascular system begins with vital signs including heart rate and blood pressure. Auscultation of the heart is performed to determine normal heart sounds and any abnormal murmurs. If a murmur is found, the parents should be asked if the murmur was previously detected. Murmurs in healthy children are usually flow murmurs. They typically are not louder than II/VI and Journal of Pediatric Health Care
occur in systole over the pulmonic or mitral areas of the chest wall. A new murmur should be evaluated by a cardiologist. Subacute bacterial endocarditis prophylaxis may be required in patients with significant heart disease. In addition, some anesthetic agents are myocardial depressants, and a child with heart disease may be at in-
(URI) merits careful evaluation. Anesthetizing a child with an active URI involves risks such as atelectasis, oxygen desaturation, bronchospasm, laryngospasm, postintubation croup, and pneumonia. Compared with other children, those with acute URIs have a twofold to seven-fold increase in respiratory-related events during and
Anesthetizing a child with an active URI involves risks such as atelectasis, oxygen desaturation, bronchospasm, laryngospasm, postintubation croup, and pneumonia. creased risk for complications. A complete neurologic evaluation is not necessary for a healthy child. Much information can be gained by observation of the child’s behavior. An interactive, playful child is unlikely to have a severe neurologic problem. However, a basic neurologic assessment, including an observation of the cranial nerves, motor and sensory function, reflexes, and cognitive function, should be performed. Any history of cervical spine instability also should be documented because precautions will need to be taken when intubating the patient, particularly in children with Down syndrome (Ferrari, 1997). A child who has had a recent upper respiratory tract infection
after surgery (Cohen & Cameron, 1991). If the child has an active or recent upper respiratory infection, he or she is at greater risk for adverse respiratory events such as oxygen desaturation, breath holding, and severe coughing. These risks are further increased if the patient requires intubation (Tait et al., 2001). Although most studies concur that children with active or recent URIs are at increased risk for perioperative complications, these events are mostly manageable and without long-term sequelae. However, most anesthesiologists would agree that any child with severe URI symptoms should have surgery postponed for at least 4 weeks (Tait & Malviya, 2005). Because uniform guidelines for preoperative laboratory testing do November/December 2005 377
not exist, the patient’s history and physical examination, as well as the judgment of the health care provider, are most commonly used as the basis for testing (Meneghini, Zadra, Zanette, Baiocchi, & Giusti, 1998, & Pasternak, 2002). Preanesthesia testing should be based on the relevance the results may have on the anesthetic plan. For example, surgeries that may result in a large amount of blood loss and fluid shifts may require a preoperative hemoglobin and hematocrit, coagulation screening, and an order for banked blood. A child with congenital heart disease or other cardiac problem may benefit from a cardiology consult and/or echocardiogram prior to surgery. Urinalysis is not routinely indicated preoperatively. However, depending on hospital policy, mandatory pregnancy screening may be required for female adolescents. In general, healthy patients having minor procedures usually do not require preoperative laboratory testing. A myriad of issues may occur in the hours, days, and weeks after surgery, and the patient’s primary health care provider usually will be the first contact. Children with a history of recurrent croup or with a recent history of cold symptoms are at an increased risk for the development of postoperative croup (Ferrari, 1997). The incidence of croup is highest in the hours after intubation; however, parents should be educated about the signs and symptoms of stridor as well as the appropriate intervention (ie, cool mist, humidified air, and emergency department referral if necessary). Once the patient has returned home, the primary care nurse practitioner should be available for questions concerning pain management. Another issue that should be closely monitored in the hours after surgery is the child’s hydration status. It is not uncommon, particularly after procedures involving the upper airway (ie, adenotonsillectomy) for patients to 378 Volume 19 • Number 6
have decreased oral intake. Intake should be monitored by the caregivers and information regarding dehydration should be provided. Research has shown that children may exhibit behavioral disturbances in the days and even weeks following hospitalization (Keaney, Diviney, Hare, & Lyons, 2004). Such changes may include anxiety, bedwetting, night terrors, or regression. The study done by Keaney et al. compared the behavioral responses of children who had received one of two different inhaled anesthetic agents and evaluated whether the use of these agents translated into prolonged behavioral changes well after their administration. It was found that
sent, but the primary care nurse practitioner may introduce the notion that there are always risks with the use of general anesthesia and precautions should be taken to minimize these risks. In general, the safety of pediatric anesthesia has greatly improved over recent years, with decreases in anesthesia-related mortality (Motoyoma, in press). The American Society of Anesthesiologists (ASA) (1963) developed the physical status categories, shown in Table 1, to make an overall assessment of the degree of illness or physical state prior to administering anesthesia. This information can be used to estimate a patient’s fitness for the surgery and for anesthetic technique; however,
A detailed history that focuses on significant previous anesthetic experiences, birth history, medical diagnoses and their management, as well as a recent physical examination, is necessary for the anesthesia team to customize the anesthetic plan to the patient’s particular needs. 65% of patients exhibited some negative behavioral changes in the month following surgery, and these changes occurred more frequently with decreasing age. Furthermore, it was concluded by Kain, Wang, Mayes, Caramico, and Hofstadter (1999) that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. Parents may ask the anesthesia team whether their child would be an appropriate candidate for premedication with sedating agents. The anesthesia staff will review the risks and benefits of anesthesia prior to obtaining informed con-
it is not intended to represent an estimate of anesthesia risk. According to Morray et al. (2000), patients who experienced anesthesia-related cardiac arrests were most strongly associated with ASA PS categories 3 to 5 and emergency surgery. The highest incidence of anesthesia-related deaths is in children younger than 1 year of age and in patients with severe underlying disease (Morray et al.). Parents often want to know the risks associated with anesthesia. Serious risks include laryngospasm, bronchospasm, dental trauma, major drug reactions, aspiration, pneumonia, hypoxemia, arrhythmia, and coma. However, most of these risks are usually not life-threatenJournal of Pediatric Health Care
ing. Minor temporary complications include sore throat, nausea and vomiting, postintubation croup, coughing, hoarseness, and oral trauma (Ferrari, 1997). It is important to reassure parents that modern anesthetic medications and practice are very safe and the equipment utilized to monitor patients is sophisticated. The overall risk of anesthesia-related mortality is very low. In summary, when performing a preanesthesia assessment, thoroughly assess the patient and document all medical issues. A detailed history that focuses on significant previous anesthetic experiences, birth history, medical diagnoses and their management, as well as a recent physical examination, is necessary for the anesthesia team to customize the anesthetic plan to the patient’s particular needs. In addition, a preanesthesia consult either via phone or in person with an anesthesia team member may be warranted in children with severe underlying disease, those known or suspected to have an airway that is difficult to manage, or those with a family history of malignant hyperthermia or pseudocholinesterase deficiency. Communication between the anesthesia staff and the primary health care provider is central to ensuring a safe perioperative course. Special thanks to James A. Greenberg, MD, Clinical Associate Professor of Anesthesiology, University of Pittsburgh School of Medicine. REFERENCES Alexander, D. R. (2002). Pseudocholinesterase deficiency. eMedicine. Retrieved June 3, 2003, from http://www. emedicine.com/med/topic1935.htm
Journal of Pediatric Health Care
American Academy of Pediatrics. (1996). Evaluation and preparation of pediatric patients undergoing anesthesia. Pediatrics, 98, 502-508. American Society of Anesthesiologists. (1963). New classification of physical status. Anesthesiology, 24, 111. Ang-Lee, M. K., Moss, J., & Yuan, C. (2001). Herbal medicines and perioperative care. JAMA, 286, 208-216. Cohen, M. M., & Cameron, C. B. (1991). Should you cancel the operation when a child has an upper respiratory tract infection? Anesthesia & Analgesia, 72, 282-288. Cote, C. J., Zaslavsky, A., Downes, J. J., Kurth, C. D., Welborn, L. G., Warner, L.O., et al. (1995). Postoperative apnea in former preterm infants after inguinal herniorrhaphy: A combined analysis. Anesthesiology, 82, 809-822. Crowe, S., & Lyons, B. (2004). Herbal medicine use by children presenting for ambulatory anesthesia and surgery. Paediatric Anaesthesia, 14, 916-919. Ferrari, L. R. (1997). Cleared for anesthesia: What it means, how to do it. Contemporary Pediatrics Archive. Retrieved August 27, 2004, from http://www. contemporarypediatrics.com Ferrari, L. R., Rooney, F. M., & Rockoff, M. A. (1999). Preoperative fasting practices in pediatrics. Anesthesiology, 90, 978-980. Flick, R. P., Schears, G. J., & Warner, M. A. (2002). Aspiration in pediatric anesthesia: Is there a higher incidence compared with adults? Current Opinion in Anaesthesiology, 15, 323-327. Hofer, K. N., McCarthy, M. W., Buck, M. L., & Hendrick, A. E. (2003). Possible anaphylaxis after propofol in a child with food allergy. Annals of Pharmacotherapy, 37, 398-401. Kain, Z. N., Wang, S., Mayes, L. C., Caramico, L. A., & Hofstadter, M. B. (1999). Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesthesia & Analgesia, 88, 1042-1047. Keaney, A., Diviney, D., Hare, S., & Lyons, B. (2004). Postoperative behavioral changes following anesthesia with sevoflurane. Pediatric Anesthesia, 14, 866-870. Malviya, S., Swartz, J., & Lerman, J. (1993). Are all preterm infants younger than 60 weeks postconceptual age at risk for
postanesthetic apnea? Anesthesiology, 78, 1076-1081. Maslow, A. D., Regan, M. M., Israel, E., Darvish, A., Mehrez, M., Boughton, R., et al. (2000). Inhaled albuterol, but not intravenous lidocaine, protects against intubation-induced bronchoconstriction in asthma. Anesthesiology, 93, 1198-1204. Meneghini, L., Zadra, N., Zanette, G., Baiocchi, M., & Giusti, F. (1998). The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children. Paediatric Anaesthesia, 8, 11-15. Morray, J. P., Geiduschek, J. M., Ramamoorthy, C., Haberkern, C. M., Hackel Caplan, R. A., Domino, K. B., et al. (2000). Anesthesia-related cardiac arrest in children: Initial findings of the Pediatric Perioperative Cardiac Arrest (PCOA) Registry. Anesthesiology, 93, 6-14. Motoyama, E. K. (in press). Safety and outcome in pediatric anesthesia. In Motoyama E. K., & Davis, P. J. (Eds.), Smith’s anesthesia for infants and children (7th ed). St. Louis: Mosby. Pasternak, L. R. (2002). ASA practice guidelines for preanesthetic assessment. International Anesthesiology Clinics, 40, 31-46. Pasternak, L. R., Arens, J. F., Caplan, R. A., Connis, R. T., Fleisher, L. A., Flowerdew, R., et al. (2002). Practice advisory for preanesthesia evaluation: A report by the American Society of Anesthesiologists task force on preanesthesia evaluation. Anesthesiology, 96, 485-496. Pollard, J. B. (2002). Economic aspects of an anesthesia preoperative evaluation clinic. Current Opinion in Anaesthesiology, 15, 257-261. Stoelting, R. K., & Miller, R. D. (2000). Basics of anesthesia, 4th ed. Philadelphia: Churchill Livingstone. Tait, A. R., & Malviya, S. (2005). Anesthesia for the child with an upper respiratory tract infection: Still a dilemma? Anesthesia & Analgesia, 100, 59-65. Tait, A. R., Malviya, S., Voepel-Lewis, T., Munro, H. M., Siewert, M., & Pandit, U. A. (2001). Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology, 95, 299-306.
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