Preoperative Care
Friday, March 6, 2009
Consultation
Prior to surgery for any patient, surgical consultation occurs. This provides a meeting and introduction between child and surgeon and proceeds to a complete history and physical examination. Since many children meet a surgeon for the first time on referral, the results of a prior history and physical examination are often available. If that is the case the previous findings are reviewed, verified, and further information is sought that may elucidate the diagnosis.
The meeting may be brief but creates the foundation for further interaction between surgeon and child. It is certainly an opportunity for the surgeon to create a friendship, or at least trust, between a frightened child and the person who will ultimately perform surgery. This meeting also is the chance to create communication and trust with anxious parents. Consequently, child and parents must be given adequate opportunity to present their understanding of the diagnosis, raise questions concerning surgery and in-hospital care, and discuss worrisome questions such as pain control, postoperative management, ultimate outcome and long-term results.
If a crowded clinic schedule precludes adequate time to cover all aspects of anticipated surgery, it is quite appropriate to schedule further visits or simply to arrange time for phone conferences with all concerned. Frequently, the surgeon can include other significant family members (grandparents, aunts, and uncles, siblings) by arranging for evening phone conversations.
Since many presurgical patients have already undergone diagnostic testing, it is important to review these tests and share the surgeon’s interpretation with the child and family. Sometimes this entails consultation with other specialists at the children’s hospital (radiologist, pathologists, and pediatric subspecialists). The results of these consultations will generally not be available at the time of the surgical consultation, but the results or discussion can easily be shared with child and family members via phone, e-mail, or fax. Communication at present is one of the easier, but most important, aspects of patient care.
Physical Examination
Abnormal findings on physical examination are often reported to a surgeon prior to the patient encounter. This does not preclude another examination at the time of 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 the careful reexamination of the pediatric
surgeon to clarify. 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 prior to surgical intervention.
Diagnostic Studies and Laboratory Investigations
The need for diagnostic studies varies from none to extensive. In the case of a child with a reducible inguinal hernia, a good, but simple, physical examination constitutes the best diagnostic study. Further tests, radiographs, blood examinations, etc. are invasive, bothersome, expensive and unwarranted unless there are other findings or complaints. However, the child who presents with severe, recurrent abdominal pain without any physical findings may need extensive studies to demonstrate the causative pathology (or lack thereof). Suffice 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.
It is clear that a healthy child on a standard diet requires nothing as far as preoperative testing if the surgical problem is simple, can be done under outpatient general anesthetic without hospital stay. For example, a two-year-old child with uncomplicated bilateral inguinal hernias, eating until a few hours before surgery, whose cheeks and lips betray no sign of anemia can and should undergo operative repair without diagnostic testing. Careful questioning of the family history adequately excludes inherited diseases and bleeding dyscrasias. Examination of the child provides all the further information needed to make a correct decision concerning the need for further tests. In contrast, a two-year-old child with previous diagnosis of biliary atresia with unsuccessful Kasai procedure and progressive biliary cirrhosis clearly needs a very complicated and extensive diagnostic evaluation to allow a determination as to whether he can 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
One of the greatest concerns for child or parents when approaching a surgical event is the problem of postoperative pain control. Most children are not particularly concerned about the technical details of the surgery they will undergo, but they are greatly fearful of the pain that they endure in the postoperative period. Knowledge that this can be controlled in a variety of ways provides some comfort. Knowledge that they will also be in the company of their parents during this period of time is also vitally important.
Consequently, the consultation visit or phone conferences include a thorough discussion of postoperative pain management. Commonly used methods of pain control include intraoperative local anesthetic administration, intravenous narcotics, patient controlled analgesia, caudal blocks, epidural blocks and continuous epidural anesthesia. Although these can all be discussed before the surgical event, it is generally best to provide at least one to two hours in the preanesthetic room so this can be discussed a second time with the anesthesia staff. This is the time of the final decision concerning the exact pain control methods to be used. Since this is often tailored to fit the anesthesia used during the operative event, the anesthesiologist is included in this decision.
Blood Donation
Due to the tremendous 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 acknowledgement that transfusion is most unlikely, and so much so that blood is not routinely prepared for the operation anticipated. In the event that 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 necessary to involve the director of the blood bank service to fully elucidate the questions posed. Parents must fully understand that blood samples will be necessary from child and donors prior to 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.
Presurgical Visitation and Teaching
Most children’s hospitals provide a presurgical visitation and teaching program. 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 the children of their parent’s nearness and participation in the entire process, and particularly address concerns about postoperative pain. In our particular hospital, the children conclude the visit by making a mural that is taped to the entry hall wall. As the children pass to the operating rooms, they can look for their previous artwork. We hope it lessens their anxiety and certainly endorse the use of these programs if available.
Prior to surgery for any patient, surgical consultation occurs. This provides a meeting and introduction between child and surgeon and proceeds to a complete history and physical examination. Since many children meet a surgeon for the first time on referral, the results of a prior history and physical examination are often available. If that is the case the previous findings are reviewed, verified, and further information is sought that may elucidate the diagnosis.
The meeting may be brief but creates the foundation for further interaction between surgeon and child. It is certainly an opportunity for the surgeon to create a friendship, or at least trust, between a frightened child and the person who will ultimately perform surgery. This meeting also is the chance to create communication and trust with anxious parents. Consequently, child and parents must be given adequate opportunity to present their understanding of the diagnosis, raise questions concerning surgery and in-hospital care, and discuss worrisome questions such as pain control, postoperative management, ultimate outcome and long-term results.
If a crowded clinic schedule precludes adequate time to cover all aspects of anticipated surgery, it is quite appropriate to schedule further visits or simply to arrange time for phone conferences with all concerned. Frequently, the surgeon can include other significant family members (grandparents, aunts, and uncles, siblings) by arranging for evening phone conversations.
Since many presurgical patients have already undergone diagnostic testing, it is important to review these tests and share the surgeon’s interpretation with the child and family. Sometimes this entails consultation with other specialists at the children’s hospital (radiologist, pathologists, and pediatric subspecialists). The results of these consultations will generally not be available at the time of the surgical consultation, but the results or discussion can easily be shared with child and family members via phone, e-mail, or fax. Communication at present is one of the easier, but most important, aspects of patient care.
Physical Examination
Abnormal findings on physical examination are often reported to a surgeon prior to the patient encounter. This does not preclude another examination at the time of 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 the careful reexamination of the pediatric
surgeon to clarify. 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 prior to surgical intervention.
Diagnostic Studies and Laboratory Investigations
The need for diagnostic studies varies from none to extensive. In the case of a child with a reducible inguinal hernia, a good, but simple, physical examination constitutes the best diagnostic study. Further tests, radiographs, blood examinations, etc. are invasive, bothersome, expensive and unwarranted unless there are other findings or complaints. However, the child who presents with severe, recurrent abdominal pain without any physical findings may need extensive studies to demonstrate the causative pathology (or lack thereof). Suffice 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.
It is clear that a healthy child on a standard diet requires nothing as far as preoperative testing if the surgical problem is simple, can be done under outpatient general anesthetic without hospital stay. For example, a two-year-old child with uncomplicated bilateral inguinal hernias, eating until a few hours before surgery, whose cheeks and lips betray no sign of anemia can and should undergo operative repair without diagnostic testing. Careful questioning of the family history adequately excludes inherited diseases and bleeding dyscrasias. Examination of the child provides all the further information needed to make a correct decision concerning the need for further tests. In contrast, a two-year-old child with previous diagnosis of biliary atresia with unsuccessful Kasai procedure and progressive biliary cirrhosis clearly needs a very complicated and extensive diagnostic evaluation to allow a determination as to whether he can 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
One of the greatest concerns for child or parents when approaching a surgical event is the problem of postoperative pain control. Most children are not particularly concerned about the technical details of the surgery they will undergo, but they are greatly fearful of the pain that they endure in the postoperative period. Knowledge that this can be controlled in a variety of ways provides some comfort. Knowledge that they will also be in the company of their parents during this period of time is also vitally important.
Consequently, the consultation visit or phone conferences include a thorough discussion of postoperative pain management. Commonly used methods of pain control include intraoperative local anesthetic administration, intravenous narcotics, patient controlled analgesia, caudal blocks, epidural blocks and continuous epidural anesthesia. Although these can all be discussed before the surgical event, it is generally best to provide at least one to two hours in the preanesthetic room so this can be discussed a second time with the anesthesia staff. This is the time of the final decision concerning the exact pain control methods to be used. Since this is often tailored to fit the anesthesia used during the operative event, the anesthesiologist is included in this decision.
Blood Donation
Due to the tremendous 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 acknowledgement that transfusion is most unlikely, and so much so that blood is not routinely prepared for the operation anticipated. In the event that 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 necessary to involve the director of the blood bank service to fully elucidate the questions posed. Parents must fully understand that blood samples will be necessary from child and donors prior to 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.
Presurgical Visitation and Teaching
Most children’s hospitals provide a presurgical visitation and teaching program. 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 the children of their parent’s nearness and participation in the entire process, and particularly address concerns about postoperative pain. In our particular hospital, the children conclude the visit by making a mural that is taped to the entry hall wall. As the children pass to the operating rooms, they can look for their previous artwork. We hope it lessens their anxiety and certainly endorse the use of these programs if available.
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