Pediatric ambulatory anesthesia: an update

Abstract

Purpose of review Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. Recent findings The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review. Summary Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with reduced opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission.

Aggressive Prophylactic Treatments for Postoperative Nausea and Vomiting Improve Outcomes in Pediatric Adenotonsillectomy Procedure

“…10 In our hospital, adenotonsillectomy accounts for 20% to 30% of overall operating room (OR) cases. We chose adenotonsillectomy to study the incidence and the treatment effectiveness of PONV because 1) it has been identified as an independent risk factor for PONV 6,11 ; 2) it is, usually, of a predictable length; 3) it warrants routine use of prophylactic agents for PONV; and 4) has had a previously standardized anesthesia protocol at our department. Therefore, longitudinal comparisons are feasible.…”

“…5 Otoplasty and adenotonsillectomy are among surgical procedures that are independent risk factors for PONV. 5,6 Great efforts have been made toward the prevention and treatment of PONV. The multimodal approaches including combination of multiple antiemetic drugs, aggressive fluid replacement, reduction of opioids, and volatile anesthetics have some successes of dealing with this very common problem.…”

Ambulantes Operieren in der HNO-Heilkunde in Deutschland

“…Es bleibt aus dem Literaturstudium zu betonen, dass der wesentliche Erfolgsfaktor ambulanten Operierens in der kritischen Selektion der Fälle und der Antizipation von Komplikationen liegt [17,18,[21][22][23][24][25][26][27].…”

Analgesia para cirugía pediátrica ambulatoria

“…En USA se ha visto que un 4,8% de los niños (> 13 años) tienen un consumo persistente de opioides posterior a la cirugía, con riesgo de generar dependencia [8]. Por otro lado, se ha descrito mortalidad asociada a su uso en pacientes con trastornos obstructivos del sueño [9]. Considerando lo anterior, se han desarrollado protocolos ahorradores de opioides, donde una analgesia basada en AINES, dexmedetomidina, ketorolaco y bloqueos regionales proporcionan un manejo similar del dolor pero con menos EA y costos asociados [8].…”