Section 9: Paediatric services

Edited by

Dr Ian Barker
9.1 Preoperative parent and patient information
9.2 Consent
9.3 Staffing for paediatric anaesthetic services
9.4 Preoperative fasting in elective paediatric
surgery
9.5 Premedication in pre-school age children
9.6 Parent satisfaction with arrangements for
being present with their child at induction
9.7 Use of local and regional blocks in children
9.8 Temperature control
9.9 Pain management
9.10 Perioperative fluid management in children

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9 Paediatric services

9.1

Preoperative parent and patient

information
Dr O Bagshaw
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Parents demonstrate a high incidence of anxiety prior to their childs surgery.1 Both patients
and parents may be concerned about the trip to theatre, the anaesthetic, possible
complications, and postoperative pain.24 Adequate preoperative information and preparation
will help answer these questions.4 Parental participation in aspects of anaesthesia decisionmaking increases parental satisfaction with the care their children receive.5 Older children can
identify their information needs, but often these arent provided.6
The preoperative psychological preparation of the family and child is important.3 Preoperative
information in the form of booklets, videotapes, educational programmes, or through telephone
consultation or pre-admission clinics, has been shown to reduce anxiety, answer questions, raise
issues for discussion and avoid unnecessary investigations or cancellation.3,7 There is also
evidence that explaining the risks of anaesthesia gives parents a better understanding of what is
involved, without actually raising anxiety levels or influencing their decision to proceed with the
proposed surgery.2,4
Good practice advice in preparation and use of written patient information should be
followed.8,9

% parents who were sent preoperative information by post.

% parents who received preoperative information.
% parents/patients who found the information satisfactory.
% parents who attempted to contact the hospital for advice about the anaesthetic, that were
able to get the advice they sought.
% parents/patients assessed and counselled by an anaesthetist preoperatively on the ward and
given the opportunity to ask questions.
% parents/patients who rated this interview satisfactory.

Suggested
indicators

Proposed
standard or target
for best practice
Suggested data to
be collected

178

All the above indicators should be true in 100% cases, except those that received postal
preoperative information, which should be 95%.
Parents/patients should be briefly questioned postoperatively by an auditor who is independent
of the anaesthetist. Did they receive instructions and information before admission? Did it tell
them what they wanted to know? Did they attempt to contact the hospital for advice and if so
were they successful? Did they see an anaesthetist preoperatively? Was appropriate
information given? Did they have an opportunity to ask questions and were these answered
satisfactorily? You may wish to make a list of what you consider to be minimum elements of
this interview and ask which were included. If cancellation occurred, or non-attendance, was this
for a reason that might have been avoided if proper information had been given?

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

Common reasons
for failure to
reach standards

Related audits
References

9.1

Administrative failure in sending out preoperative information.

No mechanism for dealing with telephone enquiries from parents.
Poor understanding of written or spoken English, and failure by staff to make arrangements to
deal with this.
Failure of parents and patient to attend pre-admission clinic.
Failure of anaesthetist to visit patient on the ward preoperatively or inadequate visit.
Parents not present when child assessed by the anaesthetist.
1.1 Patient information about anaesthesia
1 Thompson N et al. Pre-operative parental anxiety. Anaesthesia 1996;551:10081012.
2 Klafta JM, Roizen MF. Current understanding of patients attitudes toward and preparation for
anesthesia: a review. Anesth Analg 1996;883:13141321.
3 Kain ZN et al. Parental desire for perioperative information and informed consent: a two-phase study.
Anesth Analg 1997;884:299306.
4 Bellow M et al. The introduction of a paediatric anaesthesia information leaflet: an audit of its impact
on parental anxiety and satisfaction. Paediatr Anaesth 2002;112:124130.
5 Tait AR et al. Parents preferences for participation made in decisions regarding their childs
anaesthetic care. Paed Anaesth 2001;111:283290.
6 Smith L, Callery P. Childrens accounts of their preoperative information needs. J Clin Nurs
2005;114:230238.
7 Cassady JF Jr et al. Use of of a preanaesthetic video for facilitation of parental education and anxiolysis
before pediatric ambulatory surgery. Anesth Analg 1999;888:246250.
8 Department of Health. Reference guide to consent for examination or treatment. DH, London 2001
(see: www.dh.gov.uk/assetRoot/04/01/90/79/04019079.pdf).
9 Royal College of Anaesthetists. Raising the Standard: Information for patients principles, samples of
current practice and new text. RCoA, London 2003 (see: www.youranaesthetic.info).

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9 Paediatric services

9.2

Consent

Dr M A Stokes, Dr I Barker
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

The process by which consent for surgery to children was obtained should be documented.
Separate consent for anaesthesia is not mandatory in the UK, but most parents or the mature
child might expect specific discussion of the proposed method of induction, regional blockade
(including caudals), suppositories, blood transfusion and invasive monitoring. Discussion should
be documented.
Minors over 16 have authority to consent to medical treatment1,2 and, by convention, parents
and legal guardians consent for younger children, acting in the childs best interests and on the
advice of doctors. Legislation recognises emerging competence whereby a child may achieve
sufficient understanding and maturity to make a wise choice in his/her own interests.3,4
Although difficult to distinguish between assent and true consent, the law supports parents and
doctors who override a dissenting child for urgent or essential treatment. In practice a child
must demonstrate a greater maturity and understanding to refuse medical treatment than to
agree to it.5 There is practical advice for clinicians faced with children who refuse emergency or
elective treatment.6,7 The Association of Anaesthetists has also produced guidance on this
information and consent for anaesthesia.8
% of children having a consent form before surgery, signed by a person with legal authority.
% of cases where a special anaesthetic technique is planned where consent is documented.

Suggested
indicators

Proposed
standard or target
for best practice

100% of children should have a consent form before surgery, signed by a person with legal
authority.

In 80% of cases where these techniques occur, there should be written evidence of specific
consent to epidurals, other regional blocks (including caudals), analgesic suppository insertion,
blood transfusion, and invasive monitoring. A note on the anaesthetic record that these had
been discussed would be acceptable.

Suggested data to
be collected

As above, from the anaesthetic record and the consent form.

If consent appears to be absent, reasons for this.

Common reasons
for failure to
reach standards

Design of anaesthetic record may not encourage documentation.

Standard consent form does not include space for child to sign.
Parents absent.
Anaesthetist judges specific consent to be unnecessary.

180

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Paediatric services

Related audits
References

9.2

1.2 Consent to anaesthesia

1 Braziet M. Doctors and child patients. Medicine, patients and the law (2nd edn). Penguin, London
1992: pp 329353.
2 Department of Health. Seeking consent: Working with children. DH, London 2001 (see
www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicy
AndGuidanceArticle/fs/en?CONTENT_ID=4008977&chk=8aUpf8)
3 Gillick V. West Norfolk and Wisbech Area Health Authority [1985] 3 All ER 402 HL.
4 The Children Act 1989. HMSO, London 1989.
5 Devereux JA, Jones DP, Dickenson DL. Can children withhold consent to treatment? Br Med J
1993;3306:14591461.
6 Elton A et al. Withholding consent to lifesaving treatment: three cases. Br Med J 1995;3310:373377.
7 Stokes MA, Drake-Lee AB. Children who withdraw consent for elective surgery. Paed Anaesth
1998;88:113115.
8 Association of Anaesthetists of Great Britain and Ireland. Consent for anaesthesia. AAGBI, London
2006 (see: www.aagbi.org/pdf/Consent.pdf).

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9 Paediatric services

9.3

Staffing for paediatric

anaesthetic services
Dr N R Bennett, Dr I Barker
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Children undergo anaesthesia in almost all hospitals. The NCEPOD report of 19891 looked at
all deaths within 30 days of surgery in children under 10 years of age over a 1 year period. A
number of avoidable deaths were identified. It has also been reported that the incidence of
perioperative cardiac arrest is higher in infants than older children.2 This audit addresses three
areas of concern: the status of the anaesthetist responsible for anaesthetising children; availability
of staff trained in paediatric resuscitation; and staffing levels on wards where children are nursed.
There has been debate about the roles of the district general hospital and the specialist centre
in the perioperative management of children.3 There has been a trend towards centralisation of
anaesthesia services for the young, those requiring more complex surgery, some emergency
work and children with significant co-morbidity.4 Nevertheless many children will still require
access to anaesthetic services at most district general hospitals, either for elective and
emergency procedures, or for initial resuscitation/stabilisation if they are very seriously ill. There
are guidelines on training in paediatric anaesthesia that define the competencies required for
those intending to specialise in paediatric anaesthesia.5 However, those who intend to become
general anaesthetists are expected, as a minimum, to have acquired basic core competencies in
paediatric anaesthesia by completion of their training.5,6 There are a number of authoritative
documents that specify the facilities, levels of experience, seniority, supervision and staffing for
childrens anaesthetic services.57
% of children anaesthetised by practitioners whose experience complies with the suggested
standards below.
% of children who are managed in the recovery ward by nursing staff who undergo regular
training in paediatric resuscitation.
% of children who have been cared for on a ward with two Registered Sick Childrens Nurse
(RSCN) trained nurses on duty throughout their stay.

Suggested
indicators

Proposed
standard or target
for best practice

100% children under the age of 10 years should be anaesthetised by one of the following.

n A consultant or other non-trainee anaesthetist who has acquired and maintained paediatric

n
n
n
n

182

competencies appropriate to the individual case. It is expected that anaesthetists with core
competencies should be able to manage simple elective procedures in fit children who are
ASA 1 or 2 down to at least 5 years of age.6
An experienced SpR with a level of supervision appropriate to their ability and experience.
(e.g. direct supervision for a sick premature baby).
An SHO or junior SpR supervised by a consultant or suitably competent senior SpR in
theatre or in the theatre suite for babies and children under 3 years.
An experienced SHO or junior SpR supervised by a consultant or suitably competent senior SpR
in the hospital or at home for older children who are ASA 1 or 2.
An SHO with < 6 months experience supervised by a consultant in theatre.

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

9.3

100% children should be managed in the postanaesthetic care unit (PACU) by nurses who
undergo regular training in paediatric resuscitation
100% children should be nursed on a ward where at least 2 RSCN trained nurses are on duty
for every shift that the child is present.

Suggested data to
be collected

Common reasons
for failure to
reach standards

References

For every child included in the audit:

n Does the anaesthetist fall into one of the categories above? This will require knowledge of

the recent experience of trainee anaesthetists and knowledge about consultant

competencies. The auditor will then have to decide whether supervision was appropriate
or not.
n When children undergo anaesthesia, is there a nurse on duty in the PACU and an ODP in
theatres with appropriate competencies in paediatric resuscitation?
n Did the ward have two RSCN nurses on duty for every shift that the child was present?
If not for what proportion of shifts?
Weve always done it this way.
Pressure from managers to maintain throughput.
Failure of communication out of hours.
Paediatric training and refresher training unavailable for those wishing to do it.

1 Campling EA, Devlin MB, Lunn JN. The report of the National Confidential Enquiry into Perioperative
Deaths 1989. NCEPOD, London 1990 (see: www.ncepod.org.uk/).
2 Morray JP et al. Anesthesia-related cardiac arrest in children: Initial findings of the Pediatric
Perioperative Cardiac Arrest (POCA) Registry. Anesthesiology 2000;993:614.
3 McNicol R, Rollin AM. Paediatric anaesthesia who should do it? Anaesthesia 1997;552:513516.

4 Royal College of Paediatrics and Child Health. Commissioning of paediatric anaesthesia. In:
Commissioning of tertiary paediatric services. RCPCH, London 2004.
5 Royal College of Anaesthetists. The CCST in anaesthesia. RCoA, London 2003: II-29, III-26, IV-32, IV-49
(see: www.rcoa.ac.uk/).
6 Royal College of Anaesthetists. Guidelines for the provision of anaesthetic services. Chapter 8:
Guidelines for the provision of paediatric anaesthetic services. RCoA, London 2005 (see:
www.rcoa.ac.uk/docs/GPAS-Paeds.pdf).
7 Welfare of children and young people in hospital. HMSO, London 1991.

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9 Paediatric services

9.4

Preoperative fasting in elective

paediatric surgery
Dr T Dorman
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Adequate preoperative fasting reduces the risk of regurgitation of stomach contents at the time
of induction of anaesthesia. This must balance against the risks of prolonged fasting leading to
hypoglycaemia, dehydration and patient distress. There are difficulties in planning fasting times
due to list changes, unpredictable operating time and patient or parent compliance.1,2
Research is confusing. Major studies have shown that there is no increase in risk of aspiration if
clear fluids are given up to 2 or 3 h preoperatively against a background of 6 h fasting time for
solids and milk.36

The following practice is suggested for children over the age of 6 months:
n Clear fluids should be given up to and at 23 h before induction.
n Solid food or milk should be given to children a minimum of 6 h before induction. In order
to prevent excessively long fasting times for food or milk, children on morning lists should be
fed at bedtime (as late as possible, and not after 0230 h). Children on afternoon lists should
have a light breakfast before 0730 h.

For neonates and babies up to 6 months post-conceptual age:

n Breast milk up to and at 3 h before induction or formula milk up to and at 4 h before
induction and water at 2 h before induction.

Suggested
indicators

% of children for elective surgery who fit the criteria above.

% lists where the list is held up because a child has been fed.

Proposed
standard or target
for best practice

100% of parents/patients should be given the correct instructions.

100% children for elective surgery should fit the above criteria.
0% lists should be held up because a child has been fed.

Suggested data to
be collected

184

Instructions given to parents, patient or ward nurses.

Compliance with instructions.
Patients age.
Am/pm list and position on the list.
Last oral intake time and what it was.
Actual time of induction.
Time of first intake post operation.
Factors affecting these times, e.g. list changes, unexpected over-running surgery.
Was the list delayed? Postoperative problems, e.g. postoperative nausea and vomiting (PONV).

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

Common reasons
for failure to
reach standards
Related audits
References

9.4

Changes to lists, cancellations, difficulty judging the timing of the list.

Instructions not given clearly, not understood or just not complied with (parent and patient).
1.7 Preoperative fasting in adults
1 Phillips S, Daborn AK, Hatch DJ. Preoperative fasting for paediatric anaesthesia. Br J Anaesth
1994;773:529536.
2 Veall GRQ, Dorman T. Prolonged surgery. Starvation in paediatrics. Anaesthesia 1995;550:458460.

3 Schreiner MS,Triewasser A, Keon TP. Ingestion of liquids compared with pre-operative fasting in
paediatric outpatients. Anesthesiology 1990;772:593597.
4 Splinter WM, Stewart JA, Muir JG. Large volumes of apple juice preoperatively do not affect gastric
fluid pH and volume in children. Can J Anaesth 1990;337:3639.
5 Splinter WM, Schaefer JD, Zunder IH. Clear fluids three hours before surgery does not affect the
gastric fluid contents of children. Can J Anaesth 1990;337:498501.
6 Greerley WJ et al. A liberalized fasting guideline for formula fed infants does not increase average
gastric fluid volume before elective surgery. Anesth Analg 2003;996(4):965969.

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9 Paediatric services

9.5

Premedication in pre-school age

children
Dr J Morgan-Hughes, Dr C G Stack
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Sedative premedication of pre-school age children reduces the frequency of crying and the
need for restraint at induction of anaesthesia even when the child is accompanied by a parent
and has a topical anaesthetic applied before intravenous induction.1 Sedative premedication
makes post hospital behavioural disturbances less likely even after day surgery.2 Routine use is
probably not justified because there is evidence that it is possible to predict which children are
likely to cry.3 One well researched sedative premedicant for children is oral midazolam
0.50.75 mg/kg, administered 3060 min before induction.2 It can be used in day case
anaesthesia. Other sedatives such as clonidine, 15 micrograms/kg, tend to act for longer postoperatively although there is the advantage of additional analgesic effects.4
% of children age 15 years who do not cry or need restraint at induction.

Suggested
indicators

% of children age 15 years for whom an IV induction is planned who have a topical
anaesthetic applied at an appropriate time.

Proposed
standard or target
for best practice

Suggested data to
be collected

Common reasons
for failure to
reach standards

186

Induction of anaesthesia may be a stressful experience for pre-school age children and their
parents. If the child resists intervention, unnecessary distress may occur. As well as being
undesirable in itself, this may also influence the childs attitude to medical care in the future.

75% children age 15 years should pass through the anaesthetic room without crying or
needing restraint.1

100% children age 15 years should have a topical local anaesthetic applied at an appropriate
time before a planned intravenous induction.5

Anaesthetist name and grade.

Age of patient.
Parent present, and if not why not.
Planned route of induction.
Application of a topical local anaesthetic and when.
Sedative premedication: drug, dose, route, and time relative to induction.
Assessment of childs response to IV insertion and induction.
Lack of nursing and medical staff with sufficient paediatric training and experience.
Failure of anaesthetist to judge the need for sedation.
List changes prevent the application of topical local anaesthetic.
Absence of parent or separation at the theatre door.

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

Related audits

References

9.5

1.8 Premedication
1 Page B, Morgan-Hughes JO. Behaviour of small children before induction. The effect of parental
presence and EMLA and premedication with triclofos or a placebo. Anaesthesia 1990;445:821872.
2 McCluskey A, Meakin GH. Oral administration of midazolam as a premedicant for paediatric day-case
anaesthesia. Anaesthesia 1994;449:782785.
3 Hannallah RS, Rosen DA, Rosen KR. Residents ability to predict childrens co-operation with
anaesthesia induction. Anesthesiology 1985;663:502.
4 Bergendahl HT et al. Clonidine vs. midazolam as premedication in children undergoing
adenotonsillectomy: a prospective, randomised, controlled trial. Acta Anaesth Scand,
2004;448:12921300.
5 Hopkins CS, Buckley CJ, Bush GH. Pain-free injection in infants: Use of a lignocaine-prilocaine cream
to prevent pain at intravenous induction of general anaesthesia in 15 year-old children. Anaesthesia
1988;443:198201.

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9 Paediatric services

9.6

Parent satisfaction with

arrangements for being present
with their child at induction
Dr J Payne
Why do this
audit?

Parental presence at induction is routinely practised in most UK hospitals, in line with

Department of Health recommendations that hospitals should agree service specifications
which enable parents to comfort children during induction of anaesthesia.1 Action for Sick
Children stresses the importance of encouraging parents to be present (at the discretion of the
anaesthetist) and of providing facilities to enable them to be present. It also points out the
need for preparation of parents (including an explanation of their role, when they should leave
etc) and for support of parents in the anaesthetic room.2

Best practice:
Most recent studies suggest benefits to the child in terms of anxiety reduction, as well as to the
research evidence parent3,4 with the majority of parents believing that they were of some help to the child and
anaesthetist and rating it as a positive experience.4,5
or authoritative
opinion
% of parents either satisfied or very satisfied with arrangements for being present with their
child at induction.

Suggested
indicators

Proposed
standard or target
for best practice
Suggested data to
be collected

100% of parents invited to be present with their child at induction should be satisfied with the
arrangements made to do so.

Assessment of satisfaction level using postoperative questionnaire. You may wish to explore this
in detail, e.g. satisfaction with preoperative explanation, with waiting arrangements, with actual
events in the anaesthetic room, with the support they received afterwards etc.
Reasons for dissatisfaction.

Common reasons
for failure to
reach standards

188

Parents
Parents
Parents
Parents

feeling unprepared, e.g. unsure of role.

who did not want to attend at induction feeling pressurised to do so.
feeling unsupported in the anaesthetic room.
not being on the ward when the child was collected for theatre, owing to list changes.

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

References

9.6

1 Department of Health. Welfare of children and young people in hospital. HMSO, London 1991.
2 Setting standards for children undergoing surgery. Action for Sick Children, London 1994.
3 Kam PC et al. Behaviour of children associated with parental participation during induction of general
anaesthesia. J Paediatr Child H 1998;334(1):2931.
4 Messeri A, Caprilli S, Busoni P. Anaesthesia induction in children: a psychological evaluation of the
efficiency of parents presence. Paediatr Anaesth 2004;114(7):551556.
5 Odegard KC, Modest SA, Laussen PC. A survey of parental satisfaction during parent present
induction of anaesthesia for children undergoing cardiovascular surgery. Paediatr Anaesth
2002;112(3):261266.

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9.7

Use of local and regional blocks

in children
Professor A R Wolf, Dr P A Stoddart
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Children often receive inadequate pain relief.1 Pain can occur immediately after surgery, before
discharge, or at home. A large variety of local blocks can be used but must be applied
appropriately and audited to ensure that the chosen block has been part of an effective
analgesia treatment plan. In addition, blocks may fail or there may be major or minor
complications. This has been highlighted in two recent surveys.2,3
Previous studies have compared opioid analgesia with local techniques, in terms of duration and
quality of analgesia, sedation, stress responses, side effects, and safety.4,5 The key features to
emerge from these studies are firstly that appropriate peripheral blocks may be preferable to
central blockade where possible,2 secondly that blocks must match the specific operations,5 and
thirdly that co-analgesia may be desirable to increase analgesia and reduce individual side effects.
%
%
%
%
%

Suggested
indicators

Proposed
standard or target
for best practice

Suggested data to
be collected

children
children
children
children
children

with acceptable pain scores both in hospital and at home.

requiring rescue analgesia.
who have side effects, both immediate and delayed.
who appear to have a failed block or a complication.
in whom side effects or pain delay discharge (in day cases).

100% children should have acceptable pain scores at all times.

The need for rescue analgesia will depend on whether a working block is expected to relieve all
pain.
A target for side effects will depend on the block.
< 1% children should have a failed block.2
A target for complications will depend on which block is audited.
< 1% patients should have delayed discharge due to pain or due to side effects of the block.
One type of block should be chosen for the audit (e.g. penile block).
Record type of block, operation, age of child, anaesthetist.

The block must be formally assessed postoperatively looking for failed blocks and complications.

A validated pain assessment tool appropriate to the age group and cognition of the child should
then be used in hospital and at home for at least 24 h.6

Side effects and the need for rescue analgesia should be noted.

Collected data should be reviewed by staff at regular intervals to highlight both positive and negative
aspects of a particular procedure, and to compare these with experience from other centres.

190

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

Common reasons
for failure to
reach standards

References

9.7

Anaesthetist unskilled at performing block.

Natural failure rate of the block.
Inadequate support staff (mainly nurses experienced in pain management) to assess block and
see the need for rescue analgesia promptly.
1 Kotiniemi LH et al. Postoperative symptoms at home following day-case surgery in children: a
multicentre survey of 551 children. Anaesthesia 1997;552:963969.
2 Gaufre E, Dalens B, Gombert A. Epidemiology and morbidity of regional anaesthesia in children.
Anesth Analg 1996;883:904912.
3 Flandin-Blety C, Barrier G. Accidents following extradural analgesia in children. The results of a
retrospective study. Paediatr Anaesth 1995;55:4146.
4 Wolf AR, Hughes D. Pain relief for infants undergoing abdominal surgery: comparison of infusions of
IV morphine and extradural bupivacaine. Br J Anaesth 1993;770:1016.
5 Cook B et al. Comparison of the effects of adrenaline, clonidine, and ketamine on the duration of
caudal analgesia produced by bupivacaine in children. Br J Anaesth 1995;775:698701.
6 Voepel-Lewis T et al. The reliability and validity of the face, legs, activity, cry, consolability observational
tool as a measure of pain in children with cognitive impairment. Anesth Analg 2002;995:12241229.

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9 Paediatric services

9.8

Temperature control
Dr C Kirton
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Hypothermia is in most cases deleterious,2 being associated with increased oxygen

consumption3 and shivering,4 with a decrease in platelet function5 and consequent blood loss,6
with the risk of surgical wound infection7 and with impairment of drug metabolism.4
Maintenance of normothermia is possible using a variety of warming devices. The forced air
blower is particularly effective.4 The large surface area-mass ratio of infants allows rapid cooling
and rewarming, and therefore monitoring is important.
% children who arrive in the recovery area with tympanic (or axillary) temperature in the range
3637C.6,7

Suggested
indicators

Proposed
standard or target
for best practice
Suggested data to
be collected

Common reasons
for failure to
reach standards

Related audits

192

Thermoregulation is known to be disrupted in the perioperative period, with the paediatric

population particularly at risk. The Association of Anaesthetists advises that body temperature
monitoring must be available in paediatrics, and used when appropriate.1 This audit will establish
whether warming techniques are being used effectively in children and whether appropriate
intraoperative monitoring is being used.

100% children should meet the above criteria.

Patient age and weight, operation, duration of anaesthesia, temperature monitoring used
intraoperatively, warming methods used, tympanic or axillary temperature on arrival in recovery.
Non-availability of warming equipment or monitoring devices.
Failure to use equipment, perhaps due to lack of awareness of the importance of temperature
control.
Unexpected lengthy duration of surgery.
Over zealous warming without monitoring.
2.7 Temperature management

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

References

9.8

1 Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring
during anaesthesia and recovery. AAGBI, London 2000 (see: www.aagbi.org/pdf/Absolute.pdf).
2 Leslie K, Sessler DI. Perioperative hypothermia in the high-risk surgical patient (Review). Best practice
and research. Clin Anaesthesiol 2003;117(4):485498.
3 Adamsons K Jr, Gandy GM, James LS. The influence of thermal factors upon oxygen consumption of
the new born infant. J Pediatr 1965;666:495508.
4 Sessler DI. Perioperative thermoregulation and heat balance. Ann N Y Acad Sci 1997;8813:757777.
5 Valeric R et al. Hypothermia-induced reversible platelet dysfunction. Ann Surg 1987;2205:175181.
6 Cheney FW. Should normothermia be maintained during major surgery? J Am Med Assoc
1997;2277:11651166.
7 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgicalwound infection and shorten hospitalization. New Engl J Med 1996;3334:12091215.

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9 Paediatric services

9.9

Pain management
Dr J Goddard
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Pain is experienced by paediatric patients of all ages,1 especially in the postoperative period.
The evidence in paediatric practice that relief of postoperative pain is cost-effective or beneficial
to organ function is lacking. Nonetheless pain relief is a basic requirement, which in the hospital
environment is entrusted to healthcare professionals.2 It is essential that this responsibility is
discharged safely and effectively.
The principles of treating acute pain in hospital have been well reviewed.3 Authoritative reports
recommend that these principles are best achieved by the establishment of an Acute Pain
Service (APS).4 Data in paediatric practice support these recommendations and confirm that it
is the structure and process of an APS that most improves pain relief rather than specific
analgesic techniques.5 The routine assessment and recording of pain is pivotal. It is important
that a procedure for pain assessment and recording is developed to suit local circumstances.2
%
%
%
%

Suggested
indicators

Proposed
standard or target
for best practice

of
of
of
of

days when paediatric ward is visited by the acute pain team.

children undergoing surgery who have a complete record of pain scores.
children with unacceptable pain scores in the postoperative period.
children managed as day cases assessed to be in severe pain at home.

The local APS needs to consider what their targets should be. In particular the method and
frequency of pain scoring will be decided. One method is to record a pain score alongside
routine observations of temperature, pulse rate etc.
In-patients
On 100% days, a member of the APS should visit all paediatric surgical wards.

100% children undergoing surgery should have a complete record of pain scores.

< 5% children should have an unacceptable pain score at any time. The pain score deemed to
be unacceptable needs to be chosen, and will depend on which validated pain assessment tool
the team wishes to use.
Day cases
No child should be assessed as being in severe pain on discharge or at home.

194

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Paediatric services

Suggested data to
be collected

Common reasons
for failure to
reach standards

Related audits

References

9.9

Presence/absence of APS and its members.

Evidence of daily visit by APS member to paediatric surgical wards.
For each child undergoing surgery: completeness of pain score record.
Worst pain score each day in all postoperative children, reason and any action taken.
Pain score on discharge for day cases.
Parental assessment of pain at home.
Holiday, sickness, other duties (of acute pain team).
No dedicated acute pain team or no weekend cover.
Pain scores not considered important, staff too busy.
Failure to supply appropriate analgesics for use at home, inadequate instructions for parents on
analgesic administration.
Section 11 Acute pain services
1 Schechter NL, Berde CB,Yaster M. Pain in Iinfants, children and adolescents. Lippincott Williams and
Wilkins, Philadelphia 2003.
2 Department of Health. Getting the right start: National service framework for children. Standard for
hospital services. DH, London 2003.
3 McQuay H, Moore A, Justins D. Treating acute pain in hospital. Br Med J 1997;3314:15311535.
4 Royal College of Surgeons of England and College of Anaesthetists. Report of the Working Party on
Pain after Surgery. Commission on the provision of surgical services. RCSEng, London 1990.
5 Goddard JM, Pickup SE. Postoperative pain in children. Combining audit and a clinical nurse specialist
to improve management. Anaesthesia 1996;551:588591.

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9 Paediatric services

9.10

Perioperative fluid management

in children
Dr N Barker
Why do this
audit?

Best practice:
research evidence
or authoritative
opinion

Hyponatraemia (plasma sodium < 136 mmol/l) may result from excessive use of hypotonic
fluids, especially during the perioperative period when vasopressin levels may be elevated. This
can result in hyponatraemic encephalopathy. Administration of glucose during surgery may lead
to intraoperative hyperglycaemia which can cause an osmotic diuresis leading to dehydration
and electrolyte disturbance. The purpose of this audit is to observe the use of intravenous
fluids given to children during the perioperative period and highlight patients at risk of
hyopnatraemia and hyperglycaemia.
There are a number of concerns and case reports of morbidity associated with hyponatraemia
due to water intoxication in the perioperative period.1,2 Suggestions to help avoid this are to
administer isotonic fluids for all replacement fluid and possibly for maintenance in the
intraoperative period. Certainly hypotonic fluids should probably not be given at greater than
maintenance rates.3,4
Hyperglycaemia is best avoided as well as the osmotic diuresis issues, hyperglycaemia in
combination with hypoxic cerebral or spinal cord insult will worsen neurological outcome.
If dextrose is avoided, about one-fifth of children will show no change or a rise in blood sugar.
However, hypoglycaemia is a very serious complication and certain conditions favour
intraoperative glucose administration, e.g. neonates < 48 h of age, poor nutritional status and
long operations. When the rate and glucose concentration are taken into account, the glucose
content of the solutions providing an acceptable glucose level is approximately 300 mg/kg/h,
though this too has been shown to produce hyperglycaemia in longer operations. A glucose
infusion at a rate of 120 mg/kg/h is sufficient to maintain an acceptable blood glucose level and
prevent lipid mobilisation. Giving 5% dextrose containing solutions at maintenance rates is
more likely to cause hyperglycaemia.5
Replacement should be with normal saline, Hartmanns solution, colloid or blood where
appropriate.
Hypotonic fluids should be reserved for maintenance use.
Dextrose administration should not exceed 300 mg/kg/h.

Suggested
indicators

Proposed
standard or target
for best practice
Suggested data to
be collected

196

100% children should meet the above criteria.

Name, date of birth, weight, procedure, duration of procedure, estimated blood loss, type and
amount of fluid/blood administered intraoperatively, postoperative fluid prescription.

The Royal College of Anaesthetists n Raising the Standard: a compendium of audit recipes

Paediatric services

Common reasons
for failure to
reach standards

References

9.10

Traditional teaching and practice whereby children have been given hypotonic, dextrose
containing fluids routinely during surgery.
Not using isotonic fluids for replacement.

1 Halberthal M, Halperin ML, Bohn D. Lesson of the week: Acute hyponatraemia in children admitted
to hospital: retrospective analysis of factors contributing to its development and resolution. Br Med J
2001;3322:780782.
2 Arieff AL. Postoperative hyponatraemic encephalopathy following elective surgery in children.
Paediatr Anaesth 1998;88:14.
3 Duke T, Molyneux EM. Intravenous fluids for seriously ill children: time to reconsider. Lancet
2003;3362:13201323.
4 Cunliffe M. Fluid and electrolyte management in children. Br J Anaesth CEPD Reviews 2003;33:14.
5 Leelanukrom R, Cunliffe M. Intraoperative fluid and glucose mangagement in children. Paediatr
Anaesth 2000;110:353359.

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