Health care strategies are targeted for curing the multitude of diseases. Some of the complications developed require surgical intervention at the earlier stage.
Prior understanding the emergency care in relation to anesthesia is very essential.
Most probably, the cases that need surgery require anesthesia before the actual process. It is well known fact that Anesthesia is given to relieve pain. The management of pain is one of the major issues surrounding the patient care in operation theatres. So here the practitioner role for obstetrics is concerned with addressing the issues related to complications in pregnancy like anesthesia, pain management and immmunocopromise.
Questionnaires conducted from the anesthesia unit have revealed that nearly 52 % patients have derived benefits from the invasive treatments provided by anesthesia practitioners. Whereas 40 % percent given the feedback that the pain management performed at home or hospices was fruitful and needs invasive pain management techniques. In addition, some barriers to access the anesthetic pain management was commuting, need of more anesthesia practitioners and relevant services in communities of small size. Simialrly, cost was also frequently identified as the intervening factor (Lukowski et al. 2001). Hence, the need for pain management is essential for emergency surgery.
One of the most important group of cases that need anesthetic care may be obstetric, pediatric cases. These patients need anesthesia depending on the complication associated with the case. For example, pregnant women while delivering the baby may be left with two choices. Either the case could be a natural delivery or the caesarian mode of delivery. The earlier case may not require anesthesia whereas the latter case involves anesthesia. The practitioner may try for non-routine anesthetic situations by recommending the strategy of alternative birth settings to pregnant women who opt for and need little or avoid, medical intervention as it has significant childbirth outcome (Hodnett et al. 2012).
Newborns especially infants of premature period do not possess fully matured immune system. So, the etiopathogenesis of pediatric patients whose immune system is compromised may have association with conditions like severe combined immunodeficiency syndrome (SCID), hypogammaglobulinemia of primary nature or sickle cell disease, cystic fibrosis of secondary nature. Hence, the peri-operative management should understand the basic immunology of the pregnancy which might get deviated from the normal function (Castro 2008).
Anxiety is common among patients and their family members on the day of surgery and may also be induced due to sudden or non scheduled surgery. So, the practitioner’s role for non scheduled and emergency surgery is to inform about the surgical preparation program to enable the children and the care providers or families to become ready for the surgical or emergency intervention. It is essential that all such programs conducted should provide a satisfactory outcome. In a study, by a specially, designed instrument, anxiety was measured among children aged between 5 and 11 who were having elective otolaryngology surgery.
This was aimed at preintervention and post intervention anxiety levels of children. Based on score measurement, children who received pre-operative preparation did not develop anxiety compared to the children group who were excluded from the preparation. This indicated that preoperative preparation is beneficial to children thus suggesting the health care professionals to manage the children’s capabilities to face the surgical procedure. Hence, pediatric surgery performers may help to overcome the anxiety levels among children. This has strengthened another study on the role of pediatric patient in surgery.
Here, children of ages between 7 and 12 were selected and classified into pre-test and post test categories in a randomized controlled trial experiment. The children were included in the elective surgery in a day surgery unit. Parents were also involved in the study. Children in the experimental group received therapeutic play intervention and those in the control group were given general information preparation.
It was revealed that in the experimental group of pre- and post-operative periods, the children and their parents were found with lower state anxiety scores. Further there were hardly any signs of negative emotional behaviors in children in the experimental group. Parents have expressed good satisfactory levels. This indicated that there is a need of support for the concept of psycho educational preparation of children when it comes to the task of pediatric surgery. The significance of parental involvement and therapeutic play intervention is a mandatory component surgical preparation of children. (Li, Lopez & Lee 2007).This information will facilitate a good knowledge and progress towards independent practice of the surgical procedure in the pediatrics. Hence, operating department procedures should implement this strategy of preparation for the effective pediatric surgery.
Next, for the pediatric surgery, awareness on Anatomy /Physiology of pediatrics patient is essential. Some these include: Children have a short neck, a prominent occiput and large head, large tongue. They have anterior and high larynx positioned at the leve of C3 – C4.Breathing by neonates occurs through nose and the problem is that the nasal passages are narrow often interrupted by internal secretions, prone to damage by inserted tubes. Children have a Cardiac output of 300-400 ml/kg/min during the period of birth which becomes 200 ml/kg/min after few months.
In the first two years of life, children have increased vascular resistance and this makes renal blood circulation and glomerular filtration low. Infants fail to excrete a sodium load in excess and therefore until eight months tubular function is immature. Children have immature liver function in the beginning stages with low output of hepatic enzymes. As such, opioids and Barbiturates, have a prolonged action potential as a result of low metabolism. Children possess hemoglobin molecules of 70-90 % HbF. In three months duration, these HbF levels fal to nearly 5% and HbA dominates. Hemoglobin level in new borns is nearly 18-20 g/dl that reflects a 0.6 haematocrit. These levels fall in 3-6 months to 9-12 g/dl as the rise in circulating volume is huge than the function of bone marrow (Paediatric anatomy 2012).
Neonates have poor blood brain barrier. Drugs like bilirubin, antibiotics, opioids, barbiturates cross the barrier leading to their action of long duration. As far as physiology is concerned, infants below 6 months of age are not prone to emotional disturbances when isolated from parents care and willing to get acquainted easily with a stranger. Whereas, children of 4 years easily get disturbed when they are isolated from their parents and when they face the situation of staying in unknown atmosphere. As such, rationalizing is complex task with children of this age and likewise the behavior too could not be predicted (Paediatric anatomy 2012).
Children of school age are more prone to upset when they confront with a situation of surgery due to the fear of pain. Children of adolescent group feel the phobia of pain and narcosis, no self control and failure in coping mechanisms to withstand illness effects.
And on hospitalization, these complaints become aggravated (Paediatric anatomy 2012). Therefore, the ODP should consider the anatomy and physiology of the pediatric patients. Yet, the more related one to pediatric surgery, the obstetric surgery do has many complications with reference to ODP. Obstetric patients undergoing surgery may be prone to surgical site infections. Overcoming the problem is very essential to provide remedy at the earliest stage.
In this context, a study was carried out with the objective of evaluating the surgical site infection in women who had infection in the initial 30 days after surgery. The severity of infection was similar in abdominal hysterectomy and cesarean section and even comparatively more for destructive delivery. The emergency obstetric conditions in majority had increased risk for Surgical Site Infections at double the rate of that observed in elective surgery. The contributing factors to the severity of infections are Perioperative blood transfusion, Perioperative blood transfusion, presence of meconium, and Chorioamnionitis.The infection severity was also connected with the failure to make a follow up of antenatal care.
Hence, for enhancing the Antenatal care, surgical site infections are important to consider as their interference is more than the accepted standards. Apart from this, other factors to consider are local clinic recruiting process with high number of experienced birth attending individuals, enhancing emergency obstetric care services, utilizing enhanced surgical techniques and ameliorating the infection reduction strategies to lessen the infection rates to the normal standards at an acceptable range (Amenu, Belachew & Araya 2011).From the above information on pediatric and obstetric surgery, ODP seems to be a complicated task in this area. Applying the Gibbs mode of reflection, the description is on pediatric surgery is focusing on immuncomprise, anxiety and emotion and preparation prior to operation.
It was thought prior to the literature analysis that pediatric surgery does not involve any complications that might interfere with the coping levels of children and their families. But it was felt that, these components need a serious clinical attention. The good about the experience understood the role of the intervening factors and implementing the proper care and improving the success of the ODP. The bad about the experience was unawareness up to some extent which may leave the pediatric surgery unit to deliver non standardized and unacceptable surgical care. From the situation, it can be analyzed that pediatric surgery needs rapid understanding of children’s and their families psychological feelings with regard to the
Surgey.This is because most people have poor knowledge on the surgery process which may put them in a state of unnecessary emotional disturbances.
So, to better manage this issue is to think and develop a patient friendly brochure that minimizes the fear of surgery among patients and makes them psychologically fit for the mission. Similarly, the other things which could be done is to improve the number of skilled attendees; revise the existing equipment or purchase new items that have good quality over the conventional ones (Neumuth et al.2009). The practitioner’s role is to effectively manage the instrument system by reviewing the analytical procedure.
If the condition of anxiety and fear arises again, then the strategy is to enhance the communication skills among the multidisciplinary team involved in the perioperative procedures, to develop awareness to the patients about the surgery (Saunders, 2004). This aspect is in agreement with the Health Professions Council (HPC) Standards of Proficiency which emphasizes the need of promoting effective communication throughout the care of the service and offer reliable care (Standards of proficiency 2008).Similarly, the description relevant to surgery is a condition of immunocompromise in pregnant women, surgical site infections. It was thought prior to the literature analysis that pregnant women have potential immune system to fight against infections (Tincknell et al. 2007). With this, patient care in busy hospitals could not be put at risk (Tincknell et al. 2007).
Pediatric anesthesia often involves the risk of condition known as compromised airway. So, awareness on pediatric anesthetic breathing system is important during the surgery. These systems constitute the network of components which link the anesthetic machine to the patient’s airway. It involves Mapleson E system where fresh gas supply is very ear to the face mask with corrugated tube open in length and without expiratory valve or reservoir bag or expiratory valve. Mapleson F system also known as Ayre’s T-piece where fresh gas supply is also close to face mask but with the presence of corrugated tube and expiratory port containing reservoir bag and no expiratory valve (Shankar & Kodali, n.d.). Therefore, knowledge in this area could prevent potentially hazardous anesthetic situations.
Further, in order to prepare a safer environment, awareness of normal and abnormal head and neck anatomy and its impact on the maintenance of airway potential is highly needed (Waage, Baker & Sedano,2009). During surgeries, patient-controlled analgesia (PCA) has emerged as an indispensible tool to manage pain in emergency departments (ED). It provides better analgesic potential and satisfaction of patient. Several studies have provided valuable insights on the efficacy of PCA administration in ED in the management of conditions like acute traumatic pain, sickle cell disease, hip fractures etc (Motov Sergey 2011). To say, PCA currently exists in several modalities for providing treatment of acute postoperative pain, like oral PCA, epidural (PCEA),
and intravenous (IV) PCA. PCEA and IV PCA are routinely referred options, but IV PCA is considered as the more standard and reliable choice for postoperative pain management. But there are certain limitations in the use of PCA. So, noninvasive PCA systems have been developed like patient-controlled intranasal analgesia (PCINA) delivery systems, (IONSYS Ortho-McNeil Pharmaceutical, Raritan, NJ), and fentanyl hydrochloride patient-controlled transdermal system (PCTS) (Miaskowski 2005).
Further, operating procedures involve the application of pain rating scales. These include Numerical Rating Scale, Verbal Rating Scale and Visual Analogue Scale. It was described that the all the pain-rating scales very much efficient for the clinical practice. Numerical Rating Scale and Verbal Rating Scale are more preferred than Visual Analogue Scale due to its practical constraints. For a better sensitivity and statistical analysis of audit applications, numerical Rating Scale is the best choice. Especially, patient in need of sensitive pain-rating scale would prefer numerical rating scale. However, verbal rating scale is chosen for simple tasks but it does not possess sensitivity and data generated from it is misinterpreted (Williamson & Hoggart 2005).
Thus, obstetric patients should be monitored at the earliest stage to assess complications like antepartum estimation of fetal heart rate baselines in twins (Bernardes et al.2000), cardiotocography plus, ST-analysis of the fetal electrocardiogram (STAN) (Olofsson, 2003). Mechanical ventilation is essential for the units housing the pediatric patients with reference to pressure limitation and decreased tidal volumes. This application is needed more in intensive care units, and future emphasis is expected to develop greatly on surfactants, airway pressure release ventilation and high frequency oscillatory ventilation (Turner & Arnold, 2007).
Knowledge of medication is important as the dosage errors are contributing to 17.8% of hospitalized children. This is due to the use of medication in dosage more than the normal level (Hoyle et al. 2012). The intervention of certain strategies like color-coded drug dosing chart would reduce the dosage errors, say, epinephrine dosing errors in the prehospital treatment of children (Kaji et al. 2006).Development of anesthesia for trauma, non scheduled surgery and emergency is mandatory for the hospital professionals.
This is better accomplished by knowing the available anesthetic drugs in the departments under properly stored conditions. Awareness on the indications and contraindications of anesthetic drugs is very crucial to execute better patient care in the surgical or emergency units. For example, emergency anesthetic drug, Suxamethonium Chloride, is applied as adjuvant to relax abdominal wall smooth muscles and contraindicated in patients who have sever burns, muscular rigidity, neurological defects etc (Suxamethonium Chloride 2004). A strict proforma on the validity and utility of anesthetic drug dosage should be developed by the hospital authorities.
The knowledge accumulated in the research literature should be implemented on an evidence based practice approach. Multimodal evidence-based work combined with fast track method lessens morbidity (Kehlet & Wilmore, 2008). Computer based protocols have provided evidence-based care of sepsis (McKinley, 2011).Sepsis is one of the major contributor of pregnancy deaths and is responsible for perinatal mortality (Guinn, Abel & Tomlinson, 2007).So, evidence-based sepsis program was instituted in intensive care units to help in informed decision-making (Vandijck, Blot & Vogelaers,2009).This is with regard to the handling of pregnancy and pediatric patients admitted in the emergency departments.
The role of preoperative practitioner is vital in offering the service to the patient effectively. Practitioners should emphasize on collaborative service-led educational programmes to implement better practice (Livesley, Waters & Tarbuck,2009).
More probably, the emergency room guidelines need to be strictly followed to avoid all kinds of misunderstandings. Emergency departments should understand the needs of pediatric and obstetric patients who often become emotionally disturbed or upset due to surgery fear. Therefore, pediatric and obstetric surgeries are significant health concerns for the modern practitioner today. Mostly, the interference of associated complications like anxiety, emotional disturbances has left the health care professionals in deep crisis situations to mange the cases. So, the practitioner’s role is better reflected in reviewing the guidelines developed by various government institutes and supporting protocols from the accumulated research evidence have brought forward many modalities to the existing practice (Neumuth et al.2009). This approach may better reflect the role of preoperative practitioner in understanding the needs of obstetric surgical patients and assist them.
Gibbs model of reflective cycle has played vital role for the existing information. Basic knowledge of anatomy and physiology are vital for the practitioners. It was felt that unawareness in this area may contribute to the unnecessary risks. For example, poor knowledge on the airway passages of neonates may lead to improper surgical intervention at the relevant site. Failure to provide necessary sterilization of surgical equipments may lead to surgical site infections. Obstetric monitoring has vital role to influence the fetal outcome.
Here, consents should be obtained from the patients while taking admission in the emergency departments to develop awareness on the risks associated with the interventions. Parameters like cardiotocography, ST analysis of the fetal ECG have tremendously influenced the base line monitoring of fetus. Consents also should be obtained from the patients while getting admitted in the emergency departments, to develop awareness on the risks associated with relevant intervention.
It is essential that the peri-operative practitioner understand the benefits of information updates and implement them in evidence based practice manner in the future endeavors.
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