Surgery is a stressful event for everyone, and even more so for children who may not understand the reason for their surgery. A well-designed anesthetic plan is necessary to allow for safe and effective surgery and also to reduce the amount of stress children and their families face at the time of surgery.

The goals of the anesthesiologist are given below.

A. Allay Fears Early

Preparation for school-age children should start 5 to 7 days in advance to be effective. Besides discussing the risks and benefits of a certain procedure with the parents (and the patient if age is appropriate), it is usually helpful to describe to the family what to expect when they arrive at the hospital. Printed materials with instructions and a description of the perioperative process are frequently given to parents in the surgeon’s office (see an example of our brochure which attempts to explain some of the common questions asked about anesthesia in a child; Fig. 27-1). Some hospitals give tours for prospective patients and their families where they can see the check-in area, surgical holding area, recovery room, and pediatric ward or intensive care unit (ICU) if admission is planned. Other hospitals may have online videos to view for those patients who live far away or have difficulty getting to the hospital for a tour (see our example at http://www.amc.edu/patient/services/anesthesiology/videos/preop_screening_ video.cfm). Extensive preparation may be less helpful in children younger than 3 years or those who were hospitalized previously.

B. Who Needs to Be Prescreened?

Not every child has to be evaluated by an anesthesiologist in a formal prescreening clinic. For the majority of healthy patients, a phone interview several days before surgery may be sufficient. Patients with systemic diseases, syndromes, and/or a history of problems with anesthesia should be referred to a more formal prescreening process. The goal of preoperative evaluation is to collect all necessary information before the patient arrives at the hospital and to thereby avoid surprises and possible delays or cancellations on the day of surgery.

Upper respiratory infection is frequent in young children scheduled for surgery in a cold season. It is associated with a higher incidence


of respiratory complications (laryngospasm, bronchospasm) after general anesthesia. If the child is febrile, has a productive cough, or lower airway involvement (active wheezing or rales that do not clear with coughing), then it is prudent to delay surgery until the illness is over, ideally for six weeks.

C. ASA Classification of Physical Status (by the American Society of Anesthesiologists)

1. Class 1: There is no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which the operation is to be performed is localized and is not a systemic disturbance.

2. Class 2: Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes.

3. Class 3: Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality.

4. Class 4: Indicative of the subject with a severe systemic disorder already life threatening, not always correctable by the operative procedure.

5. Class 5: The moribund subject who has little chance of survival but is submitted to an operation in desperation.

D. Common Syndromes with Specific Implications for Anesthetic Management (Not Meant to Be an All-Inclusive List)

1. Beckwith-Wiedemann syndrome: Difficult airway, neonatal hypoglycemia.

2. Down syndrome (trisomy 21): Difficult airway, sleep apnea, atlantoaxial instability, congenital heart disease.

3. Goldenhar syndrome: Difficult airway, congenital heart disease.

4. Hemolytic uremic syndrome (HUS): Renal failure, hepatic dysfunction, seizures, coagulopathy.

5. Pierre Robin syndrome: Difficult airway, congenital heart disease.

6. Prune belly syndrome: Difficult airway, congenital heart disease.

7. VATER (or VACTERL) syndrome: Congenital heart disease, gastrointestinal (GI) atresias, tracheoesophageal fistula, renal issues.

E. NPO Guidelines

Fasting prior to surgery is necessary to ensure an empty stomach and to minimize the risk of aspiration during induction of anesthesia when protective airway reflexes are lost.

The American Society of Anesthesiologists recommends the following fasting times for healthy patients without delayed gastric emptying.