Care of the Pediatric Patient in Surgery: Neonatal Through Adolescence ”

Home , Pediatric nursing, Pediatric surgery

CARE OF THE PEDIATRIC PATIENT IN SURGERY : NEONATAL THROUGH ADOLESCENCE

1961 1961 CARE OF THE PEDIATRIC PATIENT IN SURGERY : NEONATAL THROUGH ADOLESCENCE

STUDY GUIDE

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Care of the Pediatric Patient in Surgery: Neonatal through Adolescence

TABLE OF CONTENTS

PURPOSE/GOAL ...... 5 OBJECTIVES ...... 5 OVERVIEW ...... 6 Developmental Stages ...... 6 Resources used in table ...... 7 Neonate: ...... 8 Toddler ...... 8 Pre-School ...... 9 School Age ...... 9 Adolescence ...... 9 Fear and Anxiety ...... 10 Anxiolytic Premedications ...... 10 Parent Present Induction ...... 11 Rapid Sequence Induction ...... 11 Inhalation Induction ...... 12 Patient Positioning ...... 12 Pressure Injury Prevention ...... 12 Electrosurgical Considerations ...... 13 Maintenance of Normothermia ...... 13 Fluid and Electrolyte Balance ...... 14 Emergence Delirium ...... 15 Pain Control ...... 15 Patient-controlled Analgesia ...... 16 Sedation ...... 16 Discharge Teaching ...... 16 Cast Care ...... 17 SUMMARY ...... 17 REFERENCES ...... 18 POST-TEST ...... 23 POST-TEST ANSWERS ...... 26

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PURPOSE/GOAL The purpose of this video and study guide is to review pediatric developmental stages, the importance of preoperative assessment in providing safe care, the basic principles of patient centered care and parent present induction, and critical aspects of intraoperative and postoperative care.

OBJECTIVES After viewing the video and reviewing the accompanying study guide, participants will be able to: 1. Discuss the importance of pediatric developmental stages. 2. List the essential aspects of the preoperative assessment. 3. Identify the basic principles of parent present induction. 4. Relate the critical aspects of postoperative care.

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OVERVIEW on an outpatient basis, home care concerns related to pain Care of children in the perioperative environment is complex control and wound surveillance are presented. and must take into account the fact that children are not just small adults. A thorough understanding of the stages of DEVELOPMENTAL STAGES development from the neonate throughout childhood and A basic understanding of pediatric developmental stages is culminating in adolescence is essential. In addition, the preop, essential to all phases of perioperative nursing care and affects intraop, postop, and discharge phases of pediatric patient care how the nurse interacts with the large variety of patients in the are multifaceted and include many factors that must be pediatric population. It is important for the nurse to establish considered. Aspects addressed within this study guide include a connection with the parents as this will help establish trust the effect of developmental stages, psychological preparation with the child. The nurse must also remember that chronologic of the child and parents, medication safety, thermoregulation, age is not always the same as developmental age; this can be and pain control. Pediatric patients come in a wide range of particularly important for children with developmental issues, sizes. Because of this, equipment must be appropriately sized whose chronological age may have no relationship to their for the pediatric patient and should be quickly obtainable. Care cognitive stage. Several fears that seem almost universal of the pediatric patient is a team effort, best accomplished throughout the pediatric population include separation anxiety through collaboration among anesthesia providers, surgeons, and fear of pain, disfigurement, and loss of control. The and the nursing staff throughout the continuum of care. Lastly, following table delineates some of the key differences given the frequency with which pediatric surgery is performed throughout the various developmental stages and typical age ranges for each stage. Stage of Life Neonate Infant Toddler Pre-school School age Adolescent Age Range First 30 days 1-12 months 2-3 years 4-5 years 6-12 years 13-18 years Vital Signs R 30-50 R 20-40 R 15-25 R 15-20 R 12-20 R 12-18 P 90-180 P 100-180 P 65-140 P 65-140 P 65-90 P 55-110 BP 60±10 BP 80-90s±30 /45- BP 100 ±25 BP 100 ±25 BP 110-120±20 /65- BP-120s ± 20 /32±10 65±25 / 65± 25 / 65± 25 70 ±15 /75 ± 15 Cognitive growth Physiologic Object permanence Developing memory, Improved language Logical thought Developing abstract adaptation to Rely on senses imagination, cause & skills, questioning Problem solving skills reasoning, hypothetical life outside Ever-increasing effect, Language Developing thinking & reasoning thinking, synthesis skills womb motor skills (Comprehension skills Gaining perspective Realistic view of death Learning to separate greater than Less egocentric, Early understanding self & world verbalization) sharing of body functions, & Stranger anxiety ≥ 6 egocentric Magical thinking/ death mo. Play fantasy Learning right & Inquisitive, curious wrong Psychosocial Bonding to Developing trust Asserts Environmental Industry vs. inferiority Strong sense of self parents Bonding to parents independence, wants exploration Gaining self control Independence, self Oral exploration control, Self confidence Achievement determination Rely on parental Limited language developing oriented Developing values, social attendance Developing emotional Gender identity skills, relationships with & bodily control Respect for authority opposite sex & rules Peers important Imaginary friends Mixes fantasy with reality Fears Separation Parental separations Long separations Separation Loss of control /autonomy Pain Abandonment Loss of control Loss of control Bodily injury & pain Distrust Dark Bodily injury & pain Bodily injury, Disfigurement Loss of control Frustration disfigurement & pain Disability Bodily injury & pain Imagined threats Death Humiliation Loss of peer acceptance Peer pressure

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Stage of Life Neonate Infant Toddler Pre-school School age Adolescent Age Range First 30 days 1-12 months 2-3 years 4-5 years 6-13 years 12-18 years Reactions Crying Crying Resistance Aggression Increased Varied Detachment Stranger anxiety Aggression Uncooperative verbalization of Mood swings Stress reactions Detachment Uncooperative Regression fear/feelings Depression Regression (behavior Withdrawal Isolation/ withdrawal Helplessness & toileting) Anger/ guilt Inquisitiveness/ Tough attitude-this Temper tantrum Fantasy questioning can’t hurt me Hyperactivity Displaced anger/ total Anger Unfamiliar frustration Stoicism environment Demanding behavior Stubbornness decreases coping skills Perioperative Comfort measures Comfort measures Security object Acknowledge & Acknowledge & Detailed , Interventions (pacifier, security (pacifier, security Encourage verbal encourage encourage comprehensive items, items, expression of feelings verbalization of fears, verbalization of fears explanations stroking/patting back) stroking/patting back) Avoid hunger use puppets Encourage Acknowledge & Avoid hunger Avoid hunger (schedule in AM) Demo / touch questioning, provide encourage (schedule in AM) (schedule in AM) Accept regressive equipment thorough answers verbalization of fears 10% Dextrose Warm room behavior Medical play Allow simple decision /concerns infusion available /equipment incorporate Integrate Pre-operative tours related to care Respect privacy Warm room (80F)/ Utilize fluid warmers home routine Avoid “go to sleep” Hands-on equipment Encourage peer equipment for irrigation & IV /activities use special sleep demo visitation /acceptance Utilize fluid warmers solutions Offer appropriate /nap (thing of putting Pre-operative tours Include patient in for irrigation & IV Wrap / cover head choices pets down) Be upbeat concerning decision making solutions with plastic Avoid “go to sleep” Warm room results process /allow Wrap / cover head Minimize extraneous use special sleep /equipment Promote situational control when with plastic noises/ activity /nap (thing of putting Utilize fluid warmers mastery possible/ appropriate Minimize stressors/ Prompt parental pets down) for irrigation & IV Teach coping skills Parent Present extraneous noises/ reunion/ involvement Warm room solutions (distraction, Induction at CHILD’s activity Place second pulse /equipment PPI breathing, discretion Avoid preps with dyes ox probe (as a back- Utilize fluid warmers Videos, electronic visualization) Music during (tattooing risk) up) for irrigation & IV games during Pre-operative tours induction Post-op may need to solutions induction /education Encourage peer remain intubated Videos, electronic Prompt parental PPI socialization Prompt parental games during reunion Encourage peer Continue with school reunion/ involvement induction socialization work Place second pulse Parent Present Continue with school ox probe (as a back- Induction (PPI) work up) Prompt parental Music during reunion/ involvement induction Videos, electronic games during induction

Resources used in table Clancy J, McVicar A, Boyd S. The surgical neonate. Br J Perioper Nurs . 2001;11(1):21-27.Leack, K. M. (2007). Perioperative preparation of the child and family. In Browne NT, Flanigan LM, McComiskey CA, Pieper, P.,eds. Nursing Care of the Pediatric Surgical Patient . 2nd ed. Sudbury, MA: Jones and Bartlettt Publishers; 2007:4.

Hesselgrave J. Developmental influences on child health promotion. In Hockenberry M, Wilson D, eds. Wong’s Essentials of Pediatric Nursing. 8th ed. St. Louis, MO:

Mosby Elsevier; 2009:73-79.

Shields L, ed. Perioperative Care of the Child: A Nursing Manual . Oxford, UK: Willey-Blackwell; 2010:104, 169. Silverman AM, Wang VJ. Shock a common pathway for life-threatening pediatric illness and injuries. Pediatr Emerg Med Pract. 2005;2(10):8.

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Neonate through age 1 (Lönnqvist, 2011; Maxwell, 2007). Postop apnea is a danger until 60 weeks postconceptual age, which includes early infancy. The neonatal larynx is located higher in the neck, affecting the ease of application of cricoid pressure (Luginbuehl, 2011; Maxwell 2007). Circulating blood volume changes throughout an infant’s early life, starting at 90 ml/kg in the premature infant, decreasing to 85 mg/kg in the early neonatal period, then increasing transiently to 105 mg/kg for the first few days. This is followed by a measured decline through the first six months of age to 75-77 mg/kg, which is typical of older children (Luginbuehl). Other hematologic values undergo similar changes as the child progresses through infancy. The nurse should ensure that age- The neonatal period is generally recognized as the first 30 appropriate pediatric laboratory reference ranges are used days of life. Typically, neonates are sensitive to light and when reviewing pediatric lab results. sound, have difficulty controlling their heads, are obligate nose breathers, have increasing muscle tone, and are frequently difficult to console. Neonates have a large surface Infant area in relation to their weight and blood volume, which makes them prone to hypothermia. Another contributing factor to developing hypothermia is their thin skin, which also makes them vulnerable to water loss through evaporation, potentially leading to dehydration. The neonate is particularly sensitive to stress, which can result from a surgical intervention and all that it entails. The perioperative nurse must be sensitive to the neonatal stress response, which results in alteration in systemic hormonal and metabolic changes, evidenced by changes in vital signs. This stress response affects postoperative recovery due to the catabolic breakdown of fat, carbohydrate, and protein stores Subjects that the perioperative nurse may be able to address and increases the potential for delayed wound healing and the with parents during the first year of a child’s life include risk of postop sepsis. (Easley, Brady, Wolf, Anand and Tobias) proper sleeping position and prevention of shaken baby Additionally, the neonate may experience rapid, syndrome. Parents may request to accompany their infant to disproportionate heat loss, stimulating the secretion of the OR as they see other parents doing; norepinephrine which can cause peripheral vasoconstriction, however, the preoperative nurse should leading to anaerobic metabolism and resulting in metabolic explain that parent present induction acidosis, increased oxygen consumption, and/or respiratory (PPI) has little benefit for the infant, acidosis from pulmonary vasoconstriction, all three of which and that the team members need to can cause or contribute to serious hypoxia (Luginbuehl, I). keep all of their attention on the infant during the induction of anesthesia. It is As part of adaptation to life outside the womb, fetal circulation common, particularly with chubby changes to systemic circulation, although not all changes infants, for the team to attempt occur immediately upon birth (Maxwell, 2007). The foramen multiple IV starts before success, and ovale typically closes within 1 to 2 hours of birth and the it is beneficial to explain to parents that ductus arteriosus begins to close between 10 to15 hours after this is typically done after the infant is birth, with full closure typically occurring by day 2 asleep. (Lönnqvist). The neonate may also experience periodic breathing and irregular respirations, typically subsiding During the preoperative interview, the nurse should gather beginning at 44 weeks postconceptual age and approaching information that will be helpful to the entire team. This low risk at 60 weeks postconceptual age, but may still occur includes a comprehensive birth history and any post-delivery

7 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE issues the infant experienced (e.g., presence of congenital For example, offering the option of being carried, walking, or abnormalities, history of respiratory syncytial virus or other transported in a wagon when going to the OR is appropriate. significant infections), and any history of recent colds. This However, asking “Do you want to go now?” is not appropriate information helps the team anticipate potential complications because, more often than not, the toddler will say no, and not and plan intraop and postop care preferences. Assessing the going back to the OR is not a real option. If a toddler says no types of fluid intake (i.e., breast vs formula) and delivery and you take them to the OR anyway, by ignoring their choice device (i.e., bottle vs sippy cup) is helpful and should be you have lost any trust they may have had in you. clearly documented. Toddlers may view surgery as a type of punishment. Often, Toddler children of this age are engaged in the process of toilet training, and hospitalization and the surgical process can result in regression or temporary loss of toilet skills, in addition to coping skills. Toddlers have difficulty localizing pain (Luginbuehl), and are easily influenced. Therefore, pointing to specific areas of the body or asking leading questions when asking about pain levels can cloud the picture and provide inaccurate information. It is better to use open-ended statements such as “Tell me what hurts,” or “Tell me where it hurts.”

Preschool

Play, frequently described as the work of childhood, begins to occur during the toddler ages of 1 to 3. Children in this active, energetic age group are constantly exploring their environment, and much of this exploration takes place through the process of trial and error. Discussions with the parents about whether the toddler sleeps in a crib or has moved into a bed are important, as placing a child who has graduated to a bed in a crib may not be accepted well by the child or parent. The toddler is beginning to become an individual, expressing egocentric or ritualistic behaviors. Toddlers can be prone to With both toddler and preschool age groups the perioperative temper tantrums or a lack of cooperation when they do not get nurse needs to recognize that the child’s burgeoning language their own way. As a result, the toddler should be allowed skills leave the possibility of misinterpretation wide open. For reasonable choices when possible. example, telling a toddler or preschooler that “You will be put to sleep for surgery” may bring back memories of a favorite pet going to the vet to be put to sleep, never to return home again. More appropriate language would be, “You will take a special nap.” It is also important with these age groups to avoid words that have multiple connotations or disconcerting meanings. This is particularly important with preschoolers who tend to also have budding imaginations. Consider this example—a patient was told that we would “cut him open and fix his bones.” The child fixated on the word cut and, throughout his transport from another facility, cried, “Please don’t cut me open!” It is also important to use age-appropriate, truthful explanations and avoid inflammatory or anxiety-producing

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words or phrases. Preschoolers are believed to be the youngest impending surgical experience. Depending on the child’s group that that can benefit from preoperative preparation exposure to pop culture, they may fear waking up during programs, which can improve their ability to cooperate and surgery, or even death. Despite having increased coping skills, avoid misinterpretation of the surgical experience. they are still prone to stoicism, stubbornness, and anger. They fear loss of control and independence, and this fear, coupled School Age with embarrassment, may manifest as noncompliance with School age children surgical restrictions. This potential for noncompliance can be mature at their own mitigated by allowing the child input into decisions about the rate, based on their impending surgery, such as timing during the school year. The personality and nurse should allow the adolescent patient to give input and experiences, making choice throughout the surgical experience whenever possible. care for this age group The perioperative nurse should recognize that the adolescent complex. What works may not want to share information about controversial topics with one seven-year- such as smoking, drug use, or sexual activity and that these old will not necessarily topics should be addressed in private. work with the next. Their fears cover a Interventions to help adolescents deal with surgery are widely broad spectrum, varied and highly dependent on the child’s degree of maturity. including loss of control, pain, and disfigurement, as well as Preteens between 10-13 years of age are just starting to begin what will happen during surgery, including the possibility of the process of separation from their parents and prefer to death. Children in this age group have growing insight into spend time with peers rather than family. They are beginning their bodies and how they function, so providing simple, age- to develop abstract thought and can build on previous appropriate explanations can mitigate their fears and quell knowledge. This fact can be crucial in helping them cope with their imaginations. For children who will have prolonged surgery. Finding out what the preteen knows about their hospitalizations, recognition of the importance of peer groups impending surgery is a great place to start, and then building is essential, as is planning for keeping up with school work. on this existing knowledge or correcting misinterpretations is beneficial. Adolescence Middle adolescence encompasses ages 14-16. These children Adolescence encompasses ages 12 through 18. In this age tend to be ambivalent to parental participation and may not group, as with the school age group, there is a wide range of want parents to accompany them to the OR. Other reactions developmental progress, and individual children will have include defiant, insubordinate behaviors and a desire to quarrel countless nuances in their development. Similar to the school or debate with care providers or parents. age child, peer groups and keeping up with school work are important—for the adolescent, the importance is even greater. Late adolescence includes the ages 17-18 and some experts feel that late adolescence extends through age 21. This group Adolescents have mature thought processes and have is exceedingly autonomous and peer focused, and has strong developed hypothetical thinking. Children in this age group personal beliefs that they desire to have respected by care may attempt to act bravely and deny their fears about the providers. (Dreger, and Tremback)

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Preoperative pregnancy testing during adolescence is a touchy question and each facility should develop a policy with input from anesthesia—the potential to deliver anesthesia to a patient that is unknowingly pregnant is one of the driving concerns. Anesthesia providers may choose to modify their anesthetic technique, eliminating or minimizing the use of potentially teratogenic medications. One of the potential issues that can arise with pregnancy testing of minors is the issue of informing the patient and parents. Each state may have Preparation programs need to be designed from the child’s different requirements as to whether this information should point of view and, for maximum effect, explanations should also be shared with the parents. If the information is not shared contain little to no medical jargon. It is important to provide with parents and the planned surgical intervention is cancelled, an opportunity to address parental concerns, because it has parents may have questions that may not be able to be been established that parental anxiety can affect the pediatric answered. patient’s actions and reactions. Timing of preparation varies Fear and Anxiety based on the age of the patient. Estimates differ on the number of children who develop Children ages 4-7 significant fear and anxiety prior to their surgical experience. should, ideally, receive One article concluded that between 50 and 75 percent of kids this information as close experience some degree of fear and anxiety (Kain and as possible to the day of Caldwell-Andrews). Through age appropriate preoperative surgery, while more preparation of the pediatric patient, nurses may decrease fears mature 7-year-olds and lessen anxiety that the child may have about the through 12 years of age impending surgical experience (Perry, Hooper and should receive teaching Masiongale). It is believed that beginning around age four, 1 to 2 weeks in advance children benefit from being able to see and touch, through (Ireland). There is some evidence that children under the age medical play, the equipment that they will encounter of 3 may experience a negative effect from exposure to throughout the experience. preoperative preparation programs (Perry, Hooper and In larger facilities, staff members may have access to a child Masiongale). However, age-appropriate preparation programs life specialist whose primary focus is to make the entire are an evidence-based technique that has been shown to surgical and hospital experience as atraumatic as possible. The reduce anxiety, recovery issues, and regressive behaviors, such child life specialist is a great resource for staff, particularly as bedwetting and nightmares. In addition, these programs those with limited experience caring for children. reduce the prevalence of emergence delirium; decrease opioid needs, and can result in an earlier postoperative discharge. The pediatric patient’s reaction to the surgical experience can also be affected by things out of the nurse’s control, such as previous experiences, family dynamics, and parenting practices or styles.

Anxiolytic Premedications The use of anxiolytic premedication in the pediatric population is a contentious issue. When used, the goal of anxiolytics is to allay anxiety and promote smooth induction of a nervous, scared, or unruly child. Karsli and Isaac delineated the ideal properties of an anxiolytic to “1) be painless and easily accepted; 2) have a rapid onset of

10 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE anxiolysis; 3) have minimal side effects; 4) have a short potential for paradoxical excitation in some children and duration of action to reduce postoperative sedation and delay delayed emergence, which is particularly seen in procedures of discharge; and 5) prevent postoperative anxiety and that last less than the drug’s duration of action. Diazepam is secondary behavioral disturbances”(p. 670). Splinter and Kim typically reserved for older children and has an onset of action (2011) stated that current literature does not clearly of 15-30 minutes and a long half-life, which can be a benefit demonstrate that a perfect premedication has yet been if the surgery is delayed. developed. Appropriate indications for use of anxiolytic Clonidine given orally has an onset of action of 35-40 premedication include: minutes; intranasal administration has an onset within 50 • children with a history of previous surgery; minutes. One potential advantage of clonidine is superior • clinging children; sedation compared to midazolam and some evidence that it may help with postoperative pain (Karsli and Isaac). However, • children with neurologic, developmental, or mental its long onset of action is a potential disadvantage, especially health issues with concurrent behavioral when the previous surgery ends early, resulting in the patient manifestations; being taken back to the OR sooner than anticipated. • children with comorbid conditions that make a smooth induction medically beneficial; or Parent Present Induction • other times when PPI is not appropriate (Splinter and Kim, 2011). Patients who may require closer monitoring after premedication administration include, but are not limited to, children with obstructive sleep apnea, adenotonsillar hypertrophy, neurologic impairment, or muscular dystrophy; small infants; and patients with cyanotic heart disease or hypertrophy of the tongue, such as children who have Down syndrome. Increased use of premedication can be attributed primarily to two things, increased comfort of anesthesia providers (Drager, and Tremback), and increased availability of palatable oral preparations. At An alternative approach used to decrease anxiety in pediatric one time, IV patients is PPI, although this is another potentially contentious preparations were alternative. A 2010 Cochrane review ascertained that the given orally and presence of parents did not significantly reduce a child’s found, in many anxiety preoperatively (Mainer). However, the review also cases, to be quite concluded that PPI with calm parents may be helpful and bitter tasting. should be considered based on individual circumstances associated with specific patient care events. Key aspects in the Medications that are typically used as preoperative anxiolytics decision process should be the potential effect on patient include midazolam, diazepam, and clonidine. The use of safety and how helpful the parental presence will be, taking ketamine has typically been reserved for highly uncooperative into consideration that an overly anxious parent may be more children because of the production of a dissociative state and of a hindrance than a help—Karlsi and Isaac (2011) concluded the potential for vivid dreams and hallucinations, in addition that separation from an anxious parent may be more beneficial to problematic anesthetic emergence (Chalkiadis). In than having the anxious parent present for the induction. combative children who have refused or spit out oral Parent present induction may increase patient and parental premedication, ketamine has been given intramuscularly due satisfaction with the surgical experience, which may in turn to its rapid onset of action, which is approximately 16 minutes. positively affect patient satisfaction scores. An assessment Midazolam has the advantage that it can be given intranasally should be made jointly by the anesthesia care provider, with an onset of sedation within 5 minutes, in contrast to oral surgeon, and nurse as to the appropriateness of PPI. When PPI delivery where sedation is achieved within 20-30 minutes is used, it is essential that parents are adequately prepared for (Chalkiadis). Disadvantages of midazolam include the their role; in particular, they should be informed as to what

11 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE types of physiologic and psychological reactions their child children. If the child has been given a premedication they may exhibit during induction. Older patients may not want typically won’t remember the experience and are less likely their parents present. Examples of patient specific conditions to be traumatized. Given this information, fighting with the not amenable to PPI include patients with full stomachs or child to apply all monitors, potentially adding to the trauma unstable airways, procedures involving the airway, infants, of the experience, may not be worth the risk. A simpler trauma patients, and other instances where rapid sequence approach might be to simply ensure that the pulse oximeter is induction is anticipated. applied, because this is considered by some to be the most important monitor (Karsli and Isaac, p.670). This single Rapid Sequence Induction monitor may suffice until the child is asleep. This approach is In a rapid sequence induction, it is frequently the circulating acceptable in children that are not considered high risk or do nurse’s responsibility to apply cricoid pressure for the not possess significant comorbidities. Turbulent inductions anesthesia care provider. Great care must be taken with may increase the potential for breath holding and pediatric patients not to push too hard. Unfortunately, at this laryngospasm (Romino, Keatley, Secrest and Good). Calm time there are no validated studies to establish the exact force children tend to have increased oxygenation levels, increasing required in children (Karsli and Isaac). The cricoid cartilage the margin of safety if intubation is difficult. (Romino, in infants and smaller children is located higher in the neck Keatley, Secrest and Good) than in adults, and may be difficult to locate due to the child’s short neck. Typically, cricoid pressure, or the Sellick Inhalation Induction maneuver, can be accomplished by placing a single finger horizontally across the cricoid and applying gentle pressure. This is usually sufficient to occlude the esophagus (Shields). If improperly applied, cricoid pressure can actually make the laryngoscopy more challenging and, consequently, the intubation more complicated. Contraindications for application of cricoid pressure in pediatric patients are similar to those in adults and include patients with foreign bodies in the upper airway, unstable cervical fractures, active vomiting, or a history of complicated airway management (Beavers, Moos, & Cuddeford). With children, there is the additional challenge of applying Typically, inhalational induction of a child is done with the the cricoid pressure without scaring the child. Pressure on their agent sevoflurane , because of its rapid onset of action and the airway tends to make children afraid in general and may make fact that it is the least pungent smelling of the inhalation them feel as if they are suffocating. To alleviate some of this agents. Once the child has been induced, the circulating nurse fear, the perioperative nurse should explain to the child that is frequently responsible for placing the monitors and starting there will be pressure on their neck as they go to sleep, and the IV while the anesthetist provides ventilation and monitors that it will get heavier as they get sleepier, and that it is a very the airway status. School-age children should be assessed for important safety precaution. the presence of loose teeth, which may become dislodged and Actions and interventions during the induction process should potentially aspirated during laryngoscopy. The airway may be be focused on making the process as atraumatic as possible. secured by an endotracheal tube or laryngeal mask airway that Efforts should be made to avoid a so called “brutane is selected by the anesthesia care provider. The determination induction,” which is when you basically muscle and wrestle an of which device to use will be influenced by the patient’s age uncooperative child until the anesthetic gases take effect. One and the planned surgical procedure. In pediatric patients, the study showed that 70% of patients who had this type of endotracheal tube may be placed without the use of muscle induction developed negative behavioral changes relaxants (Collins & Everett) because no short-acting, postoperatively (Kain and Caldwell-Andrews). In addition, nondepolarizing muscle relaxant exists. However, there is a there is some evidence that patients having such an induction risk for laryngospasm if the patient is not sufficiently deep. may go on to develop a post-traumatic stress-like response; Traditionally, uncuffed endotracheal tubes have been used in however, this type of induction is sometimes unavoidable infants and smaller children to decrease the risk of edema of especially for mentally handicapped or extremely upset

12 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE the cricoid (Shields), typical stirrups are too big for these patients. One option tracheal stenosis, or chosen by some surgeons is to use the frog-leg position at the ulceration (Shields). foot of the bed. A second option is to use appropriate-sized One recent innovation is gel rolls and place them behind the child’s knees, creating a the advent of the slight pelvic tilt with the legs hanging over the bed. Such a microcuff endotracheal position is reminiscent of older style knee crutch stirrups. tube, which has a When patients are positioned in this manner, care needs to be shorter, more pliable exercised to prevent compression of the neurovascular cuff. This tube may be structures in the popliteal (Gruendmann & Fernsberner, 1995). employed to allow a more precise placement Pressure Injury Prevention of the cuff at the tracheal level in an attempt to avoid pressure It is common knowledge that facilities and regulatory agencies on the subglottic portion of the airway (Veyckemans). currently focus on prevention of hospital-acquired injuries. Multiple inflations and deflations of the cuff can result in This is also a critical concern for patients and parents. In the creation of sharp folds that can increase the risk of mucosal OR, this focus can be centered on the prevention of pressure- injury (Veyckemans). If an endotracheal tube is placed, the related injuries. All patients, including children, are at anesthesia care provider will typically listen for a leak by ear increased risk of pressure injuries while under general or stethoscope over the child’s mouth or neck. If the leak anesthesia, due to the effect of anesthetic agents on the ability occurs at greater than 20-25 cm of water, a larger endotracheal of blood vessels to vasodilate and constrict, potentially tube typically replaces the originally selected tube (Maxwell, decreasing perfusions at or around bony prominences 2007). (Gruendmann & Fernsberner, 1995). Complicating accurate information on the prevalence of pressure ulcers credited to Patient Positioning surgical positioning is the reality that surgically generated Patient-specific positioning begins with consideration of the pressure ulcers present differently than traditional pressure specific surgical site and the patient’s age, weight, height, and ulcers. In surgically-acquired pressure injuries, the damage comorbidities. Padding of bony prominences is important begins in the subcutaneous layers and evolves towards the regardless of the age of the patient (Harrington, Simmons, more superficial dermal and epidermal layers (Galvin & Thomas, & Scully, 2008). It is difficult, if not impossible to Curley, 2012). apply safety straps to infants and neonates safely given their Currently, no validated perioperative pressure injury risk small size and propensity to roll and wiggle. Instead, the safest assessment tool exists, let alone one specific to the pediatric course of action may be to have a staff member at the patients’ population (Galvin & Curley, 2012). Galvin and Curley sides at all times, particularly during induction and emergence. recently reported on a quality project designed to develop a Some surgeons may position infants and small children at the pediatric pressure injury risk assessment tool along with the end of the bed in either a supine or frog-legged position identification of nursing action aimed at preventing pediatric (Harrington, Simmons, Thomas, & Scully, 2008, pg. 220; pressure injuries (2012). The tool the authors developed is the Harres, 2007, pg. 43). When the child is positioned at the foot Braden Q+P Pressure Risk Assessment Tool, which combines of the bed, it is helpful to rotate the mattress pad on that the framework of the existing Braden Q Scale, along with a section of the table 180° to prevent the patient from falling pressure ulcer prevention bundle. While the tool developed into the cutout designed to assist in the lithotomy positioning by Galvin and Curley still needs further validation and of older patients (Harrington, Simmons, Thomas, & Scully, reliability testing, many of the interventions the tool 2008). For neonates and small infants, some surgeons may incorporates deserve consideration for use with pediatric prefer to turn the patient 90° on the OR bed to provide easier patients. Specific interventions advocated by the authors access and still keep the patient in close proximity to the include padding tubes and wires to prevent skin contact, anesthesia care provider (Harrington, Simmons, Thomas, & protecting areas of skin-to-skin contact, positioning heels Scully, 2008; Harres, 2007). Infants and small children are elevated off the bed, the use of drip towels while prepping, prone to hemodynamic shifts when moved, so positioning transparent film dressings over reddened bony prominences should be done slowly and in conjunction with the anesthesia and the use of clear plastic incise drapes to prevent pooling of care provider in an attempt to prevent such shifts (Harrington, irrigation. Simmons, Thomas, & Scully, 2008). Placing infants and toddlers in lithotomy position can be challenging because

13 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE

Electrosurgical Considerations potentially devastating because it can create a cascade of Once the patient is positioned, consideration must be given to interrelated events, culminating in significant hypoxia site selection for the return electrode if an electrosurgical unit (Luginbuehl, I). A child may lose as much as 3.6° F (2° C) in will be used. one hour simply from the induction and maintenance of anesthesia (Luginbuehl, I). Patients are prone to hypothermia intraoperatively because while under general anesthesia the threshold temperature at which efforts to compensate or prevent hypothermia is lowered by 2.7° F (1.5° C) — compensatory mechanisms tend not to kick in until core body temperature reaches 93.2-95° F (34-35° C). These mechanisms include “peripheral vasoconstriction and nonshivering thermogenisis” (Salvadore, Engelhart and Tobias). At temperatures less than 93.2° F (34° C), there is some evidence that platelet counts decrease while thrombin times are lengthened, which may contribute to increased blood loss (Verma, Eisses, and Richards). In the first hour, core body Various sizes are available and selection should be based on temperature drops rapidly as much as 2.7° F (1.5° C), and heat patient weight and surface area available for placement. Pads loss can persist for as much as 3 hours. Active warming with return electrode monitoring should be used whenever methods such as warming the OR suite and using circulating possible. Typical sites for pad placement for infants include water blankets, radiant heat lamps, or forced air all are the upper back, abdomen, or thigh. Choosing the area with acceptable methods to preserve or elevate body temperature. greatest muscle mass is ideal. With the increasing popularity Some data has revealed that forced air warming devices may of piercings, particularly among adolescents, a careful be most effective. In neonates and infants, head coverings that assessment for body jewelry should be made preoperatively. prevent heat loss through the head are particularly helpful. Adolescents may deny body piercings if they are not typically Heat loss can also be inadvertent, such as when the bowel is visible, especially if questioned in front of parents. run and left outside the abdomen and subsequently returned The return electrode pad may be near the area of the surgical to the abdomen. This conductive heat loss can potentially be skin prep, especially in neonates, infants, and toddlers, mitigated by the use of a bowel bag containing warm saline if resulting in a need for extreme care to avoid pooling of prep the bowel will be remaining exterior to the abdomen for more solutions interfering with contact between the skin and pad. than a few moments. In adolescents, the presence of tattoos may interfere with placing the return electrode as close to the incision site as Fluid and Electrolyte Balance possible, because placing the return electrode over top of a Maintenance of fluid and electrolyte balance is affected by an tattoo is a risk for pad interference. When operating on smaller infant’s relatively large percentage of total body water. children, surgeons may choose to use needle point electrodes, Newborns are typically 75-80% water, and this typically levels some of which are insulated. Consequently, the settings on the off at about 60% water by age 1 (Ead). Up until 2 years of electrosurgical generator for these needle point electrodes are age, a child’s kidneys are immature and incapable of significantly lower. A point of caution: due to the risk of fire, efficiently concentrating or diluting urine. The effect of this scrub personnel should never allow the use of red rubber is that if a young child is fluid overloaded, the kidneys may catheters to insulate an uninsulated tip. be incapable of increasing urine production, resulting in hypervolemia (Ead). In children, one parameter for Maintenance of Normothermia assessment of hydration status is urine output, which in infants Neonates, infants and toddlers tend to lose heat faster and and toddlers is typically greater than 2-3 ml/kg/hour. In more easily than older children and require efforts aimed at children ages 4 to 7, urinary output is greater than 1-2 maintaining normothermia. Their immature temperature ml/kg/hour, and for ages 7 to 18, output of 0.5-1ml/kg/hour is regulating mechanisms and thin layer of brown fat contribute desired (Shields). In smaller children, precise calculation of to neonate and infant heat loss (Verma, Eisses, and Richards). blood loss is essential and requires precise monitoring of Also, neonates are not able to shiver to maintain their body irrigation fluids used, as well as the degree of saturation of temperature, further hampering temperature maintenance sponges with blood. (Maxwell, 2007, pg. 111). In neonates, hypothermia can be

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Blood replacement in neonates, infants, and toddlers may be specific factors include age (i.e., 2 to 5 years), degree of milliliter for milliliter, depending upon the procedure, amount preoperative anxiety, high anxiety higher risk, temperament, of blood loss, and patient comorbidities. The rationale for this and children who do not adapt easily or are impulsive or is based on the fact that these age groups have a larger blood sensitive. The anesthetic agents sevoflurane and desflurane volume per kilogram of body mass (Shields). A deficit of as have been tied to increased risk of emergence delirium. Seeing little as 10% in a neonate, infant, or young child’s blood one’s child experience emergence delirium can be quite volume may result in hypovolemic shock (Shields). Infants devastating, so parents need reassurance that it is a temporary less than 6 months of age tend to have a coagulation system state with no long-term consequences. that is not fully formed (Verma, Eisses, and Richards). One intervention nurses can facilitate is the splitting of blood units Pain Control in order to prevent waste and potential overload. For neonates and other at risk children, consideration may be given to irradiating blood products to decrease the risk of graft-versus- host disease being induced by white blood cells (Lopez,R.D. 6/28/11 personal communication). In older children, the options of autologous donation may be exercised for elective surgery. One advantage to this option is reduced risk of the child developing alloimmunization, or development of antibodies (Verma, Eisses, and Richards). The alternative of cell salvage is increasingly available as a choice because of the availability of small-volume processing bowls.

Emergence Delirium Pain control is a crucial issue for any patient, possibly even more so in pediatric patients than the general population, because they may not understand why they hurt and that they will get better with time. People once believed that neonates and infants could not feel pain, but this has been proven false (Harres, 2007). There is also some evidence that failure to adequately control the pain of neonates may create pain pathways or pain memory that make them more susceptible to pain in the future (Lönnqvist). Pain medication in patients can be administered several ways by nurses, including orally, intravenously, nasally, and rectally (in infants). The intramuscular route is typically avoided because of the trauma associated with receiving a shot. Dosage of medications is Emergence delirium is reported in the literature to occur in as typically weight based, but depending on the patient’s pain much as 50% of pediatric cases or as little as 10%. This wide tolerance and surgical procedure, some customization of range is due to the complexity of the phenomenon and varying dosing may be required. In these instances, the overriding definitions of the term (Salvadore, Engelhart and Tobias). In concern must be to avoid respiratory depression. addition, some feelings experienced by extremely young Consideration should be given to admitting the child while children, such as desire for food or drink, pain, and fright, may analgesics are titrated or changed. Infants and neonates can be mislabeled because children cannot adequately verbalize be particularly sensitive to the respiratory-depressant effects what they experience or desire. Emergence delirium is also of opioid pain medications (Clancy, McVicar & Boyd, 2001). sometimes called emergence agitation and typical Just because a child is sitting quietly reading a book or playing manifestations include any or all of the following: a game does not necessarily mean that child is pain free. It is “nonpurposeful restlessness, agitation, thrashing inconsolable possible that the parents’ reaction to pain or the perception that crying moaning, disorientation and incoherence” (Salvadore, their child is in pain can affect how the child reacts and reports Engelhart and Tobias, pg.914). Some risk factors for pain, and the child of stoic parents may deny pain. Children’s emergence delirium include rapid emergence and some types perception of pain can also be influenced by their own of surgery, especially of the head and neck region. Patient-

15 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE expectations; if they expect it to be excruciating, they may Patient-controlled Analgesia perceive the pain as severe (Brown and McGrath). A contentious issue in pediatric pain management is the use of patient-controlled analgesia (PCA). The child must be If children derive secondary gains from experiencing pain, capable of understanding how the PCA works; they may report it as more severe than it really is. Consider developmentally-impaired children may not be appropriate this example: every time mom shows up the pain goes through candidates for PCA. There are some reports of facilities that the roof, and subsequently mom dotes on the child; but the use PCA controlled by the nurse to facilitate pain control to moment mom leaves the pain becomes virtually nonexistent. bypass delays inherent in obtaining the medication, In this case, mom’s actions calculating the correct volume for the ordered dosage and may be affecting the second nurse verification. (Burd, Mellender, and Tobias, reporting of the pain 2006). The PCA is set up based on a PRN dosage order with severity. the lockout interval set to the minimum time between PRN Evaluation of pain should doses. Then, all that the nurse has to do when the patient or always be with validated parent requests pain relief is to go to the bedside, make an age or developmentally- assessment, and, if appropriate, administer the dose. Explicit appropriate pain scales. parent teaching is required, emphasizing that the only person Nurses working with who can push the button is the nurse, never the parent. pediatric patients should be given detailed training on Sedation the pediatric pain scales Sedation in pediatric patients should only be administered by they employ in the facility. those qualified to do so, and each facility should set minimum qualifications for nursing staff who will be administering the Increasingly, postoperative sedation. One paper cited by Smith, Ong, and Sury (2011), pain control for pediatric reported 95 catastrophic sedation events that included 51 patients is administered in deaths and 9 patients with unrelenting, continuous the OR, sometimes with the neurological impairment. Minimum requirements for safe use of a local anesthetic either subcutaneously, intra– sedation include well-trained staff proficient in rescue articularly, or intrathecally depending on the location and type techniques that may be needed during sedation; readily of surgery. These medications are generally administered from available and appropriately-sized emergency equipment; the sterile field by the surgeon. Alternatively, the anesthesia knowledge of appropriate dose ranges, including maximum care provider may perform a regional block, selective nerve doses; and strict adherence to selection, recovery, and block, or multiple nerve blocks; the exact type of block is discharge criteria. Children who will undergo procedures via dictated by the location of the surgery, along with the skill or sedation or local anesthesia should be carefully selected, comfort level of the anesthesia care provider with any given because not all children are appropriate candidates. Some alternative. Ideally, anesthesia care providers should provide contraindications include in-service training for nursing staff throughout the perioperative care continuum on the blocks commonly used • presence of abnormal airway in their patient population, desired outcomes such as location • increased intracranial pressure of numbness, and complications to be alert for and report to • altered level of consciousness the provider. Some anesthesia care providers employ regional nerve blocks with catheters. Nurses caring for patients who • sleep apnea have received any type of local anesthetic should be familiar • active respiratory infection with the signs and symptoms associated with overdoses. • distress or failure Nurses should also be familiar with lipid rescue for local • cardiac failure anesthetic toxicity and have the necessary dosage and supplies readily available in the OR, and possibly the post-anesthesia • neuromuscular disease care unit, depending on the proximity of the two areas • bowel obstruction (increased risk of vomiting) (Agarwal and Polaner). • history of undesirable reactions to sedation • allergy to requisite pharmaceuticals

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• distraught or agitated child information is that it allows the parents to digest the content • behavioral issues and then, prior to discharge, the nurse can reiterate key points and answer questions. These benefits may be worth the extra • parental or patient refusal effort this approach requires. Staff members should carefully screen every child each time sedation is required and be willing to speak up if they are Whenever discharge teaching is administered, some topics uncomfortable proceeding with sedation for any reason. should always be covered. These include activity restrictions, Similar considerations should be given to which types of wound care, medication administration, dietary advancement, patients are appropriate candidates for strictly local care of drains and implants, and surgery-specific procedures. AORN’s recommended practices for sedation or complications (e.g., fracture care). Depending on the type of local procedures should always be followed. If available, a surgery, the child may be restricted to light activity for some child life specialist can help with coping strategies, distraction, time, as little as the day of surgery or significantly longer. or mentally occupying the child who is going through a Parents need to be made aware of when and how activities procedure with sedation or local anesthesia. may be increased prior to the first postop visit. Teaching on medication administration includes not only how and when to Discharge Teaching administer pain medication, but also if any of the child’s preoperative medications should be resumed, if the dosage has changed, or if the preoperative medication is no longer needed. When it comes to wound care instructions, it is important to include monitoring for signs of bleeding and infection. Parents may need to know that some minor bleeding into the dressing may occur and at what point they should contact the surgeon if the bleeding increases. Procedures such as tonsillectomy and adenoidectomy may require more specific instructions because bleeding is not immediately visible. The parents should be warned to watch the child for excessive swallowing—particularly when not eating or drinking, Increasing numbers of pediatric surgeries are being performed vomiting of fresh raw blood, skin pastiness, excessive fatigue, on an outpatient basis, including those for moderately or a racing heart. complex surgical procedures on children with limited to no comorbidities. As a result, discharge teaching must be Basic wound care can seem overwhelming to parents, but accomplished the day of surgery, prior to discharge, while covering the basics and giving them concrete resources can parents are generally stressed about the process. One alleviate some of the anxiety parents feel. Basic information innovation that has been attempted in some facilities is to that should be covered include signs and symptoms of present key information while the child is in surgery (Shields; infection, such as elevated temperature, wound discharge, Ruiz, Rivers and Pop, 2012). This approach has the advantage odors emanating from the dressing or wound, redness, of the parents not being distracted by caring for their child. puffiness, inflammation, or an increase in pain. Typical The downside to the approach is that the parents can be discharge instructions include keeping the dressing dry for 2 concerned about how the surgery is progressing and how the to 3 days (Shields). When the dressing is to be removed may child is tolerating the procedure. One way to deal with this vary based on the surgery, postop appointment, and surgeon potential disadvantage is to provide the parents an update preferences. Some surgeons may specify on what postop day before beginning the teaching session and promise that the to remove the dressing, while others may prefer to remove it nurse will check in on the progress of the surgery and at a postop appointment. Parents may need suggestions and condition of the patient personally at the end of the educational guidance and a resource to call with questions and assurances session. Privacy is a concern when discussing patient that they should not be afraid to request that someone see their information and care. In a smaller unit, there may be a lack of child if they are unsure. Based on personal experience, space to accommodate the teaching while preparing and sometimes leaving a bandage over the wound may be helpful, recovering other patients. The advantage of having particularly for inguinal hernia repairs where the surgeon undistracted parents and the opportunity to present chose to use removable sutures. Typically, hernia incisions are

17 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE quite near the waistband of a child’s underwear so a child may be experiencing a compartment syndrome that could could forget about the incision and then rush to the bathroom necessitate further surgical intervention. Casts should be kept at the last minute, ripping their underwear down, and tugging dry at all times unless otherwise instructed by the surgeon; on the skin suture, which can result in inflammation. A simple this may require putting the cast in a bag during bathing or solution would be to keep a larger bandage over the incision showers. If the fracture is in the leg, the child and parents will while the child is at school and remove it in the evening. Such need crutch training and possibly other resources for mobility a simple suggestion could avoid parental concern and a at school. A special car seat may be required, as with children premature postop appointment. in spica casts. It is unusual for a child to be discharged home with drains As with any patient being discharged, written discharge present. However, if this does happen, the discharge nurse instructions should be given to the caregiver, along with needs to cover basic drain care. This includes concepts most resource numbers to call with questions. Discharge nurses are comfortable with such as how to properly open and instructions should be provided in non-technical language and close the drain in order to empty it, how to perform dressing in the preferred language of the care provider—a health care changes, and signs of inflammation or infection to report to translator should be used to translate if necessary. It is not the surgeon. For some outpatient urologic procedures, the acceptable to use the child or their siblings for translation. child may be discharged with a Foley catheter in place. In this Instructions should be given a few at a time and opportunities case, parents should be taught basic Foley care. for questions and clarifications provided by the nurse. Having the parents summarize, repeat the key points back to the nurse Sometimes children with special needs will have devices or provide a return demonstration can provide an opportunity implanted such as gastrostomy tubes, indwelling tunneled to assess understanding and correct misunderstandings. The catheters, or implanted ports. These devices will necessitate child may need a written note from the surgeon addressing in-depth education of the parents as to how to properly care when it is appropriate to return to school and any activity for these devices. Some patients may be discharged with restrictions, possibly including when the child can return to indwelling pain catheters with attached reservoirs for pain full activity. (Shields) medications. In this case, parents need to be taught about the device and how and when to remove the catheter. Most pain Summary reservoirs and catheters present on discharge have self- When the family is regulating dosage mechanisms, virtually eliminating the provided appropriate potential for overdose. This fact should be clearly explained resources for meeting the to the parents. needs of both the parent Discharge teaching must also take into account that many and child, surgery can be procedures have specific postop concerns and interventions a successful event with that parents need to be educated about, as well as changes that limited effect on the child necessitate immediate medical intervention. It is beyond the long term. The resources scope of this study guide to cover all of these. However, given required for pediatric the number of broken bones that children have a propensity surgery are well within to experience, it is appropriate to mention postop cast care. the repertoire of any nurse, although the nurse Cast Care may need to put forth a Cast care includes simple interventions, such as observing the concerted effort to extremity distal to the cast for swelling and watching for pain become comfortable with some of them and others may not alleviated by prescribed pain medications, color change, require the nurse to review concepts such as developmental lack of warmth, lack of movement, and numbness or tingling, care, prevention of hypothermia, age-specific normal all of which can indicate the cast is too tight (Shields). To laboratory values, pediatric pain scales, and postop teaching prevent or mitigate swelling, the extremity should be elevated priorities. To paraphrase the comments of an unknown as much as possible, particularly when the child sleeps. pediatric surgeon: Great technical, surgical skills would Parents need to be instructed to contact their surgeon if any amount to naught without the commitment and devotion of of the mentioned symptoms occur and are not relieved by the nurses charged with caring for pediatric surgical patients. elevation, as the cast may need to be evaluated, split, changed, (APSNA, 2011, p.9) or a splint applied. Even more critical to mention, the child

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REFERENCES 1. Abraham M, Moretz JG Implementing patient- and family-centered care: part 1—understanding the challenges. Pediatr Nurs. 2012; 38(1): 44-47. 2. Agarwal R, Polaner DM. Acute pain service. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:2132-2140. 3. Pediatric surgical nursing: scope and standards of practice: draft for public comment. American Pediatric Surgical Nurses Association. http://www.apsna.org/assets/documents/PediatricSurgicalNursingScopeStandards.doc Published July 31, 2011. Accessed December 13, 2012. 4. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495- 511. 5. Beavers RA, Moos DD, Cuddeford JD. Analysis of the application of cricoid pressure: implications for the clinician. J Perianesth Nurs. 2009;24(2):92-102. 6. Brown SC, McGrath PA. Chronic and recurrent pain in the pediatric patient. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:273-290. 7. Burd RS, Mellender SJ, Tobias JD. Neonatal and childhood perioperative considerations. Surg Clin North Am. 2006;86(2):227-247. 8. Chalkiadis GA. Pharmacology of premedication and sedative agents in children. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:491-524. 9. Clancy J, McVicar A, Boyd S. The surgical neonate. Br J Perioper Nurs. 2001;11(1): 21-27. 10. Collins CE, Everett LL. Challenges in pediatric ambulatory anesthesia: kids are different. Anesthesiol Clin. 2010;28(2): 315-328. 11. Dreger VA, Tremback TF. Management of preoperative anxiety in children. AORN J. 2006;84(5):777-804. 12. Ead N. Fluid and electrolyte management of the pediatric surgical patient. In Browne NT, Flanigan LM, McComiskey CA, Pieper, P, eds. Nursing Care of the Pediatric Surgical Patient . 2nd ed. Sudbury, MA: Jones and Bartlettt Publishers; 2007:17-27. 13. Easley RB, Brady KM, Wolf AR, Anand KJS, Tobias JD. Development and evaluation of pain and the stress response. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011: 259-272. 14. Galvin PA, Curley MA. The Braden Q+P: a pediatric perioperative pressure ulcer risk assessment and intervention tool. AORN J. 2012;96(3):261-270. 15. Gruendmann BJ, Fernberner B. Positioning in the surgical patient. In Comprehensive Perioperative Nursing: Part 1. Boston, MA: Jones & Bartlett Publishers Inc; 1995:388-410. 16. Harres AE. Minimally invasive neonatal surgery. J Perinat Neonatal Nurs. 2007;21(1)39-49. 17. Harrington S, Simmons K, Thomas C, Scully, S. Pediatric laparoscopy. AORN Journal. 2008;88(2):211-236. 18. Hesselgrave J. Developmental influences on child health promotion. In Hockenberry M, Wilson D, eds. Wong’s Essentials of Pediatric Nursing. 8th ed. St. Louis, MO: Mosby Elsevier; 2009:71-96. 19. Ireland D. Unique concerns of the pediatric surgical patient: pre-, intra-, and postoperatively. Nurs Clin North Am. 2006;41(2): 265-298. doi: 10.1016/j.cnur.2006.01.007 20. Kain ZN, Caldwell-Andrews AA. Preoperative psychological preparation of the child for surgery: an update. Anesthesiol Clin North America. 2005;23(4):597-614. doi: 10.1016/j.ac.2005.07.003

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21. Karsli C, Isaac LA. Induction of anesthesia. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:669-689. 22. Kollar K, Moss R. Care of the pediatric patient. In Phippen ML, Ulmer BC, Wells MP, eds. Competency for Safe Patient Care During Operative and Invasive Procedures. Denver, CO: Competency and Credentialing Institute; 2009:1301-1351. 23. Leack, K. M. (2007). Perioperative preparation of the child and family. In Browne NT, Flanigan LM, McComiskey CA, Pieper, P.,eds. Nursing Care of the Pediatric Surgical Patient . 2nd ed. Sudbury, MA: Jones and Bartlettt Publishers; 2007: 3-16. 24. Lönnqvist, PA. Management of the neonate: anesthetic considerations. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:1437-1475. 25. Luginbuehl I. Temperature regulation: physiology and pharmacology. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:221-358. 26. Luginbuehl RO. General growth and tissue development throughout childhood. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:20- 43. 27. Mackey W L, Manworren RCB. Care of children with acute pain: operative, procedural, and traumatic. In Browne NT, Flanigan LM, McComiskey CA, Pieper, P., eds. Nursing Care of the Pediatric Surgical Patient . 2nd ed. Sudbury, MA: Jones and Bartlettt Publishers; 2007:59-74. 28. Mainer JA. Nonpharmacological interventions for assisting the induction of anesthesia in children. AORN J. 2010;92(2):209-210. 29. Maxwell LG. Anesthetic management for newborns undergoing emergency surgery. ASA Refresher Courses Anesth. 2007;35(1):107-126. 30. Moloney G. Which endotracheal tube in neonates, infants and small children. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:747-752. 31. Moss R, Schramm C. Facilitate care after the procedure. In: Phippen ML, Ulmer BC, Wells MP, eds. Competency for safe patient care during operative and invasive procedures. Denver, CO: Competency and Credentialing Institute; 2009:533-580. 32. Perry JN, Hooper VD, Masiongale J. Reduction of preoperative anxiety in pediatric surgery patients using age- appropriate teaching interventions. J Perianesth Nurs. 2012;27(2): 69-81. doi: 10.1016/j.jopan.2012.01.0003 33. Romino SL, Keatley VM, Secrest J, Good, K. Parental presence during anesthesia induction in children. AORN J. 2005;81(4):780-792. 34. Ruiz M, Rivers N, Pop RS. Evaluating the effectiveness of the timing of postoperative education in the pediatric population. J Perianesth Nurs . 2012;27(1):10-17. 35. Salvadore M, Engelhart T, Tobias JD. Acute complications during anesthesia. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:905-923. 36. Shields L, ed. Perioperative Care of the Child: A Nursing Manual . Oxford, UK: Willey-Blackwell; 2010. 37. Silverman AM, Wang VJ. Shock a common pathway for life-threatening pediatric illness and injuries. Pediatr Emerg Med Pract. 2005;2(10):1-22. 38. Smith JH, Ong K, Sury M.R. Acute complications during anesthesia. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:886-904. 39. Splinter WM, Kim J. Premedication, sedation and preoperative fasting. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:584-593. 40. Tinkham MR. The importance of the preoperative history and physical. OR Nurse. 2012;63(3):40-46.

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41. Verma D, Eisses M, Richards M. Blood conservation strategies in pediatric anesthesia. Anesthesiol Clin. 2009;27(2):337-351. doi: 10.1016/j.anclin.2009.05.002 42. Veyckemans F. Anesthesia equipment. In: Bissonette B, ed. Pediatric Anesthesia: Basic principles—State of the art—Future. Shelton, CT: People’s Medical Publishing House; 2011:594-668.

21 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE

POST-TEST CARE OF THE PEDIATRIC PATIENT IN SURGERY: NEONATAL THROUGH ADOLESCENCE Multiple choice. Please choose the word or phrase that best completes the following statements.

1. Fears that are common to virtually all children 7. Pop culture can create fears in children, specifically include all of the following except: a fear of not being all the way asleep during surgery a. loss of control. and feeling pain. b. pain. a. True c. recovery. b. False d. separation anxiety. 8. At what age can a child benefit from the following 2. If children see that their parents trust the nurses and activities: investigate, lay a hand on, come into doctors, they will have absolutely no fear of surgery. contact with, and check out medical supplies? a. True a. Eight b. False b. Four c. Seven 3. Adolescents tend to have varied reactions to surgery, d. Three including all of the following except: a. anger. 9. The goal of the use of premedication with b. cowardice. anxiolytics is to: c. depression. a. allay anxiety. d. willfulness. b. hasten induction. c. placate parents. 4. Hypothermia in the neonate can create a cascade of d. sedate the child. events leading to hypoxia. Which of the following is the accurate sequence of events? 10. In rare instances, which premedication is given a. Anaerobic metabolism, decreased oxygen intramuscularly to highly uncooperative or consumption, pulmonary vasoconstriction. combative children? b. Anaerobic metabolism, pulmonary a. Clonidine vasoconstriction, respiratory acidosis. b. Diazepam c. Peripheral vasoconstriction, increased oxygen c. Ketamine consumption, respiratory acidosis. d. Midazolam d. Peripheral vasodilatation, increased oxygen 11. A 2010 Cochrane review established that parent- consumption, respiratory alkalosis. present induction was obligatory for patients with 5. Postop apnea in infants and neonates is a recognized preoperative apprehension. risk until they reach: a. True a. 44 weeks post-conceptual age. b. False b. 6 weeks post-conceptual age. 12. The use of which monitor is most important during c. 2 months post-conceptual age. the inhalation induction of a child? d. 60 weeks post-conceptual age. a. Blood pressure cuff 6. Managing pain in toddlers requires specific b. Capnography questioning, highlighting the surgical incision c. EKG leads location. d. Pulse oximeter a. True b. False

22 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE

13. A recent innovation that has allowed more specific 20. Sedation is appropriate for pediatric patients, except placement of endotracheal tubes in pediatric patients when is the microcuff endotracheal tube. a. appropriate dosage ranges are used. a. True b. cautious patient selection is used. b. False c. staff members are proficient in rescue techniques. 14. Galvin and Curley suggested specific interventions d. the parent or patient refuses. for use with pediatric patients, including: a. protecting areas of skin to skin contact. 21. Discharge topics to cover with parents include of the b. sheepskin under all bony prominences. following, except c. towels to prevent pooling of solutions. a. activity restrictions and return-to-school dates. d. use of rolled towels/diapers for positioning. b. appropriate disciplinary tactics. c. nutritional needs. 15. Adolescents can hide body jewelry from their d. signs of wound infection. parents. This is a fact that perioperative nurses need to be aware of, and nurses should therefore question 22. Viable options used to familiarize children with adolescents about body jewelry in front of their surgery include: parents to ensure full disclosure. a. books, videos, and virtual tours. a. True b. detailed written instructions b. False c. interactive computer games d. preoperative phone calls 16. Hypothermia below 34° C can contribute to increased blood loss by: 23. NPO guidelines developed by the ASA for children a. decreasing platelet counts and lengthening include: thrombin times. a. breast milk no more than 6 hours before surgery. b. decreasing platelet counts and lengthening b. clear liquids up until 2 hours before surgery. prothrombin times. c. formula no more than 4 hours before surgery. c. peripheral vasodilatation. d. juice 2 hours be for surgery. d. thinning the blood through increased blood cell 24. Concerns unique to the pediatric history and death due to shivering. physical include: 17. Hypovolemic shock can occur when neonates, a. birth history and pregnancy compilations. infants, and toddlers lose as little as b. colds and preop labs. a. 1.5% of blood volume. c. recent immunizations, history of respiratory b. 10% of blood volume. syncytial virus, and diaper rash. c. 15 % of blood volume. d. the presence of adult teeth or congenital d. 5% of blood volume. abnormalities. 18. Emergence delirium can be mislabeled and confused 25. AORN standards recommend that security items be with washed by parents prior to surgery to decrease the a. indulgence. risk of surgical site infection. b. pain and fear. a. True c. stubbornness. b. False d. willfulness. 19. Distraction with play, books, or video games can completely alleviate a child’s pain. a. True b. False

23 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE

26. Which of the following statements about site marking is not correct? a. Alternate site marking can decrease the risk of skin tattooing. b. Site marking should be considered when parents object to marking the child. c. Site marking should always be used for neonates, infants, and toddlers. d. Site marking should be used when the patient is uncooperative with the process. 27. Pediatric medications are age-based for dosage guidance. a. True b. False 28. Nursing staff members need to question parents about recent respiratory infections because of the potential for a. emergence delirium due to poor oxygenation. b. laryngospasm. c. post-op infections. d. respiratory depression. 29. PRN pain medication is best for children because of parents’ fear of overdose and addiction. a. True b. False 30. Examples of procedure-specific discharge instructions include all of the following except a. cast care. b. excessive swallowing post tonsillectomy. c. gastrostomy tube care. d. pain control medications.

24 CARE OF THE PEDIATRIC PATIENT IN SURGERY : N EONATAL THROUGH ADOLESCENCE

POST-TEST ANSWERS

CARE OF THE PEDIATRIC PATIENT IN SURGERY: NEONATAL THROUGH ADOLESCENCE

d . 0 3

b . 9 2

b . 8 2

b . 7 2

c . 6 2

a . 5 2

c . 4 2

b . 3 2

a . 2 2

b . 1 2

d . 0 2

b . 9 1

b . 8 1

b . 7 1

a . 6 1

b . 5 1

a . 4 1

a . 3 1

d . 2 1

b . 1 1

c . 0 1

a . 9

b . 8

a . 7

b . 6

d . 5

c . 4

b . 3

b . 2

c . 1