Children Are Not Small Adults
Every year, hundreds of surgical or diagnostic interventions are performed on children at the American University of Beirut (AUB) for which administration of anesthesia is required. Pediatric anesthesia is not merely adjusting doses to smaller body weights. It entails an adapted global approach that starts the moment children or parents learn about the impeding intervention and extends until the convalescent child is ready to leave the hospital.
Preparing children for their operating room experience is of paramount importance. It helps alleviating parental anxiety by assuring them that their child will receive the best anesthetic care possible. It also decreases children’s anxiety and subsequently allows smoother induction and recovery from anesthesia. An anesthesiologist is always available for the preoperative evaluation and psychological preparation of the child in the preadmission unit of the hospital or on the ward the day before surgery. The amount and type of information that we provide is dependant on a number of variables including patient age, timing of the intervention and the child’s prior hospital experience. In addition to the medical evaluation, the aim of the preoperative visit is to establish rapport and win the confidence of the family and child, as well as to explain the type of anesthesia and to optimize the psychological preparation by pharmacological prescriptions. Also, fasting policies are explained and parents are instructed that their children can safely drink moderate amounts of water up to two hours before surgery in order to increase comfort. In a busy hospital, such as AUB, parents or children may feel that the time provided by the anesthesia team is limited in the preoperative period; therefore, phone calls to the anesthesiology department are encouraged and are considered as useful adjuncts to the preoperative visit, because they allow additional information to parents or children to be offered.
The day of the surgery, all children scheduled will transit through a holding area before they reach the operating room. They will be received in a child-friendly environment accompanied by their parents. A final assessment will be done and premedication will be administered to relieve separation anxiety. The child is admitted to the operating room, only when the anesthesia team judges him ready to separate from his parents. Allowing parents with their child into the operating room is not routine practice in our institution; however, exceptions can be made when judged necessary. In this case, the parent will separate from the child following induction of anesthesia. It is common practice to use face mask induction of anesthesia in young children because they commonly have needle phobias. However, insertion of an intravenous cannula and induction of anesthesia using the intravenous route is also a valid option in compliant children and/or after preparation of the puncture site with EMLA cream. Both techniques offer excellent safety profile. During induction, maintenance and recovery from anesthesia children are continuously monitored in compliance with the American Society of Anesthesiologists standards. Recently, the improved knowledge and safety of loco-regional techniques in pediatrics has led to an increase in their use worldwide. The anesthesiology team at the AUB is also following this trend and considers that regional anesthesia in pediatric patients is a valuable adjunct to general anesthesia. The use of regional anesthesia offers the advantage of an improved postoperative analgesia. In addition, spinal anesthesia is emerging as a valid alternative to general anesthesia in preterm and older children.
Following emergence from anesthesia, children are admitted to the post anesthesia care unit (no parent is allowed to remain with the child during the whole length of stay to decrease the anxiety related to his presence in a hostile environment. Postoperative agitation and anxiety are addressed using instinctive comforting measures, distraction techniques and parental involvement. All potential side effects, such as nausea and vomiting or pain that may follow anesthesia or surgery are treated before the child is discharged to the pediatric ward. Increased awareness concerning the problem of postoperative pain in children has led to an improved assessment and treatment. The occurrence of pain following surgery in young children with inadequate communication skills makes its identification problematic. Age-adapted and validated pain assessment tools and scales are used in our department to overcome this problem. Considered as the fifth vital sign, pain is assessed frequently and its treatment is carefully tailored to ensure comfort, safety, and smooth recovery. Following discharge from the PACU, the anesthesia-based acute pain service of the hospital continues to be involved in the treatment of postoperative pain on the ward.
Caring for the surgical child and his family is a team effort which requires that the nurses, surgeons, pediatrician and anesthesiologists are all involved. In a joined effort with all health care providers, the aim of the anesthesiology department of the American University of Beirut is to provide a dedicated care to pediatric patients in order to offer them a stress-free hospital experience.