Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI)

BACKGROUND

The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures.

METHODS

We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations.

RESULTS

We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio.

CONCLUSION

Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Undetected central core disease myopathy in an infant presenting for clubfoot surgery

A 1-year-old child was scheduled for two stage bilateral clubfoot surgery. Preoperative evaluation was normal and total intravenous anesthesia with a continuous sciatic nerve block was performed. Two months later, before the second clubfoot correction, a hip subluxation was evident suggesting a provisional diagnosis of neuromuscular disease. Anesthesia was identical, except that a femoral nerve block, necessary to permit a diagnostic muscle biopsy was performed. The perioperative course was uneventful but result of the muscular biopsy was surprising in that central core disease was diagnosed. Although congenital myopathies of all grades and severity exist, they are often mild and underestimated. Patients affected by central core disease are considered susceptible to malignant hyperthermia. Because a high prevalence of myopathic changes is reported in children undergoing clubfoot surgery, anesthesiologists must take precautions including a hightened awareness of these events and a high index of suspicion.

[Ex utero intrapartum technique]

Upper airway obstruction of a neonate constitutes an emergency. The ex utero intrapartum technique (EXIT) is a procedure for safely managing airway obstruction at birth, in which placental support is maintained until the airway is evaluated and secured. The anaesthetist is involved in preventing uterine contractions that impair oxygenation of the foetus and cause placental separation, in providing foetal anaesthesia to help airway manipulations, in maintaining foetal pattern of circulation, in preventing and treating maternal hypotension and in resuscitating the neonate. General anaesthesia with high concentration of inhalational agents is preferred as it provides surgical tocolysis and foetal anaesthesia. Additional uterine relaxation may be obtained using tocolytic drugs like nitroglycerin or beta-adrenergic agonists. During EXIT the foetus is delivered only as far as the shoulders or thorax leaving the cord entirely in utero to maximize the duration of placental support and to minimize heat and water loss. In this position foetal airway is examined and secured, which may involve tracheal intubation, bronchoscopy or tracheostomy. The umbilical cord is divided and the neonate is completely delivered only after the airway has been secured. With EXIT, a potential life-threatening emergency at birth can be managed like an elective procedure that can improve the prognosis for foetuses with airway obstruction.

Quality control of sedation for diagnostic radiological procedures in paediatric patients (waiting for guidelines)

BACKGROUND

The number of children requiring sedation for radiological procedures is increasing. Anaesthesiologists are increasingly involved in giving sedation or general anaesthesia in the rooms of the Radiology Department. This activity is not easy, and can be dangerous. The procedure is often performed on an ambulatory basis, so the child must be alert and discharged rapidly after the procedure.

METHODS

We reviewed the medical charts of 488 patients in order to evaluate the incidence of complications during deep sedation for diagnostic radiological procedures. The patients were sedated with intravenous thiopental or propofol, or with oral chloral hydrate. All the patients were breathing spontaneously and received only supplemental O(2).

RESULTS

We found only a few cases of complications, immediately treated without any recourse to tracheal intubation: respiratory failure with arterial desaturation to 94%, regurgitation, vomiting and persistent cough.

CONCLUSIONS

On the basis of our experience, we believe that deep sedation with endovenous drugs guarantees safety and rapid discharge after the procedure.

EXIT procedure in a twin gestation and review of the literature

Prenatal diagnosis can show masses of the fetal neck, mouth, and face that can potentially cause respiratory distress at birth. To prevent such an emergency, the EXIT (ex utero intrapartum technique) is performed: it is the intrapartum intubation of the fetus at term while still connected to the placenta. The EXIT procedure was first performed in a case of cervical teratoma. Up to now a total of 34 cases are described, mostly cervical teratomas (13 cases), lymphangiomas (7), epignathus (3); babies' outcome has been successful in 25 of them, with one death related to the procedure. Among the reported cases we are aware of only one where EXIT was performed in a twin gestation, in which the normal twin was delivered first. In our case the normal fetus was posterior to the twin with cervical malformation, requiring us to work on the latter while the former was still in the uterus. After having safely secured the airway in twin A, twin B was prompt delivered with excellent general conditions. Our limited experience enlarges the possibility to perform this prenatal procedure even in "nonstandard" conditions, such as a twin gestation, and may prove useful to those who are going to deal with such issues.

[Caudal block in pediatrics]

Caudal block is the single most popular regional anesthetic technique used in infants and children. A review of the literature concerning complications related to this technique reveals that it is safe and it has a low failure rate. Probably the incidence of complications of caudal block is 7/10.000, the lowest of all the central blocks. High success rates in performing caudals in children are achieved after a lower caseload than for other regional anesthetic procedures. The success rate in children under 7 years of age is 99%, but most failures occur in the oldest. Caudal anaesthesia can be used for anything surgical under the umbilicus and is an acceptable alternative to general or spinal anaesthesia in premature and high-risk infants, where a regional anaesthesia alone may be preferable. Caudal morphine has been used successfully for postoperative analgesia in children of all ages, including neonates after open-heart surgery. Possible complications of this technique are: local anesthetics overdose, vascular penetration and intravascular injection of local anesthetics, dural puncture and total spinal anaesthesia, intraosseous injection, infections, meningitis, respiratory depression (when morphine is used). Authors analyze all these complications and the safety rules for their prevention.

[Post-intubation subglottal stenosis in children: risk factors and prevention in pediatric intensive care]

BACKGROUND

Endotracheal intubation (EI) may result in significant injury to the larynx and trachea; subglottic stenosis is the most dangerous consequence of this injury in the pediatric age. It is well known that there are potential risk factors for post-intubation subglottic stenosis, and namely the underlying disease requiring EI, the age and body weight at EI, the duration and number of EI, the absence of sedation and the occurrence of infectious, hypotensive or hypoxic events during the period of EI and the traumatic EI. On the basis of our data an attempt is made to understand which factors are more important in the pathogenesis of this complication and whether post-intubation subglottic stenosis is a preventable complication of EI in children.

METHODS

The clinical records of 32 out of 35 children with post-intubation subglottic stenosis referred to our institution because of this complication in the period 1990-1997 (8 years) have been examined. Three children were excluded from the study because of partial data. Our surgical division is specialized in the diagnosis and the management of pediatric laryngotracheal diseases. The diagnosis was confirmed by videolaryngotracheoscopy under general anesthesia and by computerized tomography or magnetic resonance imaging in 10 children whose tracheal stenosis was critical. The degree of the stenosis was determined according to Cotton's classification.

RESULTS

The analysis of our data confirms that post-intubation subglottic stenosis is a more frequent complication in infants and particularly in low birth weight infants. It occurred after long lasting EI, but after short lasting EI too. Many of the children observed had their trachea intubated several times during their illness and many EI were traumatic. Sedation during EI was only seldom took into account by pediatric intensivists.

CONCLUSIONS

Prevention of post-intubation subglottic stenosis is possible through a better management of the EI and of the child with a tracheal tube. Sedation of intubated children and skill in the EI technique and in the tube size selection are very important. Many intubations can be avoided with a better attention to the tube fixation and to extubation criteria. Some children at high risk for this complication can be identified.

Eight years' experience with foreign-body aspiration in children: what is really important for a timely diagnosis?

BACKGROUND/PURPOSE

Aspiration of foreign bodies remains a major cause of morbidity and mortality in childhood. The aim of this study was to evaluate the predictive diagnostic value of clinical signs and symptoms, the history, and the radiology to perform early diagnosis and therapy.

METHODS

From January 1990 to March 1998, 87 children were admitted to the Pediatric Surgery Department of Universita di Padova because of suspected foreign body aspiration. Sensitivity and specificity of the considered diagnostic tools were evaluated.

RESULTS

Neither clinical signs and symptoms nor radiology have sufficient diagnostic sensitivity, and especially specificity, on which to rely for the diagnosis. Only the choking crisis, when present in the history, has good sensitivity and specificity (respectively, 96% and 76% in this series).

CONCLUSIONS

A choking crisis in the child's history should alert physicians to the possibility of a foreign body aspiration. In the present series, complications always were related to the diagnostic delay.

The usefulness of routine preoperative laboratory tests for one-day surgery in healthy children

Since 1984, laboratory tests have not been routinely required for healthy paediatric patients scheduled for one-day surgery in our Paediatric Surgery Department. We reviewed the medical charts of all children ASA physical status 1 and 2 who underwent a minor surgical procedure in the last 15 years. We excluded all former preterm infants of less than 60 weeks postconceptual age. The series under examination includes two groups of patients: group A includes 1884 children who underwent routine preoperative laboratory tests; group B includes 8772 children who had preoperative, selected laboratory tests performed only when the child's history and/or clinical examination revealed some abnormalities. The following data were collected: demographic data, ASA physical status classification, surgical procedure, anaesthetic technique, major and minor complications, length of hospital stay, the difference between the expected length of hospitalization and the actual length, number and reasons for cancellations of surgery. On the basis of our experience we believe that a thorough clinical assessment of the patient is more important than routine preoperative laboratory screening, which should be required only when justified by real clinical indications. Moreover, this practice eliminates unnecessary costs without compromising the safety and the quality of care.

Hangman's fracture in a paediatric patient: considerations for anaesthesia

Cervical spine injuries are quite uncommon in children. When occurring, these lesions are of particular concern for the anaesthesiologist. This case refers to an hangman's fracture diagnosed in a four-month-old female infant, which probably occurred at birth. We describe the anaesthetic management adopted in this infant undergoing diagnostic procedures and conservative treatment. The problems related to airway control and the anaesthetic management utilized to diagnose and treat this unusual paediatric pathology are highlighted.

Use of the peridural catheter with subcutaneous port in a 13-year-old girl: 120 anesthesia procedures in 31 months

The authors report their experience using a peridural catheter with a subcutaneous port. This was used to obtain 120 peridural anesthesia inductions during a program of surgical debridement in a 13-year-old girl. The authors advocate the use of epidural dexamethasone to treat the ineffective anesthetic injection through a long-lasting catheter.