Factors influencing postoperative pain following discharge in pediatric ambulatory surgery patients

Study objectiveTo identify demographic, intraoperative, and parental factors that influence the postoperative pain experience in ambulatory surgery pediatric patients. We also monitored postoperative maladaptive behavior changes (PMBCs) to investigate the relationship between pain and PMBCs.DesignProspective cohort study.SettingDischarge period after ambulatory surgery.Patients204 patients ages 1–6 years undergoing ambulatory orthopedic, urology, general surgery, and otolaryngology surgical procedures who were American Society of Anesthesiologists (ASA) physical status I or II.InterventionsNone.MeasurementsWe administered telephone questionnaires to parents of ambulatory surgery patients 1–6 years old exploring pain ratings, behavior change ratings, and medication compliance at 2–3 days and 1–2 weeks after surgery. Pain and behavioral change scores were obtained using the Parents Postoperative Pain Measure (PPPM) and Post-Hospital Behavior Questionnaire (PHBQ). Parental medication compliance was defined as parents who followed the discharge instructions for pain medication administration.Main resultsFor our cohort, 69% of patients experienced pain after 2–3 days and 17% after 1–2 weeks post-discharge. PMBCs were reported in 55% after 2–3 days, and in 15% after 1–2 weeks. In addition, PMBCs occurred in the absence of pain (PPPM = 0) at rates of 20% and 5% at 2–3 days and 1–2 weeks after surgery, respectively. Female sex, anesthesia duration, and otolaryngology procedures correlated with higher postoperative pain (PPPM) scores in univariate and multivariate analysis. Intraoperative medications did not correlate with PPPM or PHBQ scores. Higher pain scores were associated with parents who were compliant with discharge instructions for pain medications.ConclusionsMany pediatric patients experienced short-term pain and PMBCs after ambulatory surgery, but these largely resolved by 1–2 weeks following discharge. Patient sex, anesthesia duration, and surgical procedure influenced postoperative pain and/or PMBCs. Furthermore, PMBCs were associated with, but not solely a manifestation of, postoperative pain.     

Pain as a factor complicating recovery and discharge after ambulatory surgery

Pain complicates the recovery process after ambulatory surgery. We surveyed 175 ambulatory surgery patients to determine pain severity, analgesic use, relationship of pain to duration of recovery, and the relative importance of various factors to predicting these outcomes. Multivariate regression analysis was used to determine unique contributions of predictor variables to outcome. Surgical procedures included knee arthroscopy (n = 50), hernia surgery (n = 25), pelvic laparoscopy (n = 25), transvaginal uterine surgery (n = 25), surgery for breast disease (n = 25), and plastic surgery (n = 25). Maximum pain (on a scale of 0-10) varied from 2.3 +/- 0.5 to 5.1 +/- 0.5 (mean +/- SE), depending on surgical procedure; 24% of patients had pain scores of > or =7, and 24% were delayed in Phase 1 recovery by pain. Pain scores were lower if local anesthetic or ketorolac was administered intraoperatively (22% and 26% respectively). Fentanyl dose during recovery correlated with maximum pain scores; fentanyl dose was 42% less if ketorolac was administered intraoperatively. In females, the recovery fentanyl dose increased in proportion to the intraoperative fentanyl dose. The maximum pain score was predictive of total recovery time (135, 172, and 212 min of recovery for maximum pain scores of 0-3, 4-6, and 7-10, respectively; P < 0.001). We conclude that improvements in pain therapy are warranted to improve patient comfort and to expedite recovery. IMPLICATIONS: Moderate to severe pain is common after ambulatory surgery and is a frequent cause of delayed discharge. Postoperative pain, opioid-related side effects, and time to discharge were less when nonsteroidal antiinflammatory drugs or local anesthetics were used intraoperatively to prevent pain before patient awakening.     

Factors implicated in discharge disposition following elective bariatric surgery

BackgroundCurrent bariatric surgery studies have focused on traditional outcomes such as mortality and morbidity and have thus far have neglected an important marker of surgical care- discharge destination.ObjectivesThe aim of this study was to 1) characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery with respect to discharge disposition and to 2) evaluate factors which predict alternate care facility (ACF) discharge.SettingParticipating Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) centers.MethodsData was extracted from the MBSAQIP data registry from 2015 to 2018. All primary Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included while prior revisional surgeries and emergency surgeries were excluded. Our primary objective was to characterize the prevalence of and clinical characteristics of patients who undergo bariatric surgery and are discharged to an alternate care facility (ACF). Our secondary outcome was to identify predictors of discharge to an ACF using multivariable logistic regression modeling.ResultsMost patients (n = 588,256; 99.6%) were discharged home while only a small proportion were discharged to an ACF (n = 1502; .4%). Patients discharged to an ACF were older (51.5 ± 13.5 yr versus 44.4 ± 12.0 yr; P < .0001), of increased body mass index (49.7 ± 11.9 kg/m² versus 45.3 ± 7.8 kg/m²; P < .0001), and more likely to be of male sex (26.8% versus 20.4%; P < .0001). Patients with hypertension (65.2% versus 47.9%; P < .0001), dyslipidemia (40.1% versus 23.7%; P < .0001), sleep apnea (52.7% versus 38.1%; P < .0001), and medication-dependent diabetes (39.5% versus 26.3%; P < .0001) were more likely to be discharged to an ACF. Multivariable logistic regression revealed that partially dependent and dependent functional status were the single greatest preoperative predictors of ACF discharge with an 8- and 7-fold respective increase in odds of ACF versus patients of independent functional status.ConclusionImpaired functional status was the single greatest independent preoperative predictor of ACF discharge, providing evidence against the current use of a strict age cut-off criteria and support for implementation of a more patient-centered functional approach in selection of surgical candidates.     

Factors affecting the healing of the perineum following surgery

Introduction

The aim of this study was to establish patient and procedural factors associated with the development of an unhealed perineum in patients undergoing a proctectomy or excision of an ileoanal pouch.

Methods

A review of 194 case notes for procedures performed between 1997 and 2009 was carried out. All patients had at least 12 months’ follow-up. Univariate and multivariate analyses were performed in 16 parameters. For those patients who developed an unhealed perineum, Cox regression analysis was performed to establish healing over a 12-month period.

Results

Two hundred patients were included in the study, of which six had unknown wound status and were subsequently excluded. This left 194 study patients. Of these, 86 (44%) achieved primary wound healing with a fully healed perineum and 108 (56%) experienced primary wound failure. With reference to the latter, 63 (58%) healed by 12 months. Comparing patients with an initially intact perineum with those with initial wound failure showed pre-existing sepsis was highly relevant (odds ratio: 4.32, 95% confidence interval [CI]: 2.16–8.62, p<0.001). In patients who had an unhealed perineum initially, perineal sepsis and surgical treatment were both significantly associated with time to healing (hazard ratio [HR]: 0.54, 95% CI: 0.31–0.93, p=0.03; and HR: 0.42, 95% CI: 0.21–0.84, p=0.01).

Conclusions

The presence of pre-existing perineal sepsis is associated with an unhealed perineum following proctectomy in inflammatory bowel disease (IBD) and non-IBD surgery. Further studies are indicated to establish perineal sepsis as a causative factor.     

Complications following paediatric ambulatory surgery

The overnight admission rate following paediatric ambulatory surgery, reasons for such admission and post-hospitalization complications reported by parents during 1988–1991 (n = 15 245) were compared to previously reported data for patients undergoing ambulatory surgery during 1983–1986 (n = 10000) in the same institution. The overnight admission rate decreased from 0.9 to 0.3%. Vomiting, complicated surgery and croup were the most common reasons for overnight admission in both series, accounting for nearly 60% of admissions. We were able to contact 10 319 (67.7%) parents on the day following surgery. Of these, 59.9% reported a complication or discomfort following discharge from the ambulatory unit. Vomiting continues to be the leading cause of postoperative morbidity.     

Unanticipated admissions following ambulatory surgery

The principal causes of unanticipated admission to the ambulatory surgery unit at Viladecans Hospital between October 1990 and January 1997 were analyzed. Of 7006 patients who underwent outpatient surgery in our facility, 108 were admitted (1.54%). The mean age was 38 years and 93.5% were American Society of Anesthesiologists' (ASA) physical status classification I and II. The principal reasons for admission were surgical complications 42.5% (46); anaesthetic complications 15.7% (17); uncontrollable pain 13% (14); infections 8.3% (9); protracted vomiting 7.4% (8); and coexisting medical problems 6.4% (7). The percentage of admissions in our facility is comparable to that of other ambulatory surgery units. Haemorrhage and pain were the principal causes of admission, vomiting was not common, and we address the role of infection, which has been overlooked as a reason for admission in other published series, perhaps due to the fact that it occurs after discharge.     

New concepts in recovery after ambulatory surgery

The recovery care after ambulatory surgery is in a state of flux. There is increasing emphasis on rapid discharge home after ambulatory surgery. Discharge after surgery should be based on clinical criteria rather than based on time. Recent studies suggest that the insistence on oral intake and voiding before discharge is unnecessary and can delay discharge. This article reviews the recent developments in the recovery process after ambulatory surgery.     

Factors predicting deviation from an enhanced recovery programme and delayed discharge after laparoscopic colorectal surgery

Aim The study aimed to identify factors that predict postoperative deviation from an enhanced recovery programme (ERP) and/or delayed discharge following colorectal surgery. Method Data were prospectively collected from all patients undergoing elective laparoscopic colorectal resection between January 2006 and December 2009. They included Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) variables, body mass index (BMI), sex, preoperative serum albumin, pathology, conversion from a laparoscopic to an open approach and postoperative length of hospital stay. Results There were 176 patients (90 women) of mean age 68 years. Fifteen (9%) operations were converted from laparoscopic to open. The remainder were completed laparoscopically. Fifty‐five (31%) deviated from the ERP, with most failing multiple elements. The most common reason was failure to mobilize, which often occurred in conjunction with paralytic ileus or analgesic failure. Factors independently predicting ERP deviation on multivariate analysis were pathology and intra‐operative complications. The median length of stay was 5 days. Sixty‐four (36%) patients had a prolonged length of stay that was predicted by age, number of procedures and ERP deviation. Conclusion Pathology and intra‐operative complications are independent predictors of ERP deviation. Prolonged length of stay can be predicted by age, multiple procedures and ERP deviation. Failure to mobilize should be considered as a red flag sign prompting further investigation following colorectal resection.     

A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit

STUDY OBJECTIVE: To determine the significance of pain and other symptoms on the recovery process after ambulatory surgery, by surveying pain, analgesic use, and related aspects of recovery in the first 48 hours after discharge from an ambulatory surgery unit. DESIGN: Prospective, observational, surveillance survey. PATIENTS: A total of 175 patients were studied, 25 in each of 6 surgical groups including knee arthroscopy, hernia repair, pelvic laparoscopy, transvaginal surgery, surgery for breast disease, and plastic surgery. INTERVENTIONS: Patients were treated in a manner considered normal or "usual" for the surgeon and the institution. MEASUREMENTS: Pain scores (0 to 10), analgesic use, symptom frequency, symptom distress scores, activity level (% of normal), and satisfaction scores were obtained by telephone interview 24 and 48 hours after discharge. Group means (+/-SE), proportions and correlations between predictor variables were determined in relevant groups. MAIN RESULTS: The response rate to postoperative telephone calls was 89% at 24 hours, and 82% at 48 hours. At 24 hours, maximum pain was >3/10 in 60%, or >7/10 in 20% of patients. Pain prevented or disrupted sleep in 46% of patients. Activity level was reduced to 33% of normal at 24 hours; pain was reported as the primary or secondary reason for limiting activity by 54% of patients. At 24 hours, average pain scores correlated inversely with activity (r = -0.49, p = or < 0.0001); least pain score correlated best with satisfaction (r = 0.03, p = 0.0005). CONCLUSIONS: Improvements in pain therapy after discharge appear warranted to provide more consistent pain relief, and hasten return to normal activity.     

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.     

Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery.

OBJECTIVE: Fate of MR following CABG is variable. Predictors of MR regression following CABG alone are not known. METHODS: From our surgical registry, CABG patients with both pre-operative and post-operative resting echocardiograms at our institution were screened. Of the 523 patients identified, 92 had 3+ (n = 65) or 4+ (n = 27) MR on the pre-operative echocardiogram on a 0-4 scale, who had isolated CABG. MR regression was correlated with clinical, operative, electrocardiographic and echocardiographic variables. RESULTS: Patient characteristics: age 68+/-11 years, 62% male, and LVEF 37+/-15%. MR grade decreased from 3.3+/-0.5 to 2.3+/-1.2 post-CABG. Residual 3 or 4+ MR post-CABG was present in 43 (47%) patients. Regression of MR (n=49) was associated with reductions in LV end-diastolic (P = 0.006) and end-systolic (P = 0.0005) dimensions, improvement in LVEF (P = 0.01), longer cross-clamp time (P = 0.04), use of beta-blockers (P = 0.04) and lower presence of CVA as a possible marker of lower atherosclerotic burden (P = 0.03). There was a trend towards increased mortality (P = 0.3) with residual 3-4+ MR over a mean follow-up of 3.9 years. CONCLUSIONS: In nearly half of patients with 3-4+ MR, MR does not regress with CABG alone. Residual MR may be associated with increased mortality. Regression of MR is related to LV size reduction and improvement in LV function. Presence of myocardial viability, adequate revascularization, lack of excessive atherosclerotic burden and therapy with beta-blockers and ace-inhibitors may be critical for MR regression following CABG alone.     

Factors affecting regression of mitral regurgitation following isolated coronary artery bypass surgery.

OBJECTIVE: Fate of MR following CABG is variable. Predictors of MR regression following CABG alone are not known. METHODS: From our surgical registry, CABG patients with both pre-operative and post-operative resting echocardiograms at our institution were screened. Of the 523 patients identified, 92 had 3+ (n = 65) or 4+ (n = 27) MR on the pre-operative echocardiogram on a 0-4 scale, who had isolated CABG. MR regression was correlated with clinical, operative, electrocardiographic and echocardiographic variables. RESULTS: Patient characteristics: age 68+/-11 years, 62% male, and LVEF 37+/-15%. MR grade decreased from 3.3+/-0.5 to 2.3+/-1.2 post-CABG. Residual 3 or 4+ MR post-CABG was present in 43 (47%) patients. Regression of MR (n = 49) was associated with reductions in LV end-diastolic (P = 0.006) and end-systolic (P = 0.0005) dimensions, improvement in LVEF (P = 0.01), longer cross-clamp time (P = 0.04), use of beta-blockers (P = 0.04) and lower presence of CVA as a possible marker of lower atherosclerotic burden (P = 0.03). There was a trend towards increased mortality (P = 0.3) with residual 3-4+ MR over a mean follow-up of 3.9 years. CONCLUSIONS: In nearly half of patients with 3-4+ MR, MR does not regress with CABG alone. Residual MR may be associated with increased mortality. Regression of MR is related to LV size reduction and improvement in LV function. Presence of myocardial viability, adequate revascularization, lack of excessive atherosclerotic burden and therapy with beta-blockers and ace-inhibitors may be critical for MR regression following CABG alone.     

Factors affecting leakage following esophageal anastomosis

Esophageal anastomotic leaks remain the most serious problem following extirpative procedures for esophageal carcinoma. We conducted a retrospective analysis of 352 patients with carcinoma in the thoracic esophagus who had undergone esophageal anastomosis following esophagectomy at the Kurume University Hospital between 1981 and 1990. Of these, 94 patients (27%) developed anastomotic leaks, and out of this subgroup, 21 (6%) died as a direct result of the leak. A further 20 patients (6%) underwent repair of the leak, after which they were able to tolerate oral intake. The anastomotic leak healed spontaneously in the other 53 patients (15%). The risk factors predisposing to leaks from esophageal anastomoses were determined as: (1) the anastomosis being performed via a retrosternal or subcutaneous route as opposed to an intrathoracic route, (2) the use of colonic interposition as opposed to a gastric pedicle, (3) performing a manual anastomosis as opposed to a mechanical anastomosis, and (4) employing an end-to-end anastomosis, as opposed to an end-to-side anastomosis, using a mechanical method. By introducing an anastomotic stapling device, a microvascular technique, a staged operation based on the preoperative risk analysis, and improvement in pre- and postoperative management, the incidence of anastomotic leakage could be decreased from 35% to 14%, and that of consequent hospital mortality, from 9% to 2%.