Page 17 - 59peadiatric-surgery-speciality8-14_opt

56 Anaesthesia and Perioperative Care

room temperature for the newborn needs to be closely monitored; in intracardiac shunt lesions, which can be very helpful information for the
areas where the outside environment has more impact on the theatre anaesthesia plan. Respiratory problems, such as adenoid hypertrophy,
temperature, the use of warming pads and even small heating units may cleft palate, upper airway infections, and asthma, are commonly seen
need to be utilised to maintain the patient’s body temperature. The use in the surgical patient and add to the anaesthesia risks. Typically, if a
of the type of heating pad that can be purchased in most African capital patient presents with an acute productive cough, fever, or wheezing,
cities needs to be monitored in the theatre setting, as this pad can cause then elective surgeries need to be cancelled for a minimum of 2 weeks
burns in the neonate if the controls and the patient’s temperature are to allow for resolution of the underlying infectious process and the
not monitored diligently. Also, the use of warmed fluids at appropriate corresponding airway effects. For the preterm infant, the incidence
levels needs to be considered in any theatre where paediatric surgery of apnoea and bradycardia increases the need for cardiorespiratory
is more common. monitoring in the postoperative period for 12–24 hours, depending
Haematology upon the severity of the problem.
The red blood cells in the newborn are very different from those of Fasting Guidelines
adult haemoglobin because fetal haemoglobin dominates, and at 6–8 The preoperative NPO guidelines for surgical procedures for the pae-
months of age, this subunit of haemoglobin is absent. Foetal haemo- diatric population will be different from those for the adult population.
globin has a higher affinity for oxygen; hence, the oxygen-carrying An infant younger than 12 months of age can have breast milk or clear
capacity is higher. Many paediatric patients in the African setting may liquids up to 4 hours presurgery. After the age of 12 months, clear liquids
present for surgery with a relative anaemia, and some may need further up to 4 hours and solids (including formula) up to 6 hours presurgery are
investigations. Although nutritional causes of anaemia need to be con- allowed. All children on diets with fatty foods need to wait 8 hours after
sidered first, there are many potential causes, such as malaria, sickle a solid meal for elective surgery. Of course, emergency surgery cases
cell disease, intestinal worms, and even drug-induced anaemias. Many need to proceed without consideration of the NPO status, and precau-
paediatric patients can have elective surgery when their haemoglobin tions should be taken to avoid pulmonary aspiration of gastric contents.
is less than 8 gm/dl, but these patients will have a better postoperative The glucose status of a neonate who presents for surgery and has had an
course with supplemental oxygen. In the context where sickle cell hae- intravenous line needs close evaluation so that hypoglycaemia does not
moglobin analysis is not available, blood is given to sickle cell disease interfere with the anaesthesia management.
patients who present for surgery with a haemoglobin level below 8g/dl. Premedication
Preoperative Assessment and Preparation The use of preanaesthetic medication to remove anxiety is common in
The emotional stress evident in the eyes of the paediatric patients and the paediatric population. The use of anticholinergics, benzodiazepines,
parents in the preoperative setting prompts one to make every effort and narcotics can be adjusted by the anaesthesia care provider to pro-
to alleviate this aspect of the anaesthesia and surgical experience. The duce the desired effect with weight-appropriate doses. There are risks
preparation by the anaesthesia care provider should include a preop- involved in a setting with few nurses per patient population in the ward,
erative visit at which the provider determines the need for surgery, the as an elevated dose of the drug may be given inadvertently because the
physiological implications for anaesthesia, the necessary laboratory doses are small volumes for the paediatric patient and the side effects
evaluations, and the psychological condition of the patient and family. may be difficult to detect.
If this is done in advance, and all questions by the family as well as Premedication should be individualised to each patient on the
the surgical team are answered, then the overall care of the paediatric basis of age, weight, level of anxiety, previous anaesthetic experience,
patient will improve. The patient may indeed benefit from a preopera- allergies, and expected level of cooperation. The oral route remains
tive sedative or other medication so that the transfer from floor care to the commonest way of giving premedication. It has the advantage of
the theatre care will be smoother. being painless, but may have an unpredictable onset or a bitter taste.
Psychological factors, which include the patient’s age, the cultural Midazolam, a short-acting water-soluble benzodiazepine, is widely
norms for surgery, the impact of previous medical care prior to the used for premedication in paediatric practice. It has a fairly reliable
patient arriving at the institution, and the pathophysiological condition onset and duration of action and can be given through a variety of
of the patient, all impact the preoperative preparation. Children between routes, including oral, nasal, sublingual, rectal, intravenous, and
the ages of 6 months and 5 years tend to demonstrate the most fear intramuscular (IM). It does not appear to prolong recovery room stay or
when presenting to the theatre setting. A carefully arranged preoperative time to hospital discharge. Other commonly used premedication drugs
environment that can help with these fear issues may allow for easier include fentanyl, ketamine, sufentanil, clonidine, and, increasingly,
transfer to the operating theatre. Also, a good physical exam that includes dexmedetomidine. Although some of these agents may not be available,
the cardiorespiratory system, nervous system, and gastrointestinal each institution needs to assess its drug availability and budget and then
system will allow the anaesthesia care provider the opportunity to seek an alternative to these agents if they are available.
develop an anaesthesia plan that is more informed and safe. Premedications should be avoided in the patient with elevated
Disorders of the central nervous system (CNS) are common in the intracranial pressure and carefully titrated in the patient with congenital
paediatric patient; trauma—which is very high in this population in heart disease as well as the severely depressed child who presents for
every country in the world—can produce closed head injury patients emergency surgery. The generalities that are presented in this section
who present in the acute and the chronic phases of trauma. Seizure prompt anaesthesia care providers and surgeons to carefully assess
disorders with anticonvulsant drugs need to be evaluated for their their specific clinical situations and then determine whether the use of
efficacy and such haematologic side effects as low platelets. Cerebral premedication is safe and advantageous for their specific population of
palsy, neuromuscular diseases, and polio are all common aetiologies paediatric patients.
for a paediatric patient who presents for an orthopaedic procedure or an
emergency surgery, and special care needs to be taken in the anaesthesia Anaesthetic Management
plan for such populations. At the end of the preoperative assessment, an anaesthetic plan is made
The incidence of congenital cardiac diseases is more common in that takes into consideration the medical condition of the child, the
the paediatric surgical patient than it is in the general population. If needs of the proposed surgical operation, and a way of allaying any
a murmur is discovered in the preoperative work-up, it needs to be anxiety being felt by the parents and the child. All medications and
evaluated. Even a pulse oximetry reading that is normal rules out many materials, including blood and intravenous fluids, must be ready before