Pediatric outpatient surgery is a common practice occurring in hospitals, freestanding surgery centers, and even some office-based settings. Some tertiary care hospitals quote that at least 60% of their pediatric surgical procedures are performed as outpatient [1]. Pediatric outpatient surgery offers numerous benefits, including decreased costs to patient, reduced disruption to a child’s daily life, reduced hospital resource utilization, and lower risk of infections [1]. In general, children are good candidates for outpatient surgery and typically have good postoperative care from parents and family members. Further, pediatric surgical procedures tend to be straightforward with quick recovery times. However, the medical considerations surrounding pediatric outpatient surgery must be considered and discussed to ensure the safety and well-being of young patients.

One major consideration for outpatient pediatric surgery is the type of procedure. Typical procedures performed outpatient include scopes (such as esophagogastroduodenoscopies and colonoscopies), circumcisions, hydrocele, hernia and hypospadias repairs, and superficial skin lesion excisions. Adenotonsillectomies may be performed safely on an outpatient basis, but one concern is preoperative airway obstruction which can quickly worsen postoperatively [2]. Those without obstructive symptoms can be considered for outpatient surgery but must be evaluated to ensure low risk of postoperative complications [3]. Thorough evaluation for outpatient surgery selection is an important first step, using the American Society of Anesthesiologists (ASA) physical status classification system to classify patients based on severity and control of comorbidities [1]. Healthcare providers must carefully assess the child’s overall health, medical history, and any existing conditions that may impact the surgery or recovery. Proper patient selection ensures that children are appropriate candidates for outpatient procedures, minimizing the risk of complications.

Fasting guidelines and preoperative anxiety are another topic of consideration for pediatric surgery. Children who fast before midnight the day of surgery are at risk of both dehydration and hypoglycemia [4]. Literature recommends fasting with permission of clear liquids up to 2 hours before surgery [1]. Preoperative anxiety is a common problem for pediatric patients and the majority of anesthesiologists believe anxiolytics should be provided to at-risk patients to reduce the risk of postoperative psychological trauma [5]. While pharmacological management has been found to be most effective, having parents present at time of induction has also been shown to reduce preoperative anxiety [6]. Using evidence-based guidelines for fasting and pharmacology, physicians can provide appropriate perioperative care for pediatric patients.

Intraoperative management for outpatient pediatric surgery is similar to that of inpatient surgery. It includes anesthetic choice, muscle relaxants, and inhalational agents. Anesthesia providers must consider the child’s age, weight, and medical history when determining the appropriate drug and dosage. Continuous monitoring during the procedure is essential to address any potential complications promptly. After surgery, effective pain management using a multimodal approach combining medications, regional anesthesia, and non-pharmacological interventions can help control pain while minimizing potential side effects.

Despite careful planning, unforeseen emergencies can occur during pediatric outpatient surgery which can lead to unanticipated hospital admissions. Outpatient surgical models should be well equipped with available resources in the case overnight observation is needed. This includes preoperative anticipation of a bed arrangement, a well-trained surgical team, and clear communication protocols to ensure a coordinated response [1]. For patients who live further from the hospital and may feel safer being observed overnight, longer postoperative observations can be useful to ease postoperative care anxiety for parents and caretakers. Further, healthcare providers should establish a robust follow-up plan. Clear communication with parents regarding postoperative care instructions and signs of complications is essential for the child’s ongoing recovery and mitigating potential complications.

References

1. Emhardt JD, Saysana C, Sirichotvithyakorn P. Anesthetic considerations for pediatric outpatient surgery. Semin Pediatr Surg. 2004 Aug;13(3):210-21. doi: 10.1053/j.sempedsurg.2004.04.003.
2. Ross AT, Kazahaya K, Tom LW. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg. 2003 Mar;128(3):326-31.
3. Colclasure JB, Graham SS. Complications of outpatient tonsillectomy and adenoidectomy: a review of 3,340 cases. Ear Nose Throat J. 1990 Mar;69(3):155-60.
4. Welborn LG, McGill WA, Hannallah RS, Nisselson CL, Ruttimann UE, Hicks JM. Perioperative blood glucose concentrations in pediatric outpatients. Anesthesiology. 1986 Nov;65(5):543-7.
5. Payne KA, Coetzee AR, Mattheyse FJ, Heydenrych JJ. Behavioural changes in children following minor surgery–is premedication beneficial? Acta Anaesthesiologica Belgica. 1992 ;43(3):173-179.
6. Kain ZN, Mayes LC, Wang SM, Caramico LA, Krivutza DM, Hofstadter MB. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology. 2000 Apr;92(4):939-46.