Preoperative Evaluation

Information Required

1. History

2. Physical exam. Focus on airway, cardiovascular, respiratory and neurological systems.

3. Assess for associated congenital anomalies. If any cardiac anomalies present, obtain an electrocardiogram (EKG) and an echo study.

4. Prematurity. If born before delivery date, obtain additional history.

a. Apnea and bradycardia. If present, treat with caffeine or theophylline.

b. Retinopathy of prematurity. Avoid hyperoxia and employ oxygen level to maintain O2 saturation between 93 and 95%.

c. Immature metabolic control:

i. Glucose. Maintain 2.5% Dextrose in lactated Ringer's solution (D2.5LR) or normal saline for maintenance of fluids intraopera-tively and while patient is NPO.

ii. Calcium. Monitor carefully.

iii. Temperature. Infants and children are at high risk for heat loss because of their large surface to mass ratio.

5. Assess whether the ICP is raised.

a. Signs and symptoms of raised ICP in an awake patient include nausea and vomiting, headache, lethargy, irritability in infants and focal neurological deficits.

Pediatric Neurosurgery, edited by David Frim and Nalin Gupta. ©2006 Landes Bioscience.

b. Imaging studies such as a brain computed tomography (CT) scan may demonstrate cerebral edema, mass effect and/or midline shift.

c. In a patient with an ICP monitor, the cerebral perfusion pressure (CPP) can be directly calculated (CPP = MAP-ICP).

Latex Precautions

Latex precautions are employed routinely with children who have spina bifida. Some physcians take similar precautions when treating children who may undergo repeat surgical procedures, such as placement and revision of cerebrospinal fluid (CSF) shunts. These children are suceptible to developing a latex allergy because of repeated exposure to latex products in the operating rooms (OR), as well as repeated bladder catheratizations, required if a neurogenic bladder is present. Several steps can be taken to reduce exposure to latex, which is ubiquitous in the hospital environment:

1. Schedule as the first case of the day. This decreases exposure to powder from latex gloves that were removed by OR personnel in the previous cases.

2. Accurate allergy history is important. Specifics include previous anaphylaxis during surgical procedures, allergic reactions during dental procedures and allergic reactions to ballons. Other potential patients who may harbor a latex allergy are healthcare workers (occupational exposure), and those with a history of anaphylaxis of unknown cause, or atopy (asthma, allergic rhinitis, or atopic dermatitis) .

3. Post signs on OR door and patient's bed which state "Latex Precautions/ Allergy".

4. Change anesthesia equipment. Many hospitals now have a latex-free cart and protocol to ensure that latex-free products are easily identifiable. Most medical products are now labeled regarding any latex content; if not specified the manufactuer should be contacted. A list of equipment that may contain latex is provided in Table 1.

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