Anesthesiology Clin N Am 22 (2004) 27 43

Age-associated issues in preoperative evaluation, testing, and planning: pediatrics

Lynne G. Maxwell, MD, FAAP
Department of Anesthesiology and Critical Care, Childrens Hospital of Philadelphia, Room 9329, 3400 Civic Center Blvd., Philadelphia, PA 19104, USA

Preoperative assessment and preparation of infants, children, and adolescents differs from management of adult patients in many respects. The purpose of this study is to highlight recent changes in pediatric perioperative practice, emphasizing those areas that differ substantially from adult practice. Although awareness of these issues is of importance to anesthesiologists, it is also essential to disseminate this information to providers of primary care to children, who are increasingly being called on to perform preoperative assessment and preparation.

Preoperative assessment and preparation Assessing risk of anesthesia in infants and children Although anesthesia-related morbidity and mortality has declined steadily over the past 3 decades, risk for adverse events continues to be higher in infants and young children compared with older children and adults. Between 1978 and 1982, anesthesia mortality for French children less than 15 years of age was 1 in 40,000 [1]. The incidence of anesthetic complications was 0.7/1000; cardiac arrest occurred in 12 of 40,000 patients but resulted in only one death. The incidence of complications was much higher in infants less than 1 year (4.3/1000). In a study reviewing the experience in an American hospital from 1969 to 1983, the overall mortality rate was 0.9/10,000 anesthetics with an incidence of cardiac arrest of 1.7/10,000 [2]. In this study, children less than 12 years of age had a threefold higher incidence of cardiac arrest (4.7/10,000) when compared with adult patients (1.4/10,000). Complications leading to cardiac arrest in these studies were caused by complications of airway management (laryngospasm, difficult intubation, and pulmonary aspiration of gastric contents), or were related to the effects of high halothane concentrations (hypotension, arrhythmia, or both).

E-mail address: Maxwell@email.chop.edu 0889-8537/04/$ see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0889-8537(03)00110-X

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Infants less than 1 month had the greatest risk for serious intraoperative complications (cardiac arrest) and the highest perioperative death rates. This may be because infants of this age are more likely to be having major surgery (intrathoracic or intraabdominal) than are older children, and have more serious underlying disease; a greater percentage are American Society of Anesthesiologists (ASA) physical status 3 5. Data published from the more recent closed anesthesia malpractice claims study revealed that complications in pediatric cases were related to respiratory events with a greater frequency than adult cases (43% versus 30%), and the mortality rate was greater in the affected children (50% versus 35%) [3]. The findings of the ongoing pediatric perioperative cardiac arrest (POCA) registry were most recently reported in 2000 [4]. The incidence of anesthesia-related cardiac arrest was similar to previous studies, 1.4/10000, but the etiology was cardiovascular rather than respiratory in origin in a greater proportion than in previous studies (32% versus 20%). 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. Many of the cardiovascular event cases involved halothane, but two physical status (PS) 3 patients arrested during induction with sevoflurane. Twenty-seven percent of arrests were medication related including four that occurred during caudal injection of bupivacaine with epinephrine. Infants younger than 1 year of age accounted for 55% of arrests, and PS 3 to 5 and emergency surgery increased the incidence of mortality. The goal of preoperative assessment and preparation is to identify factors that may increase the risk for adverse perioperative events to appropriately inform parents (and the rest of the surgical team) of potential risks and to allow for management strategies that will minimize known risks. Upper and lower respiratory tract infections Pediatric patients have a higher incidence of respiratory events (laryngospasm and bronchospasm) than do adults. Olsson et al [5] found an incidence of laryngospasm of 17:1000 in the 0- to 9-year-old age group, but in patients with active respiratory infection, the rate increased to 96:1000, and in patients with a history of reactive airway disease, the rate rose to 64:1000. The presence of underlying conditions (eg, prematurity) or respiratory or airway diseases (eg, asthma, viral upper or lower respiratory tract infections, or bronchopulmonary dysplasia) greatly increases incidence of respiratory morbidity in children. Children who have acute or recent viral or bacterial upper respiratory infections (URI) are at increased risk for airway and pulmonary complications during anesthesia [6,7]. This risk exists during the acute infection and persists for up to 6 weeks after symptoms have subsided [8]. Anesthetic complications that occur commonly in children who have anesthesia during or shortly after the resolution of an acute respiratory infection include bronchospasm, laryngospasm, intraoperative and postoperative hypoxia, atelectasis, and postextubation croup. Endotracheal intubation significantly increases the risk for these respiratory com-

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plications. Unfortunately, for some operative procedures avoiding intubation may be impossible. In elective situations it may be best to avoid intubation (if the surgical procedure and fasting status permits), administering general anesthesia by way of mask or laryngeal mask airway (LMA). A recent randomized prospective study demonstrates a much lower incidence of bronchospasm in children with URI managed with LMA rather than ETT (0% versus 12.2%) [9]. In addition, the incidence of all respiratory complications was reduced by 50% for the LMA group (19% versus 35%). Therefore, LMA may be an excellent alternative for airway management for patients with URI if the planned surgical procedure and nothing by mouth (NPO) status are compatible with its use. Although the overall consensus is that respiratory infections confer increased risk, several studies have found no significant increase in respiratory complications among children anesthetized during an acute URI [10]. This has led some to advocate not canceling surgery for these children. The different conclusion may be related to lack of agreement as to criteria for diagnosis of upper versus lower respiratory infection. In addition, comparison is difficult between studies that evaluated patients having brief procedures without intubation (ie, myringotomy tubes) versus those having longer procedures requiring intubation. It is the authors belief that the physiologic, psychologic, and financial implications of delays in surgery must be weighed against the risks of increased perioperative complications of anesthetizing a child who has an URI. Timely and appropriate preoperative evaluation and communication with families should be managed to detect in advance children whose symptoms mandate surgical rescheduling [11]. Patients who have signs and symptoms of lower respiratory tract infection (productive cough, crackles, wheezes, or positive chest radiograph findings) or who have fever greater than 38.5C should have the surgical procedure delayed for 4 to 6 weeks after the resolution of symptoms [8]. Surgery and anesthesia usually can proceed safely in children whose symptoms are confined to clear rhinorrhea and upper airway congestion, particularly if they do not require endotracheal intubation [12]. Asthma Asthma is one of the most common and most serious underlying medical conditions that can complicate the management of children undergoing general anesthesia [13,14]. Many procedures performed routinely during anesthetic management, most notably laryngoscopy and intubation, are potent and intense stimuli that can produce bronchospasm. Intraoperative bronchospasm can be catastrophic; it may make ventilation difficult, if not impossible, and may result in hypercarbia, acidosis, hypoxia, cardiovascular collapse, and death. Fortunately, this need not and should not happen. Maximal preoperative optimization of a patients medical management may prevent or, at the very least, limit all of the perioperative complications of asthma (the best defense in a good offense). In general, asthma medical therapy must be escalated preoperatively even in wellcontrolled or asymptomatic patients to limit or prevent intraoperative broncho-

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spasm. Thus the child who takes asthma medications only on an as-needed (prn) basis should begin routinely prescribed inhaled beta-agonists or oral medications 3 to 5 days preoperatively, in the manner in which they would be administered during an acute asthma exacerbation [15]. The child taking medications on a chronic basis (oral or inhaled) should have steroids added in doses that would be used for an acute exacerbation (prednisone 1 mg/kg/day, which may be administered as a single morning dose) [16]. Finally, the difficult asthmatic child who takes bronchodilators and steroids regularly may require intensification in the frequency of nebulizer treatments, added bronchodilators, increased steroids, or on occasion, all of these [15]. Although the preoperative use of steroids in the fashion described earlier has been associated anecdotally with decreased morbidity in children and adults with reactive airways disease, no randomized controlled studies have been done to document such efficacy. Elective surgery should never be performed in children who are wheezing actively or who have had a recent asthma attack. Decreased peak expiratory flow and forced expiratory volume in the first second of expiration (FEV1) occur in adults and children for up to 6 weeks following an acute asthma attack, and airways are more responsive and prone to bronchospasm in this period (see paragraphs on Upper and lower respiratory tract infections earlier in this article) [17]. Therefore a recent asthma exacerbation requiring hospital admission or emergency therapy within 6 weeks of surgery precludes elective surgery. Elective surgery in asthmatic children who have an upper respiratory tract infection should also be delayed 6 weeks, even if they have no wheezing on auscultation, because the incidence of bronchospasm is likely to be increased greatly beyond even that seen in non-asthmatic children. There is an eleven-fold increase in respiratory complications when children with URI require endotracheal intubation as part of anesthetic management [12]. Adult studies have also shown a dramatic increase in complications in asthmatic patients anesthetized during acute exacerbation [18]. Corticosteroids are effective in preventing perioperative wheezing, even in patients who have severe asthma [15], but require 6 to 8 hours for onset of effect; maximal effect requires 12 to 36 hours. Therefore patients should receive 1 mg/kg of prednisone orally once daily for 3 days before surgery and on the morning of surgery. Although the chronic administration of high-dose corticosteroids for the treatment of asthma can be associated with severe systemic side effects, the short-term perioperative administration described is safe and effective in decreasing the incidence of perioperative bronchospasm. All oral medications may be taken with small amounts of water on the morning of surgery. Finally, treatment with an inhaled beta-agonist (by way of either metered dose inhaler or nebulizer) immediately before surgery can decrease airway hyperreactivity. Pulmonary function tests Pulmonary function tests (PFT) often are used to assess the response to bronchodilator therapy in patients in whom bronchospasm is reversible. Children with asthma often are followed with repeated measurement of peak expiratory

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flow rate (PFR) to monitor treatment, even in the home setting. If a patient is so followed, PFR in the maximum range for a patient should suffice to ensure that the pulmonary function is optimal before surgery. Although full PFT are rarely necessary preoperatively in most pediatric patients, these tests may be useful in predicting whether children who have pulmonary or thoracic cage abnormalities are at increased risk for perioperative complications. The studies used most commonly are pulse oximetry, forced vital capacity (FVC), and FEV1. The absolute values obtained and the ratio of the two measurements (FEV1/FVC) may be useful predictors of the need for postoperative mechanical ventilation among patients at risk (eg, cystic fibrosis, severe scoliosis, or kyphoscoliosis). In adults, an FEV1/FVC less than 50%, an FEV1 less than 35% predicted, or an absolute FVC less than 25 mL/kg is associated with an increased incidence of need for postoperative mechanical ventilation, but direct correlation between level of impairment and outcome is often absent [19]. No such studies are available in children. The accurate measurement of FEV1 and FVC requires patient cooperation; therefore it usually is not possible to obtain reliable results in children younger than 6 years. In addition, those in whom PFT would be the most helpful (sedentary patients for anterior-posterior spine surgery for scoliosis) frequently cannot cooperate with the testing (because of brain injury or metabolic diseases with mental retardation or cerebral palsy). Prematurity and apnea Infants born prematurely (<37 weeks) have a significantly increased risk for developing postoperative apnea ( > 15 seconds) [20]. Former pre-term infants who undergo general anesthesia have an increased incidence of apnea, periodic breathing, and bradycardia for up to 24 hours after surgery when compared with full-term infants. Regardless of a patients age, all general anesthetics, sedatives, hypnotics, and opioids produce dose-dependent and drug-specific alterations in the mechanics and central control of the respiratory system. This places the prematurely born infant at particular risk for developing apnea because the central and peripheral chemoreceptors are immature and limit effective responses to hypoxia and hypercarbia, even without the additional burden of drug-induced depression. Furthermore, vapor anesthetics decrease muscle tone in the airways and chest wall, and thereby depress the efferent limb required in the normal ventilatory response to hypoxia and hypercarbia. Several studies have demonstrated an increased risk for apnea to develop postoperatively in former preterm infants undergoing minor and major surgical procedures [21]. This risk can be minimized by the perioperative administration of caffeine, the use of spinal anesthesia instead of general anesthesia, and the delaying of surgery until the child is older than 48 to 60 postconceptual weeks [22,23]. Welborn et al [22] in a double-blind study demonstrated that 10 mg/kg of caffeine base (which is equivalent to 20 mg/kg of caffeine citrate or benzoate) given intravenously after the induction of general anesthesia virtually eliminated

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periodic breathing and postoperative apnea in a small number of ex-premature infants less than 44 weeks postconceptual age. These investigators and others also have demonstrated that spinal anesthesia (particularly in inguinal hernia surgery) decreased the risk for postoperative apnea significantly [23]. In addition to prematurity and postconceptual age, anemia (hematocrit <30) has also been shown to be an additional risk factor, especially in infants younger than 43 weeks postconceptual age [24]. A recent Cochrane review of regional (spinal, epidural, and caudal) versus general anesthesia for inguinal herniorrhaphy in preterm infants showed a possible reduction in risk for postoperative apnea (RR 0.39) only in the subgroup of patients having spinal anesthesia with no other sedative or anesthetic agents [25]. It is the authors belief, albeit conservative, that the risk for postanesthesic apnea has been defined clearly [24] and that the use of caffeine and spinal anesthesia as prophylaxis has been studied only in small patient populations. Therefore, it is the authors practice to admit all at-risk patients, regardless of the anesthetic technique used, to monitor high-surveillance inpatient units for 24 hours after anesthesia and surgery. Galinkin and Kurth [26] have devised a useful algorithm for decision-making on eligibility for day surgery in young infants, both full term and prematurely born, although some pediatric anesthesiologists may have more liberal age limits (eg, 52 weeks post-conception) if a specific infant had an uncomplicated neonatal intensive care unit (NICU) course. In addition, former premature infants who were intubated and ventilated as neonates are at increased risk for subglottic stenosis. Although a negative history does not exclude the diagnosis, a history of croup or stridor is an important warning sign of possible subglottic narrowing. The anesthesiologist should always be prepared to use an endotracheal tube 0.5 1 mm smaller in internal diameter than expected for the childs age in these patients. Bronchopulmonary dysplasia Bronchopulmonary dysplasia (BPD) significantly complicates the anesthetic management of children. BPD is a chronic lung disease that occurs in children born prematurely. The incidence of BPD has not decreased over the last 2 decades despite improved neonatal intensive care. Most infants who develop BPD currently are born at the gestational ages between 24 and 28 weeks and rarely are older than 32 weeks. The current definition of BPD is: oxygen dependence at 36 weeks post-conceptual age (with a total duration of oxygen therapy of less than 28 days) in infants born at birthweights between 500 and 1500 g [27]. Patients with BPD may have increased risk for bronchospasm and desaturation perioperatively in the first year of life, well after their discharge from the NICU. Several effects of anesthesia, together or separately, may produce life-threatening consequences. These patients are vulnerable to exaggerated pulmonary vasoconstriction to various stimuli (hypothermia, pain, and acidosis) because of hypoxia-induced changes in the pulmonary vascular bed. In settings of inadequate anesthesia, this pulmonary vasoconstriction will aggravate ventilation-

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perfusion mismatch and can lead to profound hypoxemia. This occurs in these patients even in the face of the usual pulmonary vasodilating effects of vapor anesthetics. Anesthetic effects on myocardial contractility can result in impaired right ventricular function, reduced cardiac output, pulmonary hypoperfusion, and profound cardiovascular compromise with hypoxemia resembling acute cor pulmonale. Increased airway reactivity during induction of or emergence from anesthesia can result in a severe exacerbation of BPD with an increased ventilation-perfusion mismatch. Increased oral and bronchial secretions induced by the anesthetic can compromise airflow and lead to airway or endotracheal tube plugging. Because of diminished respiratory reserves in these patients, such plugging can cause death quickly. These children also may have a degree of increased airway reactivity and tracheomalacia. Intraoperative bronchospasm or airway collapse poses a serious intraoperative risk. Finally, infections of the respiratory tract occur frequently in children who have BPD, and the presence of pneumonia can complicate the perioperative course significantly. Infants with mild forms of BPD improve with age and may become asymptomatic, but airway hyperreactivity may persist. Parents may not be aware of the existence of BPD even when their child received prolonged mechanical ventilation as a neonate. It is appropriate, therefore, to assume that a child has or had BPD and has reactive airways disease if that child was born prematurely and was mechanically ventilated for more than 1 week during the neonatal period. Inguinal hernia is often present in infants with BPD, probably as the result of continually increased abdominal pressure resulting from airway obstruction and increased inspiratory effort. It is essential that the pulmonary status of these children be optimized before surgery and anesthesia. Bronchodilators, antibiotics, diuretics, and corticosteroid therapy may all be of benefit. Respiratory infections or bronchospasm in children who have BPD must be managed intensively before elective surgery. In children who have severe BPD and bronchospasm, preoperative treatment with increased inspired oxygen tension may decrease pulmonary vasoreactivity and improve cardiovascular function. The possibility of associated right ventricular dysfunction always should be considered and, where indicated, evaluated with ECG and echocardiography. Because these children are at major risk for perioperative mortality and morbidity, the situation should be explained to parents before surgery. In addition, these children may require continuous postoperative monitoring and ventilation for an extended period (24 48 hours). Risks of general anesthesia and intubation in infants with BPD sometimes can be avoided with the judicious use of regional anesthesia (caudal or spinal) alone for operations such as hernia repair in infants less than 6 months. Parents must be cautioned, however, that regional anesthesia may not be 100% successful and that general anesthesia and intubation might still be required. Some of the most severely affected patients with BPD take diuretics such as furosemide or aldactone, which may result in electrolyte abnormalities. Patients who are on these drugs must have serum sodium and potassium determined preoperatively.

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Obstructive sleep apnea Children who have long-standing obstructive sleep apnea secondary to adenotonsillar hypertrophy, obesity, or other cause, also can develop significant pulmonary hypertension and cor pulmonale [28]. Patients at greatest risk are those who demonstrate daytime somnolence, complete or frequent obstructive apnea events, cyanosis during sleep, poor growth, or signs of cardiopulmonary dysfunction [29]. Preoperatively, these children who are believed to have chronic, severe obstructive apnea should have a hematocrit (may be elevated if chronic nocturnal hypoxia occurs) and ECG. Like children who have BPD, these youngsters are at risk for perioperative hypoxemia and acute right heart failure. Postoperatively, they should be admitted to the pediatric intensive care unit because the incidence of obstructive events actually may increase during the first 24 hours after surgery. [28] If intensive postoperative monitoring is planned, some surgeons choose to forgo sleep study because it is costly and would not change management. The greatest risk postoperatively, in fact, is continued upper airway obstruction, because of tissue edema and secretions, and the possible central effects of narcotics administered for analgesia.

Cardiovascular Intra-cardiac shunts Most anesthetic agents decrease vascular tone and thus decrease both pulmonary and systemic vascular resistance. The relative changes in these resistances can alter the dynamics of intracardiac shunts. Thus, during general anesthesia a left-to-right intracardiac shunt (eg, ventricular septal defect) may produce pulmonary over-circulation and failure. In contrast, during anesthesia pulmonary vascular resistance may increase acutely as a consequence of hypoxia, hypercarbia, acidosis, hypotension, or hypothermia. Thus a predominantly left-to-right shunt can be converted to a right-to-left shunt, which can have catastrophic consequences (eg, hypoxemia, or acute cor pulmonale). Children who have intracardiac shunts also can have a paradoxical embolism, which is produced by air or a thrombus traveling from the venous circulation into the systemic circulation (eg, cerebral arteries). For these reasons, intracardiac shunts must be identified preoperatively. Murmurs Cardiac murmurs are common in children. Murmurs are either functional or pathologic. Patients who have congenital anomalies of the heart or great vessels must be identified before anesthesia. Generally, the child who has a murmurbut who has a normal S1 and S2, normal exercise tolerance, is acyanotic, and is growing welltolerates a general anesthetic without complication. However, even asymptomatic patients who have a previously unrecognized pathologic murmur should be assessed appropriately, and may require antibiotic prophylaxis.

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Appropriate preoperative evaluation reasonably includes a thorough physical examination and an ECG. If there is any question of a significant structural cardiac abnormality, preoperative echocardiography and evaluation by a pediatric cardiologist are mandatory. The presence of an abnormal murmur, cyanosis, decreased exercise tolerance, poor weight gain, sweating, decreased femoral pulses, or a precordial heave necessitates a more complete preoperative evaluation (hematocrit, ECG, chest radiograph, oxygen saturation, and cardiology consultation). If a child who has known congenital heart disease presents for preoperative evaluation, the anesthesiologist should become familiar with the precise details of any previous surgery, current intracardiac anatomy, cardiac conduction defects, and myocardial function, cardiac medications being taken, and the relative stability or lability of the patients clinical condition. Subacute bacterial endocarditis prophylaxis Antibiotic prophylaxis to prevent bacterial endocarditis is indicated for many children who have congenital heart disease and are undergoing any procedure in which the patient is at risk for transient bacteremia (eg, dental, sinus, airway, genitourinary, gastrointestinal) or when the surgical site, though normally sterile, is contaminated. Patients who have shunts and patients who have hemodynamically insignificant lesions (bicuspid aortic valve, mitral valve prolapse, or a history of infective carditis) also require perioperative prophylaxis. All patients who have undergone palliative or corrective cardiac operations require prophylaxis for the rest of their lives. The only exceptions are those children who have had ligation of a patent ductus arteriosus or who have had a primary closure of a secundum atrial septal defect without a prosthetic patch; these two groups of patients require prophylaxis for only the first 6 months postoperatively. Oral endotracheal intubation by itself is not an indication for SBE prophylaxis, but nasotracheal intubation does require prophylaxis. The antibiotic regimen recommended by the American Heart Association [30] should be followed. It usually is acceptable for the antibiotic to be given when the intravenous (IV) is started after induction of anesthesia because the interval between start of the IV and the incision generally is long enough (5 minutes) to achieve adequate blood levels. It is unnecessary to start an IV in a child who is awake solely to administer antibiotics for subacute bacterial endocarditis prophylaxis. The necessity for continuing the antibiotic therapy postoperatively should be emphasized to the family because the child may be discharged as early as 1 to 2 hours after surgery in ambulatory surgical settings. Neuromuscular diseases Patients with central nervous system or peripheral neuromuscular abnormalities pose unique problems. Because virtually all potent inhalational agents produce cerebral vasodilation and thereby may increase intracranial pressure, children at

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risk for intracranial hypertension (eg, hydrocephalus, brain tumor, and blocked ventriculoperitoneal shunts) must be identified before surgery. Any existing cerebrospinal fluid (CSF) shunt must be evaluated appropriately for patency and proper functioning before surgery. In addition, because residual anesthetic effects may impair airway reflexes in the immediate postoperative period, any evidence of brainstem dysfunction (eg, vocal cord paralysis, swallowing dysfunction, or aspiration) should be noted in the preoperative evaluation. Patients who have neuromuscular and degenerative diseases are at increased risk for postoperative weakness, and may require postoperative respiratory care and prolonged mechanical ventilation. In children who have progressive diseases of nerve or muscle, hyperkalemia or malignant hyperthermia occur more commonly after succinylcholine administration. The fear of fatal hyperkalemia following succinylcholine administration in patients who have undiagnosed muscular dystrophy has led the Food and Drug Administration to recommend avoiding succinylcholine administration for routine intubations in all children [31]. Because succinylcholine is still the best muscle relaxant for accomplishing rapid intubation, anesthesiologists still use it for strong indications in children (bowel obstruction and NPO violation). A careful history should be obtained in all children to evaluate for signs of possible muscular dystrophy (eg, delayed walking, calf hypertrophy, and Gowers sign [walking up the legs with the arms to stand from a sitting position]). Patients receiving anticonvulsant medication should have blood concentrations measured to ensure therapeutic levels in the perioperative period. These children may require perioperative intravenous administration of anticonvulsants because postoperative fasting or vomiting may not allow maintenance of therapeutic blood levels with orally administered drugs. However, most anticonvulsants have long half-lives, and the omission of one dose does not decrease the blood level significantly. Patients who have been seizure-free for 2 years and have had no adjustment of their anticonvulsant dose do not require the determination of anticonvulsant levels. Patients on chronic steroid therapy Patients on long-term corticosteroid therapy and those who have congenital adrenal insufficiency have suppression of the hypothalamic-pituitary-adrenal axis, and lack the ability to mount an appropriate stress response (ie, Addisonian crisis). These children are routinely treated with corticosteroids in stress doses perioperatively (2.5 5 mg/m2 of prednisone orally the night before and 50 mg/m2 of hydrocortisone after the IV is started before or after anesthetic induction). There is no evidence to support this practice [32]. Sickle cell anemia Patients who have sickle cell anemia have an increased risk for complications from general anesthesia and surgery. Sickling readily occurs with hypoxia, hy-

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percarbia, acidosis, hypothermia, hypovolemia, and hypoperfusion states, all of which may occur perioperatively. Decreased functional residual capacity and altered ventilation-perfusion ratios, which occur commonly during general anesthesia, may give rise to transient hypoxemia, which may precipitate sickling and contribute to postoperative acute chest syndrome and stroke. Immobility, vasoconstriction, increased insensible fluid loss, and position on the operating table may produce regional hypoperfusion and stasis. Children who have sickle cell anemia and who are significantly anemic may benefit from simple red cell transfusions preoperatively and such transfusion may prevent perioperative complications. In two recent studies of patients undergoing tonsillectomy or adenoidectomy or minor surgery without tourniquet application, no difference in perioperative complications was seen between receiving simple transfusion to a hemoglobin level of 10 g/dL and those receiving exchange transfusion to a target hemoglobin S level of less than 30% [33,34]. For prolonged or extensive operations, multiple simple or exchange transfusions to achieve hemoglobin S levels less than 30% are recommended [35], but vigilance is mandatory, because the incidence of postoperative complications is high, even in patients who have been adequately tranfused, especially those with a history of pulmonary disease [34]. Measures should be taken to ensure adequate perioperative hydration, because patients who have sickle cell anemia have hyposthenuria: the urine will remain inappropriately dilute, even in the face of significant intravascular volume depletion. Sickle cell anemia frequently is associated with cardiomyopathy, nephropathy, central and peripheral neuropathy, or chronic respiratory dysfunctionall of which may complicate general anesthesia or the perioperative course. Because of the potential for further impairment during general anesthesia, the degree of involvement of these organ systems should be documented. The preoperative assessment also should describe the type of sickle crises the child usually experiences and the date of the most recent crisis.

Preoperative pregnancy testing Performing routine preoperative pregnancy tests in adolescent females remains controversial but, it was recommended by the most recent American Society of Anesthesiologists Task Force on Preanesthesia Evaluation [36]. Recently, however, ethical objections have been raised regarding routine pregnancy testing and the level of evidence of the adverse effects of anesthesia during early pregnancy. This has resulted in the following statement: The Task Force recognizes that patients may present for anesthesia with early undetected pregnancy. The Task Force also recognizes that the literature is insufficient to inform patients or physicians on whether anesthesia causes harmful effects on early pregnancy. Pregnancy testing may be offered to female patients of childbearing age and for whom the result would alter the patients management [37]. Because of the high rate of sexual activity among increasingly younger teenagers, and because many

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anesthetic medications increase the incidence of miscarriage and are potential teratogens at various doses, it is the authors practice to perform preoperative urine human chorionic gonadotropin (HCG) screening tests on the day of surgery in all postmenarchal patients, regardless of sexual history. Both patient and parents are informed in advance of the reason for the urine specimen.

Latex allergy In March, 1991, the FDA circulated a Medical Alert [38], warning health care practitioners of an accumulating mass of reports of severe allergic reactions to latex-containing medical devices in the hospital and operating room environment. Although many reports involved anaphylactoid reactions during barium enemas, many were related to anaphylaxis in patients undergoing surgery. A large number of these patients were children with spina bifida. The earliest report of this phenomenon was in 1989 [39]. An excellent review of the problem was published recently [40]. Despite multiple case reports and increasing experience with patients both at risk for and with known latex allergy, no clear consensus for their perioperative management has emerged. Although contact dermatitis to rubber products has been well known for many years, the incidence of reactions to latex products has recently been increasing (6% to 7% of medical personnel and 18% to 34% of patients with spina bifida [41], with some estimates in the latter population as high as 73%) [42]. The high incidence in patients with spina bifida as been attributed to a higher incidence of atopy, or genetic predisposition versus repeated exposure to latex, by way of bladder catheterization, and multiple surgeries [43,44]. Although all medical personnel have an increased risk for sensitization compared with the general population, a recent study has highlighted an even greater risk among anesthesiologists [45]. Speculation about the etiology of the increasing prevalence of latex sensitization centers around the increased use of universal precautions since 1987 [46], the resultant larger market for latex gloves, and associated changes in the processing of latex for use in medical devices and gloves [47]. Most children who have had intraoperative anaphylaxis caused by latex have had spina bifida. A smaller but significant number have had urinary tract abnormalities, most often exstrophy of the bladder [48]. A typical intraoperative anaphylactic reaction to latex usually occurs 20 to 30 minutes after incision and usually involves the exposure of a mucosal surface (usually peritoneum) to latex gloves worn by the surgeons. The reaction is heralded by hypotension, tachycardia, bronchospasm with increased peak inspiratory pressure, and wheezing. In Holzmans series [49], oxygen saturation fell from 100% to a mean of 92%, and there was a slight fall in end-tidal carbon dioxide. There may also be associated urticaria or generalized flushing of the skin. Children who have had intraoperative anaphylaxis should be tested for the drugs to which they were exposed, and latex. Blood is obtained for radioallergosorbent testing (RAST) at the time of the intraoperative episode, and patients

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should be referred for allergy testing before surgery is rescheduled. The performance of skin testing should be delayed until 4 to 6 weeks after the anaphylactic event to allow time for cellular inflammatory mediators released as a consequence of the reaction to be reconstituted [50]. Performance of testing before allowing time for reconstitution increases the risk for false negative results. While RAST is specific, it is less sensitive than skin-prick testing, which only recently has become standardized adequately [51]. Prevention of anaphylactic reactions to latex begins with careful history taking. Parents of patients who are at risk (eg, myelodysplasia, urinary tract abnormalities including exstrophy, atopy, and multiple previous surgeries) should be carefully questioned about reactions to latex-containing products, including balloons. These patients frequently have a history of mouth or facial redness or swelling after touching or blowing up balloons. There is no consensus with regard to the necessity of preoperative allergy testing for patients who have no history of anaphylaxis. It seems most prudent and cost-effective to simply avoid latex products in high-risk groups of patients, especially those with myelodysplasia and bladder exstrophy [49]. Investigators in an institution that implemented a program to avoid latex exposure in children with spina bifida reported a significant reduction in the development of sensitization [52]. A recent study suggested that all children have increased risk for the development latex allergy with increasing number of surgical procedures, not just those with spina bifida, with patients in the study who had an average of 7.7 operations having the astounding incidence of 55% latex sensitization [53]. The investigators recommended instituting latex precautions after the fifth surgery for all children, although this recommendation has not been adopted widely. All personnel involved in the patients perioperative care to be informed of the patients potential reaction to latex products and products in the hospital environment that contain latex. The latter is somewhat problematic because this information frequently is not readily available from manufacturers, and sometimes conflicting data exist regarding whether a product is or is not latex-free. A listing of latex-containing equipment and latex-free alternatives should be posted prominently in the operating room when individuals at risk for latex reactions are operated on, so that all personnel will be reminded of safe practice. Such a listing is available at the web site of the American College of Allergy, Asthma, and Immunology (http://allergy.mcg.edu). The Johns Hopkins site (http://med.jhu.edu/nursing) offers other policies for dealing with patients at risk for latex allergy. Other web sites that provide useful information about both products and latex allergy are available to physicians and patients. With recent increasing awareness of the problem of latex allergy in medical personnel and patients, improved non-latex and powder-free low allergen latex gloves have become available, which are more acceptable to surgeons. In addition, many manufacturers of devices used in hospitals, such as intravenous infusion sets are eliminating latex from these products. So-called chemoprophylaxis for latex allergy has also been debated in the literature, with some groups enthusiastically recommending prophylaxis consist-

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ing of H-1/H-2 receptor antagonists such as diphenhydramine and ranitidine and corticosteroids administered from 24 hours before until 24 hours after surgery [54]. The investigators and other practitioners recommend only the avoidance of latex-containing products without prophylaxis because there have been reports of anaphylaxis despite such prophylaxis [55]. Recent studies indicate that prophylaxis is indeed ineffective [49] and should not substitute for meticulous avoidance of latex-containing products.

Fasting guidelines The classic literature and texts of anesthesiology have been replete with the mantra of the association of gastric fluid volume with risk for aspiration pneumonia and resulted in rigid guidelines that were NPO after midnight, for adult and pediatric patients. A comprehensive recent examination of many studies [56], including an ASA taskforce, has concluded that these associations, formerly considered iron-clad, are anything but iron-clad. Because such rigid guidelines in children caused fussy, possibly hypoglycemic patients in the age of outpatient surgery, studies documenting no increase in gastric volume with liberalization of clear liquid administration have led to a relaxation of fasting guidelines in practice, in the United States [57] and the United Kingdom [58]. This change in practice has recently been confirmed by the recommendations of the ASA taskforce (web site: http://asahq.org/Practice/NPO/NPOguide.html). These guidelines can be most easily summarized as 8-6-4-2 (i.e., 8 hours solids, 6 hours formula, 4 hours breast milk, 2 hours clear liquids). This change in practice can result in decreased numbers of canceled cases, and pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction. The liberalization, however, applies only to clear liquids, and communicating the correct guidelines to parents can be problematic, resulting in some patients who still consume formula and must be delayed, and in others who still have been NPO since midnight. Patients undergoing emergency surgery, those with anatomic bowel obstruction, and those who are not NPO, must have their risk for aspiration balanced against the urgency of the surgery. Most trauma patients and others requiring emergency surgery have delayed gastric emptying, reducing the usefulness of having to wait a prescribed period of time until induction of anesthesia. Those patients should have a rapid sequence induction in any case.

Summary The author has reviewed recent developments in preoperative assessment and testing, emphasizing issues that are of greatest concern in pediatric patients. Attention to these areas during the process of preoperative preparation and appropriate communication of conditions that may contribute to increased perioperative risk will provide greater predictability for families, surgeons, and op-

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erating room staff. This predictability is an important component to improved patient or family satisfaction and operating room efficiency.

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