Incidence and predictors of postoperative nausea and vomiting in children undergoing electrophysiology ablation procedures

Anaesthetic management of paediatric patients undergoing electrophysiology study and ablation for supraventricular tachycardia: A focused narrative review

Every year, 80,000-100,000 ablation procedures take place in the United States and approximately 1% of these involve paediatric patients. As the paediatric population undergoing catheter ablation to treat dysrhythmia is constantly growing, involvement of anaesthesiologists in the cardiac electrophysiology laboratory is simultaneously increasing. Compared with the adult population, paediatric patients need deeper sedation or general anaesthesia (GA) to guarantee motionlessness and preserve comfort. As a result, the anaesthesiologist working in this setting should keep in mind heart physiopathology as well as possible interactions between anaesthetic drugs and arrhythmia. In fact, drug-induced suppression of accessory pathways (APs) conduction capacity is a major concern for completing a successful electrophysiology study (EPS). Nevertheless, the literature on this topic is scarce and the optimal type of anaesthesia in EPS and ablation procedures in children is still controversial. Thus, the main goal of the present review is to collect the literature published so far on the effects on cardiac conduction tissue of the drugs commonly employed for sedation/GA in the cath lab for EPS and ablation procedures to treat supraventricular tachycardia in patients aged <18 years.

Determination of Risk Factors for Nausea and Vomiting in Children After Appendectomy

PURPOSE

This study aimed at investigating the risk factors for postoperative nausea and vomiting (PONV) in pediatric patients undergoing appendectomy.

DESIGN

This is a prospective, descriptive, cross-sectional study.

METHODS

The study involved 163 children aged 5 to 18 years who underwent appendectomy in the pediatric surgery clinic of a tertiary hospital between December 2022 and June 2023. The study data were collected through the patient information form, Baxter Retching Faces scale, and Wong-Baker Faces Pain Rating Scale, which included questions about the descriptive and clinical characteristics of the participants and was prepared by the researcher consistent with the literature.

FINDINGS

A significant relationship was observed between the severity of postoperative pain and the occurrence of PONV in patients with both nonperforated and perforated appendicitis (P < .001). In addition, operative time and the time to the first oral feeding were shorter in patients with nonperforated appendicitis in the non-PONV group (P = .005 and P = .042, respectively) Logistic regression analysis revealed that postoperative pain, family history of PONV and appendix perforation were risk factors for PONV in children with both nonperforated and perforated appendicitis (P < .001, P = .040, and P < .001, respectively).

CONCLUSIONS

In children undergoing appendectomy, family history of PONV, severity of postoperative pain, increased operative time, and increased transition time to oral feeding are risk factors for PONV. Pediatric nurses, who have an important role in the management of PONV, should evaluate patients in terms of PONV risk in the preoperative period within the scope of evidence-based practices and perform pharmacological or nonpharmacological interventions according to the degree of risk.

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

Background

Postoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.

Methods

A prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.

Results

On the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8-19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9-11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1-1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5-4.4) and diclofenac (OR 2.0, 95% CI: 1. 3-3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9-4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7-11.6).

Conclusions

The main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome.

Subanesthetic-dose propofol infusion for preventing emergence agitation in children: a retrospective observational study

PURPOSE

Anesthesia maintenance using propofol and a propofol bolus dose at the end of surgery have been shown to prevent emergence agitation (EA). However, the preventive effect of subanesthetic propofol infusion during sevoflurane anesthesia on EA remains unknown. We aimed to evaluate the effect of subanesthetic propofol infusion on EA in children.

METHODS

We retrospectively compared the incidences of severe EA requiring pharmacological intervention in children who underwent adenoidectomy, tonsillectomy with or without adenoidectomy, or strabismus surgery between maintenance with sevoflurane alone (sevoflurane group) and maintenance with subanesthetic propofol with sevoflurane (combination group). A multivariable logistic regression model adjusted for confounders was used to assess the association between anesthesia methods and the occurrence of EA. Additionally, we estimated the direct effect of anesthesia methods by a mediation analysis, excluding the indirect effects of intraoperative fentanyl and droperidol administration.

RESULTS

Among 244 eligible patients, 132 and 112 were in the sevoflurane and combination groups, respectively. The crude incidence of EA was significantly lower in the combination group (17.0% [n = 19]) than in the sevoflurane group (33.3% [n = 44]) (P = 0.005). After adjusting for confounders, the incidence of EA was still significantly lower in the combination group (adjusted odds ratio [aOR]: 0.48, 95% confidence interval [CI] 0.25-0.91). The mediation analysis revealed a direct association of anesthesia methods with a lower EA incidence in the combination group (aOR: 0.48, 95% CI 0.24-0.93) than in the sevoflurane group.

CONCLUSION

Subanesthetic propofol infusion may effectively prevent severe EA requiring the administration of opioids or sedatives.

Delayed Adverse Events after Procedural Sedation in Pediatric Patients with Hematologic Malignancies

Background and objectives: Procedural sedation for bone marrow examination (BME) and intrathecal chemotherapy (ITC) is necessary for pediatric patients with hematological malignancies. There has been no report on adverse events after discharge from the recovery room. This retrospective study evaluated the types and incidences of delayed adverse events among pediatric patients scheduled for BME or ITC under deep sedation in a single center for 3 years. Materials and Methods: The patients were divided into two groups: inpatients (group I) and outpatients (group O). All patients were managed during the procedures and the recovery period. In total, 10 adverse events were assessed; these occurred 2 h (T1, acute), 12 h (T2, early), and 24 h (T3, delayed) after the procedure. The duration of each adverse event was also recorded and was classified as 2 h (D1), 12 h (D2), or 24 h (D3). The data of 263 patients (147 inpatients and 116 outpatients) who met the inclusion criteria were analyzed. Results: The overall incidence of adverse events was statistically significant difference: 48.3% in group I and 33.6% in group O (p = 0.011). The rates of adverse events at T1 and T2 were significantly different between groups I and O (42.8% vs. 11.2% and 7.5% vs. 20.7%, respectively) (p < 0.001). The adverse events were mostly of D1 or D2 duration in both groups. Patients with a higher proportion of ketamine in a propofol−ketamine mixture had a significantly higher proportion of adverse events at T1 (34.6%), as compared with those with a mixture with a lower proportion of ketamine (21.1%) or propofol alone (17.9%) (p = 0.012). Conclusions: The most common adverse events were dizziness or headache; typically, they did not last longer than 12 h. The propofol-ketamine combination with a higher proportion of ketamine seems to produce more adverse events within 2 h after the procedure. Nevertheless, all sedative types appear safe to use without additional management.