The term perioperative care refers to all the clinical activities that take place around a surgical intervention, from the preoperative assessment to the postoperative discharge. In modern institutions, perioperative care is performed in a defined physical area that usually accommodates scheduling, admission, preoperative preparation, the procedure itself (the operating room or a procedural suite), recovery from the procedure (phase I and II), and discharge. Support services—including sterile processing, materials management, the pharmacy, the laboratory, pathology, and diagnostic imaging—are frequently adjacent. The success and subsequent demand for new procedures such as cardiac catheterization or endoscopy, which are not strictly surgical but require expertise and equipment similar to surgery, have created a need to duplicate existing perioperative resources in other areas. The same principles that are detailed here for surgical procedures apply to these procedural areas.
PREOPERATIVE ASSESSMENT AND CARE
Nearly all parents and children experience anxiety at the prospect of surgery. Preparing children for their surgical and operating room experience should begin before the patient makes contact with their anesthesiologist. The surgeon or primary care provider should be the first ones to ensure that the child receives the best perioperative care possible and to assure the child’s family that this will be the case, answering their questions or facilitating access to someone who can answer them.
Many institutions arrange orientation and a preoperative tour days before surgery to instruct and educate the child and parent on what to expect. As part of the preoperative program, most of these institutions have developed child-friendly environments, with coloring books, tours, videos, and the invaluable help of a child-life specialist who can help reduce the level of anxiety. Allowing children to take a favorite toy or blanket into the operating room provides great comfort to many children.
The primary goal of preoperative assessment and care is preparing a patient for surgery, and ensuring that a full assessment of risk has been performed. This involves the following points: (1) screening for conditions that may require consultation workup or treatment, (2) optimizing any pre-existing medical conditions, and (3) counseling patients and parents about the expected course of anesthesia and surgery. The anesthesiologists should make every effort to see the child and the family to understand their needs and expectations and to perform a complete preoperative evaluation. The anesthetic, postoperative pain management, and discharge plans can all be explained to the child, if appropriate, and to the family at this time. This is also a good opportunity to obtain informed consent.
The preoperative evaluation usually consists of a careful history and an targeted physical examination aimed at establishing surgical risk and designing anesthetic planning and postoperative care. The physical examination should be sufficiently complete to detect any major problems and should be informed by the medical history (Table 109-1).
TABLE 109-1THE PREANESTHETIC HISTORY, SYSTEMIC ...