Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

The high-risk pediatric patient for ambulatory surgery.

PURPOSE OF REVIEW: The aim of this article is to briefly review the pediatric ambulatory surgery landscape, identify two of the most common comorbidities affecting this population, examine the influence of pediatric obesity and sleep disordered breathing (SDB)/obstructive sleep apnea (OSA) on perioperative care, and provide information that can be used when formulating site specific criteria for ambulatory surgical centers. RECENT FINDINGS: Most pediatric surgeries performed are now ambulatory, a majority of which take place outside of academic centers. Children with comorbidities such as obesity and SDB/OSA are undergoing surgical or diagnostic procedures which were previously deemed unacceptable for ambulatory surgery. The increase in pediatric ambulatory surgery coupled with a recent shortage of pediatric anesthesiologists means many children will receive anesthesia care from general clinicians who care for children intermittently and may be unfamiliar with the perioperative risks these comorbidities can present. SUMMARY: Our pediatric ambulatory surgical population is anticipated to demonstrate increasing rates of obesity and SDB/OSA. Bringing attention to potential perioperative complications associated with these comorbidities provides a stronger foundation upon which to formulate criteria for individual ambulatory centers. It allows for targeted anesthetic management, influences provider assignments and/or staffing ratios, and informs scheduling times. For anesthesiologists who do not practice pediatric anesthesia daily, knowing what to anticipate plays a significant role in the ability to eliminate surprises and care for these patients safely.

The effect of intranasal administration of remifentanil on intubating conditions and airway response after sevoflurane induction of anesthesia in children.

BACKGROUND: Intubation without the use of muscle relaxants in children is frequently done before IV access is secured. In this randomized controlled trial, we compared intubating conditions and airway response to intubation (coughing and/or movement) after sevoflurane induction in children at 2 and 3 min after the administration of intranasal remifentanil (4 mcg/kg) or saline. METHODS: One hundred eighty-eight children, 1-7-yr old, were studied. Nasal remifentanil (4 mcg/kg) or saline was administered 1 min after an 8% sevoflurane N2O induction. The sevoflurane concentration was then reduced to 5% in oxygen, and ventilation assisted/controlled. An anesthesiologist blinded to treatment assignment used a validated score to evaluate the conditions for laryngoscopy and response to intubation. Blood samples for determination of remifentanil blood concentrations were collected from 17 children at baseline, 2, 3, 4, and 10 min after nasal administration of remifentanil. RESULTS: Good or excellent intubating conditions were achieved at 2 min (after the remifentanil bolus) in 68.2% and at 3 min in 91.7% of the children who received intranasal remifentanil versus 37% and 23% in children who received placebo (P<0.01). The mean remifentanil plasma concentrations (+/-sd) at 2, 3, 4, and 10 min were 1.0 (0.60), 1.47 (0.52), 1.70 (0.46), and 1.16 (0.36) ng/mL, respectively. Peak plasma concentration was observed at 3.47 min. There were no complications associated with the use of nasal remifentanil. CONCLUSIONS: Nasal administration of remifentanil produces good-to-excellent intubating conditions in 2-3 min after sevoflurane induction of anesthesia.