60. Paediatric day-case surgery Flashcards
You are asked to anaesthetise a fit 3-year-old child for circumcision as a
day case. Is this an appropriate patient for day case anaesthesia?
Yes, provided the child has a suitable social set-up and no potential issues with
general anaesthesia.
Suitability for day case may be assessed on four areas.
Patient factors
Surgical factors
Anaesthetic factors
Social factors
Patient factors
Either fit and well or well-controlled systemic diseases such as asthma.
Age > 50–60 weeks post-conceptual age if pre-term due to apnoea risk.
Absence of active viral or bacterial infections particularly respiratory tract
infections (excluding isolated runny noses, as this is usually benign seasonal
rhinitis and is very common). The presence of respiratory tract infections
should result in deferral of surgery for 2–4 weeks to reduce the risk of
intra-operative laryngospasm, bronchospasm and post-operative hypoxia.
Absence of undiagnosed murmurs (should be investigated pre-operatively)
or significant congenital heart disease.
Absence of diabetes mellitus.
Surgical factors
Surgical factors
Duration <1 hour
Surface or laparoscopic procedures
Minimal anticipated blood loss
Anticipated post-operative pain controllable with simple analgesics.
Anaesthetic factors
Anaesthetic factors
Absence of known anaesthetic problems such as difficult airway or family
history of MH.
Social factors
Social factors
Adequate parental support, cooperation and understanding of instructions
Telephone in home or nearby
Access to transport and proximity to hospital (<1 hour away)
The child with a cold
It is very common to have a child with a runny nose.
Probably OK to continue if the child is at the end of a cold, is
constitutionally well and has a normal temperature and no chest signs,
otherwise postpone.
Increased risk of laryngospasm, bronchospasm, airway secretions and
airway obstruction.
Postpone for 2 weeks for an URTI and 4 weeks if lower respiratory
tract signs are present.
Pre-term infants with post-conceptual ages less than 50–60 weeks are
unsuitable for day case because of increased apnoea risk in the
post-operative period. Some centres will not accept term infants below this
age while others will consider well, term infants for minor procedures.
What pre-medication would you consider using in paediatric day case?
- Cutaneous local anaesthesia with EMLA (eutectic 2.5% lidocaine and 2.5%
prilocaine) or Ametop (4% tetracaine gel – Tetracaine was previously known
as Amethocaine in the UK, hence the name Ametop).
EMLA should be applied > 1 h before cannulation and is unlicensed below
1 year. Ametop has a more rapid onset and may be applied >45 min before
cannulation. It is not recommended below 1 month of age.
Profoundly anxious children or those with behavioural or learning
difficulties may require sedative pre-medication.
- Midazolam 0.5 mg/kg orally or nasally will usually result in adequate
sedation if given 30–45 min prior to induction. While post-operative
sedation is seldom a problem, it may occur.
Other traditional sedatives result
in too much post-operative sedation to be used in day case. - Simple analgesia may be given pre-emptively as a pre-med.
What anaesthetic agents would you use in paediatric day case?
Induction with either intravenous Propofol (2.5–4 mg/kg) or inhalation with
Sevoflurane are acceptable techniques. Thiopentone may result in delayed
recovery.
Maintenance with a volatile agent in oxygen/air or oxygen/nitrous oxide
may be used and facilitate spontaneous breathing. The use of nitrous oxide
in day case has not been shown to increase the incidence of PONV in
children. Sevoflurane offers rapid emergence and is well tolerated, though
in short procedures there is not likely to be a benefit in terms of discharge
time compared with isoflurane that justifies the extra cost.
Desflurane has been advocated due to rapid wake up but may cause airway irritation and coughing in spontaneously breathing patients.
TIVA with Propofol may be
of use if PONV is anticipated.
What analgesics would you use in paediatric day case and how would
you administer them?
Paracetamol may be given orally as pre-med (
loading dose of 20 mg/kg if aged over 3/12 or 15 mg/kg below),
rectally (single dose of 40 mg/kg) or intravenously (15 mg/kg).
NSAIDs are suitable agents for day case and Ibuprofen 5 mg/kg orally
pre-operatively or Diclofenac 1mg/kg orally or rectally are the most
commonly used.
The majority of children with asthma do not have NSAID
sensitivity, the exception being those with nasal polyps.
Opioids may produce significant sedation and PONV.
Ideally, only short-acting agents such as fentanyl (1–2 ug/kg i.v.) or
Local anaesthetic blocks may reduce or obviate the need for opioids.
How would you anaesthetise this child?
Pre-operative:
Full anaesthetic history from the parents including fasting
status and examination of the child including weight measurement.
Explanation and consent for penile block under general anaesthesia and
consent for rectal analgesia.
Cutaneous anaesthesia with EMLA or Ametop
on the ward and calculation of drug doses.
Preparation of emergency drugs,
atropine 20 ug/kg and suxamethonium 1.5–2 mg/kg.
Intra +
Induction: Full anaesthetic monitoring. i.v. induction with Propofol or
inhalation with Sevoflurane if cannulation is difficult. Insertion of LMA
(probably size 2).
Analgesia: Penile block after induction. IV Paracetamol and Diclofenac.
Maintenance: Spontaneously breathing on Sevoflurane in oxygen/air mix
(or oxygen/nitrous oxide). Intravenous fluid if prolonged starvation (either
10 ml/kg bolus or calculation of deficit and replacement). Some
anaesthetists advocate prophylactic anti-emetics, particularly in high risk
patients. Suitable agents are Ondansetron 0.15 mg/kg and Dexamethasone
0.15 mg/kg.
Emergence:
Emergence: 100% oxygen in left lateral position.
Discharge criteria post-operatively:
Stable vital signs.
Pain and nausea controlled.
Able to pass urine and drink fluids.
What other blocks may you consider?
An alternative to a penile block would be a caudal block. The potential
problems with a caudal in an ambulatory child would be temporary leg
weakness and the risk of urinary retention, which may delay discharge.
Penile block:
Penile block:
Take consent from the parents.
Full preparation with trained assistant and resuscitation equipment
available.
Calculate toxic dose of local anaesthetic to prevent over-dose. (Bupivacaine
or levobupivacaine 2 mg/kg). Adrenaline containing local anaesthetics must
be avoided.
After induction of anaesthesia leave the patient in the supine position.
Full asepsis with skin preparation.
Palpate the distal symphysis pubis.
Pass a 21G block needle just distal to the palpating finger.
When the needle contacts the distal edge of the symphysis pubis, it should
have passed through Buck’s fascia and be in proximity to the dorsal nerves
of the penis.
After careful aspiration, inject local anaesthetic (Bupivacaine 0.5% 1ml +
0.1 ml/kg). Some advocate performing injections either side of the midline
because of a possible midline septum.
The block is completed by subcutaneous injection across the base of the
penis (Bupivacaine 0.5% 2 ml).
