Fig. 11.1
(a) The child is anesthetized topically with eye drops before irrigation of the lacrimal passage; (b) the child is undergoing irrigation of the lacrimal drainage system
The evaluations of systemic conditions.
- 1.
Observe the pediatric patient’s consciousness, expression, competence of emotional and verbal exchanges, nutritional status, and intelligence development.
- 2.
Learn about the child’s systemic condition based on the results of routine blood and urine tests, serum biochemistry, four blood coagulation indexes (PT, APTT, TT, FIB), hepatorenal function, electrocardiogram (ECG), and chest X-ray.
- 3.
Note the presence of any systemic syndrome. As in the case of Marfan syndrome, it is frequently accompanied by severe systemic anomalies, including cardiac insufficiency and systemic connective tissue diseases.
- 4.
Rule out severe anomalies of the cardiovascular system, respiratory system, and nervous system.
The evaluations of psychosocial conditions.
The child’s psychological status and level of cooperation in treatment and examination are evaluated. The parents’ moods, educational levels, and financial situation are noted, as well as the main caretaker’s understanding of disease-related knowledge [1].
11.1.2 Nursing Measures
11.1.2.1 Mental Care
Most of pediatric patients show resistance and fear for surgery. The nursing staff should proactively communicate with pediatric patients and provide appropriate counseling on the mental status of pediatric patients at different ages. A friendly atmosphere in the hospital and a good rapport between nurses and pediatric patients should be established based on the age and personality features of these children. Explain surgical considerations to the parents of pediatric patients and the older children directly to eliminate their fears. Children’s parents are prone to such undesirable emotions as anxieties toward their children’s disease conditions, surgeries, and prognoses. Therefore, the nursing staff should provide psychological counseling for parents and try to win their trust and cooperation [2].
11.1.2.2 Safety Care
- 1.
Children usually lack cognitive faculties and thus have poor hazard recognition; worse still, they do not have the capability for self-defense. Lively and active, children with a curious mind are very liable to tumbling, aspiration and ingestion of foreign objects, falling out of bed, getting lost, and trauma. Therefore, nurses must possess high safety awareness, provide better safety education, and give guidance to the family members about how to take safety precautions.
- 2.
Children tend to be uncooperative in examination and treatment, and, worse still, ophthalmic nursing procedures are more delicate and difficult. Hence, in order to avoid damage to ocular tissue due to the child’s resistance to examination and treatment, the manipulation should be light, precise, steady, skillful, and fast. The following immobilization and sedation methods can be adopted. Immobilization of a pediatric patient is done as follows: The child lies supine on the treatment table with the upper and lower limbs and the body wrapped in a sheet; meanwhile, a nurse or another healthcare provider helps fix his/her head (Fig. 11.2). For sedation, 10 % chloral hydrate can be given orally or by retention enema before the examination for a pediatric patient who is not cooperative. At present, we also use dexmedetomidine in nasal drops for anesthesia in pediatric patients.
Fig. 11.2
(a) The immobilization of the pediatric patient for examination and treatment; (b) the immobilization of the pediatric patient’s head
11.1.2.3 Hygiene Care
Parents are given guidance on how to give their children a full-body cleaning, including hair, body, and face washing, as well as nail trimming. Maintain periocular hygienes on the day of surgery and change in clean surgical gowns.
11.1.2.4 Preoperative Ocular Preparation
Antibiotic and mydriasis eye drops are instilled in the operated eye as directed. Press the lacrimal sac for 3–5 min to reduce the absorption of drugs via the nasal mucosa. After the pediatric patient is anesthetized, flush the eye with normal saline.
11.1.2.5 Preoperative Anesthetic Preparation
Preoperative measurement of body temperature, pulse, and respiration is carried out to confirm the absence of respiratory infections and pyrexia and to establish intravenous access.
11.2 Anesthesia Care of Pediatric Lens Surgery
The organ systems of children (particularly those under the age of 1 year) are immature, and their circulatory and respiratory systems have poor tolerance to general anesthesia. As a consequence, more rigorous requirements are set on the anesthetic care of children compared with that in adults.
11.2.1 Preanesthetic Preparation
11.2.1.1 Preoperative Visit
Preoperative visit helps the pediatric patient and his/her parents with mental preparation for surgery and anesthesia and relieves anxiety. The pediatric patient is observed for the presence of upper respiratory infection (URI), loose teeth, and excessive nasal discharge. Moreover, cardiopulmonary function is evaluated to rule out severe congenital malformation.
11.2.1.2 Preoperative Fasting
The pediatric patient and his/her parents are informed of the importance of preoperative fasting from solid food and clear fluids. Before anesthesia, be sure to confirm that the child’s fasting time is as directed by the anesthetist. For the time of fasting from solid food and fluids, see Chap. 10 “General Anesthesia for Pediatric Lens Surgery” for reference.
11.2.1.3 Environmental Support
Due to the imperfect thermoregulation function in children, labial and respiratory mucosae may become drier with increased thirst, if the room temperature is excessively high with low humidity. But if the room temperature is excessively low, the pediatric patient will be susceptible to URI. Therefore, it is more reasonable that the temperature in the operating room is kept within 22–25 °C and the relative humidity is between 40 and 60 %.
11.2.2 Electrocardiogram (ECG) Monitoring
The pediatric patient’s respiration, heart rate, heart rhythm, and oxygen saturation are closely observed via the monitor during the surgery. Abnormality of any parameter should be immediately reported and collaborated resuscitation with doctors initiated instantly.
11.2.3 Management During Anesthesia Recovery
Monitored anesthesia care is a continuous process, and the management of recovery phase is mainly to test and assess the residual effects of the drugs administered intraoperatively to determine when the pediatric patient can be discharged from the recovery room. The early stage of resuscitation is a dangerous period in which airway obstruction and other severe complications usually occur. Thus vital signs and oxygen saturation should be closely observed with the respiratory tract kept patent. Continuous administration of low-flow oxygen can last till the pediatric patient is wide awake. When the child is found to have lip cyanosis and masticatory muscle spasm causing difficulty in opening the mouth, remove nasopharyngeal secretions and vomitus promptly, that is, to hold up the lower jaw of the child for such emergency measures as sputum aspiration and oxygen inhalation. During the course of recovery, a few of the pediatric patients develop restlessness, unconsciousness, hallucination, and other manifestations, who may remove the oxygen catheters and infusion tubes. Therefore, protective constraints should be strengthened with both hands fixed in a functional position. After the pediatric patient becomes fully conscious, a small amount of water is given. Observe whether the swallowing function is fully regained before eating is allowed [3, 4].
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