DAY-CARE SURGERY IN CHILDREN Children are excellent candidates for day care management as they are usually healthy and predominantly require minor or intermediate surgery of short duration.

1. DAY-CARE SURGERY
IN CHILDREN
Presenter : Dr. Gautham Patel
Moderator : Dr. Preethy Mathew

2. Introduction
• Children are excellent candidates for day care management as they are
usually healthy and predominantly require minor or intermediate
surgery of short duration.
• A successful paediatric day-case service is one which minimizes
postoperative morbidity, has low in-patient admission rates and
demonstrate high parental and child satisfaction.
• Good quality anaesthesia is essential to achieving these goals with
experienced clinicians working in child-friendly facilities.

3. Advantages of
paediatric
outpatient
anaesthesia
• Minimizes parental separation
• Uninterrupted feeding
schedule/sleep patterns
• Less risk of nosocomial infections
• Convenience/Improved patient
satisfaction
• Availability of beds for complex
,needy patients
• Reduced cost of hospitalization

4. Historical perspective
The practice of day-care
surgery was first reported by
Nicholl in 1909.
1909
In 1916, Ralph Waters opened
the first outpatient clinic in
Sioux city, Iowa.
1916
Outpatient anaesthesia was recognized as a
specialty and Society for Ambulatory
Anaesthesia (SAMBA) was organized in
USA in the year 1984.
1984
American Society of
Anaesthesiologists (ASA) has
amended its guidelines in 1998
for ambulatory anaesthesia and
surgery.
1998

5. Procedures Performed
Specialty Procedures
Otolaryngology Myringotomy and ventilating tubes, adenoidectomy , tonsillectomy, frenulectomy,
branchial cleft cysts, endoscopic sinus surgery, examination under anaesthesia
including some bronchoscopy
Ophthalmology Examination under anaesthesia, strabismus repair, nasolacrimal duct probe,
intraocular lens implantation, trabeculectomy
General pediatric surgery
and urology
Herniorrhaphy and hydrocelectomy, orchiopexy, uncomplicated hypospadias,
cystoscopy and cystoscopic surgery, circumcision, esophagoscopy, lumps

6. SPECIALTY PROCEDURES
Gastroenterology Endoscopy
Plastic surgery Cleft lip and some cleft palate repair, placement of tissue expanders, scar
revision, minor reconstructive procedures (otoplasty, septorhinoplasty,
etc.)
Orthopaedics Hardware removal, casting, percutaneous tenotomy, arthrograms
Percutaneous pinnings and simple ORIF
Radiology Imaging studies, radiation therapy
Dentistry Extractions, restorations, examinations
Nerve treatments, crowns, sealants, and fillings

7. Establishing paediatric 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 office based.
• 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.

8. Contd..
• 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.
• 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.

9. Patient Selection
• 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.
• The smoothness and success of entire hospital experience depends
upon proper planning and parental guidance during the preliminary
work up.

10. Preoperative screening
• To expedite the evaluation process and to ensure some degree of
uniformity, preoperative screening process is a very useful tool.
• 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 surgical
O.P.D. or during a telephonic conversation.
• This is followed by patient’s review and necessary laboratory
work up.

11. Exclusion criteria
Age and medical
exclusions
Surgical and anaesthetic
considerations
Social exclusions

12. Age and
medical
exclusions
• Former pre-term infant < 50 weeks
post-conceptual age
• Inadequately controlled systemic
disease
• Active viral or bacterial infection
• Complex congenital heart disease
• Uninvestigated cardiac murmur
• Diabetes mellitus
• Sickle cell disease
• Sleep apnoea

13. Surgical and
anaesthetic
considerations
• Inexperienced surgeon or anaesthetist
• Prolonged procedure (> 1 h)
• Risk of excessive peri-operative
haemorrhage
• Body cavity surgery
• Difficult airway
• Malignant hyperthermia
• Postoperative pain unlikely to be
controlled by simple analgesia

14. Social exclusions
Lack of parental
support
No telephone
Lack of transport
facilities
Long journey home

15. Indian perspective
• In a developing country like ours, cost is a very important factor. With
long waiting lists, practice of daycare surgery is likely to improve the
situation.
• 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, transport and health care facilities. Illiteracy,
incapable or reluctant to look after the sick child at home.
• We must be considerate about these issues and selection criteria need
to be modified accordingly.

16. Pre anaesthetic considerations
• The preoperative evaluation and assessment is just as crucial in
outpatient surgery as in all other surgical procedures.
• 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.
• 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.

17. 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
Absence from work/ extra visits (screening,
postoperative follow up)

18. Upper Respiratory Tract Infections
• The most common problem to confront the anesthesiologist caring for
children in outpatient surgery.
• Both upper and lower respiratory tract viral infections can increase
airway inflammation, irritability, and respiratory tract secretions by
mechanisms as diverse as increased production and decreased
degradation of tachykinins and other neuropeptides, viral induced
damage to M2 muscarinic receptors in the airways leading to vagal-
mediated hyperreactivity, and increased volume and viscidity of
airway secretions causing subsegmental atelectasis.

19. Contd..
• Laboratory tests are usually not useful; clinical impression is more
reliable, such as noting the presence of toxicity, fever, purulent nasal
discharge, productive cough, or wheezing.
• If physical examination suggests pneumonia, a chest radiograph may
be confirmatory. There should be a lower threshold for postponing
surgery in patients at increased risk, such as former premature infants,
children with underlying pulmonary disease, infants younger than 1
year of age, and children with sickle cell disease.

20. Contd..
• Patients who are to undergo surgery involving the airway should be considered
at increased risk.
• The risk of airway complications in children with URIs is least with a
conventional face mask, intermediate with a laryngeal mask airway (LMA), and
greatest with an endotracheal tube.
• If a child is deemed too ill for anesthesia and surgery to proceed, it is best to
wait 3 to 4 weeks from the resolution of the URI to reschedule the operation to
allow for resolution of airway hyperresponsiveness.
• One should anticipate that the child with a URI might have a modest
prolongation in PACU stay because of transient oxygen requirements or other
mild respiratory symptoms that can delay discharge.

21. Preparation of child and family
Family- Centred Care Preoperative Teaching
and Parental Presence
Premedication

22. Family- Centred Care
• There has been increasing emphasis in pediatric medicine on the care
of the child within the context of the family.
• The parent or primary caregiver becomes the surrogate nurse once the
child is discharged home and therefore must be involved to a greater
degree in the postoperative experience even before discharge from the
day-surgery unit.
• Parental involvement to include preoperative tours of the operating
room and PACU, parental presence during induction of anesthesia, and
admission of the parents to the PACU very soon after the child’s
arrival and emergence from anesthesia.

23. Preoperative Teaching and Parental Presence
• Outpatient surgery is an intense experience for both parents and
children. Many things happen within a short time span.
• Preoperative teaching programs have become common methods of
education to help families understand what to expect on the day of
surgery.
• The explicit goals of these programs are education and the efficient
transmission of information, an implicit goal is reduction of anxiety
and undesirable behavioral consequences of the stress of the
perioperative experience.

24. Contd..
• Although parental satisfaction was clearly increased by parental
presence during induction, and highly anxious children benefited from
presence, children’s anxiety and behavior were more effectively
modulated using premedication.
• Part of the art of pediatric anesthesia is the ability to rapidly establish
effective and reassuring communication with the parent and child.
• In the outpatient setting, where time is more constrained, the value of a
quick game, trick, should not be underestimated. Bringing a security
item, such as a blanket or favorite toy into the operating room, can
provide additional comfort to the child.

25. Premedication
• The use of sedative premedication has been shown to be the most
effective means of reducing preoperative anxiety, postoperative recall,
and maladaptive behavior in children undergoing outpatient surgery.
• Oral midazolam(0.25-0.5mg/kg) has become the most commonly used
premedicant.
• Oral midazolam have found that the drug delayed recovery, but the
actual time of discharge from the hospital was not prolonged.
• In institutions where the PACU is divided into phase I and phase II
areas, this translates to a longer stay in phase I recovery only.

26. Contd..
• Nasal (0.2 to 0.3 mg/kg), transmucosal (0.2 mg/kg), and rectal (0.3
mg/kg).
• In exceptionally uncooperative child Ketamine , often in combination
with midazolam and glycopyrrolate, is the most commonly used agent.
The usual doses range from 3 to 5 mg/kg; the lower doses are
administered in combination with 0.1 mg/kg of midazolam.

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