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Special considerations for the pediatric patient in the office-based ambulatory surgery setting
Managing Your OR
Special Considerations for the Pediatric Patient in the Office-based Ambulatory Surgery Setting “Managing Your OR” focuses on various aspects of aesthetic surgery in the ambulatory surgical setting.
A
s the number of ambulatory surgical cases being performed in office-based settings continues to rise over the next decade, there will be a corresponding increase in office-based cosmetic pediatric surgery, which encompasses patients aged 6 years through adolescence. The clinician should be aware of special concerns regarding the care of pediatric patients in such a setting. Patient safety and control over the environment are primary concerns in office-based pediatric surgery. Patient selection is also important, because the office setting may not be ideal for some pediatric patients. Pediatric patients usually require more preoperative and postoperative care than adult patients. Very young pediatric patients, as well as those with congenital medical conditions and/or premature birth, may be predisposed to increased risk in the office setting due to limited access to more varied equipment, which is readily available in the hospital setting. The most common pediatric cosmetic procedures performed in the office setting are otoplasty, treatment of gynecomastia, rhinoplasty, and removal of nevi and other lesions. Other plastic surgical procedures—including cleft lip, cleft palate, and congenital malformation reconstruction procedures—are more likely to be performed in the traditional hospital setting. Preoperative education of both patient and parents is extremely important in reducing anxiety over an impending procedure. It is helpful for the anesthesiologist to call the parents and child several days before the operation to discuss all aspects of perioperative care. Preoperative sedation should be discussed but is usually unnecessary with proper preoperative education. In our institution, parents are encouraged to accompany their children into the operating room and stay with them until the induction of anesthesia is complete. Parental presence during anesthesia induction has been found to reduce anxiety in parents and children.1
AESTHETIC
Nothing-by-mouth (NPO) guidelines for elective outpatient surgery have changed during the past several years, especially with regard to pediatric patients. Recent studies have confirmed that new pediatric NPO guidelines allowing the ingestion Kevin Glassman, MD, Lake Success, NY, is a boardof clear liquids 2 to 3 hours certified anesthesiologist. before general anesthesia are associated with no differences in safety or aspiration risk in comparison with previous more rigid NPO standards of 8 hours.2 The anesthesiologist, surgeon, operating room staff, and recovery room staff must appreciate several special perioperative concerns regarding the care of these young patients. Proper equipment—including a variety of airway management tools, smaller ventilator circuits, pediatric advanced cardiac life support (ACLS) drugs, and proper anesthetic inhalants—is essential. Because many pediatric patients will not tolerate an intravenous (IV) placement before induction of anesthesia, the use of Sevoflurane as an inhaled induction agent is extremely useful, inasmuch as it provides rapid inhalational induction (with little, if any, airway irritation) and rapid recovery. The use of EMLA cream (Astra Pharmaceuticals, Wayne, PA) as a topical anesthetic before an IV is started is also effective in patients who will allow IV placement preoperatively, but it must be applied to the skin at least 45 minutes before the start of the IV to be effective. In the uncooperative patient, preoperative sedation can be achieved with oral, rectal, or nasal applications of a variety of compounds, although I have rarely needed to use these medications in my pediatric practice. I use oral midazolam in a dose of 0.5 mg/kg 30 minutes before surgery when necessary. This sedative is extremely effective and can smooth the induction of anesthesia. Before caring for pediatric patients, all perioperative staff should be at least familiar with, and preferably certified in, pediatric advanced life support. Because physiologic
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
523
Managing Your OR
considerations are different for infants and children, all drug dosages, airway management equipment, and pediatric advanced life support and malignant hyperthermia treatment protocols should be reviewed. Certain important physiological changes in the pediatric patient should be considered during the perioperative period. Hypothermia usually develops rapidly in infants and children because of the high surface area–to–weight ratio. Cutaneous heat loss is proportional to surface area and metabolic heat production is largely a function of mass; consequently, it is relatively easy for children to lose large amounts of heat through the skin surface.3,4 It is important to gauge the temperature in the operating room and to have accessory warming devices, such as warming blankets, on hand.
recovery. Pediatric patients tend to become combative and uncommunicative in the immediate postoperative period, and an additional nurse in the postanesthetic care unit may be necessary to properly staff and supervise the immediate recovery of these patients. Many procedures can be safely performed without the use of general endotracheal anesthesia; this provides for a smoother postoperative course. Otoplasty and gynecomastia procedures can be performed with the pediatric patient under local anesthesia with intravenous sedation. In addition, the recent use of pediatric-sized laryngeal masked airway devices now allows for the use of general anesthesia without endotracheal intubation and permits spontaneous respiration during surgery, leading to a smoother postoperative course.
Cardiovascular changes in infants and children should also be considered, including (1) a left ventricle that is relatively noncompliant in comparison with that of an adult and (2) a fixed stroke volume with a cardiac output that is more heart rate-dependent than that of an adult. Functional residual capacity in the pulmonary system is decreased in the pediatric population, and there is an increased oxygen consumption (6 cc/kg/min vs 3 cc/kg/min in adults); this leads to a more rapid drop in oxygen saturation in children than in the average adult. As children move toward adolescence, these physiological differences usually become less important, with the parameters approaching those of adults.
Both during and after office-based surgery, pediatric patients present greater challenges to all professionals involved in their care. An ever-growing number of pediatric procedures are now being performed in the office setting. With proper equipment and preparation, these procedures can be performed safely and successfully, with positive outcomes for young patients and their families. ■
Pain control, prevention of nausea and vomiting, and disorientation caused by residual anesthetics are common problems found in both pediatric and adult postoperative patients. Use of potent antiemetics, as well as adequate analgesics and nonsteroidal anti-inflammatory drugs, when appropriate, are critical to an uneventful recovery period. Use of an intraoperative acetaminophen suppository in a dose of 30 to 40 mg/kg is also effective in aiding
3. Simbruner G, Weninger M, Popow C, Herholdt WJ. Regional heat loss in newborn infants, I: heat loss in healthy newborns at various environmental temperatures. S Afr Med J 1985;68:940-944.
524
AESTHETIC
SURGERY
JOURNAL
~
References 1. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology 1998;89:1147-1156. 2. Ferrari LR, Rooney FM, Rockoff MA. Preoperative fasting practices in pediatrics. Anesthesiology 1999;90:978-980.
4. Anttonen H, Puhakka K, Niskanen J, Ryhanen P. Cutaneous heat loss in children during anaesthesia. Br J Anaesth 1995;74:306-310.
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/111424 doi:10.1067/maj.2000.111424
NOVEMBER/DECEMBER
2000
Volume 20, Number 6
Special Considerations for the Pediatric Patient in the Office-based Ambulatory Surgery Setting “Managing Your OR” focuses on various aspects of aesthetic surgery in the ambulatory surgical setting.
A
s the number of ambulatory surgical cases being performed in office-based settings continues to rise over the next decade, there will be a corresponding increase in office-based cosmetic pediatric surgery, which encompasses patients aged 6 years through adolescence. The clinician should be aware of special concerns regarding the care of pediatric patients in such a setting. Patient safety and control over the environment are primary concerns in office-based pediatric surgery. Patient selection is also important, because the office setting may not be ideal for some pediatric patients. Pediatric patients usually require more preoperative and postoperative care than adult patients. Very young pediatric patients, as well as those with congenital medical conditions and/or premature birth, may be predisposed to increased risk in the office setting due to limited access to more varied equipment, which is readily available in the hospital setting. The most common pediatric cosmetic procedures performed in the office setting are otoplasty, treatment of gynecomastia, rhinoplasty, and removal of nevi and other lesions. Other plastic surgical procedures—including cleft lip, cleft palate, and congenital malformation reconstruction procedures—are more likely to be performed in the traditional hospital setting. Preoperative education of both patient and parents is extremely important in reducing anxiety over an impending procedure. It is helpful for the anesthesiologist to call the parents and child several days before the operation to discuss all aspects of perioperative care. Preoperative sedation should be discussed but is usually unnecessary with proper preoperative education. In our institution, parents are encouraged to accompany their children into the operating room and stay with them until the induction of anesthesia is complete. Parental presence during anesthesia induction has been found to reduce anxiety in parents and children.1
AESTHETIC
Nothing-by-mouth (NPO) guidelines for elective outpatient surgery have changed during the past several years, especially with regard to pediatric patients. Recent studies have confirmed that new pediatric NPO guidelines allowing the ingestion Kevin Glassman, MD, Lake Success, NY, is a boardof clear liquids 2 to 3 hours certified anesthesiologist. before general anesthesia are associated with no differences in safety or aspiration risk in comparison with previous more rigid NPO standards of 8 hours.2 The anesthesiologist, surgeon, operating room staff, and recovery room staff must appreciate several special perioperative concerns regarding the care of these young patients. Proper equipment—including a variety of airway management tools, smaller ventilator circuits, pediatric advanced cardiac life support (ACLS) drugs, and proper anesthetic inhalants—is essential. Because many pediatric patients will not tolerate an intravenous (IV) placement before induction of anesthesia, the use of Sevoflurane as an inhaled induction agent is extremely useful, inasmuch as it provides rapid inhalational induction (with little, if any, airway irritation) and rapid recovery. The use of EMLA cream (Astra Pharmaceuticals, Wayne, PA) as a topical anesthetic before an IV is started is also effective in patients who will allow IV placement preoperatively, but it must be applied to the skin at least 45 minutes before the start of the IV to be effective. In the uncooperative patient, preoperative sedation can be achieved with oral, rectal, or nasal applications of a variety of compounds, although I have rarely needed to use these medications in my pediatric practice. I use oral midazolam in a dose of 0.5 mg/kg 30 minutes before surgery when necessary. This sedative is extremely effective and can smooth the induction of anesthesia. Before caring for pediatric patients, all perioperative staff should be at least familiar with, and preferably certified in, pediatric advanced life support. Because physiologic
SURGERY
JOURNAL
~
NOVEMBER/DECEMBER
2000
523
Managing Your OR
considerations are different for infants and children, all drug dosages, airway management equipment, and pediatric advanced life support and malignant hyperthermia treatment protocols should be reviewed. Certain important physiological changes in the pediatric patient should be considered during the perioperative period. Hypothermia usually develops rapidly in infants and children because of the high surface area–to–weight ratio. Cutaneous heat loss is proportional to surface area and metabolic heat production is largely a function of mass; consequently, it is relatively easy for children to lose large amounts of heat through the skin surface.3,4 It is important to gauge the temperature in the operating room and to have accessory warming devices, such as warming blankets, on hand.
recovery. Pediatric patients tend to become combative and uncommunicative in the immediate postoperative period, and an additional nurse in the postanesthetic care unit may be necessary to properly staff and supervise the immediate recovery of these patients. Many procedures can be safely performed without the use of general endotracheal anesthesia; this provides for a smoother postoperative course. Otoplasty and gynecomastia procedures can be performed with the pediatric patient under local anesthesia with intravenous sedation. In addition, the recent use of pediatric-sized laryngeal masked airway devices now allows for the use of general anesthesia without endotracheal intubation and permits spontaneous respiration during surgery, leading to a smoother postoperative course.
Cardiovascular changes in infants and children should also be considered, including (1) a left ventricle that is relatively noncompliant in comparison with that of an adult and (2) a fixed stroke volume with a cardiac output that is more heart rate-dependent than that of an adult. Functional residual capacity in the pulmonary system is decreased in the pediatric population, and there is an increased oxygen consumption (6 cc/kg/min vs 3 cc/kg/min in adults); this leads to a more rapid drop in oxygen saturation in children than in the average adult. As children move toward adolescence, these physiological differences usually become less important, with the parameters approaching those of adults.
Both during and after office-based surgery, pediatric patients present greater challenges to all professionals involved in their care. An ever-growing number of pediatric procedures are now being performed in the office setting. With proper equipment and preparation, these procedures can be performed safely and successfully, with positive outcomes for young patients and their families. ■
Pain control, prevention of nausea and vomiting, and disorientation caused by residual anesthetics are common problems found in both pediatric and adult postoperative patients. Use of potent antiemetics, as well as adequate analgesics and nonsteroidal anti-inflammatory drugs, when appropriate, are critical to an uneventful recovery period. Use of an intraoperative acetaminophen suppository in a dose of 30 to 40 mg/kg is also effective in aiding
3. Simbruner G, Weninger M, Popow C, Herholdt WJ. Regional heat loss in newborn infants, I: heat loss in healthy newborns at various environmental temperatures. S Afr Med J 1985;68:940-944.
524
AESTHETIC
SURGERY
JOURNAL
~
References 1. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology 1998;89:1147-1156. 2. Ferrari LR, Rooney FM, Rockoff MA. Preoperative fasting practices in pediatrics. Anesthesiology 1999;90:978-980.
4. Anttonen H, Puhakka K, Niskanen J, Ryhanen P. Cutaneous heat loss in children during anaesthesia. Br J Anaesth 1995;74:306-310.
Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/111424 doi:10.1067/maj.2000.111424
NOVEMBER/DECEMBER
2000
Volume 20, Number 6