Which pediatric patients are candidates for outpatient surgery? Which patients would NOT be candidates for outpatient surgery?

How old does a child need to be in order to qualify for outpatient surgery? What are the risk factors that would increase outpatient surgery risk?

What is the significance of an upper respiratory tract infection (URI) for outpatient surgery in this patient? If surgery is postponed, how long should you wait to perform anesthesia?

What is the significance of the child’s heart murmur? Should there be a cardiology consultation prior to the anesthesia? What specific questions would you have for a cardiologist?

The age of patients appropriate for outpatient procedures depends on the underlying health and history of the patient. The primary concern is the incidence of apnea and bradycardia – which may occur in very young patients after general anesthesia. Apnea is strongly and inversely related to both gestational age and postconceptual age. A patient may be discharged to home after brief general anesthesia after approximately 5–6 weeks of age if he/she was born at full term and has had no other health issues – particularly no apnea or bradycardia. For patients who were born premature, the risk of apnea and bradycardia is significantly greater. Any former premature infant (born at less than 37 weeks’ gestation) should be admitted after anesthesia for approximately 12–24 h of observation if they are less than 54 weeks postconceptual age. In addition, if a child was born at term and has had any issues with apnea and bradycardia, or if they have a sibling who experienced sudden infant death syndrome (SIDS), that child should likewise be admitted for observation until 58–60 weeks postconceptual age. In the past, it was thought that patients who received only regional anesthesia (such as a spinal) were not at risk for apnea; however, more recent data indicates that apnea may occur perioperatively in this population as well (although at a reduced incidence) and these patients should likely be admitted for observation [1–3].

URI illnesses are extremely common in children particularly in infancy and toddler age groups where the point prevalence in the middle of winter is approximately 30 %. URI is defined as an illness limited to the head and neck, which may be associated with increased nasal secretions, but is not associated with systemic signs of illness such as fever or chills. A URI is also not associated with any lower respiratory symptoms such as wheezing, rhonchi, or rales. When anesthesia is administered to children who have a URI, there is an increased incidence of adverse respiratory events such as bronchospasm, laryngospasm, and coughing. On the other hand, anesthesia in children with these illnesses has not been found to be associated with an increased incidence of serious morbidity such as respiratory or cardiac failure requiring ICU admission – or death. The period of increased airway reactivity after a significant URI lasts between 2 and 4 weeks. If elective surgery is postponed because of illness, it should not be rescheduled for at least this period of time. In this case, I would proceed with the surgery and anesthesia but would inform the mother of increased risk of minor respiratory events prior to beginning the case [4, 5].

Innocent heart murmurs in infants and young children are common. The two most common murmurs that fall into this category would be Still’s murmur or the murmur associated with peripheral pulmonic stenosis. Still’s murmur is due to resonance of blood as it flows through the left ventricular outflow tract during systole. It is “vibratory” or “musical” in quality and is heard most prominently at the left upper sternal border during systole. The murmur of peripheral pulmonic stenosis is heard best at the superior aspect of the left lower sternal border and is limited to systole. These “functional” murmurs are characteristic in that they are “soft” – less than 3/6 intensity. They may be positional – that is, heard in the supine position but not when sitting or standing. The child is otherwise healthy with no concerns about growth and no symptoms of heart failure, and the child tolerates periods of exertion (feeding and vigorous crying) without developing cyanosis or symptoms of heart failure such as dyspnea. Innocent murmurs are not be associated with a palpable thrill and are generally limited to systole. In this case, if the child is appearing well and the pediatrician believes this murmur is characteristic of an innocent murmur of infancy, I would accept the diagnosis after examining and confirming the history with the parents. If the child was sent to a cardiologist, I would want to know (1) if the cardiac anatomy was normal, (2) if the ECG was normal, (3) if the ventricular function was normal, and (4) if there was any evidence of shunting [1].