Indian J.
SEN
CHARI, Anaesth. 2004; 48 (5) :ANAESTHESIA
: AMBULATORY 387-393
PAEDIATRIC AMBULATORY SURGERY
- PERIOPERATIVE CONCERNS
Dr. Pramila Chari1 Dr. Indu Sen 2
Introduction
Pediatric surgery in an ambulatory setting shortens
hospital stay, reduces exposure to nosocomial infections,
and allows for the active parental participation (table 1).
The popularity of this subspecialty has created new
challenges and rewarding opportunities for pediatric
anaesthesiologists. Thorough preoperative screening, proper
patient selection, optimum perioperative care and follow
up are considered the most important issues in the day care
system.
Table - 1 : Advantages of pediatric outpatient anaesthesia
• Minimizes parental seperation
• Unintruppted feeding schedule/sleep patterns
• Less risk of nosocomial infections
• Convenience/Improved patient satisfaction
• Availability of beds for complex ,needy patients
• Reduced cost of hospitalization
Historical perspective
The practice of day-care surgery was first reported
by Nicholl1 in 1909. He presented to the British Medical
Association the data of 8,988 outpatient operations done at
Glasgow Royal hospital for Sick Children over a period of
ten years. In 1916, Ralph Waters opened the first outpatient
clinic in Sioux city, Lowa.2 Outpatient anaesthesia was
recognized as a specialty and Society for Ambulatory
Anaesthesia (SAMBA) was organized in USA in the
year1984. American Society of Anaesthesiologists (ASA)
has amended its guidelines in 1998 for ambulatory anaesthesia
and surgery. ASA encourages anaesthesiologists to play a
leading role as perioperative physicians in various
ambulatory facility settings.
1. M.D., D.Ac, MAMS, FAMS, Prof and Head
2. M.D., Asst. Prof.
Department of Anaesthesia and Intensive Care
Post Graduate Institute of Medical Education and Research
Chandigarh -160012
Correspond to :
Dr. Indu Sen
E-mail : senramesh@rediffmail.com
387
Establishing pediatric outpatient facilities
Proper designing and layout are integral part of
overall efficiency of ambulatory surgical units (ASU). They
may be either attached to the hospital (integrated units),
free standing or officebased. The facility must be established,
constructed, equipped and operated in accordance to
minimum mandatory standards and the felt need of the
locality. In most of the institutions both inpatients and
outpatients share the same operating room suites. This
reduces perioperative costs and allows for efficient use of
existing equipment and personnel. Various systems like
“Everyday Fixed Hours/Block Time or Chosen Workdays”
are available for allocation of operating rooms and case
scheduling. For smooth functioning of the unit adequate
space should be allocated for patient evaluation, pre and
postoperative care and backup emergency management.
Pediatric holding areas should be made colorful with
appropriate décor and toys to make operative experience
pleasant for child. These are known to improve cooperation
and facilitate parental separation for induction. It is desirable
to have a post anaesthesia recovery unit (Phase I PACU)
near the main operating suite and a separate post recovery
lounge (PRL/Phase II PACU) located close to patient
changing rooms. Specific guidelines are available for medical
personnel involved in pediatric patient care and for provision
of perioperative environment.3
Patient selection for ambulatory surgery
The major concern is to determine which patients
are appropriate to be scheduled for ambulatory surgery.
Criteria used for selecting outpatients depends upon physical
status, type of surgery, special anaesthetic or postoperative
considerations and attitude of the parents.4 Surgeon is the
first member of perioperative team whom the parents meet.
The smoothness and success of entire hospital experience
depends upon proper planning and parental guidance during
the preliminary work up. Availability of a list of day-care
surgical procedures, which is updated periodically is a useful
aid.
Pre operative screening : To expedite the evaluation
process and to ensure some degree of uniformity,
preoperative screening process is a very useful tool.5 Aim
is to identify patients who are inappropriate for day-care
and should preferably be treated as inpatients This can be
accomplished by completing a questionnaire either in the
388 PG ISSUE : PAED ANAESTH
surgical O.P.D. or during a telephonic conversation.6 This
is followed by patient’s review and necessary laboratory
work up. Presently, the impact of a computer based tool to
prepare patient summaries, drugs or test orders and
evidence-based recommendations prior to preoperative
anaesthesia checkup (PAC) is being evaluated. Some healthy
patients can even be allowed to bypass the PAC clinic,
possibly increasing the percentage of DOSA (day of surgery
admission) patients towards the target standard of 70%.7
Routine preoperative laboratory investigations and chest
roentgenogram for healthy children are not required.8,9
The incidence of positive pregnancy test in adolescent
girls varies between 0.5-1.2%,10,11,12 so careful menstrual
history should be taken.
Exclusion criteria: Initially, outpatient anaesthesia
was limited to brief surgical procedures in healthy children
(ASA physical status I or II). Now a days, depending upon
availability of resources, children with controlled medical
illnesses are also being accepted for ambulatory surgeries.4
Age is not a contraindication to outpatient surgery with few
exceptions: Neonates and ex-premature infants (<52-60
weeks postconceptual age) are not suitable candidates for
outpatient surgery.13,14,15 Marked physiological changes occur
in first few weeks of life, such as closure of patent ductus
arteriosus,decrease in pulmonary vascular resistance,
increase in functional residual capacity, rise in glomerular
filteration rate and physiological jaundice. Infants with
history of bronchopulmonary dysplasia and siblings of
sudden infant death syndrome should be hospitalized for
surgical procedures. Other exclusion criteria are inadequately
controlled systemic illnesses (e.g. epilepsy, asthma, acute
upper respiratory tract infections, and uninvestigated cardiac
murmurs). Complex CDH, sickle cell disease or history of
significant sleep apnoea are contraindications for day-care
services. Interactions between congenital abnormalities, their
surgical correction and anaesthesia can be complex, so the
safety of patient must be kept in perspective.16 Considerations
are given to the risk of postoperative bleeding,17 major
intra-thoracic, intra-abdominal or intracranial procedures
and extremely painful procedures where postoperative pain
is unlikely to be relieved by oral analgesics.
Indian perspective
In a developing country like ours, cost is a very
important factor. With long waiting lists, practice of day-
care surgery is likely to improve the situation. Availability
of costly newer drugs and monitoring devices are not absolute
necessities to start day-care facilities.18 The need of the
hour is to reorient ourselves, educate our masses and
popularize ambulatory services. Most of our patients belong
to villages and may not have access to proper communication,
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004
transport and health care facilities. Illiterate parents/
grandparents may be incapable or reluctant to look after
the sick child at home. We have to be considerate about
these issues and selection criteria need to be modified
accordingly. Whenever in doubt, it is best to err our
decisions on the conservative side and admit the child.
Pre anaesthetic considerations
From the anaesthesiologist’s point of view, the
preoperative evaluation and assessment is just as crucial in
outpatient surgery as in all other surgical procedures.19
Theoretically, it is suggested that all patients should follow
a sequential preoperative pathway. But, approach needs to
be flexible as different methods work for different age
groups. Unfortunately there is a tendency to associate
outpatient surgery with minor procedures and healthy
patients. This may lead to problems when patients having
undiagnosed acute diseases or asymptomatic patients with
chronic heart disease arrives (table 2). Risk of anaesthesia
in this group of patients may be more than that of surgery.20
Hence, appropriate measures need to be taken to minimize
delays and last minute cancellations. At times, it is difficult
to avoid cancellations, but parents should tactfully be
convinced about the risks involved. A structured telephonic
interview on evening prior to surgery is known to reduce
anxiety and ensures optimum compliance to instructions. If
child is suffering from some acute problem demanding
postponement of surgical procedure, visit to hospital and
expenses involved can be curtailed by this telephonic
conversation. Furthermore, surgery can be rescheduled.
Table- 2 : Problems in providing out-patient care.
• All patients are not medically uniform
• Children with acute / chronic undiagnosed diseases
• Lost hospital records/recommendations
• Inaccessible telephone, transport facilities
• Illiterate parents, incapable of postoperative care
• Cost effectiveness ?
• Absence from work/ extra visits (screening, postoperative follow up)
Preparation of child
Recognition of prolonged behavioral derangements
following the anaesthetic surgical hospital experience and
the prominent role that the physicians play in modifying
these have dramatically changed the contemporary
pediatric perioperative care.21 There is a need to establish
rapport with the parents and get a sense of their psychological
needs.22 Detailed information reassures parents and
CHARI, SEN : AMBULATORY ANAESTHESIA
improves co-1operation. It is even more important to treat
child as a center of attention, converse and assess his/her
behavior. It is during this interaction that we chalkout
our effective induction plan. Many institutions offer
preadmission orientation programmes along with visit to
OPD to familiarize the child and parents with what will
happen on the day of surgery.23 These may include a puppet
show or a video film. It is a good habit to provide detailed
written instructions preferably in a language well understood
by the parents.
Preoperative fasting
Arbitrary overnight restriction of fluids in healthy
children is no more recommended prior to ambulatory
pediatric surgery. Several studies have now demonstrated
that clear liquids can safely be given upto two hours
before surgery.24,25,26 Prolonged fasting produces anxious,
irritable ,un co-operative child who may be hypoglycemic.
26
Optimum hydration status reduces incidence of
drowsiness, dizziness, thirst and PONV after surgery.
Recent fasting guidelines have been published by ASA
task force in 1999 (table 3). These recommendations are
applicable to all procedures under general anaesthesia,
regional anaesthesia or monitored anaesthesia care.
Table - 3 : Pre operative fasting guidelines
(ASA task force 1999)
Clear liquids Milk (breast /formula) Solids
Neonates 2 hours > 4 hours >6 hours
Infants 2 hours 4 - 6 hours >6 hours
Children 2 hours 4 - 6 hours >6 hours
Premedication for children
Premedication allays axiety and allows for easy
separation. In day-care practice, pharmacological
premedication may affect recovery after anaesthesia or
produce emetic side effects.27,28 Moreover children can be
smoothly induced after verbal reassurance especially if
parents are allowed to accompany the child to the operation
room.29,30 Parental selection and counseling are essential to
make their presence useful during conduct of anaesthesia.
Anxious parents can make their children more upset.31
Premedicants definitely benefits children who are
very apprehensive, too young or mentally retarded. Midazolam
oral/nasal (0.2-0.5 mgkg-1, maximum dose 10 mg), syrup
chloral hydrate 40 mgkg-1 and oral/nasal fentanyl citrate
(OTFC) 15-20 mgkg-1 are the short acting premedicants
which are known to provide reliable sedation and smooth
induction of anaesthesia.32,33 Rectal midazolam 1 mgkg-1 is
389
as effective as oral preparations.34 These drugs improve
separation and does not delay discharge. For uncooperative
children low dose ketamine (2-3 mgkg-1) administered
intramuscularly produces appropriate conditions for
inhalational induction within 7-10 minutes.35
Choice of anaesthesia
It is important to ensure that anaesthetic techniques
and perioperative care continue to be safe in ambulatory
surgeries. Essential preoperative requirements for safe
conduct of anaesthesia in outpatients are the same as those
for inpatients. Standard monitoring needs to be established
in day-care surgery. Now a days depth of anaesthesia
monitors are also being used in ASU to maintain adequate
depth of anaesthesia. Though expensive, equipment cost is
justified as they are known to reduce the consumption of
anaesthetic agents and hasten recovery.9,21
Inhalational induction : It is the anaesthetic
technique of choice for needlephobics or for children
with difficult intravenous cannulation.36 Transparent face-
masks impregnated with food flavourings and coloured
reservoir bags with stickers improve acceptability of the
technique. Halothane, being sweet smelling has been
standard inhalational agent of choice. New agents with
low blood gas partition coefficient are known to provide
fast induction and rapid recovery.37 Recently, a controversy
has been raised regarding emergence delirium following
administration of inhalational agents. However, it is difficult
to delineate the influence of pain, separation, anxiety or
hunger on child’s emergence behavior.38 Thus carefully
crafted balanced anaesthetic technique along with adequate
pain control is most effective.
Intravenous induction : Amongst the agents
thiopentone remains to be the hypnotic drug of reference,
but propofol’s versatility is causing it to gain wider
acceptance.39 Ketamine, a dissociative intravenous
anaesthetic plays a significant role in analgesia and sedation
for ambulatory surgeries. Adjunctive use of ketamine
attenuates propofolinduced hypoventilation and is known to
reduce opioid requirement for pain relief. The use of
atracurium or vecuronium is justified if the doses are
properly adjusted. Mivacurium is better avoided because
its action may be prolonged in patients with plasma
cholinesterase deficiency. Laryngeal mask airway (LMA),
being minimally invasive are replacing tracheal intubation
in appropriate situations.40 In fact, with the availability
of small sizes (table 4) and flexible LMA’s, device is
gaining popularity in day-care procedures and is known to
facilitate fast tracking process. Should tracheal intubation
be necessary, laryngeal edema may be avoided by gentle,
cautious laryngoscopy, the use of a tube without a balloon.41
390 PG ISSUE : PAED ANAESTH
Table - 4 : Laryngeal mask airways.
Patient weight (Kg) LMA size Maximum inflation
volume (ml)
Neonates upto 6.5 1 2-4
6.5-10 1.5 5 Inappropriate postoperative care can increase the
10-20 2 10
20-30 2.5 15
30-50 3 20
Regional anaesthetic techniques
These alone may be used in co-operative adolescents,
wherever feasible. Locoregional anaesthesia offers a number
of advantages: blockade of nociceptive stimuli, avoidance
of opioid drugs, rapid and pleasant awakening and less need
for postoperative analgesics.
Perioperative fluid management
Venous access should be established in all but minor
procedures. Administration of intravenous fluids for brief
surgical procedures is not necessary, until and unless child
has prolonged preoperative fasting, associated medical
illness or in surgeries associated with high incidence of
PONV (squint, tonsillectomy, dominant pinna correction).
Optimum hydration status reduces incidence of drowsiness,
dizziness, thirst and PONV after surgery; this avoids delay
in discharge from hospital.42
Pain management
Postoperative pain is a major complaint in pediatric
ambulatory surgery The overall anaesthetic plan must
include provision for adequate pain relief.43 Intraoperative
analgesics include meperidine, fentanyl or remifentanil;
morphine is better avoided. Earlier use of opioids in infants
and neonates was limited because of perceived issues of
sensitivity to narcotics. This opioid sensitivity was attributed
to water solubility of morphine and immaturity of the
newborn infant blood brain barrier. Currently, there is an
emphasis on increasing opiate specificity and hemodynamic
stability and opioids with improved pharmacokinetic and
pharmacodynamic profiles have been developed. Remifentanil
, a m agonist with flat context sensitive half time has been
found to be a potentially useful and predictable anaesthetic
agent for neonates and infants.44 Another alternative is
multimodal strategy which is known to reduce the adverse
events and provide optimum pain relief. In children role of
various blocks like caudal, penile and ilioinguinal/
iliohypogastric is well established.45 If regional techniques
are not feasible a peripheral acting parenteral analgesic
like acetaminophen (15-25 mgkg-1) or NSAID (diclofenac,
INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004
ketorolac, COX-2 inhibitors) can be combined with
smaller dose of opioids.(fentanyl 1-2 mgkg-1).46,47 Rectal
acetaminophen (40 mgkg-1) is quite safe and effective
postoperative analgesic.48
Postoperative course
rate of unwanted admissions and medico legal problems49
The postoperative complications seen most often are
related to respiration making routine postanaesthetic pulse
oximetry a recommendation. Laryngospasm usually an
immediate postoperative event can occur in recovery
room also if patient chokes on pharyngeal secretions.
Therefore child should be placed in the head down lateral
position postoperatively. Postintubation croup may appear
within three hours of extubation. This is usually seen in
early childhood (age 1-4 years), repeated intubation
attempts, larger endotracheal tubes, and excessive movement
of the tube. Gerber et al50 prospectively studied the risk
of postoperative respiratory compromise in patients
undergoing adentonsillectomy. They observed the
patient for oxygen desaturation (SpO2 < 90%), obstructive
breathing pattern or respiratory distress requiring
intervention two hours after surgery. Risk factors for
postoperative respiratory compromise included age <3 years,
neuromuscular disorders, chromosomal abnormalities, loud
snoring with apnoea or respiratory tract infection within
4 weeks of surgery.
Postoperative nausea and vomiting (PONV), if
neglected, may delay discharge from ASU.49 Patients at
increased risk should receive antiemetic prophylaxis.51,52
The concept of balanced antiemesis has been put forth in
the recent years and multi modal PONV management
approach has been suggested. This includes combination
therapy with antiemetic medications acting at different
neuroreceptor sites, less emetogenic anaesthesia techniques,
adequate intravenous hydration and adequate pain control.53
Discharge criteria
Rapid recovery and early postoperative ambulation
are major objectives in pediatric outpatient surgery. We
need to ensure safety after discharge. Time-tested objective
recovery scores like Steward, Aldrete54 should be used
for assessing children before discharge. Marshall and
Chung reviewed discharge55 and complications after
ambulatory surgery using modified quantitative scoring
systems (table 5, table 6). Later on Patel et al56 suggested
fast track eligibility criteria for children in
2001. Special consideration need to be given to stable
haemodynamics, normal respiratory pattern, absence of
excessive nausea/vomitting and dizziness, and a state of
CHARI, SEN : AMBULATORY ANAESTHESIA
Table - 5 : Modified Aldrete post anaesthesia recovery
score (PARS).
Activity
Able to move 4 extremites voluntarily or on command
Able to move 2 extremites voluntarily or on command
Unable to move extremites voluntarily or on command
Respiration
Able to breath deeply and cough freely
Dyspnea or limited breathing
Apneic
Circulation
BP +20% of pre anaesthetic level
BP+40% of pre anaesthetic level
BP +20% of pre anaesthetic level
Consciousness
Fully awake
Arousable on calling
Not responding
Oxygen saturation
Able to maintain O2 saturation >92% on room air
Needs O2 inhalation to maintain O2 saturation >90%
O2 saturation <90% even with O2 supplementation
A score of > 9 required for discharge from acute post anaesthesia care unit
consciousness appropriate to the developmental level
Every child regardless of age must have an escort home
who stays overnight with the child.57 Written instructions
concerning the child’s home care and a list of signs that
might herald a complication should be read and handed
over to the responsible person accompanying the child. It
is mandatory that parents are able to communicate and
reach back to the hospital if needed.58 Most complications
(pain, nausea, vomiting, croup) are transient and managed
before discharge. Unwanted admission rate in day-care is
usually <2%. Besides patient factors like respiratory
compromise, protracted vomiting, drowsiness or fever,
unexpected complicated surgery, postoperative bleeding may
warrant hospitalization. Sometimes, child may need to be
admitted if family is reluctant to take the child home
postoperatively. The most frequent complications reported
after discharge are undertreated pain, loss of appetite, and
behavioral changes.59
391
Table - 6 : Modified post anaesthesia discharge scoring
system (PADSS)-Marshall and chung.
Vital signs (stable/consistent with age and pre operative baseline)
2 BP and Pulse within 20% of pre operative baseline 2
1 BP and Pulse 20%-40% of pre operative baseline 1
0 BP and Pulse >40% of pre operative baseline 0
Activity Level (Ambulation at pre operative level)
2 Steady gait, no dizziness 2
1 Requires assistance 1
0 Unable to ambulate 0
Nausea and vomiting
2 Minimal: Treated with PO medication 2
1 Moderate: Treated with IM medication 1
0 Continues after repeated treatment 0
Pain
2 Acceptable to patient; controlled with post operative medications
1 Yes 2
0 No 1
Surgical bleeding
2 Minimal: No dressing change required 2
1 Moderate: Upto two dressing changes required 1
0 Severe : More than three dressing change required 0
Maximum score =10 Score > 9 required for discharge
Conclusion
Organization is the key to efficient day-care system.
A team approach including pediatric surgeons,
anaesthesiologists, and dedicated paramedics is considered
indispensable for the safe and satisfactory day surgery.
The future challenge is to provide high quality anaesthesia
services in a wide variety of venues.60 Continuous surveillance
of existing set ups and critical evaluation of untoward
perioperative outcomes serves to make future safety
recommendations. Assumption that parents will manage
child at home necessitates research into child’s postoperative
recovery. Telephone calls or mailed questionnaires
help to determine the post hospitalization problems.
Developing a deeper understanding of parent’s peri-operative
experience will help us to make emphatic grounds upon
which to base improvements in this ever growing field.
392 PG ISSUE : PAED ANAESTH
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ANNOUNCEMENTS
u The Indian Journal of Anaesthesia has been
indexed with INDEX MEDICUS FOR WHO
SOUTH-EAST ASIA REGION (IMSEAR).
u Readers will be delighted to note that Indian
Journal of Anaesthesia is being disseminated
through internet by NIC. This great leap
forward heralds a new era for Indian Journal
of Anaesthesia. Access to our journal on
internet will be at the website.
http://indmed.delhi.nic.in
- Editor