Withholding oral fluids from children undergoing day surgery reduces vomiting

An Enhanced Recovery After Surgery (ERAS) Protocol for Orthognathic Surgery Reduces Rates of Postoperative Nausea

For many surgical procedures, enhanced recovery after surgery (ERAS) protocols have improved patient outcomes, particularly postoperative nausea and vomiting. The purpose of this study was to evaluate postoperative nausea following orthognathic surgery after the implementation of an ERAS protocol. This retrospective cohort study included patients between 12 and 35 years old who underwent orthognathic surgery at Boston Children's Hospital from April 2018 to December 2022. Patients with syndromes or a hospital stay greater than 48 hours were excluded from the study. The primary predictor was enrollment in our institutional ERAS protocol. The main outcome variable was postoperative nausea. Intraoperative and postoperative covariates were compared between groups using unpaired t tests and chi squared analysis. Univariate and multivariate regression models with 95% confidence intervals were performed to identify predictors for nausea. A P value<0.05 was considered significant. There were 128 patients (68 non-ERAS, 60 ERAS) included in this study (51.6% female, mean age 19.02±3.25 years). The ERAS group received less intraoperative fluid (937.0±462.3 versus 1583.6±847.6 mL, P ≤0.001) and experienced less postoperative nausea (38.3% versus 63.2%, P =0.005). Enhanced recovery after surgery status ( P =0.005) was a predictor for less postoperative nausea, whereas bilateral sagittal split osteotomy ( P =0.045) and length of stay ( P =0.007) were positive predictors for postoperative nausea in multivariate logistic regression analysis. Implementing an ERAS protocol for orthognathic surgery reduces postoperative nausea. Level of Evidence: Level III-therapeutic.

Jelly snakes to reduce early postoperative vomiting in children after adenotonsillectomy: The randomized controlled snakes trial

BACKGROUND

Despite the use of dual antiemetic agents, postoperative nausea and vomiting (PONV) occurs in an unacceptably large number of patients post-tonsillectomy. There has been increased interest in alternative and non-pharmacological treatments for PONV e.g., chewing gum. We investigated if chewing a large confectionary jelly snake had prophylactic antiemetic effects postoperatively in young children.

METHODS

Prospective, open-label randomised controlled trial of 240 patients, 2-16 years. Patients administered a confectionary jelly snake to chew postoperatively were compared with a control group. The primary outcome was the number of episodes of vomiting within 6 h of the operation on an intention-to-treat basis.

SECONDARY OUTCOMES

incidence of nausea, vomiting at 6 and 24 h, rescue antiemetic use, acceptability, delayed discharge.

RESULTS

233 patients were randomised to receive the confectionary snake (snake group, 118) or standard care (control group, 115). The number of vomiting episodes in 6 h was similar between groups on an intention-to-treat basis, with 39 episodes across 22 (19%) patients in the control group and 31 across 19 (16%) patients in the snake group (p = 0.666). From post anaesthetic care unit until 24 h there was no difference in doses of antiemetics or delayed discharge due to PONV. A secondary as per protocol analysis did not change this result.

CONCLUSIONS

Chewing of confectionery jelly snakes within one hour of waking following adenotonsillectomy with vapour-maintained anaesthesia and two prophylactic antiemetics did not further reduce the incidence of early vomiting.

REGISTRATION

prospective registration at the Australia and New Zealand Clinical Trials Registry (ACTRN12618000637246).

Postdischarge nausea and vomiting (PDNV) in children: A review and observational study

Postdischarge nausea and vomiting (PDNV) cause substantial pediatric morbidity with potentially serious postoperative complications. However, few studies have addressed PDNV prevention and treatment in pediatric patients. Here we searched the literature and processed it in a narrative review describing PDNV incidence, risk factors, and management in pediatric patients.. A successful strategy for reducing PDNV considers both the pharmacokinetics of the antiemetic agents and the principle of multimodal prophylaxis, utilizing agents of different pharmacologic classes. Since many highly effective antiemetic agents have relatively short half-lives, a different approach must be used to prevent PDNV. A combination of oral and intravenous medications with longer half-lives, such as palonosetron or aprepitant, can be used. In addition, we designed a prospective observational study with the primary objective of determining PDNV incidence. In our study group of 205 children, the overall PDNV incidence was 14.6% (30 of 205), including 21 children suffering from nausea and 9 suffering from vomiting.

Effect of the preoperative physical status on postoperative nausea and vomiting risk: a matched cohort study

BACKGROUND

The American Society of Anesthesiologists Physical Status Classification System is commonly used for preoperative assessment. Patient physical status before surgery can play an important role in postoperative nausea and vomiting. However, the relationship between the physical status classification and postoperative nausea and vomiting has not been well defined.

METHODS

Adults aged ≥ 18 years who underwent procedures under anesthesia between 2015 and 2020 were included in the study. We analyzed the relationship of postoperative nausea and vomiting with physical status classification score using propensity score matching and Cox hazard regression. Differences in intraoperative use of vasopressor and inotropes and invasive monitoring were investigated according to the classification.

RESULTS

A total of 163,500 patients were included in the study. After matching, classification 1 versus 2 included 43,400 patients; 1 versus ≤ 3, 13,287 patients; 2 versus ≤ 3, 23,530 patients (absolute standardized difference, 0-0.06). Patients with physical status classification ≤ 3 had a significantly lower postoperative nausea and vomiting risk than those with classification 1-2 (physical status classification 1 vs. ≤ 3, hazard ratio 0.76 [0.71-0.82], P < 0.001; 2 versus ≤ 3, hazard ratio 0.86 [0.82-0.91], P < 0.001). Intraoperative use of vasopressor or inotrope and invasive monitoring were noted more in the high physical status classification than the low physical status classification (absolute standardized difference [0.19-1.25]).

CONCLUSION

There were differences in intraoperative invasive monitoring and use of vasopressor or inotrope among the classifications, and a score of 3 or higher reduced the risk of postoperative nausea and vomiting more than a score of 1-2.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Observance of preoperative clear fluid fasting in pediatric anesthesia: oral and written information versus text message information. A before-and-after study

INTRODUCTION

Prolonged fasting before surgery is common in pediatrics. In the literature, it is responsible for hypotension, irritability and postoperative nausea and vomiting. Despite clear instructions given during the preanesthetic consultation, fasting rules are respected in only 30%-40% of cases. We aimed to evaluate the benefit of sending a text message the day before surgery to improve the parents' observance of fasting rules.

METHODS

We conducted a before-and-after study at the University Hospital of Poitiers. From August to October 2018, 172 parents of children under 15 years of age scheduled for all types of surgery were enrolled into two groups according to the period: the control group with parents receiving information on preoperative fasting rules during the preanesthetic consultation several days before surgery, and the text message group, receiving the same information during consultation plus a text message the day before the surgery.

RESULTS

There was a difference in observance of clear fluid fasting instructions (between 2 and 3 h before the admission at hospital) in favor of the text message group 33% versus 92% OR 29.2 (10.9-95.2) p < 0.001, and in average fasting time for clear fluids 8.7 h ± 4.8 h vs. 4.3 h ± 2.4 h (p < 0.001).

CONCLUSION

Sending of a reminder text message to the parents the day before the surgery resulted in a significant increase in observance of fasting rules in children undergoing scheduled surgery.

Hypopharyngeal packing during adenotonsillectomy by cold dissection in children: a randomized controlled trial

PURPOSE

Nausea and vomiting occur in up to 70% of children after adenotonsillectomy, ingested blood during procedure being one of the reasons for emesis. Hypopharyngeal packing (HP) is a common practice among otolaryngologists to prevent blood from being swallowed, but studies in nasal surgeries in adults failed to show efficacy of this technique in reducing postoperative nausea and vomiting (PONV). There are no studies evaluating the effect of HP in adenotonsillectomy in children. The aim of this study is to evaluate the efficacy HP during adenotonsillectomy in children in the prevention of PONV.

METHODS

This is a randomized, double-blinded, controlled trial. Children aged 4-16 years, scheduled for adenotonsillectomy due to sleep-disordered breathing were enrolled in Hospital da Criança Santo Antônio (Brazil). 192 participants were screened, while 129 were enrolled and completed follow-up for primary outcome. Patients were randomized in a consecutive manner to receive HP or not during adenotonsillectomy. PONV occurrence was assessed in the first 24 h after surgery in HP and control group and relative risk with 95% confidence interval was calculated.

RESULTS

There were 129 patients randomized, 64 in the HP and 65 in the control group. Female were 40.3% and mean ± SD age was 7.3 ± 2.9. Baseline characteristics and surgery variables were distributed similarly between the groups. Incidence of PONV was 20.3% in the HP and 23.1% in the control group. The relative risk for PONV was 0.88 (95% CI 0.46-1.70).

CONCLUSION

Our results suggest that there is no benefit of HP during adenotonsillectomy in children for the prevention of PONV.

TRIAL REGISTRATION

Brazilian Register of Randomized Trials (REBEC) identifier: RBR-3zjn27; Universal Trial Number U1111-1197-7461.

Incidence and factors contributing to postdischarge nausea and vomiting in pediatric ambulatory surgical cases

BACKGROUND

Little is known regarding the incidence and contributing factors of postdischarge nausea and vomiting in children.

AIMS

The aim of this study was to determine the incidence of postdischarge nausea and vomiting in day surgery patients and to identify demographic, intraoperative, and postoperative variables that influence the risk.

METHODS

In this prospective observational study, a postdischarge questionnaire was administered to parents of ambulatory patients who received anesthesia and the electronic records were reviewed.

RESULTS

Of 1041 ambulatory patients who received general anesthesia, 143 (14%) experienced postdischarge nausea and vomiting. Patients who did not receive intraoperative opioids had a lower incidence (8%) than those who received short-acting opioids (14%) (difference of 6%, 95% CI 1.9%-10.2%, P < .001) or long-acting opioids (24%) (difference of 16%, 95% CI 8.1%-24.3%, P < .001). Patients who received short-acting opioids also had a lower incidence than those who received long-acting opioids (difference of 10%, 95% CI 2.2%-18.1%, P < .001). The incidence also differed between those patients who received postdischarge opioids at home (29%) and those who did not (13%) (difference of 16%, 95% CI 7.5%-27.6%, P < .001). There was no association with age, gender, airway management, nitrous oxide use, amount of intravenous fluids, duration of anesthesia, intraoperative antiemetic administration or dosage, length of time from recovery room discharge to first oral intake, or length of ride home from the hospital. Multivariate generalized linear regression analysis confirmed intraoperative (short-acting opioids odds ratio 1.686, 95% CI 1.020-2.787; long-acting opioids odds ratio 3.093, 95% CI 1.634-5.874) and postdischarge (odds ratio 2.037 95% CI 1.142-3.632) opioids to be independent risk factors for postdischarge nausea and vomiting.

CONCLUSION

We found an incidence of postdischarge nausea and vomiting of 14%. Intraoperative and postdischarge opioids increase the risk, with long-acting intraoperative opioids further accentuating the risk.

Postoperative fasting after general anaesthesia: A survey of French anaesthesiology practices

BACKGROUND

Preoperative fasting is well codified worldwide. In contrast, the literature on the postoperative fasting (POF) is scarce, leading to potentially wide discrepancies among anaesthesiology practices. This survey assessed French POF practices.

METHODS

From March 2013 to January 2014, a survey was conducted among anaesthesiologists, members of the French Society of Anaesthesiology and Intensive Care Medicine (SFAR). The POF durations of either fluid or solid food intake was assessed according to airway management procedures (endotracheal intubation [EI] or laryngeal mask [LMA]) and age of the patients (adult or paediatric).

RESULTS

Seven hundred and fifty-four surveys were returned (67% from public hospital practitioners and 33% from private hospital and clinic practitioners). The majority of anaesthesiologists allowed fluid intake 2h after EI and immediately after discharge from PACU following LMA. For solid food resumption, it was 2h for children and 4h for adults after EI and 2h for both children and adults after LMA. Regardless of the airway management procedures, fasting was permitted immediately after PACU discharge more frequently in public than in private hospitals (36% vs. 33%, P<0.05). Four hours after the end of surgery, the rate was significantly higher in private than in public hospitals (93% vs. 89 %, P<0.001).

CONCLUSIONS

All in all, POF lasted less than 4hours after surgery regardless of airway management. They were shorter with regard to fluid intake, paediatric patients and LMA in comparison with solid food, adult patients and EI respectively.

Effects of intraoperative liberal fluid therapy on postoperative nausea and vomiting in children-A randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is one of the most distressing complications following surgery. Supplemental perioperative fluid therapy might be an effective strategy to reduce PONV in children.

OBJECTIVES

The study was conducted to evaluate the effects of intraoperative liberal fluid therapy with crystalloids on PONV in children.

METHODS

In this randomized trial, a total of 150 children of 3-7 years undergoing lower abdominal and penile surgery under general anesthesia were randomly assigned into two groups. "Restricted group" received 10 mL kg^-1 h^-1 and "Liberal group" received 30 mL kg^-1 h^-1 infusion of Ringer's lactate solution intraoperatively. All patients received a caudal block and intravenous paracetamol for analgesia. No opioids and muscle relaxants were used. All episodes of nausea-vomiting and the requirement of rescue antiemetic were assessed during 24 hours postoperatively.

RESULTS

The incidence of PONV was significantly less in the liberal group patients as compared to the restricted group; 33 (45.8%) patients in the restricted group had vomiting as compared to 20 (27.4%) patients in the liberal group (RR 0.59, 95% CI: 0.38-0.93, P=.021). The adjusted odds ratio of PONV for the liberal group vs restricted group was 2.24 (95% CI: 1.12-4.48, P=.022). The incidence of fluid intake during the first 6 postoperative hours was significantly higher in the restricted group patients; 60 (83%) children in the restricted group complained of thirst as compared to 12 (17%) children in the liberal group (RR 0.19, 95% CI: 0.18-0.33, P=.0001). The parents of the liberal group were more satisfied as compared to the restricted group (mean difference -0.9, 95% CI: -1.8, -0.1, P=.04). None of the children had any complication attributed to the liberal fluid therapy.

CONCLUSION

Liberal intraoperative fluid therapy was found to be effective in reducing PONV in children undergoing lower abdominal surgery.

Effects of therapeutic suggestion under anesthesia on outcomes in children post tonsillectomy

INTRODUCTION

Tonsillectomy causes discomfort in children. Positive therapeutic suggestions (TS) may be given to patients while they are emerging from general anesthesia as a potential tool to decrease distress.

PURPOSE

This study examined impact of TS on outcomes, when delivered to children emerging from general anesthesia post tonsillectomy.

DESIGN

A double blinded randomized controlled trial was conducted with 94 patient/parent pairs.

METHODS

TS and noise recordings were played via headphones post tonsillectomy upon arrival to the Post Anesthesia Care Unit until the child showed signs of waking.

FINDINGS

Pain scores at 30 minutes post extubation show significantly lower pain in the TS group, P = .04 (Mann Whitney U for independent samples). The TS group had 70% increased likelihood of receiving less intravenous (IV) opioid.

CONCLUSION

TS may help lower pain in children post tonsillectomy and decrease demand for IV opioid pain management in the 4- to 8-year-old tonsillectomy population.

Dexamethasone versus ondansetron in combination with dexamethasone for the prophylaxis of postoperative vomiting in pediatric outpatients: a double-blind, randomized, placebo-controlled clinical trial

OBJECTIVES

To determine the frequency of postoperative vomiting (POV) in children submitted to outpatient surgery and to compare the efficacy of antiemetic drugs in preventing this complication.

BACKGROUND

Nausea and vomiting are common in the immediate postoperative period following anesthetic and surgical procedures. Compared to adults, pediatric patients are more likely to develop postoperative nausea and vomiting, the incidence of which ranges from 8.9% to 42%.

METHODS

This double-blind, randomized, placebo-controlled clinical trial included 129 children. The participants were randomized into three prophylactic treatment groups: dexamethasone (n = 43), ondansetron in combination with dexamethasone (n = 44), and placebo (n = 42). The variables studied were the frequency of POV and the incidence of vomiting after the patient had been discharged from hospital, the need for antiemetic rescue therapy in the postanesthesia care unit (PACU), need for hospitalization, and the time the patient remained in the PACU. A significance level of 5% was adopted.

RESULTS

Postoperative vomiting occurred in 12.4% of the children, with no statistically significant difference between the groups: 6.8% in the group receiving ondansetron combined with dexamethasone, 14.3% in the placebo group, and 14% in the group that received dexamethasone alone (P = 0.47). Furthermore, no significant difference was found between the groups with respect to the time the children remained in the PACU, and only five patients reported having vomited following discharge from hospital.

CONCLUSIONS

The prophylactic use of antiemetic drugs failed to reduce the incidence of POV in pediatric outpatient surgery with a low emetic potential; therefore, routine prophylaxis may be unnecessary.

Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology

This guideline aims to provide an overview of the present knowledge on aspects of perioperative fasting with assessment of the quality of the evidence. A systematic search was conducted in electronic databases to identify trials published between 1950 and late 2009 concerned with preoperative fasting, early resumption of oral intake and the effects of oral carbohydrate mixtures on gastric emptying and postoperative recovery. One study on preoperative fasting which had not been included in previous reviews and a further 13 studies published since the most recent review were identified. The searches also identified 20 potentially relevant studies of oral carbohydrates and 53 on early resumption of oral intake. Publications were classified in terms of their evidence level, scientific validity and clinical relevance. The Scottish Intercollegiate Guidelines Network scoring system for assessing level of evidence and grade of recommendations was used. The key recommendations are that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery (including caesarean section) and all but one member of the guidelines group consider that tea or coffee with milk added (up to about one fifth of the total volume) are still clear fluids. Solid food should be prohibited for 6 h before elective surgery in adults and children, although patients should not have their operation cancelled or delayed just because they are chewing gum, sucking a boiled sweet or smoking immediately prior to induction of anaesthesia. These recommendations also apply to patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women not in labour. There is insufficient evidence to recommend the routine use of antacids, metoclopramide or H2-receptor antagonists before elective surgery in non-obstetric patients, but an H2-receptor antagonist should be given before elective caesarean section, with an intravenous H2-receptor antagonist given prior to emergency caesarean section, supplemented with 30 ml of 0.3 mol l(-1) sodium citrate if general anaesthesia is planned. Infants should be fed before elective surgery. Breast milk is safe up to 4 h and other milks up to 6 h. Thereafter, clear fluids should be given as in adults. The guidelines also consider the safety and possible benefits of preoperative carbohydrates and offer advice on the postoperative resumption of oral intake.

The effect of postoperative fasting on vomiting in children and their assessment of pain

BACKGROUND

Mandatory postoperative food intake has been shown to increase nausea and vomiting, and so postoperative fasting has become common practice even if patients request food or drink.

OBJECTIVE

We sought to investigate whether postoperative fasting reduces the incidence of postoperative vomiting in children when compared with a liberal regimen in which they are allowed to eat and drink upon request.

METHODS

One hundred forty-seven children scheduled for outpatient surgery were randomized to one of two groups. After anesthesia, patients in the 'fasting' group were expected to fast for 6 h. The children in the 'liberal' group were allowed to eat and drink according to their own needs. The incidence of vomiting and the children's well-being were recorded at several time points over a 24-hour period. Parents were also asked to rate, on a scale of 0-6, how much their children were bothered by fasting, pain, and nausea/vomiting.

RESULTS

Age (4.8 +/- 2.6 years), weight (20 +/- 9 kg) and gender (73% boys) were comparable between the groups. The incidence of vomiting was 15% in the liberal and 22% in the fasting group (P = 0.39) and, between 1 and 12 h after extubation, children in the liberal group were significantly happier (P < 0.001). Children in the liberal group were significantly less bothered by their pain than those in the fasting group (P < 0.001).

CONCLUSION

Postoperative fasting did not reduce the incidence of vomiting after general anesthesia in children when compared with a liberal regimen. Furthermore, the ability to eat and drink at will decrease the bothersome aspects of pain and lead to happier patients.

[Steroids for reduction of morbidity following tonsillectomy]

BACKGROUND

Of the morbidities that follow tonsillectomy, nausea and vomiting, fever, pain and inadequate oral intake are the most commonly encountered. The incidence of postoperative nausea and vomiting (PONV) has been reported as between 40% and 85%. In children, the risk of dehydration is increased owing to the delay in oral intake of fluids in the early postoperative period. In efforts to reduce postoperative morbidity, numerous modifications and adjuncts to the surgical procedure have been suggested, including the use of steroids.

PATIENTS AND METHODS

Reduction in PONV, pain and early return to a normal diet were studied as separate end-points in a review of the current literature.

RESULTS

A total of 31 studies matched our search criteria and involved paediatric and adult patient populations. Only 15 studies evaluated pain, PONV and diet. The lack of standardised surgical and anaesthetic techniques and the variations in length of follow-up, concentration of steroids administered and patient age distribution weaken the impact of the results recorded in several studies. However, two-thirds show that a single intravenous dose of dexamethasone reduces pain, although this was limited to the early postoperative period. Moreover, 15 studies confirmed a beneficial effect of dexamethasone on both PONV and early oral intake.

CONCLUSIONS

Preoperative administration of a single dose of dexamethasone to reduce postoperative morbidity resulting from tonsillectomy is supported by several studies. Adverse events have never been reported. However, further studies are warranted to determine the optimum dose required and the effect in adult tonsillectomy patients. In addition, the data should be based on standardised surgical and anaesthetic techniques to allow reliable evaluation of the significance of all outcome measures.

Management of postoperative nausea and vomiting in children

Postoperative nausea and vomiting (PONV) continues to be a frequent and important cause of morbidity in children. Postoperative vomiting (POV) is more commonly studied in children than postoperative nausea because of a child's inability to effectively express distress after experiencing nausea. POV is problematic in children and is one of the leading postoperative complaints from parents and the leading cause of readmission to the hospital. POV occurs twice as frequently in children as in adults, increasing until puberty and then decreasing to adult incidence rates. Gender differences are not seen before puberty. POV remains a main cause of morbidity in children because severe vomiting can be associated with dehydration, postoperative bleeding, pulmonary aspiration, and wound dehiscence. While children have an increased potential for dehydration and the resulting physiologic impairments, other associated results such as a delay in hospital discharge or an overnight or longer hospital admission also must be considered. The two most common emetogenic surgical procedures evaluated in children are strabismus repair and adenotonsillectomy. The approach to the management of PONV and POV in children is similar to that in adults. However, as the rate of POV is more frequent in children than in adults, more children are candidates for antiemetic prophylaxis. The management approach is multifactorial and involves proper preoperative preparation, risk stratification, rational selection of antiemetic prophylaxis, choice of anesthesia technique, and a plan for postoperative antiemetic therapy. It is important to identify children at moderate-to-high risk for POV as prophylactic antiemetic therapy is useful in these children. Antiemetics of choice for POV in children include dexamethasone, dimenhydrinate, perphenazine, ondansetron, dolasetron, granisetron, and tropisetron. The serotonin (5-hydroxytryptamine; 5-HT(3)) antagonists are the antiemetic drugs of first choice for POV prophylaxis in children because as a group they have greater efficacy for preventing vomiting than nausea. The 5-HT(3) antagonists can be effectively combined with dexamethasone with an increase in efficacy. If possible, regional anesthesia should be considered. For those undergoing general anesthesia, the baseline POV risk should be reduced. Children at moderate-to-high PONV risk should receive combination therapy with two or three prophylactic antiemetics from different antiemetic drug classes. Reference to and the use of PONV guidelines and management algorithms help improve cost-effective postoperative care.

Factors affecting recovery and discharge following ambulatory surgery

PURPOSE

Recovery and discharge following ambulatory surgery are important components of the ambulatory surgery experience. This review provides contemporary perspectives on the issues of discharge criteria, fast-tracking, patient escort requirements, and driving after ambulatory anesthesia.

SOURCE

A search was performed in the Cochrane Central Register for Controlled Trials, MEDLINE(R), EMBASE(R), CINAHL, and PsycINFO, to review factors delaying discharge following ambulatory surgery. The following subject headings were used: "ambulatory surgery, discharge, recovery, car driving, escort, transport, fast tracking, patient discharge, recovery, transportation of patients, hospital discharge, recovery room, patient transport, hospital discharge, recovery room, anesthetic recovery, patient transport, ambulatory surgical procedures, patient discharge, recovery of function, automobile driving, patient escort service, recovery room". Using the same search engines, the following keywords were used: "fast tracking, recovery, and discharge".

PRINCIPAL FINDINGS

The current literature supports that discharge scoring systems may be useful to guide discharge following ambulatory surgery. While fast-tracking has become common in some centres, further studies are required to justify more routine implementation of this practice in the management of patients undergoing ambulatory surgery. Patients at low risk for urinary retention can be discharged home without voiding. Patients should not drive until at least 24 hr postoperatively.

CONCLUSIONS

Ensuring rapid postoperative recovery and safe discharge following ambulatory surgery are important components of the ambulatory surgical program. A clearly defined process should be established for each ambulatory surgical unit to ensure the safe and timely discharge of patients after anesthesia, in accordance with current best evidence.

Prophylaxis of postoperative vomiting in children undergoing tonsillectomy: a systematic review and meta-analysis

Postoperative vomiting (POV) remains one of the commonest causes of significant morbidity after tonsillectomy in children. A variety of prophylactic anti-emetic interventions have been reported, but there has only been a limited systematic review in this patient group. A systematic search was performed by using Cochrane Controlled Trials Register, MEDLINE and EMBASE to identify double-blind, randomized, placebo-controlled trials of prophylactic anti-emetic interventions in children undergoing tonsillectomy, with or without adenoidectomy. The outcome of interest was POV in the first 24 h. Summary estimates of the effect of each prophylactic anti-emetic strategy were derived using fixed effect meta-analysis. Where appropriate, dose-response effects were estimated using logistic regression and 22 articles were identified. Good evidence was found for the prophylactic anti-emetic effect of dexamethasone [odds ratio (OR) 0.23, 95% CI 0.16-0.33], and the serotinergic antagonists ondansetron (OR 0.36, 95% CI 0.29-0.46), granisetron (OR 0.11, 95% CI 0.06-0.19), tropisetron (OR 0.15, 95% CI 0.06-0.35) and dolasetron (OR 0.25, 95% CI 0.1-0.59). Metoclopramide was also found to be efficacious (OR 0.51, 95% CI 0.34-0.77). There is not sufficient evidence to suggest that dimenhydrinate, perphenazine or droperidol, in the doses studied, are efficacious, nor were gastric aspiration or acupuncture. In conclusion, dexamethasone and the anti-serotinergic agents appear to be the most effective agents for the prophylaxis for POV in children undergoing tonsillectomy.

Perioperative fluid therapy in children: a survey of current prescribing practice †

BACKGROUND

Fluid therapy in children may be associated with iatrogenic hyponatraemia. We surveyed anaesthetists' current fluid prescribing practice during the perioperative period, departmental fluid protocols and awareness of the concerns of the Royal College of Paediatrics and Child Health (RCPCH) about the use of dextrose 4%/saline 0.18% in children.

METHODS

Questionnaire survey of 477 consultant anaesthetists in two training areas in the UK.

RESULTS

Responses were received from 289 anaesthetists (60.6%)--responses from the 203 consultants that anaesthetized children were analysed. A total of 67.7% did not have a local departmental policy for fluid prescription, and 58.1% were unaware of the concerns of RCPCH. A total of 60.1% of anaesthetists said that they prescribed hypotonic dextrose saline solutions in the intraoperative period and 75.2% did so in the postoperative period. Anaesthetists working in specialist paediatric hospitals were 5.1 times more likely to prescribe isotonic fluids intraoperatively than those working in district hospitals (95% CI 1.48-17.65, P=0.01), but they all prescribed hypotonic dextrose saline solutions postoperatively. The Holliday and Segar formula for maintenance fluid was quoted by 81.8% of anaesthetists; only 5.9% of anaesthetists would restrict fluids in the immediate postoperative period. Anaesthetists working in specialist paediatric hospitals were 13.2 times more likely to restrict fluids postoperatively than those working in district hospitals (95% CI 2.8-61.8, P=0.001).

CONCLUSIONS

The prescription of hypotonic dextrose saline solutions by anaesthetists may be putting children at risk from iatrogenic hyponatraemia. Departmental protocols for perioperative fluid prescription in children are uncommon. We suggest that national guidance is required.

The role of oral fluid intake following adeno-tonsillectomy

OBJECTIVE

To compare the incidence of complications following pediatric adeno-tonsillectomy (T&A) in patients who are encouraged to drink oral liquid versus patients who drink on a voluntary basis.

METHODS

This is a prospective, randomized, non-blinded study performed in a tertiary care medical center. Ninety-three otherwise healthy pediatric patients aged 2-12 years undergoing ambulatory T&A by a single surgeon were included in the study. Forty four patients were encouraged to drink 240 ml of clear liquid prior to discharge while 49 patients drank on a voluntary basis. Patients were followed prospectively for the incidence of emesis, dehydration and other complications.

RESULTS

Overall, emesis was experienced by 18% of patients in the post anesthesia care unit (PACU) and by 20% at home. Fifty percent of patients in the encouraged group versus 31% in the voluntary group reached the goal volume of oral liquids (p<0.05). The incidence of emesis was higher in both the encouraged (41% versus 14%) and voluntary group (40% versus 26%) when the goal volume of 240 ml was reached. There was no statistically significant difference between the two groups in terms of duration of PACU stay, incidence of emesis, number of episodes of emesis or volume of emesis. Further, there was no difference between the two groups in terms of post-operative complications including dehydration.

CONCLUSIONS

The current practice of a mandatory trial of oral fluid intake in the post-operative period may not be a necessary requirement for discharge. Further, mandatory oral fluids may result in a higher incidence of emesis.

Postoperative recovery and discharge

Ambulatory surgery provides quality care that is cost-effective. The use of innovative surgical and anesthetic techniques will allow larger numbers of patients to take advantage of the benefits of undergoing an elective operation on an ambulatory basis. Anesthesiologists will be faced with more complex surgery, which will require careful selection and assessment of patients to ensure continuity of the excellent safety record of ambulatory anesthesia. Minor adverse events, such as pain and PONV, are still common. The occurrence of these minor adverse advents is now the major area of quality assessment and an area where improvement could be targeted. Fast tracking facilitates earlier discharge, but we must ensure this has benefit to the patient as speedy discharge may mask the true incidence of adverse minor symptoms. This can lead to patient dissatisfaction and a poor impression of ambulatory surgery.

Management of postoperative nausea and vomiting in children

In spite of improvements in anesthesia techniques, the 'big little problem' of postoperative nausea and vomiting (PONV) still exists. PONV can prolong recovery room stay and hospitalization, and is one of the most common causes of hospital readmission after day surgery. While there is little evidence to support prophylactic administration of antiemetics in patients at low risk of PONV, the higher risk population could benefit from the use of adequate antiemetic drugs. A wide variety of pharmacological approaches have been reported to be effective, as well as some nonpharmacological approaches. Antiemetic drugs available to treat or prevent PONV include phenothiazines, antihistamines, anticholinergics, benzamides, butyrophenones and 5-HT(3) antagonists. Since available drugs still present undesired adverse effects and are not completely able to control PONV, clinical investigations are ongoing for more effective and better tolerated agents; indeed, the ideal antiemetic drug might be cost-effective for routine use.

Vomiting and common paediatric surgery

Postoperative vomiting is a common and unpleasant complication. The purpose of the present study was to verify if dexamethasone reduces the incidence of vomiting when injected IV in children anaesthetized with halothane for common paediatric operations. We also studied the incidence of vomiting when sevoflurane was used instead. Five hundred and 69 boys, aged 2-12 years (ASA physical status I, II), scheduled for inguinal field surgery were randomly assigned to receive halothane, halothane and dexamethasone and sevoflurane in three groups: halothane (n=180), halothane and IV dexamethasone (n=188) and sevoflurane (n=201). Anaesthesia was induced by inhalation of halothane or sevoflurane in oxygen and nitrous oxide and was maintained at minimum alveolar concentration of each agent throughout the surgery. For intra- and postoperative pain control iliac crest block was used in all the boys. Vomiting was defined as any expulsion of liquid gastric contents. The incidence of postoperative vomiting was 23% in the halothane group, which was significantly greater than that in the other groups (halothane and dexamethasone group, 9%; sevoflurane group, 13%). In conclusion, dexamethasone reduces the incidence and frequency of multiple emetic episodes when administered intravenously after halothane anaesthesia; sevoflurane reduces the overall incidence of vomiting, but not multiple emetic episodes.

Management of the paediatric patient

Recent introduction of new fast-onset short-duration anaesthetic drugs and the use of regional anaesthesia techniques in children have resulted in good control of anaesthesia and perioperative pain with few adverse effects. Ambulatory surgery has gained popularity in paediatric practice, particularly as children are often otherwise healthy and usually undergo minor surgery.