An operation is always an important moment in the life of a child. Hospitals can be a positive experience and a place to learn. Parents have an important role in preparing your child to make this as positive and non-frightening as possible. This booklet will help you explain what to expect when your child has an anaesthetic. In the days before hospitalization look at the booklet together, preferably reading it together like a storybook. Let your child tell you what they are expecting and answer their questions truthfully. Avoid lying about the procedures even if you think it is reassuring. If you have any questions about the surgery ask the surgeon or anaesthetist before the operation.

What is an anaesthetist?

An Anaesthetist is a doctor who has spent many years of additional training in anaesthetics after they graduate as doctors. You can be reassured about the ability and qualifications of the anaesthetist who will manage your child during surgery. Specialist paediatric anaesthetists in Australia are among the world's most highly trained doctors, having spent years undergoing special training in anaesthesia, pain control and resuscitation and managing medical emergencies. The anaesthetist's role is to ensure your child doesn't feel anything during the surgery and we want your child to experience as little pain and discomfort as possible after the operation. While your child is asleep, their anaesthetist will stay with them at all times during the operation and monitor them closely. Today's equipment is able to tell us a great deal about the patient during anaesthesia and allows us to control the delivery of anaesthetic drugs very carefully. Today there is so much monitoring in the operating theatre that it looks like the cockpit of a jumbo jet.

Why must children fast?

We know children don't like being hungry and thirsty but no food or drink is a must! If you don't follow this rule the operation may be cancelled or postponed in your child's best interest. The reason is that when anaesthetised, the stomach stops working and the cough and other protective reflexes stop working. If there is food or fluid in the stomach it can passively run back into the mouth and go down into the lungs.

The following guidelines are issued by the Department of Anaesthesia and Pain Management of the Royal Children's Hospital concerning fasting for all patients, whether surgical, medical or undergoing a general anaesthetic or sedation.

Fasting guidelines

For all patients having an anaesthetic, please note recent changes in fasting guidelines for clear fluids introduced November 2023

The goal of these guidelines is to minimise the fasting times for clear liquids to 1 hour. There is always an effort made to organise an operating list order such that the youngest patients are early in the list, and thus have the shortest fasting times. If your child is scheduled for later in the list, your anaesthetist may allow them to have a drink of clear liquids, or a breast feed, if time permits, however this is not always possible.

These guidelines can only be modified after discussion with the anaesthetist. If the guidelines are breached without discussion with your child's anaesthetist, then this may result in the operation being delayed or even rescheduled for another date.

For children OVER 6 MONTHS

Solids, Formula and Cow's Milk - cease 6 hours before start of elective list 

Breast Milk - cease 3 hours before start of elective list

Clear Fluids - cease 1 hour before start of elective list - there will be a 'sip until send' stipulation for emergency list patients and inpatient elective cases (i.e. NOT nil by mouth)

For children UNDER 6 MONTHS

Solids and Cow's Milk - cease 6 hours before start of elective list

Formula - cease 4 hours before start of elective list

Breast Milk - cease 3 hours before start of elective list

Clear Fluids - cease 1 hour before start of elective list

Note that morning lists start at 8:30am, and afternoon lists at 1:30pm

Cardiac Lists start at 8:00am. 

Clear liquids are transparent when held to the light. They include glucose-based drinks, cordials and clear juices. This does not include particulate or milk-based products or jelly.

If concerned or questions arise, please contact the specific Anaesthetist for the list, or ext 52000

Patients with a specific staggered admission time:

• The fasting orders above should be applied to that specific admission time.

Oral Medication:

• Please continue regular oral medications unless otherwise requested by your anaesthetist or other medical staff involved in your child's treatment
• Medications can be taken with a sip of clear liquid.

What to do if you are unsure about appropriate fasting times, or any other aspect of planning for your child's elective procedure?

Contact the Pre-Admission Resource Centre (PARC,www.rch.org.au/preadmission/contact.cfm?doc_id=12069) on 9345 4115 or 9345 4193 during office hours.

Emergency surgery and anaesthesia

Patients should be fasted from first contact until further instructions from the duty anaesthetist.

The preoperative examination: What is it and why?

What should I tell the anaesthetist? As much as possible! Your anaesthetist will want to know about:

• when your child last had anything to eat or drink
• any recent coughs or colds and fevers
• any previous anaesthetics or family problems with anaesthetics
• abnormal reactions to drugs or allergies
• any history of asthma, bronchitis, heart problems or other medical problems
• whether your child is on any medication at present
• any loose teeth

Premedication (pre-meds)

A pre-med is any thing given prior to the operation, which reduces discomfort after the operation.
The two common forms are:

1. An anaesthetic cream is applied to the back of your child's hand and a plastic dressing applied as a cover. This cream slowly penetrates the skin and numbs the area. After 60 minutes the skin is anaesthetized and the pain associated with needles is markedly reduced. Some children get a mild reaction to the cream or dressing with some redness.
2. Some children will also be prescribed a mixture or drops in the nose or mouth. This is commonly paracetamol (panadol) with or without a sedative, which calms the child. Children rarely get a 'needle' pre-med anymore.
   

Parents in the anaesthetic room

The attitude of doctors to parents in the anaesthetic room has changed. One of the parents may be allowed to accompany the child during induction of anaesthesia. If you are very nervous or upset it is best not to come into the anaesthetic room. Your anxiety is conveyed to the child and makes induction of anaesthesia more difficult. In some circumstances you will not be allowed to accompany your child. For children less than 6 months of age, emergency cases and most night and weekend cases we are unable to allow parents in the room for safety reasons. You must accept that our primary concern is the child and agree to leave when you are not feeling well, when we ask you to leave and when the child is asleep. It is common for parents to get distressed when their child is anaesthetized. With intravenous anaesthesia your child may become unconscious rapidly and look pale and floppy. It is natural to get a little teary. Your anaesthetist expects this and will be reassuring. We ALWAYS take good care of your children.

Separation from parents

Infants up to 6 months of age are minimally upset by separation from parents and home situation and have the least psychological impact from surgery even if it is major. Children from 6 months to 4 years are the most vulnerable because the child's separation anxiety is at it's maximum. Children are becoming old enough to remember, especially negative experiences, but not old enough to understand the need for surgery and hospitalization. To help in this age group premedication is common if they are upset. With this group parents at induction are most helpful. School age children are usually less upset about separation and more concerned about the surgical procedure. Sometimes they prefer not to be accompanied by their parents.

What are the different types of anaesthesia?

What is a general anaesthetic?

Occasionally parents are concerned about anaesthetics for their children because of bad experiences they had with anaesthetics as a child. Anaesthetics have changed and now most people find anaesthesia a pleasant experience as the latest agents produce a feeling of well-being. Premedication often affects the memory after the event so children rarely remember going off to sleep.There is no such thing as a light anaesthetic. Every time someone has an anaesthetic the same procedures and safety considerations are put into place. Only the length of the anaesthetic and the type of surgery varies. Small children and occasionally adults can go to sleep with a potent anaesthetic gas mixed with oxygen and nitrous oxide (laughing gas). The newer gases do not have a particularly unpleasant smell. A drip placed in the vein is a way of Ôfast-trackingÕ the onset of anaesthesia. These drugs cause sleep within a few seconds and rapid awakening at the end of the operation. During the operation it is important to control the breathing of the patient carefully. It is sometimes necessary to introduce a tube into the airway and take over control of breathing until the end of the operation. Because this tube is in contact with the vocal cords patients sometimes wake with sore throats or hoarse voices.

What is a regional anaesthetic?

Regional anaesthesia is a way of blocking painful sensations from a limb or part of the body during and after surgery with local anaesthetic. There are a great number of techniques of local and regional anaesthesia whereby most parts of the body can be numbed. In children local anaesthetic is injected after the children are sedated or anaesthetized. The best known are epidural and spinal anaesthetics.

1. Epidural anaesthesia: A special needle is placed between the bones of the back (vertebrae) and a piece of fine tubing called a catheter is placed in the epidural space. Once the catheter is in position the needle is removed and the fine catheter taped to the skin. Anaesthetic drugs are injected through the catheter into this space and can reach the nerves directly, blocking painful sensations. (This technique is very common for pain relief during labour and delivery).  After major surgery a small pump delivers the local anaesthetic continuously for two to four days after the operation.
2. Caudal anaesthesia: The principles are similar to epidural anaesthesia but the needle is placed at the very bottom of the spine. This is a very common form of anaesthetic for children and has been demonstrated to be very safe.
3. Spinal anaesthesia: The local anaesthetic is placed in direct contact with the nerves at the lower end of the spinal column with a thin needle. With this technique movement of the legs and pain are both blocked. This is used for shorter operations and is not continued after the operation.
4. Local anaesthesia: The skin around the area being operated on is infiltrated with local anaesthetic or specific nerves supplying that area are blocked to produce localized pain relief.

What happens in the recovery room?

Every anaesthetized patient must spend time in the recovery room after an operation. The nursing staff in recovery room are specifically trained to look after children who have been anaesthetised. Among other things, the staff ensure your child:

• is recovering appropriately from the effects of the anaesthetic agent
• is not in pain
• does not require drugs for nausea or vomiting
• does not have excessive bleeding from the operation site

The recovery room has a number of monitors similar to those in the anaesthetic room. Sometimes your child will require extra oxygen given with a mask to help recover from the anaesthetic.

After the operation

Common problems after the operation are:

1. Pain.
   A number of measures are used to relieve pain after the operation. Panadol is often given as a pre-med for pain after the operation. During the operation pain relieving drugs (analgesics) are given as required, and local anaesthetic is used. Children sometimes have a suppository placed in their bottom after they are asleep to provide analgesia for the two to three hours post operation. The suppository works slowly and is most effective as the local anaesthetic is wearing off. After the operation further analgesia is ordered as appropriate. These medications are usually taken orally, or, for more severe pain, into the vein via the cannula placed at the start of the anaesthetic. A   P.C.A. (Patient Controlled Analgesia)  delivery device is used by the This delivers analgesic drugs into the drip with a mechanism to increase the delivery if pain persists. If your child has pain they can get extra analgesia through the needle already in their hand or from a mixture to drink. We usually recommend continuing paracetamol every four hours for at least 24 hours after surgery.
2. Nausea and vomiting may occur. Certain operations especially ear, nose and throat operations and those on the eyes are associated with nausea after the operation. The incidence has been reduced in recent years with the use of new drugs. The anaesthetist will often give your child drugs to decrease vomiting.
3. Bleeding and bruising. Bleeding from the operation site is closely monitored and the surgeon notified if it is excessive.
4. Sore throats, muscle aches and headaches may occur and usually respond to simple pain relief mixtures. Children sometimes complain of blurred or double vision as they are recovering from anaesthetics.

When can we go home?

Over half of all surgery is now done on a same day basis where you come into hospital on the day of operation and leave on the same day. If your operation is this type you can usually leave 1-2 hours after waking from the anaesthetic. For more major surgery the length of hospital stay is often longer and is determined by the surgical team.