1. Presented by Sally Moon Clinical Nurse Specialist Recovering the Paediatric patient

2. SESSION OVERVIEW - How do Children differ from Adults Principles of Post Anaesthetic Nursing Care Complications in Recovery Recovery discharge criteria Practical tips and ideas

3. HOW ARE CHILDREN DIFFERENT ?

4. RESPIRATORY SYSTEM Smaller airways Narrow nasal passages Large tongue Larger prominent occiput / short neck Larynx high & anterior ( level c2-c3) Cricoid ring narrowest point Compliant rib cage

5. CARDIOVASCULAR SYSTEM  Metabolic rate  Cardiac Output  Heart Rate / Oxygen consumption Fixed stroke volume Smaller circulating volume  Glucose requirement

6. TEMPERATURE REGULATION  Surface area per kg Children lose heat more rapidly  Metabolic rate Insufficient body fat Infants cannot shiver

7. RENAL SYSTEM Decreased capacity to excrete free water Neonatal kidney  GFR  sodium excretion / concentrating ability

8. POST ANAESTHETIC CARE Conscious state Oxygen saturations Heart rate Respiratory rate Temperature Blood pressure Wound site / iv site Pain score

9. COMPLICATIONS IN RECOVERY Airway obstruction PONV Pain Hypothermia Hypovolaemia Emergence Delirium

10. RESPIRATORY ASSESSMENT Patency of Airway Rate / depth respirations Symmetry of Chest Expansion Gag protective reflexes Colour Presence stridor /wheeze Oxygen Saturation

11. SIGNS & SYMPTOMS AIRWAY OBSTRUCTION Inspiratory stridor Snoring Increased work of breathing Absent /silent respirations Head bopping CAUSES…..

12. MAINTAINING AIRWAY PATENCY Backward head tilt Chin lift Jaw support Suction airway secretions Positioning Oral / nasal airway Bag & mask

13. LARYNGOSPASM Defined by forceful closure of vocal cords which prevents respiration More common in children More common if URTI More common if laryngeal stimulation Managed by positive airway ventilation/100% oxygen Remove stimulus Drugs

14. PONV Distressing for paediatric patients More common after 2 of years age Prophylactic anti-emetics regularly used Additional therapy prescribed “just in case” More common in children who suffer motion sickness Squint surgery / ENT

15. PONV - Metoclopramide Dexamethasone Granisetron Droperidol Promethazine Post-operative Nausea & Vomiting guideline available on RCH website/Anaesthesia & Pain Management

16. PAIN MANAGEMENT Pain is subjective and can be influenced by many factors Anxiety Previous experience Peri operative education Anaesthetic & pain relief given Childs age

17. PAIN Appropriate pain tools for assessment Wong-Baker / Flacc Premedication Local anaesthetic Regional block /Epidural Opioid infusions / pca

18. PAIN SCALE TOOL

19. PAIN

20. HYPOTHERMIA Children more susceptible Greater surface area Can result in delayed awakening, cardiac irritability & respiratory depression Neonates,cerebral palsy, extensive surgery at greatest risk

21. HYPOTHERMIA CAUSES – Intraoperative exposure Deliberate cooling (Neuro/Cardiac) Poor thermoregulatory systems (Neonates) TREATMENT – Active warming ( Blanket /Bair hugger) Warm fluids Constant monitoring

23. HYPOVOLAEMIA Pre op factors Intra op fluid management WATCH FOR Obvious bleeding, wound / drain Tachycardia (SMALLER CIRCULATING VOLUME) Hypotension CRT prolonged

24. EMERGENCE DELIRIUM State in which the child is agitated,inconsolable,typically thrashing Children do not recognise people /familiar objects Greater incidence in children (1-5 years) Safety Carers

25. PSYCHOSOCIAL  Waking up in Recovery can be frightening  Separation anxiety  Re-orientate / Reassure  Use child’s name  Reunite family as soon as safe to do so

26. RECOVERY DISCHARGE CRITERIA Sedation score 2 or less ( UMSS ) Pain under control No active vomiting Vital sign assessments within MET Criteria

27. RECOVERY DISCHARGE CRITERIA If vital sign assessments are outside MET Criteria then MET discharge Criteria form completed Oxygen order completed if necessary Surgeon has spoken to parents

28. TIPS & TRICKS !!!

34. Questions