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.     

Post-operative symptoms at home in children following day case surgery

BACKGROUND: This prospective questionnaire-based study examined the post-operative symptoms encountered by children who had day case surgery at a dedicated day case surgery unit. The study evaluated the postoperative symptoms at home. The parents also evaluated the instructions given in the hospital for care at home. METHODS: All children aged 1 day - 14 years operated over a one year period were prospectively followed up following elective day case surgery. The incidence and duration of symptoms were evaluated using a structured questionnaire completed by the parents. Also, the instructions given in hospital for care at home were evaluated by the parents using another questionnaire. RESULTS: A total of 100 children were operated during the period. Pain (72%), emetic symptoms (16%) and difficulty with walking (7%) were the commonest symptoms occurring on the way home. There were no unplanned admissions. Two thirds of the parents did not know enough of the treatment of the wound and of the overall recovery of the child. CONCLUSION: Post operative symptoms following elective day case surgery are amenable to treatment and prevention with a wider use of available drugs for peri-operative analgesia.     

Midazolam reduces vomiting after tonsillectomy in children

The purpose of this study was to assess the effect of midazolam on vomiting after tonsillectomy in children. We compared 215 children aged 1.5–14 yr undergoing tonsillectomy or adenotonsillectomy under general anaesthesia with nitrous oxide and halothane. In a double-blind fashion the subjects were administered either placebo or midazolam 75 μg · kg^?1 iv after induction of anaesthesia. After the operation, the number of emetic episodes and the length of stay in hospital were recorded. The groups were similar with respect to age, weight, sex, mode of induction, duration of anaesthesia, surgical procedure, opioid administration and length of stay in the PAR and the Day Care Surgical Unit. The 108 midazolam-treated children had a lower incidence (42% vs 57%) of vomiting than the placebo group, P < 0.02. The placebo group had a higher incidence (9% vs 2%) of unscheduled admissions to hospital due to nausea and vomiting, P < 0.05. It is concluded that midazolam administered intravenously to children intraoperatively reduces vomiting after tonsillectomy.     

Postanaesthetic nausea in children

The incidence of emetic episodes during the first 24 h after anaesthesia was studied prospectively in 485 children aged 0-16 years in relation to age, premedication, type of induction, type and duration of anaesthesia, type of surgery and use of postoperative analgesics. The incidence of emetic episodes was 25% in the whole material. The majority of the emetic episodes were recorded after the immediate recovery period. In children under 2 years of age, vomiting was only recorded in 5%. Nausea and vomiting was most common after squint surgery (75%) and least common after endoscopies (17%). Neither premedication with diazepam nor the method of induction (thiopentone, i.v., thiopentone rectally, inhalation with halothane) influenced the incidence of nausea. For the same type of surgery, maintenance of anaesthesia with halothane resulted in a lower incidence of nausea than anaesthesia with fentanyl-pancuronium.     

Tropisetron reduces vomiting after tonsillectomy in children

Nausea and vomiting are common after adenotonsillectomy. Tropisetron is a new, long-acting serotonin antagonist that is an effective antiemetic in adults. Its effect on postoperative nausea and vomiting in children is unknown. We carried out a randomized, double-blind study of the effects of a single i.v. dose of tropisetron on vomiting after tonsillectomy with or without adenoidectomy in children. Forty-eight children undergoing tonsillectomy or adenotonsillectomy received at induction of anaesthesia either tropisetron 0.1 mg kg-1 or placebo. The incidence of vomiting was recorded for the first 24 h after surgery by nursing staff and then by parents after discharge from hospital. Children received metoclopramide 0.15 mg kg-1 as a rescue antiemetic. We found that tropisetron reduced the overall incidence of emetic episodes after surgery (29% compared with 65% in control group; P = 0.019) and the incidence of severe vomiting (0% compared with 52% in control group; P < 0.001). We conclude that tropisetron is an effective antiemetic for children undergoing tonsillectomy.      

Intraoperative ketorolac is an effective substitute for fentanyl in children undergoing outpatient adenotonsillectomy

BACKGROUND: In this prospective randomized double-blind study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of ketorolac vs fentanyl in dexamethasone-pretreated children undergoing ambulatory adenoidectomy and laser-assisted tonsillectomy (ADLAT). We evaluated the hypothesis that avoiding the use of opioids and replacing them with an equianalgesic dose of ketorolac, a nonsteroidal anti-inflammatory drug, would reduce the incidence of postoperative nausea and vomiting (PONV). METHODS: Fifty-seven ASA I and II children aged 1.710 years who underwent ADLAT were randomized to receive either intravenous ketorolac (1 mg.kg(-1)) or fentanyl (2 microg.kg(-1)) for pain control during a standardized general anaesthetic with propofol infusion. The early (postanaesthesia care unit, day surgical area) and late postoperative courses were compared between the groups. RESULTS: The incidence of PONV was low and equal in both groups. Postoperative pain scores were equal at all stages of followup. Agitation scores in the postanaesthesia care unit were significantly higher in the ketorolac group, but this had no effect on the late variables of behaviour studied. CONCLUSIONS: Ketorolac showed no advantage over fentanyl in reducing the incidence of PONV in children undergoing ADLAT.     

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.     

Adenotonsillectomy in children: a comparison of morphine and fentanyl for peri-operative analgesia.

This study compared the effectiveness and side-effects of intra-operative fentanyl with fentanyl and morphine for elective adenotonsillectomy in a double-blind study, in 60 children randomly allocated to receive either intravenous fentanyl 1 microg x kg(-1) intra-operatively or intramuscular morphine 100 microg x kg(-1) at induction. All children received a standard anaesthetic induction with intravenous fentanyl 1 microg x kg(-1) and propofol 4-5 mg x kg(-1) and maintenance with oxygen, nitrous oxide and isoflurane. Pain scores, emetic episodes and supplemental morphine requirements were recorded for 24 h postoperatively. The overall incidence of postoperative vomiting was high in both groups: 70% in the fentanyl group and 78% in the morphine group. The incidence of postoperative vomiting was lower in the fentanyl group (p < 0.03) in the first 4 h, but similar by 24 h. Children who received morphine at any time in the first 24 h had more median (range) episodes of vomiting [2 (0-7)] than children receiving fentanyl only [l (0-3); p < 0.03]. Administration of rescue anti-emetics, pain scores in recovery and pain scores over the next 24 h were similar between the two groups.     

Nausea and vomiting after strabismus surgery in preschool children

The incidence of nausea and vomiting after strabismus surgery was studied in 64 children aged one to six years. Incidence was determined in the post-anaesthesia recovery room (PARR), in the same day surgery (SDS) unit, and at home on days one and two after the operation. After induction of anaesthesia, the children received an intravenous injection of droperidol (50 micrograms . kg-1) or saline in a double-blind randomized fashion, and an intravenous injection of glycopyrrolate (7.5 micrograms . kg-1) or atropine (10 micrograms . kg-1) in an open randomized fashion. The incidence of emetic symptoms was highest in the SDS unit and at home on day one. Droperidol slightly but significantly delayed awakening and was not, at least in this particular age group, associated with any difference in postoperative sickness. Despite theoretical advantages, glycopyrrolate offered no significant benefit over atropine as far as postoperative emesis was concerned.     

A prospective survey of postoperative nausea and vomiting with special regard to incidence and relations to patient characteristics, anesthetic routines and surgical procedures

We performed a prospective study on 421 patients subjected to routine general-, orthopaedic-, urologic-, gynecological and paediatric surgery to estimate the current incidences of nausea and vomiting during the first 24 hours after surgery.
The overall incidences of postoperative nausea or vomiting were 17% and 28%, respectively. Postoperative emetic symptoms were not related to age in adults. Women had more often emetic symptoms than men ( P <0.01). In general, opiate premedication was more frequently associated with postoperative nausea and vomiting than benzodiazepines ( P <0.01), but in otherwise comparable subgroups of patients undergoing major surgery, this difference was not confirmed. Balanced general anaesthesia caused more nausea (23%) and vomiting (53%) than face-mask anaesthesia (13% and 15%, respectively) or regional blocks (12% and 7%, respectively) ( P <0.001). There was a positive correlation between the duration of anaesthesia and the incidence of postoperative emetic symptoms ( P <0.001). The incidences of postoperative nausea and vomiting after abdominal surgery were 23% and 58% respectively. Corresponding figures for orthopaedic surgery were 25% and 34%, other kinds of extra-abdominal surgery 18% and 32% and for laparoscopy 21% and 25%. After minor gynecological-, urological-and paediatric surgery the incidences were less than 20%.
In conclusion female gender, balanced anaesthesia, lengthy duration of anaesthesia, and abdominal and orthopaedic operations appeared to be most frequently associated with postoperative emetic symptoms.     

Droperidol decreases the incidence and the severity of vomiting after tonsillectomy and adenoidectomy in children

We assessed the effect of intravenous droperidol on the incidence and the severity of postoperative vomiting in children undergoing tonsillectomy and adenoidectomy. Seventy-nine ASA physical status I or II children aged 1.5 to 18 years (mean 6.1 years) were randomized into two groups. Group I received droperidol 50 μg·kg^?1 i.v. (maximum 1.25 mg), while group II received saline placebo immediately following the induction of general anaesthesia. All episodes of vomiting were recorded from the time of extubation until discharge the next morning. Of the 35 assigned to group I only 16 (46%) had one or more episodes of emesis compared to 31 of 44 (71%) in group II (P < 0.05). Patients in group I who vomited, did so only 1.9 ± 1.2 times compared to 4.6 ± 3.8 times for the control patients (P < 0.01). The authors conclude that droperidol at a dose of 50 μg·kg^?1 given at the time of induction of anaesthesia to healthy children decreases the incidence and the severity of vomiting during the first postoperative day following tonsillectomy and adenoidectomy.;     

Postoperative nausea and vomiting. A comparison between intravenous and inhalation anaesthesia in breast surgery

Nausea and vomiting during the first 24 postoperative hours after breast surgery were studied. Ninety patients scheduled for elective breast surgery were randomly assigned to one of three anaesthetic methods: total intravenous anaesthesia with propofol, or propofol or thiopental for induction followed by isoflurane anaesthesia. All three groups received fentanyl for peroperative analgesia. A total of 46 (51%) patients experienced emetic sequelae: 19 (21%) complained about nausea and another 27 (30%) vomited once or more during the postoperative course. More than 50% of the patients with nausea and 70% with vomiting first suffered from these symptoms in the surgical wards after leaving the postoperative unit. Nausea and vomiting were seen in 18 (60%), 13 (43%) and 15 (50%) for the groups propofol–propofol, propofol–isoflurane and thiopental–isoflurane, respectively. In conclusion, every second patient experienced nausea or vomiting after breast surgery, the majority of these emetic symptoms occurring after leaving the postoperative unit. Propofol for induction or as a main anaesthetic did not make any major difference with regard to postoperative nausea or vomiting.     

Postoperative epidural analgesia in children after major orthopaedic surgery. A randomised study of the effect on PONV of two anaesthetic techniques: low and high dose i.v. fentanyl and epidural infusions with and without fentanyl

BACKGROUND: The study was performed in order to improve postoperative pain management in children after major orthopaedic surgery. Two different anaesthetic techniques (sevoflurane-low fentanyl and propofol-higher fentanyl) and two different epidural mixtures (bupivacaine 1.5 mg ml(-1) and adrenaline 2 microg ml(-1) compared with bupivacaine 1 mg ml(-1), adrenaline 2 microg ml(-1) and fentanyl 2 microg ml(-1)) were investigated with regard to postoperative analgesia and side effects, primarily postoperative nausea and vomiting (PONV). METHODS: Forty-two children were randomised into one of three groups: sevoflurane anaesthesia and epidural solution with fentanyl (SBAF); sevoflurane anaesthesia and epidural solution without fentanyl (SBA); propofol anaesthesia and epidural solution without fentanyl (PBA). RESULTS: Including fentanyl in the epidural mixture resulted in excellent postoperative analgesia without any need of i.v. opioids. However, 7 out of 16 children were nauseated and needed antiemetic drugs. On average, a 55-75% higher dose of bupivacaine was necessary to assure adequate analgesia when an epidural mixture without fentanyl was used. In addition, significantly more children needed i.v. opioids. Under these conditions there was no significant difference in pain scoring between the groups. There was significantly less nausea and less use of antiemetic drugs in children having epidurals without fentanyl in the sevoflurane groups. The same tendency, although not significant, was observed in the whole material. Sevoflurane anaesthesia resulted in less PONV than propofol anaesthesia, probably due to the higher amount of intravenous fentanyl used with the latter. This difference was not significant due to the small number of children included. Incidence of pruritus related significantly to epidural fentanyl. CONCLUSION: A satisfactory postoperative analgesia can be achieved with both epidural mixtures used in the study. Epidural fentanyl results in better analgesia, but significantly more PONV and greater use of antiemetic drugs. Omitting epidural fentanyl results in less PONV, but significantly less profound analgesia and a need for additional treatment with i.v. opioids, in addition to a 55-75% higher epidural bupivacaine infusion. Both epidural treatments result in high and similar patient satisfaction and no serious complications. The study could not show any significant difference between the effect of sevoflurane and propofol anaesthesia on PONV.     

Peroperative treatment with i.v. ketoprofen reduces pain and vomiting in children after strabismus surgery

Background: Strabismus surgery is associated with both pain and vomiting. Ketoprofen is widely used in adults to treat acute pain, but there are only few reports of its use in children. This randomised, double-blind, placebo-controlled, parallel group study was designed to investigate the analgesic effect of i.v. ketoprofen and its effect on the incidence of vomiting in children after day-case strabismus surgery.
Methods: Fifty-nine ASA 1 children, aged 1–12 years, entered the study. After premedication with diazepam and glycopyrronium, anaesthesia was induced with fentanyl and propofol and maintained with isoflurane. After induction the children in the ketoprofen group received 1 mg kg⁻¹ ketoprofen followed by an infusion of 1 mg kg⁻¹ ketoprofen over 2 h. In the placebo group, children received 0.9% saline. The postoperative pain was assessed by the Maunuksela pain score (0=no pain, 10=worst possible pain). All children received fentanyl as a rescue analgesic if the Maunuksela score was ≥3.
Results: In the ketoprofen group the number of fentanyl doses was smaller compared to the placebo group (median 1, quartiles (0–2) vs. 2 (1–3), P =0.047). The children in the ketoprofen group had less pain at 30 min ( P =0.02) and the worst pain observed in the post anaesthesia care unit was lower (3 (0–6) vs. 5 (3–8), P =0.035). The incidence of vomiting was less in the ketoprofen group compared to the placebo group (17% vs. 41%, P =0.036). No serious adverse reactions occurred.
Conclusion: We concluded that ketoprofen administered i.v. during the operation produced analgesia and reduced opioid consumption and the incidence of vomiting in children after strabismus surgery.     

Postoperative morphine requirements, nausea and vomiting following anaesthesia for tonsillectomy. Comparison of intravenous morphine and non-opioid analgesic techniques

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be as effective as opioid analgesia following tonsillectomy in children. Opioids are still frequently used but tonsillectomy is associated with a high incidence of vomiting. This study has attempted to assess postoperative analgesic consumption and nausea and vomiting after general anaesthesia for tonsillectomy using either paracetamol premedication, paracetamol plus a NSAID or intravenous morphine to provide postoperative analgesia. Some children required a rescue dose of morphine in the recovery room, including some who had received intravenous morphine at induction. Least supplementary morphine was required by those who had received paracetamol plus ketorolac. Postoperative nausea and vomiting was significantly less in the two groups which were not given intraoperative morphine. The number of vomiting incidents was also much less. We conclude that the preoperative administration of paracetamol alone provides satisfactory analgesia in many children but that supplementary analgesia is still required for some.     

Increased incidence of postoperative nausea and vomiting without additional analgesic effects when a low dose of intravenous fentanyl is combined with a caudal block

BACKGROUND: The use of opioids is known to increase the incidence of postoperative nausea and vomiting (PONV). In spite of this, administration of low doses of an opioid during anaesthesia is common practice, even if a regional anaesthetic technique is used. This study was designed to estimate the effects of intraoperative intravenous administration of fentanyl on PONV in paediatric daycase surgery. METHODS: PONV and pain were evaluated in 29 boys during the first 24 h after daycase penile surgery. Anaesthesia was standardized. The patients were allocated to two groups. Fentanyl 1 micro g.kg-1 i.v. or placebo was administered in a randomized, double-blind design. A caudal block with ropivacaine 2 mg.ml-1, 0.5 ml.kg-1 was performed preoperatively and topical lidocaine gel 20 mg.ml-1 was applied over the wound area immediately after surgery. RESULTS: The total incidence of PONV in hospital and at home during the first 24 h was 36% (5/14) when fentanyl was used, whereas no PONV was reported when placebo was given (P < 0.05). The median time to first administration of analgesics after the caudal block was approximately 6 h. It did not differ between groups. Intraoperative fentanyl did not result in any reduction in pain scores nor the incidence of pain. Fentanyl caused apnoea in one-half of the cases and decreased the breathing rates during the first 10 min of surgery. CONCLUSIONS: Intraoperative use of i.v. fentanyl 1 micro g.kg-1 combined with a regional anaesthetic block is associated with an increased incidence of PONV without any significant contribution to the postoperative pain relief.     

Ketamine reduces swallowing-evoked pain after paediatric tonsillectomy

BACKGROUND: Ketamine efficacy as an analgesic adjuvant has been studied in several clinical settings with conflicting results. The aim of this study was to investigate the effect of ketamine on spontaneous and swallowing-evoked pain after tonsillectomy. METHODS: Fifty children were randomized to receive premedication with either ketamine 0.1 mg kg(-1) i.m. or placebo given 20 min before induction of a standard general anaesthesia. All children received rectal diclofenac 2 mg kg(-1) and fentanyl 1 micro g kg(-1) i.v. before surgery. RESULTS: The ketamine group showed significantly lower pain scores both at rest and on swallowing, with less total paracetamol consumption (P < 0.05) during the 24 h after surgery. Significantly more patients required postoperative morphine titration in the control group (P < 0.05). The time to the first oral intake, and duration of i.v. hydration, were significantly shorter and the quality of oral intake was significantly better in the ketamine group (P < 0.05). There were no differences in the incidence of vomiting or dreaming between the groups. CONCLUSION: Premedication with a small dose of ketamine reduces swallowing-evoked pain after tonsillectomy in children who received an analgesic regimen combining an opioid and a NSAID.     

Recovery after paediatric daycase herniotomy performed under spinal anaesthesia

In this prospective survey, recovery in hospital and at home was evaluated in 195 children aged 6 months to 10 years who had undergone herniotomy under spinal anaesthesia as a daycase procedure. Spinal anaesthesia was successful in most of the children, with only two patients being given general anaesthesia. Eighty-three percent of the children had pain at home and 19% had moderate or severe pain. Eighty-five percent of the children needed pain medication at home; the median dose of analgesics was 4 (1-9, 10th and 90th percentiles). Vomiting was noted in two of 195 children in hospital and in 10 of 192 children at home. Eleven children developed a mild position-dependent headache. Most of the children (183/191) recovered their normal daily activities during the first three postoperative days. We conclude that spinal anaesthesia is a safe and effective technique for paediatric herniotomy. Moreover, pain is common following herniotomy and children should be given analgesics for the first two or three postoperative days.     

An audit of pain and vomiting in paediatric day case surgery

Three hundred and thirteen paediatric day case patients were prospectively audited to assess postoperative pain, nausea and vomiting using data sheets completed by nursing staff, anaesthetists and parents. The incidence of nausea and vomiting was 7.3% and was commoner in older children and those who had received opioids. Forty per cent of patients had some degree of postoperative pain; 17% of these patients were scored as having severe pain. Of children who had pain on returning home (31.4%), 85% of these required paracetamol. Fifteen per cent of children had a disturbed night due to pain and/or vomiting after their operation and 28.5% of children had pain on the following day. Boys undergoing circumcision were responsible for a disproportionately high percentage of the severe pain scores. Audit has helped to highlight deficiencies in the service provided and has led staff to try and improve their methods of analgesia.     

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.