Postoperative symptoms at home following day-case surgery in children: a multicentre survey of 551 children

The incidence and duration of postoperative symptoms in children at home following day-case anaesthesia and surgery was evaluated using a questionnaire completed by parents of 551 children aged 4 months to 13.4 years (mean 3.8 years). They also evaluated the instructions given in hospital for care at home. The incidence of all symptoms was highest at home on the day of the operation. No postoperative symptoms were reported in 79 (14%) children. The incidence of pain was 56% and the only significant predictor was the type of operation, tonsillectomy being the most problematic (mild pain in 38% and severe in 25%; pain lasted 7 days or longer in 33%). Analgesics were given to 78% of all the children reported to have pain on the day of the operation, to 60% the next day and later to 58%; 19 (3%) children were given more than two doses per day. The instructions given in hospital for the treatment of pain were considered inadequate by 12% of parents. Postoperative nausea and vomiting occurred in 13% of children. Predictors by multiple stepwise logistic regression analysis were emetic symptoms in hospital, pain at home, age > 5 years and administration of postoperative opioid (pethidine or fentanyl). Opioid given during anaesthesia (fentanyl or alfentanil) did not increase the incidence. Emetic symptoms were most common after tonsillectomy (31%). The highest incidences of emetic symptoms (37%), sedation (96%) and dizziness (41%) occurred in children who had been given fentanyl for postoperative pain. Undertreatment of nausea in hospital was evident as only two children had received anti-emetics, even though 61 were reported to have emetic symptoms. Administration of effective anti-emetics should be encouraged, as emetic symptoms in hospital were the most significant predictor of nausea and vomiting at home. Treatment of pain at home and instructions for treatment of pain need to be improved.     

Postoperative comfort in paediatric outpatient surgery.

Postoperative conditions in hospital and at home were evaluated in 200 paediatric daycase patients by using questionnaires and telephone interviews. Pain was assessed by behaviour observation or a faces rating scale depending on age. Anaesthetic methods, nausea/vomiting, analgesics and parents' aspects were also recorded. Seventy per cent of the patients received regional anaesthesia. Immediate postoperative analgesia was satisfactory in 75% of the children. When the effects of intraoperatively administered analgesics wore off at home almost half the children rated higher than mild pain. The increased degree of pain at home was especially pronounced after regional anaesthesia. The total incidence of nausea/vomiting was 28% and fentanyl caused nausea and vomiting in a significantly higher proportion of cases. The study points out that immediate postoperative comfort obtained by prophylactic analgesia needs to be followed by analgesics given on a continuous basis for the first days after surgery.     

Anaesthesia in day case laparoscopic female sterilization: a comparison of two anaesthetic methods

BACKGROUND: Laparoscopic sterilization (LS) in women is a procedure frequently carried out in a day case setting. The purpose of the study was to measure postoperative pain, nausea and vomiting (PONV), the incidence of unplanned overnight admissions and patient satisfaction with two different anaesthetic methods. METHODS: From August 1997 to January 1999 the LS patients were anaesthetized with propofol + fentanyl/alfentanil, N2O and atracurium, and from January 1999 to end of 2001 they were given TIVA with propofol + remifentanil. Postoperative pain was managed with standardized high doses of paracetamol and NSAID in both groups. Data were collected from hospital records and from questionnaires given to all the patients. RESULTS: Six hundred and eighty-one women were sterilized. There were no significant differences in postoperative pain between the two groups, with 8.2 and 12.1 per cent, respectively, experiencing severe pain. Significantly fewer patients experienced moderate or severe postoperative nausea after the introduction of remifentanil anaesthesia (3.3 vs. 11.7%, P = 0.001). Eleven patients (1.8%) were admitted overnight, with no difference between the two groups. 94.5% and 96.3% of the patients were either satisfied or very satisfied with their treatment (P = 0.50). CONCLUSION: Both anaesthetic methods provide equally good postoperative pain relief, few unplanned admissions and a high degree of patient satisfaction when combined with postoperative paracetamol and NSAID. Patients anaesthetized with remifentanil and propofol have less postoperative nausea.     

Pain and activity disturbance after paediatric day case adenoidectomy

Over the past two decades outpatient surgery has become standard practice in paediatric surgery. Adenoidectomy is a common surgical procedure in children. In this prospective survey pain and pain-related outcomes such as sleep and activity disturbance were evaluated in 167 children aged 1–7 years who had undergone adenoidectomy as a day case in Kuopio University Hospital. The survey questionnaire consisted of 76 structured questions about pain, pain medication, adverse effects and daily activities during first week after the operation. Eighty-three per cent of children had pain at home and 17% of them had moderate or severe pain on a four point verbal rating scale. Eighty per cent of children used pain medication at home. Pain medication did not cause any major adverse effects. Over 90% of children were back to normal daily activities during the first three postoperative days and nearly all were able to drink during the whole postoperative period. We conclude that pain is a common problem after adenoidectomy in children but most of the children return to normal activities within three days.     

Day case laparoscopic cholecystectomy — a feasibility study

The feasibility of performing laparoscopic cholecystectomy on an outpatient basis was evaluated in 55 selected patients who underwent the procedure with careful back-up. Nine per cent of patients required overnight hospitalization whereas 5% were readmitted at a later date. Fifty-nine per cent of patients described their postoperative pain as severe or moderately severe and 27% complained of vomiting or severe nausea. Despite these findings, 66% of patients expressed complete satisfaction with the procedure as performed and 82%, given the choice, would have opted for the same method again. The advantages to the patient are the high likelihood that the procedure will take place as planned and they are able to convalesce in familiar surroundings. The advantages to the hospital are the freeing up of inpatient beds and potential cost savings.     

Analgesia following paediatric day-surgical orchidopexy and herniotomy

We surveyed 90 boys, aged 1-13 years, who had undergone either orchidopexy or herniotomy, in a cohort study. Their pain and vomiting were assessed using a simple 4-point score in the Recovery Unit by the nursing staff, and at home by the parents. There were no significant differences in pain or vomiting scores between the two groups in the immediate postoperative period. However, children having orchidopexy experienced more pain at home during the first night and the following day than those having herniotomy. Nearly one-third of the former group had moderate to severe pain at home, in contrast to less than one-tenth of children having herniotomy, who are also more likely to be painfree on the next day. We concluded that children having herniotomy can be treated adequately at home with paracetamol alone, whereas children having orchidopexy may require supplementation with stronger analgesics.     

Impact of an antiemetic protocol on postoperative nausea and vomiting in children

The objective of the study was to demonstrate a decreased incidence of postoperative nausea and vomiting (PONV) in children through the use of an antiemetic protocol. PONV was recorded in children (1.5-15 years) after inpatient surgery under general anaesthesia in a prospective, interview based survey. Group 1 consisted of children having surgery 1 month before the introduction of a formalized antiemetic protocol and group 2, 2 months after its introduction. Data were collected over a 1-month period in each group. Outcome measures of nausea, emesis, antiemetic requirement and patient satisfaction were monitored for the first 24-h postoperative period. There were 272 children enrolled: 138 in group 1 and 134 in group 2. There was a difference between the two groups for gender (P=0.03), type of surgery (P=0.017), perioperative opioid (P=0.003) and perioperative antiemetic use (P=0.024). However, multivariate analysis did not demonstrate an impact on outcome from these factors. The incidence of postoperative nausea (PON) and postoperative vomiting (POV) following the introduction of the protocol was 36% and 34%, respectively. Moderate to severe nausea was decreased after introduction of the protocol (18% versus 9%, P=0.028) but moderate to severe vomiting failed to reach significance (19% versus 11%, P=0.078). The proportion of children who had repeated nausea decreased after the introduction of the protocol (17% versus 8%, P=0.02) but repeated episodes of vomiting remained unchanged (19% versus 14%). This was attributed to a significant increase in antiemetic prescribing by protocol in group 2 (10% versus 59%, P < 0.001). Patient satisfaction was high in both groups (85% versus 90%). The introduction of a postoperative antiemetic protocol improved prescribing frequency. This resulted in a decreased incidence of moderate to severe PON and a reduction in the number of patients with repeated nausea.     

The effect of education, assessment and a standardised prescription on postoperative pain management The value of clinical audit in the establishment of acute pain services

A study involving 2738 patients in 15 hospitals in the United Kingdom was undertaken to evaluate the effect of simple methods of pain assessment and management on postoperative pain. The study consisted of four parts: a survey of current practice in each hospital; a programme of education for staff and patients regarding pain and its management; the introduction of formal assessment and recording of pain and the use of a simple algorithm to allow more flexible, yet safe, provision of intermittent intramuscular opioid analgesia; and a repeat survey of practice. One hospital from each of the former health regions of England and Wales was selected for inclusion in the project. Hospitals included representatives of different size units (university, large and small district general hospitals). As a result of the study, there was an overall reduction in the percentage of patients who experienced moderate to severe pain at rest from 32% to 12%. The incidence of severe pain on movement decreased from 37% to 13% and moderate to severe pain on deep inspiration from 41% to 22%. Similar decreases were seen in the incidence of nausea and vomiting. There was also a slight reduction in the incidence of postoperative complications. This study shows that simple techniques for the management of postoperative pain are effective in reducing the incidence of pain both at rest and during movement and should form part of any acute pain management strategy.     

Survey of postoperative analgesia following ambulatory surgery

Background: The quality of pain relief during the first 48 hours following ambulatory surgery has been poorly documented. This questionnaire study was performed to evaluate the nature and severity of pain after the patient leaves the hospital. Methods: 1100 patients in the age group 5–88 years who underwent ambulatory surgery during a period of 6months were asked to complete a questionnaire 48 h after the end of the operation. In thecase of children, parents were asked to complete a similar questionnaire. The questions were related to pain experienced during the first 48 h after surgery and to the nature andseverity of postoperative complications. Results: A total of 1035 out of the 1100 patients returned the questionnaire, 94.1%. Overall the majority (65%) of patients had only mild pain at home; however, patients undergoing certain types of surgery had moderate-to-severe pain: inguinal hernia surgery (62% patients), orthopaedic surgery (41%), hand surgery (37%) and varicose vein surgery (36%). In these patients the severity of pain did not decrease during the 2-day study period. About 10% patients had more severe pain than they had anticipated, and 20% had difficulty in sleeping at night due to severe pain. Despite this, over 95% of patients were satisfied with man-agement of postoperative pain. Nausea (20%), tiredness (20%) and vomiting (8%) were the commonest complications reported during the first 48 h. A significant association was found between the administration of a general anaesthetic and the incidence of nausea postoperatively. A large number of patients were alone at home after the operation (28.4%); some (3.8%) had no access to a relative or friend in case of need. Conclusion: Our results show that about 35% of day-surgery patients experience moderate-to-severe pain at home in spite of analgesic medication. About 20% of patients had sleep problems due to severe pain. However, only 5% of patients were dissatisfied. Better analgesic techniques are necessary for patients undergoing certain types of surgery. Patient information and follow-up routines need to be improved.     

Low-dose caudal morphine for postoperative analgesia in infants and children: A report of 500 cases

Study Objective: To determine the effectiveness of morphine 0.03 mg/kg or 0.04 mg/kg administered caudally to children for postoperative pain relief.

Design: Retrospective chart review.

Setting: University-affiliated hospital.

Patients: The charts of 500 children who had undergone various surgical procedures and who were given caudal morphine 0.03 mg/kg or 0.04 mg/kg either prior to the surgical procedure or immediately at the conclusion of the surgical procedure.

Measurements and Main Results: Parameters of respiratory rate, oxygen saturation, nausea and vomiting, voiding problems, and pruritus were recorded for each patient. There was no respiratory depression noted in the review of the 500 patients; 23% had nausea and vomiting, 3% had voiding problems needing bladder catheterization, and 7% reported pruritus, which was treated with either diphenhydramine or naloxone.

Conclusion: Statistically there were no differences between morphine 0.03 mg/kg and morphine 0.04 mg/kg in all the study parameters. There was no respiratory depression in the 500 cases reviewed. The postoperative pain relief ranged from 6 hours to over 24 hours. This method of immediate postoperative pain management proved to be effective and safe.     

Pain, nausea, vomiting and ocular complications delay discharge following ambulatory microdiscectomy

OBJECTIVE: Nowadays, microsurgical discectomy is being performed as an outpatient procedure. A retrospective chart review was done to document factors that delayed discharge or led to unanticipated admission. METHODS: After Institutional Review Board approval, the hospital medical records of 106 patients who underwent microsurgical discectomy on an ambulatory basis were reviewed. All patients were operated upon by a single surgeon at the Toronto Western Hospital. Perioperative data were collected on specifically designed data sheets. All anesthetic and surgical factors that affected discharge were noted. RESULTS: Of the 106 patients reviewed, only six required unanticipated admission. Two patients were admitted due to nausea and vomiting, one due to severe pain, one due to urinary retention and two were surgical causes (dural tear). Eight patients had delayed discharge. Anesthesia causes were severe nausea, severe pain, low oxygen saturation, sore throat and dry eyes. Two patients had surgical causes. The incidence of postoperative nausea was 61% and postoperative vomiting was 9.4%. Eighty patients (75.4%) complained of pain in the postanesthesia care unit. Of these, 33.9% had visual analogue pain scale scores more than 6. CONCLUSION: Ambulatory lumbar microdiscectomy can be carried out as an ambulatory procedure with an acceptably low unanticipated admission rate (5.7%). The percentage of patients with severe nausea (16%) and pain (33.9%) is high. Adequate perioperative pain management and effective control of nausea and vomiting may further improve the patients' experience after anesthesia for ambulatory microdiscectomy.     

Randomized clinical trial of the effect of preoperative dexamethasone on nausea and vomiting after laparoscopic cholecystectomy

BACKGROUND: Preoperative dexamethasone may reduce disabling symptoms such as pain, nausea and vomiting after laparoscopic cholecystectomy. METHODS: This was a randomized, double-blind, placebo-controlled trial. Between March and December 2004, 101 patients undergoing laparoscopic cholecystectomy were randomized to receive 8 mg dexamethasone (n = 49) or placebo (n = 52) intravenously before surgery. Six patients were excluded from the study. All patients received a standardized anaesthetic, surgical and multimodal analgesic treatment. The primary endpoints were: first, postoperative nausea, vomiting and pain; second, postoperative analgesic and antiemetic requirements. The pain scores (visual analogue and verbal response scales), the episodes of nausea (verbal response scale) and vomiting were recorded at 1, 3, 6 and 24 h, respectively, after the operation. Analgesic and antiemetic requirements were also recorded. RESULTS: No apparent drug side-effects were noted. Seven patients (14 per cent) in the treatment group reported nausea and vomiting compared with 24 (46 per cent) in the control group (P = 0.001). In the group of patients treated with dexamethasone, five (10 per cent) required antiemetics versus 23 (44 per cent) of those receiving placebo (P < 0.001). No difference in postoperative pain scores and analgesic requirements was detected between groups. CONCLUSION: Preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy, with no side-effects, and may be recommended for routine use.     

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.     

The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy

BACKGROUND: A few previous studies have suggested the efficacy of i.v. ketamine for postoperative pain relief in children after adenotonsillectomy, but none has investigated the efficacy of peritonsillar infiltration of ketamine in these children. METHODS: This randomized, placebo-controlled study evaluated the effects of peritonsillar infiltration of ketamine in children undergoing adenotonsillectomy. Ninety ASA I-II children were randomized three groups of 30 each. Group I received: 2 ml i.v. saline, group II received i.v. ketamine (0.5 mgxkg(-1)) and group III received a local peritonsillar infiltration of ketamine (0.5 mgxkg(-1)). All medications were 2 ml in volume which was applied 1 ml per tonsil 3 min prior to tonsillectomy. Modified Hannallah pain scale [observational pain scores (OPS)], nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at first, 15th, 30th and 60th min postoperatively. Patients were interviewed on the day after surgery to assess the postoperative pain, nightmares, hallucinations, vomiting and bleeding. RESULTS: Group I had higher OPS scores than group II and group III. Group II and group III had comparable scores, which were not statistically significant (P > 0.05). Group II had higher sedation score at 15th min (P = 0.015). Thirty-two children, 19 of whom were in group I had rescue analgesia in postanesthesia care unit (P < 0.05) and the time to first analgesic requirement was significantly shorter in group I than the other groups (P = 0.006). Group II and group III also had less pain than group I at home (P = 0.023). CONCLUSIONS: Low dose ketamine given i.v. or by peritonsillar infiltration perioperatively provides efficient pain relief without side-effects in children undergoing adenotonsillectomy.     

Myopexy (Faden) results in more postoperative vomiting after strabismus surgery in children

BACKGROUND: Strabismus correction in children is associated with a high incidence of postoperative nausea and vomiting. The purpose of this prospective, double-blind study was to examine the influence of the surgical method for correction of squint on the incidence of postoperative vomiting. METHODS: One hundred and twenty consecutive children aged 2-12 years, scheduled for elective strabismus surgery, were enrolled in this prospective, double-blind study. A standardised total intravenous anaesthesia was given to all children. The development of perioperative oculocardiac reflex was noted and the number of episodes of vomiting during the first 48 h postoperatively was recorded. At the completion of the study, the children who were operated with myopexy according to Faden, were allocated to a Faden group, those without a myopexy to the non-Faden group. All the patients included in this study were operated on by the same surgeon with standardised techniques. RESULTS: The Faden group was younger, lighter and the operation time was longer (P<0.05). The incidence of vomiting was greater in the Faden group; 53% versus 12% (P<0.05). The incidence of oculocardiac reflex was similar in both groups; 40% in the Faden versus 28% in the non-Faden group, respectively. The total dose of propofol and alfentanil was similar between the groups. Requirement of analgesics for postoperative pain was similar in both groups. The only independent risk factor for postoperative vomiting was the Faden operation. CONCLUSION: The surgical method used for strabismus correction in children has a great influence on the incidence of postoperative vomiting. The Faden operation is associated with a very high incidence of postoperative vomiting; this particular group of patients has to be considered as a high risk group for postoperative vomiting and deserves an antiemetic prophylaxis.     

Incidence of nausea and vomiting in children after strabismus surgery following desflurane anaesthesia

In a prospective, randomized parallel study, 60 ASA I-III children aged 1-17 years, scheduled for elective strabismus surgery, were anaesthetized with desflurane without prophylactic antiemetic medication. The objective of the study was to determine the incidence of postoperative nausea and vomiting after general anaesthesia with desflurane. To decide whether nitrous oxide further influences these symptoms, the patients were randomly assigned to two groups of 30 patients each. One group received desflurane in oxygen/air and a second group received desflurane in oxygen/nitrous oxide. In all children, after intravenous induction and tracheal intubation, anaesthesia was administered as minimal flow anaesthesia with oxygen and nitrous oxide or air according to the random plan. The patients were observed for 48 postoperative hours until their discharge from the ward. The overall incidence of nausea was found to be 37%, and vomiting was seen in 32% of all patients. No statistical correlation was found between the incidence of postoperative emesis and the administration of nitrous oxide or the duration of general anaesthesia. Instead, the incidence of vomiting was 2.5-fold higher when surgery was performed on both eyes compared with one eye. The relatively low incidence of postoperative nausea and vomiting, as well as the quick recovery from anaesthesia, permitting an early discharge from the postoperative care unit to the ward, show desflurane to be a suitable volatile anaesthetic in strabismus surgery in children.     

A prospective randomized blinded study of the effect of intravenous fluid therapy on postoperative nausea and vomiting in children undergoing strabismus surgery

BACKGROUND: Nausea and vomiting is a common postoperative complication that often necessitates the use of antiemetic agents. METHODS: In a prospective, randomized, double blind trial, the effect of perioperative fluid administration on postoperative adverse outcomes following anesthesia was studied. One hundred children undergoing strabismus repair were randomly assigned to receive 10 ml x kg(-1) x h(-1) (control group) or 30 ml x kg(-1) x h(-1) (superhydration group) of lactated Ringer's solution during the operation. During the first 24 h postoperatively, nausea and vomiting, thirst, pain, and fever were evaluated. RESULTS: Groups were similar with respect to demographic data, surgical procedures and baseline hemodynamic variables. In the first 24 h postoperatively, nausea and vomiting occurred in 27 patients (54%) of the control group and 11 (22%) of patients in the superhydration group (P = 0.001). Comparison of the superhydration group with the control group also showed a statistically significant benefit of superhydration on postoperative thirst (P = 0.0002) and fever (P = 0.02). The differences in nausea and vomiting, thirst, and fever remained significant after adjustment for age, gender, weight, and duration of surgery. There was no significant difference between the two groups in postoperative pain. CONCLUSIONS: Intravenous superhydration administration is an inexpensive and safe therapy for reducing postoperative nausea and vomiting and discomfort.     

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.     

An audit of paediatric day care surgery in a District General Hospital

At a 620 bed District General Hospital, questionnaires were issued to the patients of 142 consecutive paediatric day surgery cases and the nurses involved in the care of these children. Most of the children were not upset by day case surgery, although nearly a quarter were distressed by changing into a theatre gown. Postoperatively, pain was more of a problem than nausea and vomiting. Relatively minor problems occurred at home. The majority of the 93 parents who replied were happy with the overall care of their child. They valued being present for induction of anaesthesia and would have liked to be present in recovery when their child was awake, although the nurses felt this would not have been helpful. Nonclinical matters also influenced their assessment of the quality of care.