What are the guidelines for pediatric general anesthesia clearance?

Guidelines for Pediatric General Anesthesia Clearance

A comprehensive pre-anesthetic evaluation is essential for all pediatric patients undergoing general anesthesia, including assessment of medical history, physical examination with focused airway evaluation, appropriate fasting guidelines, and consideration of age-specific risk factors. 1

Pre-Anesthetic Health Evaluation

Medical History Assessment

• Age and weight (in kg) and gestational age at birth (preterm infants may have sequelae like apnea of prematurity)
• Health history including:
  • Food and medication allergies and previous adverse drug reactions
  • Complete medication history (prescription, over-the-counter, herbal)
  • Relevant diseases and physical abnormalities
  • Genetic syndromes that might increase airway obstruction risk
  • Obesity, history of snoring or obstructive sleep apnea (OSA)
  • Cervical spine instability (Down syndrome, Marfan syndrome, skeletal dysplasia)
  • Pregnancy status in menarchal females (approximately 1% may be pregnant) 1
  • History of prematurity
  • Seizure disorders
  • Previous hospitalizations
  • Previous anesthesia experiences and complications
  • Relevant family history (muscular dystrophy, malignant hyperthermia, pseudocholinesterase deficiency)

Physical Examination

• Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, temperature
• Focused airway evaluation: tonsillar hypertrophy, abnormal anatomy (mandibular hypoplasia), Mallampati score
• ASA physical status classification 1

Special Considerations

• Sleep-disordered breathing/OSA: Children with severe OSA may require lower opioid doses (one-third to one-half of typical doses) due to altered mu receptors 1
• Herbal medicines: St. John's wort, ginkgo, ginger, ginseng, and garlic may alter drug pharmacokinetics through cytochrome P450 inhibition 1
• Drug interactions: Medications like erythromycin and cimetidine may inhibit cytochrome P450, prolonging sedation effects 1

Fasting Guidelines

Minimum Fasting Periods

• Clear liquids: 2 hours
• Human milk: 4 hours
• Infant formula: 6 hours
• Nonhuman milk: 6 hours
• Light meal: 6 hours 1

Fasting Considerations

• Recent guidelines from pediatric anesthesia societies are moving toward a 1-hour rule for clear fluids to reduce prolonged fasting 1
• Routine necessary medications may be taken with a sip of clear liquid on the day of procedure 1
• For emergency procedures, balance the risk of aspiration against the necessity of the procedure 1

Documentation Requirements

Pre-Procedure Documentation

• Informed consent according to local requirements
• Complete pre-anesthetic assessment
• ASA classification
• Fasting status
• Emergency contact information 1

During Procedure Documentation

• Time-based record of medications (name, route, site, time, dosage/kg)
• "Time out" confirmation of patient name, procedure, and site
• Monitoring data (consciousness level, vital signs, oxygen saturation, expired CO2) 1

Special Populations and Situations

Difficult Airway Management

• For children with difficult intubation, plan extubation when fully awake
• Consider extubation over a hollow airway exchange catheter when difficult extubation is anticipated
• Ensure full monitoring, trained assistance, and difficult airway equipment availability during extubation 1

Day Surgery Considerations

• Emergence delirium is more common in young children after short procedures
• Modify anesthetic techniques to minimize emergence delirium risk
• Provide clear instructions to parents about pain management at home
• Ensure parents understand appropriate dosage regimens for analgesics 1

Common Pitfalls and Caveats

1. Inadequate fasting assessment: Always document and consider fasting status, especially for emergency procedures
2. Overlooking OSA: Children with OSA require special consideration for opioid dosing
3. Herbal medication interactions: Many herbal supplements can significantly alter anesthetic drug metabolism
4. Inadequate parent preparation: Parents need clear instructions for managing post-anesthetic care, especially pain management
5. Pregnancy status: Failure to assess pregnancy status in menarchal females (approximately 1% may be pregnant)
6. Prolonged fasting: Unnecessarily prolonged fasting can lead to dehydration and hypoglycemia; follow updated guidelines allowing clear fluids up to 1-2 hours before procedures

By following these comprehensive guidelines for pediatric anesthesia clearance, clinicians can minimize risks and optimize outcomes for children undergoing general anesthesia.