Ambulatory surgery is a somewhat lighter burden for health services, resulting in considerable cost reduction and resource saving. Paediatric orthopaedic surgery seems to be rarely done in an outpatient setting, mainly because of the postoperative pain, which all parents fear. The anaesthetic management is challenging because young children lack the ability to communicate pain, and analgesic need is often difficult to determine. Therefore, provision of adequate postoperative analgesia and parents’ education are important elements of the care plan. Inclusion criteria for ambulatory surgery proposed by Khoury et al. [1] are summarised in Table 7.1. Parents must be adequately informed on how to deal with cast, including possible complications. They should be given written instruction and a staff contact number should be available as well. Of the utmost importance is to provide the family detailed information about postoperative pain management and consequences of regional anaesthesia. For example, if the child undergoes a nerve block, parents should be aware of what is an acceptable time for resumption of active motion. The most frequent orthopaedic ambulatory procedures are cast change, arthroscopy, closed fracture reduction and manipulation, hardware removal, percutaneous tenotomies and arthrograms.

Every child has to be treated individually and it is therefore difficult to establish fixed rules regarding the perioperative anaesthetic management. For preoperative fasting, the orthopaedic setting shares the same rules of any other surgical specialty, but in this arena, trauma patients are frequent and the stomach of traumatised children is assumed never to be empty. Nonetheless, it may be necessary to treat the child as fast as possible, mandating for focused attention to advanced airway management. Preoperative anxiety may be reduced by premedication similarly to other surgical settings, but non-pharmacological strategies are available as well. Indeed, there is evidence that the viewing of animated cartoons by paediatric surgical patients is an inexpensive, easy to administer, comprehensive intervention that can be very effective in alleviating preoperative anxiety and “needle phobia” in this special surgical population [2]. Furthermore, it may be useful to apply EMLA tapes not only at the venous puncture site but also at the insertion site of the plexus or nerve block.

Anaesthetic services are commonly required for sedation during diagnostic procedures, non-invasive treatment of fractures and other short but painful procedures. Reposition or manipulation of a fractured limb without sufficient analgesia is inhuman, and, to some extent, it is comparable to severe personal injury. Closed reduction and cast immobilisation in the emergency department are usually eased by deep sedation to reduce procedure-related stress.

Deep sedation for both emergent and elective orthopaedic procedures is associated with several, rare but potentially serious adverse events like apnoea or hypotension, which require continuous monitoring and several dedicated staff members [3]. Furthermore, in these cases, preoperative fasting is mandatory, and postprocedural observation in adequate recovery area may be prolonged with relatively long time to discharge. Performing an analgesic or anaesthetic nerve block (Fig. 7.2) of the interested area based on anatomical considerations results in lighter sedation, reduced risks and shorter postoperative observation time. Indeed, the patients can be discharged 2 h after uncomplicated procedures, even with persistent sensory block. With regard to postoperative pain management, regional anaesthesia combined with postoperative non-opioid analgesics, like paracetamol, NSAIDs, or weak opioid, such as codeine or tramadol, are regularly used after ambulatory surgery.

Procedural sedation is also required for non-intrusive approaches for correction of early-onset scoliosis. This treatment in infants and toddlers is based on sequential, repeated body cast positioning, which may initiate as early as at 4 months of age. After the child is positioned on the frame, distraction and derotation of the spine will be performed in general anaesthesia or deep sedation. Plaster application, particularly around the hip, should allow bowel and bladder function, avoid skin breakdown and permit access to epidural or perineural catheters. These infants and toddlers with scoliosis, as well as other children with chronic diseases, present repeatedly for surgical or diagnostic procedures and should be treated with particular sensibility and compassion. Indeed, even a single negative experience can indelibly ruin patient and family attitude toward anaesthesia.

Anaesthetists, surgeons and nurses are all responsible for the safe positioning of surgical patients to prevent position-related complications. Paddings, pillows and special jelly frames are required for achieving the best posture on the surgical bed and to protect the patient against damage from inadvertent pressure ischemia. Nerve injuries and skin pressure injuries result from poor positioning, with direct pressure causing ischemia to that area. Spine surgery involving vertebral fusion and instrumentation often requires special operating tables and the patient in a prone position. Special attention must be paid in these cases, because cardiovascular and respiratory functions may be compromised in this position. Body weight should be distributed unburdening the abdomen in order to minimise venous congestion, and direct pressure on the eyeballs must be carefully avoided. The arms should not be abducted or extended greater than 90° from the natural position, and the weight of the arms should be evenly distributed across the forearm to avoid ulnar nerve compression at the elbow. Positioning may be even more challenging in children with important deformities and particular caution is warranted. The use of intraoperative radiologic imaging is common, radioprotective barriers should be used, and radiation exposure must be monitored by the anaesthetist, as well.

The detrimental effects of hypothermia include increased rates of wound infection, increased blood loss and increased length of stay in recovery room and hospital. Hypothermia exacerbates blood loss by decreasing platelet function, interfering with coagulation factors’ activity and slowing vasoconstriction. Therefore, the monitoring of patient’s core temperature is advisable, and several precautions help maintaining normothermia in the perioperative period. They include active patient warming using forced-air devices, the preservation of a comfortable temperature in the operating room at least until the patient is positioned and covered and an adequate warming of intravenous fluids and blood products before infusion [4]. Furthermore, some diseases, such as osteogenesis imperfecta or arthrogryposis multiplex congenita, may be associated with altered baseline temperature regulation. In these patients, core temperature monitoring is mandatory and special attention must be addressed to its perioperative maintenance (Fig. 7.3).

Tourniquets are commonly used in surgery to establish and maintain a bloodless surgical field, allowing the surgeon to work with greater technical precision and safety. Nonetheless, the widespread use of tourniquets in orthopaedic surgery in adults and children is not without risks, and the surgical literature includes numerous reports of injuries and hazards associated with tourniquet overpressurization, like pain at the tourniquet cuff site; muscle weakness; compression injuries to blood vessels, nerves, muscles or skin and extremity paralysis. Underpressurization, vice versa, may result in blood leakage in the surgical field and venous congestion of the limb. Overall, the risk of tourniquet-related injuries can be reduced minimising tourniquet inflation time, using automatic tourniquet instruments and cuffs that allow accurate pressure delivery, control and monitoring and maintaining tourniquet cuff pressure near the minimum level required to stop arterial blood flow in the operated limb. Indeed, significantly lower tourniquet cuff pressures based on limb occlusion pressure (LOP) and the use of wide contour cuffs can be used effectively and safely in the paediatric population without compromising the quality of a bloodless surgical field [5]. LOP is the minimal cuff pressure required to occlude arterial blood flow into a patient’s limb with a specific tourniquet cuff at a specific moment. LOP may be determined manually by slowly increasing tourniquet cuff pressure until distal arterial pulsations cease at the Doppler stethoscope or with a recently developed automated plethysmographic system. Previous studies in children showed that tourniquet cuff pressures based on LOP measurements before cuff inflation significantly decreased mean tourniquet cuff pressures and were sufficient to maintain a satisfactory surgical field [6]. Before tourniquet application, a flat rubber bandage named Esmarch’s bandage will be wrapped repeatedly around the limb to make it bloodless, and a soft dressing will be applied to the limb at the tourniquet site to avoid wrinkles and blisters (Table 7.2). Adequate exsanguination can also be achieved by elevation of the limb at 90° or 45° for the upper or the lower extremities, respectively. Also the anaesthetic conduct may influence the effects of tourniquet application. In fact, both the continuous propofol infusion and regional anaesthesia techniques attenuate lipid peroxidation and decrease tourniquet-related injuries in paediatric limb surgery [7]. Also intraoperative temperature regulation may be affected by tourniquet application owing to a combination of decreased heat loss from the ischemic limb and a reduced heat transfer from the central to the ischemic peripheral compartment.

Paediatric patients undergoing major orthopaedic surgery are at risk of significant intraoperative blood loss. The judicious use of blood transfusion is imperative both because of limited blood bank supply and because transfusions can lead to various complications. Awareness of infectious hazards of transfusion prompted a more thoughtful approach to blood product administration, greater tolerance of asymptomatic anaemia, more attention to medical, preoperative treatment of anaemia and greater attention to surgical haemostasis. Whenever possible, a cost-effective approach is based on the identification and treatment of preoperative anaemia, and, in most circumstances, it can be accomplished with nothing more than oral iron therapy. Fortunately, the amount of blood transfused for many surgical procedures has decreased in recent years. A close observation (or surveillance) of the operative field helps to estimate blood loss, while the monitoring of vital signs, haematocrit, urine output and central venous pressure is valuable to assess the adequacy of volume replacement and are useful tools in blood-sparing strategies [8, 9].

The absence of a family member, the strange environment, hunger, changes in body temperature, the presence of peripheral venous access or a cast are factors that may all contribute to increase the discomfort of the paediatric patient awakening from anaesthesia. A recovery room that permits awaking in the presence of parents and adequate pain control is essential in orthopaedic paediatric surgery. Caring for an alert, calm and cooperative child reduces the workload for nurses in the recovery room because children who are pain-free are less inclined to be uncooperative, and it is less likely that they interfere with the operation site (Fig. 7.4), removing dressings, drainage tubes or urinary catheters [13].