Pediatric Anesthesia 2006 doi:10.1111/j.1460-9592.2006.02098.

Review article
Pediatric anesthesia – potential risks and their
assessment: part II
B R I T TA S . V O N U N G ER N - S T E R N B E R G MD AND
W A LI D H A B R E M D P h D
Pediatric Anesthesia Unit, Geneva Children’s Hospital, Geneva, Switzerland

Keywords: anesthesia; preoperative assessment; risk factors; compli-

cation; preoperative testing

Ninety percent of diabetic children present with

Metabolism
type 1 diabetes (insulin-dependent), 2–3% with type
Obesity 2 diabetes (noninsulin-dependent) while the rest
Childhood obesity is increasing rapidly and affects have other types e.g. maturity onset diabetes of
up to one third of the pediatric population (1,2). In youth, insulin resistance syndromes, genetic syn-
order to assess the degree of obesity, body mass dromes, pancreatic defects or secondary diabetes
index (BMI) is assessed using age and sex-related (7,8).
reference curves as BMI changes substantially with Anesthesia and surgery result in a typical meta-
age. Obese children have nearly a twofold increase bolic stress response by an increased secretion of
in perioperative adverse events compared with catabolic hormones (cortisol, catecholamines, gluca-
normal-weight children (2). gons, growth hormone) and the inhibition of insulin
BHR, asthma, and respiratory tract infections are secretion (8). Therefore, intensive management of
more common in obese than normal children (3–5) the diabetic child is essential to avoid major fluctu-
Additionally, functional residual capacity and ations in blood glucose levels and electrolyte imbal-
forced vital capacity are reduced in obese children ances.
and the prevalence of OSAS is higher (2,6). Hyper- It is useful to schedule surgery for the child early
tension, noninsulin-dependent diabetes mellitus, in the morning to avoid long fasting periods.
gastroesophageal reflux and potentially delayed Intravenous infusions of dextrose and insulin pro-
gastric emptying times are also more frequent (2). vide stable glycemic control in the perioperative
Appropriate dosing regimes for obese children period (9). Most patients require between 0.01 and
rarely exist and most drugs should be given accord- 0.2 UÆkg)1Æh)1 of insulin and the amount of insulin
ing to lean body weight, which might be difficult to should be adapted to the glucose level of the patient
determine. In the perioperative period, an increased (8). Blood glucose, potassium, and acid-base estima-
risk of respiratory depression and higher prevalence tions should be performed regularly in the periop-
of OSAS should be taken into account and great erative period depending on the severity of surgery
care taken to avoid hypoxemia in this high-risk and the fasting times of the child.
population.
Long-term steroids treatment
Diabetes In spite of the lack of hard evidence, it is widely
The prevalence of diabetes mellitus in the pediatric recommended to administer corticosteroids to pa-
population is increasing together with obesity. tients who receive a long-term oral steroid therapy
(>2 months) at a ‘stress dose’ level before surgery.
Correspondence to: Britta S. von Ungern-Sternberg, Pediatric
Anesthesia Unit, 6, Rue Willy Donzé, CH-1205 Geneva, Switzer- The normal daily endogenous glucocorticoid secre-
land (email: britta.reglivonungern@hcuge.ch). tion is estimated to be 5–10 mgÆm)2 but can increase

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under stress to up to 100 mgÆm)2 day)1. Before disease and consulting a specialist for further treat-
surgery, children having long-term steroid therapy ment is highly advised prior to surgery.
should receive their daily dose orally or parenterally
and an additional ‘stress dose’ should be adapted
Chronic renal failure
dependent on the duration and the severity of
surgery to prevent side-effects of unnecessary large In children with known chronic renal failure, the
doses of steroids (poor wound healing, inadequate preoperative assessment must particularly focus on
glucose control, fluid retention, hypertension, elec- the presence of cardiorespiratory function, hyper-
trolyte imbalance, immunosuppression, etc.) (10). tension, hypo/hypervolemia, electrolyte imbalances
The authors recommend their institutional regimen and/or coagulation disorders (11).
for steroid replacement: for minor surgery (endo-
scopy, punctures, etc.), hydrocortisone 50 mgÆm)2
Congenital syndromes
i.v. is recommended which should be followed by
12.5 mgÆm)2 every 6 h on the day of surgery. For It is out of the scope of this review to discuss the
severe surgical stress, a dose of 100 mgÆm)2 is numerous congenital syndromes found in children.
recommended followed by 25 mgÆm)2 every 6 h on However, the presence of any congenital malforma-
the day of surgery, every 8 h on the first postoper- tion should alert the anesthesiologist, as it is often
ative day and every 12 h on the second postopera- associated with malformations of other organs.
tive day. On the third postoperative day, the usual Particularly important for the anesthesiologist are
treatment dose should be administered. As the the associations of numerous syndromes with car-
adrenal glands may take up to 1 year to recover diac malformations (Table 2).
completely following long-term steroid treatment,
our endocrinologists recommend to substitute until Down’s syndrome – trisomy 21
1 year following the discontinuation of corticoids. Down’s syndrome is the most commonly found
Patients with long-term inhaled steroids do not need chromosome related disorder and is found in
a stress dose before surgery. The equivalent doses of approximately 1 in 650 neonates. It is easily recog-
the different corticosteroids are given in Table 1. nized from the characteristic flat face, protruding
tongue, inner canthal folds, up-slanting palpebral
Other metabolic syndromes fissures, hypotonia and hyperflexible joints. It is also
There are numerous inborn metabolic diseases in associated with mental retardation. More than half
childhood. Some might be recognized following the children present with an associated congenital
newborn screening; some might only present later cardiac malformations (mostly endocardial cushion
in life and then only be detected during an acute defects or ventricular septal defects). Anesthesiolo-
infection or other metabolic stress. For the anesthes- gists should be aware of the difficult airway man-
iologist, therapy is mainly supportive including agement in these children and should be especially
careful control of an adequate water-electrolyte careful with regard to a potential atlantooccipital
balance as well as good blood sugar control. Treat- subluxation.
ment that is more specific depends on the particular
Allergies
Table 1
Steroids and their equivalent doses A thorough history of known medical and environ-
mental allergies should be obtained for all children
Steroid Equivalent dose (mg) Duration of action (h)
and the allergenic agents avoided. Special care must
Cortisol 20 8–12 be taken in children with a latex allergy. The highest
Cortisone 25 8–36
risk for anaphylaxis from latex is found in children
Prednisolone 5 12–36
Prednisone 5 18–36 with spina bifida, urinary tract malformations and a
Methylprednisolone 4 12–36 history of atopy or previous repeated exposures to
Betamethasone 0.75 36–54 latex. Fifty-five percent of children are sensitized
Dexamethasone 0.75 36–54
to latex following an average of 7.7 operations

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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia
 P R E O P E R A T I V E A S S E S S M E N T I N P E D I A T R I C A N ES TH ES IA 3

Table 2 vaccination have not been well studied. Many

Syndromic associations with cardiovascular diseases
countries have routine immunization schemes,
Congenital heart disease which include several vaccinations (mostly poly-
Apert’s syndrome vaccines that differ in their contents between coun-
DiGeorge syndrome
Down Syndrome (trisomy 21)
tries) within the first year of life. Many anesthetic
Edwards’ syndrome (trisomy 18) procedures are performed in this age group without
Goldenhar’s syndrome apparent sequelae. It is probably sensible to post-
Marfan syndrome
pone elective surgery for at least 3 days following a
Meckel’s syndrome
Patau’s syndrome (trisomy 13) vaccination with killed organisms (pertussis vaccine)
Polysplenia or inactivated toxins (tetanus and diphtheria tox-
Rubinstein’s syndrome oids) and 2 weeks following attenuated live organ-
Sebaceous nevi syndrome
TAR syndrome (thrombocytopenia, absent radius syndrome) isms (measles, mumps, rubella, and poliovirus
VACTERL (vertebral, anal, cardiac, tracheal, vaccines) to reduce the coincidence of the peak
esophageal, renal, limb) association systemic reactions to the vaccine with surgery (14).
Williams syndrome
Syndromes associated with cardiomyopathy
Anesthesia, stress and trauma are known suppres-
Duchenne’s muscular dystrophy sors of the immune system. Therefore elective
Farber’s disease surgery should be postponed in the case of an active
Friedreich’s ataxia
disease or following a direct contact with another
Hunter’s syndrome
Hurler’s syndrome child with an active disease (14,15). This measure
Myotonic dystrophy also helps to reduce the number of hospital-acquired
McArdle’s disease infections with children’s diseases.
Stevens–Johnson syndrome
Syndromes associated with arrhythmias or
autonomic dysfunction
Albright’s osteodystrophy
Herbal medicine
Guillain–Barré syndrome
Shy–Drager syndrome
A significant and increasing proportion of the
Wolff–Parkinson–White syndrome pediatric population (approximately 16% in chil-
Syndromes associated with ischemic heart dren presenting for ambulatory surgery) receives or
disease or thromboses
has received herbal preparations (16). For example
Ehlers–Danlos syndrome
Fabry’s disease in Australia, approximately 29% of children with
Grönblad–Stranberg syndrome asthma receive herbal medicine for their condition
Homocystinuria (17). The literature shows several case reports
Tangier disease
Werner’s syndrome highlighting the potential dangers of herbal medi-
cine (18,19). Although there is little possibility of
interaction between conventional and herbal medi-
independent of their underlying diseases (12). Only cines in children (20), the potential for interaction
the strict avoidance of latex-containing products can with anesthesia drugs exists.
help to minimize a child’s risk of latex associated A major concern is that 70% of the patients taking
anaphylaxis, as the often recommended chemo- herbal medications do not report this at the preop-
prophylaxis consisting of H1/H2 receptor antago- erative assessment for a variety of reasons (19,21).
nists is ineffective (13). Many herbal remedies decrease platelet aggregation
(e.g. bilberry, bromelain, dong quoi, feverfew, fish
oil, flax seed oil, garlic, ginger, ginkgo bilboa, grape
Vaccinations and infectious diseases
seed extract) or inhibit clotting (e.g. chamomile,
This discussion refers only to elective cases, which dandelion root, dong quoi, horse chestnut) (21). The
can be postponed without medically adverse events long-term use of echinacea, which is thought to
for the child. Vaccinations can be followed by local reduce the duration and severity of URTI, can result
swelling, pain, fever, headache, rash, malaise, and in immunosuppression that might potentially in-
myalgia, all of which can last between 1 day and crease the risk of wound infection (22). Furthermore,
3 weeks (14). The anesthetic implications of a recent it has the potential for anaphylaxis as well as for

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hepatotoxicity if used in combination with other seen through (e.g. tea, water, apple juice) up to 2 h
hepatotoxic agents (21). Other herbs (e.g. hops, kava before anesthesia neither significantly increases the
kava, passion flower) can potentiate central nervous fluid content of the stomach nor alters the pH of the
system depression in the perioperative period. stomach contents, which would increase the risk of
Ma huang (Ephedra sinica) is used for the treatment aspiration pneumonitis. Furthermore, clear fluids
of a variety of symptoms. This ephedrine-containing help the child to tolerate fasting and also avoids
drug is a cardiovascular stimulant by acting as an perioperative hypoglycemia (27–29). For solids and
alpha and beta adrenergic agonist, a potent broncho- milk, longer fasting periods should be set: 4 h for
dilator and an agent promoted for weight loss breast milk or formula milk in young infants
because it increases the metabolic rate (21). It has (<6 months) and 6 h for solids and milk in older
been associated with numerous fatalities (21). Ephe- infants and children (30–33).
dra can potentially interact with volatile anesthetic
agents and promote arrhythmias. Furthermore, there
Inpatient or outpatient procedure?
can be profound intraoperative hypotension result-
ing from ephedra in patients who have used it on a The decision whether a surgical procedure should be
long-term basis (21). performed on an outpatient or inpatient basis
A report of the World Health Organization Mon- includes several factors: minimally or well-con-
itoring Center with nearly 5000 cases of adverse trolled physiological alterations, a procedure associ-
events associated with herbal medications before ated with a low percentage of surgical or anesthetic
1996 included approximately 100 events in children complications, a short duration of anesthesia and
below10 years (21,23). Furthermore, these adverse easily controlled postoperative pain (34). The large
events are most likely underreported because of no majority of cases in the pediatric population can be
central mechanism for mandatory reporting and easily performed as outpatient surgery (35).
nonrecognition of the association of the adverse Prematurely born infants should reach 60 weeks
event with herbal medication (19). postconceptional age to be eligible for outpatient
As a result, all children and families should be surgery because of the higher rate of postoperative
evaluated for possible intake of herbal medication. apneas, periodic breathing, and/or bradycardia in
Furthermore, patients taking herbal medications are this population (36). Otherwise, they should be
more likely to avoid seeking conventional diagnosis admitted to the hospital and monitored for 24 h
and therapy and rather would use self-medication after anesthesia. A summary of the criteria for
(24). Therefore, special care should be used to detect outpatient procedures is given in Table 3.
an undiagnosed, underlying disorder causing symp-
toms treated with herbal medicine (19,24). As the
What should the minimal clinical
impact of the different herbal medications cannot be
assessment include?
quantified at present, it is recommended by the
American Society of Anesthesiologists to discon- Safety is the prime consideration for each anesthe-
tinue them 2–3 weeks before surgery in spite of the tized child. But what do we really need to know and
fact that withdrawal of conventional medication is
Table 3
associated with increased morbidity and mortality
Selection criteria for day care
after surgery (25,26). Whether this increased mor-
bidity and mortality also occurs following the Peripheral procedures
Not entering a body cavity
discontinuation of herbal medicine is unknown. Limited duration
Minimal/moderate postoperative pain which can be managed
with oral/rectal medication
Fasting times? No major physiologic disturbances
No major blood loss
The purpose of preoperative fasting times is to avoid No postoperative fasting necessary
stomach contents being vomited and aspirated, No expremature babies (<36 weeks and up to 60 weeks
especially during induction of anesthesia. The intake postconceptional age)
Significant (as opposed to mild) OSA
of clear liquids, defined as anything that print can be

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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia
 P R E O P E R A T I V E A S S E S S M E N T I N P E D I A T R I C A N ES TH ES IA 5

do to be safe? The preoperative assessment is an airway examination (congenital or acquired cranio-

evaluation of all issues that are relevant to safe facial deformities) as well as evaluation of the
anesthesia and performance throughout the periop- cardiopulmonary system (37). It is important that
erative period. A detailed medical history and this preoperative assessment precedes the ordering
physical examination by any other health care or performance of specific tests to avoid unnecessary
professional cannot ‘clear a patient for anesthesia’. testing (37).
It can only provide additional, important informa- The timing of the interview and physical exami-
tion to the anesthesiologist to aid a decision whether nation varies considerably between centers. It cer-
a child is fit for anesthesia. tainly depends on the level of surgical invasiveness
The preoperative assessment, where the anesthe- and also on the practice environment and geography
sia team meets the child and family for the first time, of the area and should be adapted to local condi-
often takes place only shortly before surgery. As the tions. We consider it appropriate to see the child as
perioperative period is a very stressful time for most close in time to the surgery as possible, but prefer-
children and families, any additional stress should ably not on the same day. This strategy helps to
be avoided. It is therefore of crucial importance that avoid cancellation of surgery if further tests are
any evaluations, tests and consultations should not required. It is increasingly important, for medicole-
be performed for routine reasons but only if there is gal reasons to see the child and parents more than
a reasonable expectation that they will result in a 24 h before elective surgery to give them sufficient
benefit, such as change in the proceedings, the time to consider different options and potential risks
timing of the anesthesia or perioperative resource involved. However, if a child has been examined
utilization that will improve the safety and effect- some time before surgery, a new, short evaluation of
iveness of an anesthetic procedure. Additionally, the the child’s health must be made on the day of
potential benefits should be carefully weighed surgery to detect any interim changes e.g. a newly
against any potentially adverse effects including developed respiratory tract infection.
interventions that result in injury, discomfort, incon-
venience, delay of surgery or increased costs that are
not commensurate with the anticipated benefits. What additional investigations might be
The preoperative visit offers the anesthesiologist warranted?
an excellent opportunity to interact with the child
Preoperative hemoglobin testing
and family or guardians in order to gain their
confidence while at the same time investigating the In spite of a lack of evidence that routine preoper-
child’s illness and physical limitations. Just by ative blood testing in healthy children is warranted,
observing the child from a distance while talking this practice is still common in some centers. Routine
to the parents, important information can be collec- preoperative blood testing in healthy children
ted, e.g. normal exercise tolerance, cyanosis, brea- reveals approximately 2.5–10% abnormal results
thing difficulties, runny nose or cough, basic but rarely has impact on the scheduled surgery
neurologic development and nutritional status? (38–40). The most commonly found abnormality is
The information obtained from the interview and mild anemia. Although mild anemia is not reliably
the records should start during gestation and detected by history taking and examining the child,
include a description of current diagnoses, treat- it is not associated with an increased perioperative
ments including medications (including over-the- morbidity (39,41,42). Furthermore, the presence of
counter-medications), recent vaccinations, allergies, mild anemia does not change the anesthesia man-
recent laboratory tests and a determination of the agement and is therefore not warranted in most
patient’s past and present medical conditions. Fur- cases. Nevertheless, in children of African origin,
thermore, the family history can be helpful in hemoglobin level testing might be warranted be-
identifying children with a susceptibility to MH, at cause of a higher risk of sickle cell disease and its
a high risk of an atypical pseudocholinesterase, an major implications for perioperative management
unknown bleeding disorder or muscular dystrophy. (43,44). We recommend that the child and family are
The basic physical examination should include an informed of both positive or negative test results and

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6 B .S . V O N U N G ER N - S T E R N B E R G A N D W . H A B R E

we provide them with a card stating the test result factor deficiencies (e.g. factor XI) can be missed but
which helps to reduce repeated unnecessary future would not change management for minor surgery
testing. (57). Thus, normal coagulation values, even in the
As many clinically relevant anomalies can be presence of an insignificant history, do not com-
predicted by careful preoperative assessment (40), pletely rule out a coagulation disorder (51). Not all
routine preoperative laboratory testing for all pa- children exhibiting preoperative abnormalities in
tients regardless of clinical evidence of disease, is not coagulation tests will have bleeding problems in the
indicated in children (38–40,45–48). However, a perioperative period and vice versa (58,59). The
strategy to perform laboratory tests is justified only commonly used prothrombin time only examines
when clinical doubt is present. This approach also the extrinsic coagulation pathway while its sensitiv-
significantly reduces the costs, patient discomfort ity to detect inherited defects is minimal. In contrast,
and even risk, that might derive from a large the partial thromboplastin time examines the intrin-
number of false-positive results (postponing surgery sic pathway and is therefore more useful in detect-
while tests are repeated, further diagnostic assess- ing inherited diseases, although it can be normal
ments are made, or even treatment of the patient even in the presence of disease (59,60).
based on these results) and from false-negative
results that lead to the omission of the usual
Arterial blood gases vs noninvasive methods
measures of caution (38,47).
Preoperative evaluation should not be used for Preoperative arterial blood gases are rarely indicated
routine health-care screening of children because in children. In addition, they are invasive and
follow-up of an abnormal preoperative test result is difficult to perform in an awake child prior to surgery
normally poor and could create medicolegal issues and do not improve the quality of risk assessment or
for the physician (49). risk stratification (61). In contrast with arterial blood
gases, pulse oximetry is a noninvasive, cost-effective,
commonly available method, which gives important
Preoperative coagulation testing
supplemental information on baseline oxygenation
Coagulation studies are often thought to be useful, especially when performed under ambient air con-
especially in children undergoing adenoidectomy ditions. In case of OSAS, an overnight recording
and/or tonsillectomy, despite the clear evidence that might be useful to stratify the risk and the postoper-
preoperative coagulation studies have a very low ative monitoring. Additionally, transcutaneous car-
positive predictive value in detecting occult bleeding bon dioxide measurements or capillary blood gases
disorders or an increased risk for perioperative can be used especially in young infants to further
hemorrhage (50–53). The American Academy of characterize impairment of respiratory function.
Otolarnygology – Head and Neck surgery therefore
recommends screening only for patients with a clear
Further preoperative blood testing
medical indication based on the history or a physical
examination that might indicate potential coagula- Further preoperative blood testing (e.g. for electro-
tion problems (54). lyte imbalance) is only warranted for children with a
While taking a coagulation history of a child, a history suggesting an underlying disease (e.g. renal
history of ‘excessive bruising’ is very subjective and impairment) or who take medication which might
frequently reported in children with and without influence the water/electrolyte balance, renal or
bleeding abnormalities (55). Large bruises, hemato- hepatic function.
mas, simultaneous bruising of several parts of the
body or unusual forms of bleeding (e.g. frequent and
Preoperative urine analysis
prolonged epistaxis, unusual bleeding after minor
trauma) are more suggestive of a clotting disorder The rationale for performing routine urine analysis
than bruising itself (55,56). prior to surgery is the detection and treatment of
Even with a careful history, mild forms of von children with unsuspected renal disease and/or
Willebrand’s disease, mild platelet dysfunction or urinary tract infection. The collection of a clean,

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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia
 P R E O P E R A T I V E A S S E S S M E N T I N P E D I A T R I C A N ES TH ES IA 7

uncontaminated specimen can be very difficult and ation of pulmonary function (e.g. spirometry) (67).
time-consuming to collect from children; a preoper- However, several studies in adults suggest that
ative urine analysis does not add significant infor- clinical identification of preexisting chronic lung
mation to a thorough clinical assessment and can disease is inadequate for the purposes of risk assess-
therefore be omitted in most cases (40). ment. Clinical identification of lung disease was
In contrast, a pregnancy test in teenagers might be thought to be comparable with spirometry to assess
warranted as the incidence of a positive pregnancy the risk of a respiratory adverse event (68,69). Some
test preoperatively varies between 0.5% and 1.3% in asthmatic patients, especially children, are unaware
spite of a negative history. This rate of unknown of significant changes in lung function, and therefore
pregnancies increases to 2.4% in patients 15 years it is unreliable to use their symptoms to assess disease
and older (62). Furthermore, detection of an severity and potential optimization of respiratory
unknown pregnancy has major implications for function (70). In such circumstances, respiratory
anesthesia management and might lead to long-term function tests (e.g. assessing peak flow or forced
cancellation of elective surgery (62,63). The Ameri- expiratory volume in 1 s) are noninvasive, easily
can Society of Anesthesiologists therefore recom- performed and inexpensive tests that can help to
mends offering pregnancy testing to any female quantify the severity of respiratory impairment,
patient of childbearing age (37). detect the response to therapeutic interventions and
In conclusion, any preoperative laboratory testing document the time course of respiratory impairment.
should only be performed in the presence of a In this context, the measurement of maximum expir-
positive finding in the history and/or physical atory flow-volume curves is a valuable clinical test but
examination or if there is a clear need for baseline is limited to children above the age of 5 years, as active
values because of anticipation of significant changes cooperation of the patient is required.
resulting from surgery or other medical intervention Spirometry is particularly useful when there is
(e.g. chemotherapy) (64). uncertainty about the presence of lung impairment,
as this has a profound effect on anesthesia and
provides the opportunity to optimize lung function
Preoperative chest X-ray
preoperatively (61). Although spirometry can en-
In the 1970s, a chest X-ray was a routine preoper- hance the diagnosis of impaired respiratory func-
ative requirement even in children. After several tion, it does not quantify perioperative risk.
studies demonstrated that chest X-rays rarely reveal Spirometry should not be used indiscriminately
clinically important abnormalities which were not but only where its use could provide further infor-
already suggested by a thorough history and phys- mation which would change perioperative manage-
ical examination, the American Academy of Pediat- ment or improve risk stratification (61).
rics now recommends, in order to minimize
radiation exposure in children, no chest X-ray unless
Cardiac evaluation
there is a clear indication that it will have significant
impact on the perioperative period (65,66). A cardiac evaluation is recommended in all patients
Preoperative chest X-rays are, however, important with symptoms suggesting cardiac disease (e.g.
for children who have cervical lymph node biopsies failure to thrive, low exercise tolerance, recurrent
for suspected lymphomas. These children can pre- respiratory tract infection). Furthermore, it should be
sent with no or only few symptoms in spite of an performed in all asymptomatic patients with a
extremely fast growing mass in the anterior medi- clinical assessment indicating the potential for
astinum, which has major implications for anesthe- underlying cardiac disease including all patients
sia management. during or shortly after chemotherapy. An echocar-
diogram is also helpful in identifying any arrhyth-
mias or conduction defects (e.g. prolonged QT
Pulmonary function testing
times).
For some time, studies suggested that it was not Patients with neuromuscular disease (e.g. Duch-
necessary to perform preoperative laboratory evalu- enne’s muscular dystrophy) also have a high

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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia
8 B .S . V O N U N G ER N - S T E R N B E R G A N D W . H A B R E

incidence of cardiac pathology and can present with of perioperative morbidity remains high. Advances
rhythm disturbances, mitral valve prolapse and in this field require targeting anesthesia manage-
ventricular wall hypokinesia. The ECG may show ment to the risks encountered in children. Thus, a
right axis deviation, atrioventricular, or intra- broad knowledge of potential risks is mandatory
ventricular conduction defects. during preoperative assessment before applying the
In conclusion, preoperative assessment is an preventative tools to improve outcome. The anes-
extremely important component for ensuring opti- thesiologist should primarily focus on a detailed
mal preparation of a child prior to surgery; physio- medical history starting from the prenatal period
logically and psychologically. While a major and while talking to the parents observe the child
improvement in pediatric anesthesia mortality has closely before carrying out a systematic physical
been seen during the last two decades, the incidence examination. Table 4 summarizes commonly found

Table 4
Symptoms encountered at the preoperative assessment, their potentially underlying disease as well as a suggestion for the action to be
taken prior to surgery

Symptom Potential underlying disease Action to be taken

Prolonged exhalation Bronchial hyperreactivity Optimize respiratory function before surgery

Chronic nocturnal cough Asthma Optimize treatment
Wheezing or recurrent URTI Beta-2-agonist preoperatively
wheeze with URTI Oral steroids if current wheezing
Passive smoking
Runny nose, cough
Snoring Obstructive sleep apnea syndrome Organize postoperative monitoring for 24 h
Nocturnal apnea Consider cardiac evaluation and/or sleep
Preferred mouth breathing study prior to surgery depending on severity
of symptoms and surgery
Expremature baby Bronchopulmonary dysplasia Optimize respiratory function before surgery
mechanically ventilated after birth Optimize treatment
Beta-2-agonists
Evaluate cardiac function
Assessment of electrolytes if treated with diuretics
Murmur Cardiac malformation Cardiology consult
No change with change in position ECG
>2/6 Echocardiography
Diastolic or pansystolic component Chest X-ray
Children <1 year
Abnormal exercise tolerance
Cyanosis
Differences between upper
and lower limb blood pressures
Enlarged liver
Large bruises, hematomas Coagulation disorder Coagulation studies, possibly hematologic consult
Simulataneous bruising of several
parts of the body
Petechiae
Unusual forms of bleeding
Unexplained epistaxis
Enlarged liver and/or spleen Metabolic disease Consult specialist for interdisciplinary
Neurologic deficits perioperative care if necessary
Several pervious operations Latex allergy Latex free environment
Spina bifida
Urinary malformations Latex allergy Latex free environment

Death in family during anesthesia Malignant hyperthermia Trigger-free anesthesia

Prolonged mechanical ventilation in family Pseudocholinesterase deficiency No succinylcholine

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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia
 P R E O P E R A T I V E A S S E S S M E N T I N P E D I A T R I C A N ES TH ES IA 9

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Following a thorough assessment, tests should only 15 Salo M. Effects of anaesthesia and surgery on the immune
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cussed in an interdisciplinary forum to minimize presurgical patients. Anesthesiology 2000; 93: 148–151.
perioperative adverse events. 19 Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and peri-
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20 Davis MP, Darden PM. Use of complementary and alternative
Acknowledgements medicine by children in the United States. Arch Pediatr Adolesc
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The authors thank J. Etlinger BA, for editorial 21 Kaye AD, Clarke RC, Sabar R. Perioperative anesthesia clinical
considerations of alternative medicines. Anesthesiol Clin North
assistance and Thierry Girard MD, Department of America 2004; 22: 125–139.
Anesthesia, University of Basel, Switzerland for his 22 Boullata JI, Nace AM. Safety issues with herbal medicine.
help with the malignant hyperthermia section of the Pharmacotherapy 2000; 20: 257–269.
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Journal compilation Ó 2006 Blackwell Publishing Ltd, Pediatric Anesthesia