Transcript Why Bother? The Comprehensive Pre

Daniel Rauch, MD, FAAP, FHM
Associate Professor of Pediatrics
Icahn School of Medicine at Mount Sinai
Which kids go to the OR electively?
 Previously healthy kids
 T&A, pyloromyotomy, inguinal hernia repair,
appendectomy, orthopedic repair, hypospadias repair
 Children with Special Healthcare Needs (CSHCN)
 Fundoplication, G-tube placement, tendon release,
shunt placement/repair
Who takes kids to OR?
 Tertiary care facilities
 Surgeons with pediatric training
 Post-op care with pediatric specialists
 Community facilities
 Surgeons with pediatric experience but less commonly
with pediatric training
 Post-op care less likely with pediatric specialists
Possible Pre-op tests
 CXR
Possible Pre-op tests
 CXR
 Studies in 70’s suggested utility
 More recent data: low yield of occult CXR findings that
would delay operation
Possible Pre-op tests
 CXR
 Studies in 70’s suggested utility
 More recent data: low yield of occult CXR findings that
would delay operation
 CBC – surely we need a pre-op HCT!
Possible Pre-op tests
 CXR
 Studies in 70’s suggested utility
 More recent data: low yield of occult CXR findings that
would delay operation
 CBC – surely we need a pre-op HCT! NO!!
 Declining incidence of anemia (less Fe deficiency)
 Most procedures with minimal blood loss
 High threshold for transfusion
Possible
Pre-op
tests
 Surely Type and Cross?
Possible
Pre-op
tests
 Surely Type and Cross?
 Most procedures with minimal blood loss
Possible
Pre-op
tests
 Surely Type and Cross?
 Most procedures with minimal blood loss
 PT/PTT? – How will we know if there may be
bleeding?
Possible
Pre-op
tests
 Surely Type and Cross?
 Most procedures with minimal blood loss
 PT/PTT? – How will we know if there may be
bleeding?
 Labs less accurate than Hx (pt and fam)
 Not even for T&A
Possible
Pre-op
tests
 Surely Type and Cross?
 Most procedures with minimal blood loss
 PT/PTT? – How will we know if there may be
bleeding?
 Labs less accurate than Hx (pt and fam)
 Not even for T&A
 Not even BMP/Chem 7?
Possible
Pre-op
tests
 Surely Type and Cross?
 Most procedures with minimal blood loss
 PT/PTT? – How will we know if there may be
bleeding?
 Labs less accurate than Hx (pt and fam)
 Not even for T&A
 Not even BMP/Chem 7?
 No routine benefit
What
can
we
do?
 History and Physical Exam
 When possible well in advance of procedure especially
for CSHCN
 Testing as indicated by pre-op visit or occasionally as
necessitated by procedure
 There are some bloody procedures
 Good opportunity to review general care and address
issues that may impact on post-op care
 Good evidence this reduces cost and LOS