Many pediatric surgeries are performed on an outpatient basis either in a hospital or a freestanding ambulatory surgery center (ASC) with tonsillectomy and/or adenoidectomy, myringotomy, appendectomy, urological procedures, and other operating room therapeutic procedures on nose, mouth, and pharynx accounting for the top five pediatric ambulatory surgical procedures ( Performing surgeries at ASCs tends to be more cost effective than performing the same procedure in a hospital setting (J Am Acad Orthop Surg 2016;24:865-71). It is reasonable to expect that pediatric ambulatory surgery volumes will rise. This article will discuss upcoming challenges facing anesthesiologists taking care of pediatric patients for ambulatory surgery.

Obesity is increasingly common in the pediatric population with a prevalence of 13.4% among 2- to 5-year-olds, 20.3% among 6- to 11-year-olds, and 21.2% among 12- to 19-year-olds; 25.6% among Hispanic children, 24.2% among non-Hispanic Black children, 16.1% among non-Hispanic White children, and 8.7% among non-Hispanic Asian children (

Unlike adults, a child’s body composition varies with age and between genders. Therefore, BMI levels among children and teens need to be expressed relative to other children of the same age and sex. BMI percentile cutoffs are used to define obesity in pediatrics (Table 1).


While obtaining BMI measurements on adult patients is standard practice for anesthesiologists, it is not the case for pediatric patients. Currently using a BMI percentile cutoff for patient selection for pediatric ambulatory surgery is not customary practice.

Obesity is associated with perioperative respiratory adverse events (PRAE), including oxygen desaturations, airway obstruction, bronchospasm, laryngospasm, and difficult mask ventilation and intubation (Br J Anaesth 2011;106:359-63). Perioperative laryngospasm is particularly common in obese children with sleep-disordered breathing, which will be discussed later in this article (Int J Pediatr Otorhinolaryngol 2013;77:2044-8). Overweight or obese children are much more likely to have coexisting asthma, obstructive sleep apnea (OSA), bronchial hyperreactivity, diabetes mellitus, hypertension, gastroesophageal reflux, dyslipidemia, steatohepatitis, and pseudotumor cerebri (Pediatr Pulmonol 2017;52:160-6; N Engl J Med 2015;373:1307-17).

Ambulatory anesthesiologists caring for pediatric patients, especially in busy otolaryngology practices, where patients tend to present for correction of sleep-disordered breathing and tend to be overweight or obese, should obtain BMI percentile information on their patients. This allows for risk stratification and patient selection. Additional considerations include:

  • Preoperative optimization of comorbidities
  • Allowing time for difficult intravenous (I.V.) access
  • Decision to obtain I.V. access with or without inhalational induction
  • Contingency plan for difficult airway
  • Availability of difficult airway equipment appropriately sized for pediatric populations
  • Drug dosing based on total or ideal body weight
  • Plan for increased sensitivity to depressant effects of anesthetics by using shorter-acting agents or opioid-minimizing techniques
  • Management plan for delayed emergence and/or emergence delirium
  • A plan for safe discharge home versus admission to the hospital for longer observation

Interestingly, most ASCs currently do not have well-defined exclusion criteria based on BMI percentiles. For the few pediatric centers that have exclusion criteria, the cutoffs are variable, ranging from 95th to 99th percentile. The question of whether there should be a BMI percentile cutoff for pediatric ambulatory surgery is an area for future research.

SDB is the disruption of normal respiratory patterns and ventilation during sleep and has wide-ranging physical, mental, and psychosocial health effects on children (Table 2). The American Academy of Pediatrics (AAP) Subcommittee on Obstructive Sleep Apnea Syndrome estimates that 1.2%-5.7% of children are affected by OSA (Pediatrics 2012;130:e714-55).


The diagnostic criteria for pediatric obstructive sleep apnea (OSA) are shown in Table 3 (Chest 2014;146:1387-94). It is not always feasible to obtain polysomnography before elective ambulatory surgery. The STOP-Bang tool is widely used to identify adults at elevated risk of OSA. The STBUR (Snoring, Trouble Breathing, Un-Refreshed) questionnaire is a simple and clinically useful tool for identifying children with SDB at risk for PRAE. It incorporates five symptoms from the Sleep-Related Breathing Disorder (SRBD) questionnaire (Table 4) (Paediatr Anaesth 2013;23:510-6). Tait et al. found the likelihood of a critical PRAE was increased three-fold in the presence of any three STBUR symptoms and by 10-fold when all symptoms were present (Paediatr Anaesth 2013;23:510-6). The STBUR tool was found to be useful in identifying patients at higher risk for prolonged phase 1 recovery, oxygen therapy requirement, and escalation of care (Paediatr Anaesth 2019;29:821-8). It is important to consider the coexistence of anatomical features contributing to OSA (large tongue, trisomy 21, Pierre Robin sequence, retrognathia, high-arched palate, malocclusion) which may render airway management difficult in these children.


Overall, pediatric ambulatory anesthesiologists can consider using the STBUR questionnaire to screen their patients for OSA and be prepared for difficult-airway management.

Statistics obtained from the Centers for Disease Control and Prevention show that ADHD, anxiety problems, behavior problems, and depression are the most diagnosed mental disorders in children, with some of these conditions coexisting (Figure). The prevalence of depression and anxiety is increasing over time, and depression, substance use, and suicide are important concerns in adolescents. One in six U.S. children aged 2-8 years (17.4%) had a diagnosed mental, behavioral, or developmental disorder (MMWR Morb Mortal Wkly Rep 2018;67:1377-83).


Pediatric anesthesiologists in the ambulatory setting need to obtain a careful history from caregivers regarding psychiatric diagnoses, any special considerations for managing preoperative anxiety, and medications the child may be prescribed. Children with severe anxiety or intellectual disabilities may be best served in a pediatric hospital setting with the involvement of child-life specialists and social work to provide a stress-free perioperative experience. This may not be possible in a busy ASC that does not have these services. Another consideration is providing trauma informed care (TIC), which is defined by the National Child Traumatic Stress Network as medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers. Almost 34 million American children younger than 18 years have faced at least one potentially traumatic early childhood experience (Arch Gen Psychiatry 2007;64:577-84). A patient diagnosed with post-traumatic stress disorder should receive TIC (Pediatrics 2021;148:e2021052580).

ASCs may have to provide this training to all their employees to benefit both pediatric and adult patients. Other important perioperative considerations for these children include non-pharmacologic approaches to allaying preoperative anxiety, consideration of patient’s medications and their potential interaction with anesthetic drugs, and prevention and management of emergence delirium.

The pediatric ambulatory anesthesiologist is more likely than ever to encounter obese children with sleep-disordered breathing and learning disabilities with concomitant psychiatric diagnoses. It is worthwhile developing a pathway for screening, selecting, and risk-stratifying pediatric patients prior to the day of surgery for these conditions and, in addition, planning intraoperative and postoperative management geared toward a stress-free experience and safe discharge home.