Kid-Friendly Care

Hospitals, surgery centers and operating rooms can be big, scary places to young children, but depending on their age and developmental level, they need to have some understanding of the procedure they’re having done. Unfortunately, some parents like to keep their kids in the dark by not telling them about what’s going on around them. Sadly, I have cared for many pediatric patients who did not know they were about to undergo surgery. Their parents were in the room whispering to me to not say anything. My advice: Tell the parents of your pediatric patients to inform their children, in an appropriate way, of the care they’re about to receive. Even a generalized description, such as “We’re going to the hospital to help you feel better,” helps to ease a child’s anxiety about the strange environment in which they’ll find themselves.

Also remind parents that their children feed off their emotions on the day of surgery. Parents who are extremely anxious make their child more nervous, but parents who are relaxed in pre-op (or pretend like they are!) will help their child remain calm before induction. Using guided imagery, engaging in therapeutic play, playing background music and providing access to shows or movies on a facility-supplied tablet can also help a child relax. I apply a flavored ChapStick, such as cherry or bubblegum, to their masks and ask them to guess the flavor. It’s a fun game that diverts their attention from the sights and sounds of surgical care.

By using guided imagery or distraction techniques, you can often redirect children’s anxiousness enough to avoid using pharmacological interventions to keep them calm. However, not all techniques work for all children. Some pediatric patients require oral midazolam — at a maximum dose of 15 milligrams — before procedures to help alleviate their separation anxiety or fears of the unknown.

Emergence delirium, which is classified as an abnormal mental state during the transition from unconsciousness to complete wakefulness that develops as a result of anesthesia administration, is quite common in pediatric patients. Children in the midst of a bout of post-op delirium roll around and thrash, can be inconsolable and usually cannot register what’s being said to them. There’s no gold standard for treating post-op delirium, but giving a small propofol bolus can help manage the condition. Dexmedetomidine has been administered before emergence — doses range from 0.5 mcg/kg to 1 mcg/kg — with good preventative effect.

Assessing a child’s pain and discomfort following surgery can be very challenging based on their developmental level and age. If they can talk, ask them to rate their pain level on a scale of one to 10. It might be more effective to use the Wong-Baker FACES Pain Rating Scale, which lets children self-assess their discomfort by pointing to a facial expression that matches how they’re feeling. If a patient is an infant or nonverbal, check their vital signs for an indication of their pain level. For example, a baby whose heart rate or blood pressure goes up during surgery is probably having a normal physiological response to pain, so you know to administer medication to help reduce it.

If a child wakes up from surgery in significant pain, you can administer morphine, fentanyl, ibuprofen or acetaminophen. Dilaudid can be used to control pain in teenage patients. Regional blocks placed during surgery are also effective ways to manage post-op pain. It’s standard practice at pediatric hospitals to administer regional anesthesia after patients are anesthetized to avoid having to manage their fears and questions during what’s likely to be a frightening and confusing procedure. As with all aspects of pediatric care, we explain the risks and benefits of regional anesthesia to parents or legal guardians, and only perform blocks if it is appropriate and we receive consent.

Kids should be assessed for PONV risks with a pediatric assessment tool because triggers in children are different than in adults. In adults, the female gender, history of PONV, non-smoking status and opioid use increase the risk of PONV. In kids, gender doesn’t impact the risk, secondhand smoke exposure doesn’t matter, opioid use is generally not an issue, and they are often undergoing surgery for the first time and therefore don’t have a history of PONV. Additionally, the chemoreceptor trigger zone (the vomiting center in the brain) isn’t fully formed or functional in children younger than two years old, so they’re typically not at increased risk of PONV. Instead, ask parents if their child gets carsick or queasy on amusement park rides. Also ask parents if they or direct relatives have had any issues with anesthesia.

Surgical case types such as eye muscle surgery, procedures involving insufflation of the abdomen and surgeries lasting longer than 45 minutes can trigger PONV. To prevent the risk in pediatric patients, who often don’t drink enough fluids at home, administer IV fluids before surgery to ensure they are adequately hydrated. Dexamethasone and ondansetron can also be administered before surgery. If children still wake up feeling nauseous in recovery, administering an antihistamine can help calm their stomach.

The great thing about children is that they’re very resilient and able to bounce back relatively quickly from surgery. Even when they’re scared or nervous, they can laugh at a silly joke or be consoled with a hug. It’s amazing to witness. I’m constantly reminded that all kids are special and deserving of the best possible care we can provide. OSM

Dr. Simon ([email protected]) is chief CRNA at Huntington Valley Anesthesia Associates and the assistant program director/didactic education coordinator at the Frank J. Tornetta School of Anesthesia, located in the suburbs of Philadelphia.