pedodontic dentistry

177The Royal College of Anaesthetists nn Raising the Standard: a compendium of audit recipes

Section 9: Paediatric services

Preoperative parent and patient information

Consent

Staffing for paediatric anaesthetic services

Preoperative fasting in elective paediatricsurgery

Premedication in pre-school age children

Parent satisfaction with arrangements forbeing present with their child at induction

Use of local and regional blocks in children

Temperature control

Pain management

Perioperative fluid management in children

9.1

9.2

9.3

9.4

9.5

9.6

9.7

9.8

9.9

9.10

Edited byDr Ian Barker

Suggested data tobe collected

Parents/patients should be briefly questioned postoperatively by an auditor who is independentof the anaesthetist. Did they receive instructions and information before admission? Did it tellthem what they wanted to know? Did they attempt to contact the hospital for advice and if sowere they successful? Did they see an anaesthetist preoperatively? Was appropriateinformation given? Did they have an opportunity to ask questions and were these answeredsatisfactorily? You may wish to make a list of what you consider to be minimum elements ofthis interview and ask which were included. If cancellation occurred, or non-attendance, was thisfor a reason that might have been avoided if proper information had been given?

178

9 Paediatric services

The Royal College of Anaesthetists nn Raising the Standard: a compendium of audit recipes

Preoperative parent and patientinformationDr O Bagshaw

Why do thisaudit?

Best practice:research evidenceor authoritativeopinion

Suggestedindicators

Proposedstandard or targetfor best practice

Parents demonstrate a high incidence of anxiety prior to their child’s surgery.1 Both patientsand parents may be concerned about the trip to theatre, the anaesthetic, possiblecomplications, and postoperative pain.2–4 Adequate preoperative information and preparationwill help answer these questions.4 Parental participation in aspects of anaesthesia decision-making increases parental satisfaction with the care their children receive.5 Older children canidentify their information needs, but often these aren’t provided.6

The preoperative psychological preparation of the family and child is important.3 Preoperativeinformation in the form of booklets, videotapes, educational programmes, or through telephoneconsultation or pre-admission clinics, has been shown to reduce anxiety, answer questions, raiseissues for discussion and avoid unnecessary investigations or cancellation.3,7 There is alsoevidence that explaining the risks of anaesthesia gives parents a better understanding of what isinvolved, without actually raising anxiety levels or influencing their decision to proceed with theproposed surgery.2,4

Good practice advice in preparation and use of written patient information should befollowed.8,9

% parents who were sent preoperative information by post.

% parents who received preoperative information.

% parents/patients who found the information satisfactory.

% parents who attempted to contact the hospital for advice about the anaesthetic, that wereable to get the advice they sought.

% parents/patients assessed and counselled by an anaesthetist preoperatively on the ward andgiven the opportunity to ask questions.

% parents/patients who rated this interview satisfactory.

All the above indicators should be true in 100% cases, except those that received postalpreoperative information, which should be 95%.

9.1

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9.1


Paediatric services

Common reasonsfor failure toreach standards

Related audits

References

Administrative failure in sending out preoperative information.

No mechanism for dealing with telephone enquiries from parents.

Poor understanding of written or spoken English, and failure by staff to make arrangements todeal with this.

Failure of parents and patient to attend pre-admission clinic.

Failure of anaesthetist to visit patient on the ward preoperatively or inadequate visit.

Parents not present when child assessed by the anaesthetist.

1.1 – Patient information about anaesthesia

1 Thompson N et al. Pre-operative parental anxiety. Anaesthesia 1996;5511:1008–1012.

2 Klafta JM, Roizen MF. Current understanding of patients’ attitudes toward and preparation foranesthesia: a review. Anesth Analg 1996;8833:1314–1321.

3 Kain ZN et al. Parental desire for perioperative information and informed consent: a two-phase study.Anesth Analg 1997;8844:299–306.

4 Bellow M et al. The introduction of a paediatric anaesthesia information leaflet: an audit of its impacton parental anxiety and satisfaction. Paediatr Anaesth 2002;1122:124–130.

5 Tait AR et al. Parents’ preferences for participation made in decisions regarding their child’sanaesthetic care. Paed Anaesth 2001;1111:283–290.

6 Smith L, Callery P. Children’s accounts of their preoperative information needs. J Clin Nurs2005;1144:230–238.

7 Cassady JF Jr et al. Use of of a preanaesthetic video for facilitation of parental education and anxiolysisbefore pediatric ambulatory surgery. Anesth Analg 1999;8888:246–250.

8 Department of Health. Reference guide to consent for examination or treatment. DH, London 2001(see: www.dh.gov.uk/assetRoot/04/01/90/79/04019079.pdf).

9 Royal College of Anaesthetists. Raising the Standard: Information for patients – principles, samples ofcurrent practice and new text. RCoA, London 2003 (see: www.youranaesthetic.info).

http://www.youranaesthetic.info

http://www.dh.gov.uk/assetRoot/04/01/90/79/04019079.pdf



As above, from the anaesthetic record and the consent form.

If consent appears to be absent, reasons for this.

Design of anaesthetic record may not encourage documentation.

Standard consent form does not include space for child to sign.

Parents absent.

Anaesthetist judges specific consent to be unnecessary.

180



ConsentDr M A Stokes, Dr I Barker

Why do thisaudit?


Suggestedindicators


The process by which consent for surgery to children was obtained should be documented.Separate consent for anaesthesia is not mandatory in the UK, but most parents or the maturechild might expect specific discussion of the proposed method of induction, regional blockade(including caudals), suppositories, blood transfusion and invasive monitoring. Discussion shouldbe documented.

Minors over 16 have authority to consent to medical treatment1,2 and, by convention, parentsand legal guardians consent for younger children, acting in the child’s best interests and on theadvice of doctors. Legislation recognises emerging competence whereby a child may achievesufficient understanding and maturity to make a wise choice in his/her own interests.3,4

Although difficult to distinguish between assent and true consent, the law supports parents anddoctors who override a dissenting child for urgent or essential treatment. In practice a childmust demonstrate a greater maturity and understanding to refuse medical treatment than toagree to it.5 There is practical advice for clinicians faced with children who refuse emergency orelective treatment.6,7 The Association of Anaesthetists has also produced guidance on thisinformation and consent for anaesthesia.8

% of children having a consent form before surgery, signed by a person with legal authority.

% of cases where a special anaesthetic technique is planned where consent is documented.

100% of children should have a consent form before surgery, signed by a person with legalauthority.

In 80% of cases where these techniques occur, there should be written evidence of specificconsent to epidurals, other regional blocks (including caudals), analgesic suppository insertion,blood transfusion, and invasive monitoring. A note on the anaesthetic record that these hadbeen discussed would be acceptable.

9.2

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181

9.2


Paediatric services

Related audits

References

1.2 – Consent to anaesthesia

1 Braziet M. Doctors and child patients. Medicine, patients and the law (2nd edn). Penguin, London1992: pp 329–353.

2 Department of Health. Seeking consent: Working with children. DH, London 2001 (seewww.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4008977&chk=8aUpf8)

3 Gillick V. West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402 HL.

4 The Children Act 1989. HMSO, London 1989.

5 Devereux JA, Jones DP, Dickenson DL. Can children withhold consent to treatment? Br Med J1993;330066:1459–1461.

6 Elton A et al. Withholding consent to lifesaving treatment: three cases. Br Med J 1995;331100:373–377.

7 Stokes MA, Drake-Lee AB. Children who withdraw consent for elective surgery. Paed Anaesth1998;88:113–115.

8 Association of Anaesthetists of Great Britain and Ireland. Consent for anaesthesia. AAGBI, London2006 (see: www.aagbi.org/pdf/Consent.pdf).

http://www.aagbi.org/pdf/Consent.pdf

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4008977&chk=8aUpf8

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4008977&chk=8aUpf8

182



Staffing for paediatricanaesthetic servicesDr N R Bennett, Dr I Barker

Why do thisaudit?


Suggestedindicators


Children undergo anaesthesia in almost all hospitals. The NCEPOD report of 19891 looked atall deaths within 30 days of surgery in children under 10 years of age over a 1 year period. Anumber of ‘avoidable deaths’ were identified. It has also been reported that the incidence ofperioperative cardiac arrest is higher in infants than older children.2 This audit addresses threeareas of concern: the status of the anaesthetist responsible for anaesthetising children; availabilityof staff trained in paediatric resuscitation; and staffing levels on wards where children are nursed.

There has been debate about the roles of the district general hospital and the specialist centrein the perioperative management of children.3 There has been a trend towards centralisation ofanaesthesia services for the young, those requiring more complex surgery, some emergencywork and children with significant co-morbidity.4 Nevertheless many children will still requireaccess to anaesthetic services at most district general hospitals, either for elective andemergency procedures, or for initial resuscitation/stabilisation if they are very seriously ill. Thereare guidelines on training in paediatric anaesthesia that define the competencies required forthose intending to specialise in paediatric anaesthesia.5 However, those who intend to becomegeneral anaesthetists are expected, as a minimum, to have acquired basic core competencies inpaediatric anaesthesia by completion of their training.5,6 There are a number of authoritativedocuments that specify the facilities, levels of experience, seniority, supervision and staffing forchildren’s anaesthetic services.5–7

% of children anaesthetised by practitioners whose experience complies with the suggestedstandards below.

% of children who are managed in the recovery ward by nursing staff who undergo regulartraining in paediatric resuscitation.

% of children who have been cared for on a ward with two Registered Sick Childrens Nurse(RSCN) trained nurses on duty throughout their stay.

100% children under the age of 10 years should be anaesthetised by one of the following.

nn A consultant or other non-trainee anaesthetist who has acquired and maintained paediatriccompetencies appropriate to the individual case. It is expected that anaesthetists with corecompetencies should be able to manage simple elective procedures in fit children who areASA 1 or 2 down to at least 5 years of age.6

nn An experienced SpR with a level of supervision appropriate to their ability and experience.(e.g. direct supervision for a sick premature baby).

nn An SHO or junior SpR supervised by a consultant or suitably competent senior SpR intheatre or in the theatre suite for babies and children under 3 years.

nn An experienced SHO or junior SpR supervised by a consultant or suitably competent senior SpRin the hospital or at home for older children who are ASA 1 or 2.

nn An SHO with < 6 months experience supervised by a consultant in theatre.

9.3

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183

9.3


Paediatric services



References

For every child included in the audit:

nn Does the anaesthetist fall into one of the categories above? This will require knowledge ofthe recent experience of trainee anaesthetists and knowledge about consultantcompetencies. The auditor will then have to decide whether supervision was appropriate or not.

nn When children undergo anaesthesia, is there a nurse on duty in the PACU and an ODP intheatres with appropriate competencies in paediatric resuscitation?

nn Did the ward have two RSCN nurses on duty for every shift that the child was present? If not for what proportion of shifts?

‘We’ve always done it this way’.

Pressure from managers to maintain throughput.

Failure of communication out of hours.

Paediatric training and refresher training unavailable for those wishing to do it.

1 Campling EA, Devlin MB, Lunn JN. The report of the National Confidential Enquiry into PerioperativeDeaths 1989. NCEPOD, London 1990 (see: www.ncepod.org.uk/).

2 Morray JP et al. Anesthesia-related cardiac arrest in children: Initial findings of the PediatricPerioperative Cardiac Arrest (POCA) Registry. Anesthesiology 2000;9933:6–14.

3 McNicol R, Rollin AM. Paediatric anaesthesia – who should do it? Anaesthesia 1997;5522:513–516.

4 Royal College of Paediatrics and Child Health. Commissioning of paediatric anaesthesia. In:Commissioning of tertiary paediatric services. RCPCH, London 2004.

5 Royal College of Anaesthetists. The CCST in anaesthesia. RCoA, London 2003: II-29, III-26, IV-32, IV-49(see: www.rcoa.ac.uk/).

6 Royal College of Anaesthetists. Guidelines for the provision of anaesthetic services. Chapter 8:Guidelines for the provision of paediatric anaesthetic services. RCoA, London 2005 (see:www.rcoa.ac.uk/docs/GPAS-Paeds.pdf).

7 Welfare of children and young people in hospital. HMSO, London 1991.

100% children should be managed in the postanaesthetic care unit (PACU) by nurses whoundergo regular training in paediatric resuscitation

100% children should be nursed on a ward where at least 2 RSCN trained nurses are on dutyfor every shift that the child is present.

http://www.rcoa.ac.uk/docs/GPAS-Paeds.pdf

http://www.rcoa.ac.uk/index.asp?PageID=57

http://www.ncepod.org.uk/


Instructions given to parents, patient or ward nurses.

Compliance with instructions.

Patient’s age.

Am/pm list and position on the list.

Last oral intake time and what it was.

Actual time of induction.

Time of first intake post operation.

Factors affecting these times, e.g. list changes, unexpected over-running surgery.

Was the list delayed? Postoperative problems, e.g. postoperative nausea and vomiting (PONV).

184



Preoperative fasting in electivepaediatric surgeryDr T Dorman

Why do thisaudit?


Suggestedindicators


Adequate preoperative fasting reduces the risk of regurgitation of stomach contents at the timeof induction of anaesthesia. This must balance against the risks of prolonged fasting leading tohypoglycaemia, dehydration and patient distress. There are difficulties in planning fasting timesdue to list changes, unpredictable operating time and patient or parent compliance.1,2

Research is confusing. Major studies have shown that there is no increase in risk of aspiration ifclear fluids are given up to 2 or 3 h preoperatively against a background of 6 h fasting time forsolids and milk.3–6

The following practice is suggested for children over the age of 6 months:

nn Clear fluids should be given up to and at 2–3 h before induction.

nn Solid food or milk should be given to children a minimum of 6 h before induction. In orderto prevent excessively long fasting times for food or milk, children on morning lists should befed at bedtime (as late as possible, and not after 0230 h). Children on afternoon lists shouldhave a light breakfast before 0730 h.

For neonates and babies up to 6 months post-conceptual age:

nn Breast milk up to and at 3 h before induction or formula milk up to and at 4 h beforeinduction and water at 2 h before induction.

% of children for elective surgery who fit the criteria above.

% lists where the list is held up because a child has been fed.

100% of parents/patients should be given the correct instructions.

100% children for elective surgery should fit the above criteria.

0% lists should be held up because a child has been fed.

9.4

9

185

9.4


Paediatric services


Related audits

References

Changes to lists, cancellations, difficulty judging the timing of the list.

Instructions not given clearly, not understood or just not complied with (parent and patient).

1.7 – Preoperative fasting in adults

1 Phillips S, Daborn AK, Hatch DJ. Preoperative fasting for paediatric anaesthesia. Br J Anaesth1994;7733:529–536.

2 Veall GRQ, Dorman T. Prolonged surgery. Starvation in paediatrics. Anaesthesia 1995;5500:458–460.

3 Schreiner MS,Triewasser A, Keon TP. Ingestion of liquids compared with pre-operative fasting inpaediatric outpatients. Anesthesiology 1990;7722:593–597.

4 Splinter WM, Stewart JA, Muir JG. Large volumes of apple juice preoperatively do not affect gastricfluid pH and volume in children. Can J Anaesth 1990;3377:36–39.

5 Splinter WM, Schaefer JD, Zunder IH. Clear fluids three hours before surgery does not affect thegastric fluid contents of children. Can J Anaesth 1990;3377:498–501.

6 Greerley WJ et al. A liberalized fasting guideline for formula fed infants does not increase averagegastric fluid volume before elective surgery. Anesth Analg 2003;9966((44)):965–969.



Anaesthetist – name and grade.

Age of patient.

Parent present, and if not why not.

Planned route of induction.

Application of a topical local anaesthetic and when.

Sedative premedication: drug, dose, route, and time relative to induction.

Assessment of child’s response to IV insertion and induction.

Lack of nursing and medical staff with sufficient paediatric training and experience.

Failure of anaesthetist to judge the need for sedation.

List changes prevent the application of topical local anaesthetic.

Absence of parent or separation at the theatre door.

186



Premedication in pre-school agechildrenDr J Morgan-Hughes, Dr C G Stack

Why do thisaudit?


Suggestedindicators


Induction of anaesthesia may be a stressful experience for pre-school age children and theirparents. If the child resists intervention, unnecessary distress may occur. As well as beingundesirable in itself, this may also influence the child’s attitude to medical care in the future.

Sedative premedication of pre-school age children reduces the frequency of crying and theneed for restraint at induction of anaesthesia even when the child is accompanied by a parentand has a topical anaesthetic applied before intravenous induction.1 Sedative premedicationmakes post hospital behavioural disturbances less likely even after day surgery.2 Routine use isprobably not justified because there is evidence that it is possible to predict which children arelikely to cry.3 One well researched sedative premedicant for children is oral midazolam0.5–0.75 mg/kg, administered 30–60 min before induction.2 It can be used in day caseanaesthesia. Other sedatives such as clonidine, 1–5 micrograms/kg, tend to act for longer post-operatively although there is the advantage of additional analgesic effects.4

% of children age 1–5 years who do not cry or need restraint at induction.

% of children age 1–5 years for whom an IV induction is planned who have a topicalanaesthetic applied at an appropriate time.

75% children age 1–5 years should pass through the anaesthetic room without crying orneeding restraint.1

100% children age 1–5 years should have a topical local anaesthetic applied at an appropriatetime before a planned intravenous induction.5

9.5

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187

9.5


Paediatric services

Related audits

References

1.8 – Premedication

1 Page B, Morgan-Hughes JO. Behaviour of small children before induction. The effect of parentalpresence and EMLA and premedication with triclofos or a placebo. Anaesthesia 1990;4455:821–872.

2 McCluskey A, Meakin GH. Oral administration of midazolam as a premedicant for paediatric day-caseanaesthesia. Anaesthesia 1994;4499:782–785.

3 Hannallah RS, Rosen DA, Rosen KR. Residents’ ability to predict children’s co-operation withanaesthesia induction. Anesthesiology 1985;6633:502.

4 Bergendahl HT et al. Clonidine vs. midazolam as premedication in children undergoingadenotonsillectomy: a prospective, randomised, controlled trial. Acta Anaesth Scand,2004;4488:1292–1300.

5 Hopkins CS, Buckley CJ, Bush GH. Pain-free injection in infants: Use of a lignocaine-prilocaine creamto prevent pain at intravenous induction of general anaesthesia in 1–5 year-old children. Anaesthesia1988;4433:198–201.



Assessment of satisfaction level using postoperative questionnaire. You may wish to explore thisin detail, e.g. satisfaction with preoperative explanation, with waiting arrangements, with actualevents in the anaesthetic room, with the support they received afterwards etc.

Reasons for dissatisfaction.

Parents feeling unprepared, e.g. unsure of role.

Parents who did not want to attend at induction feeling pressurised to do so.

Parents feeling unsupported in the anaesthetic room.

Parents not being on the ward when the child was collected for theatre, owing to list changes.

188



Parent satisfaction witharrangements for being presentwith their child at inductionDr J Payne

Why do thisaudit?


Suggestedindicators


Parental presence at induction is routinely practised in most UK hospitals, in line withDepartment of Health recommendations that hospitals should ‘agree service specificationswhich enable parents to comfort children during induction of anaesthesia’.1 Action for SickChildren stresses the importance of encouraging parents to be present (at the discretion of theanaesthetist) and of providing facilities to enable them to be present. It also points out theneed for preparation of parents (including an explanation of their role, when they should leaveetc) and for support of parents in the anaesthetic room.2

Most recent studies suggest benefits to the child in terms of anxiety reduction, as well as to theparent3,4 with the majority of parents believing that they were of some help to the child andanaesthetist and rating it as a positive experience.4,5

% of parents either satisfied or very satisfied with arrangements for being present with theirchild at induction.

100% of parents invited to be present with their child at induction should be satisfied with thearrangements made to do so.

9.6

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189

9.6


Paediatric services

References 1 Department of Health. Welfare of children and young people in hospital. HMSO, London 1991.

2 Setting standards for children undergoing surgery. Action for Sick Children, London 1994.

3 Kam PC et al. Behaviour of children associated with parental participation during induction of generalanaesthesia. J Paediatr Child H 1998;3344((11)):29–31.

4 Messeri A, Caprilli S, Busoni P. Anaesthesia induction in children: a psychological evaluation of theefficiency of parents’ presence. Paediatr Anaesth 2004;1144((77)):551–556.

5 Odegard KC, Modest SA, Laussen PC. A survey of parental satisfaction during parent presentinduction of anaesthesia for children undergoing cardiovascular surgery. Paediatr Anaesth2002;1122((33)):261–266.


One type of block should be chosen for the audit (e.g. penile block).

Record type of block, operation, age of child, anaesthetist.

The block must be formally assessed postoperatively looking for failed blocks and complications.

A validated pain assessment tool appropriate to the age group and cognition of the child shouldthen be used in hospital and at home for at least 24 h.6

Side effects and the need for rescue analgesia should be noted.

Collected data should be reviewed by staff at regular intervals to highlight both positive and negativeaspects of a particular procedure, and to compare these with experience from other centres.

190



Use of local and regional blocksin childrenProfessor A R Wolf, Dr P A Stoddart

Why do thisaudit?


Suggestedindicators


Children often receive inadequate pain relief.1 Pain can occur immediately after surgery, beforedischarge, or at home. A large variety of local blocks can be used but must be appliedappropriately and audited to ensure that the chosen block has been part of an effectiveanalgesia treatment plan. In addition, blocks may fail or there may be major or minorcomplications. This has been highlighted in two recent surveys.2,3

Previous studies have compared opioid analgesia with local techniques, in terms of duration andquality of analgesia, sedation, stress responses, side effects, and safety.4,5 The key features toemerge from these studies are firstly that appropriate peripheral blocks may be preferable tocentral blockade where possible,2 secondly that blocks must match the specific operations,5 andthirdly that co-analgesia may be desirable to increase analgesia and reduce individual side effects.

% children with acceptable pain scores both in hospital and at home.

% children requiring rescue analgesia.

% children who have side effects, both immediate and delayed.

% children who appear to have a failed block or a complication.

% children in whom side effects or pain delay discharge (in day cases).

100% children should have acceptable pain scores at all times.

The need for rescue analgesia will depend on whether a working block is expected to relieve allpain.

A target for side effects will depend on the block.

< 1% children should have a failed block.2

A target for complications will depend on which block is audited.

< 1% patients should have delayed discharge due to pain or due to side effects of the block.

9.7

9

191

9.7


Paediatric services


References

Anaesthetist unskilled at performing block.

‘Natural’ failure rate of the block.

Inadequate support staff (mainly nurses experienced in pain management) to assess block andsee the need for rescue analgesia promptly.

1 Kotiniemi LH et al. Postoperative symptoms at home following day-case surgery in children: amulticentre survey of 551 children. Anaesthesia 1997;5522:963–969.

2 Gaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anaesthesia in children.Anesth Analg 1996;8833:904–912.

3 Flandin-Blety C, Barrier G. Accidents following extradural analgesia in children. The results of aretrospective study. Paediatr Anaesth 1995;55:41–46.

4 Wolf AR, Hughes D. Pain relief for infants undergoing abdominal surgery: comparison of infusions ofIV morphine and extradural bupivacaine. Br J Anaesth 1993;7700:10–16.

5 Cook B et al. Comparison of the effects of adrenaline, clonidine, and ketamine on the duration ofcaudal analgesia produced by bupivacaine in children. Br J Anaesth 1995;7755:698–701.

6 Voepel-Lewis T et al. The reliability and validity of the face, legs, activity, cry, consolability observationaltool as a measure of pain in children with cognitive impairment. Anesth Analg 2002;9955:1224–1229.



Related audits

Patient age and weight, operation, duration of anaesthesia, temperature monitoring usedintraoperatively, warming methods used, tympanic or axillary temperature on arrival in recovery.

Non-availability of warming equipment or monitoring devices.

Failure to use equipment, perhaps due to lack of awareness of the importance of temperaturecontrol.

Unexpected lengthy duration of surgery.

Over zealous warming without monitoring.

2.7 – Temperature management

192



Temperature controlDr C Kirton

Why do thisaudit?


Suggestedindicators


Thermoregulation is known to be disrupted in the perioperative period, with the paediatricpopulation particularly at risk. The Association of Anaesthetists advises that body temperaturemonitoring must be available in paediatrics, and used when appropriate.1 This audit will establishwhether warming techniques are being used effectively in children and whether appropriateintraoperative monitoring is being used.

Hypothermia is in most cases deleterious,2 being associated with increased oxygenconsumption3 and shivering,4 with a decrease in platelet function5 and consequent blood loss,6

with the risk of surgical wound infection7 and with impairment of drug metabolism.4

Maintenance of normothermia is possible using a variety of warming devices. The forced airblower is particularly effective.4 The large surface area-mass ratio of infants allows rapid coolingand rewarming, and therefore monitoring is important.

% children who arrive in the recovery area with tympanic (or axillary) temperature in the range36–37°C.6,7

100% children should meet the above criteria.

9.8

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9.8


Paediatric services

References 1 Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoringduring anaesthesia and recovery. AAGBI, London 2000 (see: www.aagbi.org/pdf/Absolute.pdf).

2 Leslie K, Sessler DI. Perioperative hypothermia in the high-risk surgical patient (Review). Best practiceand research. Clin Anaesthesiol 2003;1177((44)):485–498.

3 Adamsons K Jr, Gandy GM, James LS. The influence of thermal factors upon oxygen consumption ofthe new born infant. J Pediatr 1965;6666:495–508.

4 Sessler DI. Perioperative thermoregulation and heat balance. Ann N Y Acad Sci 1997;881133:757–777.

5 Valeric R et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987;220055:175–181.

6 Cheney FW. Should normothermia be maintained during major surgery? J Am Med Assoc1997;227777:1165–1166.

7 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New Engl J Med 1996;333344:1209–1215.

http://www.aagbi.org/pdf/Absolute.pdf

194



Pain management Dr J Goddard

Why do thisaudit?


Suggestedindicators


Pain is experienced by paediatric patients of all ages,1 especially in the postoperative period.The evidence in paediatric practice that relief of postoperative pain is cost-effective or beneficialto organ function is lacking. Nonetheless pain relief is a basic requirement, which in the hospitalenvironment is entrusted to healthcare professionals.2 It is essential that this responsibility isdischarged safely and effectively.

The principles of treating acute pain in hospital have been well reviewed.3 Authoritative reportsrecommend that these principles are best achieved by the establishment of an Acute PainService (APS).4 Data in paediatric practice support these recommendations and confirm that itis the structure and process of an APS that most improves pain relief rather than specificanalgesic techniques.5 The routine assessment and recording of pain is pivotal. It is importantthat a procedure for pain assessment and recording is developed to suit local circumstances.2

% of days when paediatric ward is visited by the acute pain team.

% of children undergoing surgery who have a complete record of pain scores.

% of children with unacceptable pain scores in the postoperative period.

% of children managed as day cases assessed to be in severe pain at home.

The local APS needs to consider what their targets should be. In particular the method andfrequency of pain scoring will be decided. One method is to record a pain score alongsideroutine observations of temperature, pulse rate etc.

In-patients

On 100% days, a member of the APS should visit all paediatric surgical wards.

100% children undergoing surgery should have a complete record of pain scores.

< 5% children should have an unacceptable pain score at any time. The pain score deemed tobe unacceptable needs to be chosen, and will depend on which validated pain assessment toolthe team wishes to use.

Day cases

No child should be assessed as being in severe pain on discharge or at home.

9.9

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195

9.9


Paediatric services



Related audits

References

Presence/absence of APS and its members.

Evidence of daily visit by APS member to paediatric surgical wards.

For each child undergoing surgery: completeness of pain score record.

Worst pain score each day in all postoperative children, reason and any action taken.

Pain score on discharge for day cases.

Parental assessment of pain at home.

Holiday, sickness, other duties (of acute pain team).

No dedicated acute pain team or no weekend cover.

Pain scores not considered important, staff too busy.

Failure to supply appropriate analgesics for use at home, inadequate instructions for parents onanalgesic administration.

Section 11 – Acute pain services

1 Schechter NL, Berde CB,Yaster M. Pain in Iinfants, children and adolescents. Lippincott Williams andWilkins, Philadelphia 2003.

2 Department of Health. Getting the right start: National service framework for children. Standard forhospital services. DH, London 2003.

3 McQuay H, Moore A, Justins D. Treating acute pain in hospital. Br Med J 1997;331144:1531–1535.

4 Royal College of Surgeons of England and College of Anaesthetists. Report of the Working Party onPain after Surgery. Commission on the provision of surgical services. RCSEng, London 1990.

5 Goddard JM, Pickup SE. Postoperative pain in children. Combining audit and a clinical nurse specialistto improve management. Anaesthesia 1996;5511:588–591.


Name, date of birth, weight, procedure, duration of procedure, estimated blood loss, type andamount of fluid/blood administered intraoperatively, postoperative fluid prescription.

196



Perioperative fluid managementin childrenDr N Barker

Why do thisaudit?


Suggestedindicators


Hyponatraemia (plasma sodium < 136 mmol/l) may result from excessive use of hypotonicfluids, especially during the perioperative period when vasopressin levels may be elevated. Thiscan result in hyponatraemic encephalopathy. Administration of glucose during surgery may leadto intraoperative hyperglycaemia which can cause an osmotic diuresis leading to dehydrationand electrolyte disturbance. The purpose of this audit is to observe the use of intravenousfluids given to children during the perioperative period and highlight patients at risk ofhyopnatraemia and hyperglycaemia.

There are a number of concerns and case reports of morbidity associated with hyponatraemiadue to water intoxication in the perioperative period.1,2 Suggestions to help avoid this are toadminister isotonic fluids for all replacement fluid and possibly for maintenance in theintraoperative period. Certainly hypotonic fluids should probably not be given at greater thanmaintenance rates.3,4

Hyperglycaemia is best avoided – as well as the osmotic diuresis issues, hyperglycaemia incombination with hypoxic cerebral or spinal cord insult will worsen neurological outcome.If dextrose is avoided, about one-fifth of children will show no change or a rise in blood sugar.However, hypoglycaemia is a very serious complication and certain conditions favourintraoperative glucose administration, e.g. neonates < 48 h of age, poor nutritional status andlong operations. When the rate and glucose concentration are taken into account, the glucosecontent of the solutions providing an acceptable glucose level is approximately 300 mg/kg/h,though this too has been shown to produce hyperglycaemia in longer operations. A glucoseinfusion at a rate of 120 mg/kg/h is sufficient to maintain an acceptable blood glucose level andprevent lipid mobilisation. Giving 5% dextrose containing solutions at maintenance rates ismore likely to cause hyperglycaemia.5

Replacement should be with normal saline, Hartmann’s solution, colloid or blood whereappropriate.

Hypotonic fluids should be reserved for maintenance use.

Dextrose administration should not exceed 300 mg/kg/h.

100% children should meet the above criteria.

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Paediatric services


References

Traditional teaching and practice whereby children have been given hypotonic, dextrosecontaining fluids routinely during surgery.

Not using isotonic fluids for replacement.

1 Halberthal M, Halperin ML, Bohn D. Lesson of the week: Acute hyponatraemia in children admittedto hospital: retrospective analysis of factors contributing to its development and resolution. Br Med J2001;332222:780–782.

2 Arieff AL. Postoperative hyponatraemic encephalopathy following elective surgery in children.Paediatr Anaesth 1998;88:1–4.

3 Duke T, Molyneux EM. Intravenous fluids for seriously ill children: time to reconsider. Lancet2003;336622:1320–1323.

4 Cunliffe M. Fluid and electrolyte management in children. Br J Anaesth CEPD Reviews 2003;33:1–4.

5 Leelanukrom R, Cunliffe M. Intraoperative fluid and glucose mangagement in children. PaediatrAnaesth 2000;1100:353–359.

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