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FOCUS POINTS
Children with asthma are common in ambulatory surgery. Evaluation should be made for active disease. Rescheduling after a respiratory illness should be in 4 to 6 weeks.
Prematurity is less common in ambulatory practices, but still can be a significant risk. Histories for young children should be investigated and cases delayed to 45 weeks post-conceptual age (PCA) for full-term babies and ranges from 51 to 60 weeks for premature infants. Later is safer.
Congenital cardiac disease patients may be appropriate for outpatient surgery, but single-ventricle physiology should be absolutely avoided.
Embryology may be considered in evaluating children with syndromes. Those associated with abnormal airway physiology may be especially difficult in the outpatient setting.
Malignant hyperthermia (MH) is a genetic issue that may be unknown in pediatric patients prior to their exposure to an anesthetic. Neuromuscular syndromes may cause other anesthetic problems, but few are truly related to MH.
Risk factors for adverse events in pediatric anesthesia are mostly related to younger age, but also coexisting diseases and less so to types of procedure, length of procedure, and lateness in the day of procedure.
As with adults, children should be screened for sleep apnea especially in cases that involve the airway or long-term narcotic pain treatment. The STBUR score is analogous to STOP-BANG in adults.
Emergence delirium is more common in pediatric patients. Absolute cause is uncertain, but a multi-prong approach may be used by identifying risk factors and planning medications used.
Postoperative nausea and vomiting risk factors are different from adults and may be assessed case by case for age, procedure, family history, and surgery duration.
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Ambulatory surgery exploded in the 1990s. The most recent survey by the Centers for Disease Control and Prevention (CDC) in 2009 indicated that there were 53,329,000 ambulatory surgeries in the United States. Of these, 3,266,000 were carried out on patients under the age of 15 years and were evenly split between freestanding and hospital-based facilities. The pediatric cases were largely adenotonsillectomies, ear tube placements, fracture reductions/fixations, circumcisions, and diagnostic procedures such as endoscopies.1 Community providers performed most of these cases without specialty training in pediatric anesthesia.
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Ambulatory surgery centers (ASCs) are defined by the Centers for Medicare and Medicaid Services (CMS) as any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.2 This limits some procedures, but much of what a pediatric anesthesia practice covers meets these rules. A robust ASC can accommodate subspecialty cases from otolaryngology, orthopedics, general surgery, urology, ophthalmology, plastic surgery, dermatology, dentistry, gastroenterology, and even neurology, radiology, and physiatry.
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The success of an ASC depends on being prepared for the cases with not only correct staffing and instrumentation, but also patient selection. Ambulatory surgery depends on cases that are predictable with defined risks that ...