Nuts and Bolts

Parents: Facts to help you prepare.

This is where you’ll find some factual information to help you and your child prepare for their anaesthetic and about the process of children’s anaesthesia at The Women’s and Children’s Hospital (WCH).

Anaesthesia is very safe. In fact, it has probably never been safer. This is due to the high level of training of your anaesthetic team, the standards of care, state of the art equipment and the patient centred ethos of the team.

The anaesthetic team is led by a consultant anaesthetist, a doctor who has completed over 5 years of specialty training in anaesthetics after medical school, including having additional experience in the practice of children’s anaesthesia. The other members of the anaesthetic team at WCH are the anaesthetic registrars, who are doctors undertaking their specialty training and the anaesthetic nurses who provide an additional level of care to support the anaesthetist when caring for children.

The safety and comfort of children under our care is our highest priority and so we have guidelines in place to help us give all our patients the best anaesthetic experience we can. These include:

Fasting

We ask patients to fast before surgery to reduce the risk of inhaling food or fluid from the stomach. The risk is very low but it can be very serious so we have strict fasting rules for all kids coming to surgery. We have rules for solids, milk and clear fluids as they are digested at different rates. The fasting rules vary upon the age of the child.

Solids

All children need to fast from solids for at least 6 hours. If you have surgery in the morning your last food should be prior to 2:30am, for afternoon surgery last food should be prior to 7:00am.

Milk

Milk is considered a food, as it is digested at the same rate as a solid, so fasting from milk is 6 hours for everyone, except for babies under 6 months old, when the last formula or breast milk can be 4 hours prior to surgery.  This means for babies under 6 months old having morning surgery the last milk should be prior to 4:30am and for babies having surgery in the afternoon the last milk is prior to 9:00am.

Clear fluids

Clear fluids leave the stomach more quickly than milk or food and include water, apple juice and cordial. We encourage drinking of clear fluids until 1 hour prior to surgery for all ages as it means that children are more comfortable during the wait before their anaesthetic and less dehydrated when it is their turn for theatre. This means your child can drink clear fluids until 7:30am prior to morning surgery or until 12:00 noon for afternoon surgery. Your anaesthetist or nurse may suggest a drink of water after you arrive in hospital if your surgery is later on the list.

Medications

As a general rule children, who take regular medications should take these as usual on the day of their surgery with a sip of water.

Some medications such as blood thinners (for example aspirin, clopidogrel, warfarin) may need to be stopped prior to surgery.

If you have questions as to what medications your child should take in the lead up to their surgery, please contact the WCH Pre-Admission Co-ordinator (08 81617714) for clarification.

Induction of Anaesthesia (Going To Sleep)

On the day of surgery, the anaesthetist will meet with you and your child to do a pre-anaesthetic check and make an anaesthetic plan for your child. This includes planning which method of induction of anaesthesia (going off to sleep) will be best.

The choice is between a gas induction (using a mask to breathe in anaesthetic gas) or an intravenous (IV) induction (having medicine via a ‘drip’). There are many factors which influence what is the safest way of being anaesthetised and these will be discussed with you both prior to the anaesthetic.

Generally, young children have a mask induction and older children have an IV induction. If an IV induction is planned, we apply a very effective local anaesthetic cream to numb the skin so the IV insertion is comfortable.

The List Order

There are many considerations in determining the order of the list. Age, medical conditions, day surgery, surgeon and equipment availability are the main ones. The list order may change on the day.

The DOSA nurses and your anaesthetist may be able to give you a rough estimate of timing of the surgery and recovery. Things don’t always go to clockwork and we recognise that trying to entertain a fasting child before their anaesthetic can be challenging and ask for your patience and understanding. The best thing to do is to bring things to entertain and distract yourselves whilst waiting and time will go more quickly.

While waiting with your child you can use our craft area, the play area, play the computer games, read books, draw or colour in. A bit like being on holiday and waiting for the plane or the train! During the operation you can go to the cafe, go for a walk, read a book – whatever will distract you. Please ensure we have your mobile number recorded before your child comes to theatre and we ask you to keep your mobile turned on in case we need you in recovery.

Staying Calm

Our anaesthetists are very experienced at making the anaesthetic induction as smooth as possible. Part of the pre-anaesthetic check of your child involves choosing methods to help children (and parents) to relax during the induction of anaesthesia.

We routinely use techniques to distract, dissociate and empower children to manage their experience. Infrequently, but when appropriate, we can use sedative medicine such as midazolam, clonidine or ketamine prior to surgery to help calm your child.

If your child has a severe anxiety or fear of needles WCH Pre-Admission Co-ordinator (08 81617714) to discuss your concerns and to arrange a consultation prior to the date of surgery if necessary.

The initial consultation is likely to be by phone to assess the situation and decide the best strategy. Some children may benefit from meeting with one of our anaesthetists prior to the day of surgery to help them with strategies to deal with their concerns and make their experience in hospital a much more positive one.

Parental Presence at the Start of Anaesthesia

On most, but not all occasions a parent is invited into the operating room to help their child cope with the induction of anaesthesia.

If you are upset or very anxious yourself, then it will be difficult to help your child remain calm. The calmer you are, the calmer your child will be as they go off to sleep and often the calmer they are going off to sleep, the calmer they will be when they wake up from their anaesthetic.

There are many resources available on the Really Ready website to help you and your child to be calm and relaxed during your child’s visit to hospital.

On some occasions parents are not invited in or decide not to come in, and that’s fine. We are often pleasantly surprised at how well many kids will cope by themselves. These situations include babies under 8-10 months, for unwell emergency patients and for teenagers who are independent and can manage without a parent being present. That’s sometimes harder for the parent, but it’s amazing how a cup of tea or coffee will help, as you appreciate your child’s growing independence.

When children first go to sleep, it’s normal for them to have noisy breathing. It’s also normal to go through an ‘excitement phase’ as they become more deeply anaesthetised. The excitement phase lasts about 10 – 30 seconds, may involve movement of the arms and legs and some eye rolling. These are a normal part of anaesthesia, which the theatre team are very used to, however they can be surprising as a parent if you aren’t expecting it.

Once your child is asleep you may give your child a kiss if you wish and then we will show you where you can wait for your child to return to you after they have had their surgery and wake up in the recovery room.

Make plans to keep yourself occupied whilst waiting as it will help the time go more quickly. Have a coffee, a meal, a walk, read a book, look at the art work around the hospital corridors.

For safety reasons, parents aren’t permitted to stay during surgery.

Keeping Kids Comfortable

Your anaesthetist will talk to you about the techniques that we use to keep your child comfortable following surgery. At WCH it is routine for children to receive paracetamol prior to coming to theatre and this will be given by nursing staff. These days we use multi-modal techniques, which means we use a combination of analgesic medications such as paracetamol, anti-inflammatories, tramadol and opioids (such as fentanyl or morphine) in combination with local anaesthetic injection to numb the area of surgery when possible.

For major surgery and for some patients, we use other analgesic medications and specific local anaesthetic techniques. Further information about many of these techniques is available on the Children’s Acute Pain Service (link to APS page) page of our website. If any of these techniques are required or recommended for your child these will be explained by your anaesthetist prior to surgery.

Many patients and their families can look forward to a comfortable recovery. If discomfort is a problem there will a number of options available following return to the ward or day surgery. Some of these will be regularly administered by the nursing staff caring for your child and some will be prescribed on an ‘as required’ basis and may need to be requested from nursing staff if you feel your child is uncomfortable.

There are some really good ways you can help your child manage discomfort which don’t involve medications and these can be found on this website.

Eating Following Surgery

These days it is relatively routine to eat soon after surgery. We have effective medications to help your child feel like eating following surgery and these are administered to many patients. The decision to use them is based on age, patient history, type of surgery and whether opioids have been used during surgery.

Some types of surgery require the child to fast following the operation and these instructions will be relayed by nursing staff caring for your child following their operation.

Airways, Coughs and Colds

Children may have airway events under anaesthesia, however the anaesthetic and recovery team know how to look out for these events and are expert at managing them. Children who have had a cold or a respiratory tract infection within the 6 weeks prior to their anaesthetic have an increased risk of breathing difficulties during or after their anaesthetic and so it is really important to let your nurse and anaesthetist know if your child has had a recent cough or cold. If you have concerns that your child is unwell in the lead up to their surgery, please contact the WCH Pre-Admission Co-ordinator (08 81617714).

As your child’s safety is our highest priority, sometimes the anaesthetist will decide that it would be safer for your child to delay having their anaesthetic if they have had a recent respiratory tract infection. If this is the case it will be discussed with you and arrangements will be made with the surgical team to rebook the surgery for a later date.

Allergies

Children may have allergies to anaesthetic medications and we routinely monitor our patients for these adverse reactions. Severe allergy can be life threatening however these are very rare, with less than one case per year under anaesthetic at WCH. It is very important that you give your anaesthetist an accurate history of any allergies, the triggers, the reaction and the management of these reactions.

If allergy occurs or is suspected, we will let you know and discuss any follow-up that is necessary.

Teeth

During an anaesthetic, the anaesthetist may carefully place a soft piece of plastic into your child’s mouth to assist their breathing. It is important that prior to the anaesthetic you alert the anaesthetist to any loose, wobbly or vulnerable teeth (such as caps and crowns) so that particular attention can be paid to protecting these.

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