Day Surgery

Day-case surgery confers many advantages in children. Children who are admitted to hospital often develop behavioural problems perhaps as a result of separation from parents and disruption of family life. These problems manifest as an alteration of sleep pattern, bedwetting and regression of developmental milestones.

Most children make excellent candidates for day-case surgery. They are usually healthy and the procedures performed are usually of short to intermediate duration. Only experienced surgeons and anaesthetists should undertake day-case surgery. Because this form of surgery is performed by experienced personnel, even ASA III patients may be considered. Children who are under 60 weeks post-conceptual age, those who have diseases that are not well controlled (e.g. poorly controlled epilepsy) and those with metabolic disease (e.g. insulin-dependent diabetes) that may result in hypoglycaemia should always be admitted electively for overnight stay.

Parents must be given clear written instructions well before the planned date of surgery. They should be told how long their child should be fasted before surgery. They should also be asked to make arrangements so that two responsible adults with their own transport accompany the child home.

Sedative premedication is rarely required for a child who has been well prepared. Children accompanied to the anaesthetic room by their parents usually remain calm. It makes sense to use agents with the shortest half-life. Regional anaesthesia performed at induction is useful in reducing the amount of anaesthetic needed intraoperatively and also provides excellent postoperative analgesia especially when long-acting agents such as bupivacaine or ropivacaine are used. Paracetamol and diclofenac given as suppositories at the end of surgery ensure that the child remains comfortable when the local anaesthetic has worn off. It is essential to seek the parent's informed consent for regional anaesthesia and rectal analgesics.

After surgery, the child should be allowed to recover in a fully equipped and staffed recovery ward. The child is returned to the day ward only when protective reflexes have returned. The child is discharged home when oral fluids are tolerated, but if the child has received intraoperative hydration, it is possible to ignore this criterion. Another yardstick used is whether the child has passed urine or not; this is particularly important if the child has been given a caudal block. Occasionally caudal blocks and inguinal blocks result in weakness of the leg. In this case, it is advisable to wait for the block to regress before discharging the child; clearly, this applies only to children who are walking. Ondansetron is useful in the treatment of postoperative nausea and vomiting, as the lack of any sedative effect is conducive to an early discharge. Children who have undergone tracheal intubation should remain on the day ward for at least 2 h to ensure that post-intubation croup does not occur.

Parents should be given an adequate supply of postoperative analgesics. It is crucial to emphasize the importance of giving analgesics pre-emptively 'by the clock' instead of waiting for the child to complain of pain.

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