Pediatric ambulatory surgery
Myron Yaster MD, Lynne G. Maxwell MD, and Francis Veyckemans MD
It’s hard to imagine, but 40+ years ago pediatric outpatient/same day/ambulatory surgery, particularly for very young patients, was considered by many surgeons and anesthesiologists to be too dangerous and “a bridge too far” for almost all surgical procedures. Admittedly, other aspects of care back then would also astonish most of you as well, and I’m not talking about the lack of what is now basic monitoring like pulse oximetry, capnography, and even automated non-invasive BP devices. Back then, patients, both adult and pediatric, had a chest X-ray, hemoglobin, urinalysis, and an electrolyte panel routinely before surgery and were routinely admitted to the hospital for their preop preparation the night BEFORE surgery. Further, parents and family members were not allowed to stay with their children and family during this overnight hospitalization. How times have changed! In the United States, pediatric ambulatory surgery now makes up the majority of pediatric surgeries for the obvious reasons that it is safe, effective, efficient, cheaper and enhances family satisfaction when compared to impatient surgery. On the other hand, outside of the U.S., ambulatory, same day surgery may still be limited by custom and most importantly by how health care is paid for. In some countries, only in-patient, overnight admissions are fully reimbursed and outpatient surgery becomes a cost burden to hospitals and doctors.
Today’s PAAD by Vogt et al.1 is a wonderful review and would make a great teaching handout for students, residents and fellows in training. We can’t cover everything in this article so we will concentrate on highlights. And again, for those of you who teach in the OR, this article can be a terrific jumping off point for many intraoperative discussions. Myron Yaster MD
Original article
Vogt P, Abdallah C, Tran S, Yalamanchili V, Patel C. Preoperative Challenges for Pediatric Ambulatory Surgery. Int Anesthesiol Clin. 2025 Jan 1;63(1):60-68. doi: 10.1097/AIA.0000000000000468. Epub 2024 Nov 14. PMID: 39651668.
Patient Selection
Prematurity
Premature infants (born < 37 weeks before gestation) are at increased risk of developing post-operative apnea (defined as a lack of breathing > 15 seconds or <15 seconds if associated with bradycardia or desaturation). This apnea risk persists for up to 12-48 hours after surgery and anesthesia. Low birth weight, earlier gestational age and lower post-conceptual age (PCA) at the date of anesthesia are the most important predictors of post anesthesia apnea. A hemoglobin <10g% seems to be an independent risk factor while small for gestational age infants seems to be protective (no apnea reported in 18 such infants). There were inadequate data to determine if other comorbidities such as BPD, NEC, use of opioids, or relaxants were contributory. Charlie Coté, a frequent contributor to the PAAD, has written extensively on this subject and identified PCA of 54 weeks with GA of 35 weeks or PCA 56 weeks with GA 32 weeks as critical points after which the incidence of postoperative apnea declined to <1%.2 Moreover, the risk of complications, mainly adverse respiratory events, remains higher than in term-born children up to adolescence.3
Hypotonia
The authors discuss several patient groups who present with hypotonia. We will limit our discussion to those with mitochondrial disease who are at elevated risk for metabolic derangements during the perioperative period. These inherited disorders with impairments in the electron transport chain or another function of the mitochondria, which reduces its ability to oxidatively metabolize fat, carbohydrates, or amino acids leading to decreased adenosine triphosphate (ATP) production. “Metabolic decompensation can occur from the lactate load in sodium lactate solution, NPO status, surgical stress such as tourniquet use, hypothermia, pain, and postoperative nausea and vomiting (PONV). Exposure to inhaled anesthetic agents and propofol has been known to inhibit the respiratory chain complex in mitochondria4”1. Fortunately, provided total intravenous anesthesia is avoided and a glucose containing electrolytic solution is used, the vast majority of these patients can safely undergo general anesthesia. The decision to manage them as outpatients should be based on their baseline neurologic status.
Upper respiratory infection
Administering general anesthesia to children with a URI increases the risk of perioperative respiratory adverse events (PRAEs), such as laryngospasm, bronchospasm, apnea, and frequent desaturation episodes.5-7 This risk may extend for 4-6 weeks after the resolution of URI making the cancellation and timing of surgery extremely problematic and controversial. We use a rule suggested by Dr. Mark Schreiner more than 20 years ago.8 In symptomatic children, we ask the parents if they would keep their child home from school or day care? If the answer is “yes”, we cancel surgery and reschedule when symptoms disappear. We don’t wait the 4-6 week period and use techniques described by Vogt et al. to minimize airway irritation. Data from Australia show that waiting for two weeks after the end of signs and symptoms of URI is safe.6 Moreover, the decision to proceed should also take other risks factors for PRAEs into account such as passive smoking (vaping?), asthma, obstructive sleep apnea, chronic respiratory disease and other comorbidities.9
Preoperative fasting
We’ve discussed the preoperative fasting (NPO) guidelines extensively in previous PAADs. The table below compares ASA and European guidelines.
The fast for clear liquids has been reduced to 1 hour in most of the world. Indeed, in some practices, pediatric patients are OFFERED clear liquids on arrival to the preoperative center!
Pregnancy testing
We’ve discussed this recently in the PAAD (Pre anesthesia pregnancy screening: an imperative or a bubbe meise? Ethical considerations parts one and two May 14 and 15, 2024 https://ronlitman.substack.com/p/pre-anesthesia-pregnancy-screening Like the authors of today’s PAAD, we believe pregnancy testing should be offered to patients but should not be required by physicians unless there is a compelling medical reason to know whether the patient is pregnant and contrary to common belief, preanesthesia pregnancy testing is not a standard of care.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Vogt P, Abdallah C, Tran S, Yalamanchili V, Patel C. Preoperative Challenges for Pediatric Ambulatory Surgery. International anesthesiology clinics 2025;63(1):60-68. (In eng). DOI: 10.1097/aia.0000000000000468.
2. Cote CJ, Zaslavsky A, Downes JJ, et al. Postoperative apnea in former preterm infants after inguinal herniorrhaphy. A combined analysis [see comments]. Anesthesiology 1995;82(4):809-822.
3. Havidich JE, Beach M, Dierdorf SF, Onega T, Suresh G, Cravero JP. Preterm Versus Term Children: Analysis of Sedation/Anesthesia Adverse Events and Longitudinal Risk. Pediatrics 2016;137(3):e20150463. (In eng). DOI: 10.1542/peds.2015-0463.
4. Yeoh C, Teng H, Jackson J, et al. Metabolic Disorders and Anesthesia. Curr Anesthesiol Rep 2019;9(3):340-359. (In eng). DOI: 10.1007/s40140-019-00345-w.
5. Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Seiwert M, Pandit UA. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001;95(2):299-306.
6. Templeton TW, Sommerfield D, Hii J, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia-Part 2: Anesthesia-related risk and treatment options. Paediatric anaesthesia 2022;32(2):217-227. (In eng). DOI: 10.1111/pan.14376.
7. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet (London, England) 2010;376(9743):773-83. (In eng). DOI: 10.1016/s0140-6736(10)61193-2.
8. Schreiner MS, O'Hara I, Markakis DA, Politis GD. Do children who experience laryngospasm have an increased risk of upper respiratory tract infection? Anesthesiology 1996;85(3):475-480.
9. Stepanovic B, Regli A, Becke-Jakob K, von Ungern-Sternberg BS. Preoperative preparation of children with upper respiratory tract infection: a focussed narrative review. British journal of anaesthesia 2024;133(6):1212-1221. (In eng). DOI: 10.1016/j.bja.2024.07.035.