GOING to sleep in the operating room is often the scariest part of surgery for children. Making sure this is done safely and for a child to wake up comfortably is the job of the pediatric anaesthesiologist, said Head of the Anesthesiology Department and Intensive Care at Hospital Tengku Ampuan Rahimah (HTAR), Klang, Dr Sushila Sivasubramaniam.
Dr Sushila, who is also the Executive Committee Member of Malaysian Society of Anaesthesiologists (MSA) in charge of Continuing Professional Development (CPD) and Education, said pediatric anaesthesia has developed a because of the increase in complex and complicated surgeries involving children.
"Infants and children will always present a challenge to anaesthesiologists. They are not small adults and respond differently. Anatomically and physically they are different. Their bodies handle medication differently because their organs are developing. Any drug or medication to be administered to them is calculated according to the child's weight. For an obese child, we go by the ideal weight," she said.
The ultimate aim is not only to take care of the children before and after surgery, but also to manage pain during recovery.
To ensure that they have a good stay in hospital, the children are managed in child friendly or child oriented environments, like a specific children's ward.
Children of all ages are not to be treated in direct association with adult patients, whether in wards, day care or recovery areas. The children's parents and carers are also encouraged to be involved in all aspects of the decisions affecting the care of their children.
"It helps to build rapport with both parents and children. We need to talk to the parents as they are often anxious when their children are about to go to surgery and don't know what to expect. We encourage parents to be with their children in the operating theatre but exceptions are made for small or ill (unconscious) children where separation anxiety is not an issue."
Prior to the surgery parents are briefed on what to anticipate and expect when they come into the operating theatre and during the recovery stage in terms of the options of pain management.
"This helps to allay anxiety or fear. We also give the child age-appropriate information of what they will go through and we don't leave them out so they also feel that they are involved in the management of their care," said Dr Sushila.
As part of pre-operation procedure, the child's birth and medical history is evaluated to check for medical problems, or a history of any known allergy because it could affect the anaesthetic.
Dr Sushila said the advantage of having parents in the operating theatre is that it helps relieve the child's anxiety and also provides emotional support.
"We allow them to bring in a comfort item such as a toy. The parent can talk to and hold the child as we are inducing the anaesthetic. Sometimes, parents do transmit anxiety or fear and when they are worried you can see them tearing up a bit, so it is always nice to be able to talk to them to see whether they are happy to come into the operating theatre.
"Some refuse to leave the theatre because they want to be around to watch the surgery but we don't allow this. Only one parent is allowed to follow the child into the operating theatre, and ultimately the final decision on whether a parent is allowed in is up to the child's anaesthesiologist."
General anaesthesia is applied to the child to help his/her body go to sleep and is needed for certain surgeries so that the child is completely relaxed. It makes the surgery safer, easier and the child doesn't feel any pain during surgery and doesn't have any memory of it.
The anaesthesiologist's skills come to play in three stages - induction of anaesthetic, maintenance of patient's well-being during surgery and pain management during the patient's recovery. Induction is pre-operation, maintenance is inter-operation and, recovery is post-operation.
"During the induction stage for intravenous induction, a local anaesthetic is administered one hour before we set up the intravenous line. It is done with distraction and various comfort strategies such as talking to and playing with the child, or having the parent hold the child and having someone distract them by talking with them, while the other sets the line. Induction via gaseous means is to get the child to breathe a mixture of oxygen and anaesthetic through a face mask. I always call it the Power Ranger mask or special mask. Once they fall asleep, we then set the line, give further medication or whatever is needed, and then we start the anaesthetic," said Dr Sushila.
During surgery, the anaesthesiologist forms an integral part of the surgical team, she added.
"We monitor vital signs like heart rate, blood pressure, oxygen level and administer appropriate medication so the child does not experience any discomfort during surgery. We also give fluids, monitor blood loss and give blood if required."
Once surgery is over, the anaesthetic is discontinued and the child transferred to the recovery room where his/her vital signs continue to be monitored in the recovery room.
"They are watched and monitored until their condition is stable. We allow parents to wait in the recovery room so that when the child wakes up, he/she will see a familiar face and will be comforted. We also warn parents that children react differently when coming out: some cry, some may be fussy, confused or even vomit, but these reactions are normal and go away once the anaesthesia wears off. We give oral or suppositories for pain relief after the surgery but continuous pain relief like epidurals depend on the site and type of surgery." -NST
