1.1 Special aspects of childhood - 4
1.2 Psychological and medication preparation - 5
1.3 Transport to the operating suite - 5
1.4 Transfer of the patient and transport to the anaesthesia preparation room - 5
References - 6
»A child is not a small adult«: this important rule applies not only to the special physiological aspects but also to the special psychological aspects of childhood. The reactions of young patients to surgery, anaesthetic and a stay in hospital depend on age, personality structure, the child's home environment, family background, previous experience of operations and the conditions in the hospital. The main objective of perioperative care of children should therefore consist in avoiding traumatic experiences in the perioperative phase for everyone involved. Particularly where children are involved, consideration should be given to the fact that this kind of trauma can have a negative effect on the attitude to the health system over a long period of time and make future treatment extremely difficult. Children are naturally flexible and can come to terms with even difficult situations. A successful approach to helping children to cope with the »operation crisis« can even promote their emotional development. But this is only possible if everyone involved knows the potential problems encountered with children and are willing to adjust to these individually. Unpleasant experiences are encountered with particular frequency in the immediate pre- and postoperative phase when the children are still awake or have woken up again. The weakest link in the chain of everyone involved has the greatest influence on the overall success.
Influence of age. Infants younger than 6 months rarely show resistance to a hospital environment. Even separation from the parents is tolerated for short periods if a »substitute mother« is available. There are greater problems with children between 6 months and 4-5 years. On the one hand, they are old enough to be aware of threatening situations and separation from their parents, but too young to understand rational explanations. Their reactions to an operation and stay in hospital can include separation anxiety, sleeping disorders, nightmares, eating disorders, estrangement or wetting the bed. Children of school age can cope better with being separated from their parents and are better able to come to terms with new surroundings. They are frequently afraid of their bodily integrity being violated, or have irrational ideas about what happens during an operation.
Influence of the parents. The parent/child relationship can vary greatly between being extremely overprotective and almost complete independence. Frequently the parents themselves have little or no experience in coping with operations and stays in hospital and are uncertain and anxious. Other parents have had negative experiences with hospitals themselves and are afraid that their children could undergo the same. Small children in particular cannot understand why their parents leave them in a cri tical situation. Even sensible parents often find it difficult to leave a sad, crying child in the hands of strangers. The anxieties of the parents can be transferred to the children with a negative effect on their behaviour.
The surroundings. Following drastic changes in recent decades, children's wards have made great adjustments even to the needs of younger children. On the other hand, the functional atmosphere of the operating suite still differs greatly from what children understand to be pleasant surroundings. All the technical equipment, the face masks and caps worn by the staff concealing their faces and the artificial light can trigger additional and irrational anxieties (ghosts, bad people in the operating theatre, fear of mutilation, O Fig. 1.1).
Specific anxieties of children. Being separated from their parents and customary home surroundings is the main problem particularly for small children (1-3 years). Older children of preschool and primary school age have more concrete worries about the operation, anaesthetic and the actual disease itself. Many children do not want to take their own clothes off and put strange clothes on. In particular if they have had to go without food or drink for a long time, they will be hungry and thirsty. Almost all children are afraid of puncture pain, e.g. blood samples,
1.4 • Transfer of the patient and transport to the anaesthesia preparation room
injections or fitting intravenous drips (O Fig. 1.2). After the operation, they will also be upset by all the strange material, e.g. wound drains, infusion drips or catheters.
Usually the surgeon and anaesthetist will talk to the children and their parents to prepare them for the operation. This should happen as close as possible to the operation itself (on the day before) in a calm, relaxed atmosphere. What is discussed and how depends on the child's development status and previous experience. Some children's hospitals also provide video demonstrations or tours of the hospital for the families. The operation itself should then take place on the next day along the same lines as far as possible. False promises, misunderstandings arising from a lack of information and communication and short-term changes to the operating schedule mean that children and parents start to lose confidence and can make subsequent treatment extremely difficult. Long waiting times without food and drink increase anxieties and reduce compliance. This is why small children should be included right at the beginning of an operating schedule. It is usually a good idea to administer children with premedi-cation about an hour before the operation while they are still on the ward, for example oral midazolam as medicine with adapted taste, or by rectal or nasal means. Painful injections are not suitable for children and should be avoided if at all possible.
Children should be brought to the operating suite in such a way that there will not be any unnecessarily long waits, and then preferably brought to the operating suite by a nurse in the company of the parents or someone they know and trust. Many children will be reassured if they can take a favourite soft toy or cuddly blanket with them. This should be treated carefully and must certainly not be lost. Older, cooperative children who have been well prepared for the operation in psychological and medication terms usually say goodbye to their parents without any problems and can be transferred to the operating table in the operation sluice. Preschool children find it much harder to be separated from their parents. Dramatic farewell scenes are traumatic for everyone involved and should be avoided at all costs. As a possible solution, in a calm preparatory room midazolam and ketamine or methohexital can be administered rectally to the child by an anaesthetist so that the child falls asleep while the parents are still there. In rare exceptions, intramuscular injections of ketamine are possible for extremely uncooperative children. If the child has already been provided with intravenous access, sedation is naturally administered this way. Many parents will want to know whether they can stay with their child while the anaesthetic is being induced. If compatible with the available space and staffing arrangements, there are no objections to this in the case of a routine anaesthetic. But another staff member should inform the parents about the rules of behaviour in the operating suite and look after them while in the operating suite. Most families are satisfied if they can be present in the operation sluice while their child is placed under deep sedation.
1.4 Transfer of the patient and transport to the anaesthesia preparation room
In the case of infants and small children, the anaesthetic is frequently induced in the operating theatre. The simplest method is for the children to be carried into the operating theatre. Nearly all children react positively to close bodily contact and being spoken to nicely. It also helps if the face mask is left off when the children are awake so that they can see into the faces. Children must never be left unattended on the operating table because of the risk of sudden, fast movements, resulting in them falling onto the floor. Children cool down more quickly than adults because their body surface is large in relation to the body volume, so they should always be covered well. Larger schoolchildren and teenagers can be transferred directly to the operating table like adults and then taken into the anaesthesia preparation room.
1. Büttner W, Breitkopf L, Engert J, Bilz M (1989) Das Psychotrauma ambulanter und stationärer operativer Eingriffe bei Kleinkindern. Anaesthesist 38: 597-603
2. Breitkopf L (1990) Emotionale Reaktionen von Kindern auf den Krankenhausaufenthalt. Z Kinderchir 45: 3-8
3. Pinkerton P (1981) Preventing Psychotrauma in childhood anaesthesia. In: Rees GJ, Gray TC (eds) Paediatric Anaesthesia. Butterworth, London
4. Steward DJ (1994) Preoperative evaluation and preparation for surgery.In: Gregory GA (ed) Pediatric Anesthesia. Churchill Livingstone, New York
5. Sümpelmann R, Wellendorf E, Krohn S, Strauß J (1994) Perioperatives Angsterleben von Kindern. Anästh Intensivbeh 35: 311
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