In the following text I the author will provide an account of the anaesthetic care given to a paediatric patient in my care during a surgical procedure to repair her cleft palate. I will discuss the rationale behind the chosen anaesthetic technique and will analyse why the method was identified as the most suitable backing the findings up with related literature.
The text will explore the care given to the patient and the preparation needed to ensure a safe procedure starting from the pre-assessment visit right to the anaesthetic room looking at the roles of some of the multi disciplinary team members involved in the child’s care.
An episode of care for any individual patient is a complex series of interactions that make up the process of care. The recipient of this anaesthetic care is an 8-month-old female, who, as patient confidentiality forbids the use of her real name (NMC 2002a) shall be known as Eve.
Eve was born at 41 weeks gestation, during a routine prenatal scan at 23 weeks gestation an abnormality of her facial structure was noted, her parents were informed of this and counselling and advice was offered. The extent of the abnormality was not seen until Eve was born.
She was born with a unilateral cleft lip and palate, which is were there is a single cleft of the lip, and the hard, and soft palate are also divided (Shprintzen and Bardach 1995) but was otherwise fit and well. In accordance to Watson et al 2001 clefts of the lip and palate may be isolated deformities or may be a part of a syndrome. Eve has not been diagnosed with a syndrome there for this is an isolated deformity. Watson (2001) suggests that non-syndromic clefts are multi-factorial in origin and could occur due to gene involvement, various environmental factors or embryo development in relation the mothers life choices during pregnancy i.e. excessive alcohol, drug abuse etc.
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Eve had previously undergone the first stage of the surgery, which was a repair to her cleft lip. This is done between the ages of two and four months within our trust. This is mainly due to cosmetic reasons but also to encourage oral feeding and sucking and to encourage the tissues to grow at the same rate as the child’s facial structure (Watson Et al, 2001).
Eve was admitted to hospital the day prior to her surgery. Eve’s mother had requested this rather than attending pre-admission clinic as she had problems with transportation to the hospital. This highlights good communication (Department of Health, 2003) between the nursing staff and Eve’s mother, which is of benefit to both the child and the family’s needs (Clayton, 2000). The Department of Health (1989) states that the welfare of the child is paramount, however Smith and Daughtrey (2000) believe that it is also important to ensure that parental needs are also met. Wong (1999), states that good family centred care is considerate of all family members’ needs and not only the needs of the child.
The initial assessment of Eve involved her primary nurse, Eve and her mother Joanne. The cleft palate pathway was used as assessment aid and highlighted any needs that Eve and her family had. The anaesthetist (Dr A) then examined Eve and was able to explain the procedure to Eve’s mother. This meeting with Dr A provided Eve’s mother with both verbal and written information therefore equipping the family with knowledge and support (Summerton, 1998).
During Dr A’s visit she was able to assess Eve’s physical and mental condition ensuring that it would be safe to administer a general anaesthetic. During this assessment Dr A was able to request that routine blood samples were taken including cross match in case Eve should need a blood transfusion due to high blood loss during the procedure. She was able to read the operation notes from Eve’s previous visit making notes of the ET tube size used, the analgesia given, there amounts and if they had the given effects on Eve’s pain relief and do an assessment of Eve’s airway. Dr A was aware that Eve would have a difficult airway due to her cleft palate and the fact that her mother reports of her snoring whilst asleep, however she is also aware that assessment of this can be difficult due to Eve being uncooperative or asleep and that most tests used in adult practice including the mallampati scoring system are not validated for use in the paediatric population and are not really useful in the younger child (Sumner and Hatch, 1999). She was able to discuss the proposed anaesthetic and pain relief techniques and pre warn eves mother about the monitoring that she may see being used on eve in both the anaesthetic and recovery rooms. Dr A also discussed the use of premeditation such as madazalam with Joanne, it was decided that Eve would not have this as rendering her semi or fully unconscious with a respiratory depressant drug can become hazardous due to Eve’s cleft palate as her tongue may fall backwards and obstruct her already compromised airway (Sasada, M and Smith, S.2003).
All information obtained during the pre assessment by Dr A should and was relayed to the operation department practioner (ODP) who was working alongside her during the case, ensuring that all equipment needed was readily available as and when needed.
As Morton (1997) states the motto “Be Prepared” is a very important principle in anaesthesia. If things were to go wrong during the anaesthesia, intervention must be immediate to avoid harm to the patient; therefore preparation and the checking of equipment and drugs are vital.
At the start of each case careful attention to detail is required when setting up the work area. The anaesthetic machine both in the anaesthetic room and in side theatre must be checked in accordance with The Association of Anaesthetists guidelines (Appendix 1) and the manufactures guidelines, and all equipment required must be gathered. There seems to be no set guidelines stating the exact equipment needed so the anaesthetist and the ODP must work together and decide for themselves what they need.
“The success of a paediatric procedure depends not only on the skill and knowledge of the anaesthetist, but also on the possession and utilisation of the proper equipment” (Bell.1991.pg81)
Bell (1991) offers the Pre-Anaesthesia Checklist: SCOMLADI that may help towards the selection of equipment: SCOMLADI is a mnemonic for
- Laryngoscope – handle and blades
- Airway – oral, nasal, ETT, +/- LMA
- Intravenous – drips
In Eve’s case the pieces of equipment that were made available were: –
Suction, this can be a vital piece of equipment during anaesthesia. This is due to the fact that it can remove gubbings that may cause airway obstruction quickly ensuring the safety of the unconscious patient, although great care must be taken when using suction on an oral wound to ensure no further damage or trauma to the repaired area (Stoddart and Lauder, 2004)
Circuit, the Jackson Rees modification of the Ayres t-piece is the main choice as it was designing for paediatric use and it is said to decrease the resistance to breathing by eliminating valves and decreases the amount of dead space in the circuit.
Oxygen, this is readily available on the anaesthetic machine. The oxygen is delivered to the machine via a pipeline from the hospital stores. There must also be a full cylinder on the machine for use in case of a malfunction of the pipeline supply. This must be checked during the machine check.
Monitors and monitoring aids. Some of the important aids are: Pulse oximeter, this gives a continuous reading of the oxygen saturation in the blood via a fingertip sensor. Although extremely reliable the probes may not pick up a good trace if the patient is cold of has a poor peripheral perfusion. ECG, This provides us with the information of the heart rate and rhythm. This is a valuable aid in detecting bradycardia and arrhythmias in paediatric patients. Blood pressure (bp), the most common way to measure Bp is by using a cuff this is known as non-invasive. Parameters are set on the monitoring console to enable the cuff to inflate and record the patient’s blood pressure at regular intervals. Arterial Bp can be measured via a cannula placed in an artery, which attaches to a transducer, this is known as invasive monitoring and can give continuous readings. In Eve’s case a cuff was used in accordance to Dr A’s wishes. Capnography This is attached to the breathing circuit and analyses the gas mixture. The monitor displays the concentration of oxygen, nitrous oxide, carbon dioxide and volatile agents. This information is useful for assessing the adequacy in ventilation and the depth of anaesthesia. The presence of carbon dioxide on the reading confirms that the ET tube is in the right place (Morton, 1997). Temperature Infants lose heat very quickly and there ability to maintain their own temperature is blocked by the anaesthetic (Kumar, 1998). A naso/oesophageal probe is placed in Eve’s nostril instead of her mouth, as that is where the surgery is taking place. There is other methods of monitoring available such as blood gases, central venous pressure, neuro muscular transmission etc but in Eves case these would only be used if Dr A requested them.
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Laryngoscope and blade, the different choices of blades are due to the variation in the anatomy found in small infants and children, this is due to the fact that a child’s larynx lies higher and more interiorly in the neck and there epiglottis is longer and thinner than adults (Watson, 2001). The use of different size and shape blades is down to the anaesthetist’s personal choice Dr A prefers to use a lateral approach with a straight blade such as a Magill (Morton.1997). Dr A also likes to have a piece of rolled up gauze filling the cleft to ensure that the blade does not get caught in the deep cleft. The difficult intubations trolley is also essential this is because there is a large selection of different blades, handles, bougies and airway’s such as cut/uncut endotracheal tubes, guidell airways, laryngeal masks and face masks which are all available on hand.
Airways, A selection of pre-formed south facing, uncut and reinforced endotracheal tubes. The size of which can be calculated by using a formula (age / 4 + 4.5 = estimated tube size) or by the child’s weight (Morton, 1997). Eve should take a 4.0mm tube but it was noted on her last anaesthetic sheet that a 3.5mm tube was used with a gauze pack insitu due to her different anatomy.
Drugs, There are many different types of anaesthetic drugs available such as Volatile induction agents (Gas), Intravenous induction agents, muscle relaxants, reversal agents, anti emetics, local anaesthesia and analgesics. All of which have the own pros and cons for using them. Dr A has chosen to use the volatile agent Sevoflurane in order to initially anaesthetise Eve this is due to the fact that Eve’s Venous access is poor due to her being a “podgy” baby. Sevoflurane is the least pungent and irritant of the volatiles and rivals many of the other inhalation induction agents for children. Eve was induced with oxygen, nitrous oxide and 8% sevoflurane, her airway was difficult to maintain due to her tongue being large in relation to her oral cavity which is normal in infants (Wong, 1999) therefore a size 1 guedel airway was used in order to keep the tongue from causing an obstruction. Anaesthesia was maintained with oxygen, nitrous oxide and isoflurane another of the volatile agents also used within paediatrics with the feeling that this is mainly due to the low cost. Eve also had an infusion of the opioid remi-fentinal.
Intra-Venous (IV), IV access was gained when an adequate depth of anaesthesia was reached and endoteacheal intubation was achieved. In total four IV lines were inserted, one to administer IV drugs such as anti emetics, anti biotics and IV pain relief etc. another for the IV infusion of Remi fentinal pain relief. Another for the maintenance fluids and the last on as a spare of to use if blood products are needed. Fluid therapy is important in both adults and children due to the fact that they have been nil by mouth for many hours before there procedure in accordance to hospital guidelines. IV fluids are given as maintenance to preserve hydration, to compensate fluid/electrolyte defects as a result of fasting and also to replace ongoing loss due to evaporation and surgical bleeding (Wong, 1999).
As well as the preparation of the anaesthetic room the ODP must also ensure that all equipment needed inside theatre and during the procedure is available such as an operating table that is in good working order, a cleft palate mattress to ensure the correct positioning of Eve, a warming blanket to ensure temperature maintenance and a jelly mat to protect from pressure area sores (Kumar, 1998).
It is also the ODP’s responsibility along with Dr A to ensure that Eve is transferred in to theatre and on the to operating table safely, that all monitoring equipment is transferred to the inside machines and that all IV therapy equipment is connected before the surgeon preps and drapes the patient as this helps towards maintaining the sterile field around the patient.
Throughout the surgery it is seen as best practice for the ODP to remain within close proximity to the patient and anaesthetist in case there is a problem (Kumar, 1998), one such problem noted in Eve’s case was that when the surgeon inserted the gag needed to keep Eve’s mouth open he unintentionally moved the position of the ET tube causing a drop in her O2 saturations. Dr A listened to Eve’s chest with a stethoscope whilst hand ventilating her, this enable her to reposition the ET tube back in to the correct position. Once back in the right place more tape was applied, and the tube was fastened in more securely. If Dr A was unable to just reposition the tube she would have had to remove the tube and reintubate Eve, this means that she would have needed a new Et tube the laryngoscope and blade, maybe a face mask in order to pre oxygenate before re intubation. This is the main reason why all intubation equipment used in the anaesthetic room must follow with the patient into theatre.
Whilst in theatre a mechanical ventilator is use in order to ventilate Eve. The Newfield 200 is the vent used within this trust it works by intermittently occluding the expiratory limb of the t-piece and is able to compensate for any leaks around the tube. The ventilator can be adjusted in accordance to Dr A’s request meeting Eve’s needs by changing the pressures and times needed. Ventilation was once carried out purely by squeezing the bag by hand; leaving the anaesthetist with just one hand to do other important things such as administer medication or record information, meaning that the Newfield 200 is the preferred method of ventilation in recent times (Sumner and Hatch, 1999).
Following the procedure Dr A stopped the infusion of Remi Fentinal and turned off the volatile gas this was to help with the waking up procedure and the safe extubation of Eve. Dr A also ensured that the pack inserted at the beginning was removed safely without causing trauma. Extubation should take place when the patient is fully conscious with there protective reflexes fully intact (Sumner and Hatch, 1999), this is even more important in Eve’s case due to the nature of her surgery as there could be excessive bleeding or oedema due to the trauma of the oral surgery causing more obstruction to her airway.
Although suction should be available during extubation it is noted that large suction catheters such as a yanker should not be used and suction kept to a minimum this is to lower the risk of airway obstruction caused by trauma or by disruption of the surgical repair site.
Eve’s was extubated safely and was transferred to the recovery room with out the need of ICU or HDU intervention. There she was given o2 and monitored by trained recovery staff until they were satisfied that she was able to maintain her own airway and o2 saturations, there was no or minimal blood loss from the wound site and she was pain free. Dr A had prescribed Eve with analgesics to be given back on the ward if needed, this was to ensure that she had a pain free recovery preventing her from getting upset and crying which can encourage the healing process of the wound and maintaining her patient airway.
The process of Eve’s anaesthetic ran a smooth cause. She remained safe throughout the procedure. Great care and planning by both Dr A and the ODP ensured that all events that may have occurred were well prepared for.
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