Preoperative Evaluation, Premedication, and Induction of Anesthesia in Infants and Children

Preoperative evaluation and preparation of a child for anesthesia and surgery is an integral part of the process prior to surgery. The preoperative evaluation should consist of birth and neonatal history, review of systems, physical examination, height, weight and vital signs. Home use of medications such as bronchodilators, steroids and chemotherapeutic agents has significant implications for the anesthetic management. A history of medical or environmental allergies should be elicited, including questions specifically directed toward evaluating the presence of allergy to latex in children at risk, notably those with meningomyelocele or urogenital anomalies, those who undergo bladder self-catheterization, or those whose medical histories indicate frequent latex exposure in the past. Particular attention is paid to previous anesthetics and problems encountered, the successful and unsuccessful techniques used in the past for airway management. Anesthetic risks, anesthetic plans, recovery phenomena, postoperative analgesia, and discharge criteria have to be discussed in during the preoperative interview. The use of herbal medication and other alternative and complementary medicine modalities (CAM) has to be assessed as well as many herbal remedies have anesthetic implications. I. Underlying Conditions: The Former Preterm Infant: When evaluating a former preterm infant one should take into consideration the possible presence of bronchopulmonary dysplasia, anemia and the possibility of postoperative apnea. Perioperative complications from BPD generally involve reactivity of airways and the risk of severe hypoxia that can accompany boncho-spastic episodes. Bronchodilators and inhaled corticosteroids should be continued up to and including the morning of surgery. Parents should be questioned about the need for oxygen therapy at home and recent hematocrit data should be available. Upper Respiratory Infection: Several investigations have found that a child with a current URI or recovering from a URI is at increased risk to develop laryngospasm, bronchospasm, oxygen desaturation and post extubation croup. While these complications typically do not cause significant morbidity in otherwise healthy children, they may be significant in children with underlying conditions such as asthma, bronchopulmonary dysphasia, children under 1 year of age, children with sickle cell disease, children who live in a household which includes smoking parents and children who are to undergo surgery involving the airway. Patients in these categories should be carefully assessed and strong consideration should be given to postponing elective surgery. It is unclear how long surgery should be delayed following an URI, however, because bronchial hyperreactivity may exist for up to 7 weeks after a URI. The final decision must take into account the risk-to-benefit ratio of undergoing a surgical procedure in the patient’s current state of health and the likelihood of acquiring another URI prior to rescheduled surgery. The technique used for anesthesia may impact the number of airway issues encountered. For example, LMA anesthesia has been shown to be associated with a significantly lower rate of