1 The Practice of Pediatric Anesthesia
Preoperative Evaluation and Management
Parents and Child
Anesthesiologists must assume an active role in the preoperative assessment of children. Ideally, the anesthesiologist performing the preoperative evaluation will also anesthetize the child. A complete medical and surgical history; family history; medical record review; evaluation and review of laboratory, radiologic, and other investigations; and physical examination are performed on every child who is to be anesthetized (see Chapter 4). When appropriate, the child should receive preoperative medical therapy to optimize his or her medical condition or conditions (e.g., children with seizure disorders or reactive airway disease) before receiving anesthesia. In addition, the emotional state of the child and family must be considered and appropriate psychological and, if necessary, pharmacologic support provided. The anesthesia team, working in concert with surgical colleagues, nursing, and child-life specialists, should find appropriate and creative techniques (e.g., use of videotapes, booklets, hospital tours, and trained paramedical personnel) to prepare the child and family. The marked increase in the number of outpatient surgical procedures has reduced the time available for interaction among the anesthesiologist, the family, and the child. Despite this reduced contact time, these support techniques should not be neglected.
Familiarity with a child’s clinical and psychological status as well as the parental concerns is essential to delivering quality anesthesia care. To achieve the very best outcome for each child, it is essential to meet with the child and the parents (or caregiver or legal guardian) together and establish rapport preoperatively. There are many developmental issues that surround the hospital experience: for example, teenagers fear loss of control, awareness, and pain; younger children fear mutilation from their surgery; and toddlers fear separation from their parents (see Chapter 3). However, for children who are old enough to understand (usually age 5 years and older), it is reasonable to explain in simple terms what anesthesia involves and what will transpire on entering the operating room. It is vital to speak directly to the child because he or she is the person having the surgery. Children at the age of reason have the same fears as adults, but have greater difficulty articulating them. It is important to explain the differences between “sleep” from anesthesia medicine and the sleep they get at home. Even if they undergo anesthesia for hours, they will feel as if they were unconscious for only the time it takes to blink the eyelids once. Many children are also fearful of awakening during the surgery and others are fearful of not awakening at the end of surgery. Children require reassurance that they will not feel anything during surgery, that they will not wake up during the procedure, and that they will awaken at the conclusion of the surgery.
1. As your child is anesthetized, the eyes may roll up: “You might see your child’s eyes roll up and this is completely normal and happens to all of us when we fall asleep; it is just that we are not looking for it.”
2. “As people fall asleep they often make snoring noises and other noises from their throat; if your child does this it is completely normal.”
3. “As the anesthetic reaches the brain, the brain sometimes gets excited and causes movement of the arms and legs that are without purpose, or it may cause them to turn their head from side to side. This means the anesthetic is having its effect and even though your child appears to be partly awake, he (or she) has received enough anesthesia to ensure that he (or she) does not remember this.”
4. “If your child becomes frightened, we will increase the amount of the anesthesia medicine rapidly and calm your child as quickly as possible.”
5. If the child is to have an IV induction, then informing the parents that the child might suddenly look pale and that the start of anesthesia will be very rapid is also helpful so as to avoid confusion about what the parents will observe.
These preemptive explanations are important to undermine the parents’ anxiety at a time when you need to focus on the child. It is common for parents to decline to be present during induction once they hear these explanations. Finally, it is prudent to reassure the parents that for surgeries that are emetogenic and in children who have been or are prone to emesis, that appropriate prophylactic therapy will be administered before the child recovers. Similarly, explain to them that if pain is anticipated, it will be managed aggressively in the operating room and in the recovery room. Anesthesiologists can provide valuable assistance in this respect because of their knowledge of the pharmacology of sedative and opioid medications (see Chapter 6), as well as their ability to perform neuraxial and peripheral nerve blocks (see Chapters 41 to 43). The possible need for postoperative intensive care, including assisted ventilation, should be anticipated and fully discussed with the parents and child (if the child is of an appropriate age). If special monitoring is required in the operating room or postoperatively, this should be explained and the child assured that the IV catheters, airway devices, and all invasive monitoring devices will be placed after induction of anesthesia to avoid causing discomfort and will be removed as soon as the child’s postoperative condition permits.
