What are the requirements for perioperative general anesthesia clearance in pediatric patients?

From the Guidelines

Pediatric patients requiring general anesthesia should undergo preoperative clearance with a 1-hour clear fluid fasting time, as this has been shown to be safe and effective in reducing fasting times without increasing the risk of aspiration 1.

Preoperative Clearance

Preoperative clearance for pediatric patients undergoing general anesthesia should include a thorough medical history, physical examination, and appropriate laboratory testing based on the child's health status and planned procedure.

• For healthy children undergoing minor procedures, minimal testing is needed beyond a comprehensive history and physical.
• Children with chronic conditions like asthma, congenital heart disease, or bleeding disorders require specialized evaluation.

Fasting Guidelines

Preoperative fasting guidelines for pediatric patients have evolved, with recent evidence suggesting that a 1-hour clear fluid fasting time is sufficient to prevent aspiration 1.

• This guideline is supported by studies showing that gastric emptying in children is rapid for clear fluids, with the majority having left the stomach within 30 minutes to 1 hour 1.
• A 1-hour clear fluid fasting time has been shown to be safe and effective in reducing fasting times without increasing the risk of aspiration 1.

Medications and Counseling

Medications for anxiety may include oral midazolam (0.5 mg/kg, maximum 20 mg) given 20-30 minutes before surgery.

• Parents should be counseled about the anesthesia process, including potential side effects like postoperative nausea, vomiting, sore throat, and emergence delirium.
• Optimization of chronic conditions before surgery (such as ensuring good asthma control) and addressing any acute illnesses (postponing elective procedures if the child has an active upper respiratory infection) will minimize anesthetic risks and improve outcomes.

From the FDA Drug Label

The concentration of sevoflurane required for maintenance of general anesthesia is age-dependent Sevoflurane or halothane was used to anesthetize 1620 pediatric patients aged 1 day to 18 years, and ASA physical status I or II Patients who received sevoflurane had slightly faster emergence times (12 vs. 19 minutes)

The clearance of sevoflurane in pediatric patients is not explicitly stated in terms of a specific numerical value, but it is mentioned that the concentration required for maintenance of general anesthesia is age-dependent.

• Emergence times were slightly faster in pediatric patients who received sevoflurane compared to halothane.
• The incidence of adverse events during induction, such as agitation, cough, and breathholding, was similar between sevoflurane and halothane. 2

From the Research

Perioperative General Anesthesia Pediatric Clearance

• The pediatrician's role in the evaluation and preparation of pediatric patients undergoing anesthesia is crucial, as they help prepare patients and families for anesthesia and surgery 3.
• The preoperative evaluation is the first step in ensuring the safe conduct of anesthetic care in pediatric patients, and its goals are to gain information regarding the patient's current status, comorbid conditions, and the intended procedure 4.
• The preoperative evaluation allows for the identification of patients who require additional preoperative testing or those who need to be seen by an anesthesiologist prior to the day of surgery 4.
• Key components of the preoperative evaluation include the physical examination, airway examination, and laboratory testing, which help facilitate the care of patients during the perioperative period while limiting surgical cancellations resulting from patient-related issues 4.
• General anesthesia in the pediatric population is associated with perioperative, intraoperative, and short- and long-term postoperative risks, and surgeons should be aware of current practices in pediatric anesthetic care, as well as the immediate- and long-term risks of general anesthesia 5.
• Preanesthetic evaluation of pediatric patients requires specific consideration, including upper respiratory infection, fever, asthma, and ex-preterm infants, and it is essential to provide a less stressful environment and fulfill patients' satisfaction 6.
• The effects of different anesthetics, such as sevoflurane, isoflurane, halothane, and enflurane, on hemodynamic responses during an inhaled induction of anesthesia via a mask in humans have been studied, and the results show that some anesthetics can induce hyperdynamic responses, including tachycardia and hypertension 7.