The Practice of Pediatric Anesthesia

1 The Practice of Pediatric Anesthesia

IN THIS CHAPTER WE outline the basis of our collective practice of pediatric anesthesia. These basic principles of practice can be applied regardless of the circumstances; they provide the foundation for safe 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.

The possibility of postoperative pain and the relief the child will receive in the form of nerve blocks and analgesics must be clearly presented to the child and the parents. It is also important to explain to the child and the family what they can anticipate on entering the operating room and to explain the special monitoring you, as the anesthesiologist, will provide for the child. A simple explanation of the monitors can be very reassuring to parents and interesting for many children. For example, the pulse oximeter can be described as a “Band-Aid−like device” that lights up red and measures the oxygen in the bloodstream during anesthesia and recovery; the blood pressure cuff can be characterized as an “arm hugger” or “muscle tester”; and the electrocardiogram leads can be called “little sticky things that don’t hurt so we can watch the heart beat.” Simple descriptions of the measurements may also be soothing. For example, you can say: “We measure the oxygen you (your child) are (is) breathing, we measure the amount of the anesthesia medicines you (your child) are (is) breathing, and we measure the carbon dioxide you (your child) are (is) breathing so as to ensure that your (your child’s) breathing is just right throughout the anesthesia.” Sometimes asking teenagers if they have studied carbon dioxide in school science class helps them to better understand the monitors and provides reassurance, as well as making it more interesting. The detail with which this is presented will vary from family to family and child to child as well as with the anesthesiologist’s understanding of the needs of the child and family. By the end of the interview, however, the child and the parents should understand that you will be providing the quality of care that ensures the child’s safety during anesthesia, thus reducing the child’s and parents’ anxiety. Explanation is also needed to describe how anesthesia will be induced, although the degree of detail used will again depend on the developmental level of the child. For young children, one can describe a plan to breathe “laughing gas” through a flavored mask, with a flavor that he or she chooses. Older children can be given the option of an intravenous (IV) induction, with nitrous oxide by mask to establish IV access painlessly; or if they are afraid of needles, they might be given the option of an inhalational induction.

If parents are to be present during induction, it is essential to describe to them how they can assist in comforting the child and prepare them for what they might observe and experience to avoid any misconceptions. Parents should not be pressured into feeling that they must be present for induction. It must be clear that, if at any time during the induction there is a new or additional risk to the child, they may be asked to leave the operating room and will be escorted to the parent waiting room. Remind them that their presence at induction is for their child’s benefit and is a privilege, not a right. Thus, if there are issues with a difficult airway, if a rapid induction of anesthesia is needed, or if the child is very young, it would be inappropriate for the parents to be present and not in the child’s best interest for physicians and nurses to be distracted at a time when everyone’s attention needs to be focused on the child.

It is helpful and essential to explain to the parents specific changes in the child that might be observed at the time of anesthetic induction:

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.

The anesthesiologist who sits down, who speaks slowly and clearly while answering questions, and who is neither distracted nor in a rush to leave, presents a very different image to the child and parents from the anesthesiologist who stands tapping his or her toes, speaks quickly, and has one foot pointed toward the door. Details regarding the anesthetic should not be recited in a cold and technical manner, but rather with communication that addresses the parents’ and the child’s questions and concerns. This dialogue is frequently afforded too little time, leaving the parents and child insecure and apprehensive, their questions unanswered. Body language is especially important during this preoperative interview. If the family speaks a different language than the anesthesiologist, then a medical interpreter should be sought.

May 25, 2016 | Posted by in ANESTHESIA | Comments Off on The Practice of Pediatric Anesthesia
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