Day surgery for children

Paediatrics

Day surgery for childrenVinod Patil

Liam J Brennan

Abstractchildren are excellent candidates for day-case management as most are

healthy and require minor or intermediate surgery of short duration.

the cost-effectiveness of day surgery is particularly attractive to health-

care providers, and consequently the UK government have declared

that at least 50% of elective children’s surgery should be performed

as day cases. day-case management is also advantageous for children

and their families. the psychological impact of hospital admission is

avoided, hospital-acquired infection is minimized and disruption to fam-

ily routines lessened. a successful paediatric day-case service minimizes

postoperative morbidity and has low inpatient admission rates. Good-

quality anaesthesia is essential for achieving these goals, along with an

experienced multidisciplinary team working in child-friendly surroundings.

scrupulous attention to perioperative symptom control (particularly pain

and vomiting) is essential for successful day surgery. the child at risk of

postoperative nausea and vomiting should be identified and treated with

prophylactic anti-emetic medication. Post-discharge analgesia should be

prescribed regularly rather than as required to optimize pain control.

children may be discharged when their vital signs are stable, pain and

nausea are well controlled and there are no surgical concerns.

Keywords day surgery; discharge criteria; exclusion criteria; paediatric

anaesthesia; preoperative preparation

Successful paediatric day surgery requires a multidisciplinary team, involving experienced senior medical staff, paediatric nurses, play therapists and other administrative staff working in a child-friendly environment. Standards for day surgery for chil-dren are outlined in a report by Thornes.1 This is a wide-ranging multidisciplinary report, and is the blueprint for a high-quality children’s day-surgery service. The quality standards for paedi-atric day-case management adapted from this report are shown in Table 1. The advantages of paediatric day-case management are outlined in Table 2.

Vinod Patil, FRCA, is a Specialist Registrar in the East Anglian School of

Anaesthesia.

Liam J Brennan, FRCA, is a Consultant Paediatric Anaesthetist at

Addenbrooke’s Hospital, Cambridge. He trained in paediatric

anaesthesia at The Hospital for Sick Children, Great Ormond Street,

London, and has written extensively on the subject of paediatric

day-case anaesthesia.

aNaestHesia aNd iNteNsiVe care MediciNe 8:5 17

Selection criteriaMost children are healthy and are therefore suitable for day-case management. However, some children are not suitable, and the most frequent reasons for exclusion are shown in Table 3.

Ex-preterm infants less than 60 weeks post-conceptual age are generally excluded from day-case management, but may be accepted in specialist paediatric centres. In some district hospi-tals, the lower age limit may be as high as 3 years, depending

Quality standards for paediatric day-case management

• an integrated admission plan should be formulated to

include pre-admission, day of admission and post-admission

care with planned transfer of care to community services

• child and parent should be offered preparation before and

during the day of admission

• Parents should be provided with specific written information

• children should be admitted to a designated day-case area

and not mixed with acutely ill inpatients

• children should not be admitted or treated alongside adults

• specifically designated day-case staff should care for the child

• Only staff with paediatric and day-care experience should

manage the child

• care should be organized so that every child is likely to be

discharged within the day

• the building equipment and furnishings should comply with

children’s safety standards

• the treatment environment should be child-friendly

• essential documentation should be completed before the

child’s discharge to ensure efficient aftercare and follow-up

• Paediatric nursing support should be available to children at

home

adapted with permission from thornes r. Just for the day. London: NaWcH, 1991

Table 1

Advantages of paediatric day-case management

Child and family • Fewer behavioural disturbances, such

as nocturnal enuresis, regression of

treatment milestones and disturbed

sleep patterns

• reduced exposure to hospital-

acquired infection

• reduced disruption to family routines

• High parental and child satisfaction

Institutional • cost-effective

• reduced waiting lists

• enables relocation of resources to

more complex cases

Table 2

6 © 2007 elsevier Ltd. all rights reserved.

Paediatrics

on the clinicians’ training and experience of managing young children.

Anaesthetizing a child who has a significant respiratory infec-tion increases the risk of perioperative complications, such as laryngospasm, bronchospasm and atelectasis. Surgery should be rescheduled at 2 weeks after resolution of upper respiratory symptoms or at 4 weeks if the lower respiratory tract is involved. Cancelling day surgery for children with benign, non-infectious seasonal rhinitis (a clear ‘runny nose’) offers no clinical bene-fit. However, day surgery for children with moderate or severe respiratory tract infections associated with significant pyrexia (>37.5 °C), purulent secretions, productive cough and ausculta-tory signs should be postponed. Prolonged procedures (>1 hour) are a general exclusion but not an absolute contraindication to day-case management.

Preoperative screening and investigationsScreening in advance of surgery is essential for the smooth run-ning of a day-case service. It allows recognition of children who are unsuitable for day management because of medical or social difficulties (e.g. live a long distance from the hospital) and so minimizes cancellation on the day of surgery.

Nurse-led assessments with standardized questionnaires are completed by parents face to face, via the telephone or online. Face-to-face assessment allows nursing and play-therapy staff to

Exclusion from day surgery

Age and medical exclusions

• ex-preterm infant <60 weeks post-conceptual age

• inadequately controlled systemic disease (e.g. epilepsy,

asthma)

• active viral or bacterial infection (especially respiratory)

• complex congenital heart disease

• cardiac murmur that has not been investigated

• Poorly controlled diabetes mellitus

• sickle cell disease

Surgical and anaesthetic exclusions

• inexperienced surgeon or anaesthetist

• Prolonged procedure (>1 hour)

• significant risk of excessive perioperative haemorrhage

• Opening a body cavity (excluding laparoscopy)

• difficult airway

• sleep apnoea

• ? Malignant hyperthermia susceptibility

• Unlikely relief of pain by oral analgesia after discharge home

Social exclusions

• Parents incapable or reluctant to care for child at home

• Unsupported single parent with other children

• inadequate housing conditions

• No telephone

• inadequate postoperative transport arrangements (public

transport unacceptable)

• Long journey home after discharge (>1 hour)

Table 3


initiate the psychological preparation of the child. This is particu-larly important in day-case management when there is limited time on the day of surgery to orientate the child to the day’s events. At the assessment, parents are provided with literature about the day-case process and specific information regarding their child’s planned surgical procedure. These leaflets empha-size the parent’s role in preparing the child for surgery, what to expect on the day of admission and the aftercare requirements following discharge.

Investigations are rarely required for children coming for day-case procedures. For children of Afro-Caribbean origin most anaesthetists request documentation of sickle cell status.

Psychological preparationPre-admission programmes led by play specialists using play simulation, video presentations and visits to the day unit have been shown to improve the perioperative behaviour of children and decrease the requirement for sedative premedication. On the day of surgery, this approach is continued. In a child-friendly environment paediatric nursing staff and play therapists use a good range of quality toys and books to provide distraction (Figure 1). Age and developmentally appropriate activities are required. Computer games, videos and interactive personal software products are popular with older children.

Anaesthetic managementOn the day of surgery, when the anaesthetist meets the child and his or her family or carers, a review of the screening question-naire clarifies any equivocal issues. A relevant clinical examina-tion ensures that there is no contraindication to proceeding with anaesthesia. The anaesthetist should establish a rapport with the child and provide age-appropriate information concerning the anaesthetic. Information, reassurance and verbal consent for procedures such as administration of rectal medications or local anaesthetic techniques will allay parental anxiety. Finally, the parents’ questions should be queried, answered and documented on the anaesthetic chart.

Premedication: cutaneous anaesthesia with either tetracaine gel (Ametop) or a eutectic mixture of lidocaine and prilocaine

Figure 1 Patient in a child-friendly environment.


Paediatrics

(EMLA) will ensure painless venous cannulation provided it has been applied over suitable veins and has been in place for an ad-equate length of time (Ametop, 45 minutes; EMLA, 60 minutes).

Sedative premedication is not routinely used but may be ne-cessary to calm an anxious child. Oral midazolam (0.5 mg/kg) administered in a suitable vehicle such as a paracetamol elixir or a small volume of fruit cordial 20–30 minutes before surgery is very effective at decreasing the stress of induction. This does not produce excessive postoperative sedation, and does not delay discharge from hospital.

Preinduction techniques: uncooperative preschool children very occasionally require intramuscular (i.m.) preoperative sedation when oral sedation has been refused or ‘spat out’. With parental consent, low-dose i.m. ketamine (2 mg/kg) can be used as a final resort. This agent has an onset of 3–5 minutes and a minimal effect on recovery time. Anxious older children may also require preoperative sedation. However, if this fails the ‘Gillick compe-tent’ child who absolutely refuses to cooperate with anaesthetic induction should not be restrained but deferred for counselling in conjunction with their parents.

Induction: the choice of technique depends on the needs of the child, with the goal of producing a smooth atraumatic induction. Parental presence helps in achieving these aims. Intravenous induction is increasingly preferred but inhalational induction is useful for children with difficult venous access or those with needle phobia. Inhalational induction is facilitated by the use transparent, flavoured facemasks. Sevoflurane is the agent of choice because of its rapid onset of action and lack of irritation of the airways.

Propofol (up to 5 mg/kg) effectively obtunds airway reflexes, facilitating easy insertion of the laryngeal mask airway (LMA). Pain on injection with propofol is minimized by the addition of lidocaine (0.2 mg/kg) administration into a large vein or convert-ing to Propofol-Lipuro.

Maintenance with nitrous oxide, oxygen and a volatile agent (isoflurane or sevoflurane) is frequently used, but total intra-venous anaesthesia (TIVA) with propofol has definite advan-tages in cases where postoperative nausea and vomiting (PONV) is a major problem (e.g. strabismus correction). Knowledge and experience of TIVA in children is not as advanced compared with adult practice, but a paediatric algorithm for target-controlled infusion of propofol has recently become available.2

Airway managementSimple airway management techniques such as mask anaesthe-sia or the LMA should be used whenever possible for day cases. Tracheal intubation should be avoided to minimize the use of muscle relaxants and reduce the small but significant risk of post-extubation stridor. If intubation is required, the use of short-acting opioids in conjunction with propofol should be considered to facilitate larnygoscopy.

Fluid managementDay-case procedures are not usually associated with significant fluid losses, and preoperative dehydration should not occur. How-ever, perioperative hydration is beneficial if children are at risk of


PONV or perioperative haemorrhage (e.g. adenotonsillectomy), and where the child has excessive pre-operative starvation times.

Perioperative analgesiaCareful attention to pain control is critical for successful pae-diatric day surgery. Effective pain relief requires a multimodal analgesic technique.

Local anaesthesiaTopical – tetracaine eye drops for strabismus surgery or lido-

caine ointment after circumcision surgery provides simple but effective analgesia.

Wound infiltration – long-acting local anaesthetic, such as levobupivacaine (2 mg/kg) can be effective for postoperative analgesia, and may be used as the sole anesthetic for superficial procedures in cooperative teenagers.

Peripheral nerve blocks – for day surgery, nerve blocks need to be quick and easy to perform, and work reliably. For these reasons, only a limited range of techniques is used in day cases, including ilioinguinal, dorsal penile and greater auricular nerve blocks (see page 189).

Caudal extradural block – caudal blocks are easy to perform and provide reliable analgesia for surgery below the umbilicus. Care is required when using the technique in older children, as lower limb weakness may limit the ability to ambulate after surgery and hence delay discharge. Recently, ketamine (preservative-free, 0.5 mg/kg) and clonidine (1 μg/kg) have been shown to usefully prolong caudal analgesia initiated with local anaesthesia, without producing significant side effects such as drowsiness, which will delay discharge after day surgery.

Non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol: diclofenac (1 mg/kg) and ibuprofen (5–10 mg/kg) are the most commonly used NSAIDs, and are given as an oral premedica-tion or rectally after induction of anaesthesia (with prior parental agreement). Paracetamol is universally used.

Opioids: short-acting opioids like fentanyl (1–2 μg/kg) or alfen-tanil (10–20 μg/kg) are useful agents for day cases because they provide good intraoperative analgesia and decrease anaesthetic requirements. Remifentanil, an ultra- short-acting mu opioid receptor agonist, has a rapid onset of action and consistent meta-bolism, regardless of duration of infusion. These features make it a potentially attractive intraoperative analgesic option for paediatric day care, particularly in combination with propofol-based TIVA. However, it can be difficult to use remifentanil without inducing significant hypoventilation, necessitating assisted ventilation dur-ing anaesthesia. In addition, appropriate analgesic overlap must be provided before the remifentanil infusion is stopped to avoid postoperative pain and emergence phenomena.

Routine morphine administration should be avoided, as it is associated with excess sedation and high PONV rates. Codeine can be useful as ‘rescue’ analgesia postoperatively.

Postoperative nausea and vomitingCommonly performed day-case procedures (e.g. orchidopexy, otoplasty, strabismus surgery) are associated with PONV. Apart from the surgical procedure, other risk factors for this condition


Paediatrics

include previous history, sex, motion sickness and early post-operative mobilization. Reduction of PONV is achieved by minimizing exposure to known precipitants (e.g. opioids) and treating the high-risk patient with prophylactic anti-emetics. Ondansetron (0.1–0.15 mg/kg) is particularly suitable as it is non-sedating and does not produce extrapyramidal side effects. Dexamethasone has useful synergistic action in difficult PONV cases such as tonsillectomy.3

Discharge criteriaChildren are discharged when their vital signs are stable, pain and nausea are well controlled and there are no surgical prob-lems. Many centres have required children to drink before dis-charge. However, studies have shown that there is no excess morbidity in children who refuse to drink if they have received perioperative intravenous hydration.4 Similarly, the necessity to pass urine has been challenged, and is now required only on surgical grounds (e.g. after penile surgery).5

Before discharge parents should receive clear written and ver-bal advice on the care of their child, and the procedure for con-tacting the hospital in case of problems should be emphasized.

Post-discharge analgesiaThe regimen used at the authors’ day unit at Addenbrooke’s Hospital, Cambridge, is shown in Table 4. It is important to explain

Post-discharge oral analgesia

Age group Analgesia (four times daily)

<1 year Paracetamol 15 mg/kg

1–10 years Paracetamol 15 mg/kg ± ibuprofen

5–10 mg/kg ± codeine elixir 0.5 mg/kg

>10 years compound paracetamol/codeine preparations

(e.g. co-codamol) ± ibuprofen 200–400 mg

Table 4


the need to give analgesia regularly to ensure good pain relief rather than on an as-required basis. In addition to oral analgesia, topical local anaesthesia can be continued after discharge home.

Reasons for inpatient admissionThe commonest problems requiring inpatient admission are intractable vomiting and uncontrolled postoperative pain. A widely quoted benchmark for inpatient admission is 1–2%. The possibility of admission should always be discussed with parents during preoperative assessment.

SummaryMost children’s elective surgery can be performed as day sur-gery. Good preparation of the child and his/her family by skilled medical and nursing staff should make this process smooth, stress-free, and cost-efficient. ◆

REFEREnCES

1 thornes r. Just for the day. London: NaWcH, 1991.

2 absalom ar, amutike d, Lal a, et al. accuracy of the ‘Paedfusor’ in

children undergoing cardiac surgery or catheterization. Br J Anaesth

2003; 91: 507–13.

3 steward dL, Welge Ja, Myer cM. steroids for improving recovery

following paediatric tonsillectomy. cochrane database syst rev

2003; 1: cd003997.

4 schreiner Ms, Nicolson sc, Martin t, et al. should children drink

before discharge from day surgery? Anaesthesiology 1992; 76:

528–33.

5 Fisher Qa, Mccomiskey cM, Hill JL, et al. Postoperative voiding

interval and duration of analgesia following peripheral or caudal

nerve blocks in children. Anesth Analg 1993; 76: 173–7.

FuRThER READIng

Brennan LJ, Prabhu aJ. Paediatric day-case anaesthesia. BJA CEPD Rev

2003; 3: 134–9.


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