Routine laboratory testing of the pediatric surgical patient is no longer recommended. Laboratory testing should be determined by the medical condition of the child and the nature of the surgery to be performed. For the pediatric neurosurgery patient, laboratory tests that may be necessary for surgical management include a complete blood count (CBC) with differential (including hemoglobin and hematocrit), a complete or basic metabolic panel (CMP/BMP), and any others specifically indicated for the patient. Depending on the facility, females over the age of 10 years may need to provide a urine sample for a UCG or blood sample for an HCG pregnancy test.

Depending on the type of neurosurgery, it may be necessary for the child to undergo blood typing in case of the need for a blood transfusion during the procedure. For the patient who has little or no need for a blood transfusion, a type and screen should be ordered and completed. In a type and screen, the blood bank will determine the patient’s blood type and screen for antibodies, but no units of blood will be crossmatched and set aside in the blood bank for that patient until requested by the advanced practice nurse or physician. If the need for blood is expected or likely, then a type and cross is necessary. With a type and cross, units of blood will be crossmatched and held for the patient in the blood bank. If a child needs a transfusion, packed red blood cells are the preferred product, as it provides the benefits of increasing the oxygen-carrying part of the blood without adding too much extra volume. The patient who undergoes a type and screen or cross will obtain a special blood identification band that should be on the patient at all times. Care must be taken to maintain the integrity of the blood band so that identification information is readable (Fig. 16.2). It is important to note that blood bands have an expiration date, with few exceptions, which varies from facility to facility but is usually 72 h or 3 days.

Imaging tests may be necessary for a pediatric neurosurgery patient before proceeding to surgery. Depending on the nature of the condition, the patient, and the preference of the surgeon, the child may undergo x-rays, a CT or MRI scan with or without contrast, or with an image-guided protocol to help guide the surgeon. It may be necessary for the child to undergo sedation in order to obtain these images. Imaging provides the neurosurgeon with vital information necessary to perform the procedure as well as a baseline in order to monitor changes in the patient’s condition over time.

Prior to surgery, it is necessary for the patient to fast in order to reduce the risk of aspiration while under anesthesia. Children have higher fluid requirements for size than adults, and prolonged preoperative fasting may cause dehydration, hypoglycemia, ketosis, and discomfort from hunger. Therefore, the standard preoperative fasting for pediatric patients as recommended by the American Society of Anesthesiologists is clear liquids up to 2 h before surgery, breast milk up to 4 h before surgery, and infant formula, milk, or regular diet up to 6 h before surgery. It is important that the perioperative nurse clearly communicate and review the preoperative dietary restrictions with the patient and family. Utilizing the teach-back method in which the parent repeats back the eating and drinking instructions can help to ensure that the information has been clearly communicated and received. A violation of these dietary restrictions could result in a delay or cancelation of surgery or, if not detected, an increased aspiration risk to the patient.

Anxiolytic medications can be used in conjunction with or as an alternative to behavioral programs to reduce preoperative anxiety in the pediatric surgical patient. In addition to decreasing anxiety, preoperative anxiolytics provide amnesia for the separation of the patient from the family, create a quiet environment during the induction of anesthesia, and can also provide analgesia. Midazolam is the most common anxiolytic used preoperatively in children, as it has a rapid onset of action, is highly effective, and has low toxicity. The preferred method of administration of midazolam is orally in the preoperative holding area. Within 10–20 min of oral administration, patients experience amnesia (typically will not remember separation from parents or induction of anesthesia), decreased anxiety, and light sedation.

Other common preoperative anxiolytics used in pediatrics include clonidine and diazepam. Like midazolam, both can be given orally. Clonidine and diazepam take about 30–45 min to begin to take effect and thus must be given earlier than midazolam in the preoperative intake process. Both clonidine and diazepam have the additional benefit of also acting as analgesics.

Children who receive a preoperative medication for anxiety should be continually monitored in the holding area in order to ensure the child’s safety. They should be held by their parents or placed on a cart. Heart rate, respiratory rate, and oxygen saturation should be monitored. It is important to note that in susceptible individuals, anxiolytic medications, particularly midazolam, can cause a paradoxical reaction with increased anxiety, aggressive or violent behavior, uncontrollable crying or verbalization, and similar effects. Thus, it is important for clinicians and parents of the child to determine if utilizing a premedication will be advantageous for the well-being of the child.

Some facilities permit a parent to accompany the child to the operating room and be present during the induction of anesthesia, while others do not. At facilities in which parental presence at induction is not the norm, children may receive a premedication anxiolytic to aid in the separation and induction process. The practice of parental presence at induction is a common method used to decrease perioperative anxiety, and this practice has significantly increased in the United States during the past decade (Burd et al. 2006). Early studies of this practice showed that parental presence at induction was less effective at reducing anxiety, when compared to premedication with oral midazolam (Kain et al. 1998b). But more recent studies have shown that, if selectively applied and proper parental preparation is done, it can be an effective alternative to premedication (Kain et al. 2002).

For parental presence during induction, it is primarily important to ensure patient safety. If the anesthesia provider suspects that the child may have airway problems during induction, or the child is too young to warrant parental presence, then no parent will be present. Studies have shown that children who benefit the most from parental presence are those older than 4 years of age who have either a calm baseline personality or a mother who has a calm baseline personality (Kain et al. 1998b). If parental presence is acceptable to the anesthesia provider and family, the parent selected must want to be present and willing to undergo preoperative preparation for the experience (Romino et al. 2005). The parent should be informed about the sequence of events, how the child will look during anesthesia induction, and how the child may react, as well as what the parent’s role will be. The parent may sit next to the child or comfort the child in the parent’s lap as inhalation anesthesia commences. Parents are encouraged to touch, sign, tell stories, and reassure their child during anesthesia induction. The parent is escorted from the induction area/operating room when the child is no longer aware of his/her surroundings. It is helpful for a nurse to act as a support for the parent during this process and to guide them as necessary.

The potential benefits of parental presence during induction include avoiding the need for premedication, avoiding the child’s resistance to separation from parents, and decreasing perioperative anxiety and postoperative behavioral problems related to perioperative anxiety (Kain et al. 2002). An additional benefit is a more positive perioperative experience for the family. Presence at induction is viewed favorably by parents as most believe that they have contributed to reducing their child’s stress and are themselves less anxious and more satisfied (Kain et al. 2000). Patients and parents who will benefit from presence at induction should be considered on a case-by-case basis, and as stated, it is key that proper parent selection and preparation occur in order to be effective.

It is incumbent on the perioperative nurse to ensure that everything that could be needed is present on the day of surgery for each scheduled patient. In the days or even weeks before the scheduled surgical procedure, any instruments, implantable devices, and other special equipment requested by the surgeon will be ordered. This could involve customization of an implant for a specific patient, which would require that the nurse send scans, radiographs, and/or measurements to the company manufacturing the implant. It may also be necessary to educate the nursing staff on the specifics of a particular item so that all will be familiar with it on the day of surgery.

The intraoperative care of the pediatric neurosurgical patient is a collaborative effort involving the nursing staff, anesthesia providers, surgeons, and other health-care professionals with the goal to achieve the best possible outcome for patients and their families. Nurses in the perioperative setting are multifaceted, and they function in various capacities. They may scrub or circulate. They may be assistants during surgery, or registered nurse first assistants (RNFA), acting in collaboration with and under the direction of the surgeon. They may also be advanced practice nurses, such as pediatric nurse practitioners (PNP) or clinical nurse specialists (CNS). Each role is vital to the team as a whole. These nurses are educators and preceptors, teaching new operating room nurses their respective roles and responsibilities and educating future health-care professionals about the scope of practice of the perioperative nurse. Perioperative nurses provide patient care within the framework of the nursing process, utilizing skill in patient assessment, care planning, intervention, and assessing patient outcomes (Spry 2005). The perioperative nurse depends on knowledge of surgical anatomy, physiologic alterations, and their consequences for the patient, intraoperative risk factors, potentials for patient injury and the means of preventing them, and psychosocial implications of surgery for the patient and significant others. This knowledge enables the perioperative nurse to anticipate needs of the patient and surgical team and rapidly initiate appropriate nursing interventions. This is part of patient advocacy, of doing for the patient what needs to be done to provide a safe and caring environment (Meeker and Rothrock 1999).

On the day of surgery, each member of the surgical team arrives at the operating room suite and dons hospital-approved, facility-laundered surgical attire. All head hair is covered by a surgical hat, and a surgical mask is required once a sterile field is created (Association of PeriOperative Registered Nurses (AORN) 2016). Each member of the team has an assigned task. There may be a scrub nurse, an RNFA, and one or two circulating nurses, depending on the acuity of the case. All members of the team participate in getting the operating room readied for the procedure.

The air-handling system is assessed to ensure that a positive air pressure environment is maintained in the operating room in which the procedure will occur. Appropriate ventilation systems are important in controlling infection by minimizing microbial contamination (Meeker and Rothrock 1999). The ambient air temperature is elevated to assist in the patient’s thermoregulation during anesthetic induction. Each flat surface and operating light in the room is wiped with germicidal cloths and allowed to air-dry. All equipment in the operating room is placed in position for the scheduled procedure and tested to ensure it is in optimal operating condition. These may include the suction apparatus, fluid warming/slush unit, smoke evacuation system, electrocautery unit, microscope, power drill, neuronavigation system, the ultrasonic aspirator, lasers and the Mayfield, and DORO or horseshoe headrest apparatus. The arrangement of the equipment in the room is determined by the procedure to be performed.

The operating table is prepared for the patient, taking into consideration the patient’s size and the procedure being performed. A warming/cooling device is placed on the operating table to assist in the maintenance of normothermia. Perioperative hypothermia is estimated to occur in 50–90 % of all cases. It can lead to increased intraoperative bleeding, postoperative tachycardia, impaired wound healing, and greater postoperative discomfort (Meeker and Rothrock 1999). An impervious drape and then the bed linens are applied to the table. Positioning of the patient for the procedure is carefully considered, and all needed positioning aids are secured. These may include gel rolls, gel pads, gel head rings, foam head rings, foam padding, bean bags, Z-flo fluidized positioners, and arm boards to aid in positioning and prevent skin breakdown during the procedure. A forced-air machine and appropriate-size warming blanket are made available for anesthesia’s use during each procedure.

If the neuronavigation system is to be utilized, the team ensures that the correct MRI scan is loaded into the system and that the needed attachments are verified by the unit and are ready for use. Surgeon-specific irrigating solutions and intraoperative medications are retrieved from the pharmacy, paying careful attention to any documented allergies or sensitivities. Anti-embolism stockings or sequential compression devices are brought to the room to be placed on the patient for prevention of venous pooling and subsequent formation of deep vein thromboses.

The patient’s most recent MRI, CT scan, US, or radiographs are displayed for review by the surgical team. If the patient has been typed and screened or crossmatched for blood products, a call is placed to the blood bank to determine how many units of blood product are available for the patient. If neurophysiologic monitoring or corticography has been requested, the technician’s availability is ascertained. The same is true for any manufacturer’s representative who might accompany a piece of new equipment or an implantable device. If intraoperative radiographs are to be taken, the radiology technician is notified of the projected start time of the surgery.

Each surgical specialty may have surgeon-specific preference cards. It is the responsibility of the scrub nurse to ensure that the appropriate instruments and supplies are gathered for each procedure. The surgical team then prepares the sterile field, using strict sterile technique. Every piece of equipment or item to be placed on the sterile field is examined for any breach in sterility. Each product expiration date is examined. Sterile drapes are utilized to create the sterile field, and every item introduced to the field is done so in a manner that maintains the item’s sterility and integrity. Once a sterile field is created, it is constantly guarded and maintained (Association of PeriOperative Registered Nurses AORN 2010). This is the responsibility of the entire surgical team, throughout the procedure. Traffic flow is kept to a minimum, with as little movement as possible, to diminish the number of airborne microbial contaminants entering the field.

Next, the entire surgical team gathers for a daily surgical briefing or “huddle.” This allows the team to discuss the plan of care for each of their scheduled patients. This will include a review of the medical record and past medical/psychosocial history, allergies and sensitivities, laboratory test results, pertinent radiographs/scans, the planned surgical procedure, special equipment or implants needed, and any anesthesia concerns, including regional anesthesia. Teamwork and effective communication are essential to safe perioperative patient care (Rothrock 2015). Meeting in a daily “huddle” also allows for any changes to the plan of care to be discussed and begins the discussion of postoperative care for each patient. The “huddle” also helps to build a more cohesive surgical team.

With the operating room ready, the scrub nurse goes to the scrub sink and performs a surgical hand scrub, using an antimicrobial surgical scrub agent with a sponge/brush and nail cleaner. The scrub should last at least 5 min and includes all surfaces of the nails, fingers, hands, and arms up to 2 in. above the elbow. During this process, the arms are held away from the body, in a flexed position, with the fingertips pointing upward (Spry 2005). In recent years, alcohol-based hand rub products have become available. Prior to use of these products, it is necessary to perform a thorough nail cleaning and hand washing with soap and water. The hands and arms are rinsed and dried, using a clean towel. The product is applied and rubbed until dry. The scrub nurse reenters the operating room and dons a sterile gown, with the assistance of the circulating nurse, and sterile gloves and begins to organize the sterile field.

The circulating nurse introduces himself or herself to the patient and family and reviews the patient’s chart. Of primary concern to the circulating nurse is the proper identification of the patient. It is best practice that the patient’s identity be confirmed by using at least two identifiers (name, date of birth, and medical record or account number) (The Joint Commission 2012). The circulating nurse will verify that the child’s wristband is in place and accurate. Some hospitals may also issue wristbands to parents, while others have different policies regarding parental identification. Whatever the institutional policy, the circulating nurse must verify the identity of the parent/legal guardian so that information about the child is obtained from and given to proper, legally authorized persons. If the use of blood products is anticipated, the nurse also checks to see that an identification blood band is present on the patient and this number is documented on the patient’s chart.

The preoperative nursing documentation is reviewed, as is the anesthesia assessment and anesthesia consent. A current history and physical should be present and signed by the surgeon. The circulating nurse assesses the developmental level of the child, checks motor function, checks the condition of the child’s skin, and is sure that all metallic objects, such as hair adornments, and jewelry have been removed. All home medications are reviewed. Results of any ordered lab tests are present and reviewed with the anesthesia provider and the surgeon as necessary. Baseline vital signs are reviewed and any preoperative medication administration is noted.

A verbal confirmation of the NPO status and any allergies or sensitivities are received from the parent/legal guardian. The parent is asked to describe the procedure that their child will be undergoing, to acknowledge their understanding of the procedure, and their signature is verified on the operative consent. The circulating nurse then explains what will happen to the child from the time the family unit is separated until they are reunited once again. The family is told that they will be notified by phone when the procedure has begun and that they will be given updates as the procedure progresses. The child’s and family’s anxiety levels are assessed, and every attempt is made to develop a comfortable relationship with this family unit in a very short amount of time. All of the family’s questions are answered as honestly as possible.

Allowing the child to bring a toy or blanket with them to the operating room gives the child a familiar item in foreign surroundings and may increase their sense of security (Association of PeriOperative Registered Nurses (AORN) 2010). The goal is always to minimize the ordeal of separating the child from the family, and, as previously discussed, some facilities even permit a parent to accompany the child into the OR. To allow the child a sense of autonomy, they may walk to the operating room, if able. If unable or premedicated, they may be carried or brought in their hospital bed, radiant warmer, wagon, wheelchair, stroller, or a stretcher, utilizing safety straps to prevent falls during transport (Fig. 16.3).