Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2–18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05–1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.     

Oral naproxen but not oral paracetamol reduces the need for rescue analgesic after adenoidectomy in children

BACKGROUND: Our aim was to show the efficacy of naproxen and paracetamol with and without pethidine on pain and nausea and vomiting after adenoidectomy. The primary outcome was the requirement of rescue analgesic for post-operative pain and the secondary outcome was post-operative nausea and vomiting (PONV). METHODS: A randomized, double-blind, placebo-controlled study design was used. Thirty minutes before anaesthesia induction, patients (n= 180) received either a single oral dose analgesic (naproxen 10 mg/kg or paracetamol 20 mg/kg) or a placebo. Half of the children received pethidine 1 mg/kg intravenously (i.v.) at the induction of anaesthesia. Post-operative pain was evaluated using an objective behavioural pain scale (OPS 0-9) and rescue medication, i.v. fentanyl 1 mug/kg, was administered if the child suffered from moderate or severe pain (OPS > or = 4). RESULTS: When pethidine was not used, 83% of the children in the naproxen group vs. 97% in the other two groups required rescue fentanyl (P < 0.05). The use of pethidine reduced the incidence of fentanyl requirement by 30% and the number of fentanyl doses by 50% (P < 0.001). It also equalized the effects of naproxen, paracetamol and the placebo making the pain model invalid for this kind of study. The drawback associated with better analgesia was a doubling of the incidence of PONV (P < 0.001). CONCLUSIONS: Oral naproxen (10 mg/kg), but not oral paracetamol (20 mg/kg), reduces the need for rescue analgesic after adenoidectomy in children. The sensitivity of the pain model is crucial for these types of studies.     

Pediatric myringoplasty: Prognostic factors in surgical outcome and hearing threshold recovery

Conclusions: This study shows as decisive factors the history of tympanostomy tube insertion and surgical approach. The closure of the perforation observed at the 6th post-operative month is almost definitive, without finding significant differences ahead. The myringoplasty can be performed simultaneously in bilateral perforations and in a day-case basis with same success rates. Astatistically significant audiometric improvement area is described, after myringoplasty, undescribed previously in literature. Objectives: The aim of this study was to evaluate prognostic factors in surgical outcome and hearing threshold after myringoplasty, in pediatric age. Methods: A 10-year retrospective review of 142 myringoplasties performed by a single surgeon of the Pediatric ENT Department of 12 de Octubre University Hospital. Multiple prognostic factors were investigated, such as those related to perforation and surgery, contralateral ear status, and pre- and post-operative hearing threshold. Results: The overall rate of closure of the perforation was 74.64%. The re-perforation rate was directly proportional to the number of tympanostomy tube insertion (OR = 1.64). Other determining factors were the surgical approach, the graft position and side. There was a post-operative significant improvement (p < 0.001) insuring that the more affected frequencies, low (125–500 Hz) and high frequencies (4000–8000 Hz), were the more improved after the procedure.     

Day-case tonsillectomy-is it appropriate?

There is continued encouragement to increase the use of day surgery. Recent publications have suggested that day-case tonsillectomy is a safe procedure due to the low primary haemorrhage rates (0.14–3.5%). One of the suggested benefits of day surgery is that patients want it. They prefer to recover at home after an operation. With tonsillectomy, personal experience suggested that this was not the case. A review of 117 patients having tonsillectomy was undertaken. All patients stayed in for at least one post-operative night. No patients or parents thought that the post-operative stay was too long (80%‘just right', 20%‘too short') and only 7% would have been happy to go home on the day of operation. ‘Safety’ does not automatically make an operation suitable for day-case surgery. Pain, nausea, vomiting, drowsiness and anxiety about the operation and post-operative course were all reasons given for not wanting to go home on the day of surgery. The justification for the increased use of day surgery is that it increases efficiency by reducing costs per case while maintaining the quality of care. One aspect of quality of care is patient acceptability and before day-case tonsillectomy is acceptable to patients the factors responsible for the post-operative morbidity need to be addressed.     

The effect of foot massage on patients'' perception of care following laparoscopic sterilization as day case patients

This randomized-controlled study examined the effects of foot massage on patients' perception of care received following surgery. The sample of 59 women who underwent laparoscopic sterilization as day case patients were randomly allocated into two groups. The experimental group received a foot massage and analgesia post-operatively, whilst the control group received only analgesia post-operatively. Each participant was asked to complete a questionnaire on the day following surgery. This examined satisfaction, memory and analgesia taken. The 76% response rate was comparable with other patient satisfaction studies following day-case surgery. Statistical analysis showed no overall significant difference in the pain experienced by the two groups; however, the mean pain scores recorded following surgery showed a significantly different pattern over time, such that the experimental group consistently reported less pain following a foot massage than the control group. This study has attempted to explore the use of foot massage in a systematic way and is therefore a basis for further study.     

Randomized comparison of two anti-emetic strategies in high-risk patients undergoing day-case gynaecological surgery

Background: Postoperative nausea and vomiting (PONV) is a significant causeof morbidity among patients undergoing general anaesthesia.The optimal strategy for prevention of PONV, however, remainsunclear. This study compared two commonly used prophylacticstrategies in high-risk, day-case, gynaecological surgery patients. Methods: We conducted a randomized trial comparing sevoflurane combinedwith dolasetron (SD), with propofol-based total intravenousanaesthesia (TIVA) in 126 high-risk patients undergoing day-casegynaecological surgery. The primary endpoints included the incidenceand severity of nausea or vomiting before discharge and theincidence of nausea or vomiting between discharge and 24 h.To identify the factors most predictive of a complete response(no PONV at any time within the 24 h period), multiplelogistic regression models were fitted. Results: Before discharge, there was no significant difference betweenthe two treatment groups with respect to nausea and vomitingoutcomes (P = 0.3). Post-discharge nausea and vomiting (PDNV),however, were significantly more common for patients in theTIVA group (nausea, P = 0.004 and vomiting, P = 0.03). Typeof anaesthetic, adjusted for weight and anaesthesia durationwas significantly associated with complete response (odds ratio= 2.7, 95% confidence interval = 1.15 to 6.4). Conclusions: Although both TIVA and dolasetron prophylaxis reduce the predictedrate of PONV in the early postoperative period, the anti-emeticeffects of propofol are short-lived. A longer-acting drug suchas dolasetron may therefore be necessary to prevent PDNV.     

The evolution towards ambulatory and day-case management of febrile neutropenia

Febrile neutropenia (FN) is only second to chemotherapy administration as a cause of hospital admission during treatment for cancer. As FN may signify serious or life-threatening infection, management protocols have focussed on trying to prevent adverse outcomes in these patients. However, it is now possible to identify a subset of patients with FN at low risk of life-threatening complications in whom duration of hospitalisation and intensity of therapy can be reduced safely. This review discusses how the management of FN has evolved to enable patients identified as low risk to be treated on specific low risk management strategies, with an emphasis on some of the practical considerations for the implementation of such strategies.     

Desflurane or sevoflurane for gynaecological day-case anaesthesia with spontaneous respiration?

Sixty gynaecological day-case patients were anaesthetised with either desflurane or sevoflurane in oxygen/nitrous oxide, following intravenous induction. Mean end-tidal desflurane was 4.5% at 5 and 10 min post induction, whereas mean end-tidal sevoflurane was 1.7%. There were five untoward airway events (coughing, hiccoughs) in the desflurane group and three in the sevoflurane group, including one laryngospasm. Time to eye opening and orientation following anaesthesia were significantly faster in the desflurane group (2.8 min/4.8 min) than in the sevoflurane group (7.0 min/9.8 min; p < 0.0001). Time to being ready for discharge home was also significantly earlier in the desflurane group (3 h compared with 3.5 h). Telephone interview on the first postoperative day showed that in the desflurane group 29 of 31 were fully returned to normal activity compared with only 15 out of 29 in the sevoflurane group (p < 0.01).     

Small-dose selective spinal anaesthesia for short-duration outpatient gynaecological laparoscopy: recovery characteristics compared with propofol anaesthesia

A randomized controlled trial compared recovery characteristicsafter selective spinal anaesthesia (SSA) or propofol generalanaesthesia (GA) for short-duration outpatient laparoscopicsurgery. Forty women were randomized to receive either SSA (1%lidocaine 10 mg, sufentanil 10 µg and sterilewater 1.8 ml) or GA (propofol and nitrous oxide 50% inoxygen). Compared with the GA group, times to leaving the operatingroom, performing a straight leg raise, performing deep knee-bendsand achieving an Aldrete score >9 and the time in Phase IIrecovery were significantly shorter (P<0.05) in the SSA group. Br J Anaesth 2001; 86: 570–2     

Analgesia for day-case surgery

Br J Anaesth 2001; 87: 73–87