[Ambulatory pediatric anesthesia: preanesthetic evaluation, anesthetic techniques, and immediate postoperative care]

Abstract

The advantages of pediatric out-patient surgery are: 1) greater psychological ease; 2) lower rate of infection; 3) less impact on patient habits, and 4) lower cost. Surgery must not involve organs, must have a low rate of complications, and be short. The preanesthetic interview should include clinical history and complementary examinations, information on anesthetic technique, perioperative recommendations and psychological preparation of parents and child. Detailed information reassures parents and improves collaboration; their presence during induction may be useful. At this time complete fasting is not recommended; although solids are not permitted, clear liquids should be taken up to 2-3 hours before anesthesia. In this way the child is less irritable and hypoglycemia and hypotension during inhalational induction are prevented. Low doses of midazolam and ketamine have been used for premedication, which though possibly useful, is not recommended because recovery may be prolonged. Halogenated anesthetics are very useful, with nitrous oxide providing an excellent complement. The potentially toxic effect of halothane on the liver does not keep this agent from being the most popular. Recovery is fast with any of the usual hypnotics (etomidate, propofol, thiopentone). Although thiopentone continues to be the hypnotic drug of reference, propofol's versatility is causing it to gain wider acceptance. The use of atracurium or vecuronium is justified if the dose is adjusted in keeping with type of surgery and duration. Intraoperative analgesics include meperidine, fentanyl and alfentanyl; morphine is not recommended. Should tracheal intubation be necessary, laryngeal edema may be avoided by gentle, cautious laryngoscopy, the use of a tube without a balloon, and 3 h of postanesthetic observation. A laryngeal mask may serve as an alternative to tracheal intubation. Local-regional anesthesia, excepting epidural and spinal anesthesia, offers a number of advantages: blockade of nociceptive stimuli, avoidance of opioid drugs, rapid and pleasant awakening (excellent for postoperative analgesia), and less need for postoperative analgesics. The postoperative complications seen most often are related to respiration or hypertension, making routine postanesthetic pulse oximetry a recommendation. The most frequently used analgesics are paracetamol, magnesium dipyrone, diclofenac, ketorolac, or codeine compounds. Although the incidence of nausea and vomiting is low in children, they are frequently a cause of hospitalization. Inappropriate postoperative care can increase the rate of admissions and medico-legal problems.(ABSTRACT TRUNCATED AT 400 WORDS)