Day case anaesthesia & some paediatrics Flashcards
What are some benefits of day case anaesthesia?
Less disruptive to pts families (paeds)
less risk nosocomial infection
more cost-effective
What are some requirements for paediatric day facilities?
Ideally purpose-built (particularly as children require specialised staff (able to recognise & respond to deteriorating child, trained in child protection), equipment & must have facilities designed & furnished w children’s needs in mind)
If only able to be cared for on adult unit, separate area must be provided for children & their carers
Suitable equipment, toys & play area should be provided to reduce anxiety & speed recovery
Must be child-safe & child-friendly
Play specialists establishing rapport through normal play, preparing child for their perioperative experience
Pre- & post-op patients must be separated
Specific days or sessions must be dedicated to paediatrics to assist with rostering of trained staff
If day case children are to be parsed through inpatient facilities, there must be a separate area dedicated to day patients with dedicated nursing staff so that management is not focused on the sicker inpatients
Ideally a separate pre-op assessment visit should occur, videos & booklets can be helpful to prepare the child & parent, allaying the anxiety of both, written instructions particularly wrt preop fasting, regular medication, postop analgesia & wound care instructions
setup where separation of parent from child is minimised & parent should be encouraged to accompany their child for anaesthetic induction
What are selection criteria for day case anaesthesia in children?
Patient: healthy without significant comorbidities, eg:
- NOT poorly controlled asthma, NO inborn errors of metabolism or DM, NOT complex cardiac disease or cardiac disease requiring investigation, NOT sickle cell disease, NO active infection (esp respiratory)
- if term they must be >1/12 old, if preterm, they must be >=60 wks post conception age
- pt must not be a sibling of a SIDS victim
Social:
-pts must be willing & able to care for the child @ home postop, housing conditions must be satisfactory, they must have telephone contact & be a <1hr journey to hospital, they must have adequate transport
Anaesthetic:
- must be a procedure where postop pain can be managed with PO analgesia
- pt must NOT have difficult airway (incl. OSA)
- pt must NOT have MH susceptibility
- must have had experienced anaesthetist (or if trainee, be supervised by consultant with regular paediatric practice)
Surgical: operation must not be complex or prolonged
- must have had experienced surgeon
- must NOT involve opening of body cavity
- NOT high risk periop haemorrhage/fluid loss
What are examples of gen surg paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
herniotomy
upper or lower endoscopy +/- biopsy
excision of skin lesions or lymph node
What are examples of urological paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
orchidopexy
cystoscopy
minor hypospadias
circumcision/preputial lesions
What are examples of ENT or dental paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
myringotomy +/- grommets
nasal fracture reduction
adenotonsillectomy PROVIDED well child, no URTI/LRTI/sleep apnoea or surgical concerns
dental extractions
What are examples of ophthalmology paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
EUA
strabismus repair
lacrimal duct probing
What are examples of plastic surg paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
otoplasty
excision of skin lesions
scar revision
What are examples of ortho paediatric cases that may be suitable for day case (provided no sig pt or social factors)?
arthroscopy
closed fracture reduction
removal of metalwork
cast changes
what are paediatric fasting instructions?
Clear fluids (non-carbonated) freely given up to 1hr before- the last drink offered should be <3mL/kg (max 150mL)
Breastmilk up to 4hrs before (& for infants <6/12 old, infant formula without thickeners may be given up to 4hrs)
everything else 6hrs
What are some risk factors for complications of an URTI in children undergoing anaesthesia?
anaes: ETT
surg: airway surgery
pt: age <1yr copious secretions nasal congestion prematurity asthma parental smoking
If urgent surgery must proceed despite URTI, what are some options?
regional minimal airway instrumentation anticholinergics gentle suction to clear secretions adequate hydration & humidification of airway to avoid sputum plugging "smooth" induction & emergence
What may be considered an “innocent murmur”?
early systolic, soft, no associated abnormal signs or symptoms, varies in intensity with position (usually quieter when child standing upright
If anaemic, often a flow murmur ass’d with increased CO
reasonable to proceed with surgery in these pts but the child should be Ix later (eg. can’t exclude mild pulmonary stenosis)
In which cases should a child be investigated prior to surgery?
<1yo
pathological murmur- diastolic, pan systolic, late systolic, loud or continuous murmurs
abnormal S&S (FTT, recurrent chest infections, syncope/chest pain, cyanosis/desaturation, HTN, palpable heave/thrill, radio-femoral delay)
abnormal ecg or CXR
What measures minimise the need for premed?
good psychological preparation, parental presence @ anaesthetic induction
