Handbook of Ambulatory Anesthesia (eBook)

Preanesthesia Evaluation and Testing.- Minimally invasive and advanced ambulatory procedures.- Adult Clinical Challenges.- Pediatric clinical challenges.- Pediatric perioperative management.- Adult preoperative preparation: equipment and monitoring.- Sedation techniques.- Regional anesthesia.- General anesthesia.- Anesthesia outside the operating room.- Office-based anesthesia.- Postanesthesia care recovery and management.- Discharge process.- Quality management, regulation, and accreditation.- Ambulatory surgery center profitability, efficiency, and cost containment.- Administrative aspects of ambulatory surgery.

"4. Pediatric clinical challenges (p. 96-97)

Lucinda L. Everett, MD
Gennadiy Fuzaylov, MD

Pediatric patients present for a wide variety of ambulatory surgical procedures. In general, children are good candidates for ambulatory surgery, but the patient screening and selection process needs to ensure that signi? cant associated conditions are avoided, particularly in the freestanding ambulatory setting. General patient selection concepts and overall risk information for the pediatric patient are presented. Speci? c clinical challenges presented by pediatric patients are summarized in this chapter, including respiratory issues such as respiratory infection and sleep apnea, gastrointestinal re? ux, congenital heart disease, Down syndrome, neuromuscular disorders, and children with hematologic disorders and cancer.

Pediatric ambulatory surgery: basics of preoperative evaluation

Over the past two decades, ambulatory pediatric anesthesia has changed dramatically across the country. The proportion of surgical cases done on an ambulatory basis is frequently estimated to be greater than 70%. Much pediatric surgery is performed in an ambulatory setting since many required procedures are relatively minor and because children represent a population that is largely healthy and free from chronic illness. Also, children (and their parents) generally prefer to recover from surgery in the comfort and security of their home rather than the hospital environment. In the pediatric ambulatory setting, the anesthesia provider is frequently presented with clinical dilemmas.

Patient and procedure selection, as well as availability of appropriate equipment and staff, may be issues in various practice settings. There has been signi? cant evolution in the approach to preoperative evaluation over the past decade. Thorough history and physical examination are the mainstays of preoperative evaluation; the requirements for laboratory testing and other evaluation of coexisting disease depend on the magnitude of the procedure as well as the patient’s clinical picture. The pediatric literature supports testing only in selected situations.

For children having anesthesia on an outpatient basis, the ? nal assessment as to appropriateness for ambulatory status should include coexisting diseases, magnitude of the procedure, and home support systems. Willingness to accept a particular patient and procedure may also depend on the speci? c practice setting; backup in a hospital-integrated ambulatory center makes transfer or unplanned admission much easier than in a freestanding center.

Mechanisms for preoperative evaluation should be designed to identify and potentially exclude high-risk patients, to identify coexisting disease that may have special care requirements, and to identify situations that may require either further evaluation or postponement due to acute illness (especially upper respiratory infection, or URI). Most healthy children do not require a preoperative anesthesia clinic visit prior to the day of surgery as long as surgeons are educated about the appropriate criteria for ambulatory status and patients are instructed to call if they are ill. A screening telephone call from the ambulatory center can be effective in identifying any parental concerns. The remainder of this chapter will discuss common problems that anesthesiologists encounter in pediatric patients in the ambulatory setting."