Category: Reconstruction: Pediatrics
Introduction & Objective : There are widely variable practices regarding anesthesia for short, minimally-invasive procedures. Institutions may mandate placement of an endotracheal tube (ET) or laryngeal mask airway (LMA) for all cases, some require peripheral IV (PIV) placement for all cases, and some require both. Some place patients in stirrups in the dorsal lithotomy position on a standard operating table for cystoscopy, which adds to the overall time in the operating room (OR). We sought to compare total OR time and outcomes of cystoscopy and ureteral stent removal (CUSR) in pediatric patients using a "fast-track protocol" consisting of performing the procedure on the patient transport cart in the frog-leg position (Figure 1a) with mask/LMA-only anesthesia versus ET/LMA+IV. To date, safety with a fast-track protocol has not been reported.
Methods : We performed a multi-institutional, retrospective review of patients age <17 years who underwent CUSR. Those undergoing concurrent procedures were excluded. Patients were divided into 2 groups: mask or LMA with no IV (Group 1) and ET/LMA+IV (Group 2). Patient demographics, procedure time, and total time in the OR were recorded. Any adverse perioperative events (laryngospasm, conversion from mask to ET/LMA, need for IV placement, or need for IV medication administration in the PACU) were documented. Data was analyzed using SAS University Edition.
Results : 205 patients underwent CUSR at median age 45 mo (IQR 12-125), with 70 in Group 1 and 135 in Group 2. Age was not significantly different in those who did and did not have IV placed. Median time in OR for Group 1 was 15 min (IQR 13-20) versus 25 min (IQR 20-31) for Group 2 (p<0.0001). No Group 1 patients experienced laryngospasm, and none required conversion to ET/LMA. No Group 1 patients required IV placement in the OR or PACU, thus no patients in Group 1 received any IV medications.
Conclusions : General anesthesia without an IV is safe for short endoscopic procedures such as CUSR. Most procedures can be done on the patient cart, eliminating need for transfer to the operating table and use of stirrups. Conversion of standard anesthesia and patient positioning practices to a fast-track protocol can decrease anesthesia time and overall time in the operating room, thus decreasing costs. Collaboration on a fast-track protocol for these cases in conjunction with pediatric anesthesia should be considered for appropriately selected patients.
Candace Granberg– M.D., Mayo Clinic, Rochester, Minnesota
Carlos Villanueva– M.D., University of Nebraska Medical Center, Omaha, Nebraska
Dana Giel– M.D., UT Le Bonheur Children's Hospital, Memphis, Tennessee
Sean Corbett– M.D., University of Virginia Children's Hospital, Charlottesville, Virginia
Adam Hittelman– M.D., Yale School of Medicine, New Haven, Connecticut
George Chiang– Associate Professor, University of California San Diego, San Diego, California
Vijay Vemulakanda– M.D., Children's Hospital Colorado, Denver, Colorado
Jonathan Routh– M.D., Duke University Medical Center, Division of Urology, Durham, North Carolina
Patricio Gargollo– M.D., Mayo Clinic, Rochester, Minnesota
Candace F. Granberg, M.D. is an assistant professor of Pediatric Urology at Mayo Clinic in Rochester, Minnesota. She did her urology residency training at Mayo Clinic in Rochester, MInnesota, then completed a pediatric urology fellowship at Children's Medical Center / University of Texas-Southwestern Medical Center in Dallas, Texas. Her clinical and research interests include pediatric genitourinary malignancies (Wilms tumor, Rhabdomyosarcoma), minimally-invasive and robotic reconstructive surgery, pediatric stone disease, primary and reoperative hypospadias repair, fertility preservation in pre-pubertal children undergoing gonadotoxic treatment, and minimizing anesthesia and radiation exposure in children.
University of California San Diego
San Diego, California
George Chiang MD, Chief of Pediatric Urology and Fellowship Director University of California San Diego, Rady Children's Hospital
Duke University Medical Center, Division of Urology
Durham, North Carolina