What are the preoperative considerations for pediatric patients undergoing laparoscopic procedures?

Preoperative Considerations for Pediatric Laparoscopic Procedures

Pediatric patients undergoing laparoscopic procedures require mandatory preoperative evaluation by an anesthesiologist with pediatric expertise, focusing on age-appropriate assessment, optimization of comorbidities, and strict adherence to fasting protocols rather than routine laboratory screening. 1

Multidisciplinary Team Coordination

An anesthesiologist with pediatric anesthesia experience must organize the perioperative care, establishing formal communication protocols with surgeons and other services. 1 For high-risk patients (those with sickle cell disease, pulmonary hypertension, or significant comorbidities), multidisciplinary collaboration between surgeon, anesthetist, pediatric hematologist, and when applicable, transfusion medicine specialists is imperative. 1

Clinical Assessment Requirements

History and Physical Examination

Focus your preoperative clinical examination on these specific elements:

• Cardiovascular status: Identify any history of congenital heart disease, pulmonary hypertension, or exercise intolerance 1
• Respiratory comorbidities: Document recent upper respiratory infections (children with infections 3-4 weeks prior have higher peroperative respiratory complications than those with acute infections) 2, asthma severity, and baseline oxygen requirements 1
• Hematologic conditions: For sickle cell disease patients, review recent pain crises, acute chest syndrome episodes, transfusion history, and current hydroxyurea therapy 1
• Neurological history: Document any seizure disorders or developmental delays 1
• Recent infectious events: Active infection is an absolute contraindication to elective procedures 1
• Prior anesthesia complications: Specifically ask about emergence delirium, postoperative nausea/vomiting, and malignant hyperthermia family history 1
• Current medications: All medications must be reviewed and discussed; if contraindicated during surgery, appropriate substitutions must be arranged preoperatively 1

Age-Specific Risk Stratification

Infants in the first trimester of life, particularly premature babies, are at highest risk for peroperative respiratory disturbances and require heightened vigilance. 2 For these high-risk infants, consider delaying elective procedures until after 3 months of age when physiologically appropriate. 2

Laboratory Testing Strategy

Abandon systematic prescription of preoperative tests; instead, use selective and rational ordering based on patient history and clinical examination. 3

Indicated Laboratory Studies

Order these tests only when clinically indicated:

• Complete blood count with reticulocytes: For patients with sickle cell disease, chronic anemia, bleeding disorders, or malnutrition 1
• Renal and liver function tests: For patients on chronic medications, with known organ dysfunction, or undergoing procedures with significant fluid shifts 1
• Hemoglobin levels and sickledex: For at-risk populations (African, Mediterranean, Middle Eastern descent) 1
• Coagulation studies: Only if bleeding history or anticoagulant use suggests coagulopathy 1
• Blood typing and antibody screening: Essential for procedures with potential significant blood loss or for patients with sickle cell disease to expedite transfusion 1

Imaging Studies

Plain radiographs or other imaging should be obtained only when specific clinical indications exist, not routinely. 3

Preoperative Fasting Protocols

Implement evidence-based fasting guidelines to minimize aspiration risk while avoiding prolonged fasting that causes hypoglycemia and dehydration: 1

• Clear liquids: 2 hours minimum fast 1
• Breast milk: 4 hours minimum fast for neonates and infants 1
• Infant formula: 6 hours minimum fast 1
• Solid foods: Follow standard adult guidelines 1

Consider adopting a 1-hour rule for clear fluids in otherwise healthy children to reduce fasting-related complications. 1 Verify patient compliance with fasting requirements immediately before the procedure. 1

Special Population Considerations

Sickle Cell Disease Patients

For children with sickle cell disease undergoing laparoscopic procedures:

• Ensure prior immunization against encapsulated bacteria (this is standard SCD care regardless of surgery) 1
• Optimize SCD-specific therapies: Verify adherence to hydroxyurea, assess transfusion needs, ensure adequate iron chelation, and provide supplemental oxygen if indicated 1
• Preoperative transfusion decisions: Discuss exchange transfusion for high-risk procedures; for low-risk laparoscopic procedures in children on effective hydroxyurea therapy, evaluate transfusion need case-by-case 1
• No target HbS percentage or hemoglobin threshold is definitively established, but planned exchange transfusions should be discussed for high-risk procedures 1

Pulmonary Hypertension Patients

Elective laparoscopic surgery in children with pulmonary hypertension must be performed at hospitals with PH expertise, with mandatory consultation between the PH service and experienced pediatric cardiac anesthesiologists. 1 Careful preoperative planning and plans for appropriate post-procedural monitoring are required. 1

Cardiac Device Patients

For children with cardiovascular implantable electronic devices:

• Preoperative antiseptic skin preparation is mandatory 1
• Consider retropectoral pocket placement in patients with limited subcutaneous tissue or poor nutrition to reduce erosion risk (infection rate 13.8% subcutaneous vs 0% retropectoral in pediatric series) 1
• Plan for meticulous hemostasis during device manipulation to prevent hematoma formation, which increases infection risk 1

Psychological Preparation

Robust preoperative assessment minimizes day-of-surgery cancellations and reduces perioperative anxiety. 1 Implement these strategies:

• Identify particularly anxious children during preoperative assessment and develop individualized plans for the day of surgery 1
• Utilize play specialists and experienced nurses for psychological preparation to avoid distress in the anesthetic room and day-of-refusal 1
• Provide age-appropriate information to children and parents through hospital-specific materials and reputable online resources 1
• Discuss anesthesia options with parents, including gaseous versus intravenous induction, and explain what to expect in the anesthetic room 1
• Address teenager-specific concerns about loss of control, awareness, and not waking up, as these anxieties may not be readily voiced 1

Consent and Legal Considerations

Establish who has parental responsibility and ensure appropriate consent procedures are followed. 1 For female patients aged 12 and older, ascertain pregnancy status on the day of surgery with documentation per institutional policy. 1

Home Environment Assessment

Verify that the home environment is appropriate for postoperative care: 1

• Distance from hospital and access to reliable transportation 1
• Working telephone for emergency contact 1
• Parents' ability to understand discharge instructions and recognize complications requiring hospital return 1
• Availability of appropriate analgesics for home pain management 1

Day-of-Surgery Verification

On the day of surgery, confirm:

• Patient compliance with fasting requirements 1
• No new infectious symptoms or acute illness 1
• Contact information provided for parents to call if child becomes unwell before surgery 1
• All preoperative optimization completed per the individualized plan 1

Equipment and Facility Requirements

The facility must have:

• Separate preoperative unit or designated area with age- and size-appropriate equipment for pediatric patients 1
• Full selection of pediatric airway equipment including masks, supraglottic devices, tracheal tubes (as small as 2.5mm for ultrathin instruments), and pediatric laryngoscope blades 1
• Difficult airway cart with specialized pediatric equipment readily accessible 1
• Clinical laboratory capability for hematologic and chemical analyses on small samples, available at all times 1
• Nursing and technical personnel experienced in pediatric perioperative care, including ability to formulate drugs in appropriate pediatric doses, concentrations, and volumes 1

Common Pitfalls to Avoid

• Do not perform routine laboratory screening in healthy children; this wastes resources and may lead to unnecessary procedure delays 3
• Do not assume pain management will mask symptoms; appropriate analgesia makes children more comfortable and facilitates examination 1
• Do not use low-molecular-weight heparin in the immediate postoperative period, as it predisposes to hematoma formation 1
• Do not proceed with elective surgery if the child has an active infection or acute sickle cell event (vaso-occlusive crisis, acute chest syndrome) 1
• Do not delay surgery unnecessarily for minor upper respiratory symptoms in otherwise healthy children, but recognize that children 3-4 weeks post-infection have higher complication rates than those with acute infections 2
• Do not overlook the physiological hemoglobin decrease at the end of the first trimester when timing elective procedures 2