Sie sind auf Seite 1von 86

Perioperative Management of

the Pediatric Patient


Moises Auron MD, FAAP FACP
Assistant Professor of Medicine
Hospital Medicine

10/15/09 1
Disclosure Statement
• The author has no relevant financial
interest or other relationship with the
manufacturer(s) of any commercial
product(s) and/or provider(s) of
commercial services that are discussed
in this educational activity.

10/15/09 2
Outline
• Goals of pre-operative assessment
• Anesthesia associated risk
• General pre-operative management
• Pulmonary issues
• Cardiac issues
• Brief review of cardiac risk assessment and management in non-
cardiac surgery – adult guidelines
• Morbid obesity
• Neurologic issues and Epilepsy
• Musculoskeletal and craniofacial issues
• SCD
• Perioperative Management of Diabetes
• Perioperative VTE Prophylaxis
• Psychological preparation for surgery

10/15/09 3
Goal of preoperative assessment
• Detection of unrecognized conditions that
increase the risk of surgery.
• Optimize the patient’s current medical
problems and anticipate potential
complications.
– Anticipate pulmonary edema post-T/A
– OSA
– Monitor for atlantoaxial instability (Down’s)

10/15/09 4
Model of Plane Flight

PATIENT
Surgeon = Pilot Anesthesia = Co-Pilot

10/15/09 Michota F. Jaffer A. CCJM. 2006 5


10/15/09 Anesth Analg 2004;99:1058-69. 6
What is different in Pediatrics
• Age - > 70 y/o – robust indicator for post-
operative pulmonary morbidity
• Exercise capacity – unclear in infants and
toddlers
– Climb 1 flight of stairs = 4 mets = low CV risk
• Medication use
• Risk for venous thromboembolism

10/15/09 7
General perioperative concerns in
Pediatrics.
• Congenital heart disease
– Hypoxia, arrhythmias, and cardiovascular instability paradoxical
air emboli
• Prematurity
– Postoperative apnea
• Gastrointestinal reflux
– Aspiration pneumonia
• URI
– Laryngospasm, bronchospasm, hypoxia, and pneumonia
• Craniofacial abnormality
– Difficult airway

10/15/09 Childs Nerv Syst (2006) 22:834–843 8


Patient related risk Procedure related risk

Perioperative risk

Anesthetic-related risk Provider-related risk

10/15/09
Michota F, Frost S; Med Clin N Am 2002. 9
Role of the surgeon
• Surgeons are typically consulted for
evaluation and treatment of:
– healthy child who is undergoing elective
surgery
– the chronically ill child who requires surgery
– the acutely ill on injured child who requires
emergent surgery.

Pediatrics 1996;98;502-508.
10/15/09 10
Role of the anesthesiologist
• Anesthesia may begin outside the OR with
the administration of preoperative
medication.
• Patient follow up until D/C from the PACU
– Except if regional analgesia or spinal block
are used

Pediatrics 1996;98;502-508.
10/15/09 11
Anesthesia-associated risk
• Risk for adverse events continues to be higher in
infants and young children
• Overall mortality rate was 0.9/10,000 anesthetics
• Incidence of cardiac arrest of 1.7/10,000
– Adult (1.4/10,000).
– Children < 12 y/o (4.7/10,000) – 3x
– Complications of airway management (laryngospasm,
difficult intubation, and pulmonary aspiration of gastric
contents)
– Halothane (hypotension, arrhythmia, or both).

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43. 12


Anesthesia-associated risk
• Greater risk occurs in infants < 4 wk old.
– More likely to be having major surgery (intrathoracic or
intraabdominal)
– Have more serious underlying disease
– Increased percentage are (ASA) physical status 3–5.
– Reduction in respiratory-related events compared with
previous studies was believed to be because of improved
detection of impending respiratory events caused by
oximetry and capnography.
– Associated with emergency surgery, halothane or
sevoflurane, caudal injection of bupivacaine/epinephrine

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 13


ASA Classification
• Class 1 A normally healthy patient
• Class 2 A patient with mild systemic disease
• Class 3 A patient with severe systemic disease
that is not incapacitating
• Class 4 A patient with an incapacitating
systemic disease that is a constant
threat to life
• Class 5 A moribund patient who is not
expected to survive for 24 h with or
without operation
Anesthesiology 1963; 24: 111.
10/15/09 Pediatric Anesthesia 2007 17: 216–222. 14
ASA Classification in Pediatrics

Pediatric Anesthesia 2007 17: 216–222.


10/15/09 15
Preoperative Evaluation
• HPI
• PMH
– Croup
– OSA
– Cervical instability (Down’s)
• Medications – NSAID’s
• Allergies – Latex (spina bifida)

Pediatrics 1996;98;502-508.
10/15/09 16
Pre-operative evaluation
• Family history
– Anesthetic-related complications
• malignant hyperthermia
• prolonged paralysis after anesthesia
(pseudocholinesterase deficiency)
– Bleeding disorders
– Muscular dystrophy
– Drug use (aminoglycosides)

Pediatrics 1996;98;502-508.
10/15/09 17
Pre-operative evaluation
• Last meal intake
• Physical examination
– Hydration status

Pediatrics 1996;98;502-508.
10/15/09 18
Ancillary testing
• Hb - when significant anemia (<9 g/L) is
suspected
– (eg, infants, growing premature infants, and
patients with chronic illnesses)
– to establish a reference point in anticipation to
significant blood loss (Orthopedic surgery).
• Pregnancy testing

Pediatrics 1996;98;502-508.
10/15/09 19
Ancillary testing
• Coagulation profile
– history or medical condition suggests a possible hemostatic defect:
• large bruises and hematomas
• simultaneous bruising on several parts of the body
• Hematochezia
• frequent and prolonged epistaxis
• Hemarthrosis
• unusual bleeding after minor trauma (including dental extraction)
– Recent ingestion of aspirin or NSAIDS.
– Cardiopulmonary bypass – induction of hemostatic disorder by platelet
activation and consumption
– Tonsillectomy; airway surgery
– Neurosurgical patients (craniotomy)

• Minor surgery and a negative history: no tests are suggested.

Pediatrics 1996;98;502-508.
10/15/09 20
Fasting guidelines
• 8-6-4-2
• 8 hours solids
• 6 hours formula
• 4 hours breast milk
• 2 hours clear liquids

Anesthesiology. 1999;90(3):896-905
Acta Anaesthesiol Scand 2005;49:1041-1047.
Best Practice & Research Clinical Anaesthesiology. 2006; 20(3):471-
10/15/09 81. 21
Pulmonary issues
• URI – defer surgery until symptoms resolve
– Increased risk of bronchospasm
– Decreased 50% with use of Laryngeal Mask Airway
• Asthma – should be optimally controlled
– Continue bronchodilators and oral meds in AM of
surgery
– Delay surgery 6 wk after asthma attack (FEV1
remains low x 6 wk).
– Prednisone 1 mg/kg 24-48 h pre-operatively and in
the AM of surgery.
Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43
10/15/09 22
Pediatrics 1996;98;502-508.
Pulmonary issues
• FEV1/FVC -useful predictors of the need for
postoperative mechanical ventilation among
patients at risk (eg, cystic fibrosis, severe
scoliosis, or kyphoscoliosis).
• Adults - increased incidence of need for
postoperative mechanical ventilation:
– FEV1/FVC < 50%
– FEV1 < 35% predicted
– Absolute FVC < 25 mL/kg
10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 23
Pulmonary issues
• Cystic fibrosis – continue pulmonary
toilet, optimize nutritional status, continue
home meds (inhaled and systemic
antibiotics, dornase alpha, acetylcysteine,
bronchodilators).

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 24


Pulmonary issues
• Obstructive Sleep apnea
– Adenotonsillar hyperthrophy, obesity, Prader Willi,
Down’s
– Pulmonary HTN and Cor Pulmonale
– Greatest risk of post-op upper airway obstruction
• Tissue edema
• Secretions
• Sedation (narcotics)
• Pulmonary edema
– Best practice: 24 h observation in PICU

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 25


Pulmonary issues
• Prematurity and apnea
– Decreased risk with spinal anesthesia
– Preoperative use of caffeine
– Admit and monitor with SpO2.

Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43


10/15/09 26
Former Preterm  Risk for
Postoperative apnea
• Bronchopulmonary dysplasia
• Chronic hypoxemia and hypercarbia
• Tracheomalacia; bronchomalacia
• Pulmonary hypertension; Cor pulmonale
• Risk factors:
– Anemia (Hct <30%)
– Apnea at home
– Gestational age (<30 wk)
– LBW (< 1.5 kg)
– Lower weight at time of surgery
– Complicated NICU course

Murphy JJ. J Pediatr Surg. 2008. May;43(5):865-8


10/15/09 27
Post-operative atelectasis
• Impaired surfactant
• Increased gas reabsorption
• Extrinsic compression
• Favored by:
• General anesthesia
• Recumbent position – decrease FRC 0.5 – 1.0 L
• High FiO2
• Surgery close to the diaphragm

Anesthesiology 2005; 102:838–54


10/15/09 28
Curr Opin Anaesthesiol. 2007;20:37–42.
Post-operative atelectasis

Anesthesiology 2005; 102:838–54


10/15/09 29
Curr Opin Anaesthesiol. 2007;20:37–42.
Age and atelectasis
• Children age 1–3 years  atelectasis
develop more readily than in adults.
• Increased thoracic rib cage compliance 
less outward recoil of the chest wall 
less distending force on the lung.
• High closing volume (the lung volume at
which small airways begin to close)
Anesthesiology 2005; 102:838–54

10/15/09 Curr Opin Anaesthesiol. 2007;20:37–42. 30


Physiologic consequences of
atelectasis
• Decreased compliance
• Hypoxemia
• Increased pulmonary vascular resistance
• Lung injury (repetitive opening and closure of small airways).

Anesthesiology 2005; 102:838–54


10/15/09 Curr Opin Anaesthesiol. 2007;20:37–42. 31
N = 100 postop cardiac surgery patients

10/15/09 Chest 1995; 107:81-84 32


Tonsillectomy: special
considerations
• Risk for post-operative obstructive apnea
• Risk for post-obstructive pulmonary
edema
• Increased risk of bleeding – use of post-
operative NSAIDS is controversial as it is
associated with increased re-operation.

Anesth Analg 2003;96:68 –77.


10/15/09 33
Child with cardiac murmur
• Innocent murmur
• Pathologic murmur
• New Endocarditis prophylaxis guidelines
• Cardiology evaluation and f/u for a child
with complex congenital heart disease.

Pediatrics 1996;98;502-508.
Current Opinion in Anaesthesiology 2007, 20:216–220
10/15/09 34
Hypoplastic Left Heart Syndrome
and Non-cardiac surgery

10/15/09 J Pediatr Surg. 2002;37:1399-1403. 35


Prophylaxis against bacterial
endocarditis
CLASS IIa
• Prophylaxis against infective endocarditis is reasonable
for the following patients at highest risk for adverse
outcomes from infective endocarditis who undergo
dental procedures that involve manipulation of either
gingival tissue or the periapical region of teeth or
perforation of the oral mucosa:
• Patients with prosthetic cardiac valves or prosthetic
material used for cardiac valve repair. (Level of
Evidence: B)
• Patients with previous infective endocarditis. (Level of
Evidence: B)
• Patients with CHD. (Level of Evidence: B)
Circulation. 2008;118:887-896.
10/15/09 36
Prophylaxis against bacterial
endocarditis
CLASS IIa
• Unrepaired cyanotic CHD, including palliative shunts and
conduits. (Level of Evidence: B)
• Completely repaired congenital heart defect repaired
with prosthetic material or device, whether placed by
surgery or by catheter intervention, during the first 6
months after the procedure. (Level of Evidence: B)
• Repaired CHD with residual defects at the site or
adjacent to the site of a prosthetic patch or
• prosthetic device (both of which inhibit
endothelialization). (Level of Evidence: B)
• Cardiac transplant recipients with valve regurgitation due
to a structurally abnormal valve. (Level of Evidence: C)
Circulation. 2008;118:887-896.
10/15/09 37
Prophylaxis against bacterial
endocarditis
CLASS III
• Prophylaxis against infective endocarditis
is not recommended for nondental
procedures:
– transesophageal echocardiogram, EGD,
or colonoscopy) in the absence of active
infection. (Level of Evidence: B)

Circulation. 2008;118:887-896.
10/15/09 38
Antibiotic dose for BE prophylaxis
SINGLE DOSE 30-60 MIN BEFORE
• Amoxicillin p.o. 50 mg/kg
• Ampicillin 50 mg/kg IM/IV or Cefazolin or
ceftriaxone 50 mg/kg IM/IV
• Allergic to penicillins:
– Cephalexin p.o. 50 mg/kg
– Clindamycin 20 mg/kg
– Azithromycin or clarithromycin 15 mg/kg
– Cefazolin or ceftriaxone - 50 mg/kg IM/IV
– Clindamycin 20 mg/kg IM or IV

Circulation. 2008;118:887-896.
10/15/09 39
10/15/09 40
10/15/09 41
10/15/09 42
10/15/09 43
10/15/09 44
Morbid Obese patient
• Overweight: BMI > 85%le
• Obesity: BMI of more than 95%le
• Superobesity: BMI > 99 %le
• Adolescent/Adult: BMI > 40 kg/m2

Current Opinion in Anaesthesiology 2008;21:308–312.

10/15/09 45
Morbid obesity: medical etiology
• Prader–Willi syndrome
• Laurence–Moon–Biedl syndrome
• Hypercaloric diet (glycogen storage
diseases)
• Steroid induced (Hem-Onc, nephrotic
syndrome)
• Poor mobility (late stage Duchenne’s)
Current Opinion in Anaesthesiology 2008;21:308–312.

10/15/09 46
Prader Willi Syndrome

Pediatric Anesthesia 2006 16: 712–722


10/15/09 47
Morbid obesity: perioperative
considerations
• Hypertension and LVH
• Obstructive sleep apnea / hypoventilation
• Diabetes / insulin resistance
• GERD
• NAFLD / NASH

Current Opinion in Anaesthesiology 2008;21:308–312.

10/15/09 48
Morbid obesity: Pediatric
perioperative considerations
• Slipped capital femoral epiphysis
• Blount’s disease
• Cholelithiasis
• Polycystic ovary syndrome
• Idiopathic intracranial hypertension
(pseudotumour cerebri)

Current Opinion in Anaesthesiology 2008;21:308–312.

10/15/09 49
Morbid obesity: Pre-operative
examination in children
• History:
– symptoms of sleep apnea
– tolerance to exercise: breathlessness, asthma;
– recent weight loss or gain
– medications, including OTC herbs or special mixtures taken to
lose weight which can interfere with anaesthesia or
haemostasis.
• e.g. garlic, ginger, etc.
• Document BMI in percentile chart.
• Pulse-oximetry (SpO2) on room air / Nocturnal SpO2
• Fasting blood glucose
• Echocardiography (Hypertensive patient)
• Preoperative fasting – similar rules as the nonobese population.
• GERD: usual anti-reflux therapy should be administered.
Current Opinion in Anaesthesiology 2008;21:308–312.

10/15/09 50
Elective surgery in morbid obesity:
2009 AHA guidelines

10/15/09 51
Circulation. 2009;120:86-95.
Neural tube defects
• Assessment for coexistent congenital anomalies
• 90% require CSF diversion
• Subsequent surgeries:
– Infection
– Malfunction
– Outgrowing the shunt hardware
• Associated urogenital and musculoskeletal dysfunction
– UTI/VUR/hydronephrosis  renal function evaluation
– Scoliosis  respiratory function evaluation
– Lower-extremity abnormalities
• Latex allergy

Pediatrics 1996;98;502-508.
10/15/09 52
Neuromuscular disorders
• Inhalational agents: cerebral vasodilation  increase ICP
• Ensure patency and proper functioning of CSF shunt
• Immediate postop period  Impaired airway reflexes
– Document pre-operatively any evidence of brainstem dysfunction
(eg, vocal cord paralysis, swallowing dysfunction, or aspiration)
• Increased risk for postoperative weakness  postoperative
respiratory care and prolonged mechanical ventilation / PP.
• Succinylcholine  Hyperkalemia; malignant hyperthermia

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 53


Epilepsy
• Record type and frequency of seizures
• Continue antiepileptic medications on the AM of
surgery
• Uncontrolled seizures  Neurology evaluation.
• Check serum levels of anticonvulsant
• Most anticonvulsants have long half-lives, and
the omission of one dose does not decrease the
blood level significantly.
• No need to determine anticonvulsant levels if:
– seizure-free for 2 years
– no adjustment of their anticonvulsant dose
Pediatrics 1996;98;502-508.
10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 54
Epilepsy: perioperative considerations
• Tuberous sclerosis
– cardiac rhabodomyomas: obstruction, dysrhythmias
– Renal lesions  HTN, CKD
• Traditional antiepileptics: P-450 inducers
• Topiramate  NAG metabolic acidosis
• Sodium valproate  platelet abnormalities, bleeding
• Sodium valproate and Felbamate  liver failure
• Ketogenic diet  avoid lactated Ringers solution
• Sevoflurane  Epileptogenic potential
Childs Nerv Syst. 2006;22:834–843.
J Anesth. 2006;20:135–137.
Paediatric Anaesthesia 2002;12:700–704.
10/15/09 55
Phakomatoses: extra-CNS findings
• Linear nevus sebaceous of Jadassohn
– Aortic coarctation, PDA, VSD
• Neurofibromatosis
– Pheochromocytoma – 5%
– Kyphoscoliosis (type 1)
• Sturge Weber
– Aortic coarctation
• Von Hippel Lindau
– Pheocromocytoma – 10%
– RCC – 25%

10/15/09
Paediatric Anaesthesia 2000;10:121–128 56
Cervical spine instability
• Mucopolysaccharidoses (Hurler’s and Monquio’s
syndromes): odontoid hypoplasia
• Rheumatoid arthritis: atlantoaxial instability,
subaxial instability, and superior migration of the
odontoid process.
• Down syndrome: 15% asymptomatic atlantoaxial
instability
• Document pre-operative screening flexion-
extension Cervical spine Roentgenograms
• Consider fiberoptic intubation.
Pediatrics 1996;98;502-508.
10/15/09 57
Craniosynostosis
• Multidisciplinary evaluation by a craniofacial team
• Monitor for signs of increased intracranial pressure
• Nonsyndromic craniosynostosis are usually otherwise
healthy.
• Syndromic craniosynostosis can have associated
anomalies:
– Crouzon’s or Apert’s syndrome can have very abnormal airway
anatomy  fiberoptic intubation.
• Identifying a history of OSA
• Apert’s syndrome  congenital cardiac defects.

Am J Med Gen. 2005; 45(6):758 - 760.


10/15/09 Anesthesiology Clin. 2007;25:465–481 58
Sickle cell patients
• Heterozygous sickle cell trait  generally
asymptomatic
• Active sickling conditions (SS, SC, S-β
thalassemia)
– reduce risk of complications by preoperative
transfusions to reduce the total HbS level < 40%.
• Coordination among the pediatrician,
hematologist, anesthesiologist, and surgeon is
essential.

10/15/09 Fu T. Pediatr Blood Cancer 2005;45:43–47. 59


Marchant WA. Paediatric Anaesthesia 2003;13:473–489
Systemic manifestations of SCD

10/15/09 Fu T. Pediatr Blood Cancer 2005;45:43–47. 60


Marchant WA. Paediatric Anaesthesia 2003;13:473–489
Perioperative management of SCD
• Avoid dehydration – impaired renal concentrating ability.
• Deoxygenation – incentive spirometry; SpO2 monitoring
• Vascular stasis – maintaining a normal C.O., a normal
blood volume, and BP.
• Hypothermia – keeping the patient warm
• Acidosis – good hydration, warm
• Infection – prophylactic antibiotics
• Adequate analgesia, to enable effective physiotherapy
and early ambulation must be emphasized.

10/15/09 61
Regional anesthesia and SCD
• Redistribution of blood flow may lead to an increase in
capillary and venous oxygen tension in the blocked
region
• Compensatory vasoconstriction in nonblocked areas
leads to a fall in the SvO2.
• Lack of control of ventilation, regional hypoperfusion and
venous stasis.
• Cooperative Study of Sickle Cell Disease (N=3765)
– 10 y.
– 1079 surgeries (N= 717)
– Post-op SCD-related complications (painful crisis, ACS, and
CVA) were more frequent in patients who received regional
anaesthesia (P=0.058).

Koshy M, et al. Blood 1995; 86: 3676–3684.


10/15/09 62
Marchant WA. Paediatric Anaesthesia 2003;13:473–489
Transfusion in SCD with General
Anesthesia

Conclusions.
“Minor or low-risk elective surgical procedures
in children with Hb SS may not routinely
require pre-operative transfusion”

10/15/09 Fu T. Pediatr Blood Cancer 2005;45:43–47 63


Adenotonsillectomy and SCD
• Postop. pain, hypoventilation, atelectasis,
hypoxia.
– Aggressive pulmonary toilet, NIPPV,
bronchodilators and incentive spirometry
– HbS < 40%.
– Preoperative Transfusion in Sickle Cell
Disease Study Group (N=118)  no
advantage in aggressive transfusion regimen
vs. conservative regime.
Marchant WA. Paediatric Anaesthesia 2003;13:473–489
10/15/09 Waldron P. J Ped Hematol Onc 1999; 21:129–135. 64
Cholecystectomy and SCD
• Laparoscopic approach is preferred
• Avoid emergency surgery
– high morbidity
• Conservative pre-operative transfusion
– National Preoperative Transfusion Study (N=364)
– Aggressive: preop Hb 10 g/dL and HbS< 30%
– Conservative: Hb 10 g/dL independent of HbS.
• No difference between groups.
Marchant WA. Paediatric Anaesthesia. 2003;13:473–489.
10/15/09 Haberkern CM. Blood. 1997;89(5):1533-1542. 65
Orthopedic Surgery and SCD
• Aseptic necrosis of the hip occurs in up to
50% of patients.
• Conservative preoperative transfusion –
Hb (9-11 g/dL).
• Careful use of tourniquet - stasis, hypoxia
and acidosis beneath and distal to the
tourniquet cuff  favors red cell sickling.

Marchant WA. Paediatric Anaesthesia. 2003;13:473–489


10/15/09 66
Neurosurgery and SCD
• Keep Hct > 30 and HbS < 30%
– Minimize risk of stroke
• Careful use of hypertonic agents
– Urea – preferred
– Old contrast media
• Careful use of Epsilon-Aminocaproic Acid
– Generally used in spinal surgery
– Can predispose to vaso-occlusive crises
• Avoid hypothermia
10/15/09 Marchant WA. Paediatric Anaesthesia. 2003;13:473–489 67
Cardiac Surgery and SCD
• Open-heart surgery with hypothermic
cardiopulmonary bypass precipitate sickling.
• Preoperative correction of anemia
• Pre-operative exchange transfusion
– Increase in 2,3-DPG  increase DO2
• Avoidance of hypoxia and acidosis
• Avoidance of aortic cross-clamping,
hypothermia, cardioplegia and topical cooling
10/15/09 Marchant WA. Paediatric Anaesthesia. 2003;13:473–489 68
Patients on chronic steroids
• Perioperative stress dose of steroids
• Prednisone p.o. 2.5–5 mg/m2 BSA the
night before
• Hydrocortisone 50 mg/m2 before
anesthetic induction

10/15/09 Maxwell LG. Anesthesiology Clin N Am. 2004;22:27-43 69


Diabetes mellitus
• Acceptable metabolic control:
– No ketonuria
– Normal serum electrolytes
– HbA1c within target range for age:
• < 5 years: 7 – 9%
• 5 – 13 years: 6 – 8.5%
• > 13 years: 6 – 8%

Rhodes ET. Anesth Analg 2005;101:986 –99


10/15/09 70
Insulin half life

Rhodes ET. Anesth Analg 2005;101:986 –99


10/15/09 71
Insulin correction factor

Rhodes ET. Anesth Analg 2005;101:986 –99


10/15/09 72
Mixed insulin regime (NPH/Lente)

No

10/15/09 73
Rhodes ET. Anesth Analg 2005;101:986 –99
Lantus insulin regime
No

Yes

No

10/15/09 74
Rhodes ET. Anesth Analg 2005;101:986 –99
Insulin pump – for surgery < 2h

No

Rhodes ET. Anesth Analg 2005;101:986 –99


10/15/09 75
Insulin pump  Surgery > 2h

No

10/15/09 Rhodes ET. Anesth Analg 2005;101:986 –99


76
Oral hypoglycemic agents
• Hold on the morning of surgery

No

10/15/09 77
Rhodes ET. Anesth Analg 2005;101:986 –99
Post-operative DM management

No

Yes

10/15/09 Rhodes ET. Anesth Analg 2005;101:986 –99 78


10/15/09 Pediatric Anesthesia 2008 18: 478–487 79
Perioperative VTE prophylaxis

10/15/09 Pediatric Anesthesia 2008 18: 478–487 80


Perioperative VTE prophylaxis

10/15/09 Pediatric Anesthesia 2008 18: 478–487 81


VTE risk of Surgery

10/15/09 Pediatric Anesthesia 2008 18: 478–487 82


VTE Risk in the ICU

10/15/09 Pediatric Anesthesia 2008 18: 478–487 83


• Child 1–2 months – 750 ug/kg s.q. bid.
• Child 2 months–18 years – 500 ug/kg s.q.
bid.
– Maximum dose 20 mg s.q. bid.
• Adolescents of >40 kg weight
– Adult dosing of 40 mg qday

Pediatric Anesthesia 2008;18: 478–487


10/15/09 84
Psychological preparation of the
children for surgery
• 50-75% of patients develop significant
anxiety

10/15/09 Anesthesiology Clin N Am. 2005;23: 597- 614 85


Thank you!

10/15/09 86