Pediatric ambulatory anesthesia: an update

Purpose of review Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. Recent findings The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review. Summary Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with...
Source: Current Opinion in Anaesthesiology - Category: Anesthesiology Tags: AMBULATORY ANESTHESIA: Edited by Claude Meistelman Source Type: research

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Purpose of review In several guidelines, regional anesthesia and analgesia have been suggested as safer alternatives for general anesthesia and systemic analgesia for their safety profile in patients suffering from obstructive sleep apnea (OSA). However, the underlying scientific basis is still evolving. The present review is intended to provide an up-to-date account on the question whether the use of regional anesthesia improves outcomes in patients with OSA. Recent findings A number of studies found favorable effects of regional anesthesia used in patients with OSA, including reduced incidence of major perioperative...
Source: Current Opinion in Anaesthesiology - Category: Anesthesiology Tags: REGIONAL ANESTHESIA: Edited by Nabil Elkassabany Source Type: research
Abstract The prevalence of obesity has substantially increased worldwide during the last ten years. Hence, more anaesthetic procedures will be performed in obese patients in the future and more hospitals have to be prepared for the perioperative treatment of extremely obese patients including medical, technical and organisational issues. These include not only the management of the perioperative problems of adiposity, but also of its numerous concomitant diseases. Besides hyperlipidemia, diabetes mellitus, arterial hypertension and coronary heart disease, the obstructive sleep-apnea syndrome (OSAS) challenges the ...
Source: Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie : AINS - Category: Intensive Care Authors: Tags: Anasthesiol Intensivmed Notfallmed Schmerzther Source Type: research
AbstractPurpose of ReviewThe aim of this report was to review the recent literature related to the assessment and management of obstructive sleep apnea (OSA) in children under the age of 2  years.Recent FindingsAdenotonsillectomy (AT) indications are changing, with a greater proportion of younger children undergoing AT for OSA. Medical therapies may be an alternative to AT in mild-moderate OSA cases; however, further research is needed. Coblation ® intracapsular tonsillectomy may confer benefits in reduced post-operative pain and hemorrhage. Recent concerns regarding the safety of general anesthesia in young child...
Source: Current Otorhinolaryngology Reports - Category: ENT & OMF Source Type: research
This study used the STOP-Bang questionnaire to diagnose patients with possible obstructive sleep apnea (score ≥3). We hypothesized that a STOP-Bang score of 3 or greater would significantly correlate with the number of oxygen desaturation episodes during the first 48 hours after total knee arthroscopy. Methods The STOP-Bang questionnaire was administered to 110 patients preoperatively. All patients underwent spinal-epidural anesthesia with a saphenous nerve block and sedation and were connected to the Nellcor OxiMax N-600x pulse oximeter for 48 hours postoperatively. Results Final analysis included 98 patients. Th...
Source: Regional Anesthesia and Pain Medicine - Category: Anesthesiology Tags: Regional Anesthesia and Acute Pain: Original Articles Source Type: research
CONCLUSIONS: Claims related to outpatient medication management in pain medicine are multifactorial, stemming from deficits in clinical judgment by physicians, noncooperation in care by patients, and poor clinical documentation. Minimization of both legal risk and patient harm can be achieved by carefully selecting patients for chronic opioid therapy and documenting compliance and improvement with the treatment plan. Medical comorbidities such as obstructive sleep apnea and the use of long-acting opioids may be particularly dangerous. Continuing physician education on the safest and most effective approaches to manage thes...
Source: Anesthesia and Analgesia - Category: Anesthesiology Authors: Tags: Anesth Analg Source Type: research
Purpose of review: Use of perioperative opioids for surgical pain management of children presents clinical challenges because of concerns of serious adverse effects including life-threatening respiratory depression. This is especially true for children with history of obstructive sleep apnea. This review will explore current knowledge of clinically relevant factors and genetic polymorphisms that affect opioid metabolism and postoperative outcomes in children. Recent findings: Within the past several years, an increasing number of case reports have illustrated clinically important respiratory depression, anoxic brain injur...
Source: Current Opinion in Anaesthesiology - Category: Anesthesiology Tags: PEDIATRIC ANESTHESIA: Edited by Lynne R. Ferrari Source Type: research
AbstractPurpose of reviewWith a prevalence of about 10%, pediatric sleep-disordered breathing (PSDB) contributes to significant epidemiological burden. The first line of management is adenotonsillectomy (AT), which restores airflow and leads to resolution of symptoms in over 80% of children. Providing safe and effective administration of general anesthesia in this ‘at risk’ population can be a challenge in the ambulatory setting.Recent findingsSafe and effective administration of general anesthesia as well as pain management in children undergoing AT is contingent upon early recognition of risk factors and choo...
Source: Current Anesthesiology Reports - Category: Anesthesiology Source Type: research
Purpose of review: Opioids induce and increase the severity of most sleep-disordered breathing in all patients, but especially in morbidly obese patients. Discussed herein are the direct impact and mechanisms of opioids on inducing and exacerbating obstructive sleep apnea syndrome in normal and morbidly obese patients. Recent findings: Respiratory depression is a larger problem than obstructive sleep apnea syndrome during the first night after an opioid anesthesia because of the reduced amount of deep sleep and rapid-eye-movement sleep. Acute tolerance to the analgesic effects of opioids can be observed after one anestheti...
Source: Current Opinion in Anaesthesiology - Category: Anesthesiology Tags: MORBID OBESITY AND SLEEP APNEA: Edited by Frances Chung Source Type: research
Purpose of review: Perioperative opioid-based pain management of patients suffering from obstructive sleep apnea (OSA) may present challenges because of concerns over severe ventilatory compromise. The interaction between intermittent hypoxia, sleep fragmentation, pain, and opioid responses in OSA, is complex and warrants a special focus of perioperative outcomes research. Recent findings: Life-threatening opioid-related respiratory events are rare. Epidemiologic evidence suggests that OSA together with other serious renal and heart disease, is among those conditions predisposing patients for opioid-induced ventilatory imp...
Source: Current Opinion in Anaesthesiology - Category: Anesthesiology Tags: MORBID OBESITY AND SLEEP APNEA: Edited by Frances Chung Source Type: research
Abstract Abstract: The overwhelming majority of surgical procedures performed in the United States are done on an outpatient basis. Patients with complicated medical problems are routinely scheduled for ambulatory procedures that have become progressively more complex. Appropriate patient selection is paramount in ensuring optimal perioperative outcomes, and the patient with known or suspected obstructive sleep apnea presents unique challenges to the anesthesia care team with regard to airway management, pain control, and postoperative monitoring requirements. Currently, there is a relative paucity of high quality...
Source: Chest - Category: Respiratory Medicine Authors: Tags: Chest Source Type: research
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