EVALUATION OF THE DIFFICULT PEDIATRIC PATIENT - 11/09/11

Doi : 10.1016/S0889-8537(05)70304-7

Ramesh Patel, MD ^{^{*
From the Departments of Anesthesiology, Children's National Medical Center, and George Washington University Medical Center, Washington, DC}}, Phoebe Leith, MD ^{^{*
From the Departments of Anesthesiology, Children's National Medical Center, and George Washington University Medical Center, Washington, DC}}, Raafat Hannallah, MD ^{^{*
From the Departments of Anesthesiology, Children's National Medical Center, and George Washington University Medical Center, Washington, DC}}

Résumé

A decade ago only American Society of Anesthesiologists physical status (ASA PS) I or II patients undergoing short procedures were considered appropriate candidates for outpatient surgery. Today, duration of surgery is no longer a major determining factor, and procedures that last 4 to 6 hours are routinely performed on an ambulatory basis. Moreover, ambulatory surgery has been expanded to include patients who have chronic medical conditions.^{11 Patel R.I., Hannallah R.S. Complications following pediatric ambulatory surgery Ambulatory Anesthesia 1995 ; 3 : 83-86 [cross-ref]

Cliquez ici pour aller à la section Références} Benefits of ambulatory surgery to children with chronic disease include maximizing time spent outside the hospital, minimizing the child's separation from their family, reduced disruption of their schedule, and decreased exposure to other sick children in the hospital. The trend toward performing more complex surgeries on sicker patients in an ambulatory setting has created new challenges in performing rapid yet thorough evaluations and making expeditious decisions.^{11 Patel R.I., Hannallah R.S. Complications following pediatric ambulatory surgery Ambulatory Anesthesia 1995 ; 3 : 83-86 [cross-ref]

Cliquez ici pour aller à la section Références} Selection criteria for outpatients are continuously changing, such that rigid guidelines seem impractical. It seems most prudent to approach each patient individually.

The surgeon is the first physician to evaluate the patient for surgery. He or she has to decide the appropriateness of outpatient versus inpatient surgery. The surgeon also arranges for notification and consultation with various specialists, including the anesthesiologist. A preoperative visit with the anesthesiologist may be scheduled, if necessary. The anesthesiologist may also obtain information via a routine preoperative telephone screening call to the parents.^{12 Patel R.I., Hannallah R.S. Preoperative screening for pediatric ambulatory surgery: Evaluation of a telephone questionnaire method Anesth Analg 1992 ; 75 : 258-261

Cliquez ici pour aller à la section Références} Reviewing pertinent information preoperatively will help avoid cancellations and delays. In chronically ill patients, such as children with cancer, complex congenital heart disease, chronic renal disease, severe asthma, cystic fibrosis (CF), and diabetes, the patient's medical history is documented and then reviewed well in advance of the day of surgery. Occasionally, the anesthesiologist will confront an unexpected problem, such as a previously undetected heart murmur or a patient with a history suggestive of malignant hyperthermia susceptibility. In such cases no documentation may be available and the decision whether to proceed must be made promptly. Before performing ambulatory surgery in a child with a chronic disease three specific questions should be addressed:

1	Should surgery be performed on an ambulatory basis? This is decided in consultation with the surgeon, primary physician, and the family. The primary considerations are whether the patient will benefit from preoperative admission for therapy or postoperative admission for observation or therapy. Social issues, such as distance to hospital from home, parental skills and education, need for special equipment, and multidrug therapy during the immediate postoperative period, must be included in decision making.
2	Should the surgery be performed on the date scheduled? To determine the timing of surgery it must be decided if the patient is currently at his or her baseline level of health or whether additional therapy will be required to optimize the condition.
3	What laboratory tests need to be performed and where? Most children do not require any laboratory tests, but those with systemic diseases may require pertinent radiologic and laboratory studies before surgery.

Although a majority of children are healthy and undergo ambulatory surgery uneventfully, some pose special challenges for anesthesiologists. This article reviews these disease processes, treatment regimens, anesthetic implications, and considerations regarding perioperative disposition.

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Plan

Address reprint requests to Ramesh Patel, MD, Department of Anesthesiology, Children's National Medical Center, 111 Michigan Avenue, N.W., Washington, D.C. 20010