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Anesthetic considerations for pediatrics-outpatient
(day care surgeries)


April 2014
• Objective
• Introduction
• Why day case surgery?
Advantages of day case surgery
• Advances in pediatrics day case surgery
• Candidates for pediatrics ambulatory surgery
• Pre-operative assessment
• Intra-operative management
• Postoperative management
 Post operative pain management
Recovery and discharge criteria
• summary
• Reference
General objective

All we anesthetists are expected to :

• Acquire deep knowledge about pediatrics out patients
and collaborate with others for establishment and
development of day case surgery centers throughout the
Ethiopia (especially pediatrics day case surgery centers)
Specific objectives

At the end, we are expected to:

• Understand definition and basic concepts of cay case surgery
• Know about the advancement of day case surgery
• Identify good candidates for day case surgery with proper
handling of children
• Perform pre-anesthetic evaluation of pediatrics day case surgery
• Apply proper intra-operative management of pediatrics patients
• Manage post operative pain, nausea and vomiting
• Follow the principle of discharge criteria
• Make follow up after discharge

• Definition: day case surgery also known as ambulatory

surgery ,same-day surgery and outpatient surgery, is
surgery that does not require an overnight stay .the term
‘out patient’ arises from the fact that after surgery patients
go home and do not need an overnight hospital bed.
• Ambulatory surgery centers: also known as outpatient
surgery centers or same day surgery centers are health
care facilities where surgical procedures not requiring an
overnight hospital stay are performed.
Why day case surgery?
• Day surgery encompasses a spectrum of surgical procedures
that allows the patient to go home on the day of surgery,
usually after a few hours.
• Day case surgery is highly cost effective
• Day surgery represents high quality patient care with reduced
tissue trauma, enhanced recovery, effective analgesia,
minimal adverse events, provision of appropriate information
and post-operative support
• Complex procedures can be performed but, it depends on
 available facilities,
 skills of the medical team
 the patient’s fitness, the technical ease of the procedure
• Anesthetists play a pivotal part in the successful outcomes of
day surgery patients. Working as part of the multidisciplinary
team, anesthetists can contribute in more ways than
providing anesthesia. These are:

agreement, development and support of pre-operative

assessment and post-operative care guidelines and processes
Pre-operative assessment of complex patients to ensure as
many as possible are managed as day cases and for those
needing investigation and treatment referral to other
specialties liaison with surgical teams.
• The success of a day surgery unit is also determined by the
skill and experience of reassessment staff.
Advantages of day case surgery

 Ambulatory surgery can offer a number of advantages . some of

these are:
• Patient preference ,specially children
• Lack of dependence on the availability of hospital beds
• Greater flexibility in scheduling operations
• Low morbidity and mortality
• Low incidence of infection
• Low incidence of respiratory complication
• Higher volume of patients (greater efficiency)
• Short surgical waiting lists
• Lower over all procedural costs
• List pre-operative testing and post-operative medication
Advantage cont…
1. Economical advantage

Day surgery allows the treatment of large number of patients at

less cost than in-patient surgical treatment for the same
condition .costs is reduced because:
• Staff and facilities are predominantly not needed at night ,at
weekends or on public holidays
• Fewer staff are required for day case surgery facility than for
comparable in-patient surgery
• If an operation suitable for day surgery is carried out as an in-
patient ,expensive hospital beds are occupied ,there by using up
more capital equipment, patient and administrative time.
• The use of day case surgery facility reduces the number of in-
patient beds required.
Advantage cont...
2. Advantage to hospital:

• Economic savings detailed above.

• More attractive to nursing staff because there
is less shift work involved
• In-patient facilities can be run more efficiently
Advantage cont….
3. Advantage to the patient:

• A considerable reduction in the risk of cross-infection

• Reduction in risk of thrombo-embolism associated with
early ambulation.
• Less anxiety for the patient when an overnight stay in
hospital is avoided ,particularly in the case of children
• Early return to normal activities with less time off work.
• Less stress for relatives of patients ,and save time .

The specific needs of children must be considered at all stages of day

Generally the following facilities are mandatory:
• Separate day case surgery center
• Skilled professionals on pediatrics surgery
• Standard monitoring devices
• Proper medications
• Investigative centers (eg.laboratory…..)
• Proper recovery area
• Proper administration
• Near by referral(back up hospital)
Advances in pediatrics day case surgery

• Nicoll first introduced the concept of outpatient surgery in 1909 in

Glasgow, but it was abandoned due to high rate of complications.
• This was popularized after the report of Herzfeld in 1938 when he
reported to sending the infants and children some two hours after
• As further experience accrued, the advantages of outpatient
surgery became evident and this was widely accepted by medical
profession, hospital administrators and the parents.
• Ambulatory surgery has progressed from the practice of
performing simple procedures on healthy outpatients to
encompassing a broad spectrum of major procedures in
outpatients with complex preexisting medical conditions.
Advances cont…
• Presently, outpatient pediatric surgery is a rapidly advancing field
swiftly coming of age.
• Advances in anesthesia and its expert administration are the major
reasons for the safety and success of outpatient surgery in young
children, especially in neonates.
• Formal development of ambulatory anesthesia as a respected
subspecialty occurred with
 establishment of the Society for Ambulatory Anesthesia (SAMBA)
in 1984
 subsequent development of postgraduate subspecialty training
programs recognized by the American Society of Anesthesiologists
Advances con….
 Factors that contribute for growth of day case surgery:

• Increased number of patients and shortage of bed for all

• Development of subspecialty on day case surgery
• The expanding number of freestanding diagnostic and
surgical treatment centers
• The development of improved anesthetic and surgical
• The availability of rapid, shorter-acting anesthetic,
analgesic, and muscle relaxant drugs
• Development of minimally invasive surgical techniques
Advances cont…
 In Ethiopia the advancement for pediatrics day case surgery is very
minimal .
 Even though day case surgeries are performed,
 there is no standard and formal day care center
 Some patients are performed on day case base in minor /major
operation room .
The reason for this is:
• Lack of awareness about day case surgery
• shortage resources
• Absence of appropriate medications
• Lack of skilled and experienced health professionals about day case
• Absence of subspecialty for day case surgery
• Etc…
Candidates for pediatrics ambulatory
 Selection and identification of good candidates is mandatory.
 There are four main factors that affect selection of good
candidates for day case surgery. These are:
1.The patient
o Most children are healthy and well-suited for day case surgery
and children which are;
• Well controlled systemic disease
• No congenital problems
• Well healthy
Are good candidates for day case surgery.
 But children with the following problems are not good
candidates. These are:
Candidates con…
• complex congenital heart disease
 uncomplicated lesions (e.g. VHD)
 surgically corrected defects
 previously undiagnosed cardiac murmur
• children with inborn errors of metabolism (child born from DM
• child with a respiratory infection except (non-productive cough,
clear nasal secretions and a constitutionally well child)
• Pre –term or ex-preterm infants due to post- operative apnea
and problems with body temperature control
 Generally exclusion criteria for patient factors are the following
Exclusion criteria for pediatrics day case management

 Age and medical exclusions:

• preterm infant <60 weeks post-conceptual age
• Inadequately controlled systemic disease
• Active viral or bacterial infection(especially respiratory)
• Complex congenital heart disease
• Uninvestigated cardiac murmur
• Child with inborn error of metabolism
• Sickle cell disease
 Surgical and anesthetic exclusions:
• inexperienced surgeon or anesthetist
• Prolonged procedure(>1h)
• Significant risk of excessive preoperative hemorrhage
Exclusion criteria con…

• Opening a body cavity

• Difficult airway
• Sleep apnea
• Malignant hyperthermia susceptibility(not complete exclusion)
• Pain unlikely to be relieved by oral analgesia after discharge
 Social exclusions:
• Parents incapable or reluctant to care for child at home
• Inadequate housing condition
• Inappropriate postoperative transport arrangements(public
transport unacceptable)
• Long journey home after discharge
Candidates con…
2. The procedure
• A wide range of surgical and non-surgical procedures are
appropriate for day-case management
• Body surface procedures without major encroachment on a body
cavity are most suitable
• Procedures should be associated with minimal bleeding and
normally take no more than 1h to complete.
 adenotonsillectomy is highly controversial area of day care practice
 Hemorrhage is the most feared complication (4-8h)
 Pain and post-operative vomiting
 But now a days adenotonsillectomy can be performed on day care
bases if the patient is:
Candidates cont…
• Well child
• No concurrent respiratory tract infections
• No obstructive sleep apnea
 Procedures suitable for pediatrics day case surgery
 General surgery
• Hernia repair (inguinal, umbilical, epigastric)
• Upper and lower gastrointestinal tract endoscopy / biopsy
• Lymph node excision/biopsy
 Urology :Cystoscopy,Orchidopexy , Prenuptial adhesions,
circumcision, and Minor hypospadias
Candidates cont..
 ENT :Myringotomy ,Nasal fracture reduction ,Adenotonsillectomy
 Dental :Extractions
 Ophthalmology: Examination under anesthesia (EUA),Lachrymal
duct probing ,Strabismus correction
 Plastic surgery: Otoplasty ,Excision skin lesions ,Scar revision
 Orthopedics :Change of plaster ,Removal of metalwork
 Medical: Imaging techniques, e.g. CT,MRI, Interventional
radiology/cardiology, Bone marrow sampling, lumbar puncture +/-
intrathecal medication
Candidate cont..
3. Anesthetic factors
• Prolonged general anesthesia associated with prolonged recovery (> 1h)
• Absence of appropriate medications
• Inappropriate monitoring
• malignant hyperthermia triggering agents
4. The family
• Unduly anxious parents
• single parents with several other children
• Inappropriate transportation
Pre-operative assessment

Preoperative assessment is important because :

• Patients may present for ambulatory surgery with more
complex medical conditions
• May be taking medications.
• May need screening tests
• It makes ambulatory surgery both safer and more acceptable
for the patients and hospital staff.
• Plan the type of anesthetic technique
• Reduces the risks, improve patient out come and make the
surgical experience more pleasant for the patient and family.
• It minimizes patient anxiety
Pre-operative assessment con..

Preoperative assessments and investigations

The three primary components of a preoperative assessment:
• history,
• physical examination
• Laboratory testing (CBC, Hgb……)
The patient's medical history is clearly the most valuable. Evaluations
of medical consultations demonstrated that
86% of diagnosis depended entirely on the information obtained from
the patient's history.
 6% of diagnoses were discovered by careful physical examination
8% were determined by additional laboratory investigation
The remaining is from different investigations
Pre-operative assessment con
Psychological preparation

 Children and parents require careful psychological preparation

 Preparation should begin at the initial preoperative
 Parents should be given the opportunity to ask questions and
allay anxieties.
Pre-operative cont.
 Consent for surgery is a process that should start in the
outpatient clinic and then verified with verbal (written)
consent form on admission.
 Anesthetic consent (written) is usually obtained on
admission, although this may be taken at a preadmission
 Consent should be obtained from the parent
Pre-anesthetic assessment cont..
• Verbal or written instructions should be given for the patient or
• Particular emphasis should be given to Preoperative fasting and
instructions regarding regular medication.
 Fasting instructions for children before surgery
• No solids food for 6 hours preoperatively
• No breast milk for 4 hours preoperatively( breast milk whey-
based formula )
• Formula milk/cows-milk (casein based formula) for 6hrs
• Free clear fluids up to 2 hours preoperatively
Pre-operative assessment cont…
 Good psychological preparation minimizes the need for
 Premedication is not advised for children because of
unnecessary side effects, but in some conditions we can
use pre medications prior to surgery. These are:
• Midazolam is commonly used. A dose of 0.5-0.75mg /kg
acts within 10-30mins so that the child is calm and
• Clonidine: 1mcg/kg is useful as premedication. It should
be given one hour pre-operatively( anxiety)
 Notice :Opioids are suboptimal as premedication as they
can increase postoperative nausea and vomiting (PONV)
Pre-anesthetic assessment cont….
Monitoring and emergency equipment
The full range of pediatric anesthetic equipment, monitoring
devices, and disposable items must be fulfilled. These are:
•Airway management equipment - facemasks, tracheal tubes,
LMAs, oral airways
•Pulse ox meter with pediatric probe
•End-tidal CO2 monitoring
•Pediatric blood pressure cuffs
•Intravenous canola (25G, 22G)
•Temperature probe
•Resuscitation drugs and equipment
Intra-operative management
 Quality, safety, efficiency, and the cost of drugs and equipment
are all important considerations in choosing an anesthetic
technique for ambulatory surgery.
 The ideal outpatient anesthetic agent should be:
 Rapid and smooth onset of action
 Produce intra-operative amnesia and analgesia
 Provide optimal surgical conditions and with a short recovery
 Have no adverse effects in the post discharge period.
 The choice of anesthetic technique depends on both surgical and
patient factors.
 For many pediatrics ambulatory procedures, general anesthesia
remains the most popular technique
Intra-operative mgt cont..
 Spinal and epidural anesthesia (i.e., central neuraxis blockade)
has traditionally been used for lower extremity and
abdominal-perineal procedures, its use in the ambulatory
setting can delay discharge because of residual motor and
sympathetic blockade.
 Local anesthesia and peripheral nerve blocks facilitate the
recovery process by reducing postoperative pain and
minimizing the need for opoid analgesics.
 Local anesthesia or peripheral nerve block combined with GA
is more effective in pediatrics day case surgery.
Intra-operative mgt cont…
Induction of anesthesia
 In majority of children the most daunting experience of day
surgery is the visit to the anesthetic room with its unfamiliar
people and apparatus. So we have to allow parents to go to the
theatre to support those who wish to be with their child in the
anesthetic room.
Inhalational induction
 Inhalational induction is the preferred method in children ,specially
for children who are needle phobic, young children or in those
with difficult intravenous access.
 Sevoflurane is the preferred inhalational induction due to its rapid
onset, pleasant smell and non-irritating properties.
 Halothane can also be use for induction if there is no sevoflurane.
Intra-operative mgt cont…
Intravenous induction
The intravenous induction can be possible for pediatrics day case surgery.
The main problems with intravenous induction are :
 pain on insertion of the canola,
 a natural aversion of children to "needles"
 difficult intravenous access.
 Slower onset of action and recovery as compared to inhalational induction
The choice of intravenous agent for day care is between sodium
thiopentone and propofol.
Induction with propofol is generally preferred as it is relatively smooth
and can profoundly obtund upper airway reflexes facilitating early
insertion of a laryngeal mask airway (LMA). One drawback is that it can
cause pain on injection which can be reduced by use of analgesics.
Intra-operative mgt cont….
Inhaled Anesthetics
 Volatile anesthetics are most commonly used for maintenance of
ambulatory anesthesia.
 Changes in the depth of anesthesia can be achieved readily
because of the rapid uptake and elimination of these anesthetics.
 The rapid elimination of anesthetic vapors also provides for fast
recovery and potentially earlier discharge from the outpatient
 Some these inhalational agents used for pediatrics day case
surgery are:
Intra-operative mgt cont..
 It is the most preferred inhalational agent for
pediatrics day case surgery. Because:
• It is a sweet-smelling
• Fast onset of action
• Fast recovery
• Minimal effect on systems relatively
 Has minimal side effects such as nausea, vomiting and
agitation during emergence but not as mach sever.
Intra-operative mgt con…
 Not commonly used for induction but can be
use for mentainance. It is:
• Pungent smelling
• Faster onset of action than Sevoflurane
• Fast recovery than Sevoflurane
 Side effects: airway irritability, cough ,and
some systemic side effects
Intra-operative mgt cont…
 Can be used for induction as well as for
maintenance of pediatrics day case surgery and it
• pleasant-smelling
• Fast onset of action
• Fast recovery
 Side effect: cardiac arrhythmias, bradycardia
,potent trigger for malignant hyperthermia etc.
Intra-operative mgt con…
Total iv anesthesia (TIVA)
 Can be used for maintenance of pediatrics day care surgery.
Some of the drugs are:
 Thiopental is
 rapid onset
 relatively short duration of hypnotic action
 Relatively rapid recovery
However, thiopental:
• can produce a “hangover” effect
• Pain on injection
• Slight nausea and vomiting
 But can be used safely on day case bases.
Intra-operative mgt con
 Etomidate can also been used for induction(0.2 to 0.3) and
maintenance (1 to 3 mg/kg) .
 Recovery tends to be faster than thiopental
 Disadvantages of etomidate include :
• pain on injection
• high incidence of PONV,
• myoclonic movements,
• transient suppression of adrenal steroidogenesis.
 due to these side effect profile, the use of etomidate is restricted. But
in cardiac unstable patients it can be safe (e.g. if we suspect chd)
Intra-operative mgt cont
 Propofol is the safest due to:
• Fast onset of action
• extremely high metabolic clearance rate .
• Recovery after propofol anesthesia is superior from all
other iv-agents.
• More costly but cost effective
• No post operative nausea and vomiting
• fewer perioperative side effects.
• Decreases the requirement for antiemetic medications.
Intra-operative mgt cont
Muscle Relaxants
• Mostly NMB agents are not advised for p.day case surgery.
• If relaxation is mandatory we can use short acting relaxants
(eg.succinylcholine, rocuronium).
Fluid therapy
 The goal fluid therapy is
• to correct preoperative deficits
• to replace intraoperative losses.
 PONV is reduced if the child is well hydrated intraoperatively.
 A simple approach is to give 10-20ml/kg Hartmann’s solution and monitor
 Postoperatively it is safer for the child to manage their own fluid
requirements via the oral route.
Intra-operative mgt cont…
Non steroidal anti-inflammatory drugs and paracetamol
 Are the mainstay of pain relief. The advantage over opioid analgesics
• a lack of respiratory depression and sedation.
• They do not cause nausea or vomiting.
 Use of NSAIDs is not recommended below six months of age due to the
possibility of immature renal function and hepatic metabolism. Most
commonly used agents are:
• Diclofenac (1mg/kg, PO/PR 8 hourly prn)
• Ibuprofen (5-10mg/kg PO 6-8 hourly).
• Paracetamol (10-15mg/kg PO/PR/IV, maximum 60mg/kg/day <3 months,
90 mg/kg/day in older children).

Intra-operative mgt cont…
 multimodal approach using local anesthesia, paracetamol
and NSAIDs if NSAIDs alone fail to control.

 not ideal for pediatric day case surgery b/c
• produce ventilatory depression
• excessive sedation and PONV.
 Procedures such as adenotonsillectomy may require
opioid therapy so we can use fentanyll (1-2mcg/kg)
commonly .
Intra-operative mgt cont..
Regional blocks (Peripheral nerve blocks)

A wide range of peripheral nerve blocks are potentially applicable to

pediatrics day case surgery
•Penile block: for circumcision ,minor hypospadias surgery and other penile
procedures .
•Ilioinguinal-iliohypogastric nerve block: ilioinguinal and iliohypogastric
nerves block provide effective analgesia after inguinal hernioraphy and for
groin incision performed for orchidopexy.
•Greater auricular block: block of this nerve , which innervates most of the
pinna, provides excellent analgesia(decrease vomiting) after otoplasty .
•Caudal epidural block: is widely applicable in pediatrics day case surgery,
providing excellent anesthesia below the umbilicus.
Postoperative management

After day case surgery ,children should recover in a fully equipped

recovery room .
•The successful management of PONV is an important component
in the care of children after surgery. PONV may cause discomfort
and distress, delay recovery and prolong hospitalization. A
multimodal management approach is useful:
•Avoid emetogenic anesthesia techniques (e.g. morphine IV)
•Preoperative intravenous hydration
•Adequate pain control
•Multiple different antiemetic medications (double or triple
combination antiemetic therapy acting at different neuroreceptor
sites) eg.Droperidol at low dose 20micrgrm per kg.
Post- operative mgt cont…
 Some of the commonly used antiemetics include:
• Ondansetron 0.1mg/kg IV
• Dexamethasone 0.1mg/kg IV
• Cyclizine 0.5-1 mg/kg IV
Postoperative pain control
 postoperative pain should be controlled by
• Short acting Opioids
• Multimodal approach
Post operative mgt…
Discharge criteria
 Deciding appropriate time to discharge the child home
depends on
• anesthetic, surgical, and social factors
• adequacy of post operative symptom control.
Post operative mgt
 A more objective discharge scoring system has been developed to
evaluate and document the patient's readiness for discharge. The
so-called post anesthetic discharge scoring (PADS) system ; it is
based on five major criteria:
• (1) Vital signs, including blood pressure, heart rate, respiratory rate,
and temperature
• (2) Ambulation and mental status
• (3) Pain and PONV
• (4) Surgical bleeding
• (5) Fluid intake/output.
 Patients who achieve a score of 9 or greater are considered fit for
discharge (or “home ready”).
Modified Post anesthesia Discharge Scoring (PADS) System
Vital Signs   Pain  

2 Post operative mgt con…

Stable ,near normal or
2 Minimal

1 Slight abnormality 1 Moderate

0 Unstable vital sign 0 Severe
Ambulation   Surgical Bleeding  
2 Steady gait/no dizziness 2 Minimal
1 With assistance 1 Moderate
0 0 Severe
Nausea and Vomiting  

2 Minimal
1 Moderate
0 Severe
Post-operative mgt cont…
 Generally the following criteria must be met before discharge:
• Vital signs and conscious levels should be normal
• Protective airway reflexes fully regained
• No respiratory distress or strider
• No unexpected intraoperative anesthetic events
• No bleeding/surgical complication  
• PONV absent/mild
• Pain absent/mild
• appropriate ambulation
• Written or verbal instructions issued
• Escort home by responsible adult
Post operative mgt cont…
 follow up of discharged patent is mandatory for the success
and effectiveness of day case surgery. it may be by :
 phone
 Or by other communication means

•Day case surgery is procedure performed on day and the patients

are discharged on the day of surgery.
•Children are good candidates for day case surgery.
•Day case surgery is fast and young growing field and very
important for developing countries like Ethiopia.
•Proper pre-operative assessment is vital for safety of patient both
intra-operatively and post operatively.
•Proper facilities are very important for success of day case surgery.
•A variety of general surgical, orthopedic, urological, ENT and
radiological procedures can be undertaken as day cases in children.
Summary cont.
• Good psychological preparation and close involvement of family is
• The full range of pediatric equipment, monitoring devices and
resuscitative equipment should always be available
• Anesthetic technique can be chosen depending on the needs of the
• A multimodal approach is useful for successful management of
pain and control of postoperative nausea and vomiting.
• Adequate analgesia must be provided at home.
• Parents must be provided with verbal and written postoperative
instructions about wound care, analgesia, diet, mobilization and
resumption of normal activity.
What do you understand from the image? Is that proper way of
discharging pediatrics day case surgery??


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Livingstone,2009,7th edition
• Paul G.Barash.Clinical Anesthesia.Philadelphia :Brain Brawn ,
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University ,1994,10-20
• Steward DJ.Anesthesia for pediatrics out patients.Can Aneasth
• Day case and short stay surgery2.The Association of anesthetists
of Great Britain and the British Association of day surgery
AAGB.London 2011