Physical and Psychological Preparation of Children for Anesthesia and Surgery
JANE M. BRECK, FRED M. ROGERS, HEDDA B. SHARAPAN and ALBERT W. BIGLAN
Table Of Contents
PART 1: PHYSICAL PREPARATION FOR SURGERY|
PART 2: PSYCHOLOGICAL PREPARATION FOR ANESTHESIA
|When a child requires a general anesthetic for a surgical procedure, it
can be a traumatic experience. This is especially true when an operation
is going to be performed on such a sensitive organ as the eye. The
child and his or her parents need to be prepared for ophthalmic surgery
in a compassionate and supportive atmosphere. The ophthalmologist may
be distracted by concerns about performing the correct procedure and/or
by the technical details of the operation; however, he or she must
consider the health status of the child and the child's and parents' emotions
in order to make this experience a caring as well as a
Two decades ago ophthalmic surgery for a child was commonly performed in a hospital setting with the advantage of having the preoperative and postoperative care provided in the hospital. Ophthalmic surgery for a child is now performed in an outpatient setting either in a surgi-center or in a hospital. Because of this, procedures may be performed in surroundings that are not dedicated and equipped to take care of a child. This transition and reduction of time in a hospital places more of the burden of specialized preoperative and postoperative care for a child on the ophthalmologist and the child's family. The needs of the child have not changed over this period, and he or she still requires the same level of support at home, both before and after the procedure. The child's safety and emotional needs must be considered and satisfied when surgery is performed on an outpatient basis.
Preparation of the child and family for an operation begins in your office. When the ophthalmologist and the staff are sensitive and accommodating to the child, that initial contact is the first step in establishing a caring attitude and in building trust with the child.
Once it has been decided to perform an operation on a child, clear communication with the child's pediatrician or family physician is needed to outline what procedure is going to be performed and where the procedure is to be performed. The surgeon should provide the pediatrician and the family with clear printed information regarding the policies and procedures concerning hospital admission. These instructions should also contain information that helps coordinate the efforts of both the surgeon and the pediatrician in providing help to the child and parents through this stressful time. The preparation in the surgeon's office as well as in the pediatrician's office should also complement care provided by the staff in the preoperative section of the hospital, the operating room, during administration of the anesthesia, and in the postoperative recovery area. Following the operation, much of the postoperative care is provided by the parent. It is, therefore, very important to give clear instructions regarding postoperative care and to provide parents with support to help the child not only physically but also emotionally through this recovery period.
Some operations are performed on relatively healthy children, whereas others are performed on children who have severe physical disabilities or extensive health problems. In some cases, emergency surgery must be performed on a patient who has never met the surgeon before. The staff must be prepared to respond to each of these situations, and procedures must be adapted to these situations.
In the first part of this chapter Breck discusses the physical preparation of children for ophthalmic surgery. Breck focuses on the detection and resolution of problems prior to hospitalization. Details of administration of an anesthetic to a child, as well as the management of medical problems before, during, and after the anesthetic are discussed elsewhere.
In the second part of this chapter, Fred Rogers and Hedda Sharapan provide insight into the psychological preparation for anesthesia as they share their many years of experience working with children and provide insight into a child's response to a stressful situation such as an operation. Fred Rogers and his staff are people who have spent their professional lives trying to help others understand children and how certain life experiences might affect their lifelong development. As a result, they have provided some helpful guidelines and recommendations for ophthalmologists and their staff to assist children through their eye operation. Attention to the psychological as well as the physical aspects of the operation can help make the operation as caring an experience as possible.
|PART 1: PHYSICAL PREPARATION FOR SURGERY|
|The preoperative assessment and examination by the pediatrician or family
practitioner is an important prelude to a satisfactory corrective ophthalmic
surgical procedure for the young patient. The younger or more
medically complex the child, the more clinical information is needed
to assure that the child can tolerate the procedure and the anesthesia.|
The preoperative assessment should ideally cover three broad areas: (1) detection of any acute or chronic medical problems; (2) acquisition of enough medical information about the infant or child to assure that the child is in optimal health; and (3) identification of any risk factors in the medical or family history that might unexpectedly interfere with a good outcome. In this process, a pertinent medical and family history is taken, hospital and office clinical records are reviewed, a careful physical examination is performed, and the decision to obtain any laboratory studies is made.
The examination should precede and not replace consultation with the anesthesiologist. It should provide the anesthesiologist with enough information to determine the child's baseline health status and to target any ways in which the patient deviates from the norm and may require special attention or monitoring. The pediatrician should highlight for the anesthesiologist any concerns that may compromise the safe delivery of anesthesia or influence the patient's recovery.
In addition to providing the medical preparation, the pediatrician who has known the child and parents for a while and is a trusted friend can be very helpful in .allaying anxiety. By recognizing the normal concerns and feelings about any hospitalization or surgery, he or she can allow time for discussion of these issues during the examination before surgery. Parents should be reassured that the morbidity rate for elective ophthalmic surgery in a major medical center is very low.1 The pediatrician may also provide answers to questions in frank and simple terms, thus decreasing the fears that even a minor procedure may generate.
Same-day surgery minimizes the psychological impact of the hospitalization on the child, is convenient, and is cost effective.2 However, a discussion of the possibility of a lengthier hospital stay for the more medically-at-risk child must be introduced at this time if indicated. The hospital experience is routine for the physician but hardly a benign event for the child and the family.3 The pediatrician, the surgeon, and the anesthesiologist need to work together and communicate their findings and intentions clearly. This will result in the best outcome for their mutual patient.
THE MEDICAL HISTORY
While taking the medical history, the pediatrician uncovers information about the child's general health and any symptoms that may require a more detailed preoperative medical evaluation. History-taking is one of the best screens for disease.4
Specific questions should be asked about any recent symptoms of illness, fever, rashes, or recent exposures to infectious diseases. Exposure to chicken pox within the last three weeks, exposure to a streptococcal throat infection within the last 3 to 5 days, and a history of family members ill at home are significant.
Cardiac and pulmonary signs and symptoms in the child are specifically sought, including cold or cough, chest pain, wheezing, asthma or allergies, history of recent or recurrent pneumonia or bronchitis, shortness of breath, pallor, duskiness, or fatigue with exertion.5 The medical history should also determine exposure to cigarette smoke in the home as well as the possibility of lead or other toxin exposure.
Information should be obtained on neurologic status, level of cognitive function, behavior, presence of seizures (type and treatment), complaints of pain, or headaches. The extent of chronic conditions of the nervous system such as mental retardation or cerebral palsy and the presence of sensory impairment such as deafness or visual deficits should be documented.
Inquire about easy bruising, bleeding from gums, bleeding in the past during minor surgery, bleeding into deep tissue or joints, or a history of aspirin ingestion.
Nutritional history includes dietary intake, special diet or restrictions, recent weight loss or excessive weight gain, and the presence of gastrointestinal symptoms.
Recent events in the child's life that may produce stress are explored: school demands, the birth of a sibling, illness of a parent (especially the primary caregiver), divorce, separation, or a move. Attention to psychological issues helps to determine if the child is more emotionally vulnerable than usual or if the timing of the elective procedure should be changed.2
In addition to the routine questions of drug history, ask if the child is subject to motion sickness. Some references report that nearly all children subjected to motion sickness will have postoperative vomiting and recommend prophylactic treatment.1 A drug history of eye drop use is important, because phospholine iodide inhibits pseudocholinesterase and may prolong the action of succinyl choline.1
Healthy multihandicapped children frequently require ophthalmic surgery and a detailed past medical history is needed. Strabismus often occurs in patients with congenital infections, central nervous system (CNS) trauma or disease, previous craniotomy for removal of a brain tumor, history of meningitis, severe prematurity, and respiratory distress syndrome. These children require a full review of their medical history, including hospitalizations and previous surgeries, for a complete understanding of the factors contributing to the child's well-being during anesthesia and surgery.
The family history should include questions about parents' and siblings' health as well as the incidence of hereditary disease, congenital anomalies, allergies and asthma, blood dyscrasias or bleeding disorders, and the response of family members to general anesthesia. The pediatrician must inquire if any family member had a problem during or after anesthesia and surgery. There is an association between strabismus and blepharoptosis and malignant hyperthermia (hyperpyrexia). Although rare, it should be asked about.
THE PHYSICAL EXAMINATION
This examination should be done one week or less prior to inpatient surgery and one month or less prior to outpatient surgery.6 This evaluation should answer the question, “Is this child healthy and able to tolerate anesthesia and surgery?”
A complete physical examination begins with a general observation of the child in which body proportions, nutritional status, behavior, and interaction with parents are noted.
Vital signs in the normal range indicate a stable physical condition. A fever, temperature 101°F (38.4°C) or higher, is an indication to cancel elective surgery. Irregular pulse, abnormal blood pressure, tachypnea, or noisy respirations should alert the physician to investigate a potential problem.
It is very important to inspect the head and neck structures very carefully for conditions that would make intubation difficult or contribute to upper airway obstruction after sedation or induction. Because of their small size, children's airways can be easily compromised.7 Young infants are obligate nose breathers and a “stuffy nose” is a significant problem. Other sources for potential problems include small nares, narrow palate, posterior pharyngeal secretions, ear infections on otoscopic exam, large tongue, loose teeth, hypertrophied tonsils, small underdeveloped mandible, and any limitation of movement of the neck. Symptoms referable to ligamentous laxity with instability of the atlantoaxial joint of the cervical spine in Down syndrome patients is discussed in a section to follow. Patients who have a head tilt associated with a cyclovertical muscle palsy should not have an increased risk for an airway management problem.1
Emphasis is placed on the heart and lungs with a careful cardiopulmonary examination. If a heart murmur, tales in the chest, coughing, or wheezing are present, a more complete evaluation is warranted. Cardiovascular assessment includes examination of the skin and the nail beds and assessment of skin perfusion and temperature, especially in the limbs.7
Examination of the abdomen for presence of distention, increased organ size, or the presence of a mass should also be included. In children with cerebral palsy, a rectal examination should be performed. It is advisable to relieve constipation prior to surgery, as anesthesia could worsen this condition.
The child is observed for neurologic deficits or a developmental disorder, and the extent of the deficit is recorded. The child's behavior is very important to observe during the physical examination. The pediatrician's impression of the child can uncover issues that make this patient more psychologically vulnerable during surgery and hospitalization. Factors to consider include age and temperament of the child; nature and site of the procedure (eyes have a strong emotional association); predicted degree and duration of postoperative pain, discomfort, or disability; and length of time spent in the hospital for this procedure and past procedures.2
TIMING OF SURGERY
Elective surgery may be deferred or scheduled earlier depending on numerous factors: type and extent of the ophthalmic problem, age of the patient, developmental level, presence of risk factors, and need for postoperative cooperation by the patient. Early treatment may provide more appropriate developmental stimulation for the infant, remove parental anxiety, or avoid parental rejection or emotional reaction to the child's condition.8
For premature children, it is recommended that elective operations be delayed until the postconceptual age has reached 55to 60 weeks, because anesthetics may depress the control center for breathing. For the fullterm infant, elective surgery should be delayed until forty-four weeks postconceptual age.9
The younger infant may not demonstrate the degree of traumatic psychological effects that is sometimes seen in the older child. Even with minor surgical procedures, a preschool child may show some behavioral disturbances for up to one to two months after the hospitalization. Insecurity, increased dependency, and disturbed sleep are not uncommon even with the best preparation, understanding staff, parental reassurance, or a calm, confident attitude. These behaviors may be avoided or shortened with good preoperative psychological preparation.
POSTPONING SURGERY AND ANESTHESIA
Pediatricians are often faced with the questions of whether to postpone surgery in the child with an upper respiratory infection. Early studies by Tait and Knight in 1987 suggested that complications from surgery are not increased by the presence of an uncomplicated upper respiratory infection (URI).10,11 However, children with productive cough, sneezing, hoarseness, fever, or rhonchi were excluded from these studies. Cohen and Cameron12 reviewed a large pediatric anesthesia database and compared the rates of adverse events in 1,283 children with a preoperative URI with 20,876 children without URI. The risk of respiratory complications was increased twofold to sevenfold if a child had a URI compared with children without URI. Children with a URI require more observation and management during the perioperative period, because general anesthesia in children is associated with an increased risk of adverse respiratory events.13
If the surgeon elects not to operate on a child with a mild URI, and the average child has between three and six viral URIs per year that require several weeks until full recovery of respiratory function, he or she may find that there is little time for elective surgery in the fall and winter months. The current recommendation is this: those children under the age of 5 years with an acute URI, with signs of fever, hoarseness, productive cough, fussiness, purulent discharge, or rhonchi should have their surgery postponed until they are asymptomatic. There is a need for continuous monitoring of blood oxygen saturation and the administration of supplemental oxygen in the recovery period for any child with a history of a recent URI because of the potential for residual atelectasis or reactive bronchospasm, laryngospasm, epiglottic edema, atelectasis, and pneumonia. However, the older child with isolated naso-pharyngitis with no signs of systemic or lower tract disease can probably undergo minor elective surgery without increased risk.13
Preoperative assessment should not have to include routine laboratory tests in healthy children having elective outpatient ophthalmic surgery if the child is followed routinely by their pediatrician and has a normal history and physical exam.14 The value of preoperative screening tests versus their cost-effectiveness has been examined. In healthy children, results of routine laboratory screening tests have not altered decisions on whether or not to perform surgery. A hemoglobin of 10 g/dL or higher may be the only test required by some anesthesiologists to assure a minimum level required for general anesthesia.5,15 Normal hemoglobin level varies widely with age throughout infancy and childhood. In infants 8 weeks old, the lower limit of normal is 9.8 g/dL in full terms, and 7.0 g/ dL in preterms.4 Unless significant blood loss is anticipated, a hemoglobin level lower than 10 g/dL is acceptable.5 When the hemoglobin is lower than normal, the most common cause of anemia in young children is iron deficiency anemia. Iron deficiency can be treated with an oral supplement prior to an elective procedure. In older children, an evaluation must differentiate among blood loss, hemolysis, or the anemia of chronic disease. A hemoglobin and sickle cell screen should always be done for ethnic groups at risk.14 In patients in whom a white blood count determination is indicated (recent infection, lymphadenopathy and so on), the acceptable reference range is 2,400 to 16,000.9
Urinalysis is not recommended as a routine screening test.16,17 Urinalyses are costly, and the yield of important findings is small. Mitchell looked at 732 screening urinalyses in 2695 hospital admissions and found only 6 patients with urinary tract infections in the 20% of the urinalyses that were abnormal. Most of the abnormal results were not evaluated further.16 OConnor17 found 15% abnormal urinalyses in 486 children admitted for elective surgery. In only 2 cases was the abnormality important enough to cancel the operation and neither child was later found to have significant urinary tract disease.17
A chest x-ray film should not be routinely obtained in apparently healthy children. As the value of screening tests is dubious at best, what are the disadvantages? Abnormal test results from an asymptomatic patient may not indicate disease.18 Additional tests are necessary in follow-up if false positive results are obtained. The need for additional referral is not cost-effective and can cause confusion and delay of the operating room schedule. This can produce great anxiety in the patient and family.
It is important to remember that the results of the history and physical examination should dictate what laboratory tests need to be obtained. In the majority of children who have their operations cancelled, the reason for the cancellation is due to abnormalities uncovered by the history and physical exam, not by laboratory studies.
SUBACUTE BACTERIAL ENDOCARDITIS PROPHYLAXIS
The ophthalmologist can expect to see more pediatric patients requiring antimicrobial prophylaxis because survival of children with congenital heart disease has improved. Cardiac malformation is the major factor predisposing to infective endocarditis. Although dental procedures constitute the most frequent antecedent event prior to endocarditis, other minor procedures, including manipulation of the respiratory tract can also lead to endocarditis.
Antibiotic prophylaxis is recommended to prevent subacute bacterial endocarditis (SBE) for procedures associated with a high frequency of bacteremia or for patients who have had a previous episode of infective endocarditis. Endotracheal intubation alone is not universally viewed as an indication for prophylaxis against bacterial endocarditis. It is suggested that you consult your institution's anesthesiology department for the standard of care in your institution.
Prophylaxis against subacute bacterial endocarditis before and immediately following a procedure is recommended for patients with cardiac disease. Cardiac conditions for which SBE prophylaxis is required include the following19,20:
Valvular heart disease
THE COMPLICATED PATIENT
In the last fifteen years the frequency of asthma has increased from 6% to 12%.21 The reasons for the increase are yet to be explained, but pediatricians are treating an increasing number of asthmatics. Pediatric surgery will also be performed on a larger number of asthmatic children, and this must be appreciated for proper monitoring during surgery and anesthesia. The risks of ophthalmic surgery for children with asthma depend on the severity of the asthma, the degree of control of the asthma, and the prevention of postoperative pulmonary complications.
The following are three main concerns regarding surgery and the asthmatic patient:
As a rule, asthmatics who continue their regular medication and have optimal bronchodilation do well under general anesthesia. The asthma patient who has been treated with corticosteroids within 6 months before surgery, however, may have compromised pituitary-adrenal axis responsiveness and needs supplemental corticosteroids prior to surgery. Also, the patient on long-term, low-dose, corticosteroids requires preoperative steroid supplementation. Chronic treatment with corticosteroids interferes with the stress response, especially if surgery entails an unforeseen complication. Data that examine the effects of the use of inhalation steroids on the asthmatic are not as clear. Even though studies suggest that cortisol levels are normal in patients on inhalants, some data suggest that when these patients are stressed, their response is not completely normal. The significance of this problem depends on the dose and length of time the steroid inhalant was used.22
The preoperative physical examination should search for tachypnea, cough, expiratory wheezing, increased anterior-posterior diameter of the chest, use of accessory muscles, and retractions. All patients with asthma should have a chest roentgenogram prior to surgery.23 In severe asthmatics, an arterial blood gas determination should be considered to evaluate any hypoxemia and to assess pulmonary function in the child too young to cooperate with pulmonary function studies.
Should you cancel surgery for the patient with an acute episode of mild wheezing? Since wheezing is frequently triggered by a viral infection, this may be the best approach if cough, fever, and rhinorrhea are present. The asthmatic patient must continue to receive his usual dose of maintenance bronchodilator unless the child is in remission and demonstrates normal pulmonary function. The child with moderate to severe asthma requires additional involved preoperative preparation, including clearing of secretions. This may necessitate admission the night before the surgery. Do not discontinue either inhaled medication or long-acting medication. Information on the management of children with asthma during and after anesthesia occurs elsewhere in this volume.
The Premature Infant
Ophthalmic surgery for the premature infant is a special situation. It requires additional assessment, preparation, information, and monitoring during the administration of anesthesia, surgery, and in the immediate postoperative period.
The premature and the older former premature infant has had to face a challenging period of adjustment to extrauterine life. The premature birth of a child may result in severe immaturity of the pulmonary, cardiovascular or neurologic functions, and problems related to these systems must be anticipated. Problems of concern to the pediatrician, anesthesiologist, and ophthalmologist include chronic lung damage from residual bronchopulmonary dysplasia (BPD), apnea, or bradycardia of prematurity; circulatory abnormalities that may require surgery, such as an open patent ductus arteriosus; intraventricular hemorrhage that extends into the brain (IVH); feeding and nutrition problems affecting growth, liver function problems and hyperbilirubinemia; susceptibility to infection; and altered healing responses.
The premature infant under 6 months of age born at less than 36 weeks' gestation is at higher risk for post anesthesia and postoperative apnea, periodic breathing, arterial oxygen desaturation, bradycardia, and cardiac arrest.9 More discussion of the premature and postoperative care occurs elsewhere in this volume.
The Child with Down Syndrome
The child with Down Syndrome (Trisomy 21) may have special medical problems that the pediatrician needs to pay particular attention to. The presence of medical problems that may increase anesthetic or operative risk should be evaluated prior to surgery. The three most significant areas of assessment are the cardiac status, the cervical atlanto-axial joint, and the midfacial area, particularly sinuses, ears, nose, and throat.
The incidence of cardiac anomalies in Down syndrome is reported to be 30% to 60%, and it is now recommended that all infants with Down syndrome have a cardiac evaluation, including an EKG and an ultrasound study of the heart, even if they do not have an audible heart murmur. If your patient has not had a cardiac evaluation, then a preoperative EKG and echocardiogram are indicated. Also consider providing for SBE prophylaxis in a Down syndrome child with a significant cardiac lesion (except for an isolated secundum atrial septal defect).20
Intraoperative complications involving compression of the cervical spinal cord are always a theoretical possibility. Because most individuals with Down syndrome have some ligamentous laxity that can affect the cervical spine joint spaces, instability of the joint between the first and second cervical vertebrae could place the spinal cord at risk for injury due to subluxation. As stated in the Guidelines for Screening for Atlanto-axial Instability revised and approved January 28, 1991, by the National Down Syndrome Congress, all children with Down syndrome should be screened before any surgery that will require intubation of the airway, as there have been rare reports of neck injury during placement of the endotracheal tube. Asymptomatic atlanto-axial instability (AAI) is found in 13% to 14% of Down syndrome individuals, and symptoms that require treatment occur in 1% to 2%. Individuals with asymptomatic AAI should avoid activities that may hyperextend the neck. Most physicians who are knowledgeable about Down syndrome children recommend that all such children be screened with lateral x-rays of the cervical spine in flexion, extension, and neutral position during the preschool years.24 If your patient has not had a screening x-ray of the cervical spine, it must be done prior to anesthesia and surgery. During anesthesia, patients with asymptomatic AAI should not have excessive extension of the neck.
Ear, nose, and throat problems associated with down syndrome are almost a universal finding. They may arise secondary to the anatomic changes associated with Down syndrome, or they may be related to the immune system defects. The major medical issues include increased frequency of sinus, nasopharyngeal, and ear infections, hearing loss, and obstructive upper airway problems. Tonsil and adenoid tissue hypertrophy as well as relative macroglossia may lead to obstructive sleep apnea.25
Other medical conditions found with higher frequency in Down syndrome patients may or may not affect anesthesia and surgical risk but should be reviewed preoperatively. Thyroid disease (found in 35%), malabsorption (35% have trouble absorbing vitamin A), nutritional problems (especially poor weight gain in the infant and obesity in the school age child), and a higher risk for leukemia are included. Laboratory screening for thyroid hormones T4 and TSH, vitamin A, and complete blood count are usually done yearly in all children with Down syndrome. If the patient has not had these studies done within one year, he or she should have them as part of the preoperative studies.26
The child with cerebral palsy or neuromuscular disease may have difficulty with increased salivation, seizures, spasticity of the neck and jaw, and constipation due to low abdominal muscle tone. Patients affected by this static neurologic condition should be covered with their appropriate anticonvulsant medication. Providing frequent suctioning to clear secretions and monitoring with chest physiotherapy postoperatively is often necessary.
When evaluating the diabetic child prior to elective ophthalmic surgery, there are two main concerns: prevention of hypoglycemia, especially under anesthesia, and prevention of ketosis and diabetic ketoacidosis (DKA) from the stress of surgery. A pediatrician as well as a surgeon should combine their efforts to provide care for the young diabetic in the hospital. If the child with type I diabetes mellitus is resisting care or if the level of blood glucose is difficult to control, admission the day before surgery is recommended. Issues to consider in preparing the patient of surgery are achieving optimum metabolic control, reviewing previous control, providing medical care and stressing compliance with treatment, and finally, evaluating any complications related to the patient's diabetes.
Most diabetologists advise specific guidelines to prepare the child, starting the day prior to surgery. The child should eat the usual diet and receive the usual insulin dose(s). The juvenile diabetic patient should be admitted the day or evening prior to surgery with the goal of maintaining or loading carbohydrates to increase the blood sugar so the risks of developing hypoglycemia are minimized. Glucose administration should be accomplished by giving a late night snack or infusion IV glucose overnight starting at 10 PM. The calories of glucose provided should be calculated based on the glucose ingested in a normal breakfast. In addition, the diabetic patient should be placed first on the operating room schedule or if this is impossible, surgery should be performed as early in the morning as possible.
Preoperative insulin doses should be adjusted to include only two thirds of the usual NPH dose and none of the regular insulin. During surgery, intravenous (IV) glucose should be continued, and blood glucose should be monitored frequently so that insulin doses can be adjusted.27 Monitoring the blood glucose in the operating room and recovery room with visual reading of test strips is accurate if performed by a well-trained individual.28
The stable diabetic child undergoing elective ophthalmic surgery needs a preoperative blood glucose determination and a urinalysis in addition to a routine history and physical examination. Surgery should be postponed if the blood glucose level is extremely high or if ketonuria is found. In an otherwise stable diabetic child who is well known to the primary physician and has reasonable diabetic control, surgery can be performed safely if enough time for a thorough evaluation and preparation is allowed.28
This section has reviewed the preoperative evaluation of both healthy children and those with complications prior to ophthalmic surgery. The pediatrician or family practitioner must provide clearance for the patient and communicate this plus the baseline status and any special circumstances to the anesthesiologist and ophthalmologist. This history, physical examination, and behavioral observation provide vital information to prepare the child and family for safe, successful ophthalmic surgery.
|PART 2: PSYCHOLOGICAL PREPARATION FOR ANESTHESIA|
|You were a child once, too. That may be obvious, but knowing that and remembering
what it was like being a child can make a significant difference
in the relationship between you and your child patient. Some children
are fortunate enough to be treated by physicians who recall the
feelings of being a powerless vulnerable child. Those are the physicians
who are best able to engage their child patients in a partnership for
health that will serve them for all their days.|
Just as each physician is a unique person, so is each child patient and each child's parent. Learning to deal with children's feelings is a process. Just as you grow and mature professionally, like parents and teachers, you, too, will grow in your ability to deal with the psychosocial needs of the children-just by virtue of your caring about the whole child (not just his or her eyes).
Children who are less anxious are more cooperative patients. They require less medication for sedation and recuperate more quickly than children who are very apprehensive. Whatever steps are natural for you to take for establishing a trusting relationship with the children in your care will help calm them and will have benefits not only for their care time in your office or at the hospital but also for their general physical and emotional health.
Because many young children are naturally fearful of strangers, and some children are especially fearful of doctors, establishing a trusting relationship can be a great challenge. In your office you and your staff have many opportunities to let children and their parents recognize that you are not someone to be feared and that you care about them, their feelings, and their questions. You have ways to build their trust because you're a human being, and trust is essential in your life, too!
Children sense very quickly what their parents are feeling, and they are especially attuned to their parents' anxieties. Whatever you can do to help parents feel confident and calm will go a long way toward calming their children.
Along with medical concerns for their child, parents also bring to your office their emotional concerns. Whenever a child has any problem (major or minor), parents tend to feel vulnerable, sometimes powerless, and often guilty. Everyone longs to have a perfect child, and when that dream is marred by some problem (no matter how small), parents often need extra doses of reassurance and trust from the physician and the staff.
Parents are “supposed” to care for their children, but when there's a medical problem, it can seem to them that the medical staff is taking over their role of parenting. For their children's medical examinations and procedures, parents have to turn their care giving over to the medical staff, and it's no wonder they feel helpless, which often is expressed as anger and fear. Parents whose children have had multiple operations and complicated medical histories may be even more anxious, demanding, and difficult than others.
Just acknowledging that it's natural to be worried and angry can help a parent. And, because most ophthalmologic procedures are very safe, you can be very reassuring. For parents, any surgery performed on their child is a frightening experience. This is especially true of the eye, which has added emotion associated with it. When a physician truly cares about helping parents deal with their concerns, that physician's eyes, tone of voice, facial expression, and body language contribute to building a bond of trust with them and their child.
EDUCATING PARENTS AND CHILDREN
Most anxieties grow out of fear of the unknown or lack of information or understanding. Vinstainer and Wolfer (1975)29 found that for all children in their studies, including the younger ones who were three years old, information was an important factor in preventing stress, even more helpful than just supportive care without being told what would be done in the surgery. That's why it's important to discuss the procedure and its goals with the parent and the child.
Ophthalmology is a highly technical field and carries many misconceptions and misunderstandings on the part of the parents. Anything you can do to demystify your work for them helps to develop trust and reduce anxiety. Certainly it takes time and effort to answer questions, to give explanations, to use or draw diagrams, or to tell stories of other children who have had the same procedure. Demonstrating, such as holding up a trial lens to a parent' s eyes to let them know what their child sees, helps them to understand the child's problem better and helps you to forge that special connection that allows them to be part of your treatment team, which is essential for their child's health. Anything that you can do or say that helps parents get the message that you and they are allies in the enterprise of helping their child serves all of you well.
ACKNOWLEDGING CHILDREN'S FEELINGS
It's natural for children to feel frightened, lonely, or confused when they're hurting or when they're in a new environment (especially a doctor's office or hospital). Very young children have only primitive defenses. When they're upset, they cry, hit, kick, or bite. Even older children may cry, and that's understandable. When a certain procedure is going to be painful, you might say “it's all right for you to cry Johnny, but I need you to hold still.” That not only says that you can appreciate the child's feelings, but you are offering the child an opportunity to help and a chance to feel proud of himself.
It's also common for children to feel upset with you or your staff after undergoing a difficult procedure or hearing upsetting news. By acknowledging negative feelings, you can help children know you care, even when they're having a hard time. In a book that she wrote based on her own childhood experiences with surgery, Marilyn Singer described a doctor commenting to his eleven-year-old patient that he understood it was normal to be upset about her forthcoming cardiac surgery.30 His caring message was obviously meaningful, because she then said, “Well, I was glad to hear I'm normal-even if my heart isn't.”
CHILDREN'S NEED FOR AUTONOMY
A sense of autonomy is one of the most important ingredients for healthy coping no matter how old we are. Autonomy involves power, control, choices, and freedom of will. A growing child needs to incorporate some degree of these in order to grow into being a psychologically healthy adult.
In a doctor's office or in the hospital, children may feel robbed of their autonomy because the medical staff dictates what children do, when they do it, and how they do it. They even have ways of restraining children who resist. When this occurs, it is natural for children to feel overpowered and threatened, and they will resist or even withdraw or regress in their behavior.
While it can be easy for an adult to overpower a child, there is great danger for the child who may see himself or herself as a helpless victim. That's a danger, the effects of which long outlast the time the children are in your direct care. Unexplained force, restraint, and commanding language may make the child feel victimized. Being victimized in those ways is devastating to the psyche and may leave a child with lasting memories of the experience that can emerge in future encounters with the medical profession. A child may be able to endure such a trauma only by turning off feelings altogether. Children who deny feelings grow up to be people who lack empathy for others and are stunted in their own emotional growth.
Even if feelings are denied, they don't go away; they haunt us if we don't have healthy ways of dealing with them. Children who feel victimized may become untrusting of the world in general, overly dependent, and terrified of being abandoned by a parent. They may have nightmares. In the worst cases, some children with severe health problems may even lose their will to survive.
A child who is a “fighter” may be more difficult for us to manage, but that child is reacting normally to a scary situation and will be more likely to have the emotional energy needed for recuperating, as well as for the growing and learning that's ahead.
There are many ways for you to allow children to build on their developing autonomy. As with all that we've been talking about, the best start is remembering times in your past when you felt vulnerable and helpless. With your empathy, you will give your child patient many nonverbal cues that you really do understand how they're feeling. You can also help by offering choices, for example, “Which eye would you like me to put the drops in first?” Of course, there will be times with infants and toddlers or very fearful preschoolers where you may have to use restraint in order to be able to make a diagnosis or administer a treatment. Even in those upsetting situations, you can offer a caring balance just because you recognize how emotionally difficult it is for a child to be overpowered. You can say, for instance, to the parent of a toddler, “There's no way this can be pleasant for your daughter, but it can help her if you just hold her while I do it.” A young child will generally be comforted reasonably quickly in a parent's arms afterwards. Fortunately, a very young child's memory of discomfort is brief. When you've finished the examination or procedure, you can also contribute a great deal to the child's ability to deal in healthy ways with the momentary trauma of having been overpowered.
In every contact you have with a child or his or her family, whether in your office or in the hospital, you have the opportunity to offer your sensitivity in all of the ways just described.
THE PRELIMINARY EXAMINATION
The Reception Room
In addition to the concerns about the eye problem, parents and children bring to the doorstep of your office all the feelings they've ever had from their previous experiences with doctors. Imagine how much it can help if, when the family walks in the door, there are indications that your office is a place that cares about them. You can transmit that message with something as simple as pictures on the wall, perhaps of children and animals and families and other things that might be familiar to a child's experience.
You could have simple things available, like a blackboard and chalk, children's books and magazines, an aquarium with fish, and safe toys. Playthings can help because waiting time is hard for everyone, but particularly for children, who can become difficult to manage and distressed when they are bored or anxious. It would be wise to select toys that don't have small parts and that don't make noise that may upset adults.
You may want to supply medical-type toys or empty eye-drop bottles for play. Encouraging children to play about experiences in which they are relatively powerless (like a doctor's examination) can help them feel in control of some things, which can help them manage those times better.
Because your reception area is the first introduction to your office and because people spend so much time waiting there, it is a good idea to make sure that the area is well-illuminated, clean, well-maintained, and neat. You and your staff reinforce your care and feelings of concern by checking your reception area regularly to make sure that the toys are clean and neat and don't have pieces missing and that the magazines and books aren't torn or damaged.
Having a changing area in your rest rooms is an added convenience for families with young children. Having quiet private areas for mothers who are breast feeding also shows a caring concern for the parent and child.
You may want to consider scheduling children's appointments for a particular day or segment of the day so that the children can have an opportunity to play with others. That kind of scheduling may also help some of your elderly patients or those using canes or wheelchairs, who may not appreciate having the noise and commotion that children often create while they're waiting.
The Examining Room
Because of young children's naturally developing body awareness and their need for body privacy, it can be difficult for them to let doctors investigate the workings of any parts of their bodies. It even upsets children sometimes when parents come at their faces to do something as simple as wiping a drooling nose or pushing bangs aside on a forehead! You can imagine their distress, then, when eye drops need to be administered.
People of all ages may be especially sensitive about their eyes. In our feeding experiences right from birth, as infants we actively use our eyes to search the face of the person who is feeding us, reading that face like a road map to gather information about the world. At that time in our lives, our eyes help us find answers to the most basic question, “Is the world a good and trustworthy place?” As we grow, we continue to rely on our eyes as an important source of our sense of self, independence, and knowledge of what's going on around us.
Knowing that children are especially sensitive about their eyes and may be frightened about someone examining them, here are some specific suggestions for setting a caring tone when a family comes into your office:
During the Examination
Children who are old enough to understand will find it helpful when you prepare them by telling them what you're going to do and why. If you need to darken the room for your examination, remember that darkened rooms can evoke scary images. It can help to let children know ahead of time that you need to lower the lights to be able to check their eyes better.
In fact, it can always help when children are given some preparation about what to expect, for example, to say “I'm going to turn the lights off and look at your eyes with a flashlight.” It also helps children be more cooperative when you let them know truthfully which procedures are going to hurt and which are not going to hurt. Talking about what to expect helps prepare them, so they can make some effort to cope and have a better chance of coming out of your office with some dignity, instead of feeling overwhelmed and powerless.
In general, with children, your examination doesn't have to be forced into a rigorous pattern. It's far better to “let the child show you the exam” by being a careful observer. When you take the history, observe the child's head posture, eye movements, external examination, and general overall development. If you become skilled at this, you may find parents disappointed that the examination took only a few minutes, but you can help them know that in actuality, much of the examination occurred in your observations before the child sat in the examination chair.
When you're examining a baby or toddler, who's too young for explanations, you may be tempted to hold the top of that child's head in a certain position. While from your perspective that restriction of movement may seem to you to be merely uncomfortable for the child, it is, nonetheless, experienced by a child as invasive and can be interpreted as a sign of danger.
As an alternative, there are many more natural and playful ways to get a child (young or old) to move his or her eyes or head, such as the following:
using toys that are attention-getting
You may also want to consider offering children a small flashlight to hold during your examination, and possibly have some inexpensive ones (or ones that have become too dim for you to use) to offer as a gift to take home. Flashlights are seen by children as a source of power and control, as they can turn the light on and off. Furthermore, with a flashlight a child can produce a beam of light across a room, which gives a sense of extending power far beyond one's reach. Even having something to hold, like a flashlight or a stuffed animal or toy brought from home, in itself can give a child a sense of security.
Administration of Eye Drops
Having eye drops administered is a moderately uncomfortable experience, but it can be frightening for a child for many reasons. Besides the unpleasant burning sensation from drops, most children will instinctively fight having anything put in their eyes, and then they may have to be restrained, which can make them feel victimized. It can also be frightening for children to find that their vision is strange after cycloplegic drops, especially if they try to read. It's important to reassure them that the drops are making their eyes react that way and that the effect will go away in a few hours.
Other things that may help include:
Discussion After the Examination
Here are some things doctors can do to help children and parents following the examination:
Preparation for Surgery
Surgical procedures for children with eye problems are usually performed on an outpatient basis. The use of preoperative medications is uncommon, and this places the responsibility of preparing a child emotionally on the ophthalmologist and the pediatrician in the office, the nursing and operating room staff at the hospital, and on the parent at home.
Some things that can help prepare the child and parents for the day of surgery include the following:
Children's Feelings About Separation From Parents for Surgery
It can be very frightening for young children to be in an unfamiliar place and separated from their parents. Hospitalization can be particularly upsetting because children may be separated from parents just when they feel most threatened-during treatment or surgery.
Parents are a child's whole world and most trusted friends. In those situations when children are separated, they need to use all their emotional energy not to feel victimized and completely helpless; they need to use that energy to cope. Many children may look like they're managing all right, but at what cost? For lots of children, the price they pay is too high, and they can have lifelong repercussions from that experience of being terrified, helpless, and abandoned by their loved ones. The effects or fears of the trauma of separation from familiar loved ones can go on long after the healing of the eye is complete.
We strongly urge doctors to lobby for hospital rules that allow parents in an induction area and in the recovery room. A parent should be the last person a child is with before receiving the anesthetic and the first person that child sees when he or she awakens in the recovery room.
You can play an important role in encouraging your hospital or surgical center to provide a suitable space and surroundings where the parents may be with their child at these moments of stress.
It was personal firsthand experience that led British ophthalmologic surgeon, Adrian While, to be one of the leading advocates for parents in the induction area.31 He was not permitted in the induction area when his young daughter needed surgery and had to hand his own “terrified and screaming child to unfamiliar nurses at the door of the operating room.” After seeing how traumatic the separation was for his child and how vividly she recalled afterwards scary details of that experience, he became a pioneer in pleading for a parent's presence in the induction area. Although he believes that verbal preparation can be helpful, he argues that the fears of induction are so deep-seated that they dictate the necessity of a parent in that situation. Furthermore, he feels, “The younger the child the more necessary is the physical presence of the parent to reduce the sense of abandonment and minimize trauma.”
In a follow-up letter in the British Medical Journal, he states “The change in attitude needed is from a paternalistic one, which regards present practice because it suits doctors, to one which responds to the needs of small children, even when that requires changes in long-established methods.”32 Many others in the pediatric community have joined in this campaign, including The American Academy of Pediatrics, which is now encouraging parents to be with their children wherever possible during the hospitalization.
One argument against a parent's presence in those areas has to do with concerns about safety, and the consensus is that those concerns can be eliminated with careful planning.
The second argument has to do with the concerns that anxious parents make their children more anxious. However, researchers concur that when problems occurred, they did so because parents have not been well-prepared. Educating parents about what to expect as a child is anesthetized and when a child awakens from anesthesia would virtually eliminate this problem. And, allowing parents to decline if they don't want to be there would also greatly reduce the likelihood of problems. Most parents are a help to their children, and in extreme circumstances, such as potentially frightening medical procedures, children need their parent's presence whenever the children are awake and conscious.
In the recovery area, the main concern is that parents become more anxious and distracted when they see other children who have had serious procedures. It would be important, therefore, to urge that recovery areas be designed to have two levels of care, in order to separate patients having minor surgery, such as eye and ear surgery, tonsillectomies, some minor hernia repairs, from those having heart and liver transplants, trauma, or major abdominal procedures.
Some things that can help in the induction area include the following:
Follow-up Office Visit After Surgery
Some things that might be helpful after surgery include the following:
We hope this discussion has been helpful to you as you develop a deeper and broader understanding for the emotional needs of the child ophthalmologic patient. From the time the child walks into your office right through the postoperative discussions, the many ways you express your caring empathy can enable that child to cope better with the emotional experience of surgery. That, of course, helps in a quicker and smoother recovery.
As a doctor, you'ore building on a solid foundation of shared trust. Whenever your young patients are in other upsetting times later on in their lives, they and their parents will be able to use the honesty, the empathy, and the care you gave them during that potentially frightening time in their early life. One thing you can be sure of: When a child lives through a tough time and doesn't have to feel victimized, that child will have grown inside-immeasurably-and will forever be grateful-unconsciously-to all those who gave the care.
|The guidelines provided in this chapter should help you and your staff provide the best possible care for a child who requires hospitalization for eye surgery. In most cases this will be a child's first contact with the medical staff in a hospital. If the child and parents are poorly prepared and if the ophthalmologist does not spend sufficient time and effort to oversee the care of the child, this experience might be perceived as a threatening invasion of the child's sense of security and autonomy. Unpleasant memories can leave lasting psychological trauma. On the other hand, with appropriate preparation and dedication of yourself and your staff, the experience can be a positive one, one in which you are perceived as taking good care of them and their eyes.|
28. Ginsberg-Fellner F, Liguori P, Larson S: Surgical management of pediatric and adolescent patients with type I insulin dependent diabetes mellitus. In Bergman M, Sicard G (eds): Surgical Management of the Diabetic Patient, pp 169–173. New York, Raven Press, 1991