Greenlane Surgical Unit paediatric patient selection
The purpose of this guideline is to clearly outline those cases that are suitable for surgery at Greenlane Surgical Unit from an anaesthetic perspective, reflecting the infrastructure and resources available at the time of writing these guidelines
Patient patient selection guidelines for day surgery at Greenlane Surgical Unit (GSU): Criteria for Dental, General, ORL, Orthopaedic and Ophthalmology Surgery
Overview
All hospitals or units should have guidelines on the lower age limit, health status and medical co-morbidities of children they will accept for day surgery.1,2 This should reflect the available facilities and equipment, as well as the training and experience of their staff. Most children, even those with complex co-morbidities, can have safe day care if pre‐operative assessment is robust and care is individualized and delivered by experienced staff in appropriate facilities.3
Background
Greenlane Surgical Unit (GSU) is a freestanding day surgery centre with limited paediatric infrastructure and capacity to manage paediatric patients the night following surgery. The purpose of this guideline is to clearly outline those cases that are suitable for surgery at this location from an anaesthetic perspective, and reflects the infrastructure and resources available at the time of writing these guidelines (August 2020)
Cases not covered in this guideline will require their procedures to be undertaken at Starship Children's Hospital, or with prior discussion with a Starship Anaesthetic Consultant.
All children, (except those undergoing ophthalmic and orthopaedic surgery - see 'Additional criteria for specific surgical directorates' below) will only be considered for same day surgery (admission and discharge on the same day) if they meet the criteria described below.
Nature of surgery
Minor surgery, limited anticipated blood loss and with post-operative pain manageable by simple oral analgesics may be considered appropriate. Simple laparoscopic surgery, by suitably credentialed medical personnel may be undertaken.
Patient preparation and pre-assessment
All patients presenting for surgery will need to have the appropriate pre-assessment and preparation. Pathways for this are under development and will be described separately.
Patient age
Infants and older children are potentially candidates for surgical procedures at GSU providing they meet the above criteria and are in reasonable health (see 'Patient health status and co-morbidites' below). The following criteria will apply:
Term infants (born later than 37 weeks post menstrual age-PMA) and older than 46 weeks PMA will be considered.
Ex-premature infants (defined as those born earlier than 37 weeks PMA) will only be considered for day stay surgery when older than 54 weeks PMA. They must fulfill day stay criteria in all respects.
For Adenoidectomy and Tonsillectomy surgery a more restrictive age limit than that described above will apply, due to known increase in post-operative complications :
Adenoidectomy > 2 years
Tonsillectomy > 3 years
Patient health status and co-morbidities
Patients should be in good health with only stable co-morbidities unlikely to affect or be affected by anaesthesia and surgery. For most procedures patient selection will be limited to those included in the categories below:
Acceptable health status
ASA 1: A normal healthy patient
ASA 2: A patient with mild systemic disease
Asthma well controlled
Simple corrected acyanotic congenital cardiac disease (eg ASD, PDA, VSD) not requiring medical treatment
Epilepsy well controlled
Obesity Grade I and II (see Table 1 below)
Diabetes mellitus (well controlled)
Developmental/behaviour disorders
Mild developmental delay
Mild cerebral palsy
Autistic/Asperger's spectrum managed at home
Potentially acceptable health status and co-morbidities
Patients in this category will require formal anaesthetic pre-assessment before being accepted for surgery at GSU.
ASA III & IV patients - disease/condition causing systemic disturbance
Severe Obstructive Sleep Apnoea (refer below)
Obesity Grade III (see Table 1 below)
Cardiorespiratory disease
unstable asthma, symptomatic bronchiectasis or cystic fibrosis
congenital heart disease, pulmonary hypertension
Risk of haemorrhage (surgical or patient factors)
Diabetes mellitus (poor control)
Paediatric syndromes. Many paediatric syndromes or conditions have the potential for airway and cardiac problems associated with anaesthesia and surgery:
those involving face and airway eg Goldenhar, Treacher-Collins, Apert's, Crouzon, Pfeiffers
multisystem syndromes eg Trisomy 21, Mucopolysaccharidoses
BMI extremes including obesity
The degree of obesity is an important consideration as there is evidence that the level of risk increases with increasing obesity, however this is related to issues that are commonly managed by anaesthetists. With appropriate system organisation, these should not be a barrier for minor surgery at GSU. Pragmatic guidance is absent from the literature as BMI changes with age, differing definitions for obesity are used, and no paediatric studies have investigated the impact of severe obesity in paediatric day stay surgery. The following definitions based on the Centre for Disease Control and Prevention (CDC) Body Mass index- percentiles charts and modified by the Children’s Hospital of Colorado will be used at GSU4,5. These reference the child’s BMI at a specific age to those of a late adolescent, in bands frequently used with adult patients.
BMI calculations and definitions for children undergoing surgery at GSU.
Quick summary (Table 1):
| Obesity Grade | Definitions | % of 95th percentile |
|---|---|---|
| Grade I | BMI equivalent to BMI 30- 35 kg/m2 late teen aged adult | >95th percentile < 120% of the 95th percentile |
| Grade II | BMI equivalent to BMI 35- 40 kg/m2 late teen aged adult | >120th percentile < 140% of the 95th percentile |
| Grade III | BMI equivalent to BMI >40 kg/m2 late teen aged adult | >140% of the 95th percentile |
It has been decided that the “Healthy weight BMI calculator” on the Ministry Of Health website (https://www.health.govt.nz/your-health/healthy-living/food-activity-and-sleep/healthy-weight/healthy-weight-bmi-calculator) will be used for this purpose. This can be accessed directly or via Hippo▸Anaesthesia▸Clinics▸Anaesthesia Preoperative Assessment Services▸Clinical Resources and selecting ‘BMI calculator’. By entering Date of Birth, sex, height and weight, the BMI and its centile ranking will be calculated.
See the actual BMI charts by following this link
Using the CDC criteria, the following definitions will apply:
| Weight status category | Percentile range |
|---|---|
| Underweight | Less than 5th percentile |
| Normal or healthy weight | 5th percentile to less than the 85th percentile |
| Overweight | 85th to less than the 95th percentile |
| Obese | Equal to or greater than the 95th percentile |
| Low BMI in children |
|---|
Low BMI, also called Failure to Thrive (FTT) is defined as a BMI < 5%. This will be determined from the centile ranking on the Ministry of Health, “Healthy weight BMI calculator” |
| High BMI in children | |
|---|---|
| Obesity Grade I | > 95%-120% of 95th percentile (adult BMI >30 -35 equivalent) |
| Obesity Grade II | 120-140% of 95th percentile (adult BMI 35- 40 equivalent) |
| Obesity Grade III | > 140% of 95th percentile (adult BMI > 40 equivalent) |
For surgery at GSU, the following criteria regarding obesity will apply:
Obesity Grades I and II: all surgery
Obesity Grade III non-airway surgery (includes dental surgery but excludes adenoidectomy and/or tonsillectomy)
Additional criteria for specific surgical directorates
ORL surgery: adenoidectomy and tonsillectomy (additional restrictions)
Currently patients are booked for ORL surgery by different practitioners throughout Auckland, against pre-determined criteria. In addition to the general criteria listed above, further restrictions for surgery at GSU are based on patient age, BMI extremes and severe obstructive sleep apnoea (OSA) as below:
Patient age:
adenoidectomy > 2 years
tonsillectomy > 3 years
BMI extremes:
children who are severely underweight with BMI < 5 percentile and severely overweight with Grade III obesity are not suitable for adenoidectomy and tonsillectomy at GSU
Obstructive sleep apnoea (OSA): (see also https://www.starship.org.nz/guidelines/obstructive-sleep-apnoea/)
Patients with OSA are at increased risk of respiratory complications, particularly with airway surgery requiring narcotics for pain relief post-operatively. For adenoidectomy and tonsillectomy, patients with severe OSA are not candidates for surgery at GSU as they need overnight apnoea monitoring. Severe OSA is defined by overnight oximetry or Polysomnography (PSG) as:
McGill 3 or greater on overnight oximetry (3 or more events < 85% SpO2)
Polysomnography
Ophthalmology
Ideally the above criteria would apply to all children receiving their treatment at GSU, however due to surgical equipment constraints, paediatric patients requiring eye surgery are unable to have their procedures performed at Starship Children's Hospital.
Consequently ophthalmology patients outside the above criteria may need to have their surgery performed at GSU. These patients will need to have appropriate arrangements made prior to anaesthesia and surgery being undertaken, and to facilitate overnight care at Starship Children’s Hospital as per the protocol below:
Protocol for the management of neonates, ex-premature infants and other patients otherwise unsuitable for day stay admission and discharge, having eye surgery at GSU:
Prior discussion with the anaesthetist is required. Questions should be directed to the anaesthetist for the list but if not contactable, to the Starship Anaesthetic co-ordinator on 021 334 344.
Arrangements for transfer to Starship Children’s Hospital post-operatively will need to be arranged and organised prior to surgery by the Ophthalmology Department. If the patient is already an inpatient at Starship, transfer will need to be arranged to and from GSU. This should be co-ordinated through the inpatient ward. If the patient is not already an inpatient under a medical service they will need to stay overnight on ward 25A/B at Starship Children’s hospital post-operatively for observation. This will require:
Ophthalmology house officer on duty the day before surgery to phone the paediatric medical registrar on call to advise of upcoming admission under general paediatrics and confirm bed availability.
Ophthalmology surgical booker to notify parents to bring in baby car seat for transfer to Starship in Ambulance
Ophthalmology theatre co-ordinator to book bed on 25A/B for post-op observation with 25A/B CN on 021 938 785
PACU co-ordinator to book Ambulance and transit nurse
Medical handover to the paediatric medical registrar on-call who will provide medical cover on 021 740 271
Orthopaedics
Some children having orthopaedic surgery at GSU will be admitted overnight. This applies to well children (ASA 1-2). Oral analgesia will be provided post operatively, however they will need to be transferred to Starship if they require a PCA/NCA or regional infusion.