Ambulatory or same-day surgery provides significant medical, psychological, and economic benefits to children and their families.[1] [2] Much of the preoperative and postoperative patient care that in the past was provided in the hospital by the surgeon and anesthesiologist is now being performed by the child's primary care physician (PCP). Indeed, the PCP is often asked to clear children for surgery, with little, if any, guidance as to what this term means. Although outpatient procedures are generally considered to be minor and usually performed on healthy children, the anesthetics used in these procedures are not without risk. An unappreciated acute illness or undiagnosed underlying disease can increase the risk of the anesthetic beyond that of the procedure for children so affected. This chapter reviews the effects of anesthesia on children and highlights specific aspects of the child's history and physical examination that are of particular importance to the anesthesiologist and surgeon.

Although this chapter is devoted to discussion of perioperative issues, the reality is that the scope of pediatric anesthesia has changed greatly during the last decade. No longer is anesthesia an activity confined to the operating room, requiring the presence of an anesthesia machine. Today, with a syringe, a monitor, and the appropriate backup equipment, a child can be anesthetized in virtually any location. More than 4 million children in the United States receive anesthesia or deep sedation both in and out of operating rooms each year.[3] The forces driving these changes in children's anesthesia are many: cost containment, efficiency, increased use of sophisticated diagnostic tools, and the continued efforts to minimize the periprocedure trauma that a child experiences. More than 60% of elective pediatric surgery is now being performed on an ambulatory, or same-day, basis. ^* Cost concerns have shifted more pediatric surgical procedures to freestanding surgical facilities.[4] The use of diagnostic imaging (magnetic resonance imaging [MRI], computed tomography [CT], and positron emission tomography), which requires immobility, has increased greatly in children, in part, because of the ability to provide safe anesthesia in these complex environments outside the operating room. Examples of surgical and diagnostic procedures that are now routinely performed on children in an outpatient setting are listed in BOX 62-1. Although the discussion is framed with reference to preoperative evaluation, the guidelines and principles reviewed apply equally to preprocedural and presedation assessment and preparation.

^*Data from the Children's Hospital of Philadelphia study on 22,000 cases in the fiscal years of 2002 and 2006 with 63.5% and 62.7% of surgical or nonsurgical procedures performed with anesthesia being performed on an ambulatory basis; and from COMPARE database kept by the Child Health Corporation of America.

General Surgery

• Femoral, inguinal, and umbilical herniorrhaphies
• Lymph node and other diagnostic biopsies
• Central line insertion
• Fistulotomy

Genitourinary Surgery

• Orchiopexy, hydrocele
• Circumcision
• Hypospadias repair

Otorhinolaryngeal Surgery

• Myringotomy and tube placement
• Adenoidectomy (children >2 yr)
• Tonsillectomy (children >3 yr)
• Bronchoscopy
• Tympanomastoidectomy
• Tympanoplasty
• Endoscopic sinus surgery
• Cochlear implant

Ophthalmologic Surgery

• Strabismus
• Examination under anesthesia
• Cataract
• Eyelid repair for ptosis

Orthopedic Surgery

• Tendon lengthening
• Cast changes
• Fracture reductions
• Arthroscopy

Plastic Surgery

• Cleft lip repair
• Hand surgery
• Rhinoplasty