Learn to Love Your Pediatric Cases

If preparing for pediatric cases makes your palms perspire and your stomach do flips, I can sympathize. Kids are much more likely than adults to become hysterical before surgery, fight induction, and experience pain and/or vomiting. Their suffering takes a heavy emotional toll on surgery professionals, because we know that in their eyes, we are responsible for causing their misery. But kid cases don't have to be nearly so traumatic, if you are willing to do a little extra legwork prior to the case, make a couple of alterations in your normal routine and provide a little extra tender loving care. In this article, I'll relate some of the techniques we use here at the Children's National Medical Center and the Children's Hospital Ambulatory Surgery Center in Washington, DC, to allay children's fears, to induce them without incident, and to make the immediate and long-term post-op period both pleasant and virtually pain free.

Pre-op preparation
Children are smarter and more intuitive than most adults realize-they pick up immediately on their parents' anxiety, and they may have even absorbed media horror stories about botched surgeries or patients not waking up from anesthesia. If they don't ask questions, it's not because they don't have them-it's because they are unable to express them. To address these fears, educate the parents, and make sure the surgical day goes as smoothly and quickly as possible, we offer special pre-operative programs at our facilities, which the children and their parents attend the weekend before surgery.

Our programs are designed to be informative, reassuring, and even fun. We start with a tour of the center, where the children spend time playing in the waiting room and walking through the pre-op areas. We show them what an anesthesia machine looks like and have them "practice" breathing through the induction mask. They also see the nurses and anesthesiologist in full OR attire to orient them to what people will look like in the OR. Following the tour, the children and parents watch a special puppet show. The show, scripted by child-life specialists, is designed to address many of the questions children probably have but may not ask-namely, "Will it hurt?" "Will I wake up afterwards?" "Will my parents be able to stay with me?" "When will I be able to leave?"

If you perform many pediatric cases at your facility, you may want to consider developing a similar program. Children who attend them tend to be much less frightened and go home much more quickly. In any case, you should always take special precautions to pre-screen all pediatric patients. At our facilities, we interview the parents over the phone a few days before surgery to determine past or present risk factors, including a history of prematurity or cardiac or respiratory problems. In some cases, we target conditions that cause us to re-evaluate whether the child is an ambulatory surgery candidate or if he/she needs additional pre-op care (see sidebar). We make a second phone call 24 hours or less before surgery to check on the child's health, reinforce NPO orders, and discuss practical matters such as parking, what to bring to the hospital, and how long the visit is expected to take.

Making the surgical day go smoothly:
The thumb and index finger of the non-dominant hand are most likely to be injured, followed by the middle finger, other fingers, palm, and back of the hand. The non-dominant hand is a likely target, since it is often used to reposition and reach for needles, hold tissue that is being cut or sutured, or used as a retractor to protect adjacent viscera during cutting or suturing. Injuries are most likely to happen during longer procedures, procedures associated with increased blood loss, and procedures where large numbers of personnel work in a confined space.

On the day of surgery, we aim to get the children in and out of the facility as quickly and easily as possible, with minimal emotional and physical distress. You may want to adopt some of the following techniques to care for your pediatric patients.

Ease restrictions on pre-op fasting: Recent studies have shown that it's really not necessary to require children to fast for a long time (NPO after midnight) prior to surgery; this practice does not seem to significantly minimize gastric volume or acidity. We instruct parents to give children clear liquids until two to three hours prior to anesthesia induction. We don't allow solid foods, milk formula, or milk products; however, breast-fed infants are allowed to nurse up to four hours preoperatively. Liberalizing NPO requirements minimizes thirst and discomfort while awaiting surgery, helps avoid hypoglycemia, and lessens the risk of hypovolemic-induced hypotension during induction.

Keep children with the parents as long as possible: Many studies and much experience have shown us that children are significantly less upset when parents stay with them, so we try to keep them together for as long as possible. In our facilities, we have special induction rooms right outside the OR, where parents can stay with their children until they fall asleep. If you don't have induction rooms, you may want to have the parents change into scrubs or wear a cover-all gown to accompany their children right into the OR and stay until after induction.

It's important to be selective when choosing which parents can stay with their children-if the parents are extremely upset or anxious, they may upset their children even more. If both parents are present, we try to choose the calmer one to be the escort; if neither is capable, we administer fast-acting sedatives to make the separation easy.

Use creative ways to relax the child during induction: Induction is a "moment of truth" for many children-even if they seem calm beforehand, it can be terrifying for them to see and feel the mask come down over their faces. Here are some ways you can ease this process:

- Place a drop of food flavoring in the induction mask to give it a more pleasant smell. We give children an added sense of control by presenting a choice of flavors-for example, bubble gum, cherry, or orange.

- Allow children to sit up during induction, so they can see and talk to the anesthesiologist on a more equal level, rather than see the mask coming down on top of them.

- Make the induction mask part of a game or story-have the children make believe, for example, that the mask is part of a space suit or the cockpit of an airplane.

If children receive proper psychological preparation, establish a good rapport with the anesthesiologist and staff, and have parents who are able to stay with them, there's an excellent chance that they'll be able to handle the entire surgical process. If these methods don't work, however, we try one or all of the following:

- Pharmacologic premedication: If we anticipate that patients may need preoperative sedation, we try to have them arrive at least one hour beforehand to give the medications time to work. We've achieved good results with midazolam syrup (0.5 mg/kg 20-45 minutes before induction). Other options include oral ketamine (6 mg/kg), or Oral Transmucosal Fentanyl Citrate (10-15 mg/kg). Any of these agents can facilitate separation and seem to have minimal effects on recovery time.

- Pre-induction agents: In rare cases, children will seem fine up until the point of induction and then suddenly become hysterical. In these situations, it's sometimes best to postpone the surgery, but if this can't be done, the last resort is to give fast-acting pre-induction agents. We use low-dose (2 mg/kg) intramuscular ketamine, methohexital (25 mg/kg 10% solution) rectal administration, or intranasal midazolam (0.2 mg/kg). All of these agents take under 10 minutes to take effect and do not delay recovery.

- Postponing the procedure: If we have a child who is extremely hysterical, we sometimes elect to postpone the procedure, because usually there is something else that is wrong. I will always remember one four-year-old who came in for an adenoidectomy. As the induction period approached, she became inconsolable-far beyond what we expected, and we elected to delay the procedure rather than upset her further. When we questioned her mother, we discovered that the child had had a sister who died of leukemia while being treated in our hospital. The child was terrified that she was going to die as well, although she couldn't express this. This heart-wrenching experience taught us two valuable lessons-it's vital to question the parents thoroughly about their children's previous experience with doctors and hospitals, and when a child's emotional reactions seem far out of proportion, there may very well be a hidden reason. The best we could do in this case was to delay the procedure; when the child returned weeks later, we made sure she was accompanied by child-life specialists and given pre-operative sedation well before she arrived in the OR.

Anesthesia techniques

To make the induction mask more pleasant, try putting in a few drops of food flavoring.

Today's fast-acting anesthetics have made induction, maintenance, and recovery extremely safe and fast for pediatric procedures. We prefer sevoflurane for both induction and maintenance in very short procedures; it has a very pleasant smell and provides a rapid and smooth induction with no airway irritation. In longer cases, using sevoflurane for the duration of the case may not be cost-effective; in these cases, we maintain anesthesia with halothane or isoflurane (the latter usually affords a faster recovery). We avoid using desflurane for induction because it causes airway irritation, coughing, and laryngospasm. However, using it after induction with sevoflurane or halothane is an excellent technique and affords significantly faster emergence and recovery than using sevoflurane or halothane alone.

Many older children resist being put to sleep with inhalational induction. In these cases, we induce intravenously with thiopental sodium or propofol. Propofol, in particular, is associated with an extremely low incidence of post-operative vomiting, even following procedures that normally result in PONV, like strabismus surgery.

If you use intravenous induction in pediatric cases, consider using a skin-numbing cream like EMLA to lessen the pain of venipuncture. EMLA takes at least one hour to work, but you can minimize the time spent in pre-op by training parents to apply the cream and an occlusive dressing a few hours before the children arrive for surgery.

Controlling pain and vomiting
Controlling pain and vomiting is perhaps the most important thing you can do for children-there's nothing worse than having a child wake up in agony. At our facilities, we use the following multi-modal approaches to control pain:

Regional blocks: After induction, we always administer a local anesthetic block-most often a 0.25% bupivacaine injection-before surgery starts to minimize the pain around the surgical site. The blocks also allow us to use a lighter level of general anesthesia, assist in rapid recovery, and provide excellent pain control.

Acetaminophen: For years, anesthesiologists dismissed acetaminophen as a "weak" analgesic. However, when administered in the right dosage and given enough time to achieve a proper blood level, it is actually extremely effective. We usually administer a dose of 40 mg/kg rectally after induction before the procedure starts. This allows the medication enough time to build up in the bloodstream, so the patient wakes up pain free. In some cases, we combine oral acetaminophen with codeine (120 mg acetaminophen with 12 mg codeine per 5 ml) for even more effective pain relief.

We also instruct parents to administer acetaminophen (10-15 mg/kg orally) every four to six hours after the child leaves the facility to keep the drug in the bloodstream and keep the child pain free.

Other techniques: If indicated, we have used other pain control medications, including non-steroidal anti-inflammatory drugs, such as ketorolac, or narcotic analgesics, such as remifentanil, fentanyl, or meperidine.

Prolonged vomiting used to be one of the primary reasons that children were admitted to the hospital following surgery. Certain surgeries, such as orchiopexy, ear surgery, hernias, and eye muscle surgery are notorious for causing post-op PONV. Our aggressive pre-emptive treatment for PONV involves administering anti-emetic medication intravenously before patients awaken. We also provide intravenous fluids to ensure that they are well hydrated without having to drink, which can upset their stomachs. As mentioned previously, we use propofol and avoid opioids in patients who are at high risk for vomiting.

Recovery

In our facilities, children recover from anesthesia in a post-anesthesia care unit and are reunited with their parents in a special short-stay recovery unit. In recovery, we give the parents written post-op instructions and try to immediately involve them in the post-op care. For example, if a child has mild oozing, the nurse can show the parent how to care for the wound, rather than doing it herself. This helps prepare parents for what they'll have to do at home.

Again, be selective when allowing patients to join the child. If the child has a very large incision, for example, make sure he or she is properly bandaged and looks as "normal" as possible before the parents enter the room.

It's best to have specific discharge criteria to provide uniform care and ensure a complete legal record. Our discharge criteria include:

- appropriateness and stability of vital signs;
- absence of respiratory distress;
- ability to swallow fluids, cough, or demonstrate a gag reflex;
- ability to ambulate consistent with the age level;
- absence of excessive nausea, vomiting, and dizziness, and a state of consciousness appropriate to the age level.

Planning, creativity, and special sensitivity to children's needs are crucial for making an ambulatory surgery facility "kid-friendly." With careful attention to all three elements, you'll ensure that visits are as brief and easy as possible, give parents peace of mind, and get your littlest patients back on the playground in no time.