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Am Fam Physician. 2022;105(6):640-649

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

A preoperative evaluation is advised for all children and adolescents having elective surgery with anesthesia. The evaluation assesses medical and psychosocial factors that may affect surgery timing and identifies underlying conditions that may require evaluation or management before surgery. The evaluation also classifies the patient's American Society of Anesthesiologists' risk category. The history component of the evaluation should include a review of the patient's medical, behavioral, and social history; previous complications with surgery or anesthesia; a medication review; and a tobacco use history. The physical examination should involve the identification of airway anomalies that could interfere with intubation and the evaluation of cardiac, respiratory, neurologic, and fluid status. Routine laboratory testing is not recommended for healthy children and adolescents having low-risk procedures. Patients with underlying conditions may benefit from targeted laboratory and imaging studies to assess clinical stability. The HEMSTOP questionnaire can identify patients who have coagulation disorders. A pregnancy test should be considered for all adolescents who are postmenarchal on the day of surgery. Many children have anxiety about surgery, which can be reduced by educational pamphlets, videos, coaching provided to parents the week before surgery, and a parental presence during the induction of anesthesia.

Each year in the United States, 3.9 million surgical procedures are performed on children and adolescents.1 Orthopedic surgery and tonsillectomy and adenoidectomy are among the most common in-hospital surgical procedures performed in this age group and often require a preoperative outpatient evaluation.2,3 Family physicians and other primary care clinicians can play an important role in pre-operative evaluations. These evaluations allow for a detailed understanding of the patient's medical status and psychosocial situation to communicate the unique needs of each child to the surgery and anesthesia team, provide family-centered counseling, and contribute to improved postoperative outcomes and decreased costs.
RecommendationSponsoring organization
Avoid admission or preoperative chest radiography for ambulatory patients with unremarkable history and physical examination.American College of Radiology, American College of Physicians, American College of Surgeons
Avoid routine preoperative testing for low-risk surgeries without a clinical indication.American Society for Clinical Pathology
Avoid routine prothrombin time and partial thromboplastin time preoperative screening on asymptomatic patients; use instead a history-based bleeding assessment test.American Society for Clinical Laboratory Science
Do not perform routine preoperative hemostatic testing (prothrombin time, active partial thromboplastin time) in an otherwise healthy child with no personal or family history of bleeding.American Society of Hematology, American Society of Pediatric Hematology/Oncology
Do not obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery—specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss or fluid shifts are expected to be minimal.American Society of Anesthesiologists
In addition to the surgeon's discussion with the patient and family about indications for surgery, a preoperative evaluation is advised for all children and adolescents having elective surgery with anesthesia to assess medical and psychosocial factors that may affect the timing of surgery and to identify underlying conditions that would benefit from evaluation and management before surgery.48 Table 1 lists the symptoms and medical conditions that may require further evaluation or subspecialist referral before surgery.4,615 Patients whose preventive care is overdue should also be scheduled for a separate follow-up appointment to complete important developmental and psychosocial assessments, and age-appropriate immunizations.16
Primary care assessmentPreoperative recommendationsRole of subspecialists and pediatric anesthesiology
Respiratory
Airway anomaliesEvaluate Mallampati score, neck range of motion, and mouth opening
Perform dental examination
Identify craniofacial syndromes that may impact airway management (e.g., Pierre-Robin sequence, Goldenhar syndrome)
Review previous airway, head, and neck surgeries or interventions (e.g., radiation)Anesthesia: evaluate for difficult mask ventilation and/or intubation
Otolaryngology: evaluate for tracheostomy if severe craniofacial abnormalities are present
AsthmaClassification or disease severity: consider pulmonary function tests for accurate disease assessment
Determine short-acting beta-agonist requirement and maintenance medication compliance
Evaluate emergency department visits, hospitalizations, and intubations Evaluate for recent corticosteroid use
Take maintenance medication as prescribed, including on the morning of surgery
Take albuterol prophylactically on the morning of surgery
Consider oral steroids for severe asthma
Delay nonurgent procedures if patient is symptomatic
Pulmonology: consider for severe or poorly controlled cases
Cystic fibrosisDetermine disease severity
Determine medication requirement, access, and adherence
Evaluate nutritional status
Optimize pulmonary function and control airway secretions
Treat with vitamin K if hepatic function is impaired
Optimize nutrition
Anesthesia: discuss risks of anesthesia and postoperative care
Gastrointestinal and nutrition: manage poor nutritional status or hepatic dysfunction
Pulmonology: consult for disease optimization and continued maintenance
InfectionDetermine upper vs. lower respiratory tract infection
Evaluate for presence of fever
Assess for COVID-19 exposure risk
Review vaccination history
Consider delaying nonurgent procedures
Prescribe inhalers if obstructive lung disease is present
Manage symptoms with nasal saline, antihistamines, antitussives, and guaifenesin
Perform preoperative COVID-19 testing of patient and household contacts
Anesthesia: assess severity of symptoms vs. urgency of surgery; identify appropriate postoperative resources if proceeding with surgery (including possible need for admission and postoperative airway support)
Sleep-disordered breathing/obstructive sleep apnea syndromeDetermine disease severity and current signs and symptoms*
Assess for comorbid conditions (e.g., craniofacial abnormalities, neuro-muscular disease, cardiopulmonary disorder, obesity, trisomy 21)
Encourage weight loss (if obese or overweight)
Bring continuous positive airway pressure machine on day of surgery
Anesthesia: discuss preoperative sedation, risks of perioperative opioid use, and possible need for postoperative admission
Cardiology: consult if signs or symptoms of right heart dysfunction or systemic or pulmonary hypertension are present
Otolaryngology: evaluate for tonsillectomy and adenoidectomy if adenotonsillar hypertrophy present
Pulmonology: manage preexisting obstructive sleep apnea or new diagnosis; evaluate for need of polysomnography
Cardiac
Congenital cardiac diseaseAssess functional capacity, including signs or symptoms of congestive heart failure*
Coordinate with pediatric cardiologist to optimize medication regimen
Discuss management for anticoagulation, if necessary
Identify need for antibiotic prophylaxis for spontaneous bacterial endocarditis
Continue medications as prescribed (with possible exception of anticoagulants)
Minimize nothing-by-mouth time on the day of surgery
Consider preoperative electrocardiography or transthoracic echocardiography
Engage cardiology for oversight of cardiac rhythm management devices
Anesthesia: determine need for care by pediatric cardiac anesthesiologist; identify need for preoperative laboratory studies
Cardiology: consult for ongoing management of patient's condition, including medication optimization and identification of need for additional imaging, therapies, or interventions
Pharmacy/hematology: assist with anti-coagulation management
Heart murmurEvaluate for features of concerning murmur
Assess for additional signs or symptoms of congenital heart disease
Review previous transthoracic echocardiogram (if available) or obtain new transthoracic echocardiogram and electrocardiogram if murmur has concerning features
Determine need for preoperative transthoracic echocardiography and electrocardiography with further management dependent on cardiac testingAnesthesia: note this is not necessary for benign murmurs
Cardiology: consult if new-onset murmur with concerning features, patient has additional signs/symptoms of congenital heart disease, or concerning finding on transthoracic echocardiography or electrocardiography
Neurologic
Developmental delayAssess for the patient's understanding of illness state and need for surgeryConsider family-centered approach, including caregiver presence during induction of anesthesia if appropriatePsychiatry/behavioral health: evaluate for and manage comorbid mood and anxiety disorders
Seizure disorderReview disease severity, seizure frequency, and recent hospitalizations
Assess for medication interactions
Continue antiepileptic medications on the day of surgeryNeurology: consult if seizures are uncontrolled or antiepileptic dose was adjusted recently
Endocrine
Diabetes mellitus types 1 and 2Evaluate disease severity
Manage insulin preoperatively
Titrate insulin regimen to account for preoperative fasting periodEndocrinology: consult if poorly controlled illness; management of insulin pump
Nephrology: maximize renal function if chronic kidney disease or proteinuria present
ObesityEvaluate for obstructive sleep apnea and diabetesProvide counseling for weight loss and lifestyle modificationsOtolaryngology: evaluate for tonsillectomy and adenoidectomy if adenotonsillar hypertrophy present
Pulmonology: manage preexisting obstructive sleep apnea or new diagnosis
Nutrition: optimize nutritional status
Hematology/oncology
Bleeding disordersObtain clinical history and assess patient and family with validated screening tool: easy bruising, mucosal bleeding, prolonged/excessive bleeding, menorrhagiaObtain preoperative laboratory studies: platelet count, prothrombin time, international normalized ratio, partial thromboplastin time, thrombin time, fibrinogen concentration
Consider postponing nonurgent surgery for further evaluation
Hematology: refer for further workup if high level of clinical concern or abnormal laboratory studies
Discuss specific recommendations based on final diagnosis of coagulation disorder with surgeon and anesthesiologist
HypercoagulabilityIdentify personal or family history of venous thromboembolism
Identify acquired risk factors, including presence of a central venous catheter, malignancy, cardiac disease, nephrotic syndrome, or recent surgery or trauma
If strong personal or family history in the absence of acquired risk factors, consider testing for congenital conditions such as factor V Leiden, prothrombin gene mutation, protein C and S deficiency, and antithrombin III deficiency
Encourage preoperative hydration to reduce hemoconcentration
Hematology: evaluate for perioperative pharmacologic prophylaxis
MalignancyIdentify chemotherapeutic regimen and history of radiation therapyEnsure recent complete blood count, electrocardiography, transthoracic echocardiography, and chest radiography
Type and screen (if indicated for surgical procedure)
Cardiology: consider if patient has new-onset arrhythmia or reduced cardiac function related to cancer therapy
Oncology: continue to manage therapeutic regimen and communicate with anesthesia team about avoidance of specific medications
Sickle cell diseaseAssess pain control
Evaluate renal function
Maximize fluid status and hemoglobin before procedure
Consider possible preoperative admission for transfusion
Hematology: manage antisickling agents, pain, and iron overload
Genetic disorders
Malignant hyperthermiaIdentify personal or family history of malignant hyperthermiaObtain genetic testing or caffeine halothane contracture test before elective surgery, if possibleAnesthesia: prepare for nontriggering anesthetic
Genetics: discuss genetic testing or caffeine halothane contracture test
Pseudocholinesterase deficiencyConsider personal or family history of unexpected, prolonged intubation following surgery
Determine if acquired condition in patients receiving plasmapheresis
Consider plasma assay of pseudocholinesterase activityAnesthesia: avoid succinylcholine use, if possible, in patients with concern for enzyme deficiency
Trisomy 21Identify cardiac anomaly and status of repair
Examine cervical spine for presence of atlantoaxial instability
Consider flexion and extension cervical spine radiography before surgery if patient is symptomaticAnesthesia: prepare for potential difficult airway
Cardiology and cardiac surgery: manage preoperative medication and surgically repair congenital heart defects before elective surgery
Other
Jehovah's witnessIdentify religious beliefs that could affect administration of human products during medical careDiscuss and document family's wishes about the use of human blood products during medical proceduresAnesthesia: meet with family to discuss options for blood conservation and ethical and legal considerations of administering blood products to minors
Hematology: consider iron supplementation or administration of erythropoiesis if appropriate
Preterm/former preterm infantEvaluate for bronchopulmonary dysplasia, cardiac abnormalities, feeding intolerance, and neurologic deficitsCounsel parents about possible need for postoperative hospitalization due to increased risk of apnea and bradycardiaAnesthesia: discuss increased risk of apnea and bradycardia postoperatively
Pulmonology: optimize respiratory function before elective surgery
Gastrointestinal/nutrition: optimize nutrition status
The American Society of Anesthesiologists has established a physical status classification system (ASA-PS; Table 2).17 The ASA-PS can help predict postsurgical complications and mortality.18 Clinicians should use the preoperative evaluation to identify medical problems and optimize patient status before surgery to improve their overall health within a specified ASA-PS classification.
ClassificationDefinitionPediatric examples
INormal healthy patientHealthy child without acute or chronic illness
IIPatient with mild systemic diseaseWell controlled chronic illness (e.g., asthma, epilepsy, non–insulin dependent diabetes mellitus), abnormal body mass index, asymptomatic congenital heart disease
IIIPatient with severe systemic diseaseUncontrolled chronic illness, insulin-dependent diabetes, morbid obesity, severe obstructive sleep apnea, autism with severe limitations
IVPatient with severe systemic disease that is a constant threat to lifeSepsis, heart failure exacerbation, bleeding diathesis, automatic implantable cardioverter-defibrillator, severe trauma, symptomatic congenital heart abnormality
VMoribund patient who is not expected to survive without the operationMassive trauma, patient requiring extracorporeal membrane oxygenation, respiratory failure, multiple organ system failure

Components of the Preoperative Evaluation

MEDICAL HISTORY

The preoperative evaluation should include a medical and birth history review, including prematurity and associated complications. A review of previous complications with surgery or anesthesia should also be completed, particularly those involving respiratory or cardiac events. A family history should focus on anesthesia complications, such as postoperative nausea and vomiting or malignant hyperthermia, and bleeding disorders that can increase the risk of adverse events. Allergies should be identified and documented.

BEHAVIORAL AND SOCIAL HISTORY

Clinicians should review a patient's behavioral and social history and involve caregivers when appropriate. Older children and adolescents should be allowed the confidential space to discuss sexuality, stress, mood symptoms, prior and current trauma or abuse, and substance use. Gaining a comprehensive understanding of the psychosocial dynamics of the patient better informs the operative team and prepares the child and family for the postoperative recovery period, which can be a vulnerable time, particularly after more complex procedures.

MEDICATION REVIEW

A review of all prescription, over-the-counter, and herbal medications should be completed. It may be necessary to communicate with the perioperative team to determine which medications should be taken or not taken on the day of surgery and if any medications need to be held in the preceding days or weeks due to potential interactions with medications commonly used during anesthesia. Table 3 outlines common medications used by children and the respective perioperative considerations.1925
MedicationPerioperative risk/benefitPerioperative considerations
AntiepilepticsIncreased seizure risk if doses of antiepileptics are missed secondary to prolonged fasting
Possible interaction with anesthetic agents*
Administer antiepileptic medications pre- and postanesthesia to reduce the risk of seizure
Counsel patients that these medications may increase time to emergence from or prolong sedation after a surgical procedure
Histamine H2 blockers and proton pump inhibitorsDecreased gastric volume and increased gastric content pH; reduced risk of aspirationContinue H2 blockers and proton pump inhibitor medications in the perioperative period
InhalersDecreased intubation-induced bronchospasm with inhaled long-acting beta-agonists and oral corticosteroidsCounsel patients to take asthma controller medications on the morning of surgery
Take albuterol prophylactically on the morning of procedure
Nonsteroidal anti-inflammatory drugsImproved pain control in the perioperative period
Possible increased bleeding risk in certain populations
Weigh potential benefit of pain control vs. bleeding risk
SteroidsAdrenal insufficiency
Immunosuppression
Consider stress-dose steroids in patients with secondary adrenal insufficiency or high risk of adrenal insufficiency from high-dose steroids
Note increased risk of infection and sepsis in the postoperative period

TOBACCO USE HISTORY

The preoperative evaluation should include an assessment for tobacco use with cessation counseling and treatment as needed. Tobacco use, including secondhand exposure, increases the risk of perioperative respiratory events and postoperative events, including 30-day mortality, pneumonia, and re-intubation.26 

Electronic smoking devices and electronic nicotine delivery systems have gained popularity among adolescents. The nicotine and volatile organic compounds produced by these devices can cause pathophysiologic changes, including airway hyperreactivity, and contribute to hemodynamic instability.2729 Clinicians should inquire about these devices when obtaining a tobacco use history. The Society for Perioperative Assessment and Quality Improvement recommends that primary care clinicians counsel and offer cessation therapy to all patients using nicotine products, including electronic nicotine delivery systems in the perioperative period to reduce intra- and postoperative complications.30 The 5A's (Ask, Advise, Assess, Assist, Arrange) model is a recommended approach to tobacco cessation counseling.31
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