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Preoperative Evaluation/Patient Issues/Youngest Appropriate Age

QUESTION

I work in an outpatient unit that is connected by a bridge to a hospital that has no pediatrics or pediatricians. The local pediatric surgeon has just adopted us to do all of his elective surgical cases. What is the youngest appropriate age to care for non-premature infants for ambulatory procedures in this setting in order to minimize the risk of peri-anesthetic complications (apnea)?

-- Anonymous

REPLY:

Apnea risk is one of the concerns in ambulatory care of infants, but there is little evidence regarding the risk in healthy term infants. Selection of the procedure is also important; if pain can be managed with local/regional or non-opioid analgesia postoperatively then there can be greater comfort with doing the procedure on an outpatient basis. Many facilities will do healthy term infants for relatively minor procedures (hernia repair, circumcision, etc) on an outpatient basis but as a first morning case and with a somewhat longer period of observation in the facility - 4 hours being an arbitrary number often chosen (Everett LL. How young is the youngest infant for outpatient surgery? in Fleisher, L, ed: Evidence-Based Practice of Anesthesiology; Saunders, Philadelphia, 2004; pp. 419-23.) This also generally does not apply to higher risk populations such as infants with pyloric stenosis.
As the question notes, risk is higher in former premature infants, and has been stratified by Cote (Cote CJ, et al Anesthesiology 1995;82:809-21). Many facilities choose cutoff between 46 and 60 weeks postconceptual ages, or, to simplify, use 6 months post-delivery at any postconceptual age. Anemia or ongoing apnea may extend the risk.

Other concerns include experience of the anesthesia provider, age-specific competency of the nursing and other support staff, and the availability of appropriate equipment. Staff should be PALS-trained and there must be a transfer agreement in place with a facility which could accept pediatric patients. Several studies suggest some increased anesthetic risk in patients under 1 year of age (Morray JP et al. Anesthesiology 2000;93:6-14). The American Academy of Pediatrics Section on Anesthesiology has developed guidelines for the pediatric perioperative anesthesia environment (Pediatrics 1999;103:512-5) which have been echoed by the ASA (http://www.asahq.org/clinical/PediatricAnesthesia.pdf) and Society for Pediatric Anesthesia (http://www.pedsanesthesia.org/policyprovision.html). A basic component of these is the suggestion that each facility delineate what patient ages, populations, and procedures they will undertake. It also recommends that the facility define patients they consider at increased risk, and that those patients be cared for by a pediatric anesthesiologist.

-- From Lucy Everett, M.D., Seattle, WA

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