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Preoperative assessment and preparation for safe paediatric anaesthesia
PAEDIATRIC ANAESTHESIA
Preoperative assessment and preparation for safe paediatric anaesthesia
Learning objectives After reading this article, you should be able to: C use a methodical approach to assess the paediatric patient requiring anaesthesia C describe the factors that may complicate paediatric anaesthesia C discuss the risks associated with paediatric anaesthesia
Matthew Harvey Tim Geary
Information gathering Abstract
Most children undergoing anaesthesia are young and do not have significant comorbidities e in the APRICOT study, approximately 50% were less than 5 years of age and 88.8% ASA grade IeII. There is concern, however, that the number of adverse events associated with paediatric anaesthesia has been under-estimated.1 These complications contribute to perioperative morbidity, prolonged hospital admissions, increased healthcare costs and parental dissatisfaction. Prior to anaesthesia, each child should be assessed thoroughly to identify any indications for preoperative investigations, perioperative admission, postponement or adjustment to the mode of anaesthesia.
The delivery of anaesthesia to children and young people provides unique challenges. A careful, systematic approach to assessment and preparation can deliver a positive experience for the child, carers and staff while mitigating potential complications. Preparation for anaesthesia should encompass information gathering, assessment and planning for anatomical, physiological, social and behavioural elements specific to the child and the surgery. Delivery of appropriate information, consent and fasting are also key elements of ensuring positive perioperative outcomes. We consider the common components of preparation for the delivery of safe paediatric anaesthesia.
Keywords Paediatric anaesthesia; perioperative fasting; premedication; preoperative assessment
Surgical plan A review of the clinical notes and an understanding of the scheduled procedure(s) before meeting the child will provide a background and highlight potential problems requiring a more detailed history, or elective investigations. The planned surgery will not only dictate the choice of anaesthesia, but also be indicative of the risk for perioperative respiratory or cardiovascular complications, such as laryngospasm in adenotonsillectomy or bradyarrhythmias in ocular surgery.1
Royal College of Anaesthetists CPD Matrix: 1C01, 2A03, 2D02, 3D00
Providing anaesthesia for children is both uniquely rewarding and challenging. Consideration of age-dependent characteristics such as anatomical, physiological and behavioural differences is essential. Pharmacological variations mean that drug doses are calculated on surrogate markers such as known (or estimated) weight, age or calculated body surface area, putting children at greater risk of drug errors. Techniques such as regional anaesthesia, sedation or difficult airway management provide their own challenges. The perioperative assessment, induction of anaesthesia and aftercare are notable for the presence of anxious parents or carers. The rapport created by communicating effectively with the child and their carer(s) is a subjective measure of the quality of anaesthetic care and sets the tone for the entire clinical interaction. Preparation for safe paediatric anaesthesia encompasses information gathering; patient assessment; preparation of the team, equipment and environment; and preparation of the patient and their carer(s) for anaesthesia.
History The medical history should be thoroughly interrogated to ensure fitness for surgery. Assessment should include past medical history, previous anaesthesia, current medications, allergies, family history and social enquiry. The optimization of chronic diseases may require liaison with paediatric specialist teams. A positive family history may encourage further investigation, for example a history of premature cardiac death in a relative of a child with a heart murmur, or a relative with adverse events related to anaesthesia. The home circumstances can also inform risk assessment. The relative risk of respiratory complications associated with passive smoking is 1.391 and a similar increase is seen for children who are smokers. When assessing a teenager, the history should include enquiry about smoking, alcohol and recreational drug use and where appropriate, sexual activity. Some may prefer to disclose this information confidentially and it might be necessary to take this history in private. For post-pubertal girls, local protocols may mandate a preoperative urine pregnancy test, for which informed verbal consent is required.
Matthew Harvey MBChB MRCPCH PGCert is a Senior Trainee in Paediatric Intensive Care Medicine at the Royal Hospital for Children, Glasgow, UK. He also works for the ScotSTAR paediatric retrieval team. Conflicts of interest: none declared. Tim Geary MBChB FRCA FFICM is a Consultant in Anaesthesia and Intensive Care at University Hospital Crosshouse and Honorary Senior Lecturer at the University of Glasgow, UK. He is also a Consultant in Paediatric Retrieval Medicine with the ScotSTAR service. Conflicts of interest: none declared.
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Basic measurements Routine observations including temperature, heart rate, respiratory rate, non-invasive blood pressure and oxygen saturation in
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PAEDIATRIC ANAESTHESIA
room air must be documented. A small number of children will find this distressing. All children should have their height and weight measured to allow titration of medications and intravenous fluids, both of which may be dosed by either weight or composite measures (e.g. body surface area, lean body weight, fat free mass). This will also guide selection of equipment and infusion pumps, which may be guided by age, or weight-based algorithms.
Preoperative investigations
Minor Intermediate Major
Regular medications Most regular medications can be safely given on the day of surgery, even to the fasted child. Children with diabetes should be listed early and have a specific perioperative glycaemic management plan. Children on oral anticoagulants should have a clearly documented plan of cessation, alternative cover (e.g. systemic heparinization for metallic valves) and reintroduction of their anticoagulants. Most oral antiepileptic drugs (AEDs) can be safely taken on the day of anaesthesia; however, most have an effect long enough that omitting a single dose is unlikely to cause harm. Caution is required as some AEDs can reduce inhalational MAC by up to one third, whereas others may increase intravenous agent requirements. Children on long-term steroids or those with adrenal insufficiency may require additional steroids perioperatively. Consider non-allergic contraindications to specific drug classes. Depolarizing neuromuscular blocking drugs should be avoided in some conditions which can result in hyperkalaemia after administration such as neurological deficits involving spinal cord injury, peripheral nerve injury or acute muscle wasting. Similarly, excessive potassium release can occur in trauma or burns 24 hours after injury for up to 1e2 years. Malignant hyperthermia is associated with conditions such as central core disease, but may also be triggered by anaesthetic agents in the absence of a comorbid predisposition. Genetic testing is available and where this is unequivocal skeletal muscle biopsy can be performed.
Investigations
Endoscopy, dental procedures, grommets Adenotonsillectomy, inguinal hernia repair Joint reconstruction, laparotomy
No routine pre-operative investigations No routine pre-operative investigations FBC, U&E, Urinalysis
Table 1
response to surgery. This ‘double-hit’ model induces glycogenolysis, ketogenesis, release of free fatty acids and transient insulin resistance. This response is a risk factor for postoperative complications and prolonged hospitalization. Non-caloric fluids are inadequate to modulate this response. Preoperative carbohydrate drinks may induce an insulin response, inhibiting the fasted state physiology, but data of their efficacy in children is limited. Hunger and thirst caused by excessive fasting may contribute to the difficult behaviours encountered in preoperative assessment. Traditional guidelines advocate fasting for 6, 4 and 2 hours for solids, breast milk and clear fluids, respectively. Formula feeds are often considered with solids, as the lower whey:casein ratio prolongs gastric emptying. These conservative practices have been challenged by recent literature showing that children on more liberal fasting regimes (see Table 2) have increased gastric pH, less risk of hypoglycaemia, reduced glycogenolysis and improved fluid homeostasis. They are also less thirsty, hungry and irritable. A recent series of 10,015 children shows a favourable safety profile, with an incidence of aspiration of 0.03%.2 The APAGBI, ESPA and ADARPEF released a consensus document in April 2018 encouraging clear fluids (3 ml/kg) up to 1 hour before surgery.
Allergies The nature of all suspected allergies should be determined, including the precipitant, type and severity of reaction, recurrence, investigations and treatment. Latex is the most common non-drug allergy and is associated with food allergies including kiwi fruit, bananas and avocados. Latex allergy would usually mandate first place on the theatre list and strict precautions by all theatre staff.
Investigations Most children who are systemically well do not require preoperative investigations. For elective cases, a surgical severity score, in conjunction with National Institute for Health and Care Excellence (NICE) guidelines (www.nice.org.uk/guidance/ NG45) can guide decision making (see Table 1). Other investigations are considered in Special circumstances.
Fasting The risk of aspiration is lower than that quoted in the adult literature and it has been suggested that children should fast from clear fluids for only one hour prior to elective surgery. Fasting times have progressively prolonged, owing to cognitive biases, patient safety initiatives and guidelines based on non-fasted emergency surgery studies, or gastric residual volumes e a poor surrogate for the risk of aspiration. Fasting may be further extended by operative delays, or by parents not wakening their child for fluids overnight. In emergency surgery, heightened concern is valid as children are more prone to gastric paresis secondary to opioids, trauma and pain. Prolonged fasting induces an anabolic state, with potentially deleterious effects when combined with the neuroendocrine
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Examples
Special circumstances: Anaemia e children with known or suspected anaemia should have a FBC and haematinic (e.g. vitamin B12 and folate) assessment. Blood transfusion e obtain initial group and save samples in preoperative or preassessment clinics. Transfusion services increasingly require two separate samples, prior to releasing products for non-emergency scenarios. Cardiothoracic surgery e for cardiothoracic surgery, a chest X-ray and ECG should be reviewed. Chronic disease e it is advisable to consider a chest X-ray in children with chronic lung disease, cystic fibrosis, congenital heart disease or significant neurodisability.
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PAEDIATRIC ANAESTHESIA
Diabetes e a recent HbA1c should be reviewed in diabetic patients. Obstructive sleep apnoea e children with a history of obstructive sleep apnoea or sleep disordered breathing should be considered for paediatric respiratory assessment and polysomnography. Sickle cell disease e children with a family history of sickle cell disease should have an early haematology referral and preoperative investigations. Pregnancy e young women of childbearing age should have a pregnancy test; some institutions will routinely test all young women over 12 years of age. Vaccination e it is common to encounter a child requiring surgery soon after administration of routine vaccinations. The national immunization guidelines (Green Book 2013, available at www.gov.uk) state that imminent surgery or anaesthesia are not contraindications to immunizations. The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) recommends a delay of 48 hours following administration of inactivated vaccines as the rates of post-immunization pyrexia are greater than live attenuated vaccines. Child protection e all doctors must safeguard the wellbeing of children and young people. In the event of child protection concerns, the safety of the child is of utmost importance and the multidisciplinary team should always act in the child’s best interests. More information is available in the intercollegiate document Child Protection and the Anaesthetist (see Recommended Resources).
children has an incidence of 1.3% with specific groups making up a high proportion of this. Predictors of a difficult airway include limited mouth opening, dysmorphic features, micrognathia, retrognathia, inability to prognath, poor dentition and decreased neck mobility. Other factors include obesity, obstructive sleep apnoea and a history of previous difficult intubation. The Colorado Pediatric Airway Score (COPUR) is a detailed scoring system that can overcome some of the reliability concerns associated with individual tests such as the Mallampati score.4 A number of congenital syndromes are associated with a difficult airway (see Table 3) that may improve with age (e.g. Pierre-Robin sequence) or become progressively challenging (e.g. Treacher-Collins syndrome). Some groups of disorders are associated with notoriously difficult intubation (e.g. mucopolysaccharidoses). Airway abnormalities may also be acquired, for example, subglottic stenosis, tumours, arteriovenous malformations and disorders of the temporomandibular joint or cervical spine. Irrespective of anticipated difficulty, preparation to instrument the paediatric airway differs from adult practice. Standard rapid sequence induction, for example, is less practicable as apnoeic time is reduced and young children may be poorly compliant with pre-oxygenation.5 A failed intubation plan should form part of the briefing, airway adjuncts and an alternative means of establishing an airway must be immediately to hand and consider gentle insufflation using the facemask, prior to administering neuromuscular blockade. Help should be requested early, as more than two attempts at direct laryngoscopy is associated with failure and adverse outcomes. All anaesthetists should be familiar with the paediatric guidelines for difficult mask ventilation, unanticipated difficult intubation and the ‘can’t intubate, can’t ventilate’ scenarios, published by the APAGBI and the Difficult Airway Society, available via their website (www.das.uk.com).
Patient assessment Airway Management of the paediatric airway is usually not problematic but failure of airway management is a major cause of perioperative morbidity. Perioperative airway issues are commonly caused by functional airway problems such as laryngospasm, tonsil hypertrophy, bronchospasm or muscle rigidity. Inadequate anaesthesia or muscle relaxation and poor mask or airway management can contribute to this. Assessment of the airway should be focused by three questions3: 1. Ease of oxygenation via bag mask ventilation? 2. Ease of ventilation via supraglottic airway? 3. Ease of intubation and consideration of surgical rescue techniques? Difficult mask ventilation or intubation are rare and the combination of both even more so. Difficult laryngoscopy in
Breathing Intercurrent respiratory tract infection is common amongst preschool children and is associated with adverse events during anaesthesia, including breath-holding, laryngospasm, bronchospasm and desaturation. It can, however, be difficult to schedule a young child for elective surgery when they have multiple viral respiratory tract infections per year and a number of children will have persistent non-infective rhinorrhoea. A blanket cancellation policy will unnecessarily postpone large numbers of children who could proceed under the care of an experienced anaesthetist. A delay of 1e2 weeks is recommended for children with purulent rhinitis and temperature, reduced SpO2 and/or audible signs on auscultation. There has been a demonstrated and cumulative increase in relative risk of severe perioperative respiratory critical events with each of the following risk factors - asthma, wheezing, recent respiratory tract infection, snoring and passive smoking. The relative risk increases from 1.8 for one risk factor to 4.6 for three or more. Symptoms of obstructive sleep apnoea (OSA) should be elucidated, as these children are at increased risk of laryngospasm, desaturation and airway obstruction. They are more sensitive to respiratory depression with sedatives and opioids, less responsive to hypercapnoea and there is an increased
Example of a liberal fasting regime Type of feed
Infants
Children (>1 year)
Clear fluids Breast milk Formula milk Solid food
0 4a 6a 6
0 e 6 6
a
Some consider breast and formula milk equivalent in terms of fasting times.
Table 2
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PAEDIATRIC ANAESTHESIA
Syndromes associated with airway abnormalities and congenital heart disease Syndromes associated with difficult airways Syndrome
Abnormalities
Difficult mask ventilation/intubation
Apert syndrome Beckwith Wiederman syndrome Crouzon syndrome Downs syndrome
Midface hypoplasia Macroglossia Midface hypoplasia Macroglossia, brachycephaly, atlanto-axial instability Midface/hemifacial hypoplasia Macroglossia, craniofacial abnormality, TMJ dysfunction adenoid and tonsil hypertrophy Cervical fusion Micrognathia, retrognathia Micrognathia
Mask Ventilation Both Mask Ventilation Both
Goldenhar syndrome Mucopolysaccharidoses, e.g. Hurlers/Hunters Syndrome Klippel-Feil syndrome Pierre Robin Syndrome Treacher Collins Syndrome
Intubation Both Intubation Intubation Intubation
Syndromes associated with congenital heart disease Syndrome
Associated cardiac anomalies
Down syndrome (Trisomy 21)
Atrioventricular septal defects, atrial septal defects, ventricular septal defects, tetralogy of fallot Coarctation of the aorta, bicuspid aortic valve, aortic stenosis Tetralogy of Fallot, aortic arch abnormalities, truncus arteriosus Pulmonary stenosis, atrial septal defect, hypertrophic cardiomyopathy Aortic stenosis, peripheral pulmonary stenosis
Turner syndrome (45X) DiGeorge syndrome (22q11.2 deletion) Noonan syndrome (RAS-MPK) Williams syndrome (7q11.23) Table 3
incidence of postoperative complications including desaturation and pulmonary oedema.6 Nocturnal symptoms include loud snoring, disturbed sleep and witnessed apnoea, and children with OSA will often adopt an extended head position when sleeping. Daytime symptoms are less specific and include excessive somnolence, poor concentration and behavioural difficulties that may cause concern at home, nursery, school or during planned activities. Untreated OSA is associated with adverse neurodevelopmental outcomes, failure to thrive and (rarely) cor pulmonale. Other risk factors for respiratory complications include age less than 3 years, asthma, craniofacial abnormalities, neuromuscular disorders, failure to thrive and obesity. Children considered at high risk should be referred for management in a tertiary centre, with access to paediatric critical care facilities.6
Innocent murmurs are asymptomatic, soft (grade IeII), short, occur in systole, may vary with the posture of the child and are never associated with a thrill. Flow murmurs are particularly common during intercurrent illnesses and should be reassessed in the community to ensure resolution. In the newborn or young infant a history of tachypnoea, poor feeding, failure to thrive, sweating or cyanosis is concerning. In the older child, dyspnoea, reduced exercise tolerance and episodes of syncope should raise alarm. A family history of sudden death is concerning for hypertrophic obstructive cardiomyopathy, or an inherited channelopathy. The asymptomatic child with an innocent murmur and otherwise normal examination can proceed to elective surgery, with outpatient follow-up. All symptomatic patients or those with abnormal examination findings should have an ECG and be referred for assessment. In the UK, routine prescription of antibiotics as prophylaxis against endocarditis is no longer recommended. Guidance is available NICE Clinical Guideline 64 (www.nice.org.uk/ guidance/cg64).
Circulation Congenital heart disease affects approximately 9 per 1000 live births. Cardiac murmurs are a common finding during paediatric assessment and an innocent murmur may be heard in up to 80% of children during their lifetime. Anaesthetizing the child with an undiagnosed cardiac lesion carries significant risk; in contrast, children with previously repaired simple lesions (e.g. VSD or ASD) do not confer additional risk outwith specialist centres. A number of inherited syndromes are associated with cardiac anomalies, examples are included in Table 3.
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Neurology The risks associated with anaesthetizing the child with neuromuscular disease are numerous. Multisystem comorbidities including cardiac or respiratory dysfunction, gastro-oesophageal reflux and electrolyte disturbance are common. Children with
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PAEDIATRIC ANAESTHESIA
need for enhanced observation, elective admission to the children’s ward postoperatively, or referral to a tertiary centre.8
obstructed CSF drainage are at risk of raised intracranial pressure caused by hypercapnoea or drug-induced cerebral vasodilatation. The child with cerebral palsy is the most common example of chronic neurodisability and the range of comorbidities the anaesthetist must consider in this diverse group of patients. They may present for multiple procedures, involving several organ systems, e.g. adenotonsillectomy for OSA, gastrostomy and fundoplication for reflux and feeding, spinal surgery for scoliosis and orthopaedic procedures for flexion deformities or hip dislocation. Abnormal posture may complicate airway management, particularly in combination with abnormal dentition, copious oropharyngeal secretions and temporomandibular joint dysfunction. Chronic lung disease, recurrent chest infections, chronic microaspiration and poor cough with inadequate clearance of secretions predispose the child to postoperative atelectasis, hypoxia and other complications. Gastro-oesophageal reflux is common and may be exacerbated by scoliosis, reduced lower oesophageal sphincter tone and semi-recumbent positioning. A seizure disorder is seen in up to 50% of children with cerebral palsy. Fixed flexion deformities of the limbs and trunk can challenge optimal positioning for airway management, vascular access, invasive monitoring and the planned procedure. Low total body fat, poor musculature and thin skin create challenges with thermoregulation beyond that expected for an agematched peer. These features also predispose the child to pressure sores, so rigorous attention to bony prominences and pressure points is essential. Postoperative pain, anxiety and agitation may provoke painful muscle spasms and the use of regional anaesthetic techniques, while potentially technically challenging, can be of great benefit.7
Anxiety Few children are particularly uncooperative at the time of induction and genuine preoperative anxiety is age-dependent. Young infants can often be calmed by parental surrogates with soothing voices, holding and rocking. In older children, a controlled intravenous induction can be enabled by the use of local anaesthetic gel and distraction techniques to aid cannulation. Inhalational induction can be aided by making a game of it, e.g. ask the child to ‘blow up the balloon’ (reservoir bag) or apply the facemask as the ‘fighter pilot prepares to take off’. For an optimal perioperative experience, the carers and child must be well informed and empowered to engage fully in the process. The use of age-appropriate language to explain the anaesthetic plan to young children encourages their trust in the team and reduces the fear of the unknown. Hospital passport coping kits can be of use. The POEMS charity course (Positive Outcome and Experience Management Strategies; www. poemsforchldren.co.uk) empowers multidisciplinary professionals to manage anxious children calmly and effectively. Older children can benefit from distraction techniques including books, music and games. For the computer literate child, the APAGBI endorses a number of iPad and Android apps, which can also aid distraction (see Recommended Resources). The inconsolable child should prompt discussion of the urgency of surgery and the best interests of the child, with consideration given to postponement. The physical restraint of a child should be a last resort as the additional distress can contribute to challenges including bedwetting, sleep disturbance and disruptive behaviour.
Neonates and preterm infants Preterm infants are at increased risk of apnoea and bradycardia in recovery, this risk extends to neonates and infants with the sequelae of prematurity. Infants who have been ventilated recurrently, or for protracted periods of time in the neonatal period may have subglottic stenosis. Children with chronic lung disease may have an oxygen requirement prior to admission, have less compliant lungs and are at increased risk of postoperative respiratory complications including apnoea and lower respiratory tract infection. Gastro-oesophageal reflux is common and anti-reflux medications should be continued preoperatively. Fasting should be restricted where possible as there is an increased risk of hypoglycaemia.
Premedication There are multiple combinations of drugs suitable for premedication.1 Premedication is typically reserved for the most anxious, least prepared children or those with special educational or behavioural needs. Table 4 lists some commonly used drugs and their doses. Special educational needs Children with special educational needs (SEN) commonly present for surgical intervention. The spectrum of conditions is wide and includes those with specific learning difficulties, speech and language disorders, autistic spectrum disorders and profound neurodisability. They may display heightened anxiety, difficult behaviour and may simply not understand the hospital environment, planned intervention or change to their daily routine. Their own communication difficulties may heighten their anxiety. Choice of language is important, as children with autistic spectrum disorders may be unable to relate to colloquial terms used to explain interventions to their peers. It may be pertinent to use pictures, drawings or seek additional communication aids. Children with SEN are often known to the hospital and/or community paediatric team and often have personalized care packages or communication aids. Development of individual patient hospital coping kits, information folders and a departmental record of how to support these children are all good practice to ensure standards of care for those requiring multiple hospital admissions or surgery.
Obesity Childhood obesity and its associated comorbidities are increasingly prevalent and contribute to higher risk anaesthesia. Consideration should be given to the presence of comorbid OSA, asthma, hypertension, type 2 diabetes and gastro-oesophageal reflux, which are as common as in obese adults. In the presence of respiratory symptoms or sleep-disordered breathing, preoperative pulmonary function tests or polysomnography may be indicated. Drug dosing based on actual body weight may result in overdose; dose based on alternative measures (e.g. ideal body weight, lean body weight, normal fat mass, body surface area) may be better. Children with a history of OSA will require admission overnight and this may mandate referral to a paediatric centre. In other cases, the anaesthetist must consider the
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PAEDIATRIC ANAESTHESIA
Common premedication drug doses Drug
Dose (oral unless stated otherwise)
Onset
Comments
Midazolam Lorazepam Clonidine Ketamine
0.5 mg/kg 50-100 mcg/kg 2-4 mcg/kg 2e8 mg/kg
20e30 30e60 30e60 30e40
Diamorphine
0.1 mg/kg intranasal
15e30 minutes
minutes minutes minutes minutes
Risk of paradoxical excitement Risk of prolonged sedation (up to 6 hours) Unfavourable cardiovascular effects Nurse in a quiet, calm environment. Emergent hallucinations may be unpleasant Mild, early stinging sensation
Table 4
Clinicians should be familiar with the equipment available within their own department. The theatre environment should be adjusted to reflect the needs of the child, for example, the ambient temperature may be as high as 28 C in neonatal surgeries, which most would find uncomfortably warm. Appropriate equipment is equally important when conducting anaesthesia outwith the theatre environment, e.g. radiology, emergency department, cardiac catheter laboratory and during patient transfers. Children anaesthetized in these settings may have complex comorbidities, critical illness or severe injury. The MRI suite offers an additional degree of complexity. All equipment must be MRI compatible and in many departments, monitoring is remote, by means of slave devices. In the event of an emergency, the patient should be removed from the scanning room to an area suitable for resuscitation.
Vascular access Venous cannulation in children is complicated by the calibre and mobility of the veins. The subcutaneous fat of a healthy toddler can make visualizing and palpating veins difficult and young infants are less likely to sit still during cannulation attempts. In the difficult child, the dorsal veins of the foot, great saphenous and scalp vessels may be more readily accessed. In the moribund, or obtunded child, the Trendelenburg position may aid cannulation of the external jugular vein. Ultrasound has an increasing role. Trauma and the critically unwell child Trauma is the leading cause of death and disability in children over 1 year of age. Most seriously injured children have multiple injuries, often including a head injury, which contributes to 75% of all traumatic deaths. The mechanism of injury varies with developmental motor skill attainment; non-accidental injury should be considered in infants and young children, while teenagers are more often involved in road traffic accidents and sporting accidents, reflecting a more adult pattern of injuries.9 All anaesthetists providing care to paediatric patients should be able to assist with the resuscitation and stabilization of critically ill and traumatically injured children. The response to such a child must be prompt, with the early support of senior clinicians. Local ‘damage control’ surgery may be required to stabilize a patient, prior to transfer. Specialist transport teams retrieve more than 90% of children requiring transfer to a paediatric intensive care unit (PICU), a small number of time-critical cases will need to be transferred by the referring team, e.g. neurosurgical emergencies or major trauma.
Consent and capacity Written consent for anaesthesia is usually not required, verbal consent should discuss the main risks associated with anaesthesia (see Communicating risk). For all but the most urgent surgery and in mass casualty scenarios, where children may have been separated from their carers, a signed surgical consent form is mandatory. Medical or surgical procedures may be performed on a child or young person with their consent, if they have capacity. Otherwise, consent must be authorized by a parent, an individual with parental rights, or the courts. In order to exhibit capacity, an informed child must be able to understand, retain, interpret and evaluate the information presented and communicate their decision. Ensuring consent is obtained from the appropriate individual is essential. Under 16 years of age: a young person under the age of 16 may have the capacity to consent, but this may depend upon the nature and implications of the intervention. Young people may have the capacity to consent to low risk treatment, but not to complex or high-risk treatments with potentially serious consequences. In Scotland, parents cannot overturn the decision of a competent minor to refuse treatment.
Preparation Environment and equipment Ideally, children should be welcomed, assessed and recovered in dedicated areas. The paediatric reception is often brightly coloured and age-appropriate entertainment including computer games, music, DVDs and toys are available. Where possible a separate area should be available for adolescents. The national standards of monitoring in paediatric anaesthesia are the same as in adult practice (https://www.aagbi.org/ sites/default/files/Standards_of_monitoring_2015_0.pdf). Some children will not tolerate routine monitoring during induction and this should be applied as soon as practically possible. Alarm limits should be age-appropriate and may need adjusted on a case-by-case basis, e.g. cyanotic congenital heart disease.
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Over 16 years of age: a young person aged 16e18 years who lacks capacity is considered differently throughout the UK. In England, Wales and Northern Ireland the parents can consent to investigations and treatment in the young person’s best interests. Treatment can also be provided without parental consent. In Northern Ireland, treatment can be provided if a parent cannot be
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support psychological preparation for surgery, with the input of play therapists and use of videos, pictures and storybooks.
contacted, though court approval should be considered for nonemergency surgery. In Scotland, a young person over the age of 16 years, who lacks capacity, should be considered under the Adults with Incapacity Act.
Play therapy Trained play therapists are an invaluable addition to the multidisciplinary team. Their active engagement with toys, videos and other activities distracts children, reduces anxiety, supports parents and builds rapport with hospital staff. Therapists will often readily identify the small number of children for whom elective premedication will be beneficial.
Communicating risk In obtaining consent for anaesthesia, the proposed anaesthetic technique should be clearly explained and consent obtained for invasive procedures including central venous access, nerve blockade, epidural infusions and transfusion of blood products. Common adverse events should be discussed including sore throat, headache, dizziness, nausea and vomiting, pain and emergence phenomenon. The parents should be advised about postoperative analgesia. National societies differ in their opinion on the discussion of neurotoxicity associated with childhood anaesthesia. Adverse respiratory and cardiovascular events are most common in neonates and infants and increase respective to ASA grade and cumulative comorbidities. Adverse neurological events are rare, occurring in less than 0.02%. The risk of anaphylaxis is 1 in 10,000, cardiac arrest less than 0.1%1 and the risk of death attributable to anaesthesia is approximately 1 in 200,000. The destination of postoperative care, e.g. recovery, paediatric ward, NICU or PICU should be made clear and opportunities provided for children and their carers to ask questions. The risk of unanticipated admission to PICU following complications of anaesthesia is 0.2e0.6%.
Psychology There should be a designated pathway for referral to paediatric psychology services to support a child for whom attending for operative intervention is distressing. This may also be of benefit for children with needle phobia, or specific learning difficulties. Parents It is common practice to invite a parent (or carer) to be present at the induction of anaesthesia; this reduces anxiety for both the child and parent. A small number will be unable to tolerate this, or will project their own anxieties to the child. Seeing their child anaesthetized may be upsetting and experienced staff must be available to escort them to a suitable waiting area and provide reassurance. It is routine for families to be present during the resuscitation of a child critically unwell, or injured child assuming they do not impede the resuscitation efforts. It is less appropriate to be present during the induction of a critically unwell child, a child requiring rapid sequence induction, or with a potentially difficult airway. During resuscitation efforts, it is important to have an experienced staff member support the family throughout and ensure they are updated when time allows.
Postoperative nausea and vomiting (PONV) PONV is approximately twice as common in children as in adults and contributes to postoperative morbidity, complications and parental frustration. The aetiology is multifactorial, with afferent inputs from the neurological, gastrointestinal and vestibular systems and multiple mediators of biochemical pathways. Rare below 3 years of age, relative risk increases annually, with a peak in puberty, after which female sex is a risk factor. Additional risk factors include a previous history of PONV or motion sickness. PONV is increased in strabismus surgery, adenotonsillectomy and otoplasty. Anaesthetic factors include the use of high dose neostigmine, inhaled nitrous oxide, volatile anaesthesia and opioid analgesia. Intraoperative fluids and total intravenous anaesthesia may confer some risk reduction. Ondansetron and dexamethasone, used alone, or in combination are recommended for the prophylaxis and treatment of PONV in children undergoing emetogenic procedures. For children at high risk of PONV with a contraindication to ondansetron or dexamethasone, droperidol can be considered as an alternative agent. There is some evidence to suggest that acupuncture is an effective prophylaxis and treatment, it is not commonly utilized in UK anaesthetic practice. PONV is discussed in more detail in the 2016 APAGBI guideline ‘Prevention of Post-operative Vomiting in Children’ (see Recommended Resources).
Resuscitation It is rare for a child to require cardiopulmonary resuscitation during anaesthesia. The aetiology is often multifactorial and includes hypoxaemia and low cardiac output state. Staff should be trained in paediatric life support and the APAGBI has provided guidance on the maintenance of these skills (see Recommended Resources). Patient safety The safety of the child undergoing anaesthesia is paramount and the approach multi-faceted. The incidence and severity of complications is influenced by multiple factors including age, premorbid condition, procedural urgency and the experience of the anaesthetic team. Too few children require anaesthesia to ensure continued exposure for all anaesthetists and there is international variation in the minimum staffing and expertise required when anaesthetizing children.1 Development of nontechnical skills including teamwork, communication and situational awareness is important and the entire team should be empowered to communicate openly about safety concerns. Safe handoff by means of a concise, structured handover is essential at all transitions of care and a postoperative handover should include: patient demographics; procedure(s) and surgeon(s); premedication; mode of induction; airway device(s) used/in situ; IV access; estimated blood loss; fluids given (and
Preadmission Children should be offered a pre-assessment visit, with nurse-led documentation of relevant medical history and a tour of the children’s ward or theatre waiting area. Pre-assessment can also
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prescribed); analgesia (given and available); immediate or expected complications and emergency contact(s) including the parents/carers. The World Health Organization surgical safety checklist should be used for all cases.10 Compliance may be tested in the anaesthetic room, where the agitated child may not tolerate additional delay. Additional perioperative checklists often include issues of particular relevance to paediatric anaesthesia, e.g. flushing IV cannulae prior to discharge to the recovery suite. The Safe Anaesthesia For Every Tot collaborative (www. safetots.org) seeks increasing emphasis on the safe conduct of anaesthesia, challenging the recent international focus on the uncertainty of neurotoxicity to emphasis on the known causes of perioperative neurological morbidity. Their ‘Ten-N’ approach can serve as a useful standard for any level of anaesthetic intervention. ‘Safety II’ systems and programs like Learning from Excellence (www.learningfromexcellence.com) encourage shared learning from good practice, which can create new learning opportunities and improve resilience within teams. While adverse incident and near miss reporting remain important to highlight medical error, many anaesthetic teams are embracing learning from examples of their best practice. A
8 Owen J, John R. Childhood obesity and the anaesthetist. Cont Educ Anaesth Crit Care Pain 2012; 12: 169e75. 9 Cullen P. Paediatric trauma. Cont Educ Anaesth Crit Care Pain 2012; 12: 157e61. 10 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491e9. RECOMMENDED RESOURCES APAGBI: Apps for Distraction http://www.apagbi.org.uk/professionals/ education-and-training/apps-distraction APAGBI: Update on Paediatric Resuscitation for the Non Training Grade http://www.apagbi.org.uk/sites/default/files/images/Resus %20training2016rev.pdf APAGBI: Guidelines on the Prevention of Post-operative Vomiting in Children http://www.apagbi.org.uk/sites/default/files/images/ 2016%20APA%20POV%20Guideline-2.pdf British National Formulary for Children https://bnfc.nice.org.uk/ Guidelines for the Provision of Anaesthetic Services (GPAS) 2017. Chapter 10 Guidelines for the Provision of Paediatric Anaesthetic Services https://www.rcoa.ac.uk/system/files/GPAS-2017-10PAEDIATRICS.pdf Child Protection and the Anaesthetist www.rcpch.ac.uk/system/files/ protected/page/CHILD%20PROTECTION%20AND%20THE% 20ANAESTHETIST.pdf DAS Paediatric Difficult Airway Guidelines https://www.das.uk.com/ guidelines/paediatric-difficult-airway-guidelines GMC 0e18 years: guidance for all doctors https://www.gmc-uk.org/0_ 18_years___English_1015.pdf_48903188.pdf GMC Additional communication aids https://www.gmc-uk.org/ learningdisabilities/333.aspx What? Why? Children In Hospital. A UK charity website, with excellent resources for preparing parents, carers and children for a positive hospital experience https://www.whatwhychildreninhospital.org. uk/
REFERENCES 1 Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicenter observational study in 261 hospitals in Europe. Lancet Respir Med, 2017; https://doi.org/10.1016/S2213-2600(17) 30116-9. published online March 28. 2 Andersson H, Zare n B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Pediatr Anesth. 2015; 25: 770e7. 3 Weiss M, Engelhardt T. Cannot ventilateeparalyze!. Paediatr Anaesth 2012; 22: 1147e9. 4 Lane G. Intubation techniques. Operat Tech Otolaryngol 2005; 16: 166e70. 5 Newton R, Hack H. Place of rapid sequence induction in paediatric anaesthesia. BJA Educ 2016; 16: 120e3. 6 Powell S, Kubba H, O’brien C, Tremlett M. Paediatric obstructive sleep apnoea. BMJ 2010; 340: c1918. 7 Prosser S, Sharma N. Cerebral palsy and anaesthesia. Cont Educ Anaesth Crit Care Pain 2010; 10: 72e6.
Acknowledgements With thanks to Dr Judith Short and Dr Joanna Gordon for their assistance with previous versions of this article.
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Preoperative assessment and preparation for safe paediatric anaesthesia
Learning objectives After reading this article, you should be able to: C use a methodical approach to assess the paediatric patient requiring anaesthesia C describe the factors that may complicate paediatric anaesthesia C discuss the risks associated with paediatric anaesthesia
Matthew Harvey Tim Geary
Information gathering Abstract
Most children undergoing anaesthesia are young and do not have significant comorbidities e in the APRICOT study, approximately 50% were less than 5 years of age and 88.8% ASA grade IeII. There is concern, however, that the number of adverse events associated with paediatric anaesthesia has been under-estimated.1 These complications contribute to perioperative morbidity, prolonged hospital admissions, increased healthcare costs and parental dissatisfaction. Prior to anaesthesia, each child should be assessed thoroughly to identify any indications for preoperative investigations, perioperative admission, postponement or adjustment to the mode of anaesthesia.
The delivery of anaesthesia to children and young people provides unique challenges. A careful, systematic approach to assessment and preparation can deliver a positive experience for the child, carers and staff while mitigating potential complications. Preparation for anaesthesia should encompass information gathering, assessment and planning for anatomical, physiological, social and behavioural elements specific to the child and the surgery. Delivery of appropriate information, consent and fasting are also key elements of ensuring positive perioperative outcomes. We consider the common components of preparation for the delivery of safe paediatric anaesthesia.
Keywords Paediatric anaesthesia; perioperative fasting; premedication; preoperative assessment
Surgical plan A review of the clinical notes and an understanding of the scheduled procedure(s) before meeting the child will provide a background and highlight potential problems requiring a more detailed history, or elective investigations. The planned surgery will not only dictate the choice of anaesthesia, but also be indicative of the risk for perioperative respiratory or cardiovascular complications, such as laryngospasm in adenotonsillectomy or bradyarrhythmias in ocular surgery.1
Royal College of Anaesthetists CPD Matrix: 1C01, 2A03, 2D02, 3D00
Providing anaesthesia for children is both uniquely rewarding and challenging. Consideration of age-dependent characteristics such as anatomical, physiological and behavioural differences is essential. Pharmacological variations mean that drug doses are calculated on surrogate markers such as known (or estimated) weight, age or calculated body surface area, putting children at greater risk of drug errors. Techniques such as regional anaesthesia, sedation or difficult airway management provide their own challenges. The perioperative assessment, induction of anaesthesia and aftercare are notable for the presence of anxious parents or carers. The rapport created by communicating effectively with the child and their carer(s) is a subjective measure of the quality of anaesthetic care and sets the tone for the entire clinical interaction. Preparation for safe paediatric anaesthesia encompasses information gathering; patient assessment; preparation of the team, equipment and environment; and preparation of the patient and their carer(s) for anaesthesia.
History The medical history should be thoroughly interrogated to ensure fitness for surgery. Assessment should include past medical history, previous anaesthesia, current medications, allergies, family history and social enquiry. The optimization of chronic diseases may require liaison with paediatric specialist teams. A positive family history may encourage further investigation, for example a history of premature cardiac death in a relative of a child with a heart murmur, or a relative with adverse events related to anaesthesia. The home circumstances can also inform risk assessment. The relative risk of respiratory complications associated with passive smoking is 1.391 and a similar increase is seen for children who are smokers. When assessing a teenager, the history should include enquiry about smoking, alcohol and recreational drug use and where appropriate, sexual activity. Some may prefer to disclose this information confidentially and it might be necessary to take this history in private. For post-pubertal girls, local protocols may mandate a preoperative urine pregnancy test, for which informed verbal consent is required.
Matthew Harvey MBChB MRCPCH PGCert is a Senior Trainee in Paediatric Intensive Care Medicine at the Royal Hospital for Children, Glasgow, UK. He also works for the ScotSTAR paediatric retrieval team. Conflicts of interest: none declared. Tim Geary MBChB FRCA FFICM is a Consultant in Anaesthesia and Intensive Care at University Hospital Crosshouse and Honorary Senior Lecturer at the University of Glasgow, UK. He is also a Consultant in Paediatric Retrieval Medicine with the ScotSTAR service. Conflicts of interest: none declared.
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Basic measurements Routine observations including temperature, heart rate, respiratory rate, non-invasive blood pressure and oxygen saturation in
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room air must be documented. A small number of children will find this distressing. All children should have their height and weight measured to allow titration of medications and intravenous fluids, both of which may be dosed by either weight or composite measures (e.g. body surface area, lean body weight, fat free mass). This will also guide selection of equipment and infusion pumps, which may be guided by age, or weight-based algorithms.
Preoperative investigations
Minor Intermediate Major
Regular medications Most regular medications can be safely given on the day of surgery, even to the fasted child. Children with diabetes should be listed early and have a specific perioperative glycaemic management plan. Children on oral anticoagulants should have a clearly documented plan of cessation, alternative cover (e.g. systemic heparinization for metallic valves) and reintroduction of their anticoagulants. Most oral antiepileptic drugs (AEDs) can be safely taken on the day of anaesthesia; however, most have an effect long enough that omitting a single dose is unlikely to cause harm. Caution is required as some AEDs can reduce inhalational MAC by up to one third, whereas others may increase intravenous agent requirements. Children on long-term steroids or those with adrenal insufficiency may require additional steroids perioperatively. Consider non-allergic contraindications to specific drug classes. Depolarizing neuromuscular blocking drugs should be avoided in some conditions which can result in hyperkalaemia after administration such as neurological deficits involving spinal cord injury, peripheral nerve injury or acute muscle wasting. Similarly, excessive potassium release can occur in trauma or burns 24 hours after injury for up to 1e2 years. Malignant hyperthermia is associated with conditions such as central core disease, but may also be triggered by anaesthetic agents in the absence of a comorbid predisposition. Genetic testing is available and where this is unequivocal skeletal muscle biopsy can be performed.
Investigations
Endoscopy, dental procedures, grommets Adenotonsillectomy, inguinal hernia repair Joint reconstruction, laparotomy
No routine pre-operative investigations No routine pre-operative investigations FBC, U&E, Urinalysis
Table 1
response to surgery. This ‘double-hit’ model induces glycogenolysis, ketogenesis, release of free fatty acids and transient insulin resistance. This response is a risk factor for postoperative complications and prolonged hospitalization. Non-caloric fluids are inadequate to modulate this response. Preoperative carbohydrate drinks may induce an insulin response, inhibiting the fasted state physiology, but data of their efficacy in children is limited. Hunger and thirst caused by excessive fasting may contribute to the difficult behaviours encountered in preoperative assessment. Traditional guidelines advocate fasting for 6, 4 and 2 hours for solids, breast milk and clear fluids, respectively. Formula feeds are often considered with solids, as the lower whey:casein ratio prolongs gastric emptying. These conservative practices have been challenged by recent literature showing that children on more liberal fasting regimes (see Table 2) have increased gastric pH, less risk of hypoglycaemia, reduced glycogenolysis and improved fluid homeostasis. They are also less thirsty, hungry and irritable. A recent series of 10,015 children shows a favourable safety profile, with an incidence of aspiration of 0.03%.2 The APAGBI, ESPA and ADARPEF released a consensus document in April 2018 encouraging clear fluids (3 ml/kg) up to 1 hour before surgery.
Allergies The nature of all suspected allergies should be determined, including the precipitant, type and severity of reaction, recurrence, investigations and treatment. Latex is the most common non-drug allergy and is associated with food allergies including kiwi fruit, bananas and avocados. Latex allergy would usually mandate first place on the theatre list and strict precautions by all theatre staff.
Investigations Most children who are systemically well do not require preoperative investigations. For elective cases, a surgical severity score, in conjunction with National Institute for Health and Care Excellence (NICE) guidelines (www.nice.org.uk/guidance/ NG45) can guide decision making (see Table 1). Other investigations are considered in Special circumstances.
Fasting The risk of aspiration is lower than that quoted in the adult literature and it has been suggested that children should fast from clear fluids for only one hour prior to elective surgery. Fasting times have progressively prolonged, owing to cognitive biases, patient safety initiatives and guidelines based on non-fasted emergency surgery studies, or gastric residual volumes e a poor surrogate for the risk of aspiration. Fasting may be further extended by operative delays, or by parents not wakening their child for fluids overnight. In emergency surgery, heightened concern is valid as children are more prone to gastric paresis secondary to opioids, trauma and pain. Prolonged fasting induces an anabolic state, with potentially deleterious effects when combined with the neuroendocrine
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Examples
Special circumstances: Anaemia e children with known or suspected anaemia should have a FBC and haematinic (e.g. vitamin B12 and folate) assessment. Blood transfusion e obtain initial group and save samples in preoperative or preassessment clinics. Transfusion services increasingly require two separate samples, prior to releasing products for non-emergency scenarios. Cardiothoracic surgery e for cardiothoracic surgery, a chest X-ray and ECG should be reviewed. Chronic disease e it is advisable to consider a chest X-ray in children with chronic lung disease, cystic fibrosis, congenital heart disease or significant neurodisability.
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Diabetes e a recent HbA1c should be reviewed in diabetic patients. Obstructive sleep apnoea e children with a history of obstructive sleep apnoea or sleep disordered breathing should be considered for paediatric respiratory assessment and polysomnography. Sickle cell disease e children with a family history of sickle cell disease should have an early haematology referral and preoperative investigations. Pregnancy e young women of childbearing age should have a pregnancy test; some institutions will routinely test all young women over 12 years of age. Vaccination e it is common to encounter a child requiring surgery soon after administration of routine vaccinations. The national immunization guidelines (Green Book 2013, available at www.gov.uk) state that imminent surgery or anaesthesia are not contraindications to immunizations. The Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) recommends a delay of 48 hours following administration of inactivated vaccines as the rates of post-immunization pyrexia are greater than live attenuated vaccines. Child protection e all doctors must safeguard the wellbeing of children and young people. In the event of child protection concerns, the safety of the child is of utmost importance and the multidisciplinary team should always act in the child’s best interests. More information is available in the intercollegiate document Child Protection and the Anaesthetist (see Recommended Resources).
children has an incidence of 1.3% with specific groups making up a high proportion of this. Predictors of a difficult airway include limited mouth opening, dysmorphic features, micrognathia, retrognathia, inability to prognath, poor dentition and decreased neck mobility. Other factors include obesity, obstructive sleep apnoea and a history of previous difficult intubation. The Colorado Pediatric Airway Score (COPUR) is a detailed scoring system that can overcome some of the reliability concerns associated with individual tests such as the Mallampati score.4 A number of congenital syndromes are associated with a difficult airway (see Table 3) that may improve with age (e.g. Pierre-Robin sequence) or become progressively challenging (e.g. Treacher-Collins syndrome). Some groups of disorders are associated with notoriously difficult intubation (e.g. mucopolysaccharidoses). Airway abnormalities may also be acquired, for example, subglottic stenosis, tumours, arteriovenous malformations and disorders of the temporomandibular joint or cervical spine. Irrespective of anticipated difficulty, preparation to instrument the paediatric airway differs from adult practice. Standard rapid sequence induction, for example, is less practicable as apnoeic time is reduced and young children may be poorly compliant with pre-oxygenation.5 A failed intubation plan should form part of the briefing, airway adjuncts and an alternative means of establishing an airway must be immediately to hand and consider gentle insufflation using the facemask, prior to administering neuromuscular blockade. Help should be requested early, as more than two attempts at direct laryngoscopy is associated with failure and adverse outcomes. All anaesthetists should be familiar with the paediatric guidelines for difficult mask ventilation, unanticipated difficult intubation and the ‘can’t intubate, can’t ventilate’ scenarios, published by the APAGBI and the Difficult Airway Society, available via their website (www.das.uk.com).
Patient assessment Airway Management of the paediatric airway is usually not problematic but failure of airway management is a major cause of perioperative morbidity. Perioperative airway issues are commonly caused by functional airway problems such as laryngospasm, tonsil hypertrophy, bronchospasm or muscle rigidity. Inadequate anaesthesia or muscle relaxation and poor mask or airway management can contribute to this. Assessment of the airway should be focused by three questions3: 1. Ease of oxygenation via bag mask ventilation? 2. Ease of ventilation via supraglottic airway? 3. Ease of intubation and consideration of surgical rescue techniques? Difficult mask ventilation or intubation are rare and the combination of both even more so. Difficult laryngoscopy in
Breathing Intercurrent respiratory tract infection is common amongst preschool children and is associated with adverse events during anaesthesia, including breath-holding, laryngospasm, bronchospasm and desaturation. It can, however, be difficult to schedule a young child for elective surgery when they have multiple viral respiratory tract infections per year and a number of children will have persistent non-infective rhinorrhoea. A blanket cancellation policy will unnecessarily postpone large numbers of children who could proceed under the care of an experienced anaesthetist. A delay of 1e2 weeks is recommended for children with purulent rhinitis and temperature, reduced SpO2 and/or audible signs on auscultation. There has been a demonstrated and cumulative increase in relative risk of severe perioperative respiratory critical events with each of the following risk factors - asthma, wheezing, recent respiratory tract infection, snoring and passive smoking. The relative risk increases from 1.8 for one risk factor to 4.6 for three or more. Symptoms of obstructive sleep apnoea (OSA) should be elucidated, as these children are at increased risk of laryngospasm, desaturation and airway obstruction. They are more sensitive to respiratory depression with sedatives and opioids, less responsive to hypercapnoea and there is an increased
Example of a liberal fasting regime Type of feed
Infants
Children (>1 year)
Clear fluids Breast milk Formula milk Solid food
0 4a 6a 6
0 e 6 6
a
Some consider breast and formula milk equivalent in terms of fasting times.
Table 2
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Syndromes associated with airway abnormalities and congenital heart disease Syndromes associated with difficult airways Syndrome
Abnormalities
Difficult mask ventilation/intubation
Apert syndrome Beckwith Wiederman syndrome Crouzon syndrome Downs syndrome
Midface hypoplasia Macroglossia Midface hypoplasia Macroglossia, brachycephaly, atlanto-axial instability Midface/hemifacial hypoplasia Macroglossia, craniofacial abnormality, TMJ dysfunction adenoid and tonsil hypertrophy Cervical fusion Micrognathia, retrognathia Micrognathia
Mask Ventilation Both Mask Ventilation Both
Goldenhar syndrome Mucopolysaccharidoses, e.g. Hurlers/Hunters Syndrome Klippel-Feil syndrome Pierre Robin Syndrome Treacher Collins Syndrome
Intubation Both Intubation Intubation Intubation
Syndromes associated with congenital heart disease Syndrome
Associated cardiac anomalies
Down syndrome (Trisomy 21)
Atrioventricular septal defects, atrial septal defects, ventricular septal defects, tetralogy of fallot Coarctation of the aorta, bicuspid aortic valve, aortic stenosis Tetralogy of Fallot, aortic arch abnormalities, truncus arteriosus Pulmonary stenosis, atrial septal defect, hypertrophic cardiomyopathy Aortic stenosis, peripheral pulmonary stenosis
Turner syndrome (45X) DiGeorge syndrome (22q11.2 deletion) Noonan syndrome (RAS-MPK) Williams syndrome (7q11.23) Table 3
incidence of postoperative complications including desaturation and pulmonary oedema.6 Nocturnal symptoms include loud snoring, disturbed sleep and witnessed apnoea, and children with OSA will often adopt an extended head position when sleeping. Daytime symptoms are less specific and include excessive somnolence, poor concentration and behavioural difficulties that may cause concern at home, nursery, school or during planned activities. Untreated OSA is associated with adverse neurodevelopmental outcomes, failure to thrive and (rarely) cor pulmonale. Other risk factors for respiratory complications include age less than 3 years, asthma, craniofacial abnormalities, neuromuscular disorders, failure to thrive and obesity. Children considered at high risk should be referred for management in a tertiary centre, with access to paediatric critical care facilities.6
Innocent murmurs are asymptomatic, soft (grade IeII), short, occur in systole, may vary with the posture of the child and are never associated with a thrill. Flow murmurs are particularly common during intercurrent illnesses and should be reassessed in the community to ensure resolution. In the newborn or young infant a history of tachypnoea, poor feeding, failure to thrive, sweating or cyanosis is concerning. In the older child, dyspnoea, reduced exercise tolerance and episodes of syncope should raise alarm. A family history of sudden death is concerning for hypertrophic obstructive cardiomyopathy, or an inherited channelopathy. The asymptomatic child with an innocent murmur and otherwise normal examination can proceed to elective surgery, with outpatient follow-up. All symptomatic patients or those with abnormal examination findings should have an ECG and be referred for assessment. In the UK, routine prescription of antibiotics as prophylaxis against endocarditis is no longer recommended. Guidance is available NICE Clinical Guideline 64 (www.nice.org.uk/ guidance/cg64).
Circulation Congenital heart disease affects approximately 9 per 1000 live births. Cardiac murmurs are a common finding during paediatric assessment and an innocent murmur may be heard in up to 80% of children during their lifetime. Anaesthetizing the child with an undiagnosed cardiac lesion carries significant risk; in contrast, children with previously repaired simple lesions (e.g. VSD or ASD) do not confer additional risk outwith specialist centres. A number of inherited syndromes are associated with cardiac anomalies, examples are included in Table 3.
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Neurology The risks associated with anaesthetizing the child with neuromuscular disease are numerous. Multisystem comorbidities including cardiac or respiratory dysfunction, gastro-oesophageal reflux and electrolyte disturbance are common. Children with
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need for enhanced observation, elective admission to the children’s ward postoperatively, or referral to a tertiary centre.8
obstructed CSF drainage are at risk of raised intracranial pressure caused by hypercapnoea or drug-induced cerebral vasodilatation. The child with cerebral palsy is the most common example of chronic neurodisability and the range of comorbidities the anaesthetist must consider in this diverse group of patients. They may present for multiple procedures, involving several organ systems, e.g. adenotonsillectomy for OSA, gastrostomy and fundoplication for reflux and feeding, spinal surgery for scoliosis and orthopaedic procedures for flexion deformities or hip dislocation. Abnormal posture may complicate airway management, particularly in combination with abnormal dentition, copious oropharyngeal secretions and temporomandibular joint dysfunction. Chronic lung disease, recurrent chest infections, chronic microaspiration and poor cough with inadequate clearance of secretions predispose the child to postoperative atelectasis, hypoxia and other complications. Gastro-oesophageal reflux is common and may be exacerbated by scoliosis, reduced lower oesophageal sphincter tone and semi-recumbent positioning. A seizure disorder is seen in up to 50% of children with cerebral palsy. Fixed flexion deformities of the limbs and trunk can challenge optimal positioning for airway management, vascular access, invasive monitoring and the planned procedure. Low total body fat, poor musculature and thin skin create challenges with thermoregulation beyond that expected for an agematched peer. These features also predispose the child to pressure sores, so rigorous attention to bony prominences and pressure points is essential. Postoperative pain, anxiety and agitation may provoke painful muscle spasms and the use of regional anaesthetic techniques, while potentially technically challenging, can be of great benefit.7
Anxiety Few children are particularly uncooperative at the time of induction and genuine preoperative anxiety is age-dependent. Young infants can often be calmed by parental surrogates with soothing voices, holding and rocking. In older children, a controlled intravenous induction can be enabled by the use of local anaesthetic gel and distraction techniques to aid cannulation. Inhalational induction can be aided by making a game of it, e.g. ask the child to ‘blow up the balloon’ (reservoir bag) or apply the facemask as the ‘fighter pilot prepares to take off’. For an optimal perioperative experience, the carers and child must be well informed and empowered to engage fully in the process. The use of age-appropriate language to explain the anaesthetic plan to young children encourages their trust in the team and reduces the fear of the unknown. Hospital passport coping kits can be of use. The POEMS charity course (Positive Outcome and Experience Management Strategies; www. poemsforchldren.co.uk) empowers multidisciplinary professionals to manage anxious children calmly and effectively. Older children can benefit from distraction techniques including books, music and games. For the computer literate child, the APAGBI endorses a number of iPad and Android apps, which can also aid distraction (see Recommended Resources). The inconsolable child should prompt discussion of the urgency of surgery and the best interests of the child, with consideration given to postponement. The physical restraint of a child should be a last resort as the additional distress can contribute to challenges including bedwetting, sleep disturbance and disruptive behaviour.
Neonates and preterm infants Preterm infants are at increased risk of apnoea and bradycardia in recovery, this risk extends to neonates and infants with the sequelae of prematurity. Infants who have been ventilated recurrently, or for protracted periods of time in the neonatal period may have subglottic stenosis. Children with chronic lung disease may have an oxygen requirement prior to admission, have less compliant lungs and are at increased risk of postoperative respiratory complications including apnoea and lower respiratory tract infection. Gastro-oesophageal reflux is common and anti-reflux medications should be continued preoperatively. Fasting should be restricted where possible as there is an increased risk of hypoglycaemia.
Premedication There are multiple combinations of drugs suitable for premedication.1 Premedication is typically reserved for the most anxious, least prepared children or those with special educational or behavioural needs. Table 4 lists some commonly used drugs and their doses. Special educational needs Children with special educational needs (SEN) commonly present for surgical intervention. The spectrum of conditions is wide and includes those with specific learning difficulties, speech and language disorders, autistic spectrum disorders and profound neurodisability. They may display heightened anxiety, difficult behaviour and may simply not understand the hospital environment, planned intervention or change to their daily routine. Their own communication difficulties may heighten their anxiety. Choice of language is important, as children with autistic spectrum disorders may be unable to relate to colloquial terms used to explain interventions to their peers. It may be pertinent to use pictures, drawings or seek additional communication aids. Children with SEN are often known to the hospital and/or community paediatric team and often have personalized care packages or communication aids. Development of individual patient hospital coping kits, information folders and a departmental record of how to support these children are all good practice to ensure standards of care for those requiring multiple hospital admissions or surgery.
Obesity Childhood obesity and its associated comorbidities are increasingly prevalent and contribute to higher risk anaesthesia. Consideration should be given to the presence of comorbid OSA, asthma, hypertension, type 2 diabetes and gastro-oesophageal reflux, which are as common as in obese adults. In the presence of respiratory symptoms or sleep-disordered breathing, preoperative pulmonary function tests or polysomnography may be indicated. Drug dosing based on actual body weight may result in overdose; dose based on alternative measures (e.g. ideal body weight, lean body weight, normal fat mass, body surface area) may be better. Children with a history of OSA will require admission overnight and this may mandate referral to a paediatric centre. In other cases, the anaesthetist must consider the
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Common premedication drug doses Drug
Dose (oral unless stated otherwise)
Onset
Comments
Midazolam Lorazepam Clonidine Ketamine
0.5 mg/kg 50-100 mcg/kg 2-4 mcg/kg 2e8 mg/kg
20e30 30e60 30e60 30e40
Diamorphine
0.1 mg/kg intranasal
15e30 minutes
minutes minutes minutes minutes
Risk of paradoxical excitement Risk of prolonged sedation (up to 6 hours) Unfavourable cardiovascular effects Nurse in a quiet, calm environment. Emergent hallucinations may be unpleasant Mild, early stinging sensation
Table 4
Clinicians should be familiar with the equipment available within their own department. The theatre environment should be adjusted to reflect the needs of the child, for example, the ambient temperature may be as high as 28 C in neonatal surgeries, which most would find uncomfortably warm. Appropriate equipment is equally important when conducting anaesthesia outwith the theatre environment, e.g. radiology, emergency department, cardiac catheter laboratory and during patient transfers. Children anaesthetized in these settings may have complex comorbidities, critical illness or severe injury. The MRI suite offers an additional degree of complexity. All equipment must be MRI compatible and in many departments, monitoring is remote, by means of slave devices. In the event of an emergency, the patient should be removed from the scanning room to an area suitable for resuscitation.
Vascular access Venous cannulation in children is complicated by the calibre and mobility of the veins. The subcutaneous fat of a healthy toddler can make visualizing and palpating veins difficult and young infants are less likely to sit still during cannulation attempts. In the difficult child, the dorsal veins of the foot, great saphenous and scalp vessels may be more readily accessed. In the moribund, or obtunded child, the Trendelenburg position may aid cannulation of the external jugular vein. Ultrasound has an increasing role. Trauma and the critically unwell child Trauma is the leading cause of death and disability in children over 1 year of age. Most seriously injured children have multiple injuries, often including a head injury, which contributes to 75% of all traumatic deaths. The mechanism of injury varies with developmental motor skill attainment; non-accidental injury should be considered in infants and young children, while teenagers are more often involved in road traffic accidents and sporting accidents, reflecting a more adult pattern of injuries.9 All anaesthetists providing care to paediatric patients should be able to assist with the resuscitation and stabilization of critically ill and traumatically injured children. The response to such a child must be prompt, with the early support of senior clinicians. Local ‘damage control’ surgery may be required to stabilize a patient, prior to transfer. Specialist transport teams retrieve more than 90% of children requiring transfer to a paediatric intensive care unit (PICU), a small number of time-critical cases will need to be transferred by the referring team, e.g. neurosurgical emergencies or major trauma.
Consent and capacity Written consent for anaesthesia is usually not required, verbal consent should discuss the main risks associated with anaesthesia (see Communicating risk). For all but the most urgent surgery and in mass casualty scenarios, where children may have been separated from their carers, a signed surgical consent form is mandatory. Medical or surgical procedures may be performed on a child or young person with their consent, if they have capacity. Otherwise, consent must be authorized by a parent, an individual with parental rights, or the courts. In order to exhibit capacity, an informed child must be able to understand, retain, interpret and evaluate the information presented and communicate their decision. Ensuring consent is obtained from the appropriate individual is essential. Under 16 years of age: a young person under the age of 16 may have the capacity to consent, but this may depend upon the nature and implications of the intervention. Young people may have the capacity to consent to low risk treatment, but not to complex or high-risk treatments with potentially serious consequences. In Scotland, parents cannot overturn the decision of a competent minor to refuse treatment.
Preparation Environment and equipment Ideally, children should be welcomed, assessed and recovered in dedicated areas. The paediatric reception is often brightly coloured and age-appropriate entertainment including computer games, music, DVDs and toys are available. Where possible a separate area should be available for adolescents. The national standards of monitoring in paediatric anaesthesia are the same as in adult practice (https://www.aagbi.org/ sites/default/files/Standards_of_monitoring_2015_0.pdf). Some children will not tolerate routine monitoring during induction and this should be applied as soon as practically possible. Alarm limits should be age-appropriate and may need adjusted on a case-by-case basis, e.g. cyanotic congenital heart disease.
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Over 16 years of age: a young person aged 16e18 years who lacks capacity is considered differently throughout the UK. In England, Wales and Northern Ireland the parents can consent to investigations and treatment in the young person’s best interests. Treatment can also be provided without parental consent. In Northern Ireland, treatment can be provided if a parent cannot be
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PAEDIATRIC ANAESTHESIA
support psychological preparation for surgery, with the input of play therapists and use of videos, pictures and storybooks.
contacted, though court approval should be considered for nonemergency surgery. In Scotland, a young person over the age of 16 years, who lacks capacity, should be considered under the Adults with Incapacity Act.
Play therapy Trained play therapists are an invaluable addition to the multidisciplinary team. Their active engagement with toys, videos and other activities distracts children, reduces anxiety, supports parents and builds rapport with hospital staff. Therapists will often readily identify the small number of children for whom elective premedication will be beneficial.
Communicating risk In obtaining consent for anaesthesia, the proposed anaesthetic technique should be clearly explained and consent obtained for invasive procedures including central venous access, nerve blockade, epidural infusions and transfusion of blood products. Common adverse events should be discussed including sore throat, headache, dizziness, nausea and vomiting, pain and emergence phenomenon. The parents should be advised about postoperative analgesia. National societies differ in their opinion on the discussion of neurotoxicity associated with childhood anaesthesia. Adverse respiratory and cardiovascular events are most common in neonates and infants and increase respective to ASA grade and cumulative comorbidities. Adverse neurological events are rare, occurring in less than 0.02%. The risk of anaphylaxis is 1 in 10,000, cardiac arrest less than 0.1%1 and the risk of death attributable to anaesthesia is approximately 1 in 200,000. The destination of postoperative care, e.g. recovery, paediatric ward, NICU or PICU should be made clear and opportunities provided for children and their carers to ask questions. The risk of unanticipated admission to PICU following complications of anaesthesia is 0.2e0.6%.
Psychology There should be a designated pathway for referral to paediatric psychology services to support a child for whom attending for operative intervention is distressing. This may also be of benefit for children with needle phobia, or specific learning difficulties. Parents It is common practice to invite a parent (or carer) to be present at the induction of anaesthesia; this reduces anxiety for both the child and parent. A small number will be unable to tolerate this, or will project their own anxieties to the child. Seeing their child anaesthetized may be upsetting and experienced staff must be available to escort them to a suitable waiting area and provide reassurance. It is routine for families to be present during the resuscitation of a child critically unwell, or injured child assuming they do not impede the resuscitation efforts. It is less appropriate to be present during the induction of a critically unwell child, a child requiring rapid sequence induction, or with a potentially difficult airway. During resuscitation efforts, it is important to have an experienced staff member support the family throughout and ensure they are updated when time allows.
Postoperative nausea and vomiting (PONV) PONV is approximately twice as common in children as in adults and contributes to postoperative morbidity, complications and parental frustration. The aetiology is multifactorial, with afferent inputs from the neurological, gastrointestinal and vestibular systems and multiple mediators of biochemical pathways. Rare below 3 years of age, relative risk increases annually, with a peak in puberty, after which female sex is a risk factor. Additional risk factors include a previous history of PONV or motion sickness. PONV is increased in strabismus surgery, adenotonsillectomy and otoplasty. Anaesthetic factors include the use of high dose neostigmine, inhaled nitrous oxide, volatile anaesthesia and opioid analgesia. Intraoperative fluids and total intravenous anaesthesia may confer some risk reduction. Ondansetron and dexamethasone, used alone, or in combination are recommended for the prophylaxis and treatment of PONV in children undergoing emetogenic procedures. For children at high risk of PONV with a contraindication to ondansetron or dexamethasone, droperidol can be considered as an alternative agent. There is some evidence to suggest that acupuncture is an effective prophylaxis and treatment, it is not commonly utilized in UK anaesthetic practice. PONV is discussed in more detail in the 2016 APAGBI guideline ‘Prevention of Post-operative Vomiting in Children’ (see Recommended Resources).
Resuscitation It is rare for a child to require cardiopulmonary resuscitation during anaesthesia. The aetiology is often multifactorial and includes hypoxaemia and low cardiac output state. Staff should be trained in paediatric life support and the APAGBI has provided guidance on the maintenance of these skills (see Recommended Resources). Patient safety The safety of the child undergoing anaesthesia is paramount and the approach multi-faceted. The incidence and severity of complications is influenced by multiple factors including age, premorbid condition, procedural urgency and the experience of the anaesthetic team. Too few children require anaesthesia to ensure continued exposure for all anaesthetists and there is international variation in the minimum staffing and expertise required when anaesthetizing children.1 Development of nontechnical skills including teamwork, communication and situational awareness is important and the entire team should be empowered to communicate openly about safety concerns. Safe handoff by means of a concise, structured handover is essential at all transitions of care and a postoperative handover should include: patient demographics; procedure(s) and surgeon(s); premedication; mode of induction; airway device(s) used/in situ; IV access; estimated blood loss; fluids given (and
Preadmission Children should be offered a pre-assessment visit, with nurse-led documentation of relevant medical history and a tour of the children’s ward or theatre waiting area. Pre-assessment can also
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PAEDIATRIC ANAESTHESIA
prescribed); analgesia (given and available); immediate or expected complications and emergency contact(s) including the parents/carers. The World Health Organization surgical safety checklist should be used for all cases.10 Compliance may be tested in the anaesthetic room, where the agitated child may not tolerate additional delay. Additional perioperative checklists often include issues of particular relevance to paediatric anaesthesia, e.g. flushing IV cannulae prior to discharge to the recovery suite. The Safe Anaesthesia For Every Tot collaborative (www. safetots.org) seeks increasing emphasis on the safe conduct of anaesthesia, challenging the recent international focus on the uncertainty of neurotoxicity to emphasis on the known causes of perioperative neurological morbidity. Their ‘Ten-N’ approach can serve as a useful standard for any level of anaesthetic intervention. ‘Safety II’ systems and programs like Learning from Excellence (www.learningfromexcellence.com) encourage shared learning from good practice, which can create new learning opportunities and improve resilience within teams. While adverse incident and near miss reporting remain important to highlight medical error, many anaesthetic teams are embracing learning from examples of their best practice. A
8 Owen J, John R. Childhood obesity and the anaesthetist. Cont Educ Anaesth Crit Care Pain 2012; 12: 169e75. 9 Cullen P. Paediatric trauma. Cont Educ Anaesth Crit Care Pain 2012; 12: 157e61. 10 Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360: 491e9. RECOMMENDED RESOURCES APAGBI: Apps for Distraction http://www.apagbi.org.uk/professionals/ education-and-training/apps-distraction APAGBI: Update on Paediatric Resuscitation for the Non Training Grade http://www.apagbi.org.uk/sites/default/files/images/Resus %20training2016rev.pdf APAGBI: Guidelines on the Prevention of Post-operative Vomiting in Children http://www.apagbi.org.uk/sites/default/files/images/ 2016%20APA%20POV%20Guideline-2.pdf British National Formulary for Children https://bnfc.nice.org.uk/ Guidelines for the Provision of Anaesthetic Services (GPAS) 2017. Chapter 10 Guidelines for the Provision of Paediatric Anaesthetic Services https://www.rcoa.ac.uk/system/files/GPAS-2017-10PAEDIATRICS.pdf Child Protection and the Anaesthetist www.rcpch.ac.uk/system/files/ protected/page/CHILD%20PROTECTION%20AND%20THE% 20ANAESTHETIST.pdf DAS Paediatric Difficult Airway Guidelines https://www.das.uk.com/ guidelines/paediatric-difficult-airway-guidelines GMC 0e18 years: guidance for all doctors https://www.gmc-uk.org/0_ 18_years___English_1015.pdf_48903188.pdf GMC Additional communication aids https://www.gmc-uk.org/ learningdisabilities/333.aspx What? Why? Children In Hospital. A UK charity website, with excellent resources for preparing parents, carers and children for a positive hospital experience https://www.whatwhychildreninhospital.org. uk/
REFERENCES 1 Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicenter observational study in 261 hospitals in Europe. Lancet Respir Med, 2017; https://doi.org/10.1016/S2213-2600(17) 30116-9. published online March 28. 2 Andersson H, Zare n B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite. Pediatr Anesth. 2015; 25: 770e7. 3 Weiss M, Engelhardt T. Cannot ventilateeparalyze!. Paediatr Anaesth 2012; 22: 1147e9. 4 Lane G. Intubation techniques. Operat Tech Otolaryngol 2005; 16: 166e70. 5 Newton R, Hack H. Place of rapid sequence induction in paediatric anaesthesia. BJA Educ 2016; 16: 120e3. 6 Powell S, Kubba H, O’brien C, Tremlett M. Paediatric obstructive sleep apnoea. BMJ 2010; 340: c1918. 7 Prosser S, Sharma N. Cerebral palsy and anaesthesia. Cont Educ Anaesth Crit Care Pain 2010; 10: 72e6.
Acknowledgements With thanks to Dr Judith Short and Dr Joanna Gordon for their assistance with previous versions of this article.
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Ó 2018 Published by Elsevier Ltd.
Please cite this article in press as: Harvey M, Geary T, Preoperative assessment and preparation for safe paediatric anaesthesia, Anaesthesia and intensive care medicine (2018), https://doi.org/10.1016/j.mpaic.2018.05.004