Address for
Correspondence: Dr. MC Rajesh MD, MBA, Senior Consultant
Anaesthesiologist, Baby Memorial Hospital, Kozhikode, Kerala,
India. PIN: 673004. E- mail: rithraj2@yahoo.co.in
Introduction
The International Association for Ambulatory Surgery (IAAS)
defined Ambulatory surgery in 1995 as a ‟surgical or
diagnostic interventions, currently performed with traditional
hospitalisation, that could, in most cases, be accomplished
with complete confidence without a night of hospitalisation.
Among other things, these procedures require the same
technically sophisticated facilities as when done on an
inpatient basis, rigorous pre-operative selection procedure
and post operative follow up of for several hoursˮ.
There has been a tremendous push for day care surgery
especially in the last two decades. With the objective of
developing day care procedures, Society for Ambulatory
Anaesthesia (SAMBA) came into force in 1984. As in adults;
paediatric surgical practice is no exception in popularising
this concept. The obvious benefits like minimising healthcare
costs, optimal utilization of resources at the face of
shrinking healthcare resources (maximizing efficiency with
fewer costs), less disruption of family schedule and decreased
exposure to nosocomial infections (particularly beneficial in
Oncological and immune compromised patients) has further made
day care procedure more acceptable.
Ambulatory surgery is much favoured in children since they are
usually healthy with no major co morbidities and many of the
procedures are superficial without significant haemodynamic
disturbances. There are many factors which contributed to the
rapid growth of this concept like the psychological and
emotional advantage of avoiding inpatient admission for the
family, the newer anaesthetic and analgesic agents with rapid
recovery profile, judicious use of regional anaesthesia and
improvements in surgical techniques [1]. In fact, the European
Charter of children's rights states that ‟children should be
admitted to hospital only if the care they require cannot be
equally well provided at home or on a day basis [2]ˮ. But for
the anaesthesiologist to decide upon whether to take up for a
day case or not depends on many factors like the control
of any coexisting diseases, extent of surgical procedure and
the available home support system. However there are
challenges in organizing the structure especially in a set up
with scarcity of resource [3].
Design
Paediatric ambulatory units are usually customized and
specially designed setups with toys, cartoon pictures and
games to reduce their anxiety. A well designated day care unit
increases the efficiency, patient satisfaction and cost
cutting for the organization. These advantages are not
achieved when the day care procedure in children are mixed
with adults or with more complicated paediatric populations.
But most of the time due to resource and space constraints, we
are forced to mix-up adults and paediatric populations in the
same surgical unit. In such scenarios, special considerations
should be given to the needs of paediatric populations.
Committing for an ambulatory surgery is in no way a compromise
from the requirements for the inpatient surgical population.
In fact the sterility, record keeping and specifications for
the anaesthetic and recovery areas should be of the same
quality as for any in - hospital patients. Standard
resuscitation equipments specific to paediatric patients of
all ages and difficult airway cart should also be available.
Facility for prolonged recovery, observation and if need
arises for overnight stay must be fulfilled by the ambulatory
centre.
Free standing ambulatory unit is an autonomous centre. Here
the ambulatory surgical unit may be in association with a
hospital, but in a separate building that share no space or
patient function. These are basically autonomous units which
do all the preoperative evaluation, surgery and recovery
within the unit [5].
Office based procedures are done in conjunction with
physicians office, wherein they carry out limited ambulatory
procedures.
Procedures
Some of the usual day care procedures include
Myringotomy,grommet insertion, herniotomy, dental extractions,
upper and lower gastrointestinal tract endoscopy, cystoscopy,
circumcision, orchidopexy, chemotherapy, nail bed repair,
radiological imaging, intra thecal medications, lacrimal duct
probing, examination under anaesthesia, laparoscopic
appendicectomy, radiotherapy, tendon repair, incision and
drainage, wound debridment etc. But with the advances in
surgical and anaesthesia techniques and with the introduction
of newer anaesthesia drugs with good recovery profile, more
and more complex surgical procedures are now carried out in a
day care unit.
If you look into the basic characteristics of the procedures,
they are all the same. That is of limited duration, minimal
physiological alterations, no requirement for prolonged post
operative care or observations, low risk of
surgical/anaesthesia complications, expected minimal or
moderate post operative pain that can be easily managed by
simple oral analgesics [6].
The decision regarding accepting the procedure must also
include the comfort level of the assigned anaesthesiologist in
handling the expected peri operative events and the specific
environment in which the procedure is to be done.
Patient selection
The paediatric population in general are good candidates for
ambulatory procedures. But the screening should ensure child
to be healthy with no co existing uncontrolled medical illness
and the operation is not complex and not prolonged. Proper
selection of patients is the first and foremost thing for the
successful delivery of ambulatory surgery [7]. The historical
limitations of day care procedures like body mass index, ASA
status and age are now questioned [6].The goals of patient
selection is achieved by satisfactorily answering the
following questions [6]: 1) Is the surgery appropriate for day
care procedures? 2) Is there any benefit of overnight
admission which could not be done at home? 3) Is the patient's
home circumstances adequate for day surgery? (Reliable
caregiver, distance from hospital, communication and
conveyance facilities at home etc).
Contrary to popular belief, patients with chronic medical
conditions like asthma or epilepsy can be safely managed in a
day care unit with minimal disruption to their routine
activities [6] provided the disease is well controlled before
procedure.
Geographical proximity of the home to the surgical unit is an
important factor. Some of the centres consider a traveling
time more than one hour as a relative contra indication for
certain procedures like tonsillectomy [8].
There is a lower cut off age in many institutions such as 56
weeks post conceptual age in former premature infants and 4 to
6 weeks for term infants. These children are scheduled as
early morning cases with extended period of observation.
Anaesthesiologist must be aware of conditions/co-morbidities
that require special considerations for a day care surgery
like prematurity/ex prematurity, obese children, uncorrected
or haemodynamically significant congenital heart disease,
difficult airway, obstructive sleep apnoea, inborn errors of
metabolism, history of delayed emergence from anaesthesia,
known coagulation disorders etc.
Preoperative evaluation and Preparation
It is imperative to have a thorough discussion with the family
about the sequence of events that are likely to be faced
during anaesthesia and recovery. Surgery on a child is always
a stressful event for entire family. Children with anxious
parents can display an exaggerated signs of preoperative
anxiety themselves. So the preparation of parents is crucial
and they should be encouraged to clarify. For grown up
children the procedures can be explained in simple language.
Parental presence at induction is encouraged by some centres
to reduce the separation anxiety [9]. The anaesthesiologists
must explain the parents very clearly what to expect at the
time of induction and they must agree to leave the area
immediately when asked to do so [10]. Unduly anxious or
hysterical parents should not be encouraged to be present for
induction because they can be counterproductive increasing
their children's anxiety [10]. But this is a very
controversial topic and there is a strong school of thought
which believe that parental presence does not reliably
alleviate the anxiety of children nor parents. Ambulatory
surgery in fact diminishes the trauma of separation by
minimizing the separation time between parents and children.
But most proven methods to relieve anxiety for children are
the use of short acting sedative premedication and specific
pre surgery preparation programs for the children as well as
for the parents.
A written information about planned procedure, pre operative
and post operative care must be given to the parents to take
informed decision for the surgery. Preoperative assessment
should be done as soon as the decision for surgery is taken to
stabilize medical condition and to avoid last minute
cancellations.
Paediatric literature supports lab investigations only in
selected cases [3]. Need for blood investigations depend upon
magnitude of surgical procedure as well as patient's clinical
condition. Optimization of preoperative hydration and
prophylaxis for post operative nausea and vomiting (PONV) are
important considerations in ambulatory surgery. Optimally
hydrated children are less likely to have intraoperative
hypotension and hypoglycaemia.
Anaesthetic agents and techniques
A sedative premedication effectively reduces preoperative
anxiety and peri operative recall and post operative
agitation. Establishing a protocol driven approach and
maintaining a proper communication between the pre operative
area and operating room will facilitate timely administration
of premedication and avoiding delays in patient induction.
Midazolam remains the most popular anxiolytic premedication
for paediatric patients. After receiving an oral dose of 0.5
mg, children can be separated from their parents within 30
minutes and has not shown to prolong discharge time [11].
Midazolam given as premedication can also blunt the emergence
agitation after Sevoflurane anaesthesia and mental functions
are found return to normal within four hours [12].
Both rectal Etomidate (3-6mg/Kg) and Ketamine (5-10mg/Kg)
produces rapid onset of hypnosis without cardio respiratory
depression. Ketamine in doses of 2 to 4mg/Kg is a useful drug
for intra muscular induction in an uncooperative or mentally
challenged child. But home readiness is often delayed with a
larger dose (more than 5mg/Kg) [13]. Low dose Ketamine has
hypnotic, analgesic and amnesic effects.
Dexmedetomidine is a more selective alpha 2 agonist and a
recent study comparing trans nasal dexmedetomidine at one
microgram/Kg dose showed more sedation scores than 0.5mg/Kg of
oral Midazolam [14] when the children are taken for procedure.
But there is no difference in behaviour scores at separation;
induction and wake up score at extubation between these two
groups [14].
Major advances in day care anaesthesia practice happened with
the introduction of Propofol and inhalational agents which
allowed rapid induction and emergence (Sevoflurane,
Desflurane) [15,16]. Judicious use of local anaesthetics has
got opioids sparing effects. (Eg. Digital blocks, Caudal
blocks, wound infiltration with local anaesthetics or even
combining with non steroidal anti inflammatory agents [16].
Low dose Ketamine is a time tested analgesic with short
duration of action. But there is serious apprehension of
combining an anti cholinergic with Ketamine due to fear of
temperature rise [17]. Round the clock analgesics (not as
needed) should be given for the post operative pain and at the
time of discharge. Depending on the age and maturity of the
child different types of pain scales can be used (Eg:
Wong-Baker, CHEOPS). Parental presence at the time of recovery
is believed to reduce the analgesic requirements.
Acetaminophen remains the gold standard for most of the minor
procedures. The initial large dose can be given rectally in
the operation theatre16.
There is lack of evidence with regard to superiority of
specific technique {Gas Anesthesia (GA) vs Total Intravenous
Anesthesia (TIVA)} with regard to discharge criteria [16,18].
The introduction of short acting opioids like Fentanyl and
Remifentanil resulted in a paradigm shift with regard to the
use of opioids for day care procedures. A comparative study
between these two agents showed Remifentanil has better
analgesia and haemodynamic stability compared to Fentanyl
(19). But an addition of proper antiemetic is a must along
with opioids.
Post-operative nausea and vomiting (PONV) is one of the main
causes for unplanned readmission after day care procedure. As
per Society for Ambulatory Anaesthesiology consensus
guidelines, various classes of drugs can be used for the
management of PONV (20). Dexamethasone is usually given at the
time of induction of anaesthesia. Other agents can be
administered at the end of surgery. For the treatment of PONV,
different class of pharmacological agent from the prophylaxis
drug initially given is used. If no prophylaxis is used, a low
dose 5-HT3 antagonist is the drug of choice [20]. Use of
Propofol, optimal hydration, short acting opioids and minimal
use of narcotics also reduces the incidence of post operative
nausea and vomiting.
Early post operative ambulation and timely discharge are the
dictum in ambulatory surgery. There are different discharge
scoring systems (Eg: Modified post anaesthesia discharge
scoring system or PADSS) [21]. Presence of parents in the
recovery room will reduce the recovery time and the need for
high nurse to patient ratio [22]. It is also known to reduce
the negative behavioural changes in the post operative period
[23].
Complications of outpatient anaesthesia
Unplanned readmission, chances of negligence in pre op
assessment (for eg if carried out by telephone), lesser
compliance to preoperative fasting instructions and intake of
preoperative medications are some of the drawbacks of day care
procedures. Inability to control problems like post operative
pain, nausea and vomiting, lack of expert opinion if need
arises are practical challenges. Of course, there should be a
knowledgeable care giver who can carry out the preoperative
and post operative instructions effectively. Clear verbal and
written instructions regarding pre-operative and post
operative plans specific to anaesthesia and surgery must be
given to the care givers.
Conclusion
Children are excellent candidates for ambulatory surgical
procedures. As in any scenario, the preoperative assessment
should include a good history taking and pre operative
examination to exclude cases with significant co morbidities
and anticipate peri operative complications. Scientific
advances in anaesthesia and surgery made a tremendous positive
impact for the rapid growth of this concept. The extend of
surgical procedure, previous surgical complications, comfort
level of anaesthesiologist and proximity of patients home to
the centre are significant factors to be considered before
listing the patient as a day care procedure. Anaesthetic
techniques employed should ensure smooth emergence and
recovery with the patient free of pain and vomiting.
References
1. Collins CE, Everett LL. Challenges in pediatric ambulatory
anaesthesia:kids are different. Anaesthesiol Clin 2010;4:72-9.
2. Priscilla Alderson. European charter of childrens rights.
Bulletin of Medical Ethics.1993, 13-15.
3. Naresh T Row. Progress of day surgery in India. Ambul Surg
2010;16:15-6.
4. Meneghini L, Zadra N, Zanette G, et al. The usefulness of
routine preoperative laboratory tests for one day surgery in
healthy children.Paediatr Anaesth.1998;8:11-15.
5. Verma R, Alladi R, Jackson I, Kumar C, Page R et al. Day
case and short stay surgery: Anaesthesia 2011;66:417-34.
6. Daniel J Quemby, May E Stocker. Day care surgery
development and practice:Key factors for a successful pathway.
Continuing Education in Anaesthesia, Critical care and Pain
2014;14:256-61.
7. Gangadhar S, Gopal T, Sathyabhama, Paramesh K. Rapid
emergence of day care anaesthesia: A review. Indian J
Anaesthesia 2012;56:336-41.
8. Anand Bangera. Anaesthesia for adenotonsillectomy. An
update. Indian J Anaesthesia 2017;61:103-9.
9. Hannallah RS: Who benefits when parents are present during
anaesthesia induction in their children? Can J Anaesth1994;
41:271-5.
10. Hannallah RS: Pediatric ambulatory anaesthesia: Role of
parents.J Clin Anaesth 1995;7:597-9.
11. Jayashree Phaltankar,Milin Shash.Oral Midazolam as a
Pre-medication in Paediatric patients.MVP Journal of Medical
Sciences 2017;4:30-54.
12. Kumar, S. Sathish. Premedication with Midazolam in
Pediatric Anaesthesia. Anesthesia Analgesia 2000;90:498.
13. Hannallah RS, Patel RI. Low dose intramuscular Ketamine
anaesthesia pre induction in young children undergoing brief
outpatient procedure. Anaesthesiology 1989;70: 598.
14. Kumar L, Kumar A, Panikkaveetil R, Vasu BK, Rajan S, Nair
SG. Efficacy of intra nasal dexmedetomidine versus oral
midazolam for paediatric premedication. Indian J
Anaesth2017;61:125-30.
15. Uman RD, Desai SP. History of anaesthesia for ambulatory
surgery. Curr Opin Anaesthesiol 2012;25:641-7.
16. Satish Kulkarni, SS Harsoor, Adarsh Chandra Swami, S
BalaBhaskar et al. Consensus statement on anaesthesia for day
care surgeries. Indian J Anaesthesiol 2017;61:110-124.
17. Kyung Woo Kun, Won Joo Choe, Jun Hyun Kin, Kyung-Tae Kim
et al. Anticholinergic premedication induced fever in
paediatric ambulatory Ketamine anaesthesia. Journal of
International Medical Research 2016;44:817-23.
18. GIrish P, Joshi. Rapid recovery from ambulatory surgery:
The new paradigm in Ambulatort Anaesthesia. IARS 2013: Review
course lectures. Available from:
http://www.iars.org/assets/1/7/RCL-01.pdf
19. Hamid AMA, Shady AFA, Azeem ESA. Remifentanil infusion as
a modality for opioid based anaesthesia in paediatric
practice. Indian J Anaesthe 2010.54;318-23.
20. Gan TJ, Diemunsch P, Habib AS, Kovac A. Consensus
guidelines for the management of post operative nausea and
vomiting. Anesth Analg 2014;118:85-113.
21. Pramila Chari, Indu Sen. Paediatric ambulatory
surgery-Peri operative concerns. Indian J
Anaesthe.2004;48:387-93.
22. Patel RI, Verghese ST, Hannallah RS, Aregawi A et al. Fast
tracking children after ambulatory surgery. Anesth Analg
2001;92:918-22.
23. Lardner DR, Dick BD, Crawford S. The effects of parental
presence in the post anaesthesia care unit on childrens post
surgical behaviour: A prospective, randomized controlled
study. Anesth Analg 2010;110:1102-8.