The Postoperative Period

Although advances in paediatric surgery and anaesthesia have virtually eliminated unexpected perioperative mortality, considerable morbidity remains. Pain and vomiting are common postoperative problems that are physically and psychologically harmful to the child. Pain can be reduced or eliminated by a planned approach to the conduct of anaesthesia and the management of the postoperative period. A continuous infusion of morphine or other opiate analgesics is safe even in small infants, minimizing the risk of respiratory depression and vomiting. Similarly, the use of long-acting local anaesthetic agents for neural blockade can guarantee profound analgesia for prolonged periods. The local and regional techniques employed in adults can be safely applied to co-operative children either intraoperatively or postoperatively. The incidence of vomiting after anaesthesia remains unacceptably high in most institutions. It can be reduced by avoidance of opiates for premedication and the use of continuous low-dose infusions of opiates and neural blockade for postoperative analgesia.

Infants and children, like adults, undergo a metabolic response to surgery including catabolic and anabolic phases. Although less profound, increased metabolism, fluid retention and wasting still occur. The infant in the first two years of life has a markedly reduced respiratory reserve. Immaturity, structural defects of the respiratory and other systems, and postoperative pain and abdominal distension may precipitate respiratory failure. The infant is also prone to airways obstruction, largely as a result of the small calibre of the airways in absolute terms. Facilities for paediatrically orientated intensive care must be available for hospitals contemplating neonatal and infant surgery. On most occasions, the need for postoperative cardiorespiratory support and intensive observation can be anticipated, although rarely it may be required as a result of unexpected complications.