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The information contained herein is a point of departure that leads on to the further study of problems or conditions that afflict our children. For various reasons, they have not participated in the second edition, but their original contributions were invaluable and in many cases have survived within the second edition. Arensman Consultation Most children and their parents will meet a surgeon for the first time on referral.
This generally means that a prior medical history and physical examination exist and are often available to the pediatric surgeon at the time of the initial visit. If so, previous findings are always reviewed and verified, but further information is sought that may elucidate the diagnosis and aid in therapy planning. For relatively straightforward surgical problems, consultation visits may be brief. However, they create the foundation for further interaction between surgeon and child.
Consequently, it is imperative that the surgeon attempts to create a friendship, or at least a relationship of trust, between a frightened child and the person who will ultimately perform surgery. Young patients seldom come through consultation without anxious parents. Therefore, initial visits are a time for the surgeon and the parents to create an opportunity for information exchange.
Specifically, parents must be given adequate time to fully understand the current diagnosis and raise appropriate questions concerning surgery, in-hospital care, pain control, postoperative management, ultimate outcome and long-term results. If crowded schedules preclude adequate time to cover all aspects of the anticipated surgery, it is necessary to schedule further visits or to arrange time for phone conferences with all concerned. This may well include grandparents, aunts, uncles, older siblings, or individuals significant in the life of the young patient.
Since many patients have undergone diagnostic testing before the referral, it is necessary to review these tests. If unavailable at the time of the referral, they need to be sought. The unavailability of all these components at the initial visit frequently necessitates telephone conferences, e-mail communication, or fax communication.
Fortunately, all of these are quite available at the present time and are an important aspect of patient care. Physical Examination The pediatric surgeon often knows of abnormal findings on physical examination before the patient encounter. This does not preclude another examination during the consultation visit. Additional findings may be demonstrated and certainly one wishes to confirm the previously reported findings.
Such simple matters as hernias or hydroceles are often confused and need clarification by the pediatric surgeon during careful reexamination. In addition, associated findings, well known to the pediatric surgeon, may not be common knowledge to the referring pediatrician or family practitioner.
Therefore, a good physical examination is always advisable before surgical intervention. For example, a child with a reducible inguinal hernia needs only a simple physical examination as the best diagnostic study. Radiographs, blood examinations and biopsies are invasive, bothersome, expensive and unwarranted unless findings or complaints justify their need. Suffice it to say, diagnostic studies are chosen and done that are needed to completely and safely make a diagnosis and sufficient to advise a child and family concerning the need for surgical intervention.
Review of preoperative testing on healthy children reveals that a child on a standard diet requires nothing as far as preoperative testing if the surgical problem is straightforward and can be done under outpatient general anesthetic without hospital stay.
For example, a 2-year-old child with uncomplicated bilateral inguinal hernias whose cheeks and lips portray no sign of anemia and who is eating a general diet until a few hours before surgery requires no diagnostic testing. Careful questioning of the family adequately excludes a history of inherited diseases and bleeding dyscrasias.
Any further need for preoperative diagnostic testing flows directly from the examination of the child. In contrast to the previously mentioned healthy child with bilateral inguinal hernias, a 2-year-old child with a previous diagnosis of biliary atresia and an unsuccessful Kasai procedure now progressing to biliary cirrhosis clearly needs a very complicated and extensive diagnostic evaluation to determine if he can safely undergo hepatic transplantation.
In summary, the diagnostic regimen is designed to be sufficiently brief or thorough to correctly and adequately identify the surgical problem s and formulate the best and safest surgical plan.
Pain Management Children are not particularly concerned about the technical details of the surgical procedure they may undergo, but they and their parents are greatly fearful of the pain they may endure in the postoperative period. Knowledge that children will be in the company of their parents throughout their time in the hospital and that pain can be controlled in a variety of ways provides comfort.
Consequently, the consultation visit or phone conferences should include a thorough discussion of postoperative pain management. Intraoperative local anesthetic administration, intravenous narcotics, patient controlled analgesia, caudal blocks, epidural blocks and continuous epidural anesthesia are the current commonly used methods of pain control.
All of these modalities can and should be thoroughly discussed before the surgical event; however, it is generally best to provide at least hours in the preanesthetic room so that these can be discussed a second time with the anesthesia staff when the final decision concerning the exact pain control methods is made.
Since the type of pain management is often tailored to fit the anesthesia during the operative event, the anesthesiologist should be included in this decision.
Blood Donation Due to the extensive information on the hazards of blood transfusion, most parents want to discuss possible transfusion thoroughly.
Since transfusion is a rare event, discussion can be limited to acknowledgment that transfusion is most unlikely and so much so that blood is not routinely prepared for the operation anticipated.
If transfusion is a possibility, discussion centers on the use of banked blood versus donor directed blood. This is both a controversial and emotional subject so it is sometimes 1 4 1 necessary to involve the director of the blood bank service to fully answer the questions posed. Parents must fully understand that blood samples are necessary from the child and donors before the surgical date. Furthermore, they need to fully understand that all donor directed blood is subjected to the same testing required for all other blood donations.
Finally, parents need to understand that type match does not necessarily predict cross match and that fulfillment of all these requirements requires adequate time before the surgery date. These programs allow children to visit all portions of the operative suite prior to surgery. They become familiar with the holding area, the operating room and the postanesthesia recovery area.
Suggested Reading From Textbooks 1.
Principles of Pediatric Surgery. Louis: Mosby, Puri P, Sweed Y. Preoperative assessment. In: Puri P, ed. Newborn Surgery. Oxford: Butterworth-Heineman, Preoperative and postoperative management of the neonate.
Operative Surgery. London: Butterworths From Journal 1. Maxwell LG. Age-associated issues in preoperative evaluation, testing and planning: Pediatrics. Anesthesiol Clin North America ; Bambini The postoperative care of surgical neonates and children begins upon completion of wound closure. The level of postoperative care administered is dependent upon the procedure performed, but some general guidelines are provided below. Specific guidelines for postoperative management of many pediatric surgical conditions are provided throughout this handbook.
Wound and Dressing Care Prior to the removal of the sterile surgical drapes, the skin surrounding the surgical wound is cleansed with warm saline-soaked sponges or lap pads to remove any debris, blood, or prep solutions surrounding the wound.
The area is gently padded dry and a sterile towel or dressing is placed over the wound to prevent contamination at the time of drape removal. The type of dressing applied to surgical wounds is selected according to surgeon preference, the type of wound created and the method of closure.
For clean procedures, a dry, sterile dressing i. Antibiotic ointments and other wound applicants are generally not necessary. To minimize the stress and pain of later dressing removal, dressings are secured in position with the minimal amount of tape or occlusive barrier that achieves coverage of the wound.
Extubation and Transfer Intraoperative monitoring devices should be left in place until after extubation. A physician member of the surgical team should be present at the time of extubation and assist in the transfer of the pediatric surgical patient to the postanesthesia care unit or appropriate intensive care unit.
If respiratory rate or inspiratory tidal volumes are inadequate, the child should be observed in the OR until breathing has improved.
Special attention to body temperature and measures to prevent hypothermia after drape removal should be instituted including infrared heating lights, wrapping with warm blankets and increasing the ambient room temperature.
Postoperative Orders The postoperative orders are individualized for each patient. In general, outpatient procedures will require only simple postoperative care and specific wound care instructions for the parents.
Arrangements for office follow-up visits are discussed. Arrangements for intensive care unit beds are made preoperatively. Attending Physician and Consultants: List the attending physician and all consultants who will participate in the care of the patient.
Clearly inform the nursing staff regarding who is contacted for questions about care and for any problems that arise. Allergies: List any known drug allergies or other sensitivities i.
This is the weight that is used to calculate medication dosages, fluids, nutritional requirements, etc.
Vital Signs: Provide instructions for the frequency at which vital signs are monitored and recorded. Clearly specify parameters for changes in vital signs that require notification of the surgical team. Ventilator Settings and Respiratory Care: For patients requiring postoperative ventilatory support, provide specific instructions regarding ventilator mode, tidal volume, peak inspiratory pressure, inspired oxygen concentration, etc.
If other respiratory interventions i. Intravenous Fluids: Provide maintenance and replacement fluid orders. Specific information regarding postoperative fluid and electrolyte management are provided in Chapter 6.
Diet: Specify special diets i. Physical therapy may be helpful to some hospitalized patients and is initiated when appropriate. Medications: Record clearly and accurately all medications including doses, routes of administration and frequencies of administration. When appropriate, order analgesic and antiemetic medications. Calculate doses on a per weight basis. Reduce medication dosing errors by confirming and reconfirming dosage calculations.
Review chronic medications and preoperative medications and adjust appropriately. Wound Care: Provide special instructions for dressing care or surgical wounds when applicable.
Immediate Postoperative Care 7 Drains: Include in drain care orders specific requests for suction, stripping, frequency of emptying and quantification of output. Place Foley catheters to gravity drainage. Obtain chest radiographs in the recovery room or intensive care unit for all patients who remain intubated or who had intraoperative placement of central venous lines or catheters.
Laboratory Tests: Routine laboratory testing is often not necessary in pediatric surgical patients, especially those who have procedures in the surgicenter and are discharged shortly after surgery. Obtain specific laboratory studies if the results are expected to alter clinical management of the patient. Laboratory tests are often indicated in children who undergo extensive and complicated procedures.
Pain Management Achieving adequate pain relief is important in children, although children often do not or cannot complain specifically of pain.
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Pain may adversely affect recovery of infants since painful stimuli may result in decreased arterial saturation and increased pulmonary vascular resistance. Effective pain control allows earlier ambulation and faster recovery in older children. Local anesthetics administered in the operating room can provide prolonged pain control.
For larger operations, intravenous narcotics provide excellent pain control. Since the type of pain management is often tailored to fit the anesthesia during the operative event, the anesthesiologist should be included in this decision. Due to the extensive information on the hazards of blood transfusion, most parents want to discuss possible transfusion thoroughly.
Since transfusion is a rare event, discussion can be limited to acknowledgment that transfusion is most unlikely and so much so that blood is not routinely prepared for the operation anticipated. If transfusion is a possibility, discussion centers on the use of banked blood versus donor directed blood. This is both a controversial and emotional subject so it is sometimes Pediatric Surgery necessary to involve the director of the blood bank service to fully answer the questions posed.
Parents must fully understand that blood samples are necessary from the child and donors before the surgical date. Furthermore, they need to fully understand that all donor directed blood is subjected to the same testing required for all other blood donations. Finally, parents need to understand that type match does not necessarily predict cross match and that fulfillment of all these requirements requires adequate time before the surgery date.
A paediatric vade-mecum
Presurgical Visitation and Teaching Most childrens hospitals provide a presurgical visitation and teaching program for patients. These programs allow children to visit all portions of the operative suite prior to surgery.
They become familiar with the holding area, the operating room and the postanesthesia recovery area. They have an opportunity to try on scrubs, gowns, masks and caps. The nurses from the various areas answer questions, reassure children of their parents nearness and participation in the entire process and particularly address concerns about postoperative pain. These teaching programs appear to lessen childrens anxiety; we certainly endorse the use of these programs if available.
Suggested Reading 1. Principles of Pediatric Surgery. Louis: Mosby, Puri P, Sweed Y.
Preoperative assessment. In: Puri P, ed. Newborn Surgery. Oxford: Butterworth-Heineman, Another download to problems is the luminescence to read receivers of national Handbook from those of top contents.
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