Introduction

For years we have been doing outpatient paediatric surgery under general Anaesthesia but only for real minor cases such as I and D abscesses, reduction of closed fractures, excision of small lumps and circumcision. But for last decade or so we have started doing more and more cases as day care, of course the success has been attributed to advances in surgical techniques and in the field of anaesthesia.

However patient’s safety can never be compromised in the name of ‘fast tracking and cost containment’. Top priorities for successful outpatient surgery are the 4 A’s—Alertness, Ambulation, Analgesia and Alimentation.

All of you must have experienced that patients demand quality care these days.

The parents have multiple questions and you must spend time giving satisfactory answers to their questions:

1. How long the child needs to be starved?
2. Can you put the child to sleep in our presence?
3. How will you look after my hyperactive child?
4. Will the child get lot of pain after the surgery?
5. When can we start feeding the child?
6. When the child can return to various activities?

For successful outcome of day surgery we have to take careful decision regarding:

1. Selection of patient
2. Selection of procedure
3. Information to family members
4. Anaesthetic consideration
5. Postoperative management
6. Discharge criteria
7. Prevention of complications.

Special risk factors and Exclusion criteria

1. Premature babies – Babies less than 60 weeks PCA.
2. H/O Sudden death syndrome in family.
3. URTI-increases perioperative respiratory complications –cough, Laryngospasm and bronchospasm.
4. Asthma- Treatment continued in preoperative period.
5. Heart condition- Murmur should be investigated and patient should be stable on treatment, Antibiotic coverage essential.
6. Seizures-patient should be well controlled and stable. Medication should be continued.
7. Hepatic and kidney functions should be within normal range.
8. Mental handicaps and Autism-patients should be stable.
9. Diabetes Mellitus-patients are not suitable for day care surgery.
10. Sickle cell disease-patients need proper preoperative vigilance and preparation so they are excluded.
11. Obesity- they have multiple problems, hence they are excluded.
12. Syndromic babies – may have metabolic problems, difficult airway, hence excluded.
13. Malignant hyperthermia – susceptibility, therefore, excluded.

Procedures commonly performed as day care

1. Gen. surgery – circumcision, hernia, orchidopexy, exc, of lumps, I and D of abscesses, tongue-tie release and many more major surgeries.
2. Diagnostic and therapeutic procedures – Laryngoscopy, tracheo-bronchoscopy, oesophagoscopy, dilatation, gastroscopy, colonoscopy, cystoscopy, CT Scan, MRI,

   Transoeso-echocardiography, cardiac catheterization.

3. ENT- Tonsil and adenoid surgery, Myringotomy, tube insertion, closed reduction of nasal fracture.
4. Dental – Extraction, restoration.
5. Ophthalmology – EUA, Lacrimal duct probing, exc. of chalazion or cyst.
6. Plastic Surgery – Otoplasty, exc. of skin lesions, scar revision, procedures for syndactyly and polydactyly.
7. Orthopaedic - closed reduction of fractures and arthroscopy, cast changes, removal of pins and plates.

In these procedures there are no physiological disturbances, such as, major fluid or blood loss, minimal risk of anaesthetic and surgical complications.

Simple nursing care is required post-procedure that can be taken by parents, such as, administration of oral medication like analgesics, antibiotics and anti-emetics. No major limitations on child’s activities are required.

Preoperative assessment and tests

Day care surgery demands the highest standards of professional skill and organization. Although the operation could be minor, an anaesthetic is never minor.

It is advisable to operate the patients with physical status of ASA grade I and II only. Routine screening includes CBC, Routine urine examination. Investigations appropriate to clinical complaints and examination findings are done additionally.

Coagulation profile may be done in appropriate situation.

Preoperative fasting

(In emergency surgery we have to follow a full stomach routine, which is not common in day surgery).

Pre-medication

Pharmacological pre-medication is extremely useful

1. To allay anxiety
2. To facilitate separation from parents
3. To allow smooth induction by mask or IV.
4. To reduce autonomic reflexes.
5. To reduce airway secretions.

When one tries to anaesthetise a crying and howling child, there is an increased incidence of cough and laryngospasm.

The choice of premedicant is based on patient’s age, physical status, emotional maturity, the surgical procedure and personal preference. Out of the oral, rectal, nasal, sublingual and transmucosal routes, the oral route is more popular.

Commonly used drugs in a paediatric patient are:

(Since both are bitter in taste they can be given with honey.)

Local anaesthetic skin preparation such as tetracaine gel or Lignocaine –prilocaine mixture cream is excellent. Painless venepuncture in the pressure of parents and small sedative dose given before wheeling the patient to OT, is well appreciated.

Induction of Anaesthesia

Ideal agent should produce rapid smooth induction, rapid emergence, prompt recovery and minimal side effects, so the patient can be discharged early.

Inhalational Induction

Halothane and sevoflurane, are the two preferred agents. They have pleasant smell and within few breaths the babies can be put to sleep, then intravenous line can be taken.

Sevoflurane offers better cardiovascular and haemodynamic stability. It helps rapid induction and emergence, it provides excellent intubating conditions, it is not linked with hepatitis and does not sensitize myocardium to catecholamines.

Intravenous Induction

It is smooth when painless venepuncture is performed. Propofol is the drug of choice as it offers safe smooth induction with low incidence of side effects. Dose recommended is 2-3 mg/kg.

Advantages of Propofol

1. Respiratory depression and depression of Laryngeal reflexes, more than thiopentone, allows easy placement of Laryngeal mask airway or intubations, without muscle relaxant.
2. It has anti-emetic property.
3. Emergence is fast without hangover. Pain while injecting can be minimized by adding Lignocaine 0.2 mg/kg IV with Propofol. Thiopentone can be used in the dose of 5-7 mg/kg.

Intramuscular induction

Ketamine in the dose of 4-6 mg/kg can be given 5-10 min. before wheeling the patient to O.T., atropine or Glycopyrolate should be added to minimize salivary secretions. Ketamine must be given in a monitored care setting.

Midazolam can be given IV in the dose of 0.05 mg/kg. To sedate the child so other monitoring devices can be applied and then, induction can be started.

Maintenance

Short or medium acting muscle relaxants such as Atracurium, Rocuronium or vecuvonium can be used and analgesia can be provided with Fentanyl or Pethidine or Pentazocine. Relaxants should be adequately antagonized at the end. For maintenance halothane or Isoflurance are popular for their easy availability; however, servoflurane or Desflurane can also be used. Succinyl choline is indicated in emergency situation or during difficult airway for its short action. It should be avoided in undiagnosed myopathies as it can cause life threatening hyperkalaemic cardiac arrest.

MRI or CT scan in children can be done under propofol alone, as these procedures are painless.

Propofol, 100-150 µg/kg/min, can be infused through the syringe pump. However, monitoring of airway is absolutely essential.

Airway Maintenance

Indications for intubations do not differ between outpatients and inpatients. Most procedures around head and neck need intubation. Laryngeal mask airway or combined, pharyngeal airway can be used without the use of muscle relaxants. However, in emergency situation one must be aware that they do not protect airway against the aspiration of gastric contents.

Fluids

Every patient should have intravenous line and adequate maintenance fluids. Deficit for the fasting should be given in the form of Isolyte-P or Dextrose-saline. The fluids should be continued in the postoperative period until the child starts taking oral fluids.

Pain Management

For day care surgery it is extremely important part of paediatric anaesthesia. We have to consider multimodal pain management, which extends intraoperative analgesia to postoperative analgesia. Intraoperative Fentanyl or Pethidine or pentazocine is supplemented with regional blocks or peripheral nerve blocks according to the type of surgery.

Penile Block

Dorsal nerve of the penis is the most reliably blocked by bilateral injection method to overcome septation of the sub pubic space and to avoid midline vessels. Injections are made bilaterally from sub pubic margin 0.5 cm lateral to midline with short bevelled 24-25G needle. It is useful to use the bone of the pubic arch as depth gauge and withdraw needle a little before aspirating, then injecting. plain Bupivacaine 0.5%, 0.1 ml/kg per injection.

Ilio-inguinal / Ilio-hypogastric block

Injection of Bupivacaine 0.25%, 0.3 ml/kg, using a short bevelled 22G needle deep to external oblique aponeurosis will ensure block of both nerves at a point one finger’s (patient’s) breadth medical to anterior superior iliac spine.

Metacarpal / Metatarsal blocks

Can be given for syndactyly or polydactyly surgery. The effect of Bupivacaine in these blocks can last for 6-8 hours.

Caudal-epidural block

Single injection is very effective for orchidopexy, inguinal hernia, orthopaedic surgery of lower extremity.

Bupivacaine 0.25%, 0. 5 ml/kg for sacral or lumbar blockade, 0.75 ml/kg for lower thoracic blockade (T10) and 1 ml/kg for mid thoracic blockade (T8). Caudal block lasts for about 4-6 hours. The duration can be doubled by adding clonidine-1 µg/kg or quadrupled by adding preservative free Ketamine - 0.5 mg/kg. These additives should not be used in infants.

Brachial plexus block

For upper extremity surgery is very useful and lasts for 6-8 hours. There are different approaches such as inter-scalene, para-scalene, axillary or supra-clavicular. Axillary approach is easier, safer and reliable.

22G short bevelled needle can be used and single shot injection can be given at the highest point in the axilla just above the axillary artery. ‘Pop’ can be felt when sheath of the neurovascular bundle is pierced. Bupivacaine 0.25% and 1% Lignocaine with adrenaline, mixed in equal volume, can be given in the dose of 0.5 to 0.75 ml/kg.

Sciatic, Femoral or 3-in-one block

It can be given for surgery on lower extremity. Mixture of 0.25-0.5% Bupivacaine and Lignocaine with adrenaline can be used in the quantity of 1 ml/kg with a short bevelled long needle.

Ankle Block

It can be given for surgery on the foot. One must remember that patients with lower extremity block are prone to injury when discharged. So they should be properly looked after at home.

When it is not possible to give above blocks, surgeon can properly infiltrate the surgical wound in layers while closing and this simple method can give good analgesia postoperatively.

Postoperative analgesia can be supplemented with oral analgesics before the onset of pain when the effects of regional and peripheral blocks have worn off.

Oral Analgesics

For mild pain paracetamol 10-15 mg/kg alone or in combination with NSAID can be given. Keterolac 10 mg/kg or Ibuprofen or Paracetamol can be given in the form of rectal suppositories to young children every 6 hourly.

Complications

Most commonly seen complications are:

• Pain,
• Sore throat, headache and drowsiness,
• Postoperative nausea and vomiting, which can be prevented can be prevented by Ondansetron 0.1 mg/kg IV or Dexamethasone oil: 0.1-0.15 mg/kg or Metoclopramide 0.1 mg/kg can be given.

Promethazine 0.5 mg/kg—may prolong recovery time.

Croup

This may occur immediately after extubation or within 3 hours. Treatment involves humidified O2 and if severe, nebulization with epinephrine. Patients should be observed for 2-3 hours after they settle down.

Our problems can be enlisted as:

1. Lack of proper organized day care facility.
2. Lack of proper information and understanding of the parents.
3. Lack of proper pre and postoperative monitored care area.
4. Lack of certain drugs and equipment.
5. Lack of insurance cover by some insurance companies.

Discharge Criteria

1. Vital signs and conscious level normal.
2. Protective airway reflexes fully regained.
3. No respiratory stridor
4. No active bleeding.
5. O2 saturation above 95% on room air.
6. Nausea, vomiting absent.
7. Only mild pain or discomfort.
8. Appropriate ambulation for age.
9. Written or verbal instruction and contact number issued.
10. Responsible person to take the child home.

Conclusion

Success and popularity of out patient surgery can be attributed to proper evaluation in the clinic, appropriate preoperative fasting, and use of newer anaesthetics, anti emetics and analgesics with better monitoring in peri-operative period.

#Printed with the permission of the Editor, Day Surgery Journal of India *Ex-HOD Anaesthesia, Wadia Children Hospital. Consultant Paediatrician, Anaesthesiology, Breach Candy Hospital, Mumbai 400 026.