The pediatric patient requires special attention and care in the PACU (Post Anesthesia Care Unit). The nurse must be ever vigilant for potential complications that can occur in the pediatric population. There are major differences between pediatric postoperative patients and adult postoperative patients. We will deal with some of these differences in the text that follows. Children and infants have more airway difficulties than adults including obstruction, stridor, laryngospasm, and hypoventilation.
Careful monitoring:
As with all post anesthesia patients careful monitoring of p02, blood pressure, EKG and pulse, respirations, and temperature is especially crucial in the pediatric patient. Immediate interventions must be instituted with our pediatric patients.
Respiratory complications:
Common problems in the pediatric patients include airway obstruction, croup, and aspiration. An airway of children under the age of five differs dramatically from the adult airway. Infants and neonates have proportionately large heads, short necks, and large tongues that can easily exacerbate airway obstruction. Laryngeal spasm in the newborn, and infant is especially frightening to new nurses in the PACU. Treated promptly and effectively however, laryngospasm does not have to be life ending.
Intubation of the pediatric patient:
Intubation prior to the institution of general anesthesia is more difficult for anesthesia personnel to perform than in the adult. The larynx is more cephalad in the infant and the shape and angle of the epiglottis is different as well. Since children have large heads and short necks, hyperextension of the neck can by itself cause airway obstruction. Adults respond to hypoxia and hypercarbnia with stimulation of the respiratory drive whereas neonates respond with respiration depression. Infants respond with an increased respiratory effort depleting glycogen stores when hypoxic.
Infants small airway
Since the infant's airway is so small and has more areolar tissue around the glottis, 1mm increase in edema can reduce the airway lumen by 75% producing life-threatening airway obstruction. Symptoms of increasing laryngeal edema will include:
Croupy cough
Hoarseness
Stridor
Increased restlessness
Tachypnea
Accessory muscle utilization with paradoxical movement of the chest and abdomen
Other Physiological differences:
Other physiological differences in the pediatric patient vs. adult patient should be noted as well. The thoracic cage of the infant is small, with the ribs positioned at a more horizontal slant than the downward slope of the adult. The adult uses a "bucket handle" type of respiratory motion to expand the chest cavity, while the infant relies on diaphragmatic-abdominal breathing. There is a significant difference between the respiratory rates of the adult and those of the infant and child. The respiratory rate is higher for the infant and child due to greater oxygen demand and increased metabolic rate. The average respiratory rate for the infant is 40 breaths per minute. The preschooler averages 30 breaths per minute, while the school-aged child averages 20 breaths per minute. Since the infant has a metabolic rate twice as high as the adult, his or her ventilatory requirement per unit lung volume is greatly increased. The infant also has less reserve in lung surface area; the small airways are the primary cause of airway resistance in the pediatric patient under 5 whereas, in the adult, the larger airways are the more significant factory in airway obstruction. Lung compliance is higher in infants and children than adults, tending to cause premature closure of small airways.
