Paediatric preoperative assessment

Learning objectives.

By reading this article, you should be able to:

• •Outline how paediatric preoperative assessment services can be organised in line with the new Association of Paediatric Anaesthetists of Great Britain and Ireland Best Practice Guidance.
• •Explain the role of preoperative assessment for common chronic conditions, including asthma and diabetes mellitus.
• •Discuss the perioperative management of anticoagulation therapy for children.

Key points.

• •Preoperative assessment is the opportunity to prepare and optimise a patient before surgery.
• •Preoperative assessment can be virtual or face to face depending on the individual needs of the child.
• •Most children attending preoperative assessment are of ASA Grade 1 or 2 having ambulatory surgery.
• •Increasing numbers of children with complex comorbidities are presenting for elective surgery.
• •Health screening for conditions, such as obesity, should occur at preoperative assessment.

Anaesthetic preoperative assessment of adult patients is a well-established part of perioperative practice, supported by an increasing body of evidence.¹ Preoperative assessment for children and young people lags behind adult services, occurring more sporadically and with no formalised standards of care until recently. This situation probably stems from the view that children are at ‘lower risk’ and do not require preoperative interventions, which historically was a valid argument. However, the last few decades have seen significant reductions in neonatal mortality without corresponding reductions in morbidity or preterm birth.² Diagnosis and management of disease in childhood have evolved, and surgical presentations are now more complex. The argument for high-quality, consistent preoperative assessment services, described in the recent Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI) Best Practice Guidance, is therefore an easy one to make.³

Preoperative assessment encompasses many elements, which facilitate improved service delivery and satisfaction from patients and carers. It is an opportunity for detailed anaesthetic assessment and allows for multidisciplinary planning, shared decision-making, optimisation of chronic conditions and provision of information before surgery. It allows early identification and management of anxiety and reduces potential long-term negative psychological effects from perioperative experiences. Finally, preoperative assessment is a ‘teachable moment’ for opportunistic health screening and intervention, bringing together objectives from the NHS Long Term Plan and the campaign ‘Making Every Contact Count’.³

Delivering paediatric preoperative assessment

All children having procedures under anaesthesia should have preoperative assessment before the day of surgery, specifically tailored to their needs in an area designed for them.

The key organisational elements of paediatric preoperative assessment include^3,4

• (i)Triage: children and young people should pass through an electronic or paper-based triage system to individualise their care. This system aims to establish the type of assessment needed and any additional requirements. Suggested criteria for face-to-face assessment are shown in Box 1.
• (ii)Nurse-led preoperative assessment: the central part of the service is nurse-delivered preoperative assessment, which can be face-to-face or virtual.
• (iii)Consultant anaesthetist review: children with complex medical or behavioural comorbidities or children undergoing complex procedures should be reviewed by a consultant anaesthetist.

Box 1. Criteria for face-to-face preoperative assessment2.

Criteria requiring face-to-face assessment
Preterm infants less than 60 weeks post-conceptual age
Potential difficult airway
Poorly controlled chronic illness (e.g. asthma)
Kidney or liver disease
Cardiac disease (including a new heart murmur)
Genetic disorder
Diabetes mellitus or metabolic disease
Learning difficulties or autism
Haemoglobinopathy, anaemia or clotting problem
Hypertension requiring treatment
Safeguarding concerns or children requiring consent by social services
Previous history or family history of problem with anaesthesia
Complex physical disability
Requires any investigations (e.g. blood tests and swabs)
Request from the patient or carer

Alt-text: Box 1

The timing of preoperative assessment varies depending on the complexity of the case and the scheduled procedure. It should occur at least 2 weeks before admission to hospital. With more complex cases, referral may occur before surgery is scheduled. This is to allow sufficient time for information gathering, investigations, optimisation and preparation. Perioperative plans should be created for all children using a collaborative multidisciplinary approach. Shared decision-making should be used throughout.^3,4

Preoperative assessment also has broader roles within healthcare. It is an important part of efficient service delivery, ensuring conditions are managed at the most appropriate hospital for the patients' needs. Cooperation between preoperative assessment and operational delivery networks also potentially allows for a wider regional collaborative approach to reducing waiting lists.³

Established preoperative assessment clinics can provide a central contact point for patients and families, improving consistency of perioperative advice. One of the most common reasons for day-of-surgery cancellation is upper respiratory tract infections. A central contact number with nurse-delivered flowcharts creates an opportunity for earlier postponement of children who are unwell and optimisation of valuable operating theatre time.⁴

History and examination

A standardised history should be taken recording birth history, immunisation status, chronic or congenital conditions, prior anaesthetic experiences, anxiety or behavioural concerns, medications and allergies. Patients with conditions affecting the conduct of anaesthesia, for example neuromuscular disease, previous anaphylaxis or reactions to anaesthesia (malignant hyperthermia or suxamethonium apnoea), should be reviewed and an individualised plan for anaesthesia made. Children receiving non-invasive ventilation, home oxygen or with a tracheostomy may also need more detailed planning.

Anxiety occurs in up to 80% of children presenting for surgery. Early identification allows for planning and preparation, including the use of play therapists, psychologists, premedication and virtual or actual hospital tours. A detailed discussion of the management of anxiety is beyond the scope of this article but should be considered by all.

Every child should have their height, weight and appropriate observations (heart rate, oxygen saturations, temperature and blood pressure in children ≥3 yrs old) measured. Children who are suitable for telephone preoperative assessment can have these measurements taken on the day of surgery. Airway assessment is essential, including loose deciduous teeth, previous upper airway problems and suspected airway challenges. Examination should also include potential i.v. access sites and auscultation of the chest, which is important even in children who are well, to detect undiagnosed heart murmurs.

It is important to establish specific communication needs of both patients and carer. For some patients, early involvement of the hospital's learning disability team is appropriate.^3,4

Investigations

Well children undergoing ambulatory surgery do not routinely require investigations. A full blood count (FBC) and group and save should be performed before surgery, where there is a possibility of significant blood loss, or in children at risk of anaemia. Other investigations are only necessary for children with more complex medical problems (Table 1).^3,4

Table 1.

Investigations at preoperative assessment²

Investigation	ASA 1	ASA 2	ASA 3–5
Full blood count	Minor surgery: not routinely Major surgery: yes	Minor surgery: not routinely Major surgery: yes	Minor surgery: not routinely Major surgery: yes
Urea and electrolytes	Minor surgery: not routinely Major surgery: yes	Minor surgery: not routinely Major surgery: yes	Minor surgery: If at risk of acute kidney injury Major surgery: yes
Coagulation screen	Minor surgery: not routinely Major surgery: not routinely	Minor surgery: not routinely Major surgery: not routinely	Minor surgery: not routinely Major surgery: discuss with consultant anaesthetist
ECG	Minor surgery: not routinely Major surgery: not routinely	Minor surgery: not routinely Major surgery: not routinely	Minor surgery: discuss with consultant anaesthetist Major surgery: discuss with aconsultant anaesthetist

Outcomes from preoperative assessment

At completion of the preoperative assessment visit, each child should have an individualised plan and enough information to prepare them and their carers for the perioperative journey. This plan should include.

• (i)Suitability for day-case surgery and type of inpatient bed required
• (ii)Referral of children to a more specialist centre if services required before or after surgery are not available locally
• (iii)Specific logistics relating to anaesthesia, for example remote site
• (iv)Anaesthetic and analgesic plans should be discussed with children and their carers, including pre-medications, preferred induction strategy and advanced analgesic techniques.
• (v)Decisions concerning the perioperative management of medications for children with chronic conditions should be taken with the parent medical team. A written plan should be provided for patients and carers to help with the management of any changes.
• (vi)Verbal and written information on local fasting policy should be provided.
• (vii)Risks of anaesthesia should be communicated in line with General Medical Council (GMC) guidance.
• (viii)Families should be counselled about key events on the day of surgery, including pregnancy tests and viral swabs.
• (ix)Information and preparation resources should be provided. These may include virtual resources or apps, sequencing cards, leaflets or online links. Some children may benefit from targeted play specialist input.
• (x)The results of health screening should be described capturing the surgical motivator for positive behavioural change.

Patients' and clinicians' satisfaction with the preoperative assessment service should be audited at all stages.^3,4

Health screening

Preoperative assessment provides the ideal opportunity to address health and lifestyle changes. Obesity, smoking, mental health, chronic pain and dental care can all be assessed.³

Oral health

Twenty-five percent of children aged ≤5 yrs have dental decay. Children identified with poor oral health should be referred to NHS dental services. It may be worth considering dental interventions at the time of their surgery. Parents can be directed to the Health Education England resource ‘Mini Mouth Care Matters’ for further information.³

Obesity

All children attending preoperative assessment should have their BMI calculated. Almost a quarter of paediatric patients undergoing surgery are overweight (>91st centile), have obesity (>98th centile) or have severe obesity (>99.6th centile). Children with obesity are more challenging to anaesthetise and prone to perioperative complications.⁵

The psychological impact of weight should be explored and lifestyle advice offered. Local pathways should be in place to identify children who would benefit from further interventions, which may include.

• (i)Detailed assessment of the airway
• (ii)Investigations to screen for comorbidities (fasting glucose, HbA_1c, liver function, thyroid function, lipids and vitamin D, sleep study, ECG, ECHO and spirometry)
• (iii)Referral to community weight management programmes or paediatric specialists
• (iv)Review of any safeguarding concerns

All preoperative assessment units should have their own pathways for children with obesity taking into account national guidance.^3,5

Tobacco smoking

Environmental exposure to tobacco smoke increases the incidence of adverse perioperative events. Children living in households with smokers are more likely to develop chronic conditions, such as asthma, and are at higher risk for acute illnesses, such as middle ear infections and bacterial meningitis.

Screening for parental smoking should be incorporated in the preoperative assessment health questionnaire. All smokers should be offered smoking cessation advice. A model for such intervention is ‘very brief advice’, which comprises three main domains.

• (i)Ask about exposure.
• (ii)Advise on risk to the child's general and perioperative health.
• (iii)Act to refer for smoking cessation support.

Parents who smoke are more likely to stop in these circumstances, and this ‘teachable moment’ should be exploited throughout the perioperative process.^3,6

Specific conditions

Respiratory

Asthma

Children with asthma are at increased risk of perioperative respiratory adverse events (PRAEs). Key markers of increased risk are.

• (i)Respiratory tract infection within 4 weeks
• (ii)Previous exacerbation under anaesthesia
• (iii)Moderate or severe asthma
• (iv)Previous artificial ventilation for acute asthma
• (v)Children ≤5 yrs old⁷

The latest respiratory clinic letter and the child's asthma management plan should be reviewed. Completion of the ‘asthma control test’ is useful with referral back to the asthma team or general practitioner, where indicated.³ If control is poor, deferral of elective surgery should be considered. Severe cases should be seen by the parent medical team and reviewed by a consultant anaesthetist. Additional investigations are not usually necessary.

Asthma medications should be given as usual before surgery to reduce the chance of exacerbations. In some instances, short courses of oral corticosteroids may be helpful. Children with recurrent infections may benefit from preoperative antibiotics. Smoking cessation advice should be given to any smoker within the household.^3,7,8

Sleep-disordered breathing

Sleep-disordered breathing is a spectrum of disorders ranging from simple snoring to obstructive sleep apnoea (OSA). Obstructive sleep apnoea is classified as mild (apnoea hypopnoea index [AHI] of <5 h⁻¹), moderate (AHI 5–10 h⁻¹) or severe (AHI >10 h⁻¹) on polysomnography. The most common cause is adenotonsillar hypertrophy, with diagnosis peaking aged 2–6 yrs. Other causes include chromosomal abnormalities, craniofacial syndromes, cerebral palsy, neuromuscular disorders and obesity. Adenotonsillectomy is the mainstay of treatment for moderate-to-severe OSA.^9,10

Diagnosis is primarily clinical, with a history of snoring three or more times per week, audible or witnessed apnoea three or more nights per week and behavioural symptoms. All children presenting to preoperative assessment should be asked about these symptoms. The gold-standard diagnostic investigation is polysomnography, but this test is reserved for cases where diagnostic uncertainty exists. Overnight pulse oximetry is less expensive but not as diagnostically reliable and is a poor predictor of PRAEs. An echocardiogram should be considered for patients where there are signs of right ventricular dysfunction or severe desaturation (<70%) on polysomnography.^9,10

Obstructive sleep apnoea is an independent risk factor for PRAEs. Risk stratification is important for perioperative planning. Risk factors to consider are.

• (i)Age (≤3 yrs old)
• (ii)Weight (above 99.6 BMI centile or below 0.4 BMI centile)
• (iii)Severe OSA
• (iv)Comorbidities (cardiac complications, craniofacial abnormalities, cerebral palsy, neuromuscular disorders, mucopolysaccharidosis, achondroplasia and other significant comorbidity)^9,10

In the UK, secondary centres can treat children ≥2 yrs old and ≥12 kg without additional risk factors. Patients <3 yrs old should generally be admitted overnight. Children who have additional risk factors or who are <2 yrs old should be managed at centres with appropriate critical care facilities. Perioperative risk stratification is not straightforward and may require multidisciplinary planning.^9,10

Cystic fibrosis

Perioperative management of cystic fibrosis (CF) in children is complex and should always involve the parent CF team. Preoperative assessment should ascertain disease severity, functional status, glycaemic control and additional organ involvement. Frequency of exacerbations and sputum volume in younger children are good indicators of severity. Recent imaging should be reviewed. Patients may be admitted to hospital before surgery for physiotherapy, bronchodilators and mucolytics, and in some cases antibiotic therapy. Preoperative planning is important to enable timely physiotherapy, allocation of side rooms, list scheduling and involvement of the CF team. The need and timing of i.v. access should be considered, as it may affect the planning of anaesthesia.¹¹

Tracheostomy

Children with a tracheostomy have a greater perioperative risk. The indication for the tracheostomy, type and size, usual care regimen, details of previous upper airway management and any home ventilation protocols should be recorded.

Postoperative care depends on the individual needs of the child. Some children can be discharged the same day, whereas others may require critical care input. Not all tracheostomy tubes are compatible with MRI, and these should be changed before scanning. Multidisciplinary involvement, including the respiratory team, is paramount.¹²

Endocrine

Diabetes mellitus

Diabetes mellitus (DM) is the most common endocrine disorder in childhood. Glucose control is disrupted in the perioperative period, and multidisciplinary planning with input from the child's endocrine team is essential. The child should be reviewed by a consultant anaesthetist and an individual management plan created. This will depend on the child's current treatment regimen, type and timing of surgery and expected starvation period.¹³

Modification of the child's usual insulin regimen is adequate for minor surgery. Children on a basal bolus regime can continue long-acting insulin and halve or omit immediate-acting insulin with the missed meal. A variable-rate insulin infusion may be needed for children having major surgery, where oral intake is unlikely to resume immediately. Type 2 DM in children receiving insulin can be managed in the same way. Oral hypoglycaemics can be given up until the day of surgery, except for metformin.¹³

A recent HbA_1c (within 3 months), serum electrolytes, current blood glucose and blood or urinary ketones should be recorded. Any previous episodes of hypoglycaemia and corresponding symptoms should be noted. Elective surgery should be postponed if diabetes is not well controlled (HbA_1c >8.5%/69 mmol mol⁻¹), and the child should be referred for optimisation. Patients should be scheduled early on the operating list to minimise the duration of fasting.¹³

Children with other more complex endocrine conditions, such as thyroid disease, diabetes insipidus or phaeochromocytoma, should be reviewed by a consultant anaesthetist and a multidisciplinary plan developed with paediatric endocrine teams well in advance of surgery.

Metabolic disorders

Children with metabolic disorders are at high risk for acute decompensation in the perioperative period. Infection, fasting and the stress response to surgery can all trigger decompensation. Metabolic disorders in children should be managed in centres with appropriate critical care facilities and in collaboration with the paediatric metabolic team. Supplemental co-factors and special diets should be continued. Fasting times should be minimised with patients scheduled early on the list, and where there is risk of hypoglycaemia, i.v. solutions containing dextrose 10% started. A preoperative FBC, urea and electrolytes, blood gas, ammonia concentration and capillary blood glucose are recommended. Patients should be reviewed by a consultant anaesthetist for individualised planning.¹⁴

Renal disease

Multidisciplinary care is essential for children with renal disease. History should include the cause, duration and severity of impairment and involvement of other systems. Daily urine output, fluid restriction, blood pressure, mode of dialysis and medication should be ascertained. Recent blood tests and ECG should be reviewed. Surgery should be timed with preoperative dialysis.¹⁵

Anaemia

Anaemia increases the need for perioperative blood transfusion and mortality after surgery. All children undergoing major surgery or with risk factors for anaemia should have a preoperative FBC. In children with a new diagnosis of anaemia, haematinics (folate, B12 and ferritin concentrations) and iron studies should be measured, and the general practitioner informed. Iron deficiency remains the most common cause of anaemia and should be treated with preoperative oral iron and response checked. I.V. iron should be considered if there is no response. If the child is anaemic and haematinics and iron studies are normal, clinical review and haematology referral are recommended. Children with a known inherited anaemia should be reviewed by a consultant anaesthetist and a plan made in collaboration with the haematology team.^3,16

Sickle cell anaemia

Sickle cell anaemia in children requires careful multidisciplinary management with the haematology team involved. Day-case surgery is usually not advised. Recommended investigations include FBC, cross match, haemoglobin electrophoresis and urea and electrolytes. Additional investigations depend on whether chronic complications are present. The fasting period should be minimised with children scheduled early on the operating list, and i.v. fluids considered once fasting commences. The acute pain team should be made aware of children undergoing major surgery, especially children with a history of chronic pain. Preoperative transfusion should optimise haemoglobin concentrations to ≥10 g dl⁻¹. Children having high-risk surgery may also require an exchange transfusion, so the haemoglobin S level is <30%. Severe cases may need review by a consultant anaesthetist. Children with sickle cell trait rarely have any clinical symptoms and usually cope well with surgery. They should be identified at preoperative assessment so that any necessary adjustments to their perioperative journey can be made.¹⁷

Cardiac disease

Children with cardiac disease having non-cardiac surgery have a higher 30-day mortality and an increased incidence of perioperative cardiac arrest. Risk stratification is important to determine where these children should be managed in the perioperative period and whether surgery is appropriate. Complex and decompensated disease; pulmonary hypertension, cardiac failure, arrhythmias or cyanosis, should be managed in a specialist cardiac centre. Highest-risk lesions for adverse events are cardiomyopathy, aortic stenosis and single-ventricle circulations. Children having major surgery and children <2 yrs old should be referred to a specialist centre. Cardiac disease in low-risk patients (e.g. physiologically normal, or well compensated disease, in an older child having minor surgery) can be managed locally, although discussion with their specialist team is recommended.^18,19

Preoperative assessment should include a discussion with the child's cardiology team and most recent cardiac investigations. Difficult venous access should be anticipated in the child who has undergone multiple procedures and intensive care admissions.

Most cardiac medications should be continued, but this approach should be reviewed on an individual basis. Antithrombotic therapy may need to be altered or stopped in the perioperative period. Decisions should be made in conjunction with the cardiology, haematology and surgical teams. In general, aspirin should be continued, especially in children with shunts, to prevent thrombosis. Angiotensin-converting enzyme inhibitors are omitted routinely in adult practice; the evidence in children is less clear and is done on a case-by-case basis.^18,19

Neurological

Epilepsy

Epilepsy is one of the most common neurological presentations in children. Seizure history, including type, frequency and control, should be ascertained. Anti-epileptic drugs should be continued and a rescue plan for seizures documented. The most recent epilepsy review should be obtained, including blood tests and drug concentrations. Additional investigations depend on specific patient factors (e.g. cardiac involvement in patients with tuberous sclerosis). A consultant anaesthetist should review children with epilepsy syndromes or poorly controlled disease.²⁰

Cerebral palsy

Cerebral palsy is a non-progressive brain injury that occurs in the neonatal period. Severity varies greatly, making every patient unique. Common associations include problems with muscle tone and movement, joint contractures and scoliosis. Patients may also present with epilepsy, visual and hearing problems, communication and behavioural challenges and gastrointestinal issues. It is important to establish precise patient needs in preoperative assessment. This affects list organisation, surgical positioning, airway management, venous access, pain assessment and postoperative care. The multidisciplinary team should be involved throughout.²¹

Neuromuscular disease

Patients with neuromuscular disease require specific planning, related to respiratory and cardiac function and the impact of underlying disease on anaesthetic technique. Considerations include.

• (i)Degree of respiratory and cardiac impairment and requirement for postoperative critical care
• (ii)Rhabdomyolysis: the risk is highest in younger children (<8 yrs old). Known triggers (volatile agents and suxamethonium) should be avoided.
• (iii)Malignant hyperthermia (MH): known triggers (volatile agents and suxamethonium) should be avoided in children with a confirmed diagnosis, significant family history or specific predisposing condition (central core disease, King–Denborough syndrome and Evans myopathy).²²

Antithrombotic therapy

Management of anticoagulant therapy for children is a balance between the bleeding risk from surgery and the risk of perioperative thrombosis. A written plan should be put in place for both stopping and restarting medications. Therapy can be continued when the procedure is a low risk for bleeding, for example dental treatment. When risk of thrombosis is low, therapy can usually be stopped temporarily. Children at high risks of both bleeding and thrombosis may require bridging with a heparin infusion (Table 2).²³

Table 2.

Management of anticoagulant therapy for children.²³ LMWH, low-molecular-weight heparin; VTE, venous thromboembolism

Anticoagulant	Minor thrombosis risk (e.g. long-term secondary prevention)	Intermediate thrombosis risk (e.g. VTE last 6–12 weeks or stroke last 3 months)	Major thrombosis risk (e.g. VTE within 6 weeks or metallic heart valve)
Oral anticoagulant (e.g. rivaroxaban)	Minor surgery: stop >24 h; stop >48 h if impaired renal function Major surgery: stop >48 h After surgery: restart after 6–8 h if no risk of bleeding; give prophylactic LMWH 6–12 h after if risk of bleeding	Minor surgery: stop >24 h; stop >48 h if impaired renal function Major surgery: stop >48 h After surgery: restart after 6–8 h if no risk of bleeding; give prophylactic LMWH 6–12 h after if risk of bleeding	Minor surgery: stop >24 h; stop >48 h if impaired renal function Major surgery: stop >48 h After surgery: restart after 6–8 h if no risk of bleeding; give prophylactic LMWH 6–12 h after if risk of bleeding or consider heparin infusion
LMWH	Before surgery: stop 1 day before After surgery: give prophylactic LMWH after 6–12 h	Before surgery: stop 1 day before After surgery: give prophylactic LMWH after 6–12 h	Before surgery: stop 1 day before; consider substituting with prophylactic LMWH or a heparin infusion if >24 h until surgery After surgery: give therapeutic LMWH after 6–12 h
Warfarin	Preoperative: stop 4 days before After surgery: give prophylactic LMWH after 6–12 h	Preoperative: stop 4 days before; give prophylactic LMWH 3 days before surgery After surgery: give prophylactic LMWH after 6–12 h	Preoperative: stop 4 days before; give therapeutic LMWH 3 days before surgery or consider heparin infusion After surgery: give therapeutic LMWH after 6–12 h

Implantable devices

Children with implantable devices, such as cardiac pacemakers, programmable shunts, vagal nerve stimulators and deep brain stimulators, require special precautions and input from the consultant anaesthetist. Plans may include decisions about positioning, use of diathermy and MRI compatibility of the device. Not all devices are compatible with MRI imaging, and discussions with manufacturers are vital if there is doubt. The surgeons should be informed, as medical devices may have implications for surgical technique.

Some devices require cardiac or neurophysiologists to reprogramme them. This process may affect the organisation of the operating list. If there is a chance of any electromagnetic interference during surgery, implantable cardiac defibrillators should be switched off and external pads applied. Children with pacing dependency should have the device reprogrammed to an asynchronous mode during surgery.²⁴

Conclusions

Formalised preoperative assessment in paediatrics is a desirable development, bringing the care of children in line with that of adults. It allows for individualised care, shared decision making and informed consent. It improves satisfaction and reduces the risk of day-of-surgery cancellation. In stretched healthcare systems with long waiting times and social demand for timely care close to home, preoperative assessment allows children and young people to be assessed and undergo surgery safely and efficiently at the right time, right place and with the right team.

Declaration of interests

The authors declare that they have no conflicts of interest.

Biographies

Hannah Lewis MSc FRCA is a consultant paediatric anaesthetist at The Royal London Hospital. She is joint chair of the national Paediatric Anaesthesia Trainee Research Network (PATRN). Her areas of specialist interest are preoperative assessment, quality improvement and anxiety management in children.

Amy Norrington BSc Hons, DCH PGCertMedEd FRCA is a consultant paediatric anaesthetist and lead for paediatric anaesthesia and preoperative assessment at South Tees NHS Trust. She was a contributing author for the recent Association of Paediatric Anaesthetists of Great Britain and Ireland Best Practice Guidance for paediatric preoperative assessment services. Her areas of interest include preoperative assessment and management of perioperative anxiety in children.

Matrix codes: 1I05; 2A03; 3D00

MCQs

The associated MCQs (to support CME/CPD activity) will be accessible at www.bjaed.org/cme/home by subscribers to BJA Education.