Cutting-Edge Pediatric Anesthesia for the Outpatient
Author: Helen V. Lauro, MD, Clinical Assistant Professor of Anesthesiology, Department of Anesthesiology, State University of New York, Downstate Medical Center, Brooklyn, NY; The Long Island College Hospital, Brooklyn
Peer Reviewer: Lawrence S. Berman, MD, Associate Professor of Anesthesiology and Pediatrics, University of Florida School of Medicine, Gainesville
Introduction
It is estimated that up to 60% of pediatric surgery in the United States is performed on an outpatient basis.1,2 These include ear, nose, and throat procedures such as bilateral myringotomy and tube insertion (BMT), adenoidectomy, tonsillectomy; genitourinary procedures such as circumcision; ophthalmic procedures such as ptosis and strabismus surgery; and general surgery such as hernia repair and hydrocelectomy.
Children naturally lend themselves to consideration for outpatient surgery due to relatively short procedures and the general health of the patient population. Ideally, optimal techniques would include cost-effective screening methods for preanesthetic evaluation; short-acting premedicants; drugs that provide for rapid induction and emergence, together with minimal to no pain or post-op nausea and vomiting (PONV) in the recovery room; and faster reunion with parents and discharge. Currently, surgery centers are closer than ever to achieving these goals.
Preoperative Evaluation: Current Methods
Many methods are in current practice for the preoperative evaluation of pediatric outpatients. In teaching programs, it is common for resident physicians, physician assistants, or nurse anesthetists who are supervised by an attending anesthesiologist to evaluate all pediatric patients who come in for a traditional "anesthesia appointment."
Other institutions perform preoperative screening of pediatric patients. This can range from simple telephone screening to assessment by physician assistants. The Long Island College Hospital (LICH) is piloting a preanesthetic evaluation program,3 whereby pediatric patients are screened at the surgeon’s office by a registered nurse and her staff for eligibility to bypass a traditional anesthesia appointment (Pediatric Easy-Pass). A "Pediatric Easy-Pass Eligibility Tool," which has been created at LICH, is used to facilitate rapid determination of eligibility.
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Children with no known medical history or with mild co-existing disease (ASA I-II) are eligible for bypass. If the patients meet criteria for bypass, they are directed to an open-house meeting where the parents receive a brochure,4 and the children receive a coloring book5 as coping devices. The families and patients see a children’s video6 providing general information about pediatric anesthesia, preoperative preparation, and induction techniques, and they examine anesthesia equipment consisting of masks and circuits. As a group, they meet with an attending anesthesiologist, and any questions are answered. On the day of surgery, the attending anesthesiologist performing the case meets the patients and their families and does a focused physical examination and assessment. LICH had a very favorable response thus far to the pilot program.
Pediatric NPO Guidelines: An Update
The period of time that a child can safely fast has been reconsidered in the past years. At State University of New York (SUNY), Downstate Medical Center/LICH, the protocol is a four-hour fast from milk and solids for infants younger than 6 months of age; a six-hour fast from milk and solids for children 6-36 months of age; and an eight-hour fast from milk and solids for children older than 36 months of age.
Breast milk is not considered a complete solid. Some institutions also accept a four-hour restriction for breast milk and a six-hour restriction for nonhuman formula7 for children younger than 6 months of age. Currently, there is no consensus on how to treat infant formula or how to categorize breast milk. Recent studies have shown that clear liquids can be administered safely until two to three hours before the time of surgery without adverse consequences.
Purported benefits include lower incidence of hypovolemia, hypoglycemia, and flexibility in the OR schedule should procedures be moved earlier in the day. Studies by Splinter, et al,8 found no significant difference in gastric residual volume or pH in children who were allowed to have clear liquids until two to three hours before surgery, compared with controls with standard preoperative fasting.
The Child with a Cold
It often is a contentious point how to manage the child with a cold who presents for elective outpatient surgery. First, it is important to establish criteria for what constitutes an upper respiratory tract infection (URI). Traditional criteria include fever, purulent rhinitis, and productive cough. In an article by Parnis, et al,9 eight variables were identified as predictors of an adverse event: tracheal intubation; parents reporting their "child has a cold" snoring; passive smoke; thiopental or halothane induction rather than sevoflurane or propofol; productive cough; lack of anticholinesterase; and nasal congestion.
A scoring system was created that the clinician can use to calculate the probability of the patient having an adverse anesthetic event. Most children with mild URIs can be managed safely without canceling the surgery.
A retrospective study by Schreiner, et al,10 concludes that parental confirmation of URI is a better predictor of laryngospasm than the use of predetermined criteria. In a recent prospective study by Tait, et al,11 concerning risk factors for adverse respiratory sequela in 1,076 children ages 1 month to 18 years presenting for elective surgery who had coexisting URIs, the authors concluded that there were no differences in the incidence of laryngospasm and bronchospasm in children with active URIs, recent URIs (within four weeks), and asymptomatic children.
Children with active and recent URIs did have more breath holding, oxygen desaturation episodes (< 90%), and a greater incidence of overall adverse respiratory events than healthy children. Independent risk factors for adverse respiratory events in their study included use of endotracheal tube, history of prematurity, history of reactive airway disease, paternal smoking, surgery involving the airway, presence of copious secretions, and nasal congestion.
Thus, children with active and recent URIs (within four weeks) are at increased risk for adverse respiratory events, particularly if they have a history of reactive airway disease, require surgery involving the airway, have a history of prematurity, are exposed to tobacco smoke, have nasal congestion or copious secretions, or require placement of an endotracheal tube.
Ultimately, the decision to proceed with surgery after providing informed consent as to risks/benefits depends on the individual patient, the type of surgery and anesthetic, and the judgment and experience of the anesthesiologist. If possible, the anesthesiologist should consider alternatives to traditional endotracheal intubation such as mask ventilation or the laryngeal mask airway in children with mild URIs.
What is the Best Sedative Premedicant?
Sedative premedication in children virtually has been revolutionized by oral midazolam, which has a long history of proven safety and efficacy in the pediatric population. Recent studies looking at alternatives such as oral clonidine compared to oral midazolam continue to show the superiority of oral midazolam.12 Furthermore, administration of oral midazolam has been shown by Brosius, et al,13 to not result in any significant difference in awakening time, time to postanesthesia care unit (PACU) discharge, awakening concentration of sevoflurane/nitrous oxide, and measurements of the Bispectral Index (BIS, Aspect Medical Systems, Newton, MA).
Sedative Premedication vs. Parental Presence
Another controversial area concerns the effectiveness of sedative premedication vs. parental presence during induction. Many institutions have policies that prohibit parental presence during induction due to concerns about possible disruptive behavior, parents becoming lightheaded and fainting in the OR, and general discomfort on the part of the staff.
In a recent randomized study by Kain, et al,14 oral midazolam was found to be more effective than parental presence in an induction room or no intervention in so far as managing preoperative anxiety. Despite this, induction rooms are used successfully at a number of prominent children’s hospitals.
In these circumstances, the anesthesiologist should assess the parents’ level of anxiety regarding the procedure. If it is high, they probably should not be present on induction, because children in this context usually are more upset if their parent is present than if they are not.15
Parents need to be instructed on what events normally happen during the induction process (eyes rolling back, snoring, involuntary movements, agitation, and deep sleep), and they need to be escorted outside when the induction process is complete.
Which is Best — Sevoflurane or Halothane?
A variety of inhalation induction techniques are in practice including the use of scented masks, distraction techniques ("blow up the balloon"), hypnosis techniques (i.e., "a day at the zoo; pilot flying airplane"), or steal inductions. In general, gradual application of the mask is ideal because of a lessened feeling of suffocation, although the concern of pollution in the room always is raised. It is the safest practice to start the intravenous, if it is required, while the child is spontaneously breathing.
A controversial area is the merits of sevoflurane vs. halothane in pediatric anesthesia. Concerns with the use of halothane have included laryngospasm, myocardial dysrhythmias, and halothane hepatitis. Concerns with the use of sevoflurane have revolved primarily around cost issues. These cost concerns are mitigated by the fact that, in most studies, induction of anesthesia with sevoflurane was significantly faster than with halothane.16 Emergence also is more rapid with sevoflurane compared to halothane, but it may be associated with greater agitation. Additionally, sevoflurane has been shown to be preferable in strabismus surgery because of a decreased incidence of oculocardiac reflex and airway irritability.17
Studies on the effects of the breakdown product of sevoflurane, Compound A, in children are limited, but are consistent with safe use18 so long as sevoflurane is not used with low gas flows (less than 2 liters/minute).
Uncuffed vs. Cuffed Tubes in Children
Another area of continuing controversy revolves around the choice of uncuffed vs. cuffed endotracheal tubes in children. Traditionally, anesthesiologists would use uncuffed tubes for children up to 8-10 years of age, and cuffed tubes were recommended for use only in special circumstances. A recent study by Khine, et al,19 has suggested no increased incidence of post-intubation stridor or other laryngotracheal sequelae in children intubated with cuffed vs. uncuffed tubes.
Despite this, in a recent survey by Orliaguet, et al,20 concerning the use of cuffed vs. uncuffed tubes, only 25% of pediatric anesthesiologists use a cuffed tracheal tube routinely for more than 80% of their patients. The most common concern includes fear of airway mucosal injury.
At SUNY, Downstate Medical Center/LICH, most pediatric anesthesiologists selectively choose a cuffed endotracheal tube, one-half size smaller than they would normally use in a pediatric patient, for certain procedures such as tonsillectomy and adenoidectomy, where surgical bleeding is an issue, or for cases of extremely long duration, where a large leak would be an inconvenience. A cuffed tube can be used safely if it is barely inflated at a pressure of 15-20 cm H2O until the leak disappears.
Intravenous Insertion Techniques
Many anesthesiologists actively encourage children older than 11 to have an intravenous (IV) placed before induction, unless they request an inhalation induction. With that in mind, there are three techniques to diminish the discomfort of IV placement. The use of an emulsion of lidocaine 2.5% and prilocaine 2.5% (EMLA cream, Astra Pharmaceuticals, Westborough, MA) is a well-established method of providing topical anesthesia; however, it has certain disadvantages.
It requires between 45-60 minutes for peak effect, which makes it impractical when the child arrives in the holding area a short time before surgery is to commence. Also, the cream causes vasoconstriction, which makes it more difficult to see the vein when it is time to start the IV. A recent development is the technique of iontophoresis for anesthetizing the skin.
Iontophoresis produces anesthesia by the transdermal delivery of local anesthetic by means of a low-level electric current.21,22 Our practice at SUNY, Downstate Medical Center/LICH is to inject a small amount of 1% lidocaine subcutaneously with a 25-gauge needle for topical anesthesia in cooperative children.
Routine Use of Muscle Relaxants
The routine use of muscle relaxants in pediatric outpatient anesthesia is controversial and depends on the duration of the case, whether intubation is planned, the status of the patient, and the preference of the anesthesiologist. Traditionally, pancuronium has been the muscle relaxant of choice in pediatrics, secondary to the effect of tachycardia, which is beneficial in this patient population as well as low cost. The potential long duration of action is mitigated by the larger volume of distribution in the pediatric population. Nonetheless, new muscle relaxants have gained popularity.
Rocuronium, a relative of vecuronium, has a rapid onset of action of two to four minutes and a duration of action of 20-45 minutes. At LICH, the majority of anesthesiologists do not administer muscle relaxant to facilitate endotracheal intubation in the majority of pediatric outpatient cases; instead, they prefer to intubate the patient while deeply anesthetized with volatile agent. Rocuronium is popular for surgical cases in which IV access has been achieved ahead of time, except in the neonatal/infant population, with whom pancuronium is preferred.
Maintenance Strategies
Maintenance of general anesthesia traditionally is provided by an inhaled anesthetic, opioid, and muscle relaxant. This method has the advantage of being a balanced technique with rapid awakening and reduced excitability/myocardial depression secondary to effects of volatile agents.
Alternatively, maintenance can be conducted with simply a volatile agent without a muscle relaxant. Clonidine in doses of 2 mcg/kg IV after induction has been shown to reduce the incidence of agitation without resulting in clinically significant bradycardia and hypotension.23
Currently, the effect of BIS monitoring in children has been shown in a randomized prospective study to result in less anesthetic use and faster recovery in patients undergoing tonsillectomy and/or adenoidectomy.24
Postoperative Pain Strategies
Postoperative pain strategies have focused on methods to provide adequate analgesia without respiratory compromise. Acetaminophen 10-15 mg/kg orally is the most commonly used analgesic for pediatric outpatient surgery. Acetaminophen also can be given prophylactically intraop by rectal suppository, but the dose needs to be higher (25-40 mg/kg) to provide effective analgesia in the PACU.
Narcotic analgesics offer excellent pain relief, albeit with concern for respiratory depression and PONV. Fentanyl up to a dose of 2 mcg/kg, or meperidine in a dose of up to 0.5 mg/kg can be administered by IV. The maximum dose for fentanyl is 5 mcg/kg if the patient is ambulatory, and the maximum dose for meperidine is 2 mg/kg. Recently, studies have shown that nasal fentanyl results in a therapeutic blood level similar to that following IV administration.25 This is potentially useful in short procedures such as BMT which do not require IV access, and use of narcotics might reduce agitation on emergence.26
Newer nonsteroidal anti-inflammatory drugs (NSAIDs) that are specific cyclooxygenase isoenzyme 2 inhibitors (COX-2), without targeting COX-1, are undergoing Phase 3 investigations in pediatric populations.
This will allow selectively blocking pain receptors without the gastrointestinal side effects long associated with other NSAIDs such as ketorolac.
Regional anesthesia, while generally impractical in pediatric outpatients as a sole anesthetic technique, offers excellent results for postoperative pain management, when combined with a light general anesthetic.
One of the most frequent regional techniques in children is the caudal anesthetic, which can be done with bupivacaine, levobupivacaine, or ropivacaine in many varied concentrations from 0.125%-0.25%, with and without epinephrine, depending on the anesthesiologist’s preference and clinical experience. The technique usually is performed after an inhalation induction with the child in the lateral position.
Many anesthesiologists at LICH subscribe to the "5-year-old/50 lbs. rule" that if the child is older than 5 years of age or weighs more than 50 lbs., a caudal anesthetic should be discouraged because of concerns for motor blockade.
In that instance, other regional blocks by the surgeon are encouraged depending on the type of surgery (dorsal nerve block of penis for circumcision and ilioinguinal/iliohypogastric for hernias).
Postoperative Nausea/Vomiting
The most frequent side effect of general anesthesia in the pediatric population is PONV. These complications are the most common cause of delayed discharge from the PACU and the most common cause of unanticipated hospitalization following pediatric outpatient surgery.27
PONV has an incidence in children ranging from 5% to 80%,28 depending on factors such as age and gender of child, type of surgery, type of anesthetic, and administration of opioids. Strategies to prevent or mitigate PONV in pediatric outpatients have surged in recent years.
Traditional medications such as droperidol or metoclopramide have been associated with concerns in the pediatric population for sedation, extrapyramidal reactions, headache, and confusion.
Recently, the use of droperidol has been prohibited because of the potential for serious proarrhythmic effects of death (risks of QT prolongation and/or torsades de pointes). Studies by Aouad, et al,29 have established that IV dexamethasone 0.5 mg/kg is beneficial on PONV and return of oral intake in children undergoing adenotonsillectomy.
The 5-hydroxytryptamine 3-receptor antagonist class of medications (ondansetron, dolasetron) have enjoyed increasing popularity in recent years, particularly in cases such as adenotonsillectomy, with or without dexamethasone. A low dose of ondansetron 75 mcg/kg with or without dexamethasone has been shown to result in a decreased incidence of PONV (< 5%) compared to dexamethasone alone, in children undergoing strabismus surgery.30
While some institutions routinely administer ondansetron prophylactically to all pediatric outpatients, concerns are that routine ondansetron may not be cost-effective. Studies by Scuderi, et al,31 have shown no significant difference between prophylactic and symptomatic ondansetron for outcomes related to levels of satisfaction, time to discharge, and unanticipated admission in adults.
No matter what variations occur in the practice of the institution, the importance of developing an antiemetic protocol to be administered has been shown to result in decreased moderate to severe PONV, and reduction of patients with repeated nausea.32 The importance of adequate hydration in reducing PONV cannot be overemphasized.
Postanesthesia Care and Discharge Home
Many hospitals transport all pediatric patients with blow-by oxygen, the tanks of which are always full and on stretchers. It is important to be able to assess the status of ventilation during transport; a hand holding the child’s chin up can serve as a monitor of breathing by the exhaled breath being felt on the hand. A precordial stethoscope also can be used in the transport process as a monitor of ventilation and circulation; however, this use may be limited in the child with an extremely agitated emergence. Bumpers should be placed on the sides of the stretcher during transport.
Traditionally, children go directly from the recovery room (phase 1 recovery) to a step-down unit (phase 2 recovery), from which they are discharged home. Discharge criteria for the recovery room originally were developed by Aldrete and Kroulik,33 who assigned a score of 0, 1, or 2 to activity, respiration, circulation, consciousness, and color; a score of 8 being required for discharge.
The Steward post-anesthetic recovery score34 differs in that color and circulation are eliminated since it is thought that color is hard to interpret in children and that blood pressure has little constant relation to recovery from general anesthesia in children. Some anesthesiologists have used pulse oximetry instead of color in recovery scores.35
Discharge from phase 2 recovery step-down depends on having an awake, responsive patient, with minimal pain, and absence of PONV, with no evidence of complications.
The Future: Fast-Tracking
Fast-tracking in pediatrics, while still limited in the pediatric outpatient population, offers intriguing possibilities that children who undergo extremely short procedures such as BMT and hernia repairs can bypass phase 1 recovery and go directly to phase 2 recovery (ambulatory surgery unit step-down).35 Purported benefits include earlier reunion with family, earlier discharge, and decreased need for antiemetics and analgesics. More studies need to be done in this area.
Summary
Outpatient surgery is advantageous in the pediatric population in terms of decreased cost, minimized hospital stays, earlier reunion with family, and decreased need for analgesics and antiemetics.
A cutting-edge approach in pediatric outpatient anesthesia can achieve all of the above goals with short-acting premedicants, drugs that provide for rapid induction and emergence, short-acting muscle relaxants, and revolutionary analgesics and antiemetics.
References
1. Hannallah RS. "General Anesthesia Techniques." In: White PF, ed.: Ambulatory Anesthesia and Surgery: An International Prospective. London: WB Saunders; 1997, pp. 573-582.
2. Hannallah RS, Patel RI. "Pediatric Considerations." In: Twersky RS, ed.: The Ambulatory Anesthesia Handbook. St. Louis: Mosby; 1995, pp. 145-170.
3. Lauro H, Twersky RS. Pre-anesthetic Preparation of Pediatric Outpatients: A Design for a Pediatric Pre-anesthetic Evaluation (PAE) Program. Publication pending.
4. American Society of Anesthesiologist. Anesthesia & You . . . When Your Child Needs Anesthesia. Park Ridge, IL; 2001.
5. American Society of Anesthesiologist. My Trip to the Hospital Coloring Book. Park Ridge, IL; 2001.
6. Tirotta C. A Hospital Trip with Dr. Bip: A Medical Orientation Video for Children. Miami: Kidz-Med; 1994.
7. Ferrari LR, Rooney FM, Rockoff MA, et al. Preoperative fasting practices in pediatrics. Anesthesiology 1999; 90:978-980.
8. Splinter WM, Stewart JA, Muir JG, et al. Large volumes of apple juice preoperatively do not affect gastric pH and volume in children. Can J Anaesth 1990; 37:36-39.
9. Parnis SJ, Barker DS, Van Der Walt JH, et al. Clinical predictors of anaesthetic complications in children with respiratory tract infections (RTI). Paedtr Anaest 2001; 11:29-40.
10. Schreiner MS, O’Hara I, Markakis DA, et al. Do children who experience laryngospasm have an increased risk of upper respiratory tract infections? Anesthesiology 1996; 85:475-80.
11. Tait AR, Malviya S, Voepel-Lewis T, et al. Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections. Anesthesiology 2001; 95:299-306.
12. Fazi L, Jantzen EC, Rose JB, et al. A comparison of oral clonidine and oral midazolam as preanesthetic medications in the pediatric tonsillectomy patient. Anesth Analg 2001; 92:56-61.
13. Brosius KK, Bannister CF. Effect of oral midazolam premedication on the awakening concentration of sevoflurane, recovery times and bispectral index in children. Paediatr Anaesth 2001; 11:585-590.
14. Kain ZN, Mayes LC, Wang SM, et al. Parental presence during induction of anesthesia versus sedative premedication — which intervention is more effective? Anesthesiology 1998; 89:1,147-1,156.
15. Bevan JC, Johnston C, Haig MJ, et al. Preoperative parental anxiety predicts behavioral and emotional responses to induction of anaesthesia in children. Can J Anaesth 1990; 37:177-182.
16. Lerman J, Davis PJ, Welborn LG, et al. Induction, recovery, and safety characteristics of sevoflurane in children undergoing ambulatory surgery: A comparison with halothane. Anesthesiology 1996; 84:1,332-1,340.
17. Allison CE, DeLange JJ, Koole FD, et al. A comparison of the incidence of the oculocardiac and oculorespiratory reflexes during sevoflurane or halothane anesthesia for strabismus surgery in children. Anesth Analg 2000; 90:306-310.
18. Frink EJ Jr., Green WB Jr., Brown EA, et al. Compound A concentration during sevoflurane anesthesia in children. Anesthesiology 1996; 84:566-571.
19. Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology 1997; 86:627-631.
20. Orliaguet GA, Renaud E, Lejay M, et al. Postal survey of cuffed or uncuffed tracheal tubes used for paediatric tracheal intubation. Paedtr Anaesth 2001; 11:277-281.
21. Irsfeld S, Klement W, Lipfert P, et al. Dermal anaesthesia: comparison of EMLA cream with iontophoretic local anaesthesia. Br J Anaesth 1993; 71:375-378.
22. Zempsky WT, Anand KJ, Sullivan KM, et al. Lidocaine iontophoresis for topical anaesthesia before intravenous line placement in children. J Pediatr 1998; 132:1,061-1,063.
23. Kulka PJ, Bressem M, Tryba M, et al. Clonidine prevents sevoflurane-induced agitation in children. Anesth Analg 2001; 93:335-338.
24. Bannister CF, Brosius KK, Sigl JC, et al. The effect of bispectral index monitoring on anesthetic use and recovery in children anesthetized with sevoflurane in nitrous oxide. Anesth Analg 2001; 92:877-881.
25. Galinkin JL, Fazi LM, Cuy RM, et al. Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2001; 93:1,378-1,383.
26. Finkel JC, Cohen IT, Hannallah RS, et al. The effects of intra-nasal fentanyl on the emergence characteristics following sevoflurane anesthesia in children undergoing surgery for bilateral myringotomy tube (BMT) placement. Anesth Analg 2001; 92:1,164-1,168.
27. Watcha MF, White PF. Postoperative nausea and vomiting: Its etiology, treatment, and prevention. Anesthesiology 1992; 77:162-184.
28. Baines D. Postoperative nausea and vomiting in children. Paedtr Anaesth 1996; 6:7-14.
29. Aouad MT, Siddik SS, Rizk LB, et al. The effect of dexamethasone on postoperative vomiting after tonsillectomy. Anesth Analg 2001; 92:636-640.
30. Splinter WM: Prevention of vomiting after strabismus surgery in children: dexamethasone alone versus dexamethasone plus low-dose ondansetron. Paedtr Anaesth 2001; 11:591-595.
31. Scuderi PE, James RL, Harris L, et al. Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999; 90:360-371.
32. Drake R, Mueser KT, Torrey WC, et al. Impact of an antiemetic protocol on postoperative nausea and vomiting in children. Paedtr Anaesth 2001; 11:85-91.
33. Aldrete JA, Kroulik D. A post-anesthetic recovery score. Anesth Analg 1970; 49:924-934.
34. Steward DJ. A simplified scoring system for the postoperative recovery room. Can J Anaesth 1975; 22:111-113.
35. Patel RI, Verghese ST, Hannallah RS, et al. Fast-tracking children following ambulatory surgery. Anesth Analg 2001; 92:918-922.
CE/CME Objectives
After participating in this CE/CME activity, the participant will be able to:
- identify anesthetic techniques to avoid when a 5-year-old child with particular symptoms presents for right inguinal herniorrhaphy;
- list methods of current prophylaxis or treatment of postoperative nausea and vomiting in children;
- identify methods that are currently being used or investigated in postoperative pain management;
- list purported benefits of current NPO guidelines.
To earn CME credit for this issue of Same-Day Surgery Reports, please refer to the enclosed Scantron form for directions for taking the test and submitting your answers.
1. A 5-year-old child presents for right inguinal herniorrhaphy. The child has a runny nose of 3-4 days duration, not associated with fever or productive cough. Anesthetic techniques to avoid include:
A. general anesthesia by mask.
B. laryngeal mask airway.
C. regional techniques.
D. endotracheal intubation.
2. Methods of current prophylaxis or treatment of postoperative nausea and vomiting in children include:
A. limitation of IV hydration.
B. ondansetron.
C. droperidol.
D. metoprolol.
3. Methods that are currently being used or investigated in postoperative pain management include:
A. nasal remifentanyl.
B. intravenous acetaminophen.
C. COX-2 inhibitors.
D. COX-2 activators.
4. Current NPO guidelines in the pediatric population encourage administration of clear liquids two to three hours prior to surgery. Purported benefits of this include:
A. a significant difference in gastric residual volume and pH in children who were allowed to have clear liquids until two to three hours before surgery, compared with controls with standard preoperative fasting.
B. higher incidence of anesthetic-induced hypotension or hypovolemia.
C. flexibility in the operative schedule should the procedure occur up to one hour earlier than expected.
D. higher incidence of hypoglycemia, and increased need for glucose-containing IV solutions.
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