SAMBA - Educational Guidelines, Core Curriculum

Preoperative outpatient evaluation has taken on a variety of modalities. It has been suggested that the goals of preoperative screening are to reduce perioperative complications, reduce patient anxiety, identify medical problems and patients unsuitable for ambulatory surgery, determine which laboratory tests to order, and improve operating room efficiency.

A. Modes of preoperative screening and the usefulness of preoperative patient contact - TOP

Barnes PK, Emerson PA, Hajnal S, Radford WJ, Congleton J. Influence of an anaesthetist on nurse-led, computer-based, pre-operative assessment. Anaesthesia 2000 Jun;55(6):576-80

In this study trained nurses using a rule-based computer program successfully carried out pre-anaesthesia screening. All medical problems and abnormal laboratory results were reviewed by an experienced anaesthetist. Following the introduction of this system, there was a reduction in the frequency of cancellations of patients from elective orthopaedic operating lists from 4.8% to 1.8%.

Egbert LD, Battit GE, Turndorf H, Beecher HK: The value of the preoperative visit by an anesthetist. JAMA 185:553, 1963

Another important reason for preoperative screening is to help alleviate a patient’s anxiety. In this classic study, the preoperative visit by an anesthesiologist was more effective in decreasing anxiety than administration of a barbiturate. Other authors also have confirmed the value of a preoperative visit.

Klopfenstein CE, Forster A, VanGessel E. Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Can J Anaesth 2000 Jun;47(6):511-5

The results of this study confirm that an anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety, when compared with an assessment on the evening before surgery.

In screening the preoperative patient, several sources of risk, each with potentially modifiable components, must be considered. These include risks related to the proposed procedure, anesthetic, and medical illnesses present in the patient. To screen effectively, one must look for potential factors in each area that may affect perioperative morbidity and mortality. Once risk areas are identified, it is helpful to quantify them further through a focused testing approach, especially when the anticipated surgical or anesthetic risks are high. Data obtained through this process should guide the optimization of the patient's medical status to modify risks when possible. Sharing information obtained during the preoperative assessment with both anesthesiologists and surgeons helps to refine plans for management and may better ensure patient safety in the perioperative period.

Parker BM, Tetzlaff JE, Litaker DL, Maurer WG. Redefining the preoperative evaluation process and the role of the anesthesiologist. J Clin Anesth 2000 Aug;12(5):350-6

This study shows that efficient, cost-effective patient care can be provided by implementing an ambulatory preoperative evaluation patient triage system. Changes made included a computer-based preoperative assessment, an internal medicine clinic designated specifically for preoperative evaluation and medical optimization, disease specific algorithms for both preoperative patient assessment and management, and a preoperative anesthesia clinic that no longer performed preoperative medical optimization. Notably, surgical delays decreased 49% during the study period.

Patel RI, Hannallah RS.Preoperative screening for pediatric ambulatory surgery: evaluation of a telephone questionnaire method. Anesth Analg. 1992 Aug;75(2):258-61.

Pollard JB, Olson L. Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations? Anesth Analg 1999 Aug;89(2):502-5

The operating room cancellation rate for outpatients evaluated 2-30 days before surgery was compared with the cancellation rate for outpatients who received their anesthesia evaluation within 24 h of surgery. Because both groups had similar cancellation rates, outpatients may be seen at a convenient time without adversely affecting operating room cancellations.

Roizen MF. Preoperative evaluation: a shared vision for change. J Clin Anesth 1997 Sep;9(6):435-6

Roizen MF, Klock PA, Klafta .J How much do they really want to know? Preoperative patient interviews and the anesthesiologist.Anesth Analg 1996 Mar;82(3):443-4

Tsen LC, Segal S, Pothier M, Bader AM. Survey of residency training in preoperative evaluation. Anesthesiology 2000 Oct;93(4):1134-7

Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth 1993 Nov;40(11):1022-7

The purpose of this study was to estimate the frequency with which routine postoperative chest x-rays lead to clinically relevant new information. All articles in English, French and Spanish relating to routine chest radiography in North American or European populations were reviewed, using the Medline database and references listed in reviews and periodicals published from 1966 to 1992, inclusive. Twenty-one reports which supplied sufficient information were included for meta-analysis. On average, abnormalities were found in 10% of routine preoperative chest films. In only 1.3% of films were the abnormalities unexpected, i.e., were not already known or would not otherwise have been detected (95% CI: 0 to 2.8%). These findings were of sufficient importance to cause modification of management in only 0.1% (95% CI: 0 to 0.6%). The frequency with which the new information influenced health could not be estimated. Assuming only the direct cost to the health care system of each radiograph ($23), each finding which influenced management in any way would cost $23,000. It is concluded that in North American or European populations when a reliable history and a clinical examination are carried out, the cost of this test is so high relation to the clinical information provided that it is no longer justifiable.

Callaghan LC, Edwards ND, Reilly CS, Utilisation of the pre-operative ECG. Anaesthesia. 50(6):488-90, 1995.

The utilisation of the pre-operative ECG in patients undergoing routine surgery was investigated in 354 adult patients. In 62% of patients with known cardiac disease and 44% of patients with strong risk factors for ischaemic heart disease (in the absence of known disease) the ECG was abnormal. This compares with only 7% of patients aged over 50 with no risk factors in whom the ECG was abnormal. These findings suggest that there is room for improvement in the utilisation of the pre-operative ECG, which may have cost implications.

Charpak Y, Blery C, Chastang C, Szatan M, Fourgeaux B. Prospective assessment of a protocol for selective ordering of preoperative chest x-rays. Can J Anaesth 1988 May;35(3 ( Pt 1)):259-64.

This study shows that the abandonment of routine ordering of preoperative chest x-rays does not produce adverse effects on patient care.

Gagner M, Chiasson A. Preoperative chest x-ray films in elective surgery: a valid screening tool. Can J Surg 1990 Aug;33(4):271-4.

The authors reviewed retrospectively 1000 patients who had a preoperative chest x-ray film made and who underwent elective surgery. Results showed that 5.8% of women and 10.5% of men (7.4% of all patients) had an abnormal preoperative chest x-ray film. These abnormalities were much more frequent (30%) in patients over 50 years of age than in younger patients (3%). Of the 74 patients whose films revealed abnormalities, 68 (92%) had a history or symptoms of cardio-respiratory disease. Of the six patients with x-ray film abnormalities but without symptoms or a pertinent history, none had a change in clinical outcome because of radiography. Guidelines are recommended for selectively ordering preoperative chest x-rays in surgical patients.

Gold BS, Young ML, Kinman JL, et al: The utility of preoperative electrocardiograms in the ambulatory surgical patient. Arch Intern Med 152:301-305, 1992

In a retrospective study, preoperative ECGs were abnormal in 43% of outpatients. Abnormalities occurred more frequently in patients with advanced age, underlying medical disease, and male gender. There were 12 adverse perioperative cardiovascular events (1.6%), and the preoperative ECG may have been useful in only 6. Neither preoperative ECGs nor responses to preoperative screening questionnaires were predictive of adverse cardiovascular events.

Jones T, Isaacson JH, Preoperative screening: what tests are necessary? [Review]. Cleveland Clinic Journal of Medicine. 62(6):374-8, 1995.

The preoperative evaluation often includes more tests than are necessary. This article reviews the usefulness of and indications for nine commonly ordered preoperative tests.

Kaplan EB, Scheiner LB, Boeckmann AJ, et al: The usefulness of preoperative laboratory screening. JAMA 253:3576-3581, 1985.

Appropriate testing could be generated from the surgeon's preoperative visit. Even a partial history indicated all but 22 abnormalities in over 2,785 preoperative blood tests.

Macpherson DS. Preoperative laboratory testing: should any tests be "routine" before surgery? Med Clin North Am 1993 Mar;77(2):289-308

Routine preoperative testing of all patients before elective surgery is unjustified. The frequency of unanticipated abnormalities or abnormalities shown to change patient management is too low to justify a practice pattern of testing all patients. Furthermore, little evidence exists that test result abnormalities are associated with perioperative morbidity.

O'Connor ME, Drasner K. Preoperative laboratory testing of children undergoing elective surgery. Anesth Analg 1990 Feb;70(2):176-80

This study makes the case that routine UA adds little to the preoperative evaluation of a healthy child, and should be omitted.

Patel RI, DeWitt L, Hannallah RS. Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice. J Clin Anesth 1997 Nov;9(7):569-75

This survey study evaluates current practices in preoperative testing of healthy children undergoing elective surgery that is not expected to result in significant blood loss. A total of 1,200 questionnaires were mailed to all members of the Society for Pediatric Anesthesia. All members were asked to specify which tests were routinely performed and to state why. Specific questions were asked about performing complete blood count (CBC), hemoglobin (Hb), hematocrit (Hct), and urine analysis (UA) in all patients, pregnancy test in adolescents, prothrombin time (PT) and activated partial thrombin time (PTT) prior to tonsillectomy, and sickle cell testing in black and/or Mediterranean children. 685 of 1,200 (57%) questionnaires were returned. Hb testing is routinely performed in 27% to 48% of the children depending on the age of the patient. UA is ordered preoperatively in less than 15% of the children. Pregnancy test was ordered by 43% of the respondents. Hemostatic tests prior to tonsillectomy were conducted by 45% of the anesthesiologists. The results indicate the present practice of routine preoperative laboratory testing for children undergoing elective outpatient surgery. In spite of the many studies that indicate no specific benefits of performing routine preoperative testing in healthy children undergoing scheduled surgery, many physicians continue to order these tests in all such children.

Perez A, Planell J, Bacardaz C, Hounie A, Franci J, Brotons C, Congost L, Bolibar I. Value of routine preoperative tests: a multicentre study in four general hospitals. Br J Anaesth 1995 Mar;74(3):250-6.

This study assessed the value of routine preoperative tests in asymptomatic patients and their influence on anesthetic and surgical decisions. We studied 3131 ASA I and II patients from four general hospitals undergoing elective surgical procedures. A retrospective review of the medical records revealed that 853 (27%) patients had some abnormal test result, of which 465 (15%) were previously unknown and not suspected at the preanesthetic visit; these comprised 8.6% chest radiographs, 5.6% electrocardiograms and biochemical tests, and 2.9% hematological tests. Perioperative management was altered in only 0.56-0.26% of patients, depending on the particular test. The present study confirms the need for selective and rational ordering of preoperative tests, the basis of which should be the clinical assessment during the preanesthetic visit.

Power LM, Thackray NM. Reduction of preoperative investigations with the introduction of an anesthetist-led preoperative assessment clinic. Anaesth Intensive Care 1999 Oct;27(5):481-8

Preoperative investigations, when used to screen for disease not clinically evident, have been shown to be unnecessary. The aim of this study was to rationalize the ordering of preoperative investigations by introducing guidelines and screening all investigations ordered at a new Day of Surgery Admissions clinic. There are significant reductions in most types of investigations (electrocardiogram, chest X-ray, liver function tests, urea and electrolytes, full blood examination, coagulation profile) ordered with the Day of Surgery Admissions clinic intervention. This resulted in an estimated reduction of preoperative investigation costs by 38%. It was concluded that the clinic intervention was associated with a reduction in indiscriminate preoperative investigation ordering patterns.

Rabkin SW, Horne JM: Preoperative electrocardiography: Effect of new abnormalities on clinical decisions. Can Med Assoc J 128:146-147, 1983.

Anesthetic or surgical plans were altered in only two of 1,165 patients in whom "new" abnormalities - those not indicated by history - were found on an ECG.

Roizen MF. More preoperative assessment by physicians and less by laboratory tests. N Engl J Med. 2000 Jan 20;342(3):204-5.

Roizen MF, Kaplan EB, Schreider BD, et al: The relative roles of the history and physical examination, and laboratory testing in preoperative evaluation for outpatient surgery: The "Starling" curve of preoperative laboratory testing. Anesthesiol Clin North Am 5(1):15-34, 1987.

The authors strongly emphasize that the history and physical examination are still the best means of preoperative screening and that laboratory tests other than those indicated by the history and physical examination are not cost-effective, do not provide medicolegal protection, and in fact may harm the patient. A "Starling" curve for laboratory testing is proposed whereby more testing is actually harmful rather than beneficial to the patient.

Roizen MF: Preoperative evaluation. In Miller RD (ed): Anesthesia, 4th ed, Vol 1. New York, Churchill Livingstone, 1994, p 827-882.

An extensive review of the literature. In epidemiological studies, the history and physical examination were the best means of determining what preoperative tests should be performed.

Roizen MF, Foss JF, Fischer SP: Preoperative Evaluation. In Miller RD (ed): Anesthesia, 5 th ed, Vol 1. New York, Churchill Livington, 2000, p824-883

Schein OD, Katz J, Bass EB, Tielsch JM, Lubomski LH, Feldman MA, Petty BG, Steinberg EP. The value of routine preoperative medical testing before cataract surgery. Study. N Engl J Med 2000 Jan 20;342(3):168-75

Routine preoperative medical testing is commonly performed in patients scheduled to undergo cataract surgery, although the value of such testing is uncertain. This large randomized controlled trial assigned 19,557 elective cataract operations in 18,189 patients at nine centers to be preceded or not preceded by a standard battery of medical tests (electrocardiography, complete blood count, and measurement of serum levels of electrolytes, urea nitrogen, creatinine, and glucose), in addition to a history taking and physical examination. Adverse medical events and interventions on the day of surgery and during the seven days after surgery were recorded. Medical outcomes were assessed in 9408 patients who underwent 9626 cataract operations that were not preceded by routine testing and in 9411 patients who underwent 9624 operations that were preceded by routine testing. The most frequent medical events in both groups were treatment for hypertension and arrhythmia (principally bradycardia). The overall rate of complications (intraoperative and postoperative events combined)was the same in the two groups (31.3 events per 1000 operations). There were also no significant differences between the no-testing group and the testing group in the rates of intraoperative events (19.2 and 19.7, respectively, per 1000 operations) and postoperative events (12.6 and 12.1 per 1000 operations). Analyses stratified according to age, sex, race, physical status (according to the American Society of Anesthesiologists classification), and medical history revealed no benefit of routine testing.The study concluded that routine medical testing before cataract surgery does not measurably increase the safety of the surgery.

Silvestri L, Maffessanti M, Gregori D, Berlot G, Gullo A. Usefulness of routine pre-operative chest radiography for anaesthetic management: a prospective multicentre pilot study. Eur J Anaesthesiol 1999 Nov;16(11):749-60

This prospective twenty-hospital study indicates that in healthy, female patients, < or = 60-year-old patients, submitted for standard surgery, the probability of a useful pre-operative chest radiograph ranges from 0.2% to 3.5% according to the hospital. The probability increases in male or elderly subjects, or in the presence of co-existing respiratory diseases, or in ASA classes > or = 3, but there is a wide variation between hospitals.

Tait AR, Parr HG, Tremper KK. Evaluation of the efficacy of routine preoperative electr-ocardiograms. J Cardiothorac Vasc Anesth 1997 Oct;11(6):752-5.

The positive predictive value of an abnormal ECG for a perioperative event was slightly greater for patients with cardiovascular risk factors than for those without (42.7 vs. 34.7). In addition, a normal ECG was just as predictive as an abnormal one. Results of this study suggest that the practice of routine ECG screening for patients with no cardiovascular risk factors is a poor predictor of perioperative complications in this patient population. A review of the current criteria for ordering preoperative ECGs may reduce the number of unnecessary tests and improve cost-effectiveness.

Turnbull JM, Buck C: The value of preoperative screening investigations in otherwise healthy individuals. Arch Intern Med 147:1101-1105, 1987.

Zarlenga G. Coordinating preoperative outpatient testing. Nursing Management. 2 7(l):48F, 48H, 1996.

A lack of a centralized system was causing high outpatient cancellation rates and significant delays. As a result, an Operating Room Tracking Committee created scheduling and outpatient coordinator positions to provide a centralized, coordinated approach to preoperative outpatient processing.

C. Patient selection - TOP

Although length of anesthesia has little relationship to the length of postoperative recovery, longer operations should probably be performed as early as possible in the day.

Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery--a prospective study. Can J Anaesth 1998 Jul;45(7):612-9.

This study was undertaken to determine the incidence, reasons, and predictive factors for unanticipated admission after ambulatory surgery. The overall incidence of unanticipated admission was 42% with admitted patients more likely to be older, male, and ASA status II or III. Duration of anaesthesia was longer, and surgery was more likely to be completed after 3 pm. Length of stay in the Postanaesthesia Care Unit and the Ambulatory Surgery Unit was longer as well. Surgical reasons were cited in 38.1% of admitted patients; anaesthesia-related reasons were cited in 25%; social reasons accounted for 19.5%, and medical reasons for 17.2%. Ear, nose and throat (ENT) patients had the highest unanticipated admission rate (18.2%), followed by urology (4.8%) and chronic pain block (3.9%). Gynecological patients had the lowest rate (0.4%). Among the predictive factors found were male, ASA status II and III, long duration of surgery, surgery finishing after 3 pm, postoperative bleeding, excessive pain, nausea and vomiting, and excessive drowsiness or dizziness. The authors concluded that earlier operating time for certain surgical procedures, screening for proper support at home, and implementation of clinical pathways to deal aggressively with problems such as pain, nausea and vomiting should decrease the incidence of unanticipated admission.

Freeman LN, Schachat AP, Manolio TA, Enger C: Multivariate analysis of factors associated with unplanned admission in 'outpatient' ophthalmic surgery. Ophthalmic Surg 19:719, 1988

The variable most highly correlated with admission was completion of surgery later in the day.

Meridy HW: Criteria for selection of ambulatory surgical patients and guidelines for anesthetic management: a retrospective study of 1553 cases. Anesth Analg 61:921, 1982

Mingus ML, Bodian CA, Bradford CN, Eisenkraft JB. Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients. J Clin Anesth 1997 Sep;9(6):446-50.

Surgery duration of 60 minutes or longer was the most important predictor of unanticipated admission following scheduled ambulatory surgery.

Pedersen T, Eliasen K, Hendriksen E: A prospective study of mortality associated with anaesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 37:176,1990.

This article relates that the type of operation (major vs minor) is more important in predicting outcome than either patient age or medical history.

Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital visits after ambulatory surgery. Anesth Analg 1997 Feb;84(2):319-24

The purpose of this retrospective study was to examine the frequency of return hospital visits after ambulatory surgery discharge and to identify any predictor variables for its occurrence. Data on return hospital visits that resulted in rehospitalization (as an inpatient or to the ambulatory surgery unit [ASU]) or treatment as an outpatient in the emergency room were recorded. A total of 6243 patients underwent ambulatory surgery over 12 consecutive months and 187 returned to the same hospital of which 1.3% were for complications. Of all the returns, 54% returned to the emergency room (ER) and 46% were rehospitalized as inpatients or to ASU. Results of a multivariate analysis on matched case controls identified urology as the only significant surgical service that predicted returns. (Odds ratio 27.87; confidence interval [CI] 3.78-74.86; P = 0.0002) while patients undergoing varicocelectomy and hydrocelectomy procedures were 8.3 times more likely to return (CI 2.090-23.75; P = 0.0042); patients undergoing dilation and curettage were three times as likely to return (CI 1.78-5.55; P = 0.0002). Bleeding was the most common reason for all hospital returns (41.5%), with 76.5% of these patients treated and discharged through the ER. As patients with bleeding were most likely to return to the ER and discharged, more effective pre- and postprocedure patient education may further reduce this occurrence.

Some surgeons are uneasy about performing transfusion-requiring operations in an ambulatory setting because blood loss may be a factor in unexpected hospital admission after surgery.

Badran HA, Kodeara KZ, Mabrouk MH. Blood conservation in massive suction lipectomy. Plast Reconstr Surg 1993 Dec;92(7):1298-304

The safety of this technique lies in proper fluid and blood replacement. Blood conservation techniques are therefore needed to avoid or minimize homologous transfusion. The use of a combination of predeposited autologous blood and acute intraoperative normovolemic hemodilution in the management of 150 patients requiring massive liposuction is reported. Since it is possible to anticipate the amount of blood loss in liposuction, a formula is proposed to monitor the hematocrit of the patient during the procedure and therefore predict the need for homologous transfusion. The technique reported enabled the authors to aspirate up to 11 liters in a single stage. Homologous transfusion was either avoided or markedly reduced. The degree of

Hetter GP: Blood and fluid replacement for lipoplasty procedures. Clin Plast Surg 16:245, 1989

Mandel MA. Blood and fluid replacement in major liposuction procedures. Aesthetic Plast Surg 1990 Summer;14(3):187-91

Major liposuction procedures require considerable fluid resuscitation to make them safe. A simple fluid replacement formula is presented that will estimate crystalloid and blood losses. It takes into account the daily fluid requirement, volume extracted, and the multiplicity of areas treated. Removal of 1500 mL required single-unit autotransfusion while amounts greater than 2500 mL necessitated a two-unit autotransfusion. These figures must be tempered by the surgeon's clinical assessment of each patient. The keys to successful and safe management of the liposuction patient are proper preoperative preparation and adequate fluid replacement.

Practice Guidelines for Blood Component Therapy. A report by the ASA Task Force on Blood Component Therapy. Anesthesiology 84:32, 1996.

An extensive review of risks, benefits and guidelines for blood and blood component therapy.

Although somewhat controversial, many feel that patients of ASA physical status III or IV are appropriate candidates for ambulatory surgery providing their systemic diseases are medically stable. Most medical problems that older individuals may experience are not caused by age, but by specific organ dysfunction. For that reason, all individuals, whether young or old, deserve a careful preoperative history and physical exam.

ACC/AHA task force report. Special report: guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Cardiothorac Vasc Anesth 1996 Jun;10(4):540-52

Belzberg H, Rivkind AI. Preoperative cardiac preparation. Chest 1999 May;115(5 Suppl):82S-95S

Preoperative preparation of the cardiac patient is based on matching the cardiac reserve to the blood flow demands imposed by surgical stress and the underlying disease state. Evaluation must include functional assessment of any coronary artery disease or other organic cardiac disease that may place myocardial tissue at risk of ischemia as demand for cardiac output increases. Monitoring should be individualized based on anticipated problems and the risk assessment of the patient. Preoperative therapy should include maneuvers that reduce congestive heart failure, optimize volume status, and provide adequate cardiac output to deliver oxygen sufficient to meet or exceed demand. Underlying electrical and metabolic abnormalities should be corrected and controlled in the perioperative period. Long-term therapy should be evaluated and modified in the context of the anesthetic and surgical plan. Preventive interventions such as fluid loading and low-dose dopamine should be considered prior to surgery.

Celli BR: What is the value of preoperative pulmonary function testing? Med Clin North Am 77:309-325, 1993.

The reason to perform pulmonary function testing is presented, followed by a means to estimate and minimize risk based on clinical presentation as well as pulmonary function testing.

Celli BR: Perioperative respiratory care of the patient undergoing upper abdominal surgery. Clin Chest Med 14:253-261, 1993.

This article summarizes the treatments that may help prevent the development of postoperative pulmonary complications in patients undergoing upper abdominal surgery.

Centers for Disease Control: Guidelines for prevention of transmission of human immunodeficie-cy virus and hepatitis B virus to health care and public safety workers. MMVR 38 (5-6):1,1989

This paper discusses the risks of infectious disease transmission and how to lessen the incidence of infection.

Chung OY, Beattie C, Friesinger GC. Assessment of cardiovascular risks and overall risks for noncardiac surgery. Cardiol Clin 1999 Feb;17(1):197-211

Appropriate care of the elderly patient requires a concerted multi-disciplinary approach before, during, and after surgery to optimize functional outcomes, with the principal focus placed on improving quality of life and strategies for risk reduction. Perioperative physicians must be able to assess the biologic, not the chronologic, age of geriatric patients and their capacity for independent function. Physicians need to understand alterations in the physiology of elderly patients attributable to the normal aging process as well as the prevalence of concurrent pathologic conditions that necessitate special precautions. Maintaining autonomy and function as a result of an acute surgical intervention may be the most important outcome to the elderly patient. Most of the data available and guidelines promulgated do not specifically address the elderly population. It is important to collect data prospectively and use sophisticated methods for analyses to develop better management algorithms for these (often complicated) clinical issues in the elderly.

Doyle RL. Assessing and modifying the risk of postoperative pulmonary complications. Chest 1999 May;115(5 Suppl):77S-81S

Preoperative pulmonary evaluation and preparation involve first identifying patients at risk for complications and then attempting to modify that risk. For most patients without underlying lung disease, a thorough history and physical examination and preoperative instruction in the use of incentive spirometry is sufficient. In patients with known or suspected lung disease, preoperative pulmonary function tests, while unproven as prognostic tools, may reduce risk by aiding in medical management, and in the case of the lung resection candidate, by helping determine very directly his or her viability for the procedure.

Duncan PG, Cohen MM, Tweed WA, et al : The Canadian four-centre study of anaesthetic outcomes: III. Are anaesthetic complications predictable in day surgical practice? Can J Anaesth 39:440-448, 1992

Preexisting medical illness is a factor in both intraoperative difficulties and postoperative complications, such as unexpected admission.

Eagle KA, Brundage BH, Chaitman BR, Ewy GA, Fleisher LA, Hertzer NR, Leppo JA, Ryan T, Schlant RC, Spencer WH, Spittell JA, Twiss RD, Ritchie JL, Cheitlin MD, Gardner TJ, Garson A, Lewis RP, Gibbons RJ, O'Rourke RA, Ryan TJ. Guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery. Circulation 1996 Mar 15;93(6):1278-317

Ergina PL, Gold SL, Meakins JL: Perioperative care of the elderly patient. World J Surg17:192-198, 1993.

This article reviews perioperative care of the elderly surgical patient with particular attention to pulmonary and cardiac complications and postoperative confusion.

Erstad BL, Barletta JF. Treatment of hypertension in the perioperative patient. Ann Pharmacother. 2000 Jan;34(1):66-79.

Ferguson MK. Preoperative assessment of pulmonary risk. Chest 1999 May;115(5 Suppl):58S-63S

Postoperative pulmonary complications occur after 25 to 50% of major surgical procedures. The accuracy of the preoperative assessment of the risk of such complications is fair. The routine assessment for all preoperative patients includes age, general physiologic status, and the nature of the planned operation. Specific tests such as measurement of spirometric values and diffusing capacity are indicated routinely only for patients who are candidates for major lung resection or esophagectomy. The authors concluded that pulmonary complications are an important form of postoperative morbidity after major cardiothoracic and abdominal operations. The appropriate preoperative assessment of the risk of such complications is well defined for lung resection and esophagectomy operations, but it requires refinement for general surgical and cardiovascular operations.

Finucane P, Phillips GD Flinders. Preoperative assessment and postoperative management of the elderly surgical patient. Med J Aust 1995 Sep 18;163(6):328-30

The population undergoing surgery is aging and this trend will continue for many decades to come. Better anesthetic and surgical techniques are lowering the risk-benefit ratio for surgery, making it an increasingly attractive treatment option. Good preoperative assessment and postoperative management form an integral part of strategies to minimize morbidity and mortality while maximizing hospital efficiency.

Fleisher LA, Barash PG: Preoperative cardiac evaluation for noncardiac surgery: A functional approach. Anesth Analg 74:586-598, 1992.

This is an interesting review article to help the clinician in the preoperative evaluation of a patient with a recent MI, angina, or at risk but without overt symptoms of coronary artery disease.

Gavin LA: Perioperative management of the diabetic patient. Endocrinol Metab Clin North Amer 21:457-475, 1992.

Glucose levels should be maintained between 120 and 180. Patients who do not require insulin may need insulin during the perioperative period. A flexible insulin regimen is desirable.

Gerberding JL: Management of occupational exposure to blood-borne viruses. N Engl Med 32:444,1995.

The article discusses the risk of hepatitis B, hepatitis C and HIV to the health care worker and methods of prophylaxis.

Gilbert K, Larocque BJ, Patrick LT. Prospective evaluation of cardiac risk indices for patients undergoing noncardiac surgery. Ann Intern Med 2000 Sep 5;133(5):356-9

Prediction of perioperative cardiac complications is important in the medical management of patients undergoing noncardiac surgery. Several indices have been developed to aid prediction, but their performance has not been systematically compared. This prospective study compared four existing methods for predicting perioperative cardiac risk at two teaching hospitals in London, Ontario, Canada. It inclused 2,035 patients referred for medical consultation before elective or urgent noncardiac surgery. End points included myocardial infarction, unstable angina, acute pulmonary edema, or death. The indices were compared by examining the areas under their respective receiver-operating characteristic (ROC) curves. Cardiac complications occurred in 6.4% of patients. The area under the ROC curve was 0.625 (95% CI, 0.575 to 0.676) for the American Society of Anesthesiologists index, 0.642 (CI, 0.588 to 0.695) for the Goldman index, 0.601 (CI, 0.544 to 0.657) for the modified Detsky index, and 0.654 (0.601 to 0.708) for the Canadian Cardiovascular Society index. These values did not significantly differ. The authors concluded that existing indices for prediction of cardiac complications perform better than chance, but no index is significantly superior. There is room for improvement in our ability to predict such complications.

Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Report of the ACC/AHA Task Force on Practice Guidelines. Circulation 93:1278,1996.

This article presents practice guidelines for the perioperative evaluation and care of patients with cardiac disease scheduled for noncardiac surgery. Recommendations are based on the patient's history and physical exam, exercise and functional states and on the proposed surgery. A detailed stepwise approach is presented.

Hall JB, Wood LD: Management of the critically ill asthmatic patient. Med Clin North Am 74(3):779-796, l990.

Provides algorithms for managing the asthmatic patient scheduled for ambulatory surgery; includes an extensive bibliography.

Hirsch IB, McGill JB, Cryer PE, White PF: Perioperative management of surgical patients with diabetes mellitus. Anesthesiology 74:346-359, 1991.

An excellent review article with well-referenced sections that specifically address the perioperative management of insulin-dependent and non-insulin-dependent diabetic patients who need ambulatory surgery.

Hollenberg SM. Preoperative cardiac risk assessment. Chest 1999 May;115(5 Suppl):51S-57S

Preoperative cardiac evaluation is aimed at evaluating the patient's current medical status, making recommendations concerning the risk of cardiac problems in the perioperative period, and providing a clinical risk profile that the patient, primary physician, consultants, anesthesiologist, and surgeon can use in making treatment decisions. Patients can be stratified on clinical grounds into low-, medium-, and high-risk categories. Use of these categories, along with consideration of the type and urgency of noncardiac surgery, allows for a reasonable approach to preoperative testing. In general, indications for cardiac testing and treatment are similar to the nonoperative setting, but their choice and timing is dependent on factors specific to the patient, the type of surgery, and the clinical situation. Use of invasive and noninvasive testing should be limited to situations in which the results of the tests will clearly affect patient management. Further research is necessary to define the most appropriate role of such testing, both in terms of efficacy and of cost-effectiveness. Cardiac intervention is rarely necessary to lower the risk of surgery, but noncardiac surgery often represents the first opportunity for a patient to receive an appropriate assessment of short- and long-term cardiac risk, and this should be taken into consideration in planning perioperative evaluation.

Hurford WE. The bronchospastic patient. Int Anesthesiol Clin 2000 Winter;38(1):77-90.

Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999 Nov 8;159(20):2405-11

Surgery in the patient with diabetes mellitus is relatively common, as the numbers of persons with diabetes is increasing and diabetes predisposes to medical conditions that require surgical intervention. An estimated 25% of diabetic patients will require surgery, and advances in perioperative care of these patients allow them to safely undergo the most complicated surgical procedures. This article reviews issues of preoperative, intraoperative, and postoperative care of diabetic patients.

Kaplan RF, Hillman RA: Availability of dantrolene in hospitals, surgicenters and oral surgery clinics-update. Anesth Analg 80:5226, 1995.

43% of hospitals, 68% of surgicenters and 85% of oral surgery centers were not fully prepared to treat MH.

Klimberg IW, Locke DR, Leonard, E, Madore R, Klimberg SR: Outpatient transurethral resection of the prostate at a urological ambulatory surgery center . J Urol 151:1547, 1994

Transurethral resection of the prostate has been performed in an ambulatory setting in patients 42 to 93 years of age.

Laslett L. Hypertension. Preoperative assessment and perioperative management. West J Med. 1995 Mar;162(3):215-9.

Levin P, Stanziola A, Hand R: Postoperative hospital retention following ambulatory surgery in a hospital-based program. Qual Assur Util Rev 5:90, 1990

Increasing age may be a factor related to increased incidence of admission after ambulatory surgery.

Mangano DT. Assessment of the patient with cardiac disease: an anesthesiologist's paradigm. Anesthesiology 1999 Nov;91(5):1521-6

McAnulty GR, Robertshaw HJ, Hall GM. Anaesthetic management of patients with diabetes mellitus. Br J Anaesth 2000 Jul;85(1):80-90

McLeskey CH, Nibel DM: Anesthesia for the geriatric outpatient. In White PF (ed): Outpatient Anesthesia. New York, Churchill Livingstone, 1990, pp 343-367.

These authors describe age-related perioperative risk, the pathophysiology of aging, and the effects of concomitant disease. The anesthetic management of geriatric patients and the assessment of recovery from anesthesia with discharge criteria are discussed.

Muravchick S. Preoperative assessment of the elderly patient. Anesthesiol Clin North America 2000 Mar;18(1):71-89, vi.

Organ system functional reserve variability increases progressively with age. In elderly patients, cardiopulmonary, central nervous system, and metabolic functional reserve seem to be the most important predictors of the ability to undergo surgery. Directed testing for the assessment of organ system functional reserve and identification of organs at risk, rather than the diagnosis of disease itself, is the primary goal of preoperative evaluation prior to surgery and is essential to the formulation of an effective anesthetic plan. The risks of adverse drug interaction, already high in the elderly, make a thorough review of the indications and dosage of perioperative medication an important part of the preoperative assessment process.

Osborne GA, Rudkin GE: Outcome after day-care surgery in a major teaching hospital. Anaesth Intensive Care 21:822, 1993

In a study of 6000 ambulatory surgery procedures in a public teaching hospital, perioperative complications related to surgery (1:105) were more frequent than those related to preexisting medical problems (1:500).

Osborne GA, Rudkin GE: Outcome after day-care surgery in a major teaching hospital. Anaesth Intensive Care 21:822, 1993

In a study of outcome including patients older than 90 years, after 6,000 procedures, recovery time was not correlated with increasing age.

Pasternak LR: Preoperative Evaluation-A systematic approach. 1995 ASA Refresher Course Lecture #421.

This Refresher Course presents the Johns Hopkins Risk Classification System which categorizes surgical procedures based on their risk to the patient independent of the patient's preoperative medical condition. A scheme for preoperative evaluation is also presented.

Pereira ED, Fernandes AL, da Silva Ancao M, de Arauja Pereres C, Atallah AN, Faresin SM. Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery. Sao Paulo Med J 1999 Jul 1;117(4):151-60

This prospective study investigated associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery at a tertiary university hospital. 408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications. Preoperative pulmonary function tests (PFT) were performed on 247 patients. The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009). There were three major

clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p<0.001). PFT is indicated when there are uncertainties regarding the patient's pulmonary status.

SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 265:3255, 1991.

Well managed hypertension reduces the risk of stroke in the elderly by 36% over 5 years.

Shulman MS. Preoperative pulmonary evaluation. N Engl J Med 1999 Aug 19;341(8):613-4

Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999 Mar 25;340(12):937-44

Varon J, Marik P. Preoperative pulmonary evaluation. N Engl J Med 1999 Aug 19;341(8):613; discussion 614

Warner MA, Sheilds SE, Chute CG: Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 270:1437, 1993.

The authors studied 38, 598 patients 18 years or older undergoing 45,090 procedures. There were 4 deaths and 29 other major events.

The risk of apnea following anesthesia in an ex-premature infant is well known. Various studies advocate different age limits for ambulatory surgery. Malignant hyperthermia susceptibility (MHS) is not a contraindication to outpatient surgery, since dantrolene availability is recommended for all anesthetizing areas. Furthermore, patients with MHS do well with nontriggering agents, even without the preanesthetic use of dantrolene.

Adams DM, Ware RE, Schultz WH, Ross AK, Oldham KT, Kinney TR. Successful surgical outcome in children with sickle hemoglobinopathies: the Duke University experience. J Pediatr Surg 1998 Mar;33(3):428-32.

Surgery in patients with sickle hemoglobinopathies can be problematic because of the potential for sickling events in the perioperative and postoperative period. The authors and others have previously reported successful surgical outcomes using an aggressive erythrocyte transfusion regimen, designed to alleviate anemia and to reduce the percentage of sickle hemoglobin to below 30%. Recently, a randomized trial compared this aggressive regimen with a more conservative transfusion regimen and found no differences in perioperative complications. The incidence of complications, however, was very high in each group (31% to 35%). The authors therefore analyzed retrospectively their surgical experience in children with sickle hemoglobinopathies over the past 10 years to determine the efficacy of an aggressive transfusion regimen and skilled perioperative care in their patient population. A total of 130 surgical procedures were performed on 92 children including 54 cholecystectomies (42%), 23 splenectomies (18%), 12 ENT procedures (9%), 11 central line placements and removals (8%), 7 herniorrhaphies (5%), 7 appendectomies (5%), and 16 miscellaneous operations (13%). The mean age of the children was 10 years (range, 1 to 22 years), and the mean weight was 32.1 kg (range, 9.9 to 76.8 kg). The average hemoglobin (mean +/- 1 SD) at the time of surgery was 11.2+/-1.3 g/dL, and the average percent hemoglobin S was 21+/-11%. CONCLUSIONS: Relatively few transfusions were required to achieve these endpoints, and the complications resulting from transfusions were minimal. Similarly, the number of perioperative and postoperative events was very low.

Bauchner H, May A, Coates E: Use of analgesic agents for invasive medical procedures in pediatric and neonatal intensive care units. J Pediat 121:647, 1992.

Cohen MM, Cameron CB: Should you cancel the operation when a child has an upper respiratory tract infection? Anesth Analg 72:282-288, 1991.

In a large prospective study of 20,876 children, those with a URI were two to seven times more likely to experience a respiratory-related adverse event perioperatively. The risk was higher in those who underwent general endotracheal anesthesia.

Corcino AJ. Anesthetic considerations for pediatric ophthalmologic surgery. OR Nurse 1995 Jul-Aug;17(4):16-21.

Cote CJ, Zaslavsky A, Downes JJ, Kurth CD, et al.: Postoperative apnea in former preterm infants after inguinal herniorrhaphy: a combined analysis. Anesthesiology 82:809, 1995.

The authors evaluate the risk of postoperative apnea in ex-premies. The authors consider both gestational age and postconceptual age in determining risk.

DeSoto H, Patel RI, Soliman IE, et al: Changes in oxygen saturation following general anesthesia in children with upper respiratory infection signs and symptoms undergoing otolaryngological procedures. Anesthesiology 68:276-279, 1988.

Children ages 1 to 4 years who were scheduled for tonsillectomy and adenoidectomy, bilateral myringotomy and tube placements, or a combination of the procedures, and who had signs and symptoms of a URI at the time of surgery or a history of URI in the previous week were at increased risk of developing transient postoperative hypoxemia.

Frumiento C, Abajian JC, Vane DW. Spinal anesthesia for preterm infants undergoing inguinal hernia repair. Arch Surg 2000 Apr;135(4):445-51.

The authors concluded that spinal anesthesia is safe, effective, and eliminates the need for post-operative hospital admission in an outpatient population of preterm infants undergoing inguinal hernia repair This results in considerable cost savings without compromising quality of care.

Greenberg CP, Hall SL, Karan SM, et al.: MH during outpatient pediatric ENT surgery-an anesthesia concern. Anesthesiology 83:AlOO4, 1995.

An ASA abstract concerning the question of the incidence of MH during outpatient surgery in pediatric patients.

Griffin TC, Buchanan GR. Elective surgery in children with sickle cell disease without preoperative blood transfusion. J Pediatr Surg 1993 May;28(5):681-5.

It is generally recommended that patients with sickle cell disease receive red blood cell (RBC) transfusions before undergoing general anesthesia and surgery. Since RBC transfusions are costly, inconvenient, and may cause serious complications, it might be useful to identify groups of patients for whom they are not absolutely necessary. We report our experience with 54 pediatric patients undergoing 66 elective surgical procedures without preoperative transfusion preparation. All patients were felt to be clinically and hematologically stable in the immediate preoperative period. For the majority of procedures (57/66, 86%) no transfusions were administered at any time during the perioperative course. There were no intraoperative complications or postoperative deaths. Overall, some type of postoperative complication was encountered after 17 procedures (26%). Complications were usually minor and were more likely to occur after procedures involving thoracotomy or laparotomy (10/20, 50%) and tonsillectomy/adenoidectomy (T&A) (5/9, 56%) than other procedures (2/37, 5%; P < .001). Pulmonary complications were especially more prevalent in the group undergoing thoracotomy, laparatomy, or T&A (9/29 v 0/37 for all other procedures, P < .001). We conclude that preoperative transfusions might be avoided in children with sickle cell disease who undergo most minor surgical procedures on an elective basis. Patients undergoing thoracotomy, laparotomy, or T&A are at a relatively higher risk of developing postoperative complications and would comprise ideal groups for evaluation of preoperative transfusion regimens in prospective carefully controlled, randomized studies.

Hall SC, Stevenson GW: Anesthetic considerations in the pediatric cancer patient. Sem Surg Oncol 6:148-155, 1990.

Hannallah RS, Epstein BS: Outpatient Anesthesia, in Pediatric Anesthesia 3rd Edition.

Halvorson DJ, McKie V, McKie K, Ashmore PE, Porubsky ES. Sickle cell disease and tonsillectomy. Preoperative management and postoperative complications. Arch Otolaryngol Head Neck Surg 1997 Jul;123(7):689-92

Patients with sickle cell disease are recognized as having a relatively higher risk for postoperative complications, including fever, atelectasis, pneumonia, or sickle cell vascular occlusion. This study retrespectively reviewed seventy-five patients with sickle cell disease who underwent tonsillectomy with or without adenoidectomy. Preoperative management was documented, and risk factors were assessed. Intraoperative management was reviewed, and postoperative complications were identified and compared with preoperative data and management. Operative time, technique, and blood loss were not statistically significant risk factors. The average length of hospitalization was 4.8 days. The authors concluded that children with sickle cell disease presenting for elective tonsillectomy should be given a transfusion to a hemoglobin S ratio less than 40% in an attempt to reduce postoperative complications. Additional factors, such as age and presence of obstructive sleep apnea, only increase the potential risks.

Hannallah RS, Epstein BS: Outpatient Anesthesia, in Pediatric Anesthesia 3 rd Edition. Edited by Gregory G, Churchill Livingstone, New York, NY, 1994, pp. 781-782

Hannallah RS, Patel RI: Pediatric Considerations, in Twersky RS, Editor: The Ambulatory Anesthesia Handbook. Mosby, St. Louis, MO, 1995, pp. 145-170.

Hopkins PM. Malignant hyperthermia: advances in clinical management and diagnosis. Br J Anaesth 2000 Jul;85(1):118-28

Jacoby DB, Hirshman CA: General anesthesia in patients with viral respiratory infections: An unsound sleep? Anesthesiology 74:969-972, 1991.

An editorial emphasizing that a recent viral infection can be a risk factor for perioperative pulmonary complications, owing to airway hyperresponsiveness. Viral infections, by causing a significant decrease in airway neutral endopeptidase activity, potentiate the bronchoconstrictor effects of tachykinins, thereby increasing airway smooth muscle resistance.

Karlet MC. Malignant hyperthermia: considerations for ambulatory surgery. J Perianesth Nurs 1998 Oct;13(5):304-12

Patient care offered on an ambulatory basis continues to grow as evidenced by the high percentage of surgical procedures now being performed in such a setting. Many ambulatory surgical facilities are free standing and remote from the primary hospital location. As the popularity of ambulatory surgical care increases, so does the likelihood of encountering malignant hyperthermia-susceptible patients or of experiencing a malignant hyperthermia crisis. The management of this unique population creates new challenges in the free-standing ambulatory setting. A comprehensive plan of patient care under these circumstances includes (1) the ability to identify the high-risk patient and to plan their care accordingly, (2) early recognition of the signs and symptoms of malignant hyperthermia, and (3) being prepared to promptly and efficiently treat a malignant hyperthermic event. This review article will offer guidelines for managing the malignant hyperthermia-susceptible patient in the remote ambulatory surgical setting.

Krane EJ, Hasberkem CM, Jacobsen LE: Postoperative apnea, bradycardia, and oxygen desaturation in formerly premature infants: prospective comparison of spinal and general anesthesia. Anesth Analg 80:7, 1995.

Children born before 37 weeks gestation have an increased incidence of postoperative apnea and oxygen desaturation.

Kunst G, Linderkamp O, Holle R, Motsch J, Martin E. The proportion of high risk preterm infants with postoperative apnea and bradycardia is the same after general and spinal anesthesia. Can J Anaesth 1999 Jan;46(1):94-5

Kurth CD, Spitzer AR, Broennle AM, Downes JJ: Postoperative apnea in preterm infants. Anesthesiology 66:483-488, 1987.

An infant's risk of prolonged (>15 sec) and short (6-15 sec) apnea was related to a young postconceptional age and to a history of necrotizing enterocolitis. The preoperative pneumocardiogram was not a reliable test for predicting postoperative apnea. The authors concluded that preterm infants younger than 60 postconceptional weeks of age should be monitored continuously for at least 12 hours postoperatively to prevent apnea-related complications. Conclusions from this study may not be as useful for ambulatory patients, because patients undergoing procedures not typically performed in an ambulatory setting (e.g., laparotomy) were included in the study.

Lawson GR. Controversy: Sedation of children for magnetic resonance imaging. Arch Dis Child 2000 Feb;82(2):150-3

Levy L, Pandit UA, Randel GI, Lewis IH, Tait AR: Upper respiratory tract infections and general anesthesia in children. Perioperative complications and oxygen saturation. Anaesthesia 47:678, 1992.

Children with an active or recent URI have an increased incidence of airway events, although these events may be mild or self-limited.

Management and Therapy of Sickle Cell Disease. National Institutes of Health Publication No. 89-2117. Bethesda, September, 1989.

An NIH consensus conference concluded that no single measure can replace good clinical judgment as the basis for raising patients' hemoglobin levels before surgery. For those patients with sickle cell diseases (SS, SC, SBthal) having minor surgery of brief duration, many experts favor simple transfusion to a hemoglobin level of slightly greater than 10 g/dl. For patients with sickle cell diseases undergoing major surgery of long duration (i.e., operations not performed on an outpatient basis), partial exchange or multiple transfusions are typically recommended, to a level at which HbS represents less than 50% of the hemoglobin and the hemoglobin level exceeds 10 g/dl. However, to date there is no documented evidence to support this practice. One must appreciate that transfusion therapy may be associated with a variety of significant risks.

Martin LD. Anesthetic implications of an upper respiratory infection in children. Pediatr Clin North Am 1994 Feb;41(1):121-30.

Pediatricians and pediatric anesthesiologists are frequently confronted with the dilemma of a child scheduled for elective surgery with or recently recovered from an upper respiratory tract infection. Modifications of routine anesthetic practice may decrease but not eliminate risks of associated complications. Guidelines for the evaluation and triage of these children are presented

McDowall RH: Anesthesia considerations for pediatric cancer. Sem Surg Oncol 9:478-488, 1993.

Anesthetic considerations for children with cancer are explained. The multidisciplinary approach to the care of children with cancer demands an understanding of all aspects of its treatment. Recognition of potential anatomic and physiologic derangements which may result from specific types of malignancy allows optimal preoperative preparation. Understanding the anesthetic implications of cancer chemotherapy, irradiation and surgery, and the medical complications which result, is essential. The anesthesiologist is involved in critical perioperative issues during surgical resection in the operating room, but just as importantly plays a crucial role in a variety of procedures performed in remote locations. An awareness of special problems related to cancer and its treatment allows optimal anesthesia care while dealing with such issues as radical surgery, organ system failure, acute and chronic pain, and terminal illness.

Mitchell V, Howard R, Facer E. Down's syndrome and anaesthesia. Paediatr Anaesth 1995;5(6):379-84

Down's syndrome is a common congenital abnormality associated with characteristic morphological features, impaired intellectual development and disorders of many organ systems with a broad spectrum of severity. Many of these, including defects in cosmetic appearance, are amenable to surgical correction. The risks of anesthesia are increased in these children. In this article the anesthetic implications of the syndrome are reviewed and the principles of perioperative management discussed. Comment in: Paediatr Anaesth. 1998;8(2):182-3

Moore RA, McNicholas KW, Warran SP: Atlantoaxial subluxation with symptomatic spinal cord compression in a child with Down's syndrome. Anesth Analg 66:89-90, 1987.

Down's syndrome can be associated with blunting of the styloid process of the second cervical vertebra, which may allow atlantooccipital subluxation or dislocation and resultant spinal cord injury. Cervical hyperextension, hyperflexion, and excessive neck rotation should be avoided perioperatively.

Rautiainen P, Meretoja OA: Intravenous sedation for children with Down's Syndrome undergoing cardiac catheterization. Paediatric Anaesthesia 4:21, 1994.

This article deals with the special considerations in the pediatric patient with Down's Syndrome.

Sims C. Masseter spasm after suxamethonium in children. Br J Hosp Med 1992 Jan 23-Feb 4;47(2):139-43

This review examines the nature of masseter spasm, its controversial relation to malignant hyperpyrexia, and the management of the child who develops it during induction of anesthesia.

Somri M, Gaitini L, Vaida S, Collins G, Sabo E, Mogilner G. Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison between spinal and general anesthesia. Anaesthesia 1998 Aug;53(8):762-6

The incidence of inguinal hernia is higher in premature infants, particularly in low birth weight neonates. This latter group may also incur increased postoperative respiratory complications and inpatient admissions. The purpose of this study was to compare the effects of general and spinal anesthesia on postoperative respiratory morbidity and on the length of hospital stay in high-risk infants undergoing inguinal herniorrhaphy. Forty patients, all high-risk infants who underwent unilateral or bilateral herniorrhaphies, were randomly assigned to receive general anesthesia (n = 20) or spinal anesthesia (n = 20). There was a significant difference in respiratory morbidity between the two groups, as well as a significant difference in the inpatient hospital stay. The present study suggests that spinal anesthesia can be used safely for high-risk infants, preterm or formerly preterm, undergoing inguinal hernia repair.

Steward DJ. Assessment of pediatric patients for general anesthesia: the child with an upper respiratory infection and the ex-premature infant. Semin Pediatr Surg 1999 Feb;8(1):13-7.

There are two types of patients that commonly lead surgeons and anesthesiologists into discussions relating to the possible cancellation or postponement of a minor pediatric surgical procedure; the child with a recent upper respiratory infection, and the patient who was born prematurely. Current opinion of the risks of anesthesia in such patients and the factors that influence perioperative course are reviewed, and a plan of management is suggested.

Strazis KP, Fox AW: Malignant hyperthermia: a review of published cases. Anesth Analg 77:297-304, 1993.

Published cases of patients who developed malignant hyperthermia are reviewed. The majority of cases occurred in male children less than 15 years. Congenital defects and musculoskeletal surgical procedures were more common, as were previous uneventful anesthetics and the absence of positive family history. Since 1985, mortality from malignant hyperthermia has decreased, partly owing to dantrolene therapy and better vigilance and awareness.

Tait AR, Knight PR: Intraoperative respiratory complications in patients with upper respiratory tract infections. Can J Anaesth 34:300-303, 1987.

A retrospective study found no increased risk of respiratory complications in children with uncomplicated URIs who underwent anesthesia and surgery. However, patients who were currently asymptomatic but had a recent history of URI were at significantly increased risk for the development of intraoperative complications. The authors postulate that airway reactivity may be increased in the postinfection stage.

Tait AR, Knight PR: The effects of general anesthesia on upper respiratory tract infections in children. Anesthesiology 67:930-935, 1987.

A prospective study suggesting that morbidity is not increased in children with acute uncomplicated URIs who undergo minor surgery and who do not require tracheal intubation.

Tobin JR, Spurrier EA, Wetzel RC: Anesthesia for critically ill children during MRI. Br J Anaesth 69:482, 1992.

Van der Walt J. Anaesthesia in children with viral respiratory tract infections. Paediatr Anaesth 1995;5(4):257-62.

The effects and consequences of anesthesia in a child with a respiratory tract infection (RTI) are controversial. There is a high incidence of viral RTI in children presenting for surgery and anesthesia. The social and economic impact of postponing the procedure is significant; for the child, family and institution. The clinical effects of the common cold are well known, affecting the respiratory tract from the nose down to the small airways and lung parenchyma. There is an increased incidence of intra- and postoperative respiratory related complications up to six weeks after a RTI. These include airway obstruction, laryngeal spasm, vagally mediated reflex bronchoconstriction, increased bronchial secretions, desaturation, atelectasis and postoperative respiratory complications. Children with symptoms of a moderate to severe RTI presenting for elective surgery should be postponed for six weeks. Emergency surgery should proceed with a mask anaesthetic for minor surgery or by adopting a modified rapid sequence induction (atropine but no cricoid pressure) to gain rapid control of the airway to avoid laryngeal spasm and vagally mediated reflex bronchoconstriction; IPPV, awake extubation, postoperative monitoring of respiratory function and appropriate analgesia. Comment in: Paediatr Anaesth. 1997;7(4):353-4

Vichinsky EP, Haberkern CM, Neumayr L, Earles AN, Black D, Koshy M, Pegelow C, Abboud M, Ohene-Frempong K, Iyer RV. A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease. The Preoperative Transfusion in Sickle Cell Disease Study Group. N Engl J Med 1995 Jul 27;333(4):206-13.

Preoperative transfusions are frequently given to prevent perioperative morbidity in patients with sickle cell anemia. There is no consensus, however, on the best regimen of transfusions for this purpose. We conducted a multicenter study to compare the rates of perioperative complications among patients randomly assigned to receive either an aggressive transfusion regimen designed to decrease the hemoglobin S level to less than 30 percent (group 1) or a conservative regimen designed to increase the hemoglobin level to 10 g per deciliter (group 2). Patients undergoing a total of 604 operations were randomly assigned to group 1 or group 2. The severity of the disease, compliance with the protocol, and the types of operations were similar in the two groups. The preoperative hemoglobin level was 11 g per deciliter in group 1 and 10.6 g per deciliter in group 2. The preoperative value for hemoglobin S was 31 percent in group 1 and 59 percent in group 2. The most frequent operations were cholecystectomies (232), head and neck surgery (156), and orthopedic surgery (72). With the exception of transfusion-related complications, which occurred in 14 percent of the operations in group 1 and in 7 percent of those in group 2, the frequency of serious complications was similar in the two groups (31 percent in group 1 and 35 percent in group 2). The acute chest syndrome developed in 10 percent of both groups and resulted in two deaths in group 1. A history of pulmonary disease and a higher risk associated with surgery were significant predictors of the acute chest syndrome. A conservative transfusion regimen was as effective as an aggressive regimen in preventing perioperative complications in patients with sickle cell anemia, and the conservative approach resulted in only half as many transfusion-associated complications. Comment in: N Engl J Med. 1995 Jul 27;333(4):251-2.

Warner MA, Lunn RJ, O'Leary PW, Schroeder DR. Outcomes of noncardiac surgical procedures in children and adults with congenital heart disease. Mayo Perioperative Outcomes Group. Mayo Clin Proc 1998 Aug;73(8):728-34

This retrospective study assessed the outcomes and risk factors for morbidity associated with anesthesia and noncardiac surgical procedures in children and adults with congenital heart disease. In all children and adults 50 years of age or younger with congenital heart disease who underwent one or more noncardiac surgical or diagnostic procedures and anesthesia, we analyzed the risk factors for 30-day perioperative morbidity and mortality. The overall frequency of complications among the 276 patients who underwent 480 noncardiac surgical procedures and anesthesia was 5.8% (28 of 480), and only 1 patient died intraoperatively. Major risk factors univariately associated with complications for the first procedures (15 of 276 patients or 5.4%) included the presence of cyanosis (P = 0.002), current treatment for congestive heart failure (P<0.001), poor general health (P<0.001), and younger age at the time of the procedure (P = 0.027). Procedures performed on the respiratory and nervous systems also were associated with high frequencies of complications. Complications in patients undergoing ambulatory surgical procedures were infrequent (1.7%). The authors concluded that the frequency of perioperative complications in children and adults who have congenital heart disease and undergo noncardiac surgical procedures and anesthesia is low. Patients who have pulmonary hypertension, congestive heart failure, or cyanosis and children with congenital heart disease who are younger than 2 years of age have an increased frequency of perioperative morbidity.

Welborn LG, Hannallah RS, Fink R, et al: High-dose caffeine suppresses postoperative apnea in former preterm infants. Anesthesiology 71:347-349, 1989

A prospective study of ex-premature infants who underwent inguinal hernia repair with inhalational anesthesia supplemented with neuromuscular blockade (without barbiturates or opioids) showed that IV caffeine 10 mg/kg was effective in controlling apnea in otherwise healthy ex-premature infants between 37 and 44 weeks of postconceptional age. It is still recommended, however, that all infants at risk be monitored postoperatively for at least 12 hrs for apnea and bradycardia.

Welborn LG, Hannallah RS, Luban NLC, Fink R, Ruttimann UE: Anemia and postoperative apnea in former preterm infants. Anesthesiology 74:1003, 1991

Anemia (hematocrit < 30) is associated with an increased incidence of apnea in preterm infants < 60 conceptual weeks.

Welborn LG, Rice LJ, Hannallah RS, et al: Postoperative apnea in former preterm infants: Prospective comparison of spinal and general anesthesia. Anesthesiology 72:838-842, 1990.

Preterm infants 51 weeks postconceptional age or younger were randomly assigned to receive either spinal or general anesthesia for inguinal hernia repair. A subset of the infants receiving spinal anesthesia also received ketamine sedation, 1-2 mg/kg, prior to placement of the spinal. Infants who received spinal anesthesia with sedation or general anesthesia developed postoperative bradycardia, prolonged apnea or periodic breathing. Only spinal anesthesia without ketamine sedation was associated with no postoperative apnea. Standard postoperative respiratory monitoring of these high-risk infants is recommended for at least 12 hours postoperatively following all anesthetic techniques.

Bell DM, Shapiro CN, Ciesielski CA, Chamberland. Preventing bloodborne pathogen transmission from health-care workers to patients. The CDC perspective. Surg Clin North Am 1995 Dec;75(6):1189-203

The development of recommendations to manage the risk of bloodborne pathogen transmission from health-care workers to patients during invasive procedures has been difficult, primarily because of the limitations of available scientific data. Ultimately, both health-care workers and patients will be protected best by compliance with infection control precautions and by development of new instruments, protective equipment, and techniques that reduce the likelihood of intraoperative blood exposure without adversely affecting patient care.

Doig C. Education of medical students and house staff to prevent hazardous occupational exposure. CMAJ 2000 Feb 8;162(3):344-5

Gostin LO. A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens. JAMA 2000 Oct 18;284(15):1965-70

In 1991, scientific uncertainty about the risk of transmission of human immunodeficiency virus or hepatitis B virus (hepatitis B e antigen [HBeAg]-positive) led the Centers for Disease Control and Prevention to recommend that infected health care workers (HCWs) be reviewed by an expert panel and inform patients of their serologic status before engaging in exposure-prone procedures. The data demonstrate that risks of transmission in the health care setting are exceedingly low, suggesting that the national policy should be reformed. Implementation of the current national policy at the local level poses significant human rights burdens on HCWs, but does not improve patient safety. A new national policy should focus on the management of the workplace environment and injury prevention by creating a program to prevent blood-borne pathogen transmission; by encouraging infected HCWs to promote their own health and well-being; by discontinuing expert review panels and special restrictions for exposure-prone procedures, which stigmatize HCWs; by discontinuing mandatory disclosure of a HCW's infection status in low-level risk procedures; and by imposing practice restrictions to avert significant risks to patients. Inclusion of these principles would achieve high levels of patient safety without discrimination and invasion of privacy.

Murphy. Hepatitis B, vaccination and healthcare workers. Occup Med (Lond) 2000 Aug;50(6):383-6

Hepatitis B viral infection is transmitted in adults by transfer of body fluids containing the virus. The outcomes following infection can be significant in terms of both health and employment. It is for these reasons that effective preventative health care is the goal of occupational health practitioners. This evidence-based review of the literature provides a basis upon which practice can be established and highlights some of the issues that may confront practitioners of the future.

Schalm SW, van Wijngaarden JK. Doctor-to-patient transmission of viral hepatitis B: is it a problem, is there a solution? J Viral Hepat 2000 Jul;7(4):245-9.

It is well-established that hepatitis B may be transmitted from surgeons to their patients. Clear strategies are needed to reduce the risk of transmission whilst not discriminating unnecessarily against surgeons who may pose no risks to their patients. This review outlines the current position and provides a blueprint for action that may reduce the risks to patients whilst minimizing the impact on practicing surgeons.

JAMA 1997 Oct 1;278(13):1056-7. From the Centers for Disease Control and Prevention. Recommendations for follow-up of health-care workers after occupational exposure to hepatitis C virus.

MMWR Morb Mortal Wkly Rep 1998 May 15;47(RR-7):1-33 Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. Centers for Disease Control and Prevention.

This report updates and consolidates all previous PHS recommendations for the management of health-care workers (HCWs) who have occupational exposure to blood and other body fluids that may contain human immunodeficiency virus (HIV); it includes recommendations for HIV postexposure prophylaxis (PEP) and discusses the scientific rationale for PEP. The decision to recommend HIV postexposure prophylaxis must take into account the nature of the exposure (e.g., needlestick or potentially infectious fluid that comes in contact with a mucous membrane) and the amount of blood or body fluid involved in the exposure. Other considerations include pregnancy in the HCW and exposure to virus known or suspected to be resistant to antiretroviral drugs. Assessments of the risk for infection resulting from the exposure and of the infectivity of the exposure source are key determinants of offering PEP Systems should be in place for the timely evaluation and management of exposed HCWs and for consultation with experts in the treatment of HIV when using PEP.

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