Abstract
Paediatric day case surgery is suitable for many children and procedures, offering benefits to patients, families and organizations. For day surgery units to be successful, thorough processes must be followed to ensure that patients are correctly selected and prepared, lists are organized appropriately, and resources are in place to manage day case smoothly. Techniques for anaesthesia and analgesia should be tailored to facilitate day case discharge with clear information provided to patients and families.
After reading this article you should be able to:
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explain inclusion and exclusion criteria for day surgery based on surgical, patient and organizational factors
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recognize the importance of preoperative assessment and preparation of patients and families
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demonstrate perioperative techniques to support rates of day case surgery and reduce unplanned admissions
Paediatric cases are well suited to day case. The concept of day surgery by default has been introduced in recent practice. In this article, day case surgery refers to patients being discharged on the same day as their procedure without an overnight stay in hospital, as is used by the NHS in the UK. It is worth noting that in some countries, day surgery or ‘23-hour surgery’ may refer to surgery where the patient is discharged within 24 hours. There are benefits to day case surgery for:
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patients and families as there is less disruption to routines, school and work.
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organizations as inpatient beds are not required, reducing waiting times and costs.
Published national or international consensus guidelines can be used to support the delivery of day case surgery, such as the British Association of Day Surgery’s Directory of Procedures or specific procedural guidelines such as for paediatric adenotonsillectomy.
Inclusion and exclusion criteria
These may be considered in terms of surgical, patient and organizational factors.
Patient factors
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Age – term infants >46 weeks corrected gestational age (CGA) are suitable, for ex-premature infants the extent of prematurity, CGA and medical conditions need to be considered. See Figure 1 .
Figure 1
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Children <1 year should not have general anaesthetic (GA) cosmetic procedures e.g. accessory digit removal or religious circumcision, these should be deferred until >1 year when risks of GA complications are lower.
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American Society of Anesthesiologists (ASA) grade 1–2, however experienced tertiary units may be able to manage ASA 3 patients.
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Stable conditions such as asthma, epilepsy, type 1 diabetes mellitus can be managed as day case. Indeed patients with these conditions are likely to be able to manage their own conditions better in their own environment than as inpatients.
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Patients with difficult airways can be managed as day case provided that the appropriate skill mix and equipment is available.
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Obesity alone is not a contraindication to day surgery, it should be considered in the context of any other medical conditions and the proposed procedure.
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Long-term ventilation patients or those on home oxygen having minor procedures may be suitable, tertiary units should have pathways in place to support this where appropriate.
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History of malignant hyperthermia (whether personal or familial) does not exclude day surgery provided appropriate measures are undertaken.
Surgical factors
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Many surgical procedures are amenable to day case surgery. Procedures should generally be of relatively short duration, not preclude patients from oral intake postoperatively, and be manageable with oral analgesia postoperatively. There should be low risk of post operative bleeding.
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Longer superficial procedures (e.g. mastoidectomy) may be suitable.
Social factors
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Patients should live within 1 hour of hospital. This does not need to be the site where their procedure is carried out; access to a local hospital if required with ability to contact the treating hospital for advice will suffice.
The mainstay of day case surgery is elective work, however, appropriate minor urgent cases can be undertaken on a day case basis. See Box 1 for examples. Hospitals should develop robust protocols for reviewing these patients and listing them for day case surgery on dedicated urgent lists. Patients and families should be given information including fasting guidelines to allow them to proceed on the same day if appropriate. These patients can be managed on the same unit as elective patients, with protocols in place to ensure good flow of patients through the system.
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Minor orthopaedic and plastics trauma, e.g. fracture manipulation, nail bed repair, washout and closure of lacerations
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Abscess drainage
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Foreign body removal
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Eye trauma
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Paraphimosis
Preoperative assessment and patient preparation
This is vital to ensure smooth running of day surgery units, reduce same day cancellations and unplanned admissions.
All patients should be triaged by preoperative assessment, commonly in nurse-led clinics, which may be telephone or face to face. Some centres now use online health questionnaires completed by patients and families to gather information. There is a dual purpose to preoperative services. This is firstly to gather information about the patient to identify whether they are suitable for day surgery, and secondly to provide information to the patient and family about what to expect on the day of surgery, provide fasting guidelines and advice to contact preop in the event of the patient becoming unwell prior to surgery. Pre-operative services should offer a structured assessment of patients by systems and liaise with other specialties and organizations involved in the patient’s care to gather information. Nurse-led services should have access to consultant anaesthetic support for triage of more complex patients when assessing suitability for day case surgery.
List organization
Day case lists should be populated based on patient and surgical factors. Batched admission times (e.g. 0730, 0930, 1200 and 1400) allow patients to have individualized fasting times, reduced waiting times in hospital, which decreases anxiety, and is more family-centred, providing a better patient experience. This is universally beneficial, with the greatest advantages being for younger patients, those with learning difficulties, or complex needs who may struggle with waiting times. By following these principles, list order does not need to be bound by the concept of youngest patient first, allowing more flexibility without affecting patient experience. It also benefits the organization, as staff (administrators, nursing staff, anaesthetists and surgeons) have fewer patients in each batch, allowing them to prepare in a streamlined fashion.
Patients who are likely to need longer recovery times due to surgical or medical factors including the use of sedative premedication should be scheduled earlier in the day. Ideally patients requiring premeds should not be first on the list, as this allows time for the premed to be given and take effect while starting with a simple case, preventing delays to the list.
Facilities and staffing requirements
Day surgery works optimally when the service operates within a self-contained unt separate from inpatient areas within the hospital. This allows for improved flow of patients through the process, and staff can be trained in specific aspects of day surgery care, leading to improved success rates. Paediatric patients should ideally be managed on a separate unit to adult patients, which may be more difficult in district general hospitals. However, as a minimum, paediatric patients should be batched together on lists and have separate admission, first and second stage recovery areas from adults. Waiting areas for parents and carers need to be considered, locating these adjacent to recovery allows access to patients when they are ready for transfer to second stage recovery.
Staff should be appropriately trained for management of paediatric emergencies, with staff in recovery and postoperative areas undergoing regular updates to paediatric resuscitation training, particularly in units that care for both adults and children. Management of day surgery units should be led by those with specific expertise in day surgery. Anaesthetic departments should have a lead for day surgery, and day-to-day management should be overseen by a dedicated manager who may come from a nursing or operating department practitioner background.
There should be protocols in place for transfer of patients to tertiary paediatric settings should the need for these arise emergently.
Day of surgery
Fasting guidelines prior to GA are required to reduce the risk of gastric aspiration while optimizing comfort of patients preoperatively. The more liberal policy of ‘sip to send’ reduces thirst, irritability and detrimental physiological parameters with adequate clearance of gastric contents to baseline within 1 hour. Glucose-containing clear fluids can be used to reduce the risk of hypoglycaemia. The guidelines shown in Box 2 are used in our institution.
Related posts:
Crystalloids, colloids, blood and blood products and substitutes
Procedural sedation for children: principles and practice
Pain assessment in children
An update of systemic analgesics in children
Regional anaesthetic techniques for paediatric surgery
Total intravenous anaesthesia in children: a practical guide
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