The Pantera webstore Secrets of surgery and anesthesia. Learn what they do with you or your kids when you have surgery and never told about explisitly Mail: aquila_grande@yahoo.no

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About preparation of patients for surgery, surgical techiques and care after surgery

This is an account of everything that happens during and around a surgical intervention and sometimes also when complicated examinations are performed.

When a child, a teenager or an adult have surgery, the patient himself and the staff make several preparations in a specific sequence to make the surgery practically possible and safe. The patient will also be prepared for anesthesia and anesthesia is started. During the surgery the bodily functions of the patient is supported and monitored by the means already prepared before the surgery as such. After the surgery the anesthesia and the supporting measures are disconnected in a specific sequence.

All these measures are essentially the same for children and adults, but the psychological preparations will differ for different age groups and the supporting measures will sometimes be more numerous for children.


Preparations for surgery done at home

There will always be some initial preparations, of which some often will take place in home before going to hospital.

For surgeries in the stomach area the digestive often system has to be totally empty and clean. This is achieved by instructing the patient to stop eating and only keep on drinking up many hours before surgery, sometimes as much as two days. The patient will also be instructed to take in some laxative solution that will loosen all stomach content and stimulate the intestines to expel the content effectively during toilet visits.

When a total cleanse is not necessary, the patient will be instructed to stop eating the day before surgery. All patients will be instructed to stop drinking typically 4 hours before surgery.

A patient should be totally clean all over the body before surgery. In the older days patients typically got a bath at the hospital. Nowadays with a more stressed hospital logistics the patient is usually instructed to take a bath at home and dress in clean clothes.


Initial preparation and office work just after the arrival at the hospital

When the patient arrives in hospital a nurse will receive him and he will be instructed to shift to some kind of hospital dressing, which will typically be a gown and underpants, or a sort of pajama.

Then the nurse will take measures of vitals like temperature, blood pressure and pulse rate and weight the patient.

If the intestines have to be totally clean, the patient will often get an enema. This can be given as one or more fillings of the colon through the rectal opening with expelation at the toilet, or it can be given by repeated flushes through a tube with the patient in laying position.

In many cases the area to be operated on is shaved. Often also the genital or rectal area is shaved even though the surgery is not done at that area. It is typically used with a razor and some kind of deinfectant sope. A wash of the area to be operated on and a great area around is usually also done. Often they also wash the anogenital area. The policy of shaving differs however much from place to place. At some places thay prefere not to shave areas where there is not any significant hair growth.

Then the patient also his family members will have a talk with the anesthetist that explains particularities of the coming procedure and performs a further examination to ensure that the patient is fit for surgery, like listening to the heart and lungs, palpating the stomach area, examining the throat and nose and asking about actual symptoms. The anesthetist may also ask the patient if he has certain wishes about the anesthesia and pain control.

Technically most surgeries, except surgeries in the breast and a few others can be performed with the patient awake and only with regional or local anesthesia. Many hospitals have however a policy of using general anesthesia for most surgeries on adults and all surgeries on children. Some may have a general policy of local anesthesia for certain surgeries to keep down cost. Some will ask the patient which type of anesthesia he prefers and some will switch to another kind of anesthesia than that of the policy if the patient demands it.

In most societies the patient himself or his parents must allow the anesthesia and surgery to take place before it happens. In many jurisdictions a child also has the right to oject after a certain age. If the objection is ignored, the staff breaks the law. There are often some explicit exceptions to that principle. One exception is emergency surgery where the patient is not able to express his consent or denial in a credible way. Another exception made in certain jurisdictions regards patients that are deemed not to be able to understand the consequences of a denial because of mental disease or impairments.

If the parents of a child or a child objects to a procedure, the staff will in some societies take the case to the child protective agency or to court to let the procedure be performed mandatorily if the staff thinks the surgery is important enough. If the case also is an emergency or hasted case, the staff will might do the procedure right away and seek the consent thereafter. Such cases are however difficult for all parts, because the staff runs the risk og being sued or prosecuted if a second opinion deems the surgery or the method used as not in the best interest of the child. If the surgery also get wrong after an objection, the staff is alost certain to get their career ruined.

In some societies consent is assumed implicitly if the patient or parents do not actively make objections. In many societies, however, the patient or parents must sign a consent formula that also describe accurately what shall be done.


The patient gets premedication to calm down

When the anesthetist have signaled green light for the surgery to take place, the nurse will give the patient a premedication, typically consisting of a type of benzodiazepines like midazolam or versed, that calms down worry, relaxes muscles and make the patient drowsy. The premedication is usually admistered as a fluid to drink. Children ill sometimes get it as drops in the nose or as an injection through the rectal opening.

The purpose of this medication is to make tha patient calm and drowsy, to take away worries, to alleviate pain and hinder the patient from memoring the preparations that follow. The repression of memory is seen as the most important aspects by many medical professionals, but this repression will never be totally effective. The patient, and especially children, will often get funny feelings by this premedication and will often say and do strange and funny things before he is so drowsy that he calms totally down.

The most common drug for this purpose is midalzolam, also called versed, which belongs to the diazepine group to which also the commonly used tranquilizing drug diazepam belongs.

Then the patient is wheeled into a preparatory room where the induction of anesthesia takes place, or right into the operation room.

They make the patient ready for the full anesthesia

Before anesthesia is initiated, the patient will get a sensor at a finger tip or at a toe connected to a device that will monitor the pulse rate and oxygen saturation in the blood. he will also get a syringe or a tube into a blood vessel, typically a vein in the arm. A couple of electrodes with wires are also placed at the chest or the shoulder by the anesthetist to monitor his heart activity.

Before proceeding the anesthetist will now check all the vitals of the patient to ensure that all parts of the body work in a way that allows the surgery to take place or to detect abnormalities that require special measures during surgery.

Right before the definite anesthesia the anesthetist may gives the patient a new dose of calming medication, often propofol, through the IV line. This dose gives further relaxation, depresses memory, alleviates pain and often makes the patient totally unconscious.

The effect of this drug starts very rapidly but the drug looses effect after a short time so that it will not longer be in effect when the patient wakes up of general anesthesia. The drug does not alleviate pain very much, so it may be combined with a barbiturate like fentanyl if reduction of pain is important at this stage.


How general anesthesia is induced and administered

The anesthetist will start the induction of anesthesia by giving gas blended with oxygen through a mask. It can as an alternative be initiated with medication through the intravenous syringe or through drippings into the rectum.

Once than patient is dormant, we will always get gas blended with a high concentration of oxygen for some while to ensure a high oxygen saturation in the blood. Then the anesthetist or a helper will give a dose of medication through the IV that paralyzes all muscles in the body, including the respiration, except the heart.

Then the anesthetist will open up the mouth of the patient and insert a laryngeal tube through his mouth and past the vocal cords. There is a cuff around the end of the laryngeal tube that is inflated to keep it in place. The anesthetist will aid the insertion with a laryngoscope, an instrument with a probe that is inserted down the throut that enables him to look down into the airways and guides the laryngeal tube during insertion.

Then the patient will be given artificial ventilation through the laryngeal tube that provides oxygen and anesthetic gas continually during the whole surgery process.


The preparation for surgery is compleated

Then all clothes are take off the patient so that he will be totally naked. More IV lines will now often be inserted into a vessel in the other arm, at his groin or at his thighs. A special IV line can also be screwed into the marrow in a bone at special occations.He will typically also get more electrodes to monitor the heart activity, for example at the thighs.

Often a tube called a Foley catheter is inserted through the urethral opening all the way into the bladder that then will drain the urine during surgery. At special occasions a thin tube is inserted through the wall of the lower abdomen into the bladder instead, a so called supra-pubic catheter.

The patient ill often get a probe inserted to monitor the core body temperature during surgery. The probe can go into through the anus, or be laced don his esophagus. Sometimes a Foley catheter with equipment for measurement of temperature is used instead.

Some surgeries require flushing or drainage of the intestines during and after surgery. Then a tube will be inserted through the anus and up into his colon for that purpose.

Often also a tube is is inserted through the nose and down trough the esophagus into the stomach that will stay in place during and often after surgery. The tube is used to keep the stomach empty for secrets or for instillation of nutrients if the patient will not be able to eat for some time after surgery.

A big electrode will be placed onto the body of the patient, most often under the buttocks. This is necessary because the surgeon typically will use some kind of electric cutting tool, often called a harmonic knife, of which the cutting point will serve as the other electrode.

Then the surgery site and a wide area around is painted with a solution of the yellow antiseptic agent betadine.

The nurses then lays the patient in the position necessary for surgery, which can be at back with straight kegs, at the side, at the stomach or at back with legs parted and flexed up, and many variations of these positions. The arms are often tied up above the shoulders of the patient or are held straight out from the bode at special supports.

Then all of the patient except the surgical site and the head is draped in blankets.


Local, regional, epidural and spinal anesthesia

For some surgeries anesthesia comprising body parts are used instead of general anesthesia or in addition to general anesthesia to ease pain after surgery. When used as the only anesthesia, it will typically be admistered early before many of the other preparations. When used as an additional aid, it will typically be admistered late.

One type of anesthesia used is so-called epidural anesthesia. By this technique the numbing medication is injected into the room where the spinal cord passes inside the vertebra, but over the dura mater and archnoidea, two tissue sheets that surround the spinal cord. Sometimes a thin catheter is also inserted through the needle. This will remain when the needle has been pulled out and anesthesia is then admistered continually through that catheter afterwards.

A similar techique is spinal anesthesia. Here the medication is injected into the room between the arachnoidea and pia mater. The pia mater is the immediate dressing of the spinal cord. This anesthesia cannot be placed too high up on the back, because it can then hinder breathing and there is then also greater danger for injury to the spinal cord.

By regional anesthesia one inserts a needle near to a nerve that furnishes a greater body part so that this body part is numbed and lamed. Also now the needle can be used to insert a catheter for continuous admistering of anesthesia. By local anesthesia the anesthetic is injected near to nerves that only serve a small area.

Also when regional or local anesthesia is used as the main mode, the patient will typically get some calming medication through an IV catheter in addition.


Extracorporeal circulation and oxygenation - Cardiopulmonary bypass

During many heart surgeries and in some other instances of complex surgeries in the chest area, the heart and lungs must be deactivated and the movement of blood and furnishment of oxygen to the body must be maintained with mechanisms outside the body, usually by a device calles heart-lung-machine. The machine is connected usually after they have opened the chest. One inserts a tube into the right atrium of the heart or into the vena cava and the forum veins which are great veins leading blood to the heart and this tube will lead the blood to the machine. One also inserts a tube into the ascending aorta, which is a great vessel leading blood from the heart. The tube will conduct the blood from the machine back to the body. It is also possible to insert the tubes in a femoral vein and a femoral artery high up near the groin, which are the vessels serving the legs, which make it possible to connect the machine also before the chest has been opened.

Just before the insertion, the ventilation of the patient is stopped. The blood vessels going into the heart are clamped. Then the heart will also stop. Then the tubes are quickly inserted. If If the tube has been inserted into the right atrium of the heart, the clamps at the vains leading to the heart are opend again. Then they start the machine.

The machine circulates the blood and furnishes oxygen to the blood. It can also cool the blood and thereby the whole body. In a cooled state the body and especially the brain needs less oxygen, so that the risk of getting brain damage due to lack of oxygen is less. In the cooled state, one can also stop all circulation to the body up to 45 minutes, which sometimes are done during complex surgeries. The machine can also warm the blood up again.

When the machine is working anesthesia is supplied into the blood stream. From the heart-lung machine.



The position of the patient during surgery

the position of the patient will often vary with the face of preparations and the surgical work. The position shall make it easy to do the work, but it shall also ensure that the patient does not get injured from pressure, over-stretching or over-twisting and that the bood flow is not hindered. Sometimes however the position is chosen to diminish bloo flow in an area.

Since children have more flexible joints than adults, one often take the opportunity to flex the limbs and torso of a child more than that of an udult to ease the work. The patient is often restraint at severeal points with straps to secure the position and one often used paddings to hinder injury from pressure.

Supine position - Here patient lies on his back with the legs more or less steright. A variant of this is the Trendenburg position where the operating table is swung so that the upper body of the patient is lowered and the lower bodyrised. Another variant is the reverse Trendenburg position where the upper body is held higher than the lower body.

Frracture Table Position - This position is used for fractures at the hip and lower limbs. The patient lies on the back. There are typically straps at the torso and firm paddings between the legs. The ancles are also strapped. The unaffected leg is usually held rised. The affected leg is stretch out in a position that make all broken part lie in a correect alignment

Litothomy position - The patient lies at the back. The legs are flexed up at the hip joints, spread apart and the knees flexed so that the genital and anal area ges exposed. the legs are usually held in stirrups.

- If the legs of the patient is only moderately flexed, one usuallly call it Lloyd-Davies position

- If the legs are flexed up near to the chest, is sometimes called frog position. Such variants are most often used on children.

Fowler's position - The lower body is like in the supine position, while the upper body is rised at an angle as much as 90 degrees. A similar posision with the upper body bent less than 85 degrees is called semi-Fowler posision. During these posision the head of the patient is strapped. .

Prone position - Here the Patient lies with the stomach and breast side down .

Jackknife position - Here the patient lies with the stomach and breast side down, while the surgery table is bent so that the patient's hip are high and the legs and head low.

Knee-chest position - Here the patient lies with the stomach and breast side down, while the hip joints and knees of the patient are flexed knee at a 90 degree angle.

Lateral position or Side-lying position - The patient lies at the side with the hip joints and knees more or less flexed to give stability and expose the hip region.

- A variant is the lateral chest position where the the hip joints and legs are flexed so that the knees come near to the chest.

- Another variant is the kidney position where the torso of the patient is sidewise bent up, usually with the help of some padding, to get the kidney area is exposed.

- Still another variant is the Sim's position where the patient is on the side, usually the left, the lower leg streight while the upper leg flexed up and and the upper knee touching the table. It gives an easy eccess to the anus.

The armes of the patient is always restrainted to hinder movement that can disturbe the work. If the surgery is at the arms or shoulders, the armes are flexed up or out in a way that ease the surgery. In surgery at other places, especially the breast and abomen, the arms are often flexed up over the head to get the body stretched. Often one arm is heald streight out and strapped down to the side to use the arm for venous catheters.


Patient care and working methods used during surgery

Anesthesia will be furnished during the whole time of the surgery and body functions will be monitored. Through the IVs several types of medications will be adminstered. The medication will have purposes like paralyzation of muscles, adjustment of heart activity and adjustment of blood coagulation. Nerval activities will also be monitored to ensure that the anesthesia is effective.

It is a common belief based on history that the surgeon uses an ordinary knife and stops the bleeding with various kind of pinches. For parts of the work where very great presicion is needed, knives are still used. And to close great blood vessels, pinches are still the tool. is needed. Bur for the most part he uses more modern cutting tools that also stop the bleeding at once.

The most common tool is a harmonic knife. This is a peak probe through which alternating current is sent into the tissue. The current warms up the tissue exactly at the point where the probe touches so that water boils in the tissue at that point and the tissue splits apart. The alternating current also maked the blood coagulate.

Another tool is a laser that warms up the tissue so that it splits apart and blood coagulates. The surgeon can also use a coblation tool. This tool releases fine drops of water with dissolved iones that have been energetically excited by an alternating voltage. The ions etch and dissolve tissue and the tool also sucks away the dissolved tissue. This kind of tool is mostly used where lumps of tissue shall be taken away, for example by tonsile surgery.

By orthopedic surgery where bone is cut, the surgeon will typically use tools like electric saws and drills.

The traditional way of recomposing the tissue has been by needle and threads, which still may be used. But nowadays the surgion often use means like staples and glue also. By surgery in bone, screws are often used.

The surgery finishes by closing of the incisions and by wound dressing. Often the surgeon will first places tubes that goes from the inside of the surgical site to the outside, and these will remain some time during healing. The catheters drain the site for blood and fluid that leak from the tissues. They can also be used for flushing of the surgical site and to instill antimicrobial drugs.

Modern surgery is often performed through tiny holes instead of large cuts. Through these holes, tubes called cannulas are placed. Through one of the cannula a camera is inserted. Other cannulas are used to insert the tools for the work. The body cavity where the work is done is typically inflated by a gas. In the most modern settings, the whole battery of equipment is driven mechanically and is controlled from a computer unit where the surgeon sits. Such a setting is called robotic surgery.


Patient care after the surgery has been completed

Just after the surgery, the patient often gets a supository in his anus. This is most often to administer pain medication after small surgeries. After more complicated surgeries such medication is administered through IVs instead though.

After surgery the anesthesia is discontinued and the patient is allowed to wake up, but artificial ventilation continues.

At this point the Foley catheter may be taken out in some cases, in others it will stay for hours or days after surgery. Most IVs and monitoring electrodes will be taken out, but at least one IV, the puls oxymeter and the electrodes at the breast area will be left to stay some time. Also catheters for adminsering of local anesthesia and for drainage will be left to stay.

It is customary to place back the clothes on the patient at this point, at least at the lower body, which provides that the patient often will not know that he has been totally naked.

When the patient i nearly awake, the ventilation is discontinued and they take out the laryngeal tube. The patient will now typically begin breathing of his own. If that does not occur effectively at once, one will ventilate him with a mask until he is better awake.

When stable, the patient will be transferred to a post-operative bed unit where he will be monitored tightly for some hours. During hours and sometimes days after surgery the patient will typically be given medication to alleviate pain and nausea and for relaxation. Pain medication will typically be achieved with opiates. For sedation and nausea treatment they mostly use diasepines like midazolam/versed.

It is not good for the patient to lay still long after surgery, becasue that can cause complications like blod clots. Therefore one tries to make the patient rise up some times as soon as possible. To avoid complications due to slow blood circulation, patients may be equipped with cuffs around the legs that are constantly inflated and deflated in a wave-like fashion.

Then he will be transferred to an ordinary hospital rooms. At some point the rest of the IVs, the electrodes and the catheter will be taken out.

One will make sure that the patient is able to urinate and pass stool before a too long time has passed. If that does not occur well, laxatives will often be administered orally. If that is not working, the next try is a supository. Only seldome will there be given enemas after the surgery, but it might happen.


About the staff in the operating room

The person superiorily reponsible for the anestheseia, is a fyciscian called an anesthetist. Often the anesthetist himself do not participate during the surgery. Often instead a specially trained nurse called a nurse anesthetist will be the practical perfomer of the anesthesia. By more complicated surgeries the phyciscian anesthetist will typically do the anesthetist's work.

By special surgeries a nurse anesthetist will do the practical anesthetic werk, while the fyiscian is also prensent to perform more specialisized tasks, like induction of regional anesthesia, and oversee the total well-being of the patient.

Also in cases where the anesthesia is performed by a nurse anesthetist, the fysciscian will serve as the general mentor and will be present in the unit so he can be called into the operating room to help when complications occur.

The surgeon will often have one or two more surgeons by him to assist, or the assistant will be a doctor not yet having the status as a surgean, but is under specialized education.

One or two operating room nurses will help to prepare the patient for surgery. A scrub nurse will have the responsibility to prepare clothes and surgical equipment and will handle the necessary equipment to the surgeon during work.

By special operations, like heart surgery, an engineer called a perfusionist will have the responsibility to prepare the equipment for extracorporeal circulation and oxygenation and to run this equipment under the operation.


About general anesthesia and children

There is a widespread assumption in medical comunities that it is not psychologically good for children to experience any pain during surgical procedures and examinations. There is also the asumption that the experience of procedures and the memory of procedurs are frightening, poses psychological harm and can cause general fair of doctors or hospitals thereafter.

Probably the staff at many places nowadays is also generally afraid that children shall know explicitly that they will be totally naked some time, know about intimate procedures involving the genitals and the rectum, shall tell about these procedures to other children and other adults and thereby cause general fair or acusations of sexual abuse.

Based on these asumptions many medical institution has the policy of using general anesthesia even for small surgical intervetions and and even non-surgical examinations.

But this practise creates problems too. General anesthesia is more acutely hazardious to children than adults, and especially small children. There is also evidence that general anesthesia disturbs the development of the brain and the nervous system. Furthermore, the induction of anesthesia and the aftermath of the general anesthesia can be as umpleasant as the procedure itself when done with only regional anesthesia .

One tries to solve the dilemma by monitoring children much more tightly than adults, and adminstering more medication to calm own before anesthesia and to take away unpleasant symptoms like nausea afterwards, but that imply more use of drugs that have a potential harmful effect on the long run. The cost of the procedures also increases markedly by such extra measures.

Because of this dilemma some institutions has begun to go away from consequent use of general anesthsia and instead tries to make the whole setting and procedures more child-friendly.


You or your children are videotaped during surgery

There is a general practice in most hospitals that the whole preparation and surgery is videotaped, often from several angles and without any discretion whatsoever, and the video of the whole ordeal is stored. This practice is seldome told to the patient. It is done to have material for instruction of students and doctors having surgical training. It is also done to have evidence if there should be some litigation about the procedure after the surgery.


You or your child might be used as a training objects for medical student during anesthesia or as a researech object

There is a pretty high chance that you or your child will be used as a training object for medical students or for surgeons under education during anesthesia or that extra procedures are performed on you for research purposes. There will often be one or more surgeons under training in the room, and these will typically do some of the work during the surgery, but under supervision of a fully trained surgeon. But in addition there is a high chance that you are also used as a training object for medical students and they will practice procedures on you that have nothing to do with the surgery itself.

Such use of patients is most common by uncomplicated surgeries that take short time, so that it is plenty of time for additional procedures. Even though this practice is fairly common, it is generally held secret and often plainly denied when information about it comes forth in mass media. Often however, patients wake up with so distinct symptoms or even injuries at surprizing parts of the body that it is certain something additional has been done, and it is published in mass media. The particular practice most often published and discussed in mass media has been the use of asnestitized women as training objercts for gynecological examinations. Another common occurence is children having oral surgeries like tonsillecties, but the surgery taking a suspisciously long time, and the child waking up with strong pain, injuries or other surprizing symptoms in the genital region.


When your child is under anesthesia the staff or staff from outside will often perform examinations that they do not tell you about

In many societies there is a growing tendency to survail kids in all thinkable ways. Kids are surveilled individually and selected kids are used to obtain statistical information about growth, habits and development status. Also there is a growing tendency to supect any parent of kids with health problems for negelect or abuse, and then subject the kid for extensive examinations to find evidence for these paranoid suspicions.

These societies will often investigate by subjecting children for intrusive examinations with endoscopes inserted througj body openings, most often the openings in the intimate zones, to extensive investigations with radiological methods, to endoscopic investigations through holes made into the stomach or chest, and by photographing all body areas in all details.

These societies often prefer tp do these investigations when the child is under anesthesia for some other purpose.

If your kid is under anetshesia unexpectedly long, if you see staff apparently not belonging to the surgical team before or after the surgery or your child has significant symptoms afterwards in other body areas than those of the surgery, it is likely that some other things have been done that you are nor told about.



Management of Children and Teenagers in Intensive Care Units

A child or teenager which is seriously ill, has gone through surgery or have hadexaminations under general anestesia will usually stay in an intensive care unit where administration of drugs are exactly controlled, where all body fuctions are monitored, and where body functions are aided in various ways. The stay can vary from a few hours to days or weeks.

In the followeing is a descriptions of the arrangements on, in and around the kid during the stay in the intensive care unit.

THE POSITIONING OF THE KID AND ENVIRONMENT CONTROLE AROUND THE KID

The kid will lay in a bed with extensive posibilities for positions. Most often he will be shifting laying with streight legs on his back and on his sides with legs flexed for stability. But in special cases his legs is raised in various ways or flexed and placed in stirrups. The child will be totally uncloded, but usually be covered by a blanket.

The kid will often have stockings on him to keep his legs warm and to hinder loss of heat from his body. Sometimes he will have inflatable cuffs around his legs that are continually pumped up and deflated to aid the flow of blood and lynph in his legs and lower body parts up towards the heart. This arrangement is mostly used for very sick kids and kids that stay long in the unit.

MONITORING EQUIPMENT INSTALLED ON THE KID

The kid will always have one of more IV tubes or intervenous tubes going into veins, usually in arm or leg. This tube alwys deliver pain killing medication and nearly always medication that makes the child relaxed and sleepy. But the de degree of sleepyness one aims at varies:

- The kid can be made just calm and drowsy, which is called conscious sedation. He can be made unscscious, but not deeper than he can be awaked by stimulation.

- He can be made incoscious to a degree that he cannot be waked, which is called induced coma. In this case he usually also gets medication so that all muscles are paralyzed, and this is combined with artificial breething.

The kid will have electodes at his chest and lower body, typically his upper tighs, to measure heart rate and the electric activity in his heart. Wrapped around an arm or a leg there wil also be a cuff to measure blood pressure. This will be pumped up at regular intervals for the measurment which can be automatic or manual. Sometimes the kid will have electrodes at his hea to monitor brain activity and wakedness. These are used to ensure the anesthesia has the right level and to ensure the working status of the brain.

The kid will always have a sond with a probe installed into him to monitor temperature. This will usually go in through his anus. But occationally other tubes installed into the kid will also have an integrated probe to record temperature, for example the urinary catheter.

MANAGEMENT OF THE KID'S BLADDER, URINATION AND GENITALS

A kid in an intesive care unit always has a tube called foley catheter going itto his bladder to drain urine and monitor urin output. In boys this will usually enter through the urethral opening a'in his penis, and in girls through the urethral opening between her inner genital lips, just over her vaginal opening. But sometimes it enters directly through a hole made in the lower stomach area.

The catheter often also has other functions. It can contain an electronic sensor to measure body theperature. It is also used to measure in the stomach area of the kid, by means of a pressure monitor one connect to the catheter when this shall be done. It can be connected to a machine that flushes the bloadder width fluid containing medicines, or pumps up the bladder periodically for treatment purposes.

Boys in the preteen period and during puberty need special care in their urinary system during stay for more that a few hours in an intensive car unit, because they tend to get erections and secret prostate fluid. Usually the penis will be arranged to be pointing upwards towards the navel, and the catheter and penis held in that position with a belt round his lower body. Thus the penis can glide up and down around the catheter.

MANAGEMENT OF THE KID'S NUTRITION

The kid will usually get carbohyrdats and minerals through an intravenous tube. With stays in the PICU up to a few days, this will be all. It is possible to supply all nutrients intravenously, but it is expensive and it is not good for the digestive system to be left idle a long time. For longer stays nutrients will be provided into the stomach.

A slightly sedated kid will usually manage to eat normally or feed fluid nutrition normally through the mouth. Heavely sedated kids will get a tube into the stomach for feeding. This is usually passed through the nose, from there through the esophagus and into the stomach, and it will usually stay permanently and through it fluid nutrients will be fed.

MANAGEMENT OF THE KID'S LOWER DIGESTIVE SYSTEM, ANUS AND BOWEL EMPTYING

When a kid enters an intesive care unit, he has typically underwent a process of making his digestive system void of food andstool, and he will typically get intravenous, so there will typically be little on a daily base that has to come out. But depending on the state of the didgestive system, there will still be secretion of slime, possibly bleeding and possibly seepings from sores, so there will always be something that have to be managed if the stay in the unit takes some time.

If the kid is fed through a gastric tube or eats by himself, there will also be stool that must be managed. If the kid is only slightly sedated he can usually pass stool or secretions in the normal way to a bedpan. Otherwise some kind of flushing must be used.

One way of doing so is to insert a tube through his anus and flush his colon at regular intervals.

Sometimes the kid wil have a tube that enters the anus and go some way up in the rectum or colon permanently installed, and through wich fluid is pumped in and out at regular intervals and thereby one washes out secretions or stool. This happens if the colon has to be kept constantly clean and empty for treatment purposes or to reduce pressure in the stomach region or if other metods create pain.

MANAGEMENT OF THE KID'S RESPIRATION

When the kid is only slightly sedated and the respiratory organs are in order, one generally lets the kid breath by itself, but will often have got a tube with two ends that are brought in through each of his nositrils that provide oxygen.

A heavy sadated kid or a kid brought into the kind of general anesthesia called induced coma will get medicines through an IV that paralyzes all the muscles, including the breathing apparatus, and will get artificial breathing by a machine.

The artificial breathing is provided with a tube down the throut and past the vocal cords, called an endotracheal tube.