AAP clarifies pediatricians’ preferred role in prepping patients for anesthesia and surgery

A free clinical report published in Pediatrics, the journal of the American Academy of Pediatrics (AAP) examines the role that pediatricians should play in evaluating and preparing patients and families for anesthesia and surgery.

It focuses on two major areas of concern. The first is preparation and optimization of the patient for surgery, including making sure the patient and family members are “emotionally and cognitively ready for surgery.” The second surrounds logistics, specifically addressing “the necessary communication and prerequisites to enable safe passage through the perioperative process.”

The report writes that many pediatric patients have "complex comorbidities or are undergoing extensive or complicated surgery/procedures that require addressing their medical conditions and optimizing their health status prior to receiving anesthesia or sedation.

“The perioperative period can be stressful and anxiety provoking for pediatric patients and their families. The pediatrician is uniquely situated to help address the developmentally appropriate needs of the child or adolescent when procedures requiring anesthesia or sedation are contemplated. The pediatrician may be aware of unique considerations for the patient’s chronic conditions and recent exacerbation or changes in their medical/social situations. Pediatricians may be aware of unique social situations and social drivers of health, including current living circumstances, ability to afford medications, transportation needs, language barriers, or health literacy, which can affect pre- and postoperative/discharge planning. Excellent communication among all medical care providers can improve outcomes and ensure the safest, least disruptive experience for the patient.”

It states that pediatricians’ “in-depth knowledge of the patient’s past medical history, medication use, and current medical concerns can facilitate safe perioperative care and optimize outcomes.” Effective communication between pediatricians and anesthesia teams, it states, is “not only beneficial to patients and medical staff but at times is critical.”

To maximize patient safety and prevent delays to scheduled surgeries, the report recommends that the patient should have a “timely and comprehensive medical evaluation” whenever possible, ideally coordinated between the pediatrician and the patient’s anesthesia team. This evaluation, the report states, is helpful to ensure that:

• Patients can continue to use controller medications for asthma or reactive airway disease until the day of surgery.
• Patients with known congenital heart disease or arrhythmias have had a recent follow-up with their cardiologist.
• Patients with new or concerning murmurs are evaluated by a cardiologist.
• Patients on anticoagulation medications are optimized for surgery by their cardiologist or hematologist.
• Patients remain on antiepileptic medications, including on the day of surgery, provided they comply with NPO instructions.
• Patients with cervical neck instability have radiographs that are available to the anesthesia team.

It also states that the pediatrician should inform the anesthesia team of:

• known or suspected airway abnormalities including anatomic abnormalities
• recent or recurrent respiratory tract infections or airway reactivity
• the presence of pacemakers and automated implantable cardiac defibrillators, pulmonary hypertension, and any unusual electrocardiographic findings
• whether the patient is on a ketogenic other specialized diet that may influence fluid or medication management.
• recent head trauma or recurrent concussions suffered by the patient.

Additionally, it states that pediatricians can help advise and set expectations for families that patients who are younger than three years with both obstructive sleep apnea and comorbidities such as Down syndrome, mucopolysaccharide disease, craniofacial anomalies, neuromuscular disorders, and sickle cell disease may need to be admitted for postoperative monitoring, and that patients receiving deep sedation or general anesthesia for imaging and procedures should follow the same preoperative guidelines as other patients receiving anesthesia for surgery.

Read the full clinical report here.