periop care in children

1. LAXMI DAHAL
LECTURER
PERIOPERATIVE CARE OF
PA EDI ATRICS PATIENT
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2. INTRODUCTION
Pre-op care is important in assessing whether patient
is fit for surgery and to prepare them for surgery.
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3. 5 MAIN TASKS
1. To explain to the relative the nature of the illness,
implications of the surgery and prognosis.
2. Identification of potential operative
mortality and post operative morbidity.
3. To assess the fitness for operation.
4. Identification of the risks of potential
postoperative complications and prophylactic
measures.
5. Planning of operation and consent.
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4. MEDICAL HISTORY
 Birth history: full-term, pre-term
 Determine post-conceptual age
 History of previous hospitalization and
surgical procedure.
 Concurrent medical illness
 Respiratory history
Recent URTI, noisy breathing, history of
intubation, sleep apnea, feeding
problems, rapid breathing, productive
cough, purulent nasal discharge
 Allergies
Possible problems
 Pulmonary: lung
immaturity,
bronchopulmonary
dysplasia, elevated
pulmonary vascular
resistance
 Airway:
tracheomalacia,
subglottic stenosis
 Multiple medication
 Apnea, bradycardia
FOR FORMER PRETERM PATIENTS
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5. P A T I E N T I S C O U G H I N G ?
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 It is difficult to secure airway in pediatric patient with
ongoing URTI
 In severe URTI, surgery should be postponed for at
least 4-6 weeks.

6. FAMILY HISTORY
 Parental history: diabetes mellitus, preeclampsia,
alcohol abuse
 Unusual reaction to surgery or anesthesia
 Malignant hyperthermia
 Sickle cell anemia
 Thalassemia
 Atypical pseudo cholinesterase
 Neuromuscular disorder
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7. PHYSICAL EXAMINATION
Done to assess difficulty of intubation
 Any inspiratory/expiratory stridor?
 Signs of respiratory distress?
 Is mouth accessible?
 Macroglossia?
 Hypoplastic mandible?
 Neck mobility
 Purulent discharge from nose??
A I R W A Y A S S E S S M E N T
L U N G S
Auscultate for bronchial breath sounds, wheeze, crackles
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8. PHYSICAL EXAMINATION
D E N T I T I O N
 To avoid unnecessary dental damage and traumatic
intubation
 Poor dentition (crowded teeth, tooth decay)
 Age 5-12 more susceptible to teeth avulsion (injury)
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9. PHYSICAL EXAMINATION
H E A R T M U R M U R S
 Must differentiate between an innocent murmur and a
pathological murmur.
 Any congenital cardiac problems poses a 2 folds increase in
mortality rate if it is a non-cardiac surgery
 High suspicion if associated down syndrome, VACTERL,
CHARGE, Turner.
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10. PHYSICAL EXAMINATION
N E U R O L O G I C S T A T U S A N D D E F I C I T
Irritability, sudden mood change, ataxia, nuchal rigidity,
photophobia, opisthostonos, Kernig sign, Brudzinski etc
S K I N R A S H E S
May be having active viral infection, poses threat to
other patient, hospital staffs.
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11. INVESTIGATIONS
Evaluation of:
• medical condition
• assessing the psychological status of the child,
• allaying anxiety of the child as well as the parent
and
• understanding the special needs of the surgical
procedure planned.
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12. ROUTINE
AllINVESTIGATIONS
F U L L B L O O D C O U N T
All Children should have CBC.
Anemia: CBC with iron profile
B L O O D U R E A & S E R U M E L E C T R O LY T E
Check electrolyte balance for hydrational status.
C O A G U L A T I O N P R O F I L E
B L O O D G R O U P A N D C R O S S M A T C H I N G
 All cases
U R I N E I N P U T A N D O U T P U T C H A R T
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13. RADIOLOGICAL IX
E C H O C A R D I O G R A M
Echocardiography should be considered if:
New murmur
Poor functional capacity
Syncope or dizzy spells
C H E S T X - R A Y
 To check if there is any abnormality in the lungs and to
access if the lung is clear cause children are more prone to
URTI.
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14. P O S T- O P E R T I V E CAR E
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15. PURPOSES
1. To enable a faster and successful recovery of the
patient posteratively.
2. To reduce post operative mortality rate.
3. To reduce length of the hospital stay.
4. To provide quality care service.
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16. The immediate postoperative period: recovery room
• Formal hand over to the recovery staff.
• The information provided should include the patient’s name,
age, the surgical procedure, existing medical problems,
allergies, the anaesthetic and analgesics given, fluid
replacement, blood loss, urine output, any surgical and
anaesthetic problems encountered or expected.
• Patient’s vital parameters, consciousness, pain and hydration
status are monitored in the recovery room and supportive
treatment is given.
GENERAL MANAGEMENT
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17. The patient can be discharged from the recovery
room when they fulfil the following criteria:
 Patient is fully conscious.
 Respiration and oxygenation are satisfactory.
 Patient is normothermic, not in pain nor nauseous.
 Cardiovascular parameters are stable.
 Oxygen, fluids and analgesics have been prescribed.
 There are no concerns related to the surgical procedure
GENERAL MANAGEMENT
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18. COMPLICATIONS
R E S P I R A T O R Y C O M P L I C A T I O N S
second most common postoperative
complication for all pediatric surgeries, after
infection.
recovery room complications:
 hypoxaemia,
 hypercapnia and
 aspiration.
Pneumonia tend to appear later in the
postoperative period.
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19. COMPLICATIONS
M A N A G E M E N T O F R E S P I R AT O R Y C O M P L I C AT I O N S
 Patients with hypoxia should be treated urgently.
 If the patient is breathing spontaneously, administer oxygen
using a non breathing mask.
 A head tilt, chin lift or jaw thrust should relieve obstruction
related to reduced muscle tone.
 Suctioning of any blood or secretions may be needed.
 Inform the anaesthetist if tracheal intubation or manual
ventilation may be needed.
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20. 1. Hypotension
Causes:
 surgical bleeding, sepsis, arrhythmias, myocardial infarction,
cardiac failure, tension pneumothorax, pulmonary embolism,
pericardial tamponade and anaphylaxis should be also sought.
COMPLICATIONS
C A R D I O V A S C U L A R C O M P L I C AT I O N S
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21.  most common surgical complications.
 Pain assessment
 Adequate postoperative pain control is required to
maintain maximum physical function, psychological
well-being, and quality living.
COMPLICATIONS
PA I N
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22.  Anaesthesia induces loss of thermoregulatory control.
 This, in turn, leads to increased cardiac morbidity, a
hypocoagulable state, shivering with imbalance of oxygen supply
and demand, and immune function impairment with the
possibility of wound infection.
 Active warming devices should be used to treat hypothermia as
appropriate.
COMPLICATIONS
H Y P O T H E R M I A A N D S H I V E R I N G
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23. COMPLICATIONS
F E V E R
• About 40 per cent of patients develop pyrexia after
major surgery.
• The inflammatory response to surgical trauma may
manifest itself as fever, and so pyrexia does not
necessarily imply sepsis.
• However, in all patients with a pyrexia, a focus of
infection should be sought.
• The causes of a raised temperature postoperatively
include:
Days 2–5: atelectasis of the lung
Days 3–5: superficial and deep wound infection
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24. Day 5: chest infection, urinary tract infection and
thrombophlebitis
>5 days: wound infection, anastomotic leakage,
intracavitary collections and
abscesses
DVTs, transfusion reactions, wound haematomas,
atelectasis and drug reactions, may also cause pyrexia of
non-infective origin.
Patients with a persistent pyrexia need a thorough review.
Relevant investigations include full blood count, urine culture,
sputum microscopy and blood cultures
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Fever

25. COMPLICATIONS
W O U N D C A R E
 Within hours of the wound being closed, the dead space fills up
with an inflammatory exudate. Within 48 hours of closure, a layer
of epidermal cells from the wound edge bridges the gap. So,
sterile dressings applied in theatre should not be removed before
this time.
 Wounds should be inspected only if there is any concern about
their condition or the dressing needs changing.
 Infected wounds and hematoma may need treatment with
antibiotics or even a wound washout.
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26. 5th
 Wound dehiscence most commonly occurs from
the to the 8th postoperative day when the
strength of the wound is at its weakest.
COMPLICATIONS
W O U N D D E H I S C E N C E
 Wound dehiscence is disruption of any or all of the layers in a
wound. Dehiscence may occur in up to 3 per cent of abdominal
wounds and is very distressing to the patient.
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28.  Patients discharged home need a ‘discharge
letter’ which includes the diagnosis, treatment,
lab results, complications, discharge plan and
follow ups.
 They should be adviced regarding follow up
visit.
DISCHAGE OF PATIENTS
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29. THANK YOU
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