Chapter 127

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2100 PART 6 ■ Specific Considerations TABLE 127-10. Incidence (%) of Postoperative Symptoms Following Day-Case Surgery in Children (n = 551) at Different Observation Times After Discharge 107 Symptom In Hospital, % Same Day at Home, % Next Day, % Duration ≥2 days Pain 17 56 37 19 Emetic symptoms 11 12 2 1 Vomiting 7 7 2 1 Sedation 39 77 37 9 Dizziness 10 16 1 1 Headache not determined 11 4 1 Difficulty in walking 5 17 6 3 anesthesia compared to standard general anesthesia after major surgical procedures. 115,116 The need for postoperative ventilation was significantly reduced in neonates receiving combined caudal catheter and light general anesthesia compared to general anesthesia alone following esophageal atresia repair. The use of an epidural catheter reduced also postoperative morbidity and days of oxygen therapy following fundoplication in children. In addition, several small randomized studies have examined pain scores and minor complications (e.g., nausea) and found benefits from regional anesthesia for minor procedures. In ex–premature infants scheduled for hernia repair, spinal anesthesia without sedation is associated with less postoperative apnea than general anesthesia or spinal anesthesia plus ketamine. 117 Therefore, in this particular subgroup of patients, spinal anesthesia without sedation has definitely some advantages over other anesthetic techniques reducing postoperative morbidity. Excitement upon recovery from anesthesia has been the subject of many studies since the introduction of newer volatile agents into clinical practice. An excellent review was recently published on the subject, 118 highlighting the fact that there are more questions than definite answer to this phenomenon of uncertain etiology. Briefly, a variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a role in the development of such an event. Possible etiological factors include rapid emergence, intrinsic characteristics of an anesthetic (mainly sevoflurane), postoperative pain, type of surgery (ENT, eye surgery), young age (
CHAPTER 127 ■ Mortality, Morbidity, and Outcome in Pediatric Anesthesia 2101 TABLE 127-11. Examples of Anesthesia Risk Management Considerations 146 Risk Identification Risk Modification Risk Management Patient Practitioner Practice Underlying medical problems Congenital anomalies Anatomic abnormalities Clinical competence Appropriate training and experience Impairment Appropriate equipment Standard of practice Medical interventions Surgical interventions Supervision Training Treatment for impairment Department policies and procedures Fund of knowledge Appropriate informed consent Preoperative assessment Credentials Continuing education Fund of knowledge “Drills” for rare events Quality improvement monitoring Continuous improvement program morbidity and mortality in pediatric anesthesia may be achieved by improving several aspects of perioperative management: ● ● ● ● ● ● Better preoperative evaluation of risk factors Adequate monitoring and equipment and use of safer drugs Optimizing perioperative fluid therapy Training and continuous education Human factors Pediatric networking Preoperative Evaluation Contributes to Improved Safety of Anesthesia The preoperative visit is the best opportunity to note foreseeable anesthesia-related difficulties. 123 The major purpose and process of the clinical interview is the exchange of information. It was de - monstrated several years ago that a preadmission visit contributes to a lessening of maternal anxiety during and after the child’s hospitalization. 124,125 The preadmission visit was also associated with a reduction in the incidence of negative post-hospital be - havior, particularly in children aged 6 to 7 years. However, the effects of a behavioral-based preoperative preparation program vary with the child’s age, the timing of intervention, and any history of previous hospitalization. 79,126 It has also been reported that most American parents prefer to have comprehensive infor - mation concerning their child’s perioperative period. 127 Detailed anesthetic information regarding what might go wrong does not increase parental anxiety and has the advantage of allowing parents a fully informed choice. These studies emphasize the importance of planning the preoperative visit several days before surgery to give the parents enough time to understand what was said. In France, the preoperative visit is mandatory and has to be performed several days before surgery, but this is not the case in most European and North American countries. Most children scheduled for surgery are ASA physical status 1 or 2. One of the most common problems during the winter is the high frequency of URI in young children. The presence of an active URI increases the risk of perioperative respiratory complications in children, as discussed previously. The risk/ benefit ratio of postponing elective surgery should be discussed on an individual basis and recommendations have been proposed by Cohen and colleagues 50 as follows: For children with asymptomatic or mild URI, elective procedures should be postponed in children younger than 1 year old. For children older than 1 and younger than 5 years, the risk/benefit ratio of the surgical procedure must be considered on an individual basis. Older children are less at risk because of anatomically larger airways. Children with significant preoperative symptoms of URI should have their surgery postponed for 2 to 6 weeks following cessation of symptoms. 128 However, canceling surgery at the last minute may be emotionally unsettling, inconvenient and costly, and may have an impact on the efficiency of the operating department. In an American survey regarding the attitude of consultants facing a child with an URI, 129 34.5% of the respondents reported that they seldom (1–25% of the time) cancelled cases due to an URI, and 20.9% stated that they usually (76–99% of the time) cancelled in the event of an URI. Factors that were considered most important in making decision included the urgency of surgery and the presence of asthma. This survey contradicts the traditional dogma of routine cancellation and reflects the wide range of opinions and approaches to this enduring clinical dilemma. In general, the presence of an elevated temperature, cough, and chest signs indicative of infection involving the lower respiratory tract should prompt a postponement of elective surgery. Elective surgery that is cancelled because of the presence of a lower respiratory tract infection should not be rescheduled for at least 3-4 weeks to minimize the risk associated with bronchial hyperreactivity. Information on current and past medications should be obtained. This should include the use of aspirin or other nonsteroidal agents. Although there is no evidence that recent immunization affects the outcome of anesthesia, some children exhibit systemic toxic reactions to the vaccines that commonly occur 2 to 3 days after diphtheria-tetanus-pertussis and hemophilus influenza B vaccines but as late as 2 weeks after measlesmumps-rubella vaccine. 130 In general, it is advisable to avoid elective surgery during these periods. 131 Allergies to drugs and other substances should be noted. Allergic or immediate reactions to natural latex have been reported with increasing frequency since their first description in 1979. A group of high-risk patients to latex anaphylaxis has been described. This includes patients with spina bifida, bladder exstrophy, and should be extended to all patients having multiple surgical procedures, especially those operated in the neonatal period. 132–135 Susceptible patients should benefit from a “latex-free” environment when surgery is planned. The role of preoperative visit is crucial to identifying at-risk patients. Information about difficulties or complications encountered in previous anesthetic experiences should be obtained, especially those related to intubation or respiratory or cardiovascular compromise. Expected difficult intubation—common in some congenital or acquired syndromes—should be planned and
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Chapter 127

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