Tips on how to handle the pediatric patient
June 1, 2000 4 minutes read
Tips on how to handle the pediatric patient
By Stephen W. Earnhart, MS
President and CEO
Earnhart & Associates
Dallas
Big surprises often come in small packages. That is one reason that dealing with the pediatric patient in the operating room is such a challenge. It’s not just a challenge from the viewpoint of anesthesia, but from the point of dealing with the parents (sometimes more difficult than the child) and siblings of the patient, should they accompany them to surgery.
Anesthesia considerations include the increased risk in small patients and infants just from an airway standpoint for the following reasons:
• The tongue is relatively large.
• The epiglottis is short, stubby, and angled away from the trachea.
• The vocal cords have a lower attachment.
• The narrowest portion of the airway is the level of the cricoid cartilage, while in adults it is the glottic opening.
Other areas of concern with infants and small children come from the fact that they have a higher metabolic rate with increased oxygen consumption. Thus, they have less oxygen reserve and can become hypoxic much faster than the adult.
Often, and I speak from experience as a parent, NPO (nothing by mouth) status doesn’t mean much to hungry children. Many times crumbs and smudges on their fingers and clothes give clues that a snack was smuggled out of the kitchen while no one was looking. As a rule, many anesthetists are suspicious of NPO compliance in outpatient surgery on a young child coming in from home.
Many centers allow parents to accompany the pediatric patient into the operating room and even stay through the induction of anesthesia, a practice I have done as far back as the late ’70s. Not only is it comforting for the child, but often (if handled properly) a greater comfort for the parents. Nothing is more frightening than watching your small child, lost in a clump of sheets and blankets, being wheeled behind those double doors on a stretcher!
A good procedure might be for the parents to walk the child back to the operating room with the nurse or use a brightly colored wagon for the staff to pull the child to the operating room. Fainting parents rarely are a problem, but staff should be prepared for a swooning mother or father. A stern look by the nurse will usually quiet a talkative family member.
While some hospitals and ambulatory surgery centers (ASCs) don’t allow this practice, it’s usually because the staff are uncomfortable with the concept — not the patients. It’s a very worthwhile service that more facilities should adopt.
Interestingly, the state of Pennsylvania, in its recently revised ASC Licensure Rules and Regula-tions (October 1999), has addressed many specifically related ASC regulations concerning pediatric care. Earnhart & Associates is working with many facilities in Pennsylvania and also developing exclusive pediatric surgery centers, and we applaud these changes.
While the new regulations often can be challenging, we think that state is on the right course. Following these regulations, even if you’re not located in Pennsylvania, will help you avoid risk management problems with your pediatric patients. Some of the new Pennsylvania regulations include:
• No patients younger than 6 months of age may receive treatment.
• The medical record must include documentation that the child’s primary care provider was notified by the surgeon in advance of the procedure and that an opinion from the primary care provider was obtained as to the appropriateness of the procedure in the ambulatory surgery facility setting. When an opinion from the primary care provider is not obtainable, documentation explaining why an opinion could not be obtained must be in the medical record.
• Anesthesiology services must be provided by a graduate of anesthesiology residency program that is accredited by the accrediting council for graduate medical education or equivalent, or a certified registered nurse anesthetist trained in pediatric anesthesia. Both must have documentation of historical and continuous competence in pediatric care.
• The surgeon performing the procedure will be board certified or have pre-board certified status from the Board of Medical Specialties, of Osteopathic Surgery, of Pediatric Surgery, or of Oral and Maxillofacial Surgery.
• A medical professional must have completed a course in advanced pediatric life support offered by the Elk Grove Village, IL-based American Academy of Pediatrics and either the American College of Emergency Physicians or the American Heart Association, both in Dallas. That medical professional must be present in the facility when a pediatric patient is in the facility.
• The governing body is responsible to ensure the presence of a medical professional certified in pediatric life support is in the facility at all times when a pediatric patient is present.
These are interesting requirements that might be somewhat difficult to absorb, but great for our younger patients! Bottom line: When the pediatric patient goes south, they do so with alarming speed. Regulations, pre-planning, and constant diligence keep us all prepared!
(Earnhart and Associates is an ambulatory surgery consulting firm specializing in all aspects of surgery center development and management. Earnhart can be reached at 5905 Tree Shadow Place, Suite 1200, Dallas, TX 75252. E-mail: [email protected]. Web site: www.earnhart.com.)
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