Child For Day Case Surgery

Question 1

A 6-year-old child is listed for day case adenoidectomy on your ENT list.

How is day case surgery defined in the UK?

Answer 1

• The patient is admitted and discharged on the same day, with day surgery as the intended management (AAGBI).

Question 2

What are the age limits for paediatric patients undergoing day case surgery?

Answer 2

• All hospitals should have individualised guidelines based upon their available facilities, equipment and staff training and experience, as well as the child’s comorbidities.
• Tertiary centres may adopt a lower limit of 44–46weeks post-menstrual age (gestational plus chronological age).
• For ex-preterm infants, the limit is usually 60 weeks post-menstrual age if they are medically ft.

Question 3

What are the benefits of day case surgery in paediatric patients?

Answer 3

• Decreased cost to the hospital and parents.
• Separation of day case patient pathways and duration of hospital stay,
  reducing the nosocomial infection risk (CP, CF, GDD) and transfer of infections from certain patient populations (classically multi-drug- resistant Pseudomonas in patients with cystic fibrosis).
• Reduced starvation time and less reliance on intravenous fluids.
• Reduced risk of cancellation (if an overnight bed is not required).
• Day surgery lends itself to protocols; protocolised day care pathways improve patient care and safety.
• Decreased child and parental anxiety.
• Less disruption for the child, particularly if they are of school age.

Question 4

You review the child preoperatively. His mother says that he has had a runny nose for the last 2 days. How do you proceed?

Answer 4

History:
* A full medical and anaesthetic history should be taken:
- If the child has a history of asthma or obstructive sleep apnoea, this needs to be explored further to assess the risks and benefits of
day case surgery.
- Ask about the child’s susceptibility to a runny nose: is this “normal” for the child?

• A history of the coryzal illness should be taken, focusing particularly on:
• The presence of a fever or productive cough.
• Loss of appetite, fatigue or feeling generally unwell.
• Parental concern (should not be underestimated).

Examination:
* Chest auscultation: the presence of crackles or wheeze in a child is a worrying sign.

• Child looking generally unwell: listless, drowsy or dehydrated.

Investigations:
* Basic observations should be done to assess for signs of infection or sepsis (fever, tachycardia, hypotension, tachypnoea).

Question 5

Aside from the runny nose, the child has had no other symptoms and their observations are normal. You proceed with induction of anaesthesia and secure the airway with a laryngeal mask airway. As the surgeon begins operating you notice an inspiratory stridor.
What is your immediate management?

Answer 5

• Alert the theatre team and surgeons and ask them to stop surgery immediately and remove any stimulus.
• Call for help early.
• Carry out an immediate assessment of the airway to include oxygen
  saturations, end tidal carbon dioxide, laryngeal mask airway position
  and adequacy of ventilation.
• Switch to the bag function if not self-ventilating and increase the
  inspired oxygen concentration to 100%.
• Gently attempt to manually ventilate the patient to assess airway
  patency and auscultate the chest.
• Tis patient may have developed laryngospasm. Te following
  treatment should be carried out quickly and efciently:
• Apply CPAP.
• Consider simple airway manoeuvres e.g. jaw thrust.
• Deepen anaesthesia by increasing the concentration of inhalational agent and/or administering a bolus of propofol appropriate to the patient’s weight.
• Remove the laryngeal mask airway and apply CPAP using the facemask if the above measures do not show any improvement.
• Ask the anaesthetic assistant to prepare the airway trolley for
  intubation.
• If the patient further deteriorates despite the above interventions,
  administer a weight-appropriate dose of suxamethonium to induce muscle relaxation and facilitate intubation with a correctly sized endotracheal tube.
• Consider passing an orogastric or nasogastric tube to defate the stomach following intubation.
• Reassess the chest, focusing on the risk of atelectasis and secretions, which may require re-infation and passage of a suction catheter.
• If the symptoms have resolved and an adequate, safe airway is in situ, consider restarting surgery.