Care of the child during the perioperative phase

Introduction
This assignment will focus on the care of a two year old child throughout his time in the perioperative environment. It will begin with the preoperative assessment and provide any background information and history about this patient. This paper will then go through the theatre experience and what care this child received and why, such as the type of anaesthesia used, their surgery and the recovery of this patient up until they were discharged back to their ward. This assignment will underpin how a child’s anatomy is different to the adult anatomy and why this affects what care is given to children. This assignment will focus on the role of the operating department practitioner (ODP) and how they assist in providing care for this individual throughout their time in the operating theatre. It will touch on how the parents/guardians can be involved in some stages of this child’s care too. Various pieces of research from current debates, testimonies/policies, journal articles, books and internet sources will be included. Furthermore, references to these sources of research will provide evidence of the decision making process in providing the necessary care for this particular patient.
There are many differences between the anatomy of paediatrics and adults such as differences in size, anatomy, physiology, pharmacology and psychology Pescod (2005):

Infants have larger heads that need to be stabilised during intubation. Their tongues are larger and their necks shorter, therefore their airways are more prone to obstruction than in adults. Infants and babies mainly breathe through their noses and therefore their nostrils are very small and easily obstructed too. A child’s larynx is located further forward and at a higher level relative to the cervical vertebrae compared to an adult. A child’s epiglottis is longer and U shaped compared the adult’s and also their trachea is quite short. When intubating children it is advised that both lungs be listened to using a stethoscope, this will ensure that the endotracheal tube is not only in one lung (Macfarlane 2006).
In pre-pubescent children, the narrowest section of the airway is the cricoid ring and after puberty the narrowest part is then at the same level of the vocal cords. A complication caused by pressure from the endotracheal tube can be the production of a mucosal oedema and post extubation stridor. It is advised that pre-pubescent children should have an un-cuffed endotracheal tube and that the correct sized endotracheal tube is selected (Black 2008).
Brown (2000) cited in Clarke (2010) states that infants have a higher metabolic rate and an increased oxygen consumption level compared to adults. De Melo (2001) cited in Clarke (2010) explains that this is why induction and emergence from anaesthesia in children is much quicker. Higher oxygen consumption means that infants will rapidly consume their oxygen reserves and become cyanotic if they are apnoeic. Higher oxygen consumption leads to a higher carbon dioxide production, which requires increased ventilation to remove it (Pescod 2005).
Respiratory rates in children are faster due to paediatric lung immaturity and smaller lung volume reserves therefore paediatric breathing equipment is essential.
Blood pressure is lower in children than adults because of low peripheral resistance (Krost et al 2006). Children have a relatively small blood volume, for example a 5kg infant will have a blood volume of only 400 ml (Macfarlane 2006).
The World Health Organisation (WHO) (2005) states that infants are at a greater risk of cooling when exposed to a cold environment because the ratio of body surface area to body weight is much more than in older patients. Skin and subcutaneous fat is thinner, providing less insulation and greater heat loss. Temperature regulation is immature and infants must be kept warm. The operating theatre should be heated and the infant kept covered and intravenous fluids should be warmed.
The differences in physiology of the infant will alter the effect of some drugs. Decreased renal and liver function results in certain drugs being excreted more slowly. The dosing interval should be increased to avoid toxicity (Pescod 2005).
The minimum alveolar concentration (MAC) of inhalational agents is greater in the young and decreases with increasing age. There is a smaller margin of safety between adequate anaesthesia and cardiovascular and respiratory depression in infants compared with adults. Both induction and recovery from inhalation agents is more rapid in children than adults (Pescod 2005).
Preparation for surgery is paramount and evidence proves that it reduces associated stress and can even promote recovery. As a result of this evidence, many hospitals have a pre-admission preparation programme for patients including children who are due to undergo emergency or elective surgery (Chambers and Jones 2007). Preoperative assessment takes place in an outpatient clinic following with a nurse or a consultant no more than one month before admission to hospital. For emergency cases, the preoperative assessment is carried out shortly before the surgery takes place. In an evaluation on the effectiveness of a pre-assessment clinic for children undergoing day surgery at Oxford Radcliffe children’s hospital, Higson and Finlay (2010) concluded that pre-assessment clinics prove to be very effective. Pre-assessment clinics support surgical planning and aid everybody in preparation for the surgery from medical staff to the child and their family. These clinics also provide parents with information about the surgery, gives them a chance to present any fears or questions about the surgery and the well being of their children throughout the whole perioperative experience. It also helps them and their children prepare for admission.
The National Health Service (NHS) (no date) state in a patient information leaflet that during a pre-assessment appointment, depending on the patient’s age, medical history and the nature of the operation, various routine investigations are performed. These may include blood tests, electrocardiogram’s (ECG’s), blood pressure and pulse monitoring and weight measurements. During the appointment the patient’s medical history and details of any medication being taken is recorded. The patient/family members will then have the opportunity to ask the nurses any questions about their operation and their stay in hospital. In another patient booklet the NHS (2004) state that the main aim of pre-assessment clinics are to assess the patient and ensure that they are fit for surgery. It also gains the patient’s consent for the operation and to confirm that the admission date is acceptable for them. Pre-operative assessment clinics also provide an opportunity to organise anaesthetic assessment if required.
The child chosen to be studied for this assignment received scalds across his chest from a hot drink which he had accidentally pulled from a shelf at home. This child only received partial thickness burns and suffered pink and red, blistering burns. He received more than 10% burns and therefore was admitted as an in-patient. There was no evidence of respiratory distress. During the pre-operative assessment the parents were told what to expect so that they could prepare themselves and their child for the procedure. Patient history was gathered from the parents; however the child had no previous medical history. Their consent was also given for the child to receive surgery. The reason for the procedure was explained and the anticipated outcome, potential risks and benefits were also explained. It was also ensured that the child was medically fit for the operation. It is widely accepted that the child’s parents/carers be involved in all decisions affecting the treatment and care of the child and in the physical and psychological support of the child too (Chambers and Jones 2007). The surgical care of infants and children can present difficult ethical dilemmas. The nurse’s/ODP’s role involves acting as the child’s advocate and in supporting decision making together with the child and family. Basic ethical principles beneficence, nonmaleficence and justice should be applied. All actions should be of benefit to the child and family and ultimately do the child no harm. All individuals should be treated equally and with fairness and ethical decisions should be made with the involvement of the child and the family (Chambers and Jones 2007).
During the pre-operative assessment appointment there was an opportunity for the child to become accustomed to to the environment, play with and become familiar to theatre equipment such as monitoring, stethoscopes and masks. It was checked that the child was in the best nutritional state possible as good nutrition will aid in healing wounds (Pescod 2005).
According to WHO (2005) surgery may cause blood loss and the anaesthetic may affect oxygen transport in the blood. This child’s haemoglobin was checked to see if it was normal for the age of the child, it was ensured that the child’s blood was cross matched and that reserve blood transfusions were available in case of situations where anaemia must be corrected quickly.
On the day of surgery during the preparation of paediatric airway equipment, it was ensured that the ODP assisting the anaesthetist had appropriate endotracheal tube sizes available, particularly one size smaller and larger than the tube intended for use. Because paediatric patients can deteriorate rapidly, an emergency intubation trolley was available providing a range of different sized paediatric equipment. This included small cannulae, guedel airways, nasal and oropharyngeal airways, bougies and stylets and Magill forceps. There were other various pieces of equipment available from the trolley too such as different sized endotracheal tubes and fibre optic laryngoscopes. It was ensured that all necessary equipment and monitoring were checked and available. Also drugs including emergency drugs were immediately available such as suxamethonium and atropine.
Children have much smaller diameter airways than adults and it makes them susceptible to airway obstruction (Clarke 2010). This child was intubated as it helps to protect an airway during surgical procedures. It is recommended to have tubes one size bigger and smaller available.
Prior to anaesthetic children may become very distressed and so having a parent or carer in the room is an advantage as it lessens the child’s level of anxiety. On this occasion, the child’s mother came into the anaesthetic room along with a member of staff from the children’s ward. The anaesthetist had already met the child and his mother and had developed a relationship. Communication is also essential between the anaesthetic assistant (or ODP) and the child and his parents to build up a relationship and rapport (Amin et al 2010). The parents were very concerned about the safety of their child so therefore any questions were answered honestly and truthfully with support and reassurance.
Once the child had arrived in the anaesthetic room his details were checked and the consent was clarified with his parents. It was also confirmed that the child had an empty stomach prior to receiving a general anaesthetic and all allergies were noted (Pirotte and Veyckemans 2004). All of the pre-op checks were recorded on a theatre care plan which was devised to enable the correct recording and documentation of the care received by the child whist in theatre. It was compatible with the care plans used on the children’s ward so that continuity of care could be maintained (Pirie S 2011). Care plans are also a useful tool in recovery for use at handover to ensure that everything is communicated to the ward staff (Chambers and Jones 2007).
Routine monitoring was attached and this gave an opportunity to play games with the child to ease tension whilst he became familiar with his surroundings. ECG was attached and a pulse oximetre placed on the child’s foot. The blood pressure was attached once the child was asleep. While the child remained seated on his mother’s lap and continued to play games he was anaesthetised by inhaling sevoflurane, a volatile anaesthetic agent together with nitrous oxide and oxygen through a mask which was held nearby to his face. Inhalational induction is an excellent technique for young children and/or children who fear needles (Macfarlane 2006). Once the child had lost consciousness, the parents returned back to the ward with the ward nurse. The ODP or anaesthetic assistant assisted in airway maintenance and ventilation whilst the anaesthetic cannulated the child. Once cannulation was achieved the child was given propofol intravenously and the child was intubated.
Because children have an increased metabolic rate compared to adults, it was paramount that there was plenty of intravenous fluid available. Due to an interruption of normal fluid intake, replacement fluids were determined hourly, based on the child’s weight to provide maintenance fluid and to cover ongoing losses. Hartmann’s compound sodium lactate solution was selected instead of saline. It was ensured that too much intravenous fluid was not given through the use of a burette. Fluids were also heated through a warming device to a body temperature.
Children lose heat more rapidly than adults because they have a greater relative surface area and are poorly insulated. This is important as hypothermia can affect drug metabolism, anaesthesia, and blood coagulation. Hypothermia was prevented ensuring that the air conditioning was switched off and the room was at the correct temperature of more than 28?C particularly for a child with burns. It was also important that there were not many or no exposed parts of the child. A heating blanket was used to cover the lower body of the patient and the child’s temperature was monitored throughout the operation via a nasal temperature probe. Throughout the surgery the child was continually examined and reviewed. His responses to pain medication, boluses of IV fluids, oxygen, and IV transfusions, where appropriate were monitored. A catheter was not inserted on this occasion due to the length of the operation. IV fluids given intravenously were closely monitored because of the risk of fluid overload leading to heart failure or cerebral oedema.
Prior to the child entering the theatre it was paramount that the operating theatre was correctly prepared. Children are susceptible to pressure ulcers and prevention is essential. Chambers and Jones (2007) have clearly states that infants should be lying with their limbs in a neutral position so that nerves are not damaged during surgery. All monitoring leads and intravenous lines were not underneath or on top of the patient where they could cause damage, instead they were positioned alongside him and the breathing circuit was secured by a tube holder
A team meeting was carried out where the anaesthetic team shared information about the patient such as his allergies and what the operation was about to entail. Prior to the commencement of surgery, the scrub nurse/ODP checked the consent form against the child’s name band with a circulating nurse. It was the scrub nurse’s/ODP’s duty to ensure that the child was not at any risk of harm from the weight of the drapes or surgical instrumentation being applied incorrectly or placed on top of the patient. It was also their duty to make sure all equipment such as instrument sets and dressings were available for this operation.

The burnt skin was carefully cleaned; debrided and the blisters were pricked and dead skin removed. A thin layer of biobrane film was also applied and held in place with skin glue. Biobrane is a biosynthetic wound dressing constructed of a silicone film with a nylon fabric partially imbedded into the film (Smith and Nephew no date). It is a temporary skin covering which is used to aid the healing of superficial/partial thickness burn or scald injuries (Latenser and Kowal-Vern 2002). Biobrane acts as a temporary dressing that remains in place for up to two weeks or until the wound underneath has healed. Biobrane helps to reduce levels of pain and discomfort for the patient, the need for painful dressing changes and may also lead to a reduction in scarring for the patient (NHS 2010) (Mandal 2007). In a randomised controlled trial by Kumar et al (2004) it was concluded that biobrane significantly reduces the time taken for partial thickness burns to heal. After the biobrane had been applied, a dressing was placed over the top to protect the biobrane and to help prevent any infections.
Once the surgical operation had been completed, the child was transported to recovery. Children are generally recovered in a child friendly environment preferably away from adult patients. The recovery used for this child in the burns unit only contained one recovery bay and so there were no adult patients close by. Also the recovery staff trained in recovering paediatrics had notification of the child’s arrival and therefore all the specific paediatric equipment was prepared. This included paediatric breathing systems, non-invasive blood pressure cuffs, small face masks and airways. There was clear communication with the ward staff and family about the outcome of the operation, problems encountered during the procedure, and the expected postoperative course. The parents were notified of their child’s progress and encouraged to be with their child in recovery. This helps minimise any emotional trauma as soon as they are fully awake and suitably recovered. All vital signs were monitored, the respiratory rate, pulse and a one off blood pressure was taken too, ensuring there were no abnormal readings (Fisher 2011).
The Australian and New Zealand College of Anaesthetists (ANZCA) (2005) cited in Baulch I (2010) explain that indicators of infants in pain can be observed in their behaviour and may include crying, and altered facial expressions and body movement. Infants may also display individual reactions such as withdrawal or fighting to alleviate their pain. Physiological changes may also be observed, with increases in blood pressure, heart and respiratory rate, and sweating. This child arrived into recovery having already received a lot of analgesic and so did not show any signs that he was experiencing pain. Once he had fully recovered from the anaesthesia the child was discharged back to the children’s ward with his parents.
The ODP acts as an integral part of the team in the operating department working with surgeons, anaesthetists and theatre nurses to help ensure every operation is as safe and effective as possible. ODPs provide high standards of patient care and skilled support alongside medical and nursing colleagues during perioperative care.
The care of children with burns requires a multidisciplinary team approach (Williams 2011). The best possible care of a child in the operating theatre requires psychological preparation, planning for each individual’s specific needs, and good communication between the child, family, the ward staff and the theatre nurses, with all the potential risks to the child being safely managed. Effective collaboration between families and the multidisciplinary team is imperative to the long term success of any surgery. The child and parent should always be kept well informed of the care plan and treatment at each stage. Families should be given a clear forecast of the outcome of the surgery, ensuring that expectations are realistic (Chambers and Jones 2007).
References
Amin A, Oragui E, Khan W and Puri A (2010) Psychosocial considerations of perioperative care in children, with a focus on effective management strategies. Journal of Perioperative Practice. 20 (6), pages 198 – 202
Baulch I (2010) Assessment and management of pain in the paediatric patient. Nursing Standard. 25 (10), pages 35 – 40
Black A (2008) Laryngospasm in paediatric practice. Paediatric Anaesthesia. 18 (4), pages 279 – 280
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Pescod D (2005) Paediatric anatomy and physiology and pharmacology. Available at: http://www.developinganaesthesia.org/index2.php?option=com_content&do_pdf=1&id=48 Accessed on 21/04/11
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