Pediatric Ambulatory Anesthesia

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Key points

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    Risk stratification is important to determine when it is safe to proceed with anesthesia in a child with current or recent upper respiratory infection.

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    Patients at risk of apnea should be admitted for overnight monitoring; these include former premature infants younger than 55 to 60 weeks postconceptual age, full-term infants younger than 44 weeks postconceptual age who demonstrate any respiratory abnormalities, and certain children with sleep apnea who are recovering from tonsillectomy.

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    In

Patient selection

Appropriate patient selection is critical to the success of outpatient surgery. Special areas of concern with children presenting for ambulatory anesthesia include upper respiratory tract infection (URI), apnea risk (among infants and those with sleep apnea), cardiac disease, and undiagnosed myopathy. The facility and expertise of available staff must also be considered in selecting younger or higher-risk children for outpatient surgery.

Nonpharmacological Anxiolysis

Anxiolytic premedication may be problematic in a rapid-turnover ambulatory surgery setting. For example, midazolam may delay recovery and discharge, whereas clonidine may require a lengthy onset time.51, 52 There are several nonpharmacological techniques to reduce preoperative anxiety, including professional entertainers (eg, clowns and magicians), audiovisual material (eg, videos, games, music), verbal techniques (eg, humor and distraction), and parental presence during the induction of

Intubation Without Neuromuscular Blockade: Remifentanil

Tracheal intubation without neuromuscular blockade (NMB) has become increasingly common in pediatric anesthesia,67 even though NMB use may actually be associated with lower PRAE risk.14 In the ambulatory surgical setting, there are several reasons to avoid NMB: there are no truly short-acting nondepolarizers; emergence may be delayed if the NMB is not reversible in time; and incomplete NMB reversal may produce subtle findings such as difficulty swallowing and visual changes, which delay street

Summary

Ambulatory anesthesia is safe for a variety of procedures in the pediatric population with careful attention to patient selection. Respiratory concerns include identifying significant upper respiratory infection, and ensuring appropriate overnight monitoring for patients at risk of apnea (ie, former premature infants or patients with significant OSA). Patients with muscular dystrophy or mitochondrial disorders must be evaluated carefully and drugs chosen to minimize the impact of anesthesia on

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      In light of this, there has been an evolving focus on outpatient procedures in many orthopedic interventions over the past 30 years.1,2 Although most prevalent in adult orthopedic surgery, this trend has been observed in the pediatric population as well.3,4 As experience with outpatient surgery increases, selection criteria has widened.5

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    Disclosure: Neither author is affiliated with companies that have a direct or competing financial interest in the material discussed in this article.

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